Provider Claims Alert

Date: 11/19/18

Notification of 2018 EOP Changes for Ambetter Providers

Since the inception, the Marketplace instance of Amisys has had a certain Amisys system flag set to “N”, which causes the denied amount to equal allowed amount on a denied service line. Our team believes this was carried over from the Medicaid instance, which also has the flag set to “N”.  When the flag is set to “Y”, the denied amount will equal the billed amount on denied lines, which is industry standard.

Due to the fact the denied amounts a member owes is not clearly defined this makes it difficult for provider to bill patients for the correct amounts they owe.

The new system can be used as of 11/19/2018.

Frequently Asked Questions:

Does this update apply to both par and non-par Marketplace claims?

This change applies to both par and non-par Marketplace claims and applies to any denied lines with any EX denial reason.

Why is the change happening?

The true driver behind this change is that more and more providers are complaining about how we handle denied amounts in our payables process, and what we do is not industry standard.

How will providers be impacted?

Many providers use the denied amounts to populate/pull their AR.  This may cause some providers to overstate their AR.