BlueChoice HealthPlan Medicaid An Overview

Transcription

1 BlueChoice HealthPlan Medicaid An Overview 1

2 Provider Responsibility These are the responsibilities of facilities that help members maintain healthy lifestyles: Provide covered benefits to all members regardless of race, creed, color, religion, physical/mental handicap, sexual orientation, marital status, national origin/ancestry or health status. Facilities shall notify BlueChoice HealthPlan Medicaid within 30 days of any change in the facility status or demographics. This includes adding new services and/or closure of existing sites/services. Facilities must notify the plan of any admission or service at the time the member is admitted or the service is rendered. If the member is admitted or service rendered on a day other than a business day, the hospital is required to notify the plan by the morning of the next business day. 2

3 Access and Availability Appointment Type Routine Care Appointment Sick Care Appointment Urgent Care Emergency Care Office Wait Time Access Standard Within four to six weeks Within three days of presentation Within 48 hours Immediately upon presentation Within 45 minutes of appointment We require primary care physicians (PCPs) to provide members with access 24 hours a day, seven days a week. Providers must have a way for members to either contact them directly or have access to a provider on call 24 hours a day, seven days a week. 3

4 Access and Availability Appointment Type Routine Care Appointment Sick Care Appointment Urgent Care Emergency Care Office Wait Time Access Standard Within four to six weeks Within three days of presentation Within 48 hours Immediately upon presentation Within 45 minutes of appointment You can accomplish this with an answering machine that instructs patients to call the local hospital switchboard to page or beep the doctor. Or, with an answering service that will page or contact the physician on call or with whom the physician checks regularly. 4

5 Access and Availability Appointment Type Routine Care Appointment Sick Care Appointment Urgent Care Emergency Care Office Wait Time Access Standard Within four to six weeks Within three days of presentation Within 48 hours Immediately upon presentation Within 45 minutes of appointment Please Note: An answering machine, which instructs the patient to go to or call the local emergency room for triage will not meet access and availability standards. 5

6 BlueChoice HealthPlan Medicaid Contacts Remember that all contact information for BlueChoice HealthPlan Medicaid is different than our commercial product for BlueChoice HealthPlan. Website: Customer Care Center: (verify eligibility, benefits, claims status, general questions, etc.) Voice: Monday to Friday: 8 a.m. to 6 p.m. Fax: or TTY: Hour Nurseline Voice: TTY:

7 BlueChoice HealthPlan Medicaid Contacts Remember that all contact information for BlueChoice HealthPlan Medicaid is different than our commercial product for BlueChoice HealthPlan. Utilization Management (Prior Authorization and Hospital/Facility Admission Notification): Voice: Monday to Friday: 8 a.m. to 5 p.m. Fax: Case Management (Care Coordination and WIC Information): Voice: Monday to Friday: 8 a.m. to 5 p.m. WIC: hours a day, 7 days a week 7

8 BlueChoice HealthPlan Medicaid Contacts Remember that all contact information for BlueChoice HealthPlan Medicaid is different than our commercial product for BlueChoice. ExpressScripts, Inc. (Pharmacy Benefits) ExpressScripts is an independent company that provides pharmacy services and pharmacy benefit management services on behalf of BlueChoice HealthPlan. Voice: Monday to Friday: 8 a.m. to 9 p.m. Fax: Saturday to Sunday: 8 a.m. to 6 p.m. 8

9 Provider Relations We have four provider representatives dedicated to BlueChoice HealthPlan Medicaid. 72 VIP Providers PCPs who have 200+ members. This accounts for 80 percent of our total membership. Agenda-driven monthly visits to cover bulletins, claims issues and distribute reports.

10 Provider Education Territory Map 10

11 Available Resources Provider Directory Provider Operations Manual (POM) Services Requiring Authorization Forms Pharmacy Information Health Education SBIRT- Screening, Brief Intervention, Referral to Treatment 11

12 Covered Benefits Medicaid Managed Care Organization (MCO) plans are required to offer at a minimum the same benefits as Healthy Connections (FFS). Plans can choose to offer additional benefits. There is a small copay for office visits, prescriptions, home health, medical equipment, outpatient hospital and inpatient admissions. 12

13 Copayments Benefit Copayment Primary Care Visits, RHCs and FQHCs $3.30 Specialists Visits (Including Optometrists) $3.30 Medical Equipment $3.40 Chiropractor $1.15 Home Health (Limited to 50 visits) $3.30 Prescription Drugs (Brand and Generic) $3.40 Outpatient Hospital $3.40 Inpatient Hospital $

14 Copayment Exceptions These beneficiaries are exempt from copayment requirements: Children under 19 years of age Pregnant women Institutionalized individuals Individuals receiving emergency services in the emergency room Individuals receiving Medicaid hospice services Members of a federally recognized Indian tribe (exempt when Catawba Service Unit in Rock Hill renders services and when referred to a specialist by Catawba) 14

15 Copayment Exceptions These services are not subject to copayments: Medical equipment and supplies DHEC provides Family planning End stage renal disease services Infusion centers Urgent/minor care clinics 15

16 Pre-certifications In-Network Precertification Process Providers can contact via fax: or phone: List of services requiring prior authorization (PA) is available at More than 85 percent of all requests completed within three business days (14-day standard) All urgent requests completed within 24 hours (72-hour standard) Please note: The list of services requiring authorization provided on the website is not an all-inclusive list. Please contact Utilization Management if you have questions about a particular CPT code. 16

17 Prescription Authorizations Copayments are $3.40 per prescription/refill on brand-name and generic medications for members ages 19 and over. Members who are 21 years of age and older are limited to four prescriptions per-month. If medically necessary, more prescriptions may be added after PA. These are exempt from the monthly prescription limit: Insulin syringes Home-administered injectables Aerosolized pentamidine Clozapine therapy Family planning drugs and devices Diabetes strips 17

18 Prescription Authorizations All medications will be limited to a one-month (maximum 31-day) supply at all retail pharmacies. If a medical condition warrants a greater quantity than the defined one-month supply of medication, PA will ensure access to the prescribed quantity. Members should refer to their Evidence of Coverage (EOC) for benefit details, exclusions and limitations. Express Scripts, Inc. Prior Authorizations Voice: Fax:

19 Laboratory Services BlueChoice HealthPlan Medicaid has a preferred agreement with LabCorp for all labs. Labs sent to LabCorp do not require precertification. You can send anatomical pathology and cytology specimens to a local contracting pathology group or to LabCorp without precertification. See website for a complete list of labs you can do in your office and bill to BlueChoice HealthPlan Medicaid. You can send STAT labs to a contracting hospital. 19

20 Most Common Denials Member Not Eligible at the Time of Service Remember to ask for an ID card and check the Department of Health and Human Services (DHHS) eligibility website at each visit. Out-of-Network (OON) Claims Denial We pull OON claims reports weekly to identify claims filing issues as well as OON providers. Here are the top OON denial reasons: Claims filed with no rendering NPI in block 24J Billing with a non-credentialed physician/practitioner as the rendering provider. Duplicates If we denied your claim the first time, please do not simply refile it. If a correction is necessary, please use our corrected claim form. If you are unsure why it is denying, please contact our call center for assistance. 20

21 Verifying Eligibility Providers must check member eligibility during each visit. Why? After being assigned to a health plan, a member can switch plans within his or her initial 90 days. Members can also lose their eligibility at any time or have a status change. Member ID card Customer Care Center: SC Medicaid Interactive Voice Response System (IVRS) SC 21

22 22

23 Identification Card In addition to this BlueChoice HealthPlan Medicaid ID card, members are required to carry their South Carolina DHHS-issued Healthy Connections ID card. 23

24 Tools to Assist You Membership Reports We update these reports monthly for our PCP providers. They identify all members who are assigned to each of your physicians. These reports are available via the website. Medical Loss Ration Reports We generate these reports on a quarterly basis. They show the breakdown of costs associated with your practice. Emergency Room (ER) Diversion Reports We generate these reports monthly for our PCP providers. These reports identify members assigned to your physicians who have visited the ER over the last month. It lists the diagnosis for which the member received services. You can use these reports to follow up with patients seen for actual emergencies as well as to contact members who are using the ER as their PCPs. 24

25 ER Diversion Project Project began March 31, 2013, and its goal was to reduce ER usage Involved three hospitals as well as their surrounding 12 PCPs Visited all ERs, surrounding PCPs and surrounding urgent care centers and educated them on the project Provided all PCPs with monthly ER Diversion reports that showed all of their members who visited the ER. These reports contained the date visited as well as the diagnosis for which the member received services. 25

26 ER Diversion Project These PCPs were encouraged to reach out to these members For members who were using the ER as their PCP for symptoms such as earache, headache, fever, etc., PCPs can try to establish care. For the members who were seen for actual emergencies, PCPs can contact them for follow up appointments. 26

27 Provider Directory New Look This searchable directory allows you to search for a specific physician or physician group. You can now search by: Accepting New Patients Gender Board Certified Distance Provider Specialty Language Hospital Affiliation 27

28 Provider Updates You must report all updates in your office to This will ensure that your updates are completed across all the Blues lines of business. Things we need to know: A physician is leaving your practice A physician is joining your practice You have added a new satellite location You have closed a satellite location You want to close your panel and no longer accept new patients Please use the form found on our website to report these changes. We are credentialing nurse practitioners, so if you have any who have not been credentialed, please contact us. 28

29 Value-Added Benefits No copayments for urgent care services Free Boys and Girls Club memberships Free Girl Scout memberships, and choice of free uniform or Journey Booklet I-Select MD services New Baby New Mom program Discounts on health and wellness programs Low copayments for generic and brand medications No cost for check-ups, circumcisions and flu shots 29

30 Value-Added Benefits Free manual breast pumps Gift cards (for healthy behaviors) 24-Hour Nurseline Disease management Car seat program 30

31 i SelectMD In an effort to decrease ER usage, BlueChoice HealthPlan Medicaid has partnered with iselectmd for a pilot project. iselectmd employs board-certified, credentialed physicians. Should members not be able to visit their PCPs, they have access to these physicians seven days and week, 24 hours a day for non-emergent issues, such as sinus infections. Physicians can prescribe medication if needed. iselectmd will send all information about the visit, including prescribed medications, to the PCP. 31

32 Claim Submission Electronic Data Interchange (Payer ID 00403) Preferred and fastest way to submit your claims. You can also submit corrected claims electronically. For set-up and information, call Hard Copy Claim Submission, Corrected Claims and Correspondence If you need to file a hard copy claim, submit a corrected claim, file an appeal or submit any type of correspondence, please mail to: BlueChoice HealthPlan Medicaid ATTN: Medicaid Claims PO Box Columbia, SC

33 Timely Filing, Re-submissions and Appeals Claim Filing Limits All providers are allowed 365 days to submit claims. Claims Denied for Requests for Medical Records We must receive medical records within 60 days of the request. Corrected Claims We must receive corrected claims within 90 days from the process date to consider them for payment. These include changes to coding, units, NPI, etc. You can submit corrected claims electronically or hard copy. 33

34 Timely Filing, Re-submissions and Appeals You must submit corrected claims hard copy with the Claim Follow Up form. Appeals We must receive appeals within 90 days from the process date to consider them for review. You must submit appeals with the Provider Dispute Resolution form. 34

35 BlueBlast 35

36 Thank you for your participation! BlueChoice HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Healthy Connections is administered for BlueChoice HealthPlan by WellPoint Partnership Plan, LLC, an independent company. 36