amerigroup nursing facility presentation documents/txtx_nfcarveintraining.pdf · • star kids is a...

TXPEC-1989-17 March 2017

Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance Company; all other Amerigroup members in Texas are served by Amerigroup Texas, Inc.

Amerigroup Nursing Facility Presentation

STAR+PLUS and Amerigroup STAR+PLUS MMP

(Medicare-Medicaid Plan)

Provider Services

• Nursing Facility: 1-866-696-0710, option 5

• STAR+PLUS: 1-800-454-3730

• Amerigroup STAR+PLUS MMP: 1-855-878-1785

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Plan overview: STAR+PLUS STAR+PLUS integrates acute care and long-term care services to Medicaid adults with disabilities (Supplemental Security Income [SSI], SSI-related and elderly members). • Nondual members are eligible to receive all long-term

services and supports (LTSS) services and value-added services based on need. Acute care benefits are provided in conjunction with the defined benefit set for Texas Medicaid programs.

• Dual-eligible members are eligible to receive LTSS benefits based on assessed need and covered value-added services. Acute care benefits are provided and paid per the defined benefit set of CMS Medicare programs.

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Plan overview: STAR+PLUS (cont.) • Amerigroup offers this plan for Medicaid-eligible members

who reside in the following service areas: o Bexar o El Paso o Harris o Jefferson o Lubbock o Tarrant o Travis o West Medicaid Rural Service Area

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STAR+PLUS service areas

Plan overview: Amerigroup STAR+PLUS MMP

• Amerigroup STAR+PLUS MMP is a Texas plan contracted with CMS and the Texas Health and Human Services Commission (HHSC).

• Amerigroup integrates care and reimbursement for Texas members who have Medicare Part A, Part B, Part D and Medicaid benefits (dual-eligible members) and consolidates their care through one MMP for full access to both their Medicare and Medicaid benefits.

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Plan overview: Amerigroup STAR+PLUS MMP (cont.)

• Amerigroup offers this plan for dual-eligible members who reside in one of these four counties:

o Bexar

o El Paso

o Harris

o Tarrant

• Members will have one ID card, one health plan and one Member Service team for their health care MMP benefits.

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Amerigroup STAR+PLUS MMP service county area

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Plan overview: STAR Kids • STAR Kids is a new Texas Medicaid managed care program

that began providing Medicaid benefits beginning November 1, 2016, to children and adults 20 and younger who have disabilities and meet the STAR Kids requirements.

• STAR Kids is designed to meet the unique needs of youth and children with disabilities. The program will provide benefits such as prescription drugs, hospital care, primary and specialty care, preventive care, personal care services, private duty nursing, and durable medical equipment (DME) and supplies.

• Children and youth who get additional services through the Medically Dependent Children Program (MDCP) will receive their MDCP services through STAR Kids.

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Plan overview: STAR Kids (cont.) • If a STAR Kids member lives in a community-based

intermediate care facility for individuals with intellectual disabilities (ICF/IID), related condition or nursing facility, the long-term services will be provided the same way they are now.

• For STAR Kids members who receive Medicare, their Medicare benefits won’t change. The members will keep using Medicare for basic health services and medicine ordered by their doctor.

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Plan overview: STAR Kids (cont.) • Through STAR Kids, families will also receive help with

coordinating care. Each health plan will provide service coordination that will help identify needs and connect members to services and qualified providers. STAR Kids managed care organizations (MCOs) will assess each member's service needs that will be used to help the family and the MCO create an individual service plan.

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STAR+PLUS design model

• Designed to integrate acute, behavioral, social, environmental and LTSS for the elderly and persons with disabilities.

• Service coordination is the cornerstone to the program. Local, dedicated Service Coordination teams help members and providers navigate health care delivery systems and interface with Amerigroup.

• Multidirectional communication means members and providers can talk with the Service Coordination team.

• Service coordinators act as the member’s advocate. They will collaborate with the nursing facility clinical staff to assess member needs, collaborate on the development of a care plan and arrange for the delivery of the needed services or care.

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STAR+PLUS eligibility • To get services through STAR+PLUS the member must: (1) be

approved for Medicaid, (2) live in a STAR+PLUS service area and (3) be one or more of the following: o Age 21 or older, receiving SSI benefits and able to get

Medicaid due to low income o Not receiving SSI and able to receive STAR+PLUS

Home- and Community-Based Services (HCBS) waiver services.

o Age 21 or older, receiving Medicaid through a Social Security Exclusion program and meeting program rules for income and asset levels

o Age 21 and older and residing in nursing facility • Effective September 1, 2017, the Medicaid Breast and Cervical

Cancer (MBCC) program members will be carved into STAR+PLUS

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Amerigroup STAR+PLUS MMP eligibility

Clients can be in the demonstration if they meet all of these criteria:

• Are age 21 or older

• Receive Medicare Parts A, B and D and are receiving full Medicaid benefits

• Are eligible for or enrolled in the STAR+PLUS program.

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Amerigroup STAR+PLUS MMP eligibility (cont.)

Excluded populations:

• Dual-eligible children (age 20 and younger) who have chosen to receive their Medicaid services through the STAR+PLUS managed care program will be excluded. These children are now in the STAR Kids program.

• Individuals receiving services in a community-based ICF/IID.

• Individuals not eligible for STAR+PLUS today, including those receiving services in the following ICF/IID 1915 (c) waivers:

o HCBS

o Community Living and Support Services

o Texas Home Living

o Deaf-Blind Multiple Disabilities

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STAR+PLUS benefits • Nondual members are eligible for all LTSS services and

value-added services based on need. Acute benefits are provided in conjunction with the defined benefit set for Texas Medicaid programs. At a high level, these benefits include:

o Nursing facility services and all services covered under the custodial/residential care facility Medicaid benefit.

o Acute inpatient services (does not include skilled nursing

facility care).

o Physician services.

o Behavioral health/substance abuse inpatient services.

o Acute outpatient and ancillary services.

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STAR+PLUS benefits (cont.) o Outpatient behavioral/mental health/substance use

services.

o Emergency services.

o Pharmacy/prescription drug.

o Available LTSS benefits based on need and provided in a community setting.

o Value-added benefits.

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STAR+PLUS benefits (cont.) • Dual-eligible members are eligible to receive LTSS benefits

based on assessed need and as value-added services. Acute benefits are provided and paid per the defined benefit set of CMS Medicare or Medicare Advantage programs. o All acute services — Medicare or Medicare Advantage o Pharmacy/prescription drug — Medicare Part D programs o Nursing facility services and all services covered under the

custodial/residential care facility Medicaid benefit o Coinsurance/copays — coordinated through Amerigroup

with State Medicare plan benefits and based on the member’s other health insurance (OHI) carrier policy amounts

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STAR+PLUS benefits (cont.) o Medicare skilled nursing facility care coinsurance —

amount is covered all or in part by Amerigroup depending on the member’s OHI, Medicare Advantage or traditional Medicare coverage benefits

o Medicare — always primary for acute care benefits and pharmacy services

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Amerigroup STAR+PLUS MMP benefits

• In the demonstration, Amerigroup must provide the full array of Medicaid and Medicare services such as:

o Acute Medicare services — Parts A and B o Medicare pharmacy/prescription drug — Medicare Part D

programs o STAR+PLUS LTSS service array o STAR+PLUS nursing facility o Applicable coinsurance/copays, such as Medicare skilled

nursing facility coinsurance

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Service Coordination model

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Identify needs

• Members contacted and screened for complex needs and high-risk conditions

• Identify complex and high-risk members

Service delivery

• Member selects providers from the network.

• Service coordinator works with care team to authorize and deliver services as necessary.

• Service coordinator ensures all appropriate services are authorized and delivered according to the service plan.

Service plan

• Service coordinator makes a minimum of four quarterly visits and conducts a comprehensive assessment of all medical, behavioral, social and long-term care needs.

• Service coordinator works with the nursing facility team of experts to develop a service plan to meet the members needs.

• Service coordinator contacts the member’s PCP/specialist for concurrence if necessary.

• Member and member’s family reviews the service plan.

Reassess and evaluate

• Service coordinator contacts member and reassess the member’s needs and functional capabilities.

• Service coordinator in collaboration with the nursing facility team and member/member family evaluate and revise the service plan as needed.

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Nursing facility service coordinator roles and responsibilities

Nursing facility service coordinators will: • Make a minimum of four quarterly visits and conduct a

comprehensive assessment of all medical, behavioral, social and long-term care needs.

• Work with the nursing facility team of experts to develop a service plan to meet the members needs.

• Contact the member’s PCP and/or specialist for concurrence if necessary.

• Work with the member and member’s family to ensure the service plan is delivered as expected. Service coordinator will also work to assist the nursing facility in collection of the applied income.

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Money Follows the Person program

• Money Follows the Person — A program offered through STAR+PLUS and Amerigroup STAR+PLUS MMP to eligible members that want to leave an institutional setting and return to an independent, community-based living setting.

• Amerigroup service coordinators will work with identified members, their nursing facility clinical case manager and any key parties that the member designates to fully assess the member and their individual capability to safely reside in an independent community living setting.

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Money Follows the Person program (cont.)

• Amerigroup service coordinators will utilize the LTSS benefit of Transition Assistant Services to facilitate the member’s return to the community. This benefit provides:

o A one time $2,500 benefit to purchase the necessary items or services to allow the member to exit the nursing facility.

o Contracts with several providers that perform the coordination of this service.

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Personal care critical incident reporting requirements

• Allegations of abuse, neglect and exploitation of a consumer must be reported, as well as the death of a consumer, the involvement of law enforcement and any environmental

hazards that compromise the health and safety of a member.

• Reports made to Amerigroup or referred to Amerigroup will be investigated through our Quality Review department

nursing staff.

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What providers should know — member informed consent

Every member has the right to make informed decisions regarding his or her health care and to: • Be informed of his or her health status. • Be involved in his or her care planning and treatment. • Request, consent or refuse treatment. • Receive information in a manner that is understandable. • Delegate the right to make an informed decision to someone

else.

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What providers should know — member informed consent (cont.)

Every provider has the responsibility to respect a member’s right to informed decision making by: • Communicating adequate information about the member’s

care and/or treatment in an understandable way. • Respecting the member’s decisions. • Following the member’s wishes.

This extends to decisions made by authorized representatives or written in an advance directive.

Respecting a member’s right to informed consent does not imply an obligation to provide care that is medically unnecessary or inappropriate.

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Health Insurance Portability and Accountability Act

• Privacy regulations allow the transfer or sharing of member information to conduct business and make decisions about care.

• We strive to ensure both our staff and contracted providers conduct business in a manner that safeguards patient/ member information in accordance with the privacy regulations enacted pursuant to HIPAA.

• Providers may reference the provider manual for information regarding faxing, mailing, emailing and leaving voice mails that include member information.

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Cultural competency

Cultural competency is the integration of congruent behaviors, attitudes, structures, policies and procedures into a system or agency or among professionals. Cultural competency helps

providers and members:

o Acknowledge the importance of culture and language.

o Assess cross-cultural relations.

o Embrace cultural strengths with people and communities.

o Expand their cultural knowledge.

o Understand cultural and linguistic differences.

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Cultural competency (cont.) Cultural awareness includes:

• The ability to recognize the cultural factors (norms, values, communication patterns and world views) that shape personal and professional behavior.

• The ability to modify one’s own behavior to respond to the needs of others while maintaining one’s objectivity and identity.

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Cultural competency (cont.) The quality of the patient-provider interaction has a profound impact on the ability of a patient to communicate symptoms to his or her provider and to adhere to recommended treatment. Some of the reasons that justify a provider’s need for cultural competency include: • The perception of illness and disease and their causes vary by

culture. • The belief systems related to health, healing and wellness are

very diverse. • Culture influences help-seeking behaviors and attitudes

toward health care providers.

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Cultural competency (cont.) • Individual preferences affect traditional and nontraditional

approaches to health care. • Patients must overcome their personal biases within health

care systems. • Health care providers from culturally and linguistically diverse

groups are under-represented in the current service delivery system.

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Interpreter services

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We provide interpreter services to help you communicate with all of our members. • Call Provider Services at 1-800-454-3730 for Medicaid

services or the Dedicated Service unit at 1-855-878-1785 for MMP.

• Services are available 24 hours a day, 7 days a week.

• Call at least 24 hours before the member’s office visit to request an interpreter.

Nonemergent ambulance • All nonemergent medical transportation (NEMT) services

require precertification and medical necessity review.

• Prior authorizations for NEMT of Medicaid members must be requested by a physician, nursing facility or other health care

provider. Prior authorization requests cannot be submitted directly by ambulance/transportation providers.

• To find a contracted ambulance provider, our website offers

an online directory lookup tool at amerigroup.prismisp.com.

• The ambulance provider is ultimately responsible for ensuring

that a prior authorization has been obtained prior to

transport.

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http://amerigroup.prismisp.com/

Pharmacy program • Pharmacy benefits — unless otherwise covered in the nursing

facility unit rate: o Members that are Medicaid only must adhere to the Texas

Vendor Drug Formulary administered by the Amerigroup pharmacy benefit manager.

o Members with Medicare continue to access pharmacy benefits through a Medicare Part D provider.

o Amerigroup STAR+PLUS MMP members will access pharmacy benefits through the Amerigroup Medicare Part D program manager.

• Preferred Drug List/Formulary is: o Available at https://providers.amerigroup.com/TX. o Developed by the Texas Vendor Drug Program or the

National Pharmacy and Therapeutics Committee.

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https://providers.amerigroup.com/TX



Pharmacy program (cont.) • Nonformulary drugs are subject to precertification. • Many over-the-counter products are covered with a written

prescription (encouraged as first-line treatment). • Unless otherwise covered in the nursing facility unit rate,

precertification is required for: o Nonformulary drug requests. o Brand-name medications where there is a generic

available. o High-cost injectables and specialty drugs. o Others as identified on the formulary.

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Pharmacy program (cont.) • Fax precertification forms to Amerigroup at 1-800-601-482 or

call 1-855-215-4496. • Precertification are processed by pharmacy technicians and

pharmacists: o Requests not meeting medical necessity criteria are

reviewed by plan medical director for determination.

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STAR+PLUS member ID card

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Amerigroup STAR+PLUS MMP member ID card

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Billing — STAR+PLUS and Amerigroup STAR+PLUS MMP

• All nursing facility services must be billed using an electronic billing format that is 5010, level 7 edit compliant via the HIPAA 837I format for a CMS-1450 claim form. No paper claims will be accepted.

• Providers can bill all nursing facility services by using one of the following options: o Texas Medicaid & Healthcare Partnership (TMHP) claim

website (not applicable to Part A services) o Approved Amerigroup clearinghouses

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• Approved Amerigroup clearinghouses: o Availity — payer ID: 26375 o EMDEON — payer ID: 27514 o Capario — payer ID: 28804 o Smart Data Solutions — payer ID: 81237 o Amerigroup Electronic Data Interchange hotline —

1-800-590-5745

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Billing — STAR+PLUS and Amerigroup STAR+PLUS MMP (cont.)

• Nursing facility providers must adhere to the following guidelines and time limits for claims to be considered for payment.

• Clean claim standards are defined per the DADS claim standards for nursing facilities.

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• Claim timely filing: o Nursing facility daily unit rate claims —365 days from the

date of service o Skilled MMP services — 365 days from the date of service o Nursing facility add-on services — 95 days from the date of

service o Part B services — 95 days from the date of service o LTSS services — 95 days from the date of service o Corrected claims — 120 days from the date of the

Explanation of Payment (EOP). Corrected claims may be submitted using Availity, with a type of bill (TOB) 217 and referencing the original claim number.

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• Claim turnaround:

o Daily unit rate services will be processed within 10 calendar days from the date of submission.

o Add-on service and all other claims billable to Amerigroup by a nursing facility will be processed within 30 calendar days or less upon Amerigroup receipt of the clean claim.

Reimbursement is based on the Texas Medicaid methodology for nursing facilities. Daily unit rates are

provided per licensed/certified Texas Medicaid nursing

facilities on a regular basis to Amerigroup for claim payment.

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Reimbursement is based on the Texas Medicaid methodology for nursing facilities for rehabilitative therapy services. These rates are posted by HHSC at

least annually. Amerigroup retrieves these rates from the HHSC Rate Analysis website for claim payment purposes at: legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs.

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http://legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs/








• Amerigroup will automatically adjust previously adjudicated daily care claims within 30 days from the date of receipt of a change in data from the State to reflect adjustments to such

items as nursing facility daily rates, provider contracts, service authorizations, applied income and level of service (resource utilization group [RUG]). Any adjustments besides the ones listed previously and some denials, may require a corrected

claim by the nursing facility provider.

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The following services must be billed to Amerigroup:

RV code Process code

Modifier 1

Modifier 2

Modifier 3

Daily unit rate: 0100

Ventilator full: 0230 94004 U1 UA U7

Ventilator partial:

0230 94004 U1 UA U8

0230 94005 U1 UA U8

Child tracheostomy — age 21-22 only:

0410 99199

Respite 0663 S5151


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Respite should be billed on a UB in accordance with nursing facility rules. One unit equals one day. • Claim form/billing requirements: Nursing facility providers billing

for respite will bill on a CMS-1450 billing form. Nursing facilities will have flexibility in the TOB, using one of the following TOBs: 11X, 13X or 21X.

• Authorizations: Authorizations must be on file for the members for respite. Authorizations are generated by Amerigroup, as opposed to Statistical Analysis Software (SAS) records.


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Reimbursement: Nursing facility reimbursement for respite is based on the contract terms or the Texas nursing facility base RUG rate.

Billing — STAR Kids • Contract requirements: Nursing facility providers must

contract with Amerigroup for the STAR Kids program to provide respite to STAR Kids members.

• Claim form/billing requirements: Nursing facility providers billing for STAR Kids respite will bill on a CMS-1450 billing form. Nursing facilities will have flexibility in the TOB using one of the following TOBs: 11X, 13X or 21X.

• Authorizations: Authorizations must be on file for STAR Kids members for Respite. Authorizations are generated by Amerigroup, as opposed to SAS records.

• Reimbursement: Nursing facility reimbursement for STAR Kids respite is based on the contract terms. For STAR Kids, 15 minutes equals to one unit.

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Billing — STAR Kids(cont.)

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Respite: HCPC Codes

Revenue codes

Modifier 1 Modifier 2 Service description

T1005 663 UA Level 10: SE3

T1005 663 U9 Level 9: RAD and SE2

T1005 663 U8 Level 8: SSC, SE1, RAC

T1005 663 U7 Level 7: SSA, SSB, RAB

T1005 663 U6 Level 6: RAA

T1005 663 U5 Level 5: CB2, CC1, CC2

T1005 663 U4 Level 4: BB2, CA2, PE1, IB2, PD2, CB1, PE2

T1005 663 U3 Level 3: PB2, BB1, PC1, PC2, IB1, CA1, PD1

T1005 663 U2 Level 2: BA1, PA2, IA1, PB1, BA2, & IA2

T1005 663 U1 Level 1: PA1

T1005 663 UA U3 Level 10: SE3 with partial vent

T1005 663 U9 U3 Level 9: RAD & SE2 with partial vent

T1005 663 U8 U3 Level 8: SE1, & RAC with partial vent

T1005 663 U7 U3 Level 7: SSA, SSB, RAB, SSC with partial vent

T1005 663 U6 U3 Level 6: RAA with partial vent

T1005 663 U5 U3 Level 5: CC1, CC2 with partial vent

T1005 663 U4 U3 Level 4: PE1, IB2, PD2, CB1,PE2, CB2 with partial vent

T1005 663 U3 U3 Level 3: BB1, PC1, PC2, IB1, CA1, PD1, BB2, CA2 with partial vent

T1005 663 U2 U3 Level 2: PA2, IA1, PB1, BA2, IA2, PB2 with partial vent

T1005 663 U1 U3 Level 1: PA1 , BA1 with partial vent

T1005 663 UA U5 Level 10: SE3 with trach

T1005 663 U9 U5 Level 9: RAD , SE2 with trach

T1005 663 U8 U5 Level 8: SE1, RAC with trach

T1005 663 U7 U5 Level 7: SSA, SSB, RAB, SSC with trach

T1005 663 U6 U5 Level 6: RAA with trach

T1005 663 U5 U5 Level 5: CC1, CC2 with trach

T1005 663 U4 U5 Level 4: PE1, IB2, PD2, CB1,PE2, CB2 with trach

T1005 663 U3 U5 Level 3: BB1, PC1, PC2, IB1, CA1, PD1, BB2, CA2 with trach

T1005 663 U2 U5 Level 2: PA2, IA1, PB1, BA2, IA2 and PB2 with trach

T1005 663 U1 U5 Level 1: PA1 and BA1 with trach

T1005 663 UA U7 Level 10: SE3 with full vent

T1005 663 U9 U7 Level 9: RAD and SE2 with full vent

T1005 663 U8 U7 Level 8: RAB, SSC, SE1, RAC with full vent

T1005 663 U7 U7 Level 7: SSA, SSB with full vent

T1005 663 U6 U7 Level 6: CC2 and RAA with full vent

T1005 663 U5 U7 Level 5: CB1, PE2, CB2 and CC1 with full vent

T1005 663 U4 U7 Level 4: PD1, BB2, CA2, PE1, IB2, PD2 with full vent

T1005 663 U3 U7 Level 3: BB1, PC1, PC2, IB1, CA1 with full vent

T1005 663 U2 U7 Level 2: IA1, PB1, BA2, IA2, PB2 with full vent

T1005 663 U1 U7 Level 1: PA1, BA1, PA2 with full vent


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RV Code Procedure code Modifier 1 Modifier 2 Modifier 3

Medicare coinsurance*

0101

*A nursing facility billing for a skilled nursing bed and coinsurance will use a CMS-1450 format and can bill both the bed type and the RV 0101 for the coinsurance.

Add-on services: The following add-on services must be billed by the provider rendering the service: • Emergency dental — Amerigroup utilizes DentaQuest. • DME— Participating Amerigroup DME vendors — see our

Provider Network Directory. • Augmentative communication devices — Participating

Amerigroup DME vendors — see our Provider Network Directory.


• For services that are covered by both Medicare and Medicaid, the provider can submit one bill to the MMP. The primary benefit coverage rules will apply for the bill form.

o For example: Acute hospital services will be billed on a CMS-1450 format and any applicable coinsurance covered under Medicaid will be coordinated using that single claim

and its applicable attachments.

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• For services that are covered by only the Medicare benefit or only by Medicaid, the provider should use the appropriate Medicare or Medicaid defined bill form or electronic version

defined in their provider contract.

o For example: A nursing facility billing for a skilled nursing bed and coinsurance will use a CMS-1450 format and can

bill both the bed type and the RV 0101 for the coinsurance.

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• The following nursing facility services are not the responsibility of Amerigroup and should continue to be billed by the nursing facility to TMHP for payment: o Services for residents under the age of 21 o Services identified as pre-admission screening and resident

review services o Services for hospice daily care o Services for daily care in a Veterans Affairs (VA) home o Services for hospice daily care in a VA home

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Sample EOP

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Authorization process • Precertification is required for the following nursing facility

coordinated services:

o Rehabilitative therapy (physical, occupational or speech therapy)

o Emergency dental

o DME

o Augmentative communication devices

o Nonroutine laboratory and radiology services defined by Amerigroup

o Nonformulary drugs

o Services performed by nonparticipating providers or facilities

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Authorization process (cont.) • Custodial nursing care:

o Amerigroup receives the SAS file from the State. The file is uploaded into the system which automatically generates an authorization for the facility.

• MMP Part A and readmissions:

o Nursing facility request for precertification should be faxed to: 1-844-206-3449.

The nursing facility should send clinical information to substantiate medical necessity and medical criteria along with a written physician order, test, treatments, prior and current level of function, intervention performed and results or outcomes.

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Authorization process (cont.) The request is reviewed by the MMP Utilization

Management team within 72 hours of receipt.

Upon approval or denial, an MMP utilization nurse will contact the facility via telephone to provide the verbal authorization or denial.

If the authorization is medically necessary and approved, the authorization will be effective on the date of notification.

A complete list of all covered services that require precertification can be found at https://providers.amerigroup.com/TX.

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Authorization process (cont.) Skill in Place program

• Amerigroup STAR+PLUS MMP encourages skilling a member in place for noncritical conditions rather than transferring member to an acute care facility. Please note that members/residents admitted to the hospital or treated in the emergency room, and requiring skilled services upon return to the nursing facility are not opportunities for Skill in Place and are subject to medical necessity review and prior authorization.

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Authorization process (cont.) What to expect:

1. An authorization for a Skill in Place at a skilled nursing level-of-care is required.

2. The skill nursing facilities will receive an initial three-day approval for a Skill in Place request with subsequent approval based on medical necessity.

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Authorization process (cont.) Process for obtaining Skill in Place authorization: 1. Notification to Amerigroup Star-Plus MMP within 24 hours or

one business day of Skill in Place treatment. • Fax the request to 1-844-206-3449. • Write “SKILL IN PLACE” on the request coversheet. • Include all pertinent clinical information to substantiate

medical necessity (orders, labs, radiology reports, therapy evaluation, etc.).

2. After the initial three-day approval, the facility will be required to submit additional clinical for approval of on-going treatment based on medical necessity.

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Authorization process (cont.) MMP Part B:

• Nursing facility request for precertification should be faxed to: 1-866-959-1537 or 1-888-235-8468.

o The nursing facility should send clinical information to substantiate medical necessity and medical criteria along with the facility tax ID and NPI number, plan of care, evaluations, prior and current level of function, requested CPT codes and date span.

o The request is reviewed within 72 hours of receipt.

o Upon approval or denial, a MMP utilization nurse will contact the facility via telephone to provide the verbal authorization or denial.

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Authorization process (cont.) o If the authorization is medically necessary and approved,

the authorization will be effective on the date of notification.

o A complete list of all covered services that require precertification can be found at https://providers.amerigroup.com/TX.

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Authorization process (cont.) • Notification of admission, discharge or significant change in

condition:

o Nursing facilities are required to notify Amerigroup within one business day of :

New admission for an existing Amerigroup member.

Discharge of a member due to:

• Emergency care.

• Hospitalization.

• Death.

• Extended leave from the facility.

• Significant change in condition.

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Authorization process (cont.) • The notification can be submitted via fax to 1-844-206-3445

for STAR+PLUS and to 1-844-206-3448 for Amerigroup STAR+PLUS MMP.

• Nursing facilities should continue to complete and file to TMHP as necessary 3618 and 3619 notifications. HHSC will forward these notifications to Amerigroup on a regular basis.

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Authorization process: approved authorization template

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Amerigroup logo

Date processed

Thank you for contacting Amerigroup regarding patient:

Member name: Doe, Jane Subscriber ID: 72xxxx

Authorization approved:

You may request for an extension or additional visits/units five days prior to the end date of this authorization by faxing supporting documentation of medical necessity to 1-866-XXX-XXXX.

Thank you for contacting Amerigroup regarding authorization for this member.

Authorization number Code

Name of service approved (codes/modifiers):

Physical therapy specify: 97xxx, G0xxx

Units approved 20 visits/80 units

Dates approved 1/18/2017 to 2/16/2017


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https://providers.amerigroup.com/TX (CONT.)

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Availity — log in

Log into Availity and make sure your account is set to Texas.

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Availity — eligibility and benefits

Most provider and resident information should prepopulate. Fill in all other fields that have an asterisk.

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Availity — eligibility and benefits (cont.)

Eligibility screen:

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Availity — claims Once you have pulled up the eligibility information, you can enter the claim information and the resident information will be prepopulated. Go to Claim > Facility Claims and fill in the fields with a red asterisk.

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Availity — secondary insurance Enter secondary insurance information in fields with a red

asterisk if applicable.

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Availity — claims

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Enter billing provider information in fields with a red asterisk. Many fields will prepopulate if you have loaded your provider information in Availity.

Availity — claims (cont.)

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Enter attending provider information and diagnosis codes in fields with a red asterisk. Attending provider fields will prepopulate if you have loaded your provider information in Availity.


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Enter claim information in fields with red asterisks.


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Enter claim information in fields with red asterisks. Make sure to include the secondary remit as an attachment for claims with secondary claim information.

Availity — corrected claim

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To correct a claim in Availity, follow the steps above and in the billing frequency, use either a 7 for a corrected claim or a 8 for a cancelled claim. Under Patient Control Number/Claim Number, enter the original claim number. Enter the corrected dates of service and units.

Availity — appeals From the Amerigroup website, go to Claims > Appeal Claim >

select Go to Availity.

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Availity — appeals (cont.) Pull the claim up through Claim Status Inquiry. Click on the date

section of the claim and scroll to the bottom of the page. Select Dispute this claim. Fill in the fields with red asterisks and submit. This can be used if it is within 120 days of the EOP.

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Reporting From Availity, go to More > My Payer Portal > Provider Self-Service. You will be redirected to the Amerigroup site. Select Claim Status Listing and fill out the required fields. The report will cover 30 days at a time and can search claims two years prior to the date of search.

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Please contact your Provider Relations representative for nursing facility custom reports.

Appeals

Appeals related to:

• Provider’s assessment — These appeals should continue to be filed to TMHP as Amerigroup is not responsible for the provider’s process.

• RUG level of care — These appeals should continue to be filed to TMHP as Amerigroup is not responsible for the RUG determination process.

• Eligibility for Medicaid Nursing Facility waiver — These appeals should continue to be filed to TMHP as Amerigroup is not responsible for this process.

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Payment and medical appeals

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Your support system

• Your Service Coordinator team

• Your Provider Relations

representative

• Nursing Facility Provider Services number

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Nursing Facility Provider Services: 1-866-696-0710, option 5

STAR+PLUS and Amerigroup STAR+PLUS MMP Provider Relations team

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Name Title/role Texas market/county E-mail Phone

Selase Dow PR network manager Amerigroup STAR+PLUS MMP

[email protected] 832-459-0594

Monique McGowan

PR manager senior Amerigroup STAR+PLUS MMP


Brittany Eicholz PR network consultant

Amerigroup STAR+PLUS MMP


Tiffany Martin PR manager I STAR+PLUS [email protected] 214-604-9862

Leticia Garcia PR representative Bexar [email protected] 1-800-454-3730, ext. 55924

Rhonda Smith PR representative El Paso [email protected] 1-800-454-3730, ext. 59652

Shawncy Watts PR representative Harris [email protected] 1-800-454-3730, ext. 55686

Tim Matthews Deborah Robertson Amy Clay

PR representative

Tarrant [email protected] [email protected] [email protected]

1-800-454-3730, ext. 57915 ext. 55687 ext. 54712

Cheryl Green PR representative Lubbock [email protected] 1-800-454-3730, ext. 55688

STAR+PLUS and Amerigroup STAR+PLUS MMP Provider Relations team (cont.)

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• For a listing of Provider Relations representatives by facility, please visit https://providers.amerigroup.com/Public%20Documents/TXTX_NFPRRepList.pdf.

• The Amerigroup Provider Relations triage and escalation process is listed below.

Fourth-level contact: director

STAR+PLUS: Jessica McFarlin — 817-456-6720

Amerigroup STAR+PLUS MMP: Selase Dow — 832-459-0594

Third-level contact: manager of Provider Relations

STAR+PLUS: Tiffany Martin — 214-604-9862

Amerigroup STAR+PLUS MMP: Monique McGowan — 713-725-6958

Second-level contact: individual Provider Relations representative

1-866-696-0710 — Extensions for each representative included in the listing of Provider Relations Representatives by Facility on the Amerigroup website.

First-level contact: Nursing Facility Provider Hotline

1-866-696-0710, option 5

https://providers.amerigroup.com/Public Documents/TXTX_NFPRRepList.pdf



STAR+PLUS and Amerigroup STAR+PLUS MMP Nursing Facility Clinical team

• For a listing of STAR+PLUS service coordinators by facility, please visit: https://providers.amerigroup.com/Public%20Documents/ TXTX_NF_ServiceCoordAssignments.pdf.

• The Amerigroup clinical triage and escalation process is listed below.

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Third-level contact

STAR+PLUS: Rachel Poe, BSN, RN 512-382-4970, ext. 54947

Amerigroup STAR+PLUS MMP: Gloria Burton LMSW, CCM, 713-218-5100, ext. 55497

Second-level contact: individual service coordinator

Phone number for each service coordinator is included in the listing of service coordinators by facility on the Amerigroup website.

First-level contact: Precertification Hotline

Phone: 1-866-696-0710, fax: 844-206-3445






Q&A

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Thank you for partnering with us!

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