UniCare Health Plan of West Virginia, Inc. A true partnership with our provider community

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1 A true partnership with our provider community Medicaid Managed Care

2 Welcome! We would like to thank everyone for taking time out of their busy schedule to be here today! Thank you for the dedicated care and time you provide our UniCare members each day. 2

3 UniCare facts Plan history o Operational November 2003 o Four counties, 700 members Marketplace o Statewide o Enrollment 143,000+ o One of four managed care organizations (MCOs) o Largest Medicaid MCO No Commercial product 3

4 UniCare facts (cont.) Products o Mountain Health Trust o Vendor relationships for dental (adult emergency/children), pharmacy and vision o Behavioral health o West Virginia Health Bridge (Affordable Care Act expansion) o Social Security Income effective January 1,

5 Provider education Resources available

6 Provider Orientation Webinars UniCare offers a monthly provider orientation webinar the third Tuesday of each month from 12:00 p.m.--1:00 p.m. Topic covered o Who we are o Health Care Management Services o Case Management o Community Outreach o Resources Available o Many more topics.. 6

7 Provider Online Reporting Tool UniCare s new web base reporting tool to retrieve your monthly member rosters Upcoming Educational Webinar o April 19, :00 p.m.--1:00 p.m. Topic covered o How to register o Basic Navigation o Resource Available Requirement: Active Availity account 7

8 Prenatal Risk Screening Instrument (PRSI) Effective January 1, 2017, UniCare is discontinuing our pregnancy notification form and adopting the West Virginia Prenatal Risk Screening Instrument(PRSI) The PRSI is intended to promote early and accurate identification of prenatal risk factors. Submit PRSI to UniCare within seven days of the first prenatal visit. o the completed form to prsi.unicare@anthem.com. Please type SECURE PRSI in the subject line. o Fax the completed form to

9 Precertification Lookup Tool (PLUTO) A tool to assist with determining a code s precertification requirements Finding PLUTO: o Go to o On the top menu bar, under OTHER UNICARE WEBSITES, select Providers. o Under Resources for:, select State Sponsored Plans on the right side of the page. o Select West Virginia Medicaid Managed Care. o On the resulting Provider Resources page, find the Authorization and Preservice Review section. o Select Precertification Look UP Tool (PLUTO). 9

10 PLUTO (cont.) Once in PLUTO: o Select West Virginia in the Market drop-down o Select Medicaid/SCHIP/Family Care in the Line of Business drop-down. o Enter your data into the CPT/HCPCS Code or Code Description field. o Choose Submit once done. 10

11 Prior Authorization Effective April 1, 2017, UniCare will no longer accept and review claims with medical records attached in place of required prior authorization(pa). If a claim for service requiring a prior authorization is received without the appropriate PA, the claim will be denied for lack of PA. Once you have received a PA, remember to include the PA on the claim you submit o CMS-1500: PA number in field 23 o CMS-1450: PA number in field 63 11

12 Utilization Management Peer-to-Peer When to request a Peer-to-Peer? o A request is denied as not medically necessary and you wish to discuss with our peer clinical reviewer (PCR) o Call the Peer-to-Peer Line at , option 3 This process allows attending, treating and ordering physicians to discuss their case with the PCR who made the initial adverse determination as well as offer additional information for reconsideration Peer-to-Peer review must be requested within 24 hours of the denial notification Peer-to-Peer review is not an appeal 12

13 Utilization Management Appeals Appeals are accepted for up to 90 days after a denial is issued. A physician clinical review specialist of same or similar specialty who was not involved in any previous level of review or decision making reviews the provider appeal. The physician specialist may not be the subordinate of any person involved in the initial determination. The physician specialist reviews the case and contacts the provider as necessary to discuss appropriate alternatives, render a decision and document a decision. 13

14 PCP changes Members have the ability to change their PCP at any time. Members can check eligibility before each visit. PCP selection form can be found here: o Go to o On the top menu bar, under OTHER UNICARE WEBSITES, select Providers. o Under Resources for:, select State Sponsored Plans on the right side of the page. o Select West Virginia Medicaid Managed Care. o On the resulting Provider Resources page, find the Forms and Tools section. o Select Forms Library from the list. 14

15 Appointment availability requirements Type of appointment Emergency examinations Urgent (sick) examinations Nonurgent (sick) examinations Nonurgent routine examinations Specialty referrals Standard Immediate access during office hours Within 48 hours of request Within 72 hours of request Within 21 days of request Within three weeks for routine referrals; within 48 hours for urgent referrals 15

16 Appointment availability requirements (cont.) Type of appointment First trimester (use the Pregnancy Notification Report found on the provider site) Second trimester (use the Pregnancy Assessment Form Second Trimester Reassessment found on the provider site) Third trimester (use the Pregnancy Assessment Form Third Trimester Reassessment found on the provider site) High-risk pregnancy Postpartum exam (use the Postpartum Checkup found on the provider site) Standard Within 14 calendar days of request Within seven calendar days of request Within three business days of request Within three business days of identification or immediately if an emergency exists Three to eight weeks after delivery of appointment standard 16

17 After-hours care Members will have access to quality, comprehensive health care services 24/7. Members can receive help with emergency calls. System is in place to ensure that members can reach the PCP or an on-call provider. Members can also call the 24/7 Nurse Line ( ) Suggested text for answering machines: o Hello, you have reached [physician/office name]. If this is an emergency, hang up and dial 911 or go to the nearest hospital emergency room. If this is not an emergency and you have a medical concern or question, please call [insert contact phone or pager number]. You will receive a return call from the on-call physician within [time frame]. 17

18 Provider changes UniCare requires all providers, including hospitals, to send any administrative change requests to us so that we have correct information in our system. This includes changes in your practice or facility name, address, fax and information, tax identification number (TIN), and other similar changes. All providers with the exception of hospital-based providers must be credentialed. Submit the information via: o Fax: o ssbdatamanagementservices@anthem.com 18

19 Provider changes (cont.) The Provider Profile Update Form can be found here: o Go to o On the top menu bar, under OTHER UNICARE WEBSITES, select Providers. o Under Resources for:, select State Sponsored Plans on the right side of the page. o Select West Virginia Medicaid Managed Care. o On the resulting Provider Resources page, find the Forms and Tools section. o Select Provider Profile Update Form. 19

20 Availity Web Portal Expansion of our provider website services through Availity o Availity Web Portal ( a multi-payer website that gives physicians, hospitals and other health care professionals access to multiple payer information with a secure, single log-in o Availity s Web Portal offers a variety of online functions to help providers reduce administrative costs by eliminating paperwork and phone calls o Target date for Access Point retirement:

21 Availity Web Portal (cont.) Multiple payers, one website, one log-in o Claim status inquiry and claims submission o Eligibility and benefits check o Remittance advices retrieval o Monthly member rosters access o 24/7 availability from any computer with internet access o Real-time information exchange means highest accuracy of information o Free services for providers 21

22 Availity Web Portal (cont.) Simple to use o The portal has a consistent look and feel. o Expert client service representatives and free training are available to you. o To register for the Availity Web Portal, go to o If you have questions or need additional registration assistance, contact Availity Client Services at AVAILITY ( ). 22

23 Important Contact Information Resources available

24 Customer Care Center services Dedicated to UniCare s Medicaid Managed Care Program o Assistance for providers o Eligibility verifications o Claims inquiries o PCP assignment and changes o Benefit information o Interpreter services o Provider website navigation Call or TTY:

25 Utilization review resources Authorizations o Phone: o Fax: (Medical prior authorization) o Fax: (Medical concurrent review) o Fax: (Behavioral health inpatient) o Fax: (Behavioral health outpatient) Pharmacy prior authorizations (PA) o Phone: o Fax: Grievance/appeal fax o Fax: Review turnaround times PA general 7 days PA urgent 3 days Current inpatient admission 24 hours Expedited appeals 3 days Routine appeals 30 days 25

26 Utilization review resources (cont.) Continued stay review o Phone: o Fax: Customer Service o Phone: Peer-to-Peer Line o Phone: , option 3 26

27 Submitting claims Submit via EDI: o EDI Payer ID #80314 o Technical Support: Phone: E-Solutions.Support@unicare.com Live chat: Submit paper claims to: o P.O. Box 91 Charleston, WV

28 UniCare territory map As of September 12, 2016 Carrie Blankenship Chris Bates Beth Roach Cell: Office: MASON JACKSON WOOD WIRT ROANE PLEASANTS RITCHIE CALHOUN TYLER MARSHALL WETZEL DODDRIDGE GILMER BRAXTON HANCOCK BROOKE OHIO LEWIS HARRISON MONONGALIA MARION UPSHUR TAYLOR BARBOUR PRESTON RANDOLPH TUCKER GRANT PENDLETON Terri Roush Network Relations Manager MINERAL HARDY HAMPSHIRE MORGAN BERKELEY JEFFERSON PUTNAM CABELL KANAWHA WAYNE LINCOLN BOONE LOGAN MINGO WYOMING WEBSTER CLAY NICHOLAS FAYETTE GREENBRIER RALEIGH SUMMERS MONROE POCAHONTAS Angie Richards Jill Miller Mary Straface Beth Daniel MCDOWELL MERCER

29 Questions? 29

30 Thank you for teaming up with UniCare Health Plan of West Virginia, Inc. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. UWVPEC January