A Message from the CEO

Transcription

1 Physician Update Community Health Group Newsletter 2014 A Message from the CEO This has been a busy time for Community Health Group one full of growth and change. The Cal MediConnect Program began voluntary enrollment in April with passive enrollment beginning in May. Our team has been working for two years to implement this new program and was excited to see its official kick-off. We believe this program allows for full coordination of our members with both Medi-Cal and Medicare benefits. We now have the ability to offer the full scope of services for our participating members including coordination of their long term care needs. To meet the needs of our new members and the growth of this program, we have added additional staff to our team. You may have noticed new staff in our Member Services, Health Care Services and Pharmacy Departments. Our new team members allow us to connect with members with specific social and health care needs. For those of you who are partnering with Community Health Group to serve this new program thank you. Thank you for the quality care and service you are providing to our new members. We understand that change can sometimes be difficult. Please don t hesitate to reach out to us if you or your staff has any questions or need additional training. HIGHLIGHTS AT A GLANCE HEDIS Provider Training September 25th Health Care Services Updates Member s Rights & Responsibilities Report Fraud call CHG s toll-free Compliance Hotline (800) Mil Gracias, Norma Diaz Chief Executive Officer 2420 Fenton Street Suite 100 Chula Vista California TEL 1 (800)

2 Community Health Group is pleased to Welcome. Dr. Adla Tessier as our new Associate Medical Director. Dr. Tessier has a long history working with Community Health Group as a consultant and member of our P&T, QI, UM, Behavioral Health and Credentialing Committees. CONTACTS FOR PHYSICIANS GABRIELA RUBALCAVA, HEDIS MANAGER (619)

3 Compliance Update! Community Health Group would like to offer our providers with updates to our compliance department s contact information. Please report any compliance concerns to our Regulatory Affairs & Compliance Manager, Roberto Fierro-Chavez at Rfierr@chgsd.com or (619) Additionally, we would like to remind you that CHG has a 24/7 anonymous hotline available to you. If you observe what you think may be operational compliance issues, ethical concerns or healthcare fraud, report it to our toll-free 24-hour compliance hotline at

4 Health Care Services Update What's new in the Health Care Services Division? Personal Care Coordinators (PCC's). We now have 10 Personal Care Coordinators to help our most vulnerable members access medical, social, behavioral health and community based services. Our PCC's help providers and staff identify care coordination, high risk case management and disease management options for identified high risk members. In many cases, our PCC's will meet with members in their home and with their caregivers when appropriate. In addition, all Cal Medi- Connect members are assigned to a PCC to help with individualized care coordination. In Home Supportive Services (IHSS). IHSS helps Medi-Cal beneficiaries who are over 65, or disabled or blind be able to live in their home. Services include housecleaning, meal preparation, laundry, shopping and personal care. IHSS is now a benefit covered by Medi-Cal Managed Care Plans. The IHSS Program continues to be administered by the San Diego County Aging and Independence Services. To access IHSS for one of your patients you can refer them or their caregiver to the Counties Aging and Disability Resource Connection (ADRC) at (800) A County Social Worker will interview your patient in their home to determine eligibility. If your patient meets the eligibility requirements, you will be asked to complete a Health Care Certification Form. Community Health Group's website homepage has a link to the ADRC where this form can be obtained. 4

5 What's new in the Health Care Services Behavioral Health Division? Behavioral Health Services. Our Behavioral Health Services is available to assist all Community Health Group members access behavioral health care. In the past all Medi-Cal members, including those on a Medi-Cal Managed Care Plan received their behavioral health services through the County Mental Health Plan. Effective January 1, 2014, the Department of Health Care Services created a new outpatient mental health benefit for Medi-Cal beneficiaries with a Mild to Moderate mental health condition. Community Health Group has a large network of behavioral health providers available to treat our Medi-Cal members with a mild to moderate mental health condition. If you feel your patient has a serious mental health problem they should be referred to the San Diego County Access & Crisis Line at (888) For Community Health Group members on CommuniCare Advantage or Cal MediConnect, inpatient and outpatient treatment is Community Health Group s responsibility. There is no need for a referral from your office. Simply have your patient call our Behavioral Health Services Department at (800)

6 New CMS Quality Improvement Organization Effective August 1, 2014 Effective August, 1, 2014, the existing Medicare Quality Improvement Organization (QIO), HSAG, will be replaced by Livanta. Livanta is a Beneficiary and Family-Centered Care Quality improvement Organization (BFCC-QIO) that will be responsible for conducting quality of care reviews, discharge and termination of service appeals, and other areas of required review in the various provider settings. Please include the updated BFCC-QIO information listed below in all notices that you may issue to Community Health Group members, such as the Notice of Medicare Non-Coverage (Form CMS NOMNC) and Important Message from Medicare (Form CMS-R- 193-IM). Livanta BFCC-QIO Program 9090 Junction Drive, Suite 10 Annapolis Junction, MD Toll-free Number: TTY: Fax - Appeals: Fax - All other Reviews: The restructuring of the QIO program to replace QIOs with BFCC- QIOs is intended to improve both patient care and health outcomes, and to save taxpayer resources. For more information about the QIO restructuring, please refer to the CMS press release at: If you have any questions about the QIO program, contact the QIO Program mailbox at QIOProgram@cms.hhs.gov.

7 CHG Eligibility Online Community Health Group (CHG) understands that your staff s time is valuable. CHG would like to remind all of our providers of our on line tools that can make the work of your staff more efficient when verifying eligibility, authorizations or claim status. This means that your staff no longer needs to take time from their busy schedule to call Member Services to verify eligibility. For this reason, CHG would like to inform you that effective immediately, our member services staff will not be able to provide your staff with this information over the phone. Below are instructions to Log on to CHG s On-Line Tools! STEP ONE: Log on to Select Providers Select Provider Access STEP TWO: Type Assigned Login/Password Click Login Select Providers (Drop down menu will appear) STEP THREE: Select Member Eligibility, Authorization Status or Claims (From Drop down Menu) Type Health Plan ID Number, SSN or CIN Click Submit If your office does not have an online account to verify eligibility, authorization or claims status, please contact CHG s Provider Relations Department at (619) or vmgonza@chgsd.com. If you have further questions you may log on to our FAQ s on the web portal at We sincerely appreciate your cooperation, support and look forward to assisting you and your staff. 7

8 UPDATE: Skilled Nursing Facility Procedures In an effort to streamline our case reviews and expedite authorizations for Community Health Group (CHG) members in SNFs, we would like to ask for your assistance with the following procedures: For members requiring initial authorization and/or are in your facilities and require extensions: Confirm member s eligibility is currently active with CHG and at a minimum re-confirm eligibility monthly thereafter (authorizations are only valid for members with active CHG eligibility) Submit a facility face sheet documenting facility name Complete the CHG SNF review form which is attached and specify the clinical justification, name of the facility and name of the hospital (or other facility) the member was transferred from When request is by the case manager, submit clinical documentation along with the SNF Review Form supporting the clinical justification (for example, progress notes, doctors orders, history and physical reports) For members being discharged from your facilities: Complete the CHG SNF Review Form and specify the discharge plan needed (including codes for all services such as home health, durable medical equipment, etc.) Submit the discharge plan no later than 5 days prior to scheduled discharge date Claims Claims must be submitted within 120 calendar days following the date of discharge or within 120 calendar days of the date of service Send all claims to: Community Health Group, P.O. Box 1267, Chula Vista, CA Any questions please feel free to contact our inpatient support staff at (619) We appreciate your cooperation, partnership and look forward to answering any questions or concerns regarding these revised procedures. 8

9 Providing a Quality Language Assistance Program Community Health Group is committed to providing quality health care services to all members with a special focus on members of diverse communities. For members with Limited English Proficiency (LEP), or who are vision or hearing impaired, CHG s Language Assistance Program ensures members have timely access to interpretation and translation services. Many of our contracted providers and staff speak various languages. For providers who may not speak the languages spoken by our members and need to access our Language Assistance Services, here are a few friendly reminders: For current information on the language spoken by your patients, please access your enrollment listings through our secured web page, Listings are updated monthly. Please contact our Member Services Department to access our Language Assistance Program and schedule interpretation services for CHG members. Our staff coordinates interpretation services for all points of contact where language assistance is needed. Our staff is available 24 hours a day, 7 days a week. You may reach our Member Services staff at (800) The designated threshold languages for San Diego County are: English, Spanish, Vietnamese and Arabic. Language Assistance Services are made available by CHG at no charge to members or providers. Through various methods, our members are informed of the following: their right to have access to language assistance services for all points of contact and at no charge; members are discouraged to use minors, family or friends as interpreters; their access to Language Assistance Services is simple and available; and their right to file a complaint or grievance if linguistic needs are not met. Please help us remind our members, your patients, that they have access to quality Language Assistance Services. If you offer these services and members refuse, please document their refusal in your medical record. If a member informs you that they are not satisfied with the Language Assistance Services provided by CHG, please help us remind them of their right to file a grievance and seek an independent medical review in threshold languages and through oral interpretation. Grievance forms are found in all threshold languages via our web site, Community Health Group has translated vital documents in threshold languages. Key documents such as: Evidence of Coverage, Grievance forms, Other documents are available upon request and at no charge. If you need to access vital documents in a threshold language, please contact our Member Services Department or visit our website at Through self reporting, CHG monitors the languages spoken by you and your staff. This information is maintained in our provider directories. To keep this information current please notify us if there is a change in your staffing by contacting Victor Gonzalez at (619)

10 Community Health Group Quick Reference Guide Interpreter Services This service is free to the member and the provider. When a Community Health Group member needs interpreter services (face to face or telephonic) please call: Member Services Department (619) or (800) days a week 24 hours a day They will coordinate the needed services (please allow 3 days advanced notice to arrange for face to face interpreter services). Please remember that it is not allowed to ask a family member or friend to interpret However, if the member requests using a family member to interpret and refuses to use our interpreter services, please be sure to document this in the member s chart. Teletypewriter (TTY) If there is a need to coordinate TTY services, you and your patients, our members, may contact Member Services at (619) or (855) Health Education Member Materials Health education materials are available in the threshold language (Arabic, English, Spanish and Vietnamese). If you need additional copies of the materials previously provided to your office, please call Carmen Mancilla, Preventive Health Specialist, at (619) Telephone Advice Nurse Members may call (800) to obtain health advice from the Telephone Advice Nurse (TAN) 7 days a week, 24 hours a day. If members have other language needs, our TAN line has access to language line 24 hours a day. Our staff is always here to assist you and your patients, our members, with their interpreter needs. Do not hesitate to call us 24 hours a day, 7 days a week. 10

11 Save the Date! Provider HEDIS Training! Date: Thursday, September 25, 2014 Time: 12:00 p.m. to 1:30 p.m. (LUNCH WILL BE PROVIDED) NEW LOCATION: Community Health Group Paul Dato Board Room 2420 Fenton Street, Suite 100 Please note our Chula Vista, CA NEW ADDRESS The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. Community Health Group is committed to offering our providers tools to help improve their HEDIS scores and ensure staff is trained on proper HEDIS coding. This training is set to be informative and will provide an opportunity for you and your staff to ask questions related to HEDIS. We look forward to seeing you here! Who should attend? Practitioners, Office Supervisors/Managers, Billers and/or Front office staff. For more information, please contact Victor Gonzalez at (619) Please submit your RSVP to Victor Gonzalez at Fax: (619) or vmgonza@chgsd.com no later than September 24,

12 Effort to Reduce Inappropriate Emergency Room Visits Community Health Group is on a mission to promote appropriate use of the Emergency Room (ER) and with your help we plan to achieve this goal. A strategy to reduce inappropriate use is to ensure that patients are referred to an Urgent Care Center instead of the ER. CHG has over 38 contracted Urgent Care Centers countywide. To access a listing of our contracted Urgent Care Centers, please log on to our Web site at Click on the Providers tab, look under Provider Services to the right and click on Urgent Care. We would also like to ask for your cooperation in reminding your patients/our members at every visit of the importance of accessing primary care as their first point of contact and using the Emergency Room for true medical emergencies. If your patients need assistance finding an Urgent Care Center, please remind them to contact Member Services at (800) ; our staff is available 24 hours a day, 7 days a week. For after hour access, they may contact our Telephone Advice Nurse line at (800) Remember, with your support we can improve your patients/our members knowledge of appropriate emergency room usage. Have you moved? Added a new physician to your practice? If so, please call Community Health Group s Provider Relations Department at (619) or via at vmgonza@chgsd.com so we can update your information. Remember, our regulators require we provide 30 days written notice to our members prior to your practice relocation or change in physician assignment. We know you are busy and sometimes there is a lot to coordinate during these transitions; however, your assistance in this matter will be greatly appreciated. 12

13 Community Health Group Members Rights & Responsibilities Community Health Group (CHG) members have rights and responsibilities. These rights are made available to protect our members as health plan consumers. CHG members have the right to: Receive information about Community Health Group, its services and its doctors and other providers in a way that may be easily understood. Receive information about your rights and responsibilities as a CHG member. Be treated with respect and dignity. Privacy. Choose a primary care provider from within our network of contracted providers. Participate with your doctor in decision making about your health care, and to refuse treatment. An open and honest discussion of your treatment options regardless of cost or health plan benefits. Get appointments within a reasonable amount of time. Complain about CHG or the care you receive. Appeal when you don t agree with a decision CHG has made. Ask someone to explain or translate if you don t understand something that is said or written. Request an interpreter at no charge to you. Use interpreters who are not your family members or friends. File a complaint if your linguistic needs are not met. Prepare Advance Directives. Have your medical records kept private. See your medical records. Make recommendations regarding CHG s rights and responsibilities policies. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Exercise these rights without adversely affecting how you are treated by CHG, its providers, or the State. CHG members have the responsibility to: Give correct information to CHG, its doctors and other providers so that they can care for you. Follow the plans and care instructions that you have agreed to with your doctor and others who provide care to you. Know your doctor s name. Bring your member ID card(s) with you when getting medical care. If you have other insurance, take that card too. Use emergency services only in cases of an emergency or as directed by your provider. Remember what your doctor tells you about your health problem. Understand your health problems and participate in developing treatment goals. Ask questions if you don t understand what you are told. Keep follow-up visits with your doctor. Tell your doctor if you don t want to follow a treatment plan. Make and be on time for medical appointments or cancel appointments at least one business day ahead of time. Treat all Community Health Group personnel and health care providers respectfully and courteously. Go with your children who are under age 18 (if they are enrolled in the plan) when they are getting medical COMMUNITY HEALTH GROUP VICTOR GONZALEZ, PROVIDER RELATIONS SUPERVISOR (619) CONTACTS FOR PHYSICIANS NOREEN KOIZUMI, DIRECTOR, HEALTH CARE OPERATIONS (619)