The Alliance | TPAs - Creating a Clear Explanation of Benefits


TPAs Home The Alliance Connection Help, Information, Answers About Self-Funding Alliance Logos TPA Toolkit Contacts	Home :: TPAs :: TPA Tookit Creating a Clear Explanation of Benefits Clear Explanation of Benefits (EOB) and Provider Remittance Advices are very important. Without accurate and complete information, the employee may be subject to unnecessary balance billing. Make sure the following are clearly identified on an EOB: Billed charges Co-payments Deductibles Paid benefit amounts Clearly stated reduction in payment based on contracted arrangements. It is also important to create an EOB and Remittance Advice even if no benefit payment is being made. This is because many of our participating provider agreements contain language that allows Alliance fees to be applied to non-covered benefits. This would include services whose cost falls solely on the employee due to an exhausted dollar threshold. Need More Information? See page 28 of your TPA Toolkit. Questions? Please contact customer service or call 608.210.6601 or 800.223.4139. Alliance Status Messages Status messages are crucial to determining the level of payment on the claim. The information here will help you understand these messages. Bundling of Charges On occasion our Third-Party Administrators (TPAs) will ask us to alter codes as submitted by the provider to mirror codes identified as appropriate by their bundling software and to obtain corrected repricing. We are not able to assist with these requests. Creating a Clear Explanation of Benefits Creating a Clear Explanation of Benefits Clear Explanation of Benefits (EOB) and Provider Remittance Advices are very important. Creating and Issuing Accurate ID Cards Creating and issuing accurate ID cards guarantees that employees receive appropriate Alliance savings. It also prevents misdirected claims and telephone calls, and leaves customers satisfied. Modifiers The Alliance repricing reflects multiple surgery and other modifier reductions where appropriate. Non-Covered Benefits Many Alliance participating providers have agreed to accept Alliance repricing as full payment whether or not the service is a covered benefit under the plan, and whether or not the employer, their plan administrator, or the employee is responsible for the charges. Service Area County ZIP Code Listing Alliance repricing applies to all participating and non-participating providers in this ZIP code range. Timely Payment of Claims Timely payment of claims is important because claims that remain unpaid for more than 30 days may result in the loss of The Alliance negotiated fee to the employer/employee. What Does The Alliance Not Reprice? The Alliance does not reprice all claims.