Medical claims and reimbursement process of the Southern Ute Tribal Health Dept.

Photo Credit: Southern Ute Health Services

Greetings Southern Ute Tribal Membership,

The Tribal Health Department would like to continue the effort to help individuals understand the sometimes-complex world of health.  This article will cover some, but not all basic information about the medical billing and reimbursement process within the Tribal Member Health Benefits Plan.      

Currently the Tribal Health Department (THD) staff are working directly with two reps at the Forrest County Potawatomi Insurance Department (FCPID) to streamline claims processing and reimbursement requests.  The two reps then work the claim or reimbursement through their internal processes which are below:

Your provider can send claims via paper to FCPID’s Eagan, MN address which is listed on your card or to their electronic payor ID which also on your card. Some providers will also email or fax them claims or invoices directly (usually these are smaller providers, such as chiropractors or massage therapists or counselors). They do prefer to have the claims come in through their Eagan address so that the claims can then be entered electronically into their system. They are then assigned to the group’s examiner who is also one of our reps, and then if it’s a clean claim, it’s processed promptly, and payment goes out. Typically, what makes it not a clean claim is due to needing the primary explanation of benefits (EOB) or other claims errors. A denial is then mailed to the provider stating what is needed.  In most cases, the provider sends back the EOB by fax or by submitting a corrected claim.  Sometimes the provider will reach out to FCPID if the primary insurance has ended and the member hasn’t updated their insurance information. The primary EOB is necessary on claims because it shows the remaining balance that the primary insurance did not cover (usually because of a deductible or coinsurance or co-payments) an allows us to pay the correct amount. 

Other times, they will receive statements that have been forwarded to them via email from THD staff or members themselves. When statements are received in this manner, the member’s files are checked to make sure that the claim hasn’t already been received by them electronically and that the member is not being balance billed. If enough information is on the statement, it can be processed as a claim and payment can be sent out to provider. If there is not enough information on the statement to process it, then FCPID customer service attempts to reach out to provider to get the needed information for processing. A claim and primary EOB, if needed, are requested to be either faxed or mailed to the Eagan address. If they are unable to get this specific information sent to them, they try to get enough information to process a claim. As an example, date of service is needed along with the tax ID number of the provider. Codes are also needed to show what services were provided to the member to show medical necessity. FPCID tries to get as much information as possible to ensure that the services that are being billed are medically necessary and that the services follow the benefits of the Southern Ute Indian Tribe’s benefit plan.

When THD staff receive a reimbursement request from a member because they have paid a medical claim out-of-pocket, they forward that request to the FCPID reps.  There are several pieces of information required on the reimbursement document for efficient processing to occur.  An itemized statement must include member name, date of service, coding and amount paid.  Once all required information is received, FCPID will process a check directly to the member and send via mail to the address that is listed with Southern Ute Tribe’s Vital Statistics Department.  This process can take up to 30 days for completion.

If the member forwards a collection’s notice to the THD staff that claim is then processed immediately through the Tribe’s purchasing card (p-card) process via Finance for immediate payment to the collection agency.  THD staff continually process collections notices as soon as they are received and in most cases as long as they are paid at that point, they do not end up on the member’s actual credit report.

Thank you for your time and please look forward to the next article summarizing your prescription benefits through Silverback RX.  The THD Benefits Team is continuing to work through the tribally issues “Stay at Home” Order.  Office phones are forwarded to assist the tribal membership between 8 a.m. through 5 p.m. Monday through Friday.  We hope that each and every one of you are continuing to stay safe and follow the public health orders issued to help slow or stop the spread of COVID-19.

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