BMS/Molina 2017 Fall Presentation HEALTHPLAN.ORG

Transcription

1 BMS/Molina 2017 Fall Presentation HEALTHPLAN.ORG

2 Introductions Christy Donohue, Director, Medicaid Roxanne Loughery Manager, Network Support Services

3 Corporate Office Update THP s corporate office is coming back to WV 400 employees will make the move to: 1110 Main Street Wheeling, WV Toll-free numbers will remain the same Direct telephone numbers with 740 exchange will change

4 Medicaid Updates HEALTHPLAN.ORG

5 Medicaid Prior Authorization Prior authorization required before a service is rendered Includes outpatient & inpatient services Authorization required next business day for after hours, weekend or holiday services Authorization requests received after next business day will not be processed Failure to follow prior authorization guidelines will result in denied claims Non-participating providers must obtain prior authorization in order for claim to be reimbursed

6 Drug Testing Policy Policy Reminder: Effective January 1, 2017, THP is following Medicaid s policy for drug testing. Maximum one presumptive urine drug test per member per DOS Maximum one definitive urine drug test per member per DOS Limit 24 screens per member/per calendar year WITHOUT prior authorization) Prior authorization required for > 24 drug screens in a calendar year

7 Drug Medicaid Testing Updates Policy Per BMS contract, MCOs are required to only reimburse rebateable J Codes/NDC codes Effective September 1, 2017, THP will follow same processing guidelines as fee-for-service Updates have been made to the Medicaid section of the Provider Manual (Section 5_25 Miscellaneous Items) DRG payment based upon discharge date PT/OT modifiers Claims not payable w/o appropriate modifier

8 Medicaid Updates RBRVS fee schedule claim adjustments occurring Front end editing software - future effective date Readmissions to same facility w/i 24 hours handled as one inpatient stay One DRG will be reimbursed

9 Dental Updates Revisions to adult dental guidelines effective July 1, 2017 Documentation required If extracting > three teeth on same DOS Submit with claim to support emergent/urgent Wisdom teeth excluded unless emergent/urgent Documentation required for all wisdom teeth extractions

10 THP Dental Network Contracting for THP Dental Network is underway Dental provider network to service D-SNP & Commercial members Jessica Legg is the contact person or

11 Overpayments When submitting refunds to The Health Plan: Include a copy of the payment voucher circling or underlining the claim Include the reason for the overpayment Submit refunds to: The Health Plan 1110 Main Street Wheeling, WV

12 Sample ID Cards HEALTHPLAN.ORG

13 Mountain Health Trust/TANF ID Card Medicaid ID card re-design includes color and formatting changes Notice group number for MHT population Note TANF logo Contact for Pharmacy benefit

14 WV Health Bridge ID Card Group number for Bridge population Note WV Health Bridge logo

15 SSI ID Card Note SSI Group Number Note new mailing address for claims SSI also has the TANF logo

16 Network Updates HEALTHPLAN.ORG

17 Provider Policy Change Nurse practitioners are permitted to be chosen as PCPs Must contact THP and request PCP status No auto assignment Listed separately in THP Provider Directory Physicians assistants are now permitted to be ordering provider Labs MRI/MRA

18 Behavioral Health HEALTHPLAN.ORG

19 Behavioral Health Updates Currently revising the Behavioral Health Provider Manual BH Contracting and Credentialing ALL BH & medical providers required to enroll in Medicaid fee-forservice (FFS) to service Medicaid members by 1/1/18 Although required to enroll in FFS, providers not required to service FFS members May choose FFS only, MCO only or both Value-add providers (LGSW, LSW, LISW, etc.) enroll for MCO only Until enrolled in FFS providers may not service Medicaid members

20 PCPs Treating Depression PCPs are encouraged to evaluate patients for depression Adopted guidelines available on website: "Treatment of Patients with Major Depressive Disorder published by the American Psychiatric Association: psychiatryonline.org/guidelines "Adult Depression in Primary Care published on the National Guideline Clearinghouse site: guideline.gov/content Contact Behavioral Health Services Department for assistance for referral to a behavioral health provider Call Behavioral Health Services Department 24 hrs/day at

21 D-SNP/FWA HEALTHPLAN.ORG

22 What is SNP? Special Needs Program A Medicare Advantage plan Available to populations with special needs within the overall Medicare population

23 Coordination of Medicare & Medicaid D-SNP Members have benefits under both Medicare and Medicaid Member ID card identifies as DSNP Treat as COB Bill THP primary Bill copays, coinsurances and deductibles to fee-for-service Member has $0 responsibility

24 Member Rosters Reminder to PCPs and OB/GYNs to work member rosters Rosters have keys to LOB Reminder not to collect copay/coinsurance/deductible from D-SNP members Opportunity to gain new patients

25 Fraud, Waste & Abuse Providers are required to complete FWA training annually For specific requirements, expectations and helpful links, refer to our website at The Health Plan tracks network providers to ensure the required training has been completed Proof of training must be submitted to The Health Plan A dated sign in sheet is acceptable Proof of compliance training is to be maintained for 10 years after contract termination

26 Claims Information HEALTHPLAN.ORG

27 Claims Electronic claims accepted Claims submitted via secure provider website Register at Paper claims are accepted, HOWEVER Red and black claims only No black and white claims Mailed or faxed B&W claims are not accepted THP scanner cannot read info in each block

28 Mailed Claims New mailing address for paper claims: The Health Plan 1110 Main Street Wheeling, WV DO NOT MAIL PAPER CLAIMS TO MORGANTOWN OR CHARLESTON OFFICE ADDRESSES

29 Resubmission Policy HEALTHPLAN.ORG

30 Resubmission of Claims/Paper When resubmitting a claim that has been denied, include the following: A new CMS 1500 form and/or UB form A copy of the payment voucher Explanation and/or additional documentation why the claim is being resubmitted Indicate on the claim form Corrected Claim or Resubmitted Claim Contact Customer Service or Provider Relations for assistance on why claim denied and how to resubmit your claim Mail claims to the Wheeling, WV address 180 days to resubmit

31 Resubmission of Electronic Claims Place reason code 7 in the claim information 2300 Loop Segment CLM05 Claims received with this code will be processed as a replacement or resubmitted claim Indicate the original claim number in the free text field Place reason code 8 in the claim information 2300 Loop Segment CLM05 to VOID a claim Indicate the original claim number in the free text field Failure to follow the resubmission guidelines or designating your claims as corrected or resubmitted could result in a denial for duplicate

32 Electronic Communication HEALTHPLAN.ORG 32

33 Provider Portal Public website - Billing and claims information Forms Find a provider Provider newsletters ProviderFocus quarterly notification sent when available Compliance documents Provider Secure Portal accessed via public website Claims submission Claims and referral status Vouchers Member rosters Member eligibility Pre-authorizations January 1,

34 Automated s Automated s notify providers of changes, updates & ProviderFocus newsletter Multiple s can be stored Contact Provider Relations or EDI Department to add address s are not secure Do not use PHI Use only the claim # or ID # 34

35 Accessibility and Availability of Care HEALTHPLAN.ORG 35

36 Standards for Timeliness Urgent care must be seen within 48 hours Routine care must be seen within 21 days Other than clinical preventive services An initial prenatal care visit scheduled w/i 14 days of the date on which the woman is found to be pregnant

37 Accessibility and Availability of Care Par providers required to maintain 24/7 telephone access for their patients Provider responsible for on-call and after-hours coverage THP standard for returning a member call is 30 minutes Ensure your staff is familiar with the Appointment Accessibility and Availability Standards Visit THP website at & services/quality-measures for addt l guideline information 37

38 HEDIS & Medicaid Incentives HEALTHPLAN.ORG

39 What is HEDIS? Healthcare Effectiveness Data and Information Set Consists of 88 measures Standardized way to measure and compare Used by employer groups, CMS, BMS, etc. for standardized measurement

40 Importance of HEDIS? The foundation for: Quality Initiatives Submitted to CMS, BMS, NCQA Accreditation Required for our Medicaid contract Plan Comparison Employer groups, individuals, MCOs, provider profiling

41 Contact Information HEALTHPLAN.ORG

42

43 THANK YOU We would like to take this opportunity to thank you for partnering with The Health Plan. We appreciate the quality health care services that you provide for our members.