Division of Medical Assistance Programs. Services Directory

Transcription

1 Services Directory DMAP Organization Chart... 1 Quick reference... 2 Main contact information... 2 DMAP mail codes addresses by topic... 2 Helpful telephone numbers... 2 Office of the State Medicaid Director... 3 Medicaid Policy and Planning Section... 3 Coordinated Care Support Unit... 3 CCO Contract Administration Team... 4 Federal Waiver, State Plan and Policy Initiatives Unit... 4 Medicaid Policy Unit... 5 Office of Client and Community Services... 5 Client Services Unit... 6 Medical Program Eligibility Policy... 6 Outreach and Training... 7 OHA Statewide Processing Center... 7 Operations and Provider Services Section... 8 Business Service Unit... 8 Electronic and Encounter Data Unit... 8 Provider Services Unit... 9 Provider Enrollment Unit... 9 Program Support Section Client & Provider Education Hearings Unit Quality Assurance/Improvement and Clinical Services Section Medical Program Development Quality Assurance and Improvement Unit RN Medical Case Management Technical Authorization Review Client and Provider Education

2 DMAP Organization Chart DMAP Services Directory 1 Last updated 10/25/2013

3 Quick reference Mailing address Oregon Health Authority 500 Summer St NE, [Mail Code] Salem OR DMAP mail codes See unit listings for exceptions. Office of the State Medicaid Director Office of Client and Community Services Operations, Quality Assurance/Improvement and Clinical Services Medicaid Policy and Planning; Program Support E49 E40 E44 E35 addresses by topic Administrative rules coordination Communications Electronic Data Interchange for HIPAA Managed/coordinated care enrollment updates Medical eligibility questions Pharmacy program questions Provider billing and customer service Provider enrollment Provider outreach Provider training Provider Web Portal assistance Helpful telephone numbers Also see APD Medically Fragile Children s Unit Automated Voice Response Client Services Unit DMAP Reception or EDI Support Services Member Enrollment Services (formerly CES) OHA Statewide Processing Center OHP Application Center OHP Benefits/RN Hotline OPAR Health Insurance Group (HIG) OPAR Medical Payment Recovery PA Hotline Provider Enrollment Provider Services Unit DMAP Services Directory 2 Last updated 10/25/2013

4 Office of the State Medicaid Director This office carries out the goals and objectives of the (DMAP) to manage the design, implementation, and evaluation of multiple statewide programs and activities in support of the Oregon Health Plan (OHP). The Medical Director provides clinical support, medical policy recommendations, and acts as an external, clinical, professional liaison. Responsibilities include: Provide leadership Determine policy and program priorities Assure conformance to legal requirements Integrate and coordinate interagency activities Ensure effective use of resources Medicaid Policy and Planning Section This section is responsible for all medical service programs and coordination of activities related to the administration of the Title XIX Program and the Title XXI Children s Health Insurance Program (CHIP). It also coordinates DMAP s administration of Medicare Modernization Act (MMA) policy implementation, and conducts administrative reviews. It oversees Medicaid program policy for School-Based Health Services, Medical Transportation, Administrative Exams and Reports, and services to members with both Medicare and Medicaid coverage. Staff design, develop, implement, monitor and maintain Medicaid medical service programs to comply with state and federal regulations. They also develop cost control measures to ensure expenditures are within budget. Specific services include State Plan Amendments Contract development and coordination Coordination with federal project officers Staff also produces policy analyses, initiates program implementation, and fulfills information requests from the Legislature, Governor s Office, other divisions within DHS/OHA, providers, community partners, and policymakers. Coordinated Care Support Unit Phone Fax This unit monitors the managed care organizations (MCO) and Coordinated Care Organizations (CCOs) for some elements of contract compliance; supports CCOs in their transformation efforts to meet the Triple Aim (better health and better care at lower cost); facilitates member access to services through enrollment and technical assistance to MCO/CCO delivery systems; and collaborates with MCOs/CCOs to manage the MCO/CCO enrollment capacity and reconciliation. DMAP Services Directory 3 Last updated 10/25/2013

5 Account Representatives A liaison between DMAP, the MCOs/CCOs and their assigned Innovator Agents, this team provides MCO/CCO customer service support for issue resolution related to member access, capitation and CCO transformation. This team is the main point of contact for the Innovator Agents in regard to DMAP processes for CCOs. Coordinated Care Team The team requests and oversees changes in the Medicaid Management Information System (MMIS) to support correct member enrollment and MCO/CCO service area changes as well as system improvements. The team also provides support to ensure accurate and timely capitation payments, member materials and member enrollment status updates. Member Enrollment Services (formerly Client Enrollment Services) This team maintains the integrity of the MCO/CCO member enrollment profiles by assisting DHS branch offices with member enrollment issues, monitoring exceptions/exemptions to enrollment, and resolving MCO/CCO inquiries about appropriate enrollment or capitation. CCO Contract Administration Team Staff manages the CCO contracting process, new contracts, certification process, amendments, interpretation for internal and external stakeholders, monitor reporting and contract deliverables, coordinate financial solvency monitoring, and coordinate validation and review of reports and deliverables. Manage contracting and amendment time lines Track submission of Contractor reports and deliverables Distribute draft and final language and collect comments and edits Oversee interactions with CMS on review and approval of templates and executed agreements Facilitate changes to the Oregon Health Plan (MCO and CCO) administrative rules Evaluates the financial solvency of the MCOs/CCOs Federal Waiver, State Plan and Policy Initiatives Unit This unit is responsible for the Title XIX, Title XXI State Plan which is the officially recognized document describing the nature and scope of Oregon s Medicaid and Children s Health Insurance Program (CHIP) activities. Staff serves as liaisons with state and federal agencies, MCOs/CCOs, advocacy groups, and professional provider organizations to maintain Medicaid program policy related to Medicaid and CHIP State Plan Amendments. Other work includes Demonstration Waiver development, program renewal and evaluation and recommending changes to benefits, eligibility standards and processes. DMAP Services Directory 4 Last updated 10/25/2013

6 Medicaid Policy Unit Staff provides program-specific operational support, such as: Referring members and case workers to other resources Investigating complaints and facilitating resolution Special research, research and follow-up Reporting and analysis of program-specific claim processing issues or concerns Staff serves as liaisons with state and federal agencies, MCOs/CCOs, advocacy groups, and professional provider organizations to maintain Medicaid program policy in the following areas: Medical and Pharmacy Services Durable Medical Equipment Home Enteral/Parenteral Nutrition and IV Services Home Health Hospice Medical-Surgical Services Pharmaceutical Services Physical and Occupational Therapy Private Duty Nursing Speech-Language Pathology, Audiology and Hearing Aid Services Vision Services Clinic and Health Center Services Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) Indian Health Services Patient-Centered Primary Care Homes Other Health Care Services Behavioral Rehabilitation Services Chemical Dependency Services Dental Services Hospital Services Medical Transportation Mental Health Services School-Based Health Centers Targeted Case Management Office of Client and Community Services The Office of Client and Community Services is a hub for member support and community outreach related to services provided by the. Policy related to eligibility for state medical benefits is developed here, and applications for those benefits are processed by OCCS staff. OCCS also offers customer service for members currently enrolled in a medical insurance plan through the state. DMAP Services Directory 5 Last updated 10/25/2013

7 Outreach coordinators based in this office provide statewide outreach, collaborating with partner organizations to make Oregonians aware of the health care coverage opportunities available to them and to help them enroll. Client Services Unit Call Center th Ave NE, Suite 155 Fax Salem OR This unit is the customer service center for OHP members. Staff members help members navigate a complex system of health financing rules and MCO/CCO protocols. CSU is organized in 2 teams: Client Hotline This team answers the OHP Hotline and obtains information from the caller to help address member concerns about access to, limitations on, or quality of their OHP benefits or services. If they cannot resolve the issue over the phone, staff refers the call to the appropriate resource. Duties include: Provide general information about OHP medical, dental and mental health benefits Coach clients on how to resolve problems involving access or quality of care Refer inquiries to appropriate offices for investigation if necessary Refer members of managed care to their CCO/plan s customer service when necessary Refer medical bills to appropriate units for resolution Answer general questions about eligibility issues Issue Certificate of Creditable Coverage requested by clients leaving OHP and moving to commercial health insurance Issue Certificates of Non-Eligibility for clients requesting services through other resources Process individual requests for client handbooks/materials Process requests for changing an assigned pharmacy Answer general questions about denied pharmacy claims, prior authorizations, TPL issues Special Assistance This team researches and assists members with issues requiring follow-up action, including medical bills received from OHP providers. Duties include: In depth research to resolve any issues referred by Client Hotline staff Adding and removing TPL Research allegations of inappropriate denials of covered benefits Coordinate enrollment changes for CCO/plan members and contact clients when change has been approved or denied Respond to and call inquiries regarding OHP rules and processes. Inquiries come from stakeholders, clients, plan/cco staff, OHA/DHS staff, branch caseworkers, advocates and others. Medical Program Eligibility Policy medical.ssp-policy@state.or.us The OCCS Medical Program Eligibility Policy Unit maintains the group of Oregon Administrative Rules that apply to OCCS medical program eligibility. The Eligibility Policy Unit assures that OARs are aligned with the Oregon State Plan and Federal Regulations governing the programs. This unit also: DMAP Services Directory 6 Last updated 10/25/2013

8 Provides policy clarifications as needed for field staff or other sections of DHS/OHA, Maintains eligibility worker resource manuals for OCCS medical programs, Issues communications to OHA and DHS field offices regarding policy and procedure changes, Provides guidance regarding the development of field training and staff procedure. Outreach and Training The Outreach and Training Unit includes two teams: Community Outreach Team The Community Outreach team responsibilities are to: Facilitate application assistance training Establish and nurture relationships with community members and leaders Coordinate and implement statewide and local outreach campaigns Bring linguistically and culturally responsive health care directly to the community Coordinate collaboration between local community partners Seek and coordinate opportunities for Oregonians to access application assistance and enrollment Business Team The Business team responsibilities are to: Administer outreach and enrollment grants and volunteer contracts awarded by our agency Ensure that program goals align with grantees outcomes OHA Statewide Processing Center Call Center This unit is a statewide application processing center for Oregon Medicaid applicants. Staff members determine eligibility for all medical programs and provide customer service to members, partners and the public. The Processing Center is organized into four teams: Phone Bank This team assists callers with resolving questions, access to care issues, plan enrollment, explaining eligibility decisions, and referrals to other resources. Eligibility Workers This team determines initial and on-going eligibility for state medical benefits according to agency guidelines. Training Unit This team delivers policy and procedural training to incumbent and new OHP employees. Hearings Unit This unit reviews hearing requests from members, presents agency cases in administrative hearings, and assists staff/others with compliance issues. DMAP Services Directory 7 Last updated 10/25/2013

9 Operations and Provider Services Section This section ensures the delivery of payments to health care providers. It also ensures delivery of care coordination activities to members. Specific services include: Claims management, adjudication, and exception claims processing (non-clinical) Customer service for OHP providers Reports and analysis on claims processing and other Operations functions Electronic data interchange (EDI) support services Liaison services for MCO/CCO encounter claims Medicaid Management Information System (MMIS) liaison Provider enrollment Workflow analysis and design Electronic funds transfer Premium payment coordination Technical and encounter data management Provider training This section also develops and monitors contracts assigned to Operations, including the OHP premium contract. Program staff authorizes Medicaid EHR Incentive Program incentive payments by making determinations on provider compliance with eligibility requirements. They are also the primary contact for providers and hospitals that have questions on eligibility, application processes, Provider Web Portal access, and other reporting requirements under the program. Business Service Unit Phone Fax This unit s primary responsibility is to ensure that the Medicaid Management Information System (MMIS) operates according to DHS/OHA business needs. It also coordinates staff training on MMIS subsystems. Staff acts as the liaison between DHS/OHA business units and DHS/OHA s MMIS Operations and Maintenance contractor, Hewlett Packard Enterprise Services (HPES). Each team responds to MMIS service requests to troubleshoot MMIS functionality, and facilitates compliance and coordination of MMIS requirements. This unit is also responsible for working with the DHS/OHA business units to assess user training needs, and coordinate DHS/OHA user training statewide. This team also works with DHS/OHA managers on MMIS security access. Electronic and Encounter Data Unit Phone Fax This unit ensures appropriate processing of encounter claims submitted by MCOs and CCOs. It also approves providers and MCOs/CCOs for electronic data interchange (EDI) through testing for submissions. It acts as the liaison for MCO/CCO claims submissions to meet federal and state standards. DMAP Services Directory 8 Last updated 10/25/2013

10 This unit is also the OHA compliance coordinator for HIPAA Transactions and Codes Sets standards. It is also the contract administrator for Medicare s Coordination of Benefits Agreement (COBA) contractor, GHI and providers using a value added network (VAN) connection for eligibility inquiries. It includes the following teams: Encounter Data Encounter staff ensure the integrity and validity of encounter claims submitted by the MCOs/CCOs serving OHP members. They monitor MCO/CCO data submissions for contract compliance, and enroll MCO/CCO providers into the MMIS. They also assist with hysterectomy and sterilization compliance reconciliation and pharmacy rebate dispute resolution. EDI Support Services Call Center EDI staff ensures that claims submitted via Electronic Data Interchange (EDI) enter the payment system for processing. They help providers register for, test, and successfully exchange EDI transactions with DHS/OHA for billing and claims/eligibility inquiries. They facilitate the HIPAA EDI Transaction and Codes Sets (TCS) implementation process, and educate DHS/OHA providers about how to comply with TCS standards. Provider Services Unit Phone Customer Service Center Fax dmap.providerservices@state.or.us team.provider-access@state.or.us This is the customer service center for DMAP fee-for-service (FFS) providers. Staff interpret DMAP rules and policy to assist providers in billing and resolving billing issues with DMAP. They answer DMAP s Provider Services 800 number, and obtain claim information from providers to help them review the status of their claims. They also help providers with Provider Web Portal access and navigation issues. Staff ensures appropriate processing of FFS claims and processes suspended FFS claims based on system defined reviews for appropriate billing practices, prior authorizations, service limitations and missing or invalid information. Special handling for County-60 member services, transplant services, nursing facility, administrative examination and state institutions claims for special handling, and requests for redetermination of denials or payments. Provider Enrollment Unit Phone Customer Service Center Fax provider.enrollment@state.or.us This unit validates, re-certifies and manages ongoing enrollment for providers who serve OHP members. For each provider type, staff determines if the provider meets established enrollment criteria, such as valid licensure with the appropriate licensing authority. They also maintain National Provider Identifier and taxonomy code information for enrolled Medicaid providers. DMAP Services Directory 9 Last updated 10/25/2013

11 They also add and update Durable Medical Equipment Resource Center (DMERC) codes and Universal Provider Identification Numbers (UPIN) from Medicare; add new changes to the PCM files; add mass rate changes; and maintain electronic provider enrollment files. They also process provider applications for Electronic Funds Transfer of claim payments. Program Support Section This section is responsible for activities that support or involve multiple DMAP sections. Specific services include: Program and administrative budget oversight Administrative hearings related to health care services Audits, payment reconciliations and cost settlements to hospitals, FQHCs and RHCs Communications to OHP members, plans, providers and stakeholders Federal matching funds oversight Invoice payments LEAN and Continuous Improvement activities MMIS business implementation Work with DHS/OHA staff to coordinate processes and communication needed for successful system implementation Business office Manages and provides oversight for the support staff pool, 3 rd floor reception, personnel actions and space planning Pricing for policy options, reduction options and proposed legislation Client & Provider Education Fax dmap.distribution@state.or.us This unit is responsible for drafting, editing and distributing written material for OHP members, MCOs/CCOs, health care providers, other state agencies, and the general public. The unit is also responsible for maintaining the Oregon Health Plan website and DMAP intranet. Hearings Unit Phone This unit processes and coordinates requests from members for administrative hearings related to health care services. DMAP Services Directory 10 Last updated 10/25/2013

12 Quality Assurance/Improvement and Clinical Services Section This section provides MCO/CCO/FFS quality assurance and improvement monitoring. It also provides Medicaid program clinical consultation and development, FFS payment authorizations (PA) and medical claims review. Special areas include: Medical management case reviews FFS medical case management and disease case management services Prior authorization and RN hotline Liaison to Health Evidence Review Commission Coordination and promotion of preventive health care strategies, such as tobacco cessation. Transplants and out-of-state service authorizations Quality oversight for health care delivery systems Services authorized by this section include: Dental services and hospital dentistry DME and supplies Hearing aid services Home health (nursing only) Home enteral/parenteral Mental health services Physical/occupational therapy Private duty nursing Radiology Speech/hearing/audiology Surgical procedures Visual services Medical Program Development This unit provides the following functions: Coordination, development and promotion of preventive health care strategies and clinical services, such as tobacco cessation and disease case management with other DHS/OHA partners; Law Enforcement Medical Liability program oversight and review; Assessment and remediation of policy, systems and clinical impacts to Medicaid services and program operations related to Health Evidence and Technology Review Commission activities. DMAP Services Directory 11 Last updated 10/25/2013

13 Quality Assurance and Improvement Unit Phone This unit implements, evaluates and monitors the quality assurance (QA) and quality improvement (QI) processes of the MCO/CCO/FFS delivery systems serving OHP members. The Medicaid Quality Strategy and performance improvement activities are essential responsibilities of this unit. RN Medical Case Management RN Hotline This unit performs the following functions: RN Authorization & Claims Analysis: Registered nurses (RNs) authorize medical services for payment, and provide medical consultation to providers and DHS/OHA staff as it relates to the program policies and OHP coverage limitations. Answers the OHP Benefits/RN Hotline to determine line placement of condition/treatment pairs on the Prioritized List of Health Services. Provides Intensive Case Management and transitional care activities for Medicaid members. Technical Authorization Review PA Hotline This unit authorizes services not requiring RN licensure and refers authorization requests to RN staff as needed. They also answer the PA hotline. DMAP Services Directory 12 Last updated 10/25/2013