October 2009 Indiana Care Select Presented by EDS Provider Field Consultants.

October 2009

Indiana Care Select

Presented byEDS Provider Field Consultants

INDIANA CARE SELECT2 / October 2009

Agenda

•Session Objectives•Care Management Organizations•Enrollment Broker•Program Population •Eligibility Verification Systems•Primary Medical Providers •Program Features•Care Coordination Conference•Hospital Treatment Notification•Claims Processing •Referrals•Self-Referred Services•Prior Authorization•Helpful Tools•Questions


Session ObjectivesSession Objectives

Following this session, providers will be able to:

• Identify the two care management organizations (CMOs)

• Identify the enrollment broker

• Identify when a member is eligible for Care Select

•Understand the role of the primary medical provider (PMP)

•Understand the various features of the program

•Understand the new hospital notification process

•Be familiar with the referral process


Care Management Organizations

•Two health plans function as CMOs for the Care Select program

– ADVANTAGE Health Solutions• www.advantageplan.com• 1-800-784-3981 – Care Select• 1-800-269-5720 - Traditional

– MDwise• www.mdwise.org• 1-866-440-2449 – Care Select


Enrollment Broker

•MAXIMUS performs the following functions for Care Select:

– Provides counseling to members in the selection of a PMP that best meets their needs

– Gives unbiased education about the Care Select program

– Facilitates initial member enrollment in the program

– Performs member-initiated PMP changes

•Contact the enrollment broker at:

1-866-963-7383


Population Served

•The following IHCP members are covered by the Care Select program:

– Aged

– Blind

– Physically and mentally disabled

– Members receiving adoption assistance

– Members in the waiver program

– M.E.D. Works participants (Medicaid for Employees with Disabilities)

– Wards of the court and foster children


Ineligible Members

•The following IHCP members are not covered by the Care Select Program:

– Members on Spend-down

– Medicare Medicaid dually eligible

– Qualified Medicare beneficiary (QMB) members

– Specified low-income Medicare beneficiary (SLMB) members

– Members in the hospice program

– Undocumented aliens

– Aid to Residents in County Homes (ARCH) members

– Members enrolled in the 590 Program

– Members enrolled in the Breast and Cervical Cancer Treatment Services program


Eligibility Verification

•Once members are assigned to the Care Select program, the Eligibility Verification Systems (EVS) identify the following:

– Member is eligible for Package A Standard Plan

– Care Select PMP name with contact telephone number

– Assigned CMO with contact telephone number

•Providers should verify member eligibility on each date of service

•Three EVS are available 24 hours per day:

– Web interChange

– Automated Voice Response (AVR)

– Omni swipe machine


Eligibility Verification SystemsWeb interChange

Care SelectPMP and MCOinformation is found in theManaged Caresection of thescreen


Eligibility Verification Systems

•The following enhanced features are only available through Web interChange:

– Detailed third-party liability (TPL) information

– Online TPL update requests

Web interChange


Eligibility Verification Systems

AVR provides the following:

•Member eligibility verification

•Benefit limits

•Prior authorization

•Claim status

•Check write

Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770

AVR instructions are in Chapter 3 of the IHCP Provider Manual

Automated Voice Response System


• Is cost effective for high-volume providers

•Uses plastic Hoosier Health card

•Allows manual entry

•Prints two-ply forms

•Requires upgrade for benefit limit information (refer to IHCP Provider Bulletin BT200711)

See Chapter 3 of the IHCP Provider Manual for more information

OmniEligibility Verification Systems


Primary Medical Provider Enrollment

•To be a Care Select PMP, the provider must:– Be enrolled in the Indiana Health

Coverage Programs (IHCP)– Sign the Care Select Addendum and

submit it to chosen CMO– Provide demographic, scope of

practice, and panel size information to the CMO(s)

•The CMO will electronically enroll the PMP in IndianaAIM via the secure Web interChange


Primary Medical Providers

•Physicians from the following specialties are eligible to enroll as PMPs and will receive auto-assignments:– Family Practitioner

– General Practitioner

– General Internal Medicine

– General Pediatrics

– OB/GYN

•Other physician specialties may enroll as a PMP but will not receive members through auto-assignments– Members must actively choose these providers to

be their PMP


Program Features•ADVANTAGE Health Solutions and

MDwise:– Maintain and update their

contracted PMPs’ demographic, scope of practice, and panel size informationNote: PMPs are required to

communicate changes to their respective CMO(s)

• Care Select and Hoosier Healthwise panels are maintained separately

•PMPs have flexibility in determining panel size– Panel size can be as low as 1

•PMPs may enroll with one or both CMOs


Program Features

•PMPs receive a two-digit certification code quarterly from EDS

•PMPs receive member rosters generated on the 11th and 26th of each month – This roster informs who is included in the PMP’s panel– Rosters are sent to the Mail To address on file in the

provider’s profile

•PMPs also receive an administrative fee roster on the 3rd Wednesday of each month– This roster coincides with the administrative fee paid to the

PMP each month

– PMPs receive a $15 per member per month administrative fee •Members included in the administration fee roster differ

from those included in the member roster due to PMP changes during the month

•The Remittance Advice (RA) issued on the following Tuesday reflects the PMP administrative payment


Care Coordination Conference

•Care coordination conferences between the CMO and PMP

– Bill care coordination conferences with CPT 99211 with the SC modifier – Office or other outpatient visit for the evaluation and management of an established patient

– Reimbursement for care coordination conferences is limited to two one-hour conferences per rolling 12-month period

– Care coordination conferences are reimbursed at $40 for each encounter



•Reimbursement for care coordination conferences can also be made when performed by a nurse practitioner (NP) employed by the same group as the PMP

•When the nurse practitioner is enrolled in the IHCP, indicate the NP’s rendering National Provider Identifier (NPI) on the claim

•The nurse practitioner is not required to be enrolled in the IHCP. When the NP is not enrolled:

– Append the SA modifier (for example, 99211 SC SA)

– Report the rendering NPI of the PMP on the claim

Care Coordination by Nurse Practitioner



•EOB 1050 – The recipient is enrolled in the Care Select Program. Care Management service must be billed by the member’s assigned Care Select PMP or nurse practitioner in the same group as the Care Select PMP– Applies when claim for a care coordination conference is

received by a provider other than the member’s Care Select PMP, or a nurse practitioner who is not in the same group as the PMP

•EOB 6925 – Care Select Care Coordination service is limited to two units of service per member, per rolling 12 months– Applies when a claim for care coordination service is

received after the benefit limit is reached

Care Coordination Edits


Outpatient Treatment and Inpatient Admission Notification

•Aligns the Care Select goals of managing member care

•Hospital staff is responsible for checking eligibility

•Care Select Notification button will be present on Care Select member eligibility

•Hospital staff will enter:

– Date of treatment

– Type of treatment

– Presenting signs, symptoms and/or diagnosis


Care Select Notification


Notification Screen Completed


Outpatient Treatment and Inpatient Admission Notification

•Once the information is saved, CMO is notified of visit

•CMO’s are better able to assist with facilitation of care and resources when member is discharged

•CMO’s assist hospital staff in PMP notification

•CMO’s assess the nature of the visit and provide follow up management in conjunction with hospital clinical personnel


Covered Services

•A listing of covered services is available by referencing RFS 7-62 Attachment E: Care Select Program Description and Covered Benefits at www.indianamedicaid.com in the Managed Care section – Care Select home page


Claims Processing

•EDS processes claims for Care Select members

•The CMOs review claims that suspend due to medical policy audits– Claims are reviewed by the

CMO to which the member is assigned on the date of service

•Traditional Medicaid fee-for-service claims that suspend for medical policy audits are reviewed by ADVANTAGE Health Solutions


Claims Processing

•Claims submitted by providers other than the PMP, must contain the PMP’s two-digit certification code and NPI, unless the service is exempt from PMP requirements (self refer):

– CMS 1500 form • Field 17B must have PMP NPI• Field 19 must have the two-digit certification

code

– UB-04 form• Field 37 must have the two-digit certification

code• Field 78 must have the PMP NPI


Claims Processing

•Claims systematically deny when services requiring a referral contain a missing or invalid certification code. Edits include:

– 1047 – The Certification Code is Missing-Care Select. Please verify and resubmit.

– 1048 – The Certification Code is Invalid-Care Select. Please verify and resubmit.

– 1049 – The recipient is enrolled in the Care Select Program. Claim must have recipient’s primary medical provider information. Please provide information and resubmit.

Certification Code Edits


Referrals – Coordinating Care

•Referrals to other providers must be made by telephone or in writing

•PMPs provide specialists with their NPI and certification code

•PMPs provide hospitals with their NPI, certification code (outpatient services)


Self-Referred Services

•Self-referred services do not require a certification code or PMP authorization. They include:

– Podiatry

– Chiropractic

– Mental health

– Dental

– Vision

– Family planning

– HIV/AIDS targeted case management

– Immunizations

– Diabetes self-management

– Pharmacy



•Self-referred ancillary services include:

– Emergency services (emergency primary diagnosis code)

– Lab

– Radiology

– Anesthesia

– Transportation

– Durable Medical Equipment / Home Medical Equipment

– Home Health Services

– Waiver Services

Ancillary Services



•Self-referred outpatient therapy services include:

– Physical Therapy (specialty 170)

– Occupational Therapy (specialty 171)

– Respiratory Therapy (specialty 172)

– Speech Therapy (specialty 173)

•Other self-referred services include:

– School Corporations

– First Steps

– Medical Review Team (MRT)

– Pre-Admission Screening and Resident Review (PASRR)

Outpatient Therapy Services


Prior Authorization

•Each CMO is responsible for processing medical service PA requests and updates for members assigned to their organization

•Traditional Medicaid fee-for-service PA requests are processed by ADVANTAGE Health Solutions

•Pharmacy PA requests are processed by Affiliated Computer Services (ACS)


Prior Authorization

•Alphanumeric PA numbers identify the CMO that processed the PA

•Providers must verify member eligibility to determine the CMO that will process the PA or update request– CMO information via Web interChange is real time

– Send the PA request to the assigned CMO as of the date of the request

– Send PA updates to the assigned CMO to which the member was assigned when the original PA was requested

– If the member changes from one CMO to the other before the PA request is approved, the originating CMO will transfer the PA approval to the receiving CMO


Prior Authorization

•PA requests are suspended when additional information is needed by the member and/or provider

•Requested documentation must be received within 30 calendar days

•Suspended requests that are later approved are authorized with the dates of service indicated on the original request

•When a member is reassigned to a different CMO after a PA request is suspended:

– Providers must send the added documentation to the CMO that initiated the request

Suspended Requests


Prior Authorization

•Members can change between traditional Medicaid fee-for-service, Hoosier Healthwise, and Care Select

•The receiving organization must honor PAs approved by the prior organization for the first 30 days following the reassignment, or for the remainder of the PA dates of service, whichever comes first

Example:

Member transitions from Hoosier Healthwise MCO to a Care Select CMO June 14, 2009. The MCO approved PA for dates of service 5/22/09 through 7/20/09.

The Care Select CMO must honor the approved PA for 30 days from June 14, 2009.

Outstanding Prior Authorizations


Prior Authorization

•Paper and faxed requests are rejected– Requesting provider will receive a decision

letter advising of rejected status– The decision letter advises where the PA

should have been sent•PA requests sent electronically via the 278

transaction are rejected with reason code 78 – Subscriber/Insured not in Group/Plan identified– Requesting provider does not receive a

decision letter•Providers will need to resubmit the PA request

to the appropriate CMO•PA requests sent via Web interChange are

systematically routed to the correct CMO

Request Sent to Wrong CMO


Prior Authorization

•Providers may exercise PA appeal rights to the organization that denied the PA request

– If the member is reassigned to another program after the PA request is denied, the provider may send a PA request to the new organization, or appeal to the organization that denied the request

– Appeals sent to the wrong CMO are returned to the provider unprocessed

•Refer to Chapter 6 of the IHCP Provider Manual regarding the hearing, appeal, and administrative review procedures

Hearing, Appeal, and Administrative Review


Prior Authorization

•The following provider types can submit PA requests via Web interChange:– Chiropractor– Dentist– Doctor of Medicine– Doctor of Osteopathy– Home Health Agency (authorized agent)– Hospice– Hospitals– Optometrist– Podiatrist– Psychologist endorsed as a Health Service

Practitioner in Psychology (HSPP)– Transportation providers

Web interChange


Prior Authorization

• ADVANTAGE Health Plan (fee-for-service)P.O. Box 40789Indianapolis, IN 46240800-269-5720

• MDwise – CMOP.O. Box 44214Indianapolis, IN 46244-0214866-440-2449

• ADVANTAGE Health Plan – CMOP.O. Box 80068Indianapolis, IN 46280800-784-3981

• ACS866-879-0106866-780-2198 (Fax)

Contact Information


• IHCP Web site at www.indianamedicaid.com

•Care Select E-mail: [email protected]

• IHCP Provider Manual (Web, CD-ROM, or paper)

•Customer Assistance– 1-800-577-1278, or

– (317) 655-3240 in the Indianapolis local area

•Written Correspondence– P.O. Box 7263

Indianapolis, IN 46207-7263

•Provider Relations Field Consultant – View a current territory map and contact

information online at www.indianamedicaid.com

Avenues of Resolution

Helpful Tools

October 2009

Questions

October 2009

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October 2009 Indiana Care Select Presented by EDS Provider Field Consultants.

Documents

Transcript of October 2009 Indiana Care Select Presented by EDS Provider Field Consultants.