Welcome! Medicaid Operations Conversion Go-Live: August 1 , 2 0 1 5 - - PDF document

6/5/2015 1

Medicaid Operations Conversion Provider W orkshop

PR3170_Plan Approved 06032015

Better Health | Better Care | Better Cost

2015 Medicaid Conversion

Welcome!

Medicaid Operations Conversion Go-Live: August 1 , 2 0 1 5

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Agenda

1 New member ID card 2 Claim submission 3 Sterilization and Hysterectomy Process 4 Explanation of Payment/ 835/ EFT 5 PCP Change Form 6 LineFinder tool 7 InTouch for Providers 8 Referrals and preapprovals 9 PCP Capitation Rules

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New Member ID Card

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New Member ID Card

Issuing Dates

• Members eligible as of July 1, 2015 will be mailed

an old ID card on July 7, 2015.

• Members who enroll after July 1st may have a

delay in receiving their new member ID card.

– During this time, providers should use the member’s Medicaid ID to verify eligibility.

• ALL members will be issued there new ID cards
• n or around July 17th.

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New Member ID Card

New Information

• The new ID cards will include:

– OHP issued enrollee ID number – New PacificSource member ID number (begin with an “8” and are nine numerical digits in length) – Primary care provider (PCP) name – Dental plan – Pharmacy information – Customer Service contact information – Electronic claims payor ID number

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New Member ID Card

Sample ID card

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Front Back

Claim Submission

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Claim Submission

Electronic claims

New electronic claim s payor I D: 2 0 4 1 6

• New affiliated clearinghouses include:

– Affiliated Network Services; Emdeon; Trizetto Provider Solutions; HeW (Health E-Web); MCPS; Office Ally; Payer Connection; RelayHealth

• Begin using new payor ID on July 1 0 , 2 0 1 5 –

DO NOT USE PRI OR TO THI S DATE

– Claims submitted to an old payor ID after November 1, 2015 will be rejected.

• Claims will be accepted with either member ID

number (OHP assigned/ PacificSource assigned)

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Claim Submission

Paper claims (UB-04/CMS 1500)

New paper claim s m ailing address:

PacificSource Community Solutions, Inc. PO Box 7068 Springfield, OR 97475-0068

• Begin submitting paper claims to this address on

July 1 0 , 2 0 1 5 .

– Paper claims submitted to the old address after November 1, 2015 will be returned.

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Claim Submission

Other important dates

• 7 / 1 0 / 1 5 – Claims received via new payor

ID or new claims address will be held.

• 7 / 2 0 / 1 5 – Held and transferred claims

will load into Facets.

• 7 / 2 8 / 1 5 – Last check run by PH Tech.
• 8 / 9 / 1 5 – First check run in Facets.

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Claim Submission

Secondary Claims

• If PacificSource Medicare/ commercial is

prime:

– Claim will crossover automatically in Facets. – Do not submit a secondary claim.

• If submitted, the claim will deny as a duplicate.
• When any other payor is prime:

– Claims accepted electronically or via paper. – If submitting paper, include primary EOB.

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Claim Submission

Corrected Claims

• Institutional claims (UB-04) can be submitted

electronically with bill type indicating claim is corrected (xxx7).

• Professional claims (CMS 1500) must be

submitted via paper with corrected claim form attached.

– Begin using the corrected claim form on July 1 0 , 2 0 1 5 . – The corrected claim form can be found on our website at CommunitySolutions.PacificSource.com/ Providers/ Docu mentsAndForms.

• All claims reprocessing will occur in Facets,

regardless if it originally processed through CIM.

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Sterilization/Hysterectomy Process

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Sterilization/ Hysterectomy

Process Reminder

• PacificSource Community Solutions

requires the completion of the appropriate consent forms:

– DMAP Consent to Sterilization form (DMAP 742) for all sterilizations. – DMAP Hysterectomy Consent form (DMAP 741) prior to surgery.

• For more details and instructions, please

review our Medicaid Provider Manual.

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Sterilization/ Hysterectomy

Process Reminder

• Access the manual on our website at

CommunitySolutions.PacificSource.com/ Prov iders/ DocumentsAndForms.

• Submit the completed consent form to

PacificSource Community Solutions prior to billing or attached to the claim.

• Incomplete forms will result in claim denial.

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Explanation of Payment 835 and EFT

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Explanation of Payment

Sample EOP

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Payment History

Accessing historical claims data

• To access historical claims payment

information previously available through CIM, please contact Customer Service.

• Customer Service can answer questions

regarding claim detail and/ or provide a copy of the payment voucher.

• Historical claims data will not be

accessible through InTouch.

• CIM will be turned off August 1, 2015

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835 and EFT

Electronic remittance file and funds transfer

• If you currently receive 835/ EFT from

PacificSource for other lines of business, you will automatically be enrolled for the Medicaid line of business.

• To sign up for 835/ EFT:

– Complete the enrollment form and return it to Provider Network. – Takes approximately two weeks to process.

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PCP Change Request

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PCP Change Request

New Form

• Providers can continue to submit a PCP Change

Request on a member’s behalf.

• Beginning July 2 7 , 2 0 1 5 submit requests via fax
• r email, not through CIM.

– Complete the PCP Change Request form available (July 24th) on our website at CommunitySolutions.PacificSource.com/ Providers/ Docu mentsAndForms. – Obtain member signature. – Fax or email the form to Customer Service.

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LineFinder T

• ol

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LineFinder Tool

• New LineFinder tool is available now
• Go to Intouch.PacificSource.com/ LineFinder/

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LineFinder Tool

Instructions

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LineFinder Tool

Instructions

Search results appear

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LineFinder Tool

Instructions

Expand the line details

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Prioritized List

To access the current prioritized list go to: Intouch.PacificSource.com/ LineFinder/

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InT

• uch for Providers

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InTouch for Providers

Secure online provider portal

I nTouch – Replacing CI M

• Use InTouch to:

– Verify member eligibility and PCP – View member benefits – View and submit referral/ preapproval requests (medical, behavioral health, and pharmacy) – Check claim status – View/ print your Explanation of Payment (EOP)

• CIM will be turned off August 1, 2015

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InTouch for Providers

Secure online provider portal

• Providers can access InTouch through OneHealthPort.

– Web portal that provides access to secure health plan websites with a single user ID and password.

• If you are already a OneHealthPort user, you do not

need to register again to access InTouch.

• To register for OneHealthPort access, go to

www.OneHealthPort.com/ content/ registration-

• verview.
• Your clinic will need to assign an administrator to

manage multiple user log-in’s.

– Administrator registration can take up to 72 hours from completion of application.

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InTouch for Providers

Secure online provider portal

Access InTouch log-in through our website at CommunitySolutions.PacificSource.com/ Providers

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Referrals and Preapprovals

Referrals and Preapprovals

• There are no changes to the current

guidelines for referrals/ preapprovals.

• We will continue to allow subreferral

authority.

• Authorizations for advanced imaging

services should be subm itted through I nTouch.

– AIM will not be used for Medicaid.

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Referrals and Preapprovals

• Referrals and preapprovals will not be accepted in

CIM after July 24, 2015.

• Online submissions will not be accepted

July 25th - 26th in InTouch due to system load. Options for submitting requests during this time include:

– Hold request submission until July 27th. – Submit hardcopy request form via fax to (541) 382-6898.

• Forms can be found on our website at

CommunitySolutions.PacificSource.com/ Providers/ Documen tsAndForms

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Referrals and Preapprovals

• Historical referral and preapproval data

will be loaded into InTouch from CIM and accessible to view on July 27, 2015.

– Each one transferred will receive a new InTouch reference number. – You can search by CIM reference number or newly assigned InTouch reference number.

• New online submissions must be

submitted through InTouch beginning July 2 7 , 2 0 1 5 .

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Referrals and Preapprovals

Methods of Submission

Online: Subm it via I nTouch ( preferred)

• Faster turn-around
• May qualify for automatic approval
• CommunitySolutions.PacificSource.com/ Providers

Fax: Request form s available on our w ebsite

• CommunitySolutions.PacificSource.com/ Providers

/ DocumentsAndForms

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Referrals and Preapprovals

Referral Reminder

• When submitting a referral request – refer

to in-network providers only.

– Referrals to out-of-network providers have recently increased. – Referrals to out-of-network provider will be denied in most cases. – Requests to see an out-of-network provider must be subm itted though the preapproval process.

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PCP Capitation Rules

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PCP Capitation Rules

Process Update

• Capitation will be issued for members

effective on the 1st of the month

– Members who enroll after the 1st, capitation will be issued the following month

• Checks will be issued on or around the

15th of each month

• Pro-rating capitation payments

– Example: If member assigned to provider for four days of a month, the provider will receive a pro-rated capitated amount

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PCP Capitation Rules

Process Update

• Retroactive payments

– PacificSource will issue capitation payment back to the effective date of the assignment

• Recoupment

– If the member retroactively terminates, changes PCP , etc., PacificSource will recoup capitation payments issued

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PCP Capitation Rules

Process Update

• Newborns will no longer be exempt from

the auto-assign process

• PCP offices are able to call and request

assignment on behalf of newborns

– Applies to members six months and younger

• PacificSource is now tracking provider

patient capacity on all PCPs

– PCP offices are requested to provide PacificSource with each providers maximum patient capacity to ensure we do not over-assign

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Provider Resources

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Provider Resources

T

• ols for Providers
• CommunitySolutions.PacificSource.com
• InTouch for Providers
• Provider Manual
• Latest Notices and Updates
• Provider Bulletin
• On-site training: Contact your PacificSource

Provider Service Representative to schedule

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Contact Information

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Contact Information

• Customer Service

– (800) 431-4135 Central Oregon – (855) 204-2965 Columbia Gorge

• Health Services

– Referrals/ Preapprovals

• (541) 330-7301
• (541) 382-6898 Fax
• Behavioral Health

– (800) 431-4135 – (541) 330-4910 Fax

• Pharmacy Services

– (888) 437-7728

• Provider Network

– (800) 624-6052 ext. 2580

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Questions?

We look forward to working with you to make this conversion successful.

Thank you!

2015 Medicaid Conversion