Anthem Blue Cross and Blue Shield. Medicaid

Transcription

1 Anthem Blue Cross and Blue Shield Medicaid

2 Introduction Ken Groves Manager, Provider Network Management Jackie Richie Network Relations Specialist 2

3 Service Area Statewide - except Region 3 counties We are an option for Medicaid-eligible members within our service area. 3

4 Our Membership As of January 1, 2014, Anthem enrolled members who were newly eligible through the Affordable Care Act. As of July 1, 2014, Anthem also became a new Medicaid option for other populations, including Temporary Assistance for Needy Families (TANF) and the Kentucky Children s Health Insurance Plan (KCHIP) in all regions, except Region 3. Total membership as of 10/6/14 = 48,628. Medicaid Open Enrollment 10/27/14 12/12/14. 4

5 Claims 99% of claims are paid within 30 days Turn around time for paper claims: 3.8 Days Turn around time for electronic claims: 2.2 Days 5

6 Provider Network The Medicaid provider network was built by amending the Anthem commercial network agreements to add the Medicaid product and plan requirements. We have a very comprehensive, statewide network that includes over 16,000 providers. Facility 104 OB/Gyn 492 PCP 2424 Pediatric 425 Specialist 12,965 Behavioral Health 1,125 6

7 What Anthem Has To Offer

8 Provider Collaboration and Incentive Programs Collaboration and Incentive Program Options: Pay for Performance Achieving preset quality targets, such as HEDIS measures New Market PCP Shared Savings Medical loss ratio target with risk corridor Essential PCP reports Provider Quality Incentive Program (PQIP) Medical loss ratio shared savings program that incorporates a quality threshold which impacts the amount of shared savings paid to the PCP. Essential PCP reports Risk Arrangements 8

9 Value Added Benefits NO COPAYS **Effective September 1, 2014** Free Crib or Car Seat **Effective September 1, 2014** Free Sports Physicals **Effective September 1, 2014** Free Membership to Participating Boys and Girls Clubs Free Gift Cards for checkups in our Pregnancy Rewards Program 1 st Trimester=$25 Gift Card-Wal-Mart 3 rd Trimester=$25 Gift Card-Wal-Mart Postpartum visit=$25 Gift Card Wal-Mart $50 Wal-Mart Gift Card for Well Child visits 9

10 Member Eligibility Medicaid eligibility is determined by the Department for Community Based Services (DCBS) in the county in which the member resides. The Department for Medicaid Services (DMS) provides eligibility information to Anthem on a daily basis. Eligibility begins on the first day of each calendar month when the member joins. Primary Care Physician Selection A member must select a primary care physician (PCP). A member s PCP can be changed within 24 hours from the time the change request has been made. A member can see a specialist without a referral

11 Member ID Card 11 11

12 Credentialing Process Credentialing will follow the existing Anthem process in Kentucky. There may be some providers who were not previously required to be credentialed that may need to be credentialed under the Medicaid program. If a provider has already been credentialed for the Anthem commercial plan, the credentialing requirements for Medicaid may have already been met

13 Medicaid ID Number In order to be reimbursed for providing Medicaid covered services, providers are required to have an active Medicaid number in Kentucky. If a potential provider does not have a Medicaid number assigned, the health plan will work with the provider and the state to complete the necessary paperwork and assist the provider with obtaining a Medicaid number. Forms are available on the KY DMS website

14 Provider Website The provider website is available to all providers, regardless of participation status. Registration is required to perform many key transactions. Separate and distinct from existing MyAnthem registration. The Anthem Medicaid ID is required for registration

15 Website - Public Information Registration and login not required for access: Key tools include: Claim forms Precertification Lookup Tool Provider Manual Clinical Practice Guidelines News & Announcements Provider Directory Fraud, waste and abuse information Formulary 15 15

16 Website - Secure Information Registration and login required for access: Note: Anthem Medicaid ID required for registration. Key tools include: Precertification submission Precertification status lookup Pharmacy precertification PCP panel listings Member eligibility Claim status * Some functionality will be accessed via the Availity provider portal

17 Precertification Lookup Submit precertification requests through our provider website, via fax or by calling Provider Services. Check the status of your request on the website or by calling Provider Services. Our Precertification Lookup Tool lets you search by market, member s product and Current Procedural Terminology (CPT)

18 Provider Maintenance Forms Key changes can be requested directly on the provider website: Change practice name Add or update site, billing/remit, address, phone or fax number Tax ID changes: new signed contract will be required Provider name changes Add or terminate provider Add NPI, Medicare, or Medicaid numbers Initiate the Council for Affordable Quality Healthcare (CAQH) numbers for new providers

19 Claims Submission There are several ways to submit Medicaid claims to Anthem: Availity Electronically -Professional Payer ID: Institutional Payer ID:00160 Paper Submission Kentucky Claims Anthem Blue Cross and Blue Shield P.O. Box Virginia Beach, VA * Filing limit: 180 days from the date of service unless otherwise stated in contract

20 Encounter Submissions to DMS Anthem has been testing encounter files with DMS for several months, with a deadline for completion of 12/31/14. As of 9/14/14, many of the Anthem encounter files moved into production with DMS. Anthem offered a solution to the Encounter Workgroup to submit the specific file, which contains the data necessary to calculate FQHC and RHC wrap payments, ahead of other files from a catch up perspective and received approval to submit in this adjusted order. This solution was governed by a submission window of 10/12 10/14/14 and DMS s daily record count limit of 250K records. DMS will process wrap payments accordingly

21 National Vendors Dental Scion Dental Vision eyequest Pharmacy Express Scripts AIM Specialty Health* * Precertification for certain radiology services must be requested from AIM Specialty Health. These services include: Magnetic Resonance Angiograms (MRAs) Magnetic Resonance Imaging (MRI) Computerized Axial Tomography (CAT) scans Nuclear cardiology Positron Emission Tomography (PET) scans Computerized tomography

22 Anthem Medicaid Contact Information 22 22

23 Anthem Medicaid Contact Information Provider Services: Member Services: Provider Relations: Nurse Triage Line: Precertification: Fax : Pharmacy Prior Authorization: Fax: Paper Claims Submission: Kentucky Claims Anthem Blue Cross and Blue Shield P.O. Box Virginia Beach, VA Electronic Claims Submission: Professional Payer ID: Institutional Payer ID: Website:

24 Thank You! Legal Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AKYPEC A [December 2013]