August SutterSelect Administrative Manual

Transcription

1 August 2014 SutterSelect Administrative Manual

2 Introduction This SutterSelect Administrative Manual has been prepared as a resource for providers who are caring for members of SutterSelect health plans. The Manual includes information about requesting prior certification, how to submit claims, and a guide to using the SutterSelect Provider website. Please refer to the Table of Contents for a complete listing of the sections enclosed in this Manual. This Manual may be updated as needed. Visit our website at for the most up-to-date information. We hope that you find this Manual to be a valuable tool and thank you for helping to deliver quality health care to our members. SutterSelect Administrative Manual i

3 Table of Contents Introduction i Table of Contents ii Background 1 SutterSelect Products...1 SutterSelect Provider Network...1 About UMR...1 Plan Design and Options 2 EPO or EPO Plus Option...2 PPO Option...2 Eligibility 3 Member ID Cards...3 Prior Certification 4 UMR Care Management Certification Requests...4 Referrals to Specialists...4 Responsibility and Member Penalty...4 Prior Certification Request Form... 5 Pharmacy 12 Preferred Product List (PPL)...12 Medication Reviews...12 Prior Authorization...12 Pharmacy Network...12 Mail Order Pharmacy...12 Behavioral Health 13 Contact Information...13 Emergency Care...13 Online Benefits and Claim Inquiry 14 Home Page Provider Login...15 Reset Password...15 Navigating the Website...16 Provider Directories 17 SutterSelect EPO, EPO Plus and PPO Tier 1 Provider Information...17 Quick Reference List 18 Clinical Management 6 Contact Information...6 Utilization Management...6 Case Management...6 Disease Management...7 Nurse Advice Line...7 Claims 8 Claims Submission Guidelines...8 Claims Inquiries...9 Claims Submission Address...9 Timely Filing...9 Coordination of Benefits...9 Subrogation...9 Provider Remittance Advice...10 RA Field Explanations...11 SutterSelect Administrative Manual ii

4 Background SutterSelect is Sutter Health s self-funded medical plan, developed to take the place of an outside insurance company. Self-funding allows Sutter Health affiliates to deliver consistent medical plan coverage from year to year through a stable, predictable medical plan. In turn, affiliates can design benefit plans, wellness programs and more with employees and their families in mind. SutterSelect Products SutterSelect manages EPO and PPO self-funded medical plans for its customers. Product descriptions are detailed in the Plan Design section on page 2. SutterSelect Provider Network The SutterSelect provider network includes more than 8,000 physicians, and is comprised predominately of Sutter Health providers. Additionally, the PPO plan offers in-network providers from the broader HealthSmart Preferred (formerly known as Interplan Health Group) network inside of California or the PHCS Healthy Directions network outside of California. About UMR Sutter Health has partnered with UMR to administer the plan. UMR is the largest employee benefits third-party administrator in the United States and is fully compliant with HIPAA requirements for health data security. The organization serves more than 1,400 clients and more than 2 million plan members, processing over 65 million claims each year. UMR is a subsidiary of UnitedHealthcare, a UnitedHealth Group company. Pharmacy benefits management is provided through UMR s service organization, OptumRx. The OptumRx pharmacy network includes a national network of more than 67,000 community pharmacies and also offers a mail order prescription service. UMR is the primary contact for provider and member information and assistance with SutterSelect. The illustration on the following page provides information about the SutterSelect medical plan options. SutterSelect Administrative Manual 1

5 Plan Design and Options Plan Design EPO or EPO Plus Option In-network benefits only. No coverage for out-of-network services, except emergencies. PPO Option In-network and out-of-network benefits through three coverage tiers. Out-of-pocket costs depend on which tier (and provider network) accessed. Able to choose a different tier each time care is needed. Primary Care Physician Designation No Primary Care Physician requirement.* See any network provider for office visits, including specialists. No Primary Care Physician requirement. See any network provider for office visits, including specialists. Network Uses the SutterSelect network, comprised predominantly of Sutter Health providers. Network access depends on tier. Choices include SutterSelect network, comprised predominantly of Sutter Health providers (Tier 1), or a broader network (Tier 2) and out-of-network (Tier 3), which is not available for all plans. Costs The lower cost medical option in terms of monthly premium costs and out-ofpockets costs. Higher premium cost option due to flexibility in choosing providers. Outof-pocket expenses are higher under Tiers 2 or 3. *The Sutter Health Central Valley and Sacramento Sierra Region EPO plan options have a primary care physician requirement. SutterSelect Administrative Manual 2

6 Eligibility It is important to verify eligibility prior to rendering services. Eligibility rules vary by plan and employer. Eligibility can be verified by two methods: Telephone: Call SutterSelect Customer Service at Provider service representatives are available from 7:00 a.m. 6:00 p.m. Pacific Time, Monday Friday. Online: The website provides access to eligibility information 24 hours a day, seven days a week. Member ID Cards Important key information and resources are highlighted on the below sample identification card. Cards may differ slightly between plans or plan options. Front of ID Card Plan name (benefits and coverage may vary between SutterSelect plans) Plan option Member s ID card will list copay amounts for their plan option UMR is the SutterSelect third party administrator Back of ID Card Call UMR Care Management for prior certification Claims submission information EDI # UMR, PO Box Salt Lake City, UT Provider Customer Service Eligibility and claims Provider network directory General inquiries SutterSelect Administrative Manual 3

7 Prior Certification To obtain a prior certification determination, call the telephone number listed on the back of the member s ID card. A list of services requiring prior certification is available in the member s Health Plan Summary Plan Description (SPD). The SPD for a member can be viewed online by logging on to the provider website at Most plans utilize the SutterSelect standard list of services which require prior certification; however, a few Plans utilize a custom version. Please call SutterSelect Customer Service at or logon to for details. Emergency services may be authorized or certified after care is delivered. Most service requests will require submission of medical records to establish medical necessity. Requests are also reviewed to assure they meet benefit criteria as defined by the Plan. UMR Care Management Certification Requests Telephone: Call the number on the back of the member identification card to request certification prior to the scheduled procedure or service, in order to allow for fact gathering and independent medical review, if necessary. Hours of operation: 7:00 a.m. 6:00 p.m. Pacific Time, Monday Friday. Fax: Complete the request form (a sample of the form is on the next page) and fax with pertinent medical records to Online: An online request form can be completed at From the MyMenu tab on the left side of the screen select Get preauthorization to begin the online process. Request Response UMR Care Management will contact your office via telephone or letter with the certification number, if approved. If more information is needed, you will be contacted for requested records needed to make the medical necessity determination. If the request is denied, you and the member will receive a written notice, including appeal rights and process. Request turnaround time frames: o Concurrent Urgent 24 hours o Pre-service Non-urgent 15 days o Pre-service Urgent 72 hours o Post-service 30 days Referrals to Specialists Most SutterSelect plans offer the ability for members to see any provider within the network, including specialists, without a referral. Refer to the member ID card to determine if the member s plan has a Primary Care Physician (PCP) designation, in which case specialty care must be coordinated through the PCP listed on the card. Responsibility and Member Penalty Providers need to submit requests for prior certification on behalf of members. Failure to obtain prior certification will result in a financial penalty for the member. This penalty does not apply to emergency services. Emergency service is any otherwise covered service that a prudent layperson with an average knowledge of health and medicine would seek if he/she was having serious symptoms and believed that without immediate treatment his/ her health would be put in serious danger, his/her bodily functions, organs or part would become seriously damaged or would seriously malfunction. SutterSelect Administrative Manual 4

8 prior certification request Requesting Provider Information Provider Name Tax ID Number Provider Specialty Address Patient Information Patient Name Date of Birth Address City, State & Zip City, State & Zip Phone # Contact Name Member ID # Phone # Fax # Group # diagnosis Current Diagnosis ICD-9 Code(s) Comments Complete the applicable section below. office services Referred to Provider Name Number of Visits Requested Inpatient or outpatient services Facility Name Facility TIN (Optional) Address Phone # City, State & Zip Fax # Date of Procedure Procedure Estimated Length of Stay (Inpatient Only) CPT Code(s) other services Referred to Provider Name Type of Service Code(s) Number/Frequency of Services Comments Medical documentation is required. Please fax completed form to SutterSelect Administrative Manual 5

9 Clinical Management SutterSelect contracts with UMR Care Management, to provide telephonic clinical management programs. There is no fee to patients or providers for these programs. Clinical Management services include: Utilization Management Case Management Disease Management* Health Information Independent Medical Review Contact Information Telephone: Call , 5:30 a.m. 7:00 p.m. Pacific Time, Monday Friday Utilization Management Prior Certification Review The prior certification review process is outlined in the Prior Certification section on page 4. Concurrent Review Concurrent review provides review of medical necessity and level of care for members while they are accessing services in the hospital inpatient, acute rehabilitation, skilled nursing facility or home health setting. Independent Medical Review (IMR) IMR provides clinical review and determinations for medical necessity by independent clinical reviewers. IMR also manages the appeals process and investigational treatment requests. Case Management Case Management provides authorization, discharge planning and care coordination for complex and high dollar cases including organ/tissue transplants and high risk neonates. Care and benefits are coordinated across the continuum of care. * Disease management services are provided by Sutter Care Management for the Sutter Health Central Valley and Sacramento Sierra Regions and Sutter Health Support Services Plans. Call , 9:00 a.m. 4:30 p.m. Pacific Time, Monday Friday or [email protected] for information. SutterSelect Administrative Manual 6

10 Clinical Management Disease Management Patients are invited to enroll in disease management programs based on claims data. Disease management case managers provide telephonic and written education and self-management tools to patients with chronic disease including: Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes Depression Hypertension Disease management services for the Sutter Health Central Valley and Sacramento Sierra Regions and Sutter Health Plans are provided by Sutter Care Management. Call , 9:00 a.m. 4:30 p.m. Pacific Time, Monday Friday or for information. Nurse Advice Line NurseLine SM is an advice line for members to speak to a registered nurse regarding medical questions, information, education and health-related concerns. It can be accessed 24 hours a day, seven days a week by calling SutterSelect Administrative Manual 7

11 Claims Providers are encouraged to submit claims via electronic claims submission. UMR s EDI Claim Payer ID Number is If you wish to obtain more information about electronic claims submission, please call UMR at Claims Submission Guidelines All paper claims should be submitted on a standard HCFA/CMS 1500 form or UB, as applicable, and contain the following information: UB Forms Provider Name, Address and Telephone Number Patient Control Number Type of Bill Federal Tax ID Number Statement Covers Period Patient s Name Patient s Address Patient s Birth Date Patient s Gender Patient s Marital Status Admission Date/Start of Care Admission Hour Type of Admission Discharge Hour Occurrence Span Code and Dates Revenue Code Revenue/HCPC/CPT Description HCPCS Rates Service Date Service Units Total Charges Non-Covered Charges Payer Identification Provider Number Release of Information Assignments of Benefits Cert. Information Prior Payments Insured s Name Patient s Relationship to Insured Group Name Insurance Group Number Employment Status Code Principal Diagnosis Code Admitting Diagnosis Principal Procedure Code and Date Attending/Referring Physician NPI Provider Representative Signature Date HCFA/CMS 1500 Forms Patient s full name (as printed on Health Plan ID card) Patient s date of birth Policyholder/subscriber, Insurance Name and ID # (include any suffix numbers shown on the card to assist with dependent coverage verification) Diagnosis (ICD-9-CM code is required) Date(s) of service CPT-4 procedure codes with description and modifier, if applicable Name should be shown of PA, FNP, rendering provider Referring physician s name, if applicable NPI Federal Tax ID Number Information on other insurance coverage Prior certification number, if applicable Signature of provider rendering service SutterSelect Administrative Manual 8

12 Claims Claims Inquiries Claims inquiries should be directed to SutterSelect s Customer Service Line at Claims Submission Address UMR PO BOX SALT LAKE CITY UT Timely Filing Complete claims are to be submitted to the third-party administrator, UMR, as soon as possible after services are received, but no later than six months from the date of service. A complete claim means that the Plan has all information that is necessary to process the claim. Claims received after the timely filing period has expired will not be considered for payment. Coordination of Benefits Coordination of benefits (COB) applies whenever a member has health coverage under more than one plan. The purpose of coordinating benefits is to pay for covered expenses, but not to result in total benefits that are greater than the covered expenses incurred. The order of benefit determination rules determine which plan will pay first (primary plan). The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays for covered expenses after the primary plan has processed the claim, and will reduce the benefits it pays so that the total payment between the primary plan and secondary plan does not exceed the covered expenses incurred. Up to 100 percent of charges incurred may be paid between both plans. Subrogation Claims identified as possibly accident related may pend for additional information. When these claims are identified, a questionnaire is generated to the member asking if they received treatment for an injury or illness that may be accident related. The member must complete and return the questionnaire by mail or fax. The member can also respond to the inquiry by calling SutterSelect Customer Service or online at If there is an indication that the claim was for an illness or injury that was not caused by another person or party, the claim(s) will be reprocessed. If there is an indication that the claim was for an illness or injury that was caused by another person or party UMR will reprocess the claim(s) and pursue the plan s right of reimbursement of the medical bills paid by the plan. Failure by the member to return the completed questionnaire will result in denial of the claim(s). SutterSelect Administrative Manual 9

13 Claims Provider Remittance Advice UMR produces weekly check runs. Provider Remittance Advices (RA) and member Explanations of Benefits (EOB) are an integral part of finalization of the patient/physician experience. To help familiarize you with the Remittance Advice that your office will receive, below is a key to explain each field in detail. Claim specific details are also available to you by logging on to SutterSelect Administrative Manual 10

14 Claims RA Field Explanations 1. Remittance Advice for Period Ending: Last day of the week for the period covering claims listed on this particular remittance advice. 2. Identifying Plan Header: Header that identifies organizational plan that patients are associated with. Header includes name, address and return telephone number. 3. Plan Name: The plan name that patients are associated with. 4. Employer Name: The company name the patients are associated with. 5. Provider Name and Address: The provider s name and address. 6. Federal Tax ID No.: The provider s federal tax ID number. 7. Dates From/To: Displays the first date of service through the last date of service for the services performed. 8. Service Code: CPT/HCPCS procedure code. (Hospital charges display as ) 9. Charged Amount: Total amount charged per service. (Hospital per diem charges will display on one line with one total charge amount.) 10. Allowed Amount: Total amount of charge considered for payment. 11. Deductible: The portion of the charge applied to the patient s deductible, if applicable. 12. Co-pay: The portion of the charge applied to the patient s co-pay, if applicable. 13. Coinsurance: The portion of the charges applied to the patient s coinsurance, if applicable. 14. Discount Managed Care Adjust: Includes the amount of the provider s negotiated discount and the amount not allowed per contracted fees. (Difference between the actual charge amount and the contracted allowable amount.) 15. Ineligible: Amount not allowed due to plan provisions. 16. Withheld: The portion of the approved charge that is withheld based upon negotiated rates. 17. OC: Number of occurrences per line of service. 18. ANSI Code: American Standard Institute (ANSI) code provides reason why charges are not allowed. 19. Paid: Amount paid to provider per line of service. (This amount may differ from amounts paid on EOB due to withhold amounts.) 20. Patient Responsibility: Amount the patient is responsible for paying per line of service. 21. Employee: The employee s name. (Last name, first name, middle initial.) 22. Patient: The patient s name. (Last name, first name, middle initial.) 23. Cert No.: The employee s health plan identification number. 24. Account Number: The patient s account number, submitted by the provider of service. 25. Claim Number: The internal claim control number. 26. Total: Total amounts per column. 27. The Primary Insurance Paid: If applicable, displays the total amount the patient s primary insurance paid on the claim. 28. Subtotal: Subtotals for columns if pages follow. 29. Provider Total: Total combined amounts for each provider, displayed on final page. 30. CP Number: Banking source code (specific to each customer). 31. Internal Number: Ten-digit internal sequence number matching remittance advice to the appropriate payment check. 32. Plan Administrator Website Address SutterSelect Administrative Manual 11

15 Pharmacy OptumRx is the prescription benefits administrator for SutterSelect plan members. If you have questions or need assistance getting prescriptions for members, you can contact OptumRx customer service, 24 hours a day, seven days a week via: Telephone: Call the OptumRx customer service center at Online: o Click the Enter Website link. Preferred Product List (PPL) SutterSelect uses a Preferred Product List (PPL) instead of a formulary. The PPL is updated twice per year. To find out what drugs are on the PPL, contact OptumRx via telephone or check the SutterSelect provider website at and click the OptumRx Preferred Product List link under the MyTools tab. Medication Reviews The physicians and pharmacists who serve on the OptumRx Pharmacy & Therapeutics (P&T) Committee are responsible for reviewing all new medications as they come to market. With each agent, they consider whether a medication should be covered under the prescription benefit. In addition, they may recommend quantity limits and prior authorization to ensure appropriate use. When making a recommendation, the P&T Committee focuses on the medication s overall health benefit as well as the cost. The P&T Committee will consider FDA recommendations, manufacturer package labeling instructions, and published clinical recommendations, such as the Journal of the American Medical Association (JAMA). Prior Authorization Contact the OptumRx prior authorization department at to begin the prior authorization process. Pharmacy Network The OptumRx pharmacy network includes more than 64,000 retail pharmacies nationwide. For specific information call the customer service center or use the pharmacy finder link on the website. Telephone: Call the OptumRx customer service center at Online: o Click the Enter Website link. Mail Order Pharmacy* The Mail Order Program allows a member s prescription products to be ordered through the mail service pharmacy. Using mail order offers plan members the advantage of obtaining up to a 90-day supply of prescription products. * The Sutter Health Central Valley Region SutterSelect mail order pharmacy program is administered through the Memorial Medical Center Outpatient Pharmacy. SutterSelect Administrative Manual 12

16 Behavioral Health Optum (formerly known as United Behavioral Health) administers the Mental Health, Substance Abuse and Chemical Dependency benefits for all SutterSelect plans. Peninsula Coastal Region SutterSelect plan members have a second choice for Mental Health, Substance Abuse and Chemical Dependency benefits through the SutterSelect Behavioral Health network of providers. Call for authorization before providing inpatient or outpatient mental health or substance abuse services. Contact Information for Optum Telephone: Call Optum customer service at , 24 hours a day, seven days a week. Contact Information for SutterSelect Behavioral Health (Peninsula Coastal Region Plan members only) Telephone: Call SutterSelect Behavioral Health at , 24 hours a day, seven days a week. Emergency Care If the member needs emergency services, you do not need to obtain prior authorization from the behavioral health carrier prior to providing emergency care. However, you must notify the carrier within 24 hours and once emergency care has ended, call the carrier to get authorization to provide any additional services. SutterSelect Administrative Manual 13

17 Online Benefits and Claim Inquiry Access information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week by going to Logging on to this website provides you and your office the following: Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to whom payment was made. Eligibility and benefits information, including patient specific plan information, claim submission details, prior certification requirements and member benefit levels. Contact phone numbers and an notification form to contact a member of the UMR team with your questions. If you have questions or problems related to the website, please contact the UMR technical support team at Home Page Click: Provider SutterSelect Administrative Manual 14

18 Online Benefits and Claim Inquiry Provider Login If you do not already have a username and logon, click New user? Register here. to complete the registration process using your name and password. Reset Password Should you forget your password, you can select the Forgot username or password? option to change it. SutterSelect Administrative Manual 15

19 Online Benefits and Claim Inquiry Navigating the Website You can view an online video tutorial to learn about site navigation and available features. SutterSelect Administrative Manual 16

20 Provider Directories Which Network a provider belongs to will determine how much a member will need to pay for certain services. To obtain the highest level of benefits under this Plan, members need to see an in-network provider, however SutterSelect does not limit a member s right to choose his or her own provider or medical care. If a medical expense is not a Covered Expense under the medical benefit plan, or is subject to a limitation or exclusion, a member still has the right and privilege to receive such medical service at his or her own personal expense. To find out which network a provider belongs to, please refer to the Provider Directory or call the toll free number that is listed on the back of the member s identification card. The participation status of providers may change from time to time. SutterSelect EPO, EPO Plus and PPO Tier 1 Provider Information Telephone: Call the SutterSelect Customer Service Line at Online: Available at Providers must login to view the information. To find a mental health provider in the Optum network, go to and enter the access code healthy. SutterSelect Administrative Manual 17

21 Quick Reference List SutterSelect Eligibility Verification Customer Service 7:00 a.m. 6:00 p.m. PST Benefit Inquiries (Providers) Monday Friday Claim Inquiries Prior Certification Provider Appeals Pharmacy Information Website Benefit Inquiries Claim Status Eligibility Verification Provider Directories Claim Submission UMR EDI Claim Payer ID: PO Box Salt Lake City, UT Care Management Utilization Review/Prior Certification SutterSelect Customer Service (Members) or SutterSelect Administrative Manual 18