Superior HealthPlan. Assisted Living, Residential Care and Adult Foster Care SHP_

Transcription

1 Superior HealthPlan Assisted Living, Residential Care and Adult Foster Care SHP_

2 Who is Superior HealthPlan? Superior HealthPlan is a subsidiary of Centene Management Corporation, a Fortune 500 Company, located in St. Louis, Missouri. Centene s managed care model utilizes integrated programs that can only be delivered effectively by a local staff combined with centralized finance, information systems, and claims processing Superior HealthPlan Inc., is a licensed HMO in all 254 counties of the State of Texas Superior HealthPlan offers different products to help ensure eligible Texans across the income, age and acuity continuum Our Products: Contracted through Texas HHSC to provide: STAR+PLUS, STAR, CHIP, STAR Health (Foster Care) Contracted through Federal Government to provide: Advantage by Superior HealthPlan dual Special Needs Plan (SNP) HMO (Medicare Advantage Plan), and Ambetter (Health Insurance Marketplace) Superior HealthPlan manages healthcare for over 900,000 members across the State

3 How is Eligibility Verified? Texas Medicaid Benefits Card TexMedConnect Superior HealthPlan Identification Card Superior HealthPlan Secure Web Portal - Superior HealthPlan STAR+PLUS Member Services: Verify eligibility the 1st of each month using our website or by contacting Member Services

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5 Member ID Cards STAR+PLUS STAR+PLUS Dallas

6 Service Coordination Single Point of Contact for the member Review Assessments and develop plan of care utilizing input from member, family and providers Coordinate with the member s PCP, specialist and LTSS providers to ensure the member s health and safety needs are met in the least restrictive setting Refer member to support services such as disease management and community resources

7 Service Coordination Authorize LTSS services Service Coordination utilizes a multidisciplinary approach in meeting members needs including behavioral health Conduct mandatory telephonic or face to face contacts Service Coordinator member caseloads are assigned by mixed model that includes member s level of acuity, zip codes, DAHS facility assignment and other applicable factors

8 Locating Member s Service Coordinator Effective 9/1/2014 Members and Providers will be able to access the name and phone number of the assigned Service Coordinator via the secured member and provider web portal Members will find their assigned Service Coordinator and phone number on their front page under Health Alerts When providers access eligibility on a specific member, the assigned Service Coordinator and phone number is displayed on the Eligibility Overview page under Care Gaps Call Service Coordination at

9 Authorization Specifics Services are initiated as the need is identified by the following avenues: The Member s Service Coordinator The Provider, PCP, Hospital or Nursing home discharge planner Medical Necessity Level of Care Assessment (waiver specific) To initiate pre-authorization requests or any changes to an authorization, providers may call the Service Coordination department or fax a 2067 Form Superior HealthPlan sends summary reports to providers each month listing all members in the facility to assist with reconciliation and ensure accuracy of authorizations Any applicable copay is determined by the STAR+PLUS Support Unit and provided to Superior HealthPlan. The provider is responsible to collect room & board and copays from the member or their representative

10 How do I get authorizations for LTSS services? All authorizations for LTSS services are obtained through the Service Coordination Department A member s specific Service Coordinator s name can be seen when a member s eligibility is confirmed through the Superior HealthPlan secure portal Then call to speak to a Service Coordinator

11 Billing Requirements All claims must be billed with appropriate modifiers. The authorization will also include procedure codes and modifiers. Do not deduct Room & Board or applicable copay from claims. Copay is deducted from the claim upon adjudication. Place of Service Codes- Procedure codes- Taxonomy Code Assisted Living /Residential Care 12 - Adult Foster Care Assisted Living/ Residential Care - T2031 Adult Foster Care - S5140 * If provider bills less than contracted amount, the claim will be eligible for reimbursement at the lesser of billed charges. Units 1 Day Assisted Living / Residential Care X Adult Foster Care - 311ZA0620X

12 Provider Portal SUBMIT CLAIMS ON-LINE! Check claim status Verify eligibility View Provider Directory View Provider Manual Submit Online Authorizations (acute care only) Request copy EOP Link for Providers to file On-Line complaints Provider Group Training Schedule Provider On-Line Training Schedule Links for additional Provider Resources