Online Provider Orientation & Training

Transcription

1 Online Provider Orientation & Training

2 Orientation Guide This comprehensive Provider Orientation includes key informationfor new and established providers. Once you have completed the orientation in its entirety, please complete the Provider Orientation Attestation by accessing the hyperlink at the end of this orientation program. 2

3 Our History Our Mission & Core Values The Populations We Serve Our Health Care Policy WHO IS COMMUNITY HEALTH PLAN OF WASHINGTON 3

4 About CHPW In the fall of 1992, Washington s local Community Health Centers voted to create a not for profit managed care company Community Health Plan of Washington. Our plan membership grew from 14,000 members in 1993 to over 300,000 currently. Our network includes: 21 Community Health Centers that operate more than 125 clinic sites More than 2,600 primary care providers More than 14,000 contracted medical specialists More than 100 hospitals CHPW is a local not for profit f health plan in Washington State. 4

5 About CHPW To access our Provider Directory, including Mental and Behavioral Health Providers, please go to: search/ 5

6 About CHPW Health Care Policy Community Health Plan of Washington fills the gap left by other health plans. CHPW is a vocal, visible catalyst for change, responding to emerging needs and improving existing systems. The health plan passionately advocates for policy that ensures access to health care for every Washington resident. To learn more about CHPW, please visit us online at From the homepage, click on About Us 6

7 About CHPW Our Mission Community Health Plan of Washington's mission is to deliver accessible managed care services to meet the needs and improve the health of our communities, and to make managed care participation beneficial for community responsive providers. 7

8 Washington Apple Health Community HealthFirst Medicare Advantage Community HealthEssentials Special NeedsPlan & Model of Care Plan CHPW LINES OF BUSINESS 8

9 CHPW Lines of Businesses Washington Apple Health, continues to expand coverage in 2015 to individuals and families who have incomes below 138% of the Federal Poverty Level (FPL). Ouraffordable MedicareAdvantage HMOplansprovidemembersvaluable provide valuable extended coverage and services. CHPW s individual commercial insurance plan offered inside the Washington Health Benefits Exchange in

10 Washington Apple Health Together with our valued and committed contracted Providers, Community Health Plan of Washington is serving many members with Washington Apple Health! CHPW serves Washington Apple Health members statewide except in the following nine counties: Clallam, Columbia, Garfield, Jefferson, Klickitat, Lincoln, Mason, Skamania, Whitman 10

11 Medicare Advantage Special Needs MA Special Needs Plan (005): Service Area: Adams, Benton, Chelan, Clark, Cowlitz, Plan (005) Douglas, Ferry, Franklin, Grant, Grays Harbor, King, Kitsap, Lewis, Okanogan, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, Whatcom, and Yakima Counties Plan Highlights: $0 monthly premium $100 every two years for supplemental leyewear $875 per year for supplemental dental services $0 copay for acupuncture visit 11

12 MA Special Needs Plan and Model of Care Centers of Medicare and Medicaid Services (CMS) requires CHPW to provide basic Special Needs Program (SNP) and Model of Care (MOC) training every year to: CHPW s regular and/or contracted Employees Participating Providers that deliver routine care to SNP members Non Participating Providers that deliver routine care to SNP members Any staff members in a clinic i setting who provide care to this population on a routine basis RNs, LPNs, MAs, ARNPs, Physician Assistants and etc. Clinic Managers/Administrators should ensure their Providers and Staff who render routine services or care to SNP members access CHPW s Model dlof Care training i program at: providers/training/ For assistance and training options, please contact: Carmen Switzer Carmen.Switzer@chpw.org (206)

13 Medicare Advantage Plan (006) Enhanced Medicare coverage with low premium. Plan includes coverage for routine eyewear and dental services. Plandoes not include prescription drug coverage Part D. Service Area: Clark, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, and Thurston Counties Plan Highlights: $15 monthly premium $0 primary care copay $0 copay for diabetic supplies $100 every two years for supplemental eyewear $500 per year for supplemental dental services $0 copay for acupuncture visit 13

14 Medicare Advantage Plan (008) Enhanced Medicare coverage with low premium. Plan includes coverage for routine eyewear, dental services, and prescription drugs. Service Area: Clark, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, and Thurston Counties Plan Highlights: $50 monthly premium $0 primary care copay $0 copay for diabetic supplies $100every two years for supplementaleyeweareyewear $500 per year for supplemental dental services $0 copay for acupuncture visit 14

15 Medicare Advantage Plan (009) Enhanced Medicare coverage with low premium. Plan includes coverage for routine eyewear, dental services, and prescription drugs. Service Area: Adams, Benton, Chelan, Cowlitz, Franklin, Grant, Grays Harbor, Lewis, Pend Oreille, Stevens, Whatcom, and Yakima Counties Plan Highlights: $87 monthly premium $0 primary care copay $0 copay for diabetic supplies $100 every two years for supplemental eyewear $500 per year for supplemental dental services 15

16 Medicare Advantage Plan (010) Enhanced Medicare coverage with low monthly premium. Plan includes routine eyewear and prescription drugcoverage coverage. Service Area: Clark, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, Thurston, and Yakima Counties Plan Highlights: $12.10 monthly premium $10 primary care copay $0 copay for diabetic supplies $100 every two years for supplemental eyewear 16

17 Vision Service Plan (VSP) Community HealthFirst Medicare Advantage has vision benefits through VSP: Effective January 1, 2015 VSP administers the Plan and Vision Benefits on behalf of CHPW, including: Claims processing Quality Credentialing OON provider services Data/reporting Regulatory compliance 17

18 Vision Service Plan Summary of Vision Benefits One routine eye exam every year $100 allowance towards frames, lenses and contacts every 2 years VSP covers lenses for glasses in full $100 allowance for frames or contact lenses VSP has a large selection of frames to choose from that are within the $100 allowance. Members may choose to buy up and pay the difference out of pocket. 18

19 Vision Service Plan (VSP) Exam/Lens/Frame Frequency Plan Summary Exam/Eyeglass Copay Exam: Every 12 months Lenses & Frames: Every 24 months Provider Network Exams Exam and basic lenses covered in full $100 allowance towards frames or contacts VSP Advantage Network Well Vision exam covered in full $0/$0 Lenses Glass or plastic: Single vision Covered in full Lined bifocal Covered in full Frame Frames covered in full up to $100 20% off any amount above retail value Elective Contact Lenses Out of Network Reimbursement (if applicable) Lined trifocal Lenticular Covered in full Covered in full Instead of eyeglasses, elective contact lens fitting and evaluations services and any type of prescription contact lenses are covered up to $100 15% off contact lens fitting and evaluation services, excluding materials Exam $45 Lenses: Single vision $30 Lined bifocal or Progressive $50 Lined trifocal $60 Lenticular $75 Frame $45 Elective contact lenses (in lieu of lenses and frames) $85 19

20 Community HealthEssentials Healthcare Exchange Product There are three different Community HealthEssentials coverage levels available in 26 counties: Gold, Silver, and Bronze. Important facts: CHPW partnered with First Choice Health (FCH) to serve as the Preferred Provider Organization (PPO) network and Third Party Administrator (TPA) for Community HealthEssentials commercialproducts. November 15, 2014 Open Enrollment Begins for 2015 through Washington Healthplanfinder January 1, coverage begins February 15, 2015 Open Enrollment Ends for 2015 Qualified Health Plans offered through Washington Healthplanfinder 20

21 Community HealthEssentials Contact Numbers for Community Health Essentials through First Choice: Customer Care 1 (800) Express Scripts (pharmacy) 1 (866) TTY: 1 (800) Medical Pre authorization 1 (800) Behavioral Health Pre Auth 1 (800) Alere Tobacco Cessation 1 (866) Nurse Advice Line 1 (866) VSP Vision 1 (800) TTY: 1 (800)

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23 Member Enrollment Member PCP Assignment Q&A PCP/Clinic Changes Member Roster MEMBER ENROLLMENT & PCP ASSIGNMENT 23

24 Member Plan Selection Effective May 11, 2015 enrollees will have the opportunity to select their Plan and Clinic/PCP during the initial enrollment application on WA Healthplanfinder. If the enrollee wishes to apply any changes to their Plan or Clinic/PCP selection after they made the selection on the WA Healthplanfinder, they could do so through the Healthplanfinder or Provider One portals. 24

25 Member Assignment: FAQs This FAQ section applies to both WA Apple Health and Community HealthFirst Medicare Advantage through CHPW. If a CHPW member is assigned to a clinic outside of your organization, can the member be seen without a Plan referral? No, if the member is assigned to a clinic outside of your organization, a Plan authorized referral would be required. 25

26 Member Assignment: FAQs When a Clinic Change Form is submitted, when will the member be assigned to your clinic? If the Clinic Change Form is submitted before the 15 th of the month, the clinic assignment switch can be retroactive to the 1 st of the current month. If the Clinic Change Form is submitted after the 15 th of the month, the clinic assignment switch can be effective the 1 st of the following month. 26

27 Member Assignment: FAQs If a CHPW member is assigned to a clinic in your organization, are they able to see any primary care provider in the clinic? Yes Note: The rendering doctor/provider must be credentialed and issued an effective date by CHPW. If a CHPW member is assigned to one of many clinics in your organization, and is seen by a different clinic in your organization, will a Plan referral be required? No If a CHPW member is assigned to a clinic in your organization, and is seen by a clinic within your organization that operates under a different Tax ID, will a Plan referral be required? No 27

28 Member Clinic/PCP Change Forms Providers can submit a Clinic/PCP Change Form one of two ways: Electronic Fax (206) / Attn: Eligibility Coordinator Go to and on the homepage: Click on For Providers Click on Forms and Tools Electronic submission, clickon Clinic/PCP Selection Form (ELECTRONIC) Fax submission, click on Clinic/PCP Selection Form (PDF) Questions? Please call 1 (800)

29 Member Rosters How to access Member Rosters: Providers may access Member Rosters through the HIP portal. HIP access is available through the following avenues: OneHealthPort: HIP: Rosters are available in two formats Excel Worksheets and CSV. HIP Support Phone Number: 1 (800)

30 Language Assistance Culturally and Linguistic Appropriate Service (CLAS) Provider Resources

31 CHPW s Commitment CHPW supports providers in meeting CLAS standards and meets them ourselves by: 1. Training on key items, like the standards and tools we recommend for good care. 2. Resources to use with CHPW members in need of language assistance. 3. How to gain additional resources on CLAS and culturally competent care. A complete training program on CLAS standards could be found here: providers/training/. This is a mandatory training program for providers.

32 Language Assistance CHPW interpretation services are available: Apple Health: The Health Care Authority s vendor provides this service at (800) Medicare: CHPW provides this service at (866) with the following log in: Enter Account Number: Enter PIN Number: 0044 Enter Cost Center: 44

33 More Information For more information, access the following websites: Office of Minority it Health lthclas Standards: d lh lth hh Ethnomed Resources for Providers: Community Alliance for CLAS: If you have any questions, please contact: Carmen Switzer CHPW Provider Relations Administrator Carmen.Switzer@chpw.org Phone:

34 Access Standards Specialty Access ACCESS STANDARDS 34

35 Access Standards Providers must meet the following access standards: Primary Care & Pediatric Primary Care Schedule routine/preventive visits within 30 calendar days. Schedule an urgent visit within 24 hours. Schedule transitional care visit within 7 calendar days after discharge from inpatient/institutional care facility. Schedule non urgent, symptomatic care appointments within 10 calendar days. Behavioral & Mental Health Provide non life threatening emergency care within 6hrs. Schedule transitional care visit within 7 calendar days after discharge from inpatient/institutional care facility. Schedule an urgent care visit within 48 hours. Schedule a routine office visit within 10 business days. 35

36 Specialty Access Community Health Plan of Washington wants to know if our providers are experiencing barriers with referring to Specialist. If our providers need assistance with Specialty access, please go to click For Providers, Tools and Resources and click on the following on line form: Specialty Access Assistance Request The on line form will give you the opportunity to answer the following questions: What specialty or specialties are you having access issues with? In your opinion, what is causing the issue(s)? The form is completed and submitted online. 36

37 Health Information (HIP) Portal JIVA Care Management Portal PROVIDER PORTALS 37

38 Health Information Portal (HIP) Provider Portals Registered users have access to the following information: Eligibility and Benefit Details Member Rosters View Referrals & Authorizations View Claim Status Once registered, providers can access HIP through a single sign in at: OneHealthPort, or Support Phone Number: 1 (800)

39 Provider Portals CHPW JIVA Care Management Portal The portal is the preferred method for you to submit and track all Care Management requests. Request or check the status of the following: Eligibility/Referrals/Prior Authorizations Notify CHPW of Inpatient Admissions To register for JIVA, contact: To access website, go to: 39

40 Timely Filing Electronic Transactions Balance Billing CLAIMS & BILLING 40

41 Timely Filing & Claims Submission Timely Filing = 365 days from Date of Service Questions/ Claims Status: WA Apple Health Customer Service 1 (800) Medicare Advantage Customer Service 1 (800) Where to Send Claims Paper Claims: CHPW Claims POBox Plano TX, Electronic Claims Submission: Availity Payor ID: CHPWA Emdeon Payor ID: SB613 41

42 Electronic Transactions CHPW supports the following Electronic Transactions: 270: Eligibility, coverage or benefit inquiry 271: Eligibility, coverage or benefit information 276: Health care claim status report 277: Health care information status tt notification 834: Benefit enrollment and maintenance 835: Health care claim payment advice 837: Health care claim ACH payments: Automated clearing house (ACH) payments are electronic payments often referred to as direct deposit or electronic funds transfer (EFT). To enroll in any of the electronic transactions that we support, please 42

43 Balance Billing Providers may not bill members for co payments, coinsurances, deductibles or covered services for the following lines of businesses: Washington Apple Health MA Special Needs Plan (005) Nobalance billingispermitted is by Federal and State agency guidelines. 43

44 Balance Billing Providers must accept payment by CHPW as payment in full. Balance billing is not permitted unless the provider and member fully complete and sign an HCA form Agreement to Pay for Healthcare Services. Services must be rendered within 90 days from signing the HCA form, otherwise a new form must be completed and signed. The HCA form must be translated into the member s primary language if he or she has limited English proficiency, and if necessary, an interpreter must be provided for the member. If an interpreter is used to complete and sign the form, the interpreter s t signature must also be obtained. All other requirements for the HCA form apply, as outlined in WAC , 42 CFR , and HCA Memo #

45 Balance Billing: FAQs Washington Apple Health and Medicare Advantage Special Needs Plan Q: When a Provider bills an Apple Heatlh or MA Special Needs Plan member, do they need to contact CHPW and report the incident? A: Yes, providers must contact CHPW s Customer Service and report balance billing the member. Q: What happens when a Provider or a Member reports a balance billing incident? A: The incident is recorded and Providers are given information on balance billing guidelines. Repeated offenses can lead to corrective action. A complete training program on Balance Billing could be found here: providers/training/. 45

46 Balance Billing Special Needs Plan (SNP) SNP members should not be billed, as they are dual covered by Medicare and Medicaid. When a member presents to your clinic or hospital with a CHPW Medicare Advantage ID card with a Group 005 plan type, the member should ldbe registered it din your billing system as follows: Community HealthFirst as primary Medicaid (DSHS FFS) as secondary 46

47 2015Prior Authorization List Prior Authorizations Plan Authorized Referrals PRIOR AUTHORIZATION & REFERRALS 47

48 Prior Authorization CHPW uses the following procedures to ensure appropriateness, medical need, and efficiency of healthcare services: Prior Authorization Concurrent Review Post Payment Review Audit Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines to ensure medical necessity and appropriateness of care are met prior to services being rendered. Note: CHPW is expected to add procedures that will require a PA effective July 1, Go to and access our updated Prior Authorization List. 48

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53 Prior Authorizations Submitting Requests for a Prior Authorization (PA): TheCare Management Portal (JIVA) allows you to submit PriorAuthorization requests online. Providers can check eligibility and authorization status, print approval letters, and submit requests online 24/7. 53

54 Prior Authorizations Prior Authorization request forms can be faxed to: Fax: (206) Fax: (206) To obtain a copy of our PA form, visit us online at *CHPW will not retro prior authorizations. 54

55 Plan Authorized Referral When a Plan Referral is required: Member is referred to a non par provider Clinic/PCP visits when: Member is assigned to your clinic, and services are rendered by a Clinic/PCP outside of your organization. Member is assigned to a clinic outside of your organization, and you render services to the member. Urgent Care Visits (if claims are billed with a POS 11 and when the member is not assigned to the group affiliated with your Urgent Care). 55

56 Plan Authorized Referral Submitting Requests for a Plan Authorized Referral: The Care Management Portal (JIVA) allows you to submit Plan Authorized Referral requests online. Providers can check eligibility ibilit and referral authorization ti status, t print approval letters, and submit requests online 24/7. 56

57 Plan Authorized Referral Plan Authorized Referral request forms can be faxed to: Fax: (206) Fax: (206) To obtain a copy of our Referral form, visit us online at 57

58 Plan Authorized Referral CHPW will not process retro referrals. Note: Providers can appeal a no referral denial by submitting a document from the referring Provider which supports the intent to refer the member. 58

59 Medicare Appeals Medicaid Appeals DRG, Fee Schedule, and Refund Disputes PROVIDER & MEMBER APPEALS 59

60 Medicare Appeals Who can file an Appeal? The enrollee (including his or her representative); An assignee of the enrollee (i.e., a physician or other providerwho rendered services to the enrollee); The legal representative of a deceased enrollee s estate; or Any other provider or entity (other than the Medicare health plan) determined to have an appealable interest in the proceeding. 60

61 Medicare Appeals Examples of when appeals are filed by an enrollee, enrollee representative, or a participating provider: Pre service Appeals Servicerequest request was denied for medical necessity. Service was denied as a non covered benefit. The treating provider or PCP can appeal on the enrollees behalf without a consent. Example: Provider orders an MRI and the Plan does not approve. 61

62 Medicare Appeals Post service Appeals Administrative denials Fee schedule disputes Cost shares Non covered benefit The provider and enrollee must complete and sign an AOR form for anyone (including the provider) to appeal on the enrollees behalf. 62

63 Medicare Appeals The appeals process has 5 levels: Level 1: Reconsideration from the Health Plan Level 2: Review by an Independent Review Organization (IRO) Level 3: Hearing before an Administrative Law Judge (ALJ) Level 4: Review by the Medicare Appeals Council (Appeals Council) Level 5: Judicial review by a Federal District Court If the enrollee disagrees with the decision made at any level of the process, they can take it to the next level. 63

64 Medicare Appeals Level 1: Reconsideration from the Health Plan If the enrollee disagrees with the Plans initial decision, the enrollee or representative can request a reconsideration (a second look or review) a Level 1. If the enrollees appeal is for a pre service, the PCP or Provider can request a reconsideration on behalf of the enrollee without an AOR. 64

65 Medicare Appeals Level 2: Review by an Independent Review Organization (IRO) If the Level 1 decision is not in the enrollee's favor, the appeal will automatically be sent to the IRO Level 2. Level 3: Hearing before an Administrative Law Judge (ALJ) If the enrollee, representative or provider disagree with the IRO s decision in Level 2, they will have 60 days to request an Administrative Law Judge (ALJ) hearing Level 3. Level 4: Review by the Medicare Appeals Council (Appeals Council) If enrollee, representative or provider disagree with the ALJ s decision in Level 3, they will have 60 days to request a review by the Appeals Council Level 4. 65

66 Medicare Appeals Level 5: Judicial review by a Federal District Court If enrollee, representative or provider disagree with the Medicare Appeals Council in Level 4, they will have 60 days to request a judicial review Level 5. Note: The are timelines to meet at each level and some appeal levels require a claim minimum dollar amount to allow an appeal to be filed. For more information go to: 66

67 Medicare Part D Determination Coverage determination is any decision made by the Part D Plan as follows: Receipt of, or payment for, a prescription drug that an enrollee believes may be covered. The amount that the Plan requires an enrollee to pay for a Part D prescription drug and the enrollee disagrees with the Plan. A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement. Note: Not a complete list. 67

68 Medicare Part D Determination An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by filing a request with the Plan as follows: Standard or expedited requests for benefits may be made orally by calling CHPW s Customer Service at or in writing; fax to appeals Standard requests for payment must be made in writing. Written requests may be made by using the Model Coverage Determination Request Form. Note: Use of the Model Coverage Form is optional. The Plan must accept any written request for a coverage determination, including any request submitted on the model form. 68

69 Medicaid Appeals Who can file an Appeal? The enrollee (including his or her representative); An assignee of the enrollee (i.e., a physician or other providerswho rendered services to the enrollee); or A legal representative (at the enrollees expense) 69

70 Medicaid Appeals Examples when an appeal may be filed by an enrollee, a representative, or a provider: Plan did not approve a medical service. Planreduced the medicalservice. Plan ended the approval for service. 70

71 Medicaid Appeals The appeals process has 4 steps: Step 1: CHPW Appeal Step 2: State Hearing Step 3: Independent Review Step 4: Review Judge Decision Step 1: Enrollees have 90 calendar days from the CHPW denial letter to file an appeal. Enrollee may chose someone, including an attorney (at the members expense) or provider, to represent them. Enrollee must complete and sign a consent form if they chose a representative to appeal on their behalf. 71

72 Medicaid Appeals CHPW will respond within 72 hours in writing to acknowledge receipt of the appeal. CHPW will submit a decision in writing within 14 calendar days, unless CHPW notifies the enrollee that more time is needed, but within a maximum of 30 days. If the member disagrees with CHPW s decision, the member can request a State Hearing Step 2 The member can continue to appeal through h to Step 4. Step 4 appeal decision is final. *Post Service: Providers have the right to appeal on their own behalf. 72

73 Medicaid Appeals Enrollee Patient Review and Coordination (PRC) Program Appeals Enrollee can file an appeal for their placement in the PRC program. Enrollee should file the appeal through the standard process within 90 days. CHPW s medical director will review the appeal and make a final determination whether or not the enrollee will remain in the PRC program. Enrollee can file an appeal for non payment of services rendered for care that is not covered due to their placement in the PRC program. Providers can submit the appeal on the enrollee s behalf with a signed consent. 73

74 Appeal Timelines Participating providers have 24 months from the date of the denial to file a level 1 appeal. If they disagree with the decision in Level 1, they have 180 days to file a Level 2 appeal. Unless the Providers contract includes a provision for the right to arbitration, Level 2 is the final appeal option with the Plan. Currently CHPW extends a courtesy non par providers to file an appeal within 90 days. 74

75 DRG, Fee Schedule, and Refund Disputes Submit DRG, Fee Schedule, or Refund disputes one of the following ways: Mail: Community Health Plan of Washington Provider Customer Service Attention: Claims Investigation i Unit (CIU) 720 Olive Way, Suite 300 Seattle, WA Fax: (206) cs.claimsdistribution@chpw.org 75

76 Reporting Provider Changes Provider Effective Dates Credentialing Inquiries PROVIDER DATA & CREDENTIALING 76

77 Reporting Provider Changes/Updates CHPW providers must give notice to CHPW at least 60 days in advance of any provider changes such as: Provider Terms Provider Adds/Updates Tax ID Group and/or Individual NPI Billing and/or Pay to addresses Clinic locations (where services are rendered) Send changes and updates to: Note: Claims processing errors, rejections, denials and/or delays are often due to outdated Provider information in our systems. 77

78 Provider Effective Dates Specialist Provider Effective Date Delegated dcredentialing Groups: Dt Date listed on the Provider credentialing roster. Non Delegated Credentialing Groups: Date will be determined when CHPW completes the credentialing process. PCP Provider Effective Date Delegated Credentialing Groups: 1 st day of the month following the credentialing date on the Providers Roster. Non Delegated Credentialing Groups: Date will be determined when CHPW completes the credentialing process. 78

79 Credentialing Inquiries Delegated Credentialing Groups should send their rosters and credentialing inquiries to: Non Delegated Credentialing Groups should send their credentialing inquiries to: 79

80 Provider Orientation Provider Mandatory & Optional Training Programs PROVIDER TRAINING & EDUCATION 80

81 Provider Orientation Community Health Plan of Washington offers provider orientation and training programs. Some training programs are mandatory and others are optional. Provider Orientation New Providers (Mandatory) All new providers with Community Health Plan of Washington must complete orientation within 90 days of their contract effective date. Established Providers (Optional) Established providers with Community Health Plan of Washington may access our orientation for a refresher and updates. 81

82 Provider Mandatory and Optional Training Programs Mandatory Training 1. Special Needs Plan (SNP) Model of Care Who is required to complete this training: Healthcare workers who routinely care for the Special Needs population; i.e., Doctors, RN s, LPN s, Social Workers and etc. 2. Patient Rights and Responsibilities & Advance Directives Who isrequired to complete this training: All Healthcare workers, front desk staff, medical records staff, clinic managers, doctors, clinical staff, etc. 3. Culturally and Linguistic Appropriate Service (CLAS) Provider Resources Who is required to complete this training: AllHealthcare workers, frontdesk staff, medical records staff, clinic managers, doctors, clinical staff, etc. Optional Training 1. Balance Billing (highly recommended) 2. Provider Portal Training: Health Information Portal (HIP) Care Management Portal (JIVA) To complete training programs, go to: providers/training 82

83 For Providers Member Center CHPW ONLINE 83

84 CHPW.org: For Providers To access CHPW s Provider page online, go to and from the homepage, click: >For Providers Welcome Bulletin Board Provider Manual Orientation, Training, and Education Prior Authorization Forms and Tools Care Management Pharmacy Join Our Network From the For Provider tab, you can select the items bulleted above. 84

85 CHPW.org: Member Center CHPW designed a Member Center where members can access information to help them manage their health and wellness. Members can download or review the following items and more: Apple Health Handbook Dental Benefits Children First Well Child Form Children First Well Prenatal Form Assurance Wireless Cell Phone Program Members can register for an online account to access and print their member ID cards. 85

86 Contact Guide for Providers CHPW CONTACT GUIDE 86

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88 CMS General Compliance/Fraud, Waste, and Abuse Training Mandatory Training You must also complete the CMS General Compliance and/or Fraud, Waste and Abuse Training and submit an annual Attestation to CHPW to attest that training has been completed. CMS requires the following to be completed every year: Complete General Compliance and/or Fraud, Waste and Abuse Training. Maintain individual training documentation for all staff members (i.e. sign-in sheets, electronic certification, etc.). Submit an Attestation form to CHPW, attesting that training requirements have been met. 88

89 CMS General Compliance/Fraud, Waste & Abuse Training Mandatory Training As stated by CMS, there is one exception to the Fraud, Waste and Abuse training and education requirement. CMS implemented a deeming exception for an entity or an individual who is enrolled in Medicare Part A or B. This means that your training requirement for FWA is satisfied if you are enrolled in Medicare Part A or B; therefore, your annual Attestation would only apply to General Compliance. CMS General Compliance and/or, Fraud, Waste and Abuse Training must be completed by: Providers and all staff (I.e., MD, DO, ARNP, RN, LPN, Administrators, Office Managers, Medical Assistant, Receptionists, Medical Record Coordinators, Referral Coordinators, etc.). 89

90 CMS General Compliance/Fraud, Waste & Abuse Link to access Attestation Form: Link to access General Compliance/Fraud, Waste & Abuse Attestation FAQ s: Link to CMS s General Compliance/Fraud, Waste & Abuse Training Program: MLN/MLNProducts/ProviderCompliance.html 90

91 HCA Pregnancy Program First Steps Maternity Support Services First Steps is a program that helps lowincome pregnant women get the health and social services they may need and covers a variety of services for pregnant women and their infants. First Steps is available as soon as a woman knows that she is pregnant and is covered by Washington Apple Health (Medicaid). First steps services include medical, enhanced, drug and alcohol and other services. Maternity Support Services (MSS) are preventive health and education services to help women have a healthy pregnancy and a healthy baby. When a pregnant woman finds out she is pregnant and approved for pregnancy medical through Washington Apple Health, she may elect to have enhanced Maternity Support Services. Pregnant women with Apple Health coverage can receive Maternity Support Services during pregnancy and through the end of the month of the 60th day following the end of the pregnancy. Services can begin any time during the prenatal, delivery or postpartum period. However, the goal of the program is to get a pregnant woman into the program as early in her pregnancy as possible. For more information on First Steps and Maternity Support Services Programs and to access screening tools -- MSS Prenatal (form ) and Post Pregnancy (form ), go to: 91

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93 Sign Up for CHPW Updates/Notices Contact Provider Relations for an On site Visit Important ACTION REQUIRED Thank you! COMPLETE YOUR ORIENTATION THE FOLLOWING SLIDES INCLUDE IMPORTANT INFORMATION AND FINAL STEPS IN COMPLETING YOUR ORIENTATION. 93

94 To receive updates and notices from CHPW, please provide us with addresses from thefollowing staff/departments: Payor Contract Managers Billing Managers Clinic Managers Team Members (billers, receptionists, medical record clerks, etc.) Sign up now! 94

95 If you wish to have an on site visit with a Provider Relations (PR) representative, please Provder.Relations@chpw.org org and your PR Representative will contact you. 95

96 IMPORTANT ACTION REQUIRED A Provider Orientation Attestation is required for all providers upon completion of this provider orientation webinar. If your Attestation is not submitted, your mandatory participation will not be met. Please click on the following link to complete your Attestation today: Online Attestation Form 96

97 Thank you for completing your provider orientation and for submitting your attestation. We hope that you found the information helpful! On behalf of your partners at CHPW, we want to thank you for joining our network! We are excited about the opportunity to work with You! 97