Medicaid Modernization: How to Build a Relationship with an MCO

Transcription

1 Medicaid Modernization: How to Build a Relationship with an MCO 2015/2016 Agenda Building a positive relationship with providers is critical to a smooth transition to managed care. We are here to help you better serve our members! Introduction Contracting & Credentialing Next Steps Billing & Claims Q&A 2 1

2 Programs Effective January 1, 2016, United Healthcare Community Plan of Iowa and the other three MCOs contracted with Iowa DHS will manage care for Iowans with developmental disabilities, chronic medical conditions and/or low incomes. We manage: hawk-i Iowa Wellness Iowa Marketplace Choice Family Planning Seven Home and Community-based Services waiver programs 3 Overview All the programs currently available to your patients will remain the same. During this transition and always, take advantage of the online resources available to help you. Verify eligibility Request authorizations Obtain reimbursement for your services 4 2

3 Establish Relationships with the MCO Staff UnitedHealthcare Community Plan network of providers (acute care, specialists, durable medical equipment, facilities and hospitals) Optum Behavioral Solutions 5 Contracting with MCOs In order to ensure appropriate reimbursement for covered services, it is important to outreach and contract with the MCOs. 1. Enroll with Iowa Medicaid Enterprise 2. Outreach to contracting departments at the MCOs 3. Review contract The RFP & MCO contracts with DHS place strict requirements around many aspects of the contract language 4. Return contract and credentialing information to MCO 6 3

4 How to Reach Each MCO MCO Contact Information UnitedHealthcare Community Plan of Iowa Existing Providers: Contact your current contract manager Phone: AmeriGroup Iowa, Inc. AmeriHealth Caritas Iowa, Inc. WellCare of Iowa, Inc. Phone: Phone: Phone: Credentialing MCOs are required to be NCQA/URAC accredited and to credential all contracted providers to ensure providers meet all State and Federal rules and regulations. Confirm with each MCO their credentialing requirements specific to your provider/facility type Return credentialing materials along with contract to ensure timely processing You will receive a Welcome Letter once approved by the credentialing committee 8 4

5 Next Steps The MCOs strive to improve quality of and access for members and promote accountability for outcomes. In order to do so, it is vital we have a positive working relationship with providers. 1. Understand MCO s resources available to you Training opportunities Dedicated contract managers / provider advocates Online tools (e.g. websites, provider web portals) Care coordination and case management tools 2. Understand prior authorization requirements 3. Understand claims and billing requirements 9 WebEx Training Sessions January, 2016 Tues., Jan. 5, 2016: 2:00 p.m. Tues., Jan. 12, 2016: 10 a.m. Wed., Jan. 13, 2016: 10 a.m. 10 5

6 Other Training Options We encourage you to take advantage of the many training opportunities at UnitedHealthcareOnline.com Reference guides Video tutorials Facilitator-led webinars 11 PCA18493_2015mmdd Proprietary Information of UnitedHealth Group. Care Coordination - UHC Community-based Case Managers identify needs: Develop and maintain a Person-Centered Care Plan Facilitate access to care Assesses each member to customize care Coordinate services For more information about our Person-centered Planning and Home Health Homes, visit UHCCommunityPlan.com > For Health Care Professionals > Iowa > Billing Guides and References > Our Coordination of Care 12 6

7 Authorizations MCOs are required to follow IME guidelines for covered services. However, they may set their own Prior Authorization requirements. Review MCO provider manuals for Prior Authorization (PA) requirements Confirm with MCO how to request PA Web portal Fax Phone UHC Authorizations 13 Authorizations UHC Transition Timeline Providers and Services Authorization Timeline Care providers 90 days from Jan. 1 to Dec. 31, 2016 Minimum 30 days, effective Jan. 1, 2016 In-patient stays Until the member is discharged from acute care or for 60 days after disenrollment, whichever is less, unless the member is no longer eligible for Medicaid In-patient psychiatric stays As long as the services continue to be medically necessary In-patient stay services other than inpatient hospital services (e.g., New health plan is responsible for payment at the effective date of physician services) disenrollment Long Term Services and Supports Providers Until we complete a new service plan and it is agreed on by the member or resolved through the appeals or fair hearing process Nursing facility long term care Intermediate care facilities for the intellectually-disabled and Support for the member to live in a residential setting controlled by the member or the provider, funded through 1915(i) Habilitation waiver provider or a 1915(c) Home and Community-based Services (HCBS) waiver Residential care providers serving members with a dual diagnosis of behavioral health condition and developmental disorder Up to one year At least one year Non-network residential care providers serving members with a dual At least 30 days, maybe more, to allow for continuity of care while diagnosis of behavioral health condition and developmental disorder transferring to a network provider Out-patient providers serving members with a dual diagnosis of behavioral health condition and developmental disorder Minimum of three months as long as the services continue to be medically necessary, unless the care provider is no longer available or when a change in providers is requested in writing by the member or the member s representative 14 7

8 Authorizations UHC Easy Access to Eligibility and Authorizations Online: Phone: Quick access to eligibility information If an authorization is necessary, you will receive an Immediate pop up. Follow the link to complete the prior authorization request in our minimal click format. Call Provider Services at for eligibility 15 Authorizations - UHC Faxing Prior Authorization Requests Fax: Acute Medical Fax: Fax forms are located at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Forms > Prior Authorization Faxed Request Form OR Prescription Drug Prior Authorization Request Form fax to (Or see the Pharmacy Program tab for some drug-specific forms.) See the complete listing of what requires prior authorization online at UHCCommunityPlan.com > For Health Care Professionals > Iowa (link). 16 8

9 Prescribing Information - UHC Each MCO is responsible for monitoring the Pharmacy benefit for their members. MCOs must follow State PDL and PA requirements. Preferred Drug List (PDL) is located at UHCCommunitiyPlan.com > For Health Care Professionals > Iowa > Pharmacy Program tab. See the authorization section of this presentation for prior authorization information or call our provider services at to speak to the prescriber help desk. 17 Claims & Billing In order to ensure appropriate reimbursement for covered and rendered services, it is important to be contracted with the MCOs. Key Considerations: Member liability (e.g. co-payments, client participation) Acceptable billing methodology (e.g. EDI, web portal, paper claims) EFT & ERA set up Adjustments & Recoupments Claims Appeals 18 9

10 Billing the Member Some members will owe money for services and will have to pay up front with a co-payment before receiving treatment. You will know if they owe a co-payment when you check for eligibility You may bill the member for their portion Members may tell you they are unable to pay the co-payment. You may not deny care or services to any member because of his or her inability to pay the co-payment Check with the MCO s Provider Services department if you have questions about a member s financial responsibility. Always check for a third-party liability before submitting claims. 19 Claims & Payments - UHC There are two ways to submit a claim for payment: Online: UnitedHealthcareOnline.com > secure login > Claims & Payments. Use payer ID Submit correct claims within 90 days of the date of service (or per your contact with us). Mail: UnitedHealthcare Community Plan P.O. Box 5220 Kingston, NY

11 Electronic Payments & Statements - UHC Electronic payments and statements help to streamline the claims and reimbursement process. Confirm EFT & ERA requirements with each MCO. Enroll in our electronic payments & statements (EPS) to receive direct deposit payment of your claims and access online provider remittance advices. Go to myservices.optumhealthpaymentservices.com and click How to Enroll (link). 21 Doing Business with Us We re here for to work with you. Remember to be currently enrolled as an Iowa Medicaid provider in order to deliver services to our members. Our Advocates are available to assist you in navigating our processes to better serve our members. Our Mission is to Help People Live Healthier Lives

12 UHC Advocate Staff in Iowa 23 New Provider Checklist - UHC Medical Benefits Register with UnitedHealthcareOnline.com Sign up for provider newsletter Network Bulletin at UnitedHealthcareOnline.com Register with Link Register with Electronic Data Interchange Support Services (EDISS) Apply for Electronic Payment and Statements Get to know the Community-based Case Manager(s) for your patients and your Provider Advocate 24 12

13 What Else Can Be Done 25 Questions? Thank You