HFMA Presentation 11/19/2015. Quality health coverage. It s Our Mission.

Transcription

1 HFMA Presentation 11/19/2015 Quality health coverage. It s Our Mission.

2 Who We Are A not-for-profit, mission-based health insurance company serving more than 1.3 million members across New York State Ensure all residents have access to quality, affordable coverage Cover children and adults in all 62 counties, through Medicaid Managed Care and Child Health Plus Also offer Medicare Advantage, Managed Long Term Care, NY State of Health metal-level plans, and the Essential Plan (January 2016) 2

3 What Makes Fidelis Care Unique? One Mission To provide New York State residents with quality, affordable health insurance coverage through State-sponsored programs, Child Health Plus, Medicaid Managed Care, Managed Long Term Care, NY State of Health metal-level products, as well as a variety of Medicare options for seniors Quality is our top priority Home visits to reach the uninsured Statewide strength; local commitment Cultural diversity; multilingual staff Statewide provider network 3

4 Product Portfolio Medicaid Managed Care Child Health Plus Managed Long Term Care Medicaid Advantage Plus Fidelis Medicare Advantage Products Fidelis Medicare Advantage without Rx Fidelis Medicare Advantage Flex Fidelis Medicare Advantage $0 premium Fidelis Dual Advantage Products (Special Needs Program) Fidelis Dual Advantage (HMO-SNP) Fidelis Dual Advantage Flex NY State of Health Marketplace Essential Plans (1,2,3,4), metal-level plans (Platinum, Gold, Silver, Bronze, and Catastrophic Coverage) 4

5 Family Planning Policy In accordance with the Ethical and Religious Directives for Catholic Healthcare Services, as adopted by the National Conference of Catholic Bishops, Fidelis Care s family planning policy is as follows: Fidelis Care does not cover certain family planning and reproductive health services, such as abortion, sterilization, and prescription birth control. New York State has arranged for Child Health Plus members to receive these non-covered services and to obtain information regarding these services by calling: Child Health Plus members Emblem: ; press Option 1 NY State of Health Marketplace Unified IPA, LLC

6 Family Planning Policy Medicaid Members: New York State requires Fidelis Care to inform members that they can use their Medicaid or New York State Benefit Identification Card to get these services from any doctor, clinic, or drugstore that accepts Medicaid. Members do not need a referral. If members have questions or need information about these non-covered services, they can call the New York State Growing Up Healthy Hotline at for information on where to get these services. Also, the New York State Department of Health mails members a letter with information and a listing of State-approved Medicaid providers. The web address is: /prenatal/guh/htm Medicare Medicare members can obtain these service through fee-for-service Medicare. 6

7 Provider Relations Provider Relations roles and responsibilities: Provider Services Coordination: Assure that all provider orientations, site visits, and access and availability studies are completed within designated time frames Provider Quality Programs: Educate providers on the Fidelis Care provider incentive programs. Facilitate retrieval of Fidelis Care member health care records to ensure achievement of optimum QARR scores Troubleshooting: Clarify the provider's problem; determine the cause of the problem; select and explain the best solution for the problem and expedite correction or adjustment; follow up to ensure resolution 7

8 Provider Tools fideliscare.org Provider Manuals Quality Care Management Incentive Program Bulletin Special Announcements and Publications Provider Access Online Member Eligibility Claim Status Remittance Advice Member Roster Medical Record Request Provider Tip Sheets 8

9 Verifying Eligibility Fidelis Care s Provider Access Online Provider Access Online provides resources such as membership eligibility verification and primary care physician assignment Identify Restricted Recipients Identify your Account Administrator to sign up to become an authorized user through fideliscare.org IVR (Integrated Voice Response System) To verify eligibility, providers can also use Integrated Voice Response (IVR) by calling FIDELIS ( ) 9

10 PCP Changes Rosters: Monthly rosters are a picture of what a provider s panel looks like the day the report is generated. Provider offices are urged to verify eligibility to determine a member s status. Providers can access a copy of their monthly roster by using the Fidelis Care Provider Access Online website: PCP Fax Change Form: Use this form when the member arrives at your office and needs to have his/her PCP changed. Please fill out the form, make sure to include the member s ID number, current PCP and provider number, desired PCP and Tax ID number, member s signature, and date Fax the form to: Member Portal: Members have the ability to change their PCP via the Member Portal 10

11 Admission/Inpatient Stays Prior authorization is required for all hospital admissions, excluding admissions through the Emergency Room In an emergency, the hospital must: Triage and stabilize the patient Call Fidelis Care s Quality Health Care Management Department on the next business day to notify of the admission: FIDELIS ( ) 11

12 Fidelis Care Billing/Claims You may check the status of claims on Fidelis Care s Provider Access Online website: Primary and Specialty Claims - Fidelis Care requires the electronic submission of CMS 1500 for all services rendered by primary and specialty care providers within 90 days of the date of service Request for Claims Administrative Review Claim appeals should be submitted within 60 business days of receiving the denial. Inquiries received after this time frame may be denied for failure to comply within the specific time period new forms are available on our website Mail to: Fidelis Care Claims Department (Reconsiderations) 480 CrossPoint Parkway Getzville, NY

13 Fidelis Care Billing/Claims Appeals for Medical Necessity Claim appeals should be submitted within 60 business days of receiving the denial It is recommended that the following information be submitted within the appeal: Summary of appeal Copy of original denial Member s medical record Mail to: Chief Medical Officer Fidelis Care Queens Blvd. Rego Park, NY

14 Fidelis Care EDI Electronic Claim Submission Submitting claims electronically means: Faster processing and reimbursement of clean claims Reduction and/or elimination of the number of claims not being received Proof of timely submission through electronic acceptance reports Completing the ecommerce Request Form found on fideliscare.org will enable you to: Submit 837 electronic claims directly to Fidelis Care Receive 835 electronic remittance advices from Fidelis Care Fidelis Care Payer ID:

15 Fidelis Care EDI Electronic Claim Submission If you do not have the ability to bill electronically, Fidelis Care has partnered with the following vendors to assist your office: Post-N-Track M.D. On-Line Relay Health SSI Gateway EDI Emdeon (aka WebMD, Envoy, and NEIC) 15

16 National Drug Codes Effective July 1, 2015, Fidelis Care will REJECT claims with drug codes that do not contain the required National Drug Code (NDC). This is a mandatory requirement that applies to all provider types and is in accordance with Section 6002 of the 2005 Federal Deficit Reduction Act (DRA) Claims must include the 11-digit NDC, in addition to the CPT/HCPCS code and units. The NDC dispensing quantity and the NDC unit of measurement are also mandatory. NDC information can be obtained from the drug invoice and/or package information The NDC requirement is applicable for all Fidelis Care lines of business 16

17 ICD-10 Transition The Provider section of fideliscare.org provides the latest updates and FAQ documents to assist our providers with the ICD-10 transition Fidelis Care is working closely with clearinghouses to monitor ICD-10 rejections The conversion to ICD-10 allows Fidelis Care to accept and process the new ICD-10 code set, but does not change medical policies that are currently in place The Fidelis Care Provider Manual and QCMI Brochure have been updated to reflect ICD-10 updates 17

18 Fidelis Care at Home Managed Long Term Care Members enrolled with the following products can receive MLTC services: Fidelis Care at Home (FCAH) Medicaid Advantage Plus (MAP) Eligibility requirements include: Must be 18 years of age Have Medicaid Receive or be eligible to receive Medicare (Medicare and Medicaid coverage required for MAP) The intent of the programs is to have members remain safely in their homes and communities 18

19 Marketing and Provider Partnership Opportunities Build relationships throughout the community Focus on grassroots partnerships Host on-site Health Insurance Open House events Provide public relations and promotional opportunities 19

20 Help for Uninsured Patients Fidelis Care Representatives are required to offer all Managed Care products to all potential candidates Make the enrollment process as easy as possible Meet applicants at work, home, school, provider office, or convenient locations in the community Available after hours and on weekends 20

21 Fax Referral Process Personalized fax referral form Uninsured patient completes; provider office faxes to number on form Referral assigned to a Representative who will attempt to contact individual by phone or mail If eligible, Representative will set up appointment at convenient location All referrals are tracked, enrollment rates are measured, and reported back to the provider 21

22 Important Phone Numbers Name Phone Number Provider Services (Option 2, then Option 4) Medical Authorizations (Option 2, then Option 2) Behavioral Health Authorizations DentaQuest Davis Vision Caremark Pharmacy (Option 2, then Option 3) 22

23 Thank You! Fidelis Care looks forward to working together as partners in providing the highest quality service and care to our members 23