2014 Ohana Health Plan

Transcription

1 2014 Ohana Health Plan Medicaid Provider Orientation 1/30/14 NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 1

2 Course Rules and Tools Duration: 40 minutes Approximate time this course will require. Bookmarking: Yes The course tracks where you left off and returns you to the same page when you reopen. Completion Type: Yes Attestation certifies you have viewed all slides Completion Rule: Yes All online modules require the learner to view all slides or successfully complete a quiz in order for a completion to be registered. Audio: No None for this course. Attachments: No Click the Attachments button at the top of the player window to access and print attachments WellCare Health Plans Inc. All rights reserved WellCare 2013 WellCare Health Plans Inc. 2

3 Objectives After completing this training, you should be able to: Identify the benefits of participation. Describe the billing and payment processes. Explain the Compliance program requirements. Locate provider and member specific resources. Determine member eligibility and benefits. Discuss the plan s covered services. Explain how to utilize Ohana s Provider Relations and Customer Services. Identify Provider and Member Rights and Responsibilities. Describe Advance Directives and Cultural Competency. Explain Ohana s Quality Improvement Program. Describe the EPSDT and Members with Special Health Care Needs requirements. Discuss the Appeals and grievances process WellCare 2013 WellCare Health Plans Inc. 3

4 Section 1 Overview NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 4

5 About 'Ohana 'Ohana Health Plans, Inc. ('Ohana) is a family of health plans that works with physicians and other healthcare professionals to provide our members with quality care. Ohana currently operates in Hawai i under Ohana Health Plan, a health plan offered by WellCare Health Insurance of Arizona, Inc. (also a subsidiary of WellCare Health Plans (WellCare). Many of the resources and tools we reference in this training can be found on the Ohana website at WellCare 2013 WellCare Health Plans Inc. 5

6 About 'Ohana (cont.) Lines of Business 1. Medicare Advantage Plans a) Ohana Liberty Plan - Dual Special Needs Plan (DSNP) for members with Medicare and Medicaid coverage. b) Ohana Value Plan Designed for members who only have Medicare coverage. 2. QUEST Integration (QI) 3. Community Care Services (CCS) Behavioral Health Services for members deemed to be Seriously Mentally Ill (SMI). Three Office Locations Oahu- Kapolei & Honolulu Maui- Kahului Big Island- Hilo Local Customer Service answering provider and member calls 2013 WellCare 2013 WellCare Health Plans Inc. 6

7 Plan Resources Providers have access to a variety of easy-to-use reference materials at including: Information on Plan/Product availability, by island Resource Guides related to claims, authorizations, EFT and how to contact us Provider Manuals Clinical Practice and Clinical Coverage Guidelines Provider & Pharmacy lookup Quick Reference Guides that provide contact information for specific departments and authorization information Provider Education Insert Screenshot of Ohana Healthplan.com website 2013 WellCare 2013 WellCare Health Plans Inc. 7

8 Plan Resources (cont.) By registering for Ohana s secure, online Provider Portal, providers have access to member eligibility and co-pay information, authorization requests, claims status and inquiry, a provider inbox to receive specific messages from Ohana, and provider training. Provider Relations representatives are available to assist in many requests. Contact your local market office for assistance WellCare 2013 WellCare Health Plans Inc. 8

9 Section 2 Eligibility and Benefits NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 9

10 Eligibility Membership enrollment in the Plan s Medicaid Programs is solely determined by DHS. For eligibility criteria, please refer to the DHS website at Providers must verify patient eligibility and enrollment prior to service delivery. The Plan is not financially responsible for non-covered benefits or for services rendered to ineligible recipients. Verification of Member Eligibility Through the secure, online Provider Portal at Automatic Voice Response System Contacting Ohana Customer Service 2013 WellCare 2013 WellCare Health Plans Inc. 10

11 Covered Services Primary and Acute Services Diagnostic Testing (lab and imaging services) Dialysis DME Emergency Medical Services EPSDT (including fluoride varnish) Habilitation Services Hospice Services Immunizations Non-Emergency Transportation Pregnancy-related services Prescription Drugs Inpatient Services Medical and Surgical Care Post-Stabilization Maternity and Newborn care Sterilization and Hysterectomies Rehabilitation services including cognitive rehabilitation services (both inpatient and outpatient) 2013 WellCare 2013 WellCare Health Plans Inc. 11

12 Covered Services (cont.) Behavioral Health Services Inpatient Psychiatric Hospitalizations to include psychiatric services and substance treatment services Ambulatory Mental Health Services that include crisis management Medications and Medication Management Psychiatric or psychological evaluation and treatment Medically necessary alcohol and chemical dependency services Methadone management services 2013 WellCare 2013 WellCare Health Plans Inc. 12

13 Covered Services (cont.) Outpatient Medical or Behavioral Health Family Planning Home Health Medical services related to dental needs Nutrition Counseling Physician and other practitioner services Podiatry Post-Stabilization services, if applicable Preventive services Smoking Cessation Urgent Care Vision and Hearing services Outpatient Hospital/Ambulatory Surgical Center (include but not limited to) Sleep Laboratory Services Surgeries performed in a free-standing ambulatory surgery center (ASC) and hospital ASC Maternity and Newborn care Sterilization and Hysterectomies 2013 WellCare 2013 WellCare Health Plans Inc. 13

14 Long-Term Services and Support (LTSS) (cont.) Home and Community Based Services Adult day care and day health Assisted Living, Residential Care including E-ARCH and Community Care Foster Home Community Care Management Agency (CCMA) Counseling and training Home Delivered Meals Non-medical transportation Environmental accessibility adaptations, home maintenance, moving assistance, specialized medical equipment and supplies Personal assistance services, respite care, skilled (or private duty) nursing Personal Emergency Response Systems Institutional Services Acute Waitlisted ICF/SNF Nursing Facility, Skilled Nursing Facility, or Intermediate Care Facility Sub-acute Facility Services 2013 WellCare 2013 WellCare Health Plans Inc. 14

15 Behavioral Health Ohana provides a behavioral health benefit for QI members Standard Behavioral Health Services include inpatient psychiatric hospitalizations, ambulatory mental health services, medication management, psychiatric/psychological evaluation and treatment, alcohol and chemical dependency services, and methadone management services. Members age 3-21 that meet SEBD criteria are eligible for intensive mental health services through DOH, Child and Adolescent Mental Health Division (CAMHD). For QI, additional intensive behavioral health services are available through the DHS Community Care Services (CCS) program managed by Ohana. In the event a member is in need of a referral to a behavioral health provider, contact Customer Service. QI adult members aged 21 or older with a SPMI/SMI diagnosis may be eligible for additional behavioral health services. Please contact Ohana for more information. Member eligibility for additional behavioral health services is regularly assessed. Ohana strongly encourages open communication and collaboration between PCPs and behavioral health providers. Ohana also offers the Community Care Services (CCS) Behavioral Health program for Medicaid members WellCare 2013 WellCare Health Plans Inc. 15

16 Pharmacy Services To ensure members receive the most out of their pharmacy benefit, please consider the following guidelines when writing prescriptions: Follow national standards of care guidelines for treating conditions Prescribe drugs on Ohana s Preferred Drug List (PDL) Prescribe generic drugs when therapeutic equivalent drugs are available within a therapeutic class Evaluate medication profiles for appropriateness and duplication of therapy Ohana has pharmaceutical utilization management (UM) tools that are used to optimize the Pharmacy program. These UM tools are described in further detail in the Provider Manual, including: Preferred Drug List (PDL) Drug Evaluation Review (DER) process Mandatory Generic Policy Step Therapy (ST) Quality Level Limit (QL) Pharmacy Lock-In Program 2013 WellCare 2013 WellCare Health Plans Inc. 16

17 Pharmacy Services (cont.) Additional important information covered in the Provider Manual includes: Non-covered drugs and/or drug categories that are excluded from the Medicaid benefit. Over-the-Counter (OTC) medications that are available to the member with a prescription. Requesting additions and exceptions to the PDL through the Drug Evaluation Review (DER) process, including information on: How to submit a DER When a DER is required, including, but not limited to: - Most self-injectable and infusion medications - Drugs not listed on the PDL - Drugs listed on the PDL but still require a Prior Authorization - Brand name drugs when a generic exists Requesting an appeal of a DER decision WellCare 2013 WellCare Health Plans Inc. 17

18 Sample ID Cards Ohana Liberty Medicare/Medicaid (dual coverage) Ohana Value Medicare Advantage Only Ohana Community Care Services (CCS) Behavioral Health QUEST Integration (QI) 2013 WellCare 2013 WellCare Health Plans Inc. 18

19 Section 3 Rights and Responsibilities NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 19

20 Provider Responsibilities All participating providers are responsible for adhering to the Participation Agreement and the Provider Manual. The Provider Manual supplements the Agreement and provides information on requirements such as: Provider Billing and Address change. Access and availability, including after-hours coverage. Credentialing and Re-credentialing requirements. Assisting members with special health care needs, including mental, developmental and physical disabilities and/or environmental risk factors. Claims and Encounter data submission. Specific medical records requirements including accuracy of, record retention timeframes, Advance Directive and Living Wills documentation, and that the documentation must be tied to claims submission or encounter data. Mandatory participation in Quality Improvement projects and medical record review activities such as HEDIS. Adhering to 'Ohana s, including Ohana Health Plans, compliance requirements, including provider training and safeguarding member confidentiality in compliance with HIPAA WellCare 2013 WellCare Health Plans Inc. 20

21 Member Rights Member rights are outlined in the Member Handbook, which is mailed to all newly enrolled members. Member rights include, but are not limited to: Being treated with fairness, respect and dignity. The availability of language designated materials, hearing-impaired interpreter and sign language services (see slides 28-29). The ability to make complaints about Ohana or the care provided. The ability to appeal medical or administrative decisions Ohana has made by using the Appeals and Grievances system (see slides 45-54). The ability to have their privacy protected. The ability to have a say in Ohana s member rights and responsibilities policy. Having all these rights apply to the person who can legally make health care decisions for the member. Using these rights no matter what their sex, age, race, ethnic, economic, educational or religious background. Providers shall not impose a no-show fee for QI program members who were scheduled to receive a Medicaid covered service WellCare 2013 WellCare Health Plans Inc. 21

22 Member Responsibilities Members are responsible for: Knowing how Ohana works by reading the Member Handbook. Carrying their Plan card and state-issued Medicaid card with them at all times and to present their cards prior to receiving services. Being on time for appointments. Canceling and rescheduling an appointment prior to missing their scheduled appointment. Respecting providers, staff and other patients. Asking questions if they do not understand medical advice provided. Helping set treatment goals that they agree to with their provider. Ensuring their provider has previous medical records, or access to. Informing Ohana within forty-eight (48) hours, or as soon as they can, if they are in a hospital or go to an emergency room WellCare 2013 WellCare Health Plans Inc. 22

23 PCP Roles and Responsibilities The PCP is responsible for: Supervising, coordinating, and providing all primary care to each assigned member. Coordinating and initiating referrals for specialty care, maintaining continuity of each member s health care and maintaining the member s medical record that includes documentation of all services provided. Coordinating, monitoring and supervising the delivery of medically necessary primary care services for each member, including EPSDT services for members up to the age of twenty-one (21). Seeing members for an initial office visit and assessment, including EPSDT screenings, within the first ninety (90 ) days of enrollment in the Plan; for pregnant women, the first fourteen (14) days of enrollment; for newborns, within the first twenty-four (24) hours of birth WellCare 2013 WellCare Health Plans Inc. 23

24 PCP Roles and Responsibilities (cont.) PCPs can require a transfer of a member from their panel by completing the PCP Request for Transfer form located on our website: Members can change their PCP by calling Customer Service: Specialists may act as a PCP for members with chronic conditions when the member has a had a previous relationship with the Provider acting as a PCP and the Health Plan has confirmed that the specialist agrees to assume PCP responsibilities. Members with primary coverage other than Ohana Health Plan are not assigned to a PCP WellCare 2013 WellCare Health Plans Inc. 24

25 Medicare Information Members with a primary Medicare Advantage Plan are not required to choose a PCP; all other members, including members with Medicare FFS, must choose a PCP WellCare 2013 WellCare Health Plans Inc. 25

26 Section 4 Compliance NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 26

27 'Ohana s Compliance Program All providers, including provider employees and sub-contractors, their employees and delegated entities, are required to comply with 'Ohana s compliance program requirements, including those contracted with Ohana Health Plan. 'Ohana s compliance program requirements include, but are not limited to, the following: Provider Training Requirements Limitations on Provider Marketing Code of Conduct and Business Ethics Cultural Competency and sensitivity Americans with Disabilities ACT (ADA) For more information on the ADA please visit To access interpreter and sign language services, please contact our Customer Service toll free line Fraud, Waste and Abuse (FWA) 2013 WellCare 2013 WellCare Health Plans Inc. 27

28 Disability Awareness Linguistic Services Linguistic and Interpreter Services Providers will identify members that have potential linguistic barriers for which alternative communication methods are needed and will contact the Plan to arrange appropriate assistance. Members may receive interpreter services at no cost when necessary to access covered services through a vendor, as arranged by the Customer Service Department. The Interpreter services that are available include: Verbal translation Verbal interpretation for those with limited English proficiency Sign language for the hearing impaired. These services will be provided by vendors with such expertise and are coordinated by the Plan s Customer Service Department Written materials are available for members in large print format, and certain non- English languages, prevalent in the Plan s service areas. To access interpreter and sign language services, please contact our Customer Service at WellCare 2013 WellCare Health Plans Inc. 28

29 Disability Awareness How Can You Help Provide Quality Service to Our Members with Disabilities? Members that are hard of hearing may require you to repeat information. Be patient, confirm understanding. Members with speech disabilities may take longer to express their needs. Be patient, trying not to interrupt. Members may use a Relay Operator for a TTY/TTD call. Ensure you address the member, not the operator, in your conversations. Refer to the Relay Operator online resource document located in WellCare Link. Members with a disability or supporting providers may need to request specific medical equipment Durable Medical Equipment (DME). Reference the Provider Manual for further DME information. To access interpreter and sign language services, please contact our Customer Service toll free line at WellCare 2013 WellCare Health Plans Inc. 29

30 What Does Fraud, Waste and Abuse Look Like? Fraud Intentional deception, concealment or misrepresentation made by someone with knowledge that the deception will result in benefit or financial gain. Abuse A practice that is inconsistent with accepted business or medical practices/standards results in unnecessary cost. Can be thought of as potential fraud, where the provider s intent may have been unclear. Waste Includes any practice that results in unnecessary use/consumption of financial or medical resources. May not involve personal gain, but often signifies poor management decisions, practices or controls WellCare 2013 WellCare Health Plans Inc. 30

31 What Ohana does to prevent FWA `Ohana Health Plan is committed to compliance with applicable federal and state laws, rules, and regulations related to Fraud, Waste and Abuse (FWA). The Company has created a Special Investigation Unit (SIU) which works with the State of Hawai`i with regard to FWA and is responsible for the following: Detection Prevention Investigation Reporting Correction Deterrence 2013 WellCare 2013 WellCare Health Plans Inc. 31

32 What Ohana does to prevent FWA (cont.) The SIU investigates cases and reports to the State of Hawai`i some of the following types of behavior indicative of FWA: Prescription drug shorting Billing non-covered/non-chargeable Services Reciprocal billing Patterns of waiver of member cost-share or deductible Improper billing practices Claims not medically necessary, or not to the extent rendered Quality of Care Failure to maintain adequate medical or financial records Refusal to furnish records Refusal to permit on-site inspections and audits Payment for excluded medications Incorrect calculation of true out of pocket expense (TrOOP) Prescription drug shorting Failure to offer negotiated prices Prescription stockpiling Questionable member eligibility Cover-Ups in coordination of benefits 2013 WellCare 2013 WellCare Health Plans Inc. 32

33 Section 5 Member Care and Quality NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 33

34 Utilization Management (UM) Ohana s Utilization Management (UM) program includes review processes such as notifications, referrals, prior authorization, concurrent review and/or retrospective review. Prior Authorization Ohana requires prior authorization for elective or non-emergency services, as designated by Ohana. Reasons for requiring authorization may include: Review for medical necessity Appropriateness of rendering provider Appropriateness of setting Case and Disease management considerations Decision timeframes are determined by either NCQA requirements, contractual requirements or a combination of both. See the Provider Manual for decision timeframes. Prior authorizations may be requested online via the secure Provider Portal (depending upon the specialty), fax, or phone for urgent requests WellCare 2013 WellCare Health Plans Inc. 34

35 Utilization Management (UM) (cont.) Concurrent Review/Discharge Planning Planning is initiated as soon as Ohana is notified of a member s admission to a hospital, skilled nursing facility or acute rehabilitation facility. Subsequent reviews are based on the severity of the individual case. Facilities are required to request for prior authorization and provide clinical information by the next business day after the admission, as well as concurrently upon request from Ohana s Concurrent Review team. Failure to submit necessary documentation may result in non-payment. Discharge Planning begins upon admission and is designed to identify the member s posthospital needs. The attending physician, hospital discharge planner, PCP, ancillary providers and/or community resources are required to coordinate care and post-discharge services to ensure that the member receives the appropriate level of care. Service Coordinators will be consulted for complex discharges and can assist with ensuring a smooth transition. Transitional Care Management identifies members in the hospital, and/or recently discharged, who are at risk for hospital readmission. The member is contacted by a Service coordinator post hospitalization to assist the member in reducing avoidable readmissions and/or offer Service coordinator and/or Disease Management WellCare 2013 WellCare Health Plans Inc. 35

36 Utilization Management (UM) (cont.) Retrospective Review 'Ohana reviews post-service requests for authorizations of inpatient admissions or outpatient services when there are retro-eligibility instances (please show screen shot of the retro eligibility when submitting a retro review request). For retrospective reviews that fall in this category and are greater than 60 days retrospective, we may request the review to be performed by the corporate UM team in order to focus on concurrent cases. For retrospective requests not due to retro-eligibility, the hospital stay or outpatient services may be denied due to no prior authorization. Retrospective review includes making coverage determinations for the appropriate level of services, quality issues, utilization issues and the rationale behind failure to follow 'Ohana s prior authorization guidelines. A retrospective review can be initiated by 'Ohana or the provider. Retrospective reviews may take up to 30 days to make a determination WellCare 2013 WellCare Health Plans Inc. 36

37 Utilization Management (UM) (cont.) Transition of Care During the first 90-days of enrollment, authorization is not required for certain members with previously approved services rendered by a contracted or non-contracted provider. During annual enrollment and members dis-enroll from Ohana and transition to another Hawaii Medicaid plan, Ohana will provide Transition of Care data to the State. For members who are transitioning to Ohana from another health plan while hospitalized in an acute setting, the previous plan will be responsible for the hospitalization until the member is discharged or there is a drop in level of care where the member no longer qualifies for acute/snf services. At this point, it is the providers responsibility to notify Ohana of the continued stay immediately to ensure that concurrent review is continued and authorizations are obtained WellCare 2013 WellCare Health Plans Inc. 37

38 Service Coordination Service Coordination (SC) is a program available to QI members with Special Health Care Needs and those receiving Long-Term Services and Support (LTSS). Members may be assigned to a Service Coordinator upon enrollment or after performing a mini Health Risk Assessment to identify service needs. If a member does not know if he or she has been assigned a Service Coordinator they can contact Customer Service by calling Once enrolled into the SC program, Service Coordinators are responsible for: Completing a health and functional assessment (HFA) of the member. Planning and assisting the member with coordinating needed medical services, including the development of the service plan, with a team of decision makers to include the member s PCP, other providers and others determined by the member. Monitoring progress with EPSDT requirements. Coordinating benefits with other providers and community programs. Ensuring member encounters meet member needs. Providing assistance in resolving concerns about care delivery or providers. Completing and submitting the Nursing-Facility Level of Care (NF LOC) assessment to the PCP and DHS, as applicable, for NF LOC members and at risk members. Assisting members to maintain continuous Medicaid benefits; this includes identifying at risk members and ensuring continuity. Forms are located as Provider Resources under Forms and Documents WellCare 2013 WellCare Health Plans Inc. 38

39 Quality Improvement Program Ohana s Quality Improvement (QI) Program activities include, but are not limited to: Monitoring and improving clinical indicators and outcomes Monitoring appropriateness of care Quality studies Healthcare Effectiveness Data and Information Set (HEDIS ) measures Medical records audits Improving member and provider satisfaction Providers are contractually responsible for participating in QI projects and medical record review activities. HEDIS is a mandatory process that occurs annually. It is an opportunity for Ohana and its providers to demonstrate the quality and consistency of care that is available to members WellCare 2013 WellCare Health Plans Inc. 39

40 Section 6 Billing and Payment NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 40

41 Claims Submission Requirements Claims, paper and electronic, should include all necessary, completed, correct and compliant data including: Current CPT and ICD-9 (or its successor) codes Tax ID and NPI number(s) (Certain LTSS Providers are excluded from NPI requirement) Provider and/or practice name(s) that match those on the W-9 initially submitted to 'Ohana Correct taxonomy code consistent with Provider Demographic information for the Covered Services being rendered A preauthorization number, if applicable Ohana encourages providers to submit electronically via Electronic Data Interchange (EDI) or Direct Data Entry (DDE), which is less costly than paper and, in most instances, allows for quicker claims processing. Clearinghouse MDONLINE ADMINISTEP, ETC All claims and encounter transactions are validated for transaction integrity/syntax based on the Strategic National Implementation Process (SNIP) guidelines. Send paper claims to the following address: Ohana Health Plan Claims Department P.O. Box Tampa, Fl WellCare 2013 WellCare Health Plans Inc. 41

42 Balance Billing (cont.) Non-Covered Services Plan members may be billed for non-covered services like cosmetic procedures and items of convenience (i.e., televisions). If the provider bills a member for non-covered services, she/he shall inform the member and obtain prior agreement from the member regarding the cost of the procedure and the payment terms at time of service WellCare 2013 WellCare Health Plans Inc. 42

43 Balance Billing Covered Services Providers shall accept payment from the Plan for Covered Services provided to Plan members in accordance with the reimbursement terms outlined in the Agreement. Providers are prohibited from billing members for the following: No-show fees for QI program members who were scheduled to receive a Medicaid Covered Service. The difference between actual charges and the contracted reimbursement amount. Services denied because of timely filing requirements. Services denied due to failure to follow Plan procedures. Covered Services for which a claim has been returned and denied for lack of information. Remaining or denied charges for those services where a contracted provider fails to notify the plan of a service that required prior authorization. Payment for that service will be denied. Covered Services that were not medically necessary, in the judgment of the Plan, unless prior to rendering the service, the provider obtains the member s informed written consent and the member receives information that they would be financially responsible for the specific services. Sales tax or GET on services rendered WellCare 2013 WellCare Health Plans Inc. 43

44 Reporting Requirements Providers are required to report any change in credentialing status such as with licensure, accreditation or good standings to practice within their specialty type. Providers should submit a letter to Ohana Health Plan for demographic changes in writing to: 949 Kamokila Blvd., Ste. 350, Kapolei, HI Fax: The following are the changes that need to be reported: Change in address (Correspondence, Physical, or Billing) Contact information such as phone, fax, or Additional languages spoken Established capacity of accepting new members Fraud, Waste and/or Abuse Providers should report suspected member abuse to: The Child Welfare Services for Child Abuse. The Adult Protective Services for Dependent Adult Abuse. Provider Disputes/Grievances Filing appeals on the member s behalf. Other changes such as licensure or tax ID also require a provider letter and an updated W-9. Provider Relations Representatives can assist with preparing the documentation WellCare 2013 WellCare Health Plans Inc. 44

45 Section 7 Appeals and Grievances NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 45

46 Appeals and Grievances Provider Appeals Providers have the right to file Provider Payment Dispute/Administrative Appeal regarding provider payment or contractual issues, and must be filed within one hundred twenty (120) calendar days from the original utilization management or claim denial. Upon review of the appeal, 'Ohana will either reverse or affirm the original decision and notify the provider for appeals submitted on the providers own behalf. When submitting an appeal: Supply specific, pertinent documentation that supports the appeal. Include all medical records that apply to the service. Submit the appeal and accompanying documentation to the address in the Quick Reference Guide. Ohana will review the authorization denial, claim or claim-related issue for resolution and respond to provider within sixty (60) calendar days of the day after the date of submission to the Plan WellCare 2013 WellCare Health Plans Inc. 46

47 Appeals and Grievances (cont.) Member Appeals Providers may act on behalf of the member by submitting a Member Appeal with the member s written consent and supporting documentation within 30 days of the initial denial/notice of action to the Appeals Department. For Appeals submitted on the member s behalf with the member s written consent, notification will be provided to both the member and the provider. Ohana will send a letter within five business days from the receipt of the appeal letting the member know we received it. Ohana will review the appeal and send the member a letter within 30 days telling them of their decision. The member, or someone they choose to act for them, can review all of the information Ohana used to make the decision. The member, or his or her representative, may call the State eligibility worker or access the administrative hearing process by submitting a letter to the Administrative Appeal Office (AAO) within thirty (30) days from the receipt of the member s appeal determination to the following address: State of Hawai i Department of Human Services - Administrative Appeals Office PO Box 339 Honolulu, HI WellCare 2013 WellCare Health Plans Inc. 47

48 Appeals and Grievances (cont.) Expedited (Fast) Member Appeals Ohana s criteria for determining if they will grant a fast appeal is based on whether the provider says that waiting could seriously harm the member s health. The member or their provider may ask for a fast appeal. To request a fast appeal call or fax Ohana: Toll-free (TTY/TDD ). Fax to Monday through Friday, 7:45 a.m. 4:30 p.m. HST. If the request was filed verbally, written notice is not needed. Ohana will send a letter with the appeal decision within 3 business days of receiving the verbal request. If Ohana decides that the fast appeal is not needed, we will: Transfer the appeal to the timeframe for standard resolution. Make reasonable efforts to try to call you. Follow up within two days with written notice. Inform you verbally and in writing that you may file a grievance about the denial of the expedited process WellCare 2013 WellCare Health Plans Inc. 48

49 Appeals and Grievances (cont.) Continuation of Benefits The Plan will continue the member s benefits during an appeal or State Administrative hearing if: The member requests an extension of benefits The appeal or request for State administrative hearing is filed in a timely manner, meaning on or before the later of the following: Within ten (10) calendar days of the Plan mailing the notice of adverse action. The intended effective date of the Plan s proposed adverse action The appeal or request for State administrative hearing involves the termination, suspension or reduction of a previously authorized course of treatment. OR The services were ordered by an authorized provider. The original authorization period has not expired WellCare 2013 WellCare Health Plans Inc. 49

50 Appeals and Grievances (cont.) Continuation of Benefits When an appeal or hearing has been requested by the member, the member has a right to receive benefits while the appeal or hearing is pending, but the member may be held liable for the costs of those benefits if the health plan s adverse action is upheld. If the Plan continues or reinstates the member's benefits while the appeal or State administrative hearing is pending, the Plan will continue all benefits until one of the following occurs: The member withdraws the appeal The member does not request a State administrative hearing within ten (10) calendar days from when the Plan mails a notice of adverse action A State administrative hearing decision adverse to the member is made The authorization expires or authorization service limits are met If the final resolution of the State administrative hearing is adverse to the member, that is, upholds the Plan s adverse action, then the Plan may recover the cost of the appealed services (those services furnished to the member at the member s request while the appeal was pending) WellCare 2013 WellCare Health Plans Inc. 50

51 Appeals and Grievances (cont.) Grievances Providers shall have the right to utilize the provider grievance system to resolve any issues or disputes with the plan. An enrollee or an enrollee s representative may file a grievance orally or in writing. A decision must be made as fast as the enrollee s condition requires, but no more than thirty (30) calendar days from the date the grievance was received by the plan. A written resolution shall be mailed. Providers will be made aware of grievance processes and procedures in the form of the Provider Manual, which shall include: The enrollee s rights/requirements and timeframe to file grievances and appeals. A description of how to file a grievance, complaint or an appeal. The availability of assistance in filing a grievance. The enrollee s right to have a provider or authorized representative file a grievance on his or her behalf, provided he or she has provided written consent to do so. The enrollee s right to a state grievance review, how to obtain a hearing, and rules on representation at a hearing WellCare 2013 WellCare Health Plans Inc. 51

52 Appeals and Grievances (cont.) Grievances Toll-free number and address to file a grievance, complaint or an appeal. Providers may act on behalf of the enrollee with the enrollee s written consent. In the event a enrollee is dissatisfied with the grievance decision reached by 'Ohana, the enrollee, or the provider acting on behalf of the member, may request a State Grievance Review. If a grievance is filed by a provider on behalf of an enrollee but there is no record of written authorization by the enrollee, the plan makes and documents a reasonable effort to secure the necessary appointment form. Health plan enrollees may request a State Grievance Review within thirty (30) days of the enrollee's receipt of the grievance disposition from the health plan. A State Grievance Review may be made by contacting the MQD office, or mailing a request to: Med-QUEST Division Health Care Services Branch PO Box Kapolei, HI WellCare 2013 WellCare Health Plans Inc. 52

53 Appeals and Grievances Sample Letters Member Grievance Closure Letter (Sample) 2013 WellCare 2013 WellCare Health Plans Inc. 53

54 Appeals and Grievances Sample Letters Notice of Action Letter (Sample) 2013 WellCare 2013 WellCare Health Plans Inc. 54

55 Section 8 Resources NA016395_PRO_PRS_ENG 2014 WellCare Health Plans Inc. 55

56 For More Information Review the Provider Manual for more detailed information about provider requirements and how-to instructions, including: Provider and Member Administrative Guidelines Utilization Management and Case & Disease Management Claims Quality Improvement Credentialing Appeals and Grievances Delegated Entities Compliance Pharmacy Services Refer to the Provider Resource Guide and Provider How-To Guide as your onestop-shop guides to the most common transactions with 'Ohana, including: Registering for, and how to use, 'Ohana s provider portal such as member eligibility and co-pay information, authorization requests, claims status and inquiry, provider news and more. How to file a claim via paper, electronically, or via 'Ohana s Direct Data Entry (DDE) How to file a grievance How to file an appeal 2013 WellCare 2013 WellCare Health Plans Inc. 56

57 For More Information Refer to the Quick Reference Guide for authorization requirements, addresses, and phone numbers for key departments. Refer to the Clinical Practice Guidelines and Clinical Coverage Guidelines to determine medical necessity, criteria for coverage of a procedure or technology, and best practice recommendations based on available clinical outcomes and scientific evidence WellCare 2013 WellCare Health Plans Inc. 57

58 Provider Outreach You can expect Ohana to consistently communicate and outreach to providers in an effort to keep you informed. Ohana offers access to Provider Relations representatives on your island who are dedicated to serving your needs. Provider memos outlining key information, including health plan changes, new programs and more, will be sent to you via fax, letter, newsletter and/or online through our secure Provider Portal (if registered). In an effort to ensure you are notified timely, remember to always update your contact information with Ohana in the event you move or your contact information changes. We are proud to serve you, and our members. Feel free to contact your Provider Relations representative to schedule an in-service meeting. You may contact Provider Services by calling toll free at WellCare 2013 WellCare Health Plans Inc. 58

59 Summary In this training, we: Identified the benefits of participation. Described the plan s billing and payment processes. Explained the Compliance Program requirements. Located provider and member specific resources. Determined member eligibility and benefits. Discussed the plan s covered services. Explained how to access Ohana s Provider Relations and Customer Services. Identified Provider and Member Rights and Responsibilities. Described Advance Directives and Cultural Competency. Explained Ohana s Quality Improvement Program. Described the EPSDT and Members with Special Health Care Needs requirements. Discussed the Appeals and grievances process WellCare 2013 WellCare Health Plans Inc. 59

60 Training Completion Attestation Thank you for your attention! We hope you have found the Ohana Medicaid Provider Orientation helpful. For reporting purposes, please return to the Provider Training Portal now and complete the attestation of completion for this training module. If you do not complete the attestation, our reporting will indicate that you have not completed this requirement. In the event that your Provider Portal session has timed out, click this link to log back in and return to the Provider Training Portal in order to complete the attestation of completion. For the Ohana Health Plan, please click this link If you should have any questions, please contact your Provider Relations representative or Provider Services. We very much appreciate your collaboration and the care and services you provide to your patients, our members WellCare 2013 WellCare Health Plans Inc. 60

61 Exiting the Course Thank you for your attention today! To exit this course, please click the Exit button on the top right corner of the course player window. Once the tab opens, click the Exit Now button WellCare 2013 WellCare Health Plans Inc. 61