Provider Workshop September 19, 2011

Provider Workshop September 19, 2011 Date: September 19, 2011

Highmark West Virginia NIA Privileging Program Date: September 19, 2011

NIA s Privileging Program Comprehensive Program for Evaluating Imaging Providers Selected to Participate in the Highmark West Virginia Outpatient Imaging Program. Primary Purpose of the NIA Privileging Program: To ensure Highmark West Virginia imaging providers meet minimum standards required to adequately perform the technical and professional components outlined in the Highmark Privileging guidelines. Effective January 1, 2012 NIA A Magellan Health Company 4 NIA A Magellan Health Company 4

NIA s Privileging Program Difference between Credentialing and Privileging: Credentialing places emphasis on primary source verification: (Note: Highmark WV completes the credentialing process) Physician s education Licensure Certification Privileging focuses on the imaging facility: (Note: NIA manages the privileging program for Highmark) Facility accreditation Equipment capabilities Physician and technologist Education, Training, Certification Facility Management Components NIA A Magellan Health Company 5

NIA s Privileging Process To access Highmark WV Privileging Requirements and Diagnostic Imaging Procedure (DIP) levels: Via Highmark WV sponsored NaviNet system, or Providers tab on the Highmark WV Web site www.highmarkbcbswv.com Click on Resource Center Click on Highmark Radiology Management Program To access the online Privileging Application: Direct your Web browser to www.radmd.com. Click on the link for Highmark WV Privileging Application (located under Online Tools) Enter your login and click Login NIA A Magellan Health Company 6

NIA s Privileging Process A separate privileging application is required for each practice location performing diagnostic imaging services Any questions regarding the Privileging Application or process contact: NIA s Provider Assessment Department 888-972-9642 RADPrivilege@Magellanhealth.com NIA A Magellan Health Company 7

Thank You

REDUCING ADMINISTRATIVE BURDEN, IMPROVING QUALITY THE CAQH APPROACH September 19, 2011

AN INTRODUCTION TO CAQH CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. CAQH SOLUTIONS: Help promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration Facilitate administrative healthcare information exchange Encourage administrative and clinical data integration m 10

THE SOLUTION: UNIVERSAL CREDENTIALING DATASOURCE SINGLE APPLICATION. CENTRAL LOCATION. PROVIDER OWNERSHIP. Replace multiple plan-specific paper processes with a single, uniform data collection system Key features include: Completely free for providers Providers can complete application online or via fax Supporting documents are imaged and attached to electronic record Participating organizations can access data in electronic format at any time if authorized by provider Data refreshed periodically to avoid recredentialing cycle problems Updates can be made at any time and are immediately available to authorized organizations Toll-free help desk to assist providers 888-599-1771 11

REQUESTING A CAQH ID ELECTRONICALLY Go to www.highmarkbcbswv.com Click on the Providers Tab and select Credentialing from the dropdown. Click on the Resource Center Click on the CAQH Credentialing Application 12

Highmark West Virginia CAQH ID REQUEST PROCESS 13

Highmark West Virginia CAQH ID REQUEST PROCESS CONTINUED 14

INITIAL PROVIDER CREDENTIALING REQUEST CONFIRMATION SCREEN 15

LOGGING IN CAQH FOR THE FIRST TIME Registration Kits are sent to all practitioners appearing on at least one roster. The Registration Kit contains the unique CAQH Provider ID, as well as instructions on how to access the Online Application System (OAS) at www.caqh.org. Once the Logging in for the first time Hyperlink is clicked, the Getting Started screen will display. This screen provides a high-level overview of the online application including a summary of information required, suggested materials to have available, and an estimated time to complete the online portion of the process. 16

AUTHENTICATION SCREEN Before creating a login and password, a practitioner must authenticate his or her identity. The practitioner will enter the CAQH Provider ID from the welcome packet. At least one of the following additional must be entered pieces of information (the more information provided, the better the match response): Social Security Number (XXX-XX-XXXX) Date of Birth (mm/dd/yyyy) DEA Number UPIN Number 17

CREATING A PASSWORD The practitioner must enter his or her registration information. (NOTE: The Contact Method is how the practitioner is notified concerning the application status. Keep in mind that many of these messages are sent overnight, so one may not want to enter a home fax machine number.) The Registration Successful screen will Display. If the registration is unsuccessful, a dialog box will appear indicating the field(s) requiring attention. Once re-entered, the practitioner clicks SUBMIT. 18

NAVIGATING THE START PAGE From the Start Page, the practitioner may navigate by clicking on the tabs at the top of the screen or clicking on the menu bubbles to get to the desired location. 19

COMPLETING THE APPLICATION THE ONLINE APPLICATION IS COMPLETED MUCH LIKE TAX-PREPARATION SOFTWARE. ALTERNATINELY, A PAPER APPLICATION CAN BE REQUESTED FROM THE TOLL-FREE HELP DESK AT 888-599-1771. Interview-style questions help practitioners navigate application one section at a time. Drop-down menus are used where possible to save time and prevent data entry errors. 20

AUTHORIZATION OF DATA RELEASE PROVIDER S MUST AUTHORIZE RELEASE OF HIS OR HER DATA TO HIGHMARK.c. Authorization screen ensures practitioners have complete control over which organizations have access to their information. Before a practitioner can release data, the organization must roster the practitioner, or the organizations name will not appear here. 21

RREQUIRED DOCUMENTS PROVIDER FAXES ANY REQUIRED SUPPORTING DOCUEMENTS. THESE DOCUEMENTS ARE IMAGED AND ATTACHED ELECTRONICALLY TO THE PROVIDER S FILE. The last step for practitioners is to fax all necessary supporting documentation. Requirements are displayed on the fax cover sheet, or on the Documents tab of the main menu. 22

PROVIDER S EXPERIENCE WITH UTILIZING THE UNIVERSAL PROVIDER DATASOURCE FINDINGS SHARED AT BEST PRACTICES CONFERENCE Participating organizations reported the following efficiencies: Decreased average processing turnaround time by 8-10 days Reduced frequency of returned provider correspondence due to poor address quality from 30-40% to 6% Discontinued sending initial credentialing packets via mail to 97% of new providers Reduced legacy re-credentialing mailings by 15,000 units ($5-8 ea) -- provider perspective is that need for recredentialing is nearly eliminated Updating provider directories real-time Reallocated legacy paper credentialing application storage space Facilitating implementation of NPI BENEFITS PRACTITIONERS HAVE SHARED WITH HIGHMARK Reduction in administrative paperwork by being able to complete one application for multiple health plans Streamlined credentialing and recredentialing processes to provide better service with: Reduction in processing times Reduction of misplaced documentation Decreased development 23

WEST VIRGINIA UTILIZATION AS OF AUGUST 1, 2011 West Virginia National Providers Receiving CAQH ID Numbers 7683 1,314,544 Providers Registering 5329 944,575 Providers Complete 4950 881,001 According to FSMB, there are 4,445 Licensed and Practicing Physicians (MD,DO) in West Virginia. 69% of these (3,084) are using the Universal Provider DataSource 24

WEST VIRGINIA PARTICIPATING ORGANIZATIONS Aetna CIGNA CIGNA Behavioral Coventry Healthcare Davis Vision First Health Network General Vision Services Great West Highmark Inc. Humana/Choice Care Network Health Net Medical Mutual of Ohio Multiplan TRIAD Healthcare, Inc. United Healthcare United Behavioral US Army National Guard Wellpoint, Inc. 25

STAKEHOLDER ASSOCIATION SUPPORT 26

ACCREDITATION ORGANIZATION COMPLIANCE 27

STATE ACTIVITIES IN, KY, KS, MD, MO, NM, OH, RI, VT and DC have adopted CAQH's form as the state form. TN, LA and NJ have adopted CAQH's form as a preferred option KY, NY, PA and TN Medicaid programs have implemented CAQH s UPD 28

QUESTIONS? 29

Provider Information Management Provider Maintenance (Formerly known as PPR in West Virginia) Overview September 19, 2011

Introduction to Provider Maintenance The Provider Maintenance Department is responsible for housing and updating all provider files. We maintain license, tax id and NPI information, group and network affiliation, address information and banking information. We also capture/maintain all transparency data. The following are frequently used forms for the Provider Maintenance area: Provider Reimbursement Change Form Provider Electronic Fund Transfer Form 31

When would I complete the PRCF? Any demographic updates to your file can be submitted on the PRCF. Things such as: Establishing a new group TAX ID/Name change Address change Terminating an existing account or practitioner An addition to your staff or practice location Change in office hours Requirements for the form: Sign and date if the form is not signed and dated it will be returned for a signature and date. Please be sure to complete all necessary fields marked on the form to ensure timely processing. 32

Provider Reimbursement/Change Form 33

What is needed to complete the Provider Electronic Fund Transfer Form? What are the form requirements? We need a copy of the voided check or savings account deposit slip All fields on the form will need completed The provider must choose from the following: Provider EFT Enrollment Provider EFT Change Provider EFT Cancellation The form will need signed and dated by an authorized representative. 34

Provider Electronic Fund Transfer Form 35

Where can I find the forms? 36

Where can I submit my information? Providers can submit all information to: Highmark West Virginia Provider Maintenance PO Box 1948 Parkersburg, WV 26102 Or Fax to: 304-424-7713 Note Highmark West Virginia Provider Maintenance Department works within a paperfree environment we encourage our providers to fax all information to us so we can continue to reduce our administrative cost and support our green initiatives For any questions providers can contact the Provider Maintenance area at 1-800-798-7768. 37

Questions/Comments 38

Provider Resource Center Enhancements September 19, 2011 Highmark West Virginia 2011 Provider Conference Days Hotel Conference Center Mike Gworek michael.gworek@highmark.com Corrine Satriano corrine.satriano@highmark.com www.highmarkbcbswv.com

Today s Provider Resource Center

2 Ways To Access the Provider Resource Center 41

Provider Sites Today 42

Tomorrow s Provider Resource Center October 17, 2011

New Features 44

Bookmark This Page 45

Special Bulletins & Newsletters 46

Provider News 47

Provider Forms 48

Provider Forms 49

Provider Online Training 50

Search 51

resourcecenter@highmark.com 52

Enhancements for December 2011 and Beyond December 17, 2011

Provider Newsletter Redesign 54

Facility Bulletin Search 55

E-subscribe Presentation Title or Footnote area 56

Timeline Now Directions for future location of pages Announcement in Provider News Buzz from your Provider Relations Representative 10/17/11 Consistent content on all PRC (highmarbcbswv.com and NaviNet) Immediate change to look & feel New Today s Messages Bookmark This Page Feature 12/17/11 Newsletter Page Redesign Facility Bulletin Search Medical Policy Search More Online Training 2012 & Beyond e-subscribe Enhancements from your feedback Search Capability Contact Us 57

Questions? resourcecenter@highmark.com 58

Highmark Provider Network Innovations & Partnerships Highmark West Virginia 2011 Statewide Provider Workshop Presented by Twyla Johnson Manager, Provider Engagement, Performance & Partnerships

Agenda Current Healthcare Landscape PCMH Overview Primary Care Physician Engagement Clinical Quality Consultant Role 60

Patient Centered Medical Home Today s underlying problem The U.S. Healthcare System has major gaps in access and affordability and is built on a flawed competitive and economic foundation that rewards volume with limited consequences for poor quality. 61

Per Capita Health Care Expenditure Patient Centered Medical Home Uncontrolled cost $6,000 15.0% 15% $5,000 $4,000 $3,000 $2,000 $1,000 11.1% 9.9% 10.1% $904 $688 $653 $2,099 $2,215 $2,343 8.4% 7.9% $562 $396 $1,696 $1,743 11.5% $1,569 $2,212 7.7% $370 $1,861 $3,133 $2,502 10% 5% Healthcare as % GDP $0 Canada France Germany Italy Japan Switzerland UK US 0% The U.S. has the highest per capita public and %GDP spend and 24 th of 30 industrialized nations in poorest outcomes of care/life expectancy. Source: Organization for Economic Co-operation and Development, Health Data 2005: Statistics and Indicators for 30 Countries 62

Patient Centered Medical Home Uncontrolled Cost The Reform Agenda The average annual growth in national health spending will be 5.8% through 2020, with an 8.3% year-on-year The U.S. rise Healthcare in 2014, followed System is by 6.2% annually through 2020, according spending$2.5 to a study Trillion published (Hospitals in the journal Health Affairs. Demand for 31%, services Physicians will increase 20%, Rx as more people get health care insurance under drugs10%) the PPACA, and the report's authors predicted that spending will rise the most on doctor visits, clinical services and prescription drugs. Source: Reuters July 28, 2011 Spending on healthcare in the United States is growing at an unsustainable rate of 6 8% 1. Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2010. 63

Patient Centered Medical Home Chronic Disease Statistics Almost half all Americans live with at least one chronic Disease Chronic Diseases account for 1/3 of the years of potential life lost before age 65 Annually, chronic diseases account for 70% of American deaths Chronic care patients often experience extended pain and decreased quality of life Center for Disease Control, 2009 64

Patient Centered Medical Home Realities of Current U.S. system Who s in Charge? Preventive Care Often Overlooked Providers Paid Based on Volume Treatments Vary Too Much Lack of holistic approach Limited time focusing on behavioral/ lifestyle changes Majority of physicians reimbursed on a per service basis Less than 20% of PCPs currently review or comply with accepted national guidelines Unnecessary duplication of medical services Primary focus of providers is to treat sick patients Health outcomes not considered in reimbursement Delays in diagnosis, wrong diagnosis, delays in treatment Fragmented patient care Increased ER Visits Serious Preventable Events 65

Medical Care: Coordination, Transitions & Handoffs PCP Hospital Podiatrist Patient Rheumatologist Ophthamologist General surgeon Cardiologist 66

Patient Centered Medical Home Ineffective transitions lead to poor outcomes Ineffective Transition Wrong treatment Delay in diagnosis Severe adverse, preventable events Duplication of tests/services Poor Access to Care Outcome Increased hospital admissions/readmissions/length of stays Lack of Patient Compliance/Adherence; Lack of patient Engagement and Activation in their care Litigation (malpractice cost drivers); Increased use of ED setting of care Increased Costs Source: Australian Council for Safety and Quality In Health Care. Report. March 2005. 67

PCMH Overview

Patient-Centered Medical Home 6 common fundamental elements 1 Continuous Care 6 Appropriate Reimbursement 2 First Contact Access Patient-Centered Medical Home 5 Coordination of Care Comprehensive Evidence-Based Care 4 3 Performance Measurement 69

Patient Centered Medical Home Origins of the concept 1967 American Academy Pediatrics coined the phrase Medical Home 2007 AAP, AOA, AAFP, ACP agreed to Joint Principles of Medical Home Personal physician Physician directed care Whole person orientation Coordinated/integrated care Quality and safety Access Alignment of incentives 70

Patient Centered Medical Home Traditional Care The PCMH model is a paradigm shift away from the current model of acute reactive care Patient makes an appointment for a rash Patient receives care for the acute illness Patient leaves and picks up prescription 71

Patient Centered Medical Home Care within the PCMH model Patient makes an appointment for a rash Physician sees patient and directs course of action Care for rash and diabetes provided During pre-visit chart review, care manager sees that patient is diabetic and over-due for tests Care coordinator reviews findings with physician Care coordinator schedules educational follow up for diabetic group visit Receptionist requests that patient completes tests before visit At visit patient is first seen by care coordinator Care coordinator calls patient to enquire about diabetic care plan progress and schedules follow-up appointment with physician 72

PCMH Will Impact Core Medical Costs Future PCMH objectives Complete Care Coordination Focus on Preventive Care Aligned Incentives Treatment Based on National Standards Designation of a physician of record accountable for care coordination Clearly articulated care coordination responsibilities for all providers Proactive outreach to keep patients healthy and engaged in treatment compliance Reimbursement for patient education and counseling Physicians reimbursed based on patient outcomes (quality not quantity) Aligning incentives to adhere to evidence based guidelines Sources: JAMA; Merritt Hawkins; 73

The Patient-Centered Medical Home model will serve as a Care Coordination Hub for patients, with the PCP and the PCP team serving as the Quarterback for care Care Team Roles Diagnostics/Drugs Manage drugs Avoid duplicate tests Allied Health Care Coordination PCP Team- Based Care Coordination of Care Transitions Nutrition Counseling Diabetic Education Highmark Care Management Fitness Coaching PCP Care Team Specialists Referrals Discharge follow-up Coordinate with outpatient and inpatient procedures Plan treatment with specialists Coordinate care 74

Patient Provider Insurer Patient-Centered Medical Home Advantages of a New Care Model Holistic approach to care Patient becomes engaged in their health Better health outcomes Less fragmented care Motivated patients Focus on team based care Ability to work at top of licensure Less duplication of services New reimbursement model Better quality outcomes Bending the cost curve Foundation for Accountable Care Organization 75

Highmark s PCMH program builds upon earlier market efforts, providing additional support to drive transformation Highmark s PCMH program builds upon earlier market efforts, providing additional support to drive transformation Provides guidelines on becoming a PCMH Evaluation of practice process measures Provide financial support to facilitate practice transformation and reimburse for outcomes/performance Uses NCQA+ designation to gauge PCMH progress Collection of clinical quality, cost, and utilization measures with a focus on chronic diseases Provides support for practice transformation, including additional reimbursement, dedicated care management and practice coaching personnel, and enhanced data exchange PCMH requirements based on NCQA, URAC, PCPCC Joint Principles, and existing national PCMH initiatives Collection of and reimbursement on practice process, clinical quality, outcomes, utilization, and cost measures

Highmark s Medical Home Pilot Details Requires broad support and coordination throughout the entire provider practice organization/system 2-year pilot, started in June 2011 Practice Locations Western Pennsylvania Central Pennsylvania West Virginia Physician Advisory Board 77

PCMH Advisory Board Physician group Advisory Board Representative Region Annville Family Medicine PC Dr. Bob Nielsen East Berlin Family Practice Dr. Karen Jones Lititz Family Medicine Dr. Paul Conslato UPG Fishburn Road Dr. William Bird Pinnacle - TBD Holy Spirit -TBD Family Care HealthCenter Dr. Mary Buffington Jenkins Family Care HealthCenter Martha Cook Carter Central PA Central PA Central PA Central PA Central PA Central PA West Virginia West Virginia Wheeling Hospital Inc Dr. Robert Marks West Virginia Preferred Primary Care Physicians (PPCP) Dr. Lou Civitarese Premier Medical Associates Dr. James Costlow Washington Family Practice Dr. Jeff Minteer St Vincent Family Medicine Dr. Caitlin Clark Western PA Western PA Western PA Western PA 78

Patient Centered Medical Home Pilot Participants Preferred Primary Care Physicians Premier Medical Associates Saint Vincent Family Medicine Washington Family Practice 26 Locations Annville Family Medicine PC Wellspan Lancaster Hershey Holy Spirit Pinnacle Family Care Wheeling Hospital Inc 138 Primary Care Providers Approximately 40,000 attributed Highmark members 79

Patient-Centered Medical Home Standards NCQA (National Committee for Quality Assurance) PCMH Standards for Accreditation Access and Communication Patient Tracking and Registry Functions Care Management Patient Self-Management and Support Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communication Electronic Prescribing 80

Reimbursement Moving from fee-for-service to fee-for-quality outcomes Current State PCMH Pilot 2011 Near Term PCMH Future State Fee-for-service Today s standard: provide a service, get a payment Pay-for-performance An opportunity for additional reimbursement, based on quality Fee-for-service Pay-for-performance An opportunity for additional reimbursement, based on quality Prospective payment Fee-for-service Retrospective payment Based on outcomes Shared Savings Bundled Payments Upfront financial support Helps practices make changes Retrospective bonus Back-end bonus to properly encourage quality outcomes 81

Performance Measurement PCMH reimbursement will need to be based on appropriate reporting measures to ensure that pilot practices are improving care outcomes What is measured in the PCMH pilot? Prospective payment Retrospective performance based payment PCMH Deliverables Quality Utilization Cost Practice conducts patient education on PCMH Patients have 24 hour access to clinical decision maker by phone Prevention Asthma/ COPD Diabetes CAD/CHF/ HTN Hospital admissions ER visits Readmission after 7 and 30 days Inpatient cost ER cost Total patient cost PMPM Primary care cost Patient Satisfaction Need to capture this data and develop reporting mechanisms to provide continual snapshot of how each pilot practice is improving outcomes. Note: These represent examples of performance measures. This list is not exhaustive. 82

Care Management Building a bridge between Highmark and PCPs will ensure that patient care is coordinated and optimally delivered PCMH Practice Option 1 Option 2 Embedded Case Management Highmark case mangers will be physically present at PCMH practice Allocation of case manager resources will depend on size of the Highmark patient panel Case managers will provide in-person support to Highmark members Virtual Case Management Highmark case managers will provide support virtually May be utilized in case of geographic/rural limitations in providing embedded model Physician offices that already have an inoffice, employed case manager may opt for this model Benefit Information Highmark Programs Member Information Specialty CMs Over the long term, care management responsibilities will primarily reside in physician offices, with a bridge back to Highmark for available programs and information. 83

Data Exchange and Reporting Longer-term goals of the Data Exchange and Reporting Team will be to incorporate currently unavailable data elements and move to a more automated system PCPs Real-time, automated data on patient encounters (e.g., ER) Automated reports for performance measurement Automated data pulls from HM (e.g., CM treatment plans, EBM guidelines, patient education) Highmark Automated report generation and data visibility for internal operations (e.g., PCMH provider identification) Receipt of clinical information from PCPs, specialists and members Utilization of available, relevant, un-mined data (e.g., Quest) Members Access to personal health records Pull data (e.g., lab results, treatment plans, goal progress) Push data (self-reported HbA1c) Caregiver connection to PCP and CMs Specialists Automated referral from PCPs Automated, real-time transfer of lab results (including images and diagnostic tests) and treatment plans to PCPs and CMs 84

Communication, Education and Training Managing both internal and external communications will be important to the successful launch of the PCMH pilot Internally 85

Communication, Education and Training Internally 86

87

88

Primary Care Physician Engagement: Clinical Quality Consultant (CQC) Role

Your WVA Clinical Quality Consultant (CQC) Team Our CQC team has an extensive background in working with physicians and other health-care providers and facilities to improve clinical care and quality outcomes. The team also has experience in a variety of health care settings, including: Family practice nursing Skilled nursing and rehabilitation Hospital nursing Outpatient Surgery Center nursing and management Senior Medical Underwriting Physician Credentialing 90

Your WVA Clinical Quality Consultant (CQC) Team The WVA CQC team is part of a larger CQC team that has been in existence for 14 years providing clinical quality consulting services to Primary Care Physicians in the Western and Central Pennsylvania regions which encompasses 49 counties, and over 3,650 physicians. The CQC team has an outstanding reputation with their respective practices and have become the experts that these practices turn to for guidance on all subjects related to clinical quality practice, continuous improvement processes, efficiency and patient safety/satisfaction. 91

92 CQC Pennsylvania Geographic Reach Adams Adams Adams Adams Adams Adams Adams Adams Adams Berks Berks Berks Berks Berks Berks Berks Berks Berks Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Cumberland Cumberland Cumberland Cumberland Cumberland Cumberland Cumberland Cumberland Cumberland Dauphin Dauphin Dauphin Dauphin Dauphin Dauphin Dauphin Dauphin Dauphin Franklin Franklin Franklin Franklin Franklin Franklin Franklin Franklin Franklin Fulton Fulton Fulton Fulton Fulton Fulton Fulton Fulton Fulton Juniata Juniata Juniata Juniata Juniata Juniata Juniata Juniata Juniata Lancaster Lancaster Lancaster Lancaster Lancaster Lancaster Lancaster Lancaster Lancaster Lebanon Lebanon Lebanon Lebanon Lebanon Lebanon Lebanon Lebanon Lebanon Lehigh Lehigh Lehigh Lehigh Lehigh Lehigh Lehigh Lehigh Lehigh Mifflin Mifflin Mifflin Mifflin Mifflin Mifflin Mifflin Mifflin Mifflin Montour Montour Montour Montour Montour Montour Montour Montour Montour Northampton Northampton Northampton Northampton Northampton Northampton Northampton Northampton Northampton Northumberland Northumberland Northumberland Northumberland Northumberland Northumberland Northumberland Northumberland Northumberland Perry Perry Perry Perry Perry Perry Perry Perry Perry Schuylkill Schuylkill Schuylkill Schuylkill Schuylkill Schuylkill Schuylkill Schuylkill Schuylkill Snyder Snyder Snyder Snyder Snyder Snyder Snyder Snyder Snyder Union Union Union Union Union Union Union Union Union York York York York York York York York York Allegheny Allegheny Allegheny Allegheny Allegheny Allegheny Allegheny Allegheny Allegheny Armstrong Armstrong Armstrong Armstrong Armstrong Armstrong Armstrong Armstrong Armstrong Beaver Beaver Beaver Beaver Beaver Beaver Beaver Beaver Beaver Bedford Bedford Bedford Bedford Bedford Bedford Bedford Bedford Bedford Blair Blair Blair Blair Blair Blair Blair Blair Blair Butler Butler Butler Butler Butler Butler Butler Butler Butler Cambria Cambria Cambria Cambria Cambria Cambria Cambria Cambria Cambria Cameron Cameron Cameron Cameron Cameron Cameron Cameron Cameron Cameron Centre Centre Centre Centre Centre Centre Centre Centre Centre Clarion Clarion Clarion Clarion Clarion Clarion Clarion Clarion Clarion Clearfield Clearfield Clearfield Clearfield Clearfield Clearfield Clearfield Clearfield Clearfield Crawford Crawford Crawford Crawford Crawford Crawford Crawford Crawford Crawford Elk Elk Elk Elk Elk Elk Elk Elk Elk Erie Erie Erie Erie Erie Erie Erie Erie Erie Fayette Fayette Fayette Fayette Fayette Fayette Fayette Fayette Fayette Forest Forest Forest Forest Forest Forest Forest Forest Forest Greene Greene Greene Greene Greene Greene Greene Greene Greene Huntingdon Huntingdon Huntingdon Huntingdon Huntingdon Huntingdon Huntingdon Huntingdon Huntingdon Indiana Indiana Indiana Indiana Indiana Indiana Indiana Indiana Indiana Jefferson Jefferson Jefferson Jefferson Jefferson Jefferson Jefferson Jefferson Jefferson Lawrence Lawrence Lawrence Lawrence Lawrence Lawrence Lawrence Lawrence Lawrence McKean McKean McKean McKean McKean McKean McKean McKean McKean Mercer Mercer Mercer Mercer Mercer Mercer Mercer Mercer Mercer Potter Potter Potter Potter Potter Potter Potter Potter Potter Somerset Somerset Somerset Somerset Somerset Somerset Somerset Somerset Somerset Venango Venango Venango Venango Venango Venango Venango Venango Venango Warren Warren Warren Warren Warren Warren Warren Warren Warren Washington Washington Washington Washington Washington Washington Washington Washington Washington Westmoreland Westmoreland Westmoreland Westmoreland Westmoreland Westmoreland Westmoreland Westmoreland Westmoreland

CQC Engagement Philosophy Highmark - Healthcare Provider-Account-Member Collaboration Dedicated Clinical Consultants Dedicated Medical Directors Clinical Pharmacy Consultants Network Provider Relations Representatives Accounts, Clients Members Network, Peer, Customized Data, Trends Reports, Action Plans, Performance Targets Evidence Based Care Tools, Best Practices and Information Improved Health Status Patients; Shared Savings and Efficiencies 93

Scope of Consulting Services Developing a Culture of Quality Establish relationships with physicians and staff to facilitate development of Quality Improvement Committees Analysis of data to provide support for the need to change Development of reports to show performance patterns over an extended period of time Dashboard reports (Highmark) Chart audits to identify patterns of care (Practice / Highmark) Process Analysis (Practice / Highmark) Provide research documents and evidence based standards to support process improvement 94

CQC Collaboration Clinical Quality Indicators Practice Process Improvement Generic Prescribing Best Practice Clinical Initiatives Collaboration Member Access to Care Meaningful Use Education NCQA Recognition Programs Professional Presentations Shared Value Projects 95

CQC Partnerships Care & Case Management Provider Information Management Provider Business Support Provider Communications Program Enhancement & Maintenance Provider Relations Product Development Reimbursement Systems Fee Based Pricing & Analysis 96

CQC Initiatives

CQC Provider Initiatives Diabetic Outreach Programs Program to reach out to all diabetic patients to provide education in nutrition, availability of supplies, counseling services and on the spot testing (labs, urine, eye exams and foot exams) Diabetic Group Visits Working with groups to provide an alternative approach in caring for the diabetic patient. Collaborative efforts with an outside vendor to provide conversation mapping and educational tools Keeping Abreast of Your Health An initiative with providers and an employer group to provide education and opportunities for female employees to schedule appointments for mammogram appointments Colorectal Screening A collaborative effort with physician groups in process improvement of prevention, education, detection and treatment if needed 98

CQC Provider Initiatives UrgiCare Center Pilot A collaborative effort to document increased quality of care and cost savings through decreased number of ER visits by providing extended hours of care (Presented at AHIP Medical Leadership Forum, Healthcare Challenge in a Changing Political Environment conference) Drugs to Avoid in Elderly Collaborative effort to identify high volume / high risk drugs prescribed to elderly patients and identify alternative solutions Improvement of Diabetic Care with Implementation of EMR A collaborative effort that measured compliance of measures of comprehensive diabetic care (HbA1c, LDL, nephropathy screening) before and after EMR implementation Results showed with implementation of EMR there was an improved rate of compliance in measurement for each of the following components 15% improved compliance rate for HbA1c 14% improved compliance rate for LDL 15% improved compliance with nephropathy screening and 20% improved compliance with diabetic eye screening (Presented at the IHI Redesigning the Clinical Office Practice Conference in 2008) 99

CQC Provider Initiatives NCQA Certification Collaborative initiative with physicians (PCP and Specialists) across Central & Western PA in receiving NCQA Recognition 1,010 physicians from 255 practices accepted into the program 639 physicians achieved NCQA recognition - 370 in Western and 269 in Central PA 429 in Diabetes 185 in Heart / Stroke 25 in PPC the precursor to PCMH (Presented at the IHI Redesigning the Clinical Office Practice Conference in 2008) Medication Adherence Collaborative effort with 5 physician groups to look at drug claims to identify potential gaps in medication use. Providers consulted with patients to identify issues, provide education and increase adherence rates (Presented at the Medication Adherence Conference 2009) 100

CQC Provider Initiatives Patient Centered Medical Home Detailed earlier Healthcare Disparities Best Practice Pilot Ten practices have implemented initiatives to eliminate possible healthcare disparity in their practices and improve care Best Practice Forums Two-three annual meetings held regionally to showcase quality improvement processes/projects implemented by network practices; CME credits offered Excellent networking, best-practice sharing opportunity Partners in Quality Newsletter Quarterly communication to the provider community on quality Recognition of top performing practices in the network for specific QualityBLUE components 101

Questions For more information, please contact : Twyla L. Johnson Manager Provider Engagement, Performance & Partnerships (412) 544-5167 F: (412) 544-8255 Twyla.johnson@highmark.com Administrative Assistant: Holly Van Wagenen (412) 544 8172 Holly.vanwagenen@highmark.com

Quick Guide to Blue Cross and/or Blue Shield Member ID Cards www.highmarkbcbswv.com

Introduction When Blue Plan members arrive at your office or facility, remember to ask to see their current member identification cards at each visit. This will help you to identify the product the member has, to obtain health plan contact information and to assist with claims processing. Remember: ID cards are for identification purposes only; they do not guarantee eligibility, or payment of your claim. You should always verify patient eligibility by calling 1.800.676.BLUE (2583).

Alpha Prefix The majority of Blue-branded ID cards display a three-character alpha prefix in the first three positions of the subscriber s ID number. However, there are some exceptions to this; ID cards for the following products/ programs do not have an alpha prefix: Stand-alone vision and pharmacy when delivered through an intermediary model* Stand-alone dental products* The Blue Federal Employee Program (FEP) has the letter R in front of the ID number* *Follow instructions on these ID cards on how to verify eligibility, submit claims and who to contact with questions. The alpha prefix is critical for any inquiries regarding the member, including eligibility and benefits, and is necessary for proper claim filing. When filing the claim, always enter the ID number exactly as it appears on the member s card, inclusive of the alpha prefix, and include this complete identification on any documents pertaining to services to ensure accurate handling by the Blue Plan. 105

Alpha Prefix (cont d) A correct member ID number includes the alpha prefix, in the first three positions, and all subsequent characters, up to a total of 17 positions. Thus, you may see cards with ID numbers consisting of the alpha prefix followed by between six and 14 numbers/letters. The following are examples of ID numbers showing the alpha prefix: ABC1234567 ABC1234H567 ABCD1234H567 ABCD1234H56789012 Alpha Prefix Alpha Prefix Alpha Prefix Alpha Prefix An example of a Blue ID card with the alpha prefix highlighted

Federal Employee Program (FEP) ID Cards FEP members ID cards do not display a three-character alpha prefix. Rather, all FEP member identification numbers begin with the letter "R," as highlighted on the sample ID card below. Effective January 2011, all FEP Basic and Standard Option members will receive new ID cards.

FEP ID Cards (cont d) Example of FEP Basic ID card: Example of FEP PPO ID card:

Benefit Product Logos Below are various logos that may be displayed on member ID cards for Blue Cross and/or Blue Shield Plans in the United States and for International Licensees licensed through BCBSA. Member ID cards may include one of several logos identifying the type of coverage the member has and/or indicating the provider s reimbursement level. TIPS FOR SUCCESS The appearance of a benefit product logo is not a guarantee of payment. A provider s reimbursement is based upon a combination of what services are covered under the member s benefit plan in conjunction with a provider s contract(s) with Highmark WV.

Benefit Product Logos (cont d) Blank (empty) Suitcase A blank (empty) suitcase logo on the front of a member s ID card signifies that the member has out-of-area coverage that is not a PPO product. Benefit products that display a blank (empty) suitcase logo on ID cards include: Traditional HMO (Health Maintenance Organization) POS (Point of Service) Limited benefits products 110

Benefit Product Logos (cont d) PPO in a Suitcase When you see the PPO in a suitcase logo on the front of the member s ID card, it means that the member has PPO or EPO type benefits available for medical services received within or outside of the United States. It also means that the provider will be reimbursed for covered services in accordance with the provider s PPO contract with the local Blue Plan. TIPS FOR SUCCESS To be certain of a member s benefit level, always verify eligibility and benefits electronically with Highmark WV or by calling 1-800-676-BLUE (2583).

Benefit Product Logos (cont d) No Suitcase Some Blue ID cards do not have any suitcase logos on them. This includes ID cards for Medicaid, State Children s Health Insurance Programs (SCHIP) administered as a part of a state s Medicaid program, Medicare Complementary and Supplemental products, also known as Medigap. Government-determined reimbursement levels apply to these products. TIPS FOR SUCCESS While Highmark WV routes all of these claims for out-of-area members to the member s Blue Plan, most of the Medicare Complementary or Medigap claims are sent directly from the Medicare intermediary to the member s Blue Plan via the established electronic Medicare crossover process.

Medicare Advantage Product ID Cards Health Maintenance Organization Member ID cards for Medicare Advantage products will display one of the benefit product logos shown here: Medical Savings Account Private Fee-For-Service Point of Service Preferred Provider Organization Network Sharing Preferred Provider Organization. When these logos are displayed on the front of a member s ID card, it indicates the coverage type the member has in his/her Blue Plan service area or region. However, when the member receives services outside his/her Blue Plan service area or region, provider reimbursement for covered services is based on the Medicare allowed amount, except for PPO network sharing arrangements.

Medicare Advantage Product ID Cards (cont d) Highmark WV participates in Medicare Advantage PPO Network Sharing arrangements, and contracted provider reimbursement is based on the contracted rate with Highmark WV. Non-contracted provider reimbursement is the Medicare allowed amount based on where services are rendered. TIPS FOR SUCCESS As of January 1, 2010, Blue Plans began issuing Medicare Advantage PPO ID cards that display the new PPO logo which includes the MA in the suitcase. These cards indicate that the member s Blue Plan is a participant in a Blue Medicare Advantage PPO network sharing arrangement. By January 1, 2012, all PPO ID cards must contain the MA PPO suitcase logo.

Limited Benefits Product ID Cards Members with Blue limited benefits coverage (that is, annual benefits limited to $50,000 or less) carry ID cards that may have one or more of the following indicators: Product names InReach, MyBasic or some other non-blue name A green stripe at the bottom of the card A statement either on the front or the back of the ID card stating this is a limited benefits product A black cross and/or shield to help differentiate it from other identification cards These ID cards may look like this:

Limited Benefits Product ID Cards (cont d) TIPS FOR SUCCESS In addition to obtaining a copy of the member s ID card, regardless of the benefit product type, always verify eligibility and benefits electronically with Highmark WV or by calling 1-800-676-BLUE (2583). Both electronically and via phone, you will receive the member s accumulated benefits to help you understand his/her remaining benefits. If the cost of service extends beyond the member s benefit coverage limit, please inform your patient of any additional liability he/she might have. If you have questions regarding a Blue Plan s limited benefits ID card/product, please contact Highmark WV.

Consumer-Directed Healthcare and Healthcare Debit Cards Here is a sample of a combined healthcare debit card and member ID card: The cards include a magnetic strip allowing providers to swipe the card to collect the member s cost-sharing amount (i.e., copayment). With healthcare debit cards, members can pay for copayments and other out-of-pocket expenses by swiping the card through any debit card swipe terminal. The funds will be deducted automatically from the member s appropriate HRA, HSA or FSA account. If your office currently accepts credit card payments, there is no additional cost or equipment necessary. The cost to you is the same as what you pay to swipe any other signature debit card.

Consumer-Directed Healthcare and Healthcare Debit Cards TIPS FOR SUCCESS Using the member s current member ID number, including alpha prefix, carefully determine the member s financial responsibility before processing payment. Check eligibility and benefits electronically through Highmark WV or by calling 1.800.676.BLUE (2583). All services, regardless of whether or not you ve collected the member responsibility at the time of service, must be billed to Highmark WV for proper benefit determination, and to update the member s claim history. Please do not use the card to process full payment up front. If you have any questions about the member s benefits, please contact 1.800.676.BLUE (2583) or, for questions about the healthcare debit card processing instructions or payment issues, please contact the toll-free debit card administrator s number on the back of the card.

Get Faster and Easier Information Electronically for Blue Members Check Eligibility Viewing Claim Status Get a faster way to verify eligibility and benefits for members of other Blue Plans. For each request, Highmark WV is committed to providing you with more detailed and robust information on member s cost sharing amounts Avoid unnecessary resubmission by checking claims status electronically for Blue members. Timely Electronic Transactions Reliable Local Service Go electronic and get faster real-time responses to your inquiries for local members and members from other Blue Plans. Most of the responses from Highmark WV will be sent to you within Highmark WV is your single point of contact for all inquiries, including submitting claims electronically. Use electronic capabilities to reduce your time completing claims forms and get faster and more accurate claims processing. 119

Verifying Blue Member Eligibility Now Easier To submit electronic eligibility requests for Blue members, follow these three easy steps: In addition to receiving eligibility verifications electronically, you can always call BlueCard Eligibility line at 1.800.676.BLUE (2583) 120

121 Easier Access to Pre-Certification/Pre-Authorization Information for Out-Of-Area Blue Members Effective April 1, 2010, when pre-certifications/pre-authorizations for a specific member are handled separately from eligibility verifications, your call will be routed directly to the area that handles pre-certifications/pre-authorizations. You will choose from four options regarding the type of service for which you are calling: Medical/surgical Behavioral health Diagnostic imaging/radiology Durable medical equipment (DME)

Medical Policy and Pre-Certification / Pre-auth Router

Medical Policy and Pre-certification/ Pre-Authorization Router Effective October 1, 2010, providers will have access to medical policies and general pre-cert/pre-auth requirements of the Home Plan. Provider will enter alpha prefix in a designated area(s) on the local Plan s Web site. Provider will be routed to the Home Plan s medical policy and/or pre-cert requirements. Providers must have access without logging in on the Home Plan s Web site. Once medical policy and/or pre-cert requirements are viewed, provider will be re-connected to local Plan s Web site.

www.highmarkbcbswv.com

Authorization List 125

Pre-Certification/Pre-Authorization Information for Out-of-Area Members 126

MEDICAL POLICY 127

Medical Policy Screens 128

Out of Area Member Medical Policy Router Page 129

130 Medicare Related What are Blue Cross and/or Blue Shield Medicare-related claims? These are claims for coverage that is secondary/supplemental to Medicare and is provided by a Blue Cross and/or Blue Shield Plan. Examples include: Medigap (also called Medicare Supplemental, Medicare Complementary and Medicare Extended) Medicare Carve-out How do I identify a member with a Medicare-related Policy? Often, members will carry more than one identification (ID) card. Member s current ID card, when Medicare is the primary payer, should be a standard Medicare card without a Blue Cross and/or Blue Shield logo. Members may also present a separate ID card with a Blue Cross and/or Blue Shield logo for Medicare secondary coverage.

Medicare Related (cont d) Where do I submit Blue Cross and/or Blue Shield Medicare-related claims? If the member has secondary coverage, submit the claim to your local Blue Plan. When Medicare is primary, submit claims to your Medicare intermediary and/or Medicare carrier. It is essential that you enter the correct Blue Plan name as the secondary carrier, which may be different from the local Blue Plan. Check the member s ID card for additional verification. The member ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage and key to facilitating prompt payments.

Medicare Related (cont d) After receipt of the explanation of payment, or Medicare Remittance Notice from Medicare, look to see if the claim has been automatically forwarded (crossed-over). If the remittance shows that the claim was crossed-over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. You can make claim status inquiries through (name of local Plan). If the claim was not crossed-over, submit the claim to (name of local Plan) with the MRN. For claim status inquiries, contact (name of local Plan).

Medicare Related (cont d) (Reminders for Remittance Advice: Do not submit Medicare-related claims to your local Blue Plan before receiving a Medicare Remittance Notice from the Medicare intermediary and/or Medicare carrier. Duplicate claims submissions can delay claim processing and create administrative inefficiencies for you and the insurance plan. If you have any questions, please contact Highmark WV.

NaviNet & Electronic Requirements September 19, 2011

ELECTRONIC REQUIREMENTS Phase I: Effective October 1, 2010, all assignment accounts and practitioners who were newly participating were automatically enrolled in NaviNet, EFT and paperless EOB s. Phase II: By March 31, 2011, all practitioners currently enrolled with NaviNet were required to enroll in EFT. Phase III: By June 30, 2011, all practitioners doing business with Highmark BCBSWV, are required to enroll in NaviNet and EFT. Effective March 18, 2011, CMS 1500 billers that are both NaviNet and EFT enabled, now receive paperless EOB s. Effective April 29, 2011, UB billers that are both NaviNet and EFT enabled, now receive paperless EOB s / Remittances.

NaviNet online availability is from 5:00 a.m. until 3:00 a.m. Monday through Saturday and from 5:00 a.m. until 5:00 p.m. on Sunday. Using Internet Explorer, enter the following URL to access NaviNet. We recommend you set this as a Favorite. https://navinet.navimedix.com

Authorization Submission This feature lets you submit authorizations directly to Highmark WV without having to phone or fax in your information. You can enter a date of service up to 10 days in the past and up to 1 year in the future for most services. There are various choices of authorizations that can be requested in NaviNet including; Professional Home Care/Hospice, Behavioral Health Facility At this time physical therapy, occupational therapy and speech therapy authorizations cannot be submitted via NaviNet unless it is through the Home Care /Hospice transaction. This transaction is only for Local Highmark West Virginia and HHIC members. FEP and Blue Card/Out-of-Area members are exclusions. Remember, the Eligibility & Benefit screen has a field to indicate if NIA authorizations are required for the member. A specific list of services and codes that require an authorization can be found on the Resource Center.

NIA AUTHORIZATION SUBMISSION

Enter user name & password. Website is www.navinet.navimedix.com

Choose Auth Submission 140

JONES, JOHN FAMILY MEDICINE 123456789001 03/20/1957 Choose your Category Enter step 1, step 2 and step 3. 141

JONES, JOHN FAMILY MEDICINE 123456789001 03/20/1957 Choose the Service, click on Add Category/Service 142

JONES, JOHN FAMILY MEDICINE 123456789001 03/20/1957 When you have selected the category alike this. Now click Sund service and clicked on Add Category/Service, your screen will look like this. Now click Submit 143

DOE, PPO JACKIE 03/20/1957 PPO 123456789001 The Request Form page appears with the service (s) you have requested. Enter a Referred to Provider or Referred to Facility (next slide). Remember you can store up to 50 preferred providers or facilities. 144

2233344401 WV MEMORIAL HOSPITAL - 22333444001 ADD FACILITY ADD DIAGNOSIS CODE(S) ADD CONTACT INFORMATION 145

JONES, JOHN Comments section is optional, enter comments if desired, then click submit 146

147

148

149

150

DOE SuperBlue Plus JACKIE 03/20/1957 PPO 123456789001 THIS AUTHORIZATION REQUEST HAS BEEN AUTOMATICALLY APPROVED (STATUS IS APPROVED). REQUEST HAS BEEN SENT TO NIA. YOUR AUTH # IS A02397473. STATUS COULD ALSO HAVE ALSO BEEN PENDED 151

All authorizations submitted via NaviNet can be found on the Referral/Auth Log located under Office Central. There are different search criteria you can use. We ve searched based on Member ID in this example. Hyperlink under the patient name will return you to the Response Form on the previous slide. 123456789001 DOE, JACKIE 03/20/1957 123456789001 WV MEMORIAL HOSPITAL 152

All your Authorizations can be tracked under the Referral/Auth Inquiry transaction. This will show pended, approved, denied or requests for additional information. In addition, any status change on your NaviNet submitted auths will sent back to you as an Action Item. Note the flag icon below. 153

WV MEMORIAL HOSPITAL 001712345/2233344401 A023974073 09/10/2010 DOE, JACKIE METRO FAMILY MEDICINE WV MEMORIAL HOSPITAL The Select button will burst open more detail of this approved authorization.. 154

Click on the orange flag, and get back new/incomplete action items. The hyperlink under the summary will burst open the update. DOE, JACKIE 123456789001 155

QUESTIONS ON NIA AUTHORIZATION?

NaviNet / Interqual Presentation on Automated Care Management

BENEFITS OF PERFORMING AUTO AUTHORIZATIONS: Immediate approval response (real-time) Saves facilities staffing time by not having to phone or fax in the authorizations Aides in more efficient discharge planning

General Information ACM process will only be performed on urgent admissions that meet InterQual acute inpatient criteria NaviNet authorization submissions, including the ACM process can not be used for any FEP member (Federal Employees) or Blue Card members As with all transactions, Highmark WV will monitor facilities performing ACM submissions to ensure proper transmissions are occurring and results are being properly displayed.

CRITERIA COMPONENTS Severity of Illness (SI) Objective clinical indicators of illness (symptoms, findings) Intensity of Service (IS/*IS) Services that can only be administered at a specific level of care Discharge Screens (DS) Clinical indicators of stability and recommended alternate levels of care

Choose the authorization type Choose the authorization type

General Hospital 000123456/0123456789 10/01/2011 General Hospital 000123456/0123456789 11223344001 09/01/1979 Choose Inpatient Choose Inpatient Urgent Urgent Admission, Admission, Submit Submit

DOE 11223344001 JANE Patient information Patient and service information detail is and returned service to you detail is returned to you 10/01/2011 Choose or enter billing provider. You can build Choose your or own enter list billing of 25 provider. preferred You can providers build your own list of 25 preferred providers

Add contact Add contact information information Enter diagnosis Enter diagnosis code(s) code(s) General Hospital 0123456789 Medical Lane, Anytown, WV 22222 Grant

General Hospital 0123456789 Medical Lane, Anytown, WV 22222 Grant Summarize clinical information here, Submit. You will go to the InterQual criteria screens next. Summarize clinical information here, Submit. You will go to the InterQual criteria screens next.

DOE, JANE / 11223344001

DOE, JANE / 11223344001 Select category & subset

DOE, JANE / 11223344001 Check the appropriate clinical data. Note the red criteria not met box above.

DOE, JANE / 11223344001 Continue with clinical data. Criteria Met! Submit-takes you to admission survey

Three Surveys: Three Surveys: Admission Survey: Automatically routed to when InterQual is met Admission Survey: Automatically routed to when InterQual is met Discharge Planning Survey: Alerts Mountain State Health Service staff Discharge Planning Survey: to a Alerts member s Mountain possible State discharge Health Service needs. staff Please complete if member is an inpatient to a member s > 5 days. possible discharge needs. Please complete if member is an inpatient > 5 days. Discharge Survey: Needs to be completed when the member is Discharge discharged Survey: Needs to be completed when the member is discharged

10/01/2011 11223344001 10/01/2011 DOE, JANE Complete the admission survey

10/01/2011 11223344001 10/01/2011 DOE, JANE Complete the 5 survey questions. Submit

10/01/2011 11223344001 10/01/2011 DOE, JANE Enter discharge date Enter discharge date and complete the 7 and complete the 7 survey items. survey items. Submit Submit

DOE JANE Response Form; status is Approved & Auth # displayed 10/01/2011 ABC Physicians Group 99887766655 General Hospital / 0123456789

All NaviNet initiated authorizations are stored on the Referral/Auth Log DOE JANE 09/01/1979 ABC Physicians Group / 0123456789 General Hospital / 0123456789

DOE 10/01/2011 DOE, JANE DOE, JANE DOE, JANE 11223344001 11223344001 11223344001 There are a variety of searches that can be performed (ex: name, ID#, referral #)

Another way to view ALL your Mountain Another way to view ALL your Mountain State Authorizations whether they were State Authorizations whether they were submitted via NaviNet, fax or phone submitted via NaviNet, fax or phone

General Hospital / 000123456/0123456789 10/01/2011 10/01/2011 Enter auth # Enter auth #

General Hospital / 000123456/0123456789 10/01/2011 10/01/2011 Option to select into the authorization detail or Option to select into the into other surveys. authorization detail or into other surveys. 10/01/2011 NA/ General Hospital ABC Physicians/ General Hospital

QUESTIONS / ANSWERS 184

General Updates and Reminders September 19, 2011

DME Authorizations should be submitted through NaviNet Effective April 18, 2011 CMNs are accessible via NaviNet and must be thoroughly completed and submitted. 186

Reimbursement Updates RBRVS Effective July 1, 2011 Current Highmark WV Fee Schedule (using CMS 2009 RVUs) will continue for 2011 2009 CMS RBRVS value to include WV Geographic Practice Cost Index 93613 ( Intracardiac Electrophysiologic Three Demensional Mapping) Change in Reimbursement Effective November 1, 2011 Current total component and technical component will be removed Professional reimbursement fee will be applied 187

Reimbursement Updates cont. DRG Grouper Effective July 1, 2011 Converting from MS-DRG Grouper Version 27 to MS-DRG Version 28 Effecting hospital discharges on and after 7/1/2011 Lab Fee Schedule Effective July 1, 2011 120% multiplier of West Virginia CMS lab fee schedule Including Venipuncture 36415 reimbursement Urgent Care Effective July 22, 2011 Place of Service 20 required on claim submissions on or after 7/22/11 188

PCP and Medical Specialist Accessibility Expectations In office waiting time for scheduled appointments now 15 minutes Reasonable attempt should be made to notify patients of delays 189

Highmark West Virginia Radiation Safety Awareness Program Effective August 22, 2011 Program tracks CT, PET and nuclear cardiology modalities Inpatient and outpatient setting Program does not apply to patients with a cancer diagnosis or those 65 and older 190

Highmark WV to Privilege Imaging Network Effective January 1, 2012 NIA will assist in the privileging process April 2011 letters mailed to providers who will be required to be privileged Online application required for imaging providers to complete for each site location 191

Automated Care Management Tool for Inpatient Authorizations Effective 3 rd and 4 th quarter of 2011 Tool allows hospitals to submit their inpatient authorization requests and their online acute to acute transfer requests via NaviNet Submitted information is then automatically compared to the InterQual medical necessity criteria and in many cases an authorization number can be provided immediately 192

Star Rating CMS annually rates the quality of the private plans that are offered to Medicare beneficiaries through the Medicare Advantage program Health plans rated on a one to five-star scale, with five stars representing the highest quality Highmark priority is to improve scores for certain outcomes and offer the highest quality plans to members Opportunity exists for meaningful improvement in Medicare Health Outcomes Survey measures: reduce the risk of falling, improving bladder control and monitoring physical activity 193

Primary EOB submission When billing paper copies make sure only the patient the claim is being submitted for is shown on the EOB Privacy is the upmost discretion and all other patients on the EOB should be removed Secondary electronic submissions should be submitted electronically through your clearinghouse or NaviNet 194

Questions? 195