Phys Claims Overview

COSMOS Physician Claims : 

1 COSMOS Physician Claims

Overview : 

2 Overview This presentation will give a high-level explanation of the COSMOS Claims System and how it interacts with other core COSMOS applications. Physician and hospital Claims adjudication process will be examined and a brief summary of it’s dependencies will be discussed.

Physician Claims : 

3 Physician Claims Physician and Hospital claims are sent to COSMOS in the same fashion (either via electronic submission or paper submission). Physician and Hospital claims are handled differently by COSMOS.

Physician Claims - Point of Entry : 

4 Physician Claims - Point of Entry Submission of Claims to COSMOS: - ‘True’ electronic Claims - Keyed electronic Claims - Paper Claims ‘True’ electronic claims means the claim was sent to COSMOS directly from the Physician’s office. Keyed electronic claims are sent to a third party vendor for keying into COSMOS (often referred to as RMO’s - Remote Mail Offices). Paper claims are sent directly to the health plans from the Physician’s office. Paper claims are either keyed directly into COSMOS or CPW (Claims Processing Workstation).

True/Keyed Electronic Claims : 

5 True/Keyed Electronic Claims All claims are sent to UFE (United Front End) to determine if the claim should be processed in COSMOS or UNET. UFE makes the determination to what legacy system to route the claim to. UFE will use member information such as SSN (Social Security Number) to recognize the member and to know what system they reside on.

True/Keyed Electronic Claims - UFE Process : 

6 True/Keyed Electronic Claims - UFE Process Once the determination has been made by UFE, the Claims routed to COSMOS will undergo a series of edits to ensure COSMOS can enter the claim into the system based on the information received. If the claims submission does not meet all requirements, the claim is sent systematically to CPQ (Claims Pre-Processing Queue).

True/Keyed Electronic Claims - CPQ : 

7 True/Keyed Electronic Claims - CPQ Claims that are sent to CPQ will require manual intervention to process the claim any further. Processors will manually clear all reviews (or edits) on a claim. The edits can consist of a variety of errors, such as, invalid group number, invalid member number, invalid ICD9 codes, to name but a few.

Physician Paper Claims : 

8 Physician Paper Claims Physician paper claims, as mentioned earlier, are either keyed directly into COSMOS or CPW. Unlike electronic claims, if edits are not met, the claim will not be sent to an error queue and all errors will need manual intervention at point of entry into COSMOS.

Physician Claims - Time of Entry : 

9 Physician Claims - Time of Entry Once all edits have been cleared for both electronically and paper submitted claims, COSMOS will assign the claim an audit number. As this point, how the claim was submitted becomes insignificant to the adjudication process and the claim is recognized in COSMOS by it’s audit trail.

System Dependencies : 

10 System Dependencies Physician Claims will use the following applications during pre-payment processing: General Inquiry - houses member & provider information, Claims details by inquiry. Tables - houses service code, reviews and payment determination data Claims - on-line and automated logic for edit/review and claim directional data AdjudiPro - Uses AI (Artificial Intelligence) to check claims for appropriate coding and adjudicate claims errors.

Physician Claims - On-line Edits : 

11 Physician Claims - On-line Edits It is at this stage that all Claims on-line edits are invoked. Such edits, for example, will verify if the provider/member is on-hold, whether or not authorizations (now called notifications) are required and whether the claim is medical or UBH (United Behavioral Health) claim. Any edit that will impact the payment of the claim is also determined at this point.

The ‘Calc’ Process : 

12 The ‘Calc’ Process Once all on-line edits are cleared, the claim will go through the ‘OOPS deductible calculation’ process (or Calc). This process ‘freezes’ the claim and posts any out of pocket or deductible amounts to the member’s out-of-pocket limits. Once the claim has successfully completed the Calc, it’s ready to be processed by Checkwrite.

Checkwrite : 

13 Checkwrite The Checkwrite process pays the claim (cuts a check) and will generate & send a PRA (Provider Remittance Advice) to the provider. An EOB (explanation of Benefits) will also be generated and sent to the member detailing how the claim was processed.

Additional Information : 

14 Additional Information Claims Customer Support e:mail address DUL-Cosmos-Cust-Support/Unitedmail L&D website - CBT course Registration http://ld.uhc.com/registrar_office/catalog/index.htm PMO website - PowerPoint Presentation