Provider FAQ. Humana s Medicare Advantage Preferred Provider Organization (PPO) HumanaChoicePPO (Individual Plan) 1392ALL1213-A GHHHS62EN 0414

Transcription

1 Provider FAQ Humana s Medicare Advantage Preferred Provider Organization (PPO) HumanaChoicePPO (Individual Plan) 1392ALL1213-A GHHHS62EN 0414

2 New for 2014 The content for this FAQ document has been changed to reflect updates for the 2014 plan year. See below for information about changes to the HumanaChoicePPO plan, a Medicare Advantage PPO plan. Members will select a primary physician for health care services and to coordinate their care. For members who do not select a primary physician, one will be assigned for them. The member's primary physician will be listed on the back of the member's Humana ID card. Any Humana Medicare Advantage PPO participating health care provider may see a HumanaChoicePPO member as an in-network provider. If a member chooses a new primary physician, the member will receive a new member ID card that reflects the change. Health care providers do not need a referral to see HumanaChoicePPO members, even if the provider is not listed as the primary physician on the member's ID card. HumanaChoicePPO members can see any Medicare health care provider. HumanaChoice (PPO) A Medicare Health Plan with Prescription Drug Coverage CARD ISSUED: MM/DD/YYYY MEMBER NAME Member ID: HXXXXXXXX Plan (80840) RxBIN: XXXXXX RxPCN: XXXXXXXX RxGRP: XXXXX Copayments OFFICE VISIT: $XX SPECIALIST: $XX HOSPITAL EMERGENCY: $XX CMS XXXXX XXX Member/Provider Service: If you use a TTY, call 711 Pharmacist/Physician Rx Inquiries: Primary Physician: XXXXXXXXXXXXXX Claims, PO Box 14601, Lexington, KY Medicare limiting charges apply Please visit us at Humana.com Additional Benefits: DENXXX VISXXX HERXXX Note: As of today this PDF meets Compliance/CMS guidelines and could be subject to change Humana has created a collection of questions and answers for providers. They have been divided into three sections: General Questions Reimbursement Questions Operational Guidelines 2

3 General Questions Q: How are contracted physicians reimbursed? A: Reimbursement is based on the contracted rate, which is typically a percentage of the Original Medicare rate. Providers should check their contracts for details. Q: How are noncontracted physicians reimbursed? A: Noncontracted physicians are reimbursed according to Original Medicare s fee schedule for the area. Q: If a Humana MA PPO member comes to me, a primary physician, and presents an MA PPO ID card with the name of a different primary physician, can I treat this patient? A: Yes, you can treat this person even if the name of a different primary physician appears on the back of the member's ID card. If you are a Humana MA PPO-participating physician, your claim will be considered against the Humana-covered patient's in-network benefits. If you do not participate in Humana's MA PPO plan, your claim will be considered against the Humana-covered patient's out-of-network benefits. Members who have Humana Medicare Advantage PPO plans are required to identify their primary physician in For members who do not select a primary physician, one will be automatically be assigned. The name of the physician that a member identifies, or is selected for him or her, will be listed on the back of the member's ID card. This is part of an effort to strengthen the relationship between members and their primary physicians to focus on members' health care needs and coordinate care as needed. This will also assist specialists in identifying the primary physician of their Humana-covered patients. Please note the following for Humana MA PPOparticipating physicians: A member is not required to see the physician identified on his or her MA PPO ID card. No referral is needed for the member to be treated by a physician who is not listed on the member's ID card. No referral is needed for the member to be treated by a specialist. Primary physicians and specialists are expected to follow standard MA PPO authorization requirements as outlined in their Humana agreements and in their Humana Provider Manual. Q: Are National Provider Identifiers (NPIs) required on claims submitted to Humana? A: Yes. NPIs, taxonomy number, as well as the health care provider s tax ID are required to price and process the claims appropriately. Facilities should use subunit identifiers with their facility ID when submitting claims. Q: What happens if a member disenrolls from a Humana Medicare Advantage (MA) Preferred Provider Organization (PPO) plan and goes back to Original Medicare? How are the member s cost-shares calculated? A: If a member disenrolls from the Humana MA PPO plan and returns to Original Medicare, then Original Medicare cost-sharing provisions would apply. Q: What happens if a member disenrolls from Humana's MA PPO plan and joins a different plan? How are the member s cost-shares calculated? A: If a member enrolls in a different MA plan, the copayments and deductibles specified in the member s Summary of Benefits for the new MA plan would apply. Q: What format is required for claims? A: Use the same format used for Original Medicare. Humana s MA PPO plans accept paper claims and electronic claims in 837i (institutional) or 837p (physician) format. If the provider's office currently submits claims electronically to Humana, it can submit Humana s MA PPO claims using the same process. Submit paper claims to: Humana MA PPO c/o Humana Claims Office P.O. Box Lexington, KY

4 Q: D o additional documentation requirements (ADR) apply to this plan? A: The same ADR requirements apply as they do for Original Medicare. Q: Are there contracted labs? A: Yes. There are contracted lab providers under this plan. The labs under contract vary by market. Please refer to the provider directory for the appropriate market. The provider directory is available online by going to Humana.com/ providers. Scroll to the bottom right of the page and click on "Provider finder." Q: D o Humana s MA PPO plans require advanced beneficiary notices (ABNs) for services that may not be covered under Humana's MA PPO plan? A: No. However, Humana MA PPO members must be notified in advance when a specific service may not be covered. The notice may be verbal or in writing, and the provider is encouraged to document the discussion and bill using the appropriate modifier. Providers should not use the CMS advanced beneficiary notice for MA members, effective March 1, Q: Can physicians or health care providers go online to review their claim status or to verify patient eligibility? A: Yes. Physicians and other health care providers who have filed claims can log onto Humana.com/ providers and find the status of claims submitted for their Humana MA PPO patients. Providers can also check eligibility online. Physicians and health care providers interested in using these services can go to Humana.com/providers and then "Register for Provider Self-Service" or they can call provider relations at for additional information. Q: What recourse do health care providers have if they wish to dispute a payment? A: The payment dispute process is included in the Humana provider manual. Q: Some MA PPO plans have greater benefits than others. How can I know what to expect as the member's copay/cost-shares? A: Certain copays and/or cost-shares are referenced on the front of the member's ID card. However, plan benefits can vary. To learn what services are covered and to what level, providers can verify Humana member eligibility and benefits in two ways: 1. They may go to Humana.com/providers anytime and check the secure area of the provider website. Registration is required. 2. They may call the "Member/Provider Service" phone number that is listed on the back of the member's Humana ID card. 4

5 Reimbursement Questions Q: How are payments for inpatient hospital services determined? A: The allowable amount for inpatient hospital services is based on contracted rates. These rates are typically a percentage of the Medicare Severity Diagnostic Related Group (MS-DRG) payment system, less certain MS-DRG components that HumanaChoicePPO may not pay. See the applicable contract for each facility for details. Q: How are payments for outpatient hospital services determined? A: The allowable amount for outpatient hospital services is based on contracted rates. These rates are typically a percentage of Original Medicare s Ambulatory Payment Classification (APC) payment amount, less certain APC components that Humana may not pay. In addition, Humana s MA PPO has turned off many of the outpatient code editor (OCE) edits that Medicare applies to the claim. Q: Teaching hospitals receive an extra payment from Medicare. Does Humana s MA PPO pay the teaching hospitals this extra payment as well? A: No. Humana s MA PPO does not pay this extra payment to teaching hospitals. CMS has carved out operating Indirect Medical Education (IME) and direct Graduate Medical Education (GME) from the payment to Medicare Advantage contractors. Medicare pays these add-ons to providers directly through its CMS contractors [Fiscal Intermediary, Medicare Administrative Contractor for Parts A and B or Durable Medical Equipment Medicare Administrative Contractor (DME MAC)]. Q: Under Original Medicare, hospital patients must fill out a Medicare Secondary Payer (MSP) questionnaire. Are hospitals required to implement this process for Humana MA PPO members? A: No. CMS does not require MSPs for Medicare Advantage members. However, hospitals should have their patients fill out the MSP questionnaire. Humana reimburses physicians or other health care providers and attempts to recover the money from any third party that might be liable after the fact. Q: What is an Essential Hospital? A: The Medicare Modernization Act (MMA) includes provisions designed to increase beneficiary choice in rural areas by providing both structure and incentives that will broaden health plan service areas. This designation is given to a hospital by the regional PPO (RPPO) and approved by CMS. If your hospital has been notified by CMS that it is designated as an "Essential Hospital" and you have further questions, please contact Humana's provider relations department at Q: How are rural providers, such as Rural Health Clinics (RHCs), Critical Access Hospitals (CAHs) and Federally Qualified Health Clinics (FQHCs), reimbursed? A: Medicare reimburses rural providers using a methodology other than the Prospective Payment System (PPS) standard for Medicare, and thus, we take this into consideration during contract negotiations. A copy of the Fiscal Intermediary (FI) letter outlining your current interim rates is typically needed for negotiating your provider agreement. For nonparticipating providers, a copy of your FI letter is mandatory in order for Humana to reimburse your claims appropriately. Please contact Humana s provider relations department at for directions on providing that document to us. 5

6 Operational Guidelines Q: Does Humana s MA PPO follow Medicare guidelines as administered by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)? A: Yes. Humana applies NCDs and recognizes that in certain regions LCDs are more specific for selected procedures and diagnoses. In cases in which LCDs exist, Humana will apply the LCD. Q: Does Humana s MA PPO follow all Medicare rules for readmits? A: Yes. Humana s MA PPO follows all Medicare rules for readmits. Q: Can hospitals collect copayment amounts upfront? A: Yes. The hospital can request the copayment upfront and/or at the time of discharge. Q: What are the enrollment and disenrollment guidelines? A: Enrollment and disenrollment guidelines are determined by CMS. Please visit the CMS website at for more information. Q: Are Social Security disability patients eligible for enrollment in a Medicare Advantage PPO? A: Yes. Q: Does Humana s MA PPO require hospitals to give the CMS Important Message from Medicare to all inpatient Medicare patients at time of admission? A: Yes. The Centers for Medicare & Medicaid Services (CMS) issued a final rule, effective July 2, 2007, concerning how hospitals must provide notification to Original Medicare and Medicare Advantage beneficiaries who are inpatients about their hospital discharge rights. The regulation requires that hospitals provide and explain to all Medicare Advantage beneficiaries the standardized notice titled Important Message (IM) within two days of admission and obtain the signature of the beneficiary or the beneficiary s representative. The signed copy may be stored electronically and must contain the following: Right to benefits for inpatient and posthospital services Right to request immediate review of the discharge decision and the availability of other appeal processes if the beneficiary does not meet the deadline for immediate review Liability for charges for continued stay Right to receive additional information Not more than two days before discharge, a copy of the signed IM must be delivered by the hospital to the beneficiary or the beneficiary's representative. The follow-up notice is not required if the original IM is delivered within two calendar days of discharge. The physician who is responsible for the inpatient care must concur with the discharge. Q: Is there an on-site reviewer? A: Yes. In some instances, on-site nurses may be available in some markets. Certain cases are identified for case management on an outpatient basis through postdischarge calls to members. Depending on their condition, certain members are identified for further case management. Case management is handled by phone. 6

7 Q: C ase management services apply to Medicare Advantage PPO products. Are they on-site? A: On-site nurses may be available in some markets. For those markets without on-site reviewers, case management is provided via telephone. Check with the local market office to determine which facilities have on-site nurse reviewers. Disease management services are also available for a specific set of chronic conditions. Humana handles disease management services by phone. Q: E xplain Humana s involvement in discharge planning. A: Humana s case managers work with facility discharge planners to create, implement and follow up on discharge plans. In addition, Humana collaborates and coordinates discharge planning with the member and/or member representative and physician. Q: Does Humana do concurrent reviews in all markets? A: Yes. Humana conducts concurrent reviews in all PPO markets. Q: What kind of criteria does Humana s MA PPO use for medical necessity? A: Humana s MA PPO plans use Medicare coverage guidelines, Milliman criteria, as well as internally developed guidelines to determine medical necessity. Q: What do I need to do if my question is not listed here? A: Contact Humana's provider relations department at or your Humana provider contractor. Q: What is the process for preauthorization? A: Preauthorization of all in-network inpatient admissions (except urgent or emergent), and some outpatient procedures is required. For some other outpatient services, we request notification to maximize member benefits, including disease and case management programs. Please contact Humana s medical management team at Q: W here can I find a list of services requiring preauthorization? A: The list can be found online by going to Humana. com/providers. Click on "Preauthorization & Notification Lists" under "Critical Topics." Q: Does Humana have on-site associates who present letters to doctors and patients explaining the appeal process? A: Since there are only a limited number of on-site Humana associates to deliver letters, appeal rights letters for members need to be coordinated with hospital employees for delivery. 7

8 1392ALL1213-A GHHHS62EN 0614