Connect
← Return to What does in-network access at Mayo Clinic mean?
Discussion
What does in-network access at Mayo Clinic mean?
Visiting Mayo Clinic | Last Active: Oct 21, 2022 | Replies (15)Comment receiving replies
@caretakermom
OK, your explanation helps. I hope my explanation of what I ran into that was similar helps.
I ran into this problem multiple times many years ago with a private insurance company Optum. Optum was a secondary, my primary at time was Blue Cross. Only claims dealing with Behavior Health went to Optum. If they sent those claims to Blue Cross, BC would denied and I would have to ask Mayo to resubmit to correct ins company. Optum used NPI to determine who was in network, so sometimes even though Mayo submitted to correct insurance company (Optum) it was denied due to NPI. It was a mess.
I did find an old message in my portal from 2018 when I was trying to resolve the claim, it took long time (months) it get it corrected. Optum would reject claim with message "Rendering Clinician has not been individually credentialed." When I contacted billing, they referred claim to their denial team for review. That was 4 years ago, so not sure what process is now.
To find out what provider's NPI is not showing up as in-network, look at the EOB for the claim being denied; what provider did you see on that day? Mayo had a process that updated insurance companies with individual provider's NPI that work for Mayo. I did not realize they still did it, I thought it was based on TaxId.
Years ago, this was done by a different dept then billing / insurance, but they would not let me contact them directly.
So I think Mayo has to do one of two things:
- Make sure that specific claim went to right ins company, it not they need to resubmit to correct insurance company.
- If they submitted it to correct insurance company, and it is being denied due to NPI, Mayo needs to update the insurance company that provider works for Mayo. This is something that has to be initiated by Mayo.
Hope that helps,
Laurie
Replies to "@caretakermom OK, your explanation helps. I hope my explanation of what I ran into that was..."
@roch,
I apologize for my last response to your comment. I was in a hurry and didn't read all of your comment!!
Yes, your last paragraph is right on point, Mayo is submitting to our secondary but not using in-network NPIs per Member Services. I suspect you're correct that Mayo has to initiate the update on their in-network NPI database. But no one in Mayo Billing is able to give an answer. The billing supervisor says she would look into it but I have yet gotten a response. I have questioned this since June of this year, basically when I found out the claims were being processed as out-of-network. At first I questioned Anthem(our secondary), then eventually found out it was Mayo who was submitting out-network claims. Our secondary says they cannot process as in-network unless the claims are submitted as in-network, i.e., both tax ID and NPI(s) are in-network.
We are trying to find out else, besides Billling, we can contact about this. You know, like perhaps the dept who actually verifies insurance and decides how claims should be processed? It makes a huge difference when we have a non-covered Medicare service and the bill gets forwarded to our seconodary as out-network.
We are just stunned that this is happening, esp when my husband had to go thru pre-verifications, pre/post treatments when insurance were approved.
I hope you understand my concerns and what I'm trying to get across. I just hope we can find someone at Mayo who can explain why they billing our secondary this way.
I should also mention that, prior to Medicare being primary, ie. when Anthem was primary we didn't have any billing issues!!
You've been extremely helpful and I very much appreciate your inputs. If you think of anyone else, other than Billing, who can help with a resolution, please don't hesitate to comment! Thank you!
@roch, just one more thing so that you get the whole picture. Our secondary has not changed since the first time we used it at Mayo. The only different now is Medicare is the primary. What is covered or the our secondary plan has not changed!
Connect
@roch, according to member services, both Tax ID and NPIs have to be used for our 2ndary to process claims as in-network. Thank you for your inputs!