Medicaid Operations Conversion Provider...

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Medicaid Operations Conversion Provider WorkshopPR3170_Plan Approved 06032015

Better Health | Better Care | Better Cost

2015 Medicaid Conversion

Welcome!

Medicaid Operations ConversionGo-Live: August 1, 2015


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Agenda1 New member ID card2 Claim submission3 Sterilization and Hysterectomy Process4 Explanation of Payment/835/EFT5 PCP Change Form6 LineFinder tool7 InTouch for Providers8 Referrals and preapprovals9 PCP Capitation Rules

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New Member ID Card2015 Medicaid Conversion

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New Member ID CardIssuing Dates

• Members eligible as of July 1, 2015 will be mailed an old ID card on July 7, 2015.

• Members who enroll after July 1st may have a delay in receiving their new member ID card.– During this time, providers should use the member’s

Medicaid ID to verify eligibility.

• ALL members will be issued there new ID cards on or around July 17th.


New Member ID CardNew Information

• The new ID cards will include:– OHP issued enrollee ID number– New PacificSource member ID number (begin with an

“8” and are nine numerical digits in length)– Primary care provider (PCP) name– Dental plan– Pharmacy information– Customer Service contact information– Electronic claims payor ID number


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New Member ID CardSample ID card


Front Back

Claim Submission2015 Medicaid Conversion

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Claim SubmissionElectronic claims

New electronic claims payor ID: 20416• New affiliated clearinghouses include:

– Affiliated Network Services; Emdeon; Trizetto Provider Solutions; HeW (Health E-Web); MCPS; Office Ally; Payer Connection; RelayHealth

• Begin using new payor ID on July 10, 2015 –DO NOT USE PRIOR TO THIS DATE– Claims submitted to an old payor ID after November 1,

2015 will be rejected.

• Claims will be accepted with either member ID number (OHP assigned/PacificSource assigned)


Claim SubmissionPaper claims (UB-04/CMS 1500)

New paper claims mailing address:

PacificSource Community Solutions, Inc.PO Box 7068Springfield, OR 97475-0068

• Begin submitting paper claims to this address on July 10, 2015.– Paper claims submitted to the old address after

November 1, 2015 will be returned.


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Claim SubmissionOther important dates

• 7/10/15 – Claims received via new payor ID or new claims address will be held.

• 7/20/15 – Held and transferred claims will load into Facets.

• 7/28/15 – Last check run by PH Tech. • 8/9/15 – First check run in Facets.


Claim SubmissionSecondary Claims

• If PacificSource Medicare/commercial is prime:– Claim will crossover automatically in Facets.– Do not submit a secondary claim.

• If submitted, the claim will deny as a duplicate.

• When any other payor is prime:– Claims accepted electronically or via paper. – If submitting paper, include primary EOB.


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Claim SubmissionCorrected Claims

• Institutional claims (UB-04) can be submitted electronically with bill type indicating claim is corrected (xxx7).

• Professional claims (CMS 1500) must be submitted via paper with corrected claim form attached.– Begin using the corrected claim form on July 10, 2015.– The corrected claim form can be found on our website at

CommunitySolutions.PacificSource.com/Providers/DocumentsAndForms.

• All claims reprocessing will occur in Facets, regardless if it originally processed through CIM.


Sterilization/Hysterectomy Process2015 Medicaid Conversion

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Sterilization/HysterectomyProcess Reminder

• PacificSource Community Solutions requires the completion of the appropriate consent forms:– DMAP Consent to Sterilization form (DMAP 742)

for all sterilizations.– DMAP Hysterectomy Consent form (DMAP 741)

prior to surgery. • For more details and instructions, please

review our Medicaid Provider Manual.


Sterilization/HysterectomyProcess Reminder

• Access the manual on our website at CommunitySolutions.PacificSource.com/Providers/DocumentsAndForms.

• Submit the completed consent form to PacificSource Community Solutions prior to billing or attached to the claim.

• Incomplete forms will result in claim denial.


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Explanation of Payment835 and EFT


Explanation of PaymentSample EOP


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Payment HistoryAccessing historical claims data

• To access historical claims payment information previously available through CIM, please contact Customer Service.

• Customer Service can answer questions regarding claim detail and/or provide a copy of the payment voucher.

• Historical claims data will not be accessible through InTouch.

• CIM will be turned off August 1, 2015


835 and EFTElectronic remittance file and funds transfer

• If you currently receive 835/EFT from PacificSource for other lines of business, you will automatically be enrolled for the Medicaid line of business.

• To sign up for 835/EFT:– Complete the enrollment form and return it to

Provider Network.– Takes approximately two weeks to process.


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PCP Change Request2015 Medicaid Conversion

PCP Change RequestNew Form

• Providers can continue to submit a PCP Change Request on a member’s behalf.

• Beginning July 27, 2015 submit requests via fax or email, not through CIM.– Complete the PCP Change Request form available

(July 24th) on our website at CommunitySolutions.PacificSource.com/Providers/DocumentsAndForms.

– Obtain member signature.– Fax or email the form to Customer Service.


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LineFinder Tool2015 Medicaid Conversion

LineFinder Tool

• New LineFinder tool is available now • Go to Intouch.PacificSource.com/LineFinder/


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LineFinder ToolInstructions



Search results appear


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Expand the line details


Prioritized List

To access the current prioritized list go to:Intouch.PacificSource.com/LineFinder/


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InTouch for Providers2015 Medicaid Conversion

InTouch for ProvidersSecure online provider portal

InTouch – Replacing CIM• Use InTouch to:

– Verify member eligibility and PCP– View member benefits– View and submit referral/preapproval requests (medical,

behavioral health, and pharmacy)– Check claim status– View/print your Explanation of Payment (EOP)

• CIM will be turned off August 1, 2015


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• Providers can access InTouch through OneHealthPort.– Web portal that provides access to secure health plan websites

with a single user ID and password.

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

• To register for OneHealthPort access, go to www.OneHealthPort.com/content/registration-overview.

• Your clinic will need to assign an administrator to manage multiple user log-in’s.– Administrator registration can take up to 72 hours from

completion of application.



Access InTouch log-in through our website at CommunitySolutions.PacificSource.com/Providers


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Referrals and Preapprovals


• There are no changes to the current guidelines for referrals/preapprovals.

• We will continue to allow subreferral authority.

• Authorizations for advanced imaging services should be submitted through InTouch.– AIM will not be used for Medicaid.


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• Referrals and preapprovals will not be accepted in CIM after July 24, 2015.

• Online submissions will not be accepted July 25th - 26th in InTouch due to system load. Options for submitting requests during this time include:– Hold request submission until July 27th.– Submit hardcopy request form via fax to

(541) 382-6898. • Forms can be found on our website at

CommunitySolutions.PacificSource.com/Providers/DocumentsAndForms



• Historical referral and preapproval data will be loaded into InTouch from CIM and accessible to view on July 27, 2015.– Each one transferred will receive a new

InTouch reference number.– You can search by CIM reference number or

newly assigned InTouch reference number.• New online submissions must be

submitted through InTouch beginning July 27, 2015.


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Referrals and PreapprovalsMethods of Submission

Online: Submit via InTouch (preferred)• Faster turn-around• May qualify for automatic approval• CommunitySolutions.PacificSource.com/Providers

Fax: Request forms available on our website• CommunitySolutions.PacificSource.com/Providers

/DocumentsAndForms


Referrals and PreapprovalsReferral Reminder

• When submitting a referral request – refer to in-network providers only.– Referrals to out-of-network providers have

recently increased.– Referrals to out-of-network provider will be

denied in most cases.– Requests to see an out-of-network provider

must be submitted though the preapproval process.


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PCP Capitation Rules2015 Medicaid Conversion

PCP Capitation RulesProcess Update

• Capitation will be issued for members effective on the 1st of the month– Members who enroll after the 1st, capitation

will be issued the following month• Checks will be issued on or around the

15th of each month• Pro-rating capitation payments

– Example: If member assigned to provider for four days of a month, the provider will receive a pro-rated capitated amount


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• Retroactive payments– PacificSource will issue capitation payment

back to the effective date of the assignment• Recoupment

– If the member retroactively terminates, changes PCP, etc., PacificSource will recoup capitation payments issued



• Newborns will no longer be exempt from the auto-assign process

• PCP offices are able to call and request assignment on behalf of newborns– Applies to members six months and younger

• PacificSource is now tracking provider patient capacity on all PCPs– PCP offices are requested to provide PacificSource

with each providers maximum patient capacity to ensure we do not over-assign


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Provider Resources2015 Medicaid Conversion

Provider ResourcesTools for Providers

• CommunitySolutions.PacificSource.com• InTouch for Providers• Provider Manual• Latest Notices and Updates• Provider Bulletin• On-site training: Contact your PacificSource

Provider Service Representative to schedule


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Contact Information2015 Medicaid Conversion

Contact Information

• Customer Service– (800) 431-4135

Central Oregon– (855) 204-2965

Columbia Gorge

• Health Services– Referrals/Preapprovals

• (541) 330-7301• (541) 382-6898 Fax

• Behavioral Health– (800) 431-4135– (541) 330-4910 Fax

• Pharmacy Services– (888) 437-7728

• Provider Network– (800) 624-6052 ext. 2580


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Questions?

We look forward to working with you to make this conversion successful.

Thank you!


Medicaid Operations Conversion Provider...

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