QUEST Integration Provider FAQ

Transcription

1 QUEST Integration Provider FAQ 08/18/17 General Information Where can members get a copy of the QUEST Integration member handbook? QUEST Integration member handbook may be downloaded from Handbooks are available in English, Chinese, Ilocano, Korean, or Vietnamese. If the member doesn t have internet access, they may request a printed copy by calling QUEST Integration Provider Service at (Oahu) or 1 (800) (toll free) from the Neighbor Islands. How can I get a current QUEST Integration Provider Directory? HMSA provides an online resource for this. Providers can go to hmsa.com, and click on the Find a Doctor button near the upper right corner of the Home Page. If you don t have internet access, you may request a printed copy by calling QUEST Integration Provider Service at (Oahu) or 1 (800) (toll free) from the Neighbor Islands. A patient that being discharged from a hospital requires transport to home hospice or to a hospice facility. What arrangements must be made prior to discharge? If family or friends are not able to transport the patient, providers should call QUEST Provider Service at , toll-free Advance planning is needed to locate and schedule with the service provider. What are CCMAs required to do when we find out a QI patient needs to be admitted to a hospital? CCMAs need to fill out an adverse event form for hospitalizations or ER visits. At discharge, the CCMA will work with the hospital to discharge the patient back to the CCFFH if it is still an option. Member Eligibility If a member wants to cancel their QUEST Integration coverage, who do they contact? Med-QUEST is responsible for processing terminations. The member should contact their Med-QUEST worker. Should a patient s eligibility be checked at every visit? Yes, you should be checking for eligibility at each service date. A referral, authorization, or purchase order is not a guarantee of payment. The patient must be eligible at the time of service in order for payment to be made. For confirmation, you can also check eligibility on HHIN 24 hours a day, 7 days a week. You can also call QUEST Integration Provider Service at or toll-free Page 1

2 weekdays from 7:45 a.m. to 4:30 p.m. As an added measure, most medical practices verify the identity of the person using a picture ID to ensure services are provided to an eligible person. How do we know if patient is eligible for LTSS (Long Term Services and Supports)? Log on securely to HHIN to get current membership information. Members with LTSS benefits will display ABD and LTSS under the heading Plan Coverage Code. Their membership card will also contain the designation ABD and LTSS. You may also call QUEST Integration Provider Service at: Phone: Oahu 1 (800) toll-free Neighbor Islands Coordination of Benefits Other Plan QUEST Coordination Integration Secondary? Medicare Y QUEST Integration pays the Medicare coinsurance and any Medicare deductible Akamai Advantage Y QUEST Integration pays the Akamai Advantage coinsurance and any Akamai Advantage deductible Other insurance Y Benefits are coordinated up to the eligible QUEST Integration fee, less any payment from the other insurance carrier HMSA Commercial Y If the commercial plan s payment is LESS than the QUEST Integration eligible charge, the QUEST Integration plan will coordinate benefit payments. Do you need to send in the primary EOB when billing QUEST Integration for co-insurance? Primary Plan EOB Necessary? Comments Other Insurance pays No Include amount paid by primary carrier on the secondary claim HMSA Commercial denies No Other insurance denies Yes Do Medicare claims crossover electronically to HMSA QUEST Integration? No, a separate secondary claim needs to be filed to HMSA QUEST Integration. We are participating with Akamai Advantage, but non-participating with QUEST Integration. Can we bill the patient for the Akamai Advantage coinsurance? No, the patient may not be billed. You may file a claim to QUEST Integration and the plan will pay Akamai Advantage coinsurance/deductibles. Page 2

3 A member s QUEST Integration plan and another health plan both report as primary. When we've asked the patient to call QUEST Integration to report their other insurance for COB, they refuse. What do we do? Inform the member that QUEST Integration requires that they notify HMSA and DHS of other insurance coverage. The member may call QUEST Integration Provider Service at , and we will inform DHS. Neighbor Island members may call 1 (800) Providers may also call the same numbers and provide the other plan s information. Billing/Payment A PCP refers the patient to a specialist. The specialist (Specialist #1) needs to refer the patient to a second specialist (Specialist #2). Which provider s name should be entered Specialist #2 s claim as the referring physician? Specialist #1 should inform the PCP that the patient needs the services of Specialist #2, and document the reasons for the referral. The Specialist #2 would place the PCP s name in the Referring Physician section of the claim. Can we bill patients missed appointments? No. Can a Home Health Agency provider charge the patient if we schedule a visit but the patient is not home? No. Please confirm the QUEST Integration deadline for filing claims. The QUEST Integration filing deadline is 365 days from the date of service. Longer names are often truncated on the member ID card. Should we put the patient s entire name on our claim? No, please use the name listed on the membership card. How do we request a timely filing waiver if extenuating circumstances prevented us from filing a claim within a year? To request a waiver, submit a written request within 120 days of the deadline, with a copy of the late claim(s) or adjustment(s). Cases involving delayed processing of claims by the patient's primary insurance, or involving unresolved eligibility issues will be considered, but are not guaranteed a waiver of the filing deadline. The request must provide the reason for the late filing, including a detailed history of the events that led to late filing and a record of the activities that trace your efforts to resolve the claim. Documentation may include dates that the primary insurance was billed, copies of any written communication between your office, the patient, other insurance or Med-QUEST. Send requests to the QUEST Integration Provider Service supervisor at: Supervisor Page 3

4 HMSA - QUEST Integration Operations P.O. Box 3520 Honolulu, HI Where do I mail my QUEST Integration claims to? Claims may be mailed to HMSA QUEST Integration, P.O. Box 3520, Honolulu, HI We d like to start billing claims electronically to HMSA. Who do I contact? Please call (808) Can a Home Health Agency provider charge separately for medical supplies? Yes. An SNF provider asks, Does HMSA require a completed/approved DHS 1147 with the claim for hospital waitlisted SNF/ICF days or is having it completed and approved online is sufficient through HILOC? The 1147 does not need to be submitted with the claim. As long as the 1147 has been approved and is indicated in the state s HILOC system for the level of care and service dates billed, the claim will process. If we arrange for interpreter services for the patient, can our office bill QUEST Integration for those services and be paid separately for it? No. Payment for interpreter services is only made to providers who are contracted for that service. If interpreter services are required for a patient, please call QUEST Integration at (Oahu) or (toll-free NI) to place the request. Please arrange for services prior to the visit, allowing time for services to be coordinated. What do we do when a patient presents HMSA QUEST insurance information after the filing deadline? Are we able to bill the patient? No, patients may not be billed if they were covered by QUEST Integration at the time of the service. Is there anything that can be billed by Adult Day Care other than attendance? For example showers, incontinence assistance, transportation to and from the Center? Billable codes for adult day care are: S5105 Day care services, center-based, per day S Day care services, extended (day and evening), center-based, per day S Day care services, evening only, center-based, per day T Personal care, respite bath, per bath T2003 Non-emergency transportation, per trip What CPT codes are used by Community Care Management agencies and Community Care Foster Family Homes? Community Care Management agency services Page 4

5 T2022-Case management, comprehensive, per day. Community care foster family homes may use the following codes: S5140-Foster care, Level 1 adult, daily S5140-TF-Foster care, Level 1, adult, SSI recipients, daily S5140-TG-Foster care, Level 2, adult, daily S Foster care, Level 2, adult, SSI recipients, daily Is there a specific form that needs to be completed if a QUEST Integration patient elects to receive a service that is not a benefit or does not meet guidelines for coverage? Yes. The provider must have the patient sign a QUEST Integration Agreement of Financial Responsibility, and keep the document on file. The form is available at Where can I find the QUEST Integration fee schedule? HMSA makes fee schedules available through a secure website, the Hawaii Health Information Network (HHIN). To request initial access, please call Once you are granted access, go to Enter your HHIN Username and Password. On the left side of the screen, click on Fee Schedules. Click on the hyperlink for the fee schedule you wish to view. Please explain how to submit claims for take home meds or ancillary drugs dispensed to a patient that is ICF Wait Lisited. Drugs for a waitlisited confinement are considered part of ancillary services that can be billed separately on a UB-04 claim. When there is a delay in No Fault payments, are we able to submit for conditional payment? If so, then what is the timeline? If the member s condition is covered by a no-fault plan but the plan has delayed payment due to its investigation, submit documentation from the no-fault carrier with the QUEST Integration claim. If the no-fault carrier eventually pays the claim, submit an adjustment claim to QUEST Integration indicating the amount of the no-fault payment. The 365-day claim filing deadline for QUEST Integration still applies. If a claim or adjustment must be submitted after the filing deadline, the provider must request a waiver of the filing deadline to prevent a claim denial. A QUEST Integration member currently in an acute status is being referred to a SNF for possible 4 weeks IV antibiotics. Do we need an 1147 in addition to an authorization? Yes. Benefits Where can I find information on member benefits? Page 5

6 QUEST Integration benefits are contained in the Member Handbook, available at What's the difference between NON-ABD and ABD plans? ABD and non-abd are not plans, but rather eligibility categories that define the member s enrollment under QUEST Integration. The non-abd group consists of members that previously were enrolled in regular QUEST, i.e. children and families. The ABD group consists of members who were previously enrolled in QUEST Expanded Access (QExA) i.e. the aged, blind and disabled. Under QUEST Integration both groups are combined into the QUEST Integration plan. Members with cards that indicate Non- ABD and ABD have the same benefits. Members with cards that indicate ABD and LTSS qualify for Long Term Services and Supports benefits in addition to what Non-ABD and ABD members receive. Does QUEST Integration cover over the counter drugs if a prescription is written by a participating QUEST Integration provider? Yes, as long the drug is on the HMSA QUEST Integration formulary. The formulary is available at: How do I request non-emergent Interisland Air Transportation for a patient? Travel requests should be included when registering referrals for Off-island specialty care. The referral requests may be faxed to (Oahu) or (toll-free Neighbor Islands). Another option is to call QUEST Integration Provider Service at (Oahu) or (toll-free Neighbor Islands). More information is at Please clarify Hospice Benefit limitations pertaining to Room and Board. QUEST Integration pays for hospice room and board when hospice care is provided in a nursing facility. Hospice has no benefit limit as long as it is medically necessary. How do we request Ground Transportation services-e.g. when a patient has no way to get to their doctor s appointment? Patients should first seek transportation from available resources (e.g. relatives, friends, volunteer services, public transportation, etc.) If those are not available, providers may request ground transportation by contacting QUEST Integration Provider Services at Neighbor Island providers may call 1 (800) toll-free. Please note that certain services e.g. Community Care Foster Family Homes, Adult Residential Care Home, Expanded ARCH, or domiciliary homes include transportation, so patients in those settings should not be referred. For more details, see Does QUEST Integration cover incontinence supplies and does it require precertification? Incontinence supplies require preauthorization for coverage. The prescribing provider should request preauthorization. Does QUEST Integration cover oral nutrition supplements? Is precertification necessary? Page 6

7 QUEST Integration does not cover oral nutrition supplements, except for those members who have a diagnosis of an Inborn Error of Metabolism as outlined in HMSA s Medical Policy Medical Foods for Inborn Errors of Metabolism. Precertification is required. For criteria and guidelines please reference: pdf If Medicare is primary and HMSA QUEST Integration is secondary, are they eligible for HMSA Supportive Care benefits? Yes. Are bath items such as shower chairs or grab bars a benefit for QUEST Integration members? QUEST Integration members designated as ABD and LTSS on their member cards have Environmental accessibility adaptation benefits. This requires a patient assessment on DHS Form 1147 and authorization of services by the Service Coordinator. Typically, the patient s physician writes a prescription and provides the medical justification for the item/service. The DME supplier then submits the request to the Service Coordinator. More details are available at Referrals A specialist charges no show fees for patients who miss appointments. The PCP has a difficult time getting the specialist to accept a referral when that patient has previously missed an appointment. What can we do? Contact QUEST Integration Provider Service at or toll-free so that we may intervene to resolve this. We are a non-par dermatology practice with HMSA QUEST but will agree to see patients on a case by case basis. Other than referral by the PCP, is anything else necessary? The referral needs to be registered with and approved by HMSA before the PCP makes the referral to the non-par provider. If the service to be provided by the non-par provider requires precertification, the specialist must submit the request and receive approval before services are rendered. Precertification Is there a list of procedure codes that require prior authorization? While there is no master list of procedure codes, services requiring precertification are available at Most of what is listed links to medical policies applicable to the service. Within the medical policy there are often references to procedure codes applicable to the policy. For more detail on services managed by NIA, see Page 7

8 The patient s primary plan does not require precertification for a specific service. However, QUEST Integration requires it. Is it necessary to request precertification from QUEST Integration? HMSA commercial and QUEST Integration plans have the same precertification requirements. For this reason, precertification requests approved by HMSA commercial do not require separate precertification from QUEST Integration. However, if the patient s primary insurance is with other plans, precertification must be requested under QUEST Integration. Do Behavioral Health services require Precertification? Precertification is necessary for non-par Behavioral Health services, out-of-state Behavioral Health services, and methadone treatment. Beacon Health Strategies is responsible for authorizing these services. They may be reached by calling Do we need to submit a separate preauth/admission notification for each change in level of care when the patient is in the hospital? Example: patient was acute, becomes waitlisted SNF, and later returns to acute status? Notification of each acute admission is required, including re-admission from a lower level of care. The lower level of care requires an approved Form However, if the SNF-wait listed patient stay will be less than 7 days or if the patient is downgraded from Acute to SNF level of care as a result of HMSA Medical Management s UM activity, no 1147 needed. Is there a separate Precertification form for Post-acute Services? Yes. This form is available at The form may be faxed to or mailed to HMSA, Medical Management Department, P.O. Box 2001, Honolulu, HI Please clarify the Participating ENT s role in the precertification process for a hearing aid. Monaural hearing aids do not require precertification. The PCP would refer the patient to a participating hearing aid provider. However, binaural aids require precertification, which may be requested by the ENT or the patient s PCP. ENT results and audiological test results must be submitted with the precertification request. In either case, the PCP refers the patient to the participating hearing aid provider following approval. Are we able to precertify Post Acute (e.g. SNF) admissions on weekends and holidays? Precertification for Post-Acute confinement is available Mondays - Saturdays from 8 to 4:30 p.m., except holidays. Do Long Term Services and Supplies (LTSS) benefits need to be precertified? Yes. Once the Service Coordinator renders a functional assessment, they develop a service plan for the patient that may include LTSS services. At that point, either the ordering or rendering provider or Service Coordinator must request precertification and receive approval prior to services being rendered. Page 8

9 Where can I find information on how to request precertification for Outpatient Physical Therapy? evicore is HMSA s partner for outpatient physical and occupational therapy. More information is available in our Provider Resource Center: 15.pdf. What information needs to submitted on a precertification request for new admission to HCBS/Foster Homes? For new admissions or transfer of care from another health plan, please provide: Name of CCFFH: phone number and address Name of managing CCMA: Phone number and address Does HMSA QUEST Integration require preauthorization for hospital admission and hospital visits by specialists? No. When is precertification required for Rehabilitation Therapy services rendered to a QUEST Integration patient? Physical Therapy Precertification is dependent on a specific provider s status in the variable intensity review program. There are two tiers: providers who do not require precertification and those who must request precertification after the initial assessment. Requests are managed by evicore (formerly Landmark Healthcare). Occupational Therapy required after eight visits for a condition/incident. Providers should check if patients received treatment from other providers for this condition. Requests are managed by evicore (formerly Landmark Healthcare). Speech Therapy Evaluation services do not require precertification. However, all therapy services require precertification. Requests are sent to HMSA Medical Management. We received evicore precertification for physical therapy on one body part for 10 visits. After using 8 of these visits, the patient was discharged for that body part and now needs to therapy on a new body part within the same time frame of the original authorization. The new request for treatment has been denied because it falls within the initial authorization period. How should this be handled? Requests for additional visits within an already approved time period are allowed. We recommend that you submit your request via Landmark Connect using the e-form tool. The e-form will recognize that an authorization is already on file and ask for clarification as to why another request is being submitted. If you are not using the e-form tool or you are treating an Akamai Advantage patient, you should call evicore and ask that the new diagnosis be added to the existing authorization so you can use the Page 9

10 remaining 2 visits. Once the authorization period has expired, you may submit another request for more visits if needed. Cost Share Where can we get a patient s Cost Share Amount? It is available on the State s DHS Eligibility site. If a cost share client was hospitalized 8/1/16 and returns to the Community Care Foster Family Home on 8/15/16, does the hospital claim the entire cost share amount when they bill? If so, does the CCFFH put "$0.00" in their claim form? Cost share isn t applied to acute confinements. In this scenario, the CCFFH needs to collect the full cost share for the month. A patient with a cost share is confined in our SNF, but expires prior to the end of the month. If we are unable to collect the full cost share from the patient, can HMSA bill the patient s family for the balance? The member s full cost share is collected by the responsible provider at the beginning of each month. That amount is used for whatever services the member uses that month. HMSA does not direct bill members in care facilities. Service Coordination A patient is being discharged from the SNF. How does the SNF contact the patient s Service Coordinator to arrange for home care services? The SNF usually knows who a patient s HMSA Service Coordinator is prior to discharge. If this is not the case, call QUEST Integration Provider Service at: (Oahu) 1 (800) (toll free) How does provider refer a patient for Service Coordination? Providers may refer patients for Service Coordination by faxing the form at: (Oahu fax) 1 (855) (Neighbor Islands toll-free fax) Providers may also call HMSA: Oahu 1 (844) (Neighbor Islands toll-free) Page 10