HMSA QUEST Integration Plan

Par Provider Information Webinar

May 24,2017

Agenda

Excluded Providers

Member Cost Share

Service Coordination

Referrals and Pre-certifications

EPSDT

QUEST Integration Fee Schedules (HHIN)

Contact information

Q & A

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QUEST Integration members

HMSA’s QUEST Integration members

Non-ABD (Doesn't include Aged, Blind or members with

disabilities)

ABD

(Aged, Blind or members with

disabilities)

ABD and LTSS

(Aged, Blind or members with

disabilities who have additional LTSS benefits)

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Excluded Providers

Excluded Providers

What is an Excluded Provider?

Individual or Entity who is not allowed to receive reimbursement for providing Medicare or Medicaid services

HMSA is required to immediately terminate the Excluded Provider and/or affiliated provider (owners, agents or managing employees) from the provider network

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Excluded Providers

QUEST Integration Provider Responsibilities

Search Excluded Provider lists routinely (i.e. monthly) to confirm that employees or contractors are not on any list AND

Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list

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Federal Excluded Provider Lists

6/5/2017 7

• General Services Administration Excluded Parties List System (EPLS)

• https://www.sam.gov/index.html/#1#1#1

• List of Excluded Individuals and Entities (LEIE), a health care specific exclusion list

• https://exclusions.oig.hhs.gov/

State Excluded Provider Lists

Government contracting exclusion list

http://spo.hawaii.gov/for-state-county-personnel/manual/debarment/

DHS Med-QUEST Division’s exclusion list

http://www.med-quest.us/providers/ProviderExclusion_ReinstatementList.html

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Service Coordination

Service Coordination

A person-centered service delivery system

Ensures the needs of those with special health care needs and those receiving long term services and supports are met

Service coordinators assist in coordinating services with other agencies, programs, and community services

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Service Coordination

Who is eligible?

QUEST Integration members with Special Health Care Needs (SHCN). May include:

Patients with chronic conditions such as asthma, diabetes, hypertension, cancer, or COPD

Patients who are outliers for emergency room utilization

Patients being discharged from an acute care setting

Patients with hospital readmission within the previous 30 days

Children with autism

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Service Coordination Responsibilities of Coordinators

Support the PCP

Conduct member functional assessments

Develop and monitor a service plan based on results of the assessment or reassessment

Coordinate and facilitate access to services with providers, programs, and community agencies

Monitoring progress with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. As applicable

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Requesting Service Coordination Fax the form at:

https://hmsa.com/portal/provider/HMSA_QUEST_Integration_Service_Coordination_Referral_Form.pdf

Oahu fax: 944-5604

Neighbor Islands toll-free fax: 1(855) 856-4176

May also call HMSA

Oahu: 948-6997

Neighbor Islands toll-free: 1 (844) 223-9856

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Member Cost Share

What is Cost Share?

Members who do not meet Medicaid financial eligibility requirements

Cost Share amount determined by Med-QUEST

Members responsible for paying their Cost Share monthly

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Providers who collect Cost Share

• Nursing Facilities • Skilled or private duty nursing

• Hospital Wait-listed • Community Care Foster Family Homes

• Personal Assistance • Expanded Adult Residential Care Homes

• Adult Day Health • Respite Care

• Adult Day Care

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Identifying members who have Cost Share

HMSA Service Coordinator contact providers to discuss cost share amounts to collected

Service Coordinators send copy of Member’s Cost Share Agreement to the provider

Providers may check the Med-QUEST eligibility website: hiweb.statemedicaid.us

Providers may also call QUEST Integration Provider Service at 948-6486 (Oahu) or 1 (800) 440-0640 toll free Neighbor Islands

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Entering Cost Share amounts collected

on Claims

Cost Share amounts must be entered on claims

submitted by these providers

UB-04: Use Value Code 23 in Form Locator 39

CMS 1500: Enter cost share amount in Block 29

Use equivalent fields for electronic claims

Cost Share process

Med-QUEST

Division (MQD) determines

member’s cost share amount

HMSA Service Coordinator meets with member to:

1. Explain their cost share responsibility

2. Have member sign Cost Share agreement

HMSA sends copy of agreement to

provider

Payment made to provider

HMSA payment is reduced by the

amount of the cost share

Provider files claim to HMSA indicating Cost Share amount

collected

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Cost Share

If member’s Cost Share exceeds the claim amount, HMSA sends provider an invoice asking them to send the balance to:

HMSA Attn: F & A Disbursements P. O. Box 860 Honolulu, HI 96808

Providers may opt to have invoice amounts deducted from future Reports to Provider

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Cost Share

Cost Share amounts are applied to claims submitted by designated providers

Retroactive changes to Cost Share result in reprocessing of claims to reflect current cost share amounts

Referrals

Referrals

Self referrals

All other specialty care requires PCP referral

Register these referrals with HMSA

Plastic surgery services

Off - island specialist services

In-state out of network referrals

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• Behavioral health (OP) • Family Planning

• Refractive vision services • Well-woman exam and mammogram

How to Register a Referral

Referral form is at: http://www.hmsa.com/PORTAL/PROVIDER/FM.HMSA_QUEST_Referral_Form.pdf

Fax the referral form 948-5648 (Oahu) 1 (800) 960-4672 (toll-free)

Register the referral online via HHIN Select “Submit Referrals” tab, then click on “iExchange”

Call QUEST Integration Provider Service 948-6486 (Oahu) 1 (800) 440-0640 (toll-free)

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Precertification

Precertification (Prior Authorization)

List of QUEST Integration services requiring pre-certification: https://hmsa.com/portal/provider/zav_QI.01.SER.50.htm

Clearly identify urgent/emergent cases for expedited review

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Precertification (cont.)

Unit/Partner Responsible for

HMSA Medical Management

Medical/Surgical, LTSS, Post-Acute Care Services, Speech Therapy, Out of State Referrals

National Imaging Associates (NIA)

Advanced imaging, Spinal Interventional Pain Management, Lumbar Spine Surgery, selected Cardiac procedures

eviCore Outpatient Rehab Therapy

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Precertification (cont.)

Unit/Partner Responsible for

QUEST Integration Provider Service

Travel and lodging requests, In-state out of network referrals

CVS Drug

Beacon Health Options Behavioral Health

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Precertification – HMSA Medical

Management

HMSA precertification forms available online

General http://www.hmsa.com/PORTAL/PROVIDER/FM.Precertification_Request_General.pdf

Post-Acute Care Services http://www.hmsa.com/PORTAL/PROVIDER/Precertification_Request_Post_Acute_Care_Services_Form.pdf

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Precertification – HMSA Medical

Management

Mail to: HMSA – Medical Management P. O. Box 2001 Honolulu, HI 96805-2001

Fax: 1 (808) 944-5611

Phone: 948-6464 (Oahu) 1 (800) 344-6122 (toll-free Neighbor Islands) Monday-Friday : 7:45 a.m. - 4:30 p.m.

Online: Access iExchange through HHIN or Cozeva

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Precertification (Prior Authorization)

Electronic submissions accepted through HHIN

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Click on “Preauthorization” tab. Then click on “iExchange (HMSA Medical).” To request access to HHIN – call (808) 948-6255

How to Access iExchange using Cozeva

Use Firefox or Internet Explorer browser

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Click dropdown arrow for “Inbox” and select “Req Authorizations”

The window below appears. Click the button to continue to iExchange

How to Access iExchange using Cozeva

The iExchange window appears. Select “Inpatient” or “Other” to start your type of request

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Note: May have to disable popups to view iExchange

Precertification - NIA

Management of:

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MRI/MRA/MRS CT/CTA

PET CCTA

Myocardial perfusion imaging

MUGA

Stress echocardiography

Spinal interventional pain management

Implantable cardioverter defibrillator

Cardiac resynchronization therapy pacemaker

Pacemaker Cardiac catheterization

Lumbar spine surgery

Precertification - NIA

Radiology management Quick Reference Guide: https://hmsa.com/portal/provider/zav_pel.aa.rad.400.htm

NIA FAQ: https://hmsa.com/portal/provider/HMSA_Medical_Specialty_Solutions_Program_NIA_Magellan_FAQs.pdf

Does NOT include emergency room, surgery center, observation and inpatient settings

Online: RadMD.com

Phone: 1 (866) 306-9729

Clinically Urgent Cases: 1 (866) 842-1776

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Precertification - eviCore

Formerly known as Landmark Healthcare

Login at: http://www.lmhealthcare.com/Providers/LandmarkConnect.aspx

Treatment plan forms available at the website

Treatment plans may be submitted via LandmarkConnect or by fax

Fax: 1 (888) 565-4225

Questions: 1 (888) 638-7876

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Precertification – QUEST Integration

Provider Service

Phone: 948-6486 (Oahu)

1 (800) 440-0640 (toll-free Neighbor Islands

Fax: 948-5648 (Oahu)

1 (800) 960-4672 toll-free Neighbor Islands

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Precertification - CVS

Oral/Inhaled drugs

Drugs requiring precertification-Review Drug Formularies: https://hmsa.com/portal/provider/zav_IN.PHARM-FORMULARY.htm#Nav_Formularies

Fax: 1 (866) 237-5512

Phone: 1 (808) 254-4414

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Omit

Precertification - CVS

Injectable/Infused drugs

Drugs requiring precertification: http://info.caremark.com/hmsapolicies Note: most drugs have specific precertification request forms

Online: Access through HHIN – Preauthorization tab (NovoLogix tool)

Fax: 1 (866) 237-5512

Phone: 1 (808) 254-4414

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Precertification – Beacon Health Options

For BH referrals to 0ut-of-state providers, Residential Treatment, Methadone/LAAM treatment

Fax: (808) 695-7790

Phone: Oahu - (808) 695-7700

Neighbor Islands - 1 (855) 856-0578 toll-free

Mail: Beacon Health Options

599 Farrington Highway, Suite 300

Kapolei, HI 96707

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Precertification

Timeliness guidelines

Routine requests within 14 days

Urgent requests within 3 business days

If precertification is not obtained before the service is provided, submit a paper claim attaching documentation for the medical necessity

Claim will undergo medical review

Claim without documentation will be denied for no authorization

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EPSDT –

Early Periodic Screening

Diagnostic and Treatment

For PCPs

EPSDT – Early Periodic Screening

Diagnostic and Treatment

Provide Medicaid-eligible infants, children and youth with quality comprehensive health care through primary prevention, early diagnosis and medically necessary treatment of conditions

For children up to 21 years of age

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EPSDT Schedule

Health Screening Assessment schedule is at the Med-QUEST website: http://www.med-quest.us/PDFs/EPSDT/Info%20on%20Hawaii%27s%20Medicaid%20EPSDT%20Program%20_Overview_.pdf

Filing Claims for EPSDT – CMS 1500

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File claim with Preventive Medicine CPT 99381-99385 or 99391-99395 with modifier EP in block 24.d

Place “Y” in Block 24.h of the CMS 1500

99392 EP Y A 1 XXX XX

Filing Claims for EPSDT

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PCPs submit EPSDT form 8015 (or Form 8016 for catch up visits).

Paper claim - staple EPSDT form to the claim.

Electronic claim - mail EPSDT form separately to: HMSA QUEST Integration P.O. Box 3520 Honolulu, HI 96811-3520

The mailed form must be received by HMSA by the time the electronic claim processes

Filing Claims for EPSDT

Must use original printed forms only. No copies.

Ordering EPSDT 8015 and 8016 forms:

Call ACS at (808) 952-5570 on Oahu or 800-235-4378 toll free from the Neighbor Islands

Fax request to (800) 952-5595

Email request to hi.providerrelations@acs-inc.com

Only EPSDT Paid if Billed with Office Visit on the Same Day

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EPSDT Resources

EPSDT general information url: https://hmsa.com/portal/provider/zav_QI.04.EAR.50.htm

Sample EPSDT form 8015 (1/10) https://hmsa.com/portal/provider/fm_form_8015_front_and_back.pdf

Fee schedules

(Professional)

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Fee Schedules

Participating Providers Accept Eligible Charge as payment in full for covered

services

Payment based on the Eligible Charge, less applicable copayments, deductibles, and payment from third parties*

* PCPs in HMSA’s Payment Transformation Program have an alternate

reimbursement methodology

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Fee Schedules

Fee schedules are available on HHIN

Under “QUEST Integration,” click on the “Fee Schedules” tab on the left side of the home page

Note: If an eligible charge is stated in your provider agreement, terms of the agreement supersede the fee listed in HHIN

Fee Schedules

Fee schedules on HHIN separated into Non-QUEST and QUEST sections

Separate fee schedules for non-ABD and ABD members

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Resources

Provider Communications

Provider Portal - https://hmsa.com/portal/provider/

QUEST Provider Handbook

Communication Archive - HealthPro News

QUEST Integration Provider Service

Phone: 948-6486 (Oahu) or 1 (800) 440-0640 toll free Neighbor Islands

Fax: 948-5648 (Oahu) or 1 (800) 960-4672 from the Neighbor Islands

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Thank you!

Questions?

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