Doing Business with Humana. Information for healthcare providers and administrators

Transcription

1 Doing Business with Humana Information for healthcare providers and administrators

2 Presentation Overview 1. Credentialing/Recredentialing 2. Claims Inquiry Resolution Process and Code Edit Inquiries 3. Provider Payment Integrity (Financial Recovery) 4. Most Common Denial Reasons 5. Preauthorization and Notification Guidelines 6. Physician Finder Plus 7. Online Tools Making it Easy 8. ebusiness/availity 9. Key Points of Contact 2

3 Credentialing Overview 3

4 Initial Credentialing The market contractors submit a task (via our workflow system) to add a provider or facility to Humana s network. The contractor will indicate on that task, if credentialing is needed. As well as attach a completed credentialing application or the providers CAQH #. If Credentialing is needed, a credentialing task will be created and sent to the credentialing team. The credentialing team has a 7 day Service Level Agreement (SLA) for physicians and 2 day SLA for facilities. The Credentialing team will review the credentialing application to ensure all required elements are present. If the required elements are present, the credentialing team will complete the provider/facility credentialing. A letter is sent to the provider/facility advising their credentialing was approved. If the required elements are not present, the credentialing team will deny the provider/facility credentialing. An automatic notification from our workflow system is sent to the market contractor that submitted the task, to advise them that credentialing was denied and what information they need to obtain for credentialing to complete the provider/facilities credentialing. Some situations require a provider to be taken to our committee board for review and determination as to whether the providers credentialing can be approved. Reasons for taking a provider to committee are, but not limited to: Licenses with current material limitations, Adverse reactions indicated on the providers NPDB report, Restricted DEA/CDS, etc. 4

5 Recredentialing Providers and Facilities are required to be recredentialed every 3 years (unless their state mandates recredentialing more frequently). Humana will initiate the provider/facilities recredentialing 7 months prior to their recred due date. This allows plenty of time for the credentialing team to make multiple outreach attempts (phone calls, faxes and mailings) to collect the needed information to complete recredentialing. Note: Providers using CAQH As long as they ve re-attested within the last 120 days, and there isn t any expired information, we can complete their recredentialing without any outreach attempts to the provider needed. Providers not using CAQH and facilities, are required to complete a new credentialing application for their recredentialing to be processed. Providers and facilities still missing information 60 days prior to their recred due date are sent to the market contractors. The contractors then attempt to collect the needed information. Providers and facilities still missing information 30 days prior to their recred due date are sent a certified letter, advising them that if the completed credentialing application/missing information is not provided in the next 30 days, they will be decredentialed. 5

6 Recredentialing, continued Providers and facilities still missing the required information to complete their recredentialing, at their recred due date, are then decredentialed and removed from Humana s network. Providers and facilities successfully recredentialed receive a letter from Humana, notifying them that they ve successfully been recredentialed. Providers and facilities that are decredentialed are sent a letter from Humana and the market contractors are notified of all decredentialed and therefore termed providers and facilities as well. The same reasons a provider may need to go to the committee board during the initial credentialing process, may result in a provider being taken to the committee board at recredentialing as well. For example: A provider could have limitations placed on their licenses after they were initially credentialed. This would require the committee board to review the provider information and make the determination as to the providers recredentialing being approved or denied. 6

7 Claims 7

8 Claim Submission Time Frames Claim submission time frames Medicare Advantage: One (1) calendar year from date of service Commercial: Generally must be submitted within: 180 days from the date of service for physicians 90 days from the date of service for facilities and ancillary providers Please reference your contract as these timeframes may differ 8

9 Claim Payment Inquiry Resolution Guide Step 1 1. Call Humana s Provider Contact Center (PCC) at Our Provider Contact Center Agents are trained to answer many of your claims questions and can initiate contact with other Humana departments when further review or research is needed. a. Note the reference number issued to you by the Provider Contact Center Agent, as it may be needed in the future. b. You have the option to speak to a Provider Contact Center supervisor if you feel your concern is not being properly addressed. Based on availability, you will either be connected to a supervisor, or a supervisor will contact you within 48 hours of your request. c. If the Provider Contact Center associate needs to have your dispute reviewed by another department, you will receive a letter from the Humana department that completes the additional review/research. You will be notified of the review via a corrected EOR or a letter explain why the claim was upheld within 30 to 45 days. Please allow us time to properly research and resolve your inquiry before contacting us again. 9

10 Claim Payment Inquiry Resolution Guide Step 2 2. Once you have received our response to your initial Provider Contact Center inquiry and you disagree with the determination, you may escalate your concern by submitting a secure to humanaproviderservices@humana.com. Be sure to include : a. The reference number(s) associated with previous attempt(s) to resolve the inquiry (referenced in 1a above) b. Health care provider name and tax ID number c. Member name and identification number, including the relationship of the member to the patient d. Date of service, claim number and name of the provider of the services e. Charge amount, actual payment amount, expected payment amount and a description of the basis for the contestation f. Contact information for our response 10

11 Claim Payment Inquiry Resolution Guide Step 3 3. Look for an Acknowledgment of Submission with a tracking number within five business days of your submission. Please allow 30 to 45 days from the date of the acknowledgment notice for our response. The specialist assigned your inquiry will provide an update every 14 days regarding the status of your submission until the submission is complete. 11

12 Claim Code Edits Code editing is the process of evaluating information submitted on a claim. The information considered includes, but is not limited to: Procedure codes, diagnosis codes, revenue codes, billing units, and modifiers Attributes of the member, such as age or gender 12

13 Claim Code Edits, continued Humana applies code editing to: Validate the accuracy and integrity of codes submitted for payment consideration Ensure consistent and appropriate processing of member claims, based on the services billed Facilitate accurate reimbursement for providers Administer Humana s policies and industry standard coding guidelines Maintain compliance with coding, clinical and regulatory guidelines 13

14 Appeals and Reconsideration Participating providers can request a reconsideration which is handled through our Correspondence Department Provider Reconsiderations should be sent to: Humana Provider Reconsiderations PO Box Lexington, KY Appeals on behalf of the member must be submitted to Humana within 60 days from the date of the denial. Appeals should be sent to: Humana Provider Appeals P.O. Box Lexington, KY

15 Provider Payment Integrity (Financial Recovery) 15

16 Provider Payment Integrity Types of Audits Global Audits - Focuses on overpayment issues that are not provider specific (COB, Duplicates, Retro Contract Terms) Contractual Audits Focus is to ensure claims are paid in accordance with provider contract queries target provisions within provider contracts (i.e., Stop Loss, Carve-Outs, etc.) Clinical Audits - Use internal team & vendors with clinical expertise (physicians, nurses, coders, pharmacists, etc) to review medical records and identify potential overpayments due to incorrect coding and billing, services did not meet medical necessity criteria, etc. 16

17 Clinical Types of Audits Examples of audits performed (this list is not all inclusive): Intensity of Service Audit: Inpatient stays are reviewed to determine if the service/procedure could have been performed in a less-intensive setting. CMS criteria and Milliman criteria are used for the review. Diagnosis Related Group (DRG) Coding: DRG audits are performed to determine that the correct procedure codes and diagnosis codes have been billed based on the physician s documentation in the medical record. Hospital Bill Audits: Registered nurses review medical records to validate that items billed on the itemized bill were provided to the patient and a physician order is present. Humana Registered Nurse (RN) & Medical Doctor (M.D.) Audits: Cases are reviewed to determine if products and technologies are used that are not Food and Drug Administration (FDA) approved, are used in a manner different than there intent, or are not used in accordance with Humana s medical coverage policies. APC Coding (Post-payment Coding): Outpatient cases that are paid according to Ambulatory Payment Classifications (APC) are reviewed to ensure HCPCS codes and CPT codes billed are correct and supported by medical records. High Cost Drug Audits: The medical record is reviewed to determine if a drug was ordered by the health care provider, administered to the member, and units billed are supported in the documentation. Pre-Pay reviews: The itemized bill and/or medical records are requested to perform any of the audits listed above but this list may not be all inclusive. 17

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19 Provider Payment Integrity (PPI) Resolution Process For provider payment integrity inquiries (not related to a medical record review dispute), please leave a secure voice mail message for the Humana PPI Customer Care Team by calling or sending a message to the secure address: ContactPPI@humana.com. Please include the following information: Patient name Member identification number Date of service Claim number Recovery identification number Reason for your call Contact name, , mailing address, phone number, and best time to call Your preferred method of response A Humana PPI Customer Care representative will carefully research your question and provide you with a response within three business days. Be sure to note the reference number provided by the representative and refer to it if you need to contact us again regarding the same topic. 19

20 PPI Resolution Escalation Process If you feel the response to your inquiry was unsatisfactory or did not resolve your concern, you may escalate your PPI concern by sending a secure to HelpPPI@humana.com. Please note: The subject line of your should have the reference number(s) associated with the previous attempt(s) to resolve the inquiry. The body should include the required information listed above, plus the: Health care provider name Tax Identification number Charge amount, actual payment amount, and expected payment amount Description of the basis for the dispute You will receive an Acknowledgement of Submission within three business days. Please allow seven business days for review and response to your inquiry. 20

21 Preauthorization and Notification Guidelines 21

22 Preauthorization, Case Management, and Pharmacy Department Phone Number Additional Information Clinical Intake Team Referrals, authorizations, and notifications Online referrals and authorizations Availity Web Portal: Case Management Commercial: Medicare and Medicaid: Humana Clinical Pharmacy Review Authorizations, step therapy, quantity limits and medication exceptions Phone: Fax:

23 Utilization Management Vendors US Imaging Network/HealthHelp/RadSite High dollar imaging authorizations Orthonet Outpatient therapies (PT, OT, ST) Pain Management Spinal Surgery New Century Health Chemotherapy It is the physicians responsibility to obtain the authorization 23

24 Physician Finder Plus 24

25 Using Physician Finder Plus Get to Physician Finder from 2 search functions available: Just Looking or Member ID Searching by Member ID yields better results You can search by the physician s name or specialty Results are displayed within a 15 mile radius; however you can change your radius option 25

26 Online Tools on humana.com (Unsecure) 26

27 On-line Tools (Unsecure) Claims processing edits Claim coding guidelines Provider Payment Integrity policies (financial recovery) Medical and pharmacy coverage policies Preauthorization and Notification List Provider manual Medicare provider materials 27

28 Making It Easier On-demand training modules Working with Humana Making It Easier for Healthcare Providers Anatomical Modifiers Modifier 24,25, 59, and X (EPSU) Medicare Preventive Services Procedure-to-Procedure Code Editing Printable Tip Sheets Available Plus many, many, more 28

29 Key points of contact 29

30 Please visit our table for tip sheets and more information on the following: Provider Quick Reference Guide Making It Easier Flyer Claim and Provider Payment Integrity Resolution Guide Information on Humana s vendors 30

31 Questions 31