CU Health Plan. Provider Education Meetings June 2013

Transcription

1 CU Health Plan Provider Education Meetings June 2013

2 Introductions Anthem Representatives Kelly Henry, Network Director Jackie Ferguson, Provider Communication and Education Exclusive Network Representatives Rachael Boggs, CU Health Plan Medication Mgmt, Clinical Pharmacy Specialist Central Lynn Riippi, RN, BSN, Health Plan Case Manager Teresa Corwin, Managed Care Network Coordinator North Brenda Cordle, Director of Physician & Ancillary Contracting Emma Bootle, Physician Relations Manager South Brenda Cordle, Director of Physician & Ancillary Contracting Debra Miller, Physician Relations Manager 2

3 Overview

4 Anthem new payer for CU Health Plan effective July 1, 2013 The following employees / dependents are part of this employer group: University of Colorado (CU) University of Colorado Health University Hospital Memorial Hospital Poudre Valley Hospital Medical Center of the Rockies Colorado Health Medical Group University Physicians Incorporated (UPI) 4

5 New CU Health Plan Options CU Health Plan Exclusive (HMO) Central Network North Network South Network CU Health Plan High Deductible (PPO) CU Health Plan Access (Current Enrollees Only, HMO) CU Health Plan Medicare (CU Retirees Only) 5

6 CU Health Plan ID Cards

7 How to identify CU membership CU specific Alpha Prefixes Separate alpha prefixes have been assigned for most of the CU Health Plans to help differentiate from other Anthem plans. Prefix ACCOUNT NAME Product Type UCF Exclusive Central HMO UCD Exclusive North HMO UCV Exclusive South HMO UCL High Deductible Health Plan PPO XFY Open Access HMO (Closed Plan) HMO XFE Medicare Primary Medicare Note: XFY and XFE are not specific to CU and are used by all Anthem membership within these products. 7

8 CU Health plan ID card information New ID Cards will be distributed to CU members by July 1, 2013 Each dependent will receive an ID card for HMO products ID cards will include the following elements: Anthem Blue Cross and Blue Shield or HMO Colorado logo CU Health Plan logo Product indicator (i.e. Exclusive, High Deductible Health Plan, or Medicare) PCP information, if applicable Alpha Prefix (most CU products have a customized alpha prefix) Exclusive Network indicator (Central, North or South), if applicable Copay, deductible, or coinsurance information Claims address and contact information 8

9 CU Exclusive Central (HMO) sample card: HMO Colorado logo Exclusive product indicator AND Central network indicator CU Health Plan logo PCP information UCF Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 9

10 CU Exclusive North (HMO) sample card: HMO Colorado logo Exclusive product indicator AND North network indicator CU Health Plan logo PCP information UCD Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 10

11 CU Exclusive South (HMO) sample card: HMO Colorado logo Exclusive product indicator AND South network indicator CU Health Plan logo PCP information UCV Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 11

12 CU High Deductible Health Plan (PPO) sample card: Anthem Blue Cross and Blue Shield logo High Deductible indicator CU Health Plan logo UCL Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 12

13 CU Open Access HMO (Closed Plan) sample card: HMO Colorado logo Access Network indicator CU Health Plan logo XFY Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 13

14 CU Medicare Primary sample card: Anthem Blue Cross and Blue Shield logo Medicare indicator CU Health Plan logo XFE Specific Alpha Prefix Note: These are sample ID cards which currently show a dummy alpha prefix. Copay information Back of ID card shows address and contact information 14

15 CU Health Plan Exclusive (HMO) Central, North and South Networks

16 Contract Requirements The Exclusive plan networks will utilize your Anthem HMO (HMO Colorado) reimbursement rate There is not a separate contract for these networks. 16

17 CU Health Plan Exclusive Overview Exclusive limited network specifics: includes a subset of PCPs and Specialists from Anthem s standard HMO network. provides coverage only when using the selected PCP groups, specialists, and facilities; includes all behavioral health and chiropractic providers in Anthem s standard HMO network Exclusive product specifics: requires member selection of a PCP; requires referrals for most specialty care; no out-of-network benefits or access to most specialists without a referral Exceptions: emergent/urgent care and specialty care as required by state law 17

18 CU Health Plan Exclusive Networks 3 networks dependent on selected Primary Care Physician: Exclusive Central network includes: University Physicians Inc. (UPI) University of Colorado Hospital (UCH) The Children s Hospital Select community physicians associated with the University of Colorado School of Medicine/UPI Limited services at Boulder Community Hospital Exclusive North network includes: Poudre Valley Hospital Medical Center of the Rockies Greeley Emergency & Surgery Center Colorado Health Medical Group (formerly PMVG) Select community physicians associated with both facilities Exclusive South network includes: Memorial Hospital The Children s Hospital at Memorial Colorado Health Medical Group (formerly MPN) Select community physicians associated with Memorial Hospital 18

19 Directory Access How to access our online Provider Directory: Go to anthem.com Select the Provider link in the top center of page Select Colorado from drop down list and enter From the Provider Home tab, select the blue box titled Find a Doctor to search our online Provider Directory 19

20 Directory Access How to search for an Exclusive network provider: 1. Enter which type of provider for your inquiry 2. Enter information about the provider (optional) 3. Enter the location for your inquiry 4. Enter the insurance plan information: 1. Select I d like to search by selecting a plan option 2. Select Colorado for the state 3. Select HMO for the Plan Type 4. Under the Plan Name, you will see each CU Health Plan HMO option under the drop down list. 20

21 Exclusive Plan Network Requirements The following services must be referred to a University of Colorado Health facility location for all of your patients with the CU Health Plan Exclusive. Inpatient services and outpatient services, including outpatient surgery (north and south networks do include UCHealth-affiliated (JV) locations) Laboratory service Radiology services, including high technology imaging Urgent care services Rehabilitation services including; inpatient and outpatient for occupational therapy, physical therapy and speech therapy Sleep study services For services normally provided in-office, the Exclusive Plan allows providers to continue performing services such as laboratory work, plain-film X-rays, mammogram screenings and DEXA scans in their offices, versus requiring you to refer them Please see the following websites for facility locations: Exclusive Central: Exclusive North: Exclusive South: 21

22 Exclusive Plan Network Referral Requirements Referral Requirements: PCP issues a referral for all visits outside PCP office that require a referral. University Physicians Inc. (UPI) is delegated for utilization management. You will submit your referral requests through UPI/UMA/MedNet, who will communicate the referrals to Anthem for claim purposes. Specialist to specialist referrals DO require a referral from the member s PCP. Note: If you are a specialist seeing a patient with a chronic condition, referrals are good for 3 visits in 4 months. Global referrals are available for cancer, radiation, dialysis, and allergy injections. 22

23 Exclusive Plan Network Referral Requirements Referrals required for most specialty care: Specialty/Services NOT requiring a referral: Obstetrics and Gynecology Ophthalmologists Emergent or urgent care Any services provided by hospital based providers (radiology, anesthesiology, pathology and emergency room) Services provided by hospitalists Any other service for which applicable law requires the member to have open access. Mental health and substance abuse providers (referrals not required however, authorization may be required through Anthem Behavioral Health) 23

24 Pre-authorizations Requirements: Follows Anthem s authorization requirements with the addition of Abortion,HSG, and Hyalgan/Synvisc, Colonoscopy, EGD and a few others. Includes high end imaging (MRI, MRA, etc) Send prior auth form or radiology request form to UPI/UMA/MedNet, who will communicate the authorization to Anthem for claim purposes. See Exclusive Plan Prior Authorization List in your packet Forms Referral Form Prior Authorization Form Radiology Request Form All forms can be faxed to: North Central South 24

25 Referral/Authorization Contact Information Central Network: Lynn Riippi, RN, BSN, Health Plan Case Manager Teresa Corwin, Managed Care Network Coordinator North Network: United Medical Alliance (UMA) South Network: MedNet /

26 Primary Care Physicians The following specialty types may be selected as a primary care physician: Family Practice General Medicine Internal Medicine Pediatricians Note: OB/GYNs are not an option for a PCP. Member must select a PCP. If a PCP is not chosen, a PCP will be selected for the member. Members can change PCPs at any time. The effective date will be the first of the following month that the change is made. 26

27 Drug Formulary

28 Formulary For the most current version of the prescription drug list, please visit anthem.com Select the Provider link in top center of page Then select the RxSearch button 28

29 Important Changes to Pharmacy Benefits Most birth control pills will be covered with no out-of-pocket costs (100% covered, $0 copay / $0 coinsurance). All CU Health Plan members diagnosed with diabetes may be eligible to have diabetic medication and supplies filled with no out-of-pocket costs (100% covered, $0 copay / $0 coinsurance). 29

30 Where can members fill prescriptions? For all plans, the UCH Mail Order Prescription Service is the only covered mail order option. UCH Mail Order Prescription Service Phone: (800) , Fax: (720) CU Exclusive Plan North, Central, and South (HMO): Maintenance medications and specialty medications must be filled through UCHealth Pharmacies by the third refill in order to be covered May fill up to a 30-day supply at any Anthem participating retail pharmacy Up to 90-day supplies are only covered through UCHealth Pharmacies Prescription Costs: Members pay a set copay amount (or less if the cost of the drug is less than the copay) according to a 4-tier formulary; the higher the tier, the higher the member copay amount CU High Deductible Health Plan (PPO): May fill up to a 30-day supply at any Anthem participating retail pharmacy Up to 90-day supplies are only covered through UCHealth Pharmacies Prescription Costs: Member pays 100% medication cost up until deductible is met, 20% of medication cost after Deductible is met, and then 0% after Out-of-Pocket Maximum is met. 30

31 Where can members fill prescriptions? CU Open Access HMO (Closed plan): May fill up to a 30-day supply at any Anthem participating retail pharmacy Up to 90-day supplies are only covered through UCHealth Pharmacies Prescription Costs: Members pay a set copay amount (or less if the cost of the drug is less than the copay) according to a 4-tier formulary; the higher the tier, the higher the member copay amount CU Medicare Primary: Up to 90-day supplies are covered through either Anthem participating retail pharmacies or UCHealth Pharmacies Prescription Costs: o Through Anthem participating retail pharmacies: Member pays 100% medication cost up front, then Anthem will send reimbursement check to member. Member responsible for 100% medication cost up until deductible is met, 20% of medication cost after Deductible is met, and then 0% after Out-of-Pocket Maximum is met. o Through UCH Mail Order Pharmacy: Member pays set copay amount (or less if the cost of the drug is less than the copay) according to 3-tier formulary. Member does not have to satisfy any Deductible for prescriptions and copays do not count towards the medical Deductible or Out-of-Pocket Maximum. 31

32 Questions? Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.