CoventryCares of Kentucky. Provider Orientation Fall 2011

Transcription

1 1 CoventryCares of Kentucky Provider Orientation Fall 2011

2 Topics Covered 2 Eligibility Ineligible Member Categories Coverage Requirements Policies and Procedures Provider Rights and Responsibilities Medical Records Members Rights and Responsibilities Preventative Health Services EPSDT Program Special Health Care Programs Advanced Medical Directives Responding to Members Needs Quality Assessment/Performance Improvement EQRO Fraud, Waste and Abuse Cultural Competency Claims Submission/Payment Requirements

3 3 Who is eligible? Applications are taken at the DCBS office and are based on income guidelines of the federal poverty level Residents of the State of KY Pregnant women Children SSI recipients

4 4 Ineligible Member Categories Individuals who shall spend down to meet eligibility income criteria; Individuals currently Medicaid eligible and have been in a nursing facility for more than thirty (30) days* Individuals determined eligible for Medicaid due to a nursing facility admission including those individuals eligible for institutionalized hospice Individuals served under the Supports for Community Living, Michele P, home and community-based, or other 1915(c) Medicaid waivers Medicare Savings Members, those receiving only Qualified Medicare Benefits (QMB), specified low income Medicare beneficiaries (SLMBs) or qualified Disabled Working Individuals (QDWIs) Time limited coverage for illegal aliens for emergency medical conditions Working Disabled Program Individuals in an intermediate care facility for mentally retarded (ICF-MR) Individuals who are eligible for the Breast or Cervical Cancer Treatment Program.

5 Network Adequacy Requirements PCP s are to be within 30 miles or 30 minutes within the member s residence or place of employment in an urban area PCP s are to be within 45 miles or 45 minutes from member s residence or place of employment in a Rural area Services available 24 hours a day, 7 days a week (can include an answering service) Appointment wait times Primary Care Providers: Routine and Preventative not to exceed 30 days from date of request Urgent Care not to exceed 48 hours from request Appointment wait times Specialists: Routine and preventative - Referral appointments not to exceed 30 days Urgent care not to exceed 48 hours Behavioral Health Emergency care with crisis stabilization within 24 hours Urgent care within 48 hours 5

6 Policies and Procedures 6 CoventryCares of Kentucky (CC-KY) has policies and procedures in place which address the following topics Claims Submission & Payments Fraud and Abuse Quality Improvement Cultural Sensitivity Advance Directives Disease Management Rights and Responsibilities (Members and Providers)

7 7 Providers Rights & Responsibilities Must complete three distinct actions to become participating providers with CoventryCares of Kentucky. Complete a participating agreement Submit all necessary credentialing information Submit KYMAP-811 Kentucky Medicaid enrollment application or your Kentucky Medicaid Provider Number Must keep licenses and certifications current and in good standing and cooperate with CC-KY recredentialing program. Section 10 in the Provider Manual outlines the rights and appeals process One year from the date-of-service to file an appeal. Right to request and receive written copy of the CoventryCares utilization management criteria. Right to claims review (offered electronically through

8 8 8 Providers Rights & Responsibilities (cont.) Complaints can be called in to CC-KY Grievance and Appeals department at (888) CC-KY will provide a Provider Relations Representative to act as a liaison with the Provider. Will not deny, limit or condition the furnishing of covered health care services to members based on health factors Cooperate with CC-KY medical management procedures to identify, assess and establish a treatment plan for members with complex or serious medical conditions. Obtain authorizations for all hospitalizations as well as services specified in the Provider Manual located at

9 9 Providers Rights & Responsibilities (cont.) Ensure the completeness, truthfulness and accuracy of all claims and encounter data submitted to CC-KY including medical records data and ensure the information is submitted on the applicable form. Submit demographic or payment data changes at least 60 days prior to the effective date of change. Be available to CC-KY members as outlined in the Scheduling Appointments and Waiting Times section of the Provider Manual. Arrange 24 hour on-call coverage for their patients with providers that also participate in CC-KY.

10 Content of Medical Records 10 Member/patient identification information on each page. Personal/biographical data, including date of birth, age, gender, marital status, race or ethnicity, mailing address, home and work addresses and telephone numbers, employer, school, name and telephone numbers of emergency contacts, consent forms, identify language spoken, and guardianship information Date of data entry and date of encounter Provider identification by name Allergies, adverse reactions, and any known allergies shall be noted in a prominent location Past medical history, including serious accidents, operations, illnesses For children-prenatal care and birth information, operations, childhood illnesses

11 Medical Records (cont.) 11 Identification of current problems Consultation, laboratory and radiology reports filed in the medical review shall contain the ordering providers initials or other documentation indicating review. Documentation of immunizations Identification and history of nicotine, alcohol use or substance abuse Documentation of reportable diseases and conditions to the local health department serving the jurisdiction in which the patient resides Follow-up visits provided secondary to reports of emergency room care

12 Medical Records (cont.) 12 Record must be legible to at least a peer of the writer (any record judged illegible by one reviewer shall be evaluated by another reviewer) If any Covered Service provided requires completion of a specific form, that form shall be properly completed according to the appropriate KAR. Provider shall retain the form in the event of an audit and a copy shall be submitted to the State upon request Hospital discharge summaries Advance Medical Directives (for adults) All written denials of service and the reason for the denial

13 13 Member Rights & Responsibilities To receive good medical care no matter their race, color, religion, sex, age, disability, or nationality. To be treated with respect and dignity and to have their privacy protected. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. To have a choice about their CC-KY PCP and be able to change their PCP within the rules. To receive medical care when they need it. To ask questions and get answers about their medical condition and treatment options, including specialty care. To be told that services are not covered before they get them. To be part of all decisions about their health care including the right to refuse treatment. To ask for a second opinion.

14 14 Members Rights & Responsibilities (cont.) To have their medical records and care kept private. To look at copies of their medical records and get copies if they want them. To file a grievance, an appeal or ask for a hearing if they have problems with their eligibility or health care. To receive help with filing an appeal. To have timely access to care including specialty care. To make sure physical barriers do not limit timely access to care. To get information in a way that is easy to understand. To get free translation services if needed. To prepare Advance Medical Directives according to Kentucky laws. To ask for a description of payment methods CC-KY uses to pay providers for member care. To be told at least 30 days before any program or site changes that affect them.

15 15 Member Rights & Responsibilities (cont.) Give the best information they can so that CC-KY and their providers can take care of them. Follow their PCP s instructions and care plans. Actively participate in personal health and care decisions and practice healthy lifestyles. Call their PCP first when you need medical care, except in an emergency Go to providers who accept their CC-KY Member ID card. Show their CC-KY and Kentucky Medicaid ID card every time they receive medical services. Make sure that they only see CC-KY providers. Keep all appointments and be on time. Cancel an appointment if they cannot get there.

16 Member Rights & Responsibilities (cont.) 16 Follow CC-KY and Kentucky Medicaid policies and procedures. Follow the rules of their PCP s office or clinic. If they do not follow the rules, their provider can ask them to leave. Ask their PCP questions if they do not understand something about their medical care. Tell the truth about themselves and their medical problems. Report suspected fraud and abuse. Tell the Department for Community Based Services (DCBS) about changes to their name address, telephone number. Notify if they have a change like a birth, death, marriage or other insurance. Learn the difference between emergencies and urgent care. Understand their rights and responsibilities as a Kentucky Medicaid member.

17 17 Preventative Health Services Adult Health Screenings (details in Provider Manual) EPSDT (details in Provider Manual) Early Periodic Screening, Diagnosis and Treatment Services (EPSDT) Program - Federally mandated Medicaid program for children. In Kentucky, it is divided into two components EPSDT Screenings EPSDT Special Services Weblink

18 18 EPSDT Screenings Routine physicals or well-child check-ups for Medicaid eligible children at specified ages. It is considered preventive care. Children are checked for medical problems early. Specific tests and treatments are recommended as children grow older. Areas checked include: preventive check-ups; growth and development assessments; vision; hearing; teeth; immunizations and laboratory tests. Children should receive health check-ups regularly or before the following ages: 1 month; 2 months; 4 months; 6 months; 9 months; 12 months; 15 months; 18 months; 24 months; 30 months; 3 years; 4 years; 5 years; 6 years; 8 years and once-a-year for ages

19 19 EPSDT Special Services Can be preventive, diagnostic, treatment or rehabilitative. Examples: Additional eyeglasses up to $200 or $400 value depending on the benefit plan after the Medicaid Vision Program has paid for the first two pair in a year, Additional dental cleanings after the Medicaid Dental Program has paid for two cleanings, Nitrous oxide when used in dental treatment, Nutritional products when used as supplement rather than as the child's total nutrition, Speech therapy, occupational therapy or physical therapy when the therapy does not meet criteria for the Medicaid Home Health Program Substance abuse treatment. All EPSDT special services require prior authorization

20 20 Automated Outreach Program CC-KY uses the age intervals and EPSDT Claim CPT codes to create an automated outreach program Birthday reminders It is time for a Check-up Missed Appointments Dental Reminders Lead Screening

21 Special Healthcare Programs (Case Management and Disease Management) 21 Social workers, complex case managers and behavioral health case managers work closely with the provider, patient and family to: Coordinate the delivery of patient focused, cost-effective, quality care in the most timely manner to ensure optimal patient outcomes Develop and implement individualized patient care plans focused on improving health outcomes Educate patients about their health conditions, medications and physician s treatment plan Refer and coordinate with community resources and special programs to ensure patient s physical and psychosocial needs are met Encourage medication and treatment plan adherence

22 Special Healthcare Programs (cont.) 22 Specialized Case Management Programs: High Risk Prenatal Special Needs Population: Guardianship Foster Care Aged, Blind and Disabled Chronic Condition Management Transplant Behavioral Health Integrated approach with medical and behavioral health case managers working collaboratively to address patient needs

23 23 Advance Medical Directives PCP s are required to educate their patients on advance directives at the initial visit. All patients should qualify to have an advance directive prepared free of charge by their local legal aid program. Kentucky Attorney General s website has extensive information on advance directives.

24 24 Responding to Member Needs Access to services Delivery of services Cultural Sensitivity Mental Disabilities we offer integration with Mental Health vendor for members with overlapping behavioral and medical health conditions. Developmental Disabilities Physical Disabilities Reporting of communicable disease

25 25 Quality Assessment and Performance Improvement (QAPI) Program Encompasses all aspects of clinical care and services for all members and providers. Continuous data review Program reviews on randomly selected providers and diagnoses on a continuous basis Addresses members with special needs in the monitoring, assessment and evaluation of care and services provided Women Infants and children Adolescents and young adults Member satisfaction Provider satisfaction

26 Components of CC-KY Quality Improvement Strategy Quality management Utilization management Records management Information management Care management Member services / Enrollee satisfaction survey Provider services Organizational structure Credentialing/Recredentialing Network performance Fraud and abuse detection and prevention Access and availability to care & services Data collection, analysis and reporting 26 Compliance with NCQA and state standards HEDIS reporting Preventive care Review of translation line utilization to identify specific cultural/linguistic needs Peer review Performance improvement projects (PIPs) Oversight of sub-contractors and delegated activities Continuity and coordination of care Annual QI work plan QI program effectiveness evaluation

27 27 Quality Assessment & Performance Improvement (cont.) CC-KY has the following committees as part of its QAPI program: Credentialing Quality management Peer review Clinical criteria review Accreditation Providers may participate in the above committees

28 28 External Quality Review Organization State Medicaid programs are required to engage an independent external review body to perform an annual review of the quality of services provided by an Managed Care Organization under contract with the Commonwealth, to include the evaluation of quality outcomes and timeliness of access to services.

29 29 Fraud, Waste and Abuse Fraud is an intentional deception or intentional misrepresentation made by a person with the knowledge that the deception could result in some unauthorized personal benefit or benefit to some other person. Abuse means provider practices that are inconsistent with sound fiscal, business or medical practices, that result in unnecessary cost to the Medicaid program, or that result in reimbursement for services which are not medically necessary or that fail to meet professionally recognized standards for health care.

30 30 Provider Fraud/Abuse Examples Billing for services or equipment that the patient did not receive Charging recipients for services over and above reimbursement Double billing or other illegal billing practices Submitting false medical diplomas or licenses in order to qualify as a Medicaid provider Ordering tests, prescriptions or procedures the patient does not need Rebating or accepting a fee or portion of a fee for a Medicaid patient referral Failing to repay or make arrangements for the repayment of identified overpayments

31 31 Member Fraud/Abuse Examples Forging or altering prescriptions Card-sharing allowing someone else to use a Medicaid card to get services Intentionally seeking and receiving excessive drugs, services or supplies Collusion with providers in order to get services or supplies Providing false information in order to qualify for Medicaid Drug diversion

32 32 Reporting Suspected Fraud and Abuse Call the CC-KY Special Investigation Unit at (866) All information provided will be held in strictest confidence allowed by law. All fraud or suspected fraud is required to be reported.

33 33 Cultural Competency Providers must provide services in a culturally competent manner Cultural competency includes respecting diversity of member values, beliefs and behaviors based on cultural, social, racial, linguistic, etc., differences and eliminating barriers to care and services. Included, but not limited to, are members who are socioeconomically disadvantaged, minorities, those who speak a language other than English and those who are hearing or sight impaired. CC-KY assists providers in this practice by providing language assistive materials including Braille and Spanish language member materials and translation services.

34 34 5 Essential Elements to Becoming Culturally Competent 1) Value diversity 2) Have the capacity for cultural self-assessment 3) Be conscious of the dynamics when cultures interact 4) Institutionalize cultural knowledge 5) Develop adaptations to service delivery reflecting an understanding of diversity between and within cultures

35 35 Access to Services Interactive Voice Recognition Verify Member Eligibility Verify PCP Assignments Obtain Member ID# Check Claims Status Verify Authorizations Call Follow automated prompts Enter tax identification number (TIN) Enter Member s Medicaid Number or Coventry Number Say Agent to speak to a representative

36 Claims Submission/Payment Requirements (cont.) 36 Medical Electronic Payor ID Follow your clearinghouse s instructions Emdeon is Coventry s Preferred clearinghouse Review the R022 and R059 reject reports Electronic submission improves payment turnaround time Electronic COB claims are accepted. Submit claims with your NPI and TIN. MHNet Electronic Payor ID Paper submissions and claim reconsiderations should be sent to: CoventryCares of Kentucky P.O. Box 7812 London, KY Timely filing of the original claim and corrections is 365 days from date of service

37 37 Claims Submission/Payment Requirements (cont.) Paper claims resubmitted with questions or corrections must have Reconsideration or Correction written on them. Handwritten corrections of critical fields must be initialed. Box 33 of the CMS 1500 form must be billed by the legal owner of the TIN. VFC immunizations must be billed with the 26 modifier. NDC is required on outpatient hospital claims, revenue codes and NDC is required on physician claims corresponding to the Physician Injectible Drug List as defined by the Commonwealth.

38 38 Claims Submission/Payment Requirements (cont.) If you feel an error has been made in your payment or in the manner in which you have been paid, you may: -Call Customer Service: Send a written inquiry to: CoventryCares of Kentucky P.O. Box 7812 London, KY 40742

39 Key Contacts Customer Service (855) Authorizations (Phone) (888) Authorizations (Fax) (855) Provider Relations (855) Provider Representatives: Region 1 Barbara Jones Region 2 Mark Leonard Region 3 Christy Vowels Region 4 Melissa Powell Region 5 Kristy Cabell Region 5 Jon Gillispie Region 6 Christy Vowels Region 7 Donna Moor Region 8 Krista Hubbard