suki_26
Networker
GHI has always been bad about processing claims. We joke that they have a denial wheel and every 4 - 6 months they spin it to see what code they will start denying across the board for no reason.
We are Out of network PCPs that have our own lab so we do not have a provider Rep that we can deal with. This makes it very difficult, especially since the pandemic started, getting ahold of a customer service rep is nearly impossible. 30 minutes on hold before getting a rep is the norm. Are there any other AR folks out there having this problem and have you found a way around it?
We have written letters to the corporate office to no avail. a corrected claim might be sent by mail and then unloaded to their portal AAAND still have to be faxed before we get a response. We have been trying to utilize the message center on the GHI website and we are getting the same reply regardless of what we send.....
"We reviewed our decision for claim number *********
The claim was processed correctly. No adjustments or additional payments will
be made.
If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6
p.m., Monday to Friday. A Provider Service representative will be happy to
help.
Thank you for partnering with us to care for our members.
Sincerely,"
For this claim we sent a corrected claim and asked them to correct the diagnoses as it was a keying error. All paperwork and the corrected claim were uploaded directly to the inquiry. And the above was our reply. That doesn't even make sense!
Another example, even though Medicare crosses over their EOB's directly to GHI, we know GHI will say they don't have them so we automatically print them out and submit paper with a HCFA and mail it to GHI. We often have to send this multiple times and have even uploaded directly to their website. A lot of times it will still take a phone call where we are told they don't have the EOB so cant process. When forced the reps will "look deeper" and always find the EOB, send the claim to the "escalation dept", and it will eventually pay. Here is another Inquiry.......
We are Out of network PCPs that have our own lab so we do not have a provider Rep that we can deal with. This makes it very difficult, especially since the pandemic started, getting ahold of a customer service rep is nearly impossible. 30 minutes on hold before getting a rep is the norm. Are there any other AR folks out there having this problem and have you found a way around it?
We have written letters to the corporate office to no avail. a corrected claim might be sent by mail and then unloaded to their portal AAAND still have to be faxed before we get a response. We have been trying to utilize the message center on the GHI website and we are getting the same reply regardless of what we send.....
"We reviewed our decision for claim number *********
The claim was processed correctly. No adjustments or additional payments will
be made.
If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6
p.m., Monday to Friday. A Provider Service representative will be happy to
help.
Thank you for partnering with us to care for our members.
Sincerely,"
For this claim we sent a corrected claim and asked them to correct the diagnoses as it was a keying error. All paperwork and the corrected claim were uploaded directly to the inquiry. And the above was our reply. That doesn't even make sense!
Another example, even though Medicare crosses over their EOB's directly to GHI, we know GHI will say they don't have them so we automatically print them out and submit paper with a HCFA and mail it to GHI. We often have to send this multiple times and have even uploaded directly to their website. A lot of times it will still take a phone call where we are told they don't have the EOB so cant process. When forced the reps will "look deeper" and always find the EOB, send the claim to the "escalation dept", and it will eventually pay. Here is another Inquiry.......
Message Exchange | |||
---|---|---|---|
Reference Number: ******** Plan: GHI NOT a duplicate. MCR originally processed and applied $18.66 towards coinsurance. medicare adjusted the claim and applied $25.93 towards coinsurance. MCR EOB's .attached. Please process for the difference which is $7.27 | |||
Reference Number: ********* Dear *********, We reviewed our decision for claim number ********. The claim was processed correctly. No adjustments or additional payments will be made. If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6 p.m., Monday to Friday. A Provider Service representative will be happy to help. Thank you for partnering with us to care for our members. Sincerely, **************************************
Reference Number: ******** Dear *********, Thank you for being an EmblemHealth Partner. In response to your email, please be advised that GHI follows primary carrier rule and pay only the coinsurance amount issued by primary carrier, as there is no coinsurance amount GHI processed claim for $0.00. Please contact the member for deductible amount of $187.03 as patient's responsibility. If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6 p.m., Monday to Friday. A Provider Service representative will be happy to help. Sincerely, We have considered the Insurance Commissioners office but as most of our GHI plans are NYC employee plans they fall under self funded and therefore not handled by the insurance commissioner. If anyone has any tricks or tips at all we would be greatly appreciative. |