Welcome to Home State Health

Transcription

1 Welcome to Home State Health Quality Healthcare is at the Heart of What We Do

2 Overview 18,000 Providers WHO WE ARE Operations in 115 counties serving over 276,000 members 235+ employees in Missouri & Hospitals in our provider networks offices in St. Louis & Jefferson City OUR PURPOSE Transforming the Health of the community, one individual at a time. OUR MISSION Better health outcomes at lower costs OUR BRAND PILLARS Focus on Individuals Active Local Involvement Whole Health Our local approach provides accessible, high quality and culturally sensitive healthcare services to our members. Our integrated care coordination model can only be delivered effectively by a local staff, resulting in meaningful job creation in Missouri. 2

3 Who Is Eligible for MO HealthNet Managed Care?

4 The Basics: What you need to know. Our phone: HOME (4663) Provider Services Member Services Prior Authorization Case Management Our Website: Provider Manual Billing Manual Forms Clinical Guidelines Link to secure web portal Home State members do not have copays or any out-of-pocket expenses. 4

5 Home State Member ID Card 5

6 Checking Member Eligibility Online at MO Healthnet s online verification system. By calling MO HealthNet at Using Home State Health s secure provider portal at Call Home State Health at HOME (4663) and use the IVR automated system Or, call Home State Health Provider Services at HOME (4663) and speak to a representative 6

7 Health Coaches: Health screenings, 24/7 hotline, active case management Innovative Programs CentAccount: Provides financial awards for healthy behavior StartSmart for Your Baby: Care management techniques designed Same-Day Transportation: Helping decrease no-show appointment rates to extend the gestational period and reduce the risks of pregnancy Mobile App Technology: Members will have access to mobile applications Sickle Cell Coaches: Specialized care planning for hydroxyurea identification Mobile Technology: Increases member engagement Member Portal: Interactive member tools to stay up-to-date on health needs Member Concierge: Real-time assistance with PCP appointment setting Health Coaches: Health screenings, 24/7 hotline, active case management Primary Care Coordinators: Share high-risk member conditions & care gaps with PCPs CentAccount: Expanded financial awards for healthy behavior Start Smart for Your Baby: Care management techniques designed to extend the gestational period and reduce the risks of pregnancy 11/10/2015 7

8 Claim Operations Initial Claims must be submitted within 180 calendar days from the date of service. Secondary Claims must be submitted within 180 calendar days from the date of the primary carrier s remittance. Corrected claims must be submitted within 180 calendar days from original explanation of payment Home State s Electronic Payer ID is with the following clearinghouses: Emdeon SSI Trizetto Provider Solutions Availity A complete list of clearinghouses is available on our website at Claims may also be submitted via our secure web portal or by paper claim.

9 Billing Tips Corrected Claims- Both UB and CMS 1500 corrected claims can be submitted electronically by submitting the number 7 in field CLM05-3. Black/White and Handwritten Claim Forms-HSHP does not accept black and white copies or handwritten paper claim forms. RHC Billing Guidelines PBRHCs Claims must be submitted on a UB-04 Type of Bill in field #4 must be 71X

10 RHC Billing Guidelines, cont. IRHCs Claims must be submitted on a UB-04 Type of Bill in field #4 must be 71X Revenue code in field #42 must be 0521 HCPC procedure code T1015 must be submitted in field #44 HCPC/CPT code for all services provided MUST be submitted in field #44 in addition to code T1015 EPSDT/HCY Exam-EP modifier is only used with the T1015 when billing a full or partial EPSDT screening code. HCPC procedure code T1015EP must be submitted in field #44 when submitting The 5-digit EPSDT/HCY screening code must be shown in Field #44 in addition to code T1015EP One of the following codes must be shown as the primary diagnosis in Field #67: Z00.110, Z00.111, Z00.121, Z00.129, Z00.00 or Z00.01

11 What is EPSDT? Early Identifying problems early, starting at birth Periodic Checking children's health at periodic, age-appropriate intervals Screening Performing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Diagnosis Performing diagnostic tests to follow up when a risk is identified Treatment Treating the problems found Home State Health accepts a well child visit and a sick visit on the same claim when performed on the same date of service. Please refer to the EPSDT/HCY Billing Guide and Preventative Visit Examples for more information.

12 OB Billing Guidelines Prenatal Care -Use appropriate E&M code with TH modifier (for example, TH). -$200 bonus for 7 visits. Use above billing for all prenatal visits. -E&M codes without TH modifier will be reimbursed normally but will not be eligible for bonus. -Global codes will be denied. -Bonus payment is included with the reimbursement for the 7 th visit. Delivery Vaginal Delivery Only Cesarean Delivery Only VBAC Vaginal Delivery after Previous Cesarean Cesarean Delivery Only after attempted VBAC Delivery global codes will be denied. There is no bonus payment for deliveries.

13 OB Billing Guidelines Cont d Postpartum Care TH Postpartum Care, performed 21 to 56 days from delivery -$100 bonus will be paid for a single postpartum visit within 21 to 56 days of delivery -Use appropriate E&M code (for example, TH) or without modifier for postpartum care performed less than 21 or more than 56 days from delivery without the modifier or E&M codes for postpartum care will be reimbursed normally but will not be eligible for bonus. -Global codes will be denied EXCEPTION!!! Members eligible under the Show Me Healthy Babies program 94, 95, 96 or 98 must be billed globally, not FFS.

14 OB Billing Guidelines Cont d Early Elective Deliveries (EED) Appropriate EED code must be submitted in field 19 of the HCFA The EED codes must be submitted in a 4 character format with no spaces between the gestational age and delivery indicator. Gestational age falls between weeks. Acceptable delivery indicators are: LV, LC, IV, IC, CN, CS The gestational age must be billed leading the delivery indicator. Correct Format Example: 39LV Incorrect Format Example: 39 LV or LV39

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16 To Submit An Authorization Visit:

17 Home State Medical Management National Imaging Associates National Imaging Associates (NIA) Provides Hi Tech Radiology Management services Accredited by NCQA and URAC certified Prior Authorization is required for Non-Emergent Outpatient CT/CTA/CCTA, MRI/MRA, PET, and some Cardiology procedures i.e., MUGA Scan, and Stress Echo. The ordering physician is responsible for obtaining prior authorization but the rendering provider must ensure that prior authorization has been obtained to ensure proper reimbursement Providers can use NIA s website at and click on the RadMD Sign In for 24/7 online access RadMD provides instant access to much of the high tech imaging prior authorization information

18 Request for Reconsideration and Claims Dispute Request for Reconsideration Verbal or written request to reconsider or adjust a claim Must be submitted within 180 days of original remittance advice Claim Disputes Request for Reconsideration must be submitted first Must be submitted within 180 days of original remittance date Claim Dispute Form can be found at Written claim disputes can be sent to: Home State Health Plan Attn: Claims Dispute P.O. Box 4050 Farmington, MO 63640

19 Provider Complaints and Appeals Complaint-Verbal or written expression of dissatisfaction with any of HSHP functions such as policies, procedures, or claims. Complaints must be submitted within 30 days of the incident such as the original remit date. Appeal-The right to appeal actions of HSHP such as policies, procedures, claim or prior authorization denial. Appeals must be submitted 30 days from HSHP s notice of action. Written complaints and appeals: Home State Health Plan Complaint and Appeals Coordinator Swingley Ridge Road Suite 500 Chesterfield, MO Verbal Complaints: HOME (4663) Visit to view Provider Manual and details of Provider Complaints and Appeals

20 PaySpan Payment and Remittance Advice Home State and PaySpan Health have partnered to provide EFT and ERA services This service is FREE ERA s can be imported directly into Practice Management systems Once contracted, PaySpan will issue a registration code and the online enrollment process takes 5 to 10 minutes to complete. Contact Provider Relations for more information or visit

21 Waste Abuse and Fraud The Waste, Abuse and Fraud Program is overseen by Home State s Vice-President of Compliance. Overall responsibility and authority for carrying out the provisions of the compliance program Commitment to identify, investigate, sanction and prosecute suspected fraud and abuse Provider Network expected to cooperate fully with Waste, Abuse and Fraud investigations and proceedings Anonymous and confidential Hotline at All reports of potential waste, abuse or fraud are taken very seriously and are thoroughly investigated

22 Credentialing/What s Required? Completed Applicable Credentialing Application* Group Roster Completed Disclosure of Ownership Form W9 Advanced Directive Attestation *All FQHCs/RHCs locations must be credentialed as a facility separately from the providers in the group. All providers must also be individually credentialed. Please contact your provider network specialist for assistance with the application forms. NOTE: You will receive notice of your credentialing approval and effective date. This is separate from your contract date. To Request a Contract:

23 Web-Based Tools Through Home State website, providers can access: Provider Reference Manual Provider Billing Manual Prior Authorization List Authorization Search by Code Operational Forms HSHP Plan News Clinical Guidelines Provider newsletter Logon to and become a registered provider

24 Provider Secure Portal Through our secure portal, providers can: Verify eligibility and benefits View eligibility list View Care Plans View and submit authorizations Review payment history Submit Provider Demographic Updates Secure Contact Us Patient Analytics-Coming Soon Submit and check status of claims

25 Electronic Transactions Network providers are encouraged to participate in Home State s Electronic Claims/Encounter Filing Program which includes: Receiving an ANSI X12N 837 professional, institutional or encounter transaction (Claims) Generating an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP) Electronic Transaction speed payment to providers Reduces Manual intervention and errors

26 Provider Network Specialists Eastern Region I Central Region I Dawn Lukacina Nancy Schmidt Phone: Phone: DLukacina@homestatehealth.com Naschmidt@homestatehealth.com Eastern Region II Central Region II Manya Douglas-Clayton Lauri Elston Phone: Phone: Manya.DouglasClayton@homestatehealth.com Lauri.J.Elston@homestatehealth.com Eastern Region III Central Region III Sheri Stein Tina Bradshaw Phone: Phone: Sherri.A.Stein@homestatehealth.com Tina.M.Bradshaw@homestatehealth.com

27 Provider Network Specialists Western Region I Southeast Region Veronica Johnson Currently interviewing Phone: Phone: Veronica.R.Johnson@homestatehealth.com Western Region II Southwest Region Kimberly Slaubaugh Cristy Peck Phone: Phone: Kimberly.Slaubaugh@homestatehealth.com Cristy.R.Peck@homestatehealth.com

28 Questions?