NCN - "Out of Network" Claim Services

Payors and groups may purchase out-of-network claim services from HealthLink/National Capital PPO. National Care Network provides the services that include savings-based networks, professional fee negotiation services and related services designated to contain costs on non-participating provider claims.

To successfully implement NCN services for out-of-network claims:

• The payor’s ID card should identify that the par and non-par provider claims be routed to HealthLink (EDI #90001) with the standard P.O. Box address in St. Louis. (An NCN logo is not placed on payor-produced ID cards).


• The payor's methodology for U & C (usual and customary cut-backs) should be reported to NCN in order to set the baseline for the savings reports (Examples: 85% HIAA or 80% Ingenix (percentile and source)).


• Verify the payor will pay the NCN claims at the “out of network” benefit tier.


• HealthLink system is set with NCN in the network “hierarchy”. Claims repriced using the HealthLink-NCN services will have specific repricing organization identifiers in the range of 90001 0059 to 90001 0152.


• NCN claims will be sent to the payors in the standard (not a separate) EDI file.


• Payors need to set their system to:
  • Read the special NCN repricing organization identifiers , sending the correct corresponding EOB remark code on their EOBs to providers; or suspend claims received with codes in that range, for manual intervention on the payor's part to enter the specific EOB remarks in the payor's system.
  • If the EOB doesn't reflect the correct NCN repricing comment (method of discounting), providers may not honor the discounts.


• The EOB remark code table is provided to payors with HealthLink-NCN access.


• The EOB remark codes are available in the Outbound EDI Companion Guide.


• In the early phases of this program, HealthLink will suspend the EDI claims, send them to NCN, and enter the claim repricing detail (allowables and NCN codes) into the HealthLink system; like affiliated network repricing. The EDI claim will be identified as “par” by using 12 (PPO) in SBR09 .


• Payors (groups) will be billed for NCN services at a percentage of savings rate of 25% savings, with savings calculated from the baseline U & C. This monthly bill is separate from the access fee billing/payment process.

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