Second quarter provider updates. July 2016

Transcription

1 Second quarter provider updates July 2016

2 Agenda Introductions Healthy Indiana Plan (HIP) debit card Claim disputes Behavioral health Updated Network Relations representatives map 2

3 HIP debit card - Background HIP was created by the Indiana General Assembly to help fund health care benefits for adults who have traditionally been uninsured. It is an affordable health insurance program from the state of Indiana for uninsured, low-income Indiana residents years old. 3

4 HIP debit card Background (cont.) In the HIP program, the first $2,500 of medical expenses for covered benefits (excluding preventive care) is paid with a special savings account called the Personal Wellness and Responsibility (POWER) account. The state pays most of this amount, but participants are responsible for paying a small portion of their initial health care costs, based on their income. 4

5 HIP POWER account debit card Anthem Blue Cross and Blue Shield (Anthem) patients enrolled in HIP will receive a POWER account VISA debit card. 5

6 HIP POWER account debit card (cont.) This debit card gives providers the capability to collect payment immediately for rendered services: First, use the Eligibility and Benefits Inquiry function in the Availity Web Portal to estimate the payment based on services rendered. Then, swipe the card as you would any standard debit or credit card. The amount is deducted from the member s POWER account and paid directly to you. 6

7 HIP POWER account debit card (cont.) Required information for eligibility and benefit inquiries: Either: Prefix and member ID: YRK354T60771 Prefix and RID Medicaid: YRK and DOB: May 24, 1974 NPI:

8 HIP POWER account debit card (cont.) You have two ways to access eligibility and benefits information in the Availity Web Portal: 1.In the Availity menu, select Eligibility and Benefits, then Eligibility and Benefits Inquiry. 2.On the home page, select Check Eligibility & Benefits. To access the POWER account transfer tool, you need to submit an Eligibility and Benefits Inquiry. 8

9 POWER account balance transfer 1.Select Eligibility and Benefits Inquiry. 2.On the Eligibility and Benefits results page under the Power Account Information section, select Complete Healthy Indiana Power Account Balance Transfer Form. Note: You will be required to enter the maximum allowable amount for the procedure. Select Anthem Provider Portal to access the Anthem Fee Schedule Tool and obtain the maximum allowable amount. 9

10 POWER account balance transfer (cont.) 3.In the Healthy Indiana Plan Power Account Balance Transfer Form, complete the required fields and then select Transfer Funds to Patient Debit Card. The Service Type field displays a copay amount next to each benefit/service type. When you select a Service Type, the corresponding copay amount is populated in the Member s Copay field

11 POWER account balance transfer (cont.) 4.Review the responses to verify the correct amount has been transferred and then collect the payment. The receipt of payment balance notifies you if the maximum allowable amount exceeds the member s POWER account balance

12 HIP debit card Claim submission After collecting payment through the new POWER account debit card, follow up by submitting the claim through the standard process using the CMS-1500 form. Adjudication through the standard process ensures receipt of the correct amount

13 HIP debit card Excluded services The POWER account debit card cannot be used for: Copayments due by the member Preventive health services Hospital services, both inpatient and outpatient Transportation Pharmacy services Dental and vision services 13 13

14 Claim follow-up and disputes CMS-1500 UB

15 Claim follow-up guidelines If you have not received payment or denial within 30 business days of submission, use the Availity Web Portal to check the claim status or call Provider Services: o Hoosier Healthwise: o Healthy Indiana Plan: o Hoosier Care Connect: Note: allow 60 calendar days for adjustments to be processed

16 Claim follow-up guidelines (cont.) Remember: Network providers must file claims within 90 calendar days, and it s the provider s responsibility to follow up in a timely manner to be sure claims are received and accepted. As a reminder corrected claims must be submitted no later than 60 calendar days from the date of our letter or remittance advice

17 Claim Follow Up Form The Claim Follow Up Form that should be used for routine claim follow-ups can be found on the provider website, aimfollowupform.pdf

18 Claim resolution process Claim dispute: You may submit a claim dispute if you disagree with a full or partial claim rejection or denial, or the payment amount. Do not submit a claim dispute for an adverse utilization management decision for which services have not been rendered. A claim dispute must be received in writing within 60 calendar days (from the date on the remittance advice). Verbal requests must also be filed in writing within the time frame

19 Claim resolution process (cont.) Administrative claim appeal: If you are not satisfied with the claim dispute resolution, you may submit an administrative claim appeal. Anthem must receive this appeal within 33 calendar days from the date of the claim dispute resolution. *Providers must exhaust all administrative claim disputes and appeal processes with Anthem prior to appealing to the state

20 Behavioral health (BH) provider resources Forms on our website: Behavioral Health Outpatient Treatment Request Form Individual Authorization Form Pervasive Development Disorders (PDD) Assessment Request Form Applied Behavioral Analysis (ABA) Treatment Request Form Request for Neuropsychological/Psychological Testing Psychotherapy Notes Authorization Form Transcranial Magnetic Stimulation (TMS) Outpatient Treatment Request Form 20 20

21 BH Network Relations representative If you have BH questions, please contact our statewide BH Network Relations representative: Donnica Hinkle, MA, LMHC, LPC Behavioral Health Network Relations Representative Sr

22 Updated Network Relations representative territories Northwest region: Marvin Davis West central region: Angelique Jones Southwest region: Interim Randall Mills

23 Updated Network Relations representative territories (cont.) Northeast region: Randall Mills Southeast region: Jovita Mielke Central region: Interim Angel Dodson Interim Marvin Davis

24 Updated Network Relations representative territories (cont.) Indiana University Health, community health, St. Vincent, Franciscan and Eskenazi: Mona Green Behavioral health statewide: Donnica Hinkle

25 Thank you Thank you for your partnership in serving our Anthem members enrolled in Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC July