Amerigroup Iowa, Inc. Updates and insights

Transcription

1 Amerigroup Iowa, Inc. Updates and insights Presented to the LeadingAge Iowa Association Spring Conference May 5, 2016 Gloria Scholl Manager, Provider Network Management/Relations Amerigroup Iowa, Inc. IAPEC April 2016

2 About Amerigroup Iowa One of three MCOs participating in Iowa s IA Health Link Medicaid program 19 years of experience with members in federal and state programs. With our affiliated health plans, we provide access to health care for over six million Medicaid members in 20 states. Office located on Westown Parkway, West Des Moines; evaluating possible locations in other Iowa cities 2

3 Our goals for transitioning to managed care Improve the quality of care and health outcomes Emphasize member choice, access, safety, independence, responsibility and services delivered in the least restrictive manner appropriate to a member s health and functional status Provide physical health, behavioral health and long-term services and supports in a coordinated manner 3

4 At the heart of what you do Primary care/ specialty care Federal & state requirements Ancillary services/ supports/ pharmacy Staff training/ employment Patient/ your member Coordination with MCOs / other carriers Care planning/ discharge planning/ care coordination 4

5 Your Amerigroup team 5

6 Your Amerigroup team Amerigroup Iowa, Inc. leadership Cynthia MacDonald, Chief Executive Officer Jeff Jones, Chief Operating Officer Dr. Mark Levy, Medical Director Derek Hender, Director Provider Solutions Manager Provider Network Management/Relations o Gloria Scholl Behavioral Health o Julie Stuhr Long-Term Services and Supports o Jeff Alger Medical/Acute Care 6

7 Your Amerigroup team Provider Relations representatives Contracting and contract amending Educate providers on submitting claims and rosters Conduct provider site visits and quality visits Develop community relationships and increase Amerigroup visibility Amerigroup case managers Develop care plans to meet member needs Address member concerns or issues Issue authorizations Serve as member advocates to promote quality of life 7

8 Your Amerigroup team Provider Services Claims/claims payment status requests Claims appeals Member eligibility Benefit questions Electronic funds transfer (EFT)/electronic remittance advice (ERA) questions 8

9 Your Amerigroup team 9

10 Key contact information Provider Services: Member Services: Amerigroup on Call: (Spanish) Precertification: Phone: Pharmacy prior authorization: Phone: Fax: Website: Paper claims submission: Amerigroup Iowa, Inc. Claims P.O. Box Virginia Beach, VA Electronic claims submission: Availity: payer ID: Emdeon: payer ID: Capario: payer ID: Smart Data Solutions: payer ID:

11 Care coordination 11

12 Discharge and transition Our goal is to partner together to ensure seamless transition between facilities or residences by: Collaborating with providers when a member s needs change and a change in services/provider is necessary, and to find an appropriate placement/setting that can meet the member s needs Initiating regular face-to-face visits after members have transitioned to the community setting of their choice 12

13 Post transition monitoring Amerigroup strives to collaborate with providers to: Monitor hospital and facility readmissions for members who have transitioned to the community Develop the discharge plan based on member s wishes and assessed needs. Leverage regular face-to-face visits and contacts with members transitioning to the community to identify member needs, supports and services 13

14 Frequently asked questions and issues 14

15 Common authorization issues Submitting authorization with missing/incomplete items: Amerigroup member ID missing Member s name incorrectly spelled Member s date of birth missing Missing date spans Missing provider ID 15

16 Precertification lookup tool online Submit precertification requests via: Check the status of your request on the website or by calling Provider Services. Search by: Market Member product CPT code 16

17 Tips for preventing billing issues Use correct tax ID number (TIN) for provider rendering services Ensure provider is contracted with and credentialed by Amerigroup for the services being rendered Bill with entity name per your Amerigroup contract If you submitted a National Provider Identifier (NPI) during credentialing, ensure you submit the same NPI on claims Obtain required authorization for services 17

18 Using the right claim form Provider type Claim form accepted Medical/acute care CMS-1500 CMS-1450 (UB-04) Home- and Community-Based Services (HCBS) CMS-1500 Targeted Medical Care Form Consumer-Directed Attendant Care (CDAC) CMS-1500 (Agencies) Targeted Medical Care Form 18

19 Patient liability How will Amerigroup process patient liability? Providers will bill gross/full charges. Amerigroup will adjudicate the claim and deduct the member liability amount. In the event the sum of any applicable third-party payment and a member s financial participation equals or exceeds the reimbursement amount established for services, Amerigroup will make no payment to the provider. 19

20 Updated fee schedules/rates How do you handle updated rates from the state? Upon notice from the state that rates have been updated, Amerigroup will update our fee schedule as quickly as feasible. Once the fee schedule is updated, Amerigroup will reprocess any submitted claims from the effective date of the rate update. There is no need for providers to resubmit claims. 20

21 Critical incidents Where do major critical incidents get reported? When a major incident occurs or a staff member becomes aware of a major incident, the staff member involved will notify the staff member s supervisor, the member s case manager and the member s legal guardian by the end of the next calendar day. The staff or supervisor will then complete a Critical Incident Report Form on the Amerigroup Iowa website at 21

22 Critical incidents Where do minor critical incidents get reported? Minor incidents include: First aid administration Bruising Seizure activity Injury to self, others or property Medication errors Providers must keep records of all minor incidents but do not have to report minor incidents to the independent medical evaluation. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member s supervisor within 72 hours of the incident. 22

23 Open discussion 23