Claims

A call from member stating they receive a bill, need to know where the bill came from. If member receive a bill from doctors office it is a Claim. If the bill came from Health first it is Premium.

. Ask Where is the bill came from? is it from Health first or the provider? . Ask what is the date of service and name of the provider.

• Confirm if the member has an active insurance on that time. exp. Sep. 26, 2024 and effective date was on Oct. 01, 2024 need to confirm the effective date and the termination date.

Always Check Enrollment History

Open e PACES to check if who was the one who handled the insurance of Member if member has no active insurance that time, member need to pay the bill.

need to get the doctors or providers phone number and call the doctors office, the call should be conferenced. Once in contact with the doctor's office ask them to resubmit the claim to health first. Claims can be submitted to our mailing address or P.O. box, the conference call are only for 10 minutes.

If the provider said that they don't provide a claim to Health first or if there is no Claim on File, we need to file an appeal to appeals and grievances.

Click Claims/ Search the date of Service/

NOTEL: the name of the PROVIDER and DATE OF SERVICE should be matched. if its not match need to call the doctor's office to confirm the claim.

PENDING= If the Claim Status is on Pending do not disclose any information to member on advised member that it is still on process and it will be on 30 days standard time of process. FINALIZED= there is already a claim.

If there is a Claim on file need to click the CLAIM NUMBER.

If a member is insisting to get a Claim from out of network Facility coverage, member need to get Emergency Authorization,

TOTAL PAID and ALLOWED AMOUNT is paid by Health first 100% NON COVERED AMOUNT is not paid or not covered by Health first CO-PAY and CO-INSURANCE are Paid by member.

TOTAL BILLED AMOUNT disregard

ME1013= to check the coordination of benefits ME1083= to check when was the last update