A reflection and review of our claims and customer service performance for 2017.

Claims Repricing

Our contracts require that clean claims be repriced within three business days of receipt. A clean claim is defined as being filed on the appropriate HCFA 1500 or UB04 form and containing all the needed information to reprice the claim. Counting the day received as “0”, our average claims turnaround in 2017 was:

 Turnaround time for repricing of Alliance Claims

Claim Type Percent of all Claims Average Turnaround Time (Days)
EDI Claims 83.8% 0.03
Non-EDI Claims 16.4% 1.48
All Claims 100% 0.27

99 percent of all claims ― both clean and incomplete ― were repriced within three business days. This reflects no change over our 2016 performance level.

We experienced a slight decrease in volume of claims routed via Electronic Data Interchange (EDI) connectivity with participating providers and Third Party Administrators (TPAs) in 2017:

  • 83.8 percent of claims were filed to us electronically – down from 84.3 percent in 2016.
  • 87.6 percent of repriced claims were forwarded to TPAs electronically – down from 87.7 percent in 2016.

This decrease was driven by a trend that we had identified in 2016 where claims starting to be filed directly to the Third Party Administrators (TPAs) by our provider partners.  Claims dropped to paper and re-routed via mail from the TPA to The Alliance for repricing, result in decreased repricing efficiency and unnecessary claim payment delays for our provider partners. In 2017 we identified the two TPAs with the highest volume of claims reroutes.  These Two TPAs are namely, SISCO with 9 percent and UMR with 11 percent of their claims rerouted to us on paper for repricing.   We have been working with them increase staff and provider awareness of appropriate claims filing protocols for Alliance plan members in our ongoing efforts to increase efficiencies.  We will continue to monitor this issue, working with TPAs and providers as warranted in 2018.

Call Volumes

Overall our customer service team experienced no significant change in the number of telephone inquiries in 2017 from 2016. Providers continue to be the most frequent caller to our customer service line. The following charts outline and compare call volumes by source in 2016 and 2017:

Calls from providers represent 73.16 percent of all the calls received by our Customer Service staff in 2017. This is an increase from 68.22 percent of all telephone inquiries received by The Alliance in 2016.

Despite the introduction of our on line claims portal for provider partners, EDI connectivity efficiencies and our continuing efforts to direct callers to the appropriate party through our phone system and website, four of the top five inquiries from providers are items that are best addressed by TPAs, not The Alliance:

The percentage of these “misdirected” calls increased again in 2017 to 72.76 percent of all provider calls despite our continued efforts to lower the number of calls for initial claim status, benefit questions, eligibility verification and Pre-Authorization Inquiries as calls for these items require our Customer Service team to redirect the caller to the TPA for resolution.

If you haven’t already, we encourage you to sign up for access to our claims portal service. This service provides you with easy access to your Alliance claims history allowing you to obtain claim status as well as the ability to generate copies of Alliance repricing sheets directly from our repricing system. To enroll, simply complete and return this form to providerservices@the-alliance.org.

Not Sure Where to Call?

As mentioned above, some calls are better answered by TPAs, not The Alliance. To determine the best place to call, have staff ask themselves the following before calling:

Are you calling about:

  • Claim status, payment, and denial, or
  • Benefits and eligibility, or
  • Pre-authorization?

Then: Contact the TPA listed on the member’s health plan ID card.

Are you calling about:

  • Verification of network status, or
  • Employer identification, or
  • Claim or repricing not received by TPA?

Then: Contact The Alliance at 800.223.4139 or 608.223.4139.

As always, we welcome your feedback/ideas/suggestions on other items we should consider to help your staff understand The Alliance’s role and when it is best to contact us for assistance.

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