Wiki CLAIMS BEING PAID OUT OF NETWORK

[Pkirsch1]

I hope someone can help. Several of our claims are being paid OON with Optum.

They are going to medical instead of behavioral health. I have to call every time a claim is paid OON, tell the rep we are behavioral health, and they send the claim back for reprocessing.

Why is this happening?

Thank you for your help!

 

[TThivierge]

Pkirsch,
Some insurance claims are process medical vs beh health to differ offices. Sounds like have 2 differ office handle the differ illnesses(medical vs beh health).Also at times beh health must be preauthorized to proper office to get certain amount of therapy provided.You will get special billing number use on claim. Are the MH providers and therapist in the insurance network?
I hope this data helps you.
Lady T

 

[Pkirsch1]

Yes, they are in the network. This has been happening since the beginning of the year. My credentialing manager says it is a claims issue, but I'm thinking the credentialing and claims department are not connecting.

 

[Pkirsch1]

I'm also getting claims being paid out of network with UMR and SUREST.

 

[JDockery]

I'm also getting claims being paid out of network with UMR and SUREST.

we found out it was due to the TOB , that UMR wants something other than what we were billing

 

[jplee4279]

UHC is notorious with us for paying claims OON when we are actually INN. We have to call and have the claims reprocessed each time. It is frustrating.

 

[angel@counselingwellnesspgh.com]

Are they processing using group or individual NPI, we found that they were using the wrong NPI for our billing to be in network. Once we found a rep that would really look into it we were able to have the claims reprocessed in network.