An Administrative Orientation for Providers for Oscar Health Insurance

Transcription

1 An Administrative Orientation for Providers for Oscar Health Insurance

2 Objectives Overview of ValueOptions Overview of ValueOptions & Oscar Partnership Overview of Operational Areas Clinical Operations Claims & Payment Overview Tools, Resources and Communications Contacts and Helpful Links Questions and Answers 2

3 ValueOptions Founded in 1983 Largest independent behavioral health company Serving over 32 million members; contracts with 20 health plans More than 50 Medicaid contracts in 14 states Committed to principles of recovery and resiliency Diverse client base Commercial Division - Employer Groups, Health Plans Federal Division Public Sector Division 3

4 ValueOptions National Presence Commercial Membership Only Shared Commercial and Public Program/ Medicaid Membership Major service centers Regional support, EAP staff and corporate support offices 4

5 ValueOptions and Oscar Partnership Effective January 1, 2014, ValueOptions will manage the Oscar Health Insurance Mental Health and Substance Abuse benefit. ValueOptions will provide Mental Health and Substance Abuse services to members enrolled in Oscar Health Insurance. Service areas include Manhattan, Brooklyn, Bronx, Queens, Staten Island, Rockland County, Westchester County, Nassau County and Suffolk County 5

6 Operational Areas: National Network Services Provider Relations Ensures members behavioral health care needs are met through a geographically and clinically robust network of providers Ensures maintenance of network composition by engaging in assertive retention strategies; Engages in timely and appropriate recruitment Engages in professional, consistent, and educative communications with provider community and staff Provider Credentialing Completion of Credentialing Application required for network participation 6

7 Operational Areas: National Network Services (cont d.) Provider Recredentialing (every three years) Notifications Process 4 months prior to due date (telephonic), 1 week later ( /fax), 15 and 30 days prior to due date Failure to respond to requests will result in disenrollment from the network Complete online, prepopulated recredentialing application Attach updated license, certification and malpractice information Electronically sign the application (once signed, it is automatically submitted) 7

8 Operational Areas: National Network Services (cont d.) Provider Contracting ValueOptions Provider Agreements Questions about Contracting and Credentialing? Call :00 a.m. 8:00 p.m. ET 8

9 Operational Areas: Quality Management Quality Management Program Oversight provided by Regional Medical Director/CMO Commercial Division and Director of Quality Management Key Quality Indicators include but are not limited to: Satisfaction Survey measures Access/Availability of Services geographic access, phone statistics, appointment availability, etc. Complaints/Grievances - tracking and reporting Patient Safety adverse incidents and quality of care Coordination of Care Quality Improvement Activities/Projects Accredited with URAC and NCQA Standards 9

10 ValueOptions Quality Management cont d. Ongoing Quality Improvement Activities (QIAs) Clinical QIAs Ambulatory Follow-up and Increasing Rate of Psychiatric Evaluations for Members Diagnosed with Moderate or Severe Depression and in Outpatient Treatment with a Non-Prescribing Behavioral Health Practitioner Service QIAs Average Speed of Answer 10

11 Operational Areas: Customer Service ValueOptions Customer Service philosophy lies in our commitment to provide our members and providers with the most accurate and informed benefit, eligibility, claims, and certification information in the most effective, efficient, and compassionate manner. ValueOptions puts our members needs and concerns first and is committed to resolving inquiries promptly without the need to make a re-contact. We value our members questions and concerns and place member satisfaction at the heart of our Customer Service philosophy. 11

12 Operational Areas: Customer Service (cont d) 12

13 Transition Benefits If a new member joins Oscar Health and is in an ongoing course of treatment with a nonparticipating provider, the member may elect to continue treatment with the non-participating provider for a period up to 60 days, if provider: accepts Oscar Health s fee schedule continues to follow their policies and procedures, and provides ValueOptions with necessary medical information pertaining to the member s care. 13

14 Operational Areas: Care Management 14

15 Operational Areas: Care Management and Referral Assistance Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management. Member referral process: Emergencies are followed until disposition Urgent referrals are offered appointments within 48 hours and are called to ensure appointment is kept Providers can contact ValueOptions for referral assistance if needed Providers should contact ValueOptions 24 hours a day/seven (7) days a week if members require higher level of care or increased visit frequency Care Management staff will assist with referral to inpatient or specialty programs 15

16 Operational Areas: Utilization Management Inpatient Inpatient and higher level of care requests are completed telephonically by calling the number on the back of the member s Identification card ValueOptions Staff are available 24 hours a day/ seven (7) days a week or via ProviderConnect Outpatient Since pass through or registration no longer applies to outpatient services impacted by federal parity, authorization cannot be required. However: It is important to check benefits and authorization requirements on each member via the web or by calling the number on the member s identification card Services must be medically necessary and provided using evidence based on practices specific to the member s condition 16

17 Operational Areas: Utilization Management (cont d.) Discharge Reviews Providers can complete discharge reviews via ProviderConnect or call the assigned CCM Providers should contact ValueOptions if they need assistance scheduling discharge appointments Providers should make every effort to schedule a discharge appointment within one to two days of discharge, but in all cases within seven (7) days. 17

18 Clinical Resources for Providers Clinical information is available at ValueOptions Medical Necessity criteria Changes to Substance Use Medical Necessity Criteria Treatment Practice guidelines PCP consult line 9 am to 5 pm (Eastern Time) Intensive Case Management Services 18

19 Claims & Payment Overview Claims for services rendered by participating providers with dates of service on or after January 1, 2014 should be submitted to ValueOptions at: ValueOptions P.O Box 1347 Latham, New York Claims questions on or after January 1, 2014 should be directed to ValueOptions at between 8 AM and 6 PM ET, Monday through Friday, or send inquiry through ProviderConnect. 19

20 Member Premium Payments Failure by member to pay premiums could impact provider payments Providers can contact ValueOptions to request member premium status at from 8 am 6 pm ET 20

21 Electronic Claims Submission Advantages: It s better, faster, and cheaper! Reduced Paper Files. Reduced Labor and Postage Expenses. Reduced potential of error or mishandling. Faster claims processing improves cash flow. 21

22 Authorizations on ProviderConnect Providers can submit and review authorizations online through ProviderConnect Authorization letters showing approval for services available only on ProviderConnect Providers can access authorization within hours of a decision To obtain authorizations, providers need to register for ProviderConnect Additional training on topic available in Video section of Valueoptions.com 22

23 Tools, Resources and Communications ValueOptions Website ProviderConnect PaySpan Health Training Opportunities Communication Channels 2

24 ValueOptions.com 2

25 ProviderConnect SM Provider Online Services 2

26 Role-Based Security in ProviderConnect New level of ProviderConnect access to enhance security as required by HIPAA guidelines Level of ProviderConnect access defined by role Roles defined by user type and/or VO business rules Users assigned roles with access to certain functions i.e. claims User Types: Super User, Managed User (managed by Super User), Standard User 26

27 PaySpan Health A tool enabling you to: Receive payments automatically Receive notifications immediately upon payment View your remittance advice online Download an 835 file to use for auto-posting purposes Visit the PaySpan Health website at 2

28 Training Opportunities CEQuick Training Webinars (New regulations, updates, ProviderConnect, etc.) An Overview of ProviderConnect Tuesday, February 11, :00 PM - 4:00 PM EST Video Tutorial Library 2

29 Up to the Minute Communications Provider Pulse SM Messages Fax and Communications Provider Mailings Constant Contact Alerts Monthly Valued Provider enewsletter 2

30 Provider Contacts Customer Service (877) (8 am - 6 pm ET Monday Friday/8 am-8pm starting 1/1/14) Provider Relations, Credentialing and Contracting Questions: (800) (8 am - 8 pm ET Monday Friday) Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk): (877) (8 am - 6 pm ET Monday - Friday) or e-supportservices@valueoptions.com ProviderConnect (EDI Help Desk) (888) For PaySpan Registration Provider Support contact: (877) providersupport@payspanhealth.com Provider Support is available from 8am to 8pm Eastern time, Monday through Friday. 3

31 Helpful Links Network-specific website for Oscar Health Insurance Provider Frequently Asked Questions Presentation w_york_city_health_plans.htm#oscar 31

32 Questions? 32