11/3/2016. Meet Your Provider Relations Team.» Bethany Dumond» »

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1 2 Meet Your Provider Relations Team» Bethany Dumond» » 3 1

2 Meet Your Provider Relations Team» Rachel Fields» » 4 Our Mission To improve the health status of our members by facilitating access to quality, compassionate, accessible, and cost-effective health services through organized health delivery systems. 5 Our Vision To be the premier health financing organization, known for its ability to improve the health status of its members and for its service, quality, innovative and cost-effective financing solutions for employers, individuals, purchasers and governmental agencies. 6 2

3 Our Values To improve the health status of our members by providing quality, compassionate, accessible, cost-effective health services through an organized health delivery and financing system. 7» Clinton County» Eaton County» Gratiot County» Hillsdale County» Ingham County» Ionia County» Isabella County» Jackson County Celebrating 36 Years! PHP Was Established In 1980 Serving 13 Counties» Lenawee County (Partial)» Montcalm County» Saginaw County (Partial)» Shiawassee County» Washtenaw County (Partial) 8 PHP Provider Network Over 4,000 Providers 9 3

4 Membership» HMO 4,553» Marketplace HMO Individual 3,392» Point Of Service Plus 27,940» HMO High Deductible 0» HMO High Deductible Plus Point Of Service 489» Self Funded 15,570» Insurance Company Indemnity 8,134 60,078 Members 10 Getting a Resolution» PHP has a team approach to getting your questions and issues resolved immediately» Always start with CUSTOMER SERVICE first» Resolve questions pertaining to claims, eligibility, benefits, and much more!» Available Monday-Friday 830am-530pm» or » Provider Relations team» Bethany Dumond & Rachel Fields» Working as a team to accomplish tasks (conducting on site and off site trainings, visiting offices, and working with PHP teams to resolve issues» Available Monday-Friday 8am-5pm

5 Our website is easy to use and contains important information for our providers. 13 HealthWeb Checking patient eligibility for our Providers is a snap with PHP HealthWeb. HealthWeb provides our providers with an online method to check eligibility, co-pay/deductibles, authorization information and claim status. To login to HealthWeb simply click on Login located on the Provider Page of the website and click on My HealthWeb To obtain logins please fill out the HealthWeb User Request form located in the forms section on our website 14 Authorization/Notification Table From the Providers page, click on Care Management located in the box on the left hand side, then scroll to bottom of page to locate the most current Authorization/Notification table available to our providers 15 5

6 16 Where to Find PHP Forms 17 Authorizations From the Providers page, click on General Forms and Information located in the box on the left hand side, then scroll down the page to locate the most current Prior Authorization Forms 18 6

7 19 Pharmacy Prescription Drug List 20 Prescription Drug List From the Providers page, click on Pharmacy Prior Authorization Criteria located in the box on the left hand side, then scroll down the page to locate the most current Medications requiring Prior Authorization 21 7

8 Prescription Authorization Process From the Providers page, click on General Forms and Information then scroll to Prior Authorization Forms. Here you will find the Medication Prior Authorization Form Medication Therapy Management (MTM)» Free program to help patients understand and manage their medications and how it affects their health and wellness» Patients meet 1:1 with a clinical pharmacist at a clinic located in the Medical Arts Building» Available to ALL PHP members» Assist prescribers in avoiding potential medication-related problems Joy Wahawisan, Pharm. D. BCPS 24 8

9 PHP Updates» Integrated Voice Response (IVR): Live October 21, 2016» Updates include:» Provides basic information without having to speak directly to a customer service rep» Providers can use IVR 24 hours a day» Member Eligibility» PCP Information» Claim status (paid, denied, pending)» Member cost share on common benefits (PCP/Specialist office visit, ER, Urgent Care, Ded/Coin/OOP» Two check writes a week» Monday, Thursday, and last business day of the month 25 Telehealth Provider» PHP has partnered up with American Well (Amwell) to provide telehealth services» October 1, 2016 Available to State of Michigan enrollees only» January 1, 2017 Available to entire PHP network» How does it work?» 3 ways to connect:» Log on to PHP.amwell.com» Call 844.SEE.DOCS» Download the Amwell app 26 Amwell» Patient can obtain visits anywhere (vacation, work, home, etc)» Doctors are available 24 hours a day, 365 days a year» Board certified doctors» No appointment needed» Commonly treated conditions: Allergies, sinus infection, migraines, bronchitis, stomach flu, hypertension, pneumonia, pinkeye, vertigo, flu, gout, UTI, rash, sprains, depression, and anxiety 27 9

10 Claim Submission» Accept paper and electronic claims» Be sure to use the appropriate form» Electronic Claim Submission (through approved clearinghouse: Relay, Optum, and TTPS)» UB-04» CMS1500» Claims submitted electronically go through various validations throughout the process before they are loaded into our claims processing system 28 EDI Validation» Your clearinghouse may have frontend edits established in addition to a data validation process» You should receive a rejection report from your clearinghouse or vendor for claims PHP does not receive» PHP does not receive a copy of this report or have access to what is submitted to your clearinghouse or vendor 29 Interim/Series Billing» When submitting interim or series billing please remember the following guidelines:» Use the accurate type of bill as required for each month s services with the accurate billing requirement for the initial, continuous, and discharge» claim. See below:» Initial Claim xx2 type of bill» Continuing Claims xx3 type of bill» Final/Discharge Claim xx4 type of bill» Final/Discharge Claims for Home Health xx9 type» of bill» PHP will reject claims if they are not submitted in the appropriate order. If you are experiencing one of these rejections, remember that an xx2 (first claim) must be on file and billed before any additional continuing claims will be processed. This may require submitting an adjustment claim to get the xx2 on file before any continuing, final, or discharge bill types can be processed 30 10

11 Claims Information» Claims can be submitted electronically through one of the participating clearinghouses. In Network: PHP Electronic Payer ID 37330» PHP accepts claims from the following clearinghouses:» Relay Health» OPTUMInsight» Trizetto Trading Provider Solutions(TTPS) 31 Where to Send Claims 32 Electronic Transactions» Check eligibility for PHP members instantly on the TTPS Provider Portal or Optum Clearinghouse (270/271) to check eligibility, deductibles, out of pocket yearly and remaining amounts, coinsurances and or copayments amounts and benefit messages and limitations. PHP is currently working with other clearinghouses to make this available» Check claim status for claims submitted to PHP using the TTPS Provider Portal or Optum Clearinghouse (276/277) to check claim status, payment date, paid amount and to obtain a check number. PHP is currently working with other clearinghouses to make this available 33 11

12 Clinical Edits» PHP uses clinical edits in the processing and payment of all providers' medical claims» Clinical edits focus on correct coding methodologies and accurate adjudication of claims» Clinical edits are processed with an explanation code defining the reason for the denial» Any services denied due to PHP s clinical edits, such as bundling, clinical daily maximums, or other payment logic may not be billed to the member 34 Clinical Edits» Make sure to review general industry billing standards prior to submitting your claim, including but not limited to, the American Medical Association s (AMA) CPT Manual, Centers for Medicare and Medicaid Services (CMS), and National Correct Coding Initiative for Medicare Services (NCCI)» Claims submitted in accordance with appropriate coding and clinical edit rules are more likely to process without delay! 35 Top Clinical Edit Denials» Labs not eligible for separate professional payment» Status B code (Professional Claims - the procedure code billed is packaged into the primary procedure)» NCCI/CPT bundles procedure into another procedure on same date of service» Status N code (Facility Claims - the procedure code billed is packaged into the primary procedure)» Medically Unlikely Edits (MUE) - units for procedure exceeded» New Patient code not eligible for reimbursement» No response to medical record request 36 12

13 Top Reasons Claims are Stopped for Additional Investigation» Providers not submitting requested medical records to TC3 (Change Healthcare)» Services were not supported in the medical record documentation that was submitted and reviewed» Excessive units» Start and stop times not documented» Repeatedly billing for services included in the primary procedure» Services are investigational, experimental, or unproven» Physician orders not signed or dates of service submitted are not supported in documentation» No documentation of drug wastage 37 Electronic Funds Transfer (EFT)» Electronic Funds Transfer are now available through a partnership with PNC Bank. First-time provider receiving 835 and EFT files will receive the paper EOP for 31 days following the initial registration. After the 31 day period, the paper EOP will be discontinued. EOP information can be obtained using PHP s Web Portal HealthWeb» Requirements to receive electronic payments» Must be receiving your ERA electronically via the 835 files» Must be a participating provider with PHP» Must obtain your unique ID number from PHP» Must be registered with PNC bank» Call your Provider Relations Team today to get started 38 Marketplace Grace Period» Providers will receive a letter if their patient enters into a special grace period due to non-payment of premium» The patient and dependents is a receipt of Federal Advance Premium Tax Credits and entitled to an extended three month grace period» This means:» PHP will pend claims incurred during the second and third month of a three month grace period, until the member brings the account current. Once the account is current, all pended claims will complete processing» If the account remains unpaid, we will retroactively terminate coverage back to the beginning of the second month of the grace period in accordance with State and Federal laws» Providers may collect claims costs directly from the patient if the grace period expires and the coverage is retroactively terminated 39 13

14 Snort. Sniffle. Sneeze No Antibiotics Please Antibiotic resistance is one of the world s major public health challenges, according to the Centers for Disease Control and Prevention (CDC).» PHP would like to help raise awareness of the importance of reducing antibiotic use for treatment of viral diseases» PHP has two posters that can be ordered free of charge for display in your office» 8x10 or 17x22 40 Snort. Sniffle. Sneeze. No Antibiotics Please. Sample 1 Sample 2 Contact your Provider Relations Team at PHPProviderRelations@phpmm.org if you are interested in a poster 41 Future Changes» Provider Connection (PHP Newsletter) is currently available on PHP s website and is done quarterly. This is one way of communicating any updates and new processes. We hope to be moving towards an electronic version in the near future» Please send article ideas to phpproviderrelations@phpmm.org» Updating provider manual with protocols and requirements» Please send your feedback to phpproviderrelations@phpmm.org» New Web Portal coming on

15 Helpful Links And Information How to contact us located within PHP s online Provider Manual this document will provide each one of PHP s departments contact information including phone numbers and addresses for a quick reference. 43 Contact Phone Numbers