HMSA QUEST Integration Plan. Par Provider Information Webinar May 23,2018

Transcription

1 HMSA QUEST Integration Plan Par Provider Information Webinar May 23,2018

2 Agenda Provider Enrollment/Re-enrollment Excluded Providers Member Cost Share Service Coordination Referrals and Pre-certifications EPSDT QUEST Integration Fee Schedules (HHIN) Contact information Q & A 2

3 Medicaid Provider Enrollment/ Re-enrollment

4 Important Announcement Who? Providers enrolling in Medicaid for the first time, or Established Medicaid providers who have not re-enrolled with Medicaid within the past 5 years What? Submit Medicaid Application form (DHS 1139) and other required documents to Med-QUEST ASAP Why? Enhanced provider screening, credentialing and enrollment When? NOW! Affected providers should submit their documents as soon as possible. 4

5 Submission Requirements All providers: Completed DHS 1139 Medicaid Provider application Copies of Applicable Licenses/Certifications W-9 Copy of General Excise Tax License Copy of Certificate of Liability Insurance Allow MQD to conduct an onsite inspection 5

6 Submission Requirements Home Health Agencies, DME, Home and Community Based Services, Hotels and Transportation providers: Submit $500 application fee (money order or check) payable to: State Director of Finance c/o Med-QUEST division Individuals with 5% or more business ownership must undergo fingerprinting and criminal history fitness determination by Fieldprint. Instructions at website: Not required for non-profit organizations. 6

7 Submission Requirements Institutional providers (hospitals, nursing facilities, pharmacies) Submit $500 application fee (money order or check) payable to: State Director of Finance c/o Med- QUEST division 7

8 Send to Send all required documents and payment (if applicable) to: Med-QUEST Division Health Care Services Branch P.O. Box Kapolei, HI

9 Application form DHS 1139 application form and additional attachments for certain provider types: Questions? Call Med-QUEST at (808) or 9

10 QUEST Integration members HMSA s QUEST Integration members Non-ABD (Doesn't include Aged, Blind or members with disabilities) ABD (Aged, Blind or members with disabilities) ABD and LTSS (Aged, Blind or members with disabilities who have additional LTSS benefits) 10

11 Excluded Providers

12 Excluded Providers What is an Excluded Provider? Individual or Entity who is not allowed to receive reimbursement for providing Medicare or Medicaid services HMSA is required to immediately terminate the Excluded Provider and/or affiliated provider (owners, agents or managing employees) from the provider network 12

13 Excluded Providers QUEST Integration Provider Responsibilities Search Excluded Provider lists routinely (i.e. monthly) to confirm that employees or contractors are not on any list AND Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list 13

14 Federal Excluded Provider Lists General Services Administration Excluded Parties List System (EPLS) List of Excluded Individuals and Entities (LEIE), a health care specific exclusion list 5/22/

15 State Excluded Provider Lists Government contracting exclusion list DHS Med-QUEST Division s exclusion list 15

16 Service Coordination

17 Service Coordination A person-centered service delivery system Ensures the needs of those with special health care needs, those receiving long term services and supports are met and those who are at risk for deteriorating to nursing facility level of care are met Service coordinators assist in coordinating services with other agencies, programs, and community services 17

18 Service Coordination Who is eligible? QUEST Integration members with Special Health Care Needs (SHCN). May include: Patients with chronic conditions such as asthma, diabetes, hypertension, cancer, or COPD Patients who are outliers for emergency room utilization Patients being discharged from an acute care setting Patients with hospital readmission within the previous 30 days Children with autism Members with complex medical conditions requiring coordination of care 18

19 Long-Term Services and Supports (LTSS) Patients must meet Nursing Facility Level of Care (NF LOC) on a DHS 1147 Home and community-based services (HCBS): LTSS provided to individuals to allow them to remain in their home or community Includes Residential Settings Institutionalized care: Skilled Nursing Facility (SNF) Intermediate Care Facility (ICF) Self- Direction: Member employs their own provider(s) promoting choice and independence Individuals are mostly 65 years of older or with a disability Most members are identified on membership card as ABD and LTSS. 5/22/

20 DHS 1147 form Completed by either provider or service coordinator Only MD, DO, RN, or APRN may complete form Use DHS electronic system HILOC if you have access If no access to HILOC, complete form at link below ans-providers/provider-forms.html Search for

21 At-Risk Program Individuals do not meet nursing facility level of care (NF LOC) on DHS 1147 Do not need to be ABD to qualify Assessed at risk of deteriorating to nursing facility level of care using DHS Examples include someone who: Lives alone and has difficulty walking Had a recent hospital discharge Recent traumatic event such as a stroke Resides in own home (not home where someone is paid to care for member such as a care home) Services include personal assistance, meals, personal emergency response system, adult day home/care, and skilled nursing 5/22/

22 Service Coordination Responsibilities of Coordinators Support the PCP Conduct member functional assessments Develop and monitor a service plan based on results of the assessment or reassessment Coordinate and facilitate access to services with providers, programs, and community agencies Monitoring progress with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. As applicable 22

23 Requesting Service Coordination Providers may refer any member for service coordination Tell your patient that you are making a referral to Service Coordination this helps when we call Providers may refer patients for Service Coordination by faxing the form at: _Service_Coordination_Referral_Form.pdf Oahu fax: Neighbor Islands toll-free fax: 1 (855) Providers may also call HMSA to refer patients for Service Coordination: Oahu: Neighbor Islands toll-free: 1 (844)

24 Member Cost Share

25 What is Cost Share? Members who do not meet Medicaid financial eligibility requirements Cost Share amount determined by Med- QUEST Members responsible for paying their Cost Share monthly 25

26 Providers Who Collect Cost Share Nursing Facilities Skilled or private duty nursing Hospital Wait-listed Community Care Foster Family Homes Personal Assistance Expanded Adult Residential Care Homes Adult Day Health Respite Care Adult Day Care 26

27 Identifying Members Who Have Cost Share HMSA Service Coordinator contact providers to discuss cost share amounts to collected Service Coordinators send copy of Member s Cost Share Agreement to the provider Providers may check the Med-QUEST eligibility website: ReturnUrl=%2f Providers may also call QUEST Integration Provider Service at (Oahu) or 1 (800) toll free Neighbor Islands 27

28 Entering Cost Share Amounts Collected on Claims Cost Share amounts must be entered on claims submitted by these providers UB-04: Use Value Code 23 in Form Locator 39 CMS 1500: Enter cost share amount in Block 29 Use equivalent fields for electronic claims 28

29 Cost Share Process Med-QUEST Division (MQD) determines member s cost share amount HMSA Service Coordinator meets with member to: 1. Explain their cost share responsibility 2. Have member sign Cost Share agreement HMSA sends copy of agreement to provider Payment made to provider HMSA payment is reduced by the amount of the cost share Provider files claim to HMSA indicating Cost Share amount collected 29

30 Cost Share If member s Cost Share exceeds the claim amount, HMSA sends provider an invoice asking them to send the balance to: HMSA Attn: F & A Disbursements P. O. Box 860 Honolulu, HI Providers may opt to have invoice amounts deducted from future Reports to Provider 30

31 Cost Share Cost Share amounts are applied to claims submitted by designated providers Retroactive changes to Cost Share result in reprocessing of claims to reflect current cost share amounts 31

32 Referrals

33 Referrals Self referrals Behavioral health (OP) Family Planning Refractive vision services Well-woman exam and mammogram All other specialty care requires PCP referral Register these referrals with HMSA Plastic surgery services Off - island specialist services In-state out of network referrals 33

34 How to Register a Referral Referral form is at: _Referral_Form.pdf Fax the referral form Oahu: Neighbor Islands: 1 (800) (toll-free) Register the referral online via HHIN Select Submit Referrals tab, then click on iexchange Call QUEST Integration Provider Service Oahu: Neighbor Islands: 1 (800) (toll-free) 34

35 Precertification

36 Precertification (Prior Authorization) List of QUEST Integration services requiring pre-certification: Clearly identify urgent/emergent cases for expedited review 36

37 Precertification (cont.) Unit/Partner: HMSA Medical Management National Imaging Associates (NIA) evicore Responsible for: Medical/Surgical, LTSS, Post-Acute Care Services, Speech Therapy, Out of State Referrals Advanced imaging, Spinal Interventional Pain Management, Lumbar Spine Surgery, selected Cardiac procedures Outpatient Rehab Therapy 37

38 Precertification (cont.) Unit/Partner: QUEST Integration Provider Service CVS Beacon Health Options Responsible for: Travel and lodging requests, In-state out of network referrals Drug Behavioral Health 38

39 Precertification HMSA Medical Management HMSA precertification forms available online General rtification_request_general.pdf Post-Acute Care Services cation_request_post_acute_care_services_form.p df 39

40 Precertification HMSA Medical Management Mail to: HMSA Medical Management P. O. Box 2001 Honolulu, HI Fax: 1 (808) Phone: Oahu: Neighbor Islands: 1 (800) toll-free Monday-Friday : 7:45 a.m. - 4:30 p.m. Online: Access iexchange through HHIN 40

41 Precertification (Prior Authorization) Electronic submissions accepted through HHIN Click on Preauthorization tab. Then click on iexchange (HMSA Medical). To request access to HHIN call (808)

42 Precertification - NIA Management of: MRI/MRA/MRS PET Myocardial perfusion imaging Stress echocardiography Implantable cardioverter defibrillator Pacemaker Lumbar spine surgery CT/CTA CCTA MUGA Spinal interventional pain management Cardiac resynchronization therapy pacemaker Cardiac catheterization 42

43 Precertification - NIA Radiology management Quick Reference Guide: NIA FAQ: cialty_solutions_program_nia_magellan_faqs.pdf Does NOT include emergency room, surgery center, observation and inpatient settings Online: RadMD.com Phone: 1 (866) Clinically Urgent Cases: 1 (866)

44 Precertification - evicore Formerly known as Landmark Healthcare Login at: nnect.aspx Treatment plan forms available at the website Treatment plans may be submitted via LandmarkConnect or by fax Fax: 1 (888) Questions: 1 (888)

45 Precertification QUEST Integration Provider Service Phone: Oahu: Neighbor Islands: 1 (800) toll-free Fax: Oahu: Neighbor Islands: 1 (800) toll-free 45

46 Precertification - CVS Oral/Inhaled drugs Drugs requiring precertification-review Drug Formularies: Formulary_CVS.pdf Fax: 1 (866) Phone: 1 (808)

47 Precertification - CVS Injectable/Infused drugs Drugs requiring precertification: Note: most drugs have specific precertification request forms Online: Access through HHIN Preauthorization tab (NovoLogix tool) Fax: 1 (866) Phone: 1 (808)

48 Precertification Beacon Health Options For BH referrals to Out-of-state providers, Residential Treatment, Methadone/LAAM treatment Fax: (808) Phone: Oahu: (808) Neighbor Islands: 1 (855) toll-free Mail: Beacon Health Options 599 Farrington Highway, Suite 300 Kapolei, HI

49 Precertification Timeliness guidelines Routine requests within 14 days Urgent requests within 3 business days If precertification is not obtained before the service is provided, submit a paper claim attaching documentation for the medical necessity Claim will undergo medical review Claim without documentation will be denied for no authorization 49

50 EPSDT Early Periodic Screening Diagnostic and Treatment For PCPs

51 EPSDT Early Periodic Screening Diagnostic and Treatment Provide Medicaid-eligible infants, children and youth with quality comprehensive health care through primary prevention, early diagnosis and medically necessary treatment of conditions For children up to 21 years of age 51

52 EPSDT Schedule Health Screening Assessment schedule is at the Med- QUEST website: nddocuments/resources/provider- Resources/epsdt/EPSDT-Overview.pdf 52

53 Filing Claims for EPSDT CMS 1500 File claim with Preventive Medicine CPT or with modifier EP in block 24.d Place Y in Block 24.h of the CMS EP A XXX XX 1 Y 53

54 Filing Claims for EPSDT PCPs submit EPSDT form 8015 (or Form 8016 for catch up visits). Paper claim - staple EPSDT form to the claim. Electronic claim - mail EPSDT form separately to: HMSA QUEST Integration P.O. Box 3520 Honolulu, HI The mailed form must be received by HMSA by the time the electronic claim processes 54

55 Filing Claims for EPSDT Must use original printed forms only. No copies. Ordering EPSDT 8015 and 8016 forms: Call Conduent at (808) on Oahu or toll free from the Neighbor Islands Fax request to (808) Only EPSDT Paid if Billed with Office Visit on the Same Day 55

56 EPSDT Resources EPSDT general information url: Sample EPSDT form 8015 (1/10) _front_and_back.pdf anddocuments/provider-forms/8015-hawaii- early---periodic--screenig--diagnosis--- treatment--epsdt--exam/dhs-8015-form-final pdf/_jcr_content?type=pdf&process= 56

57 Fee schedules (Professional)

58 Fee Schedules Participating Providers Accept Eligible Charge as payment in full for covered services Payment based on the Eligible Charge, less applicable copayments, deductibles, and payment from third parties* * PCPs in HMSA s Payment Transformation Program have an alternate reimbursement methodology 58

59 Fee Schedules Fee schedules are available on HHIN Under QUEST Integration, click on the Fee Schedules tab on the left side of the home page Note: If an eligible charge is stated in your provider agreement, terms of the agreement supersede the fee listed in HHIN 59

60 Fee Schedules Fee schedules on HHIN separated into Non- QUEST and QUEST sections Separate fee schedules for non-abd and ABD members 60

61 Resources Provider Communications Provider Portal - QUEST Provider Handbook Communication Archive - HealthPro News QUEST Integration Provider Service Phone: Oahu: Neighbor Islands: 1 (800) toll free Fax: Oahu: Neighbor Islands: 1 (800) toll free 61

62 Thank you! 62