GHP Provider Update - Spring 2013

Report
EMHS EMPLOYEE HEALTH PLAN
PROVIDER ORIENTATION
May 2013
Geisinger Health Options is administered by Geisinger Indemnity Insurance
Company, an affiliate of Geisinger Health Plan.
The EMHS Difference
an accountable system of care
… providers, hospitals, and others working
together to coordinate patient care, ensure
access, reduce costs, and help people
learn how to live as healthy a life as
possible.
Together We’re Stronger
Primary Care
Through innovative primary care and
health information technology, EMHS
can reduce healthcare costs while
improving quality and outcomes.
Together We’re Stronger
Care Coordination
•
•
•
•
Close gaps in care
Better communication
Frequent patient/family interaction
Daily provider/team interaction
Together We’re Stronger
EMHS Progress to an
Accountable System of Care
ACO
Bangor
Beacon
Community
Patient Centered
Medical
Homes
IT infrastructure and
results- driven quality
improvement
Together We’re Stronger
The Difference Starts at Home
EMHS medical plan: 11,000 employees/dependents
• Wellness Coaching
• Elimination of pre-existing condition rule
• Zero copay for certain generic drugs
• Zero copay for supplies for coronary artery
disease, depression, diabetes, and hypertension
Together We’re Stronger
GEISINGER TEAM
The Geisinger Team
Duane Davis, M.D.
Ray Roth, D.O.
Janet Tomcavage
Jason Renne
Leigh Brock-Webster
Christy Spurlock
Jan Goodeluinas
Kimberly Fullmer
Chief Exec. Officer & Exec. Vice President of Insurance Operations
Chief Medical Officer, GIO
Chief Administrative Officer, GIO
Vice President, Network Innovations
Director, New Market Development
Manager, Business Operations
Team Lead
Sr. Provider Network Development Associate
7
PARTNERSHIP FOR SUCCESS
EMHS/Geisinger Partnership- why?
 EMHS: Quality- focused clinically integrated network
 Geisinger Health Plan: Proven track record for quality and innovation
 Bring physician partnership in the delivery of quality care
Why did the partnership come together?
 Advancement of quality initiatives
 Partner with country’s leading not for profit health plan
 Geisinger seeking strategic partnership outside PA with innovative
partners to implement models of care in collaboration with physicians.
8
PARTNERSHIP FOR SUCCESS
EMHS/Geisinger
Partnership for success
 Shared strengths:
Geisinger dedicated to physician led quality of care
¤ Like-minded, not-for-profit, mission focused
¤ Geisinger – “PASSIONATE” about improving quality of care; earned
national reputation for redesigning care and value.
 Compatible Interests:
¤ Build a clinically integrated delivery system
¤ Deploy Geisinger care delivery model
9
Geisinger Health System - An Integrated
Health Service Organization
Provider
Facilities
$1,564M
Physician
Practice Group
$702M
• Geisinger Medical Center
• Hospital for Advanced Medicine,
Janet Weis Children’s Hospital, Women’s Health
Pavilion, Level I Trauma Center, Ambulatory
Surgery Center
•Geisinger Shamokin Community Hospital
• Geisinger Northeast (3 campuses)
• Geisinger Wyoming Valley Medical Center
with Heart Hospital, Henry Cancer Center,
Level II Trauma Center
• South Wilkes-Barre Adult & Pediatric Urgent
Care, Ambulatory Surgery Center, inpatient
rehab, pain mgmt., sleep center
•Geisinger Community Medical Center
• Marworth Alcohol & Chemical Dependency
Treatment Center
• Mountain View Care Center
• > 69K admissions/OBS & SORUs
•1,372 licensed inpatient beds
Managed Care
Companies
$1,465M
•
Multispecialty group
• ~900 physician FTEs
• ~520 advanced practitioner FTEs
• 65 primary & specialty
clinic sites (37 community
practice sites)
• 1 outpatient surgery center
• > 2.1 million clinic
outpatient visits
• ~360 resident & fellow FTEs
•
~298,000 members
(including ~63,000 Medicare
Advantage members)
• Diversified products
• ~30,000 contracted
providers/facilities
• 43 PA counties
Note: Numerical references based on fiscal 2012 budget
plus impact of GSACH and GCMC acquisitions.
10
Our system is a model for health care
reform
“…We need to build on the examples of
outstanding medicine at places like…Geisinger
Health System in rural Pennsylvania…islands of
excellence that we need to make the standard in
our health care system.”
Remarks by President Barack Obama,
American Medical Association
Annual Conference, June 15, 2009
11
Geisinger Health Plan carries on the
tradition of quality
 Top-ranked Medicare and commercial health plan in
Pennsylvania
 #12 private and #6 ranked Medicare plan in the nation
 Ranked 4.5 out of 5 stars by CMS five years in a row.
 “Excellent” Accreditation from NCQA (since 1994)
 Named 2008 “Outstanding Health Plan” by DMAA: The Care
Continuum Alliance
* According to the National Committee for Quality Assurance (NCQA)
Health Insurance Plan Rankings 2010-11–Private and Medicare lists.
12
And our mission is to be the best
Best in the state for: Breast cancer screenings*
Ensuring recommended
medications are taken after
a heart attack*
Glaucoma Screening
Monitoring of persistent
medications
Diabetes monitoring
13
DISCLAIMER
This presentation is not intended to be all inclusive.
All information is fully delineated in the Provider Guide
(Rev 08/11), which may be amended from time to time
by written correspondence and can be found at
www.thehealthplan.com.
14
WEBSITE
www.thehealthplan.com
15
WEBSITE
www.thehealthplan.com
16
PROVIDER INFORMATION CENTER
PROVIDER/PHARMACY SEARCH
17
WEBSITE
SECURED/UNSECURED
Secured (required log-in)
Service Center
-Member benefit
-Claim/authorization data
Physician Quality Reports
Medical Policies
Member Health Alerts
Drug formulary
Health Plan Communications
Electronic Transaction
Provider Guide
Unsecured
Provider/facility search
18
SERVICE CENTER
ONLINE ACCESS:
• Service Center
• Providers have the ability to verify Member Eligibility,
Benefits, Authorizations, Referrals and Claim Status
• Registration is necessary. Complete the Service Center
Registration form called the “Super User Registration
Form.”
19
SUPER USER REGISTRATION FORM
20
SECURED MESSAGES
SERVICE CENTER
21
COMMUNICATION
22
COMMUNICATION TOOLS
Forms and Publications
Located at www.thehealthplan.com within the Provider
Information Center
• The Provider Guide
• An important part of the contract between
the Health Plan and the provider
• Operations Bulletins
• Health Plan’s method to communicate important time
sensitive information
• Briefly
• Quarterly newsletter providing useful Health Plan news and
information about changes which affect Participating Providers
These Forms and Publications are mailed to the participating providers
and accessible online.
23
WHO TO CALL
• GHP has developed a user friendly handout to help
you identify your key contacts at the Health Plan,
such as:
•
•
•
Claims/Customer Service Department – (855) 863-2429
Medical Management – (800) 544-3907
PNM Number – (800) 876-5357
• The Who To Call Card is included in your packet and
will be located on the website.
24
MEMBERS
25
IDENTIFICATION CARDS
•
Each member is issued an ID card similar to
this example.
•
Contact Customer Service using the toll free
number of the back of the ID card to confirm
eligibility and/or benefits prior to rendering
services.
DRAFT
26
MEDICAL
MANAGEMENT
27
REQUIRES PRECERTIFICATION
The following require precertification by the
Health Plan:
• Planned inpatient admission, including rehabilitation
admissions;
• Skilled level of care admissions;
• Outpatient rehabilitative services (PT/OT/ST);
• Outpatient radiology services (NIA-To be discussed
later in presentation)
• Home Health/Hospice Services by Home Health
Provider
28
PRECERTIFICATION REQUIREMENTS
•
Admitting or ordering physician is responsible for obtaining precertifications
•
All requests for prior authorization/pre-certification by the Health Plan
should be submitted by the admitting/ordering participating provider.
Requests may be telephonic, faxed, or submitted via US Mail to:
•
•
Geisinger Health Plan
Medical Management Department. 30-20
100 North Academy Ave
Danville PA 17822
(800) 544-3907 or (570) 271-6497
Mon. - Fri., 8:00 am to 5:00 pm
Please refer to the Prior Authorization/Pre-certification list available on
our website at:
http://www.thehealthplan.com/providers_us/prior_auth_list.pdf
29
PRECERTIFICATION REQUIREMENTS
• Planned admission require pre-certification no less than two
(2) business days prior to date of admission.
• Observation Services expected to exceed 23 hours require the
Participating Provider to initiate a request for pre-certification
• Non-Emergent ambulance transportation with a nonparticipating provider requires pre-certification
prior to service being rendered.
30
CONCURRENT REVIEW PROCESS
Initial Concurrent Review:
Subsequent Concurrent Review:
• Facilities are required to initiate with • Reviews will continue during the
the MM Department within one (1)
member’s entire stay.
business day of the admission.
• Please have member information readily
available during the Concurrent Review.
• Please have member information
• Nursing or therapy updates; and
readily available during the
• Plan of care with anticipated
Concurrent Review.
disposition and estimated length of
• Verification of admission date and
stay.
attending physician;
• Current inpatient needs;
• Plan of care; and
• Overall goals and anticipated
length of stay.
31
REQUIRES PRECERTIFICATION
Contact the Medical Management Department to initiate a request
for precertification at (800) 544-3907 or (570) 271-6497, option 1,
Mon. – Fri. 8:00 am – 5:00 pm.
• Skilled level of care admissions (Facilities accepting skilled admissions are
responsible for precertification)
•
•
•
Precertification is required prior to the admission.
A three (3) day prior hospital stay is not required.
Precertification is also required when the Health Plan is not the member’s
primary insurance coverage.
32
REQUIRES PRECERTIFICATION
Contact the Outpatient Rehabilitative Therapy Network to initiate a request
for precertification at (800) 270-9981 or (570) 271-5301 Mon. – Fri. 8:30am to
5:00pm.
• Outpatient Rehabilitative Therapy
• Facility Outpatient Rehabilitative Therapy Services Providers
(Outpatient Rehab. Providers) are required to initiate the request for
precertification through the Outpatient Rehabilitative Therapy
Network.
 Such requests must be initiated within seven (7) calendar days of
the initial rehabilitative evaluation.
 Precertification is also applicable to members in an intermediate
care setting.
33
OUTPATIENT REHAB FORM
34
REQUIRES COORDINATION
• Hospice Election
• Facilities are required to notify the Health Plan’s Home
Health/Hospice Network immediately upon a member’s
decision to invoke their hospice benefit.
• Infusion Therapy Services
• Facilities are encouraged to refer to their agreement for
specific information regarding the inclusion/exclusion of
infusion therapy services.
• Personal Care Facility (PCF)
• Medicare/Health Plan standards do not consider a PCF an
institutionalized facility. Therefore, members residing in a
PCF should have all services coordinated by their PCP, as
applicable.
35
NIA
NATIONAL IMAGING
ASSOCIATES, INC.
36
Geisinger Health Plan
Provider Training Program
Agenda
•
•
•
•
•
•
•
•
•
Welcome and Opening Remarks
About National Imaging Associates, Inc.
Provider Partnership
Program Components
How the Program Works:
• Authorization Process
• Authorization Appeals Process
• Claims Process
• Claims Appeals Process
Provider Self-Service Tools (RadMD and IVR)
RadMD Demonstration
NIA Provider Relations and Contact Information
Questions and Answers
38
About NIA
NIA is accredited by
NCQA and URAC certified
National Imaging Associates (NIA) - chosen by national and regional health
plans, serving more than 17 million members, and offering:
•
•
•
•
•
•
•
Distinctive clinical focus
National Committee for Quality Assurance accreditation and Utilization
Review Accreditation Commission certification
Stability reinforced by parent company, Magellan Health Services
Enhanced operational competencies
Strong IT capabilities
Comprehensive patient support tools
Financial stability promoting growth and investment in innovative
technology
Focus and Results - Maximizing quality diagnostic services and promoting
patient safety through:
•
•
A clinically-driven process that safeguards appropriate diagnostic
treatment for Geisinger Health Plan members.
Convenient access to a network of qualified providers
Overview of Program Components for
Geisinger Health Plan
NIA Product Features
Prior Authorization / Utilization
Management
Imaging Networks
NIA Program Description

NIA will implement MR, CT, PET, CCTA, Diagnostic Nuclear Medicine and Nuclear
Cardiology/MPI modalities prior authorization, clinical protocols, and user-friendly,
efficient provider tools.

NIA will use Geisinger Health Plan Free Standing Facilities, In-Office and Hospital
imaging networks for the program.
40
The Authorization Process
41
NIA Prior Authorization Is Required for:
Non-emergent outpatient
•
•
•
•
•
•
CT/CTA Scan
CCTA
MRI/MRA
PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
•
Any code specifically cited in the Geisinger Health Plan /NIA Billable CPT® Code
Claims Resolution Matrix.
•
ALL other procedures will be adjudicated and paid by Geisinger Health Plan per
their guidelines.
Authorizations are valid for sixty (60) days from date of determination.
•
42
NIA Prior Authorization is NOT required:
• When the following studies are performed in an emergency room,
observation or inpatient setting, prior authorization is not required from
NIA.
•
•
•
•
•
•
CT/CTA Scan
CCTA
MRI/MRA
PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
• Providers should continue to follow Geisinger Health Plan authorization
policies for emergency room, observation or inpatient procedures.
43
Clinical Record Validation
• Sometimes NIA will require validation of clinical criteria within
the patient’s medical records before an approval can be
made.
• We want to ensure that the clinical criteria that support the
requested test are clearly documented in the medical records.
• OTHER INFORMATION
o Required based on algorithm
• Methods of Submitting Clinical Records
o Upload through RadMD – Preferred Method
o Fax to NIA using the OCR Fax Coversheet
44
NIA’s Authorization Process
•
•
•
•
•
•
•
The ordering physician is responsible for obtaining prior authorization.
The rendering provider must ensure that prior authorization has been obtained. It
is recommended that procedures are not scheduled without prior authorization.
Requests for CCTA and Nuclear Cardiology will be reviewed using cardiac specific
algorithms, and when a physician is needed, a board certified cardiologist, who in
some scenarios may suggest an alternate study.
Procedures performed without proper authorization will not be reimbursed.
If the radiologist or rendering provider feels that, in addition to the study already
authorized, an additional study is needed, they should contact NIA immediately
with the appropriate clinical information for an expedited review. The number to
call to obtain a prior authorization is 1-866-305-9729.
If an emergency clinical situation exists outside of a hospital emergency room,
please contact NIA immediately with the appropriate clinical information for an
expedited review. The number to call to obtain a prior authorization is
1-866-305-9729.
Separate prior authorization numbers are not needed for CT-guided biopsy, CTguided radiation therapy and some MR-guided procedures.
45
NIA Clinical UM Authorization Process
Physician’s office
contacts NIA for prior
authorization of study
System evaluates request
based on physician
entered information


?
Clinical information
complete –
procedure approved
Clinical information
not complete –
additional
information needed
Request for
specific
clinical
information
needed
Initial Clinical Specialty
Team Review

?
Additional clinical
information
complete –
procedure
approved
Additional clinical
not complete or
inconclusive
Physician Review

Physician Approves
Case Without Peer-toPeer

Physician Approves
Case With Peer-toPeer
W
Ordering Physician
Withdraws Case

Physician Denies
Case
46
The Authorization Appeals Process
• In the event of a denial or you are not satisfied
with a medical decision from NIA, you may
appeal the decision through Geisinger Health
Plan .
• You will receive appeal information in the denial
letter that will be sent to you
47
The Claims and
Claims Appeal Process
How Claims Should be Submitted:
• Rendering providers/imaging providers should continue to
send their claims directly to Geisinger Health Plan as per the
current process.
• Providers are strongly encouraged to use EDI claims
submission.
Claims Appeal Process
•
In the event of a prior authorization or claims
payment denial, you may appeal the decision
through Geisinger Health Plan .
•
Follow the instructions on your non-authorization
letter or Explanation of Benefits (EOB) notification.
48
Self-Service Tools and Usage
49
NIA Provider Tools “Make it Easy” for
Providers to Partner with NIA
Clinical algorithms apply sophisticated criteria to auto-approve
most requests and send others for additional review
Phone
Web
IVR
Fax
•
•
•
•
Telephonic requests to NIA’s call center 8am to 8pm EST.
Customer Service Rep guided through the scripted process by the clinical system.
Clinical system evaluates information collected and determines the next step.
Functionality greatly reduces human error and allows expedient contact with the provider.
• RadMD is an easy-to-use and convenient way for providers to submit authorization requests to NIA.
• Proprietary clinical algorithms respond online, prompting the user to answer a few simple questions
about the request.
• Immediate approval or notification of the need for further review.
• NIA’s Clinical Guidelines - essential information on clinical criteria – easily available for download or
future reference.
• Magellan’s state-of-the-art IVR application allows providers to check on the status of an authorization
24x7x365.
• Faxed document images, both inbound and outbound, are integrated into the clinical system where they
are linked to authorization records.
50
RadMD
To get started, visit www.RadMD.com
•
Click the “New User” button on the right
side of the home page.
•
Fill out the application and click the
“Submit” button.
•
You must include your e-mail address in
order for our webmaster to respond to
you with your NIA-approved user name
and password.
•
Everyone in your organization is required
to have his or her own separate user
name and password due to HIPAA
regulations.
•
On subsequent visits to the site, click the
“Login” button to proceed.
•
If you use RadMD for another health plan
with NIA, you may use the same log on
and password for Geisinger Health Plan
52
RadMD
53
RadMD
54
RadMD
55
RadMD
• You can request up to five exams per patient
56
RadMD
57
RadMD
58
RadMD
59
RadMD
60
RadMD
61
RadMD
• You can print the fax OCR cover sheet to submit the documents.
62
NIA Provider Relations
63
NIA Contact Information
NIA Provider Relations Manager
Lori Fink
Phone: (410) 953-2621
Email:
[email protected]
Provides educational tools to ordering and rendering providers on imaging processes and
procedures.
Liaison between Geisinger Provider Relations and NIA.
Questions and Answers
65
PRESCRIPTION DRUG
COVERAGE
66
PARTICIPATING DRUG COVERAGE
• Outpatient Prescription Drug Coverage includes the use of
a Formulary and Participating Pharmacies.
• Health Plan offers multi-tiered prescription benefit levels which generate
member cost sharing contingent upon the type of medication prescribed.
• Requesting approval for non-Formulary medications or Formulary
medications requiring prior authorization or Step Therapy, designated in
the Formulary by “PA” or “ST” next to the medication name, is the
responsibility of the prescribing physician.
• Non-Formulary exception process or prior authorization can be initiated
by contacting the Pharmacy Department at the following:
Geisinger Health Plan Pharmacy Department
(800) 988-4861 or (570) 271-5673
fax: (570) 271-5610
Business Hours: Monday – Friday 8:00 AM – 8:00 PM
67
SPECIALTY PHARMACY
DRUG PROGRAM
68
SPECIALTY PHARMACY DRUG PROGRAM
• The Health Plan is able to purchase certain drugs at discounted
rates through select Pharmacy Vendors passing savings on to
Members, employers and Participating Physicians.
• The use of this Drug Program eliminates your need to purchase
these drugs, thereby reducing your out-of-pocket expenses and
eliminating the need for you to submit medication claims to the
Health Plan.
• This new program allows Participating Physicians two options:
• continue to “buy and bill” certain medications as usual at new
contracted rates, or
• utilize the Specialty Pharmacy Drug Program.
• More information on this Program along with the request form, can
be found on our website at:
http://www.thehealthplan.com/providers_us/pharmvend.cfm
69
BEHAVIORAL
HEALTH
70
Behavioral Health - OPTUM
Optum Health
www.liveandworkwell.com
(888) 839-7972
71
Claim Submission
Requirements
72
CLAIMS SUBMISSION REQUIREMENTS
All services rendered should be reported:
• Using a UB04 or a CMS1500 claim form
• Submission through electronic format
• Include summarization by revenue code, which may include
CPT-4® and/or HCPCS procedural codes with applicable
modifiers
• Include the then current ICD-9-CM diagnosis coding to the
highest level of specificity, as applicable, for all services and
procedures
• Include the NPI number
(Refer to Provider Guide for further instructions)
73
FACILITY
PROVIDERS
74
CLAIMS SUBMISSION REQUIREMENTS
• Failure to submit a HCPCS code with the revenue codes
indicated as requiring HCPCS codes will result in a denial of
that line item.
• If reporting general ambulatory surgical care services
(revenue code 490) plus operations room services (revenue
code 360), charges should be combined under revenue code
360 only.
• Please refer to the online Provider Guide for more
information.
75
CLAIM SUBMISSION REQUIREMENTS
• Skilled level of care claims for members who have been determined
to be level II or III must have accompanying therapy logs attached.
• Providers should indicate the skilled level of care in Box 84
(Remarks) on the UB04 Claim Form.
• UB04 Claim Forms must reflect the appropriate discharge status
code in Box 22 and appropriate date range in Box 6.
• EXAMPLE: If the through date on the claim is 1/31/10 and the
discharge status is 30 (still a patient), but the member was
actually discharged on 1/31/10, the claim will be denied.
76
CLAIM SUBMISSION REQUIREMENTS
• Providers can submit multiple skilled levels of care on a single claim.
Intermediate care and skilled care, however, can not be billed together.
Separate claims are required.
• Observation Services should be reported on a UB04 Claim Form using
revenue code 762.
• Revenue code 760, 761, and 769 are not appropriate for reporting
Observation Services to the Health Plan.
• The units of service should be reported in whole hours.
• Observation Services that were provided to a Member, who was
subsequently admitted to the same Facility as the Observation Services,
are not separately reimbursed as outpatient services, but may be
adjudicated as the first day of the inpatient admission.
77
CLAIM SUBMISSION REQUIREMENTS
ASC
Grouper Methodology
• Ambulatory Surgical Centers (ASCs) are reminded that the Health
Plan utilizes the “Medicare approved ASC list” when determining
whether a specific procedural code is associated with a grouper
category. The Health Plan will not reimburse procedural codes,
which are not specifically assigned to a grouper category. ASCs are
advised to monitor all scheduled procedures for compliance with
the “Medicare approved ASC list”. Additionally, ASCs may not
balance bill a member for denials related to this requirement.
APC Methodology
• APC follows Medicare guidelines.
78
CLAIM SUBMISSION REQUIREMENTS
• When reporting outpatient diagnostic testing the
ordering provider information must be completed in
Box 17 on the CMS1500 Claim Form and/or Box 82
on the UB92 Claim Form.
CLAIMS SUBMISSION REQUIREMENTS
• The referring physician’s name and NPI number must
be included in Box 76 "attending phys.id" on the
UB04 Claim Form
79
OUTPATIENT REHAB/
PHYSICAL THERAPY
80
CLAIMS SUBMISSION REQUIREMENTS
• Outpatient Rehab. Providers are required to utilize the applicable
modifiers; GN, GO, GP, etc.
• Physical medicine/rehabilitation encounter based CPT® codes
(i.e. 92507, 97001, 97003) are designed to be reported with one
(1) unit per date of service regardless of the length of
visit/treatment time.
81
ANESTHESIA
82
CLAIM SUBMISSION REQUIREMENTS
• Providers are required to report the applicable modifiers
when reporting anesthesia services ( AA, AD, QK, QX, QZ, QY).
• When reporting anesthesia administration services, the
time reported should represent the continuous actual
presence of the anesthesiologist or CRNA.
• Anesthesia services other than those performed solely by
an anesthesiologist will reflect a 50/50 split reimbursement.
83
VISION
84
VISION SERVICES
• Coverage includes one routine eye exam with refraction coverage
per benefit or calendar year.
• Routine Eye Care Guidelines
• Claims must have a refraction diagnosis code of 367.0 – 367.4X, 367.8X,
or 367.9 in the first diagnosis position on the claim.
• Utilize S0620 or S0621 when reporting routine eye exams with a
refraction.
• If the “S” code is not reported, appropriate coverage may not apply.
• Medical Eye Care
• Medical eye visits should be reported with the appropriate 92000 series
CPT code with the appropriate medical diagnosis code.
85
OB/GYN
86
CLAIM SUBMISSION REQUIREMENTS
NEWBORNS
• The Health Plan requires newborn services to be
reported under the newborn's individual Health Plan
identification number. Providers should not report
newborn services under the mother's Health Plan
identification number.
• Contact Customer Service at (855) 863-2429 to determine
the newborn's individual Health Plan identification number.
87
CLAIM SUBMISSION REQUIREMENTS
MATERNITY AND DELIVERY CARE
• Refer to the Provider Guide for instructions on
reporting Maternity & Delivery Care
• Global Care includes antepartum, delivery and
postpartum care provided by a solo provider or
group practice
• If using the CMS 1500 form - Box 24A is required to indicate
the delivery date in both the “from” and “to” locations.
88
MODIFIERS
89
BILLING INFORMATION MODIFIERS
• 50 modifier – bilateral procedures
• Number of units = 1
• 80, 81, or 82 modifiers – assistant surgeons
• There is no separate reimbursement for PAs, CNS, and/or nurse
practitioners (NP). The Health Plan requests that providers not submit
claims for these providers.
• Claims are reimbursable when submitted under the supervising
physician.
• If such services must be reported, the following information must be on
the claim:
• Modifier AS must be submitted for these services.
• Do not submit 80, 81, or 82 to represent a non-physician assistant at
surgery.
90
LOCUM TENENS
91
LOCUM TENENS
• When reporting services rendered by a locums
tenens provider, modifier Q6 should accompany the
procedure code.
A locum tenens provider may render services for a maximum
of six (6) months before they are required to begin the
Health Plan's credentialing process.
92
CLAIMS RESEARCH
REQUEST FORM
CRRF
93
CLAIMS RESEARCH REQUEST FORM (CRRF)
94
CLAIM RECONSIDERATION PROCEDURE
• Utilize the Claim Research Request Form (CRRF)
• Link to the CRRF
http://www.thehealthplan.com/documents/providers/CRRF.pdf
• Requests must be received (60) days from the date indicated on the
EOP
• Reconsiderations received after the sixty (60) day filing limit are not
eligible for reconsideration
• Submit CRRF to:
Claims Department
Geisinger Health Plan
PO Box 8200
Danville, PA 17821-8200
95
CLAIMS RESEARCH REQUEST FORM (CRRF)
• CRRF Tips
• Only submit one claim per CRRF form. Exception to this is
multiple claims with same issue.
• Include claim number and date of service
• Check the appropriate boxes (i.e. COB or Claim Edit)
• Health Plan has 45 days to review and process CRRFs
96
CLAIMS RESEARCH REQUEST FORM (CRRF)
When to use a CRRF
• UA Denials (Failure to Precert Services) – Only when there is a
compelling reason why the provider failed to precert and the
dispute is within timely filing guidelines.
• Claim Edit Denials – Be sure to check the claim edit box on the CRRF
form and attach supporting documentation.
• Timely Filing Denials – Only when there is a compelling reason for
why the provider failed to submit timely.
• When information on a PAID CLAIM needs to be corrected.
For example:
Late charges, Incorrect diagnosis, Incorrect procedure code,
Incorrect revenue code, Incorrect modifier, Invalid Member ID,
Location code.
97
CLAIMS RESEARCH REQUEST FORM (CRRF)
When NOT to use a CRRF
• Non Participating Provider
• Claim Retractions – Providers should initiate through Customer
Service or Secured Message via Web.
• When information on a DENIED CLAIM needs to be corrected.
Providers should resubmit the corrected claim through their normal
claims submission process.
• P2 or XX Denials – Questions related to provider contracts or fee
schedules should be directed to your provider relations
representative.
• Timely Filing Denials if no compelling reason exists. (COB claims are
not subject to timely filing)
• Utilization/Authorization Denials – if no compelling reason
exists.
98
NO PRIOR AUTHORIZATION
UA DENIALS
REMINDER
• Precertification of high dollar radiology services must be
obtained through National Imaging Associates (NIA)
• Services on GHP’s prior authorization list must be initiated by
the rendering provider prior to services being performed
• Compelling reason for reconsideration of a UA denial
99
TIMELY FILING
100
TIMELY FILING
REMINDER
• 120 days for initial submission of claim
• 60 days from paid date for original claim for resubmissions
• Compelling reason for reconsideration of a timely filing denial
101
PROVIDER REPORTS
102
HEALTH PLAN REPORTS
• The Health Plan provides CRMS reports to our providers that
helps them understand utilization in specific areas.
• Laboratory Utilization Report
• Physician Utilization Activity Report
• Pharmacy Utilization Report
Each report is designed to provide over and/or under-utilizations
trends on physician specific data, as well as peer comparison
data.
103
PUR ,CRMS, MEDICATION ADHERENCE &
PROGRESS REPORTS
The Health Plan provides reports for our providers that helps them
understand utilization in specific areas.
•Pharmacy Utilization Report (PUR)
•CareEnhance Resource Management System (CRMS) Report
•Medication Adherence Report
•Physician Quality Summary (PQS) Progress Report
These reports are designed to provide over and/or under
utilizations trends on physician specific data, as well as peer
comparison data.
104
ELECTRONIC
CAPABILITIES
105
ELECTRONIC CAPABILITIES
• Take advantage of three electronic capabilities
• EDI – is the electronic claims transactions
• EFT – Electronic Funds Transfer or
• Claim payments will be directly deposited to the identified provider's
bank account. No more checks to handle
• Electronic Explanation of Payment
• To begin using these capabilities, please submit the
appropriate on-line forms using the link to our website at:
http://www.thehealthplan.com/providers_us/resource.cfm
106
PROVIDER NETWORK
MANAGEMENT
107
PROVIDER REPRESENTATIVE
• Your Provider Representative is available to assist you
with any of the following issues:
(800) 876-5357
• On-Site education offered to your staff
• Policy questions
108
PROVIDER NETWORK MANAGEMENT
STAFF
Christy Spurlock: Manager, Business Operations
(304) 599-9725
[email protected]
Jan Goodeluinas: Team Lead
(570) 490-7109
[email protected]
Kimberly Fullmer: Sr. Network Development Associate
(304) 599-9727
[email protected]
Anita Gaston: Sr. Network Development Associate
(304) 599-9729
[email protected]
FAX: (304) 599-9899
109
NOTIFICATION
Maine Network for Health must be notified in writing in
advance of the following demographic or business
changes:
•Addition or departure of a provider
•Tax identification number change
•Location closure/addition
•Ownership or business name change
•Remittance address change
110
PACKET CONTENT REVIEW
111
QUESTIONS & ANSWERS
112

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