National Provider Identifier (NPI) dual-use period extended

Asuris is extending the dual-use period until further notice because many entities are still in varied stages of compliance. You may submit your NPI and tax identification (ID) numbers; or submit your NPI, tax ID and Asuris provider identifier. We will notify you at a later date when the Asuris identifier will no longer be accepted.

Patient Review and Coordination program for Healthy Options members

Effective January 1, 2008 Asuris implemented a state required Patient Review and Coordination (PRC) program for Healthy Options members. The PRC program is the mechanism utilized by the Health and Recovery Services Administration’s (HRSA) to fulfill both federal and state Medicaid requirements.   

The PRC program focuses on the health and safety of the member and the elimination unnecessary costs. Members who are seen by several different medication prescribers, have a high number of duplicative medications, use several different pharmacies and/or have a high emergency room usage will be identified for placement in the program. The member’s primary care provider (PCP) will receive a letter informing them that one of their patient’s has been placed in the program.

Members placed in the program will be restricted to specific providers including PCP’s, pharmacies, narcotic prescriber’s, mental health providers for controlled substances, and hospital’s for non-emergency services. Members may use any hospital emergency room for emergency services. Once the member is notified that they are included in the PRC program, they are asked to complete a form choosing the providers they will utilize in the program. If the member does not choose a PCP within ten working days of notification, a PCP will be designated for them, which will be effective for 12 months.

The initial restriction period for a member participating in the PRC program is twenty four (24) consecutive months. Prior to the end of the initial restriction period, each member will be reviewed for continued placement in or removal from the program.

Additional information about the program and criteria may be found in the Washington Administrative Code 388-501-0135 on the Washington State Legislature Web site at http://apps.leg.wa.gov/wac. If you have any questions, please contact our Provider Relations department at 1 (800) 245-6024.

Beginning January 1, 2008, there will be two major elements to the new COB rule affecting the way claims are processed in the secondary position.  Asuris Northwest Health is applying these changes to comply with a new rule issued by the Office of Insurance Commissioner.  This rule applies to all individual and group plans (except self-insured ERISA groups) with claims date of service on or after January 1, 2008.

What are the two elements?

1. The secondary payer must pay to the highest allowable between two plans.
2. Claims may not be denied for primary payment information.  The secondary payer must estimate the primary payment and complete processing of the claim within 45 days. 

How will the new COB changes affect me?

When claims are submitted without the primary allowed and paid amount Asuris will call the primary insurance plan for the claim payment detail.  If we are not able to obtain this information, claims will be pended for that information.  The COB pended claims will show on the back of your weekly voucher in the “Claims Pending Investigation” section. If the primary insurance claim payment detail is not received by the 45th day after receipt of the claim, Asuris will estimate the primary payment at 80% of our allowed amount and pay our portion of the claim.

What do I need to do?

For the most timely processing of your claims, please provide the following information on each electronic or paper claim submitted:

1. Charged amount
2. Primary payment
3. Primary allowed amount

How can I submit the primary payment information to Asuris for my “pended” claim?

There are three resources available: dedicated COB fax line, send an email to our COB email address or call Provider Customer Service:

• Dedicated COB Fax:  1 (888) 225-4822
• Email to secure email box: cob@asuris.com
• Customer service: 1 (800) 322-1737 from 6:00 a.m. to 6:00 p.m.

Contacting TriWest? Let Us Help You

Suggestions from TriWest Healthcare Alliance to improve your experience when calling TriWest:

Call 1-888-TRIWEST (888-874-9378) during off-peak hours (after 1:00 pm in your time zone) for a quicker response time.

• Use the Interactive Voice Response (IVR) system to receive information 24-7 without the necessity of speaking to a customer service representative.
• An IVR guide is available in the Provider Connection of www.triwest.com in the Resource Library.
• Specific sections for TRICARE reimbursement rates, referrals and authorizations, claims and reimbursement, TRICARE programs and benefits, the National Provider Identifier (NPI), Electronic Data Interchange (EDI), the Resource Library are also found in the Provider Connection
• Go to Provider Connection to find E-Seminar links allowing seminars at a time most convenient to you.
  
• Register for the secured Web site to perform functions without calling TriWest. Registered providers have access to a secure portal on www.triwest.com where they can:
• Verify patient eligibility
• Determine status of referrals/authorizations
• Submit claims online, view claims and check claim status
• Download Explanations of Benefits
• See what checks have been issued

Medicare crossover update

Coordination of Benefits Agreement (COBA) identification number not necessary for secondary crossover claims.

Recently the Centers for Medicare & Medicaid Services (CMS) changed the way in which claim-based crossover information is sent to secondary insurers. (Claim-based crossover occurs when the rendering provider bills Medicare primary, and on that claim, supplies secondary insurance information.) As of 10/1/07, CMS advised providers to obtain a Coordination of Benefits Agreement (COBA) identification number to add to these claims.

Asuris already shares its eligibility files with Medicare, and, as a result, receives secondary crossover claims directly from Medicare. It is therefore not necessary for a provider to include a COBA ID for these claims. 

If your secondary claims have not been successfully received by Asuris, please contact Customer Service at 1 (888) 344-5587 as we may need to add your patient’s Medicare coverage information to our eligibility files.