Meridian Network Regional Meetings

Transcription

1 Meridian 2017 Network Regional Meetings

2 Agenda Introductions Illinois RFP About Meridian Health Plan Member Services Provider Resources Pharmacy Benefit Manager Claims and Billing Non-Emergent Transportation Cultural Competency Care Coordination Critical Incident HEDIS Long Term Services and Supports/ Behavioral Health Contact Information Questions

3 HFS Announcement More information can be found at:

4 Illinois Regions

5 RFP Timeline 08/11/17 09/25/17 10/30/17 11/30/17 01/01/18 01/08/18 04/01/18 07/01/18 Contracts Awarded Protest Period ends Member Letters Mailed Existing Service areas Final HFS Approval New Contract/New Membership begins Member Letters Mailed New Service areas New Service Areas Members effective New Populations effective

6 MeridianHealth Our Mission Our Mission To continuously improve the quality of care in a low resource environment Our Vision Our Vision To be the premier service organization in government healthcare To be the #1 health organization based on quality, innovative technology and service to our Meridian Family

7 Meridian History 2000 Health Plan of Michigan becomes an HMO 2006 Caidan Management Company is established 2011 MeridianRx launches Medicare launches 2013 MeridianHealth - New Hampshire Opens (closes in 2014) MeridianComplete (MMAI) launches operations in IL 2015 MeridianComplete (MI Health Link) launches operations in MI Detroit HQ moves to 1 Campus Martius 1997 Dr. Cotton obtains Central Michigan Health Plan 2004 Managed Care System (MCS) is created 2007 HQ moves to downtown Detroit 2008 MeridianHealth launches in Illinois 2012 MeridianHealth opens in Iowa (closes in 2015) Chicago office moves 2014 MeridianChoice launches Healthy Michigan Plan (Expansion) launches 2016 SentinelRx launches Meridian launches new logo and brand identity

8 Meridian Programs MeridianHealth: Meridian has an executed contract with the Illinois Department of Healthcare and Family Services (HFS) to provide Medicaid covered benefits to the beneficiaries of FHP, ACA, ICP and MLTSS MeridianComplete: (MMAI) integrates managed care for individuals who are eligible for both Medicaid and Medicare Parts A&B into Managed Care Organizations that are responsible for all services covered by both Medicare and Medicaid. This initiative is designed to provide better care coordination and improve health outcomes for individuals who have historically been left on their own to navigate two separate health care systems. MeridianCare (HMO): A Medicare Advantage and Prescription Drug Plan (MAPD) in Michigan and Illinois. MAPDs are a type of Medicare health plan that provide Part A, Part B and Part D prescription drug benefits and include additional benefits that are not covered by Original Medicare.

9 Member Eligibility It is important to verify eligibility prior to rendering services to a Meridian member. PCP Identification and Verification: To verify a Meridian member s PCP, you may call Member Services department or utilize Meridian s online Provider Portal Medicaid: Medicare Advantage: To verify member eligibility with Meridian: Meridian Provider Portal: Eligibility Verification Line: Meridian Member Services: To verify member eligibility through the State of Illinois: Medical Electronic Data Interchange (MEDI) Internet Site: Recipient Eligibility Verification (REV) System: Automated Voice Response System (AVRS): Health Benefits Provider Line:

10 Member Services Department Member Services Representatives are available each business day from 8 a.m. to 8 p.m. and are able to assist with questions and resolve issues related to the following: Member eligibility PCP and site changes Women s health care provider changes Complaints/grievances Disenrollment requests Claims payment Rights and Responsibilities Questions outside of the bullet points above will be routed to the appropriate Meridian department for investigation and follow-up.

11 Contracting All public health departments must complete the ancillary agreement and provide the credentialing application. If your agency also provides primary care, please reach out and we will provide you with a practitioner agreement, as well.

12 Credentialing HFS has mandated that Medicaid providers will no longer be credentialed by MCOs starting 1/1/18. Prior to 1/1/18 all providers must provide credentialing documentation to the MCO. All providers must be registered in IMPACT. MCOs will still need to collect documentation for all providers, including, but not limited to tax and financial information

13 Provider Directory Online Search Tool at For a printed directory request to ProviderHelp.IL@mhplan.com Contact your local Network Development Representative *Please keep our directory up-to-date by submitting rosters to your Representative regularly

14 Provider Manual Meridian s Provider Manual contains information about plan policies and procedures, authorization requirements and billing guidance. Available Online at For a printed copy or on CD: request to ProviderHelp.lL@mhplan.com Contact your local Network Development Representative

15 Provider Portal MeridianHealth s Provider Portal can be accessed at Verify eligibility and member information Request prior authorizations ELECTRONIC SUBMISSIONS TO BE ACCEPTED IN 2018 Run HEDIS and enrollment reports Check claim status Refer members to Disease and Case Mgmt. To Enroll Go to: and Select Login>Provider Portal Meridian s Provider portal is free of charge and available to all contracted providers.

16 Pharmacy Benefit Manager Meridian utilizes the Pharmacy Benefit Manager, MeridianRx to manage the member s pharmacy benefit. MeridianRx provides members with the following services: An extensive pharmacy network Pharmacy claims management services A complete drug formulary Pharmacy claims adjudication All providers have access to the Meridian Pharmacy Drug Formulary for Meridian Medicaid and Medicare Advantage plans. Pharmacy benefits and prescription drug coverage is not available through Meridian for MLTSS members. Providers must prescribe from within the drug formulary unless a formulary exception is obtained. If a medication that is required is not on the drug formulary, a Formulary Exception Request Form must be filled out. Medicaid: Medicare Advantage:

17 Claims Billing Requirements Claims may be filed one of three ways: Paper Provider Portal Electronic Claims filing deadline: In Network days from service date Out of Network 180 days from service date Corrected claims/reconsideration of payment request/appeal filing deadline: 120 days from adjudication date Submit paper claims, corrected claims, requests for payment reconsideration and appeals to: Meridian Health Plan Claims Department 1 Campus Martius Suite 720 Detroit, Michigan 48226

18 Meridian Clearinghouse Partners

19 Medicaid FQHC & RHC Billing Meridian requires that FQHC and RHC providers rendering services to Medicaid members submit claims on a CMS 1500 form or 837P using the appropriate HCPCS Code T1015 for medical services and for behavioral health services. All services provided during the encounter need to be line item listed on the claim using the appropriate E/M CPT Code(s). Meridian requires the FQHC or RHC Clinic NPI number is billed as the rendering/servicing provider and the service location address is also included.

20 VFC Billing Beginning October 1, 2016, All Kids (age 0-18), title 21 and state-funded eligible kids receive private stock vaccines from providers. Title IXX eligible children continue to receive their vaccinations through the VFC program. Providers are reimbursed for immunization as well as the administration HFS will reimburse the cost of vaccines fee-forservice Providers must bill the MCO directly Fee-for-service rates will be published in the state max column of the practitioner fee schedule. *FQHCs must use fee-for-service NPI to bill appropriate vaccine-specific procedure code with GB modifier on the paper claim form or 837p.

21 Taxonomy Codes Taxonomy codes required on all claims effective 01/01/17 Taxonomy codes are designed to categorize the type, classification, and/or specialization of health care providers The taxonomy code included on the claim must match the taxonomy code Meridian has on file for the rendering provider Meridian will require all claims, both paper and electronic to include the taxonomy code of the rendering provider Claims received on or after 01/01/17 that do not contain the rendering provider s taxonomy code will be rejected as not a clean claim All rejected codes must be resubmitted within the claims filing timeframes For paper claims on a CMS 1500 this information may be included in box 24J Billing Taxonomy Code is also required Additional claim and provider updates instructions are provided under the provider resources section of our website

22 IMPACT Registration All providers must be registered in IMPACT to receive payment from Meridian Health Plan To enroll please go to the following website: roviderenrollment.aspx

23 Non-Emergent Transportation Non-Emergent Transportation is a covered benefit for Medicaid covered healthcare services Non-Emergent Transportation will be provided by Medical Transportation Management, Inc. Available for use for medical and mental healthrelated transport needs for our members Example: Dr. appt., Behavioral Health service, Pharmacy

24 Cultural Competency A set of attitudes, behaviors and policies that enable people to work effectively in cross-cultural situations Examples of practicing cultural competency Approaching a new patient slowly Greeting the patient respectfully Sitting a comfortable distance away

25 Care Coordination Team Responsibilities Medical Director -Providers guidance to the team Care Coordinator -Qualified staff -Perform face-to-face and telephonic visits -Conduct assessments and reassessments -Develop and monitor care plans -Manage services and transitions of care -Primary contact with member and family CC Team Lead -Oversee POC and manage acute transitions of care Community Health Outreach Worker (CHOW) -Link members with community resources -Respond to and facilitate social needs Behavioral Health CM -Licensed clinical staff -Conduct BH assessment -Ensure and monitor care coordination between BH and medical providers Pharmacist -Perform medication profile review -Provide education on medication adherence Nutritionist -Provide nutritional guidance to members and caregivers

26 Defining Critical Incidents Abuse Neglect Injury inflicted on an individual other than by accidental means Failure to provide someone with, or withholding someone of, the necessities of life Physical Sexual Emotional Exploitation Unfair treatment of someone, or the use of a situation to personally benefit

27 Reporting Critical Incidents When an instance or allegation of a critical instance (abuse, neglect, or exploitation) is identified, it must be reported. Notify the appropriate state agency following the discovery of the incident Notify Meridian by phone at or by at criticalincidents@mhplan.com Complete the Critical Incident Reporting Form, which is located on Meridian s website

28 What is HEDIS? Health Effectiveness Data and Information Set Deemed as core quality measures by NCQA, CMS, and the State Ensures that patients receive the appropriate care based on age and gender HEDIS data is collected through claims and medical records Medical records are extremely important to obtain Can determine if: A patient received a service that was not captured in claims A patient should be included in a particular measure or population HEDIS measures and Provider Incentive Programs will be discussed during your PNDR Provider visits

29 HEDIS Preventative Care Measures Annual Visits EPSDT Immunizations Screenings Disease Management Adults Access to Preventative/Ambulatory Health Services (AAP) Children s Well-Care Visits 0-15 months (W15) 2-6 years (W34) 3-17 years (WCC) years (AWC) Early and Periodic Screening, Diagnostic, and Treatment 0-24 months (CIS) years (IMA) Yearly flu shots Lead Mammography Cervical Cancer Screenings Asthma Comprehensive Diabetes Care (CDC) Cardiovascular Disease (CVD) Chronic Obstructive Pulmonary Disease Congestive Heart Failure

30 Sharing Medical Records Year-round EDI Electronic Data Interchange Transmit medical information in real time Used to see services that are completed PHI secure EMR Electronic Medical Records Read-only access Allows Meridian to view medical records in EMR system all year Abstraction Team Requests medical records all year Conduct onsite visits to complete a chart review 30

31 Provider Bonus Overview Pay-for-performance program that incentivizes providers for delivering quality healthcare services (HEDIS measures) Bonuses range from $15 to $200 for services such as: Immunizations, well-child visits, prenatal and post-partum care, etc. 31

32 Ways We Help Patient mailings for HEDIS reminders Patient postcards from provider portal Community events Monthly Provider Health Education Flyers Quality Provider Webinars Meridian organizes member-only and service-specific events at provider offices Current events include: Diabetic Eye Exams Breast Cancer Screenings Children s Well-Care Visits If your office would like to host an event, please contact Cherise.Mangal@mhplan.com for more information. 32

33 Long Term Services and Supports and Behavioral Health

34 LTSS & HCBS (Long-Term Services & Support & Home and Community-Based Services) The program consists of five waiver groups, each with distinct eligibility/enrollment requirements and benefits. Persons who are Elderly Waiver Age 60 or older who are otherwise eligible for nursing facility Persons with Disabilities Waiver Persons age 0-59 with disabilities Persons with Brain Injury Waiver persons of any age with a brain injury Persons with HIV or AIDS Waiver Persons of any age diagnosed with HIV or AIDS Persons residing in supported living facilities (SLF) Waiver Persons age 65 or older or persons with disabilities Members can only qualify for one of five waiver groups.

35 HCBS Waiver Home and Community Based Services Waiver Program This program provides services that allow individuals to remain in their own homes or live in a community setting, instead of in an institution

36 HCBS Home and Community-Based Services Home and Community-Based Services include the following: Personal care aides Out-of-home respite Adult day health Attendant care Community transitional services Emergency alert system Group respite Habilitation Home delivered meals Home health service Homemaker Home Modification Plumber, handyman for home safety features Supplemental adaptive and assistive devices Physical and speech therapy Specialized medical equipment and supplies Environmental accessibility adaptations Transportation with/without attendant Skilled nursing Pest control Peer supportive services Caregiver support program-nutritional training, personal care techniques, fall prevention and how to use respite care

37 MLTSS Managed Long-Term Services and Supports MeridianHealth also offers Managed Long-Term Services and Supports which fully integrates traditional Long-term Services and Supports (LTSS) and nursing facility-based services, with home and community-based services (HCBS). Members who are referred to the program and meet the program s level of care guidelines will receive a face-to-face person-centered plan of care (POC) which includes a comprehensive and risk assessment component. The POC is reviewed by an interdisciplinary team who makes recommendations for appropriateness of care. Ongoing services are provided by the Community Care Coordination team, which includes the Community Care Coordinator, interdisciplinary and community support team members. MLTSS enrollees can opt in for MMAI coverage during any month of the year. Enrollees who opt in for MMAI coverage will not require separate MLTSS coverage.

38 Behavioral Health Meridian s Integrated Behavioral Healthcare Management Program is based on Meridian s overarching commitment to the well-being of all members through the provision of high quality healthcare services in a low resource environment. The integrated Behavioral Healthcare Management Program focuses on: Care coordination and collaboration between behavioral health, medical care and the members to ensure coordinated care with a strong emphasis on patient education, coaching and knowledge

39 CMHC Services MeridianHealth reimburses and follows the HFS guidelines in accordance to Rule 132, Group A and B services including SASS services. CMHC services categorized under Group A and B include the following services: Group A Mental Health Assessment Psychological Evaluation Treatment Plan Development, Review and Modification Group B Assertive Community Treatment Case Management Client-Centered Consultation Case Management Mental Health Case Management LOCUS Assessment Case Management Transition Linkage and Aftercare Community Support (Individual, Group) Community Support (Residential) Community Support Team Crisis Intervention Crisis Intervention State Ops Mental Health Intensive Outpatient Psychosocial Rehabilitation Psychotropic Medication Administration Psychotropic Medication Monitoring Psychotropic Medication Training Therapy/Counseling

40 MeridianHealth reimburses and follows the HFS guidelines in accordance with DASA, Division of Alcohol and Substance Abuse DASA services categorized as the following: DASA Services DASA Services

41 Behavioral Health Billing Information: Providers offering both substance abuse services and mental health services from the same site may not utilize the same NPI number for billing substance abuse and mental health services. Mental Health services must be billed under a separate NPI number from the substance abuse services The corresponding taxonomy per provider type must be registered with NPPES The NPI used to submit claims must also be registered with IL Medicaid IMPACT system and MeridianHealth

42 Behavioral Health Meridian Requires a Notification Inpatient Mental Health, Substance Abuse and Detox Notify Meridian within 24 hours of admission. Initial review completed within 24 hours of notification. SASS services Services that DO require a prior authorization Substance Abuse Residential Level of Care PHP (Partial Hospitalization Program) IOP (Intensive Outpatient Program) All services provided by an Out of Network provider Business Hours: Phone AfterHours UM Phone Fax Check our website often for up-to-date prior authorization requirements:

43 Contact Information/References Member Services Phone: Fax: Provider Services Phone: Fax: Meridian Website Illinois HFS Website: