Provider Training Tool & Quick Reference Guide for Cigna-HealthSpring

Transcription

1 Provider Training Tool & Quick Reference Guide for Cigna-HealthSpring

2 Table of Contents I. mynexus Overview II. Services Requiring Authorization III. Obtaining Authorizations IV. Request for Additional Home Health Care Services V. Claim Submission a. Claims Guidelines b. Claim Inventory Report c. Remittance Advice d. Prompt Payment e. Claim Mailing Address f. Electronic Claim Submission g. Electronic Payments VI. Contact Information

3 I. mynexus Overview mynexus provides a Home Health Benefit Management Program created and designed to ensure the delivery of high quality, cost effective home health care for members of contracted health plans. The primary purpose is to provide timely evaluation and provision of requested home health services that are medically necessary and appropriate for members that are in the contracted health plan benefit plan. Our Core Operating Principles are: Fun & Engaging Workplace We have fun at work and expect all employees to be engaged in the mynexus Team. Our employees will have purpose and make a difference, because at mynexus, everyone matters. II. Services Requiring Authorization i. Skilled nursing care ii. Physical, Speech and Occupational Therapy iii. Home health aide services Compassion for Our Customers & Our Co-workers we care about others and show it in all that we do. iv. Wound Care and wound care supplies while skilled services are being provided. Service to the Communities in Which We Work and Serve We are good stewards of our resources, protect the environment and give back to our communities. v. Social Worker evaluations Pursuit of Excellence & Innovation We work towards being the best we can be; offering the best available services and technology to our customers; learn from our mistakes and celebrate our successes. viii.power wheelchair evaluations Commitment to Honesty & Integrity We always do the right thing, and expect that will lead to the best results. Results for our Customers & Our Shareholders We make decisions and take actions to provide our customers and our investors with the best outcomes. Health & Empowerment We promote health and empowerment for our employees and customers, being the best we can be, every day. vi. Patient/Caregiver education vii. Mental health nursing III. Obtaining Authorization The referral authorization process in an important component of mynexus s Home Health Benefit Management Program. The referral authorization process must be used by all referral sources (case managers, MD s, etc.) to assure that the member receives the maximum benefit and that claim(s) are considered for benefits in a timely manner and processed correctly. Service authorization requests should be faxed to mynexus using the Authorization Request Form. 1

4 mynexus will review all orders and select the most appropriate participating provider and issue an authorization for the service(s) to be rendered to the patient. All services require clinical review, assignment and prior authorization. mynexus s referral authorization process: confirms member eligibility, member benefits insures the services are reasonable for the treatment of the illness or injury, and, meets all applicable medical, health plan and regulatory criteria. Once a participating provider has accepted the patient for service, an authorization is issued and a mynexus Referral Authorization Form is sent to the home health care provider outlining the specific service being approved. The Referral Authorization Form is accompanied by the doctor s order and pertinent patient information including any member financial responsibility. The referring provider will receive a Service Notification Letter with confirmation of the authorization. The Referral Authorization Form contains; patient information, ordering provider information, clinical information, and special comments along with service date ranges and CPT4/HCPC codes and/or Revenue codes for the specific services being authorized. The authorization number remains in effect until the patient is discharged. See attached sample Referral Authorization Form. 2

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6 Participating Providers must notify mynexus immediately if services are unable to be provided for any reason. For example, a patient may not be home or the patient refuses services. The authorization process and the claims processing are closely linked. Claims are considered for benefits based on CPT4/HCPC or Revenue Codes and units authorized. Submission of accurate claims information in a timely manner is an essential part of the participating provider s role. The appropriate authorization number must be submitted on all claims. A claim submitted without an authorization number may be rejected and/or denied. IV. Request for Additional Home Health Care Services The referral re-authorization process is an important component of mynexus s Home Health Benefit Management Program. The Clinical Recommendation and Status Report Form must be used by all participating home health care providers to assure that the member receives on-going services beyond mynexus s initial referral authorization. After the member has been treated by a participating provider, their findings, diagnosis and recommendations should be faxed to the mynexus Intake Department using the attached Clinical Recommendation and Status Report Form. After the member has been seen by a participating provider and the provider desires to request additional covered medical services, the Clinical Recommendation and Status Report Form will be used to evaluate and process requests for on-going treatment/services. Failure to provide the Clinical Recommendation and Status Report Form could result in your patient s requested covered medical services being delayed and or claims payment denied. mynexus s Clinical Team will review the Clinical Recommendation and Status Report Form for medical necessity and or benefits coverage and extend existing referral authorization. The extension of medically necessary treatment/services will be authorized according to specific CPT4 Codes, HCPC code(s), Revenue code(s), units and date ranges. The initial authorization number will remain in effect until the patient is discharged. See Attached: Clinical Recommendation and Status Report Form 4

7 V. Claim Submission a. Claims Guidelines Participating providers should submit all claims on a CMS/HCFA 1500 Health Insurance Claim Form or UB04 Form. mynexus has the following guidelines: An original form is required with any submission For timely filing, claims must be received no later than one hundred and twenty (120) days after the date of services were rendered per your agreement. Claims received thereafter will be denied for late submission. Provider may only collect applicable co-payment(s), co-insurance and deductible(s) from members at the time services are rendered. Provider agrees to accept contractual reimbursements from mynexus as payment in full and will not bill the member for any covered services. mynexus will pay based on the contractual agreement minus any applicable member financial responsibility Complete all applicable boxes on the claim form and each covered service must be itemized on a separate line to expedite payment of your claims. For payment to be made directly to the provider, the following items are required: o Patient s original signature, or Signature on File or Assignment on File stamped or typed and dated. o Provider must maintain on file a valid written Assignment of Benefits from the member. This will serve as evidence that the provider is entitled to all payments for billed covered services. All documentation or information related to COB, third party liability, etc. should be attached to the CMS/HCFA 1500 Claim Form or UB04 Form for prompt adjudication of claim. b. Acknowledging Claims Received-Claims Inventory Report Paper Claims: mynexus will provide acknowledgement of receipt of claims within 15 days after receipt of the claim via mynexus s Claims Inventory Report for paper claims. The Claims Inventory Report will be sent to each participating provider from whom claims have been received two (2) weeks prior. The Claims Inventory Report will be printed by the participating provider and include the following fields. Date claim was received Patient insurance group Insured s name Patient ID number Dependent information (if applicable) Incurred date Claim number Charged/Billed amount Participating Providers are encouraged to review the Claims Inventory Report carefully. Electronic Claims: For electronically submitted claims, providers will receive an electronic acknowledgement transaction report directly from the clearinghouse within 24 hours of claim submission. c. Remittance Advice The mynexus claims processing policies, procedures, and guidelines are set in accordance with applicable state and Medicare/Medicaid statutory requirements for timely payment of claims. All fee-for-service reimbursement will be sent to participating provider with a remittance advice. d. Prompt Payment mynexus claims processing policies, procedures and guidelines follow the current applicable state and Medicare/Medicaid requirements. A clean claim is processed promptly within statutory guidelines. e. Claim Mailing Address(s): Participating Providers should mail CMS/HCFA 1500 claims forms or UB04 Forms to: mynexus P.O. Box 213 Brentwood, TN All Claim Appeals should be mailed to: mynexus Attn: Claim Appeals P.O. Box 991 Brentwood, TN f. Electronic Claim Submission In addition to submitting paper claim(s), participating providers may also submit claims electronically to mynexus. To submit claims electronically Register with Emdeon (mynexus s clearing house) by calling: Reference Payer ID# Once registered, Emdeon will provide support on submitting claims electronically. 5

8 g. Electronic Payments mynexus does offer an EFT/ERA payment option. To enroll for EFT payments, please complete and submit the EFT Application Form. This form can be downloaded from our website at the link below: VI. mynexus Contact Information mynexus P.O. Box 991 Brentwood, TN (Customer Service) (Fax number) 6