What You Need to Know about Our System Upgrade

Transcription

1 Autumn 2007 Edition Source PacificSource Health Plans Provider Newsletter What You Need to Know about Our System Upgrade We are happy to report that the first phase of our system upgrade successfully went live on July 1. As explained in the last issue of The ProviderSource, our system upgrade will be implemented in phases. At this time, only our small group and individual members have been transitioned. This represents approximately 30 percent of our members. We are now doing business on both our current and our new systems simultaneously. This dual operation will continue until the transition is complete in Please keep the following in mind during this transition period. Explanation of Payments from Two Systems Until all members are transitioned to the new system, it is likely that you will receive EOPs from both systems. For PacificSource members in the first phase of our upgrade, you ll receive an EOP that has a new look and feel. We hope that you ll find this format to be more user friendly. Clarification on New PacificSource ID Cards In June we issued new member ID cards to approximately 30 percent of our members. The remaining members will continue to use their old paper ID cards, which reflect PacificSource member ID numbers beginning with an R. Please be prepared to accept both old and new PacificSource ID cards from your patients. New InTouch System InTouch for Providers is part of our Web site at where you can verify patient eligibility and check on claims status, EOPs, preauthorizations, referrals, and much more. All of these features are currently available for members covered under large group policies. At presstime, however, benefit summaries, EOPs, and the member s original effective date of coverage are temporarily unavailable online for members with small group or individual coverage (those with ID numbers that begin with a 1 or a 2). We are aware of these issues and are working to restore that functionality as soon as possible. In the meantime, if information you normally access through InTouch is not available, please contact our Customer Service Department. We ll gladly provide the information you need by phone, , or fax. If you re a frequent InTouch user, you ll notice changes to the system as we complete the upgrade. Please note that registered users who have not logged into the site since July 1 will need to create a new password. This is necessary to ensure that our online data security standards remain current. On-screen instructions will guide you through this In This Issue Our Provider Service Representatives Short Term Medical Coverage... 2 Boise Open House Lisa Zent Returns as Provider Network Contract Lead Stephanie Meyer Your Provider Contracting Specialist Code Books Available Anticoagulant Code Reminder... 4 Provider Manual Updates Preauthorization List Change Upcoming Community Events... 5 Credentialing News Educational Opportunities Professional Liability Increase... 7 New Technologies Update New Large Employer Groups Discover the Source. 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.

2 Our Provider Service Representatives Workshops and Communication A big thank you to all of you who attended one of our Provider Workshops in May! We enjoyed meeting you face-to-face and discuss recent and upcoming changes at PacificSource, including our system enhancements. Please see this issue s article outlining what changes you can expect in the near future as we move through this transition. Of course, our commitment to customer service will continue to be the best in the business. If you need any assistance during this process, you re welcome to contact us. We ll help you work through your questions, on the phone or in person. Debbie Smith If you weren t able to attend the recent workshops, we re Stephanie De Less pleased to offer another opportunity. You can help with scheduling by letting us know what days and times work best for you. Or, if a workshop isn t ideal, we would be happy to set up a service call to go over the information from the workshop, as well as any additional questions you may have. Please watch for future workshop dates and registrations. Hello, Idaho! We re excited to be expanding our business into Idaho and working with our providers in the Boise area. Jeannette Curtis has been working closely with our Boise Provider Contracting Representative, Drew Krieg, to learn about your contracts and your area. Jeannette Curtis As Idaho s Provider Service Representative, Jeannette is available for questions or site visits at your request. Building lasting relationships is important to us at PacificSource, we think you will be pleased with the way we do business. 2 simple process and help you to find what you re looking for. If you ve never used PacificSource InTouch before and would like to take advantage of its features, just visit the For Providers area of our Web site and click on the Register for a password link next to the InTouch logo. As always, we re committed to maintaining exceptional, personal service both during this project and after its completion. We appreciate your patience with these changes and invite you to contact your PacificSource Provider Service Representative if you have any questions or suggestions. New Product Short Term Medical Coverage As of July 1, 2007, we re please to offer Short Term Medical insurance to fill the temporary gap in coverage that can occur when individuals are between permanent plans. If your patients have this type of coverage, we ask that you verify benefits and eligibility prior to performing your services. This plan is not intended to replace permanent health insurance, and benefits under short-term plans are quite different from group and individual policies. We offer four deductible options, and all of these low-cost plans share the following attributes: Coverage includes urgent care and ER services, doctor visits, inpatient and outpatient surgery, durable medical equipment, and prescription drugs. Lifetime maximum is $1 million. These policies do not have a copayment. All services are subject to the deductible, except for prescription drugs. Prescription drugs are subject to a copayment of $15 or 50 percent, whichever is greater. Out-of-network prescriptions are not covered. Services from nonparticipating providers are subject to a separate deductible and out-of-pocket limit. The reimbursement is 50 percent coinsurance for nonparticipating provider services. The preauthorization list is the same as we use for our other plans.

3 Because Short Term Medical coverage is for a limited term and is intended for unexpected injuries and illnesses, some services that are covered on other policies are not covered under Short Term Medical coverage. For example, pre-existing conditions, routine exams, well baby care, maternity care, allergy services, and mental health and chemical dependency are not covered. If you have questions, you may contact our Customer Service Department at (888) Boise Open House Celebrates Growing Network Our Provider Open House on June 26 brought local providers together with PacificSource staff in celebrating the opening of our new office in downtown Boise. PacificSource President and CEO Ken Provencher and other key PacificSource employees were on hand to talk about our commitment to serve the Boise area and to learn how we can help to provide quality healthcare in Idaho. We re excited to announce that we ve recently contracted with the following area providers: Providers from Advantage Care Network (ACN) met with PacificSource representatives at the Boise Provider Open House. From left to right: Kelli Otto, Provider Relations Representative, St. Alphonsus Medical Center Sandra Longtin, Provider Network Manager, PacificSource Ken Provencher, President & CEO, PacificSource Greg Sonnenberg, Executive Director, St. Alphonsus Michele Marcum, Contract Specialist, St Alphonsus Drew Krieg, Provider Contracting Representative, PacificSource Steven Marks, M.D., Chief Medical Officer, PacificSource Advantage Care Network (ACN), a physician hospital organization (PHO). The contract includes St. Alphonsus Regional Medical Center and six other hospitals in southwestern Idaho, as well as affiliated provider groups representing almost 650 providers. Treasure Valley Hospital Boise Elmore Medical Clinic, a critical access hospital Mountain Home Boise Heart Clinic Boise As we talk with other clinics and physicians, our provider panel continues to grow into a very competitive network. We currently contract with providers in Ada, Boise, Canyon, Elmore, Gem, Owyhee, Payette, and Washington counties, and we anticipate expanding into additional counties soon. For more information about PacificSource or to learn how you can partner with us, please contact our Boise Provider Contracting Representative, Drew Krieg, at (208) , ext. 3802, or tollfree at (888) , or by at [email protected]. Lisa Zent Returns as Provider Network Contract Lead Lisa Zent is happy to return to the Provider Network Department. For the last year and a half, she s been serving as the Provider Lead as part of the technology upgrade process. The project challenged Lisa, who was responsible for configuration, testing, and conversion activities. As her portion of the project draws to a close, Lisa is looking ahead. I m excited to be back as an Account Lead for the Provider Network Department. I am looking forward to building new relationships in my new service area, and I m ready for the challenge ahead. As Contract Lead, Lisa is building relationships with providers and negotiating agreements with both existing and new providers in her territory. If you have questions, you re welcome to contact Lisa at (541) , or toll-free at (800) , ext. 2816, or by at [email protected]. Stephanie Meyer Your Provider Contracting Specialist When the new position of Contracting Specialist became available, Stephanie Meyer jumped at the chance. While she previously set up the contract fee codes for PacificSource providers and helped them use our InTouch system, Stephanie was interested in having more direct contact with providers. As the Provider Contracting Specialist, I ll be assisting our Contract Representatives Lisa Zent Provider Network Contract Lead Stephanie Meyer Provider Contracting Specialist 3

4 with analysis and contract results, such as negotiation status, Stephanie explains. I m really looking forward to building positive relationships with providers and meeting them face to face. For now, Stephanie will be training by assisting the other staff in the contract process. If you have questions regarding network contract results or negotiations, you re welcome to contact your current Provider Network Account Lead Code Books Available at Discounted Rates For Your Convenience, You May Order Online at PacificSource is again offering our participating providers new CPT, HCPCS, and ICD-9 code books at discounted rates. The 2008 books, published by the American Medical Association, will be available until October 31, Full payment by check is required prior to shipment. There s no delivery charge, and your Service Representative will deliver your books if possible. Prices are as follows: ICD-9-CM Expert for Physicians, Vol. 1 & 2, 2007 (Spiral) $32 ICD-9-CM Professional for Physicians, Vol.1 & 2, 2007 (Softbound) $29 CPC Expert 2007 (Spiral) (Formerly CPT Expert) $67 CPT 2007 (Standard) $48 HCPCS Level II Expert 2007 (Spiral) $44 HCPCS Level II Professional 2007 (Softbound) $33 To order your books, visit our Web site, and click on For Providers to access the online order form. If you have any questions, please contact Catalina Dow at (541) , or toll-free at (800) , ext Anticoagulant Management Code Reminder Please remember that, according to CPT guidelines, anticoagulant services are defined as the outpatient management of warfarin therapy. This includes communication with the patient, International Normalized Ratio (INR) testing (ordering, review, and interpretation), and dosage adjustments as appropriate. The following codes and guidelines should be applied for anticoagulant management: Initial 90 days of therapy (must include a minimum of 8 INR measurements). Submit claim for after the eighth visit has been completed Submit claims for after each additional 90 days of therapy (must include a minimum of 3 INR measurements). Do not bill with or unless a significant, separately identifiable E/M service is performed and documentation can support it will be denied to provider write-off. If treatment with was already underway on January 1, 2007, when codes and became effective, PacificSource will allow payment of the first time it is billed. Anticoagulant management work itself is not a basis for an E/M service code or Care Plan Oversight time during the reporting period. Codes and 0074T do not apply with telephone or online services. However, if a significant, separately identifiable E/M service is performed, report the appropriate E/M service code using modifier 25. For more information on the use of these codes, please refer to your CPT book. 4

5 Provider Manual Updates The following revisions and additions were recently made to the PacificSource Physician & Provider Manual. Updated Credentialing section (4.2) Added Adequate Professional Liability Coverage (4.2.3) Updated 1500 and UB04 instructions (10.2 and 10.3) Added Overpayment/Refund Request section (10.11) Added Idaho counties in our service area (3 and 9.2) Added Short Term Medical and Idaho coverage to the Products (8.16) Removed Personal Options from Products We update our Provider Manual monthly or more often if necessary. You can access the current version from the For Providers section of our Web site. If you have any questions or suggestions for the manual, we encourage you to contact your Provider Service Representative. Preauthorization List Change The following revisions were recently made to the PacificSource Preauthorization List. Please take a moment to review these changes, as they may directly affect your practice and claims payments. Removed TENS units (E0703) when under $500 Removed Gamma knife procedure Added Scintimammography (S8080, 78801, and 78800) As always, the most recent preauthorization list can be found in the For Providers section of our Web site. Just click on Preauthorization. From there, you can click on the Experimental or Investigational link to go directly to our New and Emerging Technologies Policy. Upcoming Community Events PacificSource is proud to sponsor community events that support healthy communities and health-focused organizations. Please join us in supporting these local events: Alive After Five Summer Concert Series Wednesday evenings through September 26, Boise, ID, at The Grove Join our Boise staff members every Wednesday night for wellness and fitness demonstrations, Interested in Credentialing News? PacificSource publishes an e- newsletter filled with news and tips for Credentialing Specialists. If you re interested in receiving a copy, please contact our Credentialing Coordinator Jennifer Lawrence, CPCS, toll-free at (800) , ext contests, and prize drawings while you enjoy great live music, food, and drinks. Celebration of Courage Event September 8, Portland, OR One of the Children s Cancer Association biggest annual events. Go to and click on News & Events for more information. Sole Support for Parkinson s Walk September 16, Portland, OR Supports Parkinsons Resources of Oregon. Go to for more information. St Luke s Women s Fitness Celebration September 20 through September 22, 2007 PacificSource will sponsor the finish line party at this year s 5K, which has over 12,000 participants and is one of the largest women s run/walk events in the country. The Celebration was founded to inspire healthy attitudes in participants so that it reaches their families and communities. Learn more at Health Care Heroes Award Program September 20, 2007, Boise, DoubleTree Riverside This awards program was developed by the Idaho Business Review to acknowledge Idaho organizations and individuals involved within the healthcare industry who are the TRUE definition of the word Hero. Survivor Luncheon September 22, Portland, OR Supports the Susan G. Komen Breast Cancer Foundation. Learn more at Light the Night Walk September 28, Portland, OR 5

6 Supports the Leukemia & Lymphoma Society. Learn more at Shades of Pink October 1, Eugene, at Eugene Hilton An evening for women, wine, and wellness. Women and men are invited to this free event about health, nutrition, and beauty. Learn more at 6 Walk for the Cause Soroptomist International of Albany October 6, Albany, at Linn County Courthouse Join us as we walk through Albany downtown and historic areas to help fight breast cancer and other diseases affecting women. For more information, go to and click on Fundraisers. American Lung Association Asthma Walk October 13, Bend, McKay Park This walk supports the estimated 325,000 Oregonians who suffer from asthma. Learn more at Cascade AIDS Project October 14, Portland, Pioneer Courthouse Square This year s walk will re-energize advocacy and education around HIV/AIDS. Your participation helps draw attention to this critical issue. More information at Educational Opportunities Looking for opportunities to earn CE credits, brush up on your knowledge, or network with others in your specialty? The following professional organizations offer meetings, workshops, and other events near you. The American Academy of Professional Coders (AAPC) Portland Chapter Workshops: For more information or to register, call (800) or visit Monthly meetings: Third Tuesday of the month from 12:00 p.m. to 2:00 p.m. in downtown Portland and from 7:00 p.m. to 9:00 p.m. in Vancouver, Washington. Please contact Jonnie W. Massey, CPC, CPC-P, at (503) for details on meeting places. East Portland Chapter Monthly meetings: Third week of each month (day dependent on speaker) from 12:00 p.m. to 2:00 p.m. at OHSU. Please contact Nadine Bentley Pressly, CPC, at (503) for more details. Beaverton Chapter Monthly meetings: Second Thursday of the month from 7:00 p.m. to 9:00 p.m. at Emanual Hospital. For more information, contact Olena Czel, CPC, at (503) Willamette Valley Chapter Workshops: September 22, 2007: Anatomy November 3, 2007: How to Communicate Coding Concepts For more information or to register, call (800) or visit Monthly meetings: Second Wednesday of each month at 5:30 p.m., PeaceHealth Riverbend Annex, Springfield. For more information, contact Eileen Downs, CPC, (541) or [email protected] Linn-Benton/Albany Chapter Monthly meetings: Third Wednesday of each month at 6:00 p.m., Linn-Benton Community College, Room B203. For more information or to be added to the list, contact Debora Shandy, CPC-A, at (541) or [email protected]. Exam Date: December 7, 2007: Paperwork must be received by October 26, Bend Chapter Monthly meetings: Second Thursday of each month at 7:00 a.m. in the Physician s Lounge at Bend Memorial Clinic. Meetings typically include a guest speaker and participants earn one CEU per meeting. Nonmembers are welcome to attend.

7 Exam Dates: October 13, 2007: Paperwork must be received by September 1, December 1, 2007: Paperwork must be received by October 20, For more information about the local chapter meetings, contact Cindy Shaver, CPC, at (541) To learn more about the benefits of joining AAPC, visit their Web site at Boise Chapter Monthly meetings: Second Tuesday of each month at the Boise Community Center in Meridian. For more information, contact Launa Larson, CPC, at (208) or Twin Falls Chapter Monthly meetings: Second Tuesday of each month. For more information, contact Vicki Hepworth, CPC, at (208) , ext. 14, or Exam Date: December 8, 2007: Paperwork must be received by October 27, 2007 American Association of Medical Assistants (AAMA) The Marion-Polk Chapter Events Monthly meetings: Fourth Tuesday of the month at 6:00 p.m. at Salem Hospital. For more information, contact Kelly Fanning, CMA, at River Cities Chapter For details, contact Jocelyn Villis, CMA, by at For information about other chapters, visit the Oregon Society of Medical Assistants (OSMA) Web site at Lane Chapter Monthly meetings: Fourth Tuesday of the month at 6:00 p.m. at Willamette Valley Cancer Center. For more information, Professional Liability Coverage Increase for Chiropractors, Naturopathic Physicians, and Acupuncturists Our professional liability coverage requirements will increase to $1 million per claim and $3 million per aggregate for all participating chiropractors, naturopathic physicians, and acupuncturists. We suggest that you increase your liability limits at your next renewal. To remain compliant with your PacificSource contract, please be sure to meet the new standard in the next 12 months. To facilitate the process, please send a copy of your current professional liability coverage to us by fax at (541) or by mail to PacificSource Health Plans, Attn: Credentialing, PO Box 7068, Eugene, OR If you have any questions or concerns, you are welcome to contact our Credentialing Coordinator Jennifer Lawrence, CPCS, tollfree at (800) , ext New Technologies Update Breast Scintimammography Considered Investigational Scintimammography (S8080) is considered experimental or investigational (E&I) for routine breast screening and diagnosis. Scintimammography may also be called nuclear breast imaging, mira-luma, or breast specific gamma imaging. Effective May 1, 2007, PacificSource will only cover this procedure for specific instances requiring further diagnostic testing. It should be preauthorized in those situations. Implanon TM Covered Implanon (etonogestrel implant), 68mg, is the only single-rod implantable contraceptive that is effective for up to three years. Effective May 1, 2007, this device is part of the contraceptive coverage for those members who have this benefit. Remember, any new providers at your clinic will be considered nonparticipating until the credentialing application is submitted and approved by the PacificSource Credentialing Committee. PacificSource Performance at a Glance June 2007 Enrollment Total Enrollment: 150,311 Medical Members: 137,755 Dental Members: 50,214 Claims Processing Actual Target Turnaround Time: 11.5 days 10 days Accuracy: 100% 99% Customer Service Answer Speed: 17 secs 25 secs Abandonment Rate: 1.5 % 2.0% Customer Satisfaction Member Satisfaction: 94.4% 93% Provider Satisfaction: 94.7% 95% 7

8 New Large Employer Groups To keep you informed of potential new patients, as well as possible coverage changes for existing patients, we publicize new large employer groups that have recently enrolled with us. * Covered lives means 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. 8 Covered Lives* Organization Location Effective Date 50 Sanderson Communities, Inc. Bend March 1, Motor Coach Sales of Oregon Bend March 1, Central Oregon Veterinary Group Bend March 1, Green Gear Recycling, Inc. Eugene March 1, NW Farm Supply, Inc. Hermiston March 1, Ledford Construction Co. Medford March 1, Pain Care of Oregon Medford March 1, Gatto and Sons, Inc. Portland March 1, Fred s RV World Sandy March 1, Environmental Management Services, Inc. White City March 1, Cerus Industrial Corp Beaverton April 1, Old Mill Mortgage Group LLP Bend April 1, Cort Software, Inc Bend April 1, RTC Parts and Accessories Bend April 1, Harmon Manufacturing Corporation Coos Bay April 1, Mid Valley Glass and Millwork Eugene April 1, ,609 GPA Mills Eugene April 1, KDL Investment Co., Inc. Eugene April 1, Dunn Construction Gresham April 1, Shelter Products, Inc. Portland April 1, JDL Development, Inc. Portland April 1, Pioneer Roofers, Inc. Portland April 1, Cascade Energy Engineering Portland April 1, Pacific Air Comfort, Inc. Roseburg April 1, Romtec, Inc. Roseburg April 1, Tomco Electric, Inc. Bend May 1, George M Sutton RV Eugene May 1, The Ulven Companies Hubbard May 1, Impartial Medical Opinions, Inc. Lake Oswego May 1, Spot Security, Inc. Portland May 1, Hendon Construction Company, Inc. Umatilla May 1, Equity Financial Services, Inc. West Linn May 1, Beaverton Bakery, Inc. Beaverton June 1, Willamette Plastics, Inc. Canby June 1, Neurosurgery Specialists LLC Eugene June 1, Real Pro Systems Eugene June 1, SOFCU Community Credit Union Grants Pass June 1, Smucker Manufacturing, Inc. Harrisburg June 1, Round Up City Dodge Pendleton June 1, ,890 Special Districts Association of Oregon Salem June 1, Pioneer Nursing Home Health District Vale June 1, Anderson Logging (Gossard Pyron) Crescent Lake July 1, Best Care Treatment Services Redmond July 1, Agate Resources Eugene July 1, Vrens and Son, Inc. Hermiston July 1, 2007

9 Discover the Source. PO Box 7068 Eugene OR Not sure who to contact with questions? Just clip and save for easy reference. PacificSource Customer Service (541) from Eugene; (888) from other areas Fax (541) Questions about member benefits or eligibility Questions about the status of a specific claim or EOP PacificSource Provider Service Representatives PacificSource Health Services (541) from Eugene; (800) from elsewhere [email protected]; Fax (541) Requests for preauthorization and referral authorization Case management Phone (541) from Eugene or (800) from other areas [email protected]; Fax (541) 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: Benton, Coos, Curry, Douglas, Jackson, Josephine, Lane, Lincoln, or Linn Oregon Counties: Clackamas, Clatsop, Columbia, Marion, Multnomah, Polk, Tillamook, Washington, or Yamhill Washington Counties: Clark, Cowlitz, Klickitat, Pacific, Skamania, or Wahkiakum Oregon Counties: Baker, Crook, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Klamath, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, or Wheeler Idaho Counties: Ada, Boise, Canyon, Elmore, Gem, Owyhee, Payette, or Washington Your Service Representative is: Stephanie De Less (541) / (800) , ext [email protected] Debbie Smith (541) / (800) , ext [email protected] Jeannette Curtis (541) / (800) , ext [email protected]