Participating Provider Network Orientation. Provider Experience

Transcription

1 Participating Provider Network Orientation Provider Experience

2 Introduction Kaiser Permanente is an integrated healthcare delivery system. We are a healthcare provider and we offer medical services at our medical centers and through affiliated Participating Providers throughout the Mid-Atlantic region. 2 July 2018

3 Kaiser Permanente Medical Centers Behavioral Health Care Critical Decision Unit Primary & Specialty Care 30 Medical Centers Ambulatory Surgery Centers Pharmacy, Labs, Radiology, etc. Urgent Care Urgent Care Centers District of Columbia Capitol Hill (24hr HUB) Maryland Camp Springs Gaithersburg (24hr HUB) Kensington Largo (24hr HUB) Baltimore Harbor South Baltimore County (24hr HUB) White Marsh Virginia Fredericksburg Manassas Reston Tysons Corner (24hr HUB) Woodbridge 3 July 2018

4 Contracted Resources Contracts Affiliated Hospitals Kaiser Permanente Care Management staff at certain locations Physician Contracts Primary Specialty & Multi-Specialty Hospital Faculty Behavioral Health Urgent Care Ambulance Ancillary Services Laboratory Kaiser Permanente Medical Centers Quest Diagnostics Radiology Kaiser Permanente Medical Centers For a complete list of Participating Radiology Providers, please refer to the Kaiser Permanente Provider Manual, Chapter 12 4 July 2018

5 Membership Washington, DC Total Membership: 780,000* Baltimore City/County (includes Anne Arundel, Carroll, Harford and Howard Counties) Northern Virginia (Including Culpeper and Stafford Counties) *as of January 2018 Suburban Maryland and Frederick 5 July 2018

6 Product Overview Product Signature TM Select TM Added Choice TM Flexible Choice TM Medicare Plus Medicare Advantage Exclusive Provider Organization Virginia Medicaid & FAMIS Maryland HealthChoice Description HMO HMO 2-Tier Point of Service Plan 3-Tier Point of Service Plan Medicare Cost Plan Medicare Risk Plan Self-Funded Plan Virginia Medicaid Plan Maryland Medicaid Plan 6 July 2018

7 Signature TM Traditional HMO plan Services are accessed at Kaiser Permanente Medical Centers. Care is provided by Mid-Atlantic Permanente Medical Group (MAPMG) physicians. Referral/authorizations are required for specialty care Approved referrals are required for hospital care and other facility services Medical Advice/ Appointments Pre-certification (fax) Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

8 Select TM Traditional HMO plan Services are accessed at Kaiser Permanente Medical Centers and through Participating Providers within our service area. Members may choose a PCP from a Kaiser Permanente Medical Center or within our Participating Provider network. The PCP coordinates care. Referral/authorizations are required for specialty care Approved referrals are required for hospital care and other facility services Medical Advice/ Appointments Pre-certification (fax) Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

9 Added Choice TM 2-tiered plan HMO and OON HMO MAPMG (Signature TM ) or MAPMG & Participating Provider Network (Select TM ), copays apply OON Any licensed provider, deductibles and coinsurance apply *certain OON services may require pre-certification Medical Advice/ Appointments Pre-certification Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

10 Flexible Choice TM Administered by Kaiser Permanente Insurance Company (KPIC) 3-tiered plan HMO, PPO and OON HMO MAPMG (Signature TM ), copays apply PPO PHCS and MultiPlan providers, deductibles and coinsurance apply OON Any licensed provider, deductibles and coinsurance apply HMO Tier Medical Advice/ Appointments Pre-certification Member Services Claims: Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO Precertification Member Services Claims PPO & OON Tier KPIC P.O. Box Plano, TX July 2018

11 Flexible Choice TM Tier 1: HMO Signature Delivery System, referral/authorization rules apply Tier 2: PPO PHCS and MultiPlan Network Providers Care is selfdirected but some pre-certification is required. Deductible, coinsurance apply; no balance billing Tier 3: OON Any other licensed provider. Care is self-directed through licensed providers; some require pre-certification. Higher deductibles; coinsurance for all except emergencies. 11 July 2018

12 Medicare Plus TM Acts as a supplemental plan for Medicare when services are coordinated and authorized by Kaiser Permanente Part A Kaiser Permanente is secondary Part B Kaiser Permanente is secondary when services are accessed outside Kaiser Permanente Medical Centers Medicare must be billed primary If a member is not eligible for Part A, Kaiser Permanente should be billed as primary If a member chooses to access care outside of Kaiser Permanente, they must use their traditional Medicare benefits Traditional Medicare deductibles and co-insurance apply and are the member s responsibility Kaiser Permanente will not be responsible for unauthorized services For authorized services provided by contracted or noncontracted providers Providers send the full bill to Medicare directly Once Medicare has paid its portion, the claim is forwarded to Kaiser Permanente to pay the remaining allowable amount (minus any member responsibility) 12 July 2018

13 Medicare Advantage Members must already have Parts A & B Part D (prescription drug coverage) is included in all Kaiser Permanente Medicare Advantage plans Services are accessed at Kaiser Permanente Medical Centers and the Kaiser Permanente Medicare Advantage Network. Approved referral/authorizations are required for specialty care, hospital care and other facility services Medicare Advantage plans available in DC and MD (Harford, Baltimore, Baltimore City, Howard, Montgomery, Anne Arundel, and Prince George s counties) Kaiser Permanente must be billed as primary Medical Advice/ Appointments Pre-certification (fax) Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

14 Exclusive Provider Organization (EPO) Self-Funded plan administered by KPIC Mirrors the HMO Signature TM product Health Reimbursement Account employer owned savings account for use by members with high deductible plans. Members pay for patient liability using an employer provided Visa debit card. Medical Advice/ Appointments Pre-certification Member Services Claims KPIC Self-Funded Claims Administrator P.O. Box Salt Lake City, UT July 2018

15 Virginia Medicaid and FAMIS Virginia Medicaid Kaiser Permanente Managed Care Organization (MCO) HMO MAPMG (Signature TM ) and Virginia Medicaid Participating Provider Network Use the Kaiser Permanente Medical Record Number when billing Kaiser Permanente Medical Advice/ Appointments Pre-certification Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

16 Maryland HealthChoice Maryland Medicaid MCO HMO MAPMG (Signature TM ) and Maryland HealthChoice Participating Provider Network Use the Kaiser Permanente Medical Record Number when billing Kaiser Permanente Medical Advice/ Appointments Pre-certification Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

17 Exchanges Mirrors the Signature TM plan Identification cards are similar to the Signature TM plan cards with the exception of Capitol Hill employees Medical Advice/ Appointments Pre-certification (fax) Member Services Claims Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO July 2018

18 Referrals and Authorizations Utilization Management Operations Center (UMOC) Referral Management Unit: 8:00am 4:30pm, weekdays Home Care/DME Unit: 8:30am 5:00pm, weekdays Concurrent Review Unit: 8:30am 5:00pm, weekdays Emergency Care Management (ECM): 24/7, 365 days/yr. Referrals, Authorizations, Hospital Observation & Inpatient Admissions Online Affiliate General Number (listen for prompts) Fax Numbers: Specialty Care Referrals Concurrent Review Homecare/DME (Please send clinical information) July 2018

19 Referrals and Authorizations Utilization Management Operations Center (UMOC) Pre-service review is required for selected procedures and services List of self-referred services and services requiring pre-service review can be found in the Kaiser Permanente Provider Manual Call the UMOC for notification of observation and inpatient admissions Specialty Care Referrals Initial consultation Referral must be authorized by PCP or Specialist Referral valid for 90 days (3 months), or as otherwise specified on the referral Additional visits (specialist may initiate extension of referral) by: Faxing request (Uniform Referral Form) to the UMOC at , or Calling UMOC at and following voice prompts to request additional visits Remember you do not have to call the PCP to request additional visits, call the UMOC number above 19 July 2018

20 Claims and Billing Procedures Billing address for fully-funded plans: Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO Billing address for Flexible Choice TM plan tiers 2 & 3: Kaiser Permanente Insurance Company P.O. Box Plano, TX Billing address for Self-Funded plan: KPIC Self-Funded Claims Administrator P.O. Box Salt Lake City, UT Clearinghouse for electronic claims: Emdeon Payor ID: Fully-Funded Payor ID: Self-Funded Timely Filing: 180 days (6 months) from date of service Timely Appeals: 180 days (6 months) from date of denial Clean Claims : standard format/completed fields, attachments, current industry standard data coding All patient services must be billed on CMS1500 or UB04 Explained in detail Chapter 8 of Provider Manual 20 July 2018

21 Member Enrollment Open enrollment period occurs annually. Member may change their PCP at any time by selecting a PCP from the directory and calling Member Services. Changes made before the 20 th of any given month are effective the first of the following month. Changes made after the 20 th are effective the first of the second following month. Please see our Provider Manual for additional assistance available to Members. 21 July 2018

22 Compliance and Regulatory Policy Kaiser Permanente is committed to meeting compliance and regulatory policies enforced by federal, state/local government and health plans. For questions regarding compliance policy or to obtain a copy of the Kaiser Permanente compliance guide, Principles of Responsibility, please call Provider Relations at or visit 22 July 2018

23 Quality and Health Management KPMAS Quality of Care and Service Program addresses all medical, behavioral health and provider service to internal/external customers. Call Member Services at for more information. Providers are credentialed upon initial application and recredentialed every three (3) years. Site visits are conducted at initial and re-credentialing processes or as needed when a deficiency is identified. Please see the Provider Manual for more quality measurement standards. 23 July 2018

24 Online Resources Community Provider Portal (CPP) Provider Manual Provider directories Clinical guidelines Network newsletters Download forms Trainings News and announcements KP HealthConnect Online Affiliate Secured web-based application. Secured user ID needed. View member demographics Verify member eligibility View benefits View Kaiser Permanente medical records Check claim status 24 July 2018

25 Resources and Services Provider Relations CPP: Provider Manual, Provider Directory, forms for provider data changes, enrollment in KP HealthConnect Online Affiliate Contract questions, orientation and training Provider appeals (written form only) Claims/Member Services Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box Denver, CO Provider claims inquiries Benefits and eligibility Automated eligibility & copay line Member appeals and grievances Behavioral Access Unit (self-referred) July 2018

26 Resources and Services UMOC Referrals, authorizations, hospital observation & inpatient admissions General number Fax numbers Specialty Care Referrals Concurrent Review Homecare/DME Self-Funded Members Eligibility and Benefits Member-related issues Provider claims inquiries and disputes Referrals and authorizations follow voice prompts 26 July 2018

27 Thank you for participating with Kaiser Permanente Questions? If you have any questions regarding this presentation please contact Provider Experience at or us at 27 July 2018