YourCare Provider Orientation

Transcription

1 YourCare Provider Orientation

2 History and Overview Since 1996 Beacon Health Strategies has been a leader in the managed behavioral care industry. Locally owned and operated in the Boston area, Beacon has strived to provide exceptional value to the plans and providers it has partnered with. Beacon started small, with regional health plans and began building relationships and a strong reputation by working with and for our industry partners. Beacon is in full accreditation with both NCQA and URAQ. We have provided expertise in clinical, network, quality, operations and utilization management services to those with which we have partnered. Beacon offers statewide networks that offer a full range of clinically appropriate behavioral health services. We provide a cutting edge case management system that allows us to track and authorize services appropriately and effectively. In 2014 Beacon Health Strategies acquired Value Options to form Beacon Health Options. 2

3 Our Coverage Area 3

4 Philosophy of Beacon Health Improve the health care status of the members we cover Enhance continuity and coordination with behavioral health care providers as well with physical health care providers Establish innovative preventive and screening programs to decrease the incidence, emergence or worsening of behavioral health disorders Ensure members receive timely and satisfactory service from Beacon and our network of providers Maintaining positive and collaborative working relationships with network practitioners and ensure provider satisfaction with Beacon Responsibly contain health care costs 4

5 Beacon Provider Network Team Beacon Health Options Operational Contacts Fred Habib, GM and VP of Operations - Woburn Service Center Bill Lavey, AVP Provider Network Operations Woburn Service Center Bill Carboni, AVP Provider Network Development Woburn Service Center Julie Fine, AVP Clinical Woburn Service Center Renee Abdou-Malta, Regional Vice President, Client Partnership Debra Meyer, Program Director for YouCare Maria Richter, Manager of Provider Relations Woburn Service Center 5

6 Network Operations Network Operations is responsible for many different functions at Beacon beyond provider contracting and credentialing Our Network staff perform initial and re-credentialing site visits for our provider network We also conduct Provider trainings for eservices Add providers and services (i.e languages, groups) Make changes to demographics or billing information Assist providers with any issues in a timely manner 6

7 Network Operations Please contact us if you are updating your site information. This includes your office address, mailing address or phone number. Also contact us if you are adding any clinicians, or updating your staff roster. It is important to keep rosters up to date, to provide the most accurate information to our members. Any updates can be sent to us at or via fax at

8 Joining the Network If you are not contracted with Beacon Health Options and are a Medicaid provider, you may request participation through our website: Under the Provider section, please choose the How to Become a Provider link. Complete the Letter of Interest form, and it to provider.relations@beaconhs.com Applications and contracting materials will be sent to you in 7-14 business days. For questions regarding this process please call Provider Relations at

9 Maintaining Network Affiliation Individual providers, groups and facilities are required to re-credential with Beacon every three years. You will receive a notification in the mail. Providers are required to document continued compliance with eligibility requirements through participation in a performance review process including: Utilization review Chart review Site Evaluations Accreditation We ask providers to update Beacon regarding any provider additions or deletions to your clinician roster and office contacts. 9

10 Level of Care Criteria Developed from the comparison of national, scientific and evidence based criteria sets Criteria are reviewed and updated, at least annually, and as needed when new treatment applications and technologies are adopted as generally accepted medical practice. Beacon uses its LOC criteria as guidelines, not absolute standards, and considers them in conjunction with other indications of a member s needs, strengths, and treatment history in determining the best placement for a member. Level of Care Criteria is available to contracted providers though eservices. Please go to and choose the Provider Materials link to review this criteria. 10

11 Model of Care Inpatient Psychiatric and Related Services Inpatient Services Authorization Required Method Inpatient Mental Health Adult + Child Yes Telephonic Inpatient Electroconvulsive Therapy (ECT) Yes Telephonic Extended Observation Bed No N/A CPEP (Comprehensive Psychiatric Emergency Program) No N/A Inpatient Professional Fee ( ) If currently admitted, No. Otherwise Yes. Mobile Emergency Services No N/A Administratively Necessary Day Yes Telephonic 11

12 Model of Care Mental Health Diversionary and Outpatient Services Mental Health Diversionary & Outpatient Services Authorization Required Method Partial Hospitalization Yes Telephonic Intensive Outpatient Program (IOP) Yes Telephonic Day Treatment Yes eservices Continuing Day Treatment Yes Telephonic Home Based Therapy (HBT) Yes Telephonic 12

13 Model of Care Outpatient Behavioral Health Services Outpatient Services Authorization Required Method Outpatient Electroconvulsive Therapy (ECT) Yes Telephonically Medication Management No N/A Psychological and Neuropsychological Testing Yes eservices 13

14 eservices eservices home page 14

15 eservices eservices is simple to log into and use. You create your own username and password. 15

16 eservices Choose to register if you don t have an account. 16

17 eservices Enter your (or your organizations) NPI and tax identification number. 17

18 eservices Create your own user name, password and security question. 18

19 eservices Account administrators can determine the level of access. 19

20 eservices To locate inactive accounts, please uncheck the box circled above. 20

21 eservices Click on edit to assign level of access for the user account. 21

22 eservices You can assign the type of access by clicking on the checkboxes. Please note that all accounts must have eligibility checked in order to work. 22

23 eservices Click here Start by verifying your members eligibility by entering their plan ID, date of birth, along with their last name. 23

24 eservices Click here Once your member has been found, you can verify their benefits by clicking on Yes. 24

25 eservices Click here After you have clicked on the Yes button, this will allow you to view their benefits. At the bottom you will see the number of outpatient visits billed in the past twelve months. Click on More, for co-pay information. 25

26 eservices After clicking on the More link, there is additional eligibility information of member co-pay details. 26

27 eservices Click here Claim submission is simple and easy to complete. 27

28 eservices Choose the type of service from the drop down menu. 28

29 eservices Enter diagnosis codes Enter tax id number Choose site of service Choose site and clinician NPI s from drop down menus Enter date of service, place of service code and procedure code Add additional dates of services (if necessary) Diagnosis pointers indicate ICD code which is primary diagnosis code Hit submit to complete transaction Enter all of the appropriate and required fields for claims submission. 29

30 eservices Transaction number Now that your claim has been submitted, you will receive a transaction number. You may also print the page for your records. 30

31 eservices Inpatient claims may also be submitted through eservices. 31

32 eservices Claim reconsiderations may be done online, for claims that were submitted and denied and require an in depth review. 32

33 eservices Use the free text box to enter your explanation Always make sure to enter the original claim s RecID Once you have entered your claim info and explanation you can submit. 33

34 eservices Choose the month and year of the claim Click here Claims that may have denied for an incorrect procedure code or diagnosis code may also be re-submitted electronically. 34

35 eservices Click here Once the claim has been chosen, click on the resubmit link. 35

36 eservices After you have clicked on re-submit, the information will auto fill from the previous submission. You can then make corrections and re-submit. Resubmissions must be made within the timely filing limit. 36

37 Paper Claim Submission Member info Diagnosis code Complete the highlighted fields on the paper claim 37

38 Paper Claim Submission Member info Diagnosis code Dates of service, place of service code, procedure code and modifier Enter federal tax id number, and signature of clinician Complete the highlighted fields on the paper claim 38

39 Paper Claim Submission Member info Diagnosis code Dates of service, place of service code, procedure code and modifier Add charges, units and rendering clinician NPI Enter federal tax id number, and signature of clinician Complete the highlighted fields on the paper claim 39

40 Paper Claim Submission Member info Diagnosis code Dates of service, place of service code, procedure code and modifier Add charges, units and rendering clinician NPI Enter federal tax id number, and signature of clinician Complete the highlighted fields on the paper claim Add service location information, billing provider info, and site NPI number 40

41 Paper Claim Submission 1 Yes Provider Name, Address, Telephone # 2 Yes Service Facility if different from box 1 3 No Provider s Member Account Number 4 Yes Type of Bill (See Table 7-3 for 3-digit codes) 5 Yes Federal Tax ID Number 6 Yes Statement Covers Period (include date of discharge) 7 Yes Covered Days (do not include date of discharge) 8 Yes Member Name 9 Yes Member Address 10 Yes Member Birth Date 11 Yes Member Sex 12 Yes Admission Date 13 Yes Admission Hour 14 Yes Admission Type 15 Yes Admission Source 16 Yes Discharge Hour 17 Yes Discharge Status (See Table 7-2: Discharge Status Codes) No Condition Codes 29 No ACDT States 30 No Unassigned No Occurrence Code and Date No Occurrence Span 37 No Not used by Beacon. 38 No Untitled Yes Value CD/AMT, Include 24 followed immediately by 4 digit rate code based on facility type. 42 Yes Revenue Code (if applicable) 43 Yes Revenue Description 44 Yes Procedure Code (CPT) (Modifier may be placed here beside the HCPCS code. See Table 7-4 for acceptable modifiers.) 45 Yes Service Date 46 Yes Units of Service 47 Yes Total Charges 48 No Non-Covered Charges 49 Yes Modifier (if applicable; see Table 7-4 for acceptable modifiers) Using the highlighted fields, we can we what is required to be entered on the claim form and what is not. 41

42 Paper Claim Submission 50 Yes Payer Name 51 No Beacon Provider Id Number 52 Yes Release of Information Authorization Indicator 53 Yes Assignment of Benefits Authorization Indicator 54 Yes Prior Payments (if applicable) 55 No Estimated Amount Due 56 Yes Facility NPI 57 Yes Other ID (Rendering Taxonomy and/or Medicaid ID) 58 Yes Insured's Name 59 No Member's Relationship to Insured 60 Yes Member's Identification Number 61 No Group Name 62 No Insurance Group Number 63 No Prior Authorization Number (if applicable) 64 Yes RecID Number for Resubmitting a Claim (if applicable) 65 No Employer Name 66 No Employer Location 67 Yes Principal Diagnosis Code 68 No A-Q Other Diagnosis 69 No Admit Diagnosis. Not needed for outpatient claims 70 No Patient Reason Diagnosis 71 No PPS Code 72 No ECI 73 No Unassigned 74 No Principal Procedure 75 No Unassigned 76 Yes Attending Physician NPI/TPI, First and Last Name and NPI 77 No Operating Physician NPI/TPI No Other NPI 80 No Remarks 81 Yes Code-Code (Billing Taxonomy) Using the highlighted fields, we can we what is required to be entered on the claim form and what is not. 42

43 APG Rates Facilities that are Article 28 or Article 31 will be paid at the APG rate. The facility needs to identify to Beacon if they are Article 28 or Article 31. Beacon has logic in our internal system so that claims will pay at the APG rate through 3M. 43

44 Important Claims Reminders Outpatient visits are one per day, per service. If multiple claims are billed for the same service on any date of service, the first claim received will be paid and all others will deny. No balance billing is allowed. Member cannot be billed for denied claims or no show appointments. 44

45 Paper Claim Submission Claims for Behavioral Health services can be mailed to Beacon Health Options 500 Unicorn Park Dr, Suite 103 Woburn, MA Attention: YourCare Claims Claims for medical services or with a medical diagnosis must be sent to the health plan directly 45

46 Paper Claims Reconsiderations Reconsiderations for claim denials can be submitted either electronically through eservices, or as paper submissions. Reconsiderations have a filing limit of 180 days from the original date of service. To send a reconsideration, with proof of timely filing or other applicable information, please mail to us at: Beacon Health Options 500 Unicorn Park Drive, Suite 103 Woburn, MA Attn: Reconsiderations Reconsiderations will be reviewed by a committee who will make a determination on the claim. 46

47 Electronic Funds Transfer Beacon participates with PaySpan Health to administer EFT and to issue paper checks. Provider may choose either method of payment, but we encourage you to take advantage of EFT. To become a user, please complete the enrollment process at Follow the instructions to select EFT or paper checks as your preferred method. You can also call the PaySpan Health provider hotline at for assistance with registration. 47

48 Electronic Data Interchange (EDI) For larger providers, EDI is the preferred method for receiving claims. We accept the standard HIPPA 837 format and provide 835 transactions. Beacon also uses 270/271 transactions for eligibility purposes. Beacon does allow EDI claims to be submitted from a Clearing House or Billing Agency EDI claims may also be submitted to Beacon via Emdeon. Beacon s Emdeon payer ID is The plan id for YourCare is 156 All EDI claims submitted via Emdeon must include the members Health Plan Plan ID and Beacon s Emdeon payer ID. Using just one or the other will cause claims to reject. EDI registration forms are on the Beacon web site at After test submissions have been completed, contact EDI Operations to request a production setup. They can be reached at , or via at edi.operations@beaconhs.com. 48

49 Important Claims Reminders All claims must be received by Beacon within the plans timely filing limit. The filing limit for YourCare is 120 days from the date of service for original filing, and 60 days for resubmissions. Out of Network claims have a filing period of 15 months. Claims that require Coordination of Benefits (COB) have 120 days. All clean claim submissions (meaning no missing or incorrect numbers or information) will be processed and paid by Beacon within 30 days. The top denial reasons for claims submitted to Beacon, are as follows: Timely filing (claim denied as it was not received within the plans timely filing limit) Missing or incorrect NPI number (all claims must list the rendering clinicians individual NPI number, along with the site NPI number. If either of these numbers are missing or entered incorrectly, the claim will deny) 49

50 Contact Numbers Beacon Health Options Main fax number TTY Number (for hearing impaired) Provider Relations Provider Relations fax Credentialing fax Provider Relations Claims Hotline eservices Helpline All departments can be reached at This is the main toll free number. 50

51 Copy of Presentation For a copy of the presentation, please provider.trainings@beaconhs.com Please note, the Provider Training does not handle day to day operational issues. Please contact Provider Relations at provider.relations@beaconhs.com, or at should you have an issue that needs to be resolved. Thank you 51

52 Thank you 52