New provider orientation

Transcription

1 New provider orientation

2 Welcome 2

3 Agenda Introduction to Amerigroup Provider resources Contact numbers and questions Provider responsibilities Member benefits and services Claims and billing Preservice processes 3

4 Introduction to Amerigroup 4

5 About Us 5.8 million Medicaid members nationwide, approximately Operating in 20 states Leading provider of heath care solutions for public programs. Over 16 years Provided access to high quality, coordinated care for lowincome families, seniors and people with disabilities. Serving in 8 states Long Term Services and Support Programs 5

6 Services covered Iowa Department of Human Services (DHS) has contracted Amerigroup Iowa, Inc. to provide comprehensive health care services including: Physical health Behavioral health Long-term services and supports (LTSS) This initiative creates a single system of care to promote the delivery of efficient, coordinated and high quality health care and establishes accountability in health care coordination.

7 Iowa High Quality Healthcare Initiative coverage area 7

8 Provider resources 8

9 Provider services overview Website Key contacts: Provider Relations and more Portal and Provider Services line Eligibility verification Claims inquiry Benefit verification PCP assistance Interpreter/hearing impaired services Provider training Provider communications 9

10 Medicaid provider website providers.amerigroup.com/ia 10

11 Public website information Registration and login not required for access to: Claims forms Precertification Lookup Tool Provider Manual Clinical Practice Guidelines News and announcements Provider Directory Fraud, waste and abuse Formulary 11

12 Secure website information Registration and login required for access to: Precertification submission Precertification status lookup Pharmacy precertification PCP panel listings Member eligibility Claim status 12

13 Availity Multiple payers No charge Accessible User friendly Compliant Training Support Reporting Single sign-on with access to multiple payers Amerigroup transactions are available at no charge to providers Availity functions are available 24 hours a day from any computer with internet access Standard screen format makes it easy to find the necessary information needed and increases staff productivity Availity is compliant with HIPAA regulations No cost, live, web-based and prerecorded training seminars (webinars) are available to users; Frequently Asked Questions (FAQ) and comprehensive help topics are available online as well Availity Client Services is available at AVAILITY ( ) Monday through Friday from 7 a.m. to 6 p.m. Central time User reporting allows the primary access administrator (PAA) to track associates work 13

14 Availity, cont. The registration process is easy. There are multiple resources and trainings available to support Availity and Amerigroup site navigation. 14

15 Electronic payment enrollment Get started now: Visit for more information and to create your secure account. To learn more call: CAQH EnrollHub Helpline Representatives are available Monday-Thursday, 6 a.m. to 8 p.m. Central time and Friday from 6 a.m. to 6 p.m. Central time. 15

16 Electronic payment services Providers who enroll for electronic payment services: Receive electronic ERAs and import the information directly into their patient management or patient accounting system Route EFTs to the bank account of their choice Can use the electronic files to create their own custom reports within their office Access reports 24 hours a day, 7 days a week Amerigroup uses EnrollHub -- the secure CAQH Solution to enroll in electronic funds transfers (EFTs) and electronic remittance advices (ERAs). EnrollHub is available at no cost to all health care providers. 16

17 Key contact information Provider Services: Member Services: Amerigroup on Call: (Spanish) Precertification: Phone: Pharmacy prior authorization: Phone: Fax: Paper claims submission: Amerigroup Iowa, Inc. Claims P.O. Box Virginia Beach, VA Electronic claims submission: Availity: payer ID: Emdeon: payer ID: Capario: payer ID: Smart Data Solutions: payer ID: Website: providers.amerigroup.com/ia 17

18 Provider Relations staff Provider outreach Provider education and training Engages providers in quality initiatives Provider customer service Builds and maintains the provider network Offer support for provider claims and billing questions and issues If you ever have questions, you can contact your local Provider Relations representative. 18

19 Amerigroup on Call Members can speak to a registered nurse who can answer their questions and help decide how to take care of any health problems If medical care is needed, our nurses can help a member decide where to go The phone number is located on the back of our member ID cards Members can call Amerigroup on Call for health advice 7 days a week, 365 days a year. When a member uses this service, a report is faxed to the office within 24 hours of receipt of the call. Amerigroup on Call (TTY 711) (Spanish) 19

20 Interpreter and translation services Interpreter Services Provider Services Available 24 hours a day, 7 days a week Over 170 languages Telephonic translations Provider Services In-person translations Case Management

21 Provider communications and education Quarterly provider newsletter Fax blasts Program/process change notices Ongoing educational opportunities ICD codes Cultural competency HIPAA 21

22 Provider Manual Key provider support resource for: Precertification requirements Covered services overview Member eligibility verification requirement Member benefits Access and availability standards Grievance and appeal process And much more 22

23 Provider roles and responsibilities Primary care providers: provide preventive health screenings No discrimination against members with mental, developmental and physical disabilities: comply with ADA standards Notification of changes: billing address, name, etc. Advance directives: understand and educate members Medical records: comply with HIPAA requirements and recordkeeping standards Preventive care services: recommend to all members Identification of behavioral health needs Fraud, waste and abuse: document and bill accurately Access standards: wheelchair accessibility Appointment availability and after-hours access 23 23

24 Provider roles and responsibilities Assisted living facilities and nursing homes must retain a copy of the member s Amerigroup plan of care on file with the member s records. Assisted living facilities are required to promote and maintain a homelike environment and facilitate community integration. All facility-based providers and home health agencies must notify an Amerigroup case manager within 24 hours when a member dies, leaves the facility or moves to a new residence or moves outside the service area or state. The option to participate in the member s Interdisciplinary Care Team (ICT), dependent on the member s need and preference. Follow all federal rules and regulations as applicable.

25 Key member responsibilities Members of Amerigroup have the responsibility to: Show their Iowa Health Link ID card each time they receive medical care. Make or change appointments. Get to appointments on time. Call their PCP if they cannot make it to their appointment or if they will not be on time. Use the emergency room only for true emergencies. Pay for any services they ask for that are not covered by Iowa Health Link. Treat their PCP and other health care providers with respect. Tell us, their PCP and their other health care providers what they need to know to treat them. Do the things that keep them from getting sick. Follow the treatment plans members, their PCP and their other health care providers agree on. Refer to your Provider Manual for a full listing. 25

26 Your responsibilities Providers should review both member and provider responsibilities, which are detailed in the Provider Manual

27 Required Medicaid ID number In order to get reimbursed for Medicaid, providers are required to have an Iowa Medicaid number. If a potential provider does not have a Medicaid number assigned, the health plan will work with the provider and the state to complete the necessary paperwork and assist the provider with obtaining a Medicaid number. Forms are available on the Iowa DHS website at: dhs.iowa.gov/ime/providers/enrollment 27

28 Fraud, waste and abuse Help us prevent it and tell us if you suspect it! Reporting requirement Contact information External Anonymous Compliance Hotline: OR amerigroup.silentwhistle.com or Website: Verify a patient s identity Ensure services are medically necessary Document medical records completely Bill accurately 28

29 Cultural competency Like you, Amerigroup is dedicated to providing quality, effective and compassionate care to all patients. There are many challenges in delivering health care to a diverse patient population. We are here to help. Amerigroup offers translation and interpreter services, cultural competency tips and training, and guides and resources based on the Culturally and Linguistically Appropriate Service (CLAS) Standards

30 Member benefits and services 30

31 Benefits Coordination of care Initial health assessments (IHAs) Physician office visits inpatient and outpatient services Durable medical equipment and supplies Emergency services Case management and utilization management Pharmacy benefits through Express Scripts, Inc. Detailed benefits and services information is available in the Provider Manual located on the Amerigroup provider website at providers.amerigroup.com/ia. 31

32 Benefits: value-added services Amerigroup believes that by offering expanded programs and services, we provide opportunities to help care for the whole person and better address the specific needs for each segment of the population. Health maintenance and preventative services Tobacco cessation counseling Waived copays for specific services Weight Watchers class vouchers Personal exercise kit Healthy Families nutrition and fitness program Boys and Girls Club membership Oral hygiene kit Home-delivered meals Post-discharge stabilization kit Training and supports services Amerigroup Community Resource Link High School Equivalency Test (HiSet ) assistance Personal backpacks Comfort item Financial management support Self-advocacy memberships Travel training Supported employment Independent living skills services Additional personal care attendant supports Additional respite care services Transportation assistance Assistive devices Additional cell phone minutes through Safelink Durable medical equipment and supplies Community reintegration benefit 32

33 Claims and billing 33

34 Delegated partners Superior Vision Benefit Management, Inc. Provider Services: Member Services: Express Scripts, Inc. Prior authorization phone: Prior authorization fax: LogistiCare Reservations: Ride Assist:

35 Claims submission Clean claims Electronic claims Paper claims Claim forms ICD codes Filing limits 35

36 Claim submission There are several ways to submit an Amerigroup Medicaid claim: Availity Electronically Availity: payer ID: Emdeon: payer ID: Capario: payer ID: Smart Data Solutions: payer ID: Paper Submission Amerigroup Iowa, Inc. Claims P.O. Box Virginia Beach, VA Note: There is a filing limit of 180 days from the date of service unless otherwise stated in the contract. 36

37 Rejected vs. denied claims Find claims status information: On the website at By calling Provider Services at There are two types of notices you may get in response to your claim submission: Rejected Does not enter the adjudication system due to missing or incorrect information Denied Goes through the adjudication process but is denied for payment Should you need to appeal a claim decision, please submit a copy of the explanation of payment (EOP), letter of explanation and supporting documentation. 37

38 Grievances and appeals Separate and distinct appeal processes are in place for our members and providers, depending on the services denied or terminated. Please refer to the denial letter issued to determine the correct appeals process. Appeals of medical necessity and administrative denials must be filed within 90 calendar days of the postmark date of Amerigroup Medicaid s denial notification. Mail appeals to: Amerigroup Iowa, Inc. Claim Appeals/Correspondence P.O. Box Virginia Beach, VA

39 Preservice processes 39

40 Precertification lookup tool online Submit precertification requests via: Check the status of your request on the website or by calling Provider Services. Search by: Market Member product CPT code 40

41 Precertification requirements Cardiac rehabilitation Chemotherapy Chiropractic services Diagnostic testing Durable medical equipment (all rentals; see Provider Manual for purchase requirements) Home health Hospital admission Physical therapy (PT), occupational therapy (OT) and speech therapy (ST) treatment Sleep studies Utilization Management

42 Precertification requirements Behavioral health Electroconvulsive therapy (ECT) Inpatient psychiatric treatment Inpatient substance abuse treatment for pregnant women Intensive outpatient treatment Psychiatric residential treatment Partial hospital treatment Psychological and neuropsychological testing Some community mental health center services Utilization Management

43 Pharmacy program The preferred drug list (PDL) and formulary are available on our website Prior authorization is required for: Nonformulary drug requests Brand name medications when generics are available High cost injectables and specialty drugs Any other drugs identified in the formulary as needing prior authorization Note: This list is not all-inclusive and is subject to 43 change. 43

44 Laboratory services Notification or precertification is not required if lab work is performed: In a physician s office In a participating hospital outpatient department (if applicable) By one of our preferred lab vendors Testing sites MUST have a Clinical Laboratory Improvement Act/Amendments (CLIA) certificate or a waiver

45 Access and availability Nature of visit Appointment standards Emergency examinations Immediate access 24/7 Urgent examinations Within 24 hours of request Routine exams Within 4 to 6 weeks of request Behavioral health emergency Immediately Outpatient treatment post-psychiatric Within 7 days of discharge inpatient care Routine behavioral health visits Within 3 weeks of request Refer to your Provider Manual for a complete listing of access and availability standards 45

46 Verifying member eligibility Providers can verify member eligibility as follows: Availability for real-time member enrollment and eligibility verification for all IA Health Link programs is 24 hours a day, 7 days a week. Or, use the website to determine the member's specific benefit plan and coverage: o Automated voice response: o IA Health Link website: Contact Provider Services to verify enrollment and benefits for our members: o Phone: , Monday to Friday, 7:30 a.m.-6 p.m. Central time o On the Availity web portal at o You can also access Availity through our secure provider site (providers.amerigroup.com/ia), by selecting Eligibility and Benefits and clicking on the link to redirect to the Availity portal. 46

47 New member information New members will receive the following: Iowa Medicaid ID state card (if applicable) Amerigroup member identification card Iowa Member Handbook Access to the Provider Directory 47

48 Balance billing No balance billing Notification and authorization prior to providing non-covered services 48

49 PCP selection A member must select a PCP A member s PCP can be changed within 24 hours from the time the change request has been made A member can see a specialist without a referral 49

50 Maintaining high-quality care 50

51 Disease management Substance Abuse Transplants Asthma Bipolar Disorder Congestive heart failure Major depressive disorder Coronary artery disease Obesity Hypertension Schizophrenia Diabetes Member referral COPD HIV/AIDS 51

52 Quality management Our Disease Management Centralized Care Unit (DMCCU) programs are based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing members with chronic conditions. Our disease management programs include: Asthma Bipolar disorder Chronic obstructive pulmonary disorder (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Diabetes HIV/AIDS Hypertension Major depressive disorder Schizophrenia Substance use disorder 52

53 Additional information 53

54 Credentialing process To become a participating Amerigroup provider, you must be enrolled in the Iowa Medicaid program and must hold an unrestricted license issued by the state. You must also comply with the Amerigroup credentialing criteria and submit all additionally requested information. To initiate the process, you must complete and submitted a CAQH application, an Iowa Universal Credentialing Application or an Amerigroup Application, with all required attachments. 54

55 Practice Profile Update form Practice and provider name Site, billing/remit, address, phone and fax number Tax ID - new signed contract required Add or term provider NPI, Medicare and Medicaid numbers Initiate the Council for Affordable Quality Healthcare (CAQH) numbers for new providers 55

56 Behavioral health services overview 56

57 Behavioral health at Amerigroup Iowa, Inc. The mission of Amerigroup is to coordinate the physical and behavioral health care of members, offering a continuum of targeted interventions, education and enhanced access to care to ensure improved outcomes and quality of life for Amerigroup members. Amerigroup behavioral health (BH) services includes a robust array of both mental health services and substance use disorder services. Amerigroup works collaboratively with healthcare providers, including Community Mental Health Centers (CMHCs), Iowa Department of Public Health (IDPH) substance use disorder providers, waiver service providers and a variety of community agencies and resources to successfully meet the needs of members with mental health (MH) and substance use disorders (SUDs), including those participating in waiver programs.

58 Integration of behavioral health and physical health Integrated physical health (PH)/behavioral health (BH) case management training for all case managers Integrated Quality Management Committee, Medical Advisory Group One integrated IT system for both physical and behavioral health Criteria for BH case management includes members with co-occurring disorders Rounds include BH and PH MDs to discuss members with co-occurring medical and behavioral conditions Establishing SMEs within BH and Medical so case managers within each department know who to contact for consultation Quarterly joint staff meetings to build relationships between the physical health and behavioral health case management teams Active participation by both teams on building consistent documentation standards applicable to both physical and behavioral health Ongoing meetings between the leaders of these departments to assess current processes on integration and modify as needed Member 360

59 Health home services A health home supports a member s health care and service needs physical and mental health and social supports. A health home appoints a care coordinator, a health care team and service providers to serve as the member s health home in collaboration with Amerigroup. The health home services are provided through a network of organizations including providers, health plans and community-based organizations. When all of the services are considered collectively, they become a health home. A health home facilitates access to a range of health and community services, simplifying the process for the member. Core health home services include: Comprehensive care management Care coordination Transitions in care Support to individual and family members The facilitation of referrals to community services and supports Health promotion and self-care

60 Health home services Amerigroup will identify eligible members, or a health home may refer a member to Amerigroup for eligibility determination. Members in the following programs are not eligible for the Health Home program: *Temporary Medicaid coverage for women who are pregnant, or who need treatment for breast and cervical cancer, and children under the age of 19 who need temporary medical coverage. Intensive Care Management of Habilitation and CMH Waiver are provided through the Integrated Health Home.

61 Integrated health homes An integrated health home (IHH) is a team of professionals working together to provide person-centered, coordinated care for adults with a serious mental illness (SMI) and children with a serious emotional disturbance (SED). Eligibility for IHH services includes either: An adult with an SMI: Psychotic disorders, schizophrenia, schizoaffective disorder, major depression, bipolar disorder, delusional disorder, obsessive compulsive disorder or another mental health diagnosis with significant functional impairment A child or youth with an SED: A diagnosable mental, behavioral or emotional disorder of sufficient duration to meet diagnostic criteria specified within the most current Diagnostic and Statistical Manual of mental disorders (DSM) that results in a functional impairment.

62 Chronic condition health home A chronic condition health home (CCHH) has the care team originating in the member s primary care office which is often a Federally Qualified Health Center (FQHC). Along with ensuring core health home services of care coordination, transitions and referrals the CCHH assists the member in the management of his/her chronic disease including special emphasis the support of the member in self-management and health literacy. Adult and child/youth members are eligible for CCHH services if they have two (2) or more chronic health conditions or one (1) chronic health condition and are at risk for another. Chronic health conditions include the following: Asthma Substance use disorder Diabetes Obesity Heart Disease Mental health condition Hypertension Amerigroup identifies eligible members and works with CCHH providers to assign and engage member into this service.

63 Care coordination Amerigroup puts special emphasis on the coordination and integration of physical and behavioral health services, wherever possible. Key elements of the Amerigroup model of coordinated care include: Ongoing communication and coordination between PCPs and specialty providers, including behavioral health (mental health and substance use) providers The expectation that providers screen for co-occurring disorders, including: Behavioral health screening by PCPs Medical screening by behavioral health providers Screening of mental health patients for co-occurring SUDs Screening of consumers in substance use disorder treatment for co-occurring mental health and/or medical disorders Screening tools for PCPs and behavioral health providers can be accessed at providers.amerigroup.com/ia Referrals to PCPs or specialty providers, including behavioral health providers, for assessment and/or treatment for consumers with co-occurring disorders Involving members, as well as caregivers and family members, as appropriate, in the development of patient-centered treatment plans. Case management and disease management programs to support the coordination and integration of care between providers

64 Care coordination-con t As an Amerigroup network provider, you are required to notify a member s PCP when a member first enters behavioral health care and anytime there is a significant change in care, treatment or need for medical services, provided that you have secured the necessary release of information. The minimum elements to be included in such correspondence are: Patient demographics Date of initial or most recent behavioral health evaluation Recommendation to see PCP, if medical condition identified or need for evaluation by a medical practitioner has been determined for the member (e.g., Early Periodic, Screening, Diagnosis and Treatment screen, complaint of physical ailments) Diagnosis and/or presenting behavioral health problem(s) Prescribed medication(s) Behavioral health clinician s name and contact information

65 Questions 65

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