User Guide for the Prestige Health Choice Provider Portal Featuring the Availity Provider Portal

Transcription

1 User Guide for the Prestige Health Choice Provider Portal Featuring the Availity Provider Portal 1

2 USER GUIDE Contents SECTION 1: PRESTIGE HEALTH CHOICE PROVIDER PORTAL OVERVIEW... 3 SECTION 2: AVAILITY OVERVIEW... 4 SECTION 3: GETTING STARTED... 5 SECTION 4: AVAILITY DEMONSTRATION SITE AND SUPPORT... 9 SECTION 5: ELIGIBILITY AND BENEFITS SECTION 6: CLAIMS STATUS INQUIRY SECTION 7: REPORTS SECTION 8: AUTHORIZATIONS AND REFERRALS SECTION 9: SPECIAL FEATURES SECTION 10: AVAILITY HELP

3 SECTION 1: PRESTIGE HEALTH CHOICE PROVIDER PORTAL OVERVIEW Prestige Health Choice recognizes that our provider partnerships are a major factor in our ability to delivery quality Medicaid services and neighborhood-based care throughout Florida. Every day, Prestige s mission to provide quality, affordable care to the underserved in our communities is reflected in the care, expertise, and support that our providers offer. To access the Prestige Provider Portal, please go to and click on the Providers link in the middle of the page. Through the Prestige Provider Portal, you can access: Self-Service Tools: Provider and pharmacy directories and our formulary Resources: Member materials and provider resources Communications: Updates and changes, forms, manuals, and newsletters Training and Education: Orientation and other training material Claims and Billing: Claims submission protocols And can link to the Availity Provider Portal 3

4 SECTION 2: AVAILITY OVERVIEW Purpose of this User Guide The purpose of this guide is to provide an abbreviated, user-friendly reference tool to help your practice get started using the most common functions offered by Availity quickly and efficiently. Availity provides additional user guides and video tutorials in the Help Section on the Availity website, as outlined in Section 10 of this user guide. Availity offers your office: Reliable member information right to your desktop Cost effective tools and services Intuitive navigation to get your staff up and running quickly Increased efficiency for streamlining business processes Reliable access to the following transactions: o Eligibility and Benefits Inquiry o Claim Status Inquiry o Authorization Submission and Inquiry o Report Inquiry, including panel rosters, and Member Care Gap Reports Go to Availity at Click on the Start Registration link to begin the enrollment process. 4

5 SECTION 3: GETTING STARTED New Users Signing Up Enrollment is easy. 1. To enroll in Availity via online enrollment go to: viders/registration-details/ Registration is Free! Look here for the information you need to gather before you register for Availity. 2. Click on Start Registration. 5

6 1. Complete the registration process using this sign-up process. 2. Availity will provide Security verification and assign your user name. 3. You will be asked to create a password. 6

7 The Role of Your Security Officer HIPAA mandates that each provider office designate a security officer to be aware of the electronic storage and transmission of member information within and from your office. When you enroll in Availity for the first time, your Security Officer will be automatically assigned. TIP: Determine who is best suited to assume the Security Officer role and responsibilities prior to beginning enrollment. 7

8 Existing Users - Signing On Access the Availity website. 1. Go to Login Page 2. Type in user name and password. 3. Click the Log In button. This is the Welcome Page. From here you can get to all the transactions for all the plans you are authorized to see in Availity. 8

9 SECTION 4: AVAILITY DEMONSTRATION SITE AND SUPPORT TIP: Availity Support offers additional navigation instructions thru the Demo system. 9

10 Numerous other resources are provided to assist providers in leveraging the capability of the portal to support their practice. 10

11 SECTION 5: ELIGIBILITY AND BENEFITS THIS IS THE ELIGIBILITY and BENEFITS SEARCH PAGE 1. Select Prestige Health Choice as the health plan. 2. Easily identify the provider by using Express Entry. 3. Select your search option. 4. Add the member data and select SUBMIT. 11

12 Eligibility and Benefits Response Page 1. Provides real-time information from the Prestige Health Choice eligibility system. 12

13 Eligibility and Benefits Response Page (continued) 2. Includes information on benefits and co-pays. 3. Identifies the member s PCP. 13

14 SECTION 6: CLAIMS STATUS INQUIRY Select Claim Status Inquiry from the left menu. 1. As with Eligibility you need to identify the plan, provider and member information. 2. You also need to identify a date range for the claim(s) you are searching for. 14

15 1. The Claim Status search results will appear on this page. 2. This page gives you claim numbers, member information, service dates, amounts billed, and amounts paid. 15

16 SECTION 7: REPORTS Administrative Reports Panel Rosters From the home page, select Reports from the left menu. Depending upon your practice s assigned capabilities, you may select from the following reports: Administrative (Panel Rosters) Clinical Reports (Care Gaps) Reports Authorizations 1. To select Panel Roster Reports Select Administrative Report Inquiry. 2. Select Panel Roster Reports. 3. Click on Select. 16

17 1. Select a provider group or provider name. 2. Select your report criteria. 3. Select report type. If you would like to see your report in an Excel document, follow the steps below the screenshot. 4. Click Search. TIP: For Panel Rosters: Excel or CSV (Downloadable) option Please follow these steps to get the required report in Excel file format: Step 1: Navigate into the Panel Roster Report section, and Choose the provider group. Step 2: Start pressing the Ctrl button on your keyboard and select the Excel/ CSV option (Radio button) while continuing to press the Ctrl button. Step 3: Continue pressing the Ctrl button and click on the Search button on the report search screen. Step 4: This process would lead to a new window pop up, followed by a message box with a question Do you want to open or save this file. Step 5: Click on Save button. Step 6: Save the document with extension.csv instead of.xls. Step 7: Open the document from the destination from where ever it was saved in the previous step. Note: You might receive a security pop up after step 4, if you have not listed Availity as a safe site to visit in your browser s internet option settings. 17

18 The Panel Roster Report will provide you with our member s Member ID, Medicaid Recipient ID and Panel effective date, as well as basic demographic and contact information. 18

19 Clinical Reports Care Gap Query Care gap reports allow your practice to identify members who have overdue preventive health services such as cervical cancer screens or mammograms. Diabetes and other condition related care gaps are also provided. This easy to access information enables your practice to proactively address these patient needs. The information is provided real-time only on members who are eligible at the time the report is run. 1. For Care Gap Query Reports, select from Clinical Report Inquiry. 2. Select Care Gap Query from the pull down box. 3. Click on Select. TIP: Additional reports you can select from this page: Member Alert Stand Alone Care Gap Requests Missing and Overdue Care Gaps for All Missing and Overdue Care Gaps Adolescents Only Missing and Overdue Care Gaps Adults Only Missing and Overdue Care Gaps Pediatric Only 1. Select provider group and report criteria. 2. Select all, or target conditions. 19

20 3. Select Sort Option from the pull down menu. You can select by: Member Last Name, Provider ID, Conditions and Service. This is a sample of the Care Gap Query Report organized by Member Last Name. 20

21 SECTION 8: AUTHORIZATIONS AND REFERRALS 1. Authorizations and Referrals are accessed from the left menu bar. 2. When the menu item is selected, the user is securely transferred using single sign-on over to Prestige Health Choice s Jiva Authorization and Referral system. Reports Authorizations and Referrals 21

22 1. When the user is transferred into the Jiva system they can access Prestige Health Choice members. 2. They can submit authorization and referral requests and view the status of the requests. 3. When the user completes the work in Jiva they can easily switch back to the Availity system which is maintained in its own browser window. TIP: Make sure you have access to Authorizations and Referrals. Not all users have access. If you don t have access but need it, contact your practice s Availity Administrator who has the ability to provide you with access. TIP: For more information on Jiva, please see the Authorization and Referral Provider Portal Reference Guide. 22

23 SECTION 9: SPECIAL FEATURES Prestige Health Choice has implemented several special features of the Availity system to support providers in delivering exceptional quality of care to our members. These features are described below. Care Gap Alerts When Checking Eligibility Each time eligibility is checked via the Availity portal, Prestige Health Choice will also check to see if the member has any overdue preventative health screenings or needed exams for a chronic condition such as diabetes. If a care gap is identified a pop up will appear on the eligibility response alerting the user to the members need. More detailed information can be provided if the message is printed. 23

24 Care Profile Providers also have the ability to access a care profile on the member. The Care Profile is particularly useful for initial visits when the provider is seeking to understand the overall condition of the member. The Care Profile lists a wide range of information pulled from Prestige Health Choice s repository of claims, clinical information and analytics. This sample offers an overview of the information that can be available. Information on a specific member will depend on their clinical history. TIP: The Care Profile is a restricted transaction and requires authorization by the practices Availity Administrator to access. 24

25 SECTION 10: AVAILITY HELP From the Availity home page, select Help. 25

26 Availity Support Home Page Look here for helpful tutorials, demos and FAQs. Select a Health Plan for plan specific information. Help includes a chronological list of changes made in Availity. 26

27 Availity Help provides extensive on-line documentation for troubleshooting problems around access, display issues, and online transaction problems. 27

28 Availity Help offers tips around best practices and access to the client services Knowledge Base. 28 P2058_1404