Paramount Advantage. Facility Orientation

Transcription

1 Paramount Advantage Facility Orientation

2 Overview Paramount Advantage Toledo-based Ohio Managed Care Plan (MCP) Established 1993 Provides health care coverage to Covered Families and Children (CFC) Aged, Blind, or Disabled (ABD) All counties in the State of Ohio Member of ProMedica Accredited by NCQA (National Committee for Quality Assurance) 2

3 Overview Paramount Advantage As of , serving 94,437 Covered Families and Children (CFC) members in NW Ohio Highest overall member satisfaction rating of all Medicaid care coordination plans in Ohio since 1995 Highest ranked plan in the State of Ohio by NCQA/Consumers Report in 2009, 2010, and

4 Who to Call at Paramount DEPARTMENT ASSISTANCE AVAILABLE PHONE FAX Credentialing New Provider Applications Recredentialing Questions Member Questions Member Services PCP Change Requests Interpreter Services TTY Provider Inquiry 8:30AM 12N 1:00PM 5:00PM Monday Friday Member Benefits & Eligibility Claim Status Inquiries Claim Processing Issues Claim Adjustment Provider Relations Representatives Education - Provider & Office Staff Contract Issues Orientations/Webinars New Product Participation Requests Representative Office Visit Requests (Toledo) (Cincinnati, Cleveland, Columbus) Utilization/Case Management 8:00AM 6:00PM Monday-Friday Obtaining In-Plan & Out-of-Plan Prior Authorizations

5 Website Resources Provider Manual provider source for detailed information Paramount Advantage Provider Manual ALSO. Provider News & Bulletins Network Newsletters Provider Directory Product Information 515 5

6 Electronic Claims Submission Providers are encouraged to submit routine claims electronically For questions related to electronic claims submissions, contact our Electronic Claims Submissions Coordinator: Phone: HIPPA compliant Electronic Vendors/Clearinghouses List Provider Manual Page 8.1 Example of Electronic Claims Report Provider Manual Page 8.2 How to review rejected claim reports for correction and resubmission. Provider Manual Page 8.3 6

7 Electronic Payment & Remittance Services Emdeon Paramount is contracted with Emdeon to deliver Electronic Funds Transfer (EFT) services and Electronic Remittance Advice (ERA) files in PDF image format Enrollment is simple: Call and select Option 1 Visit Payment remittance data is delivered electronically via Emdeon payment manager by which each remittance can be viewed and printed Existing Electronic Fund Transfer customers with Emdeon may add Paramount: Call Option 2 Provider Manual Page

8 Claim Adjustments & Coding Review Requests One Form Paramount utilizes one form for adjustments and appeals Claim Adjustment/Coding Review Request Form may be found at Claim Adjustment Coding Review Request In late 2013 submission of adjustment requests will be available electronically through the Paramount website Coding Review Requests require a copy of the EOP and any of the following: CPT coded chart notes CPT coded operative notes or CPT coded diagnostic reports 8

9 Provider Direct Paramount s Interactive Website Secure online access to health plan information for our members Eliminates calls to Paramount for our providers Connect from anywhere, day or night Fully compliant with all HIPAA privacy standards To obtain access, complete Provider Direct Login Request Form available at Provider Direct Login Request Form 9

10 Member Identification Card Front Back 101

11 Diagnostic Imaging Prior Authorization Requirements The following procedures require authorization of elective, outpatient imaging studies prior to the study being done for claim payment CT Scans MRIs MRAs Nuclear Cardiology CTA Coronary Arteries Imaging studies done as part of an ER room visit or inpatient stay do not require prior authorization PET/CT scans do not require prior authorization 11

12 Diagnostic Imaging (continued) Requesting Prior Authorization To request prior authorization, use the Outpatient Imaging Prior Authorization Fax Request Form available at Outpatient Imaging Prior Authorization Fax Request Form Or, Clear Coverage - web-based prior authorization system for providers to submit Imaging requests Immediate approval (if criteria are met) Complete the form on website if you wish to become a Clear Coverage user 12

13 Web-based Prior Authorization Tool McKesson s Clear Coverage For CT, CTA of Coronary Arteries, MRI, MRA, and Nuclear Cardiology Automates authorization process Provides an instant determination Utilizes InterQual Criteria sets for medical necessity determinations New users may obtain a login online at Clear Coverage Login Request 13

14 Prior Authorization Requirements Some procedures, diagnostic services and drugs require Prior Authorization for Paramount Advantage members Prior Authorization List Prior Authorization is obtained by contacting Utilization Management Phone Fax

15 Interqual Criteria Paramount s Utilization Management Program uses the most current edition of the McKesson Interqual Criteria Interqual Criteria are applied when reviewing the appropriateness of: Inpatient acute care admissions Mental health & chemical dependency partial hospitalization Intensive outpatient services Genetic testing Elective outpatient imaging studies Adult Procedures Pediatric Procedures Behavioral Health 15

16 Inpatient Admissions Required to notify Paramount by the next business day following admission Fax preferred but phone calls accepted Clinical Review must be provided Send admitting face sheet with patient demographic information along with clinical review Authorization number with length of stay will be received from Paramount within one business day Concurrent review will be required on the expiration of the Paramountassigned length of stay Promptly fax or call in clinical information on the expiration date Weekend & holiday expiration dates faxed/called the following business day 16

17 Some Procedures Require Prior Authorization Some procedures require prior authorization: Bariatric surgery Reduction mammoplasty Orthognathic/maxillofacial surgery Potentially cosmetic surgery For a full listing, reference Paramount s prior authorization list: Prior Authorization List 17

18 Observation Stays Observation stay less than 48 hours Paramount does not need to be notified Observation stay over 48 hours: Should be converted to inpatient stay Must meet admission criteria for payment Paramount must be notified Fax is preferred method, phone calls are accepted 18

19 Post-discharge Telephone Calls Paramount makes calls to all of our members to ensure appropriate transition to the home setting The content of the phone call will include confirmation that: Discharge plans are being followed Prescriptions are filled Follow up appointments are made 19

20 Thank you for your attention Questions??