Virginia Premier Health Plan
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- Randolf Rodgers
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1 Medicaid Managed Care Virginia Premier Health Plan 2012 Virginia Commonwealth University Health System Health Plan Division 1
2 Why Virginia Premier? Why Virginia Premier? About Us Virginia Commonwealth University Health System Health Plan Division 2
3 VCU Medical Center & Virginia Premier VCU Medical Center Academic medical center in Central Virginia Referral center for Mid-Atlantic States 32,500 admissions and 500,000 outpatient visits MCV Hospitals Teaching hospital of the VCU Health System 779 licensed beds 20.5% share of the Richmond inpatient market 80,000 patients treated annually in hospital s emergency department-region's only Level I Trauma Center Children s Hospital of Richmond Pediatric specialty hospital 60 licensed beds MCV Physicians 566-physician, faculty group practice Virginia Premier Health Plan (VPHP) Medicaid Health Plan-since 1995 Virginia Commonwealth University Health System Health Plan Division 3
4 Virginia Premier s Service Area Non-Service Area Western Fredericksburg Far Southwest Area Central VA Roanoke Danville/Lynchburg Tidewater VA Premier currently has the largest Medicaid Service Area of all health plans With offices in Abingdon, Richlands, Wise, Roanoke, Harrisonburg, Virginia Beach, and Richmond, we believe in hiring locally and supporting the community with employment opportunities Virginia Commonwealth University Health System Health Plan Division 4
5 What does this mean for my patients? Member Benefits & Eligibility Virginia Commonwealth University Health System Health Plan Division 5
6 Member Benefits Include Benefits Physician visits well and sick Hospital services Emergency care Laboratory services Prescription drugs Family planning services X-ray/imaging Mental health services Home health services Rides to medical appointments Maternity and high risk pregnancy care Newborn care Immunizations (shots) for children Physical, occupational, and speech therapies Routine eye exams & glasses for children Routine eye exams for adults Programs targeted for: Pregnancy Heart condition High blood pressure Asthma or other breathing problems Mental health Diabetes Case management Virginia Commonwealth University Health System Health Plan Division 6
7 Ancillary Services Labs Radiology Vision Dental VPHP maintains a list of approved labs that may be performed in the physician s office. All other lab test(s) must be performed by LabCorp Synergy or by Solstas Labs. Lab procedures performed in the office must be performed in accordance with your CLIA certification level. Providers may bill one draw fee per patient. NIA will provide utilization management services for outpatient CT, CTA, CCTA, MRI, MRA, PET Scan, and Nuclear Cardiology imaging procedures. You may obtain prior authorization through the NIA Web site at or by calling NIA at Routine eye exams and eyeglasses are covered through Vision Service Plan (VSP). Members may self-refer for routine vision services to a participating VSP optometrist without obtaining a referral from their PCP. Dental services for children are provided by the DMAS Smiles for Children program. Adult dental services are limited to medically necessary oral surgery and associated diagnostic services such as x- rays and surgical extractions. Virginia Commonwealth University Health System Health Plan Division 7
8 Member Services Department For Members and Providers: Toll free number Hours of Operation: 8 am to 5 pm, Monday-Friday Offer Spanish/Bilingual reps Assist providers and members with the following types of issues: PCP Selection and Provider Participation Eligibility Verification Transportation Scheduling Member Orientation and Education Member address changes and ID card Request Virginia Commonwealth University Health System Health Plan Division 8
9 Verifying Member Eligibility Member eligibility must be verified monthly (a list of assigned members will be sent to you monthly) and prior to rendering services. Virginia Premier provides four convenient methods to verify member eligibility: 1. DMAS Automated Voice Response System - recommended 2. Interactive Voice Response System (IVR) 3. NaviNet a free web based program that allows providers to view member eligibility, claim status and authorizations 4. Call VPHP Member Operations Virginia Commonwealth University Health System Health Plan Division 9
10 Member ID Cards Medallion II/FAMIS Plus FAMIS FAMIS Moms Virginia Commonwealth University Health System Health Plan Division 10
11 Transportation VPHP provides non-emergency transportation to members who do not have readily available transportation. VPHP operates a fleet of vans used to transport members with offices located in Abingdon, Richlands and Norton hour prior notification is required to schedule transportation. 2. Must be a VPHP member with valid ID card. 3. Appointments are scheduled based upon availability of service. 4. Non-emergent transportation is not a covered service for FAMIS recipients. 5. Non- Emergency Ambulance transportation is arranged through Virginia Premier s Member Services, call Press 2, 8am - 5pm, M-F. Virginia Commonwealth University Health System Health Plan Division 11
12 What does this mean for my practice? Provider Benefits & Services Virginia Commonwealth University Health System Health Plan Division 12
13 Provider Benefits An expanded team of healthcare professionals working with you to meet your patient s needs Outreach Transportation Health Educators Case Managers Disease Managers PCP s have the potential to see growth as new members are assigned to their panels. Greater access to your patients information across the healthcare continuum. Virginia Commonwealth University Health System Health Plan Division 13
14 VPHP Provider Services Dedicated Provider Services Representatives located in our Abingdon office conduct regular site visits to network providers and act as a liaison between the provider and Virginia Premier. They assist providers with issues, answer questions and conduct educational in-services, as needed. Conduct quarterly educational meetings between VPHP and Participating Providers. Quarterly Newsletters to Providers. VPHP s convenient self service applications such as Navinet and IVR allow providers to check claims, eligibility and authorizations when it s convenient for them. VPHP has three local offices located in Abingdon, Richlands and Wise. This allows us to interact with our providers and members and develop business relationships within these communities. Virginia Commonwealth University Health System Health Plan Division 14
15 Provider Service Representatives Abingdon: Felicia Campbell (276) Virginia Commonwealth University Health System Health Plan Division 15
16 What does this mean for my practice? Claims Virginia Commonwealth University Health System Health Plan Division 16
17 Claims Department 1. Claims are processed within Virginia. 2. On average, 99% of claims are processed within 30 days of receipt (Medicaid standard is 90%) with a total overall accuracy of 99.8%. 3. VPHP strongly encourages providers to consider filing claims electronically which will assure claims are submitted timely, reduces timely filing denials, and reduces claims administrative costs. A complete listing of all EDI Clearinghouses that VPHP accepts can be found at the VPHP website at 4. Providers may receive payments and remits electronically. In order to receive EFT from VPHP visit our website, click on Claims and select the Forms tab to download the EFT forms. To receive ERA s please contact your clearinghouse directly. Virginia Commonwealth University Health System Health Plan Division 17
18 Claims Customer Service 1. Please contact the Claims customer service department if you have claims issues, however, if you have issues that are not resolved to your satisfaction please then contact your local Provider Service Representative. To reach the Claims Customer Service Department call: , Option Claims Customer Service can assist with questions related to claims, such as: a. verify claim status b. researching claims issues and denials 3. Claim status and claim line detail can also be viewed on Navinet, 24/7 and is free of charge. Virginia Commonwealth University Health System Health Plan Division 18
19 What does this mean for my practice? Medical Management Virginia Commonwealth University Health System Health Plan Division 19
20 Emergency Services 1. In the case of sudden onset of an unexpected medical condition and time permits, VPHP members are instructed to contact their PCP for medical advice. If the member is unable to reach their PCP or the situation arises after business hours, members are instructed to call the Nurse Advice Line at The PCP or Nurse Advice Line will assess the member s medical condition and instruct the member on obtaining appropriate medical care. 2. Members may also be directed to participating Urgent Care Centers for treatment of non-life threatening emergencies. Virginia Commonwealth University Health System Health Plan Division 20
21 Referrals & Pre-Authorization Referrals 1. VPHP does not require referrals to participating (in-network) specialist for its members enrolled with our Medallion II and FAMIS plans. 2. Members are required to visit participating providers for care and services. Referrals to non-participating specialists are permitted only if the required specialist is not available through the Virginia Premier network and the service is pre-authorized by VPHP. 3. Please utilize one of the following options to obtain an out of network authorization/referral. Navinet VPHP Medical Management (888) Pre-Authorizations 1. VPHP requires providers to obtain pre-authorizations from the health plan for certain services, procedures and all hospital admissions. 2. VPHP maintains a list of OP procedures that do NOT require pre-authorization. The list can be found at located under Medical Management and Utilization Management To obtain an out of network authorization/referral or a pre-authorization select one of the following: a. Enter the request online through Navinet at b. Fax an IP/OP Auth Form to VPHP which can be found at c. Call VPHP (888) and select the option for Medical Management. Virginia Commonwealth University Health System Health Plan Division 21
22 Integrated Case Management Program Disease Management (Population Health) 1 Disease Management Chronic Care Assessment & education Quarterly contact Level 1 Intake Assessment -no Care Plan (CP) Care Coordination 1-3 contacts 2 3 Level 2 Assessment & updates to CP Monthly contact Level 3 Intensive CM Assessment & freq. updates to CP Weekly contact until sustained improvement Virginia Commonwealth University Health System Health Plan Division 22
23 Healthy Heartbeats is VPHP s prenatal care program that includes pregnant members from conception through birth. Awarded Best Practice, their goal is: To improve health outcomes of mothers and infants by: Creating a partnership between the member, Obstetrician, and Virginia Premier Decreasing low birth weight and premature infants born into the plan Increasing early and consistent prenatal care Improving nutritional status of mothers and infants Increasing knowledge of the importance of prenatal care Virginia Commonwealth University Health System Health Plan Division 23
24 Program Components Prenatal Doctor Visits Prenatal Classes Special Teen Classes WIC Enrollment Home and Outreach Visits Case Management Incentive Awards Virginia Commonwealth University Health System Health Plan Division 24
25 What does this mean for my practice? Pharmacy Information Virginia Commonwealth University Health System Health Plan Division 25
26 Summary Virginia Commonwealth University Health System Health Plan Division 26
27 Summary 15 years of experience in Virginia VPHP is owned by a center that treats patients like yours, so we understand your challenges It is our goal to make your work easier and become your preferred Health Plan We recognize the community-wide benefits of promoting healthy living for members We look forward to partnering with you! Virginia Commonwealth University Health System Health Plan Division 27
28 Before Questions: A Word of Thanks We recognize you are providing a needed service to your community, and we sincerely appreciate what you do. Virginia Commonwealth University Health System Health Plan Division 28
29 Claims Policies 1. Timely Filing: Participating providers are required to submit their claims to VPHP within the timeframe established in their provider contract. 2. Claim Appeals: Appeals for denied claims must be submitted to VPHP within 60 days of the original date of the denial. Should a claims processing error be attributable to Virginia Premier, providers have up to 365 days after receipt of payment to appeal. 3. Claim Forms: Provider, ancillary and out patient services should be submitted to VPHP on the CMS Hospital and facility claims should be submitted to VPHP on the UB04 form. Providers must use original claim forms. 4. Pre-Authorization: For services that required an authorization that number should be submitted to VPHP in Box 23 if the CMS-1500 form. 5. Coding: Providers should always refer to the most current versions of the CPT and ICD9 coding manuals when billing services. Virginia Commonwealth University Health System Health Plan Division 29
30 Covered OTC Medications* Generic oral analgesics for pain relief Generic oral antipyretics for fever control Generic ferrous sulfate Generic antacids Generic antidiarrheals Generic antifungals (topical and vaginal) Generic scabicides and Pediculicides Generic Calcium Supplements Generic cough and cold products Generic antihistamines Generic antihistamine/decongestants Generic anti-ulcer Generic laxatives Generic prenatal vitamins Generic topical corticosteroids Generic vitamins & minerals Generic nicotine replacement therapy Insulin Insulin syringes Blood Glucose Diagnostics Glucometers Urines tests *OTC benefits are only available to Medallion II/FAMIS Plus members only. OTC medications must be written on a physicians RX pad in order to be covered. Virginia Commonwealth University Health System Health Plan Division 30
31 Questions Virginia Commonwealth University Health System Health Plan Division 31
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