TX HealthSpring Medicare Provider Program Training

Transcription

1 TX HealthSpring Medicare Provider Program Training 2017

2 Agenda Overview of Plans Plans & Benefits Member ID Cards Complaints and Appeals Questions

3 Overview of Plans High Level Cigna-HealthSpring offers 8 Medicare Advantage dental plans that have been filed as part of their Texas market with CMS. HealthSpring categorizes the plans by Contract ID. All Medicare plans operate on a calendar year January 2017 December 2017 Some of the Medicare plans have out-of-network benefits Some of the Medicare plans have co-insurance None of the Medicare plans require authorization or UM review

4 Overview of Plans What types of dental plans are offered? HealthSpring s Medicare Advantage dental plans are similar to commercial insurance plans. There are 4 different benefit sets that members can choose to buy based on where they live: Preventive Plan Preventive + Out-of-Network Plan Preventive & Comprehensive Plan Preventive & Preventive Plus Plan

5 Overview of Plans The plans with the same benefits are rolled up into the same exhibits in the ORM. The subgroup names are listed below by plan category: Preventive Plans TX HS Preferred Advantage Medicare (HMO) Subgroup: TX HS TotalCare Medicare (formerly known as TX HS Preferred TotalCare Medicare (800)) Subgroup: Preventive + Out-of-Network Plan TX HS Preferred Advantage Medicare (50% Co-Ins) TX HS Preferred Advantage Medicare (PPO) Preventive & Comprehensive Plan TX HS Preferred TotalCare Medicare TX HS Preferred TotalCare Prevent Plus Preventive & Preventive Plus Plan TX HS Preferred Advantage Medicare TX HS Preferred Preferred (HMO)

6 Preventive Plan DentaQuest Subgroups: TX HS Preferred Advantage Medicare (HMO), TX HS TotalCare Medicare Covered Plans and Counties: H Cigna-HealthSpring Preferred (HMO) Service Area: Henderson, Lubbock, Rusk, Smith, Upshur, Van Zandt H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Cherokee, Grayson, Gregg, Henderson, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt, Wood

7 Preventive Benefits Prev entive Dental Benefits Code Description Frequency Co-Pay Diagnostic D0120 Periodic Oral Evaluation one every 6 months $0 D0140 Limited Oral Evaluation One per Calendar year(s) Per patient $0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months $0 D0220 Intraoral - Periapical first film One ev ery Calendar Year $0 D0230 Intraoral - Periapical each additional film One ev ery Calendar Year $0 D0272 Bitewing, two films One ev ery Calendar Year $0 D0274 Bitewing, four films One ev ery Calendar Year $0 D0330 Panoramic Film One of (D0210 or D0330) every 36 months $0 Preventive D1110 Prophylaxis - Adult one every 6 months $0

8 Preventive + OON Benefits Plan DentaQuest Subgroup: TX HS Preferred Advantage Medicare (50% Co-Ins), TX HS Preferred Advantage Medicare (PPO), Covered Plans and Counties: H Cigna-HealthSpring Preferred (PPO) Service Area: Collin, Dallas, Denton, Johnson, Lubbock, Tarrant H Cigna-HealthSpring Advantage (PPO) Service Area: Collin, Dallas, Denton, Johnson, Lubbock, Tarrant

9 Preventive + OON Benefits Prev entive Dental Benefits Code Description Frequency Co-Pay Diagnostic D0120 Periodic Oral Evaluation one every 6 months $0 D0140 Limited Oral Evaluation One per Calendar year(s) Per patient $0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months $0 D0220 Intraoral - Periapical first film One ev ery Calendar Year $0 D0230 Intraoral - Periapical each additional film One ev ery Calendar Year $0 D0272 Bitewing, two films One ev ery Calendar Year $0 D0274 Bitewing, four films One ev ery Calendar Year $0 D0330 Panoramic Film One of (D0210 or D0330) every 36 months $0 Preventive D1110 Prophylaxis - Adult one every 6 months $0 Members have the option of going Out-of-Network to receive the preventive services on this plan. If members receive services from a non-participating (Out-of-Network) dentist they will be responsible for 50% of the dentist s charges for services (50% co-insurance).

10 Preventive & Comprehensive Plan DentaQuest Subgroup: TX HS Preferred TotalCare Prevent Plus Covered Plan and Counties: H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Bexar, Collin, Dallas, Denton, El Paso, Hood, Johnson, Parker, Tarrant, Wise

11 Preventive & Comprehensive Plan Benefits Prev entive Dental Benefits Code Description Frequency Co-Pay Diagnostic D0120 Periodic Oral Evaluation one every 6 months $0 D0140 Limited Oral Evaluation One per Calendar year(s) Per patient $0 D0150 Comprehensive Oral Evaluation - new or One per Calendar year(s) per patient. One every 36 $0 established months per provider per tax id number D0210 Intraoral - Complete Series (including One of (D0210 or D0330) every 36 months $0 bitewings) D0220 Intraoral - Periapical first film One ev ery Calendar Year $0 D0230 Intraoral - Periapical each additional film One ev ery Calendar Year $0 D0272 Bitewing, two films One ev ery Calendar Year $0 D0274 Bitewing, four films One ev ery Calendar Year $0 D0330 Panoramic Film One of (D0210 or D0330) every 36 months $0 Preventive D1110 Prophylaxis - Adult one every 6 months $0 Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $1,000 towards comprehensive services including: Restorative care Periodontics Prosthodontics Oral surgery Diagnostic and preventive services above do not count towards annual coverage limit. Full list of covered codes can be found in the ORM.

12 Preventive & Comprehensive Plan DentaQuest Subgroup: TX HS Preferred TotalCare Medicare Covered Plan and Counties: H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb, Willacy

13 Preventive & Comprehensive Plan Benefits Prev entive Dental Benefits Code Description Frequency Co-Pay Diagnostic D0120 Periodic Oral Evaluation one every 6 months $0 D0140 Limited Oral Evaluation One per Calendar year(s) Per patient $0 D0150 Comprehensive Oral Evaluation - new or One per Calendar year(s) per patient. One every 36 $0 established months per provider per tax id number D0210 Intraoral - Complete Series (including One of (D0210 or D0330) every 36 months $0 bitewings) D0220 Intraoral - Periapical first film One ev ery Calendar Year $0 D0230 Intraoral - Periapical each additional film One ev ery Calendar Year $0 D0272 Bitewing, two films One ev ery Calendar Year $0 D0274 Bitewing, four films One ev ery Calendar Year $0 D0330 Panoramic Film One of (D0210 or D0330) every 36 months $0 Preventive D1110 Prophylaxis - Adult one every 6 months $0 Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $2,000 towards comprehensive services including: Restorative care Periodontics Prosthodontics Oral surgery Diagnostic and preventive services above do not count towards annual coverage limit. Full list of covered codes can be found in the ORM.

14 Preventive & Preventive Plus Plan: DentaQuest Subgroups: TX HS Preferred Advantage Medicare, TX HS Preferred (HMO) Covered Plan and Counties: H Cigna-HealthSpring Advantage (HMO) Service Area: Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb, Willacy H Cigna-HealthSpring Preferred (HMO) Service Area: Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb, Willacy

15 Preventive & Preventive Plus Benefits TX HS Preferred Advantage Medicare, TX HS Preferred (HMO) Diagnostic and preventive services above do not count towards annual coverage limit. Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $1000 towards comprehensive services. A full list of covered services can be found in the ORM.

16 ID Cards & Welcome Letters The DentaQuest ID card will be printed at the bottom of the Member Welcome Letter. The ID card will include the HealthSpring product name & the DentaQuest subgroup name. The purpose of this is to ensure that all parties know the name of the plans (member, provider, DQ staff, HS staff). Example: HealthSpring product name: H Cigna-HealthSpring TotalCare (HMO SNP) DentaQuest subgroup name: TX HealthSpring Preferred TotalCare Medicare If a member has been active < 89 days they are considered reinstated. Reinstated members will only receive a new ID card/welcome letter. If lapse in coverage is > 90 days, they are treated as new members. New members receive an ID card/welcome letter, member handbook & EOC document.

17 Sample ID Cards

18 Member/Provider Services DentaQuest is Primary for Member Services DentaQuest HealthSpring Medicare Member Services For reference: HealthSpring Medicare Member Services DentaQuest is Primary for Provider Services (Dedicated TX MCO Line)

19 Member Complaints & Appeals DentaQuest will not handle HealthSpring Medicare member complaints. HealthSpring members should contact HealthSpring member services to file a complaint. DentaQuest will not handle HealthSpring Medicare member appeals. HealthSpring members should contact HealthSpring member services to file an appeal.

20 Provider Complaints & Appeals DentaQuest will handle HealthSpring Medicare provider complaints and appeals. Providers should follow the standard TX process to file complaints or appeals with DentaQuest.

21 Questions?