Directprovider.com section 2 11072013

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Directprovider.com TrainingPresented by Coventry Health Care

Coventry Health Care – For Public Use

In Section Two, the following will be covered: Claim Inquiry

— Searching for Claims— Viewing Claim History and Detail— Requesting Adjustments

Claim Submissions (via Emdeon) Remittance Advices Message Center

— Composing and Working with Health Planand Workers Comp Messages

Coventry National PPO Fee Schedule— Requesting Current Fee Schedules— Requesting Future Fee Schedules

Coventry National Client Listing First Health /TPA Carrier Bills Workers Comp

— Bills— Jopari Portal— Refer a Patient (Talispoint)— Provider Resources

Directprovider.com – Section Two


Claim Inquiry…

This section provides claim status, claim payment information, claim line detail, and claim history. The users are able to:

Search for claims

View specific or entire groups of claims

Submit an online claim adjustment

View/Print Remittance Advices


Claim Inquiry…


Claim Inquiry…

Fields marked with an Asterisk are required

On the Search By Member tab users can use the following Search Methods:- Member ID- Member Name/DOB


Claim Inquiry…

When searching by Member, if The member is found in multiple health Plans the user will be prompted to select the health plan and click CONTINUE


Claim Inquiry…

All date ranges are limited to 30 Days

On the Search By Status tab userscan search by date/date range fromthe following selected status:- Pended- Rejected- Denied- Approved- Paid- Unpaid


Claim Inquiry…

On the Search By Claim Number tab users can searchby a known claim for the selected Tax ID #


Claim Inquiry…

On the Search By Date tab users can search by DOS or a 30 day date range for the selected Tax ID #/HealthPlan/Provider


Claim Inquiry – Search Results…

Results Not Found

For DENIED and REJECTEDclaims the use can click the

icon to display a more detailed reason

Click the icon to displayprocessing History

Click the icon to ViewDetails for the selected claim


Claim Inquiry – Reason…

When a claim has been Rejected or Denied, the user can click the REASONbutton to display a more detailed reason for the denial or rejection


Claim Inquiry – History…

Click the HISTORY button to view the detailed processing history, which will include any Status changes


Claim Inquiry – Detail…

The claim header area includes the following detail:

- Provider information- Claim type (Original, Backout, Replacing)- Date Entered/Approved- Referral/Authorization Number (if applicable)- Patient Control # (if applicable)- Coordination of Benefits Flag- Paid Amount- Eligibility Link for the DOS



The line detail area includes allline items submitted on the claim,

Click the VIEW button in the disposition column to view detailedprocessing for the specific line item(click HIDE to close the expanded

line item disposition details)



The Payment Information area will include a link to the RemittanceAdvice (if available) as well as detailed payment information

and Patient Responsibility, the user can click the PrintFriendly link to print out the claim detail

EFT333333 ABC PEDIATRICS

EFT333333 ABC PEDIATRICS

123456

987654321



If a claim has been backed out and replaced the Related Claimsarea will be present and will have the other corresponding claims,

the user can click on a corresponding claim number to view that detail

123456789

#123456789

80111111102SALLY PUBLIC


Claim Inquiry – Adjustment Request…

Clicking the Request Adjustment link will branch the user to theADJUSTMENT REQUEST screen where the user will identify aReason for the request from the drop-down and the ContactInformation will default the users Name and Phone (but can

be changed if necessary)



Users will populate the correspondingfields depending on the circumstances

of their adjustment request



Users are able to attach up to four (4)electronic files not totaling more than

10 megabytes (click the Remove buttonif something has been attached in error);

Click Submit Request when done


Emdeon Claim Submissions…

• Coventry has partnered with Emdeon to provide online claim submission (direct data entry or claim file upload) and HIPAA electronic remittance advice access for Coventry Health Care members at no cost to the providers

• This web interface is a self-directed/administered solution that contains some of the functions a provider can use today within Emdeon Office

• Providers that submit paper claims or are able to produce HIPAA compliant EDI claim and remittance (837 and 835) files may want to take advantage of this functionality


Emdeon Claim Submissions… Small offices that only see a few Coventry members may be

interested in the direct data entry functionality1. Manually enter claims directly to the Emdeon site (via

Directprovider.com link)2. Monitor return messages from Emdeon and later from Coventry

regarding claim level accept/reject messages on the site3. Fix or reenter any claims that are rejected as applicable

Larger provider offices that are able to create their own HIPAA compliant/EDI claim files might want to use the file upload process; however, they must be able to manage the full cycle of EDI claim submission:1. Prepare HIPAA compliant 837 EDI file from billing system or

vendor2. Upload file to Emdeon website (via Directprovider.com link)3. Monitor return messages from Emdeon and later from Coventry

regarding claim level accept/reject messages4. Fix or reenter any claims that are rejected as applicable


Emdeon Claim Submissions… The system will present the Claim Submission landing page when

the left navigation link is invoked

When the user clicks <continue> the system will present Emdeon’s login page


Emdeon RAs… Within Remittance Advices, the system will present the HIPAA

835 Remittances landing page when the HIPAA 835 Remittances tab is selected

When the user clicks <continue> the system will present Emdeon’s login page


Emdeon Claim Submissions/RAs… Coventry will not have staff trained

to support this tool; Provider officestaff will need to reach out to Emdeon to request any additional informationregarding this process

Provider offices can pre-load providerand practice details (Providers and the Practice must have NPIs)

Once logged in, WebConnectusers will be able to select Direct Data Entry or Claim File Upload

All claims submitted through this process will be merged with all Coventry claims submitted under payer ID 25133


Remittance Advices…

Another option on the Navigation Bar is Remittance Advices (RAs). This section of Directprovider.com allows users to view remittance advices online.

The remittance advice (RA) available on Directprovider.com is an exact image of the paper remittance advice sent through the mail.

There will be three tabs to chose from (as applicable):— Health Plan Remittances— Coventry Consumer Choice/C3 Remittances— HIPAA 835 Remittances



The Search Methods include:- Claim(S)#- Member ID- Member Name/DOB- Check/EFT #- Service Dates- Check/EFT Dates

Click SUBMIT to Search



Within the Search Results column click the View linkto open the RA in an Adobe Reader (if you don’t haveAdobe Reader installed click the Get Adobe Reader

button to download a free version

123456789 EFT12345


Secure Messaging…

The Message Center is another alternative for Coventry providers to communicate private health information directly with the Coventry CSO.

The Message Center option allows Coventry providers the opportunity to submit secure Health Plan specific and Workers’ Comp messages to the Coventry Customer Service Organization in regards to inquiries for claims, authorizations, eligibility, and forms, to just name a few.

Secure messaging allows users to communicate private health information directly with the customer service organization.


Secure Messaging…


Secure Messaging…

Click the Subject toopen a message

Select Health Plan orWorkers’ Comp andclick Go to compose

a new message

Common formattingis used to identify

read/unreadmessages

The Paper Clip iconis used to indicate

an attachment


Secure Messaging…

When composing a new message select a Reference

(Claim #,Member ID, or Other); select an applicable Category

(such as Authorizations,Claims Adjustment, Eligibility /

Benefits, Forms, etc.); andenter a Subject

Users can attach up to4 electronic data files

(click Remove, todelete an attachment)


Secure Messaging…

Click the MessageList button to return

to the Inbox tab

Click Cancel to closeor Reply to respond

Click Trash to moveto the Trash tab orclick Print Friendly

to print the message


PPO Fee Schedules… Physicians and Ancillaries not affiliated with a

Hospital who participate with any of the Coventry National PPO Products are able to request Fee Schedule detail through Directprovider.com

Eligible providers must be registered with one or more of the Coventry National PPO Products before they can submit a Fee Schedule Request

Eligible providers may request Current or Future Fee Schedules and can designate whether they want to receive Full Schedules; Sample Schedules; a Procedure Code Range; or a Single Procedure code


PPO Fee Schedules…

Users with access to the PPO Fee Schedule functionality willselect the applicable Tax ID #,

Provider and PPO Productfrom the drop down and then

click the Submit button(Users who do not have access

will need to contact theirAdministrator to request access



Providers may have location specific rates, userswill click the Select button for the desired Rate

Code and Practice Location



Users will click the Current or Future SELECT button



Select the desired Search Method (with a Futurerequest select Changed Values for onlychanging codes/values) and a desired

Delivery Method; PDF Format (Preferred, as detail is returned within 24 hours) or US Mail

(may take 10 to 15 business days to be returned)



When requesting Fee Schedules in PDF Format, the schedule will be delivered via a Secure

Message; the Secure Message will include a link to open

the schedule in PDF Format


Client Listing… If a new administrator is registering to access the

Client List functionality, he or she will access the section of registration that is labeled PPO Fee Schedule or Client List.

— A user will identify that he or she is registering for Client List and will then have to supply his or her CPD ID to continue registration.

Existing administrators with PPO Fee Schedule access can add/edit the Client List Group; The user identifies will edit the Client List group.

— If the user chooses to edit the Client List group, then a new page will display requiring TIN and CPD ID to be added to the Client List functionality.

Users with access will have the ability to access Client Lists via a link on the left Navigation Menu.

When the link is invoked, a disclaimer page is presented. The user has to accept the disclaimer to continue to the Client List landing page.

Users will enter search criteria and execute search.

There are six required fields that must be completed in order for the ‘Find Clients’ button to be accessible.

There is one optional field to search by client/payor name.

Client Listing…


Client Listing…


Users with access will click the ACCEPT ANDCONTINUE button (if you do not have accesscontact your Administrator to request access)

Client Listing…


Enter the required Search Options; For Only Show select from:- Clients Active Today- Clients that will be active in 30 days- Clients that will be active in 60 days- Clients that will be active in 90 days

Client Listing…


Users can search for a specificClient or Payor (optional, leave

blank a complete Client List,then click the FIND CLIENTS

button

Client Listing…


A list of Clients is returned based on search criteria entered;

to view the Client Detail click the Show Detail

button for the specific client(users can also download

the list to Excel)

Client Listing (Detail)…


First Health TPA…


Users can search/reviewFirst Health TPA carrier bills;

Select the SEARCH by Patientor SEARCH by Provider tab

and then enter the desired Search Criteria

For Search By Patient:— Users can search

by Claim Number, with optional Service Dates

— Users can search by Patient Name / Date of Birth with optionalService Dates

— Users can search by Patient SSN with optionalService Dates

First Health TPA…


For Search By Provider:— Users can search

by Physician Name, with required Service Dates

— Users can search by Billing Provider Name with required Service Dates

— Users can search by Service Dates (maximum 30 day date range)

First Health TPA…


If no Bills are found based on the entered search criteria, the user will receive a message to broaden the search criteria or search with a different category

First Health TPA…


First Health TPA…


If Bills are found based on the entered search criteria, users will be able to:1. Filter the Bill List results2. Customize the viewable columns3. Sort on most columns 4. Use the Action icon to display: the

Medical Claims Pricing Systems (MCPS) Sheet or Send Inquiry1

234

First Health TPA…


Filter options include:- Physician Name- Patient Name - Billing Provider Name

Once options are checked the user will click Update Results to filter the Bill List

First Health TPA…


The Customize Table button allows users to pick and choose display fields

(by checking or un-checking fields), at least 5 fields must be selected

before the user can click OK

First Health TPA…


The user can click the Action icon and select PRICING SHEET to view the MCPS Pricing Sheet in PDF format or

click SEND INQUIRY to send aSecure Message to the TPA CSO

First Health TPA…



First Health TPA…

The user can click the Action icon and click SEND INQUIRY to send a

Secure Message to the TPA Carrier CSOfor assistance with bill disputes

(Users may also request assistance witha category of ‘Other’ to get help with contract questions or even

concerns with the quality of servicethey believe they are getting.


Clicking on the “Send Inquiry” option will open a separate window to enter the message detail.

The Tax ID #, CPD ID # and Claim # will default

Select an applicable Categoryfrom the drop down

Enter the Subject and bodyof the message

Up to 4 attachments (10 MB)can be attached

Click ‘Submit’ to send

First Health TPA…


The inquiry is sent through Navigator to the TPA CSO Web Inquiry queue for processing and response

The message will appear in the Inbox tab in the Directprovider Secure Message Center with an issue number assigned by Navigator from “First Health/TPA”

Users can reply to the message from the Message Center

First Health TPA…

Workers’ Comp – Landing Page…


Workers’ Comp - Bills…


The Bills function allows users to SEARCH By Bill, Patient

or By Provider

SEARCH By Bill Criteria:- Control #- Document ID



SEARCH By Patient Criteria:- Claim Number- Patient Name / Date of Birth- Patient SSN

For Search By Patient:— Users can search

by Claim Number, with optional Service Dates

— Users can search by Patient Name / Date of Birth with optionalService Dates

— Users can search by Patient SSN with optionalService Dates



For Search By Provider:— Users can search

by Physician Name, with required Service Dates

— Users can search by Billing Provider Name with required Service Dates

— Users can search by Service Dates (maximum 30 day date range)





If no results can be found the userwill be advised to broaden their

search criteria of callCustomer Service

Workers’ Comp – Bills…


If Bills are found based on the entered search criteria, users will be able to:1. Filter the Bill List results2. Sort on most columns 3. Use the View Details button to

display details and options for theselected bill1

23

Workers’ Comp – Bills…


Filter options include:- Physician Name- Patient Name - Billing Provider Name

Once options are checked the user will click Update Results to filter the Bill List

Workers’ Comp – Bills (View Details)…


Click the View Details button foradditional claim detail and the following options:- View Bill Image (if applicable)- View EOR or Network Pricing Sheet (as applicable)

- Send Inquiry (Secure Message)

01/18/201254321

203.89

153.8912/06/2011

279.00

if no payment info is available a message to contact the Vendor for payment details

Workers’ Comp – Bills (Pricing Sheet)…


Workers’ Comp – Bills (Bill Image)…



Workers’ Comp – Bills (EOR Image)…


Workers’ Comp – Send Inquiry…

The Send Inquiry option for Workers’ Comp is a comprehensive Secure Message that is sent to a specific

work queue within a Coventry Application called WCMS

Workers’ Comp – Message Center…


Both Workers’ Comp and other affiliated Plan messages will appear together in the Inbox

Copies of Health Plan & PPO Fee Schedule submitted inquiries are placed in ‘Sent’ folder, while immediate notifications and responses from the Health Plan reside in ‘Inbox’

For Workers’ Comp inquiries ALL messages remain in ‘Inbox’, NOTHING gets placed into ‘Sent’ tab/folder; Initial Notification remains as ONLY item and reference to submitted request/sent inquiry

— ALL follow up notes/comments are placed into ‘Message’ section of request for DP user to review until ‘Status’ is listed as Final and ‘Resolution Date’ is provided/displayed.





Example of Sent Message with several updates

Workers’ Comp – Jopari Portal…


Workers’ Comp – Refer a Patient…


Workers’ Comp – Provider Resources…


The Important Links will redirect the users to pages within the

Workers’ Comp website; Additional Documents will

open in Adobe PDF



Follow the instructionson the page to display

a State MandatedFee Schedule



To nominate a providercomplete the required fieldson the Nomination Requestand click the Submit buttonto receive more information

Thank you for your time…

For Technical Assistance, please contact Net Support at 866-629-3975


Directprovider.com section 2 11072013

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