MHS Updates Summer PR.P.PP

Transcription

1 MHS Updates Summer PR.P.PP

2 Updates Important to You Prior Authorization (PA) Updates DME Changes Therapy Authorization Process MHS Prior Authorization 101 Home Health MHS Occurrence Prior Authorization Code Update Hoosier Care Connect Member Transition Member Updates 2

3 Prior Authorization (PA) Updates 3

4 Durable Medical Equipment (DME) and Home Medical Equipment (HME) 6/1/17: non-contracted DME/HME providers require authorization Requested by ordering physician 8/15/17: Medline will be the coordinating DME/HME vendor for MHS Providers initiate all DME/HME needs directly through MHS secure portal which feeds feed into the Medline portal 4

5 How Will This Affect Providers? Provider will initiate all DME/HME orders at MHS Items/services requiring authorization will continue with the current process All authorization requests sent directly to MHS Refer to quick reference guide (QRG) Medicaid pre-auth tool Does not apply to Hospital DME/HME vendors or items provided within the provider office/facility (boots, slings, etc). 5

6 Therapy Services - (Speech, Occupational, Physical Therapy) Therapy Services do not require prior authorization for 8 visits or less If additional visits are needed after 8 visits, prior authorizations will be required and should include the following: Physician order Signed plan of care Diagnosis Treatment goals Defined progress to goals Number of visits the member has attended Why the member cannot graduate to a home treatment program Requested visits Milliman Care Guidelines used to determine medical necessity 6

7 Medical Necessity Denial and Appeal Process If MHS denies the requested service: MHS Medical Management will notify the provider verbally within one business day of the denial, provide the clinical rationale, and explain appeal rights A formal letter of denial explaining denial rationale and appeal rights will be mailed to the member and the requesting provider within 3 days If denial is based on Milliman Care Guidelines, provider has the right to obtain a copy of the guidelines upon which the denial is based 7

8 Medical Necessity Denial and Appeal Process If MHS denies the requested service: If member is still receiving services, the provider has the right to an expedited appeal, which must be requested by the attending physician If the member has already been discharged, an appeal must be submitted in writing from the attending physician within 33 days of the denial The attending physician has the right to a peer-to-peer discussion with an MHS physician Peer-to-peer discussions and expedited appeals are initiated by calling an MHS Appeals Coordinator at * Prior authorization appeals are also known as medical necessity appeals 8

9 PA Denial and Appeal Process Send Prior Authorization (PA) /Medical Necessity Appeals to: Managed Health Services Attn: Appeals Coordinator 1099 North Meridian Street, Suite 400 Indianapolis, IN Appeals must be initiated within 33 days of the receipt of the denial letter to be considered Determination will be communicated to the provider within 20 business days of receipt A PA appeal is different than a claim appeal request Applicable to members and non-contracted providers as well 9

10 Home Health 10

11 Home Health Occurrence code changes effective for dates of services on or after 2/13/2017: 61 is now replaced with code 73 which allows provider to be reimbursed for overhead 50 is now replaced with code 42 (PA within the first 30 days after hospital discharge) Prior authorization is always required for home health services except for first 30 days of hospital discharge Please refer to BT for additional information 11

12 Hoosier Care Connect Transition 12

13 Hoosier Care Connect Member Transition Effective 4/1/2017, MDwise members have been transitioned to either MHS or Anthem Members have until 8/1/2017 to make a change to a Managed Care Entity (MCE) Members can change their MCE by calling the Hoosier Care Connect Hotline at

14 Member Update 14

15 POWER Up to HIP Plus Encourage HIP members to join HIP Plus Enhanced benefit package No copays! Only pay a monthly contribution Dental coverage Vision coverage Additional therapy services Rx mail order option Chiropractic care When can members POWER Up? Open enrollment Redetermination Contact MHS Customer Service to POWER Up to HIP Plus

16 HIP 2.0: Plan Options HIP Plus Initial plan selection for all members Benefits: Comprehensive, including vision and dental Cost sharing: Must pay affordable monthly POWER account contribution: Approximately 2% of member income, ranging from $1 to $100 per month No copayment for services* HIP Basic Fall-back option for members with household income less than or equal to100% FPL only Benefits: Meet minimum coverage standards, no vision or dental coverage Cost sharing: May not pay one affordable monthly POWER account contribution Must pay copayment for doctor visits, hospital stays, and prescriptions HIP State Plan Individuals who qualify for additional benefits Benefits: Comprehensive, with some additional benefits including vision and dental Cost sharing: HIP Plus OR HIP Basic cost sharing HIP Link To help member pay for employer-sponsored health insurance The employer will deduct the cost of premiums charged from the employee s pay and the State will reimburse the employee directly for the deduction, minus the 2% contribution *EXCEPTION: Using Emergency Room for routine medical care 16

17 CentAccount Member Incentive Program to promote healthy behaviors and encourage preventive health Members complete certain preventive health exams and Health Needs Screenings Once a claim is billed to MHS, reward dollars are accumulated on CentAccount card Members can use their rewards card to purchase items at local stores or pay HIP POWER Account contributions 17

18 How Can MHS Members Earn Rewards? Submitting a completed Health Needs Screening within 30 or 90 days of becoming a member Completing an annual well care visit with a primary care doctor. (One per calendar year; age 16 months old and up) Completing infant well care visits with primary care doctor up to 15 months old. These visits are recommended at 3-5 days old, before 30 days old and at 2, 4, 6, 9, 12 and 15 months old For enrolling in the smoking cessation program with the Indiana Tobacco Quitline. Call QUIT NOW ( ) Pregnancy rewards are also available. To be eligible for these rewards, a member must notify MHS they are pregnant by submitting a completed Notification of Pregnancy (NOP) form or calling. Once we are notified of their pregnancy, rewards information will be provided. 18

19 Pursuant Health Kiosks Starting 6/1/17 partnering with Pursuant Health New kiosk located in participating Walmart stores Complete new member Health Needs Screens at kiosk Benefits loaded to card immediately Use in store to buy personal care items 19

20 Envolve Dental Effective 1/1/2017, all dental claims should be billed to: Envolve Dental Claims: IN PO Box Tampa, FL Envolve Dental Provider Services: Candy Ervin, Envolve Dental Indiana Provider Relations Specialist Market Manager: 20

21 Behavioral Health Provider Network 21

22 Physical Health Provider Network 22

23 Wrap Up Prior Authorization (PA) Updates DME Changes Therapy Authorization Process MHS Prior Authorization 101 Home Health MHS Occurrence Prior Authorization Code Update Hoosier Care Connect Member Transition Member Updates 23

24 Round Table & Questions Thank you for being our partner in care. 24