Kentucky Health Net Access With My Rewards Panel Overview

Transcription

1 Kentucky Health Net Access With My Rewards Panel Overview

2 Agenda - Part 1 First Time KY Health Net access Secure Log In Member Eligibility Verification Check Benefits 2

3 KY Health Net Access Pin Release Form - This one-time form is required to obtain Provider Access. The form can be found at Electronic Claims, then EDI Forms. Any questions regarding the Pin Release can be made to the EDI Helpdesk at the access points shown on this form. Note: The person who first opens access is considered the System Administrator (SA). The SA is required to grant access to any other user who has need to access KY Health Net using that providers access. 3

4 KY Health Net Screen From the website pick the KYHealthNet tab. Enter the Username and Password you selected after the Pin was released to your provider. 4

5 Select your LOOKUP TYPE. Options are SSN or Member ID lookup. Enter the Member ID or SSN. Enter the date range you wish to check. Click SEARCH. Member eligibility is calendar month pure but you have the option to search any date range you wish, through to the current monthend. 5

6 Eligibility Group Panel shows if the patient is covered as a MCO (Managed Care Organization) member or Traditional KY Medicaid (Fee for Service) member. Plan Type If the patient is covered by the Kentucky HEALTH benefit, this panel will show if the patient is considered as in the State Benefit Plan or the Alternative Benefit Plan. Dental and Vision This panel shows if the Vision/Dental coverage is covered through Fee for Service, the MCO or My Rewards. 6

7 Eligibility Groups- Fee for Service The following Eligibility groups are considered Fee for Service. Dental/Vision benefits are processed as Fee for Service. Medicare Savings- Members have Medicare as primary payer. Program Codes: Z = QMB Only KY Medicaid covers coinsurance/deductible after Medicare or Medicare Replacement policy. If Medicare denies, Medicaid denies. Program Codes ZL, ZK, ZQ = Medicaid pays for the members MEDICARE PREMIUM ONLY (no claims coverage) *Refer to Medicare guidelines as to whether you may bill the member. Comprehensive Choices- Members who have elected Hospice benefits, HCB waiver benefits, Model Waiver II members, members who reside in a Nursing Facility, etc. Optimum Choices- Members in the Supports for Community Living Waiver, Adult Day Health Care, etc. Global Choices- Members who are incarcerated and are shown in an inpatient hospital setting for the dates of service. 7

8 Managed Care Organization (MCO) with State Benefit Plan Type 1. Eligibility Group will show MCO. 2. Plan Type shows the member as State Benefit Plan. 3. This means the member has Dental and Vision coverage through their MCO. 8

9 1. Managed Care Organization (MCO) with Alternative Benefit Plan Type 1. Eligibility Group will show MCO Plan Type shows the member as Alternative Benefit Plan. 3. This means the member has Dental and Vision coverage by My Rewards dollars. 9

10 Member shows currently in My Rewards SUSPENDED status. The applicable Suspension/Disenrollment Reasons will be populated on the members file. Possible Suspension Codes I Incarceration CP Community Engagement Penalty CS Community Engagement Suspension PP Premium Non-Payment Penalty PS Premium Non-Payment Suspension QP Recertification Penalty RP Report A change Penalty VP Voluntary Withdrawal Penalty 10

11 Copay Indicator The Copay indicator for the member will display with either a N or Y. If the indicator is a Y, a link to a PDF for copay amounts will appear. Anyone with a Y Copay indicator is required to pay copays effective January 1, *unless the Cost Share for the quarter has been met 11

12 Old field Pov Ind (Poverty Indicator) to be renamed to FPL (Federal Poverty Level) and moved. New field in the member demographic panel labeled Above FPL which will display a Y or N indicator. If the member is at or below 100% of the Federal Poverty Level, the provider may not refuse treatment based on the inability to pay the copay. If the member is above 100% of the Federal Poverty Level, you may refuse to provide services for non-payment of copays if this is the current business practice for all patients. 12

13 KY Health NET My Rewards Panel Overview 13

14 Agenda Part 2 Why Providers should Reserve My Rewards Funds KY Health NET Panel My Rewards Inquiry Reserving Funds Additional Services Cancel existing reserved funds 14

15 Why Providers should Reserve My Rewards Funds Providers should create a reservation for any non-medical dental or vision services for MCO members who are eligible under the Alternative Benefit Plan. A reservation holds that payment amount for the provider. When a reservation is made, My Rewards funds will be held for 30 days from the date of service. After the expired date, reserved funds will be returned back to the members account. If My Rewards funds are not reserved, any funds in the members My Rewards account can be reserved and/or paid to another provider. 15

16 My Rewards Dental Services will be limited to Dental and Professional claims submitted by the following billing providers or billing/rendering provider combinations. Provider Type 60 General Dentist 61 General Dentist Clinic Provider Summary 64 Individual Physician-Oral Surgeon only 65 Physician Clinic covered only if the rendering provider is an Oral Surgeon (provider type 64) 31 Primary Care Center covered only if the rendering provider type is a general dentist (provider type 60) or an Oral Surgeon (provider type 64) 35 Rural Health Center covered only if the rendering provider type is a general dentist (provider type 60) or an Oral Surgeon (provider type 64) 16

17 My Rewards Vision Services will be limited to Professional claims submitted by the following billing providers or billing/rendering provider combinations. Provider Type 20 Preventive Services 77 Optometrist 64 Individual Physician-Ophthalmologist only Provider Summary 65 Physician Clinic covered only if the rendering provider is an Ophthalmologist (provider type 64) 31 Primary Care Center covered only if the rendering provider type is an Optometrist (provider type 77) or an Ophthalmologist (provider type 64) 35 Rural Health Center covered only if the rendering provider type is an Optometrist (provider type 77) or an Ophthalmologist (provider type 64) 17

18 Provider Main Page Use the dropdown menu by hovering over My Rewards or by using the quick links shown on the lower left of the screen. 18

19 My Rewards Inquiry A listing of currently reserved funds for all members of the logged in provider will display after selecting the My Rewards Inquiry panel. The yellow highlighting shows reserved funds that have not been used/billed and are within 5 days of expiration. Expiring soon! Cancel a Reservation To Cancel a reservation, click Cancel. The funds will redeposit into the members My Reward fund. Status will show if the member is Active coverage (A) or Suspended coverage (S). Suspended means the member is not eligible for My Rewards. No claims payment is allowable while in a suspended status. 19

20 My Rewards Reservation If the member entered is not currently eligible for My Rewards, a message will be displayed stating so. From the Provider Main Page, select My Rewards Reservation. Choose the method of member lookup. Enter either the Medicaid Member ID or SSN. 20

21 Create a Reservation Enter the new reservation using the Procedure Code, Date of Service, Rendering Provider and Taxonomy (if applicable). Click Submit. The system will automatically populate the payable amount from the KY Medicaid Fee Schedule in the amount field. Enter the date of service field in MM/DD/YYYY format. Only members that are eligible for My Rewards will be available for reservations. 21

22 Reservation Complete A successfully submitted HOLD for procedure code D0150 will show a confirmation number for your information. NOTE: A Reservation can be made up to 60 days from the expected date of service. 22

23 Message received for reservation without available funds When attempting to reserve funds for a member with insufficient funds, an error message will appear and the reservation WILL NOT be successful. 23

24 EDIT UPDATE Update the Date of Service Click the Edit button beside the row to be edited. The Edit button will change to an Update button and the Date of Service will be open for editing. In the event that the date of service is updated, the expiration date will update as well. Example: Member calls to say they cannot make that days appointment. The provider can change the date of service on the hold that day. The Hold can also be cancelled and a new hold created. 24

25 Add or Edit Reservations To add an additional service to a service date reservation the member must have funds reserved for today or the previous business day. The top grid displays the reservations the provider has for the requested member for the current date of service and allows the user to either edit a procedure code or to cancel a procedure code. The bottom grid allows the provider to add an additional service/procedure code for the requested member. 25

26 Where do I submit my claims for dental and vision services? For My Rewards and Fee for Service, claims are to be submitted to the MMIS (Kentucky Medicaid). You may bill those electronically using your software, through KYHealth Net, or by paper. For MCO Dental and Vision coverage, claims are to be submitted to the appropriate MCO. 26