Anthem HealthKeepers Plus Provider Orientation Guide

Transcription

1 November 2013

2 Table of Contents Reference Tools... 2 Your Responsibilities... 2 Fraud, Waste and Abuse... 3 Ongoing Credentialing... 4 Cultural Competency... 4 Translation Services... 5 Access and Availability Standards... 5 Member Enrollment... 6 Verifying Eligibility... 6 Downloading Your Panel Listing... 7 Precertification and Notification... 7 Is Precertification Required?... 8 Precertification Requests... 8 Precertification Status Our Service Partners Lab Services Other Service Partners Pharmacy Program Submitting Claims Timely filing guidelines Rejected or Denied? Routine Claim Inquiries Grievances and Appeals Grievances Appeals Disease Management Quality Management Maternal Child Services Community Involvement HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. VAW3990 date AVAPEC

3 Page 2 of 17 Reference Tools Provider website Our provider website is available to all providers. The tools located on this site will allow you to perform many common authorization and claims transactions, check member eligibility, update information regarding your practice, manage your account, access our new reimbursement policies, and more. As a participating provider, you can submit precertification requests and claims using the site. Register as a user on our provider website, Point of Care, available 24 hours a day, 7 days a week. Your Support System As a member of the HealthKeepers, Inc. network, you are supported by many different departments as you provide care for our members.: Our Provider Relations team offers hands-on services and training to PCPs and specialists. We provide customer-focused services related to clinical and administrative aspects of care. Our Medical Management program provides precertification services, hospital concurrent review, discharge planning and case management. HealthKeepers, Inc. has many specialized teams to help you with your claim questions. Our partners in Provider Services offer assistance with any claim issues, member enrollment, questions and general inquiries. Call our Provider Services team at , Monday to Friday, 8:00 a.m. 6:00 p.m. Eastern time. Additional Resources For information about Medicaid and Medicare, visit the Centers for Medicare & Medicaid Services (CMS) website For information about National Committee for Quality Assurance (NCQA) guidelines, visit the NCQA website. For health plan information, visit the Virginia DMAS website Your Responsibilities For most products, we assign each member a Primary Care Provider (PCP) and we send both members and their PCPs reminders to make preventive care appointments. As a participating provider, you have certain responsibilities in getting members the care they need, including: Providing services to your patients without any discrimination whatsoever.

4 Page 3 of 17 Notifying us when you reach a full panel and are no longer accepting any new patients. Stressing the importance of an advance directive for your patients. Working with us to meet professionally-accepted, state and national standards of care; we regularly analyze our performance in all types of care our members receive including medical, behavioral health and long-term care against state and national benchmarks, and we ll help you identify areas needing improvement and work with you to meet those standards. We re here to help. Read more about your responsibilities in your provider contract or call us if you need assistance. We designed our policies to promote compliance with the Americans with Disabilities Act. You re required to remove any existing barriers and accommodate the needs of members with disabilities. Your office should have: Street-level access An elevator or accessible ramp into the facility Access to a lavatory that accommodates a wheelchair Access to an examination room that accommodates a wheelchair Clearly marked, reserved parking for people with disabilities, unless street-side parking is available We offer a comprehensive case management program to help coordinate care for members with chronic illnesses and behavioral health needs. Pregnant moms are risk-assessed and enrolled in high-risk obstetrics case management as appropriate. See page 16 of this guide for Maternal Child Services information. Fraud, Waste and Abuse Fraud, waste and abuse are barriers to our members care and deplete medical resources and our state partners valuable financial resources. At HealthKeepers, Inc., we are vigilant in our efforts to prevent this drain of resources. Our Corporate Investigations department identifies aberrant billing patterns and investigates allegations of fraud and abuse. This department works with the state and other health care companies to detect and stop abuses in the health care system.

5 Page 4 of 17 How can I help? Always confirm the recipients identity Ensure the services you render are necessary, completely documented in the medical records and billed appropriately If you suspect or witness fraud, waste, or abuse, tell us immediately: Call the Fraud & Abuse phone line at , Monday to Friday, 8:00 a.m. 6:00 p.m. Eastern time. Contact your Provider Services representative Read more about reporting fraud, waste and abuse in your provider contract. Ongoing Credentialing Periodically, you may receive requests from us for documents required for ongoing credentialing. These documents may include updated disclosure of ownership forms, updated licensure or updated malpractice insurance face sheets. Additionally, you may receive requests from credentialing related to expired information or changes in licensure. Recredentialing occurs every three years or sooner if required by state law. Providers are also responsible for notifying HealthKeepers, Inc. if there is any change in your licensure, specialties or other practice information to ensure we can maintain accurate records. You can contact Provider Services or log in to update your information. We participate in the Council for Affordable Quality Healthcare (CAQH) collaborative. You can submit an application using the CAQH Universal Credentialing DataSource application. Cultural Competency HealthKeepers, Inc. fosters a strong cultural competency within our company as well as our provider networks. By practicing strong cultural competency, you: Acknowledge the importance of culture and language Embrace cultural strengths with people and communities Assess cross-cultural relations Understand cultural and linguistic differences Strive to expand cultural knowledge Cultural barriers between you and your patients can: Impact your patient s level of comfort; this may increase fear of what you, the provider, might find upon examination Result in a different understanding of our health care system

6 Page 5 of 17 Cause a fear of rejection of your patient s personal health beliefs Impact your patient s expectation of you and of the treatment plan Visit our Cultural Competency Training program for additional information. Translation Services Telephonic interpreter services are available to members by calling Member Services at These services are available 24 hours a day, 7 days a week. Access and Availability Standards It s our responsibility to make sure our members have access to primary care services for routine, urgent and emergency services and to specialty care services for chronic and complex care. We make sure that our providers respond to members in a timely manner for the need or request by conducting telephonic surveys to confirm providers are meeting these standards. Appointment Standards You must arrange to provide care as expeditiously as the member s health condition requires and according to each of the following appointment standards: Appointments for emergency services shall be made available immediately upon the member s request. Appointments for an urgent medical condition shall be made within 24 hours of the member s request. Appointments for routine, primary care services shall be made within 30 calendar days of the member s request. This standard does not apply to appointments for routine physical examinations, for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or for routine specialty services like dermatology, allergy care, etc. For maternity care, providers must offer initial prenatal care appointments for pregnant members as follows: First trimester within 14 calendar days of request Second trimester within 7 calendar days of request Third trimester within 3 business days of request Appointments must be scheduled for high-risk pregnancies within 3 business days of identification of high risk to the provider or immediately if an emergency exists.

7 Page 6 of 17 Member Enrollment Reimbursement is contingent upon proof of member enrollment. Our member ID cards Medicaid FAMIS Verifying Eligibility Use our Eligibility Lookup tool to get the most up-to-date member information. To check eligibility, log in and select Eligibility under Tools > Eligibility & Panel Listings. You can also call the automated Provider Inquiry Line at to verify member eligibility.

8 Page 7 of 17 Downloading Your Panel Listing Online member panel lists are run and posted to the website as of the day prior to make available the most current information about members assigned to PCPs. You can find panel listings by logging in and selecting Claims > Eligibility & Panel Listings > PCP Member Listings. You can also call Provider Services at to obtain a copy of your panel listing. A member can change his or her PCP assignment by calling Member Services at Precertification and Notification Precertification is required for: All inpatient elective admissions Nonemergency facility-to-facility transfer Select nonemergent outpatient and ancillary services Precertification is required for all home health care services (skilled nursing visits, speech therapy, physical therapy, occupational therapy, social workers and home health aides). Home health aides must be under supervision of a registered nurse or physical therapist. Precertification is not required for: In-office specialty services Evaluation and management-level testing and procedures Emergency room visits or observation Home health care evaluations Physical therapy evaluations provided at outpatient facilities) Visit the Coverage & Clinical UM Guidelines, and Precertification Requirements page for additional information regarding services requiring precertification or notification. If our medical director denies coverage, the attending provider will have an opportunity to discuss the case with him or her. We will mail a denial letter to the hospital, the member s PCP and the member with information on the member s appeal and fair hearing rights and process. Our medical management clinician coordinates members discharge planning needs with: The hospital utilizations review/case management staff The attending physicians. The attending physician will coordinate follow-up care with the member s PCP and the PCP will contact the member to schedule it.

9 Page 8 of 17 For ongoing care, we work with you to plan discharges to appropriate settings, including: Hospice facilities Convalescent facilities Home health care programs (e.g., home I.V. antibiotics) Skilled nursing facilities For members who are hospitalized, our care management nurses will also work with the members, utilization review team and PCPs or hospitals to develop discharge plans of care and link the members to: Community resources Our outpatient programs Our Disease Management Centralized Care Unit (DMCCU) Our Maternal Child Health Case Management program Is Precertification Required? Use our Precertification Lookup tool to: Determine if a service needs a precertification Find additional information regarding precertification for DME, vision, transportation and other ancillary services. Search by your market, the product of the member and the CPT code. If you don t know the exact code, you can also search by description. Precertification Requests You can submit precertification requests: By faxing it to By calling Provider Services at Electronically by logging in and selecting Precertification You must provide the precertification nurse with appropriate information for the Anthem HealthKeepers Plus member. The servicing provider or the hospital must provide clinical documentation for medical necessity review.

10 Page 9 of 17 Precertification response time frames: Urgent, nonemergent requests: FAMIS 24 to 48 hours Medallion 24 to 72 hours Emergency requests: No precertification required Routine care requests: FAMIS 2 days from the date all information is received, but not to exceed 14 days Medallion 14 days Hospital Precertification Requirements Emergency room visits: No precertification is required. Notify us within 48 hours or the next business day if a member is admitted to the hospital through the emergency room. Emergent admissions: Network hospitals must notify us within one business day of emergent admission. Documentation must be complete; we ll ask the hospital for additional necessary documentation. Our medical management staff will verify eligibility and determine coverage. Inpatient elective admissions: We require precertification of all inpatient elective admissions and notification of all deliveries/births On the day of admission, you must notify us by phone or fax that the member has arrived as scheduled Throughout the inpatient stay, a concurrent review nurse will review and authorize the additional coverage as needed For hospital precertification requests, the referring PCP or physician can submit the request: By faxing it to By calling Provider Services at Electronically by logging in Submit precertification requests with all supporting documentation immediately upon identifying the inpatient request or at least 72 hours prior to the scheduled admission. This will allow us to verify benefits and process the precertification request. For services that require precertification, we make case-by-case determinations that consider the individual s health care needs and medical history in conjunction with nationally recognized standards of care.

11 Page 10 of 17 Precertification Status Providers and hospitals can check the status of precertification requests by logging in to the provider website and clicking Precertification > Forms and other resources, or calling Provider Services at to speak with an agent. Our Service Partners Lab Services Notification or precertification is not required if lab work is performed by a HealthKeepers, Inc. preferred lab vendor (i.e., LabCorp and their approved subsidiaries). Lab work not performed by LabCorp requires precertification (e.g., lab tests performed in the physician office that are not on the Physician Office Lab list or lab tests performed at a participating hospital outpatient department that does not hold a subcontract with LabCorp). Some lab tests on the Physician Office Lab list may require authorization. Remember, you can use the Precertification Lookup tool to determine if precertification is required. All testing sites are required to be in compliance with the Clinical Laboratory Improvement Amendment (CLIA) and have a certificate or a waiver, or high accreditation as appropriate for the specific lab test performed. Other Service Partners In addition to lab services, we partner with other service vendors to offer additional support to our members, including the following dental, vision and radiology services: American Specialty Health (ASH) Chiropractic benefit Davis Vision LogistiCare American Imaging Management (AIM) Radiology Non-emergent transportation services are available for Medicaid members only. Health Service Reviews are currently required for the following AIM services*: Computer tomography (CT/CTA) scans Nuclear cardiology

12 Page 11 of 17 Magnetic resonance (MRI/MRA) Positron emission tomography (PET) scans *We will notify you if/when procedures are added to this list. Pharmacy Program HealthKeepers, Inc. contracts with Express Scripts (ESI). Submitting Claims We encourage you to submit your claims on our website or using EDI but we also accept paper claims. Paper claims cannot be physically altered; they cannot include strikeovers, ink strikethroughs or changes made with correction fluid, or they will be rejected. We give you several options to submit claims electronically. Submit both CMS-1500 and UB-04 claims by logging in. Select the claims menu and choose the appropriate claim form. Submit 837 batch files and receive reports through the website at no charge. You must register for this service first. Submit claims electronically by using a clearinghouse via Electronic Data Interchange (EDI). Using our electronic tool helps reduce claims and payment processing expenses and offers: Faster processing than paper Enhanced claims tracking Real-time submissions directly to our payment system HIPAA-compliant submissions Reduced claim rejections Reduced adjudication turnaround time Paper claims: Submit a properly completed claim for all services performed or items/devices provided to HealthKeepers, Inc. Attn: Claims P.O. BOX Richmond, VA Ensure all required information is included Don t alter or change any billing information (e.g., using white out, crossing out, writing over mistakes, etc.); altered claims will be returned to the provider with an explanation of the reason for the return

13 Page 12 of 17 Remember: there are designated, critical fields on both the CMS 1500 and We will not accept handwritten critical fields if the claim contains any computer generated or typed data. Fields not identified as critical may contain handwritten data if it has been added for the first time. HealthKeepers, Inc. will accept claims from those providers who submit entirely handwritten claims. Timely filing guidelines For both participating and nonparticipating, timely filing is 365 calendar days. Clear Claim Connection Clear Claim Connection is a tool available to help you determine if you will be reimbursed for services based on the procedure codes and modifiers you billed for on your claim. This tool only provides guidance for code combinations you wish to submit on your claims; it does not guarantee claim payment. You can access this tool by logging in to the provider self-service site and selecting Claims > Clear Claim Connection under Forms & Other Resources. Electronic Payment Services We encourage you to enroll in the Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). Enrolling in EFT/ERA gives you the benefit of: Receiving ERAs and import the information directly into your practice management or patient accounting system Routing EFTs to the bank account of your choice Creating your own custom reports within your office Access to reports 24 hours a day, 7 days a week You will receive information on how to enroll in EFT and ERA in a separate mailing from the Clearinghouse Partner. Providers delivering care for commercial and Medicaid patients will: Receive separate remittances for HealthKeepers, Inc. (Medicaid) and commercial services. Begin receiving a second EFT payment for HealthKeepers, Inc. (Medicaid) services with the prefix 33. You do not need to do anything additional to continue receiving EFT payments.

14 Page 13 of 17 Rejected or Denied? While we want every submitted claim to pay the first time it s submitted, this isn t always the case. You may get a notice that your claim was rejected or denied. So what s the difference? Rejected claims A rejected claim does not enter our system at all for one or more of the following reasons: NPI is invalid Provider address is invalid Claim has been physically altered (e.g., with correction fluid) or is handwritten Claim was rejected by the clearinghouse Denied claims A denied claim goes through the adjudication process and is denied for payment for reasons, including one or more of the following: Member not enrolled on the date of service CPT or HCPCS codes were invalid Wrong claim form was used No authorization obtained for the date of service The Explanation of Payment (EOP) will explain the reasons for the denial. If your claim is rejected, you will receive a document ID number as a reference, not a unique claim number as you would receive with a denied claim. Routine Claim Inquiries For routine claim inquiries, your call will be handled by a specially trained call agent in our Provider Services Unit (PSU) as part of our Provider Experience Program. This program was setup to ensure provider claim inquiries are handled efficiently and in a timely manner while maximizing resolution at the point of call. Agents have the ability to both answer your claimsrelated questions as well as adjust a small set of routine claim types When you call our National Customer Care center with a claims inquiry, your call is directed to an agent trained to address the issue over the phone. When that isn t possible, the agent will coordinate resolution with the appropriate departments including our Internal Resolution Unit (IRU). The IRU coordinates the research, error correction and adjustment of your claims as

15 Page 14 of 17 appropriate. If a delay is anticipated due to the complexity of a claim, you will receive notification of the delay along with a new target date for resolution. Grievances and Appeals Grievances A grievance is your expressed dissatisfaction about any matter except a payment dispute or a proposed adverse medical action. A grievance can be submitted by any physician, hospital, facility or other health care professional licensed to provide health care services. Examples of grievances may include issues with a member panel list, your contract or rate, our authorization process, an associate s behavior, or even a member s behavior. HealthKeepers, Inc. tracks all provider grievances until they are resolved. If you disagree with the resolution, you can escalate your grievance to a higher level. Appeals Provider appeals involve issues regarding reimbursement to health care providers for medical services that have already been provided. Provider Appeals to Department of Medical Assistant Services (DMAS): If a provider has rendered services to a member enrolled in a Medicaid program and has either been denied reimbursement for the services or has received reduced reimbursement, that provider can request an appeal of the denied or reduced reimbursement. Before appealing to the Department, MCO providers must first exhaust all MCO appeal processes. Refer to the appeals chart for definitions and the appropriate process to use. Medical Appeals There are separate and distinct appeal processes for our members and providers, depending on the services denied or terminated. Refer to the denial letter issued to determine the correct appeals process. To initiate the appeal process for a medical necessity or experimental/investigational adverse decision, please send your written appeal request with all supporting documentation to the following address within either 15 months of the date of service or 180 days of the date of the adverse determination notice, whichever is later. HealthKeepers, Inc. will resolve and respond in writing to all standard appeal requests within 30 calendar days from the initial date of receipt of the appeal.

16 Page 15 of 17 Send written appeals to: HealthKeepers, Inc. Attn: Grievances and Appeals P.O. Box Richmond, VA Provider Appeal Process for Medical Necessity and Experimental/Investigational Adverse Decisions HealthKeepers, Inc. will resolve and respond in writing to all standard appeal requests within 60 calendar days. Payment Disputes There are two types of denials: administrative and medical. Administrative denials include improper coding, no authorization on file for the dates of service or the number of services exceeds the authorized services. Use Clear Claim Connection for guidance when you submit a claim and to understand why a claim is denied. If you still do not understand why the claim was denied or if you would like to have the denial researched, contact Provider Services at to speak with an agent. The agents are trained to research and, if possible, adjust your claim during the phone call. CPT code changes or errors should be stamped (not handwritten) with Corrected Claim and resubmitted. If you need to resubmit a corrected claim, attach a copy of the EOP showing the denial. Claims must have the EOP with the original claim number for review of an administrative appeal. Under the Patient Protection and Affordable Care Act, we cannot pay for services rendered by any provider located outside the United States and its territories. Those claims will be denied. To file a payment dispute with HealthKeepers, Inc., go to the appeals chart for the appropriate process to use. Submit all payment disputes with a copy of the EOP and a letter of explanation to HealthKeepers, Inc. at HealthKeepers, Inc. Attn: Richmond, VA Grievances and Appeals P.O. Box

17 Page 16 of 17 Provider Appeal Process for Resolution of Billing Disputes HealthKeepers, Inc. will resolve and respond in writing to all billing disputes within 30 calendar days. Disease Management Our Disease Management program is an integrated, member-centric care management program. Care managers focus on all the needs of the member. Each member enrolled in Disease Management receives a tailored plan of care and intervention based on his or her clinical acuity and individual needs. As appropriate, telephone calls are made by a licensed nurse or social worker to the member, guardian or physician to determine progress and the need for further intervention. Other members receive health improvement mailings. We have several programs for your patients, including: Asthma Bipolar disorder Congestive heart failure Coronary artery disease Chronic Obstructive Pulmonary Disease (COPD) Diabetes HIV/AIDS Major depressive disorder Obesity Schizophrenia Transplant Many of these programs are accredited by the National Committee for Quality Assurance (NCQA). Our Disease Management department serves as a partner to you by: Providing member education and creative solutions for overcoming barriers to obtaining care Communicating pertinent information back to you Soliciting your input for care planning Quality Management Clinical Quality Management works to ensure we are providing access to quality health care and services. They continually analyze provider performance and member outcomes for improvement opportunities. Our solutions are focused on improving the quality of clinical care, increasing clinical performance, offering effective member and provider education, and ensuring the highest member and provider satisfaction possible.

18 Page 17 of 17 Maternal Child Services Obstetrical Precertification and Notification Coverage Guidelines You must notify HealthKeepers, Inc. as follows: At the first prenatal visit Within 24 hours of delivery with newborn information. Please include: Baby s date of birth Disposition at birth Gender Weight in grams Gestational age When it comes to our pregnant members, we are committed to keeping both mom and baby healthy. That s why we encourage all our moms-to-be to take part in our New Baby, New Life program, a comprehensive case management and care coordination program that offers: Individualized, one-on-one case management support for women at the highest risk Care coordination for moms who may need a little extra support Educational materials and information on community resources Incentives to keep up with prenatal and postpartum checkups and well-child visits after the baby is born We partner with providers and moms to ensure all medical and resource needs are met, aiming for the best possible outcomes for both moms and babies. Community Involvement HealthKeepers, Inc. is committed to ensuring our members have adequate access to quality care and health education. We work in partnerships with schools and community-, government- and faith-based organizations. We organize and participate in events throughout the state. We offer education and community outreach and information sessions on HealthKeepers, Inc. benefits and services.