Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, provider orientation presentation

Transcription

1 Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, provider orientation presentation

2 Anthem HealthKeepers MMP HealthKeepers, Inc. participates in the Virginia Commonwealth Coordinated Care dual demonstration program. The program integrates care and reimbursement for dual-eligible individuals who are enrolled in both Medicare and Medicaid. The integration of the program is governed by a three-way agreement with the Centers for Medicare & Medicaid Services (CMS), the Virginia Department of Medical Assistance Services (DMAS), and HealthKeepers, Inc. 2

3 Anthem HealthKeepers MMP (cont.) HealthKeepers, Inc. serves dual-eligible individuals residing in five supported regions (Central Virginia, Northern Virginia, Tidewater, Western/Charlottesville and Roanoke) for full access to both their Medicare and Medicaid benefits. 3

4 Covered benefits Inpatient care Outpatient care Outpatient medical services and supplies Prescription benefits Preventive services, wellness and education 4

5 Your support system As a provider in the Anthem HealthKeepers MMP network, you re supported by many different departments as you provide care for our members, including: Our Provider Relations team. Our Medical Management program. Specialized teams to help you with your claim questions. Provider Services offers assistance with questions including claim issues, member enrollment and general inquiries. MMP Customer Care is available at , Monday through Friday, 8 a.m. to 8 p.m. Eastern time. 5

6 Provider communications Our provider website, is available to all providers 24/7. The tools located on the site will allow you to: Perform many common authorization and claims transactions. Check member eligibility. Update information regarding your practice. Manage your account. Access reimbursement policies. There are even more tools available on the site! 6

7 Provider communications (cont.) As a participating provider, you can also: Submit precertification requests and claims. Access provider forms. 7

8 Your responsibilities As a participating provider, you have certain responsibilities in getting members the care they need, including: Providing services to your patients without discrimination. Notifying us when you reach a full panel and are no longer accepting any new patients. Stressing the importance of an advance directive for your patients. Working with us to meet professionally accepted state and national standards of care. 8

9 Your responsibilities (cont.) Refer to the Anthem HealthKeepers MMP Provider Manual for a complete list of responsibilities. Please note: Balance billing a Virginia Commonwealth Coordinated Care member is prohibited per the Participating Provider Agreement and, for Long-Term Services and Supports (LTSS) providers only, per the Anthem HealthKeepers MMP Provider Manual Appendix A rate sheet. 9

10 Credentialing HealthKeepers, Inc. credentials health care practitioners, behavioral health practitioners and health delivery organizations (HDOs). Practitioners and HDOs are notified they have the right to review information submitted to support their credentialing applications. In the event that credentialing information cannot be verified, or if there is a discrepancy in the credentialing information obtained, the Credentialing staff will contact the practitioner or HDO within 30 calendar days of the identification of the issue. 10

11 Program integrity fraud, waste and abuse How you can help: Always confirm a recipient s identity. Ensure the services you render are necessary, completely documented in the medical records and billed appropriately. If you suspect or witness fraud, waste or abuse, tell us immediately: o Call the Fraud and Abuse Hotline at , Monday through Friday, 8 a.m. to 6 p.m. Eastern time. o Contact your Provider Services representative. 11

12 Program integrity fraud, waste and abuse (cont.) Read more about reporting fraud, waste and abuse in your provider contract or provider manual. 12

13 Cultural competency HealthKeepers, Inc. fosters a strong cultural competency within our company and provider networks. By practicing cultural competency, you: Acknowledge the importance of culture and language. Embrace cultural strengths with people and communities. Assess cross-cultural relations. Understand cultural and linguistic differences. Strive to expand cultural knowledge. 13

14 Cultural competency (cont.) Cultural barriers between you and your patients can: Impact your patient s level of comfort; this may increase fear of what you might find upon examination. Result in a different understanding of our health care system. Cause a fear of rejection of your patient s personal health beliefs. Impact your patient s expectation of you and of the treatment plan. 14

15 Cultural competency (cont.) Visit our Cultural Competency Training program for additional information found on our website at: 15

16 Translation services Telephonic interpreter services are available for Anthem HealthKeepers MMP members by calling Member Services at These services are available at no charge, 24/7. 16

17 Access and availability standards It s our responsibility to make sure our members have access to primary care services for: Routine care services. Urgent and emergency services. Specialty care services for chronic and complex care. We make sure our providers respond to members needs in a timely manner by conducting telephonic surveys to confirm providers are meeting these standards. 17

18 Appointment standards You must arrange to provide care as expeditiously as the member s health condition requires and according to each of the following appointment standards: Appointments for emergency services are to be made available immediately upon the member s request. Appointments for an urgent medical condition are to be made within 24 hours of the member s request. Appointments for routine, primary care services are to made within 30 calendar days of the member s request. 18

19 Appointment standards (cont.) This standard does not apply to appointments for routine physical examinations, regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every 30 days, or routine specialty services (for example, dermatology, allergy care, etc.). 19

20 Member eligibility Virginians eligible for the Virginia Commonwealth Coordinated Care program include full-benefit, dual-eligible adults who are: Entitled to benefits under Medicare Part A and enrolled in Medicare Part B and Part D. Eligible for full Medicaid benefits. Elderly or Disabled with Consumer Direction (EDCD) Waiver and HIV/AIDS Waiver participants. Residing in nursing facilities. Residing in assisted living facilities in some cases. Living in the demonstration service area. 20

21 Member panels Anthem HealthKeepers MMP member ID cards 21

22 Precertification and notification Precertification is required for: All inpatient elective admissions. Nonemergency facility-to-facility transfer. Select nonemergent outpatient and ancillary services. Nonparticipating providers, except for emergent services. All home health care services (for example, skilled nursing visits, speech therapy, physical therapy, occupational therapy, social workers and home health aides). 22

23 Precertification and notification (cont.) Precertification is not required for: Office visits for participating providers. (Some specialists are limited based on provider group.) Most in-office specialty services. Evaluation and management-level testing and procedures. Emergency room visits or observation. Physical therapy evaluations provided at outpatient facilities. 23

24 Precertification and notification (cont.) To confirm precertification, use our Precertification Lookup Tool to: Determine if a service needs a precertification. Find additional information regarding precertification for durable medical equipment, vision, transportation and other ancillary services. Search by your market, the program in which the member participates and the CPT code. Search by description if you don t know the exact CPT code. 24

25 Precertification requests You can submit precertification requests by fax: for initial inpatient admissions and outpatient services (except as listed below) for behavioral health outpatient services for behavioral health inpatient services for therapies, home health, durable medical equipment and discharge planning for concurrent review clinical documentation for inpatient 25

26 Precertification requests (cont.) You can submit precertification requests by phone: for Anthem HealthKeepers MMP Customer Care 26

27 Our service providers Lab services Notification or precertification is not required if lab work is performed by an Anthem HealthKeepers MMP preferred lab vendor (for example, LabCorp and their approved subsidiaries). If you have questions about LabCorp and its subsidiaries services or need to set up a LabCorp account, obtain supplies or discuss LabCorp testing options, call LabCorp at

28 Our service providers (cont.) Other service partners In addition to lab services, we partner with other service vendors to offer additional support to our members, including the following dental, vision and transportation services: DentaQuest: Davis Vision: Southeastern Trans:

29 Submitting claims We encourage you to submit your claims on our website or using electronic data interchange (EDI), but we also accept paper claims. We give you several options to submit claims electronically: Submit both CMS-1500 and UB-04 claims online. Submit 837 batch files and receive reports through the website at no charge. You must register for this service. 29

30 Submitting claims (cont.) Submit claims electronically by using a clearinghouse via EDI. Using our electronic tool helps reduce claims and payment processing expenses and offers: o Faster processing than paper. o Enhanced claims tracking. o Real-time submissions directly to our payment system. o HIPAA-compliant submissions. o Reduced claim rejections. o Reduced adjudication turnaround time. 30

31 Submitting claims (cont.) Paper claims Submit a properly completed claim for all services performed or items/devices provided to: Claims Anthem HealthKeepers MMP P.O. Box Richmond, VA

32 Routine claim inquiries For routine claim inquiries, your call will be handled by a specially trained call agent in our Provider Services Unit as part of our Provider Experience Program. This program was set up to ensure provider claim inquiries are handled efficiently and in a timely manner while maximizing resolution at the point of call. Agents have the ability to both answer your claims-related questions as well as adjust a small set of routine claim types. 32

33 Grievance and appeals Grievances A grievance is your expressed dissatisfaction about any matter except a payment dispute or a proposed adverse medical action. A grievance can be submitted by any physician, hospital, facility or other health care professional licensed to provide health care services. 33

34 Care Management and Interdisciplinary Care Team (ICT) Each Anthem HealthKeepers MMP member has a care manager and an Interdisciplinary Care Team (ICT) that provides person-centered coordination and care management for members. The ICT team consists of the following: Member and/or his or her designee Designated care manager Primary care physician Behavioral health professional Member s home care aide or LTSS provider 34

35 Care Management and ICT (cont.) The ICT team can also include other providers either as requested by the member or his or her designee or as recommended by the care manager or primary care physician and approved by the member and/or his/her designee. Complaints, Appeals and Grievances Department Anthem HealthKeepers MMP Mailstop: OH0205-A Irwin Simpson Road Mason, OH

36 Clinical Quality Management Clinical Quality Management works to ensure we are providing access to quality health care and services. They continually analyze provider performance and member outcomes for improvement opportunities. Our solutions are focused on improving the quality of clinical care, increasing clinical performance, offering effective member and provider education, and ensuring the highest member and provider satisfaction possible. 36

37 Member rights and responsibilities Providers are required to adhere to CMS, DMAS and HealthKeepers, Inc. requirements concerning issuing letters and notices. Anthem HealthKeepers MMP members have the right to timely, quality care and treatment with dignity and respect. Providers must respect the rights of all Anthem HealthKeepers MMP members. Refer to your Anthem HealthKeepers MMP Provider Manual for a complete list of responsibilities. 37

38 Thank you We appreciate your time today and the care you provide our Anthem HealthKeepers MMP members. HealthKeepers, Inc. is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVADPEC March VAPENABC 38