BlueChoice HealthPlan Medicaid Provider Education Territory Map

Report
CIMS- HBR
New Medicaid Dedicated Service Team
• BlueChoice HealthPlan Medicaid began a new
Provider Relations Team in April specifically for our
Medicaid Provider Network. If your practice has not
been visited, give us a call.
• We are there to support you- do not hesitate to
reach out to your designated PR Rep for assistance!!
BlueChoice HealthPlan Medicaid
Provider Education Territory Map
Provider Representatives
Pee Dee
23
39
37
Oconee
Pickens
Cherokee
42
11
Spartanburg
46
01
32
Lexington
19
Edgefield
09
Calhoun
02
Aiken
21
Florence
43
Barnwell
05
Bamberg
Midlands
Allendale
03
25
Hampton
14
Clarendon
45
Williamsburg
08
Berkeley
18
Colleton
Charleston
10
27
Jasper
07
Marion
34
26
Horry
Dorchester
15
17
Sumter
38
Orangeburg
06
Georgia
Richland
35
Darlington
16
40
Saluda
Karen Phillips
803-382-5778
[email protected]
Dillon
31
Lee
24
Upstate
Jon Keith
803-382-5085
[email protected]
Chesterfield
28
Kershaw
Fairfield
41
Edwina Sanders-Lisbon
803-382-5125
[email protected]
13
Newberry
Abbeville
Provider Representatives
29
Lancaster
20
36
33
McCormick
LowCountry
12
Chester
Union
30
Laurens
North Carolina
York
44
04
Anderson
Donna Thompson
803-264-3196
[email protected]
22
Contacting BlueChoice HealthPlan Medicaid
Remember that all contact information for BlueChoice HealthPlan Medicaid is different than our commercial
product BlueChoice HealthPlan.
•
Website: www.BlueChoiceSCMedicaid.com
Customer Care Center: (verify eligibility, benefits, claims status, general questions, etc.)
• Voice: 866-757-8286
Monday to Friday: 8 a.m. to 6 p.m.
• Fax: 912-233-4010 or 912-235-3246
TTY: 866-773-9634
24-Hour Nurseline
• Voice: 866-577-9710
TTY: 800-368-4424
Utilization Management (Prior Auth and Hospital/Facility Admission Notification):
• Voice: 866-902-1689
Monday to Friday: 8 a.m. to 5 p.m.
• Fax: 800-823-5520
Case Management (Care Coordination and WIC Information):
• Voice: 877-833-5736
Monday to Friday: 8 a.m. to 5 p.m.
• Fax: 866-406-2808
24 hours a day, 7 days a week
• WIC: 800-868-0404
ExpressScripts, Inc. (Pharmacy Benefits)
• Voice: 800-470-0933
• Fax: 866-807-6241
Monday to Friday: 8 a.m. to 9 p.m.
Saturday to Sunday: 8 a.m. to 6 p.m.
4
Verifying Eligibility
Checking eligibility is critical for every visit since each
member has 90 days to switch plans after assignment and
can lose eligibility at any time of the year based on a
change in their status.
•
•
•
•
•
•
Member ID card
Customer Care Center: 1-866-757-8286
www.BlueChoiceSCMedicaid.com
SC Point of Sale (POS) device
SC Medicaid IVRS
SC https://portal.scmedicaid.com/
5
Identification Card
In addition to this BlueChoice HealthPlan Medicaid ID Card, members are
also required to carry their SC DHHS-issued Healthy Connections ID card.
6
Claim Submission
Claim Filing Limits
All providers are allowed 365 days to submit claims.
Electronic Data Interchange (Payer ID 00403)
Preferred and fastest way to submit your claims.
For set up and questions call 1-800-470-9630.
Hard Copy Claim Submission, Corrected Claims and Correspondence
If you need to file a hard copy claim, submit a corrected claim, file an appeal or submit
any type of for correspondence please mail to:
BlueChoice HealthPlan Medicaid
ATTN: Medicaid Claims
PO Box 100124
Columbia, SC 29202-3124
7
Timely Filing, Re-submissions, and Appeals
Original Claims
Original claims must be submitted within 365 days of
the date of service
Corrected Claims
Corrected claims must be received within 90 days from
the process date to be considered for payment.
Corrected claims must be submitted with the Claim
Follow Up form.
Appeals
Appeals must be received within 90 days from the
process date to be
considered for review.
Appeals must be submitted with the Provider
Dispute Resolution form
8
ER Diversion and Clinic Days
•
ER Diversion Demonstration Project
–
–
–
–
–
•
Participants include 3 hospitals with highest ER utilization in 3 regions; 12 primary care groups
surrounding those facilities and all urgent and minor care clinics.
Project began 3/1/13 and will run to 12/31/13
Mail out to all members in Project area with information on place of care ( urgent versus ER), 24/7
nurse call line with refrigerator magnets and listings of urgent/minor care in their neighborhood.
Providers receive monthly listings of their assigned membership utilizing ER services
Excellent provider feedback and action
Clinic Days- HEDIS Project
–
–
–
Two Pediatric practices to participate in this new project to facilitate improvement in specific HEDIS
measure scores.
Well Child Visits to be targeted during these events to be held in July
We will schedule all our members on Gaps in Care reports for visits during event. Gift cards to be
presented to members and Provider incentive to practice.
ER Utilization Report
Group ID:570604703
Provider Group Name:Franklin C Fetter Clinic
Report Date:6/13/2013
For claims processed:5/1/2013 - 5/31/2013
Members with Emergency Room Services
First Name
Last Name
DOB
Age Phone
1/26/1953 60
Date of Service
5/16/2013
Primary ICD-9Primary ICD-9 Description
Provider
3009
NONPSYCHOTIC DISORD NOS
MEDICAL UNIVERSITY HOSPIT
11/19/2008
4
5/4/2013
49390
ASTH W/O STAT ASTHM NOS
TRIDENT MEDICAL CENTER
8/2/1948
64
5/20/2013
7242
LUMBAGO
EAST COOPER REGIONAL MEDI
3/29/2010
3
5/13/2013
9181
SUPERFICIAL INJ CORNEA
MEDICAL UNIVERSITY HOSPIT
3/29/2010
3
5/18/2013
9593
ELB/FOREARM/WRST INJ NOS
MEDICAL UNIVERSITY HOSPIT
12/29/2005
7
5/17/2013
81240
FX LOWER HUMERUS NOS-CL
TRIDENT MEDICAL CENTER
12/29/2005
7
5/26/2013
49390
ASTH W/O STAT ASTHM NOS
TRIDENT MEDICAL CENTER
2/27/2008
5
5/19/2013
4779
ALLERGIC RHINITIS NOS
ROPER HOSPITAL
7/11/1971
41
5/13/2013
931
FOREIGN BODY IN EAR
ROPER HOSPITAL
11/4/1956
56
5/13/2013
6826
CELLULITIS OF LEG
MEDICAL UNIVERSITY HOSPIT
10/6/1985
EAST COOPER REGIONAL MEDI
27
5/3/2013
13101
TRICHOMONAL VAGINITIS
5/19/2006
6
5/12/2013
8910
OPEN WND KNEE/LEG/ANKLE
TRIDENT MEDICAL CENTER
9/4/1976
36
5/1/2013
29620
DEPRESS PSYCHOSIS-UNSPEC
MEDICAL UNIVERSITY HOSPIT
First Quarter ER Diversion Results
ER Usage of Project Participating PCP's
600
511
468
500
389
400
Mar- 13
Apr-13
300
May-13
200
100
0
Mar- 13
ER Utilization
511
Apr-13
468
May-13
389
Gaps in Care Reports
What is a Patient-Centered Medical Home?
• The Patient Centered Medical Home (PCMH is a model of care
designed to strengthen the physician-patient relationship by
moving from episodic (reactive) care to coordinated
(proactive) care, while establishing on ongoing relationship
with a physician-led care team.
• In a PCMH, the care team is responsible for providing all the
patient’s healthcare needs, including appropriate referral to
other qualified physicians as needed. Emphasis is placed on
open scheduling, expanded hours, and strong communication
between patients, physicians and staff.
Why PCMH??
• So why take the plunge? Following are six reasons to
consider implementing the PCMH Model:






National recognition
Increased reimbursement
Reduction in Hospital Admission Rates
Reduction in ER Visits
Improved staff satisfaction in PCMH practices
Improved patient health outcomes
BlueChoice HealthPlan Innovation
Specialists
• Guide practices through the NCQA Recognition and PCMH
transformation
 Perform baseline assessments with each practice to gauge readiness and
identify gaps
 Develop “road maps” for each practice on their individual needs and
abilities
 Build PCMH transformation team within the practice
 Provide education on the NCQA PCMH Recognition standards
 Develop tools and resources to assist practices with the NCQA
documentation requirements- P&P, reports, mechanisms for performance
monitoring, etc.
BlueChoice HealthPlan Innovation
Specialists (2)
• Provide continued support to practices after NCQA
Recognition.
 Identify key drivers for performance improvement
 Organize learning opportunities from national experts
 Provide meaningful feedback on performance and solutions for barriers
.
PCMH Incentives – Medicaid
As RHC’s begin to apply for NCQA certification as a Patient Centered Medical
Home, they become eligible to receive quarterly reimbursement from
BlueChoice HealthPlan Medicaid based upon their certification level. The
incentive is paid out as a per member per month payment for each eligible
member assigned to the practice.
• Application Level
$.50 PMPM
• Level One Certification
$1.00 PMPM
• Level Two Certification
$1.50 PMPM
• Level Three Certification
$2.00 PMPM
Questions??
Any Questions may be directed to:
Judi Ryder
Senior Director Network Management
803 264-2068
[email protected]

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