10:00am until 1:00pm University of Mount Olive Welcome and Overview - - PowerPoint PPT Presentation

Eastpointe November 18, 2015 10:00am until 1:00pm University of Mount Olive

Welcome and Overview Karen Salacki

• Cultural Diversity News

Eastpointe Provider Network Council Barry Dixon External Operations Updates Karen Salacki

Member Call Center Reminders Kolletta Harris

Utilization Management Kolletta Harris Updates Emergency Preparedness Kate McPherson Division of MH/DD/SA GAST Updates Emily Carlyle Claims Updates Jessica Bulluck

NC Wraparound Overview Eastpointe Care Coordination and Easter Seals UCP Network Operations Melanie Weatherford Call Center

Network Operations Updates Linda Hawley Isbell

Provider Meeting Topics Karen Salacki Listserve Next Provider Meeting

Barry Dixon Eastpointe Provider Network Council

For Council Information: Go to www.eastpointe.net, then For Provider Community, the Eastpointe Provider Network Council Information Contact Information: providercouncil@eastpointe.net

Our Provider Network is closed. We are not accepting any applications for State Funded Services. We are not accepting applications for any enhanced or Innovation services. We are only accepting applications for Medicaid services for the those discussed in the upcoming slides.

Eastpointe is accepting MCO applications from Hospitals. Please contact Network Operations for the application packet.

For Agencies: An Agency can add Psychiatrists. You will need to submit an LIP application to networkoperations@eastpointe.net . The psychiatrist cannot provide services to Eastpointe members until the date that they are credentialed. For Private Practice: Eastpointe will also accept applications from Psychiatrists in private

• practice. They will need to submit an LIP

application to networkoperations@eastpointe.net .

Agencies can add an LIP to replace an LIP on a team that has left your agency.

Please submit on your letterhead to indicate which LIP is leaving that the new LIP will be replacing. Please note that it is a requirement to notify us that an LIP has left your agency and when you hire someone to replace them. You also must submit a ticket to end their access to Alpha.

Additional teams for IIH, CST, MST and ACTT are not being credentialed at this time.

All Re-Credentialing applications were due by September 11, 2015. Letters were sent out to all providers who did not submit their re-credentialing applications with a final deadline. Phone calls were then made to all providers who did not submit their Re-Credentialing application. We continue to have providers who have not submitted their Re-Credentialing applications.

All providers who do not complete the Re- Credentialing process will no longer maintain a contract with Eastpointe after December 31, 2015 as this is a requirement for contracting. These providers will be required to submit a transition plan to Network Operations by December 1, 2015.

This training is required for all EPMs that are on IPS-SE teams per the service definition, and we cannot give you a time frame as to when the training will be

• ffered again. As a reminder:

this training is not optional, it is required EPMs not having this training are not in compliance with the service definition We are unable to anticipate when and where the next EPM training will be, so best to take it now rather than wait. Please see the memo that went out on list serve on November 17, 2015 for the link to the training.

Kolletta Harris Member Call Center Supervisor

All Providers Must Submit the Appointment Follow-up notification on the slot scheduler within 24 hours of the appointment date for

• Routine. For Urgent appointments please have

the notification follow up completed by the end

• f the business day of the appointment date.

If a consumer’s appointment must be rescheduled, please ensure the appointment is scheduled within the appropriate timeframe of access to services. Saturday Appointment: Follow up will need to be

completed on the following Monday by 10am.

Choice of provider is based on the member’s or member’s guardian decision. The Call Center staff will support and facilitate the member’s decision-making by processing issues and considering variables that may influence the decision of the optimal provider. However the Member Call Center staff will not influence the member or member’s guardian in who to chose as their provider. Some of the variables include but not limited to: Presenting needs of the member Financial Eligibility Provider Geographical Location Urgency of Service Clinical expertise matched with identified need. Providers who have a contract with Eastpointe and can provide a comprehensive array of services. Providers Appointment Availability on their Slot Scheduler

Member Call Center does not have the capability to change information listed on the enrollment once handed over to the provider. The Call Center schedules initial appointments for members. Additional appointments are to be scheduled by the member’s provider.

Since implementing the Alpha system in May 2015 members can request services directly from the providers. If a member is scheduled with your agency do not ask them to call the call center prior to their appointment to have the enrollment completed. Enrollments need to be completed by the provider unless the appointment was scheduled by the Member Call Center.

Director of Member Call Center Katina Dial-Scott MA, LPC, NCC, LCAS-A Telephone: (910) 272-1244 E-mail: kdialscott@eastpointe.net Call Center Supervisor Kolletta Harris Telephone: (910) 272-1248 E-mail: kharris@eastpointe.net

Review the appropriate guidelines for the number of unmanaged sessions If a SAR is requested the unmanaged sessions will be given up. Unmanaged sessions will not be able to be billed after dates that a SAR is requested Psychological Testing codes for Medicaid funded services are no longer counted towards the unmanaged sessions Unmanaged sessions start over on 07/01/2015 for both Medicaid and IPRS.

The Clinical Coverage Policy 8C indicates the following for a service order:

Fully licensed professionals listed on page 11 in the clinical coverage policy can sign the PCP/ treatment plan and this will serve as the service order.

Due to Alpha transition issues the following Medicaid codes have had limit increases within Alpha: H2022 Assertive Engagement Psychological/ Developmental Testing Innovations Personal Care Innovations Community Networking The amount available for billing of services has to be approved on a SAR and in conjunction with the appropriate service definition limits and/or unmanaged visits.

If issues with being able to select the appropriate benefit plan, service code or site contact Network Operations call center at 1- 888-977-2160. UM can not change the following information once a request has been submitted: Site Funding source Service Service Definition UM reviews requests based on date of submission and requirements in the applicable service definition. The “ALL” procedure code is only used and valid for outpatient requests

A SAR should be submitted on or before the start date for the requested

• service. UM does not back date requests unless it is related to retroactive

Medicaid eligibility and initial Medicaid inpatient services. See the appropriate service definition for information regarding prior approval. Level of Care needs to be completed LOCUS/CALOCUS/ASAM/SNAP If Substance use indicated, please include last reported use and drug screen (if applicable, for example it may be a part of programming such as SAIOP) How each dimension of the ASAM criteria is met

Contact phone number and email for person submitting SAR to be included in SAR Justification section

A request in saved status will not be processed by UM, request needs to be in submitted status List current medications and medication adherence Complete the correct Level of care with enough detail to support medical necessity Please check the Provider Communication section for any notes back from UM Discharge SARs do not need to be submitted

If discharging a member from service, please complete a client update enrollment

Peer to peer requests are submitted through Network Operations Call Center The physician peer reviewers make an attempt to contact within one business day of request The results of the conversation should be posted in the provider communication section within 1-2 business days from the conversation. If overturned the SAR will reflect the number of units approved.

Network Operations Call Center: 1-888-977-2160 Network Operations Call Center staff will forward question to the appropriate UM staff to assist if additional information needed Lynnette Gordon, UM director lgordon@eastpointe.net 910-298-7036 Requesting a peer to peer 1-888-977-2160 Requesting a copy of the clinical rationale 1-800-513-4002 option 3

Kate McPherson, MHA North Carolina Department of Health and Human Services

GERIATRIC/ADULT MENTAL HEALTH SPECIALTY TEAM (GAST)

Provide professional training and consultation to those providing services and supports to older adults with mental health and/or substance abuse issues Enhance the understanding of mental illness Assist staff through education in successfully caring for adults with mental illness Enhance the skill and technique of staff/caregivers to prevent escalation of behaviors that could place the adult in a psychiatric hospital

PURPOSE

Nursing home staff, adult care home staff, and family care home staff serving adults with mental illness and/or dementia Caregivers of adults 60 years of age or older with mental illness (or dementia at any age) Community agencies and organizations providing services and supports to older adults with mental health/ substance abuse issues

RECEIPIENTS OF SERVICES

Mental Health Nurses Master’s Prepared Mental Health Clinicians Qualified Mental Health Professionals

TEAM MEMBERS

Provide trainings and education to staff/caregivers on a variety of topics related to mental health issues Assist in understanding the importance and components of assessing behaviors

TEAM ACTIVITIES

Provide input and support in the development and implementation of intervention plans Educate regarding psychiatric medication issues, and how to collaborate with psychiatrist, pharmacist, physicians

TEAM ACTIVITIES

Review crisis prevention techniques Establish positive relationships with community stakeholders serving the geriatric population, such as Ombudsmen and Area on Aging programs Provide resource information

TEAM ACTIVITIES

• Aging Successfully
• Behavioral Interventions
• Communication
• Death & Dying
• Neurocognitive/Neurological Disorders

Categories of Trainings

• Mood
• Other Mental Health Disorders/Issues
• Medication
• Miscellaneous and New Trainings

*Dementia Sensitivity Experience

• Hand-in-Hand Series

(CMS)

Categories of Trainings

Improve quality of care & reduce crisis! Provided by Mental Health Professionals at your site! FREE of Charge! Receive one continuing education credit per class! Wide variety of interesting and helpful topics!

WHY GERIATRIC/ADULT MENTAL HEALTH SPECIALTY TEAM ??

If you would like to schedule a class OR have any questions please contact an Eastpointe GAST Team Lead:

Kim Locklear 910-272-1242 (Lumberton) Lois Finger 252-407-2420 (Rocky Mount) Emily Carlyle 919-587-0319 (Goldsboro)

HOW DO I SCHEDULE ?

~ QUESTIONS ~

Eastpointe Claims and Funding Services

Third Party Liability (TPL) and Medicare Bypass Codes

Often Medicaid recipients have additional sources of coverage for health care services. These other sources are referred to as

• Third Party Liability (TPL) – refers to the legal obligation of third parties (e.g.,

group health plans, self-insured plans, worker’s compensation or settlements from a liability insurance) to pay part or all of the expenditures for medical assistance provided to a Member. By law all other third party resources must meet their legal obligation to pay claims before the Medicaid program pays for care of a Member eligible for Medicaid. When a Member has other coverage, the activities involved in determining which insurance plan has the primary payment responsibility and the extent to which other plans will contribute is called coordination of benefits. Some procedure codes are allowed to bypass system edits for coordination of benefits for TPL and Medicare. This is because it is known that these resources will never pay for the service. These codes are known as TPL and Medicare bypass codes.

MCO Finance Officers have agreed upon a list of codes that should bypass Third Party Liability and Medicare edits across MCOs. The list is known as the TPL and Medicare Bypass Matrix and can be found on Eastpointe’s Claims and Billing webpage. Codes included are: (inclusive of applicable modifiers when billing)

• H0040

ACTT

• H2015

CST

• S9484

Facility Based Crisis

• H2011

Mobile Crisis Management

• H2022

Intensive In-Home

• H2033

Multi-Systemic Therapy

• H0014

Ambulatory Detoxification

• H0010

Non-Hospital Medical Detoxification

TPL and Medicare Bypass Matrix codes continued

• H0013

SA Medically Monitored Community Residential Tx

• H2035

SACOT

• H0015

SAIOP

• H2012

Day Treatment

• H2017

Psychosocial Rehabilitation

• H0020

Outpatient Opioid Treatment

• H0019

Residential Level III and IV

• H2020

Residential Level II

• S5145

Therapeutic Foster Care

• S5145

Therapeutic Foster Care – IAFT Service

• RC100

ICF/IID

• H0045

Respite Individual B3

TPL and Medicare Bypass Matrix codes continued

• H2014

Developmental Therapy Paraprofessional Individual

• H2015

Community Networking

• H2016

Residential Supports

• T2014

Residential Supports

• T2020

Residential Support

• T2041

Community Guide Individual

• YP010

Hourly Respite Care

• YP020

Personal Care

• YP620

ADVP

• YP630

Supported Employment

• YP710

Supervised Living Low

• YP730

Community Respite Overnight

• YP760

Group Living Low

• YP770

Group Living

TPL and Medicare Bypass Matrix codes continued

• YP780

Group Living High

• H0045

Individual Respite B3

• T1019

Individual Support B3

• H0038

Peer Supports Group B3

• H2025

Supported Employment Services

How Long do I have to re-submit a denied claim?

Medicaid Funded

• 90 days from the claim denial date

State Funded

• 20 business days from the claim denial date

How can I submit a denied claim?

As a replacement claim. This is the recommended method. This will ensure the additional days allowed are added by the system.

• r

As a new claim; however the system will only apply the number of billing days allowed for original claims. (90 days from date of service for non-hospital and 180 days from the date of service for hospital Medicaid funded claims/60 days from date of service for State funded claims.

New Process

Effective November 9, 2015

When a Member covered under Eastpointe MCO receives retroactive Medicaid the following will occur for services requiring an approved authorization:

• 1. Claims staff will send a secure e-mail notification to Provider which will include the

Member(s) ID, Member(s) Name, Procedure Codes and Dates of Service effected by the Member’s retroactive Medicaid eligibility.

• 2. The Provider will be instructed to submit a retroactive Medicaid authorization request

to UM. Claims staff will allow 30 days for the process to be complete. (request to approval) If after 30 days there is not an approved authorization claims staff will take measures to verify if a request was made and if so what the status is.

• 3. Once an approved authorization is in place, claims staff will re-adjudicate the claims so

they will process for the correct funding source.

• 4. If a request has not been made after 30 days, the claims will be recouped and the

Provider will have to re-submit after an approved authorization is in place.

Some reasons why a claim could be re-adjudicated

• 1. Member receives retro-active Medicaid
• 2. Invalid claim denial
• 3. Retroactive rate adjustments
• 4. Benefit plan updates

What Occurs?

If the re-adjudicated claim is a paid claim

• 1. The original claim payment is reverted creating a credit memo.
• 2. A re-adjudication payment is created based on current system set up

and edits. Both of these transactions will be shown on the remittance advice (RA);

• nce as a credit memo and once as a payment.

If the re-adjudication payment is more than the original payment, a payment will be made for the difference. If the re-adjudication payment is less than the original payment, a recoupment will be made for the difference.

What Occurs? continued

If the re-adjudication payment is the same as the original payment, there will be no impact to the RA payment.

If original claim was a denied claim

• 1. A re-adjudication payment is processed based on current system set

up and edits. If the claim is approved, it will display on the RA as a paid claim for the appropriate amount. If the claim is denied again, it will display on the RA as a denied claim showing the denial code and reason.

Weekly Cut-off for Claims submission is 5:00 pm each Tuesday to be paid on the next week’s checkwrite. Covered days each week Previous Wednesday – following Tuesday at 5:00 pm. BEST PRACTICE: SUBMIT AS EARLY AS POSSIBLE

To avoid getting caught in unforeseen system issues.

Claims & Billing Webpage www.eastpointe.net

• For Provider Community
• Medicaid 1915 b/c Waiver Information
• Claims and Billing

Melanie Weatherford

If you are an Alpha user and you forget your password in the system. There is a “Forgot Password” feature where you can go in and reset your password under menu>User Profile You will not need to call into Network Operations or email support@eastpointe.net in

• rder to complete this.

Providers are calling Network Operations for new user ID’s. These request need to be submitted by the agency security officer. Updates to security officer information should be submitted to support@eastpointe.net

Network Operations receives calls from Third Party Billers inquiring about

• claims. Please be aware that in order for Network Operations to release

any information that notification must be sent by the entity that we have the contract with giving us permission to discuss your information. Network Operations Staff have seen an increase of third party billers calling to inquire about claims that do not have access in Alpha. The contracted agency, Hospital or physician group would request access for a password and login for any new users to access their Provider Portal.

Claim Adjudication results can be obtained by Providers via the Provider Portal. Results for claims submitted through the portal are made available in the portal the next day. Results for claims submitted via 837 can be reviewed in the daily current client and current claims dump files in the Transactional Download Q of the portal.

Claims Inquiries can also be made via the Claims Inquiry/Time Limit Override Form. The form will need to be completed and sent to Eastpointe's Claims Department either by mail or fax. Once reviewed, the sender will be e-mailed the findings. Network Operations staff are also available for claim

• inquiries. When requesting the status of a claim, the caller

must identify himself/herself and provide the following information.

Recipients’ name Recipients identification number Provider’ s name and tax ID number Date of Birth of recipient Date of service of recipient Billed services

If the person calling to inquire about claims is a representative from a clearinghouse or Billing agency other verification information may be required prior to assistance. Please note that if the person calling is a representative from a clearinghouse or Billing agency and does not have access to the provider’s portal, Network Operations staff will not be able to give you the denial date on the claim. This information would be on the RA and the RA can be accessed thru the Provider’s Portal. Network Operations Staff would be able to relay the status of the claim.

Linda Hawley Isbell

Once we receive a complete application packet we will upload it to our credentialing vendor, Medversant. Please note that if items are incomplete or the Criminal Background Release or Attestation are not signed we will be unable to process the application.

While Medversant is conducting the Primary Source verification, Network Operations staff will be conducting an internal quality monitoring and Provider Monitoring staff will be conducting the On Site review.

Once the primary source verification, internal quality monitoring and On Site visit are completed information will be presented to our Credentialing Committee. Please note that you may be notified with a request for additional information. Please note that if you do not provide the requested information your application will stop being processed.

Once a decision has been made you will either receive a letter stating that you have been Re- Credentialed or a letter stating that you have not been Credentialed.

We are continuing to have many providers notifying Eastpointe after they have added or moved a site. This is an out of compliance issue You must have written prior approval from Eastpointe before you add or move a site.

Please refer to Communication Bulletin #22 for specific instruction on the processes to Add or Move a Site. If you or your agency Adds a Site or moves a site without getting written prior approval from Eastpointe you will need to transition the members being served at that site and we will recoup any billing that has been submitted for that site.

You must also submit the new site information to NCTRACKS to add your new address prior to this address being added into our electronic system, Alpha. You would then need to provide evidence that either the new site has been entered in NCTRACKS or submit a copy of the Manage Change Form that you submitted.

Approval of a site is contingent on approval by NCTRACKS. Any future denial or failure of NCTRACKS to approve may result in recoupment.

Two changes were recently made to Application A and Application B. These changes are

• utlined in Communication Bulletin #30.

Please be advised that we will accept the current version of the applications posted on

• ur website but effective December 1, 2015 we

will only accept the revised versions dated November 5, 2015.

With several holidays coming up please keep in mind how you and your staff will notify members of the dates that your office may be closed.

Eastpointe offices will be closed on November 26th and November 27th 2015. Please note that our Member Call Center will remain open during this time.

We are very interested in hearing from our Provider Community about topics that you would like us to discuss at upcoming meetings. We would like to make sure that we are covering topics of interest to our Provider

• Network. Please send those to

networkoperations@eastpointe.net . Please indicate in the subject line : Provider Meeting Topics

Directions for signing up for list serve:

• 1. Go to Eastpointe’s website at

http://www.eastpointe.net

• 2. Click on For Provider Community
• 3. Go to Provider Listserv, then click on

Eastpointe Provider Listserv Sign-Up Form

• 4. Enter your email address (make sure you type

it correctly), enter your first and last name, and agency

• 5. Click on the Sign Up button
• 6. After you sign up, a Thank you page will
• pen. You have been added to the

mailing list and can exit You will receive an email that your request has been submitted

Please remember to register for Provider Meetings on our website

Under Provider Community Then Calendar of Events

Our next meeting is scheduled for December 16, 2015 from 10:00am until 1:00pm and this will be a webinar.

Website: www.eastpointe.net Network Operations Call Center: 888-977-2160 Email: networkoperations@eastpointe.net Fax: 252-407-2450 Member Call Center 800-913-6109 Fax: (910) 345-8971