PARTICIPATING PROVIDER ORIENTATION

Transcription

1 PARTICIPATING PROVIDER ORIENTATION

2 First Choice VIP Care This training program is designed to familiarize Providers with First Choice VIP Care and the Plan s Model of Care, the role of the Provider in the Model of Care and the Plan s resources available to the Provider and Member. 2

3 First Choice VIP Care is a member of the AmeriHealth Mercy Family of Companies - industry leader in managing medically complex members. Who We Are Growing our vision and mission to provide healthcare services to the underserved. First Choice VIP Care enables us to offer our existing and eligible chronically ill Medicaid members, a seamless transition to a Medicare Advantage Special Needs Plan. 3

4 Mission Statement We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. 4

5 Plan Overview Plan Overview First Choice VIP Care is contracted to provide Medicare Hospital (A), Medical (B) services, and Prescription Drug Coverage (Part D) services in the following counties; Pickens, Greenville, Spartanburg, Anderson, Laurens, Abbeville, Saluda, Lexington, Richland, Orangeburg, Berkeley, Charleston. Members must live in one of these counties to join the plan. First Choice VIP Care Will accept only those beneficiaries with dual Medicaid/Medicare eligibility. 5

6 Summary of First Choice VIP Care s Benefit Package Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Hospice Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Kidney Disease and Condition Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network catastrophic Prescriptions Outpatient Prescription Drugs Retail Pharmacy Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care 6

7 Supplemental Benefits Dental, Vision and Hearing DENTAL SERVICES Preventative Dental Oral Exams 1 every 6 months Cleaning 1 every 6 months Fluoride Treatment 1 every 6 months Dental x-rays 1 every year Non routine services, including minor restorations (such as fillings, simple extractions and denture repair) Comprehensive Dental Non-routine services $500 every two years Includes coverage for minor restorations Fillings, simple extractions and denture repair VISION SERVICES Up to one supplemental routine Eye Exam every year Up to one pair of eyeglasses or contact lenses every two years HEARING SERVICES Up to one supplemental routine Hearing Exam every year Up to one fitting evaluation for a hearing aid every three years Up to $1,000 coverage for hearing aids every three years 7

8 Supplemental Benefits (continued) OTC and Transportation Over the Counter Typically includes medicines or products that alleviate or treat injuries or illness No statement from a medical provider required or documentation of a diagnosis to use the benefit Up to $60 every three months No roll-over quarter to quarter Transportation Services Must be Plan approved location (24) one-way trips per year to a plan approved location Car, shuttle, van services, including non-emergent transportation to doctor visits, preventive services, pharmacies and fitness center Authorization and scheduling rules apply 8

9 Supplemental Benefits (continued) 24/7/365 Nurse Line If members are unable to reach their PCP s office, registered nurses are available 24/7days to assist members through the Nurse toll-free Call Line First Choice VIP Care Nurse Call Line:

10 Supplemental Benefits (continued) Rapid Response and Outreach Team The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include: Contacting members Educating members Calling Providers Calling Pharmacies Completing surveys and assessments to support special projects Providers may request RROT support directly by calling toll free at (800) , 8 am 5 pm, Monday through Friday. 10

11 Member Welcome Packet First Choice VIP Care Member welcome packet: Cover (Welcome) Letter Provider & Pharmacy Directory The Plan s Formulary Evidence Of Coverage (EOC) document Health Risk Assessment (HRA) and return envelope Multi-Language Insert Notice of Privacy Practices Member materials including a summary of benefits compared to Original Medicare and complete evidence of coverage information are accessible via our web site at 11

12 Member Identification and Eligibility Verification Member eligibility varies. Providers can verify eligibility by using the following Provider tools: Calling Provider Services at: (800) Visiting our website at and accessing NaviNet 12

13 Member Identification 13

14 Prior Authorization Requirements Elective / non-emergent air ambulance Transportation All out of network services (excluding emergency services) In-patient services All inpatient hospital admissions, including medical, surgical, skilled nursing and rehabilitation Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after cesarean. In-patient medical detoxification Elective transfers for inpatient and/or outpatient services between acute care facilities Behavioral health care (mental health and substance abuse services) Inpatient hospitalization Outpatient services Partial day services Home-based services Skilled nursing visits: authorization is required after 6 visits (per calendar year) Home Health Aide Services: authorization is required after 6 visits (per calendar year) Home infusions & injections: Authorization required for charges of $250 and over Enteral Feedings, including related DME Therapy and related services Speech therapy, occupational therapy and physical therapy provided in home or outpatient setting Chiropractic services Cardiac rehabilitation Transplants, including transplant evaluations 14

15 Prior Authorization Requirements (continued) All DME rentals and rent to purchase items Durable medical equipment/medical supply/prosthetic device purchases Purchase of all items in excess of $500 Prosthetics and orthotics in excess of $500 in total charges. The purchase of ALL wheelchairs (motorized and manual) and all wheelchair accessories (components) regardless of cost per item. Nutritional Supplements Hyperbaric oxygen Medications: 17-P and all infusion/injectable medications listed on the Medicare Professional Services Fee Schedule with billed amounts of $250 or greater; infusion/injectable medications not listed on the Medicare Professional Services Fee Schedule are not covered by First Choice VIP Care Surgery (for sleep apnea/uvulopalatopharyngoplasty (UPPP) Religious non-medical health care institutions (RNHCI) Surgical services that may be considered cosmetic Cochlear implantation Gastric bypass/vertical band gastroplasty Hysterectomy Pain management external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and injections/nerve blocks Outpatient radiology services; CT scan, PET scan, MRI, MRA, MRS, SPECT scan, nuclear cardiac imaging All miscellaneous/unlisted or not otherwise specified codes All services that may be considered experimental and/or investigational All request for services are subject to Medicare coverage and limitations 15

16 Referral Requirements Services that Require Referrals Specialist visits (except Direct Access Services see below) Podiatry services Outpatient diagnostic procedures (unless otherwise specified) Ambulatory surgery center services Diabetes self management training Direct Access Services that Do Not Require Referral Direct access to women s specialists for routine and preventive services. Direct access to mammography and influenza vaccinations 16

17 Referral Submission The PCP should follow the steps outlined below prior to advising the Member to access services outside of the office: Verify Member eligibility Determine if the needed service requires a referral or Prior Authorization Select a participating Specialist/ hospital or other outpatient facility appropriate for the Member's medical needs from the Specialist Directory, as appropriate If an appropriate Network Provider is not listed in the Network Provider Directory please call Provider Services for assistance at (800) Once a Network Provider is selected, the referral process can be completed electronically or using the traditional paper process. 17

18 Electronic Referral Submissions Electronic referrals through NaviNet: PCP offices can use Referral Submission to submit referrals quickly and easily, and can look up referrals they submitted via Referral Inquiry. Specialists, hospitals and ancillaries can use Referral Inquiry to view and retrieve referrals. Simply log on to NaviNet ( and select First Choice VIP Care from Plan Central Select Referral Submission or Referral Inquiry and follow the steps to refer a patient or view referrals To find specific instructions about these transactions, refer to the User Guides listed under Customer Service If your office is not currently using NaviNet, you can enroll on-line at: or contact Customer Service at (888)

19 Paper Referral Submissions Paper Referrals Paper referral forms may be downloaded and printed from our website at or hardcopies can obtained by calling Provider Services at (800) Issue a referral form for procedures requiring referrals. When issuing a referral form, make sure the form is legible and that all the required fields are completed. There is a sample referral form on under Provider Forms. The date of service must not be prior to the date the referral was requested. A copy of the paper referral must be submitted to the First Choice VIP Care. Please refer to the referral form or to select an option for submission. Give a copy of the referral form to the member to present to the consulting specialist/hospital or other outpatient facility. 19

20 Important Information - NaviNet What is NaviNet? A web-based solution for providers and health plans to share critical administrative, financial and clinical data America s largest real-time healthcare communications network, securely linking providers nationwide through a single website Provider portal address: Informational web site NaviNet Web Portal: Phone: (888) Must be accessed via Internet Explorer v. 7.0 or above Older versions of IE may not work appropriately Not accessible via Firefox, Safari or Google Chrome 20

21 NaviNet (continued) NaviNet Functions: View Member Eligibility Member Rosters View Third Party Liability Information (TPL) Claims Status & Updates Prior Authorization HEDIS Performance On-Line Remittance Advice Care Plans Clinical Summary Care Gaps 21

22 Provider Claims and Customer Service Provider Services (800) Provider claims issue resolution Verify member eligibility Verify PCP assignments Obtain Member ID # Verify authorizations 22

23 Claims Submission and Processing First Choice VIP Care has a state of the art claims processing system and contact centers Our average time for processing clean claims is less than 30 days Bill office visits and services on a CMS-1500 form or electronically Initial claims must be submitted within 365 days from date of service (or 60 days from receipt of primary EOB) Rejected claims (claims with missing data elements) must be corrected and resubmitted as a new claim within 90 days from the date the claim was rejected. Denied claims (claims that do not meet the requirement for payment under First Choice VIP Care guidelines must be resubmitted as corrected claims within 90 days from the date the initial claim was rejected Paper claims should be sent to: First Choice VIP Care Claims P.O. Box 307 Linthicum, MD

24 Electronic Data Information (EDI) To transmit claims electronically, contact your EDI software vendor and provide the First Choice VIP Care payer ID: A37510 Arrange electronic claims submission through your EDI vendor or through Emdeon Provider Support at (877) Electronic Funds Transfer (EFT) Simplifies the payment process by providing fast, easy and secure payments Reducing paper Eliminating checks lost in the mail Not requiring a change to your preferred banking partner Enroll through our EFT partner, Emdeon Business Services or sign up via our fast and easy links on Electronic Remittance Advice (ERA) 24

25 Access to Care Access to Care First Choice VIP Care PCPs and specialists must meet standard guidelines as outlined in the provider manual to help ensure that Plan members have timely access to care Access standards must: Assure member accessibility to health care services Establish mechanisms for measuring compliance with existing standards Identify opportunities for the implementation of interventions for improving accessibility to health care services for members The following areas will be monitored by the Plan to ensure physicians access standards are continually met: Office Accessibility PCP office hours must be clearly posted and reviewed with members during the initial office visit The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services A Medicare-eligible PCP must provide the coverage to Health Plan members 25

26 Provider Appointment Scheduling Appointment Scheduling First Choice VIP Care monitors access standards on an annual basis. Specialists who are serving in the PCP role (i.e. Internal Medicine, Pediatrics, or OB/GYN) are subject to the PCP Access Standards Timely Access Standards for appointment availability for Primary Care Physicians (PCPs) and Specialists as outlined on slide 27 Missed Appointment Tracking If a member misses an appointment with a provider, the provider should document the missed appointment in the member s medical record. Providers should make at least three attempts to contact the member and determine the reason. The medical record should reflect any reasons for delays in performing the examination Medical record should include any refusals by the member 26

27 Physician Office Standards Primary Care Providers Access standards: Specialty Care Providers Access standards: Emergent Care 24X7request Immediately or referred to ER Urgent Care Within 2 calendar days Routine Care Within 14 calendar days of member s call Routine Care Within 30 business days of request 27

28 Access to Care Access to After-Hours Care Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week. PCPs must have either an answering machine or an answering service for members during afterhours for non-emergent issues. The answering service will forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes. When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office s daytime telephone number For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room. First Choice VIP Care will monitor access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours 28

29 Provider Account Executives First Choice VIP Care prides itself on having a provider representative available to providers an Account Executive Your Account Executive will provide on-site education, issue resolution, and assistance with credentialing First Choice VIP Care will communicate through on-site orientations, routine site visits, provider workshops, letters, the provider manual, the provider resource center on the web site and provider newsletters A listing of First Choice VIP Care Account Executives may be accessed via our web site at 29

30 The Provider Manual The First Choice VIP Care provider manual is on our web site at The provider manual is an extension of your provider contract with First Choice VIP Care Identifies key provider roles & responsibilities Member rights & responsibilities The Plan s Quality programs, credentialing & utilization management The Plan s Model of Care Claims protocols 30

31 Provider Marketing Compliance The Center for Medicare and Medicaid Services (CMS) is concerned with provider marketing activities for the following reasons: Providers may not be fully aware of benefits & costs and may inadvertently misinform the member Providers may confuse the member regarding their role as their health care provider versus acting as a plan representative Providers may face a conflict of interest 31

32 Acceptable Provider Marketing Practices Acceptable Provider Marketing Practices: Provide the names of Plan sponsors with which they contract and/or participate Provide information and assistance in applying for the Low Income Subsidy (LIS) Make available and/or distribute First Choice VIP Care marketing materials Refer their patients to other sources of information, such as SHIPs, plan marketing representatives, the State Medicaid Office, local Social Security Office, CMS website at or MEDICARE Share information with patients from CMS website, including the Medicare and You Handbook or Medicare Options Compare (from or other documents that were written by or previously approved by CMS 32

33 Cultural and Linguistic Requirements Our Cultural Competency program, has been built upon 14 of the national standards for Culturally and Linguistically Appropriate Services (CLAS) as set forth by the Federal Department of Health and Human Services As a provider of health care services who receives Federal financial payment through the Medicare and Medicaid programs, you are responsible to make arrangements for: Standard 4- Language assistance at no cost to patients/consumers Standard 5- Signage and written notices of interpreter services available at no cost Standard 6- Use of qualified/certified interpreters and translators Standard 7- Translation of vital documents Language assistance information should be at all points of contact and during all hours of operation 33

34 Slide 33 PJ1 Inserted a new slide, condensing the information about CLAS Powell, Julia, 10/11/2012

35 Cultural and Linguistic Requirements Providers are required to: Provide written and oral language assistance at no cost to Plan members with limited English proficiency or other special communication needs, at all points of contact and during all hours of operation. Language access includes the provision of competent language interpreters, upon request Provide members verbal or written notice (in their preferred language or format) about their right to receive free language assistance services Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents such as patient information forms and treatment consent forms, must be made available in other languages and formats 34

36 Cultural and Linguistic Services Available We have an arrangement to make our corporate rate available to participating plan providers. For more information on using this telephonic interpreter services please contact Provider Services at (800) Providers who are unable to arrange for translation services for an LEP, LLP or sensory impaired member should contact First Choice VIP Care Member Services at and a representative will help locate a professional interpreter who communicates in the member s primary language. Providers may request a full copy of First Choice VIP Care s Cultural Competency Plan free of charge, or, access this information in the Provider Manual. For additional information and to view the CLAS standards to go For language assistance services, contact us at (866) or go to 35

37 Member Rights and Responsibilities Member Rights and Responsibilities Federal law requires that health care providers and facilities recognize member rights. Members have the right to request and receive from their health care provider, a completed copy of the Patient s Bill of Rights and Responsibilities. Providers may refer to the Provider Manual for a detailed listing of the Member s Rights and Responsibilities. 36

38 Fraud Waste and Abuse Designed in accordance with federal rules and regulations, First Choice VIP Care s compliance program is aimed at ensuring compliance with all Medicare Advantage program requirements and preventing and detecting activities that constitute fraud, waste and abuse. First Choice VIP Care has developed a Compliance and Fraud, Waste and Abuse online training program. The program includes: Compliance requirements FWA policies and procedures Investigation of unusual incidents and implementation of corrective action First Choice VIP Care has provider training materials available via its website: Materials, which are available by contacting the Provider Network Management team, include information regarding the following 37

39 Fraud Waste and Abuse Fraud Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person. The term includes any act that constitutes fraud under applicable federal or state law. As applied to the federal health care programs (including the Medicaid and Medicare programs), health care fraud generally involves a person or entity s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for, items or services payable under a federal health care program. Some examples of fraud include: Billing for services not furnished; Soliciting, offering or receiving a kickback, bribe or rebate; or Violations of the physician self-referral prohibition. 38

40 Fraud Waste and Abuse Waste Waste means to use or expend carelessly, extravagantly, or to no purpose. Abuse Abuse is defined as provider practices that are inconsistent with generally accepted business or medical practice and that result in an unnecessary cost to the Medicaid or Medicare programs or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid or Medicare programs. In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicaid program. Some examples of abuse include: Charging in excess for services or supplies; Providing medically unnecessary services; or Providing services that do not meet professionally recognized standards. 39

41 Fraud Waste and Abuse False Claims Act The Federal false claims act (FCA) is a federal law that applies to fraud involving any contract or program that is federally funded, including Medicare and Medicaid. Health care entities that violate the Federal FCA can be subject to civil monetary penalties ranging from $5,000 to $10,000 for each false claim submitted to the United States government or its contactors, including state Medicaid agencies. The Federal FCA contains a qui tam or whistleblower provision to encourage individuals to report misconduct involving false claims. The qui tam provision allows any person with actual knowledge of allegedly false claims submitted to the government to file a lawsuit on behalf of the U.S. Government. The FCA protects individuals who report under the qui tam provisions from retaliation that results from filing an action under the Act, investigating a false claim, or providing testimony for or assistance in a federal FCA action. 40

42 Fraud Waste and Abuse Reporting and Preventing FWA Compliance with state and federal laws and regulations is a priority of First Choice VIP Care. If you or any entity with which you contract to provide health care services on behalf of First Choice VIP Care beneficiaries become concerned about or identifies potential fraud, waste or abuse, please contact: First Choice VIP Care toll-free at (866) ; or You may also send an to the Medicare Compliance Officer at thomas.mapp@amerihealthmercy.com to report potential FWA; or Report suspected Medicaid Provider Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities by contacting: South Carolina Attorney General s Medicaid Fraud Unit (803) OR NO-CHEAT ( ) 41

43 First Choice VIP Care The Model of Care The First Choice VIP Care Model of Care is an Integrated Care Management Approach to health care delivery and coordination for Dual Eligible (Medicare/Medicaid) individuals. The Model of Care focuses on: Improving Health Outcomes Access to Essential Services/Affordable Care Coordination of Care through the Medical Home/Primary Care Physician Access to Preventive Services Seamless Transitions 42

44 The Model of Care - Structure and Roles Each member enrolls with a Medical Home/Primary Care Physician. The model includes care and support from health care providers, community agencies and service organizations. A 26-question Health Risk Assessment (HRA) is used to collect; Physical and behavioral health history Preventive care Level of activity Medication use The assessment is mailed with the Member s welcome packet. Staff follow up with the Member by phone and mail to collect the data. Members receive an annual postcard reminding them to call the Plan and update the HRA information. 43

45 Assessment and Plan of Care Development Data from multiple sources is used to develop the Plan of Care: Review of available claim and pharmacy history Data from the Health Risk Assessment Input from the member, Primary Care Physician and other providers 44

46 Interdisciplinary Care Team Each member has an interdisciplinary care team that address the member s unique needs: Primary Care Physician/Medical Home Specialists Physical & Behavioral Health Plan nurses, Medical Directors, & pharmacists, Home Health Care Social Workers Community Mental Health Workers Physical Therapy, Speech & Occupational Therapy 45

47 The PCP/Medical Home The PCP/Medical Home has an important role in the Interdisciplinary Team. Key Responsibilities include: Assisting members to determine which services are necessary Connecting members to appropriate service Serving as a central communication point for the member s care Review the Plan of Care sent by the Health Plan Providing feedback to the Health Plan 46

48 Updates to the Plan of Care Updates are made routinely to the Plan of Care and come from multiple sources: Member or Provider call Updated HRA (annual) Care Transition (hospital, nursing home) Claim, Pharmacy or Utilization trigger Care episode 47

49 Identifying Vulnerable Sub Populations The Plan uses several mechanisms to identify vulnerable sub-populations: Claim data is analyzed to identify members with: Conditions targeted for chronic care improvement, such as diabetes, heart disease, COPD and renal disease Health needs, such as missing preventive care or recommended condition monitoring Utilization of emergency room and inpatient services is reviewed to identify members with opportunities for improved outpatient management Predictive Risk Scores are calculated using the DxCG methodology to identify members who are at risk for future avoidable health care episodes Health Risk Assessment data is reviewed for triggers identifying unmet health needs or the presence of chronic conditions 48

50 Chronic Condition Improvement Programs The Plan offers several Chronic Care Improvement Programs: Diabetes Asthma Chronic Obstructive Pulmonary Disease Depression Members may self refer, be referred by a provider, or are identified through claim data analysis 49

51 Clinical Practice Guidelines The Plan s Clinical Practice Guidelines are: Adopted from nationally-recognized organizations Serve as a guide to practitioners, but do not replace clinical judgment Available on the Plan s website; hard-copy available from Provider Services upon request Guideline Topics: Diabetes Anxiety Disorder in Adults COPD Preventive Health Services Depression Coronary Vascular Disease Hypertension Immunization Schedules 50

52 Provider Focus on Preventive Services Remember, Medicare members have an annual preventive physical examination. During each office visit please remember to: Coach the member on appropriate physical activity Ask about falls and fall prevention Ask and coach on smoking cessation List all relevant diagnoses on the claim Check to see if the member needs: Cancer Screening Mammography or Colonoscopy Glaucoma Testing Flu or Pneumonia vaccine 51

53 High Risk Medication in the Elderly Providers, please carefully evaluate alternatives prior to starting an elderly member on the following medications: Antihistamines (promethazine, cyproheptadine, diphenhydramine, hydroxyzine) Skeletal Muscle Relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone) Oral estrogens CNS Stimulants (amphetamines, anorexiants, methylphenidate) Urinary Anti-infectives (nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin macrocrystalsmonohydrate Narcotics (pentazocine, meperidine) Others (dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines, barbiturates) 52

54 Focus on Health Outcomes The Plan s goals include improving health outcomes for: Diabetes Care HgbA1 and LDL testing/management Diabetic retinal exam Nephropathy screening Blood pressure control Cardiac Care LDL testing/management Beta-blocker treatment after heart attack Blood Pressure Control COPD Management Systemic corticosteroids and bronchodilator therapy for exacerbations Decreasing the use of high-risk drugs 53

55 Focus on Seamless Transition Everyone plays a role ensuring seamless transition: Health Plan Staff Notify PCP/Medical Home of planned or unplanned transition for admission and at discharge Contact members to verify plans, establish point of contact Provide Plan of Care information to sending and receiving facility/provider, including changes at discharge PCP Contact admitting physician to coordinate care After discharge, review and reconcile medications See the member at office visit post discharge Hospital Send discharge summary/orders with medication list to Plan Admitting Physician be available to speak with the Medical Home/PCP regarding member s care needs 54

56 Model of Care Evolution The Plan s Model of Care is evaluated using several data sources: Claims (medical, behavioral health, pharmacy) Authorizations HEDIS reports Member surveys (CAHPS, HOS) Practitioner and Facility surveys Provider workshops Complaint and grievance analysis 55

57 Communicating the Plan of Care on Transition The Transition Team collects and communicates information related to a member s transition from one health care setting to another: Transition Team With Member & Provider Input Sends Updated Plan of Care Medical Home/PCP Hospital/Facility/Agency Receiving the Member 56

58 Communication Updates and outcomes are communicated through several methods: The Plan s website Quality and Satisfaction Updates Member News Bulletin Provider News Bulletin Provider Workshops presentations are interactive via the website, face-toface workshop presentations and provider site visits. All communications are available hard copy or via the Plan s website at 57

59 Questions For additional questions, please contact your Provider Account Executive at (800)

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