An Administrative Orientation for MVP Health Care Providers

Transcription

1 VALUEOPTIONS Presents: An Administrative Orientation for MVP Health Care Providers July 2009 Forum Series 1

2 2 Contract Changes Go Into Effect on: September 1, 2009

3 Agenda Welcome and Introductions Overview of ValueOptions MVP Health Care and ValueOptions Partnership Overview of New York State Plans Network Services Provider Relations Credentialing and Contracting Network Operations Customer Service: Claims and Clinical Clinical Operations and Quality Management Claims ProviderConnect Demonstration Electronic Funds Transfer (EFT) & PaySpan Health Questions and Answers 3

4 4 Welcome & Introductions

5 Panel of Speakers Cathy Gilbert, National Director of Provider Relations Renee Abdou-Malta, VP National Network Services Dr. Christopher Dennis, VP, Regional Medical Director Janice Maurizio, VP National Clinical Services Jean Barnard, Director of Claims Operations Maggie Middleton, Director of Customer Service Sue Healey, Director of Claims Customer Service Aaron Bennett, Clinical Customer Service 5

6 6 Overview of ValueOptions

7 ValueOptions Nationwide 1 to 3 Million Lives 500,000 to 1 Million Lives 250,000 to 500,000 Lives Under 250,000 Lives 7 National Headquarters National Support Centers Regional Service Centers

8 ValueOptions Connect System PHARMACONNECT Automatic screening of medical and pharmacy claims to identify patient specific information NETWORKCONNECT Robust network management and provider relations PROVIDERCONNECT Secure, online administrative self-service for providers CARECONNECT Superior clinical case management and data collection TELECONNECT Easy-to-access telephonic self-service for providers and members SERVICECONNECT Industry-best customer service and issue resolution MEMBERCONNECT Online self-service and award-winning content for members CLIENTCONNECT Secure, online access to reports and claims payment information 8

9 Contact Information Provider Line Questions about Credentialing or Contracting (800) Clinical Authorization and Claims Customer Service For Clinical and Customer Service issues, the contact numbers will not change call the appropriate MVP Health Care number on the member s card and follow the prompts to be connected to ValueOptions. Provider Relations northeastregion@valueoptions.com National Facility Contracting Rhonda Stewart or Bill Keleher rhonda.stewart@valueoptions.com bill.keleher@valueoptions.com 9

10 10 MVP Health Care & ValueOptions Partnership Overview

11 MVP Health Care & ValueOptions Effective 9/1/09, ValueOptions will Manage Behavioral Health Services for most MVP Health Care Plans. Why ValueOptions? provide focused behavioral health care expertise to implement the Federal Mental Health Parity Act provide a robust national provider network 11

12 MVP Health Care & ValueOptions All ASO (self-funded) plans that currently have their behavioral health coverage administered by MVP will have these services administered by ValueOptions ValueOptions will administer behavioral health coverage for all fully-insured plans in New York and New Hampshire (HMO, POS, EPO, PPO, Indemnity). Primarilink will continue to administer behavioral health coverage for fully-insured Vermont plans 12

13 What will change for Employers and Members? Members will use ValueOptions provider network to access behavioral health treatment or other related services. ValueOptions will perform utilization management duties to ensure medically necessary treatment plans are approved for coverage. ValueOptions will be processing claims for coverage. 13

14 14 Overview of New York State Plans

15 New York City Service Center New York City Service Center»Over 3.5 Million Covered Commercial/Medicare/Medicaid members and retirees»utilization Review Accredited Commission (URAC) certified»valueoptions manages both the Mental Health and Substance Abuse benefits GHI-BMP GHI-Medicare Great-West Healthcare VidaCare (866) Choice PPO (866) (866) GHI-Family Health Plus (800) (866) Liberty Health Advantage (866) Senior Whole Health (866) VNS Choice Select ( 866) GHI-BMP: GHI pays the claims ValueOptions pays the claims ValueOptions pays the claims Claims are paid by Royal 15

16 Provider Relations: Address and Helpline MVP Health Care New York City Service Center (800) (866)

17 17 National Network Services: Provider Relations, Credentialing, Contracting & Network Operations

18 18 Provider Service Options

19 Continuous Program of Provider Education Welcome Package ValueOptions Newsletters E-Pub Visits to Key Facilities Representation at Trade Shows Provider Forums Annual Revision to Provider Handbook valueoptions.com 19

20 National Provider Relations Web Site Company News: Read the most recent news about our company The Valued Provider: Access articles found in our provider newsletter. Read informative articles and learn about new initiatives underway at ValueOptions Educational Opportunities: View educational articles and 2009 Provider Forum information online Provider Forms: Find administrative and clinical forms 2009 National Provider Handbook: Read about ValueOptions policies, provider responsibilities and much more 20

21 ValueOptions Contracting & Credentialing Provider Credentialing and Recredentialing Pre-populated Credentialing Application Recredentialing Required Every 3 years You can find additional information about Credentialing in FAQ (Frequently Asked Questions) document Provider Contracting ValueOptions Provider Agreements NY-CHCS IPA Agreement You can find additional information about Contracting in FAQ (Frequently Asked Questions) document Questions about Contracting and Credentialing? Call (8am 5pm EST) 21

22 Network Operations: Provider Data Verification Annually, ValueOptions sends provider data verification forms to all providers verifying all demographic information All forms must be completed and signed Completed information ensures accurate referrals and claims payment. Quick Address Solutions Validates addresses against official postal authority records Improved overall address data quality Increased productivity Reduced waste caused by undeliverable mail. 22

23 23 Customer Service: Claims and Clinical

24 Customer Service Philosophy ValueOptions Customer Service philosophy lies in our commitment to provide our members and providers with the most accurate and informed benefit, eligibility, claims, and certification information in the most effective, efficient, and compassionate manner. ValueOptions puts our members needs and concerns first and is committed to resolving inquiries promptly without the need to make a re-contact. We value our members questions and concerns and place member satisfaction at the heart of our Customer Service philosophy. 24

25 Key Areas of Expertise Clinical Customer Service Provides the following services to Members and Providers as the front end to the Clinical Department: Claims Customer Service Provides the following services to both Members and Providers: Responds to routine eligibility questions Responds to requests for authorizations Responds to referral requests Education assistance Responds to routine claims, benefits and eligibility questions via telephonr, correspondence and web inquiries Facilitates the resolution of complex claims issues via telephone, correspondence and web inquiries Responds to all Administrative Complaints and Appeals via a dedicated Appeal and Complaint Unit Provides dedicated Liasons to investigate and resolve complex client and provider issues 25

26 Customer Service Technology AVAYA Call System Service/CareConnect Member/Provider and TeleConnect BenefitConnect NICE Perform Technology 26

27 27 Clinical Operations & Quality Management

28 Care Management Paradigm Referred by Health Plan Care Manager Members Who Seek Care Via ValueOptions Clinical Referral Line Members Identified As High Risk (Multiple Channels) Members Identified By Health Plan Disease Management Screening Key Components of ValueOptions Care Management Paradigm Authorization and care management recommendations are Individualized for Diagnoses and Level of Care requests. Collaborative approach with treating providers. Symptom Complex based review processes. Utilization of treatment guidelines, Level of Care criteria and treatment algorithms. Intensive Care Management programs for high risk high cost members. Intensive Care Management activities to impact: Acute Inpatient Residential Partial Hospital Intensive Outpatient Outlier Outpatient Case Special protocols based on client nuances. Members Identified By ValueOptions PharmaConnect Application Members Identified By Predictive Modeling Software High Risk Physical Potential Co-morbid Behavioral Members Entering the Behavioral Health System In Crisis Referred From Employer EAP Provider 28

29 Referral Assistance Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management. Member referral process: Emergencies are followed until disposition. Urgent referrals are offered appointments within 48 hours and are called to ensure appointment is kept. Providers can contact ValueOptions for referral assistance if needed. Providers should contact ValueOptions 24 hours a day/seven days a week if members require higher level of care or increased visit frequency. Care Management staff will assist with referral to inpatient or specialty programs. Referral protocols in place with MVP s Disease Management, Utilization Management and Health Management programs. 29

30 Resources for Providers Clinical information is available at ValueOptions.com ValueOptions Medical Necessity criteria. ASAM criteria utilized for Substance Abuse. Treatment Practice guidelines. PCP consult line 9 am to 5 pm Intensive Case Management Services PharmaConnect analyzes pharmacy data and uses automated rules engine to screen for: Sub-optimal therapy Under-use Early discontinuation Automatic notification to providers 30

31 Resources for Providers (Continued) Clinical information is available at ValueOptions.com On Track: A client-centered outcomes management program, supports clinicians as they help clients achieve their goals. The goal of On Track is to provide clinicians with state of the art, easy-to-use tools that promote improved client outcomes. Achieve Solutions, a continuously updated and trusted behavioral health and wellness Web site that you can share with your patients. Designed with an intuitive, user-friendly interface, the site provides more than 6,000 articles on over 200 topics. 31

32 Utilization Management Process All authorizations requests should be submitted online through ProviderConnect Inpatient and higher level of care requests are completed either through the web or telephonically by calling the number on the back of the members MVP Health Care Identification card Preauthorization is required for inpatient requests. ValueOptions Staff are available 24 hours a day/ seven days a week. Outpatient requests can be mailed completed online, mailed to PO Box 1408, Latham, NY or faxed. 32

33 Utilization Management (continued) Transition benefit for those members in treatment prior to 9/1/09: Therapy: 8 sessions or 90 days, whichever comes first. An Outpatient Registration Form (ORF) is required for additional sessions. Medication management: 5 sessions or 90 days, whichever comes first. A Medications Management Form is required for additional sessions. Outpatient Utilization process: Therapy: 8 Pass through sessions per member per benefit year. Additional sessions require preauthorization. Medication Management: 12 pass through sessions per member per benefit year. Additional sessions require preauthorization. Psychological testing requires preauthorization 33

34 Clinical Forms The following forms can be found at the following location on the ValueOptions website: Outpatient Registration Form (ORF) Inpatient Treatment Report (ITR) Medications Management Form Psychological Testing Form 34

35 What is On Track Outcomes? A client-centered outcomes management program Designed to support clinicians as they help clients achieve their goals Utilizes a standardized, client-completed questionnaire and rapid feedback to provider Disclaimer: The ValueOptions On Track Outcomes program does not make recommendations or decisions about appropriate clinical care or service. Any questionnaires, reports, guidelines and other material related to this program are intended as an informational aid to network clinicians. They do not substitute for or limit in any way the use of other resources and the clinician's own professional judgment in the delivery of counseling services. 35

36 On Track Benefits for Clinicians Compare client progress to benchmarks Is this treatment working for this patient? Assist identification of potential self-harm and substance abuse risk Aggregate outcomes: evidence of value and effectiveness of counseling services Recognition: ValueSelect sm designation 36

37 Client Feedback Form (CFF) Key Fields Required to Process Forms Case Number: Numeric, provider assigned, unique to participant, but not identifiable by others Date and Session number to track progress EAP Case: Select No if using MHSA benefit Scoring: Global Distress, SA, Alliance 5-point scale items: 0 (Never) to 4 (Very often) Sum scores, divide by number of items 37

38 New users register here Print personalized CFFs Access On Track results 38

39 Resources Frequently Asked Questions On the web site, near bottom of the ValueOptions page Technical/Data/Web: to General comments or questions: to or Call On Track Customer Service

40 40 Quality Management

41 Overview of Quality Management Program Quality Management Program Oversight is provided by Medical Director Key Quality Indicators include but are not limited to: Satisfaction Survey measures Access and Availability of Services geographic access; phone statistics; appointment availability; etc. Complaints and Grievances tracking and reporting Patient Safety (adverse incidents and quality of care) Coordination of Care Quality Improvement Activities/Projects Compliance with URAC Standards Compliance with NCQA Standards 41

42 Quality Management Department Ongoing Quality Improvement Activities (QIAs) Clinical QIAs Ambulatory Follow-up Time in the Community Depression Management Risk Tracking Referral for Urgent and Emergent Tx Service QIAs Average Speed of Answer Provider Satisfaction with Utilization Management 42

43 43 Claims

44 Paper Claims Filing & Provider Summary Vouchers Are you sending in paper claims? Paper Provider Summary Vouchers? Is your cash flow not flowing the way you would like? Are you buried in paper work or back billing that needs to be done? 44

45 Solution: Electronic Claims Submission Advantages: It s better, faster, and cheaper! Reduced Paper Files Reduced Labor and Postage Expenses Reduced potential of error or mishandling Faster claims processing improves cash flow 45

46 ValueOptions EDI (Electronic Data Interchange) ValueOptions will accept claims files from any Practice Management System that outputs HIPAA formatted 837P or 837I files, as well as from EDI claims submission vendors. ValueOptions offers Direct Claims Submission on our website FREE to providers who do not have their own software, or who wish to submit certain claims outside their batch files. These claims are processed immediately, and you are provided the claim number You may submit batch claims files or Direct Claims interchangeably ValueOptions has a dedicated Helpdesk (8am to 6pm EST) for EDI issues 46

47 47 ProviderConnect Overview

48 ProviderConnect (Provider Online Services) What is ProviderConnect? ProviderConnect is an online tool where providers can: Verify Member eligibility View authorizations and authorization letters Request Authorizations Submit Claims View Claim Status Access Provider Summary Voucher Submit inquiries to Customer Service Submit updates to provider demographic information Access and print forms Increased convenience & decreased administrative processes! 48

49 ProviderConnect Benefits What are the benefits of ProviderConnect? Free, online, secure application Easily access routine information 24 hours a day, 7 days a week Complete multiple transactions in a single sitting View and print information Reduce calls for routine information 49

50 How to Access ProviderConnect? All In Network providers will be able to obtain online registration per provider ID number via the website To obtain additional logons for ProviderConnect contact the ValueOptions EDI Helpdesk at (888) and press option 3, Monday thru Friday, 8a.m. 6 p.m. EST The turn around time for additional logons is 48 hours Access thru: within the provider section of ValueOptions 50

51 51 Demonstration of ProviderConnect

52 52 ProviderConnect Login Screen

53 53 User Agreement

54 54 Search/View Member Eligibility

55 55 Member Eligibility Results

56 56 Review an Authorization

57 57 Search Authorizations

58 58 Authorization Search Results

59 59 Authorization Summary

60 60 Authorization Detail

61 61 My Practice Information

62 62 View Provider Practice Information

63 63 Provider Search Results

64 64 Provider Practice Details

65 65 Updating Provider Practice Information

66 66 Inquiry Tracking Number

67 67 My Online Registration Profile

68 68 Updating My Online Profile

69 69 ProviderConnect Message Center (Personalized!)

70 70 Inquiry Details

71 71 View Provider Summary Voucher

72 72 View Provider Summary Voucher

73 73 Provider Summary Voucher Results

74 74 Electronic Funds Transfer (EFT) & PaySpan Health Overview

75 Welcome to PaySpan Health, an enhanced payment and reconciliation solution. This new solution will enable you to receive faster payments through electronic deposits with complete remittance details. You will have numerous online capabilities! 75

76 General Features PaySpan provider site has an online security subsystem that allows you to control each user s access to specific customer applications, individual reports and web site features. PaySpan provider site s security control includes controlling access to the following functions: Managing accounts Reconciling payments Viewing payments online Viewing account configuration Administering user rights Accessing individual rights PaySpan provider site logs all user activity on the PaySpan provider site. PaySpan provider site provides Online Help on every screen. PaySpan provider site supports Internet Explorer 5.0 and above. 76

77 DEMO HEALTHCARE PARTNERS 4439 EASY ST ANYTOWN, MA your unique registration code: your unique registration code: xxxxxxxx xxxxxxxx pay to vendor number pay to vendor number for eft registration only: for eft registration only: A A To Our Providers: ValueOptions now offers Providers PaySpan Health - a solution that delivers Electronic Payments (EFTs), Remittance Advices (ERAs), and much more. FREE to (insert Payer Name here) Providers, the solution enables online presentment of remittances, and straightforward reconciliation of payments to empower our Providers to reduce costs, speed secondary billings, and improve cash flow. Convenient Payments PaySpan Health gives you the option to receive payments according to preference: electronically direct to a bank account, or by traditional paper check. You are also able to choose the method in which you receive remittance information: Electronic remittance advices presented online and printed on location. HIPAA 835 electronic remittance files for download directly to a HIPAA-compliant Practice Management or Patient Accounting System. Provider Benefits As a Provider, you can gain immediate benefits by signing up for PaySpan Health: Reduce accounting expenses Electronic remittance advices can be imported directly into Practice Management or Patient Accounting Systems, eliminating the need for manual re-keying. Improve cash flow Electronic payments can mean faster payments, leading to improvements in cash flow. Match payments to advices quickly You can associate electronic payments with electronic remittance advices quickly and easily. Maintain control over remittance formats You can choose from a large library of formats for remittance advices you will receive. Maintain control over bank accounts You keep TOTAL control over the destination of claim payment funds. Multiple practices and accounts are supported. Manage multiple Payers Reuse enrollment information to connect with multiple Payers. Assign different Payers to different bank accounts, as desired. 77

78 How do I sign up? Providers will need the following to start the Provider Registration and to access Payspan system: Provider Identification Number (PIN) ( this is your ValueOptions Pay to Vendor Number) Tax Identification Number (TIN) Bank routing information Account information found Reference Document NOTE: Do not pull this information from a deposit slip as your bank routing information is different than what is reported on the check. If you do not have the registration enrollment letter, please contact the ValueOptions Corporate Finance Department at CorporateFinance@valueoptions.com with your PIN or TIN and your registration code will be ed to you within 3 business days. 78

79 Log onto: om Select Secure Registration button. Registration Code Screen will appear. PaySpan Health Customer Service Support Phone Number: Hours 7AM 9 PM (EST) Monday - Friday. Download User Guide on Help Menu 79

80 Registration Code Screen Type in the Registration Code from the Registration Letter. Select the OK button. The Welcome page will appear. Note The person completing the process will become the administrator. Highest level of security full access. 80

81 Welcome to PaySpan Health Log in Screen The PIN is your Pay to Vendor Number. Tin Tax Identification Number. Verify Name and Address in the top right hand corner. If this information is not correct notify ValueOptions. Select the BEGIN button to start the registration process. 81

82 Registration Information Step 1 of 3 Complete the required Registration Information fields which are marked with a red asterisk ( *). The address will become your user name. Passwords must be at least 8 characters and contain a capital letter and one number. Select the Next button for Step 2 of 3. 82

83 Pay to Vendor Number What is a pay to vendor number? This is a vendor number issued by ValueOptions and indicates the mailing address for all your payments. Can a provider have more than one pay to vendor number? Yes Does each pay to vendor number need to be registered with PaySpan? Yes 83

84 Registration Information Step 2 of 3 Complete all required fields. Account Name Receiving Account Account Description Routing Number From Check Account Number Verify Account Number Account Type Business Checking Account System General Healthcare Download Format 835 Click the NEXT button. 84

85 Registration Information Step 3 of 3 Review the Registration Information Click the EDIT button for any corrections. Read the Service Agreement and then check the terms and conditions box to agree. Select the Confirm button. You have completed the process. 85

86 Registration Success An from PaySpan Health will be sent to the address set up in Step one. This confirms that the registration was setup successfully. You will received an ACH deposit in your account within the next few days in a random amount from $.01 to $.99. This will come from Payformance Corporation. You do not have to return these funds. It s a gift.. 86

87 Accessing and Using PaySpan Health Log onto: m Select the Secure Login button under Client Login. The Sign-In screen will appear. 87

88 Sign-In Screen This is the screen that will display upon signing in after successful registration. Enter the user name and password. The user name should be the user s address. User passwords are casesensitive. Select the Ok button. The Home Page will appear. 88

89 The Home Page will appear (with Pending Accounts) as illustrated below when you access the website for the first time. Home Page Note you will need to contact your bank to verify the deposit amount from Payformance. To complete the verification process: Select the Depository Account in the dropdown menu. Indicate the Deposit Amount. Select the Confirm button to finalize the verification process. 89

90 Home No new payments The following Home Page will appear once the receiving account is confirmed with no new payments. If you have an additional Registration Code from a New Payer you can enter it on the right side of this screen in the Register New Registration Code box. 90

91 Home Page New Payments The following Home Page will appear the next time you log in when New Payments have been issued. You will have the option to download these payments in an 835 format. So that you can auto post these payments. 91

92 New Payment Screen To access this screen you will click on the new payments link. There are two options available. Viewing payment data. Downloading payment data. 92

93 Payment Detail Screen The payment detail for selected item will display in an Adobe format. Please note this is a sample Explanation of Payment. 93

94 Pay Span Health Tab Features The following tab features can be accessed from the home page: Payments Administration Preferences Help Logout The Payments tab includes: Account Management Payor Management Reconciliation History The Reports tab includes: Document Archive Search Run a Report The Administration tab includes: User Administration Security Administration Users Activity Log The Preferences tab includes: Edit Profile Change Password 94

95 PaySpan Health Payments Menu Payments You may use options from the Payments menu to manage your Receiving Accounts, PaySpan Health Payers, and view previous reconciliation downloads. The options available from this menu pertain to your payments: Account Management - PaySpan Health organizes your incoming payments into Receiving Accounts. The Account Management section of the site contains information on each of the Receiving Accounts that have been set up to receive payments from registered Payers. Payer Management - The Payer Management section of the site displays information on each of the PaySpan Health Payers that have been registered to send payments. This section is controlled by security access rights. Reconciliation History - The Reconciliation History section of the site provides users with a list of all payments that have been confirmed from the PaySpan Health account and provides the ability to download past payments. 95

96 PaySpan Health Reports Menu Reports Reports allow the user to view historical records of their documents. Standard reports, such as the Payment Detail Report, are predefined and use a default set of fields when the template was initially created. Some reports require criteria input for generation so that they can be tailored to your needs. Once you enter the criteria if necessary, the report will be generated and displayed in a separate window. You will then have the option to export the report in a number of different formats, including Excel and HTML for storage and printing from your local computer. Document Archive The Document Archive provides powerful searching and online viewing capabilities for all documents that have passed through the PaySpan Health system. This includes all payments that have been downloaded for reconciliation on your behalf, as well as all documents that were only confirmed and viewed online. Performing a Document Archive Search allows you to quickly locate past documents for customer or employee support, or other administrative purposes. 96

97 PaySpan Health Preferences Menu Preferences The options available from this menu pertain to your user account for the web site. Edit Profile The Edit Profile screen allows the user to modify their individual contact information. Click on image to find more information about page elements. Change Password The Change Password screen allows the user to select a new password for accessing the site. 97

98 PaySpan Health Administration Menu Administration PaySpan Health has a Security module that will allow the Administrator to precisely designate which users will have access to the appropriate menu items and features on the web site. Administrators have access to the User Administration and Security Administration sections described below to administer users and set security access rights to the PaySpan Health Payment Center features. The Administrator may choose to restrict access to various features on the web site for process or security reasons. For example, the Administrator may restrict access to the "Account Access" or the Edit Receiving Account functionality. The Main Menu Bar will appear for all users. For a menu item to work, the user must have the correct security access set by the group administrator. 98

99 PaySpan Health User Administration Menu User Administration Administrators have the ability to view, add, edit, and change passwords for registered users. To add a new user, select the 'Add' button. To edit a user, click on the User's full name. To view Inactive Users check the 'Show Inactive Users' check box. 99

100 PaySpan Health Activity Log Menu Activity Log The Activity Log screen allows the user view their past activity on the site. Administrators will have access to the activity log entries of all users from their company, and may filter by user if desired. Users who are not Administrators will only have access to log entries of their own activities. The user has the option of filtering the activity detail by User and Date. 100

101 101 Question and Answers

102 Thank You! Please remember to complete your evaluation forms 102