Yash Patel led a discussion with Zorayda Mejia, Tania Priego, Marlen Mejía, and Etsubdink Workineh Gebeyehu regarding claims resolution, timely filing, and documentation. Key issues addressed included correcting Kaiser CIN errors, regenerating "no billable activity found" claims, reissuing claims denied due to payer discrepancies, and understanding eligibility check details. Yash Patel outlined the process for submitting authorization requests for additional units beyond the initial 12 units and emphasized the importance of detailed notes and avoiding templates for documentation to prevent audit issues.

• Error Resolution for Claims Yash Patel initiated the discussion by addressing errors in claim submissions, particularly focusing on the CIN format for Kaiser members. They noted that Kaiser does not accept a standard CIN and requires a medical record number or Kaiser member ID. Yash Patel also mentioned a temporary workaround involving removing a leading zero from the Kaiser member ID and stated that the engineering team would expand format rules to include both Northern and Southern California Kaiser formats.

• Claim Generation and Resubmission Zorayda Mejia inquired about generating old claims, and Yash Patel confirmed that claims could be generated, citing ILS's 180-day retro-billing period. Yash Patel clarified that non-Medicare member claims must be received within 180 days from the date of service, a rule specific to Kaiser, while other plans like Partnership Health Plan and Anthem allow up to 365 days, with Molina being the exception at 90 days.

• Timely Filing for Corrected Claims Yash Patel explained that a corrected claim could be submitted within a year after a denial, except for Molina, which only allows 90 days. They shared experiences of battling Molina over timely filing denials and consistently winning due to Molina's own policy contradicting their denials, emphasizing that Molina is the sole exception to the 180-day or more rule for corrected claims due to their 90-day network agreement.

• "No Billable Activity Found" Error Yash Patel discussed how to address claims with a "no billable activity found" error, advising users to delete these claims and regenerate them after correcting the format by removing excess leading zeros. They explained that this error occurs when multiple claims are created for the same date of service, leading to activity being stripped from one claim and moved to another, leaving the original claim in an error state.

• Reissuing Claims and Eligibility Checks Yash Patel demonstrated how to re-issue claims, including deleting original claims and regenerating new ones with the correct date of service. They explained that a claim denied for being transferred to the correct payer, like HealthNet forwarding to Molina, indicates a discrepancy in the member's listed insurance. Yash Patel then demonstrated how to use the eligibility check feature to verify actual insurance coverage, highlighting that HealthNet sells Molina products, which can cause confusion.

• Understanding Eligibility Check Details Yash Patel elaborated on the eligibility check feature, noting that the date of birth might be off by one day in the system. They stressed that the "health benefit plan details" section within the eligibility check provides crucial fine print about coverage, allowing users to identify the true insurance carrier, such as Molina, even if HealthNet is initially listed. They also pointed out that a Molina preferred provider listed for the PCP confirms Molina coverage.

• Correcting Insurance Information Yash Patel advised that if the eligibility check reveals Molina coverage despite HealthNet being listed, users should update the member's profile to Molina. They clarified that claims transferred from HealthNet to Molina will eventually be paid but will take longer, and that errors generated by regenerating a transferred claim should be resolved by leaving the original claim in a denied status until paid by Molina.

• Handling Closed and Old Claims Yash Patel recommended addressing timely filing denials by closing the individual claim and billing for the same activity with a new, current date, especially if within the initial 12 units. They emphasized that historical activity remains accessible, allowing for re-billing of services at a later date to ensure payment, and encouraged actively reviewing and re-billing the 31 existing closed claims.

• Generating New Claims for Errors Yash Patel reiterated that claims in an error status cannot be closed and must be deleted before creating a new claim with the correct date of service. They confirmed that users could perform this task themselves, stating that the video recording would serve as a guide.

• Billing Units and Authorization for Additional Units Zorayda Mejia asked about billing for housing and transportation services, and Yash Patel clarified that the standing order from DHCS is 12 units, not 24, for initial billing without additional paperwork. Beyond 12 units, an authorization for additional units is required, which involves submitting a plan of care for health plan approval. Yash Patel confirmed that within the first 12 units, multiple diagnosis codes related to housing instability could be billed.

• Recommended Diagnosis Codes for Housing Yash Patel recommended specific diagnosis codes for housing-related issues, including 59.01 for sheltered homelessness and 59.72 for insufficient social welfare, the latter being more effective for low-income members than 59.6, which is often denied for not being medically relevant. For legal mediations related to eviction, Yash Patel advised using 59.811 ("housing instability housed risk of homelessness, rent or foreclosure or past due") instead of general legal action codes, as it better reflects the support provided without implying legal representation.

• Processing Change Requests Yash Patel explained that change requests are initiated by the audit team and include specific notes for correction. They demonstrated how to update insurance information for a claim flagged as incorrect, such as changing HealthNet to Molina on both the member's profile and the claim activity itself, and then regenerating the claim. Yash Patel advised selecting a primary diagnosis code to prevent denials, especially for Molina claims, and suggested regenerating the claim once more after updating the primary diagnosis code to ensure accuracy.

• Addressing Inactive Coverage Yash Patel highlighted that many change requests stem from inactive insurance coverage, often indicated by an "invalid member ID" or a lack of active coverage for the billed date of service. They instructed users to contact members to obtain accurate and active insurance information, utilizing the eligibility feature to verify coverage details like start and end dates. Yash Patel confirmed that if a member's coverage is truly inactive, claims cannot be processed and users may need to help members update their insurance or switch to new coverage.

• Billing Dual-Logo Medical Cards Yash Patel clarified that for medical cards with dual logos, such as Anthem and LA Care, the primary insurance is usually Anthem, and it should be billed directly if Anthem is in network. They added that LA Care billing will be possible starting November 1st, subject to contract finalization, and advised entering both primary and secondary insurance numbers for such cards.

• Action Plan for Errors and Change Requests Yash Patel summarized the action plan, instructing users to review errors, provide accurate and updated insurance information for change requests by contacting members, update both the member's profile and claim activity, and then regenerate the claims.

• Diagnosis Code List and Z-Codes Zorayda Mejia requested a list of codes, and Yash Patel confirmed they would email a preferred Z-code list, specifically for Molina, noting that Anthem and HealthNet are more flexible with accepted codes. They advised against using Z-codes marked "archived" as they are outdated but cannot be removed from the system.

• Authorization for Additional Units Process Yash Patel outlined the process for submitting authorization requests for additional units after the initial 12 units are consumed. They explained that users should add a "review request" on the member's profile, upload a completed plan of care form, and specify 24 units for the request, as health plans prefer this volume over 50 units to control for potential fraud or abuse.

• Tracking Billed Units Yash Patel demonstrated how to track billed units by viewing the "recent claim summary" on a member's profile, filtered by year. They explained that the system counts units, not claims, to determine how many units have been billed, paid, or rejected.

• Discrepancies in Paid Amounts Marlen Mejía raised a concern that paid amounts displayed in the system did not always match calculations. Yash Patel explained that discrepancies between displayed paid amounts and invoices could be due to contractual adjustments by health plans. They clarified that a "zero dollar payment" indicates a duplicate claim, which is visible in their clearinghouse system.

• Understanding Claim Denials Yash Patel clarified that claims filed with the same procedure code are considered duplicates, even if the intake and service types differ. They explained that diagnosis codes indicate what is being billed under the procedure code, but do not distinguish separate services if the procedure code is identical.

• Importance of Documentation and Audits Yash Patel stressed the critical need for detailed notes to justify billing, especially during audits, noting that insurance companies often request records. They mentioned that review sessions for insurance companies occur monthly until December 1st, when a "code freeze" happens for internal audits, preventing new codes from being billed. Yash Patel also advised against using templates for notes and plans of care, emphasizing that documentation should be unique and detailed for each patient to avoid issues during audits.

• HIPAA Compliance and Staff Training Zorayda Mejia raised concerns about HIPAA requirements and training for volunteers and staff, especially given limited platform accounts. Yash Patel clarified that HIPAA training is required for anyone using their platform, and strongly recommended that all staff be trained and certified, as good practice within the healthcare industry. They also noted that staff should be certified for the specific work they perform, rather than general certifications like CHW if that is not their primary role.

• Accessing Training Resources Tania Priego inquired about available manuals or procedures for navigating the system and understanding processes. Yash Patel suggested contacting Nev, the customer success manager, who is spearheading the development of Help Juice articles and training materials for clients. Yash Patel offered to ensure Nev provides the necessary information, including platform usage manuals and CHW HIPAA trainings.

• Guidelines for Detailed Notes and Plans of Care Etsubdink Workineh Gebeyehu asked for guidance on the required level of detail for notes. Yash Patel referred to the Department of Health Services' All Plan Letter (APL) as the policy document for the CHW program, stating that notes should reflect the nature and duration of services provided. They advised avoiding clinical language and ensuring notes for plans of care are medically relevant, providing specific examples of how to detail challenges like financial instability in a relevant context.

• Managing Denied and Rejected Claims Yash Patel assured the team that their billing team would handle denied and rejected claims, as these are their responsibility as subcontractors. They explained that duplicate claims would be closed as they have already been paid, and Molina denials related to primary diagnosis codes would be rectified by switching to medically relevant codes. Yash Patel confirmed that their team works to resolve and resubmit claims, including those over 90 days old, with a focus on issues identified with Molina and San Francisco Health Plan.

• Client Responsibilities for Claims Management Yash Patel clarified that "change requests" and "errors" are the responsibility of the client team to address. They explained that change requests are identified by their auditing team when claims are in the "ready for screening" status, indicating issues that need to be resolved before submission. Yash Patel also noted that rejected claims, which originate from the clearinghouse, can be quickly corrected and resubmitted without a new claim number, unlike denied claims from health insurance companies that require a corrected claim with the original claim number.

• Optimizing Claim Submissions Yash Patel advised the team to utilize all 12 available units for a member by creating new activities and claims if they are still within the unit limit, even for previously closed claims. They encouraged the team to focus on resolving change requests and errors, as these are straightforward fixes that can significantly impact the number of billable claims.

• Post-Meeting Follow-Up Marlen Mejía inquired about receiving the list of primary codes, and Yash Patel confirmed they would email the Z-code list, the All Plan Letter, and other relevant information immediately. Zorayda Mejia proposed a follow-up meeting with some team members to discuss organization and task completion.

• Yash Patel will put information about Kaiser's full rule for Northern versus Southern California in the chat for the group.

• Yash Patel will request that the engineering team expand on the rules to incorporate the rules for Northern and Southern California and fix the issue where the system automatically populates the two-digit prefix and leading zeros for Kaiser numbers.

• Yash Patel will close the two timely filing claims.

• Yash Patel will look into the Anthem inactive coverage issue for the 84-year-old person.

• Yash Patel will email the preferred list of Z-codes and the form for authorization for additional units to the group.

• Yash Patel will look into why the recent claim summary is showing a discrepancy in unit count for the member.

• Yash Patel will provide more context on why some claims say they are paid but the amount is not correct.

• The group will go back to the members and follow up with them for closed claims.

• The group will go back to each of the members and collect the correct active insurance information if they don't have it for change requests.

• Zorayda Mejia will reach out to Nev to (1) set up more training for the team about the platform and new features, (2) get a manual on how to use the PRA platform correctly and effectively, and (3) get CHW HIPAA trainings for her staff.

• Tania Priego will CC Yash Patel on the email to Nev.

• Yash Patel will send the Zcode list, the all plan letter, and the independent living assisting medical record format to the team.

• The group will go through the closed claims, look up the member, and count the individual units to see if they have built less than 12 units. If so, they will create a new activity for today's date, follow up with the member, do the activity, generate the claim, and send it out.