A participation review determines if a provider has a contract with the payor. A claim appeal typically deals with a dispute on how the claim was processed. A rate code issue focuses on verification of the correct fee schedule and allowable from the provider. Balance billing addresses improper application of the network rates; it can also bring to light a provider’s practice of improperly billing the difference between the network rate and the billed charge to a member. Coordination of benefits occurs when GEHA is the secondary payor. Claim overpayment issues arise when GEHA needs assistance from the network in recovering a claim refund from the provider. And OPM issues typically occur when a member has contacted the federal government.

The department receives a variety of issues on a daily basis; the last count showed a total of 1,659 issues for this year to date. We usually receive from 185 to 200 issues per month. The key is to resolve these issues in a timely manner, and this department resolves payor issues at a rate of 95 percent or less in three business days. Quite impressive!