PARTNERS HEALTH PLAN (PHP)...BILLING WITH AN EHR---CLAIMS Upon submission of billing claims,...

Post on 09-Aug-2020

7 views 0 download

Transcript of PARTNERS HEALTH PLAN (PHP)...BILLING WITH AN EHR---CLAIMS Upon submission of billing claims,...

PARTNERS HEALTH PLANPHP CARE COMPLETE FIDA-IDD

TRAINING FOR DEVELOPMENTAL DISABILITIES PROVIDER NETWORK

June 16, 2017

AGENDA

Welcome & Introduction

Care Management/Interdisciplinary Teams (IDT)/Life Plans

Enrollment/Service Authorizations/ClaimsSubmission/Payment Options

MediSked & HS Portals

PHP MISSION AND VALUES

Mission:

PHP is a person-centered organization that supports members to live the life they choose.

Values:

PHP Promotes Wellness

PHP Supports Choice

PHP Integrates Services

PHP Respects Diversity

PHP Promotes Quality of Life

3

FIDA – IDD: PHP Care Complete

Fully Integrated Dual Advantage (FIDA)

Must be dually eligible (Medicare/Medicaid)

Federal Demonstration project

FIDA-IDD for dually eligible individuals who are 21 or older, eligible forOPWDD services; meet ICF/IDD level of care

Benefit package includes Medicare A & B; Part D; Medicaid drugs; LTSS; allDD services

No cost-sharing (deductibles/co-payments/co-insurance)

Only FIDA in the country exclusively for people with IDD

SERVICE AREA

9 COUNTIES:

Bronx

Kings

Nassau

NY (Manhattan)

Queens

Richmond (Staten Island)

Suffolk

Rockland

Westchester

The individual has a two person team, specific to their needs:

A Clinical Care Manager (CM) is a RN, or a clinically licensed SW orPsychologist. The CM administers PHP’s comprehensive IAM assessment,develops and oversees the life plan with the member and their IDT, andprovides additional medical or clinical oversight. They also provide additionalcontacts and home visits, supports to the families, transition planning,hospital/ER follow-ups, etc.

A Care Coordinator (CC), must be a QIDP and is trained as a POM interviewer.The CC administers the POM interviews, also assists with additionalassessments, accesses and monitors member services/supports, providesmember/family contacts and conducts non clinical care coordination activities,such as scheduling appointments, monitoring Medicaid/Medicare eligibility,scheduling non emergency transportation, etc.

THE CARE COORDINATION TEAM

SUMMARY OF THE PHP MODEL OF CARE

Eligibility

Individualized Assessment

Stratification Living situation

Health and BehaviorNeeds/Challenges

Individualized Service Plancalled the Life Plan integrates IPOP requirements and

POM results

IDT Team Meeting with member

Implement the Life Plan

Allows for Information to beShared Among DD Providers,Healthcare Providers, theIndividual, the Family, and theCare Coordination team

Tracking of Outcomes andEffectiveness of Care

7

WHAT MAKES IAM DIFFERENT? I AM captures and develops services to meet people’s hopes and dreams as well as more

traditional requirements for health and safety.

I AM develops a list of specific goals and actions for natural supports and service providers to follow.

I AM integrates the Council for Quality and Leadership’s Personal Outcome Measures (CQL POMs) by attaching them to specific goals.

I AM provides standard print outs of contact information, allergies, emergency fact sheets, durable equipment needs and an integrated action plan.

I AM provides a list of preferences and supportive routines which have been developed and/or reviewed by Dr. Pomeranz.

I AM also results in six vignettes written by the person or by the person’s circle of support which taken together represent the person’s story.

I AM represents the powerful voice of the person with IDD.

SPECIALIZED INTERDISCIPLINARY TEAM (IDT)

The IDT is led by the CM, and is chosen by the member/designated representative.

It’s individually tailored to help meet member’s health and safety needs as well as their personal goals.

The team includes member and/or designated representative, their care coordination team, circle of support and their Developmental Disabilities and other service providers (including PCP, specialty Drs.) active in their life plan.

The IDT meets for routine LP meetings and unscheduled events to help assess member’s needs and preferences, develop and approve the Life Plan, and authorizes most supports/services in the Life Plan.

Services/Supports are integrated into an electronic system which is shared with members and others who have approved access.

LIFE PLAN

The Life Plan (LP) document replaces a person’s current ISP. It includes all required elements of the ISP and more.

It integrates preventive and wellness services, medical and behavioral health care management, personal safeguards, along with personal preferences and dreams. It also services as authorization of person’s supports and services.

The Life Plan is generated after all assessments, reviews and team meetings are completed, through MediSked Coordinate’s system.

Two major components to a Life Plan:

Personal Safeguards

Valued Outcomes

LIFE PLAN

The interdisciplinary team meeting finalizes the Life Plan. The participant ispresent at the meeting.

Authorizations for services come from the Life Plan.

The Life Plan, with it’s safeguards and goals, is monitored monthly for progress

Full review and updates are completed semi-annually, at a minimum. Certainevents may trigger review and revision of LP more frequently.

PHP MODEL OF CARE LOOP

PHP’s INTEGRATED ELECTRONIC SYSTEMS

PHP’s electronic systemsare integrated to allow fordistribution and review ofcritical Member data in realtime.

This solution allows theMember, IDT and providersto log and respond toMember events as theyhappen.

MEMBER IDENTIFICATION CARD

CARE MANAGER (CM) AND PRIMARY CARE PHYSICIAN (PCP)

CM NAME AND PHONE NUMBER PRINTED ON ID CARD

PCP NAME AND PHONE NUMBER PRINTED ON ID CARD

A NEW ID CARD WILL BE GENERATED IF THE CM AND/OR PCP HAS CHANGED

CAN PRINT ID CARD FROM PROVIDER PORTAL

CLAIMS SUBMISSION

Change HealthCare (formerly EMDEON) EDI SUBMITTER NUMBER 14966

837 ELECTRONIC CLAIM SUBMISSIONS

EMDEON PHONE # (877) 363-3666

THIS SUBMITTER ID WILL NOT BE VIEWABLE ON THEIR DROPDOWN MENU UNTIL4/1/16

DIRECT SUBMISSIONS TO HEALTHSMART

(888) 744-6638

PAPER CLAIMS:

Partners Health Plan

PO Box 16309

Lubbock, TX 79490

BILLING WITH AN EHR--AUTHORIZATIONS

Insurance records for PHP members will be populated automatically in EHRvia the Connect Exchange interface. Insurance data will appear on themember record (in Connect, on the More Information Page in theInsurance/Private Pay section).

BILLING WITH AN EHR---CLAIMS

Upon submission of billing claims, agencies will be prompted to send PHP member claims to HealthSmart using HIPAA 837 forms through Change HealthCare (formerly Emdeon).

INSTITUTIONAL VS. PROFESSIONAL CLAIM FORM TYPES

INSTITUTIONAL

837I

UB04

PROFESSIONAL

837P

CMS1500

PLACE OF SERVICE CODE VALUES

PROFESSIONAL CLAIMS

BOX 24B

2-DIGIT VALUE

https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

12 Home

Location, other than a hospital or other facility, where the patient receives care in a private residence.

99Other Place of Service

Other place of service not identified above

PARTICIPANT ID

THIS IS THE ID NUMBER PRINTED ON THE ID CARD THAT YOU SHOULD BE USINGON THE CLAIM SUBMISSION

13-NUMERIC VALUE

4500XXXXXXXXX

NOT THE PARTICIPANT’S:

SOCIAL SECURITY NUMBER

NY MEDICAID CERTIFICATION IDENTIFICATION NUMBER (CIN)

CMS HEALTHINSURANCE CLAIM NUMBER (HICN)

AUTHORIZATIONS

IDT APPROVES AND GENERATES AS PART OF THE LIFE PLAN

DATA IS COMMUNICATED FROM CARE MANAGEMENT / UTILIZATIONMANAGEMENT SYSTEMS TO HEALTHSMART FOR CLAIMS ADMINISTRATION

ICD10

REQUIRED FOR SERVICES RENDERED ON AND AFTER OCTOBER 1, 2015

CLAIMS SUBMITTED USING ICD9 CODES OR WITHOUT AN ICD DIAGNOSIS CODEWILL NOT BE CONSIDERED FOR PAYMENT

DIAGNOSIS CONVERTER

http://www.icd10data.com/Convert

RATE CODES

OPWDD RATE CODES AS OF OCTOBER 1, 2015

ADDING PHP/HS STAFF EMAIL TO RECEIVE ENTITY-SPECIFIC REIMBURSEMENTUPDATES

RATEUPDATES@PHPCARES.ORG

REIMBURSEMENT

Provider reimbursement will be limited to the lower of either the submittedcharge/fee or the Medicare/Medicaid fee schedule (as applicable).

For example:

If a provider submits a claim with a line charged amount of $50 but the fee schedule amount for the procedure code billed is $60, PHP will reimburse the provider $50 as this is the lower of the submitted charge vs. fee schedule amount.

PROMPT PAYMENT OF CLAIMS

30 DAYS FOR ELECTRONIC CLAIM SUBMISSIONS

45 DAYS FOR PAPER CLAIM SUBMISSIONS

30 DAYS TO REQUEST ADDITIONAL INFORMATION OR DENY THE CLAIM

CHECK RUN CYCLE

WEEKLY

TUESDAY NIGHTS

WEDNESDAY PAYMENT GENERATED

CLAIM PAYMENT OPTIONS

HARDCOPY PAPER CHECK PAYMENT MAILED TO PROVIDER’S BILLING ADDRESS

STALEDATED AFTER 180 DAYS

ELECTRONIC FUNDS TRANSFER (EFT)

VPay®

IS A UNIQUE ELECTRONIC REPLACMENT FOR PAPER CHECKS THAT ELIMINATES THE HASSLES OFPAYEE EFT ENROLLMENT AND WORKS WITH EXISTING PAYEE SOFTWARE AND HARDWARE. AVIRTUAL CARD SOLUTION DESIGNED SPECIFICALLY FOR CLAIM PAYMENTS. THIS UNIQUEAPPROACH WILL SIGNIFICANTLY REDUCE YOUR COST RELATED TO PROCESSING, DELIVERING ANDRECONCILING PAPER CHECKS

DELIVERED TO THE PAYEE ELECTRONICALLY, EITHER BY FAX OR SECURE EMAIL. THE PAYEEPROCESSES THE PAYMENT JUST LIKE ANY OTHER CREDIT CARD TRANSACTION; ENTER THE CARDNUMBER, SECURITY CODE, EXPIRATION DATE AND THE AMOUNT INTO YOUR MERCHANT TERMINAL

VPay® CUSTOMER CARE 1-877-657-8560

8 am – 8 pm EST

TIMELY FILING PARAMETERS

PARTICIPATING PROVIDERS

120-DAYS FROM THE DATE OF SERVICE UNLESS CONTRACTED OTHERWISE

CLAIMS FOR DATES OF SERVICE BEYOND 365 DAYS WILL NOT BE CONSIDEREDFOR PAYMENT

INSTITUTIONAL BILL TYPES – CLAIM ADJUSTMENTS

XX5 LATE CHARGES ONLY

DENIED TO RESUBMIT AS AN XX7 REPLACEMENT OF A PRIOR CLAIM

XX7 REPLACEMENT OF A PRIOR CLAIM

WILL RESULT IN ADJUSTMENT OF ORIGINAL CLAIM SUBMITTED AND REPROCESSING OF XX7 CLAIMSUBMISSION

XX8 VOID/CANCEL OF PRIOR CLAIM

WILL RESULT IN ADJUSTMENT OF ORIGINAL CLAIM SUBMITTED

CLAIM APPEALS If a provider disagrees with an authorization-related denial or if the provider

disagrees with the manner in which a claim was processed, the provider has the right to file an appeal with PHP within 60 days from the date of determination or denial. Out-of-network providers must submit a waiver of liability with their appeal. In-network providers must submit an Appointment of Representative (CMS Form 1696). Appeals must include the following information:

Claim number

Authorization number (if applicable)

Participant name and Partners Health Plan number

Date(s) of service

Service code(s) billed

Unit(s) value billed

Amount billed

Reason for appeal

Waiver of Liability (non-contracted providers only)

CLAIM APPEALS (Cont.) Correspondence:

PARTNERS HEALTH PLAN

PO Box 16309

Lubbock, TX 79490

Appeals must be submitted in writing and mailed to:

Partners Health Plan

Attn: Appeals & Grievances

PO Box 16309

Lubbock, TX 79490

STATEMENT OF REMITTANCE (SOR)

GENERATED WITH PAYMENT

AVAILABLE ON PROVIDER PORTAL

PAPER VS. ELECTRONIC 835

DENIAL CODES

EXPLANATION OF BENEFITS (EOB)

PARTICIPANTS WILL NOT RECEIVE AN EXPLANATION OF BENEFITS

NOT REQUIRED TO GENERATE

MEMBER COST-SHARING

PARTICIPANTS DO NOT HAVE ANY OUT OF POCKET EXPENSES FOR COVERED BENEFITS

ID CARD INDICATES:

Copays: PCP/Specialist: $0 ER: $0 Rx: $0

PARTICIPANTS CANNOT BE BALANCE BILLED

PROVIDER SERVICES

1-855-747-5483 TTY 711

HOURS OF OPERATION

8AM – 6 PM WEEKDAYS MONDAY THROUGH FRIDAY

AFTERHOURS - LEAVE MESSAGE TO BE RETURNED NEXT BUSINESS DAY

CLOSED ON 10 FEDERAL HOLIDAYS

PHP WEBSITE

www.phpcares.org

HEALTH SMART PROVIDER PORTAL

From the login page, existingusers can sign in to theirregistered account, accessour self-service tools to reseta forgotten password. Newusers can initiate theautomated registrationprocess.

https://php.healthsmart.com

HEALTH SMART PROVIDER PORTAL

Automated provider registration allows newweb-users near instant access. Automatedregistration is available for all NY PHP networkparticipating providers, and out-of-networkproviders who have valid claims records onfile.

HEALTH SMART PROVIDER PORTAL

Provider Manuals, plancontact information, andother documentation isavailable under theDocuments and Resourcestabs.

HEALTH SMART PROVIDER PORTAL

Eligibility information includesgroup name and number, andeffective date for theParticipant in question. Usersmay also view the Participant’sPCP and Care Manager details.

HEALTH SMART PROVIDER PORTAL

Clicking ‘View ID Card’opens an embeddedimage of theParticipant’s actual IDcard. This image canbe saved, emailed, orfaxed from the site viathe ‘Select Action’menu.

HEALTH SMART PROVIDER PORTAL Claim results display

any claim matchingthe search criteria.

Pre-defined dateranges and calendarpop-ups for specificdate searchesprovide an easy-to-navigateexperience.

MEDISKED PROVIDER PORTAL

Provider Portal dashboard grants tailored access to member recordsand enables providers to quickly view members and notifications.

My Members

MEDISKED PROVIDER PORTAL - PLANS

45

Approved providers view and/or approve plans via the person-centered member access portal.

Plans contain POMs, goals, and action types providers mustwork on with the member.

MEDISKED PROVIDER PORTAL –PLAN APPROVAL

46

Approval or rejection messages are returned directly to themember’s Care Coordination team.

MEDISKED PROVIDER PORTAL -ASSESSMENTS

47

If granted access, providers may view “It’s AllAbout Me” assessments completed by the CareCoordinator and Care Manager.

Our Job is to keep members safe and healthy and to Support the Life They Choose!

PHP is governed by providers who have a long history of service to peoplewith IDD and their families

PHP uses a person centered process that addresses people’s health and safetyneeds and their personal goals, and helps to develop and implement a processto reach them.

PHP will work closely with members and their families to understand whatthey need and what they want, even when they are not able to communicatethrough typical means.

PHP will work closely with providers to help members “Get A Life!”

48