STAR+PLUS IN-SERVICE NURSING FACILITY. Offered by Cigna Health and Life Insurance Company or its affiliates

Transcription

1 STAR+PLUS IN-SERVICE NURSING FACILITY Offered by Cigna Health and Life Insurance Company or its affiliates MMCDTX_16_49499_PR

2 AGENDA Cigna-HealthSpring s Company Overview STAR+PLUS Nursing Facility Program Overview STAR+PLUS Nursing Facility Benefits and Eligibility Authorizations Skilled vs. Non-Skilled Services Non-Emergent Ambulance Services Interacting with Cigna-HealthSpring STAR+PLUS Claims Process Payment Dispute Form Appeals Electronic Funds Transfer Electronic Remittance Advice Cigna-HealthSpring Website & Secure Provider Portal Fraud, Waste and Abuse Important Phone Numbers Questions and Answers STAR+PLUS Nursing Facility Program Overview STAR+PLUS Nursing Facility Benefits and Eligibility Interacting with Cigna-HealthSpring STAR+PLUS Confidential, unpublished Cigna-HealthSpring property of Cigna. Do not duplicate or distribute. Website Use and distribution & limited Secure solely to authorized Provider personnel. Copyright Portal 2016 Cigna. 2

3 CIGNA-HEALTHSPRING COMPANY OVERVIEW Based in Nashville, Tennessee, Cigna-HealthSpring got its start in 2000 and is now one of the country s largest and fastest-growing coordinated care plans whose primary focus is Medicare Advantage plans. Cigna-HealthSpring currently owns and operates Medicare Advantage plans in Alabama, Arkansas, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Mississippi, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, and Washington, D.C., as well as a national stand-alone prescription drug plan. Our Mission Statement Cigna-HealthSpring is dedicated to improving the health of the communities we serve by delivering the highest quality and greatest value in healthcare benefits and services. 3

4 CIGNA-HEALTHSPRING COMPANY OVERVIEW (CONT.) Cigna-HealthSpring currently offers STAR+PLUS services in the Tarrant SDA, Hidalgo SDA and MRSA Northeast. Combined, Cigna-HealthSpring serves Members in 50 counties across the State of Texas for all three service delivery areas. March 1 st, 2015, Cigna-HealthSpring began serving all three Service Delivery Areas for Nursing Facility services. 4

5 CIGNA-HEALTHSPRING COMPANY OVERVIEW (CONT.) STAR+PLUS COUNTY COVERAGE Tarrant SDA May 1, 2011 (6 Counties) Hidalgo SDA March 1, 2012 (10 Counties) MRSA Northeast SDA September 1, 2014 (34 Counties) Denton, Hood, Johnson, Parker, Tarrant and Wise. Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, and Zapata. Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt and Wood. 5

6 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW STAR+PLUS is a Texas Medicaid managed care program designed to coordinate and provide preventive, primary, and acute care, Long-Term Services and Supports (LTSS) to community-based and Nursing Facility residents through a managed care delivery system. Health and Human Services Commission (HHSC) has carved in custodial Nursing Facility services to the Managed Care Organizations (MCO). The expectation is to improve the quality of care, and to better coordinate services and healthcare needs. 6

7 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Program Objectives Assess Member s health risks and functional needs. Assist Nursing Facility Members wanting to return to the community. Provide competent service coordination, which includes service planning, and monitoring and coordinating acute care for members with complex or chronic health care needs. Improve cost effectiveness by reducing unnecessary hospitalizations and providing appropriate medical services. 7

8 STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY Eligibility To be eligible for Nursing Facility services, a STAR+PLUS Member must meet all of the following criteria: A physician certifies the Member s medical condition. The Member s medical condition meets Medical Necessity (MN) requirements. The Member has received a Level 1 Pre-admission Screening and Resident Review (PASRR). Once a Member is admitted to the facility they will receive a Minimum Data Set (MDS) evaluation by the nursing facility to determine the Member s Resource Utilization Group (RUG). 8

9 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Program Qualifications Enrollment is required for Medicaid recipients who live in a STAR+PLUS service area and fit one or more of the following criteria: People who are have a physical or mental disability and qualify for supplemental security income (SSI) benefits or for elderly individuals who have Medicaid due to low income. People who qualify for Community-Based Alternatives (CBA) HCBS STAR+PLUS waiver services. People age 21 or older who can receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for HCBS STAR+PLUS waiver services. People age 21 or older who are receiving SSI. 9

10 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Member Enrollment Process Once a Medicaid client is determined by HHSC to be eligible for STAR+PLUS, he/she will receive an enrollment packet in the mail from HHSC's administrative services contractor, MAXIMUS. The packet contains information about the STAR+PLUS program, instructions for completing the enrollment form, and information about the MCOs available in his/her service area. MAXIMUS processes STAR+PLUS applications, assists Members who are transitioning from traditional, fee-for-service Medicaid into the STAR+PLUS Program, and assists Members in selecting a MCO and process plan changes. Members who need assistance can contact an enrollment counselor by calling the MAXIMUS Helpline at If the member enrolls before the 15 th of the month he/she will be effective the 1 st of the next month. If the member enrolls after the 15 th of the month he/she becomes effective the 1 st of the following month (e.g. 45 days). 10

11 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Unit Rate Services The Nursing Facility will continue to provide services under the Unit Rate services. This applies to the types of services historically included in the DADS daily rate for nursing facility providers, such as room and board, medical supplies and equipment, personal needs items, social services and over-the-counter drugs. The Nursing Facility Unit Rate payment from MCOs also includes applicable nursing facility rate enhancements and professional and general liability insurance. Nursing Facility Unit Rates excludes Nursing Facility Add-on Services. Add-On services, provided by either qualified Nursing Facility employees or contracted/certified individuals, are reimbursed separately by the MCO. Nursing Facilities will complete and submit the Minimum Data Set (MDS) and Long Term Care Medicaid Information (LTCMI) electronically on the LTC Online Portal system at TMHP. 11

12 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Add-on Services Nursing Facility Add-on Services are the services that are provided in the facility setting by the provider or another network provider. They are not included in the Nursing Facility Unit Rate, and are including but not limited to: emergency dental services physician-ordered rehabilitative services customized power wheel chairs augmentative communication devices Providers billing for add-on services must be in-network with Cigna-HealthSpring; contracting and credentialing may be required for the respective entity. Nursing Facilities may bill claims on behalf of employed or contracted providers for therapy addon services only. Other Services Physicians and other professional provider services are covered for NF residents. Physicians need to be contracted and credentialed with Cigna-HealthSpring. Pharmacies are contracted through OptumRX. 12

13 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW Key Elements From Clinical Notes for Add-on Services In order to establish medical necessity for therapy requests, clinical information supporting a new onset of issues is necessary to make a determination. Services can be acute due to injury, illness or an exacerbation of a chronic condition, but the clinical documentation needs to demonstrate that. Treatment Plan indicating the frequency and length of the request. Documentation demonstrating if the member can progress and respond appropriately to the therapy. One of the most frequent reasons for denials is lack of medical information. 13

14 AUTHORIZATION TURNAROUND TIMES What are the turnaround times for an authorization, and how can I escalate the authorization request? Our standard turnaround time (TAT) is 3 business days. TAT is calculated from the date and time of the receipt of call/fax/portal. If the auth request comes in on Tuesday at 1pm, it is due for a determination to the provider no later than Friday at 1pm. 3 business days includes time obtaining the clinical, the UM nurse reviewing the information, determining if it meets criteria and if not, sending the case to the medical director for review. We monitor TAT closely and if a TAT is missed, the manager has to explain why it was missed to the director. In life-threatening cases where a member is at risk, you can call UM and request the service be expedited. The TAT is then 1 business day. *Life-threatening such as swallowing issues, stroke, apnea, etc True emergencies can be reported to UM the next business day. 14

15 AUTHORIZATION REQUEST FOR INFORMATION What documentation is required for Inpatient Medical/Surgery? Complete ER record Admitting orders History and Physical Physician Treatment Plan OR report (if applicable) Clinical information Labs and imaging results Consultations and evaluations 15

16 AUTHORIZATION REQUEST FOR INFORMATION What documentation is required for Skilled Nursing Facility services? Physician s treatment plan OR Report (if applicable) History and Physical/progress notes Treatment plan, physicians orders Nutritional assessment, current weights Laboratory and radiology reports Therapy evaluation and weekly progress notes Wound care assessment and treatment sheets Discharge plan Any other pertinent clinical information such as abnormal lab results, imaging results, IV medications, consults, evaluations, etc. 16

17 AUTHORIZATION REQUEST FOR INFORMATION What documentation is required for Outpatient services? Recent Office Visit Notes Applicable labs and Imaging Current orders Current treatment plan Specifics are necessary in order to meet InterQual standards UM Milliman and/or InterQual notes only are not acceptable. Initial clinical must be time stamped with physicians name, date and time. 17

18 AUTHORIZATION REQUEST FOR INFORMATION What is required for discharge planning as a client transitions from a facility? Home health DME Infusion therapy Physical therapy Occupational therapy Outpatient speech therapy If discharge planning is provided by the Social Worker Provide Social Workers full name and phone number to: Fax: Additional notes as needed Note: Discharge planning is critical to ensuring the member has services they need as they transition home. We can assist in the process and supply names of in-network providers and begin the authorization process for services. 18

19 SKILLED VS NON-SKILLED For STAR+PLUS, the benefit allowed for our members is a non-skilled bed often known as custodial. A STAR+PLUS member can only be in a non-skilled bed. Under the Medicare-Medicaid Plan, skilled nursing facility bed is a benefit just as any other Medicare recipient is. A MMP member can be in a non- skilled bed or a skilled bed. If a MMP member is going to be admitted to a skilled bed, an authorization is needed. If a STAR+PLUS member is going to be admitted, the actual admission is not authorized, but any add-on services are such as therapies and customized wheelchairs. For Dual Eligible members needing therapies in a non-skilled bed, it is helpful for us if you note whether or not you are billing Medicare Part B or Medicaid. 19

20 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (CONT.) NON-EMERGENT AMBULANCE SERVICES Requests for prior authorization for non-emergent ambulance transports are submitted by the Nursing Facility. An ambulance provider may NOT request a prior authorization for non-emergent ambulance transports. The ambulance provider is ultimately responsible for ensuring that a prior authorization has been obtained prior to transport. Non-payment may result for services provided without a prior authorization or when the authorization request is denied by the MCO. 20

21 Unit Rate Add-on Services Complete the 3618 or 3619 forms with MDS Assessments and submit to TMHP LTC Online portal Room and board medical supplies and equipment personal needs items social services over-the-counter drugs Billing Provider: Complete and submit Cigna-HealthSpring Authorization Form emergency dental services physician-ordered rehabilitative services customized power wheel chairs augmentative communication devices Claims billed to Cigna-HealthSpring by Nursing Facility Claims billed to Cigna- HealthSpring for services provided by Nursing Facility or their subcontractors. Claims billed to Cigna-HealthSpring for services provided by a Cigna- HealthSpring in-network provider 21

22 STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.) Texas Medicaid Program Benefits (Behavioral) Pre-admission Screening and Resident Review All people who are planning to move to a partially federally funded nursing facility must undergo a Level 1 Pre-admission Screening and Resident Review (PASSR). If the person is suspected of having a mental illness, or a diagnosis of an intellectual disability or a related condition. This includes private pay individuals. Note: If the Level 1 Screening has a positive indication of conditions for MI and/or IDD a Level 2 PASRR Assessment (face-to-face) must be conducted by the Local Authority to confirm or deny these conditions by the Local Authority. People are assessed to see if they need specialized services. People who are not satisfied with their PASRR determination have the right to a fair hearing to appeal the determination. What services are provided by Local Authority or Local Mental Health Authority? Alternate placement services Customized manual wheelchairs and specialized durable medical equipment Determination of intellectual disability Specialized therapies Service coordination Vocational training 22

23 NURSING FACILITY ADDITONAL BENEFITS Cigna-HealthSpring Value Added Benefits Value-Added Services Initially, Cigna-HealthSpring notifies new members in the Welcome Kit regarding the available value-added services and how to access them. Thereafter, Cigna-HealthSpring sends benefit education materials to members annually, outlining the available value-added services and how to access them. Additional details about value-added services are available at Cigna-HealthSpring members can get assistance accessing value-added services from their Service Coordinator by calling or by calling Member Service at Note: ALL services must be obtained through a in-network provider. *Value Added Service effective September 1, Medicaid ONLY Members Dental Services Adults, age 21 and over Enhanced Vision Services Adults, age 21 and over Good Health Reward $20 gift card for annual well visit or Texas Health Steps checkup and certain labs or immunizations $20 gift card for Female Members that complete a recommended mammogram** Diabetic Members will receive a $20 gift card for completing a recommended HbA1c lab test each year. Adults age 18 to 75** ALL Members Cigna-HealthSpring Fitness Plus- Active & Fit Home Fitness Kit *Fleece Blanket *Clip-on Lamp *Reacher/Grabber Cold & Flu Kit Hygiene Kit 23

24 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Member/Provider Services-Eligibility Verification NEW Texas Medicaid STAR+PLUS ID Card: Medicaid providers should be prepared to verify a person s Medicaid eligibility with the new Your Texas Benefits Identification Card. The front of the card shows the person s unique Medicaid ID# That same number is embedded in a magnetic strip on the back Accessible with a basic swipe-style card reader; if Provider has a card reader in his/her office 24

25 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Texas Medicaid Your Texas Benefits Card *Please note the STAR+PLUS MCO will not be listed on the card* 25

26 STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY (cont.) Cigna-HealthSpring STAR+PLUS Example ID Card for Medicaid Only Eligible Member 26

27 STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY (cont.) Cigna-HealthSpring STAR+PLUS Example ID Card for Dual Eligible Member 27

28 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Member/Provider Services Eligibility Verification 3 Ways to Verify Eligibility with Cigna-HealthSpring: 1. The Cigna-HealthSpring Provider/Member Services Department by calling TexMedConnect - The State s eligibility verification system. 3. The Cigna-HealthSpring secure Provider Portal accessible through the Cigna-HealthSpring website. *Member eligibility can change each month. Please verify eligibility the 1 st of every month. 28

29 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Service Coordination Responsibilities of Cigna-HealthSpring s Service Coordinator: Provide support to the Nursing Facility in obtaining add-on services. Collaborate in the creation of a plan of care. Participate in care plan and IDT's meetings to provide feedback on possible services with discharge planning and community placement. Monitor progress toward Member s individual health goals. Assist the Nursing Facility with discharge planning or changes in levels of care. Assist the Nursing Facility by reminding members, as needed, of requirements to remit applied income to the facility. Assist Member or family members in transitioning our Member to a Hospice provider. Service Coordinator contact number:

30 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Service Coordination NF Members will be categorized as Level 1 Members and all Members within an NF will have the same assigned SC, who will perform a minimum of four (4) face-to-face visits yearly. The assigned SC will take referrals from NF Members wanting to return to the community and, when appropriate Members are identified, will develop a plan of care to transition the Member back into the community. SCs must contact the NF within 14 days once they are notified. Person-Centered Care is promoting a new way of thinking relating to people living in nursing facilities from task-oriented and schedule driven to focus on the person living in the facility and building relationships. 30

31 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Service Coordination Responsibilities of the Nursing Facility: Inviting the MCO SC to provide input for the development of the NF care plan, subject to the member's right to refuse, by notifying the MCO SC when the interdisciplinary team is scheduled to meet Notifying the MCO SC within one business day of unplanned admission or discharge to a hospital or other acute facility, skilled bed, or another nursing home Notifying the MCO SC if a member moves into hospice care Notifying the MCO SC within one business day of an adverse change in a member's physical or mental condition or environment that could potentially lead to hospitalization When resident wants to transition from a NF to community or Section Q is marked Yes on the MDS Notifying the MCO SC within one business day of an emergency room visit Notifying the MCO SC within 72 hours of a member's death Notifying the MCO SC of any other important circumstances such as the relocation of residents due to a natural disaster Providing the MCO SC access to the facility, NF staff, and members' medical information and records 31

32 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Member/Provider Services Member/Provider Services provides customer service for providers, Member s authorized personal representatives as well as vendors, etc. Services provided include: Verify eligibility, benefits and prior authorizations on file Assist providers to connect to the appropriate departments Verify claims receipt or review claims status Process demographic changes such as PCP on file or Member address changes Provide assistance with Cigna-HealthSpring s public website & secure Provider Portal Contact Provider/Member Services Department at

33 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Contracting & Provider Relations The Contracting and Provider Relations functions includes: Responsibility for maintaining the provider network, ensuring a sufficient number of providers are available in each County to serve the healthcare needs of Members enrolled in Cigna-HealthSpring s STAR+PLUS Program. Distribute contracting documents to Providers as well as respond to any inquiries related to contracting and credentialing requirements. Serve as the primary liaison with participating providers to resolve any operational challenges between the Provider and Cigna-HealthSpring. 33

34 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Claims Claims Filing Deadline Cigna-HealthSpring's claim filing deadline for daily unit rates is the same as traditional, fee-for-service Medicaid. Providers must submit Unit Rate and Medicare co-insurance claims to Cigna-HealthSpring within three hundred sixty-five (365) days from the date the covered service was rendered. If the claim is not filed with Cigna-HealthSpring within 365 days from the date of service, the claim will be denied. The required data elements for Medicaid claims must be present for a claim to be considered a clean claim and are the same as fee-for-service clean claim requirements. Cigna-HealthSpring is required to process Nursing Facility Unit Rate clean claims within 10 days of receipt. Add-on Services claims must be sent to Cigna-HealthSpring within ninety-five (95) days from the date the covered service was rendered. Providers should not collect payment from or bill Cigna-HealthSpring Members for any covered services, with exception of applied income. 34

35 CLAIMS RESPONSIBILITY FOR VISION AND DENTAL SERVICES Claims Member Coverage If Primary Payer Is And secondary payer is Vision Care Responsibility Dental Care Responsibility (except emergency dental, see page 12) Cigna-HealthSpring STAR+PLUS n/a Value Added through Cigna-HealthSpring STAR+PLUS Value Added through Cigna-HealthSpring STAR+PLUS Cigna-HealthSpring MA-PD (Medicare) Cigna-HealthSpring STAR+PLUS Cigna-HealthSpring MA-PD Cigna-HealthSpring MA-PD Other Payer MA-PD Cigna-HealthSpring STAR+PLUS Other Payer MA-PD Other Payer MA-PD Traditional Medicare Cigna-HealthSpring STAR+PLUS Medicare Medicare 35

36 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) Claims 3 ways to file a claim with Cigna-HealthSpring 1. Electronically (Payer ID# 52192) via 1 of the following 3 Cigna- HealthSpring claims clearinghouses; (1) Emdeon, (2) PayerPath, or (3) Availity. 2. Via secure Provider Portal Submit CMS 1500 and UB04; individual claims or by batch. 3. Via TMHP State s website Visit the website and click on Providers in the top header. Then Click Go to TexMedConnect in the upper right corner. TMHP claims are forwarded to Cigna-HealthSpring. 36

37 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Claims Type of Service Claims Address Add-on Services (Provided by the Nursing Facility or a Cigna- HealthSpring subcontracted Provider) Cigna-HealthSpring P.O. Box STAR+PLUS El Paso, TX Dental Services, including Emergency Dental Services Electronic Claims: Emdeon/Availity Payer ID: CX014 DentaQuest-Claims North Corporate Parkway Mequon, WI Vision Services Superior Vision 939 Elkridge Landing Road, Suite 200 Linthicum, MD

38 INTERACTING WITH CIGNA-HEALTHSPRING Payment Disputes A payment dispute is a written communication (i.e. a letter) from the Provider about a disagreement with the manner in which a claim was processed, but does not require a claim to be corrected and does not require medical records. Examples of when to use the payment dispute form: (this is not a complete list) Denial for timely filing, but provider has proof of timely Denial for incorrect applied income Denial for RUG Level Changes affecting payments previously made by Cigna-HealthSpring Denial for no coverage, but member was active during the Date of Service (DOS) Provider not being paid at correct reimbursement rate, paid incorrectly Denial for incorrect modifier, CPT code, National Drug Code (NDC) number, NPI/TIN/TPI, Place of Service (POS), Date of Service (DOS), Type of Bill (TOB), Diagnosis (DX) code, etc. and denied incorrectly Denial for no active provider contract and provider does have an active contract listed Denial for insufficient units, per authorization on file there s units available, or there s no units available due to error on our end The Payment Dispute From can be found on our website: 38

39 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Appeals & Complaints 3 ways a Provider may appeal a previously processed claim: 1. Fax the request to Cigna-HealthSpring at Electronically via HSConnect Provider Portal. 3. Mail the request to: Cigna-HealthSpring Appeals and Complaints Department PO Box Bedford, TX Requests for reconsideration must be made within 120 days from the date of remittance of the Explanation of Payment (EOP). Acknowledgement letter sent within 5 business days of receipt; appeal resolved within thirty (30) calendar days. 39

40 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Appeals & Complaints The Difference Between a Corrected Claim and an Appeal Claim Appeal An appealed claim is a claim that has been previously adjudicated as a Clean Claim and the provider is appealing the disposition through written notification to the Managed Care Organization. e.g., an appeal based on a discrepancy with the amount paid to a provider; a written notification appealing the disposition on a previously adjudicated clean claim. Corrected Claim A corrected claim is a claim that has already been adjudicated, whether paid or denied. A provider would submit a corrected claim if the original claim adjudicated needs to be changed. e.g., provider billed with an incorrect date of service/incorrect number of units: Corrected claims can be resubmitted via HSConnect, or via paper, by entering a 7 for the Resubmission code, and the original claim number as your Original Reference No on box 22 of the CMS 1500 form. The original claim number can be found on the original EOP. Follow UB04 corrected claim code as stated in the Nursing Facility Provider Manual. Corrected claims are considered claims reconsiderations and are not considered claims appeals. 40

41 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) EFT Electronic Funds Transfer (EFT) Cigna-HealthSpring contracts with Emdeon to deliver electronic funds transfer services. If you are an existing EFT customer with Emdeon and wish to add Cigna-HealthSpring to your service, please call , and select Option 1 to speak with an Emdeon Enrollment Representative. There is no cost for providers to enroll in EFT. If you would like to learn more or sign up for EFT, please visit Emdeon s epayment Web site at 41

42 INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.) ERA Electronic Remittance Advice (ERA) Providers who are able to automatically post 835 remittance data will save posting time and eliminate keying errors by taking advantage of 835 ERA file service. ERA Enrollment Process Download Emdeon Provider ERA Enrollment Form at the following location: Complete and submit ERA Enrollment Form via or Fax to Emdeon ERA Group: Fax: Any questions related to ERA Enrollment or the ERA process in general, please call Emdeon epayment Solutions at for assistance. NOTE: ERA enrollment for all Cigna-HealthSpring health plans must be enrolled under Cigna-HealthSpring Payer ID

43 CMS 1500 Overview How to Complete a CMS 1500 Form The following slides list the minimum data required to process a claim on a CMS 1500 form. Providers can view a sample CMS 1500 form in Appendix J of their provider manual. However, photocopies of the form should not be used to file claims with Cigna-HealthSpring. *Used for add-on services 43

44 UB04 Overview How to Complete a CMS UB04 Form The following slides list the minimum data required to process a claim on a CMS UB04 form. Providers can view a sample CMS UB04 form in Appendix I of their provider manual. However, photocopies of the form should not be used to file claims with Cigna-HealthSpring. 44

45 CLAIM FILING TIPS Participating Providers must submit claims within three hundred and sixty-five (365) days from the date the services were rendered for Nursing Facility unit rate services. Add-on Services claims must be sent to Cigna-HealthSpring within ninety-five (95) days from the date the covered service was rendered. Cigna-HealthSpring is required to process clean claims within 10 days of receipt for Nursing Facility unit rate services. Add-On Service claims are paid within 30 days. Providers should not collect payment from or bill Cigna-HealthSpring members for covered services, with the exception of applied income. Submit claims for one Member and one Provider per claim form. Unit rate billed separate from Add-on services. Multiple visits rendered over several days should be itemized by date of service. If there is a break in consecutive days, bill the dates as rendered on a separate line. Avoid using unlisted procedure codes when possible. Submit unlisted codes only after receiving prior authorization for the specific code. 45

46 CIGNA-HEALTHSPRING STAR+PLUS PROVIDER WEBSITE The Cigna-HealthSpring Texas Medicaid STAR+PLUS website is available at: The website includes much of the information included in today s presentation and allows providers to download numerous additional, more informative resources as well, such as: STAR+PLUS Provider Manual STAR+PLUS Quick Reference Guide STAR+PLUS Provider Directory STAR+PLUS LTSS Billing Guidelines Clinical Guidelines 46

47 CIGNA-HEALTHSPRING S PROVIDER PORTAL Cigna-HealthSpring s secure Provider Portal is available to participating providers only. Providers must have a User ID & Password to access the Provider Portal. New Providers must register a User ID & Password online when accessing the Provider Portal. The Provider Portal allows 24-hour access and is an interactive site where participating Providers are allowed to: Providers can seek assistance with the Provider Portal by calling Verify Member eligibility and PCP on file Verify Member s Service Coordinator Check claim status Request authorizations Check authorization status 47

48 CIGNA-HEALTHSPRING S PROVIDER PORTAL 48

49 FRAUD, WASTE AND ABUSE Definitions Fraud: Intentional deception or misrepresentation to obtain money or products of a health care benefit program by false or fraudulent pretenses/representation. Waste: The over-utilization of services that result in unnecessary costs. Abuse: Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments, resulting in unnecessary costs to the Medicare program or improper payment for services that fail to meet professionally recognized standards of care or that are medically necessary. What are the differences between Fraud, Waste and Abuse? One of the primary differences is intent and knowledge. Fraud requires the person to have intent to obtain payment and the knowledge that his or her actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge as Fraud. 49

50 FRAUD, WASTE AND ABUSE CONTINUED Lines of Communication Via Cigna-HealthSpring To report suspected or detected Medicare or Medicaid program non-compliance, please contact Cigna-HealthSpring's Compliance Department. To report potential fraud, waste, or abuse please contact Cigna-HealthSpring's Benefit Integrity Unit. Cigna-HealthSpring Attn: Compliance Department Cigna-HealthSpring Attn: Benefit Integrity Unit 530 Great Circle Rd 500 Great Circle Road Nashville, TN Nashville, TN By phone: , Monday through Friday, 8:00 AM to 6:00 PM CST Via HHSC Office of Inspector General Visit Under the box labeled I WANT TO click Report Waste, Abuse and Fraud to complete the online form. The site tells you about the types of waste, abuse and fraud to report. If you would rather talk to a person, call the HHSC Office of Inspector General Fraud Hotline (OIG) at

51 INTERNAL CONTACTS INTERNAL CONTACTS Phone Number Behavioral Health Substance Abuse Services Behavioral Health Crisis Hotline- Hidalgo Behavioral Health Crisis Hotline- Tarrant and MRSA-Northeast Claims Status Request Compliance Hotline Cigna-HealthSpring Automated Eligibility Verification Line Provider/Member Services Department Utilization Management Service Coordination Utilization Management Concurrent Review & Skilled Nursing Facility Utilization Management Home Health Utilization Management Inpatient Intake Utilization Management Prior Authorization

52 EXTERNAL CONTACTS EXTERNAL CONTACTS Phone Number Automated Inquiry System (AIS), Eligibility Verification Cigna-HealthSpring Pharmacy Comprehensive Care Program (CCP) Dental (DentaQuest) Provider Services Dental (DentaQuest) Member Services Change Healthcare (formerly know as Emdeon) Long-term Care Ombudsman MAXIMUS (Medicaid Managed Care Helpline) Medicaid Managed Care Helpline Medicaid Managed Care Helpline TDD Medical Transportation Organization (MTO) Tarrant SDA Medical Transportation Organization (MTO) Hidalgo SDA and MRSA Northeast SDA Texas Department of Family & Protective Services (TDFPS) Vision (Superior Vision)

53 All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. MMCDTX_16_49499_PR Cigna. Some content provided under license.