Welcome Providers. Thursday, November 11, Page 1
|
|
- Opal Franklin
- 5 years ago
- Views:
Transcription
1 Welcome Providers Thursday, November 11, 2010 Page 1
2 What is a 3 Share Plan? The 3 Share Plan is an affordable health plan for small businesses. Cost is shared among employers, their employees, and one or more sources of local, state, or federal funding. Mission is to encourage employers to provide healthy work sites and employees to embrace healthier everyday choices at an affordable low premium cost. Regional Programs:
3 TexHealth El Paso County TexHealth El Paso will provide a quality affordable healthcare coverage benefit plan to the working uninsured of El Paso County. Collaborative efforts will help to: improve the healthcare of those covered assist small businesses in remaining competitive with the healthy workforce assist to bridge the gap of those who are uninsured. Healthcare benefits include: Free Annual Physical Free Health Risk Assessment Doctor Visits and Specialty Care Emergency Room, Inpatient, Outpatient Hospital Pharmacy, Lab, X-ray Maternity Care Wellness and Care Coordination
4
5
6 Low Premiums With Premium assistance grants qualified employees may pay as little as $12.00 per month for comprehensive health coverage plan. Business Employer Qualifications Many small business employers will have employees eligible for assistance. Businesses or organizations with 2 to 50 employees. In business for at least one year prior to enrollment, and have not offered group health insurance during the last 12 months. If your business is interested in having this benefit plan for your staff, please contact : Les C. Rankin Director TexHealth 3-Share Plan Office: Cell: lrankin@umcelpaso.org Fax:
7 ER Reports Purpose Help Primary Care Providers identify members from their panel that go to the ER to seek care Provide education on true emergencies and give options of care other than the ER like After Hours and Night Clinics. To provide them with a Medical Home. Content Member name, ID number, Age, DOB, Phone number, Address, ER DOS, ER Location, Diagnosis. Page 1
8 ER Reports Time frame Initial mail out effective December 1, 2010 will reflect 6 months worth of information. Attached to STAR Rosters after the initial mailing every month. Page 1
9 SAMPLE ER REPORT
10 Texas Health Steps Updates Michelle Anguiano Provider Relations THSteps Coordinator
11 Billing Medicaid Members Source: TMHP 2010 Provider Procedures Manual
12 Billing Medicaid Members Source: TMHP 2010 Provider Procedures Manual
13 Billing Medicaid Members Source: TMHP 2010 Provider Procedures Manual
14 THSteps Checkups Concerns THSteps checkups to new members (within 90 days of enrollment) State requirement For vaccinations not recorded on ImmTrack- Provider s decision Audit results and highlights Lack of documentation of Anticipatory Guidance Lack of documentation of Newborn Screenings Lack of use of THSteps Tools (Mental Health)
15
16 Changes in the Timeliness of THSteps Medical Checkups Effective for dates of service on or after September 1, 2010, the definition of the timeliness of Texas Health Steps (THSteps) medical checkups will change for clients who are 3 years of age or older. Children who are birth through 2 years of age will still be due for medical checkups more frequently and will not be affected by this change. Source: TMHP website
17 What does not change? While the change in the definition of timeliness only applies to children 3 years of age and older, a claim for a medical checkup can be submitted based on the total number of checkups that can be provided in each age range below. This allows a provider to perform one THSteps checkup per year for a child 3 years and older and submit a claim and still receive reimbursement, even for a checkup performed prior to the birth date/due date. Source: TMHP website
18 Exceptions to Periodicity Exceptions are based on medical need such as developmental delay, environmental risk, suspected abuse, or state and federal requirements for Head Start, day care, foster care or adoption, or for dental services under general anesthesia If they client will not be available at the time the next checkup is due such as the case of children of migrant farm workers If the provider is aware that the child is not due for a checkup based on age and the date of the last checkup or their Medicaid 3087 form does not state that the client is due the visit must be submitted as an exception to periodicity. (TMHP Provider Procedures Manual 43-9)
19 Exceptions to Periodicity When billing for an exception to periodicity visit, provider must also include the most appropriate exception to periodicity modifiers. Claims for periodic THSteps medical checkups exceeding periodicity that do not include one for these modifiers will be denied as exceeding periodicity. Source: THMP Provider Procedures Manual 2009 Section
20 Developmental Screening Tools (ASQ and PEDS) These screening tools will become mandatory in If purchased and used now providers will receive an additional reimbursement. Through August 31, 2011, providers may choose to use a standardized screening tool that is not listed in the Required Screening Ages and Tools table to complete the requirements of a medical checkup visit; however, providers may not submit a claim for a tool that is not listed in the following table. Links for these tools are available at
21 Source: TMHP/ THSteps Preventive Care Medical Checkups Benefit to Change
22 Provider Relations Department THSteps Tools Monthly Members Due List Sent with STAR Roster to ALL PCPs Existing New Members Missed Appointment Referral Sheet Reduce the number of missed appointments Assist provider office staff with the issues missed appointments may create. You can access more tools when logging to our website at
23 Online Provider Education The courses currently being offered are: Pediatric Referral Guidelines Genetic Screening Case Management Oral Health Developmental/Mental Screening Prevention & Wellness Adolescent Health Overview of Best Practices and Children s Services Sensory Screening Laboratory Services Acute & Chronic Mental Conditions Pharmacy For more information please go to
24 Oral Evaluation and Fluoride Varnish Trainings Who is eligible to provide this service? Texas Health Steps enrolled physicians, physician assistants, and advanced practice nurses. Certification These providers must attend the OEFV training offered by the Department of State Health Services Oral Health Program to become certified to bill for this service. The certification code is placed on the Texas Health Steps TPI under which the provider bills their Texas Health Steps medical checkups. What is included in this visit? Intermediate oral evaluation. Fluoride varnish application. Dental Anticipatory guidance. Referral to a dental home.* *This service must be performed in conjunction with a Texas Health Steps medical checkup. To register please go to:
25 Contact Information Michelle Anguiano Phone: (915) extension 1053.
26 El Paso First OB Benefits Edna Martinez, LMSW OB Case Manager
27 First Steps-OB Team OB Team Edna Martinez - OB CM Edna Martinez - OB CM Gloria McMillan - UR Tech Gloria McMillan - UR Tech Norma Hollars Prior Auth Coord. Norma Hollars Prior Auth Coord. El Paso First Health Plans promotes community health by providing access to quality healthcare for children, families and individuals who need it most. We partner and collaborate with community providers and advocate to foster a culture of excellence. El Paso First Health Plans promotes community health by providing access to quality healthcare for children, families and individuals who need it most. We partner and collaborate with community providers and advocate to foster a culture of excellence.
28 Benefits Doctor visits Hospital (Inpatient/ Outpatient) Ambulance Services Dental care (under 21 only) Family planning Transportation Emergency Services Ambulatory Health Care Services Lab Services Vision Well-Baby and Well Child Visits Immunizations Inpatient and Outpatient Mental Health Visits
29 El Paso First Extra Benefits $15 Welcome Packet Transportation (taxi rides) Asthma, Diabetes, and Prenatal Health Education Classes $20 Wal-Mart gift card Free Gift Quarterly Newsletter
30 El Paso First Extra Benefits Ultrasounds El Paso First Members can receive four ultrasounds without prior authorization.
31 El Paso First members are invited to our baby shower/ prenatal class
32 El Paso first members may receive a $20.00 wal-mart gift card
33
34 Member Services Department
35 El Paso First CHIP Plan (CHIP) $15 Welcome packet with OTC medications. Preventive Dental Services for pregnant members. Additional 25% discount toward the purchase of lenses and frames Additional 20% discount toward the purchase of disposable contact lenses. Free Transportation for medical appointments. Additional nutritional counseling services for members age 18 and under. Gift Programs (new)
36 El Paso First CHIP Perinatal Plan (CHIP Perinatal) $15 Welcome packet with OTC medications. Free Transportation for medical appointments. Gift Program (new)
37 El Paso First Premier Plan (Medicaid) $15 Welcome packet with OTC medications. Preventive Dental Services for pregnant members over 21 years of age. Eyeglasses valued up to $125 Free Transportation for medical appointments. Additional nutritional counseling services for members under 21 years of age. Additional Behavioral Health services. Gift Programs (new)
38 El Paso First Premier Plan Happy Birthday Gift Card Program THSteps VAS Initiative (Medicaid Only)
39 Children of Migrant Farm Workers Program El Paso First has special Medicaid services for children of migrant farm workers: We help schedule THSteps Medical Checkups appointments Assist with accelerated THSteps medical services for migrant members Vision Benefits Mental Health Services Transportation
40 Claims Department Sonia Lopez Claims Director
41 CLAIM DENIALS How To Preventing Claim Denial
42 EP First Top Denials Description Totals Duplicate Claim 15,060 Timely Filing 12,524 Member Not Enrolled 11,019 Member is SSI Enrollment 7,659 NPI is Invalid / Incomplete 4,084
43 CLAIMS DEPARTMENT Important Claim Elements for Paper and Electronic Claim Submission
44 Billing Provider NPI Provider LOOP 2010AA 1500 Item Number Paper Claim Field Description ANSI 837 Loop & Segment Electronic Claim Field Description 25 Federal Tax ID Type 2010AA NM108 Provider Tax ID Type 25 Federal Tax ID Number 2010AA NM109 Provider Tax ID Number
45 Billing Provider NPI Provider LOOP 2010AA 1500 Item Number Paper Claim Field Description ANSI 837 Loop & Segment Electronic Claim Field Description 33a Billing Provider Info & PH # 2010AA NM109 Billing Provider - NPI 33b 2010AA REF02 Billing Provider Tax ID or TPI # Submit Group NPI Only in Loop 2010AA Place Group NPI ONLY in Box 33a
46 Rendering Provider LOOP 2310B 1500 Item Numb er Paper Claim Field Description Ansi 837 Loop & Segment Electronic Claim Field Description 24I ID Qualifier 2310B NM108 ID Code Qualifier ID Qualifier (Other ) 2310 REF 01 ID Code Qualifier (Other ID No.) ID Qualifier NPI 2310B NM108 ID Code Qualifier (NPI) Submit Rendering s INDIVIDUAL NPI Only in Loop 2310B Place Rendering s INDIVIDUAL NPI ONLY in Box 24J 24J Rendering Provider ID # 2310B NM B REF02 Rendering Provider NPI Rendering Provider Secondary ID
47 Provider Care Unit (PCU)
48 Contact us at Provider Care Unit When calling you will reach a Claims specialist who will: Give claim status calls. Resolve or answer claim questions. Answer Electronic claims submission rejections or questions. Assist with claims disputes. Please note you have the right to appeal any disposition of a claim through a formal appeal. Written request must be mailed to: El Paso First Health Plans, Inc Attn: Complaints and Appeals Department POBOX , El Paso, Texas Within 120 days from the date of your Provider Remittance Advice.
49 Claims Status By Phone Local: (915) Toll Free: (866)
50 Verification of Authorization FY 2010 Remember to Bill with valid Diagnosis Codes BOX 21 ember to Point your Diagnosis code to the appropriate Service BOX 24E Claims Processing Benchmarks
51 Electronic Claim Growth YR 2006 YR 2007 YR 2008 YR 2009 YR ,000 60,000 50,000 40,000 30,000 20,000 10,000 0 JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC
52 Electronic Claim Volume Portal Users, 1.4% Manual Users, 18.4% Electronic Users Manual Users Portal Users Electronic Users, 80.1%
53 CONDITION INDICATOR CODES Auto Adjudication Ratio Auto Adju Ratio Manual Adju Ratio 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
54 Questions?
Pertussis, Strep Throat testing & Resources. Michelle Anguiano C.A.R.E. Unit Manager
Pertussis, Strep Throat testing & Resources Michelle Anguiano C.A.R.E. Unit Manager Pertussis, Strep Throat testing & Resources Michelle Anguiano C.A.R.E. Unit Manager Adult vaccination recommended Pregnant
More informationProvider Information Texas Health Steps Requirements
Provider Information Texas Health Steps Requirements 2016 THSteps Background Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Federally mandated health care program of prevention, diagnosis
More informationDell Children s Health Plan Texas Health Steps program provider presentation
Dell Children s Health Plan Texas Health Steps program provider presentation TSPEC-0231-17 May 2017 Overview The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service is Medicaid s comprehensive
More informationWinter 2017 Provider Newsletter
Winter 2017 Provider Newsletter TEXAS HEALTH STEPS (THSTEPS) ADDITIONAL MENTAL HEALTH SCREENING TOOL FOR THSTEPS CHECKUPS Effective for dates of service on or after February 1, 2017, the Pediatric Symptom
More informationAncillary Provider Specialty Training
Ancillary Provider Specialty Training September 28, 2017 801741EPH072717 Agenda Rebranding: El Paso Health Provider Relations: ORP Enrollment, Medicaid Re-Enrollment Compliance: Special Investigations
More informationBenefits. Benefits Covered by UnitedHealthcare Community Plan
Benefits Covered by UnitedHealthcare Community Plan As a member of UnitedHealthcare Community Plan, you are covered for the following MO HealthNet Managed Care services. (Remember to always show your current
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationWelcome Providers. Provider Quarterly Orientation. May 14, EPF042915
Welcome Providers Provider Quarterly Orientation May 14, 2015 Learning Objectives Provider miscellaneous forms and where to locate them Texas Health Steps reminders and updates Update on Pay for Quality
More informationWelcome Providers. Provider Quarterly Training January 21, EPF122215
Welcome Providers Provider Quarterly Training January 21, 2016 Agenda Provider Relations: Federal Mandate Re-enrollment, NDC Crosswalk C.A.R.E.: THSteps Updates & Reminders Quality Improvement: Updates
More informationCOVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE
COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE This is a list of all covered services and benefits for MassHealth Standard and CommonHealth members enrolled
More informationMedicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) Provider Transition Orientation December 1, 2015
Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) Provider Transition Orientation December 1, 2015 PWP-9002-15 A Division of Health Care Service Corporation, a Mutual
More informationSuperior HealthPlan STAR+PLUS
Superior HealthPlan STAR+PLUS Provider Training (non-nursing Facility Residents) SHP_2015883 Who is Superior HealthPlan? Superior HealthPlan is a subsidiary of Centene Corporation located in St. Louis,
More informationMember Handbook. STAR Kids (TTY 711) Medicaid Members.
Member Handbook STAR Kids Dallas, El Paso, Harris, Lubbock, and Medicaid Rural West Service Areas Medicaid Members December 2017 1-844-756-4600 (TTY 711) www.myamerigroup.com/tx TX-MHB-0105-17 Amerigroup
More information3. Expand providers prescription capability to include alternatives such as cooking and physical activity classes.
Maternal and Child Health Assessment 2015 In 2015, the Minnesota Department of Health conducted a Maternal and Child Health Needs Assessment for the state of Minnesota. Under the direction of a community
More informationArticles of Importance to Read: AmeriChoice Tennessee s Provider University. Spring 2010
Important information for physicians and other health care professionals and facilities serving AmeriChoice members Spring 2010 AmeriChoice Tennessee s Provider University AmeriChoice Tennessee s Provider
More informationDIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP
DIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP Magnolia Health MississippiCAN Overview 2011 30,000 Members December 2012 77,000 Members December 2014 98,000 Members January 2015 115,000 Members
More informationDate: Illinois Health Connect PCP 6/23/14 Page 1 of 8. Signature:
Illinois Department of Healthcare and Family Services Illinois Health Connect Primary Care Provider Agreement This Agreement pertains only to the relationship between the Illinois Department of Healthcare
More informationPeachCare for Kids. Handbook
PeachCare for Kids Handbook Table of Contents What is PeachCare for Kids?...2 Who is eligible?...3 How do you apply for PeachCare for Kids?...3 Who will be your child s primary doctor?...4 Your child s
More informationCOVERED SERVICES FOR NHP MASSHEALTH MEMBERS
COVERED SERVICES FOR NHP MASSHEALTH MEMBERS Neighborhood Health Plan Covered Services for MassHealth Standard & CommonHealth, Family Assistance, and CarePlus Issued and effective October 1, 2015 nhp.org/member
More informationProvider Orientation. Amerigroup
Provider Orientation Amerigroup Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance Company; all other Amerigroup members in Texas are served
More informationNew provider orientation. IAPEC December 2015
New provider orientation IAPEC-0109-15 December 2015 Welcome 2 Agenda Introduction to Amerigroup Provider resources Preservice processes Member benefits and services Claims and billing Provider responsibilities
More informationOVERVIEW OF YOUR BENEFITS
OVERVIEW OF YOUR BENEFITS IMPORTANT PHONE NUMBERS Member Services Department (646) 473-9200 For answers to questions about your benefits or to be referred to another Benefit Fund department. Program for
More informationToday s News Brought to You by
, LLC 9702 Bissonnet, Suite 2200W Houston, TX 77036 PRESORTED FIRST-CLASS MAIL U.S. POSTAGE PAID MINNEAPOLIS, MN PERMIT NO. 32126 in focus Evercare of Texas Winter 2008/2009 Volume 8, Issue 1 Please help
More informationWelcome to the first of a four part series on Early Childhood Intervention and Medicaid managed care. Throughout the four parts, you will learn about
Welcome to the first of a four part series on Early Childhood Intervention and Medicaid managed care. Throughout the four parts, you will learn about Texas Medicaid Managed Care, Texas Early Childhood
More informationA. Encounter Data Submission Requirements
A. Encounter Data Submission Requirements APPLIES TO: A. This policy applies to all IEHP Medi-Cal Providers. POLICY: A. As of October 1, 2015, IEHP has transitioned to ICD-10 diagnosis and procedure coding
More informationAnthem Blue Cross. CCHCA Physician Handbook (7 th Edition) Updated 3/15
Part II Section B Anthem Blue Cross Introduction 1 Verifying Member Eligibility and Benefits 1 Sample Anthem Blue Cross Member ID Card 2 Anthem Blue Cross Managed Medi-Cal Program 4 CCHCA Physician Handbook
More informationBadgerCare Plus 2018 MEMBER HANDBOOK
BadgerCare Plus 2018 MEMBER HANDBOOK 2 Important Quartz Phone Numbers 3 Welcome 3 Using Your ForwardHealth ID Card 3 Choosing A Primary Care Physician (PCP) 4 Emergency Care 4 Urgent Care 5 Care When You
More informationFQHC Wrap Payment Guidelines. NM Rev. 1 09/17
FQHC Wrap Payment Guidelines NM 10.001014 Rev. 1 09/17 Overview of Methodology Managed care organizations (MCO s) will concurrently pay contracted rate, wrap payment, and any fee for service (FFS) payments
More informationDentaQuest/Superior Health Plan Training 2018 STAR Health (Foster Care) STAR + PLUS STAR Value Added Services
DentaQuest/Superior Health Plan Training 2018 STAR Health (Foster Care) STAR + PLUS STAR Value Added Services Agenda STAR Health (Foster Care) STAR + PLUS STAR Pregnant Women Value Added Service (VAS)
More informationmember news In this issue: FirstCare STAR & CHIP November 2016 FirstCare Extra Benefits pg 4 Getting Answers to Your Questions pg 6
member news November 2016 FirstCare STAR & CHIP In this issue: Quality Improvement (QI) Program pg 2 Services Needing Approval pg 3 Case Management Services pg 3 Interpretation Services pg 3 FirstCare
More informationThe Healthy Michigan Plan Handbook
The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). The Healthy Michigan Plan provides health
More informationVersion 5010 Errata Provider Handout
Version 5010 Errata Provider Handout 5010 Bringing Clarity & Consistency To Your Electronic Transactions Benefits Transactions Impacted Changes Impacting Providers While we have highlighted the HIPAA Version
More informationIA Health Link and Amerigroup Iowa
IA Health Link and Amerigroup Iowa Navigating the Transition to Amerigroup Foster Care Caretaker Orientation 1 Who is Amerigroup Iowa? A partner with the Iowa Department of Human Services (DHS), which
More informationParkland Community Health Plan
Parkland Community Health Plan Medicaid and CHIP/CHIP Perinate Provider Manual October 2013 2777 Stemmons Freeway, Suite 1750 Dallas, TX 75207 1-888-672-2277 (Medicaid) 1-888-814-2352 (CHIP/ CHIP Perinate)
More information1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS
1199SEIU Greater New York Benefit Fund OVERVIEW OF YOUR BENEFITS I HOSPITAL CARE This benefit is for the hospital s charge for the use of its facility only. Coverage for services rendered by doctors, labs,
More informationAnthem HealthKeepers Plus Provider Orientation Guide
November 2013 Table of Contents Reference Tools... 2 Your Responsibilities... 2 Fraud, Waste and Abuse... 3 Ongoing Credentialing... 4 Cultural Competency... 4 Translation Services... 5 Access and Availability
More informationProvider Newsletter. Missouri 2017 Issue III. Annual Wellness Visit and Additional. In This Issue. Annual Physical
Provider Newsletter Missouri 2017 Issue III Annual Wellness Visit and Additional Annual Physical Good news! WellCare has improved the way it pays Annual Wellness Exams and Additional Annual Physicals.
More informationImportant Billing Guidelines
Important Billing Guidelines The guidelines contained herein are meant to assist GHP Family Participating Providers in billing appropriately for medically necessary services rendered to GHP Family Members.
More informationSECTION 4: CLIENT ELIGIBILITY TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1
SECTION 4: CLIENT ELIGIBILITY TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 FEBRUARY 2018 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 FEBRUARY 2018 SECTION 4: CLIENT ELIGIBILITY Table of Contents
More informationWYOMING MEDICAID PROVIDER MANUAL. Medical Services HCFA-1500
WYOMING MEDICAID PROVIDER MANUAL Medical Services HCFA-1500 Medical Services March 01,1999 Table of Contents AUTHORITY... 1-1 Chapter One... 1-1 General Information... 1-1 How the Billing Manual is organized...
More informationBanner Message for the 01/30/06 ER&S and the 02/03/06 R&S Reports
Banner Message for the 01/30/06 ER&S and the 02/03/06 R&S Reports This file contains abbreviated messages meant to provide timely notifications that affect all provider groups (physicians, dentists, and
More informationThank you for choosing Ambetter from Sunshine Health Plan!
FROM Thank you for choosing Ambetter from Sunshine Health Plan! There s nothing more important than your health. And now, it s time for you to take charge of it. As a member of Ambetter from Sunshine Health
More informationYour Choice. 3-Tier Network Option Plan
Your Choice 3-Tier Network Option Plan What is Your Choice? Click Here to Watch Video Your Top Questions What is Your Choice? Are my doctors in the plan? Are my medications covered by the plan? If I get
More informationCalifornia Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016
California Children s Services (CCS) Program Medi-Cal Managed Care CCS Whole-Child Model Comparison Chart January 6, 2016 Authorization for Services Plan to adjudicate authorization request. Authorization
More information17.1 PRODUCT INFORMATION. Fidelis Care s Metal-Level Products
PRODUCT INFORMATION Fidelis s Metal-Level Products Following the implementation of the Patient Protection and Affordable Act, Fidelis offers Metal-Level Products covering Essential Health Benefits as defined
More informationProviderReport. Managing complex care. Supporting member health.
ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be
More informationMMA Benefits at a Glance
MMA Benefits at a Glance You must get covered services by providers that are part of the Molina plan. You must also make sure that approval is obtained if needed. Ambulance Art Therapy Assistive Care Services
More informationPROFESSIONAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, speech & occupational therapy Flu and pneumonia vaccinations Diagnostic services including
More informationMedicaid Electronic Health Record (EHR) Incentive Program:
Medicaid Electronic Health Record (EHR) Incentive Program: A Webinar for Eligible Hospitals Presenters Yvonne Sanchez, HHSC Craig Earls, CGI February 10, 2011 Overview of EHR Incentive Program Rules and
More informationEarly and Periodic Screening, Diagnosis, and Treatment Program EPSDT Florida - Sunshine Health Annual Training
Early and Periodic Screening, Diagnosis, and Treatment Program EPSDT Florida - Sunshine Health Annual Training EPSDT Overview EPSDT purpose and requirements mandated by the Agency for Health Care Administration
More informationQuick Reference Card
Amerigroup District of Columbia, Inc. Quick Reference Card Precertification/notification requirements Important contact numbers n Revenue codes https://providers.amerigroup.com/dc DCPEC-0176-17 Important
More informationOFFICIAL NOTICE DMS-2003-A-2 DMS-2003-II-6 DMS-2003-SS-2 DMS-2003-R-12 DMS-2003-O-7 DMS-2003-L-8 DMS-2003-KK-9 DMS-2003-OO-7
Arkansas Department of Human Services Division of Medical Services Donaghey Plaza South PO Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us Telephone: (501) 682-8292
More informationEl Paso - Ambulatory Clinic Policy and Procedure
Regulation Reference: El Paso - Ambulatory Clinic Policy and Procedure Title: ADMISSION & ESCORT OF PATIENTS TO UNIVERSITY MEDICAL CENTER- EL PASO AND/OR AREA HOSPITAL Policy Number: EP 3.6 Joint Commission
More informationSection 2. Member Services
Section 2 Member Services i. Introduction 2 ii. Programs and Enrollment Information 7 iii. Identifying HPSM Members 8 iv. Member Eligibility 10 v. Identification Cards and Co-Payments 12 vi. PCP Selection
More informationMedi-Cal Program. Benefit. Benefits Chart
Chart Please note that the table below is only a summary. More details about benefits can be found in the section of the Medi-Cal Evidence of Coverage booklet. All health care is arranged through your
More informationAbsolute Total Care. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program Description 2016
Absolute Total Care Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program Description 2016 TABLE OF CONTENTS INTRODUCTION: --------------------------------------------------------------
More informationHealthcare Eligibility Benefit Inquiry and Response. 270/ Companion Guide
Healthcare Eligibility Benefit Inquiry and Response 270/271 5010 Companion Guide Table of Contents Purpose...1 Contact Information...1 Preparation and Testing Requirements...1 System Availability...2 Batch
More informationKY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationWASHINGTON APPLE HEALTH MEDICAID PROVIDER MANUAL
WASHINGTON APPLE HEALTH MEDICAID PROVIDER MANUAL Last Revision: February 20, 2016 1-877-644-4613 TDD/TTY 1-866-862-9380 CoordinatedCareHealth.com Table of Contents Contents INTRODUCTION... 6 Welcome...
More informationFlorida Medicaid. Evaluation and Management Services Coverage Policy
Florida Medicaid Evaluation and Management Services Coverage Policy Agency for Health Care Administration June 2016 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1
More informationHOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will REFER you to a specialist
More informationKY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationWV Bureau for Medical Services & Molina Medicaid Solutions
WV Bureau for Medical Services & Molina Medicaid Solutions On January 1, 2014, Medicaid eligibility was expanded to qualified individuals ages 19 to 64 making 138% of the Federal Poverty Level. 112,464
More informationUTILIZATION MANAGEMENT AND CARE COORDINATION Section 8
Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five
More informationSchedule of Benefits-EPO
Schedule of Benefits-EPO [Plan Information] [Health Plan:] [Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan] [Primary Member:] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]
More informationYour Benefits A QUICK LOOK AT SOME BENEFITS & PROGRAMS AVAILABLE TO YOU. pshp.com. TDD/TTY (Hearing Impaired):
Your Benefits A QUICK LOOK AT SOME BENEFITS & PROGRAMS AVAILABLE TO YOU 1-800-704-1484 TDD/TTY (Hearing Impaired): 1-800-255-0056 pshp.com We are committed to providing our members with information on
More informationMember Handbook STAR+PLUS Members with Medicare and Medicaid Coverage.
Member Handbook STAR+PLUS Bexar, El Paso, Harris, Jefferson, Lubbock, Medicaid Rural West, Tarrant, and Travis Service Areas Members with Medicare and Medicaid Coverage TX-MHB-0090-15 06.16 1-800-600-4441
More informationSTAR, STAR+PLUS and CHIP
STAR, STAR+PLUS and CHIP Provider Training July 2017 SHP_20163727 Introductions & Agenda Provider Roles and Responsibilities STAR and STAR MRSA Texas Health Steps Program STAR+PLUS CHIP CHIP Perinate OB
More informationMedicaid 101: The Basics for Homeless Advocates
Medicaid 101: The Basics for Homeless Advocates July 29, 2014 The Source for Housing Solutions Peggy Bailey CSH Senior Policy Advisor Getting Started Things to Remember: Medicaid Agency 1. Medicaid is
More informationWelcome to the Cenpatico 2017 Provider Newsletter
Improving Lives 2017 ISSUE You want to help your patients. We re here to help you. This newsletter will provide you with information regarding our clinical and operational resources, and programs, all
More informationCovered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
More informationWelcome to Regence! Meet your employer health plan
is an Independent Licensee of the Blue Cross and Blue Shield Association Regence BlueCross BlueShield of Utah Welcome to Regence! Meet your employer health plan 1 Health insurance is a big, wonderful benefit.
More informationLetter from the CEO. At Columbia Basin Health Association, the faces of success are as varied as the faces of our patients.
2010 Annual Report Letter from the CEO At Columbia Basin Health Association, the faces of success are as varied as the faces of our patients. Success is The diabetic patient who, with the help of their
More informationMartin s Point US Family Health Plan Pre-Authorization Requirements
Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete
More informationFederal Employee Program Service Benefit Plan An independent licensee of the Blue Cross and Blue Shield Association
Federal Employee Program Service Benefit Plan 2009 An independent licensee of the Blue Cross and Blue Shield Association Federal Employee Program Two PPO Products Basic Option with (in-network benefits
More informationCHIP Member Handbook. For Harris and Jefferson Service Delivery Areas. Call toll-free TexasChildrensHealthPlan.org
CHIP Member Handbook For Harris and Jefferson Service Delivery Areas March 2018 MS-0318-149 Call toll-free 1-866-959-6555 TexasChildrensHealthPlan.org Quick Guide Who To Call If you need: Texas Children
More informationCovered (blood, blood components, human blood products, and their administration) Covered (Some restrictions)
Washington Apple Health Medical Benefits Allergy Services (Antigen/Allergy Serum/Allergy Shots) Ambulance Services (Air Transportation) by FFS* Ambulance Services (Emergency Transportation) Ambulatory
More informationKnox-Keene Regulatory Requirements
Knox-Keene Regulatory Requirements The Knox-Keene Act (the Act ) is voluminous and highly detailed. A complete outline of its requirements would fill a book. Nevertheless, there are certain requirements
More informationMedicaid Fundamentals. John O Brien Senior Advisor SAMHSA
Medicaid Fundamentals John O Brien Senior Advisor SAMHSA Medicaid Fundamentals Provides medical benefits to groups of low-income people with no medical insurance or inadequate medical insurance. Federally
More informationQuick Reference Guide
March 2017 Quick Reference Guide Superior HealthPlan Contacts Claims Inquiries/Status... 1-877-391-5921 Provider Services/Claims STAR... 1-877-391-5921 STAR+PLUS... 1-877-391-5921 STAR Kids... 1-877-391-5921
More informationFirst Look: Plan Benefit Filings
July 30, 2014 First Look: Plan Filings Maryland and Washington, D.C. 1 Disclaimers MedStar does not currently have a contract with CMS for the State of MD nor any special needs plans in Washington, D.C.
More informationMarch 2018 SHP_
March 2018 SHP_20174198 Quick Reference Guide Superior HealthPlan Contacts Claims Inquiries/Status... 1-877-391-5921 Provider Services/Claims STAR... 1-877-391-5921 STAR+PLUS... 1-877-391-5921 STAR Kids...
More informationMDwise Product Comparison
Quick Contact Guide MDwise Product Comparison Basic Information Members Served Customer Service Business Structure Claims/Reimbursement Authorization Required Other Program Responsibilities State Website
More informationPatient-Centered Specialty Practice (PCSP) Recognition Program
Patient-Centered Specialty Practice (PCSP) Recognition Program Standards Workshop Part 2 2013 All materials 2013, National Committee for Quality Assurance Agenda Part 1 Content of PCSP Standards and Guidelines
More informationPartnering with Managed Care Entities A Path to Coordination and Collaboration
Partnering with Managed Care Entities A Path to Coordination and Collaboration Presented by: Caroline Carney Doebbeling, MD, MSc Chief Medical Officer, MDwise May 9, 2013 Agenda Are new care models on
More informationBehavioral Health. Community Outreach Program
Behavioral Health How do I get into Residential Treatment? You must complete a Behavioral Health intake if not already established with Behavioral Health. Our Licensed Counselors will then evaluate for
More informationSection IX Special Needs & Case Management
Section IX Special Needs & Case Management Special Needs and Case Management 181 Integrated Health Care Management (IHCM) The Integrated Health Care Management (IHCM) program is a population-based health
More informationSTAR MEMBER HANDBOOK
December 2017 STAR MEMBER HANDBOOK Your STAR Benefits 1-888-596-0268 (TTY 711) DellChildrensHealthPlan.com/members TS-MHB-0008-17 WELCOME! Thank you for choosing Dell Children s Health Plan as your STAR
More informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2011 December 31, 2011 Los Angeles County This publication is a supplement to the 2011 Positive (HMO SNP) Evidence
More informationMedical Plans Benefit Guide
Medical Plans Benefit Guide Employers with 1-50 employees 1.1.01 Provider network built for value and quality... Wellness rewards...3 Medical Travel Support and Air or Surface Transportation... Support
More informationSuper Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Deductible
BENEFIT HIGHLIGHTS 1 Super Blue Plus 2000 WVHTC High Option-B (Non-Grandfathered) $200 Group Effective Date December 1, 2017 Benefit Period (used for and Coinsurance limits) January 1 through December
More informationHealth in Handbook. a guide to Medicare rights & health in Pennsylvania #6009-8/07
Health in Handbook a guide to Medicare rights & health in Pennsylvania #6009-8/07 Tips for Staying Healthy works hard to make sure that the health care you receive is the best care possible. There are
More informationBadgerCare Plus Member Handbook
BadgerCare Plus Member Handbook BadgerCare Plus Member Handbook Table of Contents A Ambulance...7 Making an Appointment With Your PCP...2 Missed Appointments...3 B If You Are Billed....6 When You May Be
More informationPrimary Care Provider Orientation. Over 1.4 million people have chosen Molina Healthcare
Primary Care Provider Orientation Over 1.4 million people have chosen Molina Healthcare 2012 Molina Healthcare Mission Statement Our mission is to provide quality health services to financially vulnerable
More informationCovered Services List
CAREPLUS Covered Services List For CeltiCare Health with MassHealth CarePlus Coverage This is a list of all covered services and benefits for MassHealth CarePlus enrolled in CeltiCare Health. The list
More informationSTATE OF CONNECTICUT
I. PURPOSE STATE OF CONNECTICUT MEMORANDUM OF UNDERSTANDING BETWEEN THE DEPARTMENT OF PUBLIC HEALTH AND THE DEPARTMENT OF SOCIAL SERVICES REGARDING DATA EXCHANGES Pursuant to section 19a-45a of the Connecticut
More informationAppendix A. Local Public Health Agency Services and Functions. Comparing North Carolina s Local Public Health Agencies 1
Appendix A Local Public Health Agency Services and Functions Comparing North Carolina s Local Public Health Agencies 1 There are several sources of law that influence the services provided by North Carolina
More informationMember Handbook. Effective Date: January 1, Revised October 30, 2017
Member Handbook Effective Date: January 1, 2018 Revised October 30, 2017 2017 NH Healthy Families. All rights reserved. NH Healthy Families is underwritten by Granite State Health Plan, Inc. MED-NH-17-004
More informationImportant RMHP Pharmacy Change for 2016
Fall 2015 Provider Edition Important RMHP Pharmacy Change for 2016 In an effort to control increasing medication costs, RMHP will begin using MedImpact s High Performance pharmacy network beginning January
More information