2016 Updates and Refresher Course CHPW PRESENTATION

Transcription

1 2016 Updates and Refresher Course CHPW PRESENTATION 1

2 About CHPW In 1992, Washington s local Community Health Centers voted to create a notfor-profit managed care company Community Health Plan of Washington. Our plan membership grew from 14,000 members in 1993 to over 300,000 currently. Our network includes: 21 Community Health Centers that operate more than 125 clinic sites More than 2,600 primary care providers More than 14,000 contracted medical specialists More than 100 hospitals CHPW is a local not-for-profit health plan in Washington State. 2

3 CHPW Lines of Businesses Washington Apple Health, continues to expand coverage in 2016 to individuals and families who have incomes below 138% of the Federal Poverty Level (FPL). Our affordable Medicare Advantage HMO plans provide members valuable extended coverage and services. CHPW s individual commercial insurance plan offered inside the Washington Health Benefits Exchange in

4 2016 Service Area Map

5 2016 Service Area Map

6 2016 Service Area Map

7 Together with our valued and committed contracted Providers, Community Health Plan of Washington is serving many members with Washington Apple Health! CHPW serves Washington Apple Health members statewide except in the following nine counties: Clallam, Columbia, Garfield, Jefferson, Klickitat, Lincoln, Mason, Skamania, Whitman For more information on WA Apple Health, go to: 7

8 Preventive care is CHPW s focus. CHPW covers 100% of the following services: Bone Mass Measurements Colorectal Screening Exams Immunizations Mammograms Pap Smears and Pelvic Exams Prostate Cancer Screenings The following slides covers our plan types and benefit highlights; for more information visit our Medicare Advantage (MA) website at: 8

9 Medicare Advantage (MA) Plan Options: CHPW MA Plans vary by service area (county). To enroll, member must reside in one of our service areas. Note: Plan 014 in 2016 was Plan 005 in prior years. 9

10 Plans and Benefit Highlights: Plan Highlights $0 monthly premium Up to $100 every two years for supplemental eyewear Up to $900 per year for supplemental dental services $0 copay for acupuncture visit Plan Highlights $0 primary care copay $40 specialty care copay $0 copay for diabetic supplies Up to $100 every two years for supplemental eyewear Up to $500 per year for supplemental dental services $0 copay for acupuncture visit Plan Highlights $0 primary care copay $40 specialty care copay $0 copay for diabetic supplies Up to $100 every two years for supplemental eyewear Up to $500 per year for supplemental dental services $0 copay for acupuncture visit 10

11 Plans and Benefit Highlights: Plan Highlights $0 primary care copay $40 specialty care copay $0 copay for diabetic supplies Up to $100 every two years for supplemental eyewear Up to $500 per year for supplemental dental services Plan Highlights $10 primary care copay $45 specialty care copay $0 copay for diabetic supplies Up to $100 every two years for supplemental eyewear Up to $250 every year for supplemental dental with optional rider 11

12 Vision Service Plan (VSP) Community HealthFirst Medicare Advantage has vision benefits through VSP: VSP administers the Plan and Vision Benefits on behalf of CHPW, including: Claims processing Quality Credentialing OON provider services Data/reporting Regulatory compliance 12

13 Community HealthEssentials Plus 2016 Plan Changes CHPW s Washington Health Benefit Exchange Plan Bronze metal plan will be discontinued on December 31, 2015; CHPW will not offer Bronze plans in Other updates and changes are as follows: Gold and Silver metal plans will be renewed effective on January 1, 2016 in the 14 county service area only Silver plans with Cost Sharing Reduction (CSR) have different copays and coinsurance amounts in

14 2016 Gold Standard Plan 14

15 2016 Silver Standard Plan 15

16 Community HealthEssentials Plus 2016 Plan Changes Important facts: CHPW partnered with First Choice Health (FCH) to serve as the Preferred Provider Organization (PPO) network and Third Party Administrator (TPA) for Community HealthEssentials commercial products. November 1, Open Enrollment Begins for 2016 January 1, coverage begins January 31, Open Enrollment Ends for

17 Contact Guide WA Apple Health (Medicaid) and Community HealthFirst (Medicare Advantage) Customer Service: (Apple Health) Customer Service: (Medicare Advantage) Medical Management: Website: Community HealthEssentials (Health Exchange) Administered by First Choice Customer Service: Medical Management: Website: To review and compare coverage plans offered in the Exchange marketplace in 2016 go to: To access Community HealthEssentials Plus website and information, go to: 17

18 Contact Guide Provider Relations Contacts: Carmen Switzer Provider Relations Administrator (Eastern WA) also covering: Providence Health System (Professional), DME, HME and Ancillary state-wide. Phone: Carol Wallingford Provider Relations Representative (Eastern WA) Phone: Douglas Sheldon Provider Relations Administrator (Western WA) also covering: Providence Health Systems (Facility) state-wide. Phone: General Information: Your Provider Relations Administrator could be contacted for escalated (high level) issues and inquires. Your Provider Relations Representative could be contacted for standard issues and enquiries. 18

19 Contact Guide Appeals & Grievances: Provider and Member appeals and grievances may be mailed, faxed or ed for all lines of businesses: Address: 720 Olive Way, Ste 300 Seattle, WA Fax: Claims Investigative Unit (CIU) After attempts to resolve issues through Customer Service have been exhausted and to address complicated and escalated claims issues, as outlined on CHPW s contact guide, Providers could contact the CIU directly: cs.claimsdistribution@chpw.org Fax:

20 Contact Guide Credentialing For credentialing status, Provider could contact: Phone: Provider Data Services (PDS) Contact PDS for the following: Add New Providers Provider Terminations Provider/Clinic/Facility Address Adds/Changes/Terminations Tax ID Updates & Changes Check on status of requests Fax:

21 Contact Guide Electronic Data Interchange (EDI) CHPW supports several Electronic Transactions, i.e., 270, 271, 276, 834, 835 and 837. To enroll or inquire: Provider Relations welcomes input and suggestions from Providers. If you have ideas that might improve our Contract Guide; to make it more user friendly, etc., please do not hesitate to contact: Carmen Switzer 21

22 CHPW Provider Directory To access our Provider Directory, including Mental and Behavioral Health Providers, please go to: From website: Steps to find a Mental or Behavioral Health Provider: Uncheck this box and click here: Enter Zip, City or County here and enter Behavioral or Mental here: Example results for Behavioral Health Provider search: 22

23 Timely Filing & Claims Submission Timely Filing = 365 days from Date of Service Questions/ Claims Status: WA Apple Health Customer Service 1 (800) Medicare Advantage Customer Service 1 (800) Where to Send Claims Paper Claims: CHPW Claims PO Box Plano TX, Electronic Claims Submission: Availity Payor ID: CHPWA Emdeon Payor ID: SB613 23

24 Electronic Transactions CHPW supports the following Electronic Transactions: 270: Eligibility, coverage or benefit inquiry 271: Eligibility, coverage or benefit information 276: Health care claim status report 277: Health care information status notification 834: Benefit enrollment and maintenance 835: Health care claim payment advice 837: Health care claim ACH payments: Automated clearing house (ACH) payments are electronic payments often referred to as direct deposit or electronic funds transfer (EFT). To enroll in any of the electronic transactions that we support, please 24

25 Plan Authorized Referral CHPW requires a Plan Authorized Referral as follows: Non-Par Specialist will always require a Plan Authorized Referral. Contracted Primary Care Provider/Clinic member presents to your clinic, and they are not assigned to your organization, including an Urgent Care (billed with POS 11) or After Hours clinic your group would need to request a Plan Authorized Referral from CHPW prior to rendering services. Non-Par Primary Care Provider/Clinic will always require a Plan Authorized Referral from CHPW. The CHITA form is what should be used to submit a request for a Plan Authorized Referral fax to Apple Health (206) or Medicare Advantage (206) Preferred method to request a Plan Authorized Referral is through our Care Management Portal (JIVA). Note: CHPW does not issue retro-referrals, thus a referral must be obtained prior to rendering the service. If not obtained, claims will deny correctly. Providers have appeal rights; however, if you are unable to support your appeal with extenuating circumstances, your denial would likely be upheld. 25

26 Plan Authorized Referral For other forms and tools, please go to From the Home Page: Click For Providers Click Forms and Tools or copy/paste the following link to your browser: 26

27 Prior Authorization (PA) Requests Providers could request Prior Authorizations one of two ways as follows: Complete and submit a CHPW Prior Auth form via fax to: --Apple Health (Medicaid) Community HealthFirst (Medicare Advantage) Submit requests through CHPW s care management portal (JIVA) 27

28 Prior Authorization (PA) Requests Question: Customer service advises the provider that a prior authorization is not required. What is the most useful information to document or note in your system in the event a PA denial is received? Request a call Reference number. Document the date and time. The above information should be included in your appeal. State in your appeal that you were advised by CSR that a PA for the attached denial was not required and include call reference number, date and time. CHPW will pull the call script and if the call supports your appeal, the denial may be overturned. 28

29 Prior Authorization (PA) Requests Question: What is CHPW s standard response time for PA requests? CHPW follows Medicare and Medicaid guidelines as follows: Medicaid (Apple Health) Standard PA Requests: 5 days 14 days Urgent PA Requests: 24hrs - 72hrs Medicare Advantage (Community HealthFirst) Standard PA Requests: 14 days 28 days Urgent PA Requests: 72hrs 14 days Turnaround times are extended if additional information is required. CHPW s policy is to readily request additional information after the initial request is received. To avoid delays, providers must submit complete information with the initial request. 29

30 Prior Authorization (PA) Lists Question: Is CHPW able to update their prior authorization list to include pharmacy J codes? CHPW s PA list includes which drugs require a prior authorization. CHPW s code driven prior authorization list is another source; however, is not a complete list and was designed to be a provider help list. CHPW recommends that providers use the hard copy PA list as a primary tool found here: If the drug in question is related to a drug on the hard copy PA list and the code is not found on the code driven PA list, a prior authorization request is suggested. Please note that providers will be more familiar with specific drugs than CHPW Customer Service Reps, thus it is best to submit a PA request if you are uncertain if it requires a PA. 30

31 Prior Authorization (PA) Requests Providers could request Prior Authorizations one of two ways as follows: Complete and submit a CHPW Prior Auth form via fax to: --Apple Health (Medicaid) Community HealthFirst (Medicare Advantage) Submit requests through CHPW s care management portal (JIVA) 31

32 To access CHPW s PA List and Code Look Up List, go to: -- from Home Page, go to: For Providers Prior Authorizations

33 To access CHPW s PA List and Code Look Up List, go to: -- from Home Page, go to: For Providers Prior Authorizations

34 Prior Authorization Form For other forms and tools, please go to From the Home Page: Click For Providers Click Forms and Tools or copy/paste the following link to your browser: 34

35 PA Summary of Changes For other forms and tools, please go to From the Home Page: Click For Providers Click Forms and Tools or copy/paste the following link to your browser: 35

36 PA Summary of Changes For other forms and tools, please go to From the Home Page: Click For Providers Click Forms and Tools or copy/paste the following link to your browser: 36

37 Balance Billing Providers may not bill members for co-payments, coinsurances, deductibles or covered services for the following lines of businesses: Washington Apple Health MA Special Needs Plan (014) 014 Balance billing is not permitted by Federal and State agency guidelines. 37

38 Balance Billing Providers must accept payment by CHPW as payment in full. Balance billing is not permitted unless the provider and member fully complete and sign an HCA form--agreement to Pay for Healthcare Services. See WAC and HCA Memo in final bullet below for additional information. Services must be rendered within 90 days from signing the HCA form, otherwise a new form must be completed and signed. The HCA form must be translated into the member s primary language if he or she has limited English proficiency, and if necessary, an interpreter must be provided for the member. If an interpreter is used to complete and sign the form, the interpreter s signature must also be obtained. All other requirements for the HCA form apply, as outlined in WAC , 42 CFR , and HCA Memo #

39 Balance Billing Special Needs Plan (SNP) SNP members should not be billed, as they are dual covered by Medicare and Medicaid. When a member presents to your clinic or hospital with a CHPW Medicare Advantage ID card with a Group 014 plan type, the member should be registered in your billing system as follows: Community HealthFirst as primary Medicaid (DSHS FFS) as secondary 39

40 Health Information Portal (HIP) Provider Portals Registered users have access to the following information: Eligibility and Benefit Details Member Rosters View Referrals & Authorizations View Claim Status Once registered, providers can access HIP through a single sign-in at: OneHealthPort, or Support Phone Number: 1 (800)

41 Provider Portals CHPW JIVA Care Management Portal The portal is the preferred method for you to submit and track all Care Management requests. Request or check the status of the following: Eligibility/Referrals/Prior Authorizations Notify CHPW of Inpatient Admissions To register for JIVA, contact: To access website, go to: 41

42 Access Standards Providers must meet the following access standards: Primary Care & Pediatric Primary Care Schedule routine/preventive visits within 30 calendar days. Schedule an urgent visit within 24 hours. Schedule transitional care visit within 7 calendar days after discharge from inpatient/institutional care facility. Schedule non-urgent, symptomatic care appointments within 10 calendar days. Behavioral & Mental Health Provide non-life threatening emergency care within 6hrs. Schedule transitional care visit within 7 calendar days after discharge from inpatient/institutional care facility. Schedule an urgent care visit within 48 hours. Schedule a routine office visit within 10 business days. 42

43 Specialty Access Community Health Plan of Washington wants to know if our providers are experiencing barriers with referring to Specialist. If our providers need assistance with Specialty access, please go to click For Providers, Tools and Resources and click on the following on-line form: Specialty Access Assistance Request The on-line form will give you the opportunity to answer the following questions: What specialty or specialties are you having access issues with? In your opinion, what is causing the issue(s)? The form is completed and submitted online. 43

44 Culturally and Linguistic Appropriate Service (CLAS) CHPW supports providers in meeting CLAS standards and meets them ourselves by: 1. Training on key items, like the standards and tools we recommend for good care. 2. Resources to use with CHPW members in need of language assistance. 3. How to gain additional resources on CLAS and culturally competent care. A complete training program on CLAS standards could be found here: This is a mandatory training program for providers.

45 Language Assistance CHPW interpretation services are available: Apple Health: The Health Care Authority s vendor provides this service at (800) Medicare: CHPW provides this service at (866) with the following log in: Enter Account Number: Enter PIN Number: 0044 Enter Cost Center: 44

46 Provider Training and Education Programs Community Health Plan of Washington offers on-line Provider Orientation and Training programs. Some programs are mandatory and others are optional. Following are some of our training programs: Provider Orientation For new (mandatory) and established Providers. For more information on training programs; including General Compliance and Fraud, Waste and Abuse, please go to:

47 Green Initiative CHPW is working on creating a culture of environmental responsibility; an enterprisewide strategy to reduce paper and encourage more self-service among CHPW Staff, Providers, and Members. How Provider s can help: If you receive 835 s, you could request that CHPW turn off paper remittance advices. If you are not enrolled to receive 835 s, please go to: Many providers prefer auto-recoupments who also receive refund letter requests from CHPW. If you receive refund letters and you have no use for them, you could request that CHPW turn off the submission of refund letters.

48 Green Initiative Please your Provider Relations contact directly or to make your green request today! With your request, please share your ideas on how we can be more environmentally responsible. A forest area the size of 20 football fields will be lost for paper production use alone. In the last year, logging in the Southeastern U.S. resulted in a loss of land about the size of New Jersey (5 million acres). In fact, the area of natural pine forest there has declined in size from 72 million acres in 1953 to 33 million acres in This is where most of the trees used to make paper come from (an astonishing 26% of the world's supply, to be exact), and it's clearly in critical danger. Thank you to our Providers who have already sent in your requests to participate in CHPW s Green initiative!

49 If your patient would like to: Determine eligibility for healthcare coverage with CHPW, or Change their health plan to CHPW..your team could use the Plan Change Form and fax the completed form to for processing. For a copy of this form, please contact your Provider Relations Administrator or Representative directly; or Provider.Relations@chpw.org

50 Thank you We look forward to continuing our partnership in