Provider Orientation. Aetna Better Health of Louisiana Spring 2015

Transcription

1 Provider Orientation Aetna Better Health of Louisiana Spring 2015

2 Aetna s Values 2

3 Agenda Health plan overview Provider Relations Member Services Medical Management Quality Management Grievances and appeals 3

4 AETNA BETTER HEALTH OF LOUISIANA

5 Aetna Better Health of Louisiana CEO Philosophy Focus on Quality Our Business is.compliance No Silos Our Health Plan Growth through Preferred Plan Initiatives Long-Term Support Services Behavioral Health Integration Empowering members 5

6 2014/2015 Aetna Medicaid Overview Leader in managing medically complex populations at the local, community-based level by integrating physical health, behavioral health and social economic status of members We provide services for nearly 3 million members across 17 States, 38 contracts and manage ~$13 billion dollars in premium annually Aetna serves full range of Medicaid populations: Aged, Blind and Disabled (ABD) Children in foster care (DCF) Children's Health Insurance Program (CHIP) Developmentally Disabled (DD) Dual Eligibles Individuals with General or Serious Mental Illness (GMH/SMI) Long Term Services and Supports (LTSS) Medicaid Expansion (ACA) Temporary Aid to Needy Families (TANF) Aetna Medicaid Markets Our more than 29 years of Medicaid experience has been successfully driven by: Local, community based model Clinical integration; Bio-Psycho-Social Model Technology enablement Expertise with high-risk, complex populations D.C. 6

7 Aetna Better Health of Louisiana Service Area 7

8 How have you prepared for a business interruption? At the time of a disaster or emergency have you considered? Do you have an up-to-date BUSINESS CONTINUITY PLAN for your practice? How will you COMMUNICATE business delays or closures? Can you SHARE MEDICAL RECORDS with other providers if your patients have evacuated out of the area? Have you and your staff considered VOLUNTEERING during downtime? Register with Louisiana Volunteers in Action (LAVA). Aetna Better Health of Louisiana-Provider Orientation 8

9 Aetna Better Health of Louisiana Membership By Gender 11,333 7,447 Female Male By Region 5,785 5,137 4,227 3,632 Capital Gulf North South Central Data based on claims as of 04/24/2015 9

10 Aetna Better Health of Louisiana Membership By Age 5,637 4,838 4,093 2,465 2,041 1, Pregnancy 43% Disabled 49% Asthma Foster Care Special Needs Pregnancy By Condition Asthma 0% Special Needs 0% Blind 0% Breast/ Cervical 5% Foster Care 3% Breast/Cervical Blind Disabled Data based on claims as of 04/24/

11 OVERVIEW PROVIDER INFORMATION

12 Provider Relations Liaisons Keela Dominick (interim) Keela Dominick (interim) 12

13 Provider Information Eligibility Verification Please contact us at or log into our Secure Web Portal to verify eligibility. Online Provider & Pharmacy Search Tool For a list of participating providers, including behavioral health, please access our online search tool located on Tools & Resources Website Provider manual Member handbook 24/7 Secure Web Portal Clinical guidelines forms Provider education 13

14 Provider Information Claims Claim Inquires Participating providers may review the status of a claim by checking the Secure Provider Web Portal located on our website or by calling our Claims Investigation and Research Department (CICR) at Claims & Resubmissions Aetna Better Health of Louisiana requires clean claims submissions for processing. To submit a clean claim, the participating provider must submit: Member s name Member s date of birth Member s identification number Service/admission date Location of treatment Service or procedure 14

15 Provider Information Claims Please Note New Claim Submission Claims must be submitted within 180 calendar days from the date of services (per HCAPPA) were performed, unless there is a contractual exception. For hospitals inpatient claims, date of service means the date of discharge of the member. Claim Resubmission Claim resubmissions must be filed within 90 days from the date of adverse determination of a claim. Providers may resubmit a claim that Was originally denied because of missing documentation, incorrect coding, or was incorrectly paid or denied because of processing errors 15

16 Provider Information Claims Electronic Claims Submission Providers who are contracted with us can use electronic billing software. Emdeon is the EDI vendor we use. To establish connectivity with Emdeon call (Please run a test claim prior to submitting batches) Paper Claims Submissions and/or Resubmissions Please use the following address when submitting claims to Aetna Better Health of Louisiana Aetna Better Health of Louisiana P.O. Box Phoenix, AZ For resubmissions, please stamp or write one of the following on the paper claims AND on the envelope: Resubmission, Rebill, Corrected Bill, Corrected or Rebilling 90% of clean EDI claims adjudicated within 30 days of receipt 99% of clean paper claims adjudicated within 90 days of receipt 16

17 Provider Information Credentialing Adding a new provider to existing practice (Physician/Mid-Levels) Each new provider must be credentialed before he/she can render care to a Member Utilize CAQH for credentialing or the Louisiana Standardized Credentialing Application Contact Provider Relations with the applicable CAQH number 17

18 Provider Information Vendors Language Services If a member on your panel requires information in another language or braille, please call Member Services at , TTY 711, a few days prior their appointment for more information. This also includes also sign language. LogistiCare Our transportation vendor, provides our members with a free ride to and from your office. Members can call LogistiCare at , TTY , at least three days before their appointment. 24-hour Ride Assistance Block Vision Our vision vendor is available to members by calling CVS Caremark Our pharmacy vendor and any prior authorizations are handled by Aetna Better Health of Louisiana directly. Call (TTY 711) and follow the prompts. DentaQuest Our dental vendor is available to members by calling

19 Provider Relations Department Contact Us: CLAIMS PRIOR AUTHORIZATION PROVIDER RELATIONS Option 2, Option 2, Option 2, then Option 4 then Option 5 then Option 6 19

20 OVERVIEW OF THE PROVIDER PORTALS

21 Aetna Better Health of Louisiana Provider portals On the Provider portal you can Access ProPAT directly to see if a service code requires authorization View panel roster, claims & member eligibility information Send & receive secure messages Submit authorization requests View remittance advice status Sign up to receive electronic funds transfer and remittance advices 21

22 Aetna Better Health of Louisiana Provider portals 22

23 Aetna Better Health of Louisiana Medicaid Provider portal 23

24 OVERVIEW OF MEMBER SERVICES

25 Member ID Cards back front 25

26 Eligibility For eligibility issues members should contact the Bayou Health Member Hotline:

27 Aetna Better Health of Louisiana Member portal 27

28 Aetna Better Health of Louisiana Member portal 28

29 Aetna Better Health of Louisiana Member portal 29

30 Aetna Better Health of Louisiana Member Services Provides New Member Orientation Assists members in the resolution of grievances and appeals, or billing Serves as an advocate for members Available 24 Hours/7 Days TTY 30

31 OVERVIEW OF MEDICAL MANAGEMENT

32 Medical Management Care Transition and Continuity of Care Prior Authorization Concurrent Review Care Management 32

33 Medical Management Care Transition and Continuity of Care Care Transition Transition period of 30 calendar days or less from the effective date of the member s enrollment unless member has special needs Continuity of Care for members with special needs The day before enrollment, we provide continuation/ coordination of services up to 90 calendar days or until the member may be reasonably transferred without disruption, whichever is less We may require prior authorization for continuation of services beyond 30 calendar days 33

34 Medical Management Prior Authorizations How to request Prior Authorizations A prior authorization request may be submitted by: Submitting the request through the 24/7 Secure Provider Web Portal located on the Aetna Better Health of Louisiana s website Fax the request form to (form is available on our website). Please use a cover sheet with the practice s correct phone and fax numbers to safeguard the protected health information and facilitate processing, or Through our toll-free number at To check the status of a prior authorization or confirm receipt, please visit the Secure Provider Web Portal at or call us at The portal will allow you to check status, view history, and/or a Case Manager for further clarification if needed. 34

35 Medical Management Prior Authorization cont. Requesting Prior Authorization When requesting prior authorization, please provide the following: Member s identification number Demographic information Requesting provider contact information Clinical notes/explanation of medical necessity Other treatments that have been tried Diagnosis and procedure codes Date(s) of service (DOS) Important Please Note: Emergency services do not require prior authorization. For post stabilization services, hospitals may request prior authorization by calling

36 Medical Management Prior Authorization Determination Times Urgent Pre-service: 72 hours of receipt of request Non-urgent Pre-service: 2 business days, but no longer than 14 days from the receipt request to obtain appropriate medical information 36

37 Medical Management Services Requiring Prior Authorization Inpatient services Outpatient services Surgical services Home based services including Hospice Therapy Imaging Orthotics / Prosthetics ProFax Available 24hrs/day No authorization is required for emergency services 37

38 Medical Management Concurrent Review Process 95% of concurrent review determinations within (1) business day 99.5% of concurrent review determinations within (2) business days of obtaining the appropriate medical information Rehabilitation Facilities Concurrent reviews will be conducted weekly or on a scheduled dictated by the member s diagnosis and condition either by phone, fax or onsite, depending on the volume of members and/or location of the facility Skilled Nursing Facilities Concurrent reviews will be conducted weekly either by phone, fax or onsite, depending on the volume of members and/or location of the facility 38

39 Aetna Better Health of Louisiana Behavioral Health What led to integration? Aetna Medicaid experience: behavioral health conditions drive physical health utilization and cost Inpatient admissions Emergency room visits Total PMPM Highest risk group in Medicaid Predictive Modeling [CORE]: ~0.3% of total membership $4,059 total cost PMPM [21x greater than low risk group: 97.6% of total membership] Multiple chronic serious physical health conditions Mental Health (MH) disorder prevalence: 69% Substance Use Disorder (SUD) prevalence: 69% 49.6% co-occurrence of MH and SUD PMPM Medical Cost PMPM Medical Cost by Number of Behavioral Health Conditions $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 $479 $982 $1,272 $1, Number of BH Conditions 39

40 Medical Management ICM Levels of Service Encompasses the full continuum of care management services regardless of presenting condition (including DM education as appropriate) Standard Care Management Supportive Care Management: Encompasses High Risk DM High Risk Perinatal Special Populations: Serious Mental Illness Developmental Disabilities Other Initially low risk perinatal members and specific contractually-required populations; future developments will add low risk DM and an array of prevention and wellness activities 40

41 OVERVIEW OF QUALITY MANAGEMENT

42 Quality Management Incentive Based Performance Measures DHH holds Bayou Health MCOs accountable for improving health care in Louisiana. Encourage innovation in improving health care outcomes for Medicaid recipients in the following areas: Better management of chronic conditions Reduce Diabetes Short Term Complications Reduce HIV Viral Load Increased utilization of primary care and perinatal care Increase Adolescent Well Care Visit, Post Partum Visit, Preterm Birth Prevention Appropriate utilization of services Increase Follow-up After ADHD prescription, Decrease ER Use and Decrease Cesarean section Rate for Low Risk 1 st Time Women 42

43 Quality Management How is data collected for HEDIS reporting? Administrative measures use claims/encounters for hospitalizations, medical office visits and procedures or pharmacy data only Hybrid data collection measures use data obtained directly from the member s medical record in addition to administrative data. The Ultimate Goal The ultimate goal is for providers to submit claims/encounters with coding that administratively captures all required HEDIS data via claims. This decreases or removes the need for medical record (hybrid) review. 43

44 Quality Management How you can improve your HEDIS scores? 1. Make sure you are coding correctly for all the services you provide. Reference the HEDIS Measures Tip Sheet that has been distributed 2. Use CPT II billing codes to help increase scores for BMI s, BMI percentiles, labs, etc. 3. Conduct and bill a well visit with a sick visit for a member who has not had his/her annual physical 4. Expand a basic sports physical, especially for adolescents, to include education and anticipatory guidance. Including these components will increase the Adolescent Well Visit and Well child rates. 5. Contact members that are delinquent in needed care and schedule services. 6. Make sure that follow-up instructions are clear (ex: for future appointments and what to do) 7. Schedule the next appointment before the patient leaves the office 8. Collaborate with the health plan on programs and interventions 44

45 Quality Management Monitoring and quality improvement Medical Record Reviews (MRR) Performance measures (HEDIS and DHH) PCP Quality Performance Profiles Member satisfaction Network adequacy 45

46 GENERAL MRR REQUIREMENTS Member Name or ID present on each page Personal Data All entries are legible to someone other than the writer Physician review of Lab or other study results EXPLANATION The patient s name or ID number should be recorded on each page of the medical record (i.e. all notes, lab reports and consult reports). Each record must contain appropriate biographical/personal data including age, sex, race, address, employer, home and work telephone numbers, ICE contact and marital status. All patients must have their own chart no family charts. (Prenatal only) An additional section in the medical record for the provision of prenatal care and services. The medical record should be complete and legible. Illegible medical record entries can lead to misunderstanding and serious patient injury. There is evidence of physician review of lab, x-ray, or biopsy results or other studies by either signing or initialing reports or documentation of the results in the progress notes. Abnormal lab and imaging study results have an explicit note regarding follow-up plans. Documentation indicating the patient s preferred language Documentation of offer of a qualified interpreter, and the member's refusal, if interpretation services are declined 46

47 Quality Management EPSDT CPT Codes 47

48 Quality Management Healthy Living Added Benefits 48

49 Quality Management Healthy Living Added Benefits Service Type PCP visits Annual Wellness w/ STI screenings Annual mammogram Cervical cancer screening Diabetics- LDL & A1C lab tests Diabetic dilated eye exam Adult vision refraction Sickle Cell - retinopathy screen Eye ware Colonoscopy age 50 & > Adult dental exam/twice yearly cleaning Tobacco cessation program Incentive Unlimited $25 gift card $15 gift card $15 gift card $15 gift card per test completed $15 gift card Free Free $80 benefit (frames, contacts) $25 gift card Free Pharmacy coverage of Chantix, Bupropion; Nicotine substitutes for 6 months 49

50 Quality Management Healthy Living for our Pregnant members Our Promise Program encourages pregnant members to make early and frequent prenatal and post-natal visits. The program will include case management, coverage of 17P for pre-term birth risk, text4baby (SM), and Promise program rewards. The program also includes the following incentives: A $10 gift card for the first prenatal appointment within the first trimester or within 42 days of enrollment A second $10 gift card for members who attend their postpartum visits 21 to 56 days after delivery, including family planning or long-acting contraceptive activities Free circumcisions for newborn boys We also have a multi-level completion incentive option, which gives pregnant members the chance to receive a $100, $150 or $200 Babies R Us gift card. This incentive amount varies based on the number of prenatal visits the member has. Incentive is mailed following delivery. 50

51 Quality Management Healthy Living Added Benefits Weight management program for children and adolescents For members aged 5 through 20, who meet the CDC BMI requirements for being overweight or obese Upon enrollment, each member will receive a pedometer OR exercise band Completion of goals gift card incentive (gift card values increase from $15 to $30 with completion of the first, second, and third goal for each participant) To earn the incentives the member must also have confirmed attendance at four weight management assessments and four nutritional consultations. 51

52 Quality Management Healthy Living Added Benefits Extended Member Service and Nurse Lines hours Our Member service representative and Nurses are available 24 hours a day, 7 days a week to answer questions and address concerns Members can call our 24-hour Lines at For Member Services, members will stay on the line and for a Nurse, members will select the Nurse option 52

53 OVERVIEW OF GRIEVANCES AND APPEALS

54 Grievances and Appeals Terminology Action The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service, the failure to provide services in a timely manner. Appeal A request for a review of an action. Grievance An expression of member/provider dissatisfaction about any matter other than an action, as action is defined. Examples of grievances include dissatisfaction with quality of care, quality of service, rudeness of a provider or a network employee, and network administration practices. Administrative grievances are generally those relating to dissatisfaction with the delivery of administrative services, coverage issues, and access to care issues. 54

55 Grievances and Appeals Provider Grievances Timeframes 30 calendar days to file Acknowledged within 3 business days Resolved no more than 90 calendar days from date of receipt 55

56 Grievances and Appeals Provider Appeals Timeframes 30 calendar days from date on Notice of Action letter Acknowledged within 3 business days Resolved no more than 30 calendar days from appeal receipt 56

57 Grievances and Appeals Provider Appeal Requirements If the member has not already received the requested service an Authorized Representative Form will have to be signed by the member before the appeal can be filed Form must be received within the 30 calendar day timeframe 57

58 Grievances and Appeals How to file a Grievance or Appeal [email protected] 58

59 Grievances and Appeals How to file Grievance or Appeal? Call Aetna Better Health of Louisiana Provider Relations Fax Write Aetna Better Health of Louisiana Grievance and Appeals Department 2400 Veterans Memorial Blvd., Suite 200 Kenner, LA

60 CONCLUSION

61 Your Aetna Better Health of Louisiana Team Team Member Provider Relations For your specific Provider Relations Liaison, please refer to slide 12 Network Development Member Services Medical Management Quality Management Grievance and Appeals Evon Roquemore, Director Network Keela Dominick, Contract Negotiator Andie Washington, Service Operations Manager David Daniels II, Member Advocate Andrea Soltau-Talbot, Director Medical Management Frank Vanderstappen, Case Management Manager Lee Reilly, Director Quality Management Candi Meredith, Health Care Quality Manager Courtney Dyer, Grievances and Appeals Manager Autumn Diaz, Grievances and Appeals Coordinator

62 Thank you Copyright 2015 Aetna Inc.