2014 Spring MT Provider Workshop Presentation Final · New CMS 1500 Form (Rev 02/12) The CMS 1500...

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Spring 2014 PacificSource Provider WorkshopMontana

Presented by: Shawna Talles, Provider Service Specialist

Agenda

• NCQA• Locums Tenens • HEDIS• CMS 1500 Claim Form• Electronic Claims• ICD 10• Healthcare Reform – Exchange• PacificSource Websites

PacificSource Total Membership

Total Membership:267,622 Covered Lives

Commercial Membership:210,631

Medicare Membership – OR & ID:17,759

Medicaid Membership - OR:39,232

Organizational Updates

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301Total Area

Membership:3,477

Exchange Membership:

767

Current Membership


302

Total Area Membership:

6,446


130


Current Membership

303


7,617


1,465


Current Membership

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304


3,197


1,568


Current Membership


National Committee for Quality Assurance

(NCQA)


PacificSource and NCQA• PacificSource began the accreditation

process in January of 2013.• Anticipate seeing PacificSource Health

Plans on the NCQA website in May or June.• We would like to thank you for your

patience and assistance.

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Examples of NCQA requirements• Required information on all rosters:

o Effective and termination dates for all licensure

o Provider directory enhancements−Hospital affiliation

−Board certification

−Language spoken

• PacificSource is required to notify members 30 days in advance of a provider leaving a practice.


Provider Changes• Provider groups shall use their best efforts

to notify PacificSource and/or their IPA promptly and in advance of the addition or termination of a provider.o We need notification from providers at least 45-

60 days prior.


Locum Tenens

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Locum Tenens Policy• For Locum Tenens providing coverage for 60 or

fewer consecutive days, we will require:o A Locum Tenens application

o Current DEA certificate

o Copy of professional liability coverage


Locum Tenens Policy• For Locum Tenens providing coverage for longer

than 60 consecutive days, we will require:o A full and complete practitioner credentialing

application.

• Locum Tenens must be credentialed prior to being paid under the absent provider’s contract.

• This policy applies to all PacificSource lines of business.


Billing for Locum Tenens • Each healthcare provider or supplier who is

rendering the service, must be listed in box 31 of the CMS 1500 form.

• PacificSource does not permit incident-to-billing.

• Claims billed prior to the locum tenens credentialing approval will be denied as provider write-off.

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HEDIS

What is HEDIS?• Healthcare Effectiveness Data and Information

Set• Required by CMS• Required for NCQA certification for any line of

business• PacificSource does HEDIS for Commercial and

Medicare• Set of standardized performance measures


HEDIS continued• Measure data sources: Admin (medical and

Rx claims), Hybrid (patient chart), and Survey• Measure Domains – Effectiveness of care,

Access, Availability, Cost of Care, Use of Services, and Health Plan Descriptive Info

• Measurement Year – Most look at care in most recent calendar year. Some look back >2 yrs

• HEDIS is a major data source for Medicare 5 Star Program and NCQA certification


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HEDIS continued• HEDIS medical record measures assess

compliance with accepted prevention and chronic condition guidelines.

• Some measures are calculated using claims data, some use medical record documentation, some use both.

• Many of the measure results are influenced or controlled by physicians.

• Members are randomly selected for medical record portion of HEDIS audits.


HEDIS continued• Information for HEDIS audit completion will

either be requested directly by PacificSource or on our behalf by our vendors: Outcomes Health for Commercial and Verisk for Medicare.

• Any questions regarding the HEDIS audit should be directed to:o Provider Network (800) 624-6052 ext 2580o Outcomes Health (855) 767-2650o Verisk Health (877) 489-8437



CMS 1500 Claim Form

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New CMS 1500 Form(Rev 02/12)

The CMS 1500 form has been updated to align with 5010 837P and accommodate ICD-10 reporting.

Changes on the form include:• Fields 8, 9b, 9c, 11b, and 30• Other fields were changed to

reflect usage.• 12 lines now available for

diagnosis codes.


Electronic vs. Paper Claims


Electronic Claims Transactions• PacificSource encourages electronic claims

submission and EFT/ERA enrollmento This includes coordination of benefit (COB)

claims.o Office Ally is freeo Availity claims now accepted electronically.o A list of participating clearinghouses and

enrollment forms are available on our website.

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PacificSource Administrators (PSA)• Effective April 1, 2014, PSA claims will be

payable via EFT.• If you are already set up to receive EFT

and/or ERA, you do not need to do anything.• New EFT enrollees will now be getting

payments for commercial and PSA members.• Updated EFT/835 enrollment form now

available on our website.


Dedicated ProviderCustomer Service Phone Number

(855) 896-5208*Benefit questions, claims inquiries, etc.


ICD-10

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ICD-10

• Implementation pushed to October 1, 2015 (at the earliest).

• PacificSource has completed:o System upgrades

o Impact assessments

o Translation Mapping ICD-9 to ICD-10

o End to end testing with several large health systems

Organizational UpdatesHas your organization begun ICD-10 planning?

Yes, 76.8%

No, 23.2%

151 People Surveyed

• Yes – 116

• No – 35

• Skipped Question – 16

Organizational UpdatesWhen do you anticipate starting your organization's education on ICD-10?

46%

23%

22%

7%

2%

Already Started – 46.4%

Q1 2014 (Jan-Mar 2014) - 23%

Q2 2014 (Apr-Jun 2014) – 22%

Q3 2014 (Jul-Sep 2014) – 7%

We don’t anticipate providing education on this topic. We don’t use ICD Codes – 2%

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Organizational UpdatesPlease estimate how much of the planning process your organization has completed.

47%

36%

13%

4% Answer Options

Response Percent

Response Count

0-25% 46.8% 51

25-50% 35.8% 39

50-75% 12.8% 14

75-100% 4.6% 5

ICD-10 Tip and Tricks• AAPC crosswalk from ICD-9 to ICD-10

http://www.aapc.com/ICD-10/crosswalks/pdf-documents.aspx.

• Visit AAPC for more helpful tools, such as:o Searchable databases

o Educational webinars

o Educational articles

o ICD-10 conversion issues and trends


ICD-10 Resources• If you have questions regarding

PacificSource and ICD-10, please email [email protected].

• Visit CMS’s website for another great resource on the ICD-10 transition: cms.gov/ICD10.

• If you are interested in end-to-end testing with us, please complete our brief survey at SurveyMonkey.com/s/T3CTNL6.


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Provider Bulletin


Provider Bulletin• PacificSource has combined our two

provider newsletters; CommunityCare(Medicare and Medicaid) and Provider Bulletin (Commercial).

• Beginning with the Spring 2014 edition, providers can expect to see topics related to all lines of business in the Provider Bulletin.


Provider Bulletin• The Provider Bulletin will be distributed

quarterly to those who have opted in to receive the newsletter as well as those who were on the distribution to receive the CommunityCare newsletter.

• Current and past newsletter editions may be found on any of our three websites.

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Provider Bulletin Commercial Site



AIM Specialty Health


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• Standardization of our authorization process for radiology services within our service area.

• More than 20 years experience effectively managing radiology services.

• AIM’s Safe Choices in Imaging program focuses on increasing awareness of health and safety issues related to radiation exposure in advanced imaging procedures.


Covered Modalities• Computed Tomography Scans

(CT)

• Computed Tomographic Angiography (CTA)

• Magnetic Resonance Imaging (MRI)

• Magnetic Resonance Angiography (MRA)

• Magnetic Resonance Spectroscopy (MRS)

• Nuclear Cardiology (e.g., SPECT scans)

• Positron Emission Tomography (PET)

Required Settings:

• Hospitals (outpatient)• Free-Standing

Imaging Facilities• Physician Offices

Excluded Settings:

• Inpatient Services• Emergency Room• 23-hour Observation• Ambulatory Surgery• Urgent Care Centers


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Online using AIM’s

ProviderPortal

Register at www.aimspecialtyhealth.com/goweb

Available 24-7/365

Via phone to the AIM Call Center

AIM’s call center: (877) 291-0510

Available Monday through Friday from 9:00 a.m. to 6:00 p.m. MST time*

Voice mails received after business hours will be responded to

the next business day


Additional Information• www.pacificsource.com/provider/prea

uthorization.aspx

• List of codes requiring review through AIM.

• Retro authorizations within 48 hours of the procedure are done by AIM.

• Retro authorizations outside 48 hours done by PacificSource.

Healthcare Reform

Healthcare ReformMontana Exchange

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Healthcare Reform

Plans Offered Through Exchange • Four benefit tiers (metal tiers):

o Platinum

o Gold

o Silver

o Bronze

Healthcare Reform

SmartHealth Network PlansMetal Level Exchange PlansBronze SmartHealth Value Bronze 6250

SmartHealth Value Bronze 3000SmartHealth Value Bronze 6350

Silver SmartHealth Balance Silver 2500SmartHealth Value Silver 3600SmartHealth Value Silver 3000SmartHealth Balance Silver 1500

Gold SmartHealth Balance Gold 1000

Healthcare Reform

Becoming a Participating Provider

• Credentialingo Forms online at www.pacificsource.com.

o Submit application with supporting documentation.

o Credentialing committee meets at the end of every month.

o Once approved, contracting will contact you.

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Pediatric Vision Benefit• Members through 18 years of age.

• Licensed ophthalmologist or optometrist

• One vision exam per year* including refraction

• One pair of non-collection glasses (lenses and frames) per year*

• Contact lens services and materials per year* *Benefits/frequencies are per calendar or per plan year. Limits on hardware also apply.

Healthcare Reform

ID Cards

ID Cards

ID Cards

2013 vs 2014

G = Commercial group coverageN = Individual policyGE = Group ExchangeNE = Nongroup Exchange (individual member)

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ID Cards

PacificSource Administrators

GS = Self-insured group handled through PacificSource Administrators.MUST = GSMXXXXXMUS = GS001302

PacificSource.com

PacificSource.com

PacificSource.com

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PacificSource.com

PacificSource.com

PacificSource.com

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PacificSource.com

PacificSource.com

PacificSource.com

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PacificSource.com

PacificSource.com

PacificSource.com

Provider Resources

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PacificSource.com

PacificSource.com

PacificSource.com

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PacificSource.com

PacificSource.com

InTouch Provider Portal


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InTouch Provider PortalInTouch for Providers• Secure, interactive website for providers

o Online eligibilityo View and submit preauthorization requestso Online claim statuso Explanation of payment

• Point of service directo Access real-time patient liability information

and your actual charges for each procedure billed


InTouch – OneHealthPort• InTouch for Providers is accessed through

OneHealthPort.

• OneHealthPort is a web portal that provides access to secure health plan websites with a single user ID and password.

• If you are already an OneHealthPort user, you do not need to register again to access InTouch.


InTouch – OneHealthPort• Register for OneHealthPort via their website:

www.OneHealthPort.com/Register/Index.php.

• Providers who need to use “Forgot My Password” or “Forgot My UserID” links can find them on the OneHealthPort sign in page.

• For questions or assistance with the registration process, please contact:

OneHealthPort’s Help Desk:(800) 973-4797

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03/01/193803/01/193803/01/1938

The search feature returns active member records only. Sally’s Sewing

Palace


Please reference the member’s ID card to verify if referral requirements apply.

Sally’s Sewing PalaceSally’s Sewing Palace



Sally’s Sewing Palace



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Populate the online form with the appropriate information.Fields marked with an asterisk* are required.








Submitting supporting documentation online speeds up the processing time for requests.


Once the prior authorization is generated, the requesting provider and the referred to provider will be able to view and track the referral request via InTouch.

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Online PharmacyPrior Authorization

Submissions

Online Pharmacy Prior Authorization Requests• Effective April 1, 2014, providers can now

submit pharmacy prior authorization requests online via the InTouch web portal.

• This includes requests for both Commercial and Medicare members.



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Explanation of Payments (EOPs) can also be found by selecting the “Billing” tab on the InTouch home page.


EOP Schedule• EFT delivery - Wednesday• Paper EOPs - mailed

Wednesday• InTouch EOP delivery -

Thursday• Holidays will delay delivery • EOPs are available for two

years

Questions?

Thank you!

2014 Spring MT Provider Workshop Presentation Final · New CMS 1500 Form (Rev 02/12) The CMS 1500...

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