DESCRIPTION OF THE ISSUE
Most of the claims under Optimum healthcare were in outstanding for correct TIN# information. Upon verification we found Dr. to be capitated under IPA which included both Optimum and Freedom healthcare plans as PCP with another TIN#. Hence the claims were unpaid for submission of correct TIN#
CONCEPT
Dr. being a specialist had dual TIN#, one for PCP and the other for Specialty. IPA have enrollment record of Dr. as a Specialist. So upon filing of claims with PCP TIN# got denied for request of correct TIN#.
SOLUTION
On identification of this issue, we started resubmitting the unpaid claims with appropriate TIN# on records of IPA for Dr.. This in return reflected with the Capitated payments for the provider.
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