johns hopkins healthcare llc · 1/27/2020 · • to request prior authorization, submit the...
TRANSCRIPT
Johns Hopkins HealthCare LLC
Priority Partners
Presented by:
12/30/2020Presented by: Johns Hopkins HealthCare Provider Relations Department
Agenda
• Welcome
• About JHHC
• Provider Website Review
• Priority Partners Overview
• Priority Partners Updates-New for 2021
• Cultural Competency
• Care Management
• Claims and Appeals Submission
• Referral and Preauthorization Process
• Additional Information and Resources
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Johns Hopkins HealthCare
Presented by: Johns Hopkins HealthCare Provider Relations Department
Welcome:Johns Hopkins HealthCare LLC (JHHC) provides health care
services for four health plans: Priority Partners Managed Care
Organization, Johns Hopkins Employer Health Programs (EHP),
Johns Hopkins US Family Health Plan (USFHP) and Johns
Hopkins Advantage MD.
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Johns Hopkins HealthCare
Presented by: Johns Hopkins HealthCare Provider Relations Department
Provider website includes:
– Provider Manuals
– Forms
– HealthLINK@Hopkins portal access
– Online Provider Directory
• Find participating providers on www.jhhc.com
– Policies & Procedures
– Communications Repository
Provider Website: www.jhhc.com -> For Providers
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Johns Hopkins HealthCareProvider Website: www.jhhc.com -> For Providers
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Johns Hopkins HealthCareProvider Website: www.jhhc.com -> For Providers -> Resources & Guidelines
Priority Partners Overview
• HealthChoice is a health care program of the Maryland Department of
Health and Mental Hygiene.
• The HealthChoice plan provided through Priority Partners includes
coverage for Medical Assistance for Families and the Maryland
Children’s Health Plan for pregnant women and children.
• Eligibility is based on family size, income levels, or special medical
circumstances.
• Priority Partners offers special needs and outreach programs to assist
provider’s offices in improving no-show rates by helping members get
into care and partnering with them to provide special programs for
diabetics, pregnant women and members with chronic diseases.
• Priority Partners offers programs and services to help members better
manage their health. As Priority Partners HealthChoice members,
your patients can take advantage of no and low cost services that
include:
• Low-cost prescription drugs and over-the-counter
medication. See the Priority Partners pharmacy and formulary for
more information.
• Visits to urgent care centers
• Emergency department facility services
• Dental care: Dental care for pregnant women and children is directly
provided by the Maryland Healthy Smiles Dental Program. Members
can contact DentaQuest directly at 888-696-9596. For adults 21 and
over, dental care is provided by Priority Partners through
DentaQuest. Members can contact DentaQuest at 800-698-9611.
• Vision care: Vision care is provided by Superior Vision. Members
can contact Superior Vision at 800-428-8789.
• HealthLink@hopkins: 24/7 secure online access to personal
health information. Members can login or register at ppmco.org.
• Transportation to doctor and medical appointments:
Members can call 800-654-9728 for transportation scheduling.
• Assistance in finding the appropriate health care services, as
well as help with making doctor's appointments: Members
can call 800-654-9728 for assistance and appointment scheduling.
• Care management: Priority Partners is committed to becoming the
leader in care management population health solutions. Our care
management model promotes prevention skills, performs health risk
identification, and manages member compliance to avoid costly
treatments. We not only outreach to the sickest members to stabilize
and manage conditions, we guide healthy members further along the
prevention path. Through our four main service areas of Preventive,
Transitional, Complex, and Maternal/Child, we catch members wherever
they are on the health continuum.
• Health education: Priority Partners has a team of health educators
that teach different programs to help members better manage their
health. Members can call 800-957-9760 to sign up for a program or
contact a health educator.
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Member ID Card
Enhancements for 2021:
eviCore
• Providers will be able to access the JHHC-eviCore
provider portal in HealthLINK 24/7 for prior
authorization in the aforementioned categories.
• Providers who already have an eviCore account can
also access the JHHC-eviCore portal through their
established account.
Enhancements for 2021:
eviCore
Johns Hopkins HealthCare LLC (JHHC) has partnered
with eviCore healthcare to provide patients with access to
high quality, medically appropriate care that is consistent
with evidence-based treatment guidelines.
• Beginning January 1, 2021, providers in the Priority Partners
network will be required to use the JHHC-eviCore system to obtain
prior authorization for High Tech Radiology and Cardiology
Advanced Imaging services.
• Additional services requiring preauthorization through the JHHC-
eviCore system will be added in 2021.
Enhancements for 2021:
Site of Service
• The JHHC Medical Policy Advisory Committee (MPAC) has approved changes and additions to the JHHC Site-of-Service Medical Policies for Priority Partners. JHHC is implementing this policy using a staged approach, targeting specific procedures with each phase.
Effective date for changes:• Priority Partners: Dec. 1, 2020
Enhancements for 2021:
Site of Service
As of the dates mentioned in the previous slide, JHHC will require preauthorization to include a site-of-service review for certain Musculoskeletal and Gastrointestinal procedures when performed in an outpatient hospital setting.
This requirement affects Priority Partners members of all ages. These Musculoskeletal and Gastrointestinal procedures are in addition to the services already requiring site of service review and preauthorization when performed in an outpatient setting.
Enhancements for 2021:
Site of ServiceThe site-of-service policy specifies that members receive certain outpatient diagnostic or surgical procedures in an ambulatory surgery center (ASC) when clinically appropriate. A surgical procedure performed in a hospital setting will require preauthorization and must meet medical necessity criteria for the hospital setting. The outpatient hospital setting, classified by Place of Service 22, is also known as "regulated space" within the state of Maryland.
Some procedures may also require medical necessity review using clinical review criteria specific to the procedure in ANY site of service (outpatient hospital setting, ambulatory surgery center or office). Please refer to Updates to CMS23.05 Site of Service – Outpatient Surgical Procedures for a summary of the criteria changes pertaining to the site-of-service medical policy, as well as a detailed listing of affected CPT codes.
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Provider Resource: JPAL
The Johns Hopkins Prior Authorization Lookup tool (JPAL) is a provider
resource to check and verify preauthorization requirements for outpatient
services and procedures. Located in the HealthLINK portal, JPAL offers a
user-friendly way for providers to look up preauthorization requirements.
• Providers can simply click on the JPAL link in HealthLINK under the
“Administration” tab to access this tool.
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JPAL (Continued)JPAL features:
• Search by specific procedure code or procedure description.
• Confirm the authorization requirements of all procedures before delivery
of service.
• Search results are organized by procedure code, modifiers, procedure
description, and individual lines of business.
• Clicking on the procedure code link or on any line of business link brings
up specific details, such as the rules pertaining to preauthorization for
each line of business and access to the applicable medical policy document.
NOTE: JPAL is a resource to look up preauthorization requirements only.
Authorization requests cannot be submitted through JPAL. Please follow
JHHC’s current policies and procedures to request prior authorization, which
are available on the JHHC website.
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JPAL (Continued)JPAL tips:
• Please remember to confirm the authorization requirements of all
outpatient procedures via JPAL before delivery of service.
• If preauthorization status is unclear, submit an authorization request to
JHHC Utilization Management.
• Authorizations are not a guarantee of payment.
• Instructions on how to use the JPAL tool are available on the JHHC
Provider Education webpage (scroll down to the “HealthLINK Job Aids”
section) and within HealthLINK.
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ePREP Claims DenialsPriority Partners continues to deny reimburse claims payments to providers
unregistered in ePREP, the state’s provider enrollment portal. This is now
effective. Please be aware that the claims denial only applies to providers not
yet enrolled in ePREP; if you and your group are registered, claims will be
processed as usual.
• Maryland Department of Health (MDH) requires all providers delivering
services to Maryland Medicaid members to have an active enrollment status
in the electronic Provider Revalidation and Enrollment Portal (ePREP)
every 5 years. Providers are responsible for updating their professional
license information prior to license expiration in the ePREP portal.
•
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ePREP Claims Denials (Continued)• Active enrollment applies to providers (individuals and provider groups).
Both the provider and their group must be enrolled in ePREP.
• MDH’s implementation of ePREP went into effect January 1, 2020. Priority
Partners began validating billing and rendering NPI against a weekly file from
MDH on this date.
• If billing or rendering NPI is not found on the most recent file or does not
have an active status, claim will deny with specific denial reason. The claim
will deny until the provider corrects the issue in ePREP.
• NOTE: Providers contracted with multiple MCOs only need to enroll one
time with the state’s ePREP system.
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ePREP Claims Denials (Continued)• Explanation of payment will reflect the reason for claim denial specific to
ePREP:
"Claim has been denied due to failure to obtain/maintain an active status
with the Maryland Medicaid ePrep Program. Please verify your status at
https://eprep.health.maryland.gov/ and resubmit your claim."
• Providers can resubmit claims for adjudication within timely filing deadlines
(180 days from date of service) once their status has been updated. Please
submit a new claim once the provider has been enrolled, not a corrected
claim. A payment dispute is not necessary.
• For additional information and to complete your application, please visit
health.maryland.gov/ePREP or call 844-4MD-PROV.
Claims & Appeals Process• Claims & Appeals Submission
Billing Address
Johns Hopkins HealthCare LLC Attn: Priority Partners Claims
7231 Parkway Drive, Suite 100
Hanover, MD 21076
• Claims must be submitted on CMS 1500 or UB-04 forms
• Claims from specialist or ancillary providers should include the
referring provider’s NPI in Box 17b of the CMS 1500
• Claims must be submitted with a rendering provider’s NPI in Box 24J
of CMS 1500
• Claims must be submitted within 180 calendar days of the date
of service
Claims & Appeals Process (cont.)• Administrative appeals (timely filing, care not coordinated
by PCP, authorization not on file, member not eligible at
time of service, incorrect coding) must be submitted
within 90 business days of the date of denial. The
Provider Claims/Payment Dispute Form can be used for
these issues. A web version of the form is available in
HealthLINK.
• For additional information on EDI (Electronic Data
Interchange), please send an email request to
[email protected]. EDI Payor ID #52189.
• For appeals, please use the Provider Appeal Submission
Form.
Referral and Preauthorization
• Submit Referrals by Phone or Fax
Phone: 410-424-4480 or 800-261-2421
Fax: 410-424-4603
• Maryland Uniform Consultation Referral Form (see next
slide)
Maryland Uniform Consultation
Referral Form
The Maryland Uniform
Referral Form can be faxed
to 410-424-4036.
Key Referral Information
– Patient/member name*
– Member ID*
– DOB*
– Address
– Referring provider
– Referred services
– Limitations
– Diagnosis/Procedure Codes
*Indicates required fields
Key Referral Information (cont.)Number of Visits
• If the number of visits and date span is specified in the referral, the
request will be honored up to a maximum of 50 visits and a one-year
period. If the number of visits and date span is not specified on the
referral, the referral will be considered valid for one visit and 120
calendar days.
Eligibility
• All providers should verify the member’s eligibility at the time of
service or as close to the time of service as possible by calling the State
of Maryland EVS at 866-710-1447.
Lab and Radiology Policies
• Please refer to the Priority Partners website for Lab and Radiology
Policies.
HealthLINK@Hopkins• HealthLINK@Hopkins is a secure, online web portal where
providers can check patient eligibility, claims and
authorizations status, access plan-specific reports and more.
• Register for a HealthLINK@Hopkins account at
www.jhhc.com or contact your Network Manager. First
time users must register for an account. If you need
assistance with registration, contact Provider Relations at
888-895-4998.
Health Care Performance MeasuresHealthcare Effectiveness Data and Information Set
(HEDIS®)
• The Healthcare Effectiveness Data and Information Set (HEDIS®)
is a widely used set of health care performance measures that is
developed and maintained by the National Committee for
Quality Assurance (NCQA). Examples of HEDIS® measures are
Comprehensive Diabetes Care, Childhood Immunizations, yearly
Well Child Exams for Children Ages 3-6 and yearly Adolescent
Well Care Exams. For detailed information about HEDIS®,
please go to www.ncqa.org or read our Quality Measures Tip
Sheet.
Health Care Performance Measures
(cont.)Value Based Purchasing (VBP)
• The Maryland Department of Health and Mental Hygiene (DHMH)
Value Based Purchasing (VBP) program is designed to provide
incentives and disincentives based on performance indicators
which measure access and quality of care. The VBP measures
change annually, and may differ from HEDIS® measures. The
Priority Partners HEDIS® Tip Sheet is updated annually with
information pertinent to VBP. View the Quality Measures Tip
Sheet.
Health Care Performance Measures
(cont.)Consumer Assessment Health Plan Surveys (CAHPS®)
• The Consumer Assessment of Healthcare Providers (CAHPS®)
5.0H is a member satisfaction survey whose objective is to
capture information about consumer-reported experiences with
healthcare. The focus of the survey is to measure how well plans
are meeting member expectations, determine which areas of
service have the greatest effect on overall member satisfaction,
and identify areas of opportunity for improvement.
Health Care Performance Measures
(cont.)
Health Literacy
• There are many reasons health plan members, patients and
caregivers may struggle to understand health information. Johns
Hopkins HealthCare (JHHC) has structured its goals to meet
their mission to provide quality health care and develop new
methods to improve the health of its patient community and set
standards of excellence in patient care. For more information on
health literacy tools for improved communication, visit the
Agency for Healthcare Research and Quality website.
Updating Your Information
You are required to notify JHHC’s Provider Relations department
of any demographic changes to your practice.
Provider Relations (For demographic changes, contract
status and fee schedule questions):
Email: [email protected]
CMS requires the Health Plan to validate provider information on a
quarterly basis.
Important Numbers• Medical Management
410-424-4480
800-261-2421
410-424-4603 Fax
(Referrals not needing Medical
Review)
• Inpatient
410-424-4894 or 410-424-2770 Fax
• Outpatient Medical Review
410-762-5205 Fax
• Case/Disease Management
800-557-6916 or
• DME
410-762-5250 Fax
• Customer Service (Claims,
benefits and eligibility)
410-424-4500 or 800-654-9728
• Pharmacy Services
410-424-4490, option 4 or
888-819-1043
410-424-4607 Fax
• Health Education
410-424-4821
800-957-9760
Important Numbers
• Outreach
410-424-4648 or 888-500-8786
• Superior Vision
866-819-4298
• DentaQuest
800-341-8478
• HealthChoice
800-977-7388
• State of Maryland EVS
866-710-1448
• 24-Hour Nurse Line
844-455-3083
• Mental Health Services
Optum Maryland 800-888-1965
• Behavioral Health Services
(Substance Abuse Referrals)
Optum Maryland
800-888-1965
Fax 855-293-5407
• Fraud and Abuse
410-424-4996 or
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Customer Service
• Priority Partners Customer Service
410-424-4500 or 800-654-9728
Presented by: Johns Hopkins HealthCare Provider Relations Department
12/30/202012/30/2020Presented by: Johns Hopkins HealthCare Provider Relations Department
Provider Relations: 888-895-4998
THANK YOU