IlliniCare Health Provider Orientation Webinar 4/13/2017

Transcription

1 IlliniCare Health Provider Orientation Webinar

2 Who is IlliniCare Health? Parent Company: Centene Corporation 30+ years of experience IlliniCare Health Provides: Medical, behavioral health, pharmacy, dental and vision benefits as one entity with a single care plan Employees are local and have market knowledge Integrated Care Team understands the communities we serve and their resources

3 Who is Centene Corporation? Headquartered in St. Louis, MO Employs approximately 13,400 individuals Serves over 4.1 million managed care members Currently operates health plans in 24 states Contract with over 90,000 physicians and more than 1,000 hospitals

4 Who is Centene Corporation?

5 Our Purpose Transforming the health of the community, one person at a time. Focus on Individuals Whole Health of our Members Active Local Involvement

6 Our Products Integrated Care Program (ICP) Available to seniors (65+) and individuals who receive medical benefits under the AABD program. Family Health Plan (FHP) Available to pregnant women and families with children under 19. Also available to individuals with incomes up to 138% of FPL.

7 Our Products Medicare-Medicaid Plan (MMP) Available to individuals who qualify for Medicare and Medicaid. Managed Long Terms Services and Supports (MLTSS) Available to individuals who are eligible for the Medicare-Medicaid plan, but opted out and receive HCBS Waivers or reside in a LTC facility.

8 Counties We Serve

9 Integrated Care Program (ICP)

10 ICP Eligibility Seniors (65+ years old) Adults (19+ years old) in the AABD population Must reside in one of the counties we serve Exclusions: Individuals enrolled in Medicare Individuals with spend-down Individuals in the Illinois Breast and Cervical Cancer program Individuals with Third Party Insurance Individuals with presumptive eligibility

11 ICP ID Card

12 Family Health Plan (FHP)

13 FHP Eligibility Pregnant women & families with children under 19 Individuals (19+ years old) with 138% of FPL Must reside in one of the counties we serve Exclusions: Individuals enrolled in Medicare Individuals with spend-down Individuals in the Illinois Breast and Cervical Cancer program Individuals with Third Party Insurance Individuals with presumptive eligibility

14 FHP ID Card

15 Medicare-Medicaid Plan (MMP) Also know as: Medicare-Medicaid Alignment Initiative (MMAI) and Duals

16 MMP/MMAI/Duals Medicare Medicaid Alignment Initiative (MMAI) A special integrated demonstration supported by the Federal and State governments for the dual eligible population receiving both Medicare and full Medicaid medical benefits IlliniCare Health s MMP Provides the services included in the MMAI program Coordinates care for our members Eliminates the barriers between Medicare and Medicaid

17 MMP Eligibility Adults age 21 and older Entitled to Medicare Parts A, B, and D; receive full Medicaid benefits Individuals with End Stage Renal Disease (ESRD) Exclusions: Individuals enrolled in American Indian/Alaskan Natives Program Individuals in the Illinois Breast and Cervical Cancer Program Individuals in spend-down Individuals with Third Party Insurance Individuals with presumptive eligibility

18 MMP ID Card

19 Managed Long Term Services and Supports (MLTSS)

20 MLTSS Eligibility Entitled to Medicare Parts A, B, and D; receive full Medicaid benefits but have opted out of MMP Receive either HCBS Waiver Services or reside in a LTC facility Exclusions: Individuals enrolled in American Indian/Alaskan Natives Program Individuals in the Illinois Breast and Cervical Cancer Program Individuals in spend-down Individuals with Third Party Insurance Individuals with presumptive eligibility

21 MLTSS ID Card

22 22

23 Ambetter health insurance plans are designed to deliver high quality, locally-based healthcare services to our members. Established to deliver quality health insurance through local, regional and community-based resources, our Ambetter products are offered by the Centene Corporation. Centene is a Fortune 500 company with over 30 years in the managed care industry and a robust portfolio of specialty health solutions. Ambetter is certified as a Qualified Health Plan issuer on the Health Insurance Marketplace. 23

24 Local, Helpful, Affordable Local presence of the health plan customer service by people that live and work in the community Easy to understand and helpful from enrollment through membership Ambetter helps our members navigate their healthcare Medical management programs 24/7 Nurse line 24

25 Plan Design Philosophy Focus on offering plans with affordable premiums that will also keep your clients out of pocket costs down Maximize Advance Premium Tax Credits (APTC)/ Cost sharing reductions; Low deductibles and copays as low as $1 for highly subsidized members Ambetter s exclusive provider network has strong discounts with select providers 25

26 Ambetter Plans We offer comprehensive major medical plans that use our ever expanding network Diverse portfolio with products for every type of customer. Every plan is eligible My Health Pays program Annual physical covered at 100% for all members on all plans Annual check up with OB-GYN covered at 100% on all plans 26

27 Quality Initiatives

28 HEDIS Measures HEDIS = Healthcare Effectiveness Data and Information Set Developed by the National Committee for Quality Assurance (NCQA) Standardized performance measures Measure the quality of health care services provided by IlliniCare Health Rates calculated on claims/encounter data

29 HEDIS Goals Health Risk Screening within 90 days Annual PCP visit Annual dental visit Annual flu vaccine Comprehensive diabetes care (HbA1c, ACE/ARB, etc.) Colorectal cancer screening Breast cancer screening Cervical cancer screening Adult BMI assessment Congestive heart failure care (ACE/ARB, beta, etc.) Coronary artery disease care (cholesterol, beta, etc.) Hospital admissions due to UTIs and bacterial pneumonia LTC stage II pressure ulcers

30 Prior Authorization

31 Prior Authorization Requirements Prior Auth. required for: In-patient admissions Some out-patient surgeries High-tech radiological services (NIA: Biopharmaceutical medications All out-of-network non-emergency services and providers

32 Prior Authorization Check Tool Go to website Under For Providers select Prior Auth Check Prior Auth Check Tool is categorized by specific Illinicare products

33 Prior Authorization Check Tool

34 Utilizing the Provider Authorization Check Tool By Clicking Yes to any of the questions listed, a prompter will automatically state that authorization is required. By Clicking No to any of the questions listed, the check will request additional information ; CPT code for services being rendered. The tool will tell you if authorization is required by a Yes, No or Maybe

35 Utilization Management Send authorizations to: Inpatient Services: (fax) Concurrent Review: (fax) Outpatient Services: (fax) OB Notification: (fax) Utilization Management: (phone)

36 IlliniCare Health Provider Portal Authorizations Click here to create a new authorization

37 IlliniCare Health Provider Portal Authorizations 1.To view a prior authorization request, enter the Authorization or Confirmation Number in the field, and click Search. 2. The prior authorization request will display the status, authorization number, member name, service date ranges, diagnosis, authorization type and service. 3.To view details of a prior authorization request, click the authorization number. Provider can view attached documents submitted with the request by clicking view.

38 IlliniCare Health Provider Portal Authorizations

39 Billing and Claims Overview

40 Centene Claims Timely and accurate ICP and FHP clean claims payment within 7-10 days of receipt Timely and accurate MMP clean claims payment within 14 days of receipt 75% of claims paid within 7-10 days of receipt 99% of claims paid within 30 days

41 Claim Services Timely Filing Guidelines 180 days from the date on which services or items are provided. This time limit applies to both initial and resubmitted claims. Any claim disputes / reconsiderations must be received within 180 days of the DOS or date of discharge, whichever is later. When IlliniCare Health is the secondary payer, claims must be received within 90 calendar days of the final determination of the primary payer. See the provider manual or billing manual for more detailed information about claims and billing.

42 Claims Services Providers can file claims three ways: 1. Paper claims 2. Secure Provider Portal 3. Electronic Clearinghouses (EDI partners)

43 Paper Claims Medical Claims IlliniCare Health Attn: Claims PO Box 4020 Farmington, MO Mental Health Claims Cenpatico Attn: Claims PO Box 7300 Farmington, MO Provider Claim Disputes IlliniCare Health PO Box 3000 Farmington, MO

44 Electronic Clearinghouses Providers can participate in IlliniCare Health s Electronic Claims Filing Program EDI Partner Medical Payer ID# Behavioral Health Payer ID # Availity Emdeon Smart Data Solutions SSI Trizetto Provider Solutions, LLC (formerly Gateway)

45 Contact Information Integrated Care Program (ICP) Family Health Plan (FHP) IlliniCare Health Medicare-Medicaid Plan (MMP) 999 Oakmont Plaza Drive, Westmont, IL Member & Provider Services Member & Provider Services Telephone: (866) (For: eligibility, claims, authorizations, transportation, etc.) Telephone: (877) (For: eligibility, claims, authorizations, transportation, etc.) Authorization Fax: (877) Authorization Fax: (844) Pharmacy: (866)

46 Vendor Information FHP and ICP MMP Cenpatico Behavioral Health Dental Health and Wellness Dental Services OptiCare Vision Services NIA Radiology Services US Script Pharmacy Nursewise 24/7 Nurse Advice Line Nurtur Disease Management MTM Transportation Fax: Fax: Fax: Fax: Fax: Fax:

47 Cultural and Linguistic Competency

48 Cultural Competency A set of interpersonal skills (including, awareness, attitude, behaviors, skills, and policies)that allow individuals to increase their understanding, acceptance, and respect for all cultures, races, and religious and ethnic backgrounds.

49 Linguistic Competency Patients with limited English proficiency experience: Less adequate access to care Lower quality of care Poorer health outcomes Providers must ensure patients have access to medical interpreters, signers, and TTY services to facilitate communication at no cost.

50 Linguistic Competency IlliniCare Health provides: Language Line services 24 hours a day, 7 days a week in 140 languages Information in other formats including Spanish, Russian, Audio, Braille, etc., at no cost TDD/TTY access Translators to your office or the hospital For translation services, call Member Services at or TDD/TTY:

51 Patient Privacy, Confidentiality & Security

52 Patient Privacy, Confidentiality & Security The Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, & Breach Notification Rules: Privacy: HIPAA Privacy Rule was established to protect individuals health (PHI) and personal information (PII) and to give patients rights with respect to how their information can be used and disclosed. Security: HIPAA Security Rule ensures safeguards that Covered Entities and Business Associates must implement to protect electronic PHI (ephi). Breach Notification: This requires Covered Entities to notify affected individuals, HHS, and in some cases, the media of breaches of unsecured PHI.

53 Fraud, Waste and Abuse (FWA)

54 Preventing FWA Fraud: Fraud is intentionally or knowingly submitting false information to the Government or a Government contractor to get money or a benefit to which you are not entitled. Fraud can be committed by a provider or a member. Waste: The overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is not generally considered to be caused by criminally negligent actions but rather by the misuse of resources. Abuse: This includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.

55 Critical Incidents: Abuse, Neglect & Exploitation Reporting Overview

56 Critical Incidents Types of Critical Incidents: Abuse Physical Abuse Sexual Abuse Mental Abuse Neglect Exploitation

57 Signs of Abuse, Neglect or Exploitation Abuse by Caregiver: Prevents member from speaking or seeing others Anger, indifference, or aggressiveness towards members Lack of affection Conflicting accounts of incidents Talk of member as a burden History of substance abuse, mental illness, or violence Financial Exploitation: Sudden changes in bank account Unexplained withdrawal of money Adding additional names on bank account Unapproved withdrawals of money Unpaid bills despite having enough money These signs are not necessarily proof of abuse or neglect. But they may be clues that a problem exists.

58 Reporting Critical Incidents Office of Inspector General: IlliniCare Health Provider Services: Department on Aging: Senior Help Line: Department of Public Health: