10/23/2020

Healthfirst Claims-Double Copays Charged

We, now, have 81 outstanding HealthFirst claims where double copays were charged. "They" now understand it's a computer error, but have not corrected it. We have submitted all 81 claims on the required spreadsheet with information that was not unnecessary, but extremely time consuming, and STILL have not received any reimbursement. They are now reimbursing the copays correctly, but have not paid the delinquent ones.

There are only three ways that the claims will be adjusted in order to reassign a second co-pay to pay the practice for services previously provided:

-The primary method of communication about this error should be to follow the grievances protocol outlined in the Health First provider manual. For all 81 patients, the following information would need to be gathered and mailed to the correspondence unit (P.O. Box 958438,Lake Mary, FL 32795-8438):

All written requests for Review and Reconsideration via the provider website or P.O. Box 958438 should include the following information: a copy of the EOP, the claim, supporting documentation, and a written statement explaining why you disagree with Healthfirst’s determination as to the amount or denial of payment.

Examples of information and supporting documentation that should be submitted with written requests for review and reconsideration include:

• A written statement explaining why you disagree with Healthfirst’s claim determination.
• Provider’s name, address, and telephone number.
• Provider’s identification number.
• Member’s name and Healthfirst identification number.
• Date(s) of service.
• Healthfirst claim number.
• A copy of the original claim or corrected claim, if applicable.
• A copy of the Healthfirst EOP.
• A copy of the EOP from another insurer or carrier (e.g., Medicare), along with supporting medical records to demonstrate medical necessity.
• Contract rate sheet to support payment rate or fee schedule.
• Evidence of eligibility verification (e.g., copy of Healthfirst member ID card).
• Evidence of timely filing:
• RO59 Report (Insurance Carrier Rejection Report) or Emdeon Vision “Claim for Review”/“Claim Summary” Report;
• Please note: Healthfirst does not accept copies of certified mail or overnight mail receipts, or documentation from internal billing practice software as proof of timely filing.

-If the insurance doesn’t respond to the submitted information, the issue needs to be escalated to a provider representative for the county services were provided in so they can escalate the issue internally to adjust the affected claims. This information should be available in your contract with the managed care plan, or should be able to be provided by customer service.

-Last, if no changes are made despite following the HMOs protocol, a complaint should be filed with the New York State Insurance Board outlining that all rules were followed and no changes were made with something that was identified as a processing error that led to an underpayment and assigned patient responsibility in error.