Johns Hopkins HealthCare LLC

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1 Johns Hopkins HealthCare LLC Johns Hopkins Employer Health Programs (EHP) Presented by: by: Johns Hopkins HealthCare Provider Relations Department 11/14/2018

2 Agenda Welcome About JHHC Provider Website Review EHP Overview EHP Updates-New for 2019 Claims and Appeals Submission Referral and Preauthorization Process Additional Information and Resources 2

3 Johns Hopkins HealthCare Welcome: Johns Hopkins HealthCare LLC (JHHC) provides health care services for four health plans: Priority Partners Managed Care Organization, Johns Hopkins Employer Health Programs (EHP), Johns Hopkins US Family Health Plan (USFHP) and Johns Hopkins Advantage MD & Advantage MD Plus. 11/14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

4 Johns Hopkins HealthCare Provider Website: -> For Providers Provider website includes: Provider Manuals Forms portal access Online Provider Directory Find participating providers on Policies & Procedures Compliance Guidance Communications Repository 11/14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

5 Johns Hopkins HealthCare Provider Website: -> For Providers 11/14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

6 Johns Hopkins HealthCare Provider Website: -> For Providers -> Resources & Guidelines 11/14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 6

7 Johns Hopkins HealthCare Provider Website: -> For Providers -> Resources & Guidelines -> Priority Partners -> Outpatient Referral Guidelines ( ) 11/14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

8 Johns Hopkins Employer Health Programs (EHP) Overview As a third-party administrator, Johns Hopkins Employer Health Programs (EHP) provides benefits administration to Johns Hopkins Medicine employers and other strategic partners, serving more than 60,000 members. With 20,000 health care providers and 30 hospitals in Maryland and Southern Pennsylvania, and a nationwide network of nearly 691,000 providers and 3,500 hospitals, EHP self-funded plans are designed to meet the needs of all its members.

9 EHP offers programs and services to help members better manage their health. EHP offers the EHP Benefits Explorer, an interactive tool designed to help EHP members quickly and easily find coverage information related to specific services. For detailed information on what each individual employer offers, visit benefits.ehp.org or see the schedule of benefits.

10 As EHP members, your patients can take advantage of the following: Prescription coverage: Prescription drug benefits vary among EHP employer groups. The EHP pharmacy and formulary can be viewed here. Dental care: The EHP dental benefit, offered by some EHP plans, is administered by Delta Dental. Members can call Delta Dental customer service at Visits to urgent care: Members can find urgent care centers by accessing the Provider directory or calling EHP customer service at (continued)

11 One-on-one health coaching: This gives members in most plans (excluding Broadway Services and Anne Arundel Medical Center) the opportunity to work one-on-one with a personal health coach and create an individualized action plan to help them meet their health goals. Members can call for more information. Care management program: Members are placed in one of three levels and, depending on their level, are given a variety of support, tools, and services that are specifically designed to help them better understand and manage their medical conditions. Members can call for more information. (continued)

12 Pregnancy resources: Various programs for expectant moms including Partners with Mom a high risk prenatal case management program, the BabySteps online rewards program and health coaching. Members can call Ext for more information. 24 hour nurse hotline: Members can speak to a real registered nurse 24 hours a day for general medical advice. Members should call pin #380.

13 This is the secure web portal for members' personal health information. Members can login and register at ehp.org. National medical coverage outside the state of Maryland through MultiPlan PHCS Healthy Directions Network: Members can visit for more information.

14 New for 2019 Benefit and plan changes effective January 1, 2019 include: New Additions to the Preferred Provider Network for the PPO Benefit Plan Greater Baltimore Medical Center (GBMC) and Anne Arundel Medical Center (AAMC) facilities and providers joins the Johns Hopkins Preferred Provider Network on 1/1/2019. Applies to Johns Hopkins Health System/Johns Hopkins Hospital, Bayview Hospital Providers and Facilities (PPO and EPO) Howard County General Hospital, Suburban and Sibley Hospitals Facilities only (PPO and EPO)

15 New for 2019 (continued) Exclusive Provider Organization (EPO) Plan JHHC introduces a new EPO (Exclusive Provider Organization) on 1/1/2019. This plan will have only in-network benefits EHP network (including MultiPlan out-of-state network*) and Johns Hopkins Preferred Network (including GBMC and AAMC facilities and providers). Care outside the EHP network is not covered under the EPO, except for emergency care. Applies to Johns Hopkins Health System/Johns Hopkins Hospital and Bayview Hospital Howard County General Hospital (HCGH) and Suburban Hospital *MultiPlan is also available inside Maryland for Suburban (PPO and EPO) and Sibley (PPO) members.

16 New for 2019 (continued) New Benefit for 2019 Direct Primary Care By enrolling in Direct Primary Care (DHP) pilot program, EHP members and their adult dependents (18 years or older) can receive 24/7 access to select primary care providers through a combination of longer in-person appointment times, s, phone calls, texts and video visits. DHP members experience no additional costs to their insurance plan and do not incur copayments or out-of-pocket costs for the first eight visits of the calendar year. The program will be capped at 1,600 members.

17 Additional 2019 EHP Plan Changes HCGH 2019 Plan Changes Changes for the PPO Benefit Plan: Acupuncture. Adding Medically Necessary services for pain control, and therapeutic purposes. Removing the Anesthesia only restriction. Hospital Care. Removing $40 copay for Observation Care professional fees for ER visits. Urgent Care. Removing (Patient First locations only) for physicians visits. Changing the Urgent Care copay to $40 for all urgent care facilities.

18 Additional 2019 EHP Plan Changes Bayview 2019 Plan Changes Salary tiers that determine deductibles and out-of-pocket amounts have changed for The plan codes are listed on the member ID cards.

19 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Changes for the PPO Benefit Plan: ER Copay. $125 copay, then 90% of allowed amount; deductible waived (copay waived if admitted) for EHP Network Provider, Hopkins Affiliated Facility Network, and out-of-network providers. 90% coverage for facility coverage at all Hopkins Preferred Facilities EXCEPT for infusion therapy services (continued)

20 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes EHP Network Provider Hospital Inpatient Care (Facility Fees). $100 copay per admission, then 80% of the allowed amount; deductible waived (for a service that Suburban doesn t provide: $100 copay per admission, then 90% of allowed amount deductible waived). EHP Network Provider Reproductive Health Inpatient Maternity Care and Delivery (Facility Fees). $100 co-pay per admission, then 80% of the allowed amount; deductible waived (for a service that Suburban doesn t provide: $100 copay per admission, then 90% of allowed amount deductible waived).

21 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Infertility.50% of allowed amount; deductible applies (preauthorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and x-rays; in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum. Hearing Aids. 90% of allowed amount; deductible applies (for dependent children up to age 26; up to $1,400 per aid. preauthorization required) replacement aids once every 36 months all networks combined. (continued)

22 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Private Duty Nursing. Removed for PT/OT- Sixty (60) visits per year maximum added for all networks combined; PT/OT preauthorization required for visits 13-60).

23 Additional 2019 EHP Plan Changes Sibley 2019 Plan Changes (PPO Plan) Nutritional Counseling. Limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized. Infertility.50% of allowed amount; deductible applies (preauthorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and x-rays; in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum. Chiropractic. The 12 years of age restriction has been eliminated.

24 Member ID cards

25 Claims & Appeals Submission Billing Address Johns Hopkins HealthCare LLC Attn: EHP Claims 6704 Curtis Court Glen Burnie, MD Claims must be submitted on CMS 1500 or UB-04 forms Claims from specialist or ancillary providers should include the referring provider s NPI in Box 17b of the CMS 1500 Claims must be submitted with a rendering provider s NPI in Box 24J of CMS 1500 (continued)

26 Claims & Appeals Submission Claims must be submitted within 180 calendar days of the date of service Administrative appeals (timely filing, care not coordinated by PCP, authorization not on file, member not eligible at time of service, incorrect coding) must be submitted within 90 business days of the date of denial For additional information on EDI (Electronic Data Interchange), please send an request to EDI Payor ID #52189.

27 Referral and Preauthorization Process Submit Request by Fax or Mail Mail: Johns Hopkins HealthCare LLC Attn: EHP Medical Management 6704 Curtis Court Glen Burnie, MD Fax:

28 Referral and Preauthorization Process Key Referral Information Patient/member name* Member ID* DOB* Address Referring provider Referred services Limitations Diagnosis/Procedure Codes *Indicates required fields

29 Referral and Preauthorization Process Preauthorization. Authorization from the insurance plan for a scheduled service (not requiring additional clinical documentation). Medical Review. Review process in which a nurse reviewer or medical director reviews the medical necessity for a procedure scheduled. Information must be faxed with request and clinical documentation. For a list of services that require a referral, preauthorization or medical review, please refer to the Outpatient Referral and Pre- Authorization Guidelines at

30 is a secure, online web portal where providers can check patient eligibility, claims and authorizations status, access plan-specific reports and more. Register for a HealthLINK@Hopkins account at or contact your Network Manager. First time users must register for an account. If you need assistance with registration, contact Provider Relations at

31 Health Care Performance Measures Healthcare Effectiveness Data and Information Set (HEDIS ) The Healthcare Effectiveness Data and Information Set (HEDIS ) is a widely used set of health care performance measures that is developed and maintained by the National Committee for Quality Assurance (NCQA). Examples of HEDIS measures are Comprehensive Diabetes Care, Childhood Immunizations, yearly Well Child Exams for Children Ages 3-6 and yearly Adolescent Well Care Exams. For detailed information about HEDIS, please go to or read our HEDIS Tip Sheet.

32 Health Care Performance Measures Consumer Assessment Health Plan Surveys (CAHPS ) The Consumer Assessment of Healthcare Providers (CAHPS ) 5.0H is a member satisfaction survey whose objective is to capture information about consumer-reported experiences with healthcare. The focus of the survey is to measure how well plans are meeting member expectations, determine which areas of service have the greatest effect on overall member satisfaction, and identify areas of opportunity for improvement. The survey is conducted according to NCQA protocol by an NCQA certified vendor.

33 Important Numbers Medical Management or Fax (Referrals not needing Medical Review) Inpatient Fax Outpatient Medical Review Fax DME Fax Fraud and Abuse Behavioral Health Services or Fax Case/Disease Management Health Coach Services or MultiPlan PHCS Healthy Directions Pharmacy Services , option Fax

34 JHHC Customer Service Employer Health Programs (EHP) Customer Service or /14/ /14/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

35 Provider Relations: THANK YOU 11/14/2018 Presented 11/14/2018 by: Johns Hopkins HealthCare Provider Relations Department