Special points of in- terest: Medicare Plan Update Area Network - - PDF document

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Area Network Offerings: ADV 360, Commercial PHO Networks and MEDICARE ADVANTAGE Special points of in- terest:

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Medicare Plan Update

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Medicare Remits

• nline

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Medicare Provider Ap- peals

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Medicare Wellness Codes



Medicare Retro Auths



2015 Prior Advantage Risk Auth requirements



SHO Claims transition



2015 Advantage web tools

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PR contacts

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Web resources ADVANTAGE HEALTH SOLUTIONS

February 2015

Medicare ADVANTAGE Plan Update

EFFECTIVE June 1, 2014 ALL MEDICARE ADVANTAGE claims should be submitted to the following: New EDI Payor ID: 35219

• r

PO Box 502030 Indianapolis, IN 46250 Please contact Medicare ADVANTAGE provider services for any questions regarding the claims address/payor ID change at 1.877.660.6258

ADVANTAGE 360: Indiana Statewide Direct Provider Contracts www.advantageplan.com to view claims and eligibility

MEDICARE PPO: Coming soon: Access to online claims and Eligibility 47 Indiana counties participate in Medicare PPO Commercial PHO Networks:

CHA 360

FRANCISCAN ALLIANCE Community Prohealth Select Health Network

• St. Francis Health Network
• St. Vincent CMO

SHO

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www.cmcs-indy.com/services/eservices 1. Once on the website, Provider will select the “PROVIDER” button on the left side. 2. After selecting the “PROVIDER” button, the provider will login if they have an account. If the provider does not have an account the provider will need to select “Register New User’ below the login area. 3. Once they have created the account and logged in, the provider will be able to see claims informa- tion. 4. If the provider needs assistance on the website they can call 1-888-504-5556.

EFFECTIVE January 1, 2015

In order to remain consistent with CMS, all claims submitted with CPT Codes 99381 – 99397 for Medicare Advantage Members covered by ADVANTAGE Health Solutions, Inc. will be denied as non-covered services & members should be held harmless. EDI Payor ID: 35219

• r

PO Box 502030 Indianapolis, IN 46250 Please contact Medicare Advantage provider services for any questions regarding the processing

• f provider claims at 1.877.660.6258

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Provider letterhead or individual appeal form

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Deadlines Submit—60 days from date of Remittance Advice Decision—60 days of Receipt ADVANTAGE Health Solutions, Inc. SM ATTN: Medicare Provider Appeals Provider Relations 9045 N. River Road, Suite 200 Indianapolis, IN 46240

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Medicare Provider Appeal Process Wellness Codes Access Medicare Provider Remits online at:

………..rising above the service you expect”

Coming soon: Access to Medicare online claims and eligibility @ www.advantageplan.com

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Dear Provider Partner: Advantage Health Solutions, Inc. is implementing a new Retrospective authorization policy effective November 1, 2014. Providers must provide all relevant information necessary to authorize a service within the following timeframe:

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Within 3 business days for an emergency

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No later than 2 business days before service if non-emergent Retrospective authorizations after services have begun or have been completed will be considered by Advantage Health Solutions for medically necessary services only under the following circumstances: The provider followed appropriate procedures but received invalid information. For example, documentation of authorization from an incorrectly identified payor source. The provider's documentation confirms checking eligibility but was provided erroneous infor- mation. The provider's records document that the recipient refused or was physically unable to provide the recipient identification information. All authorization requests delayed due to the three circumstances above must be submitted within 30 calendar days from identifying the member’s eligibility or member’s confirmation of insurance cover-

• age. The request must be accompanied by evidence of the provider’s failed attempts to confirm eligi-

bility (i.e. screen shots). If a claim is submitted for services that require authorization but is not ob- tained, the claim will be processed as a payment denial. The Explanation of Benefit (EOB) will include the applicable reference to denial for no authorization and includes contact information on submitting a provider dispute. If you have any questions regarding this new policy please contact Provider Relations Thank you, Provider Relations

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Provider MUST obtain prior auth through ADVANTAGE auto authorization system

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Inpatient hospitalization

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Advanced imaging: PET/SPECT & MRI’s

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Outpatient Surgery, excluding colonoscopies and endoscopies

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Durable Medical Equipment > than $750

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Home Health Care

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Home IV Therapy

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Hospice Care

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Skilled Nursing Facility

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Dialysis

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Chemotherapy/radiation

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Cardiac & Pulmonary Rehab

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Physical Therapy (after 8 visits)

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Occupational Therapy (after 8 visits)

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Speech Therapy

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Corrective Appliances/Prosthesis

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Biotech Drugs*(See Below)

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Wound Treatment

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Sleep Study

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Pain Management

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Transplants

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Tertiary/ Out of Network Services Tertiary/ Out of Network Services

*Biotech medication requests will be completed by

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Envison Specialty Pharmacy:

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Prior Authorization Phone: 877.684.0021

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Prior Authorization Fax: 330.405.8081

The product will then be delivered per the direction of the

• rdering physician*

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Behavior Health (Call phone number on back of card for Prior Authorizations)

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Authorization is required for following services:

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All inpatient services,

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Intensive Outpatient Programs

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Electroconvulsive Therapy

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Partial Hospitalizations

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Visit www.advantageplan.com for a complete listing of specialty pharmacy drugs. Behavioral Health Prior Authorizations: Specialty Pharmacy Prior Authorizations:

ADVANTAGE RISK 2015 PRIOR AUTH REQUIREMENTS

“Prior Authorization does not guarantee payment. Payment is subject to eligibility and benefits at the time of service.”

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TO: SHO PHO and St. Vincent CMO Providers RE: Transition of ADVANTAGE Claims & Medical Management to Cooperative Managed Care Services (CMCS) Suburban Health Organization (SHO) is moving the administration of Advantage Health Solution claims and medical management administration from ProHealth to CMCS effective 1/1/2015. PLEASE READ BELOW CAREFULLY. Providers will remain in their SHO PHO network and/or St. Vincent CMO; only claims processing and medical management administration will move to CMCS. The following information will need to be shared with your office and billing staff and your records updated in order to receive reimbursements: Please note: Member Services at Advantage & Credentialing at Suburban Health Organization will not change. ADVANTAGE member services phone number is 800-553-8933 or 317-573-6228. If you have any questions please contact our Provider Relations Department at ADVANTAGE Health Solutions 1-877-901-2237

• r by visiting www.advantageplan.com.

Claims Inquiries & Customer Service Information Medical Management (including all authorizations and precertifi- cation-related calls): Ph: 1- 866-873-4516 or 1-317-596-5929 Fax: 1-317-570-6822 Ph: 1-317-570-9999 or 1-866-482-5254 Fax: 800-747-3693 Paper Claims: may be submitted as early as 12/15/14 Suburban Health Organization P.O. Box 50830 Indianapolis, IN 46250 CMCS Electronic Claims Submission: may be submitted as early as 12/15/14 EDI Payer ID: EMDEON 35199

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ADVANTAGE-connect features:

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Online Service Request & Provider Demographic Changes

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View Network Authorization & Precert Requirements

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Verify Member Benefits & Eligibility

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View Claim Status

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Access to Other Health Plan Websites

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Access to Health Guidelines & Preventative Health Information

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Access to ADVANTAGE Announcements Allows providers the ability to check medical claims and current eligibility status

Allows providers the ability to check medical claims and current eligibility status for members and dependents.

• 1. Providers may select an automated interactive voice response and/or a

faxed copy of the interactive voice response.

• 2. To access the IVR system, providers can call 800-553-8933 or 317-573-6228

and select option 1.

• 3. Be sure to have the following information handy when calling: Provider fax

number, TIN, Member ID, DOB & DOS.

Automated Prior Auth Tool @ www.advantageplan.com

This tool has been built to reduce the time and resources it takes provider of- fices to request authorizations from ADVANTAGE. The tool is available 24 hours a day and 7 days a week including weekends and holidays.

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Volume 1, Issue 1

The IVR is available by calling 1-800-553-8933

• r 317-573-6228.

Inter Interacti ctive V e Voice ice Response Response

ADVANTAGE Web Tools ADVANTAGE Web Tools The Automated Prior Auth

Tool is available 24/7

including weekends and holidays. *Retro authorizations can not be completed on line.

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QUICK REFERENCE GUIDE www.adantageplan.com Providers Log on to ADVANTAGE-connect and see all of the time saving tools that are available to you!

L O G G I N G I N T O T H E P R O V I D E R P O R T A L

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Click on “Provider”

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Click on “ADVANTAGE-connect Login”

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Click on “Sig-Up” as a new user or use your existing username and password

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Click on “Agree” to register as a new use and complete Steps 1-5

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Click on "Finish” to complete registration

P R O V I D E R S E R V I C E S

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Click on “FAQs” to review most frequently asked questions and their answers

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Click on “In-Network Provider Directories” to view a listing of in network providers

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Click on “ADV 360 Provider Manuals” to view ADV 360 provider policies, ID cards, etc.

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Click on “Provider Authorizations Requests” to obtain a listing of patient services requiring prior authorization

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Click on “Provider Directory” to review network providers

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Click on “Provider Notification Form” to submit demographic changes online

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Click on “Request EOP” to request an EOP online

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Click on “Claims Submission Address” to identify members network claim information

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(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)

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Click on “View ID Card/Network Affiliation” for directions to identify members network claim information

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(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)

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Click on “Care-Advantage/Disease Management/Wellness” to learn of Advantage wellness opportunities

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Click on “Pharmacy/Authorization” to view medication requiring authorization by network

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Click on “Formulary” for directions to identify member formulary

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(Select the “Eligibility and Benefits Inquiry” Service and follow the directions indicated)

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Click, on “Provider Newsletter” to view the latest provider newsletter written by different networks

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Click on “Medical Records Confidentiality Guidelines” to view medical record guidelines

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Click on “Provider Interactive Voice Response System” to learn how to retrieve claims and eligibility information from our automated IVR system

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Click on “Contact Us” to directly connect to the Provider Relations Department by phone or online

P R O V I D E R I N Q U I R I E S

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Click on “Claims and EOPS/EOBs” (Provider have three search options: Dates of Service, Patient Search

• r Claim Number

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Click on “Eligibility and Benefits Inquiry” (Providers have two search options: Member ID Search

• r Patient Name Search)

ADVANTAGE-connect

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ADVANTAGE has a team of dedicated Provider Relations staff available to assist you with questions about our products and services.

Contact Us: 877 Contact Us: 877 Contact Us: 877-

• 901

901 901-

• 2237 Fax: 317

2237 Fax: 317 2237 Fax: 317-

• 663

663 663-

• 1895

1895 1895

Sandy Thorne – Director, Operations Strategy and Provider Relations Lisa Fennig – Provider Relations Supervisor Candy Ervin – Provider Relations Specialist Kathrina Settle – Provider Relations Specialist Katherine Shull

• Provider Relations Specialist

Laura Berry – Provider Relations Trainer/Auditor Erica Hankerson – Provider Relations Coordinator Margaret Cobb

• Provider Relations Coordinator

Rebecca Nulliner

• Provider Relations Coordinator

Jacque Driver – Provider Relations Credentialing Coordinator Kevin Goodwin – Provider Relations Database Coordinator Assistant Shannon Sellars – Provider Relations Project Assistant

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Resources

Preventive Guidelines Individual Immunization Schedules – Birth-18 Individual Immunization Schedules – Adult ChooseMyPlate.gov Women’s Preventive Services Member Appeal Rights Glossary of Health Coverage and Medical Terms Member Quick Reference Guide Rx Savings Card Brochure Tobacco Cessation Caregiver Tips Alcohol and Diabetes Alcohol and Cardiovascular Disease Preventive Guidelines Individual Immunization Schedules – Birth-18 Individual Immunization Schedules – Adult ChooseMyPlate.gov Women’s Preventive Services Member Appeal Rights Glossary of Health Coverage and Medical Terms Member Quick Reference Guide Rx Savings Card Brochure Tobacco Cessation Caregiver Tips Alcohol and Diabetes Alcohol and Cardiovascular Disease Important We Important Website Re bsite Resources: sources: ADVANTAGE Care Select Member Services: (800) 784-3981 For the hearing impaired: (866) 859-7812 Director of Network Development Contracts Kelvin Orr (317) 573-6572 Provider Relations/Contracting Specialist Dan Green (317) 816-6760 Provider Relations Specialist Katie Shull (317) 573-2795

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Prior Authorization Submission by Mail: Written requests for PA are submitted, (using an Indiana Prior Review and Authorization Request form), to

• ne of the following address’s listed below based on the program the member is associated to, which can be

determined by the eligibility verification obtained on the member. ADVANTAGE Health Solutions – FFS Prior Authorization Department P.O. Box 40789 Indianapolis, IN 46240 ADVANTAGE Health Solutions - Care Select Prior Authorization Department P.O. Box 80068 Indianapolis, IN 46280 ADVANTAGE Health Solutions MRO Prior Authorization Prior Authorization Department P.O. Box 40789 Indianapolis, IN 46240 Prior Authorization Submission by Phone or Fax:  By Fax – Providers may fax ADVANTAGE Health Solutions – FFS and ADVANTAGE Health Solutions – Care Select PA requests (using an Indiana Prior Review and Authorization Request form) to: 1-800-689-2759.  By Fax – Providers may fax ADVANTAGE Health Solutions – MRO Prior Authorization requests (using an Indiana Prior Review and Authorization Request form) to: 1-866-541-3977.  Please send them on a daily basis. Please do not send large weekly batches of PA requests  By Phone – The following PA department telephone numbers are as follows:  ADVANTAGE – FFS & MRO: (800) 269-5720  ADVANTAGE – Care Select: (800) 784-3981 The Web Interchange application on the IHCP website allows providers to submit non-pharmacy PA requests and to inquire on request via Web Interchange. Indiana Prior Review and Authorization Request Forms are available at: The IHCP website at: www.indianamedicaid.com List of Prior Authorization Request Forms

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