	Frequently Asked Questions 1. Where will medical claims be processed? Medical claims are processed in our Little Rock or Nashville office. HealthSCOPE Benefits, Inc. 27 Corporate Hill Drive Little Rock, Arkansas 72205 HealthSCOPE Benefits, Inc. 2630 Elm Hill Pike Suite 203 Nashville, Tennessee 37214 Back To Top 2. Will the client have dedicated Claim and Customer Service Representatives? Yes. HealthSCOPE Benefits utilizes the “team-approach” to claim processing and customer service. Our staffing ratio is one (1) Analyst to every 1,500 employees, and one (1) Customer Service Representative for every two (2) Analysts. The primary analyst team will be backed by a support team of analysts, who have been cross-trained on the benefit plan to assist in member inquiry. This claim and customer service team reports to a Claims Manager who oversees their service functions. The Manager reports to the Claims Director responsible for the entire claims department operation. Customer Service Support is performed on many levels. An Account Manager is responsible for coordination of implementation of the Client program/services into our organization and joint partnership, and, to maintain corporate contact between HealthSCOPE Benefits and the Client. A Claims Director will also be dedicated to your account, responsible for all claims activities and customer service roles. Customer Service Representatives and dedicated Claims Analysts assigned to your Client Service Team will communicate with your employees/members to handle inquiries. Back To Top 3. Would customer service related to medical claims be handled in one office or multiple offices? Please indicate the hours of operation for the Customer Service Department that would handle claim inquiries. The Customer Service Representatives responsible for claims inquiries are located in the claims offices listed in Question 1. The hours of operation are Monday-Friday, from 8am-5pm, CST. Additionally, HealthSCOPE Benefits provides virtual access customer service programs through an Interactive Voice Response system with Internet interface. Employees and medical providers can access self-service capability via both the World Wide Web and telephonically for enrollment verification, benefit summary, and claim inquiry status. Back To Top 4. How are customer calls handled? When a call is received on the dedicated toll-free number, the caller will be prompted for three Options: Option 1: Automated Claims and Benefit Inquiry Option 2: Medical Management and Pre-certification Inquiry, or Option 3: Customer Service Representative (CSR). If Option 3 is selected, the system will search for the first available CSR in the call group. Most calls can be handled at initial contact. (If the call cannot be resolved at initial contact, the CSR sends the call record electronically to the appropriate party in to address. All “Open Calls” are tracked and reported on a daily basis and must be resolved within 72 hours of receipt. On-line monitoring of individual call traffic is continuously maintained to prevent calls from holding above appropriate thresholds. For quality purposes all representatives have their calls randomly monitored for compliance to our standards of service, including identifying themselves, HIPAA application, interviewing, resolution, documentation and professionalism. Calls are to be resolved and the problem not handed back to the caller. Results are incorporated in the team members’ monthly bonus program along with quarterly and annual performance evaluations. HealthSCOPE Benefits’ telephone system has the ability to track the number of incoming calls by type of caller, reason for call, call status, and resolutions which is used to evaluate if steps need to be taken to prevent issues. These reports can be provided to our clients. Further, telephone calls are recorded in order to facilitate the highest levels of quality service, support the complete documentation of all contacts and act as a reference should further questions be necessary. The Automated Claims Inquiry feature is available 24 hours a day, 365 days a year. We communicate this feature to employees and providers to utilize and take advantage of placing calls at their convenience. Back To Top 5. Is there an internal training program? Yes, HealthSCOPE Benefits has an internal training program. We maintain interactive Web based training along with classroom training. Training reaches company wide on numerous subjects that cross all our lines of business. Our initial training program consists of a combination of classroom, Web on-line training and teaming new employees to observe with experienced staff. All new employees must successfully pass tests and are monitored through 100% audits of their work. The trainee must achieve and maintain standard accuracy ratios prior to full release. Training continues with Training sending material out during the month and following up each month with testing on what has been distributed. Back To Top 6. Please describe your claim payment system. Does it include auditing software to detect miscoded claims and unbundled charges? The system we utilize to process claims is a fully integrated system that is especially well suited to managed care administration. Our system includes numerous automated functions to identify and save claim dollars from provider billing discrepancies, diagnosis including subrogation opportunities and other coverage identification processes. Clinical editing software offers an on-line review of each claim and the patient’s claim history. Our claim system also performs other automated functions, such as: • Verification of employee and dependent eligibility. • System edits where required coding fields are incomplete, or contain invalid information. • Checking for valid provider, procedure, charge, and diagnosis. • Application of proper fee schedule. • Identification of duplicate charge edits. • Auto-adjudication of electronically submitted claims. • Auto-adjudication of paper claims using scanning technology. Our system is capable of administering a wide variety of benefit plan designs that automatically adjudicate claim payments. In addition to UCR and medical claims review, the system features re-bundling of unbundled services, and medical appropriations are fully integrated with Medicode’s Claim Edit System which is based on national standards. Automatic identification of duplicate charges is applied along with suspected duplicate edits for the Claims Analyst to review are applied to each claim processed. Back To Top 7. How flexible is the system regarding: Input of dollar maximums or visit maximums, etc. Our claims processing system is truly on the cutting edge of claims administration. The system includes a Maximum Frequency per Day (MFD) edit, which identifies by Utilization Severity Level (USL), the frequency of a given service that exceeds the expected norm in a 24-hour period. Services may also be controlled by a maximum occurrence allowable. For example, a plan may allow 30 visits per calendar year for outpatient counseling. The system will monitor and deny any visits greater than 30. We have the ability to set a multitude of maximums, including dollars and visits. Ad-hoc reporting capability We have the ability to provide a wide range of information via ad-hoc reporting. Utilization of multiple levels of co-payment for the same service (i.e. adapting a preferred provider or point-of-service plan design) HealthSCOPE Benefits can set multiple levels of co-payments for both in and out of network. Back To Top 8. Does the system monitor the date of submission on pending claims? All unprocessed claims are assigned a specific code based on the unprocessed reason and this is tracked on-line. Unprocessed claims activity are reviewed throughout the day by category and the number of calendar days that have passed since the claim was received. Back To Top 9. What are your administrative guidelines on COB, determination of primary benefit, and schedule for follow-up inquiries? HealthSCOPE Benefits has several ways to identify potential COB claims. First, on an annual basis, a letter is sent to all employees, with family coverage, inquiring if there is other coverage with their spouse or other dependents. Second, if a HCFA or UB92 arrives with other coverage indicated, investigation is initiated. Third, we can obtain other coverage information through our Customer Service Teams when verbal or written inquiries are received. Back To Top 10. How (and how often) do you determine reasonable and customary (R&C) expense allowances? For what services do you determine R&C allowances? At what percentile do you pay R&C expense allowances? HealthSCOPE Benefits has R&C profiles loaded from the 50th to the 95th percentiles using Medicode’s Ingenix UCR Database. This allows our customers to select percentages other than the 90th. The data is updated every 6 months within the system. Our system will also allow the addition of “buffer zones”; i.e. 90th percentile plus $5.00, to be programmed. The most common percentage requested by our clients is 90%; however, this percentage can vary depending upon the client’s plan design. In the handling of fee reductions, the circumstances will vary depending on the type of service being rendered. In the case of routine visits, charges will be reduced to R&C with an explanation code on the Explanation of Benefits (EOB) form.

Frequently Asked Questions

1. Where will medical claims be processed?

Medical claims are processed in our Little Rock or Nashville office.

HealthSCOPE Benefits, Inc.
27 Corporate Hill Drive
Little Rock, Arkansas 72205

HealthSCOPE Benefits, Inc.
2630 Elm Hill Pike Suite 203
Nashville, Tennessee 37214

2. Will the client have dedicated Claim and Customer Service Representatives?

Yes. HealthSCOPE Benefits utilizes the “team-approach” to claim processing and customer service. Our staffing ratio is one (1) Analyst to every 1,500 employees, and one (1) Customer Service Representative for every two (2) Analysts. The primary analyst team will be backed by a support team of analysts, who have been cross-trained on the benefit plan to assist in member inquiry. This claim and customer service team reports to a Claims Manager who oversees their service functions. The Manager reports to the Claims Director responsible for the entire claims department operation.

Customer Service Support is performed on many levels. An Account Manager is responsible for coordination of implementation of the Client program/services into our organization and joint partnership, and, to maintain corporate contact between HealthSCOPE Benefits and the Client. A Claims Director will also be dedicated to your account, responsible for all claims activities and customer service roles. Customer Service Representatives and dedicated Claims Analysts assigned to your Client Service Team will communicate with your employees/members to handle inquiries.

3. Would customer service related to medical claims be handled in one office or multiple offices? Please indicate the hours of operation for the Customer Service Department that would handle claim inquiries.

The Customer Service Representatives responsible for claims inquiries are located in the claims offices listed in Question 1. The hours of operation are Monday-Friday, from 8am-5pm, CST. Additionally, HealthSCOPE Benefits provides virtual access customer service programs through an Interactive Voice Response system with Internet interface. Employees and medical providers can access self-service capability via both the World Wide Web and telephonically for enrollment verification, benefit summary, and claim inquiry status.

4. How are customer calls handled?

When a call is received on the dedicated toll-free number, the caller will be prompted for three Options:

Option 1: Automated Claims and Benefit Inquiry
Option 2: Medical Management and Pre-certification Inquiry, or
Option 3: Customer Service Representative (CSR).

If Option 3 is selected, the system will search for the first available CSR in the call group. Most calls can be handled at initial contact. (If the call cannot be resolved at initial contact, the CSR sends the call record electronically to the appropriate party in to address. All “Open Calls” are tracked and reported on a daily basis and must be resolved within 72 hours of receipt.

On-line monitoring of individual call traffic is continuously maintained to prevent calls from holding above appropriate thresholds. For quality purposes all representatives have their calls randomly monitored for compliance to our standards of service, including identifying themselves, HIPAA application, interviewing, resolution, documentation and professionalism. Calls are to be resolved and the problem not handed back to the caller. Results are incorporated in the team members’ monthly bonus program along with quarterly and annual performance evaluations.

HealthSCOPE Benefits’ telephone system has the ability to track the number of incoming calls by type of caller, reason for call, call status, and resolutions which is used to evaluate if steps need to be taken to prevent issues. These reports can be provided to our clients. Further, telephone calls are recorded in order to facilitate the highest levels of quality service, support the complete documentation of all contacts and act as a reference should further questions be necessary.

The Automated Claims Inquiry feature is available 24 hours a day, 365 days a year. We communicate this feature to employees and providers to utilize and take advantage of placing calls at their convenience.

5. Is there an internal training program?

Yes, HealthSCOPE Benefits has an internal training program. We maintain interactive Web based training along with classroom training. Training reaches company wide on numerous subjects that cross all our lines of business. Our initial training program consists of a combination of classroom, Web on-line training and teaming new employees to observe with experienced staff. All new employees must successfully pass tests and are monitored through 100% audits of their work. The trainee must achieve and maintain standard accuracy ratios prior to full release. Training continues with Training sending material out during the month and following up each month with testing on what has been distributed.

6. Please describe your claim payment system. Does it include auditing software to detect miscoded claims and unbundled charges?

The system we utilize to process claims is a fully integrated system that is especially well suited to managed care administration. Our system includes numerous automated functions to identify and save claim dollars from provider billing discrepancies, diagnosis including subrogation opportunities and other coverage identification processes. Clinical editing software offers an on-line review of each claim and the patient’s claim history. Our claim system also performs other automated functions, such as:

• Verification of employee and dependent eligibility.
• System edits where required coding fields are incomplete, or contain invalid information.
• Checking for valid provider, procedure, charge, and diagnosis.
• Application of proper fee schedule.
• Identification of duplicate charge edits.
• Auto-adjudication of electronically submitted claims.
• Auto-adjudication of paper claims using scanning technology.

Our system is capable of administering a wide variety of benefit plan designs that automatically adjudicate claim payments. In addition to UCR and medical claims review, the system features re-bundling of unbundled services, and medical appropriations are fully integrated with Medicode’s Claim Edit System which is based on national standards. Automatic identification of duplicate charges is applied along with suspected duplicate edits for the Claims Analyst to review are applied to each claim processed.

7. How flexible is the system regarding:

Input of dollar maximums or visit maximums, etc.

Our claims processing system is truly on the cutting edge of claims administration. The system includes a Maximum Frequency per Day (MFD) edit, which identifies by Utilization Severity Level (USL), the frequency of a given service that exceeds the expected norm in a 24-hour period. Services may also be controlled by a maximum occurrence allowable. For example, a plan may allow 30 visits per calendar year for outpatient counseling. The system will monitor and deny any visits greater than 30. We have the ability to set a multitude of maximums, including dollars and visits.

Ad-hoc reporting capability

We have the ability to provide a wide range of information via ad-hoc reporting.

Utilization of multiple levels of co-payment for the same service (i.e. adapting a preferred provider or point-of-service plan design)

HealthSCOPE Benefits can set multiple levels of co-payments for both in and out of network.

8. Does the system monitor the date of submission on pending claims?

All unprocessed claims are assigned a specific code based on the unprocessed reason and this is tracked on-line. Unprocessed claims activity are reviewed throughout the day by category and the number of calendar days that have passed since the claim was received.

9. What are your administrative guidelines on COB, determination of primary benefit, and schedule for follow-up inquiries?

HealthSCOPE Benefits has several ways to identify potential COB claims. First, on an annual basis, a letter is sent to all employees, with family coverage, inquiring if there is other coverage with their spouse or other dependents. Second, if a HCFA or UB92 arrives with other coverage indicated, investigation is initiated. Third, we can obtain other coverage information through our Customer Service Teams when verbal or written inquiries are received.

10. How (and how often) do you determine reasonable and customary (R&C) expense allowances? For what services do you determine R&C allowances? At what percentile do you pay R&C expense allowances?

HealthSCOPE Benefits has R&C profiles loaded from the 50th to the 95th percentiles using Medicode’s Ingenix UCR Database. This allows our customers to select percentages other than the 90th. The data is updated every 6 months within the system. Our system will also allow the addition of “buffer zones”; i.e. 90th percentile plus $5.00, to be programmed. The most common percentage requested by our clients is 90%; however, this percentage can vary depending upon the client’s plan design. In the handling of fee reductions, the circumstances will vary depending on the type of service being rendered. In the case of routine visits, charges will be reduced to R&C with an explanation code on the Explanation of Benefits (EOB) form.