Illinois Health Partners (IHP) Provider Manual

Transcription

1 Illinois Health Partners (IHP) Provider Manual Illinois Health Partners Health Partner Management Committees Midwest Physicians Administrative Services (MPAS) IHP/MPAS Administrative Directory IHP Contract Health Plan Listing Member Eligibility Eligibility Verification PCP Selection / Member Assignment IHP Plan Link Copayments Health Services Utilization Management Case Management Pre-Certification Process Office Referral Procedure Referral Turnaround Times Pre-Certification List Hospitalist Program Concurrent Review Process Out-Of-Network Care Out-Of-Area Care Quality Improvement

2 Provider Reimbursement Capitation Sample PCP Capitation Detail Reports Provider Office Access Claims Claims Submission IHP Check Sample IHP Explanation of Benefits (EOB) Sample Coordination of Benefits (COB) Credentialing Initial Credentialing Process Re-Credentialing Process Medicare Advantage Coding Super Visit/Annual Health Assessment Process CMS Compliance IHP Fee for Service (FFS) Plans Medicare/Medicaid Dual Eligible Plans Blue Cross Blue Shield Community Humana Gold Plus Integrated Medicaid Humana Care Integrated Accountable Care Organization Plans Medicare Blue Cross Blue Shield PPO United Healthcare

3 Illinois Health Partners Illinois Health Partners (IHP) is a network of more than 1,800 affiliated physicians throughout the west, northwest and southwest suburbs of Chicago. This network jointly manages the health care needs of HMO and Medicare Advantage patients in the Blue Cross Blue Shield and Humana networks. IHP was formed in 2011 by DuPage Health Partners/DuPage Medical Group and Edward Health Partners/Edward Health Services. In 2013, the Elmhurst Memorial Healthcare and Elmhurst Physician Association joined IHP. The IHP network was further enhanced with the addition of Northwest Community Health Partners in Edward Hospital, Linden Oaks, Elmhurst Hospital and Northwest Community Hospital are IHP s hospital partners. Our Mission: Delivering value through quality, access and efficiency. Our Vision: To be a regional provider network recognized for delivering highly efficient and coordinated care with exceptional outcomes. Our Physicians: Illinois Health Partners offers a large panel of over 1,800 physicians. Included are primary care physicians in the areas of family practice, internal medicine and pediatrics; specialists trained in 50 different areas of medicine; and three hospitals. IHP s Program: IHP offers its members and providers the benefits of a multispecialty network including PCPs, specialists and hospitals that provide state of the art, comprehensive and efficient healthcare to meet patients medical needs. IHP Structure: IHP is dedicated to ensuring high quality and efficient care across the entire network and all its patient populations. IHP negotiates and holds the managed care health plan contracts for the IHP network. Under Illinois Health Partners there are currently three medical groups or tower divisions (DuPage Health Partners, Edward Health Partners and Elmhurst Health Partners). In 2015, Northwest Health Partners will be added as the fourth IHP Tower.

4 IHP Health Partner Management Committees IHP strategic network decisions are made at the IHP Board and Finance/Contracting Committees. Health Partner Management Committees have been formed to advise IHP leadership of system activities, provide feedback on operations and make policy recommendations to IHP. The Health Partner Management Committees meet bi-monthly to discuss IHP directives, initiatives and system operations. Each Tower Committee has its own governance and charter that outlines the Committee responsibilities and duties including: UM/QI Performance oversight Review of patient satisfaction scores Financial report review ACO and shared savings contract performance review of IHP providers Review of prospective providers requesting to join the tower Determination of bonus distribution methodology Payout approval Operating expense approval Medical Director review and oversight IHP has designated Midwest Physicians Administrative Services (MPAS) as the management organization responsible for administering and managing the operations required to successfully support its health plan contracts. Tower Management leadership also serves on the MPAS Operations Committees (UM, QI, and subcommittees) to provide medical network insight, make recommendations for administrative operations and communicate initiatives to IHP leadership, committees and network providers.

5 Midwest Physicians Administrative Services (MPAS) Midwest Physicians Administrative Services (MPAS) is IHP s management partner. MPAS provides the administrative functions required to successfully deliver high quality and efficient care to the Illinois Health Partner members and providers. IHP has an agreement with MPAS to provide the following administrative services for IHP risk contracts: Eligibility Claims Processing Credentialing Information Systems Medical Management Quality Improvement/Population Management Actuarial and Financial Services In collaboration with MPAS, this manual has been developed to provide your office with the resource information necessary to operationalize health plan benefits and effectively coordinate care as members obtain services throughout the IHP network.

6 IHP/MPAS Administrative Directory MPAS Administrative Offices 1100 W. 31 st St. Suite 400 Downers Grove, Illinois Main Phone: (630) MPAS TEAM Department Contact Name Contact # Utilization Management/Referrals Case Management & Compliance Melody Klaisner.-Manager Kathy Davis- Supervisor 630) (630) Eligibility & Revenue Recovery Susan Brown Manager (630) Eligibility & Revenue Recovery Tammy Hanc Supervisor (630) Claim Operations Bonnie Mezzano Manager (630) Claim Operations Kim Carlock Supervisor (630) Customer Service & Communications Mark Schepperley - Supervisor (630) Quality Management Linda Meyers, R.N. Director of (630) Quality Management IHP PROVIDER RELATIONS TEAM Contact Name Title Contact # Derek Johnson Derek.johnson@mpasmd.com Sheri Kowalski SKowalski@edward.org Account Mgr., Provider Relations Illinois Health Partners/MPAS Sr. Provider Relations Analyst Edward-Elmhurst Healthcare (630) (630) Kathy Rott Sr. Provider Relations Analyst (630) KRott@edward.org Edward-Elmhurst Healthcare

7 IHP Health Plan Contracts Capitated Health Plans - Managed by MPAS Commercial: BCBS HMO Illinois, BCBS Blue Advantage, Humana HMO (including employee plan) Exchange: BCBS Blue Precision (HMO) Medicare Advantage (MA): Blue Medicare Advantage, Humana Medicare Advantage Non-Risk Plan - Managed by the Health Plan MMAI Dual Eligibles: BC Community MMAI, Humana Gold Plus Integrated Medicaid: Humana Care Integrated Accountable Care Organizations Medicare Blue Cross Blue Shield of Illinois PPO United Healthcare Medicare Advantage BCBS MA PPO

8 Member Eligibility All members have a Health Plan assigned ID card that provides member specific information, the name of the medical group and/or Primary Care Physician that the member is assigned to, basic co-pay information and health plan contact resources. Member ID card samples are located on the resource section of this manual. Verifying Eligibility It is important that all providers verify member eligibility at every visit prior to providing or referring services. If a member is unable to provide an ID card at the time of service, eligibility can be confirmed electronically through the PlanLink system or by contacting MPAS telephonically (see contact list). Primary Care Physicians can also check member eligibility against their monthly capitation list. Confirming member eligibility helps ensure that the patient is assigned to IHP and the practice and is therefore eligible to receive services through Illinois Health Partners. It is recommended the office make a copy of the member s ID card at each visit to provide the most current information available. Offices may also submit a system inquiry at PlanlinkSupport@mpasmd.com. MPAS will investigate member eligibility and respond back to the office within 24 hours (one business day). Health Plan Eligibility Each contracted risk health plan provides MPAS with a member eligibility list monthly via electronic file. Files are loaded on the 16 th of the month and eligibility is provided to each PCP based on the health plan list and PCP assignment. Ineligible Members If health care services are provided to an individual and it is later determined that the patient was not an IHP member, services will not be eligible for payment by IHP. Depending on the situation, the office may be instructed to either bill the patient directly or re-bill services to the appropriate entity for processing. IHP does not forward ineligible member claims to the responsible payer. If the patient is not currently enrolled in an IHP Medical Group and requests to join, the member must contact their health plan s member services department to transfer medical sites (the number is located on their health plan card). Medical group transfers must be made by the health plan. Due to the lag time in reporting eligibility changes, patients may not be immediately eligible for services when electing a new medical group.

9 Primary Care Physician (PCP) Selection/Member Assignment BCBS requires that upon enrollment, the member select a medical group site. BCBS does not preassign member PCPs; they have delegated PCP assignment responsibility to MPAS. For BCBS members: MPAS receives a member eligibility list of members who have chosen one of the three IHP medical groups as their medical site. An IHP welcome packet is mailed to each new member. Welcome packets include IHP instructions, orientation materials and a physician PCP listing. Each member is asked to notify MPAS of their PCP choice. If a member does not respond to this request within 45 days, they will be assigned a PCP by MPAS. MPAS will advise them of their PCP assignment via mail. Humana plans require that members choose a PCP affiliation at the time of enrollment or when electing a medical group site transfer. Humana members must contact Humana directly to choose a new medical group or to make a PCP change. PCP Transfer Requests BCBS members, who are enrolled in Illinois Health Partners but are currently not assigned to a particular PCP practice, can change their PCP affiliation by calling the MPAS customer service department (see contact list). Humana members must arrange for PCP transfers through the Humana member services line (the number is located on their Humana card).

10 PlanLink Access PlanLink is a web based portal that enables Non-Epic users to connect to the IHP/MPAS system to: Submit Referrals Review Existing Referrals Add Referral Notes Check Patient s Eligibility View Patient s Benefit Information Check the Status of Claim To request a PlanLink account If your practice is not currently using PlanLink, complete a Provider Practice PlanLink Request Form and the request to IHP provider relations. Once the practice and the requested users are loaded into PlanLink, individual user passwords and training materials and will be provided for your reference. To add Plan Link users to an existing account Adding new users to an existing PlanLink account requires that the practice complete and fax a PlanLink User ID Request Form to the IT Department at (630) The request form is provided by contacting IHP provider relations departments. Once a new user s access information has been established, passwords will be communicated back to the practice and the users will be able to access the system. Planlink Help desk # (855) Epic, Epicare, PlanLink Contacts If your practice is currently using Epic, EpicCare, or you are an Edward affiliated independent practice, contact the Edward ISS help desk at (630) for system assistance. PlanLink access or inquiries from Elmhurst affiliated providers should be directed to the PlanLink help desk at (855)

11 Copayments Primary Care and Specialist physician offices are responsible for collecting service applicable copayments ("copays") at the time of the member s visit. Copays are determined by the benefit plan coverage that is offered by the member s employer or government program. Member copays differ according to their health plan benefit. Depending on the benefit plan, copays for the Emergency Room, Urgent Care, and Rehabilitation Therapy (Speech, Physical or Occupational), and Outpatient Surgical Services may apply. The member s ID card should be checked to determine if copays are applicable to the services being rendered. The PCP capitation lists also provides office visit copay amounts. Offices cannot collect copays when providing wellness and preventive care services. In general, copays are applicable when: A member is seen by their physician for an office visit as defined by an Evaluation and Management CPT code. A non-physician provider is rendering services such as allergy injections, blood draws and blood pressure checks. Preventive and sick care services are provided and documented during the same visit. Copays should always be verified and collected at the time services are rendered. If a member refuses to pay their copay and the office has made and documented a reasonable effort to collect, MPAS should be notified. Refusal to pay copayment amounts is a violation of the member s health plan agreement and may be grounds for disenrollment from the health plan. To verify whether a copay can be collected at the time of service, providers can confirm copay information by checking the member s benefit information in PlanLink, calling the health plan directly (number is located on the member card) or contacting the MPAS Eligibility Department at

12 Health Services Utilization Management The purpose of the Utilization Program is to assure that high quality patient care is provided in the most cost efficient manner. The MPAS staff works closely with health plans and network providers to ensure that appropriate services are being provided to members at all levels of care delivery. MPAS assists the network with efficient delivery of care through the following processes: Pre-certification and monitoring of referral requests for services noted on the IHP pre-certification list Initial review and determination of medical necessity and appropriateness of service and site for inpatient services Concurrent review of inpatient cases that require pre-certification or have exceeded the expected stay length Discharge planning Retrospective review of out-of-network referrals Pre-Certification Process Members requiring medical services outside of the PCP office should be referred to IHP network providers. Pre-certification is no longer required for cross-tower referrals unless the services required are listed on the IHP/MPAS Pre-Certification List. If the required services cannot be rendered within the IHP network, services must be pre-certified through MPAS. Service pre-certification is necessary for various reasons including: Health Plan liability (inpatient facility and outpatient surgeries) Monitoring of benefit limitations (physical therapy) Benefit Coverage (transplants and infertility treatments) PCPs and Specialists are both able to enter referrals. Specialists should initiate referrals for services related to the diagnosis for which the PCP referred. If a member referral is required for services outside of the scope of the specialist, the PCP should be notified and is responsible for entering required referral(s). Referrals are generally approved for a 90 day period. If global treatment referrals are required, contact the MPAS referral department to discuss extension options. Offices should refer to the IHP pre-certification list to determine whether pre-authorization is required. For precertification questions, contact the MPAS Utilization Management Department at (Option #4).

13 In some cases, the Health Plan may require MPAS contact them for pre-approval, which could delay the processing of the referral request for up to 14 days. Office Referral Procedure When referring members for services, remember to: Confirm the need for pre-certification using the IHP Pre-Certification List. If the services do not appear on the Pre-Certification listing, the member should be referred to an IHP network provider. Verify member eligibility prior to submitting the referral. Use PlanLink to electronically enter referrals. Referral Turnaround Times Pre-certification required referral requests will be processed according to the following criteria: Elective: Authorization will be returned to the office within five working days. Urgent: Authorization will be returned to the office within 3 working days. Emergent: Provide immediate care to the patient and contact MPAS within 24 hours or the next business day. On the occasion that a submitted referral is denied, the physicians will be notified verbally and has the right to appeal the denial to a group of his peer specialists or a Medical Director. Providers should contact the MPAS UM Dept. at (630) (Option #4) for assistance with initiating the appeals process.

14 Case Management Illinois Health Partners is delegated to provide Case Management services for all Blue Cross Commercial and Medicare Advantage HMO members and Humana HMO Medicare Advantage members. Case management is a collaborative process of assessment, planning, facilitation, care coordination, advocacy and evaluation. The case manager facilitates the integration of the patient and provider with consideration of cost factors by providing strategies to manage a patient s comprehensive and holistic health issues with the goal of attaining quality outcomes and enhancing the patient s quality of life. These services are free of charge to members, and members can self-refer or be recommended by providers for participation Case managers focus on improving patient s care through the following: Optimizing the patient s outcome of independence in self care Planning and delivery of care through participation as members of multidisciplinary teams Decreasing fragmentation of care Promotion of cost effective resources in collaboration with the patient s care team Population management focused on individualized goal setting to impact health risks and utilization of services; case management is focused on the promotion of the patient attaining individualized outcomes. The case manager is responsible for the process; the patient is supported with strategy to impact behavior changes to impact their quality of life. MPAS Case Management can be reached at

15 Inpatient Admissions Acute Care Hospital Behavioral Health Hospital (except Humana) Alternative Levels of Care Home Health Hospice Cardiac Rehab Diagnostic Testing Neuro Psych Testing EGD MPAS IHP Pre-Certification List 2016 Acute Rehab / LTACH Skilled Nursing Facility (SNF) Day Rehab Mental Health IOP/PHP (except Humana) Colonoscopy / Endoscopy Nuclear Medicine Studies Out of Network / Out of Area Requests Tertiary Care Providers Not Listed on IHP Rosters Ambulatory Procedures / Surgery Outpatient Hospital Ambulatory Surgery Center Lithotripsy Cardiac Cath Rehabilitation Therapy Services PT/OT/ST Applied Behavioral Analysis (ABA)-Call Case Management (630) Oncology Chemotherapy / Radiation Non-Contracted Lab Hyperbaric Treatment Dialysis Aural Rehabilitation Chiropractor/Acupuncture Gamma Knife / Proton Beam / Cyber Knife Durable Medical Equipment (DME) / Orthotics & Prosthetics (O&P) Family Planning Infertility Sterilization Benefit Determinations Cosmetic Procedures Sclerotherapy Bariatric Surgery Consults Clinical Trials Drugs Synvisc Epogen, Procrit (J0085) Termination of Pregnancy Genetic Testing Acne Surgery Dental / Oral Surgery Hearing Aids Transplants Botox Xolair (J2357) Transplant, Bariatric (including consult), Urgent and Retro requests must be submitted telephonically. Prior authorization is not required for routine labs, radiology, physician consultation (unless specified above), office visits (excluding procedures) to IHP providers. For questions, contact the UM Dept. at (630) , select option 4. Supporting clinical must be submitted with each referral request. IHP specialists offices should be entering referrals for services on diagnoses for which they were consulted.

16 Hospitalist Services In the IHP network, hospitalists are used to assist the PCP in care coordination for inpatient stays at Edward, Elmhurst, Central Dupage and Advocate Good Samaritan Hospitals. Objectives of the hospitalist program are to reduce admit length of stay, re-admissions, avoidable days, inappropriate emergency room admissions and change one-two day stay status to observations. Hospitalists coordinate care for all admission categories except NICU, Psychiatric, OB/GYN and Pediatrics. During an inpatient stay, hospitalists are responsible for: Admission of patients Communication with the PCP to maintain continuity and quality of patient care Providing continuous care, coordination and interpretation of test results and specialty consultations Conducting discharge planning and patient discharge At least one daily visit to hospitalized patients, including medical record documentation of the visit Hospitalists concurrently review inpatient stays and communicate with the patient, PCP, Specialists, health plan, staff, and patient families to ensure that care is coordinated and discharge services are timely. Concurrent Review Process MPAS UM Nurses work with the hospitalists and providers to provide concurrent review services for the BCBS HMO and the BCBS and Humana Medicare Advantage members. Concurrent review assesses the medical necessity and appropriateness of care at the acute level. The UM Nurses telephonically obtains relevant clinical information and/or consult with the attending hospitalist and physicians as necessary. Concurrent reviews are performed on precertification cases and cases that exceed their assigned length of stay. UM Nurses document potential discharge needs upon admission and monitor discharge plans throughout the patient s stay and arrange for any required services. In addition, MPAS case managers assist with out-of-network hospitalization reviews and communication with the hospitalist or PCP to arrange in-network transfer as soon as medically appropriate. Humana HMO members admitted to Edward or Elmhurst hospital are monitored by the hospital case management RNs. The hospital case managers notify Humana upon initial admission and provide clinical updates during the inpatient stay. Humana members that are admitted out of network are managed by MPAS UM Nurses until such time that the member is transferred in network or discharged from the hospital. Physicians should contact the MPAS UM Department with any questions related to acute care.

17 Out-Of-Network Care IHP providers are required to refer members to specialty physicians within the IHP network whenever possible. Occasionally, there may be a service or treatment which cannot be provided by a physician or contracted ancillary provider within the IHP network. In these cases, the provider is required to obtain pre-certification. If a provider requires clarification on whether services required can be performed by an IHP network participant, contact MPAS for assistance in identifying provider options. The Primary Care Physician is still responsible for the management of care when a member is referred outside the network and is expected to maintain communication with the out-of-network provider throughout the course of treatment. After the referred treatment, the member should be brought back into network as soon as medically possible. It is the PCP s duty to ensure that he/she receives consultation notes from these out-of-network providers and keeps them as a part of the patient s permanent medical record. The out-of-network providers should only provide those services which were pre-certified and should not refer the patients for additional care (i.e., MRI, laboratory studies, etc.) without first consulting an IHP PCP or specialist. Out-Of-Area Care If a member is out-of-area, or away from the service area, and requires urgent or emergent care: Direct the member to contact their health plan directly for authorization of service or treatment (health plan number is listed on the member s insurance card). The PCP should act in an advisory capacity with the out-of-area provider in order to stay informed of the treatment decisions and medical care rendered to the member. In this manner, the PCP will be in a better position to accept transfer of the patient and to coordinate care of the patient upon return to the service area. Most insurance carriers will only cover out-of-area emergency treatment and will not cover any routine care out-of-area. The out-of-area scope varies for each health plan. For some plans, there is a mileag determination (i.e., 30 miles from PCP, 50 miles from PCP, etc.) and for other plans this scope will involve specific counties surrounding the member s PCP office.

18 Quality Improvement IHP, through its MPAS relationship, has developed an extensive and detailed Quality Improvement (QI) program designed to improve member healthcare and comply with health plan mandated programs. To more efficiently coordinate all of the health plan s programs and initiatives, IHP is moving to a population health management philosophy. Population health management focuses on the development of tools to assist office staff and providers with documentation requirements that will facilitate optimal reporting of healthcare services across the entire IHP patient population. MPAS works with providers, health plans, government agencies and health care associations to identify guidelines for defining and achieving quality in the patient care setting. To ensure that all IHP patients receive outstanding care, IHP tracks, measures and implements programs that assist providers in continuously improving levels of care. Key components of the quality program include: Identification of standards of care using evidence based medicine. Ensuring compliance with health plans and regulatory agency standards through monitoring provider outcomes. Collection, analysis and reporting of outcome data. Working collaboratively with health plans, IHP leadership and providers to develop meaningful programs to assure patient quality at all levels of the patient care experience. Continuous assessment of performance, identification of issues and barriers and development of initiatives to improve care delivery programs. The MPAS Quality Improvement department works with IHP leadership through the IHP QM/UM committee to monitor outcomes, set network care goals and design/implement programs to improve member health care. IHP provider participation in the quality program is key to the success of the IHP organization. Physician and staff communication is the most important factor in improving patient activation, outcomes and experience. Each office is asked to identify a dedicated staff member to serve as the Quality Liaison for the purpose of facilitating communication and implementation of the quality initiatives at the practice level. MPAS Quality Specialists work directly with provider offices providing expertise, education and information resources. Physicians and office staff are encouraged to contact the MPAS Quality Department to discuss office metrics and available resources.

19 Capitation Capitation ( cap ) is a prepaid method of payment for health services. Capitation is paid on a Per- Member Per-Month (PMPM) basis and is calculated for the members assigned to each Primary Care Physician (PCP) for that current month. Monthly cap payments reimburse the PCP for all services provided by the PCP during that month, regardless of the number or nature of the services provided. Each health plan provides IHP with a monthly list of effective members. Some health plans assign members to a PCP (Humana), while others ask the member to contact the medical group and identify their PCP choice (BCBS). PCP capitation payments vary each month according to benefit plan copayments, age and sex of each assigned member. IHP has established a cap rate for each category of member and provides each PCP with a monthly capitation/eligibility list indicating the rate paid for each assigned member. To calculate the total monthly capitation payment for each PCP, IHP calculates the average member payment and pays each PCP the average payment multiplied by the total number of PCP patients assigned. Capitated physicians are paid each month based upon the established capitation rate and number of eligible members assigned to the PCP on the 16th day of the month. Cap payments are calculated following the eligibility receipt, and checks are mailed by the end of each month. IHP provides each PCP with a monthly capitation report that identifies the cap rate for all members assigned to the PCP during the current month. The total capitation paid to each PCP is based on the average member payment times the number of members assigned for that month to the PCP. Attached is a sample PCP cap report.

20 Sample Capitation-Eligibility List PROV NAME PAT NAME BIRTH DATE GENDER BENEFIT PLAN NAME PCP COPAY MEM NUMBER Physician, IHP Member A 4/22/2012 F JWG20 BA Physician, IHP Member B 5/9/2011 M 092/688 ELM/EDW EMPLOYEES 45 H Physician, IHP Member C 2/16/2013 F 092/688 ELM/EDW EMPLOYEES 45 H Physician, IHP Member D 10/8/2007 F 092/688 ELM/EDW EMPLOYEES 45 H Physician, IHP Member E 5/4/2011 F QNH20 BA Physician, IHP Member F 6/6/2010 F QNH20 BA Physician, IHP Member G 11/29/2011 F QNH20 BA Physician, IHP Member H 5/19/2010 M WRQ40 BA Physician, IHP Member I 9/10/2009 F QMH30 BA Physician, IHP Member J 11/19/2011 F QMH30 BA Sample Eligibility-Capitation List Illinois Health Partners, LLC Capitation for June 2014 CAP - Commercial CAP-MA BUSINESS NAME PHYSICIAN Members Amount Avg/Me mber Members Amount IHP Medical Group, M.D. Physician, IHP 10 $ $ Total 10 $ $ Avg/Me mber Check Total 10 $ $20.76

21 Provider Office Access Responsibilities Primary Care and Specialist Physician Offices Access to care is one of the keys to managing patient care and satisfaction. As part of the IHP contract, offices are expected to participate in the IHP programs and are required to provide member care and follow-up according to the following guidelines: Appointment for Preventive Care within four (4) weeks of request Appointment for Routine Care within ten (10) business days or two (2) weeks of request, whichever is sooner Appointment for Immediate Care within twenty-four (24) hours of request Response by IPA Physician within thirty (30) minutes of an Emergency call Notification to the member when the anticipated office wait time for a scheduled appointment may exceed thirty (30) minutes Behavioral Health Care practitioners must provide access to care for non-life threatening emergencies within six (6) hours In addition, providing members access to services outside of the traditional office hours of 9 a.m. to 5 p.m. is an important factor in: Reducing unnecessary emergency room use Increasing member satisfaction Complying with the BCBS access to care hour standards for all Primary Care Physicians BCBS requires primary care physicians to offer appointments to members 2 hours a week outside the hours of 9am-6pm Monday-Friday not including Saturday hours. IHP providers are encouraged to review their office hours and if feasible, consider providing care in the early morning or evening and on select weekends. As a reminder, IHP members are allowed to utilize the IHP network urgent care centers facilities for urgent, immediate and routine care outside of the established PCP office hours without pre-authorization or PCP approval. Once informed of a member visit for ER or urgent care services, it is recommended that the PCP or specialist (depending on the circumstances) follow up with the member to encourage them to come into the office for ER follow-up or non-urgent care.

22 Claims Submission & Payment Provider claim submission depends on the member s health plan. All Humana HMO and Humana Medicare Advantage member claims should be submitted directly tohumana for processing and payment. Blue Cross Blue Shield (BCBS) HMO, Blue Precision and Medicare Advantage member claims are submitted directed to IHP. Claims Submission Claims must be submitted within 90 days of the date of service. Claims may be submitted electronically to IHP through the clearinghouse Availity, using the IHP Payer ID, or through the clearinghouse Emdeon, using the IHP ID TH088. Humana HMO and MA claims should be mailed to: Humana Claims P.O. Box Lexington, KY All payments and co-payments are subject to the benefit information as defined by the member s Health Benefit Plan. Claim payment is always dependent on member eligibility status on the date of service. Billing and Payment Criteria Hospital and Facility vendors are required to bill on a UB04 claim form. Professional providers are required to bill on a CMS 1500 form. Electronic claims are accepted via the HIPAA standard format. Claims must be submitted using the appropriate codes as published in the AMA s CPT Level I, HCPCS Levels II and III, ICD-9-CM and revenue codes. Code all claims completely and to the most specific detail on all diagnosis and CPT codes to ensure that all services rendered accurately depict the details and level of care provided. IHP processes claims according to current year Medicare guidelines. The Correct Coding Initiative (CCI) guidelines and audits for claims payments and use of modifiers are utilized when adjudicating claims. CPT defines the standard, acceptable modifiers to be used for professional claims. HCPCS also includes acceptable modifiers for services not defined by CPT. All modifiers published by CPT and HCPCS are acceptable for billing use. Billing of unlisted procedure codes will require submission of documentation support for review.

23 BCBS Precision Exchange Member Claims IHP is contracted with BCBS for the Blue Precision Health Insurance Exchange Plan. Blue Precision members are extended a premium grace period if they do not pay their premiums during the first three months of eligibility. Upon notification from the health plan that the member did not pay paid the premium, IHP will pend any received claims with an EOB pend status stating: Exchange member: Claim pending during the premium grace period. Providers cannot bill members for rendered services that have been pended by IHP during the grace period (first three months of eligibility). When the member has either exhausted their grace periods or paid their premiums, the health plan will notify MPAS, who will process pended claims within 10 days of notification from the health plan. If a member did not pay their premiums, submitted claims will be denied and providers are allowed to bill the patient directly. When members do pay their premiums, providers will be paid for services rendered according to their contract. Interest will be calculated from the original date received and paid on qualifying claims. Claims Inquiry and Appeals Providers may check the status of a claim electronically by using PlanLink or telephonically by contacting the MPAS Customer Service unit at Providers may not always agree with claims payment decisions. Therefore, provider offices have the right to appeal claim denials within 45 days from receipt of EOB. To appeal, providers should submit the following information with documentation to support the denial appeal: Submit appeal in writing. Provide a copy of the EOB. Attach any appropriate or missing information, i.e., copy of referral form, authorization number, medical records, etc. Forward claims appeals and corresponding information to: MPAS P.O. Box 3358 Glen Ellyn, IL MPAS will review the appeal and provide a written response to the request within 30 days from date of appeal receipt. Per contractual requirements, balance billing of Illinois Health Partners patients is prohibited in most instances.

24 Subrogation Subrogation is the coordination of benefits between a health insurer and a third party insurer (i.e., property and casualty insurer, automobile insurer, or worker s compensation insurer), not two health insurers. The process to follow for subrogation is: Provider identifies third party liability insurance or other health insurance coverage information. Provider submits the claim to MPAS with any information regarding the third party carrier (i.e., automobile insurance name, lawyer s name, etc.). All claims will be processed per the usual claims procedures. Explanation of Benefits (EOB) IHP adjudicates clean claims within 30 days of receipt. Once adjudicated, an EOB will be provided as an explanation of how the claim was processed. A sample reimbursement check and EOB follow for review. An EOB adjudication code crosswalk is located in the manual s resource information section.

25 Illinois Health Partners Sample Check

26 Illinois Health Partners Sample EOB

27 Coordination of Benefits Coordination of benefits (COB) is the mechanism used to identify which health insurance is responsible for primary payment of health care services when a member is covered under two or more health plans. Identifying Primary Coverage The insured is always primary on their own insurance. The spouse s plan is secondary coverage (if member is covered). The Birthday Rule as defined by the Illinois Department of Insurance is the guideline used for determining primary coverage for dependents. This guideline states that the patient whose birthday falls first during the calendar year is the primary carrier. All legal agreements (i.e., divorce decrees) supersede this rule. Physician offices are to check with both carriers to determine primary coverage for dependents. COB guidelines IHP s claims department will pay up to the coinsurance/deductible of the primary carrier, but not more than the contracted rate IHP has with the vendor. The lesser of two copays will be assessed when the primary and secondary payers are both managed care plans. The patient liability will be determined up to, but not to exceed, the patient s HMO co-pay when Medicare is primary. An explanation of benefits from the primary carrier must be submitted with the secondary submission to the Group. Secondary claims will not be denied for lack of referral or authorization. Providers should always ask the member if they are covered under other health insurance plans at the time of service and document health plan specifics for possible claims submission.

28 Physician Credentialing Provider credentialing is a complex, ongoing process of gathering and documenting provider information. The credentialing process verifies that a provider meets the educational, licensing, and training standards required by the State, IHP and the health plans to provide care to IHP members. MPAS is delegated to conduct the credentialing functions on behalf of its contracted health plans and will work with network providers to ensure timely and accurate completion of the process. Initial Credentialing Process The initial credentialing process is conducted as part of the IHP application process and follows the National Committee for Quality Assurance (NCQA) standards. IHP requires completion of the State of Illinois Health Care Professional Credentialing and Business Data Gathering Form and submission of all corresponding documentation. Once the required documentation is received, the IHP Credentialing Committee will review and evaluate the participation application. Upon Board approval of the application, notification of participation approval and all required documentation will be forwarded to the contracted health plans for provider inclusion in the IHP network. Re-Credentialing Process MPAS follows the State of Illinois single cycle schedule for re-credentialing, re-credentialing all providers every three years (based on the last digit of the provider social security number). When a provider is up for re-credentialing, MPAS will provide a re-credentialing packet outlining the required documents for submission. Once the completed information is received, the provider s file will be reviewed by the IHP Credentialing Committee for continued participation. To meet all mandated credentialing deadlines, it is important that all providers submit requested complete and accurate documents in a timely manner. Failure to submit all required information by the established deadlines will likely delay a provider s ability to see IHP patients.

29 Medicare Advantage Plan Coding Importance The health plans and ultimately our medical group are reimbursed by CMS based on documentation of the member s medical condition. Medicare revises member payment levels annually based on coding submitted to CMS. The ICD-9 codes that are part of the documentation submitted on claims and encounter data are assigned to Medicare s Hierarchical Condition Codes. These Hierarchical Condition Codes are used to develop a patient s Risk Adjustment Score (RAF) which determines how Medicare reimburses for the care provided. The higher the RAF score, the higher the Medicare payment. Diagnosis coding drives reimbursement in the MA Model The MA coding model defines a numerical score for each disease Aggregate scores for each member s disease Incorporate factors for age, gender, Medicaid status, and previously disabled status The risk score is a sum of the scores Every member has their own risk score Member risk scores impacts premium To ensure our compensation is appropriate for the level of care our members require, it is necessary to document the member s conditions by coding all diagnosis codes to the most specific level on all claims and the health assessment form.

30 Annual Health Assessment Process Health assessment forms (see resource section) must to be submitted for every Medicare Advantage member annually. As required by the Medicare Advantage programs, Illinois Health Partners (IHP) will process and submit health assessment information to the health plans on behalf of your members. The health assessment form submission process is as follows: Complete the health assessment form during the face to face Medicare Advantage member super visit. Be sure to document to the most specific level, completing the member s medical history, current conditions, medications, life style assessment and treatment plan. Fax the completed form to the coders at A coder will review the document within 48 hours and if the form is incomplete, corrections will be faxed to your office. Please add the missing information and re-submit by faxing to the above number within three business days. When submitting your HCFA 1500 for the super visit, services should be billed as CPT code (Administration and interpretation of health risk assessment instrument). Place the original completed assessment form in the patient s medical record Provider credentialing is a complex, ongoing process of gathering and documenting provider information. IHP and CMS Compliance Requirements All providers who participate in the Medicare Advantage program are required to accept Medicare assignment. To accept assignment and maintain an NPI number, each provider and office is required to meet the CMS guidelines including the development and implementation of policies and procedures and subsequent training of their staff on the CMS mandated compliance. The IHP compliance program includes: Physician and office staff training sessions Reference materials for providers and office staff Required attestations that provider and office staff training has been completed Submission of required documentation to the health plans IHP has developed a program to assist providers with Compliance and it is required that all health care providers participate and complete the required program.

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