Neighborhood INTEGRITY MMP. Non LTSS Provider Training

Transcription

1 Neighborhood INTEGRITY MMP Non LTSS Provider Training

2 Welcome Presenting today: Alison Croke, Vice President Medicare-Medicaid Integration Gayle Dichter, Director of Pharmacy Program Marilyn Moy, Manager of Care Management Dianne Rich, Utilization Management Tracy Scates, Manager of Provider Claims Services Dianna Shaw, Manager of Long Term Services and Supports Loren Sidman, Director of Behavioral Health 2

3 Agenda Overview of INTEGRITY Care Management Authorizations Claims Pharmacy Provider Network Management 3

4 INTEGRITY Overview 4

5 NEIGHBORHOOD: History and Background Incorporated as an HMO in 1993 Founded by RI s Community Health Centers Serve majority of RI Medicaid managed care participants 6 distinct groups: Children & families, Children with special health care needs, Children in substitute care, Adults with disabilities, Expansion and Medicare/Medicaid Also participating in Exchange Individual and SHOP 50% market share in the Individual Exchange Recently received the Quality Achievement Honor from NCQA during their 25 th Anniversary celebration 5

6 MEMBERSHIP GROWTH Adults eligible for Medicaid/Medicare - Medicaid benefits (Nov 2013) Children with special health care needs (2003) Parents in RIte Care (1998) Children in RIte Care (1994) Children in foster care (2000) Medicaid-only eligible adults with disabilities (2008) Adults in Medicaid Expansion (Jan 2014) HealthSource RI Both Individual and Small Business (Jan 2014) 6

7 DUAL ELIGIBLES A longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been the financial misalignment between Medicare and Medicaid. To begin to address this issue, CMS is testing models with States to better align the financing of these two programs and integrate primary, acute, behavioral health and long-term services and supports for their Medicare-Medicaid enrollees. Dual eligibles tend to have very low incomes and limited assets. Many of these beneficiaries have multiple chronic conditions, one or more of which may result in a hospitalization or a nursing facility stay. These services are often fragmented and difficult to navigate. 7

8 INTEGRATED CARE INITIATIVE Overview The goal of Rhode Island s Integrated Care Initiative (ICI) is to improve the care and quality of life for elders and adults with disabilities who are eligible for both Medicare and Medicaid. ICI is being implemented in two phases. Phase I started November Medicaid benefits including long-term services and supports (LTSS) -Neighborhood s product name is Unity Phase II - will add Medicare benefits -Neighborhood s product name will be Integrity 8

9 INTEGRATED CARE INITIATIVE Goals Person-centered care Coordination of primary and acute care, behavioral health care and long-term services and supports Improve or maintain health and quality of life Improve transitions of care from the hospital or nursing home back to member s home Rebalance the long-term care system to support home and community-based living vs. institutional care Align financial and quality incentives to improve care 9

10 INTEGRATED CARE INITIATIVE MMP/Phase II Neighborhood, CMS and EOHHS signed the 3-way contract in April 2016 Final Readiness Review determination received at the end of May. 10

11 INTEGRITY ELIGIBILTY EOHHS determines eligibility Must have permanent residence in the state of Rhode Island for at least 6 months of year Must have full Medicaid + Medicare Part A & Part B Cannot be enrolled in Hospice at time of enrollment Cannot be a resident of Eleanor Slater, out-of-state hospital Cannot be incarcerated 11

12 Eligibility Two Enrollment Waves: Opt-in (Non-UNITY members) Passive enrollment 12

13 INTEGRITY ENROLLMENT Members can have secondary/other insurance such as Medigap or supplemental plan. 13

14 OPT IN GROUPS Neighborhood Unity + Medicare Advantage Commercial Coverage (includes Medigap/supplemental plans) Also any Unity member who chooses to join Medicaid FFS Original Medicare & PDP Medicare Advantage Commercial Coverage (includes Medigap/supplemental plans) PACE-does not receive a letter FFS members who opted out of Unity 14

15 UNITY MEMBERS ELIGIBLE FOR PASSIVE ENROLLMENT Unity + Original Medicare & PDP Unity + Medicare ACO 15

16 ICI PHASE 2 Implementation Timeline

17 INTEGRITY MEMBERSHIP As of

18 What is INTEGRITY? Medicare Medicaid / LTSS Part D (Rx coverage) 18

19 INTEGRITY Benefits Comprehensive Medical Behavioral Health Medicare Part D and OTC (Over the Counter drugs) Preventive Benefits LTSS

20 Comprehensive Medical Acute Inpatient Skilled Nursing Facility no requirement for 3 day hospital stay # days defined by need Outpatient Hospital Services Primary and Specialty Care Emergent and Urgent Care DME, Lab CT, MRI, X-Ray Hearing Aids, Eyeglasses, Routine Podiatry

21 Behavioral Health Inpatient Psychiatric Outpatient Mental Health & Substance Abuse Partial Hospitalization Court ordered MHPRR (Mental Health Psychiatric Rehabilitative Residence) ACT (Assertive Community Treatment) IHH (Integrated Health Home) MH/SUD Residential Treatment

22 Experimental procedures Abortion services except to preserve the life of the woman or in cases of rape or incest Private room in hospitals unless medically necessary Cosmetic surgery Non covered Medications for sexual or erectile dysfunction

23 Hospice Hospice members do not qualify for Integrity however if a member transitions to Hospice after becoming an Integrity member all Hospice rules and processes will apply as they do for any member. Once they are in Hospice all Hospice related services will be paid for by traditional Medicare Integrity covers all non Hospice services

24 CONTINUITY OF CARE Neighborhood seeks to minimize the disruption to members care during the transition into the MMP For this reason members will be able to maintain current providers and service levels at the time of enrollment for: 6 months for Medical Services 6 months for Part B 24

25 Pharmacy 25

26 INTEGRITY Pharmacy Benefit What s covered under the Integrity Pharmacy benefit? Formulary different from Medicaid formulary Part D drugs Medicaid drugs (OTCs) No Copays, deductibles, or donut hole for the member As with Medicaid, certain drugs have additional requirements for coverage Prior Authorization (PA), Step Therapy (SE) and Quantity Restrictions (QL) 26

27 INTEGRITY Pharmacy Benefit Where can I find out what drugs are on the Integrity Formulary? NHPRI website (www. NHPRI.org) - Click on Medicare-Medicaid/Pharmacy Benefits/List of drugs covered. Searchable by drug name (brand and generic) or drug class Listings include PA/SE/QL restrictions with criteria Call NHPRI Member Services for list ( TTY 711) 27

28 INTEGRITY Pharmacy Benefit Continuity of Care / Transition Fills Transition period is considered 90 days from date of enrollment Under Part D, members may receive an RX for a 30 day supply within the 1 st 90 days A 98 day supply is allowed under Medicaid and in a LTC This time is to allow you to switch to a formulary product or request an exception. 28

29 INTEGRITY Pharmacy Benefit B vs D Some drugs require prior authorization so that they can be bucketed correctly examples Ondansetron Part B For nausea and vomiting associated with chemotherapy Part D Methotrexate For cancer For RA All other approved uses 29

30 INTEGRITY Pharmacy Benefit How do I request non-formulary medication, exceptions or drugs requiring authorization? NHPRI has an authorization form on our website called a Drug Coverage Determination. You are allowed to use whatever form you wish, but please provide all the clinical information we need to make a determination. We have a separate fax number for Integrity fax Option to call Member Services for assistance ( TTY 711) Standard requests are reviewed within 72 hours of receiving complete information. 30

31 INTEGRITY Pharmacy Benefit What Pharmacies are in the Integrity Network? Generally the same as our Medicaid Network Go to NHPRI website and click on Medicare- Medicaid/Find a Provider or Pharmacy Searchable Pharmacy Locator search by Pharmacy name or zip code General information about hours of operation, telephone number, address, languages available included in listing 31

32 INTEGRITY Pharmacy Benefit Medication Therapy Management (MTM) To be eligible members must have at least 3 of the following disease states and be on 5 different medications to treat them Arthritis/rheumatoid arthritis Chronic heart failure (CHF) Diabetes Dyslipidemia End-stage renal disease (ESRD) Hypertension Chronic/disabling mental health conditions Asthma Chronic obstructive pulmonary disease (COPD) Osteoporosis 32

33 INTEGRITY Pharmacy Benefit Why MTM? Provides members who are the most complex pharmaceutically to have a pharmacist review their medications with them. Members may share their Comprehensive Medication Review (CMR) with you. Additionally NHPRI is staffed with Clinical Pharmacists that work with our care managers to also assist in promoting optimal medication management for our members. 33

34 INTEGRITY Care Management 34

35 Integrated and Coordinated Care for the WHOLE Person Behavioral Health Long-term services and supports (LTSS) Medical Whole Person Prescriptions: Part D Part B Medicaid overthe-counter

36 Case Management Overview The goal is to work with our members and community partners to help members achieve their highest level of health and well-being in the most appropriate setting. Members are involved in all phases of assessment and plan of care development. Program is person centered with the member s goals at the forefront of service delivery. Neighborhood staff and partners assist members in identifying and connecting with medical, behavioral and social program providers, and to become engaged in their own care.

37 Additional Neighborhood Staff Housing Specialist: works with member to find appropriate housing if previous home no longer available Rehab Specialist: PT to do home risk assessments, ensure equipment needs are met Social Workers: to address psycho/social needs Peer Navigators: to assist with accessing community resources Pharmacist: to conduct medication reconciliation Community Transitions Services: one time assistance with security deposits, furniture, household items for new apart.

38 INTEGRITY Authorizations 38

39 What Requires a Prior Authorization for Medical Services? Online Resource Tool: Prior Authorization Reference Guide Reflects all services which require a prior authorization for INTEGRITY and for all lines of business If service/code is not on the guide, or have questions about a benefit/service, please call Member Services for benefit clarification 39

40 Prior Authorization Request Forms for Medical Services Prior authorization forms are found on Neighborhood s website at: Nhpri.org/Provider/Resources and FAQs/Medical Management Request Forms Hospitals notify UM of admissions using the hospital face sheet 40

41 Medical Necessity Criteria MCAP: medical necessity criteria for inpatient level of care in hospitals and nursing facilities and some outpatient services (homecare) Clinical Medical Policies: medical necessity criteria for outpatient services Website Location: nhpri.org/provider/clinical Resources 41

42 Continuity of Care Members will be able to maintain current providers and service levels at the time of enrollment for 6 months post enrollment UM will create authorizations for 6 months if the previous Neighborhood member was actively receiving services at time of their transition to INTEGRITY 42

43 How are Medical Necessity Decisions Communicated? Certification Reports Request Form 43

44 Certification Reports Generated by Neighborhood and sent to providers whenever an authorization is entered into UM software, or is updated. Reflects member demographics, dates of service, level of care (skilled vs custodial), level of care decision, and units approved or denied Neighborhood Contact Information for Reports: Katie Arner: (401) Please call to add or delete report recipients! 44

45 Request Form When certification reports are not used, providers receive prior auth request form with decision 45

46 When Requests for Authorization are Denied: Denials are always based on criteria: Neighborhood s Physician Reviewer has the authority to override the criteria that is not met, or to deny the level of care. Neighborhood s Medical Review Nurse informs the provider/facility via telephone. Contact info for the Physician Reviewer is provided. 46

47 Churn between Unity and Integrity Members moving between Integrity and Unity - sometimes coverage appears termed from Neighborhood Internal process includes an escalation to the state for final verification of the member s line of business The state responds within 1-2 days with correct line of business Goal is to prevent barriers to access to care 47

48 New and Future Enhancements New Prior auth is no longer required for rehab services (part B) when an Integrity member is in custodial level of care in a nursing facility effective 1/1/17 Future Prior auth will soon not be required for skilled home care for Integrity members (configuration not complete yet) 48

49 Questions about Authorizations?

50 INTEGRITY Behavioral Health Authorizations 50

51 Beacon and Prior Authorization For Integrity members, outpatient and psychopharmacology visits do not require prior authorization IHH/ACT eligibility is determined by the providers using criteria established by BHDDH All other levels of care require either prior authorization or notice of admission (NOA) 51

52 Beacon and Prior Authorization (continued) Medical necessity (The RI Department of Human Services definition of medical necessity is used by Beacon UR clinicians and physician advisors in all UR decision making that involves RI Medicaid members): Medical necessity or medically necessary service means medical, surgical, or other services required for the prevention, diagnosis, cure or treatment of a health-related condition, including such services necessary to prevent a detrimental change in either medical or mental health status. Medically necessary services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the member or the service provider. Level of Care Criteria is available to contracted providers though eservices. Please go to and choose the Provider Materials link to review this criteria. 52

53 Beacon Appeals When Beacon denies authorization based on our clinical determination that the requested service does not meet medical necessity as defined by level-of-care criteria, a clinical appeal may be filed: Beacon Appeal Coordinator Appeal requests should be submitted to: Beacon Health Options Attn: Appeals Coordinator 500 Unicorn Park, Suite 401 Woburn, MA

54 Questions about Behavioral Health Authorizations?

55 INTEGRITY Claims 55

56 Checking Eligibility Navinet Updated real-time (within 48 hours) Log on or sign up 56

57 Checking Eligibility Member Services: Check eligibility Understand covered services (TTY 711) 57

58 Checking Eligibility on State Site 58

59 Member IDs All Integrity ID s start with 130 and are 11 digits. 59

60 Claims Submissions 3 Ways to Submit: EDI Direct Submissions Paper Submissions Ability (Clearinghouse) 60

61 Claims Submissions: EDI For more information on electronic claim submission, please contact Neighborhood's Electronic Data Interchange Department at: Medicaid and Unity Payer ID: Exchange and Integrity Claims Payer: ID

62 Claims Submissions: Paper Must Include Address and Payer IDs (Different from UNITY) 2 Payer IDs: Neighborhood Health Plan of Rhode Island P.O. Box #28259 Providence, RI Commercial Products and INTEGRITY Medicaid (including UNITY) 62

63 Claims Submissions: Ability Neighborhood Health Plan of Rhode Island has partnered with ABILITY to offer our network providers a way to submit claims electronically free of charge for all Neighborhood claims. ABILITY will be reaching out to providers currently submitting paper claims. If you re interested in increasing efficiency and getting your claims paid quicker, we encourage you to participate! If you re interested in signing up immediately, please send the following information via secure to: abilityinfo@nhpri.org Name zip Address phone City NPI (group and/or rendering) State Tax ID 63

64 Claims Processing Time EDI & Ability: Neighborhood receives claim in hours Claims are immediately rejected if there are problems Paper Claims: Entered into Neighborhood s system 5 10 days from mailing date If there is a problem with the claim, a letter is mailed back to the provider Paper Claims: Neighborhood has 40 days to process Electronic Claims: Neighborhood has 30 days to process 64

65 Claims Submissions All types of claims (initial, corrected, voided) can be submitted electronically. *One Exception: Secondary claims must be on paper with primary payer EOB attached. 65

66 For Claims Assistance: Provider Claims Services Contact Information: (401) Hours of Operation: 8am - 4pm Monday through Friday Remember to select the correct product line 66

67 Claims Assistance Escalation Process Level I: Provider Claims call center Level II: Speak to supervisor Level III: Speak to manager 67

68 Beacon Claims Claims can be submitted via: EDI Direct Submissions Paper Claims Beacon eservices 68

69 Claims Submission: EDI The plan ID for Neighborhood Rhode Island is 162. EDI registration forms are on the Beacon web site at ding_partner_setup.pdf After test submissions have been completed, contact EDI Operations to request a production setup. They can be reached at , or via at edi.operations@beaconhs.com. 69

70 Claims Submission: Paper Claims for Behavioral Health services can be mailed to: Beacon Health Strategies 500 Unicorn Park Dr, Suite 103 Woburn, MA

71 Beacon eservices Beacon s secure web portal supports all provider transactions, while saving providers time and money and reducing paper waste. eservices is completely free to contracted providers and no software is needed. Go to the Beacon Health Strategies homepage at In the scroll bar at the top, choose the Provider link, then choose the eservices link from the Provider page menu at the top of your screen. Verify member eligibility quickly and easily Request authorizations eauthorizations receive priority review! Confirm the status of authorizations and print all authorization details, including the number of units utilized Submit claims, including reconsiderations Check the status of claims View and print explanation of benefit (EOB) information View and print claims performance information View, update and print provider demographic and directory information View, print and download provider documentations such as manuals, forms, bulletins, mailings etc. 71

72 Claims Assistance Claims Information Claims Hotline Electronic Claims Submission/EDI Helpdesk Hours: 8 a.m. to 6 p.m. Tel: Fax: e-support.services@beaconhealthoptions.com 72

73 Questions about Claims?

74 Provider Network Management 74

75 Role of Provider Network Management Contracting Provider contract implementation and oversight Network Adequacy Maintain network adequacy requirements as defined by CMS, OHIC and EOHHS Recruit and expand the provider network Strategic Planning Work collaboratively with the provider network to develop programs and reimbursement structures that align with Federal and State requirements (e.g. appropriately rebalance Long Term Care spending in the State) Develop Alternative Payment Methodologies across the Long Term Care continuum Maintain and strengthen provider partnerships Provider Training Orient new providers to Neighborhood Provide on- going training to the provider network 75

76 Provider Network Management Does Not Handle Claims The Provider Claims Services Team address claims related issues Authorization Requests The Utilization Management addresses authorization requests and questions, level of care criteria, and Clinical Medical Policies Provider Credentialing The Credentialing Department addresses provider credentialing requirements and approval Member Enrollment & Eligibility The Member Services Team addresses member eligibility and enrollment Compliance & Audits The Corporate Compliance Department addresses compliance- related issues and provider audits 76

77 Integrity Amendment You should have received an Integrity amendment in January including rates If you did not receive it or have question please contact Dianna Shaw, Manager:

78 Beacon Network Operations Network Operations is responsible for many different functions at Beacon beyond provider contracting and credentialing. Our Network staff perform initial and re-credentialing site visits for our provider network. We also conduct Provider trainings for eservices. Add providers and services (i.e languages, groups). Make changes to demographics or billing information. Assist providers with any issues in a timely manner. 78

79 Beacon Network Operations Please contact us if you are updating your site information. This includes your office address, mailing address or phone number. Also contact us if you are adding any clinicians, or updating your staff roster. It is important to keep rosters up to date, to provide the most accurate information to our members. Any updates can be sent to us at or via fax at

80 INTEGRITY Training for Providers 6 Training Modules Required for Providers: Introduction to INTEGRITY Enrollee Rights and Protections Cultural Competence, Disability Literacy, and the ADA Model of Care, Care Planning, and Assessment Putting Cultural and Disability Competence into Practice Integration of Behavioral Health and Long Term Services and Supports Additionally, prior to providing services to INTEGRITY members. : Providers must attest to having completed the above modules Providers must complete an ADA Survey 80

81 INTEGRITY Training for Providers INTEGRITY Training, Attestation Form, and ADA Survey are located at 81

82 Americans with Disabilities Act (ADA) Survey Located on the Provider Training Page at Feeds the provider directory More importantly, allows Neighborhood to direct members with specific needs to the appropriate provider. 82

83 Questions about Provider Network Management?

84 Helpful Phone Numbers: Behavioral Health (TTY ) Compliance Credentialing Member Services (TTY 711) Hours: 8:00am 8:00pm Mon- Fri, Sat 8am-12 noon. Provider Claims Services Provider Network Management Susana Conklin, Director: Utilization Management

85 Thank you!