AmeriHealth District of Columbia and PerformCare New Provider Orientation & Training

Transcription

1 AmeriHealth District of Columbia and PerformCare New Provider Orientation & Training May 2013

2 About AmeriHealth D.C. Provider Partnerships Member Eligibility and Benefits Provider Network Information Orientation Agenda Medical Management Utilization Management Claims and Billing Provider E-Services Resources / Important Contact Info Questions? 2

3 About AmeriHealth D.C. 3

4 Who We Are AmeriHealth D.C. is a member of the AmeriHealth Caritas Family of Companies, a leading national managed care organization. AmeriHealth Caritas is headquartered in Philadelphia, Pennsylvania and is a mission-driven health care organization. AmeriHealth Caritas is: A well-established company with nearly 30 years of experience. One of the largest managed care organizations in the United States. An expert in managed care for Medicaid, Medicare and other underserved populations. An industry leader in managing medically-complex members. A national presence, operating in 14 states and touching nearly 5 million lives. A mission-driven company, working to keep families and communities healthy. An organization with diverse expertise, including Medicaid, Medicare Advantage D- SNP, Behavioral Health and Pharmacy Benefits Management (PBM) services. 4

5 Where We Are Medicaid Plans AmeriHealth Caritas Health Plan (PA) Arbor Health Plan (NE) Keystone First Health Plan (PA) LaCare (LA) MDwise Hoosier Alliance (IN) Select Health of South Carolina (SC) Florida True Health (FL) AmeriHealth D.C. (DC) Medicare Advantage (HMO SNP) Plans AmeriHealth VIP CARE (PA) Keystone VIP CHOICE (PA) First Choice VIP CARE (SC) Pharmacy Benefit Management PerformRx (CA, IL, IN, KY, MO, NJ, PA, SC, RI, WA, WV) Behavioral Health Managed Care CBHNP (PA) PerformCare (NJ, IN, SC, DC) 5

6 Who is PerformCare? PerformCare is an AmeriHealth Caritas Company specializing in behavioral health services. PerformCare was formed as Community Behavioral Healthcare Network of Pennsylvania (CBHNP) by a group of providers in Pennsylvania in PerformCare is the delegated manager of behavioral health care services covered by AmeriHealth D.C. We understand the challenges faced by behavioral health providers and are committed to working together to alleviate those challenges and to ensure the best possible care for our members. 6

7 We help people get care, stay well and build healthy communities. Our Mission AmeriHealth delivers the expertise needed for success in helping families to get care and stay well. By partnering with dedicated providers and working with underserved communities, we expect to achieve positive health outcomes throughout the District and the United States. 7

8 AmeriHealth in Washington, D.C. How did AmeriHealth come to Washington, D.C.? AmeriHealth is purchasing certain assets of D.C. Chartered Health Plan, the largest manager of health care for low-income D.C. residents. AmeriHealth will assume responsibility for Chartered s membership and operations on May 1, We will be doing business in the District as AmeriHealth District of Columbia or AmeriHealth D.C. AmeriHealth D.C. has also been chosen by the D.C. Department for Health Care Finance (DHCF) to receive a new contract, effective July 1, Under this contract, AmeriHealth D.C. will continue to serve its Medicaid and Alliance membership for physical and behavioral health, dental, vision and pharmacy services in all eight District Wards. 8

9 Why AmeriHealth D.C.? As a member of the AmeriHealth Caritas Family of Companies, AmeriHealth D.C. is uniquely qualified to provide this underserved population with the coordinated care they deserve. AmeriHealth Caritas care is the heart of our work: Nearly 5 Million Covered Lives 3,000+ Employees NCQA-Accredited 9

10 Why AmeriHealth D.C.? AmeriHealth D.C. is well equipped to provide high-level customer service to members and providers. AmeriHealth s corporate systems and centers currently: Handle more than 8,000 member and provider calls every day in our 24/7 call centers. Process 1.9 million claims each month. (Total of 25.5 million in 2012.) Receive more than 84 percent of provider claims electronically with automatic adjudication rates of more than 80 percent. Handle more than 9.5 million inquiries annually through a robust web-based provider portal. 10

11 Why AmeriHealth D.C.? The success of AmeriHealth s mission-driven programs is evidenced by the national recognition and awards received. All established AmeriHealth Medicaid plans currently rank in the top 19th percentile of Medicaid health plans: AmeriHealth Caritas (Harrisburg Area) Excellent Accreditation Keystone First (Philadelphia Area) Excellent Accreditation MDwise Hoosier Alliance (Indiana) Excellent Accreditation Select Health (South Carolina) Excellent Accreditation Based upon NCQA Health Insurance Plan Rankings , issued September 20,

12 Provider Partnerships 12

13 Provider Partnerships AmeriHealth D.C. understands and values the importance of strong provider partnerships. Our goal is to support providers with the tools needed to do business and care for Plan members. Emphasis on ease of administration and e-solutions for providers. Dedicated local staff that you know and trust will continue to assist you and meet with you face-to-face on a routine basis. Local provider committees offer avenues for input on program development and processes. Focus is placed on patient-centered medical homes to encourage coordination of care and improve the management of services. Excellent provider communication is an organization-wide priority. 13

14 Administrative Ease and E-Health Solutions Administrative efficiency will be achieved through electronic claims submission (EDI), electronic remittance advice (ERA), electronic funds transfer (EFT) and web-based inquiries/reporting. Web-Based Portal Functions Coming Soon: Member Eligibility Third Party Liability Information (TPL) Claims Status & Updates 14

15 Member Eligibility and Benefits 15

16 Who Do We Serve? AmeriHealth District of Columbia offers two products in the District: a Medicaid product (for beneficiaries of the D.C. Healthy Families Program); and, an Alliance product (for beneficiaries of the D.C. Healthcare Alliance Program). The District s Medicaid and Alliance programs are administered through the District of Columbia Department of Health Care Finance (DHCF), by contract with AmeriHealth D.C. Benefit coverage for Medicaid members differs from coverage for Alliance members. Medicaid and Alliance members are identified by two different member identification cards. 16

17 How Do Members Enroll? Eligibility for the Medicaid and Alliance programs is determined by application to the Department of Human Services, Economic Security Administration (ESA). Medicaid Newly-eligible enrollees have 30 days to voluntarily choose a Managed Care Organization (MCO) or health plan, such as AmeriHealth D.C. If an enrollee does not choose an MCO, the enrollment broker automatically assigns the enrollee to an MCO. Newly-eligible enrollees who selected or were assigned to an MCO have an additional 90 days from the date of enrollment to transfer to another MCO. Alliance Newly-eligible enrollees are automatically-assigned to an MCO or health plan, such as AmeriHealth D.C., by the enrollment broker. Enrollees receive notice of the assignment from the enrollment broker and have 30 days from the date of notice to voluntarily select a different MCO. 17

18 Member ID Cards Medicaid Alliance 18

19 How to Verify Member Eligibility As a participating provider, you are responsible to verify member eligibility with AmeriHealth D.C. before rendering services, except when a member requests services for an emergency medical condition. To Verify Eligibility: Use the Interactive Voice Response (IVR) by calling or toll-free at and selecting the appropriate prompts. Call Provider Services at or toll-free at Use AmeriHealth D.C. s real-time eligibility service. Depending on your clearinghouse or practice management system, our real-time service supports batch access to eligibility verification and system-to-system verification, including point of service (POS) devices. Effective June 2013 Visiting the provider area of to access NaviNet a free, web-based application for electronic transactions and information through a multi-payer portal. 19

20 Behavioral Health Benefits Behavioral Health Benefits AmeriHealth D.C. covers many of the behavioral health services available to D.C. Medicaid members. Specialized mental health services provided by the Department of Mental Health and all substance abuse related services, with the exception of inpatient detoxification services at a hospital, are not covered by AmeriHealth D.C. These services are available to all D.C. Medicaid members via other resources as described on the following slides. For Alliance members, the only covered behavioral health service is inpatient detoxification at a hospital. All other services are not covered by AmeriHealth D.C. Alliance program. 20

21 What Behavioral Health Benefits are Covered? The AmeriHealth D.C. Medicaid benefit package for behavioral health includes: Note: Coverage for certain services depends on medical-necessity and prior authorization of the service. o Diagnostic and assessment services o Physician and mid-level practitioner visits o Up to ten sessions of individual counseling, group counseling, family counseling and Federally Qualified Health Center (FQHC) services, without prior authorization (additional sessions will be approved if medically necessary) o Medication/somatic treatment o Crisis services o Inpatient hospitalization and emergency services o Day services o Intensive day treatment o Inpatient psychiatric facility services for members through age 20 o Patient Psychiatric Residential Treatment Facility (PRTF) services for members under 22 years of age o Mental health services for children, as included in an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) during holidays, school vacations or sick days from school o Case management services o Care coordination for outpatient alcohol or drug abuse service as needed with the Department of Health s Addiction, Prevention and Recovery Administration (APRA) o Education on how to access mental health services 21

22 Other Benefits MH/SA Screenings for Adults and Children All new AmeriHealth D.C. adult and child Medicaid members with a newly-assigned PCP who has not previously cared for the member, must receive a comprehensive initial examination and a screening for mental health and substance abuse. The mental health and substance abuse screening must be completed using a validated screening tool, approved by AmeriHealth D.C. For more information, please visit AmeriHealth D.C. PCPs are expected to assist Medicaid members with accessing substance abuse and mental health services, as needed. The AmeriHealth D.C. Rapid Response team is also available to members and providers to support care coordination and access to services. Members and providers may request Rapid Response support by calling For on-going care, the mental health and substance abuse screening must also be administered as a routine part of every child and adult preventive health examination. 22

23 Other Benefits Additional Resources for Behavioral Health Services Department of Mental Health (For specialized mental health services.) Available 24 hours a day, 7 days a week at Specialized Mental Health Services include: Community-Based Interventions (CBI) Multi-systemic Therapy (MST) Assertive Community Treatment (ACT) Community Support Crisis Intervention, including mobile crisis services Case Management Addiction, Prevention and Recovery Administration (APRA) (For drug and alcohol services.*) Assessment and Referral Center (ARC) Hours of Operation: 7 a.m. to 6 p.m. 70 N Street NE Washington, DC Telephone: Fax: *Inpatient detoxification services are covered by AmeriHealth D.C. 23

24 Does Medicaid Cover Emergency Services? Yes. For members enrolled through the Medicaid program, AmeriHealth D.C. ensures the availability of emergency services and care 24 hours a day, seven days a week (24/7). AmeriHealth D.C. will not deny payment for treatment obtained when a member had an emergency medical condition, or when the condition was in fact non-emergent in nature but appeared on presentation and/or during medical screening to be an emergency condition under the prudent layperson standard. AmeriHealth D.C. does not require prior authorization for emergency services provided by network or non-network providers when a Medicaid Plan member seeks emergency care. 24

25 Does Alliance Cover Emergency Services? Medicaid-reimbursable emergency services are covered by the Department of Health Care Finance (DHCF) for Alliance members. Through September 30, 2013, AmeriHealth D.C. will not be responsible for Medicaid-reimbursable emergency medical services provided to an Alliance member by a network hospital provider. District hospitals providing Medicaid-reimbursable emergency medical services to Alliance beneficiaries must submit claims for these services directly to the DHCF for reimbursement under Medicaid. 25

26 Other Benefits Pharmacy Services Starting May 1, 2013, AmeriHealth D.C. will provide prescription drug coverage for members. PerformRx, an affiliate of the AmeriHealth Caritas Family of Companies, is the delegated manager of pharmacy services covered by AmeriHealth D.C. AmeriHealth D.C. will implement a new drug formulary and new prior authorization criteria for medical necessity determinations. To minimize therapy disruptions, all members will be entitled to a 60 day transition supply of their current medications. Upon expiration of the 60 day transition period, some members may require a prior authorization to continue their therapy. In the event that a member needs pharmacy services before they receive their new ID card, please encourage the AmeriHealth D.C. member to: Ask the pharmacy to call Pharmacy Provider Services at to obtain the member s new ID number or if they have any questions or problems. Call our Pharmacy Member Services team at (TTY/TDD: ) if the member needs help or has questions. 26

27 Other Benefits Pharmacy Resources For more information on the provision of pharmacy services, including prior authorization forms, or to view the searchable and printable AmeriHealth D.C. drug formulary, please visit For questions regarding pharmacy services, Plan members and providers may contact PerformRx at: Pharmacy Provider Services (Medicaid): Pharmacy Provider Services (Alliance): Pharmacy Member Services (Medicaid): Pharmacy Member Services (Alliance): Pharmacy TTY/TDD: Pharmacy Prior Authorization Fax:

28 Other Benefits Lab Services LabCorp will continue to be the exclusive outpatient laboratory provider for members of AmeriHealth D.C. LabCorp will continue to file claims directly (to the appropriate entity) for members during the transition. LabCorp is also a provider for most other managed care companies operating in the District of Columbia. As a full-service reference laboratory, LabCorp provides rapid turnaround time for routine and STAT testing. LabCorp also offers a broad array of routine and esoteric tests. Providers who currently use LabCorp may continue to use the existing test-ordering method. No change is necessary, except LabCorp will need the new AmeriHealth D.C. member ID numbers on all orders. To quickly establish a LabCorp account, please call 888- LABCORP and a representative will be happy to assist you. For more information, please visit 28

29 Other Benefits 24/7 Nurse Advice Line AmeriHealth D.C. members also have 24/7 access to a dedicated telephone line for nurse triage services, provided by Sirona Health at RNs evaluate the member s health status, provide health advice and decision support, and facilitate the use of relevant healthcare practitioners and settings. Based on symptoms or health questions, RNs follow physician-authored clinical guidelines to recommend the appropriate treatment. For more information visit Transportation Services Transportation services will be provided by MTM. Members may schedule or confirm transportation by calling: Reservation & Ride Status (Medicaid Only):

30 Provider Network Information 30

31 Provider Participation PerformCare will assure access to the full scope of care and service resources within established D.C. standards of access and choice for all AmeriHealth D.C. members. All behavioral health network providers are credentialed and re-credentialed to provide clinical care and services. PerformCare has formally assigned responsibility for the credentialing and re-credentialing review function to the Credentialing Committee. The Credentialing Committee, part of the Provider Network Operations department, performs the review of behavioral health provider credentials for credentialing and recredentialing and makes recommendations accordingly. PerformCare works with the Council for Affordable Quality Healthcare (CAQH) to offer providers a Universal Provider Data source that simplifies and streamlines the data collection process for credentialing and re-credentialing. There is no charge to providers to submit applications and participate in CAQH. Providers who are not affiliated with CAQH or prefer a paper credentialing process may contact Perform Care s Credentialing department or their Provider Network Account Executive for assistance. 31

32 Provider Participation Standards Be eligible to participate in any District or Federal health care benefit program. Comply with all pertinent Medicaid regulations. Treat AmeriHealth D.C. members in the same manner as other patients. Provide covered services to all AmeriHealth D.C. members who select or are referred to you as a provider. Provide covered services without regard to religion, gender, sexual orientation, race, color, age, national origin, creed, ancestry, political affiliation, personal appearance, health status, pre-existing condition, ethnicity, mental or physical disability, participation in any governmental program, source of payment, or marital status. All providers must comply with the requirements of the Americans with Disabilities Act (ADA) and Section 504 of Rehabilitation Act of Not segregate members from other patients (applies to services, supplies and equipment). Not refuse to provide services to members due to a delay in eligibility updates. 32

33 Access Standards Access to Behavioral Health Care Emergency Psychiatric or Mental Health Care Within One Hour of the Need Being Presented to the Provider (An active crisis where the member or others are at risk, or where there is an expected risk in the next 24 hours.) Urgent Psychiatric or Mental Health Care Within the Same Day of the Need Being Presented to the Plan or Provider Behavioral Health Telephone Crisis Triage Psychiatric Intervention or Face-to-Face Assessment Hospital Discharge Follow-Up Care with an Outpatient Provider (Care following discharge from a Psychiatric Inpatient Facility or Psychiatric Residential Treatment Facility.) Community Based Interventions Screening for Children/Youth Admitted to an Acute Care Facility Routine Behavioral Health Appointments Initial Service in the Follow-Up Care Based on Results of an Assessment Waiting Time in a Provider Office Within 15 Minutes Over the Telephone Must be Available on a 24-Hour Basis, Seven Days a Week. Within 90 Minutes of Completion of Telephone Assessment, As Needed. Must be Available on a 24-Hour Basis, Seven Days a Week. Initial Assessment Within Seven Days of Discharge to the Community. Must include assessment and provision of prescriptions if needed. Plus Subsequent Appointment Within 30 Days of Discharge from an Acute Care Facility. Within 48 Hours of Admission by Contacting the Department of Mental Health Child/Youth Care Manager Within Seven Days of Request Within 10 Business Days of Completion of the Assessment Not to Exceed 45 Minutes 33

34 Provider Compliance Responsibilities Providers are required to comply with all Plan policies and with all relevant legal or regulatory standards, as set by outside legal or regulatory authorities. The primary areas of compliance with policies and regulations for Plan providers are: Americans with Disabilities Act (ADA) / Rehabilitation Act Health Insurance Portability and Accountability Act (HIPAA) Fraud, Waste & Abuse (FWA) False Claims Act Advance Directives Marketing Activities Cultural and Linguistic Requirements Section 601, Title VI of the Civil Rights Act of

35 Provider Compliance Responsibilities The Americans with Disabilities Act (ADA) and the Rehabilitation Act Section 504 of the Rehabilitation Act of 1973 ( Rehab Act ) and Title III of the Americans with Disabilities Act of 1990 (ADA) prohibit discrimination against individuals with disabilities and require AmeriHealth D.C. s providers to make their services and facilities accessible to all individuals. AmeriHealth D.C. expects its network providers to be familiar with the requirements of the Rehabilitation Act and the ADA and to fully comply with the requirements of these statutes. Health Insurance Portability and Accountability Act (HIPAA) AmeriHealth D.C. is committed to strict adherence with the privacy and security provisions of the Health Insurance Portability and Accountability Act (HIPAA) and expects its practitioners and providers to be familiar with their HIPAA responsibilities and to take all necessary actions to fully comply. Any member record containing clinical, social, financial, or any other data on a member should be treated as strictly confidential and be protected from loss, tampering, alteration, destruction, and unauthorized or inadvertent disclosure. 35

36 Provider Compliance Responsibilities Fraud, Waste and Abuse (FWA) Designed in accordance with Federal and District rules and regulations, AmeriHealth D.C. s compliance program is aimed at preventing and detecting activities that constitute FWA. The program includes FWA policies and procedures, investigation of unusual incidents and implementation of corrective action. AmeriHealth D.C. has provider reference materials that are available by contacting the Provider Services department. 36

37 Provider Compliance Responsibilities False Claims Act The Federal False Claims Act (FCA) is a Federal law that applies to fraud involving any contract or program that is federally funded, including Medicare and Medicaid. It prohibits knowingly presenting (or causing to be presented) a false or fraudulent claim to the federal government or its contactors, including state Medicaid agencies, for payment or approval. The FCA also prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved. Health care entities that violate the Federal FCA can be subject to imprisonment and civil monetary penalties ranging from $5,000 to $11,000 for each false claim submitted to the United States government or its contactors, including state Medicaid agencies, as well as possible exclusion from Federal Government health care programs. 37

38 Provider Compliance Responsibilities Reporting and Preventing FWA AmeriHealth D.C. receives District and Federal funding for payment of services provided to our members. In accepting claims payment from AmeriHealth D.C., providers are receiving District and Federal program funds, and are therefore subject to all applicable Federal and/or District laws and regulations relating to this program. Violations of these laws and regulations may be considered fraud or abuse against the medical assistance program. Compliance with Federal laws and regulations is a priority of AmeriHealth D.C. If you, or any entity with which you contract to provide health care services on behalf of AmeriHealth D.C. beneficiaries, become concerned about or identifies potential fraud, waste or abuse, please contact : Fraud Waste and Abuse Hotline at (866)

39 Provider Compliance Responsibilities Advance Directives All AmeriHealth D.C. providers are required to facilitate advance directives for individuals as defined in 42 C.F.R The Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under District law, relating to providing health care when an individual is incapacitated. If a member is an adult (18 years of age or older), he/she has the right under Federal law to decide what medical care that he/she wants to receive, if in the future the member is unable to make his/her wishes known about medical treatment. The member has the right to choose a person to act on his or her behalf to make health care decisions for them, if the members cannot make the decision for themselves. 39

40 Provider Compliance Responsibilities Provider Marketing Activities Guidelines Providers are permitted to share the following with Plan members: General and factual information about AmeriHealth D.C. and your participation in the Plan s network. Plan-provided member education materials that have been approved by the Plan and the District. Contact information for the District s enrollment broker. Providers are prohibited from participating in the following activities: Using written or oral methods of communication with members to compare benefits or other aspects of Medicaid or Alliance managed care organizations. Using written or oral methods of communication to share false or misleading information regarding the Plan or the provision of services. Performing direct marketing activities or other marketing activities on behalf of the Plan. Performing or permitting any marketing activities on behalf of the Plan at your office location. Using marketing materials that have not been approved by the Plan and the District. Assisting with or making recommendations for enrollment with the Plan, except to refer prospective members to the District s enrollment broker. 40

41 Provider Compliance Responsibilities Cultural and Linguistic Requirements Section 601 of Title VI of the Civil Rights Act of 1964 Our Cultural Competency Program, led by a cross-departmental workgroup, has been built upon the 14 national standards for Culturally and Linguistically Appropriate Services (CLAS) as set forth by the U.S. Department of Health and Human Services. As a provider of health care services who receives federal financial payment through the Medicaid program, you are responsible to make arrangements for language services for members, upon request, who are either Limited English Proficient (LEP) or Low Literacy Proficient (LLP) to facilitate the provision of health care services to such members. AmeriHealth D.C. contracts with a competent telephonic interpreter service provider. We have an arrangement to make our corporate rate available to participating plan providers. If you need more information on using this telephonic interpreter service, please contact Provider Services at or toll-free at

42 Provider Compliance Responsibilities Interpretation Services for AmeriHealth D.C. Members Health care providers who are unable to arrange for interpretation services for an LEP, LLP or sensory impaired member should contact AmeriHealth D.C. Medicaid Member Services at (TDD/TTY: ) or Alliance Member Services at (TDD/TTY: ), and a representative will help locate a professional interpreter to communicate in the member's primary language. When a member uses AmeriHealth D.C. s interpretation services, the provider must sign, date and complete documentation in the medical record in a timely manner. Note: The assistance of friends, family, and bilingual staff is not considered competent, quality interpretation. These persons should not be used for interpretation services except where a member has been made aware of his/her right to receive free interpretation services and continues to insist on using a friend, family member, or bilingual staff for assistance in his/her preferred language. 42

43 Provider Support & Accountability Provider Network Management AmeriHealth D.C. s Provider Network Account Executives function as a provider relations team to advise and educate Plan providers. Provider Network Account Executives assist providers in adopting new business policies, processes and initiatives. From time to time, providers will be contacted by AmeriHealth D.C. representatives to conduct meetings that address topics including, but not limited to: Contract Terms Credentialing or Re-credentialing Site Visits Health Management Programs Orientation, Education and Training Program Updates and Changes Provider Complaints Provider Responsibilities Quality Enhancements Self-Service Tools 43

44 Provider Support & Accountability Provider Complaint System AmeriHealth D.C. providers may file an informal dispute about AmeriHealth D.C. s policies, procedures, or any aspects of AmeriHealth D.C. administrative functions. AmeriHealth D.C. will thoroughly investigate each provider complaint using applicable statutory, regulatory, contractual and provider contract provisions. All pertinent facts will be investigated and considered. AmeriHealth D.C. s policies and procedures will also be considered. Providers may call Provider Services at or toll-free at to notify AmeriHealth D.C. of a complaint. A written notice of the outcome of the review will be sent to the provider within 90 days of receipt of the complaint. 44

45 Medical Management 45

46 Medical Management Integrated Care Management Overview AmeriHealth D.C. s Integrated Care Management program is a holistic solution that uses a population-based health management program to provide comprehensive care management services. This fully integrated model allows members to move seamlessly from one component to another, depending on their unique needs. From this integrated solution AmeriHealth D.C. delivers and coordinates care across all programs. The ICM program includes assessment, treatment and other care planning, as well as service coordination with IDEA, alcohol and drug abuse providers and community resources. The ICM program also incorporates health and illness self-management education. The program is structured around a member-based decision support system that drives both communication and Treatment Plan development through a multidisciplinary approach to management. The ICM process also includes reassessing and adjusting the Treatment Plan and its goals as needed. 46

47 Medical Management Integrated Care Management Components AmeriHealth D.C. s ICM team includes nurses, social workers, Care Connectors, clinical pharmacists, Plan medical directors, primary care providers (PCPs), specialists, members and caregivers, parents or guardians. This team works to meet our members needs at all levels in a proactive manner that is designed to maximize health outcomes. There are five core components to our Integrated Care Management (ICM) Program: Rapid Response Pediatric Preventive Health Care Bright Start (Maternity Management) Episodic Care Management (ECM) Complex Care Management (CCM) 47

48 Rapid Response/Care Coordination Rapid Response This team is designed to address the needs of members and to support providers and their staff. The team is composed of registered nurses, social workers and non-clinical Care Connectors. Together, this team performs three functions on behalf of Plan members and providers: receiving inbound calls, conducting outbound outreach activities and providing care management and care coordination support. Members and providers may request Rapid Response support, Monday through Friday, 8 am to 5:30 pm. Telephone: Fax:

49 Integrating Physical/Behavioral Health Plan staff will work with primary care and mental health providers to develop an integrated Treatment Plan for members in need of physical and mental health care coordination. Care Managers will also assure that communication between the two disciplines, providers and organizations, occurs routinely for all members with physical and behavioral health issues. Care Managers will also work to coordinate with alcohol and drug abuse providers and community resources, as appropriate. Care Managers will proactively and regularly follow-up on required physical and mental health services, joint treatment planning and provider-to-provider communication to ensure that member needs are continuously reviewed, assessed and updated. 49

50 Complex Care Management Complex Care Management (CCM) The CCM program serves members identified as needing comprehensive and diseasespecific assessments, and re-assessments, along with the development of short- and longterm goals and an individualized Treatment Plan, developed in collaboration with the member, the member s caregiver(s) and the member s physician(s). Members in the Complex Care Management program are screened for the following as part of standard protocol: Adult members receive a Mental Health Screening, based on the Adults Needs and Strengths Assessment (ANSA; Lyons, 2009), to identify risk of depression, anxiety, trauma exposure, suicide and substance abuse. Children and adolescent members receive a Mental Health Screening, based on the Child and Adolescent Needs and Strengths (CANS; Lyons, 2004), to identify risk of depression, disruptive behavior, trauma, substance abuse, autism and suicide. Subsequent detailed assessments are performed for any item that screens positive in the initial assessment. 50

51 ICM Program Participation Program Participation Participation in the ICM program is offered to all Plan members, with the ability for members to opt out upon request. Members may also self-refer into a program by contacting the Plan. Members are initially identified for specific ICM needs upon joining the Plan. Through material and telephonic outreach, members are encouraged to let the Plan know if they have a chronic condition, special health need or if they are receiving on-going care. Based upon member responses to the initial health assessment, members are identified for participation in the appropriate care management program. 51

52 ICM Program Referral Program Referral Providers are encouraged to refer members to the ICM program as needs arise or are identified. If you recognize a member with a special, chronic or complex condition who may need the support of one of our programs, please contact the Rapid Response team at Members are also referred to the ICM program through internal Plan processes. Identified issues and diagnoses that result in a referral to the ICM program may include: Multiple diagnoses (three or more actual or potential major diagnoses) Risk score indicating over- or under-utilization of care and services Pediatric members requiring assistance with EPSDT and/or IDEA services Pediatric members in foster care or receiving adoption assistance Members with dual medical and mental health needs Members with substance abuse-related conditions Members who are developmentally or cognitively challenged Members with a special health care need Pregnant members Members with certain chronic conditions or diagnosis 52

53 Quality Assurance AmeriHealth D.C. s Quality Assurance and Performance Improvement (QAPI) program provides a framework for evaluating the delivery of health care and services provided to members. AmeriHealth D.C. develops goals and strategies considering applicable District and Federal laws and regulations and other regulatory requirements, NCQA accreditation standards, evidence-based guidelines established by medical specialty boards and societies, public health goals and national medical criteria. AmeriHealth D.C. also uses performance measures such as HEDIS, CAHPS, consumer and Provider surveys, and available results of the External Quality Review Organization (EQRO), as part of its QAPI program. Preventive health and clinical guidelines are developed using criteria established by nationally recognized professional organizations and with input from the AmeriHealth D.C. Provider Advisory Council. Guidelines are distributed via the Plan s website at and hard copies are available upon request. 53

54 Quality Assurance Clinical Guidelines: Condition COPD Clinical Evidence-Based Guideline Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Diabetes American Diabetes Association: Clinical Practice Recommendations Heart Failure 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults Hypertension Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease Sickle Cell Asthma Depression NHBLI GINA Practice Guideline for the Treatment of Patients with Major Depressive Disorder 54

55 Quality Assurance Medical Record Documentation Complete and consistent documentation in patient medical records is an essential component of quality patient care. AmeriHealth D.C. adheres to medical record requirements that are consistent with national standards on documentation. A list of our medical record standards is available in the AmeriHealth D.C. Provider Manual on our website at 55

56 Quality Assurance Committees and Councils that Support the QAPI Program: Provider Advisory Council Member Advisory Council Quality Clinical Care Committee Quality of Service Committee Pharmacy and Therapeutics Committee Credentialing Committee Culturally and Linguistically Appropriate Service (CLAS) Workgroup Provider Participation We encourage provider participation in our quality-related programs. Providers who are interested in participating in one of our Quality Committees may contact Provider Services at or toll-free at or their Account Executive. 56

57 Utilization Management 57

58 Utilization Management The AmeriHealth D.C. Utilization Management (UM) program establishes processes for implementing and maintaining an effective, efficient utilization management system. Utilization Management activities are designed to assist our providers with the organization and delivery of appropriate health care services to members within the structure of the member s benefit plan. AmeriHealth D.C. does not structure compensation to individuals or entities that conduct utilization management activities to incentivize the denial, limitation or discontinuation of medically necessary services to any member. Hours and Contact Info The AmeriHealth D.C. UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. Telephone: or Fax : or

59 Utilization Management Prior Authorization The following is a list of behavioral health services requiring prior authorization review for medical necessity and place of service. Services that Require Prior Authorization Mental Health Partial Hospitalization Program Inpatient Detoxification Admissions Mental Health IP Inpatient Admissions Neuropsychological Testing Psychological Testing Developmental Testing Behavioral Health Day Treatment Residential Treatment Electroconvulsive Therapy Outpatient Behavioral Health Counseling and Therapy (individual, family, group after the initial 10 sessions) 59

60 Utilization Management Prior Authorization Services that Do Not Require Prior Authorization Outpatient Behavioral Health Counseling and Therapy (individual, family, group initial 10 sessions) Outpatient Evaluation Outpatient Medication Management Services Outpatient Nursing Services 60

61 How to Submit a Request for Prior Authorization By Telephone or Fax: Requests for prior authorization of services may be submitted by telephone or fax to the Utilization Management department at: Telephone: or Fax: or The AmeriHealth D.C. UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. Continuity of Care: AmeriHealth D.C. members will be covered for 10 initial sessions of outpatient behavioral health counseling or therapy without the prior authorization requirement, regardless of previous services provided or authorized. AmeriHealth D.C. will also honor Beacon authorizations for services for up to 90 days. Providers with current authorizations that extend beyond May 1, 2013 are encouraged to submit a request (via the process described above) with the original Beacon determination attached so that AmeriHealth D.C. may honor the authorization. 61

62 Authorizations Inpatient and Partial Hospitalization Initial Authorization: Inpatient stays, electroconvulsive therapy and/or partial hospitalization programs contact the UM department by telephone. Faxed requests may be accepted as long as all the appropriate information to support a medical necessity review and/or level of care evaluation is included. Extensions: Requests to extend authorization on these services may also be submitted by telephone to the UM department. Typical Authorization: AmeriHealth D.C. typically authorizes inpatient stays for three to five days at a time and partial hospitalization programs for one week at a time, depending on medical necessity. For additional information on how to submit a request for prior authorization, please refer to the provider area of our website at 62

63 Authorizations Outpatient Therapy and Day Program Initial Authorization: For the initial prior authorization of outpatient services (after the initial 10 sessions of behavioral health counseling or therapy or day treatment programs, please submit requests by completing and faxing the Outpatient Treatment Request Form (available at to the UM department. AmeriHealth D.C. will continue to accept the Beacon OTR Form until further notice. Extensions: Requests to extend authorization on outpatient services may also be submitted by completing and faxing the Outpatient Treatment Request Form to the UM department. Typical Authorization: AmeriHealth D.C. will authorize day treatment for 30 days at a time for day programs until further notice. 63

64 Authorizations Psychological/Neuropsychological Testing Psychological / Neuropsychological Testing should answer a clinical question about the member and recommended treatment. Testing will not be authorized under any of the following conditions: Testing is primarily for educational or vocational purposes. Testing is primarily for legal purposes. The tests requested are experimental or have no documented validity. The time requested to administer the testing exceeds established time parameters. Testing is routine for entrance into a treatment program. Request forms may be submitted via fax to the UM department or

65 Utilization Management Medical Necessity Standards Medically Necessary or Medical Necessity is defined as services or supplies that are needed for the diagnosis or treatment of the member s medical condition according to accepted standards of medical practice. The need for the item or service must be clearly documented in the member s medical record. AmeriHealth D.C. will usethe McKesson InterQual Criteria as guidelines for determinations related to medical necessity. AmeriHealth D.C. will also use the American Society of Addictions Medicine (ASAM) Patient Placement Criteria (PPC) for determinations related to substance abuse detox. When applying these criteria, Plan staff also consider the individual member factors and the characteristics of the local health delivery system. Any request that is not addressed by, or does not meet, medical necessity guidelines is referred to the Medical Director or designee for a decision. 65

66 Utilization Management Provider Medical/Administrative Appeals Providers may call the Peer-to-Peer telephone line at to discuss a medical determination with a physician in the AmeriHealth D.C. Medical Management department. Providers must call within two business days of notification of the determination (or prior to the member s discharge from a facility when the determination applies to an inpatient case). A provider requesting an administrative or medical appeal, for the reversal of a medical denial, may also submit an appeal in writing to: AmeriHealth District of Columbia Attn: Provider Appeals Department P.O. Box 7359 London, KY As a reminder, a provider may also file an appeal on a member s behalf, with the member s written consent. To file an appeal as an authorized representative on behalf of a member, a provider may call the Provider Appeals telephone line at

67 Claims and Billing 67

68 Claims Submission and Processing General Claims Submission Guidelines All claims with dates of service on or after May 1, 2013 must be submitted to AmeriHealth D.C. within 180 days from the date of service (or the date of discharge for inpatient admissions). This applies to capitated and fee-for-service claims. AmeriHealth D.C. is required by District and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims. When required data elements are missing or are invalid, claims will be rejected by AmeriHealth D.C. for correction and re-submission. Claims for billable services provided to AmeriHealth D.C. members must be submitted by the provider who performed the services. Please allow for normal processing time before re-submitting a claim either through the EDI or paper process. This will reduce the possibility of your claim being rejected as a duplicate claim. Claims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. For specific billing instructions, please refer to the AmeriHealth D.C. Claims and Billing Manual, coming to in June

69 Claims Submission and Processing Paper Claims Claims with dates of service on or after May 1, 2013 may be submitted to the appropriate address below: Medicaid AmeriHealth D.C./Medicaid Attn: Claims Processing Department P.O. Box 7342 London, KY Alliance AmeriHealth D.C./Alliance Attn: Claims Processing Department P.O. Box 7354 London, KY Electronic (EDI) Claims AmeriHealth D.C. participates with Emdeon. As long as you have the capability to send EDI claims to Emdeon, through direct submission or via another clearinghouse/vendor, you may submit claims electronically. Electronic claim submissions to AmeriHealth D.C. will follow the same process as other electronic commercial submissions. To initiate electronic claims: Contact your practice management software vendor or EDI software vendor. Inform your vendor of AmeriHealth D.C. s EDI Payer ID#: You may also contact Emdeon at or visit to for information on contracting for direct submission to Emdeon. AmeriHealth D.C. does not require Emdeon payer enrollment to submit EDI claims. 69

70 EFT and ERA Enrollment Electronic Funds Transfer (EFT) EFT simplifies the payment process by: Providing fast, easy and secure payments Reducing paper Eliminating checks lost in the mail Not requiring you to change your preferred banking partner You will be able to enroll through our EFT partner, Emdeon by completing an enrollment form or by calling New to Emdeon EFT? Go to and select Enroll Now to initiate the enrollment process. Existing Emdeon EFT User? Complete and submit the EFT Payer Add Change Delete Authorization Form available online at Electronic Remittance Advice (ERA) or 835 Transmissions For information about, or to sign up to receive Electronic Remittance Advice (ERA), check with your practice management/hospital information system vendor to confirm that you have the ability to process ERA or 835 files. Your vendor should be able to provide instructions on how to receive ERA s for AmeriHealth D.C. Many systems utilize this file to generate reports and auto-post payments. Your software vendor is responsible to facilitate ERA transmissions with Emdeon. If your vendor does not have the ability to process ERA transmission, call Emdeon's customer service at and follow the appropriate prompts for alternative ERA options. 70

71 Important Billing Reminders Timely Filing Rules Rejected claims are defined as claims with missing or invalid data elements, such as the provider tax identification number or member ID number, that are returned to the provider or EDI source without registration in the claim processing system. Rejected claims are not registered in the claim processing system and can be re-submitted as a new claim. Claims originally rejected for missing or invalid data elements must be resubmitted with all necessary and valid data within 180 calendar days from the date services were rendered (or the date of discharge for inpatient admissions). Denied claims are registered in the claim processing system but do not meet requirements for payment under AmeriHealth D.C. guidelines. They should be resubmitted as a corrected claim. Claims originally denied must be re-submitted as a corrected claim within 365 days of the remittance date on which the claim was denied for any reason(s) other than timely filing. Claims with Explanation of Benefits (EOBs) from primary insurers, including Medicare, must be submitted within 180 days of the date on the primary insurer s EOB. 71