KYHealthNet and My Rewards

Transcription

1 KYHealthNet and My Rewards

2 Agenda KYMMIS Website Overview Getting Access to KYHealthNet Provider Status Member Eligibility Verification My Rewards Panels Claims Filing and Follow-up RA Viewer Contact Information FAQ s GET TRAINING PROVIDERS ENROLL BE SUCCESSFUL 2

3 KYMMIS KYHealthNet Department for Medicaid Services Provider Directory Electronic Claims Companion Guides and EDI Guides 3

4 KYHealthNet Access Pin Release Form Electronic Claims EDI Forms 4

5 KYHealthNet Compatible only with Internet Explorer No Sharing Username/Passwords Password Reset Required every 30 days 5

6 Provider Status KYHealthNet Provider Data Sign in with Username and Password Pick KYHealthNet from Applications Page Provider Status o Provider Numbers/effective dates o Providers in your Group Practice o Taxonomy o License o Revalidation o Addresses 6

7 Member Eligibility Verification The Eligibility Verification panel allows the provider to verify the coverage of members. 7

8 Member Eligibility Verification Coverage Types: MCO (Managed Care Organization) Medicare Savings Choices packages o Optimum Choices o Comprehensive Choices o Global Choices 8

9 Eligibility Verification Page Modifications New Elements being added to KYHealthNet: Dental and Vision Coverage Member Suspension Indicators Plan Type Copay Plan 9

10 Dental and Vision Coverage The Dental and Vision panel allows the provider to verify the coverage of members for dental and vision benefits. (Traditional Medicaid beneficiaries will not use this panel). Coverage Types: o My Rewards o MCO o No coverage Dental Vision 5 Year History link 10

11 KYH Plan Type The KYH Plan Type panel allows the provider to verify the eligibility of members for benefits programs. Plan Types: o A-Alternative Benefit Plan o S-State Plan 11

12 Benefit Type by Population MCO Benefit Plans Only Kentucky HEALTH Alternative Benefit Plan Benefits and limitations similar to the Kentucky State Plan Non-medical vison/dental services covered through Kentucky HEALTH My Rewards Account Kentucky HEALTH Medicaid State Plan/CHIP No change in benefits All vision/dental services covered by MCOs Population Adult Group Benefit Package Kentucky HEALTH Alternative Benefit Plan Medically Frail Adults Medicaid State Plan (No change in benefits) Former Foster Youth to age 26 Medicaid State Plan (No change in benefits) Parents and Caretakers & TMA Pregnancy Category Children Medicaid State Plan (No change in benefits) Medicaid State Plan (No change in benefits) Medicaid State Plan (No change in benefits) 12

13 Copay Plan Indicates a value of 'Y' if the member is subjected to Co-Payments and is not subjected to Premium payments. A value of 'N' indicates the member is not subjected to Co-Payments but may be subjected to Premium Payments. This panel includes a link to open the copay plan amounts. Copay Plan panel is only used for members assigned to a MCO and is separate from the Copay Indicator panel. 13

14 Copay Plan Amounts 14

15 New Member Suspension and Penalty Codes If the member is suspended or has a penalty, the suspension indicators will display in the suspension section. CS Community Engagement Suspension PS Premium Non-Payment Suspension QP Recertification Penalty RP Report A change Penalty VP Voluntary Withdrawal Penalty CP Community Engagement Penalty PP Premium Non-Payment Penalty 15

16 Eligible Providers for Reserving My Rewards Funds Only the below Providers Types will have access to the My Rewards Pages Vision My Rewards Vision Services will be limited to professional claims submitted by the following billing providers or billing/rendering provider combinations: 77 Optometrist 64 Individual Physician/Ophthalmologist only 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) 20 Preventive Services Dental My Rewards Dental Services will be limited to Dental and Professional claims submitted by the following billing providers or billing/rendering provider combinations: 60 General Dentist 61 General Dentist Clinic 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 New HealthNet Panels for My Rewards My Rewards Reservations This page allows you to reserve funds for the KY Health Population requiring dental and vision services. My Rewards Inquiry This page allows you to view any active reservations for the logged on provider. My Rewards Additional Services This page allows you to add or amend a procedure code for a patient who is in your office on that day and needs something different done than what was expected. 17

18 My Rewards My Rewards has been added to the browser bar and to the quick links in the left lower corner. My Rewards information will only show to those providers who perform Dental and Vision services. No other provider types will need this information. 18

19 How to Reserve My Rewards Funds To Reserve My Reward Funds for an eligible member enter the member s information, procedure code, date of service and rendering provider ID. Then Submit The reservation Amount field is automatically populated with the payable amount from the Medicaid fee-schedule. A Reservation can only be made up to 60 days prior to the date of service. The date expires 30 days from the date of service. A Conf.# (Confirmation Number) field populates with a successful submission. If Funds are not available the reservation will reject. Partial Holds will not be allowed. 19

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21 If the member is not currently eligible for My Rewards, a message will be displayed. 21

22 In this example the user created a reservation for Miss Persimmon for procedure *D2530 on 2/8/2018. *fictitious data Enter the Member ID or SSN/DOB combination, if the member is eligible for My Rewards a reservation can be created. Enter in the Procedure code, Date of Service and Rendering Provider if applicable. 22

23 Miss Persimmon reservation for services was successfully reserved by the user. Reminder a Reservation can only be made up to 60 days prior to the date of service. The Date Expires (30 days from the date of service) and Conf. # (Confirmation Number) field will be populated once a successful submission has occurred. The Amount field will be populated based on the Medicaid Fee Schedule. Partial holds will not be allowed and the amount field cannot be edited. 23

24 Miss Persimmon needs an additional procedure. Her dentist completes the bottom grid to submit a new hold. This service will move to the top grid after submission. The provider can go into the Additional Services page and edit a currently reserved procedure code. This can only happen on the same Date of Service as the original reservation, or the next business day. 24

25 Member can t make the scheduled appointment and calls to reschedule. Provider can edit the Date of Service on this page. The DOS cannot exceed the expiration date. The expiration date will remain the same as the original reservation s expiration date. 25

26 New HealthNet Panel for My Rewards Inquiry How to use My Rewards Inquiry A list of currently reserved funds for all members of the currently logged on provider will be displayed. A member s current My Rewards Account status will be displayed in the inquiry page to indicate if the member has been suspended or closed since the reservation has been made. The possible statuses are listed below: A - Active Member S - Suspended I Inactive Member C Closed Member 26

27 See existing members reserved funds This page will display any ACTIVE holds for all members for the logged in provider. Or can be narrowed down by Member ID Any active reservations that are going to expire in 5 days will be highlighted in yellow to alert the provider that no claim has been submitted and the hold is about to expire. 27

28 When can you modify an existing Reservation Miss Permission is in the dental chair when her dentist discovers a different procedure is necessary. The existing reservation can be modified by clicking on the Edit button. Change the procedure code then click on Update. The provider can go into the Additional Services page and add an additional procedure code in the bottom grid. This can only happen on the same Date of Service as the original reservation, or the next business day. 28

29 Cancelling a Reservation Member calls to cancel appointment and does not reschedule. Provider can go to the Reservation or the Inquiry page to cancel the reservation to allow the funds to be released back into the member s account for future use. 29

30 Cancellation Successful Message 30

31 My Rewards Claim Edits New Edit Limiting My Rewards Claims to Submission within One Year of the Date of Service My Rewards submission will be limited to one year from the date of service regardless of whether the provider initially submits the claim within the year but it is denied. If a provider s My Rewards claim is denied they will still only be allowed to resubmit within one year of the date of service. DXC will create a new edit specific to My Rewards claims that will limit My Rewards claim submissions to one year (based on claim receipt date) from the date of service. This edit will NOT be allowed to be overridden. Provider-requested Adjustment of Paid My Rewards Claims will NOT be Allowed/New Claim Edit Dental and Vision claims paid to Medicaid-eligible providers through My Rewards will not be allowed to be adjusted by the provider. If the provider needs to change data on a My Rewards-paid claim for any reason, the provider will need to void the claim, request a new Hold/Reservation of funds, and resubmit the claim. DXC will create claim editing to deny claim adjustment requests submitted by providers for My Rewards-paid claims. My Rewards claims must be submitted to the MMIS via Electronic, Paper or KYHealthNet like Fee for Service claims are submitted today. 31

32 Claims Submission Professional Services The KYHealthNet allows instant electronic claims filing and adjudication response. Some fields autopopulate and the remainder are provider data entry. 32

33 Claims Submission Professional Services Diagnosis code entry Claim Detail Information 33

34 Claim Submission Dental Services 34

35 Claim Submission Dental Services 35

36 RA Viewer RA (Remittance Advice) is loaded weekly and must be downloaded for auditing purposes. Remittances are available for 6 months. 36

37 Provider Representative List Kelly Kitchen Extension Vicky Hicks Extension Assigned Counties Assigned Counties 001 ADAIR 044 GREEN 074 MCCREARY 003 ANDERSON 040 GARRARD 083 MENIFEE 002 ALLEN 050 HART 075 MCLEAN 006 BATH 041 GRANT 084 MERCER 004 BALLARD 048 HARLAN 085 METCALFE 008 BOONE 043 GRAYSON 087 MONTGOMERY 005 BARREN 051 HENDERSON 086 MONROE 009 BOURBON 045 GREENUP 088 MORGAN 007 BELL 053 HICKMAN 089 MUHLENBERG 010 BOYD 046 HANCOCK 090 NELSON 011 BOYLE 054 HOPKINS 095 OWSLEY 012 BRACKEN 047 HARDIN 091 NICHOLAS 013 BREATHITT 055 JACKSON 097 PERRY 014 BRECKINRIDGE 049 HARRISON 092 OHIO 017 CALDWELL 061 KNOX 098 PIKE 015 BULLITT 052 HENRY 093 OLDHAM 018 CALLOWAY 060 KNOTT 100 PULASKI 016 BUTLER 056 JEFFERSON 094 OWEN 020 CARLISLE 062 LARUE 102 ROCKCASTLE 019 CAMPBELL 057 JESSAMINE 096 PENDLETON 023 CASEY 063 LAUREL 104 RUSSELL 021 CARROLL 058 JOHNSON 099 POWELL 024 CHRISTIAN 066 LESLIE 107 SIMPSON 022 CARTER 059 KENTON 101 ROBERTSON 026 CLAY 068 LETCHER 109 TAYLOR 025 CLARK 064 LAWRENCE 103 ROWAN 027 CLINTON 069 LINCOLN 110 TODD 030 DAVIESS 065 LEE 105 SCOTT 028 CRITTENDEN 070 LIVINGSTON 111 TRIGG 032 ELLIOTT 067 LEWIS 106 SHELBY 029 CUMBERLAND 071 LOGAN 113 UNION 033 ESTILL 076 MADISON 108 SPENCER 031 EDMONSON 072 LYON 114 WARREN 034 FAYETTE 077 MAGOFFIN 112 TRIMBLE 036 FLOYD 078 MARION 116 WAYNE 035 FLEMING 080 MARTIN 115 WASHINGTON 038 FULTON 079 MARSHALL 117 WEBSTER 037 FRANKLIN 081 MASON 119 WOLFE 042 GRAVES 073 MCCRACKEN 118 WHITLEY 039 GALLATIN 082 MEADE 120 WOODFORD 37

38 Additional Contacts Addresses: = For Providers Questions pertaining to the new KYHEALTH program. (KY_EDI_Helpdesk) For questions pertaining to KYHealth Net provider web portal. Phone Numbers: Members can check their My Rewards Account balance and status Members who have questions about My Rewards or need to update their profile

39 Websites Websites: For Providers and Members Contains details about the new KYHealth program for providers and members including FAQ s, My Rewards qualifying dental/vision services, list of qualifying My Rewards activities/courses with dollars earned and more. For Members. Members can find activities to earn dollars for their MY Rewards account, check their My Rewards account balance, and view account details. benefind.ky.gov For Members. Members may verify if they are eligible for Kentucky Medicaid and enroll. Members enrolled can view My Rewards balance and may update their profile and contact information. 39

40 Frequently Asked Questions What is Kentucky HEALTH? Kentucky HEALTH is the Commonwealth s new health and well-being program for certain low-income adults and their families. The program gets its name from its mission. The word HEALTH stands for Helping to Engage and Achieve Long Term Health. What is a My Rewards Account? A My Rewards Account works like a Health Spending Account. Beneficiaries can earn dollars into their account by completing certain activities such as getting yearly physicals, taking their dependent children for well-child visits, and taking health risk assessments with their MCO to name a few. 40

41 Frequently Asked Questions Who does not have a My Rewards Account? Children and non-kentucky Health Medicaid beneficiaries will not have a My Rewards Account. How will providers know that a member is in a Copay plan? This information is available on KYHealthNet. The amount the member is required to pay based on type of service will be posted. 41

42 Frequently Asked Questions When will the initial Medically Frail identified through claims history will be notified of their status and their benefits. After June 8, 2018, if a member is identified as Medically Frail, the eligibility system will send the Notice of Eligibility (NOE) to the household. Please note, the NOE does not directly say that a member is Medically Frail, but it has the Benefit Type mentioned as "State Plan -Optional Premium" for that member with the benefit effective date. 42

43 Key Terms Assisters benefind Caretaker Relative PATH Community Engagement (Partnering to Advance Training and Health) Certified individuals that assist with applications and enrollments. Assisters inform individuals requiring Qualified Health Plans (QHPs) of the need to apply on HealthCare.gov, provide assistance with coverage options, and provide education and outreach. The website where an individual, Authorized Representative (AR) or Assister can apply for benefits such as KTAP, SNAP, and Medicaid. Any individual that provides care to a child in the household. This individual is related by blood, adoption, or marriage to the dependent child. This includes step-parents. The child resides with the caretaker relative and they assume primary responsibility for the child s care. The initiative will require certain adult Kentucky HEALTH beneficiaries to participate in community engagement and employment activities as a condition of eligibility, such as job skills training, job search activities, education related to employment, general education (i.e. GED, community college), vocational education/ training, subsidized or unsubsidized employment, community work experience, and community service/ public service. 43

44 Key Terms Copayment Department of Medicaid Services (DMS) Medically Frail My Rewards Account (MRA) A set amount a beneficiary pays when receiving a covered service. The amount can differ based on the type of service. Department of Medicaid Services (DMS) falls within the Cabinet for Health and Family Services and consists of the state Medicaid program. The Kentucky Department for Medicaid Services provided the public the opportunity to review and provide feedback to the 1115 Kentucky HEALTH waiver in July of Medically Frail individuals are individuals who are homeless, or with disabling mental disorders, chronic substance abuse, serious and complex medical conditions, or physical/intellectual/developmental disabilities. The My Rewards Account allows individuals to earn dollars to spend on additional benefits not available through their benefit package, such as Dental and Vision services. Eligible individuals may contribute to this account through health, community engagement, and job training activities. 44