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Automated Voice Response Eligibility Verification Subsystem Call Flow Manual


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Section 5 - Provider Remittance Verification

STEP 26.0 – Remittance Information For Provider


After the user presses 4 on the Main Menu, the system will respond with number of occurrences of remittance data, the remittance date and remittance amount for the provider. The user has up to 3 remittance dates and amounts. The system will respond:

“The remittance on (RA-DATE) was for amount of (RA-AMT).

If no remittance advice payment information is available for the provider, the system informs the user:

“For provider number (PROVIDER-NUMBER), no remittance is found.”

The system then proceeds to Step 2.0 for the Eligibility Main Menu.

Section 6 - Claim Status Verification

STEP 27.0 – Claim status Options


To obtain the claim status information, the user has two options. The user can enter a ICN (Internal Control Number), TCN, or enter the Medicaid Member number, dates of service, and billed amount. The system then continues with step 28.0.

STEP 28.0 – Claim Status Inquiry Menu


Once the user enters a 5 to select the option claim status portion, the system will give the user options as follows:

“Please select one of the following options followed by the pound sign.”

“For inquiring on an ICN or TCN, press 1. If you do not have an ICN or TCN, press 2. To return to the Main Menu, press *99. For assistance from a Customer Service Representative press 0.”

If the user presses 1, the system will continue the call flow at step 29.0. If the user presses 2, the system will continue the call flow at step 32.0. If the user presses *99, the system resumes the call flow at Step 2.0. If the user presses 0, the call is transferred to a Customer Service Representative.


STEP 29.0 – Claim Status Inquiry By ICN or TCN


After the user enters a 1, the system will prompt the user for an ICN or TCN as follows:

“Please enter your thirteen digit ICN or seventeen digit TCN followed by the pound sign.”

The system edits the ICN for thirteen numeric digits or the TCN for seventeen numeric digits . If the user entered a ICN in an invalid format, the system replies:

“Invalid ICN or TCN number (ICN). Please re-enter.”

If the user enters less than thirteen digits for the ICN number, the user will be prompted with the following message:

“That entry is not valid. Please re-enter your thirteen digit ICN number or seventeen digit TCN number.”

After the third attempt, if the user enters an invalid ICN number, the following message will be prompted:

“Invalid ICN or TCN number (ICN). Please contact Customer Service provider services if you need further operating assistance. Thank you for calling the Kentucky Voice Response System.”

Once the user enters a valid ICN , the system resumes the call flow at Step 29.5.

STEP 29.5 – Claim Status Host Transaction


Since the claim status information resides at the host, the system sends a transaction to the host to request claim status information. In some cases, there may be a slight delay while the system waits for the information to return from the host, so the system informs the user with the message:

“Please wait while the requested information is retrieved.”

When the system receives a reply from he host, it examines the response code to determine what message to speak to the user concerning the claims status. If the claim is not found, the system will continue at step 30.0. If the claim is found, the system continues at step 31.0

STEP 30.0 – ICN Not Found


If a ICNmatch is not found, the system will respond as follows:

“ICN (ICN) is not on file for provider.”

If a TCN match is not found, the system will respond as follows:

“TCN (TCN) is not on file for provider.”

The system continues the call flow at Step 31.5 for Claim Continue Menu.

STEP 31.0 – ICN Status


If the ICN or TCN entered has a valid status code, the following message is spoken, otherwise the call flow is continued at Step 31.2 for Further Assistance.

“ICN (ICN) …”

-OR-

“TCN (TCN) …”



If the valid status code is S, R, L, I, or X, the following message is spoken.

…this claim is currently processing as of (CURRENT_SYS_DATE).

If the valid status code is P and an RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount). Paid for amount of (PaidAmount) on RA Date (RADate).

If the valid status code is P and no RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount). Paid for amount of (PaidAmount).

If the valid status code is D and an RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount) has been denied on RA Date (RADate).

If the valid status code is D and no RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount) has been denied.

The system continues the call flow at Step 31.5 for Claim Continue Menu.

STEP 31.2 – Claim Further Assistance


If the claim status is not on this list above, the system will respond with the following message:

“This claim requires further assistance. For assistance for a Customer Service Representative, press 0. To continue, press 2.”

If the user presses 0, the call is transferred to a Customer Service Representative. If the user presses 2, the system resumes the call flow at Step 31.5. After the first time-out, the caller is disconnected with the hang-up message.

If the call is after provider representative hours, then the following message is spoken:

“We’re sorry, our office is closed. We are open from 8AM to 6PM except weekend and holidays. Please call back and we’ll be happy to assist you. Thank you for calling the Kentucky Voice Response system.”

If the user presses 2, the system resumes the call flow at Step 31.5. After the first time-out, the caller is disconnected with the hang-up message.


STEP 31.5 - Claim Continue Menu


At this point the system has completed the claim status information. The user may now do another claim status or return to the Main Menu. The system prompts the user accordingly.

“To inquire on another claim status, press 5. To return to the Main Menu, press star 99. For assistance from a Customer Service Representative, press 0. If this concludes your call, you may hang up.”

If the user presses 5, the system resumes the call flow at Step 27.0. If the user presses *99, the system resumes the call flow at Step 2.0. If the user presses 0, the call is transferred to a Customer Service Representative.

STEP 32.0 - Claim Status Inquiry By MAID


If the provider presses 2, the system will prompt the user for a Member identification number as follows:

“Please enter the ten-digit Medicaid member ID number followed by the pound sign.”

The system edits the Member number for ten numeric digits. If the user entered a Member number in an invalid format, the system replies:

“Member number (MEMBER-ID). That entry is not valid. Please enter the ten-digit Medicaid member ID number followed by the pound sign.”

Once the user enters a valid Member number, the system continues the call flow at step 32.5.

STEP 32.5 – From DOS For Claim


When the system receives a correctly formatted Member identification number, it prompts the user for a From date-of-service.

“Please enter the eight digit from date-of-service in month, day, century, year format followed by the pound sign, or enter a pound sign only for today's date.”

The user must enter the From date-of-service in a MMDDCCYY format followed by pound sign. The system edits the date to ensure it is in the correct format and is a valid, non-future date. If the From date-of-service is not valid, the system informs the user:

“That date is not valid. For example, July 01, 1995 would be entered as zero seven, zero one, nineteen, ninety-five. Please enter the eight digit from date-of-service in month, day, century, year format.”

If the From date-of-service is a future date the system informs the user:

“We are unable to process dates beyond (CURRENT-DATE-365). Please enter the eight digit From date-of-service in month, day, century, year format.”

Once the user enters a valid From date-of-service or presses only the pound sign the system call flow resumes at Step 33.0

STEP 33.0 – To DOS For Claim


When the system receives a correctly formatted From date-of-service, it prompts the user for a to-date-of-service:

“Please enter the eight digit TO date-of-service in a month, day, century, year format followed by the pound sign or enter a pound sign only if the To date of service is the same as the FROM date of service.”

The user must enter the To date-of-service in MMDDCCYY format followed by a pound sign. The system edits the date to ensure it is in the correct format, greater than or equal to the From date-of-service, and is a valid, non-future date. If the To date-of-service is not a valid date, the system informs the user:

“That date is not valid. For example, July 01, 1995 would be entered as zero seven, zero one, nineteen, ninety-five. Please enter the eight digits to date-of-service in month, day, century, year format.”

If the To date-of-service is a future date the system informs the user:

“We are unable to process dates beyond (CURRENT-DATE-365). Please enter the eight digit To date-of-service in month, day, century, year format.”

Once the user enters a valid To date-of-service or presses only the pound sign, the system continues the call flow at step 35.0.

STEP 35.0 – Claim Billed Amount


Once the system verifies the provider number, it then prompts the user to enter a billed amount as follows:

“Please enter the billed amount for Member followed by the pound sign.”

After the user enters a billed amount in the correct format, the system continues the call flow Step 35.5.

STEP 35.5 – Claim Host Transaction


Since the claim status information resides at the host, the system sends a transaction to the host to request claim, status information. In some cases , there may be a slight delay while the system waits for the information to return from the host, so the system informs the user with the message:

“Please wait while the requested information is retrieved.”

When the system receives a reply from the host, it examines the response code to determine what messages to speak to the user concerning the claim status. If the claim is not found, the system will continue at step 37.0. If the claim is found, the system continues at step 36.0.

STEP 36.0 – Valid Claim Status Information


Once a match is found with a valid status code, the following message is spoken:

“For provider number (CLAIM-PROVIDER-NO) and member number (MEMBER-ID), there (was/were) (NUMBER-CLAIMS) claim(s) found.”


STEP 36.1 – Valid Claim Status Code


If the ICN has a valid status code, the following message is spoken, otherwise the call flow is continued at Step 36.2 for Further Assistance.

“For ICN (ICN) …”

-OR-

“For TCN (TCN) …”



If the valid status code is S, R, L, I, or X, the following message is spoken.

…this claim is currently processing as of (CURRENT_SYS_DATE).

If the valid status code is P and an RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount). Paid for amount of (PaidAmount) on RA Date (RADate).

If the valid status code is P and no RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount). Paid for amount of (PaidAmount).

If the valid status code is D and an RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount) has been denied on RA Date (RADate).

If the valid status code is D and no RA Date exists, the following message is spoken.

… and dates of service from (StartDate) through (EndDate) billed for (BilledAmount) has been denied.

The call flow is continued at Step 37.5 for Claim Continue Menu.

STEP 36.2 – Claim Further Assistance


If the claim status is not on the list above, the system will respond with the following message:

“This claim requires further assistance. For assistance from a Customer Service Representative, press 0. To continue, press 2.”

If the user presses 0, the call is transferred to a Customer Service Representative. If the user presses 2, the system resumes the call flow at Step 37.5. After the first time-out, the caller is disconnected with the hang-up message.

STEP 36.5 – Multiple ICN For Same Billed Amount


If a Member is found with more than one ICN with the same billed amount, the system will respond with the following message:

“More claims exist, to hear the next one press 1, followed by the pound sign. To continue, press 2, followed by the pound sign.”

If the user presses 1, the call returns to Step 36.1 with the next claim information. If the user presses 2, the system resumes the call flow at Step 37.5.

STEP 37.0 – No Claims Found


If a match is not found using the Maid number, the system will respond as follows:

“There are no claims found for provider (CLAIM-PROVIDER-NO).

The call flow is continued at Step 37.5 for Claim Continue Menu.

STEP 37.5 – Claim Continue Menu


At this point the system has completed the claim status information. The user may now do another claim status or return to the Main Menu. the system prompts the user accordingly.

“To inquire on another claim status, press 5. To return to the Main Menu, press star 99 . For assistance for a Customer Service Representative, press 0. If this concludes your call you may hang-up.”

If the user presses 2, the system resumes the call flow at Step 27.0. If the user presses *99, the system resumes the call flow at the Step 2.0. If the user presses 0, the call is transferred to a Customer Service Representative.

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