PARTICIPATING PROVIDER ORIENTATION

Transcription

1 PARTICIPATING PROVIDER ORIENTATION

2 Keystone VIP Choice This training program is designed to familiarize Providers with Keystone VIP Choice. At the conclusion of the training, providers will be familiar with Keystone VIP Choice s Model of Care, the role of the Provider in the Model of Care and Keystone VIP Choice s resources available to the Provider and Member for Keystone VIP Choice. Keystone VIP Choice is a Medicare Advantage Dual Eligible Special Needs Health Maintenance Organization. (D-SNP/HMO) 2

3 Keystone VIP Choice is a member of the AmeriHealth Caritas Family of Companies - the industry leader in managing medically complex members Who We Are We are expanding our membership to continue our vision and mission to provide healthcare services to the underserved Keystone VIP Choice enables us to offer our existing and eligible chronically ill Medicaid members, a seamless transition to a Medicare Advantage Special Needs Plan 3

4 Why Keystone VIP Choice? As a member of AmeriHealth Caritas, Keystone VIP Choice is uniquely qualified to provide these populations with the coordinated care they deserve. AmeriHealth Caritas care is the heart of our work: Nearly 5 Million Covered Lives 3,000+ Employees NCQA-Accredited plans 4

5 Why Keystone VIP Choice? Keystone VIP Choice is well equipped to provide high-level customer service to members and providers. AmeriHealth s corporate systems and centers currently: Handle more than 2.25 million member and provider calls annually in our 24/7 call centers. Process an average of 2.1 million claims each month. Receive more than 87 percent of provider claims electronically with automatic adjudication rates of more than 81 percent. 5

6 Why Keystone VIP Choice? The success of AmeriHealth Caritas mission-driven programs is evidenced by the national recognition and awards received. The following AmeriHealth Caritas Medicaid plans have received Commendable Accreditation for AmeriHealth Caritas Pennsylvania (Harrisburg Area) Keystone First (Philadelphia Area) MDwise Hoosier Alliance (Indiana) Select Health (South Carolina) Based upon NCQA Health Insurance Plan Rankings , issued September,

7 Keystone VIP Choice and Keystone First AmeriHealth Caritas is focused on extending the services that we provide under the Keystone First Pennsylvania Medicaid Plan to members who have become eligible for Medicare due to age or disability. 7

8 Mission Statement We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. 8

9 Plan Overview Plan Overview Keystone VIP Choice is contracted to provide Medicare Hospital (A), Medical (B) services, and Prescription Drug Coverage (Part D) services in the following counties: Bucks, Chester, Delaware, Montgomery, or Philadelphia Members must live in one of these counties to join the plan. Keystone VIP Choice Enrollment Will accept only those beneficiaries with dual Medicaid/Medicare eligibility 9

10 Summary of Keystone VIP Choice s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care 10

11 Supplemental Benefits with Keystone VIP Choice - Dental DENTAL SERVICES Preventative Dental Oral Exams 1 every 6 months Cleaning 1 every 6 months Fluoride Treatment 1 every 6 months Dental x-rays 1 every year Comprehensive Dental Non routine services, including minor restorations (such as fillings, simple extractions and denture repair) $ every two years Includes coverage for minor restorations Fillings, simple extractions, dentures and denture repair 11

12 Supplemental Benefits with Keystone VIP Choice - Vision VISION SERVICES Up to one supplemental routine Eye Exam every year Up to one pair of eyeglasses or contact lenses every two years $150 plan limit on eyewear every two years 12

13 Supplemental Benefits with Keystone VIP Choice - Hearing HEARING SERVICES Up to one supplemental routine Hearing Exam every year Up to one fitting evaluation for a hearing aid every three years Up to $1,000 coverage for hearing aids every three years 13

14 Supplemental Benefits with Keystone VIP Choice Over the Counter Items OVER THE COUNTER Typically includes medicines or products that alleviate or treat injuries or illness No statement from a medical provider required or documentation of a diagnosis to use the benefit Up to $60 every three months No roll-over quarter to quarter 14

15 Supplemental Benefits with Keystone VIP Choice Non Emergency Transportation TRANSPORTATION Must be Plan approved location Thirty-two (32) one-way trips per year to a plan approved location Car, shuttle, van services, including non-emergent transportation to doctor visits, preventive services, pharmacies and fitness center Authorization and scheduling rules apply 15

16 Supplemental Benefits with Keystone VIP Choice Health and Wellness Gym Memberships Available to Keystone VIP Choice members. Members may choose which gym they would like to belong to from local gyms. Members may call member services at (800) to arrange for membership. 16

17 Supplemental Benefits with Keystone VIP Choice 24/7/365 Nurse Call Line If members are unable to reach their PCP s office, registered nurses are available 24/7days to assist members through the Nurse toll-free Call Line Keystone VIP Choice Nurse Call Line: (888)

18 Supplemental Benefits with Keystone VIP Choice Rapid Response and Outreach RAPID RESPONSE AND OUTREACH TEAM The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include: Contacting members Educating members Calling Providers Calling Pharmacies Completing surveys and assessments to support special projects Providers and Members may request RROT support directly by calling toll free at (855) am-5pm Monday Friday. 18

19 Member Eligibility 19

20 Member Rights and Responsibilities Member Rights and Responsibilities Federal law requires that health care providers and facilities recognize member rights. Members have the right to request and receive from their health care provider, a complete copy of the Patient s Bill of Rights and Responsibilities. Providers may refer to the Provider Manual for a detailed listing of the Member s Rights and Responsibilities. 20

21 Member Welcome Packet Keystone VIP Choice Member welcome packet includes: Cover (Welcome) Letter Provider & Pharmacy Directory The Plan s Formulary Evidence Of Coverage (EOC) document Health Risk Assessment (HRA) and return envelope Multi-Language Insert Notice of Privacy Practices Member grievance process Member materials including a summary of benefits compared to Original Medicare and complete evidence of coverage information are accessible via our web site at or Keystone VIP Choice member services at (800)

22 Member PCP Selection Members may select a new PCP at any point in time by calling Keystone VIP Choice member services at (800) An updated card will be sent to the member each time there is a change in eligibility or PCP. Because a member may present with a card with old information, Keystone VIP Choice encourages providers to validate member eligibility at each visit. 22

23 Member Eligibility Verification Member eligibility varies. Providers can verify eligibility by using the following Provider tools: Utilizing the Monthly Member Panel Roster Visiting our website at and accessing NaviNet Calling Provider Services at: (800)

24 NaviNet What is NaviNet? A FREE web-based solution for providers and health plans to share critical administrative, financial and clinical data. America s largest real-time healthcare communications network, securely linking providers nationwide through a single website. Provider portal address: Informational website NaviNet Web Portal: Phone: (888) Must be accessed via Internet Explorer v. 7.0 or above Older versions of IE may not work appropriately Not accessible via Firefox, Safari or Google Chrome 24

25 NaviNet (continued) NaviNet Functions: View Member Eligibility Member Rosters View Third Party Liability Information (TPL) Claims Status & Updates Prior Authorization HEDIS Performance On-Line Remittance Advice Care Plans Clinical Summary Referrals Care Gaps 25

26 Accessing Member Eligibility via NaviNet Providers must select Keystone VIP Choice when checking eligibility for Keystone VIP members

27 Accessing Member Eligibility via NaviNet

28 Potential NaviNet Issues Providers who do not see Keystone VIP Choice as an option on the Plan Central page should contact NaviNet to request access. This can occur in two ways. 1. Click on My Account at the top of the NaviNet page Support Cases will be located on the left side of the screen Providers may Open a Case or View a Case here. 2. Send an to NaviNet Support at NaviNet@NaviNet.net All Support Cases or requests submitted via should include: Tax identification Number (TIN) NaviNet user contact name and phone number Group and provider NPI s to be added or terminated Transaction access request (Eligibility, Referrals, Prior Authorization Management, etc.) 28

29 Accessing Member Eligibility via NaviNet On the Keystone VIP Choice landing page, NaviNet will provide alerts if there are issues with search functions or availability. Providers may also call Provider Services for Keystone VIP Choice (800) to verify eligibility. 29

30 30 Member Eligibility via NaviNet

31 Monthly Panel Roster Provider panel rosters will be available on a monthly basis to provide PCP offices with a listing of Keystone VIP Choice members who have chosen their practice. Member information on the panel roster will include: The member s name, address and telephone number Date of birth and age Gender Effective date with Keystone VIP Choice Plan Keystone VIP Choice Medicare Identification number State Medicaid Identification Number (if applicable) Primary Language spoken Medicare Plan Type (D-SNP-HMO) 31

32 32 Keystone VIP Choice Panel Roster

33 Keystone VIP Choice A Medicare Replacement For Keystone VIP Choice members, Keystone VIP Choice should be entered into the provider s billing system in the place of Medicare Fee for Service. If a provider has Medicare or another Medicare Advantage plan loaded in their patient management system for an Keystone VIP Choice member, Keystone VIP Choice will replace this plan. The Keystone VIP Choice member will have Pennsylvania Medicaid secondary to Keystone VIP Choice, even if the member previously enrolled in Keystone First. 33

34 Provider Participation 34

35 Keystone VIP Choice Medicare Provider Eligibility Health care providers are selected to participate in the Keystone VIP Choice Network based on an assessment and determination of the network's needs. Providers must be enrolled with the Medicare program in order to be credentialed with Keystone VIP Choice. 35

36 Provider Credentialing Keystone VIP Choice is responsible for the credentialing and re-credentialing of its provider network. Hospital-based physicians are not required to be independently credentialed if those providers serve Keystone VIP Choice members only through the hospital. All providers credentialed by Keystone VIP Choice must also be enrolled with the Medicare program and, as such, must agree to comply with all pertinent Medicare regulations. 36

37 Keystone VIP Choice Credentialing Keystone VIP Choice credentialing/re-credentialing criteria and standards are consistent with the Centers for Medicare and Medicaid Services specific requirements and National Committee for Quality Assurance (NCQA) standards. Practitioners and facility/organizational providers are re-credentialed every three years. Keystone VIP Choice works with the Council for Affordable Quality Healthcare (CAQH) to offer providers a Universal Provider Data source that simplifies and streamlines the data collection process for credentialing and re-credentialing. Through CAQH, providers submit credentialing information to a single repository, via a secure Internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. Keystone VIP Choice s goal is to have all providers enrolled with CAQH. 37

38 Medical Records Requirements Providers are required to maintain medical records in accordance with the Provider Manual. Requirements include, but are not limited to: Elements in the medical record are organized in a consistent manner, and the records are kept secure; Patient s name or identification number is on each page of record; All entries are dated and legible; All entries are initialed or signed by the author; Personal and biographical data are included in the record; Current and past medical history and age-appropriate physical exam are documented and include serious accidents, operations and illnesses; Allergies and adverse reactions are prominently listed or noted as none or No Known Allergies NKA ; Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening. 38

39 Access to Care Access to Care Keystone VIP Choice PCPs, specialists and behavioral health providers must meet standard guidelines as outlined in the Provider Manual to help ensure that Keystone VIP Choice members have timely access to care. Keystone VIP Choice Access Standards: Assure members accessibility to health care services Establish mechanisms for measuring compliance with existing standards Identify opportunities for the implementation of interventions for improving accessibility to health care services for members Office Accessibility 39 The following areas are monitored by Keystone VIP Choice to ensure physician access standards are continually met: PCP office hours must be clearly posted and reviewed with members during the initial office visit. The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services. A Medicare-eligible PCP must provide the coverage to Keystone VIP Choice members.

40 Provider Appointment Scheduling Appointment Scheduling Keystone VIP Choice monitors access standards on an annual basis. Specialists who are serving in the PCP role (i.e. Internal Medicine, Family Practice, Pediatrics, or OB/GYN) are subject to the PCP Access Standards. Timely Access Standards for appointment availability for Primary Care Physicians (PCPs), Specialists and Behavioral Health providers are outlined on slide 41. Missed Appointment Tracking If a member misses an appointment with a provider, the provider should document the missed appointment in the member s medical record. Providers should make at least three attempts to contact the member and determine the reason. The medical record should reflect any reasons for delays in performing the examination. Medical record should include any refusals by the member. 40

41 Physician Office Standards Primary Care and Behavioral Health Provider Access Standards: Emergent Care 24/7 Request Immediately or referred to ER Urgent Care Within two (2) calendar days of request Routine Care Within 14 calendar days of request Specialty Care Provider Access Standards: Routine Care Within 30 business days of request 41

42 Access to Care Access to After-Hours Care Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week. PCPs and behavioral health providers must have either an answering machine or an answering service for members during after-hours for non-emergent issues. The answering service must forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes. When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office s daytime telephone number. For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room. Keystone VIP Choice monitors access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours. 42

43 Keystone VIP Choice Referrals 43

44 Keystone VIP Choice- Referrals Services that Require Referrals Specialist visits (except Direct Access Services see below) Podiatry services Chiropractic Services Outpatient diagnostic procedures (unless otherwise specified) Ambulatory surgery center services Diabetes self-management training Direct Access Services that Do Not Require Referral Direct access to women s specialists for routine and preventive services Direct access to mammography and influenza vaccinations Behavioral Health Services 44

45 Keystone VIP Choice Referrals Keystone VIP Choice Referrals Required Will affect provider payments Electronic submission and inquiry available on NaviNet. Hard Copy forms available at Three copies must be created - Referral copies must be kept in the member s medical record, given to the member, and faxed or mailed to Keystone VIP Choice. Paper form may be faxed or mailed. Mailing may cause delay in processing. 45

46 46 NaviNet Referral Submission

47 47 Paper Referral Form

48 Keystone VIP Choice Referral Inquiry Specialists, hospitals and ancillaries can use Referral Inquiry to view and retrieve referrals on NaviNet. Simply log on to NaviNet ( and select Keystone VIP Choice from Plan Central. Select Referral Inquiry and follow the steps to refer a patient or view referrals. Specialists, hospitals and ancillaries may also call Provider Services for Keystone VIP Choice (800) to inquire about a referral status. 48

49 49 NaviNet Referral Inquiry

50 Care Management

51 Care Management Keystone VIP Choice offers a Care Management Program that is aimed at assisting members and providers in meeting the health care needs of our members. This program includes assistance with: coordinating transportation obtaining medications educational outreach developing an individual care plan for each member based on their goals. To assist members and providers Keystone VIP Choice has created a Rapid Response Outreach Team. 51

52 Care Management The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include: Contacting members Educating members Calling Providers Calling Pharmacies Completing surveys and assessments to support special projects Providers may request RROT support directly by calling toll free at (855) , 8 am - 5 pm, Monday through Friday. 52

53 Medical Management Components Prior Authorization Utilization Review Case Management 53

54 Prior Authorization Keystone VIP Choice requires Prior Authorization for certain services including, but not limited to: Elective / non-emergent air ambulance All out of network services (except emergency services) In-patient services Behavioral health care (mental health and substance abuse services) Home-based services Therapy and related services Transplants, including transplant evaluations All DME rentals and rent to purchase items High-Tech Outpatient Radiology Services For a complete list of services requiring prior authorization, please reference the Provider Manual. 54

55 Keystone VIP Choice The Model of Care Keystone VIP Choice Model of Care is an Integrated Care Management Approach to health care delivery and coordination for Dual Eligible (Medicare/Medicaid) individuals. The Model of Care focuses on: Improving Health Outcomes Access to Essential Services/Affordable Care Coordination of Care through the Medical Home/Primary Care Physician Access to Preventive Services Seamless Transitions 55

56 The Model of Care Structure and Roles Each member enrolls with a Medical Home/Primary Care Physician. The model includes care and support from health care providers, community agencies and service organizations. A 26-question Health Risk Assessment (HRA) is used to collect: Physical and behavioral health history Preventive care Level of activity Medication use The assessment is mailed with the Member s welcome packet. Staff follow up with the Member by phone and mail to collect the data. Members receive an annual postcard reminding them to call Keystone VIP Choice and update their HRA information. 56

57 Assessment and Plan of Care Development Data from multiple sources is used to develop the Plan of Care: Review of available claim and pharmacy history Data from the Health Risk Assessment Input from the member, Primary Care Physician and other providers 57

58 Interdisciplinary Care Team Each member has an Interdisciplinary Care Team to address his or her unique needs: Primary Care Physician/Medical Home Specialists Physical & Behavioral Health Plan Nurses, Medical Directors, & Pharmacists Home Health Care Social Workers Community Mental Health Workers Physical, Speech & Occupational Therapy 58

59 The PCP/Medical Home The PCP/Medical Home plays an important role in the Interdisciplinary Team. Key responsibilities include: Assisting members in determining which services are necessary Connecting members to appropriate services Serving as a central communication point for the member s care Reviewing the Plan of Care sent by Keystone VIP Choice Providing feedback to Keystone VIP Choice 59

60 Updates to the Plan of Care Updates are made routinely to the Plan of Care and come from multiple sources: Member or Provider call Updated HRA (annual) Care Transition (hospital, nursing home) Claim, Pharmacy or Utilization trigger Care episode 60

61 Identifying Vulnerable Sub-Populations Keystone VIP Choice uses several mechanisms to identify vulnerable sub-populations, including: Claim data is analyzed to identify members with: Conditions targeted for chronic care improvement, such as diabetes, heart disease, COPD and renal disease Health needs, such as missing preventive care or recommended condition monitoring Utilization of emergency room and inpatient services is reviewed to identify members with opportunities for improved outpatient management Predictive Risk Scores are calculated using the DxCG methodology to identify members who are at risk for future avoidable health care episodes Health Risk Assessment data is reviewed for triggers identifying unmet health needs or the presence of chronic conditions 61

62 Chronic Condition Improvement Programs Keystone VIP Choice offers several Chronic Care Improvement Programs: Diabetes Asthma Chronic Obstructive Pulmonary Disease Depression Members may self refer, be referred by a provider, or are identified through claims data analysis. Members or providers may contact the Member s Case Manager for enrollment. 62

63 Clinical Practice Guidelines Keystone VIP Choice s Clinical Practice Guidelines are: Adopted from nationally-recognized organizations Serve as a guide to practitioners, but do not replace clinical judgment Available on and via hard-copy from Provider Services upon request Guideline Topics: Diabetes Anxiety Disorder in Adults COPD Preventive Health Services Depression Coronary Vascular Disease Hypertension Immunization Schedules 63

64 Provider Focus on Preventive Services Medicare benefits cover an annual preventive physical examination. During each office visit, please remember to: Coach the member on appropriate physical activity Ask about falls and fall prevention Ask and coach on smoking cessation List all relevant diagnoses on the claim Check to see if the member needs: Cancer Screening Mammography or Colonoscopy Glaucoma Testing Flu or Pneumonia vaccine 64

65 High Risk Medication in the Elderly Medication alternatives should be evaluated prior to prescribing any of the following medications to an elderly member: Antihistamines (promethazine, cyproheptadine, diphenhydramine, hydroxyzine) Skeletal Muscle Relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone) Oral Estrogens CNS Stimulants (amphetamines, anorexiants, methylphenidate) Urinary Anti-infectives (nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin macrocrystalsmonohydrate) Narcotics (pentazocine, meperidine) Others (dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines, barbiturates) 65

66 Focus on Health Outcomes Keystone VIP Choice goals include improving health outcomes for: Diabetes Care Hgb A,C and LDL testing/management Diabetic retinal exam Nephropathy screening Blood pressure control Cardiac Care LDL testing/management Beta-blocker treatment after heart attack Blood Pressure Control COPD Management Systemic corticosteroids and bronchodilator therapy for exacerbations Decreasing the use of high-risk drugs 66

67 Focus on Seamless Transition Everyone plays a role ensuring seamless transition: Keystone VIP Choice Staff Notify PCP/Medical Home of planned or unplanned transition for admission and at discharge. Contact members to verify plans, establish point of contact. Provide Plan of Care information to sending and receiving facility/provider, including changes at discharge. PCP Contact admitting physician to coordinate care. After discharge, review and reconcile medications. After discharge from an inpatient behavioral health stay, follow up with behavioral health provider. See the member at office visit post discharge. Hospital Send discharge summary/orders with medication list to Plan. Admitting Physician be available to speak with the Medical Home/PCP regarding member s care needs. 67

68 Model of Care Evaluation Keystone VIP Choice s Model of Care is evaluated using several data sources: Claims (medical, behavioral health, pharmacy) Authorizations HEDIS reports Member surveys (CAHPS, HOS) Practitioner and Facility surveys Provider workshops Complaint and grievance analysis 68

69 Communicating the Plan of Care on Transition The Transition Team collects and communicates information related to a member s transition from one health care setting to another: Transition Team With Member & Provider Input Sends Updated Plan of Care Medical Home/PCP Hospital/Facility/Agency Receiving the Member 69

70 Claims Submission

71 Keystone VIP Choice Claims Keystone VIP Choice providers submit Medicare service claims to the same address and payer id number. Providers contractually have 365 days from the date of service to submit claims. Providers are encouraged to submit claims timely. Resubmissions must be submitted within 90 days from the date the original claim was processed. 71

72 Keystone VIP Choice Claims Providers may submit claims electronically through their current EDI Vendor if that vendor contracts with Emdeon, or the provider may contract directly with Emdeon. Keystone VIP Choice Payer ID is Provider may submit Paper Claims to: Keystone VIP Choice Claims P.O. Box 307 Linthicum, MD Medicaid-only services and appropriate secondary payments (deductible, coinsurance, etc.) should be sent to Pennsylvania Medicaid. 72

73 Electronic Data Interchange (EDI) To transmit claims electronically, contact your EDI software vendor and provide the Keystone VIP Choice Payer ID: Arrange electronic claims submission through your EDI vendor or through Emdeon Provider Support at: (877) Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Simplifies the payment process by providing fast, easy and secure payments Reduces paper Eliminating checks lost in the mail Not requiring a change to your preferred banking partner Enroll through our EFT partner, Emdeon Business Services or sign up via our fast and easy links on 73

74 Keystone VIP Choice Payments and Remittance Advices Initially, all providers will receive Keystone VIP Choice payments and remittance advices hard copy. Electronic Remittance Advices (ERA) and Electronic Funds Transfer (EFT) are available. Please reference your latest remittance advice for directions on enrolling in these programs. 74

75 Keystone VIP Choice Provider Services

76 Provider Claims and Customer Service Provider Services for Keystone and AmeriHealth (800) Same number to reach all Pennsylvania products Keystone Plans choose Option 1 Choose Option 1 for Keystone First. Choose Option 2 for Keystone VIP Choice. Verify member eligibility, PCP assignment, obtain member ID # (Option 1) Provider claims issue resolution or adjustments (Option 2) Obtain and verify prior authorizations (Option 3) Prescription drugs, prescription prior authorizations, and exceptions (Option 4) Assistance in coordinating care (Option 5) 76

77 Provider Account Executives Keystone VIP Choice prides themselves in having a provider representative available to providers an Account Executive. Your Account Executive will provide on-site education, issue resolution, and assistance with credentialing. Keystone VIP Choice will communicate through on-site orientations, routine site visits, provider workshops, letters, the Provider Manual, the provider resource center on the website and provider newsletters. A listing of Keystone VIP Choice Account Executives are available on our website at 77

78 The Provider Manual The Keystone VIP Choice Provider Manual is on our website at The Provider Manual is an extension of your provider contract with Keystone VIP Choice Identifies key provider roles & responsibilities Member rights & responsibilities The Keystone VIP Choice s quality programs, credentialing & utilization management Keystone VIP Choice s Model of Care Claims protocols 78

79 Provider Marketing Compliance The Centers for Medicare and Medicaid Services (CMS) is concerned with provider marketing activities for the following reasons: Providers may not be fully aware of benefits & costs and may inadvertently misinform a member Providers may confuse the member regarding their role as their health care provider versus acting as a Keystone VIP Choice representative Providers may face a conflict of interest 79

80 Acceptable Provider Marketing Practices Examples of Acceptable Provider Marketing Practices Provide the names of Medicare Advantage Plan sponsors with which they contract and/or participate. Provide information and assistance in applying for the Low Income Subsidy (LIS). Make available and/or distribute Keystone VIP Choice marketing materials developed by Keystone VIP Choice. Refer patients to other sources of information, such as SHIPs, a Medicare Advantage plans marketing representative, the State Medicaid Office, local Social Security Office, CMS website at or MEDICARE. Share information with patients from CMS website, including the Medicare and You Handbook or Medicare Options Compare (from or other documents that were written by or previously approved by CMS. 80

81 Cultural and Linguistic Requirements Our Cultural Competency program, has been built upon 14 of the national standards for Culturally and Linguistically Appropriate Services (CLAS), as set forth by the Federal Department of Health and Human Services. As a provider of health care services who receives Federal financial payment through the Medicare and Medicaid programs, you are responsible to make arrangements for: Standard 4 - Language assistance at no cost to patients/consumers Standard 5 - Signage and written notices of interpreter services available at no cost Standard 6 - Use of qualified/certified interpreters and translators Standard 7 - Translation of vital documents Language assistance information should be at all points of contact and during all hours of operation. 81

82 Cultural and Linguistic Requirements Providers are required to: Provide written and oral language assistance at no cost to Keystone VIP Choice members with limited English proficiency or other special communication needs, at all points of contact and during all hours of operation. Language access includes the provision of competent language interpreters, upon request. Provide members verbal or written notice (in their preferred language or format) about their right to receive free language assistance services. Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents such as patient information forms and treatment consent forms, must be made available in other languages and formats. 82

83 Available Cultural and Linguistic Services We have an arrangement for participating Keystone VIP Choice providers to access telephonic interpretation at a discounted rate. For more information, please contact Provider Services for Keystone VIP Choice (800) Providers who are unable to arrange for translation services for a Limited English Proficiency (LEP), Limited Language Proficiency (LLP) or sensory impaired member should contact Member Services for Keystone VIP Choice (800) and a representative will help locate a professional interpreter who communicates in the member s primary language. Providers may request a full copy of Keystone VIP Choice s Cultural Competency Plan free of charge, or, access this information in the Provider Manual. For additional information or to view the CLAS standards go to For language assistance services, contact us at (800) or go to 83

84 Fraud, Waste and Abuse Designed in accordance with federal rules and regulations, Keystone VIP Choice s compliance program is aimed at ensuring compliance with all Medicare Advantage program requirements and preventing and detecting activities that constitute fraud, waste and abuse. Keystone VIP Choice has developed a Compliance and Fraud, Waste and Abuse (FWA) online training program. The program includes: Compliance requirements FWA policies and procedures Investigation of unusual incidents Implementation of corrective action Keystone VIP Choice and has provider training materials available via its website: Materials, which are available by contacting the Provider Network Management team, include information regarding the following 84

85 Fraud, Waste and Abuse Fraud Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person. The term includes any act that constitutes fraud under applicable federal or state law. As applied to the federal health care programs (including the Medicaid and Medicare programs), health care fraud generally involves a person or entity s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for, items or services payable under a federal health care program. Some examples of fraud include: Billing for services not furnished; Soliciting, offering or receiving a kickback, bribe or rebate; or Violations of the physician self-referral prohibition. 85

86 Fraud, Waste and Abuse Waste Waste means to use or expend carelessly, extravagantly, or to no purpose. Abuse Abuse is defined as provider practices that are inconsistent with generally accepted business or medical practice and that result in an unnecessary cost to the Medicaid or Medicare programs or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid or Medicare programs. In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare and Medicaid programs. Some examples of abuse include: Charging in excess for services or supplies; Providing medically unnecessary services; or Providing services that do not meet professionally recognized standards. 86

87 Fraud, Waste and Abuse False Claims Act The Federal False Claims Act (FCA) is a federal law that applies to fraud involving any contract or program that is federally funded, including Medicare and Medicaid. Health care entities that violate the Federal FCA can be subject to civil monetary penalties ranging from $5,000 to $10,000 for each false claim submitted to the United States government or its contactors, including state Medicaid agencies. The Federal FCA contains a qui tam or whistleblower provision to encourage individuals to report misconduct involving false claims. The qui tam provision allows any person with actual knowledge of allegedly false claims submitted to the government to file a lawsuit on behalf of the U.S. Government. The FCA protects individuals who report under the qui tam provisions from retaliation that might result from filing an action under the Act, investigating a false claim, or providing testimony for or assistance in a federal FCA action. 87

88 Fraud, Waste and Abuse Reporting and Preventing Fraud, Waste and Abuse Compliance with state and federal laws and regulations is a priority of Keystone VIP Choice. If you or any entity with which you contract to provide services become concerned about or identifies potential fraud, waste or abuse, please contact: Keystone VIP Choice toll-free at (866) ; or you may also send an to the Medicare Compliance Officer at TMapp@amerihealthcaritas.com to report potential FWA; or Inspector General: HS-TIPS (800) ) Report suspected Medicaid Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities by contacting: Medicaid Fraud Control Unit Pennsylvania Attorney General's Office 1600 Strawberry Square Harrisburg, PA (717)

89 Communication Updates and outcomes are communicated through several methods: Keystone VIP Choice Website Quality and Satisfaction Updates Member News Bulletin Provider News Bulletin Provider Workshops presentations are interactive via the website, face-toface workshop presentations and provider site visits. All communications are available hard copy upon request or via the Keystone VIP Choice website at 89

90 Questions For additional questions, please contact your Provider Account Executive or Provider Services. Keystone VIP Choice (800)

91