Overview
Some plans administered by Yuzu offer a Coordinated Care benefit tier, which provides members with reduced cost sharing when they receive care arranged through Yuzu or their plan's care navigation team.
Coordinated care generally involves helping a member find a provider, schedule services, and, in some cases, negotiate a price before receiving care.
The key difference between coordinated and uncoordinated care is how the member's benefits are applied.
Coordinated care: Care arranged through the appropriate navigation process. These claims may qualify for lower cost sharing, often $0, depending on the plan.
Uncoordinated care: Care that the member arranges independently without going through care navigation. These claims generally follow the plan's standard in-network or out-of-network benefits.
How Yuzu Identifies a Coordinated Claim
A claim is not processed as coordinated based on the provider's billing alone. Yuzu applies the Coordinated Care tier when one of the following is on file:
Care event: A Set Tier care event covers the member, provider, and dates of service. This is the most common method for provider-submitted claims. See Care Events.
Direct contract or preferred provider: The provider is on a directly contracted roster that is mapped to the coordinated tier. See Direct Contracts.
Member-submitted claim: The member marked the claim as coordinated care when uploading it. See Claim Reimbursements.
If Yuzu cannot identify the claim as coordinated, it may be processed under the standard benefit tier, even if the member originally arranged the care through navigation.
How Coordination Affects Member Cost Share
The benefit tier assigned to a claim determines how the member's deductible, copay, and coinsurance apply.
Coordinated | Uncoordinated | |
|---|---|---|
Benefit tier | Coordinated Care | Standard INN or OON |
Deductible | Often waived, depending on plan | Generally applies according to plan |
Member cost share | Often $0 or reduced | Standard deductible, copay, or coinsurance |
Accumulators | Based on applicable member cost share | Based on applicable member cost share |
Reprocessing a Claim as Coordinated
If care was coordinated but the claim was processed as uncoordinated, the claim can be reprocessed after the coordination is recorded:
Confirm coordination: Reach out to the care navigation team or Plan Designer to verify that the member's care qualified as coordinated.
Verify the care event: Check whether an appropriate care event exists for the member, provider, and dates of service.
Create or update the care event: If necessary, have the appropriate team create or update the event so the claim can be recognized as coordinated.
Request reprocessing: Open a case on the claim requesting that it be reprocessed under the correct benefit tier.
Include the following in the case:
Claim number
Provider name, TIN, and NPI
Dates of service
Confirmation from the care navigator or Plan Designer that the care was coordinated
The agreed price, if one was negotiated
See Reprocess Requests for general reprocessing guidelines.
Negotiated or Direct Prices
When a price was agreed with the provider in advance, Yuzu can record it in one of two ways:
Care event rate: A Reprice Claims care event sets the rate for that provider and date range, as a percentage of Medicare or a percentage of billed charges.
Direct contract: The contracted rate is loaded for the provider and applied to all qualifying claims.
On the claim and EOB, the negotiated price appears as the allowed amount. The member's cost share is calculated from that amount. Without a negotiated price on file, the claim is priced by the network or the plan's maximum allowable amount.
How Coordinated Care Affects Accumulators
Coordinated claims follow the deductible and out-of-pocket rules configured for the member's plan. If the Coordinated Care tier has $0 member cost share and the deductible is waived, the member generally has no amount applied toward their deductible or out-of-pocket maximum for that service. If the plan requires a copay, coinsurance, or deductible, those amounts are applied according to the plan's accumulator rules.
Important: HSA-eligible high-deductible health plans have additional requirements. Certain non-preventive services generally cannot be covered before the applicable minimum deductible has been met, even when care is coordinated.
Emergency and Urgent Care
Emergency and urgent services are generally not coordinated in advance.
Emergency care: Qualifying emergency services are generally subject to in-network cost-sharing protections under the No Surprises Act, even when provided out of network. This does not automatically make the services coordinated. See How Claims Are Assigned Benefit Categories.
Urgent care: Generally follows the applicable standard benefit tier unless coordination or a specific plan rule applies.
Follow-up care: Care navigation may coordinate subsequent services, such as specialist visits or hospital transfers. Appropriate care events can be created for qualifying services.