This document provides an overview of the sections and features available in Section Two of the Directprovider.com Training. It describes how users can search for claims, view claims histories and details, submit adjustments, and access remittance advices. It also outlines how to submit claims and access electronic remittance advices through Emdeon, use secure messaging to communicate with health plans, request fee schedules, access client listings, search First Health TPA carrier bills, and manage workers' compensation information.
1. FREEdom to go direct
Directprovider.com Training
Presented by Coventry Health Care
2. Coventry Health Care – For Public Use
In Section Two, the following will be covered:
Claim Inquiry
— Searching for Claims
— Viewing Claim History and Detail
— Requesting Adjustments
Claim Submissions (via Emdeon)
Remittance Advices
Message Center
— Composing and Working with Health Plan
and Workers Comp Messages
Coventry National PPO Fee Schedule
— Requesting Current Fee Schedules
— Requesting Future Fee Schedules
Coventry National Client Listing
First Health /TPA Carrier Bills
Workers Comp
— Bills
— Jopari Portal
— Refer a Patient (Talispoint)
— Provider Resources
Directprovider.com – Section Two
3. Coventry Health Care – For Public Use
Claim Inquiry…
This section provides claim status, claim payment
information, claim line detail, and claim history.
The users are able to:
Search for claims
View specific or entire groups of claims
Submit an online claim adjustment
View/Print Remittance Advices
5. Coventry Health Care – For Public Use
Claim Inquiry…
Fields marked with an Asterisk are required
On the Search By Member tab users
can use the following Search Methods:
- Member ID
- Member Name/DOB
6. Coventry Health Care – For Public Use
Claim Inquiry…
When searching by Member, if
The member is found in multiple
health Plans the user will be
prompted to select the health
plan and click CONTINUE
7. Coventry Health Care – For Public Use
Claim Inquiry…
All date ranges are limited to 30 Days
On the Search By Status tab users
can search by date/date range from
the following selected status:
- Pended
- Rejected
- Denied
- Approved
- Paid
- Unpaid
8. Coventry Health Care – For Public Use
Claim Inquiry…
On the Search By Claim
Number tab users can search
by a known claim for the
selected Tax ID #
9. Coventry Health Care – For Public Use
Claim Inquiry…
On the Search By Date tab users can
search by DOS or a 30 day date
range for the selected Tax ID #/Health
Plan/Provider
10. Coventry Health Care – For Public Use
Claim Inquiry – Search Results…
Results Not Found
For DENIED and REJECTED
claims the use can click the
icon to display a more
detailed reason
Click the icon to display
processing History
Click the icon to View
Details for the selected claim
11. Coventry Health Care – For Public Use
Claim Inquiry – Reason…
When a claim has been Rejected or Denied, the user can click the REASON
button to display a more detailed reason for the denial or rejection
12. Coventry Health Care – For Public Use
Claim Inquiry – History…
Click the HISTORY button to view the detailed processing history,
which will include any Status changes
13. Coventry Health Care – For Public Use
Claim Inquiry – Detail…
The claim header area includes the following detail:
- Provider information
- Claim type (Original, Backout, Replacing)
- Date Entered/Approved
- Referral/Authorization Number (if applicable)
- Patient Control # (if applicable)
- Coordination of Benefits Flag
- Paid Amount
- Eligibility Link for the DOS
14. Coventry Health Care – For Public Use
Claim Inquiry – Detail…
The line detail area includes all
line items submitted on the claim,
Click the VIEW button in the
disposition column to view detailed
processing for the specific line item
(click HIDE to close the expanded
line item disposition details)
15. Coventry Health Care – For Public Use
Claim Inquiry – Detail…
The Payment Information area will include a link to the Remittance
Advice (if available) as well as detailed payment information
and Patient Responsibility, the user can click the Print
Friendly link to print out the claim detail
EFT333333 ABC PEDIATRICS
16. EFT333333 ABC PEDIATRICS
123456
987654321
Coventry Health Care – For Public Use
Claim Inquiry – Detail…
If a claim has been backed out and replaced the Related Claims
area will be present and will have the other corresponding claims,
the user can click on a corresponding claim number
to view that detail
17. 123456789
#123456789
80111111102SALLY PUBLIC
Coventry Health Care – For Public Use
Claim Inquiry – Adjustment Request…
Clicking the Request Adjustment link will branch the user to the
ADJUSTMENT REQUEST screen where the user will identify a
Reason for the request from the drop-down and the Contact
Information will default the users Name and Phone (but can
be changed if necessary)
18. Coventry Health Care – For Public Use
Claim Inquiry – Adjustment Request…
Users will populate the corresponding
fields depending on the circumstances
of their adjustment request
19. Coventry Health Care – For Public Use
Claim Inquiry – Adjustment Request…
Users are able to attach up to four (4)
electronic files not totaling more than
10 megabytes (click the Remove button
if something has been attached in error);
Click Submit Request when done
20. Coventry Health Care – For Public Use
Emdeon Claim Submissions…
• Coventry has partnered with Emdeon to provide
online claim submission (direct data entry or claim
file upload) and HIPAA electronic remittance
advice access for Coventry Health Care members
at no cost to the providers
• This web interface is a self-directed/administered
solution that contains some of the functions a
provider can use today within Emdeon Office
• Providers that submit paper claims or are able to
produce HIPAA compliant EDI claim and
remittance (837 and 835) files may want to take
advantage of this functionality
21. Coventry Health Care – For Public Use
Emdeon Claim Submissions…
Small offices that only see a few Coventry members may be
interested in the direct data entry functionality
1. Manually enter claims directly to the Emdeon site (via
Directprovider.com link)
2. Monitor return messages from Emdeon and later from Coventry
regarding claim level accept/reject messages on the site
3. Fix or reenter any claims that are rejected as applicable
Larger provider offices that are able to create their own
HIPAA compliant/EDI claim files might want to use the file
upload process; however, they must be able to manage the
full cycle of EDI claim submission:
1. Prepare HIPAA compliant 837 EDI file from billing system or
vendor
2. Upload file to Emdeon website (via Directprovider.com link)
3. Monitor return messages from Emdeon and later from Coventry
regarding claim level accept/reject messages
4. Fix or reenter any claims that are rejected as applicable
22. Coventry Health Care – For Public Use
Emdeon Claim Submissions…
The system will present the Claim Submission landing page when
the left navigation link is invoked
When the user clicks <continue> the system will present
Emdeon’s login page
23. Coventry Health Care – For Public Use
Emdeon RAs…
Within Remittance Advices, the system will present the HIPAA
835 Remittances landing page when the HIPAA 835 Remittances
tab is selected
When the user clicks <continue> the system will present
Emdeon’s login page
24. Coventry Health Care – For Public Use
Emdeon Claim Submissions/RAs…
Coventry will not have staff trained
to support this tool; Provider office
staff will need to reach out to Emdeon
to request any additional information
regarding this process
Provider offices can pre-load provider
and practice details (Providers and
the Practice must have NPIs)
Once logged in, WebConnect
users will be able to select
Direct Data Entry or
Claim File Upload
All claims submitted through this process will be merged with all
Coventry claims submitted under payer ID 25133
25. Coventry Health Care – For Public Use
Remittance Advices…
Another option on the Navigation Bar is
Remittance Advices (RAs). This section of
Directprovider.com allows users to view
remittance advices online.
The remittance advice (RA) available on
Directprovider.com is an exact image of the paper
remittance advice sent through the mail.
There will be three tabs to chose from (as
applicable):
— Health Plan Remittances
— Coventry Consumer Choice/C3 Remittances
— HIPAA 835 Remittances
26. Coventry Health Care – For Public Use
Remittance Advices…
The Search Methods include:
- Claim(S)#
- Member ID
- Member Name/DOB
- Check/EFT #
- Service Dates
- Check/EFT Dates
Click SUBMIT to Search
27. Coventry Health Care – For Public Use
Remittance Advices…
Within the Search Results column click the View link
to open the RA in an Adobe Reader (if you don’t have
Adobe Reader installed click the Get Adobe Reader
button to download a free version
123456789 EFT12345
29. Coventry Health Care – For Public Use
Secure Messaging…
The Message Center is another alternative for
Coventry providers to communicate private health
information directly with the Coventry CSO.
The Message Center option allows Coventry
providers the opportunity to submit secure Health
Plan specific and Workers’ Comp messages to the
Coventry Customer Service Organization in
regards to inquiries for claims, authorizations,
eligibility, and forms, to just name a few.
Secure messaging allows users to communicate
private health information directly with the
customer service organization.
31. Coventry Health Care – For Public Use
Secure Messaging…
Click the Subject to
open a message
Select Health Plan or
Workers’ Comp and
click Go to compose
a new message
Common formatting
is used to identify
read/unread
messages
The Paper Clip icon
is used to indicate
an attachment
32. Coventry Health Care – For Public Use
Secure Messaging…
When composing a new
message select a Reference
(Claim #,Member ID, or Other);
select an applicable Category
(such as Authorizations,
Claims Adjustment, Eligibility /
Benefits, Forms, etc.); and
enter a Subject
Users can attach up to
4 electronic data files
(click Remove, to
delete an attachment)
33. Coventry Health Care – For Public Use
Secure Messaging…
Click the Message
List button to return
to the Inbox tab
Click Cancel to close
or Reply to respond
Click Trash to move
to the Trash tab or
click Print Friendly
to print the message
34. Coventry Health Care – For Public Use
PPO Fee Schedules…
Physicians and Ancillaries not affiliated with a
Hospital who participate with any of the
Coventry National PPO Products are able to
request Fee Schedule detail through
Directprovider.com
Eligible providers must be registered with one or
more of the Coventry National PPO Products
before they can submit a Fee Schedule Request
Eligible providers may request Current or Future
Fee Schedules and can designate whether they
want to receive Full Schedules; Sample
Schedules; a Procedure Code Range; or a Single
Procedure code
35. Coventry Health Care – For Public Use
PPO Fee Schedules…
Users with access to the PPO
Fee Schedule functionality will
select the applicable Tax ID #,
Provider and PPO Product
from the drop down and then
click the Submit button
(Users who do not have access
will need to contact their
Administrator to request access
36. Coventry Health Care – For Public Use
PPO Fee Schedules…
Providers may have location specific rates, users
will click the Select button for the desired Rate
Code and Practice Location
37. Coventry Health Care – For Public Use
PPO Fee Schedules…
Users will click the Current or Future SELECT button
38. Coventry Health Care – For Public Use
PPO Fee Schedules…
Select the desired Search Method (with a Future
request select Changed Values for only
changing codes/values) and a desired
Delivery Method; PDF Format (Preferred, as
detail is returned within 24 hours) or US Mail
(may take 10 to 15 business days to be returned)
39. Coventry Health Care – For Public Use
PPO Fee Schedules…
When requesting Fee Schedules
in PDF Format, the schedule
will be delivered via a Secure
Message; the Secure Message
will include a link to open
the schedule in PDF Format
41. Coventry Health Care – For Public Use
Client Listing…
If a new administrator is registering to access the
Client List functionality, he or she will access the
section of registration that is labeled PPO Fee
Schedule or Client List.
— A user will identify that he or she is registering for
Client List and will then have to supply his or her CPD
ID to continue registration.
Existing administrators with PPO Fee Schedule
access can add/edit the Client List Group; The user
identifies will edit the Client List group.
— If the user chooses to edit the Client List group, then
a new page will display requiring TIN and CPD ID to
be added to the Client List functionality.
42. Users with access will have the ability to access
Client Lists via a link on the left Navigation Menu.
When the link is invoked, a disclaimer page is
presented. The user has to accept the disclaimer
to continue to the Client List landing page.
Users will enter search criteria and execute search.
There are six required fields that must be
completed in order for the ‘Find Clients’ button to
be accessible.
There is one optional field to search by
client/payor name.
Client Listing…
Coventry Health Care – For Public Use
43. Client Listing…
Coventry Health Care – For Public Use
Users with access will click the ACCEPT AND
CONTINUE button (if you do not have access
contact your Administrator to request access)
44. Client Listing…
Coventry Health Care – For Public Use
Enter the required Search Options;
For Only Show select from:
- Clients Active Today
- Clients that will be active in 30 days
- Clients that will be active in 60 days
- Clients that will be active in 90 days
45. Client Listing…
Coventry Health Care – For Public Use
Users can search for a specific
Client or Payor (optional, leave
blank a complete Client List,
then click the FIND CLIENTS
button
46. Client Listing…
Coventry Health Care – For Public Use
A list of Clients is returned
based on search criteria entered;
to view the Client Detail
click the Show Detail
button for the specific client
(users can also download
the list to Excel)
48. First Health TPA…
Coventry Health Care – For Public Use
Users can search/review
First Health TPA carrier bills;
Select the SEARCH by Patient
or SEARCH by Provider tab
and then enter the
desired Search Criteria
49. For Search By
Patient:
— Users can search
by Claim
Number, with
optional Service
Dates
— Users can search
by Patient Name
/ Date of Birth
with optional
Service Dates
— Users can search
by Patient SSN
with optional
Service Dates
First Health TPA…
Coventry Health Care – For Public Use
50. For Search By
Provider:
— Users can search
by Physician
Name, with
required Service
Dates
— Users can search
by Billing
Provider Name
with required
Service Dates
— Users can search
by Service Dates
(maximum 30
day date range)
First Health TPA…
Coventry Health Care – For Public Use
51. If no Bills are found based on the entered search criteria,
the user will receive a message to broaden the search
criteria or search with a different category
First Health TPA…
Coventry Health Care – For Public Use
52. First Health TPA…
Coventry Health Care – For Public Use
If Bills are found based on the entered
search criteria, users will be able to:
1. Filter the Bill List results
2. Customize the viewable columns
3. Sort on most columns
4. Use the Action icon to display: the
Medical Claims Pricing Systems
(MCPS) Sheet or Send Inquiry
1
2
3
4
53. First Health TPA…
Coventry Health Care – For Public Use
Filter options include:
- Physician Name
- Patient Name
- Billing Provider Name
Once options are checked the user will
click Update Results to filter the Bill List
54. First Health TPA…
Coventry Health Care – For Public Use
The Customize Table button allows
users to pick and choose display fields
(by checking or un-checking fields),
at least 5 fields must be selected
before the user can click OK
55. First Health TPA…
Coventry Health Care – For Public Use
The user can click the Action icon
and select PRICING SHEET to view the
MCPS Pricing Sheet in PDF format or
click SEND INQUIRY to send a
Secure Message to the TPA CSO
57. Coventry Health Care – For Public Use
First Health TPA…
The user can click the Action icon
and click SEND INQUIRY to send a
Secure Message to the TPA Carrier CSO
for assistance with bill disputes
(Users may also request assistance with
a category of ‘Other’ to get help
with contract questions or even
concerns with the quality of service
they believe they are getting.
58. Coventry Health Care – For Public Use
Clicking on the “Send Inquiry” option will open a
separate window to enter the message detail.
The Tax ID #, CPD ID #
and Claim # will default
Select an applicable Category
from the drop down
Enter the Subject and body
of the message
Up to 4 attachments (10 MB)
can be attached
Click ‘Submit’ to send
First Health TPA…
59. Coventry Health Care – For Public Use
The inquiry is sent through Navigator to the TPA CSO
Web Inquiry queue for processing and response
The message will appear in the Inbox tab in the
Directprovider Secure Message Center with an issue
number assigned by Navigator from “First Health/TPA”
Users can reply to the message from the Message Center
First Health TPA…
60. Workers’ Comp – Landing Page…
Coventry Health Care – For Public Use
61. Workers’ Comp - Bills…
Coventry Health Care – For Public Use
The Bills function allows users
to SEARCH By Bill, Patient
or By Provider
SEARCH By Bill Criteria:
- Control #
- Document ID
62. Workers’ Comp - Bills…
Coventry Health Care – For Public Use
SEARCH By Patient Criteria:
- Claim Number
- Patient Name / Date of Birth
- Patient SSN
63. For Search By
Patient:
— Users can search
by Claim
Number, with
optional Service
Dates
— Users can search
by Patient Name
/ Date of Birth
with optional
Service Dates
— Users can search
by Patient SSN
with optional
Service Dates
Workers’ Comp - Bills…
Coventry Health Care – For Public Use
64. For Search By
Provider:
— Users can search
by Physician
Name, with
required Service
Dates
— Users can search
by Billing
Provider Name
with required
Service Dates
— Users can search
by Service Dates
(maximum 30
day date range)
Workers’ Comp - Bills…
Coventry Health Care – For Public Use
65. Workers’ Comp - Bills…
Coventry Health Care – For Public Use
If no results can be found the user
will be advised to broaden their
search criteria of call
Customer Service
66. Workers’ Comp – Bills…
Coventry Health Care – For Public Use
If Bills are found based on the entered
search criteria, users will be able to:
1. Filter the Bill List results
2. Sort on most columns
3. Use the View Details button to
display details and options for the
selected bill
1
2
3
67. Workers’ Comp – Bills…
Coventry Health Care – For Public Use
Filter options include:
- Physician Name
- Patient Name
- Billing Provider Name
Once options are checked the user will
click Update Results to filter the Bill List
68. Workers’ Comp – Bills (View Details)…
Coventry Health Care – For Public Use
Click the View Details button for
additional claim detail and the
following options:
- View Bill Image (if applicable)
- View EOR or Network Pricing
Sheet (as applicable)
- Send Inquiry (Secure Message)
01/18/2012
54321
203.89
153.8912/06/2011
279.00
if no payment info is available a message to contact
the Vendor for payment details
69. Workers’ Comp – Bills (Pricing Sheet)…
Coventry Health Care – For Public Use
70. Workers’ Comp – Bills (Bill Image)…
Coventry Health Care – For Public Use
72. Coventry Health Care – For Public Use
Workers’ Comp – Send Inquiry…
The Send Inquiry option for Workers’
Comp is a comprehensive Secure
Message that is sent to a specific
work queue within a Coventry
Application called WCMS
73. Workers’ Comp – Message Center…
Coventry Health Care – For Public Use
Both Workers’ Comp and other
affiliated Plan messages will
appear together in the Inbox
74. Copies of Health Plan & PPO Fee Schedule
submitted inquiries are placed in ‘Sent’ folder,
while immediate notifications and responses
from the Health Plan reside in ‘Inbox’
For Workers’ Comp inquiries ALL messages
remain in ‘Inbox’, NOTHING gets placed into
‘Sent’ tab/folder; Initial Notification remains
as ONLY item and reference to submitted
request/sent inquiry
— ALL follow up notes/comments are placed into
‘Message’ section of request for DP user to review
until ‘Status’ is listed as Final and ‘Resolution Date’
is provided/displayed.
Workers’ Comp – Message Center…
Coventry Health Care – For Public Use
75. Coventry Health Care – For Public Use
Workers’ Comp – Message Center…
Example of Sent Message
with several updates
76. Workers’ Comp – Jopari Portal…
Coventry Health Care – For Public Use
77. Workers’ Comp – Jopari Portal…
Coventry Health Care – For Public Use
78. Workers’ Comp – Refer a Patient…
Coventry Health Care – For Public Use
79. Workers’ Comp – Refer a Patient…
Coventry Health Care – For Public Use
80. Workers’ Comp – Provider Resources…
Coventry Health Care – For Public Use
The Important Links will redirect
the users to pages within the
Workers’ Comp website;
Additional Documents will
open in Adobe PDF
81. Coventry Health Care – For Public Use
Workers’ Comp – Provider Resources…
Follow the instructions
on the page to display
a State Mandated
Fee Schedule
82. Workers’ Comp – Provider Resources…
Coventry Health Care – For Public Use
To nominate a provider
complete the required fields
on the Nomination Request
and click the Submit button
to receive more information
83. Thank you for your time…
For Technical Assistance, please contact Net Support at 866-629-3975
Coventry Health Care – For Public Use