Welcome. The Best Care. Because We Care. -1-

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1 Welcome Second Quarter 2007 EDS Workshop Presented by Corporate MDwise Sherri Miles Provider Relations Manager Jacquie Marsalis-Provider Relations Manger/CompCare The Best Care. Because We Care. -1-

2 About MDwise About CompCare Topic for Today Behavioral Health CompCare Provider Contracting Process CompCare Provider Services Overview CompCare Prior Authorization Process CompCare Claims processing requirements Claims Forms (CMS) Claims submission CompCare Quick Contact Sheet Questions and Answers The Best Care. Because We Care. -2-

3 About MDwise Not for profit organization serving the Hoosier Healthwise members since 1994 Provider sponsored Policy direction comes from community board and participating providers Created to focus on Medicaid and CHIP managed care only Mission to serve low income families Currently serving approximely 250,000 Medicaid lives The Best Care. Because We Care. -3-

4 About MDwise MDwise contracts with risk-bearing entities (i.e. large safety net hospitals, health plans, etc.) Each entity develops its own integrated healthcare delivery system and maintains contracts with physicians, hospitals, other providers. Each entity follows common rules, participates in common programs developed for all MDwise systems. All care must be coordinated inside the member s delivery system, where the provider has a contract. The Best Care. Because We Care. -4-

5 Kim to insert MDwise current quick contact sheet The Best Care. Because We Care. -5-

6 Kim to insert MDwise quick contract sheet The Best Care. Because We Care. -6-

7 About CompCare Selected as the MBHO for MDwise effective 2007 To provide BH/MH service to ALL MDwise members statewide The Best Care. Because We Care. -7-

8 Provider Contracting Process How often will I be re-credentialed? contracted Providers) At least every three (3) years beginning at the date of the initial credentialing decision. Note: Site visit is conducted at the time of re-credentialing. What if I have changes to my billing or service information? Notify CompCare in writing of any changes. CompCare must be notified in writing of any changes in Tax Identification Number. (Note: You may not assign your contract without written permission from CompCare The Best Care. Because We Care. -8-

9 Insert picture here CompCare Provider Services The Best Care. Because We Care. -9-

10 CompCare Provider Services Who do I contact if I have a concern or a complaint? Claims and Billing problems should be directed to the Customer Service Department. Concerns about clinical issues should be directed to the Care Manager or the Director of Clinical Services. Problems / Questions concerning administrative procedures and contract obligations and other provider related issues should be directed to the Provider Services Department. The Best Care. Because We Care. -10-

11 Provider Services All provider complaints should be directed to the CompCare Provider Relations at the following numbers: See quick contact sheet The Best Care. Because We Care. -11-

12 CompCare quick contact sheet inserted here The Best Care. Because We Care. -12-

13 Prior Authorization and Referrals-cover page Ask Kim for clip art The Best Care. Because We Care. -13-

14 CompCare Referral/Prior Authorization Process Members may self-refer for initial services. This initial visit will be be reimbursed without authorization only if the provider of service possess an IHCP number, which is required for payment. Note: members are only allowed (1) per benefit year (rolling 12 months for date of first intake). Additional services require prior authorization by CompCare with the exception of out-of-network psychiatrist (see notes on benefit grid). Network providers requiring additional services will have the option of submitting an OTR Form to CompCare via fax, mail or a portal on our web-site Authorizations for concurrent outpatient services are reviewed and decisions rendered within 2 days. The Best Care. Because We Care. -14-

15 CompCare Referral/Prior Authoization Process Referral/Initial Authorization Calls Should a member contact CompCare for a referral, a choice of providers are given to the member. Authorization is generated for an evaluation and follow up visits once a provider has been chosen. A certification letter is sent to the provider Additional sessions may be authorized after CompCare receives and reviews a completed outpatient treatment request (OTR) form from the provider. The Best Care. Because We Care. -15-

16 Sample authorization forms here The Best Care. Because We Care. -16-

17 Urgent calls Care Advocate transfers the call to a licensed Care Manager. Services are pre-certified using established criteria and guidelines for the appropriateness of the setting and the level of care, length of stay and/ or services requested. The pre-certification authorization number is given. A certification letter is sent via mail or fax. The Best Care. Because We Care. -17-

18 CompCare Referral/Prior Authoization Process Psychiatric Emergency Policy Notification to CompCare s 800 number should be made as quickly as possible preferably within 24 hours. Billing must occur within the timeframes outlined in the provider s contract. If a member requires transfer by ambulance, contact a CompCare Care Manager for instructions regarding this procedure. The Best Care. Because We Care. -18-

19 CompCare Referral/Prior Authoization Process Appeals Process Any of the parties involved may request a peer-to-peer discussion if during an inpatient stay, it is determined there is not enough clinical information to authorization payment for continued stay. This peerto-peer discussion is available 24/7 and is arranged at time requested by the attending behavioral health provider or designee. There are designated timeframes when this peer-to-peer discussions must be completed in order to meet State and regulatory requirements regarding UM Decision Timeliness. In some cases an expedited appeal is available. Any parties involved may request a standard appeal. Please note for standard appeals - all necessary records must be submitted in order to complete the review process. In some situations an IRO Review is available. The Best Care. Because We Care. -19-

20 CompCare Claims Submission Providers serving Hoosier Healthwise members will be paid within twenty-one (21) days of receipt of a clean electronic claim Providers serving Hoosier Healthwise members will be paid within thirty (30) days of receipt of a clean paper claim. Clean claims paid outside of the timeframes are subject to interest payments The Best Care. Because We Care. -20-

21 Claims filing limit CompCare Providers 60, 180 days Make sure you know your claims filing limit Add some graphics The Best Care. Because We Care. -21-

22 CompCare Claims Processing Requirements Charges for outpatient services should be submitted on a CMS 1500 claim form. Charges for inpatient services and facility charges should be submitted on a UB92 claim form. Both forms should be submitted with the correct coding system, I.e. CPT codes, HCPC codes, Revenue Codes, etc. ICD-9 codes for diagnosis codes and CPT, HCPCS, Medicaid Codes, and Revenue Codes for claims payment purposes are used. The Best Care. Because We Care. -22-

23 Claims Definitions of Clean Claim CompCare has adopted the definitions as set forth by OMPP Claims that are not submitted with all data elements will be denied and returned to the provider with missing fields identified For specific details on field specifications, please consult our Provider Manual via The Best Care. Because We Care. -23-

24 Claims Forms (and CMS) CompCare notice to providers here The Best Care. Because We Care. -24-

25 Fast Blast- insert here The Best Care. Because We Care. -25-

26 Clean Claims Claims that are not submitted with all data elements will be denied and returned to the provider with missing fields identified For specific details on field specifications, please consult our Provider Manual via CompCare has adopted the definitions as set forth by OMPP The Best Care. Because We Care. -26-

27 Claims Appeal Process For a contracted provider, an appeal must be submitted within the timeframes specified in the provider s contract from the date of the explanation of benefit or the manual denial letter, unless otherwise mandated contractually. The appeal must include a copy of the claim, a copy of the EOB, a cover letter including the reason for the appeal, and any other supporting documentation Appealed claims and denials are handled through a formal Claim Appeals Team chaired by the Director of Claims All appeals are addressed within the time guidelines specified by the state or within thirty (30) calendar days of the receipt of the appeal. The Best Care. Because We Care. -27-

28 Where Do I Send Claims? Electronic Claims: WebMD/Emdeon as the Clearinghouse Paper claims can submitted to: Comprehensive Behavioral Care, Inc. Attention: Claims 3405 W. Dr. Martin Luther King Jr. Blvd Tampa, FL The Best Care. Because We Care. -28-

29 CompCare Website The CompCare web-site provides a helpful resource page including the Provider Resource Manual, several clinical guides informative materials, and satisfaction survey results. If you do not have internet access and would like additional copies of the Provider Resource Guide, please contact Provider Services The Best Care. Because We Care. -29-

30 Question/Answers The Best Care. Because We Care. -30-

31 Thank you from the staff of MDwise and Compare The Best Care. Because We Care. -31-