PARTNERS HEALTH PLAN PHP CARE COMPLETE FIDA-IDD. TRAINING FOR DEVELOPMENTAL DISABILITIES PROVIDER NETWORK June 16, 2017

Transcription

1 PARTNERS HEALTH PLAN PHP CARE COMPLETE FIDA-IDD TRAINING FOR DEVELOPMENTAL DISABILITIES PROVIDER NETWORK June 16, 2017

2 AGENDA Welcome & Introduction Care Management/Interdisciplinary Teams (IDT)/Life Plans Enrollment/Service Authorizations/Claims Submission/Payment Options MediSked & HS Portals

3 PHP MISSION AND VALUES Mission: PHP is a person-centered organization that supports members to live the life they choose. Values: PHP Promotes Wellness PHP Supports Choice PHP Integrates Services PHP Respects Diversity PHP Promotes Quality of Life 3

4 FIDA IDD: PHP Care Complete Fully Integrated Dual Advantage (FIDA) Must be dually eligible (Medicare/Medicaid) Federal Demonstration project FIDA-IDD for dually eligible individuals who are 21 or older, eligible for OPWDD services; meet ICF/IDD level of care Benefit package includes Medicare A & B; Part D; Medicaid drugs; LTSS; all DD services No cost-sharing (deductibles/co-payments/co-insurance) Only FIDA in the country exclusively for people with IDD

5 SERVICE AREA 9 COUNTIES: Bronx Kings Nassau NY (Manhattan) Queens Richmond (Staten Island) Suffolk Rockland Westchester

6 THE CARE COORDINATION TEAM The individual has a two person team, specific to their needs: A Clinical Care Manager (CM) is a RN, or a clinically licensed SW or Psychologist. The CM administers PHP s comprehensive IAM assessment, develops and oversees the life plan with the member and their IDT, and provides additional medical or clinical oversight. They also provide additional contacts and home visits, supports to the families, transition planning, hospital/er follow-ups, etc. A Care Coordinator (CC), must be a QIDP and is trained as a POM interviewer. The CC administers the POM interviews, also assists with additional assessments, accesses and monitors member services/supports, provides member/family contacts and conducts non clinical care coordination activities, such as scheduling appointments, monitoring Medicaid/Medicare eligibility, scheduling non emergency transportation, etc.

7 SUMMARY OF THE PHP MODEL OF CARE Eligibility IDT Team Meeting with member Individualized Assessment Implement the Life Plan Stratification Living situation Health and Behavior Needs/Challenges Individualized Service Plan called the Life Plan integrates IPOP requirements and POM results Allows for Information to be Shared Among DD Providers, Healthcare Providers, the Individual, the Family, and the Care Coordination team Tracking of Outcomes and Effectiveness of Care 7

8

9 WHAT MAKES IAM DIFFERENT? I AM captures and develops services to meet people s hopes and dreams as well as more traditional requirements for health and safety. I AM develops a list of specific goals and actions for natural supports and service providers to follow. I AM integrates the Council for Quality and Leadership s Personal Outcome Measures (CQL POMs) by attaching them to specific goals. I AM provides standard print outs of contact information, allergies, emergency fact sheets, durable equipment needs and an integrated action plan. I AM provides a list of preferences and supportive routines which have been developed and/or reviewed by Dr. Pomeranz. I AM also results in six vignettes written by the person or by the person s circle of support which taken together represent the person s story. I AM represents the powerful voice of the person with IDD.

10 SPECIALIZED INTERDISCIPLINARY TEAM (IDT) The IDT is led by the CM, and is chosen by the member/designated representative. It s individually tailored to help meet member s health and safety needs as well as their personal goals. The team includes member and/or designated representative, their care coordination team, circle of support and their Developmental Disabilities and other service providers (including PCP, specialty Drs.) active in their life plan. The IDT meets for routine LP meetings and unscheduled events to help assess member s needs and preferences, develop and approve the Life Plan, and authorizes most supports/services in the Life Plan. Services/Supports are integrated into an electronic system which is shared with members and others who have approved access.

11 LIFE PLAN The Life Plan (LP) document replaces a person s current ISP. It includes all required elements of the ISP and more. It integrates preventive and wellness services, medical and behavioral health care management, personal safeguards, along with personal preferences and dreams. It also services as authorization of person s supports and services. The Life Plan is generated after all assessments, reviews and team meetings are completed, through MediSked Coordinate s system. Two major components to a Life Plan: Personal Safeguards Valued Outcomes

12 LIFE PLAN The interdisciplinary team meeting finalizes the Life Plan. The participant is present at the meeting. Authorizations for services come from the Life Plan. The Life Plan, with it s safeguards and goals, is monitored monthly for progress Full review and updates are completed semi-annually, at a minimum. Certain events may trigger review and revision of LP more frequently.

13 PHP MODEL OF CARE LOOP

14 PHP s INTEGRATED ELECTRONIC SYSTEMS PHP s electronic systems are integrated to allow for distribution and review of critical Member data in real time. This solution allows the Member, IDT and providers to log and respond to Member events as they happen.

15 MEMBER IDENTIFICATION CARD

16 CARE MANAGER (CM) AND PRIMARY CARE PHYSICIAN (PCP) CM NAME AND PHONE NUMBER PRINTED ON ID CARD PCP NAME AND PHONE NUMBER PRINTED ON ID CARD A NEW ID CARD WILL BE GENERATED IF THE CM AND/OR PCP HAS CHANGED CAN PRINT ID CARD FROM PROVIDER PORTAL

17 CLAIMS SUBMISSION Change HealthCare (formerly EMDEON) EDI SUBMITTER NUMBER ELECTRONIC CLAIM SUBMISSIONS EMDEON PHONE # (877) THIS SUBMITTER ID WILL NOT BE VIEWABLE ON THEIR DROPDOWN MENU UNTIL 4/1/16 DIRECT SUBMISSIONS TO HEALTHSMART (888) PAPER CLAIMS: Partners Health Plan PO Box Lubbock, TX 79490

18 BILLING WITH AN EHR--AUTHORIZATIONS Insurance records for PHP members will be populated automatically in EHR via the Connect Exchange interface. Insurance data will appear on the member record (in Connect, on the More Information Page in the Insurance/Private Pay section).

19 BILLING WITH AN EHR---CLAIMS Upon submission of billing claims, agencies will be prompted to send PHP member claims to HealthSmart using HIPAA 837 forms through Change HealthCare (formerly Emdeon).

20 INSTITUTIONAL VS. PROFESSIONAL CLAIM FORM TYPES INSTITUTIONAL 837I UB04 PROFESSIONAL 837P CMS1500

21 PLACE OF SERVICE CODE VALUES PROFESSIONAL CLAIMS BOX 24B 2-DIGIT VALUE 12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence. 99 Other Place of Service Other place of service not identified above

22 PARTICIPANT ID THIS IS THE ID NUMBER PRINTED ON THE ID CARD THAT YOU SHOULD BE USING ON THE CLAIM SUBMISSION 13-NUMERIC VALUE 4500XXXXXXXXX NOT THE PARTICIPANT S: SOCIAL SECURITY NUMBER NY MEDICAID CERTIFICATION IDENTIFICATION NUMBER (CIN) CMS HEALTHINSURANCE CLAIM NUMBER (HICN)

23 AUTHORIZATIONS IDT APPROVES AND GENERATES AS PART OF THE LIFE PLAN DATA IS COMMUNICATED FROM CARE MANAGEMENT / UTILIZATION MANAGEMENT SYSTEMS TO HEALTHSMART FOR CLAIMS ADMINISTRATION

24 ICD10 REQUIRED FOR SERVICES RENDERED ON AND AFTER OCTOBER 1, 2015 CLAIMS SUBMITTED USING ICD9 CODES OR WITHOUT AN ICD DIAGNOSIS CODE WILL NOT BE CONSIDERED FOR PAYMENT DIAGNOSIS CONVERTER

25 RATE CODES OPWDD RATE CODES AS OF OCTOBER 1, 2015 ADDING PHP/HS STAFF TO RECEIVE ENTITY-SPECIFIC REIMBURSEMENT UPDATES

26 REIMBURSEMENT Provider reimbursement will be limited to the lower of either the submitted charge/fee or the Medicare/Medicaid fee schedule (as applicable). For example: If a provider submits a claim with a line charged amount of $50 but the fee schedule amount for the procedure code billed is $60, PHP will reimburse the provider $50 as this is the lower of the submitted charge vs. fee schedule amount.

27 PROMPT PAYMENT OF CLAIMS 30 DAYS FOR ELECTRONIC CLAIM SUBMISSIONS 45 DAYS FOR PAPER CLAIM SUBMISSIONS 30 DAYS TO REQUEST ADDITIONAL INFORMATION OR DENY THE CLAIM CHECK RUN CYCLE WEEKLY TUESDAY NIGHTS WEDNESDAY PAYMENT GENERATED

28 CLAIM PAYMENT OPTIONS HARDCOPY PAPER CHECK PAYMENT MAILED TO PROVIDER S BILLING ADDRESS STALEDATED AFTER 180 DAYS ELECTRONIC FUNDS TRANSFER (EFT) VPay IS A UNIQUE ELECTRONIC REPLACMENT FOR PAPER CHECKS THAT ELIMINATES THE HASSLES OF PAYEE EFT ENROLLMENT AND WORKS WITH EXISTING PAYEE SOFTWARE AND HARDWARE. A VIRTUAL CARD SOLUTION DESIGNED SPECIFICALLY FOR CLAIM PAYMENTS. THIS UNIQUE APPROACH WILL SIGNIFICANTLY REDUCE YOUR COST RELATED TO PROCESSING, DELIVERING AND RECONCILING PAPER CHECKS DELIVERED TO THE PAYEE ELECTRONICALLY, EITHER BY FAX OR SECURE . THE PAYEE PROCESSES THE PAYMENT JUST LIKE ANY OTHER CREDIT CARD TRANSACTION; ENTER THE CARD NUMBER, SECURITY CODE, EXPIRATION DATE AND THE AMOUNT INTO YOUR MERCHANT TERMINAL VPay CUSTOMER CARE am 8 pm EST

29 TIMELY FILING PARAMETERS PARTICIPATING PROVIDERS 120-DAYS FROM THE DATE OF SERVICE UNLESS CONTRACTED OTHERWISE CLAIMS FOR DATES OF SERVICE BEYOND 365 DAYS WILL NOT BE CONSIDERED FOR PAYMENT

30 INSTITUTIONAL BILL TYPES CLAIM ADJUSTMENTS XX5 LATE CHARGES ONLY DENIED TO RESUBMIT AS AN XX7 REPLACEMENT OF A PRIOR CLAIM XX7 REPLACEMENT OF A PRIOR CLAIM WILL RESULT IN ADJUSTMENT OF ORIGINAL CLAIM SUBMITTED AND REPROCESSING OF XX7 CLAIM SUBMISSION XX8 VOID/CANCEL OF PRIOR CLAIM WILL RESULT IN ADJUSTMENT OF ORIGINAL CLAIM SUBMITTED

31 CLAIM APPEALS If a provider disagrees with an authorization-related denial or if the provider disagrees with the manner in which a claim was processed, the provider has the right to file an appeal with PHP within 60 days from the date of determination or denial. Out-of-network providers must submit a waiver of liability with their appeal. In-network providers must submit an Appointment of Representative (CMS Form 1696). Appeals must include the following information: Claim number Authorization number (if applicable) Participant name and Partners Health Plan number Date(s) of service Service code(s) billed Unit(s) value billed Amount billed Reason for appeal Waiver of Liability (non-contracted providers only)

32 CLAIM APPEALS (Cont.) Correspondence: PARTNERS HEALTH PLAN PO Box Lubbock, TX Appeals must be submitted in writing and mailed to: Partners Health Plan Attn: Appeals & Grievances PO Box Lubbock, TX 79490

33 STATEMENT OF REMITTANCE (SOR) GENERATED WITH PAYMENT AVAILABLE ON PROVIDER PORTAL PAPER VS. ELECTRONIC 835 DENIAL CODES

34

35 EXPLANATION OF BENEFITS (EOB) PARTICIPANTS WILL NOT RECEIVE AN EXPLANATION OF BENEFITS NOT REQUIRED TO GENERATE MEMBER COST-SHARING PARTICIPANTS DO NOT HAVE ANY OUT OF POCKET EXPENSES FOR COVERED BENEFITS ID CARD INDICATES: Copays: PCP/Specialist: $0 ER: $0 Rx: $0 PARTICIPANTS CANNOT BE BALANCE BILLED

36 PROVIDER SERVICES TTY 711 HOURS OF OPERATION 8AM 6 PM WEEKDAYS MONDAY THROUGH FRIDAY AFTERHOURS - LEAVE MESSAGE TO BE RETURNED NEXT BUSINESS DAY CLOSED ON 10 FEDERAL HOLIDAYS

37 PHP WEBSITE

38 HEALTH SMART PROVIDER PORTAL From the login page, existing users can sign in to their registered account, access our self-service tools to reset a forgotten password. New users can initiate the automated registration process.

39 HEALTH SMART PROVIDER PORTAL Automated provider registration allows new web-users near instant access. Automated registration is available for all NY PHP network participating providers, and out-of-network providers who have valid claims records on file.

40 HEALTH SMART PROVIDER PORTAL Provider Manuals, plan contact information, and other documentation is available under the Documents and Resources tabs.

41 HEALTH SMART PROVIDER PORTAL Eligibility information includes group name and number, and effective date for the Participant in question. Users may also view the Participant s PCP and Care Manager details.

42 HEALTH SMART PROVIDER PORTAL Clicking View ID Card opens an embedded image of the Participant s actual ID card. This image can be saved, ed, or faxed from the site via the Select Action menu.

43 HEALTH SMART PROVIDER PORTAL Claim results display any claim matching the search criteria. Pre-defined date ranges and calendar pop-ups for specific date searches provide an easy-tonavigate experience.

44 MEDISKED PROVIDER PORTAL My Members Provider Portal dashboard grants tailored access to member records and enables providers to quickly view members and notifications.

45 MEDISKED PROVIDER PORTAL - PLANS Approved providers view and/or approve plans via the personcentered member access portal. Plans contain POMs, goals, and action types providers must work on with the member. 4 5

46 MEDISKED PROVIDER PORTAL PLAN APPROVAL Approval or rejection messages are returned directly to the member s Care Coordination team. 4 6

47 MEDISKED PROVIDER PORTAL -ASSESSMENTS If granted access, providers may view It s All About Me assessments completed by the Care Coordinator and Care Manager. 4 7

48 Our Job is to keep members safe and healthy and to Support the Life They Choose! PHP is governed by providers who have a long history of service to people with IDD and their families PHP uses a person centered process that addresses people s health and safety needs and their personal goals, and helps to develop and implement a process to reach them. PHP will work closely with members and their families to understand what they need and what they want, even when they are not able to communicate through typical means. PHP will work closely with providers to help members Get A Life! 48