Hosp Claims Overview

COSMOS Hospital Claims : 

1 COSMOS Hospital Claims

Hospital Claims - Point of Entry : 

2 Hospital 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 hospital/Physician. 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 hospital/Physician. Paper claims are either keyed directly into COSMOS or CPW (Claims Processing Workstation).

True/Keyed Electronic Claims : 

3 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.

Hospital Claims vs. Physician Claims : 

4 Hospital Claims vs. Physician Claims Unlike Physician Claims, Hospital Claims have a limited amount of on-line adjudication. The majority of adjudication is performed by the Hospital Calc Process.

UFE Determination : 

5 UFE Determination 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).

Physician Claims - Time of Entry : 

6 Physician Claims - Time of Entry Once all on-line entry edits have been cleared for both electronically and paper submitted claims, by the Hospital Calc Process, COSMOS will assign the claim an audit number. At 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 : 

7 System Dependencies Hospital Claims will use the following applications during pre-payment processing: General Inquiry - houses service code, member & provider information, Claims inquiry, EDI Reject Claims. Tables - houses service code, reviews and payment determination data. Claims - on-line and automated logic for edit/review and claim directional data.

Hospital Claims - On-line Edits : 

8 Hospital 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 timely filing requirements are met. All payment calculation and determination is completed by the Hospital Calc Process.

Hospital Claims : 

9 Hospital Claims The Hospital Calc Process will pick up any claims that have reviews pending and will run the selected claims through the hospital adjudication logic. If reviews are not cleared, processors will manually work to clear outstanding reviews.

The ‘Calc’ Process : 

10 The ‘Calc’ Process Once all reviews 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 : 

11 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.

Side Note for Checkwrite Process : 

12 Side Note for Checkwrite Process Hospital claims can be submitted by a variety of parties: Inpatient and outpatient claims can submit a claim from the hospital itself for services rendered, i.e. hospital bed, meds, slippers and robe! Attending Physician, Specialists, CRNA (anesthesiologist), will also bill separately although this may all be encompassed into one hospital stay.

Additional Information : 

13 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