2010 Specialty Care Physicians Teleconference. Miami-Dade County Authorization Requirements

Transcription

1 2010 Specialty Care Physicians Teleconference Miami-Dade County Authorization Requirements

2 Accessing Specialist Power Point Select Tools & Resources Select Welcome Kit for New Physicians and Providers Select Florida Medicare Go to Miami Dade County Authorization box Double click on Specialist Teleconference power point 2

3 Accessing Specialist Power Point

4 Agenda Welcome Introductions Products in Miami-Dade County AARP MedicareComplete Plan 1 Referral/Authorization Requirements & Process UnitedHealthcare On Line Questions & Answers 4

5 Products In Miami-Dade County AARP MedicareComplete Plan 1 AARP MedicareComplete Plus Plan AARP MedicareComplete Choice Plan 2 and AARP MedicareComplete Choice Plan Essential 5

6 Miami-Dade County Products AARP/SecureHorizons Products Miami Dade County, Broward and Palm Beach Counties AARP MedicareComplete Plan 1 HMO- gatekeeper, referrals/auths required from an MSO Group Service Area: Miami Dade AARP MedicareComplete Plus Plan HMO/POS open access product no referrals required Contact UnitedHealthcare for notification. The number is listed on the back of the member s id card or go to to provide us notification for selected services. Group Service Area: Miami Dade, Broward and Palm Beach 6

7 Miami-Dade County Products AARP/SecureHorizons Products AARP MedicareComplete Choice Plan 2 and AARP MedicareComplete Choice Plan Essential - Regional PPO open access, no referrals required - Contact UnitedHealthcare for notification. The number is listed on the back of the member s id card or go to to provide us notification for selected services. - Groups-82075,82085 Service Area: State product 7

8 AARP MedicareComplete Plan 1 HMO-MAPD MAPD Product Overview Group Number

9 AARP Medicare Complete Plan 1 AARP MedicareComplete Plan 1 HMO MAPD Group $0 Premium Product Primary Care Physician selection required upon enrollment Referrals required for services outside of the PCP office Wellness benefits such as preventive dental, vision, hearing, hearing aids, and fitness (Silver Sneakers), Healthcare Catalog Non emergency transportation Payment for generics through the gap Travel Passport Benefits- Secure Horizons National Network World Wide Coverage for urgent/emergency care Silver Sneakers, is a robust fitness and wellness program to keep members healthy includes gym membership and instructor led group exercise programs. 9

10 Referral/Authorization Requirements and Process AARP MedicareComplete Plan 1 HMO-MAPD MAPD Group Number

11 Referral & Authorization Requirements AARP MedicareComplete Plan 1 is a gatekeeper product that Requires Authorizations The PCP is the gatekeeper that provides the original referral: 1. Provider must obtain a referral form from the patient s PCP prior to rendering the service. Ordering providers need to fill out the referral and submit to the corresponding Managed Service Organization for authorization if no referral form is received. 2. MSO enters the authorization directly into cosmos and provide the provider an authorization number 3. We have two MSO s that provide authorization to our provider community. MCIC and HealthMed PCP s are associated with one of the MSO s The MSO s phone number can be found on the back of the members 2010 ID cards mailed on and after 12/20/09 The MSO s phone number is also on the referral form The members ID card front and back is on UnitedHealthcareonline.com 11

12 Referral & Authorization Requirements Prior Authorization Most services require prior authorization such as; Elective Outpatient Services Inpatient Services There are a few services that do not require an authorization. They are as follows ; Routine Well Women exam with a participating physician or healthcare professional Mammography Screening Influenza Vaccine Dialysis Services while out of area Emergency Services 12

13 Referral & Authorization Requirements Prior Authorization Members require prior authorizations for Covered Services not rendered by his or her PCP, except in the case of an emergency and the other services noted in the prior slides. Authorizations will only be approved for participating physicians, healthcare professionals and ancillary providers unless the covered service is not available from a participating provider. Authorizations approved are valid for the number of visits and services authorized ; if the number of visits is not specified, the referral/ authorization is valid for one visit only. If the physician or health care professional indicates both a time limit and a number of visits, the authorization approval defaults to whichever comes first. If further visits are needed or if the authorization expires before the number of visits on the referral/authorization have been provided, a new request for authorization must be issued by the PCP or ordering/referring physician. Specialists are required to report back information to the member s PCP. 13

14 Referral & Authorization Requirements Emergency Admissions Do Not Need To Have a Referral Completed From The Ordering Provider Hospital calls the applicable MSO for authorizations 2010 Systems Will Deny Claims When Referral/ Authorization Is Not Obtained A Letter, Provider Administrative Guide amendment and referral forms were mailed on October 1, 2009 to all contracted providers (Primary Care Physicians, specialists, ancillaries and hospitals) including a provider administrative guide amendment on the referral/authorization requirements 14

15 Specialist Physician Letter

16 16 Provider Administrative Guide Amendment

17 17 Provider Administrative Guide Amendment

18 18 Provider Administrative Guide Amendment

19 19 Provider Administrative Guide Amendment

20 20 Provider Administrative Guide

21 21 Referral/Authorization Form

22 Participating Specialists Locating a Participating Specialist Participating specialists can be found by accessing the following; You may also contact our United Voice Portal at

23 Member ID Card MSO Contact Information The back of the member s ID card has the correct Managed Service Organization s phone number to call for an authorization. The ID card can be referenced at under eligibility. 23

24 UnitedHealthcare On Line Provider Welcome Kit Provider Welcome Kit 24

25 Accessing Specialist Power Point

26 26 Questions and Answers