BlueChoice HealthPlan Medicaid. Provider education 2017

Transcription

1 BlueChoice HealthPlan Medicaid Provider education 2017

2 Provider Relations 2

3 What s new Process for obtaining Makena New website feature Availity Portal Pharmacy reports now available Provider report card Behavioral health carve-in services 3

4 Makena Makena is a hormone medicine prescribed to high-risk pregnant members to lower the risk of preterm delivery. Process for obtaining Makena: The requesting provider will fill out the Universal 17-P Authorization Form and fax it to BlueChoice HealthPlan Medicaid for prior authorization. To access the form, visit and select Providers. Medical records documenting medical necessity for Makena will be required along with the form. 4

5 Makena (cont.) If the member is on bedrest and needs home delivery, the provider should still complete the Universal 17-P Authorization Form, as stated previously, but will also need to complete the Request for Pre-Service Review form. To access the form on our website, visit and select Providers. Medical records indicating that the member is on bedrest will need to be submitted. The requesting provider will send the prescription along with the authorization number to the specialty pharmacy. You can write the authorization number at the top of the Universal 17-P Authorization Form and fax this to the specialty pharmacy along with the prescription. 5

6 Makena (cont.) The requesting provider will administer the medication received from the specialty pharmacy. Please allow up to 14 days for prior authorization. 6

7 Specialty pharmacies for Makena Avella Phone: Fax: Avella is an independent company that administers specialty pharmacy services on behalf of BlueChoice HealthPlan Medicaid. 7

8 Specialty pharmacies for Makena (cont.) CVS Specialty Phone: Fax: CVS is an independent company that administers specialty pharmacy services on behalf of BlueChoice HealthPlan Medicaid. 8

9 Availity Portal Availity is an independent company that administers the secure provider website on behalf of BlueChoice HealthPlan Medicaid. Great news! Your access to BlueChoice HealthPlan Medicaid eligibility, benefits and claim status inquiry is now being offered on the Availity Portal at This link leads to a third-party website. That company is solely responsible for the privacy policies and content on its site. 9

10 Availity Portal (cont.) You will be able to view remittances, submit inpatient and outpatient prior authorization requests, and find information on your organization s precertification requests. If you are unfamiliar with Availity Portal, detailed instructions are available through your Provider Relations representative. 10

11 Pharmacy report BlueChoice HealthPlan Medicaid now offers pharmacy reports to our providers. These reports can be an important tool in identifying: Generic trends. Prescribing patterns. High-dollar members. High-dollar prescriptions. The information contained in the pharmacy report ties directly into the Medical Loss Ratio report. 11

12 Provider s report card 12

13 About Provider Relations The Provider Relations team is devoted to developing and maintaining lasting relationships with providers. The department consists of five representatives who are responsible for servicing South Carolina providers for BlueChoice HealthPlan Medicaid. Representatives are available by phone, and in person. The Provider Relations team makes periodic courtesy visits to provider offices. The Us form is no longer available. Providers should direct inquiries to the Customer Care Center first, then their respective Provider Relations representative. 13

14 Did you know We offer a Very Important Person (VIP) program to PCPs who have at least 200 members assigned to them. The VIP program offers bimonthly, agenda-driven visits with a Provider Relations representative who will discuss: Monthly reports. Bulletins and memos. Billing and claims updates. Specific questions and/or issues that providers may have. 14

15 New Provider Relations region map 15

16 Report card: Tools to assist you Reports are available monthly. The report card contains claims denials, incentives received, incentives missed, etc. Membership report: Reports are available monthly. The membership report identifies members assigned to each physician within a PCP group. 16

17 Tools to assist you (cont.) Emergency room (ER) diversion report: Reports are available monthly. The ER report identifies members assigned to a specific physician who have visited the ER within the last month. The report indicates the diagnosis(es) the member received from the ER visit. Medical Loss Ratio report: Reports are available quarterly. The Medical Loss Ratio report provides a cost breakdown associated with a specific practice. 17

18 Tools to assist you (cont.) Gaps in care report: Reports are available monthly. The gaps in care report identifies members who need to be seen for well exams, immunizations, etc. Pharmacy report: Reports are available monthly. The report breaks down pharmacy spend to the member and practitioner level. 18

19 Interpreter services BlueChoice HealthPlan Medicaid offers no-cost interpreter services for Healthy Connections members. Interpreter services are available by phone or in person. Services are available in multiple languages as well as for hearing-impaired members. Members with vision loss can request verbal assistance or alternative formats of printed materials. To access interpreter services, call our Customer Care Center at or 19

20 The BlueBlast is our monthly, provider-focused newsletter. BlueBlast typically includes: BlueBlast Important health plan updates. Healthy Connections announcements. Billing and claims information. Frequently asked provider questions. Community outreach efforts and upcoming events. If you would like to receive a copy of the BlueBlast electronically or by mail, please contact your Provider Relations representative. 20

21 Primary care availability standards Visit type: Routine visit Urgent, nonemergent visit Emergent visit Availability standard: Within four weeks Within 48 hours Immediately scheduled upon presentation at a service delivery site Wait times must not exceed 45 minutes for a routine, scheduled appointment. Walk-in patients with nonurgent needs must be seen or scheduled for an appointment. 24-hour coverage by direct access or through arrangements with a triage system should be provided. 21

22 Specialist availability standards Visit type: Routine visit Urgent medical condition care appointment Emergent visit Availability standard: Within four weeks; maximum of 12 weeks for unique specialists Within 48 hours of referral or notification from PCP Immediately upon referral 22

23 Fraud, waste and abuse 23

24 Fraud, waste and abuse provider s responsibility Providers are a vital part of the effort to prevent, detect and report Medicaid noncompliance as well as possible fraud, waste and abuse. You are required to comply with all applicable statutory, regulatory and other Medicaid managed care requirements in South Carolina, including adopting and implementing an effective compliance program. You have a duty to Medicaid to report any violations of laws that you may be aware of. You have a duty to follow your organization s code of conduct that articulates your commitment to standards of conduct and ethical rules of behavior. 24

25 Fraud, waste and abuse provider s responsibility (cont.) Visit and select Providers to view more information about fraud, waste and abuse. Fraud is an intentional deception or misrepresentation that an individual or entity makes knowing that it could result in an unauthorized benefit to the individual, the entity or some other party. Four key elements of fraud are: Intent to defraud through deliberate deception. Knowledge of wrongdoing. Misrepresentation in making a false impression. Reliance on receiving a benefit to which the recipient is not legally entitled. 25

26 Waste: Fraud, waste and abuse provider s responsibility (cont.) Waste is using health care benefits or spending health care dollars without real need. Abuse: Abuse is an activity that is not consistent with generally accepted business or medical standards/practices. Abuse consists of payment for items or services that a provider bills by mistake but Medicaid should not pay for This is not the same as fraud. 26

27 Quiz Can you name one of the key elements of fraud? 27

28 Answer Four key elements of fraud are: Intent to defraud through deliberate deception. Knowledge of wrongdoing. Misrepresentation in making a false impression. Reliance on receiving a benefit to which the recipient is not legally entitled. 28

29 Federal False Claims Act (FCA), 31 USC Section 3279 The federal FCA is a statute that covers fraud involving any federally funded contract or program, including Medicaid programs. Under the FCA, any individual or organization that knowingly submits a claim they know (or should know) is false and knowingly makes or uses a false record or statement to have a false claim paid or approved (or causes a false record or statement to be made or used) under any federally funded health care program is subject to civil penalties. 29

30 FCA 31 USC Section 3279 (cont.) The FCA also includes cases in which: An individual or organization gets money to which they may not be entitled, then uses false records or statements to retain the money. A provider retains overpayments. Under the FCA, a person, provider or entity is liable for up to triple damages and penalties between $5,500 $11,000 for each false claim it knowingly submits or causes to be submitted to a federal program. In addition to civil penalties, individuals and entities can be excluded from participating in any federal health care program for noncompliance. 30

31 Reporting fraud, waste and abuse If you suspect it, report it to your Compliance department or your sponsor s Compliance department. The Compliance department will investigate and make the proper determination. To report fraud, call the BlueChoice HealthPlan Medicaid confidential fraud hotline at or medicaidfraudinvestigations@amerigroup.com. You may also call the South Carolina Department of Health and Human Services fraud hotline at or fraudres@scdhhs.gov. 31

32 PCP auto-assignment During the health plan enrollment process, we ask members to choose a PCP. If they do not choose a PCP, BlueChoice HealthPlan Medicaid selects a PCP for them. If a member has an appointment at your office and you are not the PCP listed on their Healthy Connections member ID card, you may still see the member and file for reimbursement. Members who are interested in changing and/or selecting a PCP should contact the Member Customer Care Center. 32

33 PCP auto-assignment (cont.) Members can also complete the Primary Care Provider (PCP) Selection Form. Providers can submit the form on the member s behalf via fax. To access the form, visit and select Providers. 33

34 PCP Selection Form Members can use this form to select or change their PCP. 34

35 Discharging a member Use the Request Member Discharge from Practice Panel form to request member discharges for issues such as chronic no-shows, disruptive behavior and noncompliance. To access the form, visit and select Providers. 35

36 Physical, speech and occupational therapy benefits Therapy benefits are based on the fiscal year: July June. Claims exceeding the limits below will deny. Additional visits require an authorization. For a complete listing of covered therapy codes, please refer to the SCDHHS Private Rehabilitative Therapy Manual: Member age: Therapy benefit (per year): 0 20 years old 105 total visits or 420 units years old 75 total visits *This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site. 36

37 Behavioral health 37

38 Psychiatric residential treatment facilities (PRTFs) Effective July 1, 2017, PRTF services were carved into the managed care organizations. All PRTF admissions require authorization. Ancillary service may require authorization depending on the number of services the member has had. 38

39 PRTF prior authorization form To access this form, visit and select Providers. The turnaround time for processing prior authorization requests is five calendar days. Providers may call the Utilization Management (UM) Intake line if they have questions about the current status of their prior authorization request at , option 3. 39

40 Coding for PRTF services The revenue codes to be used by the PRTF providers are 120, 124 and 154. Therapeutic home time should be billed using revenue code 183. This is a 14-day time period that the member has to return home but can be billed by the PRTF. Please the behavioral health division at the SCDHHS to determine the number of therapeutic home time hours the member has accrued during the member s stay if they have changed plans or PRTFs. 40

41 Autism spectrum disorder (ASD) 41

42 ASD All ASD services require prior authorization. Contact information for authorization: Phone: , option 3 Fax: New patient authorizations will need the following: Plan of care Diagnosis of care Request authorization We do not require a re-diagnosis for ASD. 42

43 Coding for ASD services The following codes will be billable for medically necessary ASD services: Procedure code Service description Qualifications 0359T 0368T and 0369T 0360T and 0361T 0362T, 0363T 0364T, 0365T 0370T H2019 Behavior Identification Assessment (ABA) Adaptive Behavior Treatment with Protocol Modification Observational Behavioral Follow-up Assessment Exposure Behavioral Follow-up Assessment Adaptive Behavior Treatment by Protocol Family Adaptive Behavior Treatment Guidance Therapeutic Behavioral Services (non-aba) BCBA/BCaBA BCBA/BCaBA BCaBA/RBT II (bachelor degree + RBT hours of line therapy experience) RBT I (RBT certification) BCBA/BCaBA/RBT II Ph.D./Psy.D., LISW, LMFT, LPC, LPES Behavior Assessment (non-aba) Ph.D./Psy.D., LISW, LMFT, LPC, LPES Psychological Testing Ph.D./Psy.D., LPES 43

44 Claims and billing 44

45 Most common denials National Drug Code missing or invalid Tip: Drug manufacturers must be part of the State Rebate Program for the drug to be a covered service. Member eligible for other health coverage Tip: Remember to ask patients at every visit for all insurance information. Authorization required Tip: Always check to see if services require prior authorization. 45

46 Claims resolution Provider Services and Customer Care Center are here to assist you! BlueChoice HealthPlan Medicaid has a team of five Provider Services representatives who are available to assist you in educational issues. We have a full staff of representatives to assist you with claims issues. Representatives are located in our Customer Care Center. Please remember that the Provider Services representatives travel three days a week and are not in the office to take calls. The call center representatives are available five days a week, eight hours a day to take your calls. 46

47 Claims resolution (cont.) To assist you in the most efficient manner possible, we are asking that you follow the guidelines below. Please contact your Provider Services representative for the following services: Nonparticipating provider denials on claims for providers you know are participating Requests for on-site training sessions Clarification on policies and procedures Requests for reports 47

48 Claims resolution (cont.) Please call the Customer Care Center for the following services: Claims questions/issues Request for remits soon to be available on our website Status of appeals Status of medical records sent in on claims 48

49 Claims resolution (cont.) If the call center representative states they are handling your issue, please follow up with the call center using the tracking number they provided to you. Provider Services does not have access to the same systems as the call center and will not be able to provide a status for you. We understand that there may be instances where the Customer Care Center will not able to assist you. If you need to contact your Provider Services representative concerning a claims issue, please have the name of the call center representative and tracking number from the call available. 49

50 Claims submission Electronic data interchange (EDI) Payer ID EDI is the preferred and fastest way to submit claims. You can submit corrected claims electronically through EDI. To register or for questions, call EDI at or 50

51 Claims submission (cont.) To submit a hard copy claim, corrected claim, appeal or other correspondence, mail to: BlueChoice HealthPlan Medicaid Attn: Medicaid Claims P.O. Box Columbia, SC

52 Timely filing limits Claim filing limit: Providers have 365 days to submit claims. Claims denied due to requests for medical records: Medical records must be received within 60 days of the request. Corrected claims: Corrected claims (including changes to coding, units, NPI, etc.) must be received within 90 days of the process date for us to consider them for payment. Corrected claims can be submitted electronically or via hard copy. 52

53 Corrected claims Corrected claims: If you submit a hard copy corrected claim, the claim must be accompanied by a Claim Follow Up Form. To access this form, visit and select Providers. 53

54 Appeals: Appeals To be considered for review, we must receive appeals within 90 days from the Explanation of Payment. Appeals must be accompanied by a Provider Appeal Request Form. To access this form, visit and select Providers. 54

55 Provider updates Send all office updates to You must request to be added to BlueChoice HealthPlan Medicaid specifically. The Provider Certification department will ensure we complete your updates across all lines of business. 55

56 We need to be updated when: A physician is leaving your practice. A physician is joining your practice. You have a change in phone number. You have added or closed a satellite location. You want to close your panel and no longer accept new patients. You have a change in office hours. You have a change in the age range of members you will see. 56

57 Provider updates If you need to add or terminate a provider, please use the Request to Add or Terminate Practitioner Affiliation. To access this form, visit and select Providers. If you receive a phone call or from us requesting this information, please respond. If you have questions or if you would like information, please contact your Provider Relations representative. 57

58 Incentives Notice of pregnancy Notice of delivery Screening, brief intervention and referral to treatment Quality Incentive Program Affordable Care Act enhanced payment 58

59 Utilization management 59

60 Utilization management The right care, in the right place, at the right time What we do: Facilitate the delivery of quality, medically necessary care and services to eligible members in the most appropriate setting. Process pre-service requests and inpatient stays. Note, for postservice requests, you should send supporting clinical documentation with the claim. 60

61 Denials The medical director issues denials and overturns them. Read your copy of the denial letter. This contains important information about the rationale for the denial. If the denial is based on network status, contact your Provider Relations representative. 61

62 Denials (cont.) Peer-to-peer (P2P) reviews provide real-time discussion of the treatment for the member. To request a P2P review, the treating provider should call within 30 days of the denial letter. Submit appeals by calling the Customer Care Center at You have 90 calendar days from the date of the denial notification to file an appeal. 62

63 Care management Empowering members to self-care management What we do: Care management focuses on the timely, proactive, collaborative and member-centric coordination of services for individuals who have been identified as having complex medical conditions. How we do it: Identification: extensive predictive modeling report, utilization management, and provider and member referrals Engagement: assessment, plan of care, education and care coordination with community resources 63

64 Care management (cont.) Coordination: providers, disease management and behavioral health Outcomes: improving the lives of our members, avoiding unnecessary hospital admissions and readmissions, and providing tools for greater member self-care management 64

65 Disease management programs The Disease Management team manages members within 11 programs. This includes the following eight National Committee for Quality Assurance (NCQA)-accredited programs: - Asthma - Congestive heart failure - Diabetes - Major depressive disorder - Chronic obstructive pulmonary disease - Coronary artery disease - HIV/AIDS - Schizophrenia 65

66 Disease management programs (cont.) We also provide disease management programs for members who are diagnosed with the following conditions: Bipolar disorder Hypertension Substance use disorder 66

67 Break We will take a 10-minute break before beginning the second portion of the session. 67

68 Clinical quality management 68

69 What is HEDIS? Healthcare Effectiveness Data and Information Set HEDIS is used to measure performance in the delivery of medical care and preventive health services. HEDIS covers 81 measures across the following five domains of care: Effectiveness of care Access and availability of care Patient experience Utilization and relative resource use Health plan descriptive information 69

70 What is HEDIS? (cont.) HEDIS evaluates adherence to both physical and behavioral health Clinical Practice Guidelines. HEDIS is one component of a larger accountability system and complements the NCQA accreditation program. 70

71 Examples of HEDIS Measures Annual well-visits for babies, children and adolescents Childhood and adolescent immunization Lead screening Comprehensive diabetic care Hemoglobin A1c Diabetic eye exam Blood pressure Attention to nephropathy Nephrology referral Microalbumin or urinalysis 71

72 Examples of HEDIS Measures (cont.) Women's health Prenatal and Postpartum Care Chlamydia Screening in Women Breast Cancer Screening Cervical Cancer Screening Behavior health Antidepressant Medication Management Follow-Up Care for Children Prescribed ADHD Medication Follow-Up After Hospitalization for Mental Illness Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics 72

73 Examples of HEDIS Measures (cont.) Metabolic Monitoring for Children and Adolescents on Antipsychotics Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment 73

74 HEDIS The HEDIS hybrid medical record review process is completed annually from January May. For the review, a sample of members are selected, and BlueChoice HealthPlan Medicaid reaches out to our partners for medical records. A demonstration is made for the NCQA on how well our partners managed their members through the HEDIS hybrid medical record process. When combined, the results of NCQA accreditation and HEDIS provide a complete view of our quality. 74

75 CAHPS CAHPS is a member satisfaction survey focusing on members perception of their ability to access quality medical care as well as their recent experiences with the health plan. The survey specifically targets aspects of quality that consumers are best qualified to assess such as the communication skills of providers and ease of access to health care services. 75

76 CAHPS (cont.) 76

77 CAHPS (cont.) 77

78 CAHPS (cont.) Ways to improve member perception: Review your members referrals/consults, lab work and ancillary tests. Speak with members about their medications. Speak with members on how to navigate the process in the office. Offer members the flu shot. If the member smokes, ask them if they are interested in a smoking cessation program. 78

79 Community outreach 79

80 Community outreach Build a strong network of PCPs and specialty providers. Continue to serve more than 97,000 members statewide. Help people get the medical care they need and the respect they deserve. Work with community and faith-based organizations to help our members find local resources. 80

81 Redetermination We help members maintain health care coverage by: Renewing every 12 months from the date of enrollment. Making sure addresses are up-to-date with Healthy Connections if the individual has moved. Filling out the Healthy Connections Annual Review Form completely and accurately, and sending it back before the due date given on the form. 81

82 Redetermination (cont.) We educate the community by: Visiting and selecting Providers to make sure addresses are updated. Visiting the Healthy Connections office for other Medicaid assistance. 82

83 BlueChoice HealthPlan Medicaid Community Action transit 83

84 Meet Coach Blue GAME PLAN for health Get regular checkups Always eat fruit and veggies Make healthy choices Play hard and safe Learn ways to be healthy Aim high and set goals Exercise daily Never give up 84

85 Coach Blue in the community 85

86 Extra benefits In addition to the core benefits offered, BlueChoice HealthPlan Medicaid also offers several extra benefits: Free explorer youth program membership through Boy Scouts Free Boys and Girls Club membership Free Girl Scouts membership and uniform or journey booklet Car seat program Blue Book Club SM Community Resource Link No copay for urgent care New Baby, New Life SM Discounts on health and wellness programs 86

87 Extra benefits (cont.) Low copays for generic and brand-name medicine No cost for checkups, circumcisions and flu shots Free manual breast pumps Gift cards (for healthy behaviors) 24-Hour Nurseline Disease management Cellphone program 87

88 Lowcountry region 88

89 Pee Dee region 89

90 Upstate region 90

91 Midlands region 91

92 Marketing/Outreach team 92

93 Thank you BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections. To report fraud, call our confidential Fraud Hotline at You may also call the South Carolina Department of Health and Human Services Fraud Hotline at or BSCPEC November