ProviderSource. PacificSource to Acquire Clear One Health Plans. In this issue... POS Reminder. Continued inside. PacificSource.

Transcription

1 ProviderSource PacificSource Health Plans Provider Newsletter Winter 2010 In this issue... SBA Is Now PacificSource Administrators, Inc... 2 Important Information for IPN Providers... 2 HEDIS Reporting... 3 Free Prenatal Vitamin Program... 3 Tobacco Cessation and Weight Management Programs... 3 New Large Employer Clients... 4 PacificSource Performance At a Glance... 4 Administrative News... 5 Who to Call Reference... 6 PacificSource newsletters are provided for general information only, and are not to be used to determine benefits. If you are insured by PacificSource, your benefits are determined only by your policy. PacificSource to Acquire Clear One Health Plans We are pleased to share the exciting news that we have signed an agreement to acquire Clear One Health Plans, Inc. of Bend, Oregon. The acquisition will bring together two strong, local companies committed to providing affordable, quality healthcare to more people in the communities we serve throughout the Northwest. The completion of the transaction is subject to a number of customary conditions, including approval from the Oregon Insurance Division, the Center for Medicare & Medicaid Services, the Division of Medical Assistance Programs, and then approval of Clear One shareholders. We anticipate that the transaction could close in the second quarter of In the meantime, both PacificSource and Clear One will remain separate companies and will conduct business as usual. Many of you already do business with Clear One (formerly Clear Choice Health Plans). Founded in 1995 in Central Oregon, Clear One has evolved from the country s first provider-owned and operated Medicare Advantage plan into an independent regional health plan serving the commercial and government sectors. Licensed in Oregon, Idaho, Washington, Montana, and South Dakota, Clear One Health Plans, Inc. is a holding company for three subsidiaries: Clear One Life and Health, providing group life, disability, dental, vision, and voluntary benefits to members in Idaho, Montana, Oregon, and Washington Central Oregon Individual Health Solutions (COIHS), an administrator of the Oregon Health Plan for 26,800 Oregonians Trusteed Plans Service Corporation (TPSC), providing administrative services to 46,400 people through self-funded employer groups, associations, Taft-Hartley Trusts, and Chamber of Commerce plans This acquisition is an important step in our strategy of becoming the leading community health plan in our markets, said Ken Provencher, President and CEO of PacificSource Health Plans. Clear One has strong Medicare and Medicaid membership in Oregon, and their expertise in those areas will help us build on our strength in the commercial insurance market. Both organizations operate under a business model that emphasizes partnership, service excellence, a regional approach, and personal relationships, and all our customers can expect to benefit from those values going forward. Continued inside. POS Reminder PacificSource.com The New Year brings lots of changes, such as renewed patient deductibles and out-of-pocket expenses. Remember, you can get real-time patient cost estimates through the POS link under InTouch for Providers on our Web site. If you are not already billing us electronically, you can also use this POS link to submit claims to us directly. For more information, please contact your Provider Service Representative.

2 This acquisition is an important step in our strategy of becoming the leading community health plan in our markets. ~ Ken Provencher, President and CEO PacificSource Health Plans Clear One Health Plans, Continued from Page 1 What will happen between now and the anticipated acquisition in second quarter of 2010? Please continue to send any Clear One member claims to Clear One until further notice. The acquisition will not be final until all approvals are received and closing has taken place, most likely in the second quarter of Clear One Health Plans will remain an independent corporation and operations will continue to be separate from PacificSource. Your current contracts and reimbursements with PacificSource and Clear One will remain the same. We will continue to be proactive in sharing information with you as we develop our business and integration plans and move toward the close of this transaction. In the meantime, if you have questions, you are welcome to contact us. Select Benefit Administrators, Inc. (SBA) Is Now PacificSource Administrators, Inc. Select Benefit Administrators, Inc. (SBA) became PacificSource Administrators, Inc. on January 1, PacificSource Health Plans purchased SBA six years ago, and SBA has operated as a subsidiary company since then, providing administrative services to employers who choose to self-fund their employee health benefits. This name change will better reflect the relationship between the two organizations. New Claims Address Please send PacificSource Administrators claims to PO Box 70088, Eugene, OR or fax to (503) Payer ID Number for Electronic Claims You can continue to use the existing SBA payer ID numbers you are now using or use the PacificSource payer ID (93029). If you are not already submitting claims electronically, we encourage you to do so. The advantages of e-claims submission include faster reimbursements, reduced administrative costs, and greater accuracy. Please contact your Provider Service Representative for information on how to get started. New member ID cards Current SBA members received new ID cards in December showing the new name, logo, and claims address. In most cases, member ID numbers and group numbers remain the same. New Web Site The company s new Web site address is tpa.pacificsource.com. You can also continue to access claims information and more through InTouch for Providers at PacificSource.com. New Addresses PacificSource Administrators employee addresses have changed The first part of the address (first initial followed by last name) remains the same. You ll continue to work with the same people and can expect to receive friendly, helpful service under PacificSource Administrators. Important Information for Idaho Physicians Network (IPN) Providers As you may know, PacificSource acquired Primary Health Plan, Inc. earlier this year, and that transaction included an ownership share of Idaho Physicians Network (IPN). As part of our operational integration in Idaho, effective January 1, 2010, there are a few changes that will affect our providers in Idaho. 2

3 Provider Networks in Idaho PacificSource has begun using the IPN network throughout Idaho as of January 1, In addition to IPN, PacificSource will continue to use the BrightPath network for our BrightIdea plans. New Claims Address and Payer ID Number Effective January 1, 2010, all claims from Idaho providers should be sent to PacificSource as follows: Electronic Claims: PacificSource Payer ID number Paper Claims: PO Box 7068, Eugene, OR Your Provider Service Representative In late 2009, PacificSource s Provider Service Representative in Idaho, Hilary Meek, transitioned to a similar role within Idaho Physicians Network (IPN). Hilary will continue to be your key contact for PacificSourcerelated topics and can be reached at (208) or (888) , ext. 3805, or by at hmeek@ pacificsource.com. New Preauthorization List Includes Fewer Procedures For Idaho providers, we are reducing the number of medical services that require preauthorization. Our medical services and pharmacy preauthorization lists are posted on our Web site PacificSource.com under For Providers > Claims Guidelines. The preauthorization lists may also be accessed directly at the following address: Pacificsource.com/provider/preauthorization.aspx. Preauthorization Request Forms can be downloaded from that Web address, or you may contact your Provider Service Representative to request forms. Our preauthorization list is subject to revision as we review new technologies and standards of medical practice. The list is not intended to suggest that all items included are necessarily covered by benefits under the member s plan. HEDIS Reporting to Help Improve Healthcare Outcomes In an ongoing effort to improve healthcare outcomes in the communities we serve, we are participating in Healthcare Effectiveness Data and Information Set (HEDIS) 2010 reporting. We anticipate gaining the ability to identify specific areas for improvement and to report on quality to our employer groups. We also plan to share aspects of the data with you to begin improvement initiatives, monitor disease management, and increase preventive care. Beginning in late February 2010, a vendor contracted by PacificSource may contact you to arrange a convenient collection of specific patients medical record information. Arrangements will be made to review records in the office, or they can be submitted by fax or if preferred. You ll receive more information by mail in advance of the medical records request. We appreciate your support during this important quality improvement initiative, and for improving the health of our communities. 3 Free Prenatal Vitamin Program Supports Healthy Babies To promote healthy fetal development and optimize healthy baby outcomes, we now offer a free prenatal vitamin program, effective January 1, PacificSource members that are pregnant can receive up to six months of physician-prescribed prenatal vitamins via mail order at no cost. (Copays and deductibles are waived.) The member must have a pharmacy benefit to be eligible, and other restrictions apply. If you have a patient that would like to take advantage of this benefit, simply complete and fax our Prenatal Vitamin Home Delivery Order Form to Wellpartner pharmacy. The form, which includes questions and answers on the back, is available from the For Our Members > Forms and Materials area of our Web site, PacificSource.com, or by contacting our Pharmacy Department at (800) ext or (541) Tobacco Cessation and Weight Management Programs Available to PacificSource Members As you know, quitting tobacco and maintaining a healthy weight are two of the most important things people can do to reduce their risk of health problems. Yet for many, doing one or both of these things is daunting. Our award-winning tobacco cessation program, Free & Clear Quit For Life, helps members kick the tobacco habit with a proven combination of one-on-one support and nicotine replacement therapy. (Free & Clear is available to all members with medical coverage, except those with Short Term Medical policies.) To assist members who want to lose weight or maintain a healthy weight, we offer a Lifestlye Improvement Program through Health Manager, an online tool powered by WebMD. The program, which includes educational information, exercise planners, and meal ideas, is accessible through InTouch for Members at PacificSource.com. If you have PacificSource patients who are struggling with weight management or quitting tobacco, we encourage you to talk to them about these free programs. To learn more, please see our new informational fliers at PacificSource.com under For Providers > Forms and Materials.

4 New Large Employer Clients To keep you informed of potential new patients, as well as possible coverage changes for existing patients, we publicize large employers that have recently enrolled with us. Covered Lives* Effective October 1, 2009 Location 46 Umpqua Research Company Myrtle Creek 61 Women s Health Center of Southern Oregon PC Grants Pass 58 Whitewater Construction Eugene 115 JCK Restaurants, Inc. DBA Carl s Jr. Eugene 100 Metro Overhead Door, Inc. Portland 49 Big Country RV, Inc. Bend 40 Clarke s Sheet Metal, Inc. Eugene 50 High Desert Automotive Supply, Inc. DBA Napa Auto Parts 44 Petersen Kolberg and Associates DBA PKA Architects Bend Portland 52 Seventh Mountain Resort Bend Covered Lives* Effective November 1, 2009 Location 52 Northwest Surgical Specialists, LLP Springfield 50 Highland Laboratories, Inc. Mt. Angel 128 Rosen Aviation, LLC Eugene 213 Performance Health Technology LTD Salem 60 Ehlers Construction, Inc. Eugene 69 Marshalls, Inc. Springfield 106 Healthco Information Systems Tualatin 64 AFP Systems, Inc. Tualatin 108 Yorke and Curtis, Inc. Beaverton 352 A and M Transport, Inc. Glendale 35 The Maren Corporation Eugene Covered Lives* Effective December 1, Rainbow Valley Design and Construction, Inc. Location Eugene 50 Daniel N Gordon PC Eugene 41 The Hasson Company Clackamas 57 Elcon Associates, Inc. Portland 44 Westside International Medicine PC Portland 112 Davies, Inc. Salem 43 Western Panel Manufacturing, Inc. Eugene 41 Ken Ware Chevrolet, Inc. OADA North Bend PacificSource Performance At a Glance - December 09 Enrollment Total Enrollment: 207,149 Medical Members: 173,588 Dental Members: 66,406* * This number includes members with dental only as well as those that have both dental and medical coverage with PacificSource. Claims Processing Actual Target Turnaround Time: 13 days 10 days Accuracy: 97% 99% Customer Service Actual Target Answer Speed (seconds): Abandonment Rate: 2% 2% Customer Satisfaction Actual Target Member Satisfaction: 95% 95% Provider Satisfaction: 100% 95% * Covered lives references the approximate total of enrolled employees plus their enrolled dependents. Benefit information is printed on the patient s ID card. If you have any questions, please feel free to contact our Customer Service Department. 4

5 Administrative News & Important Reminders Oregon Legislation Brings Changes to Autorecovery Process Prior to 2010, our process for collecting refunds varied based on the terms of your provider contract. In some cases refunds were autorecovered, and in others they were requested in writing. Effective January 1, 2010, Oregon Senate Bill 508 states that providers must be provided a refund request in writing 60 days prior to autorecovery. To comply with the new law, our new policy will apply to all providers and will override any contract language. Our new refund policy is as follows: 1. We send you (the provider) an initial refund request days from initial request: If we have not received the refund, or if you have not contested the refund within this timeframe, we will send a reminder (second refund request) days after the initial request: If we have still not received the refund, the overpayment will be autorecovered on the next scheduled payment. To contest a refund, PacificSource requires the use of our Contested Refund Form, available on PacificSource.com under For Providers > Forms and Materials. In addition to the form, supporting documentation is required to contest the refund. Examples of documentation include: A new primary EOP in cases where a primary insurance payer decides to reprocess their claim Chart notes that support the original payment Preauthorization obtained, which allows the original payment to stand Telemedicine Coverage Effective January 1, 2010, in accordance with Oregon Senate Bill 24, we are now covering Telemedicine services under all of our fully insured plans (except Short Term Medical). Coverage for self-insured plans (under PacificSource Administrators, Inc.) will vary. To bill PacificSource for Telemedicine services, the following codes will be accepted: 0188T, 0189T, G0406, G0407 and G0408, plus any covered procedure code with a GT modifier. To determine coverage for any other code not listed here, please contact your Provider Service Representative. Guidelines for Using Modifier 25 Our policy for Modifier 25 states that if you provide both a service/procedure and E&M (evaluation and management) on the same day, they must be significant, separate, and identifiable. Documentation must support both services and show that the E&M was above and beyond the service or procedure provided. Please include a chart note for each service and confirm that the same patient received both services. Please note that when we receive a claim that includes a preventive care charge and an office visit charge, the claim will be pended while our Claims Research Analyst reviews the attached chart notes. 5 If no notes are present, the charges for the office visit will be processed as provider write-off with the explanation code stating that allowable charges are limited to one office or hospital visit per day, and that the patient is not responsible for the difference. Examples of when both charges would not be appropriate: A patient who has a history of hypertension is scheduled for a routine physical. You make brief mention of the hypertension and re-fill the patient s prescription. During an annual gynecological exam, a patient mentions that she is having hot flashes, and you order blood work to check hormone level. A child is seen for a well-child checkup and you note that he has an ear infection and prescribe antibiotics. Examples of when both charges would be appropriate: A patient is scheduled for a routine physical with a history of hypertension, and upon examination, you discover that the patient s blood pressure is extremely high. The patient says he is having lightheadedness and ringing in the ears. You take measures to reduce the blood pressure and counsel the patient on how to monitor the condition. During an annual gynecological exam, you find a lump in a patient s breast and order additional blood work and radiological procedures. You also take additional time to go over treatment options with the patient. Board Certification Reminder for Oregon Providers When submitting an application to PacificSource for new physicians or nurse practitioners joining your clinic, please remember to include board certification information noted on page 2, section 4 of the Oregon Practitioner Credentialing Application. If your new practitioner is a new graduate or the certification is in process or pending, please indicate that as well. PacificSource has found board certification to be one useful benchmark of quality and competency. As you know, board certification is a nationally recognized attestation of basic qualifications in one s specialty. In addition, industry standards increasingly emphasize it as a prerequisite for providers health plan participation. Please be aware that our Credentialing Committee may consider loss of certification, repeated failure to pass certifying exams, or other deficiencies as grounds for not accepting an application for credentialing or recredentialing. Old Code Books? Consider Donating Them. If you have 2009 medical code books taking up space in your office, why not put them to good use? Check with your local college to see if they have a program that might need these resources. As you know, code books are expensive, and in many cases students only need them for one class, so purchasing them can be a burden.

6 PO Box 7068 Eugene OR Not sure who to contact with questions? Just clip and save for easy reference. PacificSource Customer Service PacificSource Health Services Phone: (Eugene) or (all other areas) Fax Questions about member benefits or eligibility Questions about the status of a specific claim or EOP Phone: (Eugene) or (all other areas) [email protected]; Fax Requests for preauthorization and referral authorization Case management PacificSource Administrators, Inc. (formerly Select Benefit Administrators, Inc. [SBA]) Claims If the member ID card features the PacificSource Administrators logo, direct inquiries to PacificSource Provider Service Representatives Phone (Eugene) or (all other areas) [email protected]; Fax Your Provider Service Representative is available to provide support and education to your office staff. Please feel free to contact your representative any time you have an administrative question or wish to report a change in your practice (address, phone number, name, tax ID number, open/closed practice status, etc.). If your office is in: Oregon Counties: Baker, Crook, Deschutes, Gilliam, Grant, Harney, Jefferson, Klamath, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, and Wheeler Oregon Counties: Coos, Curry, Douglas, Jackson, Josephine, Lane Washington Counties: Benton, Clark, Columbia, Cowlitz, Franklin, Island, Kitsap, Klickitat, Lewis, Pacific, San Juan, Wahkiakum, Walla Walla, Yakima. Oregon Counties: Clackamas, Columbia, Hood River, Multnomah, Washington Idaho Counties: All Washington Counties: Asotin, Spokane, Whitman Oregon Counties: Benton, Clatsop, Lane, Lincoln, Linn, Marion, Polk, Tillamook, Yamhill Your Service Representative is: Michelle Cochran [email protected] / , ext Stephanie De Less [email protected] / , ext Renea DiDomenico [email protected] / , ext Hilary Meek [email protected] / , ext Debbie Smith [email protected] / , ext. 5439