CHOICE & HHAeXchange HHAX Implementation CHOICE transitions to - - PowerPoint PPT Presentation

Dec 10, 2018

CHOICE & HHAeXchange

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• CHOICE transitions to HHAeXchange as of October 8, 2018

with Wave 1.

• Wave 2 went live Oct 25, 2018
• All Wave 3 providers will be required to accept/deny cases

through HHAeXchange

– Dec 15, 2018: HHAeXchange Enterprise Providers – Jan 19, 2019: Portal or Non-HHAeXchange providers

HHAX Implementation

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End to End Process

CHOICE creates authorization HHAX receives authorization; case placed with a provider Provider accepts/ denies case Provider enters services via EVV

• r manually via

Provider Portal Provider submits 837i files for adjudication via a UB04 Claims can be sent to ChangeHealth (CHOICE’s clearinghouse) Claims can be sent to provider’s clearinghouse Claims processed by CHOICE’s system 835 file generated Provider can log into Provider Portal to review 835

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Member Placement Process

Current

• Contract Administration currently sends referrals

to Providers through the VNSNY placement portal

• Providers accept and decline referrals through

VNSNY placement portal

• Providers have 20 minutes to accept or decline a

referral. – If referrals time out, providers can request additional time – Contract Admin works with you to extend the time as necessary.

Future: HHAX

• VNSNY CHOICE will send referrals to Providers through the

HHAeXchange provider portal as opposed to the VNSNY Placement portal.

• Providers will accept or decline referrals directly through

HHAeXchange provider portal.

• Providers will continue to have 20 minutes to

accept/decline a referral.

• If referrals time out on portal, providers can request

additional time by reaching out to CHOICE via a communication note. – Referral types processed through the HHAeXchange portal include HHA, PCA, Consumer Direct and vendor changes – On occasion referrals will be broadcasted to multi- providers.

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AUTHORIZATIONS

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Authorization Process

Current

• No authorization number is required for

placement of referrals through OPS by Contract Administration

Future: HHAX

• All referrals will be assigned an authorization number
• Provider is responsible to:

– Verify member information using V# - V# indicates LOB

 V8 = MLTC  V7= MAP or Total  V6= FIDA

• The authorization will be for 180 days or as specified
• Universal Billing codes will replace service type codes on

referrals

• Total Bucket = Provider is required to manage hours based
• n authorization of full 180 days. The units authorized should

span the full length of the delivery of care dates.

• Services to member ends upon the ‘end date’ in

authorization even if member shows as ‘Active’ in HHAX

– 30 days after the authorization end date, the authorization will drop from the Provider’s view

• Change in schedule does not warrant a new authorization

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• Authorization Ends

– A member should only receive authorized services based on the start

• f care and end of care

– If a member shows ‘end of care dates’ in queue, but the authorization dates have lapsed, send a communication note – CHOICE will coordinate with nursing staff based on the member’s medical necessity.

• Disenrollment

– The member, though inactive, may not immediately drop from the provider’s list. Therefore, it is critical the auth end date be the source

• f truth for authorized services.

Member Authorization Ends & Disenrollment

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• It is the responsibility of the LHCSA to maintain the POC.

– Enterprise providers must maintain the POC in HHAX – For all other providers, maintain the POC outside of HHAX – 1 Personal Care Task is required

 If member refuses, refusal must be documented

• It is at the discretion of VNSNY CHOICE to request member

POC details at any time for audit purposes

Nursing Services

• Nursing services can be viewable in HHAeXchange but no

authorization is included

Plan of Care

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COMMUNICATION NOTES

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• Providers are required to use communication notes in HHAX to

communicate with VNSNY CHOICE.

• Scenarios for communication notes

– Member demographic information must be updated – Reauthorization – Questions regarding order – Interruption of Care (black out dates used) – Member death

• Travel Time and Over Time requests are required to be submitted via an

appeal to Grievance & Appeals

Communication

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Service Interruptions (Black Out Dates)

• Black-out dates are utilized in HHAX if there is an

interruption of care (ex: patient is hospitalized, on vacation, etc.)

– VNSNYC CHOICE will black out dates in HHAX for up to 15 days – Provider is notified via an automated HHAX communication note that the dates have been blacked out. – CHOICE Care Management will resume service once member returns home – Provider is notified via an automated HHAX communication note to resume service

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VISIT CONFIRMATIONS

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• All providers contracted with VNSNY CHOICE must maintain

timesheets outside of HHAeXchange.

• During an audit, VNSNY expects providers to show proof of

in order to validate services rendered.

Timesheets

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BILLING

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• As a contracted provider, there are 3 ways to submit a claim:

1. HHAeXchange generates 837i 2. 3rd Party Mgmt. System generates 837i 3. Provider directly bills CHOICE

 Electronically

• CHOICE Clearing House: Change Health
• Provider’s clearinghouse

 Manually

• Mailing address on following slide
• Upon go-live date, CHOICE expects providers to be prepared

to bill using one of the outlined options

Submitting Claims for Payment

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• Prior authorization is required for all services covered by MLTC, MAP and FIDA.
• Unless otherwise described by your VNSNY CHOICE Provider Contract, VNSNY

CHOICE requires submission on Form CMS1450 (UB-04) for all PCA/HHA Claims.

• As of 4/1/2018 VNSNY CHOICE is compliant with Universal Billing Code Guidance

as outlined by New York State and The Department of Health

• Electronic billing is preferred, will facilitate payment, and will allow you to track

your claims online. Please call the VNSNY CHOICE Provider Call Center for additional details on how to register.

• Otherwise Paper Claims can be mailed to

– MLTC and MAP Claims PO Box 4498 Scranton, PA 08505 – FIDA Claims PO Box 3715 Scranton, PA 08505

Claims Process

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• Expect a 30-45 day turnaround time for payment
• Once the claim is submitted, log in to the provider portal to check on the status

and outcomes.

– The Provider Portal will facilitate the correction and any necessary communication – Use of the Provider Portal is not contingent on the claims submission type

Claims Process Cont.

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GRIEVANCE & APPEALS

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• Providers may file appeals disputing a denial issued as a result of a

utilization management decision, a claims denial (ie: no authorization; provider not contracted to perform services; submit claim to primary carrier) or if they disagree with the amount paid on a previously processed claim.

• All appeals must be filed in writing and must include all relevant

information, including medical records, if applicable. The address to submit appeals is: VNSNY CHOICE Health Plans Grievance and Appeals P.O. Box 445 Elmsford, NY 10523

Grievance & Appeals

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Timeframe for Filing Appeal:

• 60 calendar days from the date of the denial/initial determination,

unless the provider’s contract allows for additional time to file.

Acknowledgment Letter Timeframe:

• Within 15 business Days from receipt of the appeal, Grievance and

Appeals will send a written acknowledgment letter.

Resolution Timeframe:

• Within 60 calendar days from receipt of the appeal.
• Appeals that involve a medical necessity, experimental or investigational

decisions may be further appealed through the State’s external appeal process.

• Some facilities also have the right to file an appeal with a Dispute

Resolution Entity. Please refer to your provider contract to determine if this right applies to you.

Grievance & Appeals Cont.

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Contact Information

• Follow up questions to today’s webinar?

Email: hhaxquestions@vnsny.org

• Looking for HHAX materials, please visit our site:

http://vnsnychoice.org/health-professionals

• Questions regarding claims set up?

Network Development is actively reaching out to review your billing plan and any outstanding questions

• Question regarding claims status, denial or payment?

Provider Call Center: 1-866-783-0222