AETNA BETTER HEALTH OF NEBRASKA 2014 Provider Forum

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1 OF NEBRASKA 2014 Provider Forum

2 Welcome and introductions Medical Directors Dr. Deb Esser Dr. Carol Lacroix Executive Shelley Wedergren, Chief Executive Officer Cassandra Price, Chief Operating Officer Contracting Chris Stark Tammy Clemens ProviderRelations Rick Helms Jennifer Bstandig Additional reps to be hired 2

3 Aetna Better Health of Nebraska Effective August 25, 2014 CoventryCares of Nebraska will become Aetna Better Health of Nebraska OF NEBRASKA 3

4 Our core values Behave ethically and act with integrity Be accountable and honor commitments Be passionate about the people we serve Set high expectations, be decisive and execute Communicate with candor Listen to customers, prioritize and deliver value Anticipate the future and make a difference Trust and respect each other Coach, mentor and continuously learn Be courageous, try new things and innovate Be collaborative, caring and optimistic Be open to all voices and ideas 4

5 Our members the center of what we do Quality Management Provider Relations & Provider Network Appeals & Grievances Member Services & Member Advocates Medical Management Operations & Enrollment Member Collaborative Services 5

6 Provider support Claims inquiry/claims research (Provider Services) Provider relations Member services Prior authorization Provider website and secure web portal Reconsiderations, appeals and grievances Quality Programs 6

7 Claims Inquiry/Claims Research Claims Inquiry/Claims Research will: Assist with claims questions, inquiries and reconsiderations Review claims or remittance advice Assist with prior authorization questions View recent updates Locate forms Find a participating provider or specialist Assist with changes to a practice (add locations, provider termination, etc.) Obtain a secure web portal or member care Login ID Claims Inquiry/Claims Research can be reached at (888) (no change in phone number) 7

8 Provider Relations Aetna Better Health of Nebraska has dedicated Provider Relations staff Provider Relations staff will visit provider offices regularly throughout the year to ensure Aetna is meeting their needs and addressing concerns Provider Relations will: Provide education to provider offices on a variety of topics Provide support on Medicaid policies and procedures Provide provider contract clarification Assist with demographic changes, terminations, and initiation of credentialing Monitor compliance with applicable State and Federal agencies Conduct annual Provider Satisfaction Survey Conduct member compliant investigation Maintain the provider directory Be a point of contact for provider concerns Provider Relations can be reached at (888)

9 Member Services Member Services will: Provide information on eligibility and benefits Assist providers with non-compliant members and/or discharges Assist members with available programs and resources Assist member in finding providers Assist members in filing grievances or appeals Member Services can be reached at (888) (no change in phone number) 9

10 Member ID cards New ID cards will be mailed to members prior to August 25th If the member does not have his/her new ID card, you can obtain enrollment verification at A temporary ID card also can be faxed to a provider s office by request; please contact Member Services ( ) Members can request a new copy of their card anytime by contacting Member Services 10

11 Member ID numbers Aetna Better Health will use the existing Medicaid ID number issued by the State of Nebraska Aetna Better Health of Nebraska members no longer use the CoventryCares ID numbers Aetna Better Health will accept the CoventryCares ID for 90 days after August 25th Then the Medicaid ID/Aetna Better Health of Nebraska ID will be required 11

12 Member eligibility Aetna Better Health of Nebraska member eligibility can be verified through Provider portal ( or Member Services ( ) Verifying current member eligibility through DirectProvider.com will be disabled as of 8/25/14 for the Medicaid product 12

13 Prior Authorization Please review the authorization requirements effective August 25 Authorizations provided by CoventryCares prior to August 25 will be honored through this transition Requesting new prior authorizations on and after August 25 Online: CareWebQI, access through the provider portal Phone: (888) Fax: (866) The DirectProvider.com authorization request function will be disabled effective 8/25/14 for the Medicaid product; historical authorization information will remain available 13

14 Medical criteria Aetna Better Health of Nebraska will utilize Hearst Corporation s MCG evidence-based care guidelines (formerly Milliman Care Guidelines) effective August 25, 2014 Medical criteria information is available on the provider portal McKesson's InterQual Criteria used by CoventryCares of Nebraska will no longer be effective August 25,

15 Claims submission NEW Aetna Better Health of Nebraska EDI payer ID: NEW claims mailing address: Aetna Better Health of Nebraska P.O. Box Phoenix, AZ All claims for CoventryCares of Nebraska or Aetna Better Health should be filed to Aetna Better Health beginning 8/25/14 All claims should be submitted on the most current claim forms 15

16 Claim timely filing Timely filing for Aetna Better Health of Nebraska for initial claims submission follows your Coventry Health Care of Nebraska HMO contract 90 days unless your contract differs For questions regarding your timely filing deadline, please contact Claims Inquiry/Claims Research or Provider Relations Providers will have 180 days from the date of an initial claim denial to submit corrected claims or requested information 16

17 Claim requirements: Taxonomy, NPI, Zip+4, NDCs Beginning 8/25/2014, the correct combination of billing provider taxonomy, rendering provider NPI and billing zip+4 registered with the State of Nebraska will be required on all claims If the combination billed does not match what is registered with the State of Nebraska, claims will deny, requesting corrected information Please reference your Nebraska Department of Health and Human Services provider enrollment approval letters to verify the information being billed is what is registered with the State Please check with your electronic claims vendor to ensure this information is being transmitted appropriately Beginning 8/25/2014, NDC numbers must be submitted, if appropriate Must be accurate, current, and valid NDCs 340B provider should not submit NDCs 17

18 Remittance advice For claims processed on and after 8/25/14, a new Aetna Better Health of Nebraska remit will be available Remittance advice will be available within the new provider portal ERAs will continue through your electronic vendor, if applicable Historical claims and remit information will remain available on DirectProvider.com for 180 days; claim adjustment request functions will be disabled as of 8/25/14 18

19 Remittance advice 19

20 Provider website Our provider website contains resources to assist provider interactions with Aetna Better Health of Nebraska: View and download our provider manual, communications and newsletters Searchable provider directory Reconsideration and appeal forms Clinical practice guidelines Member materials Fraud & abuse information and reporting Gateway to our secure provider web portal Information on resubmission and provider appeals Review the member and provider handbooks 20

21 Provider portal DirectProvider.com will no longer be the provider portal for the Medicaid product effective August 25th Please visit: Providers will be able to Search member eligibility and verify enrollment Search and initiate authorizations (CareWebQI) Search claims status View claim detail, explanation of benefits and remittance advice View provider lists and panel roster Contact the health plan via secure messaging 21

22 Provider portal All providers must register for the provider web portal prior Submit web portal e-registration forms online See our provider web portal navigation guide to learn more about the provider web portal available on the provider website Each TIN will have one account, with a primary representative The primary representative can add authorized representatives within their office to their account Contact Provider Relations to register and receive a demonstration 22

23 Electronic Tools Electronic claims submission Payor ID Less paperwork, less wasted time, and a more efficient office Lower claims rejection rates Faster claim delivery than by traditional mail clean claims mean less money wasted for reprocessing Faster claim payment to your office Ability to easily identify and resubmit claims with missing or invalid data 23

24 Electronic tools Electronic funds transfer (EFT) Electronic funds transfer (EFT) will be our standard payment method for provider reimbursement as of August 1, 2014 Electronic remittance advice (ERA files) RAs will no longer be mailed to your office effective August 1, 2014, or 30 days after you sign up for EFT Please work with your clearinghouse to ensure you can receive ERA & have the correct file paths Enroll in EFT/ERA electronically by visiting our Secure Web Portal Paper forms can be found on the provider website Sign up for EFT/ERA Please contact Provider Relations at or with questions or to check EFT enrollment status. 24

25 Claim resubmissions & reconsiderations Resubmission claims may be sent electronically Label all corrected claims as Corrected Claim on the claim form Send all claim lines again, not just the line being corrected Send paper reconsideration claims with attached documentation to: Aetna Better Health of Nebraska Attn: Claims Resubmission/Reconsideration P.O. Box Phoenix, AZ Please use the Reconsideration Form Found on the provider website 25

26 Appeals Our provider appeals process is utilized to dispute an adverse action of a denial, reduction or termination of a requested service Post-service appeals are initiated in writing by mail Please utilize the Provider Appeals Form located on our website The appeal must specifically state the factual and legal basis for the appeal and the relief requested Documents to support the appeal should be provided, such as a copy of the claim, remittance advice, medical review sheet, medical records, correspondence, etc. Appeals challenging a claim denial or adjudication must be made within 12 months from the date the claim processed Appeals on issues other than claims denials, such as authorization denials, must be filed no later than 90 days after the date of the adverse action Appeals are reviewed within 90 days Once you receive a notice of resolution, this will conclude your appeal process Before filing an appeal regarding a claim, providers should exhaust the Claims Reconsideration Process. 26

27 Grievances A grievance is any written or verbal expression of dissatisfaction over a matter other than an action by a member or provider authorized in writing to act on the member's behalf. Examples: Quality of care, quality of service, provider behavior, office environment, potential fraud and abuse Grievance process Acknowledged within 5 calendar days Investigated by provider relations, quality management and/or by the State s Ombudsman May involve office site visits and assessments Egregious grievances may warrant peer review and/or trigger an off-cycle credentialing review Resolution and response to the member within 90 calendar days 27

28 Fraud, waste & abuse Special Investigation Unit (SIU) Monitoring of fraudulent billing practices Verification of services Documentation review Suspected fraud, waste or abuse can be reported by Phone: (888) Electronically: Fraud, Waste, & Abuse Reporting Form on our website at 28

29 Quality programs EPSDT Monthly post card mailing & reminder calls Well Woman Monthly birthday card mailing Case Management Pediatric, adult, perinatal Disease Management Diabetes, congestive heart failure, asthma, COPD Member Advocates Prevention and Wellness Patient Centered Medical Homes Readmission Prevention ED utilization, inpatient admission & readmission reports HEDIS 29

30 Provider credentialing The Aetna Better Health of Nebraska credentialing process will be monitored by a Aetna Better Health of Nebraska dedicated Credentialing Coordinator Contact your Provider Relations representative to initiate credentialing of a new provider Please remember to contact the Coventry Commercial plan Aetna utilizes the CAQH online, universal application Aetna Better Health of Nebraska will not be able to assign retroactive effective dates for new providers 30

31 Provider manual The provider manual is a resource for policies and procedures for Aetna Better Health of Nebraska Access it online at: Please review this manual for additional information about Aetna Better Health of Nebraska and: Contacts Provider rights and responsibilities Credentialing Member eligibility and enrollment Billing and claims Reconsiderations, appeals and grievances 31

32 Skilled Nursing Facility billing changes Level of care billing changes went into effect August 1, 2014 and will continue with Aetna Better Health of Nebraska for all skilled nursing facility billing Please take handouts regarding Skilled Nursing Facility billing changes, if needed 32

33 Things to do Prior to 8/25/2014 Sign up for EFT/ERA if not already completed Update electronic systems with new payor ID Update clearinghouse info as needed View the website: Continue to use CoventryCares phone numbers and mailing addresses Please reference the DHHS provider enrollment to ensure your office is billing with the correct billing provider taxonomy, rendering provider NPI and billing zip+4 On and after 8/25/2014 Send all claims to new payor ID/claims address Call Provider Services with claims inquiries Send all reconsiderations to new claims address Contact new Provider Relations with questions or concerns Register for the provider portal: 33

34 Thank you

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