A reflection and review of our claims and customer service performance for 2012.
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 2012 was:
Turnaround time for repricing of Alliance Claims
98.1% of all claims ― both clean and incomplete ― were repriced within three business days. This was a decrease over our 2011 performance level of 98.5%.
Our Electronic Data Interchange (EDI) connectivity with participating providers and Third Party Administrators (TPAs) decreased in 2012:
- 77.9% of claims were filed to us electronically – down from 81.7% in 2011.
- 81.3% of repriced claims were forwarded to TPAs electronically – down from 88.9% in 2011.
The decrease in receipt of electronically filed claims is attributed to two items:
- The expansion of our network into Northern Illinois
- Misfiling of claims directly to Third Party Administrators
We have been working over the past twelve months to establish EDI connectivity with new network providers located in Northern Illinois as well as working with TPA partners to update member ID cards to accurately reference The Alliance claims filing address. We anticipate these efforts will help to increase our EDI receipts in 2013.
The decrease in claims forwarded electronically to our TPA partners is attributed to the new EDI exchange requirements implemented in the beginning of 2012 resulting in our inability to continue to forward claims received via paper to certain TPA partners electronically.
Overall our customer service team experienced an increase in the number of telephone inquiries in 2012 from 2011. Providers continue to be the most frequent caller to our customer service line. The following charts outline and compare call volumes by source in 2011 and 2012:
Calls from providers represent 66.16% of all the calls received by our Customer Service staff in 2012. This is a decrease from 68.32% of all telephone inquiries received by The Alliance in 2011.
Despite the introduction of our online 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, three of the top five inquiries from providers continue to be items that are best addressed by TPAs, not The Alliance:
Top 5 Provider Inquiry Reasons
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The percentage of these “misdirected” calls increased in 2012 to 64.56% of all provider calls despite our continued efforts to lower the number of calls for initial claim status, benefit questions, and eligibility verification 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 access to The Alliance claims history on demand 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 firstname.lastname@example.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:
- Claim status, payment, and denial, or
- Benefits and eligibility, or
Then: Contact the TPA listed on the member’s health plan ID card. You can also find the TPA phone number on this list: TPA Contact Information by Employer (updated January 2013)
- 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.
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.
As always, we’re here to answer your questions. Use the list below to identify the appropriate Alliance staff member to help you.
Provider Directory Updates & Credentialing Questions
800.223.4139 or 608.276.6620
Manager of Claims & Customer Service
EDI Claims and Connectivity
Manager of Claims & Customer Service
Vice President, Business Development & Provider Relations
Provider Relations Manager
Southern Region Manager
Provider Relations Coordinator
Provider Relations and QualityCounts® Coordinator