HMSA QUEST Integration Plan. Par Provider Information Webinar May 24,2017

Transcription

1 HMSA QUEST Integration Plan Par Provider Information Webinar May 24,2017

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

3 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) 3

4 Excluded Providers

5 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 5

6 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 6

7 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 6/5/2017 7

8 State Excluded Provider Lists Government contracting exclusion list DHS Med-QUEST Division s exclusion list atementlist.html 8

9 Service Coordination

10 Service Coordination A person-centered service delivery system Ensures the needs of those with special health care needs and those receiving long term services and supports are met Service coordinators assist in coordinating services with other agencies, programs, and community services 10

11 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 11

12 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 12

13 Requesting Service Coordination Fax the form at: gration_service_coordination_referral_form.pdf Oahu fax: Neighbor Islands toll-free fax: 1(855) May also call HMSA Oahu: Neighbor Islands toll-free: 1 (844)

14 Member Cost Share

15 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 15

16 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 16

17 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: hiweb.statemedicaid.us Providers may also call QUEST Integration Provider Service at (Oahu) or 1 (800) toll free Neighbor Islands 17

18 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 18

19 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 19

20 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 20

21 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 21

22 Referrals

23 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 23

24 How to Register a Referral Referral form is at: eferral_form.pdf Fax the referral form (Oahu) 1 (800) (toll-free) Register the referral online via HHIN Select Submit Referrals tab, then click on iexchange Call QUEST Integration Provider Service (Oahu) 1 (800) (toll-free) 24

25 Precertification

26 Precertification (Prior Authorization) List of QUEST Integration services requiring precertification: R.50.htm Clearly identify urgent/emergent cases for expedited review 26

27 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 27

28 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 28

29 Precertification HMSA Medical Management HMSA precertification forms available online General certification_request_general.pdf Post-Acute Care Services ification_request_post_acute_care_services_form. pdf 29

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

31 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)

32 How to Access iexchange using Cozeva Use Firefox or Internet Explorer browser Click dropdown arrow for Inbox and select Req Authorizations The window below appears. Click the button to continue to iexchange 32

33 How to Access iexchange using Cozeva The iexchange window appears. Select Inpatient or Other to start your type of request Note: May have to disable popups to view iexchange 33

34 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 34

35 Precertification - NIA Radiology management Quick Reference Guide: m 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)

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

37 Precertification QUEST Integration Provider Service Phone: Fax: (Oahu) 1 (800) (toll-free Neighbor Islands (Oahu) 1 (800) toll-free Neighbor Islands 37

38 Precertification - CVS Oral/Inhaled drugs Drugs requiring precertification-review Drug Formularies: FORMULARY.htm#Nav_Formularies Omit Fax: 1 (866) Phone: 1 (808)

39 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)

40 Precertification Beacon Health Options For BH referrals to 0ut-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

41 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 41

42 EPSDT Early Periodic Screening Diagnostic and Treatment For PCPs

43 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 43

44 EPSDT Schedule Health Screening Assessment schedule is at the Med-QUEST website: aii%27s%20medicaid%20epsdt%20progra m%20_overview_.pdf 44

45 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 45

46 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 46

47 Filing Claims for EPSDT Must use original printed forms only. No copies. Ordering EPSDT 8015 and 8016 forms: Call ACS at (808) on Oahu or toll free from the Neighbor Islands Fax request to (800) request to Only EPSDT Paid if Billed with Office Visit on the Same Day 47

48 EPSDT Resources EPSDT general information url: 4.EAR.50.htm Sample EPSDT form 8015 (1/10) _8015_front_and_back.pdf 48

49 Fee schedules (Professional)

50 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 50

51 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 51

52 Fee Schedules Fee schedules on HHIN separated into Non- QUEST and QUEST sections Separate fee schedules for non-abd and ABD members 52

53 Resources Provider Communications Provider Portal - QUEST Provider Handbook Communication Archive - HealthPro News QUEST Integration Provider Service Phone: (Oahu) or 1 (800) toll free Neighbor Islands Fax: (Oahu) or 1 (800) from the Neighbor Islands 53

54 Thank you! Questions? 54