Benefits & Services Services

Any covered individual who reviews eligible medical expenses and discovers an overcharge made by the medical facility or practitioner may provide TML Health/Group Benefits Administrator with a copy of the original billing, corrected billing, and an explanation. The covered individual will be reimbursed 30% of the amount of savings generated. The reimbursement may not exceed the covered individual’s calendar year deductible and out of pocket amount. To assist the covered individual with claim cost management, a Claim Audit Tool may be found in the Member Rights & Responsibilities Guide.

Appeals

TML Health’s Patient Advocacy Program is available to assist covered individuals in managing their out of pocket expenses.

TML Health has a software program that identifies duplicate billings at the line level of a claim. This automated process occurs before an analyst receives the claim. Therefore, a providerbilling duplicate is identified electronically and the error rate is decreased. Manual post duplicate audits are conducted to ensure duplicate payments are minimized.

Claim audits are conducted when claim costs are considered to be in excess of usual and customary for the same services, in the same locality, under similar conditions. The Claim Liaison Audit is designed to verify the legitimacy of charges, treatments, procedures, and confinements on any and all claims. The audit identifies documentation discrepancies and provides an extensive analysis and documentation of the quantity, nature and intensity of services billed, severity of illness, and unidentified and experimental therapies. An extensive clinical review using InterQual criteria to document quantity and quality of service measurements is conducted. The multi-page objective clinical review form has been designed to document inconsistencies in records and treatment protocols. Each physician and hospital bill is subjected to our Claims Edit System for unbundling and upcoding determination during the claim process.

TML Health audits all claims in excess of $30,000.

An external claim audit is conducted on non-network per diem hospital claims in excess of $20,000 paid and all network non-case rate outpatient surgery claims in excess of $15,000 paid. Secondary Network claims in excess of $15,000 paid will be referred for external audit.

TML Health maintains software programs that pre-screen network claims and pre/post screen out of network claims. The electronic screening audit assists in identifying provider billing procedures. Claims that pass the audits are sent for adjudication; claims that are identified as problematic are sent for review and adjudication.

A usual, reasonable and customary charge is deemed to be 110% of the amount prescribed by the Centers for Medicare and Medicaid Services (CMS), RBRVS, other specialty CMS fee schedules, and the Ingenix Essential RBRVS Fee Schedule.

Employee Benefit Research Institute: A New Twist on the Defined Contribution Concept in Employment-Based Health Benefits.

This analysis examines reference pricing, a form of defined contribution health benefits, where plan sponsors pay a fixed amount or limit their contributions toward the cost of a specific healthcare service, and health plan Members must pay the difference in price if a more costly healthcare provider or service is selected.

A Prompt Pay Tracking report tracks claims and related documentation belonging to the Prompt Pay provider. This tracking report is programmed utilizing the Tax ID numbers associated with that provider and accounts for noncompleted claims processing activity, as well as claims denied for additional information. Claims denied for additional information may require different tracking rules depending upon from whom the additional information is being requested.

Management or designated staff are responsible to review the report daily for claims or claim referrals. Customer Care staff will focus on claims denied for additional information and will pro-actively contact covered individuals and providers to expedite receipt of the requested additional information.

On October 1, 2006, TML Health changed the provider network to UnitedHealthcare Options PPO. The purpose of this change was to achieve more cost-effective healthcare treatment. TML Health’s Board of Trustees made the decision to enter into a long-term agreement with United Medical Resources (UMR), a wholly owned subsidiary of UnitedHealthcare.

On September 1, 2011, TML Health transitioned from the UnitedHealthcare Options PPO network to the UnitedHealthcare Choice Plus Network, except for select Employer Members in East Texas. In January 2013, TML Health transitioned all Pool Members to the Choice Plus Network. Effective January 1, 2016, TML Health will upgrade the Choice Plus Network with Premium Care Physician performance based outcome providers with appropriate network steerage plan design.

The Alliance will promote comprehensive and cost-efficient health benefit programs for political subdivisions in the state of Texas and other states. The management support and systems flexibility provided by UMR will allow for UnitedHealthcare owned systems to manage the network and claims adjudication process efficiently.

In addition, the UnitedHealthcare Choice Plus premium doctor identification provides monetized value driver performance based outcome information.

Services provided by a non-network provider are paid at the lower benefit percentage level and are subject to a separate calendar year deductible. Reasonable and customary limits are utilized in determining maximum allowable charges. If the provider is billing in excess of the designated reasonable and customary limit, the covered employee or dependent will be responsible to pay the amount over the usual and customary amount. The covered individual will always be responsible for a portion of the bill. The network and nonnetwork deductibles do not accumulate toward each other.

The PPN plan has physicians and facilities outside of Texas through the UnitedHealthcare Choice Plus Network. If a covered individual requires immediate care at a non-network provider, the Plan will pay eligible benefits at the benefit percentage referenced on the Medical Summary of Benefits and Coverage subject to the network deductible and network out of pocket. Treatment or services provided outside the United States or its territories, unless required for immediate care, are excluded.

The TML Health medical plan provides for emergency and immediate care situations. Eligible charges that are medically considered emergent or immediate care will be subject to the network deductible and reimbursed at the network benefit percentage up to the usual, reasonable and customary amount for the emergent or immediate eligible services.

The Morbid Obesity treatment must be performed at a Plan- Designated Morbid Obesity Treatment Center. The transplant must be performed at a hospital or facility designated by the Plan as a Transplant Center. A list of designated Centers of Excellence may be obtained from Multidisciplinary Medical Care Management. Center of Excellence providers must be network providers with UnitedHealthcare Choice Plus network.

Out of network claims are repriced if out of network providers participate in the Multi-Plan Supplemental Network. The discount amount will not be balance billed to the covered individual and the claim will be adjudicated at the out of network benefit percentage. The secondary network option has increased to the provision of two secondary networks, professional negotiations and patient advocacy services, and a billing audit function.

TML Health is an experienced administrator managing stop loss and is pre-approved with most major stop loss carriers. Monthly tracking reports are generated from the integrated billing, eligibility, and claims administration system.

TML Health provides administrative support services to PEBA. Due to this administrative extension, TML Health’s Membership is not required to pay the PEBA participation or proposal fees, but maintains access to PEBA benefits.