27. Will the plan pay for radiology done in the provider s office? How do providers request assistance with care management issues?...

Transcription

1 Provider Q&A

2 Contents 1. Who is Florida True Health? What is the new product name? Does the plan have a website? How will physicians be paid? (FFS or capitation) What clearing house does the Plan participate with? Where will providers send claims for payment? Can providers receive payments through EFT? How often will providers get paid, what is the payment cycle? What is the average turnaround time on clean claims payment? What are the timely filing requirements? Where do providers send paper claims? Will Eligibility and Claims Status be available electronically? What hospitals participate with Florida True Health? What reference labs participate with Florida True Health? What services will need prior approval? Are there any copayments for Florida True Health? If providers have questions, who or where do they call? Will providers be assigned a Provider Representative? How often will providers see them? How will Florida True Health communicate with providers? Who is the Plan s Medical Director? Are there practice guidelines that providers have to follow? What is the Plan s credentialing process? Does the Plan require Physician Assistants (PA) and Advanced Registered Nurse Practitioners (ARNP) to be credentialed with the Plan? Can PAs and ARNPs treat Florida True Health patients? Does the Plan contract at the individual or group level? Will the Plan require referrals to specialists?

3 27. Will the plan pay for radiology done in the provider s office? How do providers request assistance with care management issues? What are the basic benefits that will be provided by Florida True Health? Will the Plans nurses do concurrent review on site or telephonically? What is the time requirement for calling in an inpatient admission? Do you do retrospective reviews on inpatient/outpatient services? When will the provider handbook be finished? What edits will the Plan be using Medicaid or Medicare NCCI or something else? What are the rules surrounding observation, overlapping claims (such as same day and 3 day) and Condition Code 44? Will retrospective authorizations be considered? What quality measures will you monitor? How long will the credentialing process take? Will there be referral or authorization requirements for urgent care clinics? If a patient comes into the PCP office and the physician identified on the member s card is not one of our physicians and the patient wants to change PCP offices what should we do to ensure payment? Will out-of-network providers be paid if not in network?

4 1. Who is Florida True Health? Florida True Health, Inc., an affiliate of Florida Blue, has submitted applications to both the Office of Insurance Regulation (OIR) to become a licensed HMO and to the Agency for Health Care Administration (AHCA) for approval to participate in the Florida Medicaid program in Florida True Health has the strength of Florida s largest insurer and the necessary Medicaid experience and administrative support of AmeriHealth Mercy Health Plan (AmeriHealth.) 2. What is the new product name? True Blue is the Medicaid product name. 3. Does the plan have a website? Yes. The website address is and it will be updated with provider resources on an ongoing basis following approval by AHCA. 4. How will physicians be paid? (FFS or capitation) All physician reimbursement is based on the Medicaid Fee Schedule. 5. What clearing house does the Plan participate with? Emdeon. Emdeon is currently preparing for Florida True Health claims transactions and is available for provider calls at Where will providers send claims for payment? Electronic Claims Submission (EDI) If providers would like to transmit claims electronically, providers should contact their EDI software vendor, and be prepared to specify Florida True Health s payer ID # or, call Emdeon's customer service at Paper claims should be sent to: Florida True Health Claims Processing Department P.O. Box 7337 London, KY

5 7. Can providers receive payments through EFT? Yes. Electronic Funds Transfer (EFT) EFT simplifies the payment process by: Providing fast, easy and secure payments Reducing paper Eliminating checks lost in the mail Not requiring you to change your preferred banking partner Providers will be able to enroll through our EFT partner, Emdeon Business Services and complete an Enrollment and Authorization Form, or call to enroll in EFT. Electronic Remittance Advice (ERA) For information about, or to sign up to receive Electronic Remittance Advice (ERA), call Emdeon's customer service at We will include further details and information during our provider orientation and workshops. 8. How often will providers get paid, what is the payment cycle? Our payment cycle is weekly. 9. What is the average turnaround time on clean claims payment? Our average time period for paying clean claims is less than 30 days. 10. What are the timely filing requirements? Original invoices must be submitted to the Plan within 180 calendar days from the date services were rendered or compensable items were provided. Re-submission of previously denied claims with corrections and requests for adjustments must be submitted within 365 calendar days from the date services were rendered or compensable items were provided. Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer s EOB. Claims 4

6 originally rejected for missing or invalid data elements must be corrected and re-submitted within 90 calendar days from the date of the remittance. Rejected claims are not registered as received in the claim processing system. 11. Where do providers send paper claims? Paper claims should be sent to: Florida True Health Claims Processing Department P.O. Box 7337 London, KY Will Eligibility and Claims Status be available electronically? Member eligibility inquiry and claims status inquiry will be available via our provider portal, Availity at Plan go-live. 13. What hospitals participate with Florida True Health? Florida True Health will contract with hospitals to provide adequate service in the coverage area. 14. What reference labs participate with Florida True Health? Negotiations are underway for agreements with several reference labs in the service area. 15. What services will need prior approval? Services Requiring Authorization All out-of-network services (except emergency services) In-patient services All inpatient hospital admissions, including medical, surgical and rehabilitation Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal delivery and 96 hours after caesarean section In-patient medical detoxification Elective transfers for inpatient and/or outpatient services between acute care facilities Long-term care initial placement if still enrolled with the plan 5

7 Home-based services Home health care (after 12 visits for therapies and 6 visits for skilled nurse visits) Private Duty Nursing and Extended Home Health Services Private duty nursing (covered when medically necessary for under age 21) Home health extended services (for under age 21) Therapy and related services Speech therapy, occupational therapy and physical therapy (after 12 visits for each modality) Cardiac rehabilitation Transplants, including transplant evaluations Injectable medications not listed on the Medicaid Fee Schedule are not covered by the Plan Medications 17-P and all infusion/injectable medications listed on the Florida Medicaid Practitioner Fee Schedule for injectables with billed amounts of $250 or greater Surgical services that may be considered cosmetic Cochlear implantation (covered for members under 21) Gastric bypass/vertical band gastroplasty Hysterectomy Pain Management external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and nerve blocks Radiology Services* CT scan MRI MRA Nuclear cardiac imaging All unlisted and miscellaneous codes. *Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization 16. Are there any copayments for Florida True Health? No there are no copayments. 17. If providers have questions, who or where do they call? Providers may contact our provider network management team in Florida at our toll free number, , for assistance with any questions about Florida True Health. In the very near future, we will provide a one page 6

8 reference guide with important contact information and contact numbers, and we will have this available on our website. 18. Will providers be assigned a Provider Representative? How often will providers see them? A Provider Network Account Executive (AE) will be the provider representative for the Plan. AEs will work with providers as frequently as desired. At a minimum, AEs plan to meet in person with providers as follows: If a PCP the AE will meet with the provider at least quarterly, or as requested. If a Specialist the AE will meet with the provider every six months, or as requested. Hospital/Ancillary providers the AE will meet annually. Providers may request a site visit at any time to address any questions and/or concerns with the Plan. 19. How will Florida True Health communicate with providers? Communications to Florida True Health providers occur through on-site orientations for newly contracted providers, routine site visits, provider workshops, and letters to specific providers, the provider handbook, the provider web site, and provider newsletters. Additionally, Florida True Health will conduct an annual provider satisfaction survey to assess satisfaction. 20. Who is the Plan s Medical Director? Dr. Donald Grossman is the Medical Director for Florida True Health. 21. Are there practice guidelines that providers have to follow? We recognize the practice guidelines identified by NCQA and referenced as HEDIS measures. Information may be accessed at Florida True Health offers several condition management programs to address the expected high-incidence conditions for which there are evidence-based protocols that have been shown to improve health outcomes. The following programs are available for Florida True Health members: Diabetes, Heart Disease, Sickle Cell Disease, COPD and Asthma. Our programs promote the 7

9 use of the below nationally-accepted guidelines in the delivery of health care services: Condition Clinical Evidence-Based Guideline COPD Sickle Cell Disease Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) National Heart, Lung, and Blood Institute: Division of Blood Disorders and resources: The Management of Sickle cell Disease mngt.pdf CDC-Sickle Cell Disease Diabetes American Diabetes Association: Clinical Practice Recommendations Heart Disease 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease Asthma Global Initiative for Asthma (GINA) Guidelines for the Diagnosis and Management of Asthma. [National Institute of Health (NIH) 2009] 8

10 22. What is the Plan s credentialing process? Florida True Health works with the Council for Affordable Quality Healthcare (CAQH) to offer our providers the Universal Provider Datasource that simplifies and streamlines the data collection process for credentialing and recredentialing. Through CAQH, providers furnish credentialing information to a single repository, via a secure Internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. Florida True Health s goal is to have all of our providers enrolled with CAQH. There is no charge to providers to submit applications and participate in CAQH. If providers participate with CAQH they do not need to complete a full application for our Plan, just provide their CAQH provider ID # and name(s) and complete our one page check list, and authorize our Plan to obtain information from CAQH, and either fax, mail or this form to Florida True Health. Refer to the Florida True Health Provider Agreement Check List and the CAQH form. Florida True Health will submit a request to CAQH for credentialing information on the provider s behalf. If providers are unable to enroll with CAQH a full paper application form must be completed and submitted to the Plan. Providers may contact our credentialing team at to obtain the complete application and for assistance. We provide the CAQH form on our website at under provider resources, credentialing. Providers may contact the credentialing team at for assistance. Providers may call the CAQH help desk at for assistance if needed. 23. Does the Plan require Physician Assistants (PA) and Advanced Registered Nurse Practitioners (ARNP) to be credentialed with the Plan? Yes. 9

11 24. Can PAs and ARNPs treat Florida True Health patients? Yes. ARNPs and PAs when practicing under the supervision of a physician specializing in Family Practice, General Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology may also qualify as a PCP under the Florida contract. 25. Does the Plan contract at the individual or group level? We contract at the group level unless the provider is a solo practitioner or part of a diagnostic center which will require us to contract with the provider as an individual. 26. Will the Plan require referrals to specialists? No. Referrals to specialists will not be required for participating providers. 27. Will the plan pay for radiology done in the provider s office? Yes we pay for medically necessary radiology performed in a provider office. 28. How do providers request assistance with care management issues? Providers will be able to contact our care managers directly. Contact information will be provided during the provider orientation process. 29. What are the basic benefits that will be provided by Florida True Health? The following information regarding the Florida True Health s covered services is provided as a brief overview. Detailed Medicaid services information may be found in the Florida Medicaid Coverage and Limitation Handbooks and the Provider Reimbursement Handbooks which are available at Florida True Health covered services are as follows: Advanced Registered Nurse Practitioner Services Ambulance - Emergency use only Birth Center Services Child Health Check-Up Services Chiropractic Services 10

12 Community Behavioral Health Services County Health Department Services Dental Services Members receive dental benefits through DentaQuest Durable Medical Equipment and Medical Supplies Dialysis Services Emergency Room Services Family Planning Services Freestanding Dialysis Centers Hearing and Vision Services Home Health Care Services Hospital Services: Inpatient & Outpatient Immunizations Independent Laboratory Services Licensed Midwife Services Optometric Services Physician and Physician Assistant Services Podiatry Services Portable X-ray Services Prescribed Drugs Primary Care Case Management Services Rural Health Clinic Services Targeted Case Management Therapy Services: Occupational, Physical, Respiratory, Speech Transplant Services Hospital specific additional questions: 30. Will the Plans nurses do concurrent review on site or telephonically? Florida True Health nurses will conduct concurrent review telephonically. 31. What is the time requirement for calling in an inpatient admission? The Plan must be notified of an inpatient admission within one (1) business day. 11

13 32. Do you do retrospective reviews on inpatient/outpatient services? Florida True Health conducts retrospective reviews on a case by case basis if there is a reason prior authorization could not be requested. 33. When will the provider handbook be finished? The Florida True Health provider handbook is complete and has been submitted to AHCA for approval. Following approval the provider handbook may be accessed on our website at What edits will the Plan be using Medicaid or Medicare NCCI or something else? Florida True Health claim payment policies are based on guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), National Correct Coding Initiative, the American Medical Association (AMA), State regulatory agencies and medical specialty professional societies. In making claim payment determinations, Florida True Health also uses coding terminology and methodologies that are based on accepted industry standards, including the Healthcare Common Procedure Coding System (HCPCS) manual, the Current Procedural Terminology (CPT ) codebook and the International Classification of Diseases (ICD) manual. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefit design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding Florida True Health s claim payment policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, Florida True Health will use reasonable discretion in interpreting and applying payment policy to health care services provided in a particular case. Other factors affecting reimbursement may supplement, modify or in some cases, supersede claim payment policies. These factors may include, but are not limited to: legislative or regulatory mandates, the provider contract, and/or the member s eligibility to receive the health care services. 12

14 35. What are the rules surrounding observation, overlapping claims (such as same day and 3 day) and Condition Code 44? Observation services are those services furnished by a hospital on the hospital premises, including use of a bed and periodic monitoring by a hospital s nursing staff or other staff which are reasonable and necessary to determine the need for a possible admission to the hospital as an inpatient. Most observation services do not exceed 1 day. Some patients may require a second day of outpatient observation services. A maximum of 48 hours of observation may be reimbursed. When a patient receives hospital observation services and is thereafter admitted as an inpatient of the same hospital, the hospital observation services are included in the hospital's payment for the inpatient services. 36. Will retrospective authorizations be considered? Florida True Health conducts retrospective reviews on a case by case basis and depends in part on whether there is a reason prior authorization could not be requested. 37. What quality measures will you monitor? We monitor standard measures associated with HEDIS, along with member satisfaction, utilization metrics and service measures (e.g. phone answer time, appointment availability, etc.). For providers, the focus is on HEDIS measures, utilization and appointment availability/after-hours coverage. 38. How long will the credentialing process take? We are currently able to credential a physician within 7 days, provided we have all of the necessary information. We can also expedite credentialing for select urgent cases. Additionally, we will approve services from an out-ofnetwork provider on a case-by-case basis while credentialing is in process. 39. Will there be referral or authorization requirements for urgent care clinics? We will not require a referral or authorization for urgent care services from a participating provider. Urgent care from a non-participating provider will 13

15 need to be authorized however, the provider can obtain the authorization retrospectively. 40. If a patient comes into the PCP office and the physician identified on the member s card is not one of our physicians and the patient wants to change PCP offices what should we do to ensure payment? The physician s office may assist the member to call and request the PCP change the office cannot request it on their own. If it is a one-time visit, the office may call the UM line to request approval to see the member. Additionally, the urgent care comments above will apply, including the ability to retrospectively request approval for urgent care situations. 41. Will out-of-network providers be paid if not in network? Out-of-network providers will be paid for emergency medical care. They will not be paid for routine or urgent care that is delivered unless they have authorization to provide the services. 14