“With you when it matters…”
Insurance Conference
Coventry Health Care of Missouri, Inc.
Provider Relations
March 25, 2014
“With you when it matters…”
Living the
Aetna Way will
allow us to
achieve our
strategic goals
We put the people we serve at
the center of everything we do
“With you when it matters…”
Health Care Reform
Health Care Reform adds new information, requirements and details to an already
complex business. Health Care Reform has affected every aspect of our organization.
Several changes and processes have been implemented to align Coventry with current
and future policies, such as:
- Internal education
- New benefit plans built
- Communication developed for physicians, member and employer groups
- Correspondence (letters and EOB/ Remittance Advices)
- Finance, Actuary, and Underwriting changes have been made to address MLR
More information on Health Care Reform is available via the Health Care Reform link on
“With you when it matters…”
What is an Exchange?
The Exchange is an online market place where individual consumers and small group
employers can purchase insurance coverage.
• Exchanges may be offered at the State or the Federal level
• Illinois has chosen a state partnership exchange
• Missouri has opted for Federal Exchange
• On the exchange, consumers are able to:
• View Subsidy eligibility
• Review and compare all the plans available on the exchange
• Enroll in health coverage
“With you when it matters…”
Coventry’s Marketplace/Exchange Overview
• Coventry Healthcare offers Individual coverage for the Illinois and
Missouri exchanges for 2014
• Three options for the marketplace:
1. Federal (FFM) – Federally-facilitated exchange where the
state has no role in operation or management – Missouri
2. State Partnership (SPM) – Federal government builds
infrastructure but states retain authority (network adequacy,
licensure, etc.) – Illinois
3. State Base – The states create, operationalize, and maintain
their own exchange
• All other group sales remain the same for Coventry Healthcare’s offexchange markets
“With you when it matters…”
Coventry’s Marketplace/Exchange Products
1. PPO – Eastern Missouri and Southwestern Illinois
2. Carelink from Coventry is a narrow network PPO product
• Missouri and Illinois counties
• Hospital affiliated providers: Mercy, SSM, St. Elizabeth’s,
St. Anthony’s-Alton, HSHS
“With you when it matters…”
ICD-10 CM: 2014 Updates
• Our design, development, testing and deployment are aligned for the October
1, 2014 ICD-10 compliance date. We have completed all analyses, including
gap and system impact inventory, and system remediation. We have engaged
the impacted areas of our company in our business assessments. We will be
ready for the move from the ICD-9 codes to ICD-10 codes.
• The 10/1/2014 compliance date may seem far off, but the complexity of
conversion requires immediate action to address the business and clinical
issues associated with the transition. The ICD-10 conversion will affect
nearly all provider systems and many processes. The largest impacts will
likely be in clinical and financial documentation, billing and coding. It is
critical not to delay planning and preparation. It is important that providers
contact their billing or software vendor to understand their plans for
conversion and testing.
“With you when it matters…”
ICD-10 CM: 2014 Updates
• Coventry is a member of HIMSS and WEDI, and actively participates on
many industry workgroups and task forces related to IDC-10. We did
participate in the pilot; however at this time, we are not participating in the
• These industry resources will help with your planning and preparation:
• Centers for Medicare & Medicaid Services (CMS)
• Workgroup for Electronic Data Interchange (WEDI)
• Need to contact us? Coventry has two dedicated mailboxes for ICD-10
questions, information on ICD-10 testing, or surveys that need completed.
You will receive your response within two business days.
Email: [email protected]
Phone: 412-604-5566
“With you when it matters…”
Outpatient Imaging Program
• Utilized for advanced outpatient imaging management services
• Applies to Coventry Commercial HMO/POS, Select and PPO
• Applies to Medicare products: Advantra, Advantra PPO, and Gold
• Members are excluded from the Outpatient Imaging Program if
they access care through: ASO, Carelink, CMR, Coventry
National, First Health Network, and TotalCare
“With you when it matters…”
NIA, cont.
• Ordering physician responsible for obtaining prior authorization for
advanced radiology services
• Rendering facility is responsible for ensuring the prior authorization
has been obtained
• Prior Authorization’s obtained through NIA’s website,, or by phone, 800.546.4603, option 6
Procedures requiring prior authorization:
•PET Scans
•Nuclear Stress (MPI)
•Echo Stress
•Nuclear Cardiology
•Diagnostic Nuclear Medicine
“With you when it matters…”
New Century Health
Oncology Pathway Solution Drug Program
New Century Health (“NCH”) manages the Oncology
Pathway Solutions program, effective March 1, 2014.
The Oncology Pathway Solutions program uses clinical
guidelines based on nationally recognized, evidencebased criteria for determining medical necessity in
cancer care. It streamlines the complex administrative
process associated with chemotherapy preauthorizations.
“With you when it matters…”
New Century Health Prior Authorization
• Chemotherapeutic drugs and supporting agents will require
pre-authorization prior to being administered in a
physician’s office, elective inpatient, outpatient or
ambulatory setting.
• Applies to all Coventry Medicare and Commercial members
ages 18 and older.
• The requesting physician must complete the NCH
Chemotherapy Request Form (CTR).
• Applies to services for Coventry Members with coverage
under both fully insured and Medicare products. It does not
include self-funded or Carelink products.
“With you when it matters…”
New Century Health Key Features
• Provider portal available 24/7/365 offering:
• Real-time authorizations when selecting treatment care
• Reduced documentation requirements
• Easily view real-time status of authorization requests
• Eligibility verification
• Fax authorization requests 877-624-8602
• Supportive telephonic authorization 877-624-8601
• Quick turnaround time on requests submitted via fax or phone
• Peer-to-peer consultation's by medical oncologists
• NCH is a National Comprehensive Cancer Network licensee of
the Drugs and Biologics Compendia and utilizes nationally
recognized evidence-based treatment guidelines
“With you when it matters…”
Drug Program
ICORE ensures quality care and affordability for our members.
The company leads prior authorization review for drugs ordered by
health care professionals in a physician office (POS 11) and
outpatient facility (POS 22). The program supports a “buy and
bill” reimbursement model to encourage the use of medically
indicated, lower-cost options that are equal in quality and clinical
outcomes. With this commitment in mind, we implemented
changes to those drugs that are included in the review process with
ICORE. Please see updated drug list effective March 1, 2014.
“With you when it matters…”
ICORE Drugs Requiring Prior Authorization
Actemra (J3262)
Acthar (J0800)
Botox (J0585)
Euflexxa (J7323)
Gel-One (J7326)
Myobloc (J0587)
Nplate (J2796)
Orthovisc (J7324)
Remicade (J1745)
Supartz/Hyalgan (J7321)
Synvisc/SynviscOne (J7325)
Tysabri (J2323)
Plans Included: All Commercial HMO, POS, PPO, Select and Medicare
Advantage products
Plans Excluded: Self-funded ASO/CMR Groups and Carelink/Total Care
ICORE: 800-424-4157 or
Provider Hotline: 800-755-5242
“With you when it matters…”
Triad Healthcare Inc. – Quality Assurance
for Pain Management Procedures
Triad Healthcare, (“Triad”) a leading musculoskeletal health services company
focuses on the health care needs of patients with painful spine and joint conditions.
Triad administers Coventry’s quality assurance program for pain management
procedures. Triad’s mission is to improve the quality of care delivered to patients
with complaints of musculoskeletal pain.
• The new prior authorization process applies to services for CHC members with
coverage under both fully insured and Medicare products. It does not include selffunded products. Triad’s medical policies, a list of CPT codes designated as pain
management services requiring prior authorization and managed by Triad, along
with authorization forms, are available by contacting Triad or on the Providers
section of our website at Prior authorization requests and your
patient’s medical records must be submitted using any of the following methods:
* Web: * Fax: 888-229-5680 * Phone: 888-584-8742
• Triad’s evidence based medical policy is available to Coventry Health Care
providers at:
“With you when it matters…”
Advantra’s Dual Eligible - Special Needs Plan
CHC Missouri plan covers Dual Eligible (DE).
DE’s are individuals who are entitled to Medicare and some level of assistance
from Missouri Medicaid (MO HealthNet).
Advantra DE-SNP is a Medicare replacement plan
Advantra DE-SNP is NOT a Medicaid replacement plan
Members must see providers who participate in both Advantra and MO
HealthNet Networks to optimize their benefits
Members who select us must carry and use both plans’ ID cards, Advantra
DE-SNP card and MO HealthNet card
Advantra DE-SNP, like Medicare, always pays first; MO HealthNet benefits
wrap around our plan
“With you when it matters…”
Lab Services/Providers
In-Office Lab Policy
Lab specimens for CHC of Missouri’s Commercial and Medicare Advantage
should be sent to Quest Diagnostics in the St. Louis Metro area, or one of the
approved outpatient labs for those outside of the metro area. The metro area is
defined as:
– In Missouri: Franklin, Jefferson, Lincoln, St. Charles, St. Francis, St.
Genevieve, St. Louis City, St. Louis, Warren, Washington counties
– In Illinois: Madison, Monroe, St. Clair counties
Coventry Health Care reimburses in-network providers for specific lab
procedures when they are preformed in office on a STAT basis only. Please
refer to our provider manual for a detailed list of these labs. The provider
manual is available under the provider section on
“With you when it matters…”
Valuable Information Available Online at
Click “Providers” on the home page for immediate access to
these valuable resources:
• Comprehensive provider search
• Drug formulary (prescription
• Prior authorization information
• Medical injectable list
• Authorization form
• Prior authorization list
• CPT codes requiring prior
• Network participation details
• Credentialing policies, criteria
and provider rights related to
“With you when it matters…”
Visit the “Provider Document Library” to access:
Provider Manual – Includes information about claims processing, member
rights and responsibilities, and other helpful resources.
Complex Case Management – Informs providers about our complex case
management program and how to refer patients to the program.
Network News – Holds current and past issues of Network Connection, our
provider newsletter.
Quality Improvement Policies and Procedures – Notes quality improvement
annual evaluations and medical record documentation standards.
Utilization Management Policies – Displays summaries of our evaluation of
new medical technology, utilization management criteria and financial
incentives policy.
Wellness – Highlights preventive health guidelines, clinical practice
guidelines and disease management programs.
“With you when it matters…”
Services & Information Available:
• Claim Adjustment Requests
• Remittance Advices
• Eligibility/Benefit Inquiry
• Resource Library
• Secure Messaging
• Member ID cards
• Enhanced News
• Authorization Request/Inquiry/Update/Appeal
“With you when it matters…”
Select a Health Plan:
 Coventry Health Care of Missouri
 Carpenters’ Health and Welfare Trust Fund
 Coventry of Missouri (MODOT)
 University of Missouri
 Coventry Health Care of Illinois
 Coventry Health Care of Kansas and Preferred Health System
 Coventry Health Care National Network
 CoventryOne National
 Mail Handlers Benefit Plan
 Rural Carrier Benefit Plan
“With you when it matters…”
Workers Comp on
• Workers Comp link added to provide access to Coventry’s
Workers Comp (WC) business information
• Includes access to WC Bills, Pricing Sheets, Explanations
of Review/ EOR’s CMS 1500 & UB-04 Bill Images
• If you are currently registered with
for Coventry Health Plans access, just click the
WORKERS’ COMP link in the left navigation bar on the
home page and follow the instructions
“With you when it matters…”
Authorizations on Made Easy
Here are a few tips on navigating the authorization submission process:
• Submit the same type of clinical information that is needed when requesting the
authorization via phone. Either document the information in the comment section of
the authorization or attach clinical information to the authorization.
• Without clinical information, the authorization may be denied for lack of
• It is recommended to check member eligibility and current authorizations prior to
entering a new authorization.
• Online help is available on for authorization as well as other
key functions. If you have any questions or require technical support Coventry’s Net
Support Team is available 9am-5pm Monday through Friday at (866) 629- 3975.
“With you when it matters…”
2014 Training Sessions
Authorizations & Referrals – April 4, 9, 23 at 9 a.m.
Claims/Remittance Advices – April 8, 22 at 9 a.m.
Workers’ Compensation – April 11 at 9 a.m.
First Health/TPA Bills – April 4, 11 at 10 a.m.
PCP HEDIS Reports – April 3 at 9 a.m.
To register your provider office staff for
training sessions please send a email with the date you wish to
attend to: [email protected]
“With you when it matters…”

similar documents