A reflection and review of our claims and customer service performance for 2018.

Claims Repricing

In 2018, The Alliance claims department entered and repriced over 819,900 claims. Our contracts require that clean claims are repriced within three business days of receipt. A clean claim is defined as being filed on the appropriate CMS 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 2018 was:

Turnaround Time for Repricing of Alliance Claims

Claim Type Percent of All Claims Average Turnaround Time (Days)
EDI Claims 87.3% 0.18
Non EDI Claims 12.7% 1.84
All Claims 100% 0.39

Overall, 98.5 percent of all claims ― both clean and incomplete ― were repriced within three business days. This reflects a half a percentage point decrease over our 2017 performance level. This decrease is tied in part to our new system implementation as well as the success of our QualityPath® program. Both have impacted our data entry and claims repricing processes. We will continue to look for ways to improve claims entry and repricing efficiencies in 2019.

In 2018 we experienced an increase in volume of claims received electronically from our provider partners:

  • 8 percent of claims were filed to us electronically – up from 83.8 percent in 2017.
  • 87 percent of repriced claims were forwarded to TPAs electronically – down slightly from 87.3 percent in 2017.

We attribute the increase in electronic claims receipts to our focused claims filing educational efforts implemented with UMR in late 2017.  We continue to work to identify a workable solution with the TPA who is our “second-highest offender” due to accepting claims directly from the provider only to drop them to paper and reroute to The Alliance for repricing.

Call Volumes

The Alliance customer service team experienced a 20 percent increase in the number of telephone inquiries in 2018 from 2017. Providers continue to be the most frequent caller to our customer service line. The following charts outline and compare call volumes by source in 2017 and 2018:

Percent of Calls in 2018

Percent of Calls in 2017

Calls from providers represent 73.67 percent of all the calls received by our Customer Service staff in 2018. This is an increase from 73.16 percent of all telephone inquiries received by The Alliance in 2017.

Again, in 2018 four of the five top inquiries from providers were items that are best addressed by TPAs, not The Alliance.  These reasons include, Initial Claim Status, Benefit Question, Eligibility Verification and new for 2018, Incorrect Alliance:

Overall, the percentage of these “misdirected” calls decreased in 2018 to 71.86 percent of all provider calls. This decrease stems from fewer benefit and eligibility calls received from providers in 2018.

The number of calls for initial claims status did increase in 2018. 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.

The newest “misdirected” call reason is the result of a large national payer incorrectly referring providers from across the nation to us for non-Alliance plan members. As these calls adversely influence our ability to address concerns promptly for active plan participants and contracted provider partners, we have added messaging to our call flow to clarify our role. We have also been working with this insurer throughout 2018 in an attempt to get this to cease and apologize for any delays your staff has experienced when attempting to connect with us regarding claims repricing questions and concerns.

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.

As always, we welcome your feedback, ideas and 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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