SOP Insurance Discovery 5-19-2023.docx

662-23-3-5075-0026 Insurance Discovery Service Standard Operating Procedure January 6, 2023

San Francisco VA Health Care System San Francisco, CA Signatory Authority:

Rodney Collins, Chief, Business Service Responsible Owner:

Maria Lea Quiane, Chief, Clinical Command Center Service Line(s):

Business; Clinical Command Effective Date:

5/19/2023 Recertification Date:

1/31/2025

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on appropriate use of Insurance Discovery Service contract. This SOP must be followed by VA staff and contracts who support patient flow, i.e., Clinical Command Center, Social Work, Member Services, etc.

b. This SOP sets forth mandatory procedures and processes to ensure all Services understand their role and ensure Contractor does not bill beneficiaries for VA approved/rendered services. There is no governing document.

2. PROCEDURES

a. Beneficiary is admitted to San Francisco VA Medical Center, i.e., planned or unplanned admission.

b. Clinical Command Center staff contact Contractor with patient identifiable information/patient health information.

c. Contractor conducts insurance discovery research to identify payer sources, i.e., active, inactive, underinsured. Contractor must return findings to Clinical Command Center within 24 hours of request.

(1) If beneficiary is found not to have any valid payer sources, Contractor shall initiate application process with the beneficiary for any potential sources. Contractor may be required to meet bedside, in-person with the beneficiary. Contractor shall provide completed applications to assigned Social Worker for submission on behalf of the beneficiary.

d. Clinical Command Center shares confirmed payer sources with Social Work and Enrollment/Eligibility staff.

e. Social Work staff will initiate placement in the Community.

f. Enrollment and eligibility will update patient record, updating the Consolidated Patient Accounts Center.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Clinical Command Center staff shall initiate request for insurance discovery service. The CCC staff will provide patient identifiable information/patient health information to Contractor to initiate search and identification of insured, uninsured or under-insured beneficiaries. Clinical Command Center staff shall provide payer source information to Social Work to facilitate coordination of placement in the community.

b. Business Service

(1) Enrollment/Eligibility staff shall enter payer source information into the patient’s record, updating the Consolidated Patient Accounts Center.

(2) Contract Officer’s Representative shall provide contract support to stakeholders.

c. Contractor’s primary function is to provide insurance discovery and data collection from Veteran. Contractor is prohibited from taking any action toward insurance billing, billing decision process or billing identified insurances for beneficiary services authorized/rendered, on behalf of VA. Contractor shall provide the following:

(1) Status of beneficiary active/inactive/eligible payer sources within one (1) business day.

(2) Meet bedside with beneficiary to complete required forms and submit completed forms to Social Work.

4. DEFINITIONS

a. Admission- Applies to planned or unplanned patient admission.

5. REVIEW AND RECERTIFICATION

Review of SOP by all process stakeholders will be conducted upon the start of the contract and/or option year.

6. SIGNATORY AUTHORITY

Rodney Collins Chief of Business Service Date Approved: Month Day, Year Maria Lea Quiane, RN, MSN, CNL Chief of Clinical Command Center Date Approved: Month Day, Year