A reflection and review of our claims and customer service performance for 2013.
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 2013 was:
Turnaround time for repricing of Alliance Claims
|Claim Type||Percent of all Claims||Average Turnaround Time (Days)|
98.9% of all claims ― both clean and incomplete ― were repriced within three business days. This was an increase over our 2012 performance level of 98.1%.
We experienced no significant change in our Electronic Data Interchange (EDI) connectivity with participating providers and Third Party Administrators (TPAs) in 2013:
- 77.3% of claims were filed to us electronically – down from 77.9% in 2012.
- 81.4% of repriced claims were forwarded to TPAs electronically – up from 81.3% in 2012.
Overall our customer service team experienced an increase in the number of telephone inquiries in 2013 from 2012. Providers continue to be the most frequent caller to our customer service line. The following charts outline and compare call volumes by source in 2012 and 2013:
Calls from providers represent 68.04% of all the calls received by our Customer Service staff in 2013. This is an increase from 66.16% of all telephone inquiries received by The Alliance in 2012.
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, three of the top five inquiries from providers continue to be items that are best addressed by TPAs, not The Alliance:
The percentage of these “misdirected” calls increased again in 2013 to 67.51% 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 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.
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
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.
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