MHS UPDATES 0118.PR.P.PP.2 2/18

Transcription

1 MHS UPDATES 0118.PR.P.PP.2 2/18

2 Agenda Therapy Guidelines Emergency Room Physician Reimbursement Durable Medical Equipment HIP Waiver Provider Updates Using the MHS Website Member Management Forms Patient Analytics Tool My Health Direct Claim Submission and Appeals Timeframes Questions

3 Therapy Services Speech, Occupational, Physical Therapy

4 Therapy Services - (Speech, Occupational, Physical Therapy) 10/1/17 authorization is no longer required Must follow billing guidelines (GP, GN, GO modifiers) National Imaging Associates, Inc. (NIA) will conduct retrospective review to evaluate medical necessity If requested, medical records can be uploaded to RadMD.com or faxed to NIA at Medical necessity appeals will be conducted by NIA Follow steps outlined in denial notification NIA Customer Care Associates are available to assist providers at

5 Emergency Room Physician Reimbursement

6 Emergency Room Physician Reimbursement Effective February 1, 2018, MHS will provide reimbursement rates consistent with the complexity or severity of services rendered in the emergency room. This may result in lower levels of reimbursement for conditions charged at Level 4/Level 5 procedure codes.

7 Emergency Room Physician Reimbursement When a claim comes in with a Level 4/Level 5 ER visit and the final discharge diagnosis appearing on the bill indicates a lower level of complexity or severity, MHS will autoadjudicate the claim to reimburse providers at a Level 3 (99283) reimbursement rate. Providers retain the right to appeal by providing evidence for medical complexity of procedures performed

8 Durable & Home Medical Equipment

9 Durable & Home Medical Equipment Members and referring providers do not need to search for a DME provider or provider of medical supplies to service their needs. Order is submitted directly to MHS, coordinated by Medline and delivered to the member. Availability via Medline s web portal to submit orders and track delivery. Prior authorization required by the ordering physician for all nonparticipating DME providers. Does not apply to items provided by and billed by physician office Exclusions applicable to specific hospital based DME/HME vendors

10 Durable & Home Medical Equipment Requests should be initiated via MHS secure portal Web Portal: Simply go to mhsindiana.com, log into the provider portal, and click on Create Authorization. Choose DME and you will be directed to the Medline portal for order entry. Fax Number: Phone Number:

11 Prior Authorization Is Prior Authorization Needed? MHS website mhsindiana.com Quick reference guide Non-contracted provider services require prior authorization

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14 HIP Changes

15 HIP Changes MCE Selection Period (November 1 December 15) Benefit Period vs Eligibility Year Redetermination POWER Account Contribution Tier Payments Tobacco Surcharge (Effective 1/1/2019) Emergency Room Co-Pays Chiropractic Benefits added for HIP Plus HIP Maternity

16 HIP Changes Additional Information can be found on indianamedicaid.com on IHCP Bulletin BT201776

17 Provider Demographic Updates 17

18 Provider Demographic Updates Providers can utilize the Demographic Update Tool to update below information. Address Changes Demographic Changes Update Member Assignment Limitations Term an Existing Provider Make a Change to an IRS Number or NPI Number

19 Provider Demographic Updates

20 Member Management Forms

21 Member Management Forms Member Management Forms are now submitted via our Secure Web Portal and is listed under Quick Links as Member Management Forms. You must be signed in the MHS Secure Web Portal to complete and submit these forms.

22 Member Management Forms You will be able to submit Member Disenrollment and submit for Full Panel Add-Ons for Full Panels or for Panels that have been placed on hold.

23 Member Management Forms

24 Member Management Forms

25 Member Management Forms

26 Patient Analytic Tool

27 Accessing Patient Analytics When logging into Patient Analytics, the user is presented with the Patients tab as the main landing page. Across the top of the screen are the following buttons: View All Patients This button will remove any filter options and display all patients for which the user has access Filter Patients By selecting this button, an info window generates allowing the user to select patients that fit a specific criteria Manage Filters: Filter the patient list by business rules, subgroups, and Physicians. Create PDF Generate a.pdf document or printer friendly version of the patient list Export Exports the Patient List to an Excel worksheet

28 Patients Tab 1. Tabs: Allows the providers to choose between the Patients information and Reports 2. Logout Button: For security purposes, logout to protect patient information. Not shown, in upper right hand corner 3. Search: Allows providers to search by the patient s name, Medicaid, Medicare or Marketplace ID number 4. Filters and Export Features: Allows users to view all patients or filter by multiple criteria. The users will also have the ability to create a PDF document or export a detailed patient profile 4a. Manage Filters: Filter the patient list by business rules, subgroups, and physicians 5. Timeframe: Provides the date when claims have been posted, followed by a link to contact for questions or concerns

29 Search Results Patient Demographics High Priority Care Opportunities: Displays a count of care opportunities deemed to be of the highest importance Risk Score: Identifies the likelihood that the patient will incur cost and services in the next 12 months when compared to an average patient. An average patient has a health of 1.0. Higher values indicate the patient is more likely to need services in the future IP Probability: A percentage indicating the likelihood that a patient will have one or more inpatient confinements in the next 12 months Inpatient Stays in the Last 30 Days: A metric that captures the number of distinct inpatient hospitalizations in the last 30 days based on processed claims Emergency Room Visits within 90 Days: A metric that shows the number of distinct emergency room visits within 90 days based on processed claims Subgroup: Medicaid, Medicare, or Marketplace Physician: Displays the provider s name and credentials

30 Patient Profile 1. Member Demographics: Displays information about the member 2. All Care Opportunities: The default landing page for patient details. Displays care opportunities or measures that indicate if a patient has or has not received treatment for a health condition 3. Diagnosis: Shows primary and secondary diagnoses from claims data 4. Procedures: Shows patient procedures associated with primary and secondary diagnoses 5. Medications: Displays a list of medications prescribed to the patient 6. Lab/Observational: Shows lab values, interpretations, and trends 7. Care Team: Allows users to view the patient s providers. Providers are labeled as Managing Doctor or Other Doctor

31 Reports

32 Quality Measure Report Monitor Quality Measures Report Users are able to view reports by selected grouping and filtering options

33 MyHealthDirect

34 MyHealthDirect

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36 Claim Submission and Appeals Timeframes

37 Claim Submission and Appeals Timeframes Claims must be received by MHS within 90 calendar days of the date of service if Contracted Provider. Claim Corrections, Claim Appeals and Disputes must be received by MHS within 67 calendar days of the MHS EOP. (Requests received after day 67 will not be considered) Providers must follow the dispute process.

38 MHS Provider Relations Team Candace Ervin Envolve Dental Indiana Provider Relations ext Chad Pratt Provider Relations Specialist Northeast Region ext Tawanna Danzie Provider Relations Specialist Northwest Region ext Jennifer Garner Provider Relations Specialist Southeast Region ext Taneya Wagaman Provider Relations Specialist Central Region ext Katherine Gibson Provider Relations Specialist North Central Region ext Esther Cervantes Provider Relations Specialist South West Region ext hsindiana.com Mary Schermer LaKisha Browder Behavioral Health Provider Relations Specialist - West Region Behavioral Health Provider Relations Specialist - East Region ext mary.schermer@mhsindiana.com ext lakisha.browder@mhsindiana.com

39 Provider Network Territories

40 Behavioral Health Provider Network Territories

41 What You Learned Today Therapy Guidelines Emergency Room Physician Reimbursement Durable Medical Equipment HIP Waiver Provider Updates Using the MHS Website Member Management Forms Patient Analytics Tool MyHealthDirect Claim Submission and Appeals Timeframes

42 Questions? 42