REQUESTS FROM WELLNESS HMO
Meeting Date: Thursday 19th May, 2022
Wellness HMO Staff Present: Dr. Adetokunbo Adekanla 08157510826 - Head of Medical Services
Mrs Uduak Udoffa 09095800858 – Head of Claims
REQUESTS:
Mandatory parts of a claim form:
They mentioned that Healthstack should create fields that are compulsory to be filled on a claim form. These are information needed to be on a claim form which will help the HMO staff work better and vet the claim as appropriate.
The hospital or healthcare provider (HCP) facility should not be able to send the form to the HMO on Healthstack if those fields are empty. They are:
Name of Healthcare Provider.
Location of Healthcare Provider
Full name of Enrollee (First name and surname)
Enrollee ID
Enrollee phone number
Age
Sex
Total amount of Claim.
Date of encounter (day, month and year)
Diagnosis
Messaging portal:
They would like a medium through which both the HMO and the HCPs can send and receive information to themselves on the claims submission portal.
It should be possible to send just 1 message and all HCPs get it simultaneously. Also it should be possible to send a message to a particular HCP that all the other HCPs do not get.
Second amount box, accompanying comment box and grand total box:
They mentioned that there are always cases where HCPs cost an item on the claim form with an amount different from what is on the agreed tariff.
Sometimes their Quality Control Officer may discover that the HCP prescribed a drug to an enrollee and the package the enrollee is on does not cover that drug or the enrollee should not be given a certain medication due to their age.
They want to be able to type the amount on the agreed tariff, or type in zero to indicate no payment, etc., in a second amount box.
They also need to type the reason for the disparity in a comment box so that the HCP can understand when they see it. Then a grand total (that will be calculated by Healthstack) based on the amounts they inputted.
Amounts and comments entered by the HCP should only be editable by the HCP and the ones entered by the HMO should only be editable by the HMO. The comment box is for the HMO.
Save, Queried, Approved and Go Live buttons:
These are buttons the HMO will need to use in-house as they vet and work on claims sent to them without the HCPs seeing these claims from their end on Healthstack, until the HMO is done with the claim and ready to pay for it.
They want to be able to click ‘save’ after vetting and the claim shows in a folder called ‘vetted claims’.
If a submitted claim has an issue, the HMO should be able to click a ‘query’ button and send it back to the HCP with a message requesting for what the HMO wants e.g. authorization code.
They want to be able to click ‘approved’ after it has been viewed for approval and the claim shows in a folder called ‘approved claims’.
Accountants should be able to see the approved claims and make payment. Once payment has been made to the HCP, they should be able to click ‘go live’ (or whatever terminology Healthstack will call it). This is when the claim should be viewable by the HCP.
The claim that has been paid for should have a place to put ‘Paid’ and ‘Date of Payment’ as well.
Categories for Claims:
Healthstack should generate serial numbers for each claim created by the HCP and the ones worked on by the HMO. These serial numbers should be tied to the date of encounter. Healthstack should also group claims by month and year of submission e.g. March 2021 Claims, January 2022 Claims, etc.
So there can be categories of claims such as: submitted claims, vetted claims, queried claims, approved claims and paid claims, with each having month and year e.g. Submitted Claims January 2022, Vetted Claims April 2022, and so on.
Filter buttons:
There should be a filter on each menu under managed care to be able to find any document from any time frame.
For example, they want to be able to type in 3/3/2022 under Claims Payment and it pulls up all the claims paid for that date. Or a name of a HCP under Claims Payment and it pulls up all the claims paid for that HCP alone. Or the name of an enrollee or the ID of an enrollee.
Same goes for other menus such as Claims, Referrals, Check-in, Preauthorization, Beneficiaries, Organizations, Tariff, etc.
Prevent Repetition of Claims:
They asked that Healthstack should have a way to prevent HCPs from resending a claim that have been previously sent weeks or months ago.
They said sometimes it is due to an honest mistake on the part of the HCP while sometimes it’s deliberate.
They said they don’t have a way of detecting such repeated claims and so it will be better if the HCPs are prevented from doing that.
We told them that claims will most likely be sent in real time and so they might not have the issue of a claim being repeated but that we would let the management of Healthstack know.
Authorization codes:
They asked to be able to use Healthstack to generate authorization codes and send it to the HCP requesting for it.
Signatory:
For anyone who logs in to Healthstack to work on a claim, whether from the HCP or from the HMO, the name of the staff working on that claim and the date it was worked on should always show on the claim form.
REQUESTS FROM WELLNESS HMO Meeting Date: Thursday 19th May, 2022 Wellness HMO Staff Present: Dr. Adetokunbo Adekanla 08157510826 - Head of Medical Services Mrs Uduak Udoffa 09095800858 – Head of Claims REQUESTS:
Mandatory parts of a claim form: They mentioned that Healthstack should create fields that are compulsory to be filled on a claim form. These are information needed to be on a claim form which will help the HMO staff work better and vet the claim as appropriate. The hospital or healthcare provider (HCP) facility should not be able to send the form to the HMO on Healthstack if those fields are empty. They are:
Name of Healthcare Provider. Location of Healthcare Provider Full name of Enrollee (First name and surname) Enrollee ID Enrollee phone number Age Sex Total amount of Claim. Date of encounter (day, month and year) Diagnosis
Messaging portal: They would like a medium through which both the HMO and the HCPs can send and receive information to themselves on the claims submission portal. It should be possible to send just 1 message and all HCPs get it simultaneously. Also it should be possible to send a message to a particular HCP that all the other HCPs do not get.
Second amount box, accompanying comment box and grand total box: They mentioned that there are always cases where HCPs cost an item on the claim form with an amount different from what is on the agreed tariff. Sometimes their Quality Control Officer may discover that the HCP prescribed a drug to an enrollee and the package the enrollee is on does not cover that drug or the enrollee should not be given a certain medication due to their age. They want to be able to type the amount on the agreed tariff, or type in zero to indicate no payment, etc., in a second amount box. They also need to type the reason for the disparity in a comment box so that the HCP can understand when they see it. Then a grand total (that will be calculated by Healthstack) based on the amounts they inputted. Amounts and comments entered by the HCP should only be editable by the HCP and the ones entered by the HMO should only be editable by the HMO. The comment box is for the HMO.
Save, Queried, Approved and Go Live buttons: These are buttons the HMO will need to use in-house as they vet and work on claims sent to them without the HCPs seeing these claims from their end on Healthstack, until the HMO is done with the claim and ready to pay for it.
They want to be able to click ‘save’ after vetting and the claim shows in a folder called ‘vetted claims’. If a submitted claim has an issue, the HMO should be able to click a ‘query’ button and send it back to the HCP with a message requesting for what the HMO wants e.g. authorization code. They want to be able to click ‘approved’ after it has been viewed for approval and the claim shows in a folder called ‘approved claims’. Accountants should be able to see the approved claims and make payment. Once payment has been made to the HCP, they should be able to click ‘go live’ (or whatever terminology Healthstack will call it). This is when the claim should be viewable by the HCP. The claim that has been paid for should have a place to put ‘Paid’ and ‘Date of Payment’ as well.
Categories for Claims: Healthstack should generate serial numbers for each claim created by the HCP and the ones worked on by the HMO. These serial numbers should be tied to the date of encounter. Healthstack should also group claims by month and year of submission e.g. March 2021 Claims, January 2022 Claims, etc. So there can be categories of claims such as: submitted claims, vetted claims, queried claims, approved claims and paid claims, with each having month and year e.g. Submitted Claims January 2022, Vetted Claims April 2022, and so on.
Filter buttons: There should be a filter on each menu under managed care to be able to find any document from any time frame. For example, they want to be able to type in 3/3/2022 under Claims Payment and it pulls up all the claims paid for that date. Or a name of a HCP under Claims Payment and it pulls up all the claims paid for that HCP alone. Or the name of an enrollee or the ID of an enrollee. Same goes for other menus such as Claims, Referrals, Check-in, Preauthorization, Beneficiaries, Organizations, Tariff, etc.
Prevent Repetition of Claims: They asked that Healthstack should have a way to prevent HCPs from resending a claim that have been previously sent weeks or months ago. They said sometimes it is due to an honest mistake on the part of the HCP while sometimes it’s deliberate. They said they don’t have a way of detecting such repeated claims and so it will be better if the HCPs are prevented from doing that. We told them that claims will most likely be sent in real time and so they might not have the issue of a claim being repeated but that we would let the management of Healthstack know.
Authorization codes: They asked to be able to use Healthstack to generate authorization codes and send it to the HCP requesting for it.
Signatory: For anyone who logs in to Healthstack to work on a claim, whether from the HCP or from the HMO, the name of the staff working on that claim and the date it was worked on should always show on the claim form.