HCIM’s Appeals Manager™ application is designed to automate all of the letter generation and tracking requirements for California’s AB1455 appeals legislation and Provider Dispute Resolution (PDR) processing, conforming to ICE requirements. Appeals Manager provides the automated functionality to download claim and provider information from the organization’s core claims system, to be used in the generation of letters for provider dispute resolution. To make processing appeals a simple process, the application provides ease of use features, some of which are described in this article.
Downloading Claim Information
Appeals Manager can download all pertinent claim header, claim detail and provider address information needed for provider dispute appeal letters from the organization’s core claims system. To specify a claim, the user simply enters the Claim ID or searches for a claim by Member ID, Member Name, Provider ID or Provider Name.
Changing the Provider Address
After the claim information is downloaded and the user enters pertinent appeal letter information, Appeals Manager allows the user to view the downloaded provider address information. If the address needs to be changed, the user can click the “Provider Address” button to view and/or change the address. If the user changes the address, Appeals Manager will change it on the current letter (typically the acknowledgement letter) and will carry the changed address forward to any additional letters generated for that appeal (such as the decision letter).
Internal Comments
Appeals Manager provides a Comments field that can optionally be used for placing free-form comments on a letter. In addition, the application provides a feature to add Internal Comments to an appeal; the internal comments are not printed on appeal letters. Internal Comments can be added during appeal entry, appeal viewing/editing, or at any other time without opening the appeal. This is a particularly useful feature for Customer Service representatives, who can use this feature to enter notes during conversations with providers.
View Only Security
Appeals Manager has standard user security levels, such as user, manager and administrator. In addition, the application has a “View Only” security level. This provides limited access to appeals, allowing read-only access to entered appeals, the ability to lookup all appeal history and the entry of Internal Comments (described above). This is a great user security level to assign to Customer Service staff.
One Appeal/Multiple Claims – One Claim/Multiple Appeals
At times, an appeal is submitted by a provider containing two or more claims. Appeals Manager accommodates this by providing a 2-digit appeal extension. Each claim has the same appeal number, but a different extension.
Conversely, at times a provider submits an appeal that results in a decision to deny payment. According to AB1455, the provider can appeal again. In this case, Appeals Manager allows entry of a second appeal for the same claim. There is no limit to the number of appeals that can be entered for the same claim.
Appeals Manager has many other useful features and is currently on the TriZetto Facets® and MZI EZ-CAP® claims platforms. To learn more about Appeals Manager, please call 888-454-0202, ext. 5 or e-mail sales@hcim.com.
