Guiding You Through Administrative Processes Provider Forum

Transcription

1 Guiding You Through Administrative Processes 2006 Provider Forum

2 Welcome!

3 Service Center Overview Northeast Service Center established in 1992 Locally managing the Behavioral Health benefit for Capital District Physicians Health Plan (CDPHP). 295,000 covered CDPHP members 3

4 Service Center Overview (continued) Empire Plan Service Center established in 1992 Managing the Mental Health and Substance benefit for New York State Employees, retirees and participating agencies. ValueOptions (administrator) and GHI (insurer) Over 1 million covered members 4

5 Service Center Overview (continued) New York City Service Center established in 1994 Managing the Behavioral Health benefits for: o GHI-BMP, GHI Medicare Choice PPO and Family Health Plus PPO o NY Medicaid (Community Premiere Plus, VidaCare, Suffolk Health Plan and Liberty) o Great-West HealthCare (30,000 covered lives in NYS) o Over 3.5 million covered lives 5

6 Provider Relations and Network Operations Your partner at ValueOptions

7 Provider Education and Outreach Plan specific requirements Recruitment Contractual responsibilities Policies and procedures 7

8 Provider Handbook Printer friendly guide for our individual providers, affiliates, groups, and facilities that includes the following: Clinical Criteria and Treatment Guidelines EAP Forms Administration Section Participating Provider Responsibilities, credentialing and sanctions, claims, referrals, QM and UM New for 2006! Handbook highlight document a snap shot of key elements of the handbook 8

9 Provider Newsletter Published three times a year, The Valued Provider includes: Company news and updates Quality improvement information Service Center specific news Clinical articles Regulatory changes including HIPAA News and articles from your peers 9

10 Provider Relations Local Provider Relations Offices, Help Lines and addresses: Northeast : Troy, NY NortheastRegion@valueoptions.com Empire Plan : Troy, NY EmpireRegion@valueoptions.com New York City : New York, NY NewYorkRegion@valueoptions.com 10

11 National Network Operations To update your practice profile, please call or visit us on-line at Credentialing/re-credentialing issues Application status updates 11

12 Provider On-line Services ProviderConnect Web based self-service, available 24/7 designed to make routine tasks easier for our participating providers. Verify member eligibility Member benefit Claims Search Authorization Search View and print correspondence Send inquiries to Customer Service Access and update your practice profile Electronic Claims submission (all ValueOptions accounts excluding Empire, GHI/BMP) 12

13 Provider On-line Services (continued) Registering is as easy as 1, 2, 3 1. Access ProviderConnect by going to 2. Click on Register 3. Enter your Provider ID # and password Do you know your Provider ID #? Your unique Provider ID # can be obtained by calling our National Provider Line at Remember to register with your GHI PIN # if you are an Empire provider in order to view Empire claims. 13

14 Customer Service and Claims Committed to your service needs

15 Customer Service ValueOptions offers several service options you choose the preferred way to obtain information. All three options communicate together! 15

16 Customer Service Options 1. Customer Service Professionals Specialize in complex and routine cases 2. Websites Automated Call Systems TeleConnect quotes benefits, eligibility, claim status and faxes commonly used forms 16

17 Customer Service 17

18 Customer Service 18

19 19 Customer Service ghi.com

20 Claims Our Focus Tips on avoiding administrative claim denials no one likes them! HIPAA Scanning by means of Optical Character Recognition (OCR) technology allows for a more automated process of capturing information Electronic claims the key to quicker payment 20

21 Claims Administrative Claim Denials 12% 27% No Authorization Other Carrier EOB 19% Duplicate 20% 22% Submit to Medical Carrier Missing Information 21

22 Claims Optical Character Recognition Reduce turnaround time and improve quality Use original red claim forms Use machine print and black ink Print claim data within the defined boxes on the claim form. Use all capital letters Use a laser printer for best results Use white correction tape for corrections Use an 8-digit date format (e.g., ) and fixed width font (Courier for example) 22

23 Electronic Claims Filing Are you sending in paper claims? Is your cash flow not flowing the way you would like? Are you buried in paper work or back billing that needs to be done? 23

24 Electronic Claims Submission Advantages: It s better, faster, and cheaper! Reduced Paper Files Reduced Labor and Postage Expenses Reduced potential of error or mishandling Faster claims processing improves cash flow 24

25 Electronic Claims Filing Empire In 2005, 16% of claims were submitted electronically Approximately 40% of electronic claims auto adjudicate 25

26 Electronic Claims Filing For Empire and BMP HIPAA compliant files Clearinghouse or Medical Practice System GHI 7-digit provider number Electronic Payer ID Please do not submit Empire or GHI/BMP claims on ProviderConnect EMC For CDPHP/other ValueOptions Clients HIPAA compliant files Our Software, Clearinghouse, or Medical Practice System Electronic Payer ID FHC &Affiliates 26

27 ValueOptions EDI (Electronic Data Interchange) ValueOptions offers FREE EDI software EDI software can be downloaded on Runs on Windows 98 or above ValueOptions offers Single Claim Submission, directly on our website, for smaller volume Providers ValueOptions offers a dedicated Helpdesk (8am to 6pm EST) for EDI issues 27

28 EDI Requirements Complete Account Request Form from Submitter Intermediary Authorization Form (if using a billing agent or clearinghouse) Forms located on (Forms section) Fax Forms to (866) , attention E-Support Helpdesk Upon validation, User ID and Password provided received within 1 to 3 business days Files must be HIPAA compliant If using EDI claims link (version 3.0) software, this is HIPAA compliant Must submit test file to verify accurate information is included in the file 28

29 When Help Is Needed for EDI Questions? E-Support Helpdesk: (option 3) Monday Friday (8 a.m. 6 p.m. EST) Fax:

30 Clinical Operations Helping meet members care needs...

31 Clinical Operations (continued) Inpatient Treatment Report (ITR) Guide for completing telephonic reviews Current risk to self/others 0 (none) > 3 (severe) rating scale Current Impairments similar rating scale Mood Disturbance Anxiety Psychosis Thinking/Cognition/Memory Impulsive/Reckless/Aggressive 31

32 Clinical Operations (continued) Activities of Daily Living Weight Loss Associated with Eating Disorder Medical/Physical Conditions Substance Abuse/Dependence Job/School Performance Social/Marital/Family Problems Legal ASAM Dimensions Admission, continued stay and discharge review information needed 32

33 Clinical Operations (continued) Outpatient Review Process Outpatient Registration Form (ORF1) Used for requesting routine outpatient mental health treatment Same risk and impairment rating scale as ITR Outpatient Review Form (ORF2) Used for more complex outpatient cases Complete only if requested 33

34 Clinical Operations (continued) Medication Management Registration form Used for requesting medication management services only (90862 or 90805) Medication management with psychotherapy is requested via ORF Note: Remember to fully complete member and provider demographics sections! 34

35 35 Clinical Operations (continued)

36 Clinical Operations (continued) Member Pass Through Visits CDPHP 4 visits per provider/per year Empire Plan 10 visits per provider/per lifetime GHI-BMP 10 visits per provider/per year There is no change in the mailing/fax process for Northeast, NYC and Empire Plan Service Center treatment requests! 36

37 Clinical Operations (continued) Outpatient Chemical Dependency Review Process (Empire Service Center) Automated phone attendant for outpatient chemical dependency (OPCD) programs at Register clinic level of care less than 9 hours per week (x8990) Register an evaluation only visit (x8991) Request an extension of an end date for a current authorization (x8992) Confirm a discharge (x8993) Register for the Family Treatment Benefit (x8994) 37

38 Clinical Operations (continued) Information Needed Name and Street Address of the Clinic Policyholder s Name and ID Number Patient s Name and Date of Birth Evaluation Date Patient s Axis I diagnosis Number of visits remaining and new requested end date The type of discharge Name of the actively using family member If you are seeking authorization for over 9 hours of service per week, contact the Clinical Care Manager assigned to your agency during regular business hours. 38

39 Quality Management Committed to working with you toward continuous improvement

40 Clinical Quality Initiatives Increasing Family Involvement in Adolescent Outpatient Treatment Focuses on adolescents who have recently been hospitalized Goal: to involve family in outpatient treatment within first 90 days after discharge Outreach to parents by mail, telephone Outreach to providers 40

41 Clinical Quality Initiatives (continued) Substance Abuse: Engagement in Treatment Focuses on Alcohol and other Dependence Treatment Goal: 1 st visit within 14 days after initial diagnosis and at least 2 visits within 30 days thereafter Outreach to members by mail, telephone Outreach to providers 41

42 Clinical Quality Initiatives (continued) Assisting Members with Ambulatory Follow-Up After Acute Inpatient Care (HEDIS) Important to patient s long-term outcome Care Management Team helps coordinate aftercare appointments within 7 days of discharge NYC and CDPHP focused Ambulatory follow-up program for members who were admitted to inpatient psychiatric facilities Monitored for all NE health plans, Empire, and GHI- BMP 42

43 Coordination of Care Coordination of care between Behavioral Health and Primary Care Physicians (PCPs) Identify your patients who would benefit Educate member/obtain consents Acknowledge HIPAA allows for coordination of care Initiate contact with PCP 43

44 Coordination of Care (continued) Resources ValueOptions Offers to Promote Coordination of Care Sample Coordination of Care forms for your practice Member Education Flyer 44

45 45 Questions and Answers

46 Thank you!