Provider Relations Training

Transcription

1 Cal MediConnect Provider Relations Training Presented by Victor Gonzalez and George Scolari

2 Provider Relations Training Agenda Overview of Cal MediConnect Eligibility & Exclusions Enrollment & Disenrollment Covered Benefits Long-Term Supports & Services (LTSS) Care Coordination for LTSS Members Integrated Care Teams Referrals and Prior Authorizations Quality Improvements Claims Linguistic Services and Cultural Sensitivity Grievances & Appeals Compliance, Fraud, Waste &Abuse Legislative Authorities Sources of Information 1

3 Overview of Cal MediConnect Cal MediConnect is a 3-year demonstration ( ) pilot in eight California counties: Alameda, Orange, Los Angeles, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara Integrates Medicare and Medi-Cal services into one program, and managed by qualified administrators and clinicians. Includes inpatient, outpatient, pharmacy, long-term care, home- and community-based services, nursing facility, and other types of adult senior services Total of 456,000 people are eligible (8 counties) Approx. 47,000 eligible enrollees in San Diego County and Community Health Group estimates 14,000 enrollment 2

4 Who is eligible to enroll in Cal MediConnect? Persons that live in one of the 8 counties: Alameda, Orange, Los Angeles, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara Persons age 21 or Older Persons enrolled in Medi-Cal and Medicare Parts A and B, and eligible for Part D Referred to a Full Dual Eligibles A person enrolled in both programs is referred to as Medi-Medi 3

5 Who is excluded from Cal MediConnect? Persons with other private or public health insurance Persons with developmental disabilities receiving services through the Department of Development Services (DSS) 1915(c) waiver Intermediate Care Facilities for developmentally disabled persons (ICF/DD) Persons enrolled in 1915(c) waivers, including HIV/AIDS, assisted living waiver, and in-home operations waiver services Persons with End Stage Renal Disease (ESRD) Persons living in a Veteran s home Persons with Medi-Cal and Medicare (Parts A or B) are referred to as a Partial Dual Eligibles 4

6 Enrollment & Disenrollment Enrollment occurs over a 12-month period, starting April 2014, and is based on a person s birth month. Eligible people receive notifications 90, 60, and 30 days prior to enrollment into a managed care health plan. Also referred to as Passive Enrollment, as the eligible persons are automatically enrolled into a health plan. 5

7 Enrollment & Disenrollment Enrollees have the right to disenroll, or opt out, from the Cal MediConnect Program at any time The enrollment and disenrollment takes effect on a month-by-month basis, and is authorized by Senate Bill 1008 and 94. We recommend that verify eligibility monthly with each Cal MediConnect Enrollee to avoid billing issues 6

8 Covered Benefits Cal MediConnect Program includes Medi-Cal and Medicare Parts A, B, and D services: Inpatient (Hospital) Outpatient (Primary and Specialty Physicians) Emergency Room Visits Pharmacy (Prescription and over the counter medications) Supplemental Benefits (vision, non-medical transportation) Behavioral Health (mental health and substance use) Long-Term Supports and Services In-Home Supportive Services (IHSS) Community Based Adult Services (CBAS) Multi-purpose Senior Services Program (MSSP) Nursing Facility 7

9 Long-Term Supports and Services (LTSS) Long-Term Supports and Services (LTSS) include a wide variety of services and supports that help eligible beneficiaries meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. 8

10 Long-Term Supports and Services (LTSS) As described in California Welfare and Institutions Code section , Medi-Cal covered LTSS includes all of the following: Community Based Adults Services (CBAS) is an outpatient, facility-based service program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, and transportation to eligible Cal Medi-Connect members. Multi-Purpose Senior Services Program (MSSP) is a program that provides Home and Community-Based Services (HCBS) to Medi-Cal eligible individuals who are 65 years or older with disabilities as an alternative to nursing facility placement. In-Home Health Services (IHSS) is a program that provides in-home care for people who cannot safely remain in their own homes without assistance. To qualify for IHSS, an enrollee must be aged, blind, or disabled and, in most cases, have income below the level to qualify for the Supplemental Security Income/State Supplementary Program. IHSS includes the Community First Choice Option (CFCO), Personal Care Services Program (PCSP), and IHSS-Plus Option (IPO). Nursing facility is a health facility licensed under state law that is certified to participate as a provider of care as a skilled nursing facility in the federal Medicare program or as a nursing facility in the federal Medicaid program, or as both. For more information about LTSS, Contact CHG s Provider Relations Department at (619)

11 Care Coordination for LTSS members Health Risk Assessments (HRAs) are provided to each Enrollee to determine their medical, care management, and social needs. Enrollees are assessed to determine whether they need basic or complex case management services Integrated Care Teams (ICTs) are comprised of the PCP, Case Manager, Personal Care Coordinator, and others. Care plans are developed for all Enrollees, and the ICTs coordinate and track the health status of an individual. Personal Care Coordinators and Case Managers assist the Enrollees with transitions between care settings (e.g. hospitals to nursing facilities). Contact CHG s Provider Relations Department at (619)

12 Integrated Care Teams (ICT) Integrated Care Teams (ICTs) are comprised of the PCP, Case Manager, Personal Care Coordinator, and focus on the medical and social needs of the patient. ICT team members recognize and respect contributions of each team member, and demonstrate collaboration and cooperation meet the needs of the Cal MediConnect member. ICT team members develop the Integrated Care Plan (ICP), and CHG maintains the care plan and is responsible for distribution to the ICT. 11

13 Referrals and Prior Authorizations CHG staff are available to answer your questions about Cal MediConnect referrals and prior authorizations by telephone each business day from 8:00AM 5:00PM. Please contact the following CHG departments for the type of service: Behavioral Health Behavioral Health Department at (800) CBAS Health Care Services at (800) IHSS Aging and Independent Services at (800) Multi-Purpose Senior Service Programs (MSSP) Health Care Services at (800) Nursing Facilities Health Care Services at (800)

14 Quality Improvements CHG participates in a number of quality improvement projects internally, with the State of California and the Center for Medicare and Medicaid (CMS), or other partners. The goal for quality improvement is to analyze processes and practices that may lead to better health and quality of life outcomes for members. CHG maintains a mechanism to identify, analyze, and resolve quality of care and other types of health service issues. CHG s Quality Management unit reviews and resolves issues in a timely manner, and may need your assistance in this process. 13

15 Claims For Medicare claims, provider must submit claims with within one(1) calendar year from the date of service. For Medi-Cal claims, providers must submit claims within one-hundred twenty (120) days from the date of service. CHG processes clean claims within 45 business days of receipt. If you disagree with our claims payment, you have the right to appeal the decision in writing through our Provider Services Department. Your dispute must be received no later than 365 days from the action on the claim that you are disputing. In the case of inaction on the claim, your dispute must be received no later than 365 days after the date that is 45 working days following our receipt of the original complete claim. The member may not be billed if the provider fails to bill in a timely manner. CHG has established processes for receipt and review of claims disputes from contracted providers. Providers may contact the Provider Services Department at (619) for additional information and to check the status of their disputes. 14

16 Linguistic Services and Cultural Sensitivity LTSS providers are expected to ensure equal access to health care services for all members with communication disabilitities and Limited English Proficient (LEP) members. For more information on LEP, please visit the following site: Qualified interpreter services may be obtained by telephone or face-to-face by contacting CHG Member Services Department at (800) Please visit CHG s web site for more information at 15

17 Grievances & Appeals Enrollees will contact the managed health care plans to file a complaint or grievance, and request an appeal for medical coverage decisions. Appeals may be requested by Enrollees as standard or expedited (urgent). For CalMediConnect grievances and appeals, Enrollees may contact CMS, CCI Ombudsman, the Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC), and other state agencies. IHSS grievances and appeals will be managed by the California Department of Social Services (CDSS) For more information about grievances and appeals, please contact CHG s Provider Services Department at (619)

18 Legislative Authority Cal MediConnect authorized through the Coordinate Care Initiative (CCI): Adopted in July 2012 CCI includes mandatory enrollment of all Medi-Cal beneficiaries into a managed care plan for LTSS, and optional enrollment into the Cal MediConnect Program. Federally funded program through the Center for Medicare and Medicaid Systems (CMS) and the State of California. Senate Bill (SB) 1008 and SB 1036 authorizes the managed care integration between Medi-Cal and Medicare. SB 94 was chaptered in June 2013 (updates SB 1008). 17

19 COMPLIANCE, FRAUD, WASTE & ABUSE Cal MediConnect Training On line materials include: CMS Provider Training Module Fraud, Waste & Abuse Training Module Policies/Procedures Medicare Compliance Plan (Including Code of Conduct & Related Policies) First Tier, Downstream Entity & Related Entity Medicare Attestation Medi-Cal Compliance Plan First Tier, Downstream Entity & Related Entity Medi-Cal Attestation Mandatory Fraud, Waste & Abuse Reporting Methods Hotline Compliance Officer Ann Warren

20 Learn more about Cal MediConnect by visiting Community Health Group s Provider Services Portal 19

21 Key Contacts Telephone Fax Authorization/Referrals: Norma Lopez (800) or (619) (619) Behavioral Health Services: George Scolari (800) (877) Claims: Cristina Alvarado (619) Compliance & Fraud Reporting: Ann Warren (800) (619) Contracting: (619) (619) Maria Diaz Member Services: (800) or (619) (619) Eugenia Chavez Provider Relations: Victor Gonzalez (619) (619) Provider Services/Dispute: Marian Manzano (619) (619) Quality Improvement: Carole Anderson (619) (619)

22 QUESTIONS? 21