Provider orientation

Transcription

1 Provider orientation

2 Agenda About us Our members Behavioral health (BH) and intellectual/developmental disabilities (I/DD) Operations Quality management Delegated service partners Credentialing Provider resources 2

3 About us 3

4 Our approach to working with providers Who we are: Summit Community Care is a joint venture formed between the Arkansas Provider Coalition, LLC (APC) and Anthem Partnership Holding Company, LLC (Anthem), a wholly owned subsidiary of Anthem, Inc. Anthem is one of the nation s leading health care companies serving over 74 million individuals by its affiliated companies. Anthem s programs are tailored to help ensure members have access to complete, integrated and patientcentered care. This collaboration joins APC s local experience in serving Arkansans across the state with Anthem s Medicaid programs and tools from across the nation. 4

5 Our approach to working with providers (cont.) Our commitment: Our combined strengths position Summit Community Care to offer health care solutions that bring positive health results and savings through a focus on quality care and program integrity. Take a look at the Arkansas agencies and practitioners who have joined the APC and helped launch Summit Community Care at We re working together to change health care for the better for the residents of Arkansas. 5

6 Working together We are here to help you provide quality health care to our members. You play the most important role in managing care. Earning your respect and gaining your loyalty are essential to a successful collaboration in the delivery of health care. Together we can: Improve access to preventive primary care services. Ensure selection of a primary care provider (PCP) who will serve as provider, care manager and coordinator for all basic medical services. Improve health status outcomes for members. Educate members about their benefits, responsibilities and appropriate uses of care. Integrate physical and behavioral health care. We can make a real difference in the lives of our members your patients. 6

7 Our members Medicaid population ID cards Benefits and services Eligibility 7

8 Population/eligibility The Provider-Led Arkansas Shared Savings Entity (PASSE) is a Medicaid program to address the needs of people with intensive behavioral health and intellectual and developmental disabilities service needs. The PASSE program is designed to improve people s health and allow them to take a more active role in their treatment with the support of comprehensive care coordination. PASSE enrollment population includes only: Individuals receiving services through the 1915(c) Home- and Community-Based Services Community and Employment Support (CES) waiver; Individuals who are on the CES waiver waitlist; Individuals who are in private developmental disability intermediate care facilities; and Individuals with a behavioral health diagnosis and have received an independent assessment that determines they need services in tiers 2 or 3. Eligibility for coverage is determined through the Arkansas Department of Human Services (DHS). 8

9 Member ID cards ID cards: Members will receive a Summit Community Care member ID card. Please ask your patients for their new ID cards. Claims submitted with an incorrect subscriber ID will deny for no coverage. 9

10 PCP selection A member must select a PCP. If they do not select a PCP, claims history will be used to determine PCP. If no claims history exists, a PCP is systematically chosen for the member. If a member requests a change in their PCP, the change will be made within 24 hours from the time the request was made. Members can change their PCP at any time. They may select a PCP from the directory or call Member Services at A member can still see a specialist without a referral. 10

11 Covered benefits and services Some covered member benefits and services: Case management Pharmacy services Primary care services Behavioral health Adult rehabilitative day services Supportive life skills development Child and youth support services Supportive employment Crisis intervention Environmental modifications Supplemental support Specialized medical supplies Please see the Summit Community Care provider manual for complete details on covered benefits and services. 11

12 Eligibility and benefits You can verify eligibility and benefits through the below options: Submit a 270/271 electronic data interchange (EDI) transaction through the Availity Portal. You will need to use the new payer ID PASSE. Visit > Eligibility and Benefits. Select the payer Summit Community Care from the drop-down box. Tip: If an eligibility and benefits EDI transaction is not submitted with the new payer ID, a noncovered response will be received. Providers will need to correct the payer ID and resubmit the transaction. For more help/training on the Availity Portal, select Help & Training > Get Trained > search for Eligibility and Benefits For questions related to the Availity Portal: Phone: AVAILITY ( ), Monday-Friday, 5 a.m.-4:30 p.m., Central time. Online: From the Availity Portal, select Help & Training > My Support Tickets 12

13 Provider panel listing tool This is a tool for providers to research and download a complete list of past and current members assigned to a specific provider, group or independent practice association. Member listings include data captured at the close of business on the previous day. Real-time member eligibility will now be available exclusively through the Availity Portal. Member panel listings and reports are accessible via the provider online reporting application in Availity under Payer Spaces. Registration for provider online reporting is required. 13

14 Provider online reporting registration Registration: From the Availity homepage, select Payer Spaces from the top navigation bar. Select the health plan. From the Payer Spaces homepage, select the Application or Resources tab. From the Resources tab, select Provider Online Reporting. If you don t see it in the list, select Next at the bottom-right of the page. Select Register/Maintain Organization to register your organization s tax ID to the applicable program. Select Register Tax ID to register for the eligible program (member reports or panel listings). Select Maintain User/Register User to grant access to users. Complete all fields on the Register User page. Select ADD TO PREVIEW and Save. 14

15 Behavior health (BH) and I/DD Summit Community Care BH overview Integration of BH and physical health benefits Care coordination 15

16 BH at Summit Community Care Our mission is to coordinate the physical and BH care of members, offering a continuum of targeted interventions, education and enhanced access to care to ensure improved outcomes and quality of life for Summit Community Care members. BH services include a robust array of both mental health services and substance use disorder (SUD) services. Health care providers, community- and office-based mental health providers, the Arkansas Division of Behavioral Health Services, SUD providers, and a variety of community agencies and resources collaborate to meet the needs of members with mental health and SUDs. 16

17 Integration of BH and physical health The integration of BH and physical health includes: Integrated physical health/bh case management training for all case managers. An integrated quality management committee and medical advisory group. One informational technology system for both physical health and BH. Behavioral case management for members with co-occurring disorders (BH and SUD) and dual diagnoses (BH and I/DD). Physical health and BH provider rounds to discuss members with co-occurring medical and behavioral conditions. Subject matter experts in BH, I/DD and medical conditions to support case managers in consultations. 17

18 Integration of BH and physical health (cont.) Joint staff meetings to build relationships between the physical health and BH case management teams. Active participation by both teams in building consistent documentation standards applicable to both physical health and BH. Timely and coordinated access to covered services for members including early and periodic screening, diagnostic and treatment (EPSDT) and Individuals with Disabilities Education Improvement Act requirements. Ongoing meetings between the leaders of these departments to assess current processes on integration (and modify as needed). The Patient360 registry. 18

19 Patient360 Patient360 is a real-time dashboard that gives a picture of a patient s health and treatment history to help facilitate care coordination. Find specific patient details like: Demographic information. Authorization details. Care summaries. Pharmacy information. Claims details. Care management activities. To access Patient360: Log in to our secure provider self-service website at Select Member Information from the left navigation. Choose Patient360. Enter a specific member s information. 19

20 Care coordination Summit Community Care puts special emphasis on the coordination and integration of physical and BH services wherever possible. Key elements of our model of coordinated care include: Ongoing communication and coordination between PCPs and specialty providers including BH (mental health, SUD and I/DD) providers. Referrals to PCPs or specialty/bh providers for assessment and treatment for members with co-occurring disorders or dual diagnoses. Involving members, caregivers and family members in the development of patient-centered care plans. Case management and disease management programs to support the coordination and integration of care between providers. The expectation that providers screen for co-occurring disorders including: BH screenings by PCPs. Medical screenings by BH providers. Screening of mental health patients for co-occurring SUDs. 20

21 Care coordination (cont.) As a Summit Community Care provider, you re required to notify a member s PCP when a member first enters BH care and any time there is a significant change in care, treatment or a need for medical services (provided you ve secured the necessary release of information). At a minimum, include the patient demographics and the date of initial or most recent BH evaluation in your correspondence. Other elements to include: Recommendations to see a PCP if a medical condition was identified or a need for evaluation by a medical practitioner has been determined (e.g., EPSDT screen, complaint of physical ailments). Diagnosis and/or presenting BH problem(s). Prescribed medication(s). BH clinician s name and contact information. 21

22 Person-centered service planning

23 Person-centered service planning Person-centered service planning occurs through partnership and collaboration with members, their providers, their families and/or natural supports and other member-identified interdisciplinary team participants. They will plan holistically to ensure medical, behavioral, social, vocational, and educational needs are addressed to maximize health, well-being and independence in the development of a comprehensive, person-centered service plan. Person-centered service planning (PCSP) is an ongoing process to help individuals who receive I/DD and BH services plan for their futures. In PCSP, community-based care coordinators, families, representatives, and interdisciplinary teams focus on the individual s needs and vision of what that individual would like to do over the course of the plan year to help maintain or improve their health. 23

24 Provider s role in person-centered service planning Long-term services and supports (LTSS)/home- and community-based services (HCBS) providers will only deliver I/DD and BH and supports to individuals that are approved in the person-centered service plan or otherwise authorized by Summit Community Care. Obligations of the LTSS/HCBS providers include the following: Complying with all applicable statutory and regulatory requirements of the Medicaid program including program-specific requirements from the Division of Developmental Disabilities and the Division of Behavioral Health. Meeting eligibility requirements to participate in the Medicaid program as well as specific requirements applicable to particular services. Submitting required claims information. Complying with program-specific documentation and service delivery requirements. Where applicable, participate with the member s interdisciplinary team in developing and implementing the person-centered service plan. 24

25 Operations Claims submissions, status, payments and disputes Prior authorizations Utilization management Grievances and appeals Medical Policies and Reimbursement Policies 25

26 Availity Portal The Availity Portal is a secure website to access your Summit Community Care online tools and resources. It provides access to real-time information and instant responses in a consistent format regardless of the payer. Functionality available on Availity Eligibility and benefits Member ID card Claims status inquiry Claims submission Medical claim attachments Claim disputes Authorization requests and inquiries Applications in Availity Remittance inquiry Claims status listing Clear Claim Connection Patient360 Precertification Lookup Tool (PLUTO) Maternity HEDIS 26 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

27 Our provider website and our secure provider website Availity Portal The following are available on Our provider website is available 24/7 to all providers, regardless of participation status, (registration and a login are not required for access). Claims forms PLUTO Provider manual Clinical Practice Guidelines News and announcements Provider directory Fraud, waste and abuse resources Preferred Drug List (PDL) The following are available on the secure Availity Portal at Registration and log in are required for access: PLUTO Patient360 (provider facing) Multiple eligibility and benefits inquiry Provider Online Reporting Tool (POR) PCP member panel listings Interactive Care Reviewer (ICR) Pharmacy authorizations (pharmacy benefits) Claims dispute submission Claims dispute inquiry Medical appeal prior authorization submission 27

28 Availity Portal The registration process is easy. Multiple resources and trainings about site navigation are available. 28

29 Clean claims A clean claim is a claim submitted for reimbursement that contains the required data elements and any attachments requested by Summit Community Care. Find more information on the required data and attachments in your provider manual. To qualify as a clean claim, Summit Community Care requires the following attachments: A Medicare remittance notice if the claim involves Medicare as a primary payer and Summit Community Care provides evidence it does not have a crossover agreement to accept an electronic remittance notice. Description of the procedure or service which may include the medical record if a procedure or service rendered has no corresponding CPT or HCPCS code. Documents referenced as contractual requirements in a global contract (if applicable). Physician notes if the claim for services provided is outside of the time or scope of the authorization or if the authorization is in dispute. For more required attachment information and required data elements, refer to your provider manual. 29

30 Claims submissions We accept paper claims, but we encourage you to submit claims on our website or by using EDI: Submit both CMS-1500 and UB-04 claims on our website. Submit 837 batch files and receive reports through the website at no cost. You must register for this service first. Use a clearinghouse via EDI. Using our electronic tool reduces claims/payment processing expenses and offers: Faster processing than paper. Enhanced claims tracking. Real-time submissions directly to our payment system. HIPAA-compliant submissions. Reduced claim rejections and adjudication turnaround time. There is a filing limit of 365 days from the date of service (unless otherwise stated in your contract). It s your responsibility to ensure electronic claims are completed and submitted without rejection. 30

31 Claim status inquiries You can get claim status information through the Availity Portal or by calling Provider Services. Availity Portal: Submit a 276/277 EDI transaction using the new payer ID PASSE. Tip: If a claims status transaction is not submitted with the new payer ID PASSE, the claim will not be found. Providers will need to correct the payer ID and resubmit the transaction. Perform a claim status inquiry by selecting Claim Status Inquiry and select the Summit Community Care payer from the drop-down menu. Tip: Start from an eligibility and benefits response (patient card) and then select Claims, then Claim Status Inquiry (or Claims and Payments). To contact Provider Services, call Monday-Friday, 8 a.m.-5 p.m. For questions related to the Availity Portal, call Phone: AVAILITY ( ). Online: From the Availity Portal, select Help & Training > My Support Tickets. 31 For more claims help/training, select Help & Training, then Get Trained and search for Claim Status Inquiry Training Demo.

32 Rejected versus denied claims There are two types of notices you may get in response to your claim submission, rejected or denied. Rejected claims do not enter the adjudication system because they have missing or incorrect information. Denied claims go through the adjudication process but are denied for payment. You can find claims status information on the website or by calling Provider Services. If you need to appeal a claim decision, please submit a copy of the EOP, letter of explanation and supporting documentation. If your claim is administratively denied, you may file an appeal. As part of the appeal, you must demonstrate that you notified or attempted to notify Summit Community Care within the established time frame and that the services are medically necessary. 32

33 Claims overpayment recovery and refund procedure Summit Community Care seeks recovery of all excess claims payments from the person or entity to whom the benefit check was made payable. When an overpayment is discovered, Summit Community Care initiates the overpayment recovery process by sending written notification. If you are notified of an overpayment or discover that you have been overpaid, mail the refund check along with a copy of the notification or other supporting documentation to the following address: Summit Community Care P.O. Box Atlanta, GA Log in to our secure provider website at for the Recoupment Notification Form and Overpayment Refund Notification Form, located under Claims Forms. If you believe the overpayment notification was created in error, contact Provider Services. For claims re-evaluation, send your correspondence to the address indicated on the overpayment notice. If we do not hear from you or receive payment within 30 days, the overpayment amount is deducted from your future claims payments. 33

34 Inpatient concurrent review Inpatient concurrent review is the process of obtaining clinical information to establish medical necessity for a continued inpatient stay including review for extending a previously approved admission. Facilities are required to supply the requested clinical information within 24 hours of the request to support continued stay. During each concurrent review interval, the clinician will assess member progress and needs to help coordinate such needs prior to discharge. This is done to help facilitate a smooth transition for the member between levels of care or home, and to avoid delays in discharge due to unanticipated care needs. In addition, the attending provider is expected to coordinate with the member s PCP or outpatient specialty provider regarding follow-up care and services after discharge. The PCP or outpatient specialty provider is responsible for contacting the member to schedule all necessary follow-up care. 34

35 Inpatient level of care review guidelines MCG Care Guidelines are evidence-based guidelines used for clinical decisions and care planning. There are separate guidelines covering specific areas of care. MCG Care Guidelines for inpatient level of care will be used beginning March 1, The four care categories include the following: Inpatient and surgical care: Manage, review and assess people facing hospitalization or surgery proactively with nearly 400 condition-specific guidelines, goals optimal care pathways and other decision-support tools. General recovery care: Effectively manage complex cases where a single Inpatient & Surgical Care Guideline or set of guidelines is insufficient including the treatment of people with diagnostic uncertainty or multiple diagnoses. Recovery facility care: Coordinate an effective plan for transitioning people to skilled nursing facilities and inpatient rehabilitation facilities. Chronic care: Evaluate needs, identify goals, develop personalized care plans and support effective self-care. The modular design supports quick and efficient assessments and enables you to manage multiple comorbidities and BH conditions. Summit Community Care has the right to customize MCG Care Guidelines based on determinations by its medical policy and technology assessment committee. 35

36 Prior authorization Prior authorization is required for the following: Nonemergent inpatient transfers between acute facilities Elective inpatient admissions Emergency inpatient admissions within one business day Rehabilitation facility admissions Long-term acute care admissions Skilled nursing facility admissions BH levels of care (as outlined in the provider handbook and prior authorization documents) Out-of-area/out-of-network services Outpatient services (as outlined within PLUTO on our website) Outpatient DME purchases and rentals (as outlined within PLUTO on our website). Specialty drugs as noted within PLUTO Transplant services Prior authorizations approved prior to March 1, 2019 will be honored by Summit Community Care 36

37 PLUTO Certain medical procedures and pharmaceutical prescriptions require the submission and approval of a prior authorization. To verify if a prior authorization is required, use PLUTO. Detailed authorization requirements should be found using PLUTO: Search by market, member product or CPT code. This is for outpatient services only All inpatient services require an authorization. PLUTO is located under Payer Spaces on the Availity Portal: From the Availity homepage, select Payer Spaces from the top navigation bar. Select the health plan. From the Payer Spaces homepage, select the Applications tab. Select PLUTO. 37

38 Prior authorization and notification You can submit a PA request, look up a status or submit an appeal online. Log in to using your Availity credentials. From the Availity homepage, select Patient Registration from the top navigation bar. Select Authorizations & Referrals. Select Authorizations. Select the payer and organization. Select Submit. The ICR application will open. Use ICR to submit and manage (appeal) your medical prior authorizations. If you would like to fax a paper request, please use the PA fax number. Effective March 1, 2019, failure to obtain prior authorization for Summit Community Care members and failure to notify Summit Community Care of a member s admission or transfer within established time frames will result in your claims being administratively denied and providers will not receive payment for the service(s). Prior authorizations approved prior to March 1, 2019 will be honored by Summit Community Care. Providers can also call Provider Services at to start a prior authorization request including an urgent authorization request. 38

39 Prior authorization requirements Notification for all post-stabilization admissions, including transfers, should occur within one business day of admission. The following clinical scenarios are excluded: Antepartum/postpartum admission not resulting in a delivery Admission to a neonatal intensive care unit (NICU) (level three) Admission to an intensive care unit (ICU) Direct admission to an operating room (OR)/recovery room Direct admission to a telemetry floor Involuntary BH admission Prior authorization notification requirements: Summit Community Care must be notified of all member admissions or transfers within one business day of admission. Ideally, notification should occur on the day of admission; however, you have one business day to notify us without penalty. A business day is considered Monday-Friday and does not include weekends and/or weekdays that fall on federal holidays. Note: Admission to a general ward is considered in scope for our notification requirements. Failure to notify us within one business day of admission to the general ward or NICU level one or two is considered failure to notify and the administrative denial applies. Once the member has been downgraded to a general ward from the NICU level three, ICU, OR/recovery or telemetry, the requirement for notification applies. 39

40 Prior authorization for inpatient admissions All inpatient admissions, both elective and emergent, will require prior authorization. Failure to comply with notification rules will result in an administrative denial. Prior authorization with supporting documentation is required for: Emergent inpatient admissions. Planned/elective admission. Inpatient surgery. Skilled nursing facilities. Long-term acute care. Acute rehabilitation. 40

41 Prior authorization for inpatient admissions (cont.) Notification is required for the following services; however, for these services, clinical information is not needed since they do not require a medical necessity review: Observation: Only needed for nonparticipating facilities. OB deliveries: Medical necessity review will be required for anything over a 48-hour stay for vaginal delivery and anything over a 72-hour stay for a Cesarean section delivery. Emergent inpatient admissions require notification to Summit Community Care within one business day following the admission. Authorizations can be submitted via phone, fax or Availity Portal. Availity: Fax: Non BH: ; BH: Phone: Failure to comply with notification rules will result in an administrative denial. All medical emergent inpatient hospital admissions will be reviewed within one business day of the facility notification to Summit Community Care. 41

42 Prior authorization for inpatient admissions (cont.) Clinical information for the initial (admission) review will be requested by Summit Community Care at the time of the admission notification. For medical admissions, the facilities are required to provide the requested clinical information within 24 hours of the request. If the information is not received within 24 hours, a lack of information adverse determination (i.e., a denial) may be issued. If the clinical information is received, a medical necessity review will be conducted using applicable nationally recognized clinical criteria. Decisions are communicated verbally or via fax within 24 hours of the determination. 42

43 Planned/elective admissions Must receive prior approval at least 72 hours prior to the admission or scheduled procedure in order to ensure the proposed care is a covered benefit, medically necessary and performed at the appropriate level of care. Authorizations can be submitted: Availity: Fax: Non BH: ; BH: Phone: Failure to comply with notification rules will result in an administrative denial. A medical necessity review will be conducted using applicable nationally recognized clinical criteria. If needed, additional supporting documentation may be requested to determine if the request is medically necessary. 43

44 Authorization review time frames Determinations will be communicated to the facility. Expedited prior authorization request Standard authorization request Expedited prior authorization request* Time frame for decision As expeditiously as required by the enrollee s/member s condition, not to exceed 10 calendar days. As expeditiously as required by the enrollee s/member s condition, not to exceed 72 hours. 44 * Expedited requests will be completed when...following the standard time frame could seriously jeopardize the enrollee s life or health or ability to attain, maintain, or regain maximum function. (Code of Federal Regulations Title )

45 Grievances and appeals Grievance: A grievance is your expressed dissatisfaction about any matter except a payment dispute or a proposed adverse medical action. A grievance can be submitted either by a member or a physician, hospital, facility or other health care professional licensed to provide health care services. Claims appeals: Provider appeals are for issues with reimbursement(s) to health care providers for medical services that have already been provided. Medical appeals: There are separate and distinct appeal processes for our members and providers that depend on the services denied or terminated. Refer to the denial letter issued to determine the correct appeals process. Written correspondence: Grievances and Medical Appeals P.O. Box Virginia Beach, VA For grievances and appeals (including claims), contact Provider Services. Include payment disputes with a copy of the EOP, formal letter of appeal, medical records and member consent when appealing on behalf of the member. 45

46 Claim payment disputes Provider claim payment dispute process: If you disagree with the outcome of a claim, you may begin the Summit Community Care provider payment dispute process. The simplest way to define a claim payment dispute is when the claim is finalized but you disagree with the outcome. Please be aware there are three common, claim-related issues that are not considered claim payment disputes defined below: Claim inquiry: a question about a claim but not a request to change a claim payment Claims correspondence: when Summit Community Care requests further information to finalize a claim; typically includes medical records, itemized bills or information about other insurance a member may have Medical necessity appeals: a prior authorization appeal for a denied service; for these, a claim has not yet been submitted For more information on each of these, please refer to the appropriate section in the provider manual. 46

47 Claim payment disputes (cont.) How to submit a claim payment dispute Verbally (for reconsiderations only): Call Provider Services at Online (for reconsiderations and claim payment appeals): Use the secure Provider Availity Payment Appeal Tool at Through Availity, you can upload supporting documentation and will receive immediate acknowledgement of your submission. Written (for reconsiderations and claim payment appeals): Mail all required documentation including the Claim Payment Appeal Form or the Reconsideration Form located at to: Payment Dispute Unit Summit Community Care P.O. Box Virginia Beach, VA

48 Claim payment disputes (cont.) Required documentation for claims payment disputes: Summit Community Care requires the following information when submitting a claim payment dispute (reconsideration or claim payment appeal): Provider Name, address, phone number, , NPI or TIN The member s name and his/her Summit Community Care Medicaid ID A listing of the disputed claim(s), claim number, and dates of service All supporting documentation. 48

49 Claim correspondence Claim correspondence is different from a payment dispute. Correspondence is when Summit Community Care requires more information to finalize a claim. Typically, Summit Community Care makes the request for this information through the EOP. The claim, or part of the claim, may be denied, but it is only because more information is required to process the claim. Once the information is received, Summit Community Care will use it to finalize the claim. For more information, please refer to the appropriate section in the provider manual. 49

50 Medical Policies Medical Policies and Clinical Utilization Management Guidelines, which are publicly accessible online at are the primary guidelines used to determine whether services are considered to be: Investigational/experimental. Medically necessary. Cosmetic or reconstructive. MCG Care Guidelines will be used to determine medical necessity for acute inpatient care. A list of the specific Medical Policies and Clinical Utilization Management Guidelines will be posted and maintained on the website and can be obtained in hard copy by written request. To request a copy of the criteria on which a medical decision was based, call Provider Services. For more information please review the provider manual. 50

51 Reimbursement Policies Reimbursement Policies: Beginning March 1, 2019, Reimbursement Policies will become effective and are located on the Availity Portal. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions. Reimbursement Policies are available at the provider website. 51

52 Code and clinical editing For detailed claim coding and clinical editing information please refer to your provider manual. Summit Community Care applies code and clinical editing guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits. We use sophisticated software products to ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices. Editing sources include but are not limited to CMS National Correct Coding Initiative, Medical Policies and Clinical Utilization Management Guidelines. We are committed to working with you to ensure timely processing and payment of claims. For additional information, please refer to your provider manual and/or your Provider Agreement as a guide for reimbursement criteria. You can also contact Provider Services for more information. 52

53 Clear Claim Connection Use Clear Claim Connection for guidance when you submit a claim. This tool is available on our website and can help you determine whether procedure codes and modifiers will likely pay for your patient s diagnosis. It contains editing features that will determine the validity of items like diagnosis codes or revenue codes. If the codes are not valid, it will produce an edit showing such. Disclaimer: Clear Claim Connection does not guarantee coverage under a member s benefit plan. Member benefit plans vary in coverage and some plans may not provide coverage for certain services. 53

54 Electronic payment services Providers will need to enroll with Anthem s EFT process in order to receive payments from Anthem.. Providers who enroll for electronic payment services will be able to: Receive ERAs and import the information directly into your patient management or patient accounting system. Route EFTs to the bank account of your choice. Use the electronic files to create custom reports in your office at anytime. Type of electronic payment ERAs only EFTs only Website EDI Availity Client Services

55 Remittance inquiry You will be able to view/receive remittance information through the Availity Portal. Providers will receive daily remits Monday-Friday. From the Availity Portal homepage, select Payer Spaces. Select Payer Spaces > BCBS Blue Plus Medicaid or BCBS Waiver > Applications, the Remittance Inquiry application will appear as an option. Choose Remittance Inquiry to gain access to the Remittance Inquiry functionality. Choose your organization and tax ID number. If the administrator previously loaded NPIs, select your NPI from the Express Entry drop-down menu. Otherwise, enter an NPI number in the allotted box. You can choose from one of three search options: EFT number Check number Date range 55

56 Remittance inquiry (cont.) You have the option to sort your results by: Provider name. Issue date. Check/EFT number. Patient or claim. If you need an image of the remittance for your files, select the View Remittance link associated with each remit and Print or Save. Contact your administrator if you do not see this tool to request claims status access. If you don t know who the administrator is for your organization, log in to Availity and select My Administrators. For questions or additional registration assistance, contact Availity Client Services at AVAILITY ( ) Monday-Friday from 7 a.m.-6:30 p.m., Central time. 56

57 Provider roles and responsibilities Provider roles and responsibilities: To provide preventive health screenings. To comply with American with Disabilities Act standards and not discriminate against members with mental, developmental and physical disabilities; To not discriminate on the grounds of age, race, color, religion, sex, national origin or any of the protected classes that fall under federal law. To provide notification of changes in billing address, name, etc. To educate members on advance directives. To comply with HIPAA requirements and recordkeeping standards for medical records. To provide preventive care services recommended to all members. To identify BH needs. To document fraud, waste and abuse. To meet access standards (e.g., wheelchair accessibility). To provide after-hours access and flexible appointment availability. 57

58 Access and availability It s our responsibility to make sure our members have access to primary care services for: Routine care services. Urgent and emergency services. Specialty care services for chronic and complex care. We make sure our providers respond to members needs in a timely manner by conducting telephonic surveys to confirm providers are meeting these standards. Availability and access standards are specifically outlined in the provider manual. 58

59 Access and availability (cont.) Appointment standards: You must arrange to provide care as expeditiously as the member s health condition requires and according to each of the following appointment standards: Appointment purpose Emergency services Urgent medical condition Routine primary care services Time frame Immediately Within 24 hours of request Within 21 days calendar days This standard does not apply to appointments for: Routine physical examinations. Regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days. Routine specialty services (e.g., dermatology, allergy care). 59 Please review the provider manual for all additional standards including BH practitioner standards.

60 Balance billing Billing the member: Providers cannot request or accept payments from Medicaid recipients, their families, or others on behalf of the recipient for any of the following: Base rate changes Missed appointments The difference between insurance allowed amounts and usual/customary charges (provider contract reductions) If health services are determined to be experimental, investigative or not medically necessary providers may not bill the subscriber unless the provider gives the subscriber written notification of noncoverage immediately before the health services are performed and the subscriber agrees in writing to be responsible for the health services. 60

61 Fraud, waste and abuse CMS defines fraud, waste and abuse as: Fraud intentionally falsifying information and knowing that deception will result in improper payment and/or unauthorized benefit. Waste gross negligence and reckless disregard of good medical practices (including coding and billing guidelines) that result in any unnecessary cost or consumption of a health care resource. Abuse when health care providers or suppliers do not follow good medical practices, which result in unnecessary costs, incorrect payment or services that are not medically necessary. 61

62 Fraud, waste and abuse (cont.) If you suspect a provider (e.g., provider group, hospital, doctor, dentist, counselor, medical supply company, etc.) or any member (a person who receives benefits) has committed fraud, waste or abuse, you have the right to report it. No individual who reports violations or suspected fraud and abuse will be retaliated against for doing so. The name of the person reporting the incident and his or her callback number will be kept in strict confidence by investigators. You can report your concerns by: Visiting our website and completing the Report Waste, Fraud and Abuse form. Calling Provider Services at Calling our Special Investigations Unit fraud hotline at

63 Quality management Quality of care Critical incident reporting 63

64 Quality management Our clinical quality management department ensures we re providing access to quality health care and services. Clinical quality management staff continually analyze provider performance and member outcomes for improvement opportunities. Our solutions are focused on: Improving the quality of clinical care. Increasing clinical performance. Offering effective member and provider education. Ensuring the highest member and provider satisfaction possible. 64

65 Quality of care issue referral process The Quality of Care Issue Referral Form is found on the provider website at: Quality of care definition: A medical, social, environmental or economical event that has the potential to have an adverse effect on the health and welfare of our internal and external customers, members, or the organization. Purpose: To ensure quality and appropriateness of care and services rendered by monitoring for potential quality of care issues on an ongoing basis to our members. To systematically identify, investigate, and resolve quality of care issues as well as track and trend issues for reporting and recredentialing purposes. All referral forms should be completed electronically and submitted via to qoc-hkp@anthem.com. Please label the Quality of care issue. 65

66 Quality of care issue referral process (cont.) Quality of care event categories include but are not limited to: A sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Such events are called sentinel because they signal the need for immediate investigation and response. Examples include: Inpatient death unrelated to the natural course of patient s illness or underlying condition. Inpatient major permanent loss of function unrelated to the natural course of patient s illness or underlying condition. Delayed or missed diagnosis or treatment. Unplanned admission to hospital after outpatient procedure. Unplanned subsequent return to surgery for same procedure. 66

67 Quality of care issue referral process (cont.) A never event: an occurrence that should never happen in a hospital that is usually preventable Examples include: Surgery on the wrong body part, wrong patient or the unintended retention of a foreign object in a patient after surgery. Death associated with the use of contaminated drugs or devices/products. Infant discharged to the wrong person, patient suicide or attempted suicide, patient disappearance, or other occurrences related to patient protection. Patient death/disability associated with medication error, stage three/four pressure ulcers acquired after admission to a health care facility or other occurrences related to care management. Death/disability from burns, falls, electric shock or other environmental occurrences. Patient abduction, sexual/physical assault or other criminal occurrences. 67

68 Critical incident reporting We have a critical incident reporting and management system. All contracted providers must participate in critical incident reporting. Report critical incidents to us within 24 hours. The person, agency or entity making the initial report can do so verbally by calling but must submit a follow-up written report within 48 hours. Submit reports via to . Act within 24 hours to prevent further harm to any and all members and respond to any emergency needs of the member. This includes conducting an internal critical incident investigation and submitting an investigation report by the end of the next business day. 68

69 Critical incident reporting (cont.) A critical incident, also known as a major incident, includes but is not limited to: Medication errors. Severe injury or fall. Theft. Suspected physical or mental abuse or neglect. Financial exploitation. Death of a member. We ll track critical incidents and, if warranted, present them to our medical advisory committee and/or quality management committee for review. 69

70 Delegated service partners Pharmacy Transportation Radiology 70

71 Pharmacy Summit Community Care will maintain a Preferred Drug List (PDL) that is at least equivalent to the standard benefits of the state. This requirement pertains to: New drugs or equivalent drug therapies. Routine childhood immunizations. Vaccines prescribed for high-risk and special-needs populations. Vaccines prescribed to protect individuals against vaccine-preventable diseases. PDL will be available on the provider website at If a generic equivalent drug is not available, a new brand-name drug rated as P (priority) by the FDA will be added to the formulary. Coverage may be subject to prior authorization to ensure medical necessity for specific therapies. For formulary drugs requiring prior authorization, a decision will be provided in a timely manner so as not to adversely affect the member s health. Decisions are made within 24 hours of receipt of the request to comply with federal regulations. If we are missing necessary clinical information that is critical to the review, the service will be denied. 71

72 Pharmacy (cont.) We encourage the use of electronic prior authorization. Within the electronic prior authorization submission, you will find prompts for all necessary information to complete the review. If the service is denied, Summit Community Care will notify the prescriber and the member in writing of the denial. Please see the provider manual for more information regarding monthly limits, covered drugs, carve-outs and exclusions. 72

73 Pharmacy prior authorization drugs Providers are strongly encouraged to write prescriptions for preferred products as listed on the PDL. If for medical reasons a member cannot use a preferred product, providers are required to contact Summit Community Care pharmacy services to obtain prior authorization in one of the following ways: Please visit for details on our coverage policies and preferred products. Electronic submission is available at and preferred to assure that all necessary clinical information is submitted for the review. This will lower the volume of responses the prescriber will get back from our plan requiring more information. Alternatively, requests can be made by calling phone Monday-Friday from 8 a.m.-8 p.m. or 10 a.m.-2 p.m. on Saturdays or by faxing all information required and a Prior Authorization Form to for general pharmacy requests and for medical injectable requests. The form is located at 73

74 Delegated partners Transportation Dental services Vision services For assistance with scheduling transportation, refer to the state vendor NET at Dental services are covered and provided through state vendors. Vision services are covered through EyeMed Vision Network. To join the EyeMed Vision Network, please contact: Angie Mays Prior to March 1, 2019 Customer Care/additional questions a.m. to 11 p.m. Eastern time After March 1, 2019 Dedicated Summit Community Care line a.m. to 6 p.m. Eastern time Utilization management team p.m. to 8 p.m. Eastern time Claims submission, eligibility and preauthorization forms Provider training and Clinical Guidelines > Select Provider, then log in 74

75 Credentialing 75

76 Credentialing process A completed Summit Community Care application and all required attachments are needed to initiate the credentialing process. We currently utilize the Arkansas state Centralized Credentials Verification Service for physicians and the Council for Affordable Quality Healthcare Universal Provider Data Source for gathering credentialing data for other health care professionals. Under this program, practitioners use a standard application and a common database to submit an electronic application. Contact your Provider Relations representative to inquire about the status of an application. Summit Community Care credentials health care practitioners, BH practitioners and health delivery organizations (HDOs). We notify applicants of their right to review the information submitted supporting their credentialing applications. If credentialing information can t be verified or if there is a discrepancy in the credentialing information obtained, our staff will contact the practitioner or HDO within 30 calendar days of identifying the issue. 76

77 Provider Resources Provider relations Availity Portal Contact information 77