PROVIDER TRAINING APRIL 7, 2015

Transcription

1 PROVIDER TRAINING APRIL 7, 2015 Melanie Hodoh As the New third party administrator (TPA) for the CMSP Governing Board, Advanced Medical Management, Inc. (AMM) would like to thank you for partnering with us to serve needed communities under the CMSP program. Please post your questions to the AMM host using the Webex chat feature.

2 Advanced Medical Management, Inc. CMSP Webinar Agenda AMM New CMSP TPA Provider Contracting Provider Network Member ID Cards Eligibility Verification Cerecons - AMM Provider Website Care Management Grievance and Appeals CMSP Covered Benefits and Services Claims Billing and Processing Member and Provider Material AMM Contact Information 2

3 AMM New CMSP TPA As of April 1, 2015, Anthem Blue Cross is no longer the TPA for CMSP, but they will continue to process all claims through dates of service (DOS) March 31, Important factors No VSP No DentaQuest No Primary Care Physician (PCP) assignments Contracts will be between CMSP Governing Board and the provider. In the past providers contracted with Anthem directly. AMM will only administer the contracting process MedImpact will continue to administer pharmacy benefits 3

4 Provider Contracting Administration Notification Letter 4

5 Provider Contracting Return all signed agreements to: CMSP- Advanced Medical Management, Inc. Attention: Contracting 5000 Airport Plaza Drive, Suite 150 Long Beach, CA Signed contracts may also be ed to AMM s Contracting team at: [email protected] (Hospitals must mail two original copies to the address above) Send contracting questions to AMM s Contracting team at: [email protected] If you are not a Medi-Cal participating provider, you must be credentialed by AMM You will receive a credentialing packet from our Provider Network team 5

6 Provider Network Contracted Provider Search on 6

7 Member Id Cards The member receives two cards: California Beneficiary Identification Card (BIC) CMSP AMM Member ID card 7

8 Primary Eligibility Verification Providers may use the BIC to verify eligibility Swipe BIC in the point-of-service (POS) device to verify eligibility and determine if SOC applies Call the Automated Eligibility Voice System (AEVS) at (800) Log on to the Medi-Cal website at medical.ca.gov/eligibility/login.asp 8

9 Cerecons AMM s Provider Website Verify Eligibility Submit and check status of outpatient authorizations Check status of a hospital admission approval 9

10 Cerecons Login Page 10

11 Cerecons Registration Page 11

12 Cerecons Eligibility Page Secondary Source Eligibility 12

13 Care Management Outpatient authorization process Inpatient and ER notification Case management process Grievance and appeals 13

14 Outpatient Authorizations All Providers will have a Cerecons login and will submit requests online 14

15 Hospital Admission and ER Notification Fax Facesheet to (562) Call AMM Monday Friday, 8:00 a.m. 5:00 p.m. (877) After-hours, weekends and Holidays call (562)

16 Hospital Admissions Check status of admission approval by logging into Cerecons Click Cases, then Inpatient Neighborhood 16

17 Case Management Process Follow-up with patients after discharge Assign patients with chronic diseases or those with a high risk for hospitalization to an AMM Case Manager Providers may refer patients to the program by calling (877) Create customized care plans for all patients enrolled in the Case Management Program 17

18 Grievance and Appeal Process Providers may obtain grievance and appeal forms at Forms may be faxed as follows: Grievance forms to Customer Service at (562) Appeal forms to Care Management at (562) Forms may also be mailed to the following address: CMSP Advanced Medical Management, Inc. Attn: Customer Service Grievances or Care Mgmt. - Appeals 5000 Airport Plaza Drive, Ste. 150 Long Beach, CA We notify providers in writing of the resolution: within 60 calendar days of the receipt of the grievance within 60 business days of the receipt of the appeal 18

19 CMSP Covered Benefits and Services CMSP covered benefits remain unchanged For a complete list of benefits visit 19

20 CMSP Covered Benefits and Services Acute inpatient hospital Adult Day Health Care Blood and blood derivatives Chronic hemodialysis services Selected dental services Durable medical equipment and medical supplies Emergency ambulance services Hearing aids Home Health Agency services Hospital outpatient and outpatient clinic services Laboratory and radiology services Non-emergency medical transportation Covered benefits are subject to treatment authorization requirements and utilization limits 20

21 CMSP Covered Benefits and Services No authorization needed until after 24 visits for in-network providers - Outpatient heroin detoxification services - Outpatient occupational therapy services - Outpatient physical therapy services Outpatient audiology services Outpatient rehabilitation services in a rehabilitation facility Outpatient speech pathology services Prescription drugs Physician services Podiatry services Prosthetic and orthotic appliances Psychiatric services provided by a licensed psychiatrist Covered benefits are subject to treatment authorization requirements and utilization limits 21

22 CMSP Dental Benefits All dental benefits are administered by AMM All dental providers must be contracted with CMSP (Contract administered by AMM) Submit all dental claims to AMM 22

23 Claims Billing AMM will accept claims beginning with DOS 4/1/2015. AMM prefers to receive electronic claims and offers the following billing options: Clearinghouse Submissions: Office Ally use PayerID# AMM15 (Professional and Institutional) Emdeon/Capario use PayerID# CMSP1 (Professional and Institutional) ClaimRemedi use PayerID# CMSP (Professional and Institutional) Clearinghouse Name Website Support Telephone Office Ally (866) Emdeon (877) Capario (800) ClaimRemedi (800) To obtain other clearinghouse payer ID numbers or for direct submissions to AMM please contact: Santwuan Bunn (877) Ext. 315 Majken (Myken) Flores (877) Ext

24 Register for AMM Claims Manager under the Claims section 24

25 Claim Appeal Process Providers may obtain Claim Appeal/Dispute forms at Completed forms may be faxed to (562) Forms may also be mailed to the following address: CMSP Advanced Medical Management, Inc. Attn: Claim - Appeals 5000 Airport Plaza Drive, Ste. 150 Long Beach, CA AMM will send a written acknowledgement of the provider s claim appeal within 15 calendar days of receipt AMM will notify providers in writing of the resolution within 45 business days from receipt of the request 25

26 Member and Provider Material CMSP Member Guide CMSP Provider Operations Manual (POM) Available at 26

27 AMM Website Contact information Melanie Hodoh, Administrator (877) Ext

28 Thank you for attending! Questions? Please post your questions to the AMM host using the chat feature on the webinar 28