Revised/Corrected January, Dear Provider:

Transcription

1 Revised/Crrected January, 2014 Dear Prvider: Thank yu fr participating in the Anthem HealthKeepers Medicare Advantage (MediBlue Dual Eligible HMO SNP) Plan prvider netwrk. The Anthem HealthKeepers Medicare Advantage (MediBlue Dual Eligible) Plan is a Medicare Advantage Special Needs Plan (SNP) available t beneficiaries wh are eligible fr bth Medicare and Medicaid benefits (dual eligible members) r wh are Qualified Medicare Beneficiaries. We prvide cverage fr health care services t Medicare beneficiaries wh are entitled t Part A and enrlled in Part B. ffers a Medicare Advantage Special Needs Plan (SNP) and Medicare Advantage Prescriptin Drug (MA-PD) Plan. All f ur plans include Medicare Part D prescriptin drug cverage, as well as supplemental benefits cvering ther health care services. Our Special Needs Plans (described belw) have additinal eligibility requirements. Virginia Cunties Where theanthem HealthKeepers Medicare Advantage (MediBlue Dual Eligible) DSNP Plan Is Offered We ffer Anthem HealthKeepers Medicare Advantage DSNP in the fllwing cunties: Amelia, Brunswick, Carline, Charles City, Chesapeake City, Clnial Heights City, Cumberland, Dinwiddie, Empria City, Essex, Franklin City, Fredericksburg City, Glucester, Greensville, Hamptn City, Hpewell City, Isle f Wright, James City, King and Queen, King Gerge, King William, Lancaster, Lunenburg, Mathews, Middlesex, New Kent, Newprt News City, Nrflk City, Nrthumberland, Nttway, Petersburg City, Pqusn City, Prtsmuth City, Prince Edward, Prince Gerge, Richmnd, Richmnd City, Suthamptn, Sptsylvania, Staffrd, Sufflk City, Surry, Sussex, Virginia Beach City, Westmreland, Williamsburg City and Yrk. is an independent licensee f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin AVAPEC

2 2014 Anthem Healthkeepers Medicare Advantage (MediBlue Dual Eligible) DSNP Plan Benefits Highlights Benefit Details Vendr Rutine physical exams Persnal Emergency Respnse System Preventive dental cverage Cmprehensive physical exam with clinical review f bdy systems and apprpriate labratry services System and mnitring equipment nly; member must have a telephne landline Tw dental exams, tw cleanings and ne set f X-rays per year Yu may bill fr ne rutine annual visit per year (e.g., , ) with ICD 9 diagnsis cde V70.0. Critical Signals Technlgies (CST) Liberty Cmprehensive dental cverage $250 per quarter allwance Liberty Rutine visin cverage One rutine eye exam per year $100 annual allwance fr glasses r cntacts Blue View Rutine hearing services Over-The-Cunter (OTC) items Silver Sneakers fitness prgram Part D prescriptin drugs Transprtatin One rutine hearing exam per year and $1,000 annual allwance fr hearing aids Quarterly allwance fr certain OTC items. Benefit rlls frm quarter t quarter but nt year t year: $70 quarterly limit Access t a netwrk f fitness facilities Generic cverage in the Part D cverage gap: $0 fr Tier 1 and 2 drugs nly 24 ne-way trips per year. (12 ne-way trips fr preventive services nly) Lcal participating prviders DrugSurce Healthways (Silver Sneakers) ESI LgistiCare

3 2014 Anthem Healthkeepers Medicare Advantage (MediBlue Dual Eligible) DSNP Plan Benefits Highlights Benefit Details Vendr Telemnitring Cverage f in-hme equipment and telecmmunicatin technlgy t mnitr specific health cnditins. Telemnitring services supplement but d nt replace face-t-face physician visits. Critical Signals Technlgies (CST) Imprtant Cntact Infrmatin Quick Reference Infrmatin Prvider Services Dedicated Service Unit (DSU) Cntact the DSU at AT&T Relay Service Fr English call , fr Spanish call Ntificatin/ Precertificatin/Prir Authrizatin May be telephned, submitted nline r faxed: Telephne: Fax: Hme health, durable medical equipment, therapies and discharge planning: Cncurrent review clinical dcumentatin: Behaviral health utpatient services: Behaviral health inpatient services: Initial admissin ntificatins and all ther services: Data required fr cmplete ntificatin/precertificatin: Member ID number Name f referring prvider Name f individual referred t prvider

4 Quick Reference Infrmatin Number f visits/services Dates f service Diagnsis Current Prcedural Terminlgy (CPT) cde Clinical staff is available during nrmal business hurs frm 8:00 a.m. t 5:00 p.m. lcal time Clinical infrmatin is required fr precertificatin (The Precertificatin Request Frm is als available nline.) Claims Submissin: Claims Submissin: Electrnic Submit paper claims t: P.O. Bx Virginia Beach, VA Electrnic claims Payer ID: Clearinghuse Payer Number Phne Number Availity Capari Emden Fr help, call the Anthem HealthKeepers Electrnic Data Interchange Htline at Timely filing is gverned by the terms f the prvider agreement. Timely filing fr Virginia is 365 days frm the date f service. prvides an nline resurce designed t significantly reduce the time yur ffice spends n eligibility verificatin, claims status and precertificatin status at If yu are unable t access the Internet, yu may receive claims, eligibility and precertificatin status ver the telephne at any time by calling ur autmated Prvider Services number at the DSU tll free at

5 Quick Reference Infrmatin Administrative Cmplaints/Payment Disputes Medicare prvider appeals are determined by the liable party, nt by the initiatr. The time frame t review yur request will cmmence nce yur appeal is ruted t the apprpriate department. Please refer t the denial letter r Explanatin f Payment (EOP) issued t determine the crrect appeals prcess. Administrative cmplaints/payment disputes must be filed within 120 calendar days f the initial decisin. Send administrative cmplaints/payment disputes t: Payment Disputes P.O. Bx Virginia Beach, VA Medicare Member Appeals Medicare appeals are determined by the liable party, nt by the initiatr. Please refer t the denial letter r EOP issued t determine the crrect appeals prcess t fllw. All Medicare member liability appeals shuld be sent t: Medicare Cmplaints, Appeals and Grievances Department P.O. Bx Virginia Beach, VA Fax: A physician s signature is required n all appeals submitted n behalf f a member; therwise an Appintment f Representative frm (AOR) is required. In the event that failure t prvide the service is life- r limb-threatening r that waiting the standard appeal time frame wuld be harmful t the member, an expedited r fast appeal can be initiated by cntacting us in ne f the fllwing ways: Medicare Cmplaints, Appeals and Grievances Department P.O. Bx Virginia Beach, VA Fax:

6 Quick Reference Infrmatin Phne: Please indicate if yu are requesting an expedited appeal. Prvider Service Representatives Fr mre infrmatin, cntact Prvider Services at the DSU at r yur lcal Prvider Relatins representative. Fr mre infrmatin abut 2014 benefits and market-specific details, please refer t the prvider manual nline at Medicare Enrllment Prcess The Medicare Annual Enrllment Perid (AEP) begins Octber 15 and ends December 7 f each year. The Medicare Advantage Disenrllment Perid (MADP) begins January 1 and ends February 14 f each year. During the MADP, Medicare beneficiaries have the pprtunity t disenrll frm any Medicare Advantage plan and return t riginal Medicare and/r enrll in a standalne prescriptin drug plan (nt ffered by ). The Initial Cverage Electin Perid: When a persn first becmes eligible fr Medicare hspital insurance (Part A) and medical insurance (Part B), he r she has a seven-mnth perid t enrll in a Medicare Advantage plan. This usually happens arund the persn s 65th birthday. Special Electin Perid: The Centers fr Medicare & Medicaid Services (CMS) identifies several circumstances when a persn may change Medicare ptins utside f the annual r initial enrllment perids. Fr example, dual-eligible members can enrll in r disenrll frm a Medicare Advantage plan at any time thrughut the year. Special Needs Plan (SNP) enrllees may change Medicare Advantage plans at any time during the year with changes effective the first f the fllwing mnth, subject t CMS apprval. Cst Sharing Yu may nt cllect any additinal payment frm Anthem HealthKeepers members ther than thse cst-sharing amunts specified in the members plan Summary f Benefits. Fr dual-eligible members, yu may nly cllect amunts permitted by the state Medicaid prgram r federal law. Fr dual-eligible members, federal law requires yu t bill the state Medicaid agency fr cpayments r ther cst-sharing amunts.

7 T keep yu infrmed abut plan updates, we will send mnthly cmmunicatins highlighting tpics and resurces. If yu have questins, please call ur Dedicated Service Unit at We lk frward t wrking with yu. Sincerely,