Fallon Total Care Provider Orientation 2014
AGENDA Introductions Fallon Total Care Member enrollment Model of Care Doing business with FTC Provider Tools Q&A 2
About Fallon Total Care Fallon Total Care is a wholly-owned subsidiary of Fallon Community Health Plan (FCHP). FCHP is the number one Medicaid health plan in the nation according to the National Committee for Quality Assurance s (NCQA s) Medicaid Health Insurance Plan Rankings for 2012-2013, and currently serves the over-65 Medicare and Medicaid dually eligible population in Massachusetts. Fallon Total Care provides coordinated care and coverage for individuals ages 21-64 who are: dually eligible for Medicare and MassHealth live in the service area: Worcester, Hampshire and Hampden Counties are enrolled in Medicare Parts A and B are eligible for Medicare Part D are eligible for MassHealth Standard or MassHealth CommonHealth With Fallon Total Care, enrollees receive a comprehensive package of medical, behavioral, social, and long-term care services. There are no premiums, co-payments, or coinsurance for the member. A team of physicians, nurses, social workers, Independent Living and Long-Term Services and Supports Coordinators, and other health care professionals work together with the enrollee to build a personalized care plan for each member. 3
Member Enrollment Members enrollment starts with the MassHealth Enrollment Center Elective selection Member must complete enrollment decision form sent by MassHealth to member via mail Member can call MassHealth at 1-800-841-2900 M-F 8 AM to 5 PM Auto assignment Individuals who do not make a decision to enroll in a One Care Plan will be automatically assigned to a One Care Plan Auto assignments: January 1, 2014; April 1, 2014; July 1, 2014 Auto assignment notices are sent to member 60 days prior to effective date. (ex: notice sent in November 2013 for a January 2014 auto assignment) MassHealth electronically sends enrollment files to FTC Enrollments are effective the first of the month following the completed MassHealth enrollment Members can disenroll from a One Care plan at any time. Effective date is the first of the next month Members can switch plans or opt-out of the entire One Care program. 4
Benefits Available All MassHealth allowable benefits All Medicare allowable benefits Covered services as part of the Plan of Care: Day services Home care services Respite care Peer support/counseling/navigation Transitional assistance (across settings) Home modifications Community Health Workers Medication management Durable medical equipment (training in usage, repairs, modifications) Environmental Aids and Assistive/Adaptive Technology Non-Medical transportation Prescription and over-the-counter medications on the Fallon Total Care formulary Behavioral Health diversionary services 5
Model of Care (MOC) Integration Philosophy Member-directed integration of coordinated medical, behavioral and long-term services and supports at the plan and coordination at the provider (point-of-service) level. Overarching Goal of the MOC Provide a member-directed integrated plan of care with high quality delivery of services that improve our members health and support cost management. 6
Fallon Total Care Model of Care Case review Social services Individual Care Plan Centralized Enrollee Record (CER) Disease Mgmt. Vocational services Eligibility/ benefits PCA & other HCBS Case Manager LTSS Coordinator Specialists and Agency Behavioral CM Health Provider Peer Support Specialist Credentialing DME Transportation Homebased services Member services TCM/Rehab services Crisis services Pharmacist Day treatment PCP Navigator Wellness Member Social Workers Screening & assessment Family and Supports 24/7 coverage Judicial service Quality Programs Skilled Home Care Long-term Care Copyright 2012. All Rights Reserved. This material is owned by Fallon Community Health Plan, Inc. 7
Navigator (Care Coordinator) Serves as the advocate for the Enrollee and coordinates all needed services Responsible for the initial outreach to a new Enrollee and for ensuring that all care and services are communicated to the Interdisciplinary Care Team (ICT) Nurse Case Manager Assesses the Enrollee upon enrollment and at scheduled times thereafter Provides consultation to the ICT about all medical conditions and care and the medical aspects of behavioral health conditions Behavioral Health Case Manager May participate in the assessment of needs for new Enrollees and at scheduled times thereafter as clinically appropriate Becomes the lead Case Manager when the Enrollee s primary condition is behavioral Peer Support Specialist Provides consultation to the ICT about principles of recovery and resiliency and the psychosocial needs of individuals with serious mental illness (SMI) Supports Enrollees with SMI by providing opportunities to direct their own recovery and advocacy process and by teaching the acquisition and utilization of skills needed to facilitate the individual s recovery Independent Living and Long Term Services and Supports (IL-LTSS) Coordinator Evaluates the Enrollee s needs for long term services and supports and advocates on the Enrollee s behalf through the development and implementation of an integrated Individualized Plan of Care that will appropriately meet the Enrollee s needs Long Term Care Residence Enrollees: Members of the ICT for Enrollees living in a Long-term Care setting include all of the same providers described above, as well as a Liaison from the facility where the Enrollee resides. For example, an Enrollee living in an assisted living facility will have an Assisted Living Facility Liaison. 8
Process: ICT Meeting Navigator or Case Manager schedule the Interdisciplinary Care Team (ICT) meeting. ICT Meeting In-person meeting with the Member, CM, Navigator, and providers. Family members, other community constituents, and agency representatives are included as authorized by the Member (therapists, specialists, etc.). Members review draft Individual Care Plan (ICP) and make revisions. The agreed upon ICP is signed by the Member and documented in the Centralized Enrollee Record (CER). 9
Process: ICP Implementation Navigator and Case Manager coordinate the implementation and tracking of the Individual Care Plan (ICP). The ICP is a living document and will be assessed for continual appropriateness during Member outreach and communication, and in coordination with the entire ICT. Changes to the ICP can occur at any time based on sentinel events, feedback, and recommendations received by any of the team members. All changes are documented and communicated to stakeholders via CER updates, phone, fax, etc. 10
The Primary Care Provider ICT Lead Things you should know about our PCPs: Licensed by the Massachusetts Board of Registration in Medicine, Advance Practice Nurse (NP), or Physician's Assistant (PA). Either board-certified or board-eligible in Family Practice, Internal Medicine or Primary Care. Obtains annual Continuing Education Credits (CMEs or CEUs). Is a Provider in good standing with the federal Medicare program. 11
Doing business with Fallon Total Care
Credentialing process Fallon Total Care is a member of Healthcare Administrative Solutions, Inc. (HCAS) Initiating credentialing with Fallon Total Care: Fax HCAS enrollment form, W-9 and/or signature page to 1-508-368-9902 (Enrollment form is available at www.hcasma.org. Click on Resources, then HCAS Enrollment Form. ) If provider does not have an existing Council for Affordable Quality Healthcare (CAQH) ID number, one will be sent via mail from CAQH within 5-10 business days. Register and login to CAQH at www.caqh.org to complete the Integrated Massachusetts Application (IMA). For questions or assistance with the IMA process call CAQH at 1-888-599-1771. Enrollment form must be completed by contract administrator. 13
Behavioral Health Services that require prior authorization Plan prior authorization must be obtained by the requesting clinician for the following: Inpatient behavioral health services (except in an emergency) Outpatient Psychological testing Outpatient Electroconvulsive Therapy (ECT) Outpatient Trans-cranial Magnetic Stimulation (TMS) Outpatient Neuropsychological testing Community-based diversionary behavioral health care services, including: o Community crisis stabilization o Community Support Program (CSP) o Partial hospitalization o Acute treatment services for substance abuse o Clinical support services for substance abuse o Psychiatric day treatment o Intensive outpatient program o Structured outpatient addiction program o Program of Assertive Community Treatment (PACT) Note: A listing of codes requiring prior authorization can be found in the online Provider Manual located at fallontotalcare.com. Or, for the most updated information, you can use the procedure code look-up tool also located at fallontotalcare.com. 14
Prior Authorization Procedure Beacon Health Strategies (BHS) is performing utilization management for Behavioral Health Services requiring authorization*. Request Authorization Telephonically for: Inpatient Services Diversionary Community based health services Certain Outpatient services: ECT (Electroconvulsive Therapy) TMS (Trans Magnetic Stimulation) Request Authorization electronically through BHS eservices for: Level lv Detoxification Psychological testing Neuropsychological testing Process: Call the FTC Provider Line: 1-855-508-4715, prompt 3, and select option 1 to be directly connected to BHS. Note: A listing of codes requiring prior authorization can be found in the online Provider Manual located at fallontotalcare.com. Or, for the most updated information, you can use the procedure code look-up tool also located at fallontotalcare.com. *Beacon Health Strategies will not process retroactive prior authorizations. Process: Submit authorization request via BHS eservices. Register for eservices on the BHS. website: www.beaconhealthstrategies.com Plan name: Fallon Total Care 15
Behavioral Health Services Referral Procedure Outpatient mental or behavioral health care is covered and does not need a referral or prior approval except for psychological testing, Outpatient Electroconvulsive Therapy (ECT), Trans Magnetic Stimulation (TMS) and Neuropsychological testing that need prior approval. Enrollees can self-refer to an in-network provider for some Behavioral Health and Substance use services. Enrollees are encouraged to include the ICT when deciding to seek outpatient services. Prior authorization is not needed and there are no visit limits for Outpatient BH covered services. Il-LTSS (Independent Living and Long-Term Support Services) and Peer supports require a referral from the ICT. Note: A list of codes requiring prior authorization can be found in the online Provider Manual located at fallontotalcare.com. Or, for the most updated information, you can use the procedure code look-up tool also located at fallontotalcare.com. 16
RX Prior Authorization Requests Fallon Total Care utilizes CVS Caremark as a pharmacy benefit manager. The goal is to make the prior authorization process more efficient to better serve both our providers and members. CVS Caremark processes prior authorization requests for patient selfadministered drugs including oral medications (pharmacy benefit) and Fallon Total Care will process medical benefit drugs including home infusion (physician-administered drugs). Process for patient-administered drugs (pharmacy benefit) 1. Online through Caremark s epa tool, www.caremark.epa 2. You can also call in your prior authorization to 1-800-309-5849, or fax it to 1-855-633-7673. Process for Physician administered drugs (medical benefit): Fax a completed Fallon Total Care prior authorization form to 1-508-791-5101 Process for Specialty Pharmacy (pharmacy benefit, shipped to member) call CVS/Caremark at 1-800-238-7828 17
Claims: paper & electronic 1. Paper claims - Submit to: Fallon Total Care, P.O. Box 15041, Worcester MA 01615 2. Electronic claims Faster turnaround times HIPAA compliant Eliminates the need for a clearinghouse No transaction fee EDI coordinators: 1-855-508-4715, option 6 or email at edi.coordinator@fallontotalcare.com Electronic claims clearinghouses Emdeon: 1-800-845-6592 (Payor ID #45559 for professional and institutional) Capario (formerly Medavant/ProxyMed): 1-800-792-5256 (Payor ID #45559 for professional) Relay Health (formerly McKesson): 1-800-735-2963 Option 3 or visit their website at relayhealth.com (Payor ID #6744 for professional and Payor ID #6643 for institutional) Note: status checks, invoiced items (such as supply charges for serums and claims requiring attached documentation cannot be submitted electronically. 18
Claims: paper & electronic Filing limit is 60 days or as stated in your contract. Balance billing Fallon Total Care members is not allowed for covered services. Fallon Total Care reserves the right to refuse handwritten claims that are incomplete or illegible. Claim forms should be typed or computer generated to insure appropriate processing. 19
Electronic Claims Submission 1. Providers must submit claims using their assigned NPI number. 2. You must notify Fallon Total Care Provider Relations and the clearinghouse if your practice information changes (e.g., tax number, address changes). 3. New providers in your practice must be credentialed and contracted by Fallon Total Care and enrolled with the clearinghouse. 4. Include membership number (Membership number is the 13-digit number on each membership card. The number will look similar to this: 88882345678*01. You must transmit all 13 of the numbers without the asterisk; example: 8888234567801. The suffix is also required to identify the patient s date of birth. Full name and address must be entered correctly. If a claim contains an invalid or improper membership number, the wrong date of birth, or a misspelled name, it may not file in our system. 20
Electronic Claims Submission, continued 5. Submit exact names as indicated on the membership card (no nicknames or hyphenated names). 6. If you are submitting for services that took place in different settings (e.g., office, outpatient, ER) a separate claim must be submitted for the office visit, the outpatient visit and the ER visit. We cannot process claims when multiple places of service are billed. For more information contact one of our EDI coordinators at: 1-855-508-4715, option 6 or e-mail at edi.coordinator@fallontotalcare.com 21
Claims Status Checks Contact the claims customer service team to check on the status of claims you have submitted. They are available to assist you Monday through Friday from 8 a.m. to 6 p.m. The Claims Customer Service Department can be reached at: Telephone number: 1-855-508-4715, option 2 Fax number: 1-508-797-4292 Please note the following: 1. Status requests can be mailed, faxed or telephoned. Or, you can sign up for our provider tools that will provide status information on our website. 2. Inquiries are limited to three per telephone call. High volume requests should be mailed or faxed. 3. Status checks should be made 45 days after submission of a claim to Fallon Total Care. This allows us time to process your claim and you time to resubmit prior to the filing limit. 4. Please clearly mark the claim STATUS INQUIRY in order to avoid duplicate entry. 5. Please submit claims status requests separately from new dates of service. Please do not submit status requests electronically. 22
Universal Request for Claim Review Form for providers Fallon Total Care utilizes the Request for Claim Review Form developed by the Massachusetts Health Care Administrative Simplification Collaborative. This form is available at fallontotalcare.com. To file the Request for Claim Review Form, mail or fax to: Mail: Fallon Total Care Attn: Request for Claim Review/Provider Appeals P.O. Box 15041 Worcester, MA 01615 Fax: 508-368-9890 23
Claims Adjustments Adjustment A claim that can be corrected and resubmitted. DOB, DOS, procedure code, diagnosis code, invoice required, submission of operative notes Requests for claim adjustments must be submitted within 120 days of the original Remittance Advice Summary (RAS). If submitting a corrected claim via paper, please be sure to: Clearly mark the claim as a Corrected Claim. Complete the Universal Request for Claim Review form available at fallontotalcare.com Mail form and corrected claim to: Fallon Total Care, Attn: Request for Claim Review, P.O. Box 15041, Worcester, MA 01615 Or fax to: 508-368-9890 24
Electronic Claim Adjustments Electronic claim adjustments now available UB and CMS 1500 claim adjustments can be sent to Fallon Total Care electronically by using the replacement claim bill type 7 in CLM05 segment Adjusted claims must have: Same client/account # as original claim Same billing provider/pay to All claim lines need to be resubmitted Adjustment examples include: Procedure and diagnosis code changes Removing or adding charges Updating a member Updating an authorization made after the original claim was processed For more information contact Fallon Total Care s EDI Coordinator at 1-855-508-4715, option 6 or email at edi.coordinator@fallontotalcare.com Claim must have finalized status in order to submit adjustment 25
Provider appeals Appeal If you disagree with the determination made by Fallon Total Care, a provider appeal may be submitted. Lack of medical necessity Preauthorization issues Late submission Requests for provider appeals must be submitted within 120 days of the original RAS.* Must be submitted in writing with all pertinent documentation substantiating the request. Appeal determinations will be final and binding and in keeping with the provisions of your contract with Fallon Total Care. Complete the Universal Request for Claim Review Form available at fallontotalcare.com. Mail documentation and form to: Fallon Total Care, Attn: Request for Claim Review/Provider Appeals, P.O. Box 15041, Worcester, MA 01615 Or fax to: 1-508-368-9890 * Reminder: All appeals submitted after 120 days from the date of the original RAS will be denied. 26
Additional information regarding EDI Claims Fallon Total Care does not routinely waive the filing limit for EDI claims. It is the responsibility of a provider s office staff or billing service to process their EDI reports as well as remittance advice summaries on a regular basis and resubmit rejected/problematic claims within the filing limit. Due to the availability of these reporting and tracking tools, it is unusual for the Fallon Total Care Claims department to expect late claim submission. Please resubmit any claims in question immediately. If the claim cannot be resubmitted, office staff should drop the claims to paper and send them directly to Fallon Total Care within your contractual time frame. 27
Provider Tools
Provider Tools To register for accessibility to Provider Tools: 1. Download the registration packet at fallontotalcare.com 2. Complete the form and fax it to: 1-508-797-4292 3. Or mail it to: Fallon Total Care, ATTN: EDI Coordinator, 10 Chestnut St., Worcester, MA 01608-2810 4. Within two to four weeks, you will receive your username and password via the U. S. Postal Service. Once registered, you will have access to these tools on fallontotalcare.com: Eligibility verification Claims metrics reports PCP panel reports PCP Referral monitoring report 29
Also available on fallontotalcare.com Procedure code look-up Provider look-up Provider Manual Forms Request materials Contact us 30
Helpful phone numbers Provider Service Line: 1-855-508-4715 For Customer Service Department (to determine member eligibility or benefit information), prompt 1 For Claims Department, prompt 2 For referrals, prior authorizations or Case Management, prompt 3, then option 1 to be directly connected to Beacon Health Strategies (BHS). For Provider Relations, prompt 4 For Pharmacy Services, prompt 5 For EDI Coordinator, prompt 6 31
Appendix A: ID Card 32
Appendix B: Fallon Total Care business partners Beacon Health Strategies (BHS) Fallon Total Care has partnered with BHS to perform the utilization management of BH inpatient and diversionary services and for after-hours BH crisis needs. Phone 1-855-508-4715, prompt 3, and select option 1 to be directly connected to BHS Website- www.beaconhealthstrategies.com PaySpan (EFT vendor) Fallon Total Care is partnering with PaySpan Health to deliver Electronic Funds Transfers (EFTs), Electronic Remittance Advices (ERAs) and much more. PaySpan Health will give you the option to receive automated payments directly to a bank account or by traditional paper check. We are anticipating Q4 implementation. Updates will be posted fallontotalcare.com 33
Questions and Answers 34