MyCare Ohio Assisted Living Provider Orientation & Training

Transcription

1 MyCare Ohio Assisted Living Provider Orientation & Training

2 Opt IN Enrollees - Full duals with Buckeye Medicare and Medicaid benefits through Buckeye Medicare option to change plans monthly If member selects another MyCare MCP will be enrolled as a full dual with the new plan If member selects a plan outside the MyCare network, member retains Medicaid benefits with Buckeye. 2

3 Opt OUT Enrollees - Medicaid as Secondary Coverage with Buckeye Medicaid benefits only through Buckeye Option to change Managed Care Plans during initial 90 days of enrollment Locked in for remainder of benefit year until annual open enrollment Medicare benefits through other non MyCare payor including Fee for Service Secondary claims to be submitted to Buckeye. Will be adjudicated as secondary payor 3

4 Service Packages Services included: Medical benefits Behavioral health benefits Home & Community Based Services Pharmacy Dental Vision 4

5 e Services There are two types of assisted living services provided through the MyCare Ohio Waiver program: Assisted living services include personal care, housekeeping, laundry, assistance with medication management, meals, nonmedical transportation, social and recreational programming and 24-hour on-site staff availability to assist with unplanned needs. Community transition service helps consumers obtain the things they will need to successfully move from a nursing facility to an assisted living facility. basic household items items that you need to furnish a community residence 5

6 Transitions of Care Assisted Living Assisted Living Waiver: Provider will be retained at current rate for the life of Demonstration. 6

7 Transitions of Care - Exceptions During the transition period, change from the existing services or provider can occur in any of the following circumstances: 1. Consumer requests a change 2. Significant change in consumer s status 3. Provider gives appropriate notice of intent to discontinue services to a consumer 4. Provider performance issues are identified that affect an individual s health & welfare Plan initiated change in service provider can only occur after an in home assessment and development of a plan for the transition to a new provider 7

8 The Integrated Care Team Works Together with the Member to Find the Best Health Solutions Care Manager (Accountable Point of Contact) Accountable point of contact for the Integrated Care Team Registered Nurses, Social Workers and Counselor s. Program Coordinator Mixture of licensed/certification professionals. Focused on the physical, psychological and social welfare of the member. Community Health Worker Provides team support, and reaches out to members with health and preventive care information Waiver Service Coordinator Focuses on Buckeye members that receive services through a home and community based services waiver. Partnership with the Area Agency on Aging (AAA) for member age

9 Value That Centene Brings to Providers Timely and accurate claims payment (electronically submitted, clean claims) processed within 7 8 days of receipt Claims processing timeframe can be additional days 99% of claims are paid within 30 days Local dedicated resources: Care coordinators serve as an extension of physician offices Education of providers and support staff through orientations Provider participation on health plan committees and boards Minimal referral requirements & limited prior authorizations Electronic and web based claims submission Web based tools for administrative functions 9

10 Provider Through our main website, providers can access: Provider Newsletters Provider and Billing Manuals Provider Directory Announcements Quick Reference Guides Benefit Summaries for Consumers Online Forms Logon to and become a registered provider 10

11 On our secure portal, providers can: Verify eligibility and benefits View provider eligibility list Submit and check status of claims Review payment history Secure Contact Us There is no waiting, no on hold music, no time limits. Registration is free and easy. These services can also be handled by Buckeye Provider Services at

12 What Requires Prior Authorization? ALL Home and Community Based Services require prior authorization prior to the delivery of service Existing Services: New Services: Services that are currently in place for member will remain for 365 days. HCBS Care Coordinator will enter prior authorizations for each service into the system. Providers will receive a notice from Buckeye explaining transition process, and members we currently show have services with that provider. If you have questions if a service is authorized for the member, contact the HCBS care coordination team at Services will be based on the member s care plan. HCBS Care Coordinator will be in contact with both the member and provider. Once services are approved, prior authorization will be entered into the system by HCBS Care Coordinator. HCBS Care Coordinator will contact service providers with a prior authorization number, confirming service can now take place. All out of network non emergent services and providers require prior authorization. 12

13 MyCare Prior Authorization Request Form Providers may assist with the authorization process by using the MyCare Prior Authorization Request Form printable at MyCare Prior Auth Request Form.pdf When completing the form, choose one service type per form: Waiver Non skilled Skilled Attach the member s service plan if requesting waiver services Each request will be reviewed and processed separately allowing each service type to receive the appropriate authorization in a timely manner DO NOT COMBINE SERVICE TYPES AND UNITS ONTO ONE FORM 13

14 Claim Services Timely Filing Guidelines 365 Days from the date of service 180 Days to submit a corrected claim, request a reconsideration of payment, or to file a claim dispute *Please refer to our provider or billing manual online for more detailed information* Paper Claims Providers may submit to the following addresses: Buckeye Community Health Plan Attn: Claims P.O. Box 3060 Farmington, MO (866) Corrected Claims, and Requests for Payment Reconsideration Providers may submit to the following addresses: Buckeye Community Health Plan MyCare Ohio Claim Reconsideration P.O. Box 4000 Farmington, MO

15 Patient Liability Verify Patient Liability in MITS shown here on the Provider Claim Submission Program Exclusions 15

16 Patient Liability, Admissions & Discharges Patient Liability to be collected by the Assisted Living provider regardless of the Waiver Service Coordinator AAA will continue to be the waiver worker; when a MyCare consumer moves either into or out of an AL facility they communicate the move in order to update Program the Patient Exclusions Liability Recalculating Patient Liability can happen for new MyCare waiver enrollees going directly into an AL facility, as well as those already on the MyCare waiver who move between community and AL facility settings. Plans may automatically adjust amounts to the designated waiver providers by the amount as reported on the 834 Benefit Enrollment & Maintenance document. 16

17 Claim Services CLAIM SUBMISSION OPTIONS Electronic Claims Submission EDI More efficient, fewer errors Faster reimbursement 5-7 days from submission Requires EDI vendor or clearinghouse agreement Buckeye Provider Portal Requires registration and username/password Very efficient; fewer errors No cost to provider Faster reimbursement 5-7 days from submission Paper Claim Submission Less efficient Requires original claim forms Average reimbursement days from submission of clean claim 17

18 Submissions through a Clearinghouse EDI Partner Payor ID# Phone # s Emdeon (800) Gateway (800) SSI (800) Smart Data Solutions (651) Availity (800) Via the Provider Portal we can also: Receive an ANSI X12N 837 professional, institution or encounter transaction. Portal allows batch\individual claim submissions Generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). Please contact: Buckeye Community Health Plan c/o Centene EDI Department , extension or by e mail at: [email protected] 18

19 Paper Claim format All services must be billed to Buckeye using a UB04 or CMS 1500 form. Forms cannot be filled out by hand. Must be completed using computer software or a typewriter. All claims must be submitted within 180 days from the date of service. Program Exclusions Claims must be submitted to the following address: Buckeye Community Health Plan ATTN: Claims 3060 Farmington, MO

20 Billing Dos and Don ts Billing Dos Submit your claim within 90 days of the date of service Submit on a proper original form Don t circle data on claim forms CMS 1500 Don t add extraneous information to Mail to the correct PO Box number any claim form field Program Exclusions Submit all claims in a 9 x 12 or larger envelope Type all fields completely and correctly Use typed black or blue info only at 9 point font or larger Include all other insurance information (policy holder, carrier name, ID number and address) when applicable 20 Billing Don ts Submit handwritten claims Use red ink on claim forms Don t use highlighter on any claim for field Don t submit photocopied claim forms (no black and white claim forms) Don t submit carbon copied claim forms Don t submit claim forms via fax

21 EFT and ERA Buckeye partners with PaySpan Health delivering electronic payments (EFTs) and remittance advices (ERAs). FREE to Buckeye Providers Electronic deposits for your claim payments Electronic remittance advice presented online. HIPAA Compliant Provider Benefits with PaySpan Health Reduce accounting expenses Electronic remittance advices can be imported directly into practice management or patient accounting systems Improve cash flow Electronic payments for faster payments Maintain control over bank accounts You keep TOTAL control over the destination of claim payment funds. Multiple practices and accounts are supported. Match payments to advice quickly You can associate electronic payments with electronic remittance advices quickly and easily. Manage multiple Payers Reuse enrollment information to connect with multiple Payers. Assign different Payers to different bank accounts, as desired. For more information visit or contact them directly at (877) to obtain a registration code and PIN number. 21

22 Claims Submission: Buckeye Portal Login Step 1: Login with your username & password Program Exclusions Create An Account BE PREPARED! Your first entries will require: patient name, account/member ID (MMIS) date of birth date of service billing codes total charges days/units provider tax ID (or social sec) billing address location/facility address. 22

23 Claims Submission: Welcome Screen Step 2: Click the Claims icon CAROL CONSUMER MARTIN CONSUMER WILLIAM CONSUMER G G G PATTY PROVIDER Recent Claims & Status Check eligibility View Patients Send a Secure Message Manage Accounts Access Reports Submit Claims MARY CONSUMER G SAMUEL CONSUMER G

24 Claims Submission: Consumer Info, Claim Type Step 3: Click Create Claim PATTY PROVIDER Step 4: Enter Member ID (MMIS#) or Last Name and Date of Birth PATTY PROVIDER PATTY PROVIDER Step 5: Choose a Claim Type: CMS 1500 or CMS UB 04 CAROL CONSUMER 24

25 Claims Submission: General Info Patty provider Colored arrows will show your progress CAROL CONSUMER Step 6: Enter Patient s Account Number Step 7: Enter Diagnosis Code and click Add. If this is unknown to you, enter Diagnosis code must have at least 4 digits For example: 7777 or (the decimal is not required) Step 8: Click Next 25

26 Claims Submission: Lines of Service CAROL CONSUMER Polly Provider Step 9: Enter Date of Service. Only one date of service can be entered here. For example, the From date and the To date should be the same date. If there is a gap of 2 hours or more between visits, the visit should be a separate entry. Step 10: Choose Place of Service. Either 12 Home, or 13 Assisted Living Step 11: Enter Waiver Service Code, for example T2031 Step 12: Enter Modifiers U1,U2 or U3 26

27 Claims Submission: Lines of Service (cont d) Polly Provider CAROL CONSUMER Step 13: Check the box to confirm previously entered Diagnosis Code (checkmark will appear after you click in Charges box) Step 14: Enter DAILY charge billed on the Date of Service Step 15: Enter number of Units*. 27

28 Claims Submission: Lines of Service (cont d) Carol Consumer Polly Provider Step 16: Click Save/Update If you have additional Service Lines to include for this specific consumer, scroll to the top and click and repeat Steps until you complete all entries, then click Provider Details. You will notice that each Service Line entry will show listed in the gray shaded column on the left. Step 17: Click Provider Details when all entries are completed 28

29 Claims Submission: Provider Information Carol Consumer DO NOT CLICK OR ENTER INTO THIS AREA Step 18: Enter Provider Name, Address, City, State, Zip Step 19: Click Same as Billing Provider if Service Facility Location and Billing Provider address are the same. (For example: Assisting Living) If not, enter the Service Facility Location address information. Step 20: Click Next 29

30 Claims Submission: Attachments Colored arrows will show your progress Step 21: Upload any necessary Attachments as you have previously. Step 22: Click Next 30

31 Claims Submission: Review and Submit CAROL CONSUMER Colored arrows have shown your progress CAROL CONSUMER Step 24: Review your Claim to make sure it is correct and click Submit CAROL CONSUMER CAROL CONSUMER CAROL CONSUMER 31

32 Questions? Rena York - Manager, Home & Community Based Service Provider Relations Buckeye Community Health Plan MyCare Ohio Phone: ext Fax: [email protected] 32

33 Thank you!