4/8/2014 Spring 2 0 1 4 PacificSource Provider W orkshop Montana - - PDF document

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4/8/2014 Spring 2 0 1 4 PacificSource Provider W orkshop Montana - - PDF document

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4/8/2014 Spring 2 0 1 4 PacificSource Provider W orkshop Montana Presented by: Shawna Talles, Provider Service Specialist Agenda NCQA Locums Tenens HEDIS CMS 1500 Claim Form Electronic Claims ICD 10 Healthcare

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4/8/2014 1

Spring 2 0 1 4 PacificSource Provider W orkshop Montana Presented by: Shawna Talles, Provider Service Specialist

Agenda

  • NCQA
  • Locums Tenens
  • HEDIS
  • CMS 1500 Claim Form
  • Electronic Claims
  • ICD 10
  • Healthcare Reform – Exchange
  • PacificSource Websites

PacificSource Total Mem bership

Total Mem bership: 267,622 Covered Lives Com m ercial Mem bership: 210,631 Medicare Mem bership – OR & I D: 17,759 Medicaid Mem bership - OR: 39,232

Organizational Updates

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3 0 1

Total Area Mem bership: 3,477 Exchange Mem bership: 767

Current Mem bership Organizational Updates

3 0 2

Total Area Mem bership: 6,446 Exchange Mem bership: 130

Organizational Updates Current Mem bership

3 0 3

Total Area Mem bership: 7,617 Exchange Mem bership: 1,465

Organizational Updates Current Mem bership

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3 0 4

Total Area Mem bership: 3,197 Exchange Mem bership: 1,568

Organizational Updates Current Mem bership Organizational Updates

National Com m ittee for Quality Assurance ( NCQA)

Organizational Updates

PacificSource and NCQA

  • PacificSource began the accreditation

process in January of 2013.

  • Anticipate seeing PacificSource Health

Plans on the NCQA website in May or June.

  • We would like to thank you for your

patience and assistance.

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Organizational Updates

Exam ples of NCQA requirem ents

  • Required information on all rosters:
  • Effective and termination dates for all licensure
  • Provider directory enhancements

−Hospital affiliation −Board certification −Language spoken

  • PacificSource is required to notify members

30 days in advance of a provider leaving a practice.

Organizational Updates

Provider Changes

  • Provider groups shall use their best efforts

to notify PacificSource and/or their IPA promptly and in advance of the addition or termination of a provider.

  • We need notification from providers at least 45-

60 days prior.

Organizational Updates

Locum Tenens

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Organizational Updates

Locum Tenens Policy

  • For Locum Tenens providing coverage for 60 or

fewer consecutive days, we will require:

  • A Locum Tenens application
  • Current DEA certificate
  • Copy of professional liability coverage

Organizational Updates

Locum Tenens Policy

  • For Locum Tenens providing coverage for longer

than 60 consecutive days, we will require:

  • A full and complete practitioner credentialing

application.

  • Locum Tenens must be credentialed prior to being

paid under the absent provider’s contract.

  • This policy applies to all PacificSource lines of

business.

Organizational Updates

Billing for Locum Tenens

  • Each healthcare provider or supplier who is

rendering the service, must be listed in box 31 of the CMS 1500 form.

  • PacificSource does not permit incident-to-

billing.

  • Claims billed prior to the locum tenens

credentialing approval will be denied as provider write-off.

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Organizational Updates

HEDI S

W hat is HEDI S?

  • Healthcare Effectiveness Data and Information

Set

  • Required by CMS
  • Required for NCQA certification for any line of

business

  • PacificSource does HEDIS for Commercial and

Medicare

  • Set of standardized performance measures

Organizational Updates

HEDI S continued

  • Measure data sources: Admin (medical and

Rx claims), Hybrid (patient chart), and Survey

  • Measure Domains – Effectiveness of care,

Access, Availability, Cost of Care, Use of Services, and Health Plan Descriptive Info

  • Measurement Year – Most look at care in most

recent calendar year. Some look back >2 yrs

  • HEDIS is a major data source for Medicare 5

Star Program and NCQA certification

Organizational Updates

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HEDI S continued

  • HEDIS medical record measures assess

compliance with accepted prevention and chronic condition guidelines.

  • Some measures are calculated using claims

data, some use medical record documentation, some use both.

  • Many of the measure results are influenced or

controlled by physicians.

  • Members are randomly selected for medical

record portion of HEDIS audits.

Organizational Updates

HEDI S continued

  • Information for HEDIS audit completion will

either be requested directly by PacificSource

  • r on our behalf by our vendors: Outcomes

Health for Commercial and Verisk for Medicare.

  • Any questions regarding the HEDIS audit

should be directed to:

  • Provider Network (800) 624-6052 ext 2580
  • Outcomes Health (855) 767-2650
  • Verisk Health (877) 489-8437

Organizational Updates Organizational Updates

CMS 1 5 0 0 Claim Form

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Organizational Updates

New CMS 1 5 0 0 Form ( Rev 0 2 / 1 2 )

The CMS 1500 form has been updated to align with 5010 837P and accommodate ICD-10 reporting. Changes on the form include:

  • Fields 8, 9b, 9c, 11b, and 30
  • Other fields were changed to

reflect usage.

  • 12 lines now available for

diagnosis codes.

Organizational Updates

Electronic vs. Paper Claim s

Organizational Updates

Electronic Claim s Transactions

  • PacificSource encourages electronic claims

submission and EFT/ERA enrollment

  • This includes coordination of benefit (COB)

claims.

  • Office Ally is free
  • Availity claims now accepted electronically.
  • A list of participating clearinghouses and

enrollment forms are available on our website.

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Organizational Updates

PacificSource Adm inistrators ( PSA)

  • Effective April 1, 2014, PSA claims will be

payable via EFT.

  • If you are already set up to receive EFT

and/or ERA, you do not need to do anything.

  • New EFT enrollees will now be getting

payments for commercial and PSA members.

  • Updated EFT/835 enrollment form now

available on our website.

Organizational Updates

Dedicated Provider Custom er Service Phone Num ber ( 8 5 5 ) 8 9 6 -5 2 0 8

* Benefit questions, claim s inquiries, etc.

Organizational Updates

I CD-1 0

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Organizational Updates

I CD-1 0

  • I m plem entation pushed to October 1 ,

2 0 1 5 ( at the earliest) .

  • PacificSource has completed:
  • System upgrades
  • Impact assessments
  • Translation Mapping ICD-9 to ICD-10
  • End to end testing with several large health

systems

Organizational Updates

Has your organization begun I CD-1 0 planning?

Yes, 7 6 .8 % No, 2 3 .2 % 151 People Surveyed

  • Yes – 116
  • No – 35
  • Skipped Question – 16

Organizational Updates

W hen do you anticipate starting your

  • rganization's education on I CD-1 0 ?

46% 46% 23% 23% 22% 22% 7% 7% 2% 2%

Already Started – 46.4% Q1 2014 (Jan-Mar 2014) - 23% Q2 2014 (Apr-Jun 2014) – 22% Q3 2014 (Jul-Sep 2014) – 7% We don’t anticipate providing education on this topic. We don’t use ICD Codes – 2%

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Organizational Updates

Please estim ate how m uch of the planning process your organization has com pleted.

4 7 % 3 6 % 1 3 % 4 % Answ er Options Response Percent Response Count 0-25% 46.8% 51 25-50% 35.8% 39 50-75% 12.8% 14 75-100% 4.6% 5

I CD-1 0 Tip and Tricks

  • AAPC crosswalk from ICD-9 to ICD-10

http://www.aapc.com/ICD-10/crosswalks/pdf- documents.aspx.

  • Visit AAPC for more helpful tools, such as:
  • Searchable databases
  • Educational webinars
  • Educational articles
  • ICD-10 conversion issues and trends

Organizational Updates

I CD-1 0 Resources

  • If you have questions regarding

PacificSource and ICD-10, please email ICD10inquiries@pacificsource.com.

  • Visit CMS’s website for another great

resource on the ICD-10 transition: cms.gov/ICD10.

  • If you are interested in end-to-end testing

with us, please complete our brief survey at SurveyMonkey.com/s/T3CTNL6.

Organizational Updates

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Organizational Updates

Provider Bulletin

Organizational Updates

Provider Bulletin

  • PacificSource has combined our two

provider newsletters; CommunityCare (Medicare and Medicaid) and Provider Bulletin (Commercial).

  • Beginning with the Spring 2014 edition,

providers can expect to see topics related to all lines of business in the Provider Bulletin.

Organizational Updates

Provider Bulletin

  • The Provider Bulletin will be distributed

quarterly to those who have opted in to receive the newsletter as well as those who were on the distribution to receive the CommunityCare newsletter.

  • Current and past newsletter editions may

be found on any of our three websites.

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Provider Bulletin Com m ercial Site

Organizational Updates Organizational Updates

AI M Specialty Health

AI M Specialty Health

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AI M Specialty Health

  • Standardization of our

authorization process for radiology services within our service area.

  • More than 20 years experience

effectively managing radiology services.

  • AIM’s Safe Choices in Imaging

program focuses on increasing awareness of health and safety issues related to radiation exposure in advanced imaging procedures.

AI M Specialty Health

Covered Modalities

  • Computed Tomography Scans

(CT)

  • Computed Tomographic

Angiography (CTA)

  • Magnetic Resonance Imaging

(MRI)

  • Magnetic Resonance

Angiography (MRA)

  • Magnetic Resonance

Spectroscopy (MRS)

  • Nuclear Cardiology (e.g.,

SPECT scans)

  • Positron Emission Tomography

(PET)

Required Settings:

  • Hospitals (outpatient)
  • Free-Standing

Imaging Facilities

  • Physician Offices

Excluded Settings:

  • Inpatient Services
  • Emergency Room
  • 23-hour Observation
  • Ambulatory Surgery
  • Urgent Care Centers

AI M Specialty Health

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AI M Specialty Health

Online using AI M’s ProviderPortal Register at www.aimspecialtyh ealth.com/goweb Available 24-7/365 Via phone to the AI M Call Center AIM’s call center: (877) 291-0510 Available Monday through Friday from 9:00 a.m. to 6:00 p.m. MST time* Voice mails received after business hours will be responded to the next business day

AI M Specialty Health

Additional I nform ation

  • www.pacificsource.com/provider/prea

uthorization.aspx

  • List of codes requiring review through

AIM.

  • Retro authorizations within 48 hours
  • f the procedure are done by AIM.
  • Retro authorizations outside 48 hours

done by PacificSource.

Healthcare Reform

Healthcare Reform Montana Exchange

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Healthcare Reform

Plans Offered Through Exchange

  • Four benefit tiers (metal tiers):
  • Platinum
  • Gold
  • Silver
  • Bronze

Healthcare Reform

Sm artHealth Netw ork Plans

Metal Level Exchange Plans Bronze

SmartHealth Value Bronze 6250 SmartHealth Value Bronze 3000 SmartHealth Value Bronze 6350

Silver

SmartHealth Balance Silver 2500 SmartHealth Value Silver 3600 SmartHealth Value Silver 3000 SmartHealth Balance Silver 1500

Gold

SmartHealth Balance Gold 1000

Healthcare Reform

Becom ing a Participating Provider

  • Credentialing
  • Forms online at www.pacificsource.com.
  • Submit application with supporting

documentation.

  • Credentialing committee meets at the end of

every month.

  • Once approved, contracting will contact you.
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Pediatric Vision Benefit

  • Members through 18 years of age.
  • Licensed ophthalmologist or optometrist
  • One vision exam per year* including refraction
  • One pair of non-collection glasses (lenses and

frames) per year*

  • Contact lens services and materials per year*

*Benefits/frequencies are per calendar or per plan year. Limits on hardware also apply.

Healthcare Reform I D Cards

I D Cards

I D Cards

2 0 1 3 vs 2 0 1 4

G = Commercial group coverage N = Individual policy GE = Group Exchange NE = Nongroup Exchange (individual member)

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I D Cards PacificSource Adm inistrators

GS = Self-insured group handled through PacificSource Administrators. MUST = GSMXXXXX MUS = GS001302

PacificSource.com

PacificSource.com

PacificSource.com

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PacificSource.com PacificSource.com PacificSource.com

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PacificSource.com PacificSource.com PacificSource.com

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PacificSource.com PacificSource.com PacificSource.com

Provider Resources

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PacificSource.com PacificSource.com PacificSource.com

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PacificSource.com PacificSource.com I nTouch Provider Portal

I nTouch Provider Portal

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I nTouch Provider Portal

I nTouch for Providers

  • Secure, interactive website for providers
  • Online eligibility
  • View and submit preauthorization requests
  • Online claim status
  • Explanation of payment
  • Point of service direct
  • Access real-time patient liability information

and your actual charges for each procedure billed

I nTouch Provider Portal

I nTouch – OneHealthPort

  • InTouch for Providers is accessed through

OneHealthPort.

  • OneHealthPort is a web portal that provides

access to secure health plan websites with a single user ID and password.

  • If you are already an OneHealthPort user, you do

not need to register again to access InTouch.

I nTouch Provider Portal

I nTouch – OneHealthPort

  • Register for OneHealthPort via their website:

www.OneHealthPort.com/Register/Index.php.

  • Providers who need to use “Forgot My Password”
  • r “Forgot My UserID” links can find them on the

OneHealthPort sign in page.

  • For questions or assistance with the registration

process, please contact: OneHealthPort’s Help Desk: (800) 973-4797

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I nTouch Provider Portal I nTouch Provider Portal I nTouch Provider Portal

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I nTouch Provider Portal I nTouch Provider Portal

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The search feature returns active member records only.

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I nTouch Provider Portal

Please reference the member’s ID card to verify if referral requirements apply.

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I nTouch Provider Portal

Populate the

  • nline form with

the appropriate information. Fields marked with an asterisk* are required.

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I nTouch Provider Portal

Submitting supporting documentation

  • nline speeds

up the processing time for requests.

I nTouch Provider Portal

Once the prior authorization is generated, the requesting provider and the referred to provider will be able to view and track the referral request via InTouch.

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I nTouch Provider Portal

Online Pharm acy Prior Authorization Subm issions

Online Pharm acy Prior Authorization Requests

  • Effective April 1, 2014, providers can now

submit pharmacy prior authorization requests online via the InTouch web portal.

  • This includes requests for both Commercial

and Medicare members.

I nTouch Provider Portal I nTouch Provider Portal

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I nTouch Provider Portal I nTouch Provider Portal I nTouch Provider Portal

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I nTouch Provider Portal

Explanation of Payments (EOPs) can also be found by selecting the “Billing” tab on the InTouch home page.

I nTouch Provider Portal

EOP Schedule

  • EFT delivery - Wednesday
  • Paper EOPs - mailed

Wednesday

  • InTouch EOP delivery -

Thursday

  • Holidays will delay delivery
  • EOPs are available for two

years

Questions?

Thank you!