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Avoid claims denial and reconciliation of claims payments

Watch for three key differences in 2014

 

Recent changes in Wellmark’s claims processing systems could impact submitted claims with dates of service from Jan. 1, 2014 or later. Remember these important tips when submitting, reviewing or reconciling your claims:

 

1.  When submitting a claim, always use the correct member ID
Wellmark has issued new ID cards to patients who have purchased a new Affordable Care Act-compliant product in Iowa and South Dakota.

  • Existing ID card numbers: You probably already know that the patient ID is preceded by an alpha prefix (e.g., XQH for certain Alliance Select plans). These three letters are not usually required when looking up Wellmark patients online.
  • New ID card numbers: The alpha prefix may be followed by a “W” in some cases (e.g., XQFW99999999). When you see a “W” following the three-character alpha prefix, remember to enter this letter along with the eight digits that follow.

  And of course, always verify the patient’s name that appears on screen.

 

2.  When reviewing the status of claims, look for differences in acceptance reports 
Wellmark’s claims for patients with ID numbers that have a ‘W’ in the fourth position (described above) will not be reported back on the Wellmark acceptance report (Z16). These claims will continue to be shown on the transaction summary report (TXN). In either case, claims will appear in this secure Web tool within two business days of receipt of the claim at Wellmark. Providers can check the status of claims through the Check a Claim tool.

 

3. When reconciling claims, watch for separate payment documents and files
In cases where the member ID card indicates the name of the provider network (e.g., Wellmark PPOSM, Wellmark Blue HMOSM, or Wellmark Blue POSSM) providers must access separate Online PCRs. The check you receive will be written on check stock reflecting the patient’s coverage, rather than your practice location. For example, if a South Dakota member sees an Iowa PPO provider, the check will be printed on South Dakota check stock, instead of on Iowa check stock.

You may also receive multiple weekly data files and deposits. Providers who have signed up for electronic funds transfer (EFT) and/or 835 electronic remittance advices (ERA) may receive more than one EFT deposit and/or ERA files per week. For example, a provider could receive one EFT deposit and/or ERA for services to Wellmark Health Plan of Iowa patients, and separate EFT deposits and/or ERA for services to patients covered by Wellmark Blue PPOSM networks in Iowa and South Dakota.
 

 



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