Community Living. Orientation and Training for HCBS Providers
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- Shana Sibyl Underwood
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1 Community Living Orientation and Training for HCBS Providers
2 Agenda HCBS Overview Prior Authorization and Member Eligibility Claims and Payments Billing and Reimbursement Your Responsibilities Resources Contact Us
3 HCBS Overview
4 Overview HCBS services help members with everyday activities they may no longer be able to do for themselves, as they grow older or due to a physical disability. We work with Home- and Community-Based Services (HCBS) providers to help UnitedHealthcare Community Plan members with complex health problems live more independently. UnitedHealthcare Community Plan offers health coverage for: o Iowa Health and Wellness Plan Iowa s Medicaid program o Iowa HCBS waiver programs
5 HCBS Waiver Programs We provide services for seven Iowa 1915 (c) HCBS waiver programs: 1 AIDS/HIV 5 Health and Disability 2 Brain Injury 6 Intellectual Disability 3 Children s Mental Health 7 Physical Disability 4 Elderly.
6 Personal Care Model Our Personal Care Model focuses on individualized care that provides psychosocial support and enhanced preventive and wellness care. A personal care manager completes a member assessment to select services that help the member remain in the least restrictive home setting, and avoid unnecessary hospitalizations and nursing home placement. Our focus is on primary and preventive care that helps slow the progression of illness and disability.
7 Community-Based Case Managers Our community-based case managers play a central role in: o Establishing a comprehensive, person-centered plan of care, including the coordination and monitoring of care services o o Providing information about any changes in a member s health Coordinating resources across all facets of service to help minimize any negative impact to the member Contact Information If you need help identifying your community-based case manager, please call Provider Services at , 7:30 a.m. to 6 p.m. Central Time, Monday through Friday.
8 Prior Authorization and Member Eligibility
9 Prior Authorization and Member Eligibility HCBS services require prior authorization. The member s case manager handles prior authorization requests. Care providers should confirm member eligibility and check that an authorization is in place before providing services. There are three ways to check member eligibility: o Online: You can check member eligibility and review detailed benefits information using the eligibilitylink tool on Link. To access eligibilitylink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. o ia_ltss@uhc.com o Call: To submit and check the status of prior authorization requests, use the Prior Authorization and Notification tool on Link.
10 Member ID Cards To help ensure you re submitting claims accurately, check the information on the member s ID card and copy both sides for your files. You can also view member ID cards using the eligibilitylink tool on Link. To access eligibilitylink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. IA Health Link Member ID Card Sample member ID cards for illustration only; actual information varies depending on payer, plan and other requirements.
11 Claims and Payments
12 Submitting Claims We must receive your claims within 180 calendar days of the date of service to consider them for payment. Here s how to submit them: Online: Use the Claim Submission tool on Link. To access Claim Submission, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Mail: Send CMS-1500 or Targeted Medical Claim form to: UnitedHealthcare Community Plan of Iowa P.O. Box 5220 Kingston, NY Fax:
13 EDI Using Electronic Data Interchange (EDI) for all eligible UnitedHealthcare transactions can help your organization improve efficiency, reduce costs and increase cash flow. The Payer ID for UnitedHealthcare Community Plan of Iowa is There are a number of ways to get help and learn more about EDI: o Online: Go to UHCprovider.com/edi o Call: EDI Support: o ac_edi_ops@uhc.com To get started, select a clearinghouse of your choice. For more information about choosing a clearinghouse, go to UHCprovider.com/edi > EDI Clearinghouse Options.
14 Claims Reconsideration If you believe a claim was paid incorrectly, you can submit a claims reconsideration request. Here s how: Online: Use the claimslink tool on Link. To access claimslink, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Mail: Send a paper claim reconsideration request to the address on the back of the member s ID card. To access the reconsideration request form, go to UHCprovider.com/claims > Submit a Corrected Claim, Claim Reconsideration/Begin Appeal Process > Single Paper Claim Reconsideration Request Form.
15 Submitting a Corrected Paper Claim On the Claim Reconsideration Request Form, check box #4: Resubmission of a corrected claim. Complete the comments section, clearly stating what data elements have been corrected and why. Send the corrected claim and claim reconsideration request form to the address on the EOB or back of the member ID card.
16 Complaints and Appeals If you re not satisfied with the outcome of a claim reconsideration, you can submit a formal claim dispute/appeal using the process outlined in your provider manual. To learn more, go to UHCprovider.com/IAprovider > Care Provider Manuals > Iowa > View the UnitedHealthcare Community Plan of Iowa Care Provider Manual. o To access the complaint form, go to UHCprovider.com/IAprovider > Claims and Payments > Claim Administrative Disputes/Appeals > UnitedHealthcare Community Plan Claim Dispute Form. o Follow the instructions on the form for how to send it to us. We generally complete the review within 30 calendar days; however, depending on the nature of the review, a decision may take up to 60 calendar days from receipt of the claim dispute.
17 Billing and Reimbursement
18 Billing and Reimbursement Please bill for HCBS services using the current codes, modifiers and units used with the Iowa Department of Human Services. We ll reimburse for claims according to your Participation Agreement. Submit claims for payment after the service is provided. We only pay claims for services we approve in advance. Please follow all elements of the clean claim requirements listed in your provider manual when submitting claims. You should bill for services using the CMS-1500 form. Please use valid ICD-10 coding.
19 EPS With Electronic Payments & Statements (EPS), you can receive an electronic funds transfer (EFT) for claim payments. Using EPS can help: o Lessen administrative costs and simplify bookkeeping o Reduce reimbursement turnaround time o Make funds available as soon as they re posted to your bank account To receive direct deposit and electronic statements through EPS, go to myservices.optumhealthpaymentservices.com > Enroll Now. You ll need: o Bank account information for direct deposit o Either a voided check or a bank letter to verify bank account information o A copy of your practice s W-9 form For more information: o Call: , option 5 o Online: UHCprovider.com/eps
20 Your Responsibilities
21 Cultural Competency Cultural competency is the ability of care providers to deliver care that meets the social, cultural and linguistic needs of patients. Socio-cultural differences between patients and care providers can impact patient satisfaction, adherence and health outcomes. Sensitivity to a patient s language and culture can help care providers enhance communication, diagnosis and treatment. To learn more about cultural competency, go to UHCprovider.com > Menu > Resource Library > Patient Health and Safety > Cultural Competency..
22 Transition of Care Please provide 30 days advance notice if you re no longer able to provide services to a member. Please work with the member s case manager to transfer the member to a new care provider. You may need to continue providing services according to the plan of care until the member has transitioned to a new provider, which may exceed 30 days from the date of notice.
23 Critical Incident Reporting You must report critical incidents by the end of the next calendar day from the date of incident or when staff became aware of the incident by submitting the critical incident report form. To download the form, go to UHCprovider.com/IAprovider > Provider Forms and Reference Guides > Iowa Department of Human Services Forms > Critical Incident Reporting Form. There are two ways to report critical incidents: Fax:
24 Critical Incident Reporting (cont.) Please include the following information when reporting a critical incident: Member contact information: o Date of birth o Home address o Medicaid ID number o Name o Phone number Incident details: o Address where the critical incident occurred, if different from the member s home address o Date of report o Date and description of the incident o Description of outcome: Did the member receive care for this critical incident? Where did the member receive care? o Information about the injury or illness o Name of the person reporting, title and phone number
25 Fraud, Waste and Abuse It s everyone s responsibility to report suspicions of fraud, waste and abuse. Protections for those who report fraud, waste and abuse include the Federal False Claims Act and the Whistleblower Act. Suspicious activities include: o Fraud: Intentionally billing for a service that wasn t delivered o Waste: Delivering an unnecessary service and billing for it o Abuse: Billing for several units when only one unit was delivered
26 Fraud, Waste and Abuse Reporting There are several ways to report fraud, waste and abuse: Online: uhc.com/fraud Call: o Provider Services: o Iowa Department of Human Services Medicaid Fraud Hotline:
27 Resources
28 Care Provider Resources Go to UHCprovider.com for resources including: Provider Advocate Map: Go to UHCprovider.com/IAprovider > Provider Advocate Contact Information, Maps & Resources > Home and Community Based Services (HCBS) Provider Advocate Map. Care Provider Manual: Go to UHCprovider.com/IAprovider > Provider Administrative Manual and Guides > Iowa > View the UnitedHealthcare Community Plan of Iowa Care Provider Manual. Practice Matters Newsletter: Published quarterly Network Bulletin Newsletter: o Learn about changes in policies or procedures, as well as updates to the Administrative Guide and Care Provider Manuals. o To view Network Bulletin, go to UHCprovider.com > News and Network Bulletin > Sign up to receive Network Bulletin. Additional Resources: UHCprovider.com > Menu > Resource Library
29 Link Overview Link is your gateway to UnitedHealthcare s online self-service tools. Use Link to check member eligibility and benefits, manage claims, submit claim reconsideration requests and more. To sign in to Link, go to UHCprovider.com and click on the Link button in the top right corner. If you need help using Link: o Call: , Option 1 o providertechsupport@uhc.com
30 Sign In to UHCprovider.com to Access Link
31 UHC On Air UHC On Air has on-demand video broadcasts created specifically for UnitedHealthcare contracted care providers. o Instructor-led broadcasts give you the opportunity to interact with our speakers and ask questions. o We also have a library of on-demand programs for you to view at your convenience. The broadcasts can be accessed any time, from any device. To access UHC On Air: o Sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. o Select the UHC On Air tool on your Link dashboard. o On UHC On Air, choose the Iowa channel for local programming related to UnitedHealthcare Commercial, Medicare and Medicaid plans.
32 Training Go to UHCprovider.com/training for a full range of training resources, including instructor-led sessions. o o Each 30- or 60-minute session concludes with a Q&A discussion. There are many recorded webinars to choose from, as well as access to CME credit courses. If you need technical help with training: o o providertechsupport@uhc.com Call: Help Desk: , option 3, from 7 a.m. 9 p.m. Eastern Time, Monday Friday If you have general questions about training, please call Provider Services at
33 Contact Us If you have questions about HCBS, call Provider Services at from 7:30 a.m. - 6 p.m. Central Time, Monday through Friday.
34 Thank you. Doc#: PCA _
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