2017 South Dakota Day with the Payers

Transcription

1 2017 South Dakota Day with the Payers

2 HealthPartners, Inc. Founded in 1957 as a cooperative Largest consumer-governed non-profit health plan in the country We serve more than 1.5 million medical and dental health plan members nationwide Our care system includes a multispecialty group practice that of more 1,700 physicians and 6 hospitals Mission: To improve health and well-being in partnership with our members, patients and community. Vision: Health as it could be, affordability as it must be, through relationships built on trust.

3 HealthPartners Health Plan Commercial plans 1 million medical members; 600,000 dental members Major/National employers members in all 50 states, mid-size employers, small groups, individual plans, government plans We contract directly in SD, ND, MN, WI, and IA (outside of this area we have an alliance with Cigna to access their network) About 50/50 fully-insured/self-insured 35% of our members receive care within our owned clinics, 65% receive care outside of our owned clinics Open Access, Primary care clinic-based, Tiered Open Access, Accountable Care Organization (ACO) Products The majority of our members in SD are self-insured

4 HealthPartners Health Plan Government Plans Medicare Products MN State Public Programs (PMAP, MNCare, Special Needs Basic Care, MN Senior Health Options) Information on our products for commercial business and government programs is available on our Provider Portal in our Provider Resource Materials. Details in the Provider Resource Materials include: Types of products Network information Referral requirements Member ID card examples

5 HealthPartners Member ID Card Examples: Primary Clinic Plan Card: HealthPartners Peak Card: HealthPartners Achieve Card: Members can access their ID card on their smartphone and fax to you

6 Network Management Each provider organization has a Manager and Service Specialist at HealthPartners Service Specialists can handle day to day issues like claims payment, policy questions, etc. Managers can work with your groups on contract issues rate discussions If you re not sure who your Manager or Service Specialist is, please call Elise at

7 Member Services Contact with questions about benefits, eligibility and medical policies. Hours: 7 a.m. 5 p.m., Central time. Phone: ; Toll Free: Fax:

8 Claims Customer Service Contact with questions related to claims payment, why an authorization was requested or needed and general coding questions (not how to bill). Phone: ; Toll free: Fax:

9 Provider Training Manual An online training manual that includes Administrative and Claims Policies Information

10 How do I sign up for access to the portal? Go to

11 Registration

12 Ways to Register Register with Vendor # or Tax ID/NPI if a check has already been issued. PIN Validation used (when registering with US Mail) if no check available The first person to register will become the delegate. If your organization is already registered, you will need to speak with the delegate for your organization to gain access. Your specific clinic may not be listed because this application is based on your remit/billing office name and not your clinic name. Questions on portal registration or technical issues? Call: or

13 Homepage Credentialing & enrollment Information related to credentialing Provider forms Claim attachments and appeals Medical Administration forms Prior Authorization forms Pharmacy forms EDI Electronic Transactions e-services and resources

14 Applications Remittance Inquiry Eligibility Inquiry Claim Estimator Claim Status Inquiry Prior Auth Request

15 Remittance Inquiry Check/EFT # Use to look up specific claim data corresponding to a remittance check Provider info Use to view all claims paid within set date range Claim # Use if you have the claim number in question

16 Eligibility Inquiry Member # Use if Member # known Member name Must have full name and DOB Social Security # Use if known

17 Claim Estimator Allows you to calculate real time claim payment estimations based on the information available when the request is processed.* You will need to click the button to continue onto the next screen. *Estimates are not a guarantee of payment or coverage.

18 Claim Status Inquiry Allows you to check the status of the claims that have been submitted to HealthPartners

19 Prior Authorization Process and Guidelines Clicking on Request prior authorization will take you to a screen that will walk you through filling out all applicable information.

20 Prior Authorization Process and Guidelines Prior Authorization process can be found under Administrative policies The page will pull up an alphabetical list of HealthPartners admin policies. This document will go into more detail about the review process

21 How do I submit a claim? From the Provider Portal main screen, hover over the e- services tab and click on Claims submissions. This page includes information on Clearinghouses and Payer IDs Electronic claim submission is our preferred method, but in the rare instance a paper claim needs to be submitted, it can be done so to the following address: HealthPartners Claims P.O. Box 1289 Minneapolis, MN

22 Quick claim submission guide Other useful documents for claims submission can be found under Tools and Forms, and Policies

23 Coverage criteria policies HP Coverage policies can be found under the Admin tools tab

24 Credentialing Newly Contracted Provider: Submit a completed Initial Credentialing Application for each practitioner that requires credentialing at least 60 days prior to contract s effective date. Practitioners may not see HealthPartners members until their credentialing has been approved Recredentialed: Re-credentialing occurs every three years. Letters are sent to the practitioner 5 months prior to the credentialing expiration Letters are sent three times prior to terminating the provider if re-credentialing does not occur Committee Approval Process: 8 practitioners with different specialists Meets once a month to review Clean files are presented to a medical director once per week for approval Effective Date Determination: Effective date is the credentialed date. We don t retroactively add practitioners

25 Credentialing Provider Portal providers information on Credentialing including: FAQs Who we credential Credentialing plan Recredentialing Application Credentialing Support HealthPartners Credentialing Information

26 Affordability

27 Affordability Resources Members can: Call Member Services Go to the HealthPartners.com website for cost estimates at the provider level for services Providers can: Use the online Claim Estimator Provide coding info if you receive a call from HealthPartners Member Services

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29 Consumer experience Plan design Transitions in care design Tiered networks ACOs Procedurespecific networks Empower shoppable care Increase consumer engagement Align accountability Consumer-driven innovations

30 ACO Product Tug-of-War Employer: Lower cost! Better value! Minimize disruptions Exchanging open access for cost savings ACO Product Offering Provider: Better value! Keepage! More patientsgrowth! Provider does not want to see same patients at lower price 30

31 Provider/Plan Partnerships, ACOs We developed and implemented several provider/plan partnerships in Minnesota, Wisconsin and Iowa These partnerships generally include shared risk around the cost/trend and quality management of a population Plans that are offered through these partnerships include steerage to the provider partner through benefit design (tiered benefits, closed network, etc.) Commercial and government sponsored plans

32 Thank You for serving our members and your patients.

33 Contact Information Roshelle Badu, Manager Network Management Office: Katy Barto, Contract Consultant Network Management Office: