Skip to main content

Claims

The claims automation component is responsible for streamlining the entire claims process by:

  • Tracking all the services provided by Pair Team
  • Submitting claims to health plans
  • Checking claims status (health plan's responses / remittance reports)
  • Notifying problems

Arc relies on Change Healthcare, a leading provider in claims automation solutions, to integrate with multiple health plans and serve as a claims Clearinghouse in this process.

Data Models​

  • Claim represents a standard CMS 1500 form
    • Most claims only contain 1 service line (outreach / encounter), except when we have to group encounters.
  • Grouping: Encounters are grouped if multiple occurrences happen on the same day, patient and type. That will generate 1 claim with 1 service line with the aggregated duration of all of them.
  • Units calculation: Depending on the service duration, service line units are calculated and the logic could vary by health plan. IEHP example:
    • Outreaches: always 1 u
    • Encounters: 0-29 min 1u, +1u every 15 min

Billed Services​

Arc tracks provided services through Outraches and Encounters, which is the most common way to bill for ECM services.

Payment Model​

Depending on the health plan, the following payment models are implemented:

  • Fee For Service (FFS): every outreach / encounter is paid
  • Capitation / Per Enrolled Patient Per Month (PEPM): one monthly payment is made. Usually all the services are submitted through claims: one will have the capitation payment and the rest will be paid $0
info

Check claims_codes_and_rates.rb for additional details

Codes​

Diagnoses and procedure codes are usually consistent among health plans. There are some exceptions like CCAH which requires additional diagnosis codes depending on the patient's SDOH.

Diagnosis Code (ICD-10): Z02.9 (Encounter for administrative examinations, unspecified)

Procedure codes​

Pre-enrolled patients (outreaches)​
HCPCS CodeModifierPlace of service (reference)
G9008 (clinical)
G9012 (non-clinical)		U8,GQ (electronic)
U8 (in-person)		02 Telehealth Provided Other than in Patient’s Home
11 for Office visit
Enrolled patients (encounters)​
HCPCS Code [Modifier]Place of service (reference)
G9008 [U1, GQ] (clinical / electronic)
G9008 [U1] (clinical / in-person)
G9012 [U2, GQ] (non-clinical / electronic)
G9012 [U2] (non-clinical / in-person)		02 Telehealth Provided Other than in Patient’s Home
11 for Office visit

Billing providers​

All the services provided by Pair Team are billed under Pair Team Medical Group of California organization.

exception

Clinics under the old operational model (IEHP Metropolitan Clinics) use a different billing provider: Natt Balbir

Change Healthcare Resources​