SutterSelect Administrative Manual. June 2017

Transcription

1 SutterSelect Administrative Manual June 2017

2 Introduction This SutterSelect Administrative Manual has been prepared as a resource for providers who are caring for members of SutterSelect health plans. The Manual includes information about requesting prior certification, how to submit claims, and a guide to using the SutterSelect Provider website. Please refer to the Table of Contents for a complete listing of the sections enclosed in this Manual. This Manual may be updated as needed. Visit our website at for the most up-to-date information. We hope that you find this Manual to be a valuable tool and thank you for helping to deliver quality health care to our members. SutterSelect Administrative Manual i

3 Table of Contents Introduction... i Table of Contents...ii Background... 1 SutterSelect Products 1 SutterSelect Provider Network 1 About UMR 1 Plan Designs and Options... 2 EPO Plus 2 PPO 2 Options PPO 2 Eligibility... 3 Member ID Cards 3 Prior Certification... 4 UMR Care Management Certification Requests 4 Referrals to Specialists 4 Responsibility and Member Penalty 4 Pharmacy Drug Formulary 11 Medication Reviews 11 Prior Authorization 11 Pharmacy Network 11 Mail Order Pharmacy 11 Behavioral Health Contact Information 12 Emergency Care 12 Online Benefits and Claim Inquiry Home Page 13 Provider Login 14 Reset Password 14 Navigating the Website 15 Provider Directories SutterSelect Provider Information 16 Quick Reference List Clinical Management... 5 Contact Information 5 Utilization Management 5 Case Management 5 Disease Management 6 Disease Management Contact Information 6 Nurse Advice Line 6 Claims... 7 Claims Submission Guidelines 7 Claims Inquiries 8 Claims Submission Address 8 Timely Filing 8 Coordination of Benefits 8 Subrogation 8 Provider Remittance Advice 9 RA Field Explanations 10 SutterSelect Administrative Manual ii

4 Background SutterSelect is Sutter Health s self-funded medical plan, developed to take the place of an outside insurance company. Self-funding allows Sutter Health affiliates to deliver consistent medical plan coverage from year to year through a stable, predictable medical plan. In turn, affiliates can design benefit plans, wellness programs and more with employees and their families in mind. SutterSelect Products SutterSelect manages the self-funded medical plans for its customers. Product descriptions are detailed in the Plan Design section on page 2. SutterSelect Provider Network The SutterSelect provider network includes more than 7,000 physicians. Additionally, the PPO plan option offers innetwork providers from the broader HealthSmart Preferred network inside of California or the PHCS Healthy Directions network outside of California. The Options PPO plan network utilizes the UnitedHealthcare Options PPO network. SutterSelect Vendors Sutter Health partners with UMR to administer the plan. UMR is the largest employee benefits third-party administrator in the United States and is fully compliant with HIPAA requirements for health data security. The organization serves more than 1,700 clients and more than 2.5 million plan members, processing over 32 million claims each year. UMR is a UnitedHealthcare company. UMR is the primary contact for provider and member information and assistance with SutterSelect. Pharmacy benefits management is provided through MedImpact. The MedImpact pharmacy network includes a national network of more than 67,000 community pharmacies and also offers a mail order prescription service through Prescription Solutions Program (PPS). Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for all SutterSelect plans. The illustration on the following page provides information about the SutterSelect medical plan options. SutterSelect Administrative Manual 1

5 Plan Designs and Options EPO Plus PPO Options PPO Plan Design In-network benefits only. No coverage for out-of-network services, except emergencies. In-network benefits only. No coverage for out-of-network services, except emergencies. Out-of-pocket costs depend on which tier (and provider network) is accessed. Able to choose from Tier 1 or Tier 2 each time care is needed. Plan available only in certain geographic areas. In-network and out-ofnetwork benefits. Out-of-pocket costs depend on which tier is accessed. Able to choose a different tier each time care is needed. Network Uses the SutterSelect provider network. Network access depends on tier. Choices include SutterSelect provider network (Tier 1), or a broader network of HealthSmart Preferred in CA and PHCS Healthy Directions outside CA (Tier 2). Network access depends on tier. Choices include the UnitedHealthcare Options PPO provider network (Tier 1), or out-of-network (Tier 2). Costs The lower cost medical option in terms of monthly premium costs and out-ofpockets costs. Higher premium cost option due to flexibility in choosing providers. Out-of-pocket expenses are higher under Tier 2. Out-of-pocket expenses are higher under Tier 2. SutterSelect Administrative Manual 2

6 Eligibility It is important to verify eligibility prior to rendering services. Eligibility rules vary by plan and employer. Eligibility can be verified by two methods: Telephone: Call SutterSelect Customer Service at Provider service representatives are available from 7:00 a.m. 6:00 p.m. Pacific Time, Monday Friday. Online: The website provides access to eligibility information 24 hours a day, seven days a week. Member ID Cards Important key information and resources are highlighted on the below sample identification card. Cards may differ slightly between plans or plan options. Front of ID Card Plan name (benefits and coverage may vary between SutterSelect plans) Plan option Member s ID card will list copay amounts for their plan option UMR is the SutterSelect third party administrator Back of ID Card Call UMR Care Management for prior certification Claims submission information EDI # UMR, PO Box Salt Lake City, UT Provider Customer Service Eligibility and claims Provider network directory General inquiries SutterSelect Administrative Manual 3

7 Prior Certification To obtain a prior certification determination, call the telephone number listed on the back of the member s ID card. A list of services requiring prior certification is available in the member s Health Plan Summary Plan Description (SPD). The SPD for a member can be viewed online by logging on to the provider website at Emergency services may be authorized or certified after care is delivered. Most service requests will require submission of medical records to establish medical necessity. Requests are also reviewed to assure they meet benefit criteria as defined by the Plan. UMR Care Management Certification Requests Telephone: Call the number on the back of the member identification card to request certification prior to the scheduled procedure or service, in order to allow for fact gathering and independent medical review, if necessary. Hours of operation: 7:00 a.m. 6:00 p.m. Pacific Time, Monday Friday. Fax: Complete the request form (available at and fax with pertinent medical records to Online: An online request form can be completed at From the Provider tab on the left side of the screen select Get preauthorization to begin the online process. Request Response UMR Care Management will contact your office via telephone or letter with the certification number, if approved. If more information is needed, you will be contacted for requested records needed to make the medical necessity determination. If the request is denied, you and the member will receive a written notice, including appeal rights and process. Request turnaround time frames: o Concurrent Urgent 24 to 48 hours o Pre-service Non-urgent 15 days o Pre-service Urgent 72 hours o Post-service 30 days Referrals to Specialists SutterSelect plans offer the ability for members to see any provider within the network, including specialists, without a referral. Responsibility and Member Penalty Providers need to submit requests for prior certification on behalf of members. Failure to obtain prior certification will result in a financial penalty for the member. This penalty does not apply to emergency services. Emergency service is any otherwise covered service that a prudent layperson with an average knowledge of health and medicine would seek if he/she was having serious symptoms and believed that without immediate treatment his/ her health would be put in serious danger, his/her bodily functions, organs or part would become seriously damaged or would seriously malfunction. SutterSelect Administrative Manual 4

8 Clinical Management SutterSelect contracts with UMR Care Management, to provide telephonic clinical management programs. There is no fee to patients or providers for these programs. Clinical Management services include: Utilization Management Case Management Health Information Independent Medical Review Contact Information Telephone: Call , 5:30 a.m. 7:00 p.m. Pacific Time, Monday Friday Utilization Management Prior Certification Review The prior certification review process is outlined in the Prior Certification section on page 4. Concurrent Review Concurrent review provides review of medical necessity and level of care for members while they are accessing services in the hospital inpatient, acute rehabilitation, skilled nursing facility or home health setting. Independent Medical Review (IMR) IMR provides clinical review and determinations for medical necessity by independent clinical reviewers. IMR also manages the appeals process and investigational treatment requests. Case Management Case Management provides authorization, discharge planning and care coordination for complex and high dollar cases including organ/tissue transplants and high risk neonates. Care and benefits are coordinated across the continuum of care. SutterSelect Administrative Manual 5

9 Clinical Management Disease Management Disease management services are provided by the Sutter Health Department of Care Coordination Telephonic Disease Management (TDM) Program. Patients are invited to enroll in disease management programs based on claims data. A team of nurses, pharmacists, coaches, and clinical support staff reach out to patients with the below chronic conditions who have specific evidence of increased acuity of their condition, key gaps in care, or by physician or patient request. The TDM program contacts patients by letter, phone and My Health Online (MHO). Asthma Diabetes Heart Failure Hyperlipidemia Hypertension Disease Management Contact Information Telephone: Call , 8:30 a.m. 4:30 p.m. Pacific Time, Monday Friday DiseaseManagement3@sutterhealth.org Nurse Advice Line NurseLine SM is an advice line for members to speak to a registered nurse regarding medical questions, information, education and health-related concerns. It can be accessed 24 hours a day, seven days a week by calling SutterSelect Administrative Manual 6

10 Claims Providers are encouraged to submit claims via electronic claims submission. UMR s EDI Claim Payer ID Number is If you wish to obtain more information about electronic claims submission, please call UMR at Claims Submission Guidelines All paper claims should be submitted on a standard CMS 1500 form or UB, as applicable, and contain the following information: UB Forms Provider Name, Address and Telephone Number Patient Control Number Type of Bill Federal Tax ID Number Statement Covers Period Patient s Name Patient s Address Patient s Birth Date Patient s Gender Patient s Marital Status Admission Date/Start of Care Admission Hour Type of Admission Discharge Hour Occurrence Span Code and Dates Revenue Code Revenue/HCPC/CPT Description HCPCS Rates Service Date Service Units Total Charges Non-Covered Charges Payer Identification Provider Number Release of Information Assignments of Benefits Cert. Information Prior Payments Insured s Name Patient s Relationship to Insured Group Name Insurance Group Number Employment Status Code Principal Diagnosis Code Admitting Diagnosis Principal Procedure Code and Date Attending/Referring Physician NPI Provider Representative Signature Date CMS 1500 Forms Patient s full name (as printed on Health Plan ID card) Patient s date of birth Policyholder/subscriber, Insurance Name and ID # (include any suffix numbers shown on the card to assist with dependent coverage verification) Diagnosis (ICD-10-CM code is required) Date(s) of service CPT-4 procedure codes with description and modifier, if applicable Name should be shown of PA, FNP, rendering provider Referring physician s name, if applicable NPI Federal Tax ID Number Information on other insurance coverage Prior certification number, if applicable Signature of provider rendering service SutterSelect Administrative Manual 7

11 Claims Claims Inquiries Claims inquiries should be directed to SutterSelect s Customer Service Line at Claims Submission Address UMR PO BOX SALT LAKE CITY UT Timely Filing Complete claims are to be submitted to the third-party administrator, UMR, as soon as possible after services are received, but no later than six months from the date of service. A complete claim means that the Plan has all information that is necessary to process the claim. Claims received after the timely filing period has expired will not be considered for payment. Coordination of Benefits Coordination of benefits (COB) applies whenever a member has health coverage under more than one plan. The purpose of coordinating benefits is to pay for covered expenses, but not to result in total benefits that are greater than the covered expenses incurred. The order of benefit determination rules determine which plan will pay first (primary plan). The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays for covered expenses after the primary plan has processed the claim, and will reduce the benefits it pays so that the total payment between the primary plan and secondary plan does not exceed the covered expenses incurred. Up to 100 percent of charges incurred may be paid between both plans. Subrogation Claims identified as possibly accident related may pend for additional information. When these claims are identified, a questionnaire is generated to the member asking if they received treatment for an injury or illness that may be accident related. The member must complete and return the questionnaire by mail or fax. The member can also respond to the inquiry by calling SutterSelect Customer Service or online at If there is an indication that the claim was for an illness or injury that was not caused by another person or party, the claim(s) will be reprocessed. If there is an indication that the claim was for an illness or injury that was caused by another person or party UMR will reprocess the claim(s) and pursue the plan s right of reimbursement of the medical bills paid by the plan. Failure by the member to return the completed questionnaire will result in denial of the claim(s). SutterSelect Administrative Manual 8

12 Claims Provider Remittance Advice UMR produces weekly check runs. Provider Remittance Advices (RA) and member Explanations of Benefits (EOB) are an integral part of finalization of the patient/physician experience. To help familiarize you with the Remittance Advice that your office will receive, below is a key to explain each field in detail. Claim specific details are also available to you by logging on to SutterSelect Administrative Manual 9

13 Claims RA Field Explanations 1. Remittance Advice for Period Ending: Last day of the week for the period covering claims listed on this particular remittance advice. 2. Identifying Plan Header: Header that identifies organizational plan that patients are associated with. Header includes name, address and return telephone number. 3. Plan Name: The plan name that patients are associated with. 4. Employer Name: The company name the patients are associated with. 5. Provider Name and Address: The provider s name and address. 6. Federal Tax ID No.: The provider s federal tax ID number. 7. Dates From/To: Displays the first date of service through the last date of service for the services performed. 8. Service Code: CPT/HCPCS procedure code. (Hospital charges display as ) 9. Charged Amount: Total amount charged per service. (Hospital per diem charges will display on one line with one total charge amount.) 10. Allowed Amount: Total amount of charge considered for payment. 11. Deductible: The portion of the charge applied to the patient s deductible, if applicable. 12. Co-pay: The portion of the charge applied to the patient s co-pay, if applicable. 13. Coinsurance: The portion of the charges applied to the patient s coinsurance, if applicable. 14. Discount Managed Care Adjust: Includes the amount of the provider s negotiated discount and the amount not allowed per contracted fees. (Difference between the actual charge amount and the contracted allowable amount.) 15. Ineligible: Amount not allowed due to plan provisions. 16. Withheld: The portion of the approved charge that is withheld based upon negotiated rates. 17. OC: Number of occurrences per line of service. 18. ANSI Code: American Standard Institute (ANSI) code provides reason why charges are not allowed. 19. Paid: Amount paid to provider per line of service. (This amount may differ from amounts paid on EOB due to withhold amounts.) 20. Patient Responsibility: Amount the patient is responsible for paying per line of service. 21. Employee: The employee s name. (Last name, first name, middle initial.) 22. Patient: The patient s name. (Last name, first name, middle initial.) 23. Cert No.: The employee s health plan identification number. 24. Account Number: The patient s account number, submitted by the provider of service. 25. Claim Number: The internal claim control number. 26. Total: Total amounts per column. 27. The Primary Insurance Paid: If applicable, displays the total amount the patient s primary insurance paid on the claim. 28. Subtotal: Subtotals for columns if pages follow. 29. Provider Total: Total combined amounts for each provider, displayed on final page. 30. CP Number: Banking source code (specific to each customer). 31. Internal Number: Ten-digit internal sequence number matching remittance advice to the appropriate payment check. 32. Plan Administrator Website Address SutterSelect Administrative Manual 10

14 Pharmacy MedImpact is the pharmacy benefits administrator for SutterSelect plan members. If you have questions or need assistance getting prescriptions for members, you can contact MedImpact customer service, 24 hours a day, seven days a week via: Telephone: Online: Drug Formulary The SutterSelect Formulary is a list of drugs covered by the plan. The Formulary was developed to meet the needs of most members based on rational drug therapies. To find out what drugs are on the formulary, contact MedImpact via telephone or check their website at and click the Formulary link. Medication Reviews The formulary is developed and maintained by a committee comprised of physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. Prior Authorization Contact the MedImpact prior authorization department at to begin the prior authorization process. Pharmacy Network The MedImpact pharmacy network includes more than 64,000 retail pharmacies nationwide. For specific information call the customer service center or use the pharmacy locator link on the website. Telephone: Call the MedImpact customer service center at Online: o Click the view this site as a guest link. Mail Order Pharmacy* The Mail Order Program is administered by Postal Prescription Services (PPS). The program allows a member s prescription products to be ordered through the mail service pharmacy. Using mail order offers plan members the advantage of obtaining up to a 90-day supply of prescription products. Telephone: Call , Monday Friday 6:00 a.m. 6:00 p.m. or Saturday 9:00 a.m. - 2:00 p.m. Pacific Time * The Sutter Health Central Valley Region SutterSelect mail order pharmacy program is administered through the Memorial Medical Center Outpatient Pharmacy. SutterSelect Administrative Manual 11

15 Behavioral Health Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for all SutterSelect plans. Call for authorization before providing inpatient or outpatient mental health or substance abuse services. Contact Information Telephone: Call Optum customer service at , 24 hours a day, seven days a week. Emergency Care If the member needs emergency services, you do not need to obtain prior authorization from the behavioral health carrier prior to providing emergency care. However, you must notify the carrier within 24 hours and once emergency care has ended, call the carrier to get authorization to provide any additional services. SutterSelect Administrative Manual 12

16 Online Benefits and Claim Inquiry Access information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week by going to Logging on to this website provides you and your office the following: Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to whom payment was made. Eligibility and benefits information, including patient specific plan information, claim submission details, prior certification requirements and member benefit levels. Contact phone numbers and an notification form to contact a member of the UMR team with your questions. If you have questions or problems related to the website, please contact the UMR technical support team at Home Page Click: Provider SutterSelect Administrative Manual 13

17 Online Benefits and Claim Inquiry Provider Login If you do not already have a username and logon, click New user? Register here. to complete the registration process using your name and password. Reset Password Should you forget your password, you can select the Forgot username or password? option to change it. SutterSelect Administrative Manual 14

18 Online Benefits and Claim Inquiry Navigating the Website You can view an online video tutorial to learn about site navigation and available features. SutterSelect Administrative Manual 15

19 Provider Directories To obtain the highest level of benefits under this Plan, members need to see an in-network provider, however SutterSelect does not limit a member s right to choose his or her own provider or medical care. If a medical expense is not a Covered Expense under the medical benefit plan, or is subject to a limitation or exclusion, a member still has the right and privilege to receive such medical service at his or her own personal expense. To find out which network a provider belongs to, please refer to the Provider Directory or call the toll free number that is listed on the back of the member s identification card. The participation status of providers may change from time to time. SutterSelect Provider Information Telephone: Call the SutterSelect Customer Service Line at Online: Available at Providers must login to view the information. To find a mental health provider in the Optum network, go to and enter the access code healthy. SutterSelect Administrative Manual 16

20 Quick Reference List SutterSelect Eligibility Verification Customer Service 7:00 a.m. 6:00 p.m. PST Benefit Inquiries (Providers) Monday Friday Claim Inquiries Prior Certification Provider Appeals Pharmacy or Drug Formulary Pharmacy Network Website Benefit Inquiries Claim Status Eligibility Verification Provider Directories Claim Submission UMR EDI Claim Payer ID: PO Box Salt Lake City, UT Care Management Utilization Review/Prior Certification SutterSelect Customer Service (Members) or Optum Behavioral Health or www://liveandworkwell.com access code healthy Prior Certification Provider Directory SutterSelect Administrative Manual 17