Claims that are suspended will have an “S” in the Emerge claim status column. Corporate claims are suspended (not denied) when the date of service is after the group’s list bill paid-to date.

 To understand what the status code mean please search “Status codes”

 When this occurs, please do NOT tell the caller that the claim is being suspended for the employer payment. Instead, please follow the steps below.

 FIRST – Advise the caller

Received date

Processed dated

and is going through normal processing.

 IF THE CALLER PERSISTS & it is less than 60 days past due (premium)   – Tell him/her that you will research the item. Send an email to Yolonda Roulette, Twanna Tilghman & cc Jutta Hiley.

After sending the email, advise the caller that you have

escalated the item and you have requested the claims review be expedited. Please use these EXACT WORDS.

 IF THEY CALL BACK LATER AND THE CLAIM IS STILL PENDING & THE PREMIUM PAYMENT IS PAST DUE GREATER THAN 90 DAYS– Advise the caller that you will research again. Mark the email as 2^nd inquiry Yolonda Roulette, Twanna & cc Jutta Hiley.

Get the caller’s phone number and advise that we will call them back within two business days. Your supervisor and/or Account Management will tell you what to say when you call back.

 **Please follow the above instructions provided the Paid To Date is LESS than 60 days past due. IF greater than 90 days past due please send email to

 Please send Urgent email 3^rd notice
Twanna Tilghman, Yolonda Roulette and CC Jutta Hiley

 Subject Line: 3^rd notice P000xxxxxx---Full Sponsor Name---Tricare

Corporation Name

(Check Corp Manual for special instructions, such as Mantech or General Dynamics)

Paid to Date

List Bill

 YOU CAN ADVISE WE ARE WAITING ON PREMIUM TO POST WHEN THE PREMIUM IS 90 + DAYS PAST DUE.

Keep in mind, most of the polices are Corporate List Bill, the rule is CORPORATE POLICIES DO NOT LAPSE. 

The insured is pre-tax payroll deducted and has already paid for the premium. Therefore, we never say we did not get the premium nor do we say the policies is not paid. 

Set clear expectations with the EE we are working with our billing team to have the premium posted, once that happens we will process the claims. 

Please encourage the customer to go the doctor, send in all claims and reassure the customer all claims will be processed. 

If direct bill do not send to above mentioned email. 

Please explain to the insured the policy is direct bill, past due, we need premium to be caught up in order to process claims on file.

 We can take a credit card payment over the phone.

***THE POLICY CAN NOT BE IN A TERMINATED STATUS***

1. There is a one - time 3% fee, separate from the premium.
2. We can NOT process credit card payment if todays date is 28th, 29th, 30th or 31^st.
3. Explain to the insured to wait until the 1^st and they can process the payment online, with a CSR or mail the payment. Making a payment with us over the phone will have a one time 3% fee.  

If you come across a claim in emerge with a status of “R” without any date of service (there is usually and acknowledgment letter sent to insured), take the claim number and put in imaging. That would bring up the original claim form with the dos tied to the claim that is showing status of “R”. Once you place that dos in emerge it would bring up a different claim number. Below is an example:

Allen Lacey 430402 2016112102113.00 with status of “R” in emerge. Once you place that claim number in emerge it will bring up the original claim with the dos!