Insurer User Manual Chapter 4: Insurer Home Page

Transcription

1 Insurer User Manual Chapter 4: Insurer Home Page 2018 HCAI Communications

2 Table of Contents Navigating the Insurer Page... 2 Primary Navigation Bar... 3 Dashboard... 3 Plans and Invoices... 4 Claims... 4 Search... 5 Advanced Search... 5 Search for Claim Number... 6 Manage... 7 Secondary Navigation... 8 Work in Progress... 8 Adjuster Response... 8 Filter by... 9 Work Lists... 9 Work in Progress work list Plans Adjuster Response work list Plans Work in Progress work list Invoices Adjuster Response work list Invoices Insurer Home Page Claimant Information Chapter 4: Insurer Home Page Page 1

3 Chapter 4: Insurer Home Page The Insurer home page is HCAI s first point of access for an Adjuster. It offers a consistent and clear structure, facilitating the Adjuster s task of searching for a plan (OCF-18, OCF-23 or Form 1), viewing its details and initiating the approval process. This Chapter walks you through the main insurer tabs and sub-tabs displayed after signing in to HCAI as an adjuster. Navigating the Insurer Page Insurers have the ability to choose which tab they would like to set as their home page, and have it display first upon signing in to HCAI. Set a tab or sub-tab as your default home page by clicking the Set as home page button, located at the bottom left corner of every tab in HCAI. Click the checkbox to set this tab as your home page Chapter 4: Insurer Home Page Page 2

4 The upper left corner of the homepage displays your organization s name and the welcome message displays your name. Users have the ability to view tabs, manage and record decisions against submitted plans and invoices based on the roles and domains each user is assigned in HCAI. The roles assigned to users via their User Profiles determine the operations or tasks they are permitted to perform. User domains determine in which entities (work groups, branches, insurers) users can perform the specified tasks. Using HCAI s enhanced browsing and search capabilities, you can now start browsing through the different sections of the page to search for specific document information and details. The Insurer page is visually divided into five sections based on functionality and the information displayed. The different parts of the page and the purpose they serve are described in the following section. Primary Navigation Bar The Primary navigation bar consists of the following tabs. Dashboard The Dashboard tab contains your HCAI Insurer Dashboard, which displays claimant and document data and allows adjusters, managers, and claims administrator staff to oversee and prioritize their workflow. Users with adjuster level access who have the form adjuster role will see the Adjuster view of the dashboard. Users with Insurer or Branch level access who have the form manager role and/or claim-claimant administrator role will see the Insurer or Branch view of the dashboard. Hover over a piece of the Claimant Summary or Document Summary graphs to see more information about the documents contained in that section of the graph. Click a piece of the graph to view a tabular breakdown of all the claimants or documents contained in that section of the graph. Please note: The ability to click the Claimant Summary pie graph to view additional information is only available for adjuster level users who have the Claim- Claimant Editor role assigned, as well as al Insurer and Branch level users. Chapter 4: Insurer Home Page Page 3

5 Click the Download button on the right side of the Claimant Summary section or the Document Summary section to print or download the information in.csv or.xls format. Click a section of the graph to view a tabular breakdown of the documents contained within that section Click this download button to print or save the information in.csv or.xls format Plans and Invoices The Plans and Invoices tabs allow you to specify the type of document you wish to work with based on your User roles, tasks and domains to which you have access. All assigned plans and invoices are shown under the relevant tab. Claims The Claims tab contains the Claims and Claimants sub-tabs. These tabs enable you to search for a Claim, or to search for a Claimant associated with a specific Claim. For more information on managing Claims and Claimants in HCAI, refer to Claim and Claimant Management in Chapter 6. Chapter 4: Insurer Home Page Page 4

6 Search Click on the Search tab to begin to search for one or more OCFs. The Search tab allows you to look for a specific plan or invoice. Note: At any time, you can click on the <Advanced> text link next to the Search for Claim Number field on the Insurer home page to bring up the Search>Document Search tab. Included is the option to execute an Exact Search for the specific value(s) entered in that field. If the Exact Match box is checked, HCAI will search for an OCF or OCFs using the only value(s) entered in the field(s) selected. Note that Exact Match is, by default, already selected simply click the checkbox to remove the Exact Match function from your search query. Selecting Exact Match will restrict results to the specific values entered in the field For more search options, click here The more information you enter into your search query (using the search parameters provided), the faster HCAI will execute the search. Advanced Search Clicking the <Advanced Options> text link at the bottom-right corner of the OCF Document Search screen brings up additional search parameters to help narrow your search. Available search parameters are: document type, claimant status, document status, days left to respond, matched to claimant, and facility/provider. By default, searches are performed on the active database. To run a search in HCAI s archive database, go into the advanced options and select Archived under Archival Status. Chapter 4: Insurer Home Page Page 5

7 An Advanced Search will allow you to refine results by document type, adjudication status, claimant status. archival status and provider Documents are archived as a group one year after the claimant s most recent HCAI activity Use the quick search field on the Insurer home page to quickly and easily locate an OCF Search for Claim Number The quick-search field of the Insurer home page lets you search for a Claim Number in either a specific plan/invoice or in all forms. Enter the Claim number in the Search for Claim Number field. Select the specific plan/invoice you need to find from the drop-down menu or leave the default All Forms selection to include all HCAIsupported plans and invoices. When finished, click the button next to the field to carry out your search. The Document Results screen shows all the fields that match the search criteria. The results are listed with various document details available for review. Results appear in chronological order with the most recently-submitted documents at the top. Chapter 4: Insurer Home Page Page 6

8 There are also options to download the results in CSV format or refine the search. Up to 100 search results can be viewed at a time. Download search results or Refine search Manage The Manage tab provides access to the Insurer Management, User Management and Reports sub-tabs with corresponding functionalities. The Insurer Management and User Management sub-tabs are only displayed if a user has the required permissions (role and/or domain level of access). Chapter 4: Insurer Home Page Page 7

9 The Manage tab provides access to the Insurer Management, User Management and Reports sub-tabs with corresponding functionalities Insurer Management and User Management sub-tabs are only displayed if a user has the required permissions Secondary Navigation The secondary navigation options of the Insurer home page displays Plans and Invoices organized according to their different states. After selecting either the Plans tab or Invoices tab from the primary navigation bar, you can select the specific states of the documents you wish to view. Work in Progress This sub-tab lists documents that have been submitted by Facilities and have not yet been adjudicated. Adjuster Response This sub-tab lists documents that have been adjudicated and have had a decision recorded against them. Chapter 4: Insurer Home Page Page 8

10 Filter by This drop-down menu allows you to filter information based on your level of access. For example, if you have Adjuster-level access and you are authorized to view other Adjusters work lists, this feature allows you to either filter by Adjuster Record or by address. If you choose to filter by address, you will only see one worklist per adjuster. If you have been assigned claimants in several branches, this filter will help you see all of your forms in one view rather than having to review your worklist for each branch individually. When you are monitoring another adjuster s worklist, you will be able to see all of their forms from a single view. The address filter will only work properly if every adjuster has their own e- mail address entered into their adjuster profiles in the Manage > Insurer Management tab. If this information isn t entered correctly, you will see different symbols in your worklist: If an asterisk appears next to an address, it means that this address has been used for multiple people in HCAI. If you have the option for <No set up>, it means that one or more of the adjuster profiles you have been assigned access to does not have an e- mail address entered into their adjuster profile. For this reason, the <No e- mail set up> filter can potentially become a catchall for several different people s forms. If you see this option, request that an organization administrator review the addresses entered into each adjuster profile in the Manage > Insurer Management tab. If you choose to filter by adjuster record, HCAI will display one work list per branch. For example, if you have been assigned claimants in five branches, you will see five work lists. If you have been assigned to be a backup for one other person, you will see your five work lists, plus your colleague s five work lists (a total of ten). For this reason, it can be challenging to monitor for incoming forms because you have to scroll through several different work lists. Work Lists The work list is an organized collection of documents displayed on either the Plan or Invoice tab. The default sort order of the work list is by date of submission ( Date Submitted ) in descending order, from newest submission to oldest. The User can Chapter 4: Insurer Home Page Page 9

11 reverse the sort order by clicking on the column titles that have been rendered as a hypertext link. Users can choose to organize their work list filters by address or by adjuster record. When you choose address filter, you will only see one worklist per adjuster. If you have been assigned to claimants in several branches, you will see all of your forms in one view rather than one work list per branch. If you choose to filter by adjuster record, you will see one work list per branch. Work in Progress work list Plans The Work in Progress work list for Plans is the default screen that is typically displayed for most HCAI Users. This screen allows you to view all submitted Plans from participating Facilities. Plans can be accessed by clicking on the Plans tab, shown here The Work in Progress work list can be viewed by clicking on the Work in Progress subtab, shown here Plans in the work list can be sorted by column by clicking on the highlighted header of each column The Plans > Work in Progress work list contains the following columns: Document #: A system-generated reference number unique to each form in HCAI. Claim #: This shows the claim number as stored in HCAI. Claimant: This shows the last name of claimant as stored in HCAI. OCF Type: This shows the type of plan or invoice. Status: this shows the plan status (e.g. Submitted, Unmatched). Days Left: This shows the number of business days left until the due date, based on the SABS timelines. For plans, the Days Left clock recognizes the end of day as 5:00 p.m. Eastern Standard time. Any plan received after 5:00 p.m. is deemed to Chapter 4: Insurer Home Page Page 10

12 be received the next business day. This will be automatically accounted for in the Days Left clock. Date Submitted: This shows the date the plan was submitted this is the default sort order for the list. The items in the work list can be sorted in ascending or descending order, based on field type, by clicking on the highlighted header of the column you wish to sort. The Review Form button (located to the left of each item in the work list) provides access to the actual Plan displayed in the list. Click on this button to open an OCF. Adjusters can access the OCF, view its details, and make an adjudication decision. For information on applying adjudication decisions to the different Plans and Invoices, go to Using Decision Support with Plans in Chapter 7 and Using Decision Support with Invoices in Chapter 8. Flags (exclamation mark - ) are an iconic representation of the document status. For example, overdue Plans that have been submitted are highlighted and flagged. There are several states for Plans in the Work in Progress work list, as described in the following table: Plan Status Submitted Review Required Unmatched Unassigned Description The Plan has been submitted by the Facility but has not been opened by the Insurer. The Plan is being reviewed by an Adjuster, but no response has been recorded. The Plan is Unmatched only if HCAI cannot match the applicant with a known Claimant. The Claimant has not been assigned to an Adjuster. In Discussion, Response Received In Discussion, Response Sent In Review, Locked By NAME The Adjuster has received a response from the Facility on a Need to Discuss issue. The Adjuster has initiated the Need to Discuss functionality and is awaiting a response from the Facility. An Adjuster User has clicked the Take Ownership button on the summary page and is working on the form Chapter 4: Insurer Home Page Page 11

13 Adjuster Response work list Plans Plans to which an Adjuster has applied an adjudication decision move from the Work in Progress work list to the Adjuster Response work list. This work list has a similar layout to the Work in Progress work list. The work list displays the Plan status and information on the Plan amounts proposed and approved. Click on the Review Form button ( ) to access the Plan and review the decision recorded. Plan status is based on the approval decision recorded by the Adjuster. The default sort order for the work list is by Date Responded. In the Adjuster Response work list, there are four states for Plans: Approved. All components of the Plan were approved. Partially Approved. Some components of the Plan were approved. Declined. All components of the Plan were declined. Responded. In relation to the OCF-23. The Adjuster Response work list can be displayed by clicking on the Adjuster Response tab, shown here The following business rules apply to the Adjuster Response work list: Business Rules for Adjuster Response work list - Plans Only plans that have had an Adjuster decision recorded display in this work list. Plan status is based on the Adjuster decision recorded. Date Responded is the default sort order for the work list. This is the date that the Adjuster posted their decision in HCAI. An adjuster may withdraw his/her decision. If an EOB is associated with a document it is either displayed as an eye icon (draft) or green check mark icon. Chapter 4: Insurer Home Page Page 12

14 Work in Progress work list Invoices The Invoices, the Work in Progress work list contains all Invoices submitted by a Facility to an Insurer that have not yet had been adjudicated. Users can choose to organize their work list filters by address or by adjuster record. When you choose address filter, you will only see one worklist per adjuster. If you have been assigned to claimants in several branches, you will see all of your forms in one view rather than one work list per branch. If you choose to filter by adjuster record, you will see one work list per branch. Invoice can be accessed by clicking on the Invoices tab, shown here Invoice work lists can be accessed by clicking on the Work in Progress sub- tab, shown here By clicking the Review Form button ( ) Adjusters can access each Invoice, view its details, and apply an adjudication decision. HCAI highlights Invoices in the following ways, based on their due dates: Submitted Invoices that are older than 30 calendar days are flagged as Overdue ; the row is highlighted in orange; Invoices within one day of expiry are highlighted in orange. Following are the states for Invoices that appear under the Work in Progress tab: Invoice Status Submitted Review Required Description The Invoice has been submitted by the Facility but has not been viewed by the Insurer. The matched, assigned Invoice has been submitted by the Facility and opened by an Insurer but no response has been recorded. Chapter 4: Insurer Home Page Page 13

15 Invoice Status Unmatched Unassigned In Review Locked By NAME Description The Invoice is Unmatched only if HCAI cannot match the applicant with a known claimant. The Claimant has not been assigned to an Adjuster. Another Insurer User is working with the Invoice and has taken ownership. The following business rules apply to the Invoices, Work in Progress work list: Business Rules for Work in Progress Work list - Invoices Invoices that are Submitted are shown in the work list in bold, black text. Invoices are in the Submitted state until they are opened by an Insurer. Once opened, their status is marked Review Required. The default sort order for this work list is by Date Submitted in descending order, i.e., from the most recent submission to the oldest. A document is Unmatched if HCAI cannot match the applicant with a known Claimant. This state does not appear on the Adjuster s work list unless they have branch level (or higher) access. A document is flagged as Unassigned when the document has not yet been assigned to an Adjuster. This state does not appear on the Adjuster s work list unless they have branch level (or higher) access. There is no Need to Discuss feature for Invoices. Adjuster Response work list Invoices This screen allows Adjusters to view all Invoices with an Adjuster response, and displays the status and the approved amounts. By clicking the Review Form button ( view its adjudication decision. ) Adjusters can access each Invoice and Chapter 4: Insurer Home Page Page 14

16 The Adjuster Response work list can be displayed by clicking on the Adjuster Response tab, shown here The following business rules apply to the Invoices, Adjuster Response work list: Business Rules for Adjuster Response Work list Invoices Only Invoices with Adjuster responses applied to them are shown in this work list. Invoice status is based on the decision the Adjuster specifies. The options available are Approved, Responded, Declined, and Partially Approved. The default sort order is by Date Responded in descending order. This is the date that the Adjuster posted their adjudication decision to HCAI. If an EOB is associated with a document it is either displayed as an eye icon (draft) or green check mark icon. Insurer Home Page Claimant Information Clicking on any of the Claimant names listed in each of the above-mentioned work lists allows the Adjuster to view the Claimant details. Chapter 4: Insurer Home Page Page 15

17 To access the Claimant details shown here, click on the hyperlinked Claimant name in any work list The information displayed is taken from the insurer files and the facility files. If the information is not available from the Insurer files, the applicant information from the OCF is displayed. Chapter 4: Insurer Home Page Page 16