PARTNERS HEALTH PLAN (PHP)...BILLING WITH AN EHR---CLAIMS Upon submission of billing claims,...
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PARTNERS HEALTH PLAN PHP CARE COMPLETE FIDA-IDD TRAINING FOR DEVELOPMENTAL DISABILITIES PROVIDER NETWORK June 16, 2017
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
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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
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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
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
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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
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Approval or rejection messages are returned directly to themember’s Care Coordination team.
MEDISKED PROVIDER PORTAL -ASSESSMENTS
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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!”
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