PPO Claims
The NCPPO and HealthLink Claims department provides efficient and accurate claim pricing for Preferred Provider Organization (PPO) provider claims. NCPPO and HealthLink requests any pertinent data missing from claims submitted by providers.

Provider claims are received via electronic transmissions daily (via clearinghouses) or delivered to NCPPO and HealthLink twice daily by U.S. mail. Mail received is opened and prepared on the date of receipt by our “front end" vendor. Those claims that can be scanned are scanned and converted to EDI claims using optical character recognition (OCR) by the front-end vendor. Inbound electronic claims are also processed each business day.

For manual claims, the processors enter all pertinent information from the claim into our computer system. If the information on the claim is incomplete, NCPPO and HealthLink makes every effort to obtain the missing information before forwarding the information to the payor. During the nightly batch run, the system checks for exact duplicates, UR authorizations, correct coding and assigning the appropriate repriced amount, which corresponds to the specific provider contract. For the most part, application of repriced amounts is fully automated. Most inbound electronic claims are automatically repriced by the computer system.

Once repriced, the EDI claims are sent outbound to corresponding payors (either directly or through a clearinghouse). For manual claims, the repricing sheets are matched with the corresponding claims and are generally mailed to payors the same day they are completed.

Claims must meet quality (audit) and production standards. Claims turnaround is extremely important to the department as well as the entire company. Our payors and clients can expect all clean claims to be turned around in an average of seven business days. This time frame not only includes the day the mail is received, but includes the day the claims are forwarded to the payor. Electronic transmission is the most efficient method to receive network claims.

Customer Claims Resolution Unit (CCRU) (For Payor Problem Claims)
Our Customer Claims Resolution Unit (CCRU) focuses on special handling of claims needing researched for corrected pricing, updated eligibility, provider "par" status, etc. Only claims received by affiliated NCPPO and HealthLink payors that require special handling by NCPPO and HealthLink should be faxed to our CCRU at (314) 925-6632 with a fax cover sheet. Each claim should be faxed with instructions as to what is needed for the claim in question as well as instructions for return of the claim to the payor (fax number or mailing address). All claims will be sent by the outbound EDI methodology in place or mailed back, unless return by fax is specifically requested. Eligibility issues for claims may be sent through the CCRU for logging and tracking purposes. Misdirected claims (claims sent directly to the payor from the provider) should be sent back to the provider to be redirected to NCPPO and HealthLink. The CCRU averages a 5-day turnaround time for claims received from payors.