Скачать презентацию Indiana Care Select Presented by EDS Provider Field Скачать презентацию Indiana Care Select Presented by EDS Provider Field

c129f59e919db8432a96e2cb71e32eb3.ppt

  • Количество слайдов: 42

Indiana Care Select Presented by EDS Provider Field Consultants October 2009 Indiana Care Select Presented by EDS Provider Field Consultants October 2009

Agenda • Session Objectives • Care Management Organizations • Enrollment Broker • Program Population Agenda • Session Objectives • Care Management Organizations • Enrollment Broker • Program Population • Eligibility Verification Systems • Primary Medical Providers • Program Features • Care Coordination Conference • Hospital Treatment Notification • Claims Processing • Referrals • Self-Referred Services • Prior Authorization • Helpful Tools • Questions INDIANA CARE SELECT 2 / October 2009

Session Objectives Following this session, providers will be able to: • Identify the two Session Objectives Following this session, providers will be able to: • Identify the two care management organizations (CMOs) • Identify the enrollment broker • Identify when a member is eligible for Care Select • Understand the role of the primary medical provider (PMP) • Understand the various features of the program • Understand the new hospital notification process • Be familiar with the referral process INDIANA CARE SELECT 3 / October 2009

Care Management Organizations • Two health plans function as CMOs for the Care Select Care Management Organizations • Two health plans function as CMOs for the Care Select program – ADVANTAGE Health Solutions • www. advantageplan. com • 1 -800 -784 -3981 – Care Select • 1 -800 -269 -5720 - Traditional – MDwise • www. mdwise. org • 1 -866 -440 -2449 – Care Select INDIANA CARE SELECT 4 / October 2009

Enrollment Broker • MAXIMUS performs the following functions for Care Select: – Provides counseling Enrollment Broker • MAXIMUS performs the following functions for Care Select: – Provides counseling to members in the selection of a PMP that best meets their needs – Gives unbiased education about the Care Select program – Facilitates initial member enrollment in the program – Performs member-initiated PMP changes • Contact the enrollment broker at: 1 -866 -963 -7383 INDIANA CARE SELECT 5 / October 2009

Population Served • The following IHCP members are covered by the Care Select program: Population Served • The following IHCP members are covered by the Care Select program: – Aged – Blind – Physically and mentally disabled – Members receiving adoption assistance – Members in the waiver program – M. E. D. Works participants (Medicaid for Employees with Disabilities) – Wards of the court and foster children INDIANA CARE SELECT 6 / October 2009

Ineligible Members • The following IHCP members are not covered by the Care Select Ineligible Members • The following IHCP members are not covered by the Care Select Program: – Members on Spend-down – Medicare Medicaid dually eligible – Qualified Medicare beneficiary (QMB) members – Specified low-income Medicare beneficiary (SLMB) members – Members in the hospice program – Undocumented aliens – Aid to Residents in County Homes (ARCH) members – Members enrolled in the 590 Program – Members enrolled in the Breast and Cervical Cancer Treatment Services program INDIANA CARE SELECT 7 / October 2009

Eligibility Verification • Once members are assigned to the Care Select program, the Eligibility Eligibility Verification • Once members are assigned to the Care Select program, the Eligibility Verification Systems (EVS) identify the following: – Member is eligible for Package A Standard Plan – Care Select PMP name with contact telephone number – Assigned CMO with contact telephone number • Providers should verify member eligibility on each date of service • Three EVS are available 24 hours per day: – Web inter. Change – Automated Voice Response (AVR) – Omni swipe machine INDIANA CARE SELECT 8 / October 2009

Eligibility Verification Systems Web inter. Change Care Select PMP and MCO information is found Eligibility Verification Systems Web inter. Change Care Select PMP and MCO information is found in the Managed Care section of the screen INDIANA CARE SELECT 9 / October 2009

Eligibility Verification Systems Web inter. Change • The following enhanced features are only available Eligibility Verification Systems Web inter. Change • The following enhanced features are only available through Web inter. Change: – Detailed third-party liability (TPL) information – Online TPL update requests INDIANA CARE SELECT 10 / October 2009

Eligibility Verification Systems Automated Voice Response System AVR provides the following: • Member eligibility Eligibility Verification Systems Automated Voice Response System AVR provides the following: • Member eligibility verification • Benefit limits • Prior authorization • Claim status • Check write Contact AVR at (317) 692 -0819 in the Indianapolis local area or 1 -800 -738 -6770 AVR instructions are in Chapter 3 of the IHCP Provider Manual INDIANA CARE SELECT 11 / October 2009

Eligibility Verification Systems Omni • Is cost effective for high-volume providers • Uses plastic Eligibility Verification Systems Omni • Is cost effective for high-volume providers • Uses plastic Hoosier Health card • Allows manual entry • Prints two-ply forms • Requires upgrade for benefit limit information (refer to IHCP Provider Bulletin BT 200711) See Chapter 3 of the IHCP Provider Manual for more information INDIANA CARE SELECT 12 / October 2009

Primary Medical Provider Enrollment • To be a Care Select PMP, the provider must: Primary Medical Provider Enrollment • To be a Care Select PMP, the provider must: – Be enrolled in the Indiana Health Coverage Programs (IHCP) – Sign the Care Select Addendum and submit it to chosen CMO – Provide demographic, scope of practice, and panel size information to the CMO(s) • The CMO will electronically enroll the PMP in Indiana. AIM via the secure Web inter. Change INDIANA CARE SELECT 13 / October 2009

Primary Medical Providers • Physicians from the following specialties are eligible to enroll as Primary Medical Providers • Physicians from the following specialties are eligible to enroll as PMPs and will receive autoassignments: – Family Practitioner – General Internal Medicine – General Pediatrics – OB/GYN • Other physician specialties may enroll as a PMP but will not receive members through autoassignments – Members must actively choose these providers to be their PMP INDIANA CARE SELECT 14 / October 2009

Program Features • ADVANTAGE Health Solutions and MDwise: – Maintain and update their contracted Program Features • ADVANTAGE Health Solutions and MDwise: – Maintain and update their contracted PMPs’ demographic, scope of practice, and panel size information Note: PMPs are required to communicate changes to their respective CMO(s) • Care Select and Hoosier Healthwise panels are maintained separately • PMPs have flexibility in determining panel size – Panel size can be as low as 1 • PMPs may enroll with one or both CMOs INDIANA CARE SELECT 15 / October 2009

Program Features • PMPs receive a two-digit certification code quarterly from EDS • PMPs Program Features • PMPs receive a two-digit certification code quarterly from EDS • PMPs receive member rosters generated on the 11 th and 26 th of each month – This roster informs who is included in the PMP’s panel – Rosters are sent to the Mail To address on file in the provider’s profile • PMPs also receive an administrative fee roster on the 3 rd Wednesday of each month – This roster coincides with the administrative fee paid to the PMP each month – PMPs receive a $15 per member per month administrative fee • Members included in the administration fee roster differ from those included in the member roster due to PMP changes during the month • The Remittance Advice (RA) issued on the following Tuesday reflects the PMP administrative payment INDIANA CARE SELECT 16 / October 2009

Care Coordination Conference • Care coordination conferences between the CMO and PMP – Bill Care Coordination Conference • Care coordination conferences between the CMO and PMP – Bill care coordination conferences with CPT 99211 with the SC modifier – Office or other outpatient visit for the evaluation and management of an established patient – Reimbursement for care coordination conferences is limited to two one-hour conferences per rolling 12 -month period – Care coordination conferences are reimbursed at $40 for each encounter INDIANA CARE SELECT 17 / October 2009

Care Coordination Conference Care Coordination by Nurse Practitioner • Reimbursement for care coordination conferences Care Coordination Conference Care Coordination by Nurse Practitioner • Reimbursement for care coordination conferences can also be made when performed by a nurse practitioner (NP) employed by the same group as the PMP • When the nurse practitioner is enrolled in the IHCP, indicate the NP’s rendering National Provider Identifier (NPI) on the claim • The nurse practitioner is not required to be enrolled in the IHCP. When the NP is not enrolled: – Append the SA modifier (for example, 99211 SC SA) – Report the rendering NPI of the PMP on the claim INDIANA CARE SELECT 18 / October 2009

Care Coordination Conference Care Coordination Edits • EOB 1050 – The recipient is enrolled Care Coordination Conference Care Coordination Edits • EOB 1050 – The recipient is enrolled in the Care Select Program. Care Management service must be billed by the member’s assigned Care Select PMP or nurse practitioner in the same group as the Care Select PMP – Applies when claim for a care coordination conference is received by a provider other than the member’s Care Select PMP, or a nurse practitioner who is not in the same group as the PMP • EOB 6925 – Care Select Care Coordination service is limited to two units of service per member, per rolling 12 months – Applies when a claim for care coordination service is received after the benefit limit is reached INDIANA CARE SELECT 19 / October 2009

Outpatient Treatment and Inpatient Admission Notification • Aligns the Care Select goals of managing Outpatient Treatment and Inpatient Admission Notification • Aligns the Care Select goals of managing member care • Hospital staff is responsible for checking eligibility • Care Select Notification button will be present on Care Select member eligibility • Hospital staff will enter: – Date of treatment – Type of treatment – Presenting signs, symptoms and/or diagnosis INDIANA CARE SELECT 20 / October 2009

Care Select Notification INDIANA CARE SELECT 21 / October 2009 Care Select Notification INDIANA CARE SELECT 21 / October 2009

Notification Screen Completed INDIANA CARE SELECT 22 / October 2009 Notification Screen Completed INDIANA CARE SELECT 22 / October 2009

Outpatient Treatment and Inpatient Admission Notification • Once the information is saved, CMO is Outpatient Treatment and Inpatient Admission Notification • Once the information is saved, CMO is notified of visit • CMO’s are better able to assist with facilitation of care and resources when member is discharged • CMO’s assist hospital staff in PMP notification • CMO’s assess the nature of the visit and provide follow up management in conjunction with hospital clinical personnel INDIANA CARE SELECT 23 / October 2009

Covered Services • A listing of covered services is available by referencing RFS 7 Covered Services • A listing of covered services is available by referencing RFS 7 -62 Attachment E: Care Select Program Description and Covered Benefits at www. indianamedicaid. com in the Managed Care section – Care Select home page INDIANA CARE SELECT 24 / October 2009

Claims Processing • EDS processes claims for Care Select members • The CMOs review Claims Processing • EDS processes claims for Care Select members • The CMOs review claims that suspend due to medical policy audits – Claims are reviewed by the CMO to which the member is assigned on the date of service • Traditional Medicaid fee-forservice claims that suspend for medical policy audits are reviewed by ADVANTAGE Health Solutions INDIANA CARE SELECT 25 / October 2009

Claims Processing • Claims submitted by providers other than the PMP, must contain the Claims Processing • Claims submitted by providers other than the PMP, must contain the PMP’s two-digit certification code and NPI, unless the service is exempt from PMP requirements (self refer): – CMS 1500 form • Field 17 B must have PMP NPI • Field 19 must have the two-digit certification code – UB-04 form • Field 37 must have the two-digit certification code • Field 78 must have the PMP NPI INDIANA CARE SELECT 26 / October 2009

Claims Processing Certification Code Edits • Claims systematically deny when services requiring a referral Claims Processing Certification Code Edits • Claims systematically deny when services requiring a referral contain a missing or invalid certification code. Edits include: – 1047 – The Certification Code is Missing-Care Select. Please verify and resubmit. – 1048 – The Certification Code is Invalid-Care Select. Please verify and resubmit. – 1049 – The recipient is enrolled in the Care Select Program. Claim must have recipient’s primary medical provider information. Please provide information and resubmit. INDIANA CARE SELECT 27 / October 2009

Referrals – Coordinating Care • Referrals to other providers must be made by telephone Referrals – Coordinating Care • Referrals to other providers must be made by telephone or in writing • PMPs provide specialists with their NPI and certification code • PMPs provide hospitals with their NPI, certification code (outpatient services) INDIANA CARE SELECT 28 / October 2009

Self-Referred Services • Self-referred services do not require a certification code or PMP authorization. Self-Referred Services • Self-referred services do not require a certification code or PMP authorization. They include: – Podiatry – Chiropractic – Mental health – Dental – Vision – Family planning – HIV/AIDS targeted case management – Immunizations – Diabetes self-management – Pharmacy INDIANA CARE SELECT 29 / October 2009

Self-Referred Services Ancillary Services • Self-referred ancillary services include: – Emergency services (emergency primary Self-Referred Services Ancillary Services • Self-referred ancillary services include: – Emergency services (emergency primary diagnosis code) – Lab – Radiology – Anesthesia – Transportation – Durable Medical Equipment / Home Medical Equipment – Home Health Services – Waiver Services INDIANA CARE SELECT 30 / October 2009

Self-Referred Services Outpatient Therapy Services • Self-referred outpatient therapy services include: – Physical Therapy Self-Referred Services Outpatient Therapy Services • Self-referred outpatient therapy services include: – Physical Therapy (specialty 170) – Occupational Therapy (specialty 171) – Respiratory Therapy (specialty 172) – Speech Therapy (specialty 173) • Other self-referred services include: – School Corporations – First Steps – Medical Review Team (MRT) – Pre-Admission Screening and Resident Review (PASRR) INDIANA CARE SELECT 31 / October 2009

Prior Authorization • Each CMO is responsible for processing medical service PA requests and Prior Authorization • Each CMO is responsible for processing medical service PA requests and updates for members assigned to their organization • Traditional Medicaid fee-for- service PA requests are processed by ADVANTAGE Health Solutions • Pharmacy PA requests are processed by Affiliated Computer Services (ACS) INDIANA CARE SELECT 32 / October 2009

Prior Authorization • Alphanumeric PA numbers identify the CMO that processed the PA • Prior Authorization • Alphanumeric PA numbers identify the CMO that processed the PA • Providers must verify member eligibility to determine the CMO that will process the PA or update request – CMO information via Web inter. Change is real time – Send the PA request to the assigned CMO as of the date of the request – Send PA updates to the assigned CMO to which the member was assigned when the original PA was requested – If the member changes from one CMO to the other before the PA request is approved, the originating CMO will transfer the PA approval to the receiving CMO INDIANA CARE SELECT 33 / October 2009

Prior Authorization Suspended Requests • PA requests are suspended when additional information is needed Prior Authorization Suspended Requests • PA requests are suspended when additional information is needed by the member and/or provider • Requested documentation must be received within 30 calendar days • Suspended requests that are later approved are authorized with the dates of service indicated on the original request • When a member is reassigned to a different CMO after a PA request is suspended: – Providers must send the added documentation to the CMO that initiated the request INDIANA CARE SELECT 34 / October 2009

Prior Authorization Outstanding Prior Authorizations • Members can change between traditional Medicaid fee -for-service, Prior Authorization Outstanding Prior Authorizations • Members can change between traditional Medicaid fee -for-service, Hoosier Healthwise, and Care Select • The receiving organization must honor PAs approved by the prior organization for the first 30 days following the reassignment, or for the remainder of the PA dates of service, whichever comes first Example: Member transitions from Hoosier Healthwise MCO to a Care Select CMO June 14, 2009. The MCO approved PA for dates of service 5/22/09 through 7/20/09. The Care Select CMO must honor the approved PA for 30 days from June 14, 2009. INDIANA CARE SELECT 35 / October 2009

Prior Authorization Request Sent to Wrong CMO • Paper and faxed requests are rejected Prior Authorization Request Sent to Wrong CMO • Paper and faxed requests are rejected – Requesting provider will receive a decision letter advising of rejected status – The decision letter advises where the PA should have been sent • PA requests sent electronically via the 278 transaction are rejected with reason code 78 – Subscriber/Insured not in Group/Plan identified – Requesting provider does not receive a decision letter • Providers will need to resubmit the PA request to the appropriate CMO • PA requests sent via Web inter. Change are systematically routed to the correct CMO INDIANA CARE SELECT 36 / October 2009

Prior Authorization Hearing, Appeal, and Administrative Review • Providers may exercise PA appeal rights Prior Authorization Hearing, Appeal, and Administrative Review • Providers may exercise PA appeal rights to the organization that denied the PA request – If the member is reassigned to another program after the PA request is denied, the provider may send a PA request to the new organization, or appeal to the organization that denied the request – Appeals sent to the wrong CMO are returned to the provider unprocessed • Refer to Chapter 6 of the IHCP Provider Manual regarding the hearing, appeal, and administrative review procedures INDIANA CARE SELECT 37 / October 2009

Prior Authorization Web inter. Change • The following provider types can submit PA requests Prior Authorization Web inter. Change • The following provider types can submit PA requests via Web inter. Change: – Chiropractor – Dentist – Doctor of Medicine – Doctor of Osteopathy – Home Health Agency (authorized agent) – Hospice – Hospitals – Optometrist – Podiatrist – Psychologist endorsed as a Health Service Practitioner in Psychology (HSPP) – Transportation providers INDIANA CARE SELECT 38 / October 2009

Prior Authorization Contact Information • ADVANTAGE Health Plan (fee-for-service) P. O. Box 40789 Indianapolis, Prior Authorization Contact Information • ADVANTAGE Health Plan (fee-for-service) P. O. Box 40789 Indianapolis, IN 46240 800 -269 -5720 • MDwise – CMO P. O. Box 44214 Indianapolis, IN 46244 -0214 866 -440 -2449 • ADVANTAGE Health Plan – CMO P. O. Box 80068 Indianapolis, IN 46280 800 -784 -3981 • ACS 866 -879 -0106 866 -780 -2198 (Fax) INDIANA CARE SELECT 39 / October 2009

Helpful Tools Avenues of Resolution • IHCP Web site at www. indianamedicaid. com • Helpful Tools Avenues of Resolution • IHCP Web site at www. indianamedicaid. com • Care Select E-mail: [email protected] in. gov • IHCP Provider Manual (Web, CD-ROM, or paper) • Customer Assistance – 1 -800 -577 -1278, or – (317) 655 -3240 in the Indianapolis local area • Written Correspondence – P. O. Box 7263 Indianapolis, IN 46207 -7263 • Provider Relations Field Consultant – View a current territory map and contact information online at www. indianamedicaid. com INDIANA CARE SELECT 40 / October 2009

Questions October 2009 Questions October 2009

Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W 374 Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W 374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St. , Suite 1150 Indianapolis, IN 46204 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. October 2009