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Webcast Welcome

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Webcast Welcome

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    1. Central Region IPL 1 Webcast Welcome! Thank you for signing into the IntraPlan Local (IPL) TPA Web training. Please sign into the live meeting using the webcast invite: Use meeting URL Use meeting ID Use meeting key Type in your Display Name Please join the meeting using the audio conference information: Dial-in #: (866) 281-7189 Code: 010-610-7476

    2. Central Region IntraPlan Local IPL TPA Training

    3. Central Region IPL 3 IntraPlan (IPL) Claim Processing IntraPlan (IPL) claims occur when the state in which the member’s contract is based and the state in which the services are rendered are two separate WellPoint states. IPL claim situations have materialized as business that was previously processed on another system as ITS Host is migrated onto the same system where the membership is housed.

    4. Central Region IPL 4 WLP to WLP on WGS 2.0 or Star

    5. Central Region IPL 5 How to Identify a Central Region IPL Claim

    6. Central Region IPL 6 Queues The Central Region Price-n-Ship (PNS) claims will appear in function code IP as is currently used for the CA/NV/CO claims.

    7. Central Region IPL 7 IPL and Central Region Provider Price-n-Ship (PNS) Process Claims are sent to Central Region applications for clinical editing and pricing. Clinical editing is done using the PACE software application. Pricing is done using the NetworX Pricer application (also called PNS). Both clinical editing and pricing is consistent with Central Region provider contracts.

    8. Central Region IPL 8 IPL and Central Region Provider PNS Process Continued Provider data Central region provider numbers will be displayed in the billing number (BLNG NBR) and/or rendering number (RNDR NBR) fields on the DS pop-up. At least an NPI or NBR must be on the claim otherwise edits will set. The resolution processing guidelines for related edits will be available on the TPA website.

    9. Central Region IPL 9 How to Verify an IPL Claim

    10. Central Region IPL 10 Verifying the NPI on the National Provider Database (aka the UniCare Bridge) After selecting the ‘FF’ option from the EXTERNAL Profile screen, the Database Inquiry Menu will display. Place an ‘S’ next to the Alternative Key Type option, and enter ’02’ in the corresponding field. 02 = NPI 20 = BLNG / RNDR WI ID from their legacy system 32 = BLNG / RNDR MO ID from their legacy system 70 = BLNG / RNDR ID from Facets system Enter the NPI in the ALT KEY field.

    11. Central Region IPL 11 Verifying the NPI (Continued) After depressing Enter, place an ‘S’ next to the corresponding Legacy Key: T = Tax ID M = Med ID

    12. Central Region IPL 12 Verifying the NPI (Continued) After depressing Enter, the system will display: The networks to which the provider is associated; The effective and end dates; The provider’s status – whether active or inactive – within that network.

    13. Central Region IPL 13 Searching for the NPI using the Provider’s Tax ID After selecting the ‘FF’ option from the EXTERNAL Profile screen, the Database Inquiry Menu will display. Place an ‘S’ next to the appropriate ‘…Data by Tax ID’ option. Enter the provider’s tax ID in the Tax ID field. Be sure to apply the appropriate suffix to specify the type of ID: E = Employer ID # (EIN) S = Social Security # Enter the first date of service from the claim in the SVC DT – From field.

    14. Central Region IPL 14 Searching for the NPI (Continued) After depressing Enter, check the NPI number field (next to tax id). If the NPI field states ‘MULTIPLE’, depress PF15 or <SHIFT + PF03> to access the list of Alternate Keys screen.

    15. Central Region IPL 15 Searching for the NPI (Continued) Alternate Key Screen is used to find the correct corresponding provider (billing, rendering or NPI) numbers that are associated with a given Tax ID. This is used to Input the Alternate key into your DS pop up in the BLNG / RNDR field (see slide 7).

    16. Central Region IPL 16 Price-n-Ship (PNS) Specific Statuses, Routing and Edits System Routing to PNS (xxIP46 and xxIP47) A claim marked for Central PNS will systematically move to status 46 and then will change to status 47 when it has been sent MAN and XPR Edits These are soft edits that are set when the system has initially failed prior to going to PNS because of other edits on the claim.  Once all other edits are resolved, route XR claim to PNS for pricing.  XR route will send the claim to a 46 status.  MAN and XPR edits will be removed when the claim returns from PNS with pricing. When a claim returns from PNS, it will be routed to the xxIP00 or xxIP02 queue. XPF Edit Claim failed HIPAA.  Access TX pop up to get the error code.  Get error code description using the XPF edit document found in the TPA website and reject claim accordingly. T601, T301 and T101 Edits These are edits returned because the claim couldn’t be processed in the pricer due to data issues for example. The TX pop-up will reflect additional details NOTE: Specific resolution processing guidelines will be available on the TPA website. NIP and NAT Edits These are informational edits that indicate that claim processing should follow the IPL process. MJ and MN Edits Route claims with the MR edit to Medical Review for medical necessity review after claim has come back from PNS. DA3, CPI, CTI, T301, DA4, RTI Edits These are edits regarding the provider information on the WGS claim. The National Provider File (Unicare Bridge) and the claim image are used to resolve the edit.

    17. Central Region IPL 17 IPL and Central Region Provider PNS Process Continued Pricing Data will be reflected on the Line of Expense (LOE) Screen (PF32 or MP popup). Price Sheet Field: Price Sheet field value of “E” denotes externally priced. This will be set when the allowances are posted to the claim. Otherwise will be an ‘N’. If manual pricing is needed, the price sheet value will be a ‘Y’. RSN Field: This field is critical when manually pricing inpatient hospital claims when not all days are approved by UM. Allowed AMT Field: Allowances returned from PNS are under the Allowed Amt column.

    18. Central Region IPL 18 IPL and Central Region Provider PNS Process Continued Provider Participation is determined from the ENPS (PF5) screen which is accessed from the MP pop-up after a claim has returned from PNS with pricing. The PAR/NON-PAR field values are: N – Non-Par P – Par Central Region Network Clm# values are: 000000000002 for a PPO network provider NONPAR for a provider not in any network Any PNS messages will be shown in the EXT RSN column Messages of interest would be Multiple Surgery Reduction (MSR) applied; Service not payable (ZAA). The Help function will also provide more of the EXT RSN descriptions.

    19. Central Region IPL 19 IPL and Central Region Provider PNS Process Continued Clinical Editing (CE Pop-up) results are posted to the Claims Editing Summary Screen. The results of any rebundles are reflected on the LOE screen The CES reason column has a help feature which will explain the clinical editing value. CE results need to be adhered to or the MCS area should be contacted for further action.

    20. Central Region IPL 20 Medical Necessity Consideration PNS does not perform medical necessity review on inpatient facility claims. Claims will price as approved days even if not all days are approved. TPA will need to manually apply actual Utilization Management determination accordingly. Apply MRU edits that are related only to benefit review and use route code MR with text for CA MRU to review.

    21. Central Region IPL 21 Manual Pricing If Medical Review allows additional allowance, follow the workflow on the TPA website on ‘How to Manually Apply Price to a claim’. http://tpa.bluecrossca.com/

    22. Central Region IPL 22 TPA Customer Service Providers will call the phone numbers on the Remittance Advice/Voucher. TPA customer service should forward to Rancho Cordova at 1-800-688-3828. Contractual Questions Check status (Mainframe's EOB screen does not show correct check status). TPA provider correspondence should forward contractual issues to Rancho Cordova .

    23. Central Region IPL 23 Recovery Process for Central Provider IPL Claims

    24. Central Region IPL 24 Recovery Scenarios Situations that would require a VOID request: WellPoint system check is returned by provider CCR researches inquiry and determines a void request is needed Entire check paid to wrong provider Situations that would require a Stop Pay/Reissue: If the check is lost or outstanding The provider calls or sends correspondence requesting the claim status. Situations that would require a Wrong Provider Paid: Reasons that would possibly cause the check to be issued to WRONG Provider Anthem processor or Lason vendor keying error Provider submitted claim with incorrect Provider ID, PID or NPI number Electronic submission reported wrong provider number Claims cannot be altered if submitted with incorrect information; the claim must be re-submitted with correct data. Wrong provider paid, due to keying error; check is OUTSTANDING.

    25. Central Region IPL 25 Contact Process For Provider Reimbursement/Contracting type of questions Email - CentralRegionHostPNSUnit@Wellpoint.com Manager/OE of Central Region Host PNS Claim Processing Unit will be in charge of managing all emails daily Do not use this email box to have pended claims or inquires worked by the PNS Claims unit Please review the FAQ documents which will be uploaded in the TPA website to eliminate asking duplicate questions For all other types of questions call MCS Unit at 1-800-688-3828 or mail issues to MCS Unit.

    26. Central Region IPL 26 The End Do you have any Questions?

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