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The Provider Services Voice Response Unit (VRU) is intended to be a self-service tool that lets you find the information you need – when you need it – without waiting to talk to someone. This mission is accomplished most of the time, but not always. Here is a list of the most common reasons why providers call, plus additional helpful information.

Tired of Waiting on Hold?

The average wait time to speak to one of our provider services representatives was over nine minutes in a recent month. Using STATchatSM, our web-based phone call feature in My Insurance ManagerSM, the average wait time was just 25 seconds! Why wait on hold when you don't have to? It's an easy call to make!  

Top Provider Call Reasons

Eligibility and Benefits (243,701 calls)

The vast majority of calls to the VRU are to determine eligibility and benefits for a patient. These are automated calls that do not require speaking to a provider services representative. We provide benefits through our VRU, My Insurance Manager, as well as through the HIPAA Eligibility (270/271) transaction through your clearinghouse or vendor. These automated processes allow you to get the answers you need when you need them, greatly reducing the amount of time you have to spend on the phone.

Tip: When using the VRU, choose the option to have the benefits faxed to you. You will spend less time listening on the phone and have a record of the call that you can insert into the patient's medical records for future reference.

Claims Status for Resolved Claims (44,495 calls)

These calls are also automated self-service calls about claims that have either paid or rejected. Besides the VRU, you can also use My Insurance Manager or the HIPAA Claims Status (276/277) transaction.

Tip: Use My Insurance Manager to find a list of all of a patient's claims at one time with a single search. If you have a claim number, you can pull up a specific claim by entering just that number. If you have a question about a claim online, simply choose "Ask Provider Services" and either send us a question in writing or click on STATchat to be make an online call that will put you first in line for the next representative.

Professional Medical Benefits (24,082 calls)

Of the 14 benefit summaries available through the VRU, the most common request is for professional medical benefits. This includes coverage information for professional office visits, specialist visits, consultations, diagnostic services, office surgery and physician visits to the hospital.

Deductible Explanation (13,467 calls)

Unlike the previous three, this call is handled by a Provider Services representative. For every benefit summary chosen, deductible and out-of-pocket amounts are included. This includes the limits and the amounts met for an individual patient and family. In general, if the individual has met his or her deductible limit, the family amounts do not matter. If there are no individual amounts, then the family amounts take precedence.

Benefits Question (12,706 calls)

At certain times, it is necessary to speak to a provider services representative to determine benefits. Why? For one reason, you may need benefits that aren't included in our summaries. The summaries are built to provide benefits for the most requested services. You can use My Insurance Manager to determine benefits for a patient using specific procedure and diagnosis codes. This can be very important in determining specific benefits. For example, some groups choose to not cover certain diagnoses, such as anything related to obesity. Also, some procedures could either be considered investigational or the group has decided to not cover certain procedures, such as infertility treatments.

Transfer to the Prior Authorization VRU (9,917 calls)

 The VRU will automatically transfer you to the appropriate precertification area when you choose this option. Some ID cards do not have the direct number to the prior authorization area, but you can always call the provider services VRU and select the prior authorization option.

Tip: You can get prior authorization in My Insurance Manager. 

Date of Birth Not Valid or Not Found (8,809 calls)

You will hear a message when you type in a date of birth that does not match what we have on file for your patient. The VRU first asks for the member ID, then validates it. Next, to identify the specific patient under that member ID, it asks for your patient's date of birth. If we can not find that specific patient, you will hear the message indicating so.

Tip: Contact the patient to determine if you have the correct date of birth. If you don't, please correct it in your records and call again. If your records match the patient's true date of birth, please have the member contact us by calling the number on his or her ID card.

Professional Surgery and Anesthesia Benefits (8,341 calls)

Of the 14 benefit summaries available through the VRU, the second most common request is for professional surgery and anesthesia benefits. This includes coverage information for professional office, inpatient and outpatient services.

Benefits Requested – Available in VRU (3,281 calls)

This type of call indicates the provider has opted out to speak to a representative to determine a benefit while the benefits are available in the automated benefits summary options. We encourage you to use the automated eligibility and benefits menu option in the VRU, My Insurance Manager or the HIPAA Eligibility (270/271) option whenever possible. The benefit to using the automated VRU response is that you can receive it immediately – either by voice or fax – rather than waiting for the next available representative. The information you get through the VRU will be the same as what you get by speaking to a Provider Services representative, without the wait!

Claims Filing Address (2,471 calls)

We encourage you to file claims electronically for the fastest processing. You can file electronically through your clearinghouse or vendor, or file the claim online in My Insurance Manager, a secure and free method of filing claims. You can use My Insurance Manager to file claims even if you normally use a clearinghouse or vendor. 
 

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