Organizational Overview PROVIDER SEMINAR 2015

Agenda

I. YourCare Background Information

II. Organizational Strengths & Priorities

III. New Information and What’s Changing

IV. Operational Updates

V. Questions and Answers

Background Information

• Monroe Plan Established In 1970

• Not-For-Profit 501(c)(6) / IPA Look-Alike with 210 employees (Buffalo, Rochester, Binghamton)

• Current Professional Network is Approximately 10,000 Practitioners in the Buffalo, Rochester, and Southern Tier Regions

• Provider of Care Management Services for Health Homes in the Rochester and Finger Lakes Region

• Effective August 1, 2015 MPMC will be Sole Member of Univera Community Health a Not-For- Profit 501(c)(3) and NYS Designated Article 44 / Prepaid Health Services Plan (PHSP) Serving the Medicaid Managed Care and Child Health Plus Populations. The Health Plan’s new name is YourCare Health Plan

• Future Expansion into Basic Health Plan, January 1,2016

• Future Expansion To Rochester and Finger Lakes Region Effective January 1, 2016

• Enrollment @ 06/01/2015 (YourCare Region):

Total Membership 53,687 (4 Counties) Medicaid Managed Care 50,403 Child Health Plus 3,284

Strengths & Philosophies • Expertise in working with the Safety Net population and provider network

• Historical market leader with value based integrated delivery network (IDN) capitation and risk agreements with large multi-specialty hospital systems, FQHC’s, and other high volume practices

• Leader in the delivery of enhanced provider network services to support practitioner offices

• Coding analysis program, quality performance payments, education and outreach

• Data Analytics and Reporting Capabilities • Financial, Utilization, and Risk Management Reporting

• Dedicated Call Center to Provider Network

• Dedicated case and disease management • Unique to SN populations

Operational Interfaces and Structure

Provider Relations & Contracting

Clinical / UM

Claims Adjudication, Adjustments, & Benefit

Management

Health

Informatics

YourCare Health Plan

Provider/Member Services (Enrollment &

Call Center)

Practice Outreach and Education

Immediate Changes August 1st

• HMO Name – Changing from UCH to YourCare Health Plan

• YourCare Health Plan Home Office • Moving from Univera Healthcare Corporate Office on Park Club

Lane to 6400 Sheridan Drive, Suite 120.

• Professional Contracts and Provider Relations • Current professional contracts remain valid

• Provider Relations team

• Hospital and Other Ancillary Contracts • Same as above on agreements

• Facility Contracting Team is in place with YourCare Health Plan

Immediate Changes August 1st

• Member ID Cards – Changing effective August 1st

• YourCare Option will use Medicaid CIN numbers

• Child Health Plus will use new numeric ID

• ID card will be issued to members on or around July 20th

Immediate Changes August 1st

• Claims Submissions and Payment • No longer using Facets platform

• New Claims submission on or after August 1st

• Regardless of date of service

• Any Claim adjustments after August 1st

• Clearinghouse (EDI) • Smart Data Solutions (SDS)

• Payer ID (New) • 15003

• Paper Claims and Other Mail Submissions YourCare Medical Claims

P.O. Box 21455

Eagan, MN 55121

• VestaCare Electronic Funds Transfer (EFT) • To register follow: https://www.vestacare.net/jsp/eftlink/monroeplans

• Link and registration instructions at: www.yourcarehealthplan.com

Utilization Management

• Prior Authorization and Referral Requirements

• Unchanged requirements from current

• Clear Coverage will no longer be in place

• Status available on our website

• Inpatient / Outpatient reviews by YourCare

• HEALTHeNET

• Referral capability will commence around

September 2015

• Other functionality in place

• Claim adjustments via form on our website

Customer Service

• Customer Operations Center • Dedicated provider and member call center

• Monday-Thursday, 8am-5pm (closing 12-1pm)

• Friday, 9am-5pm (closing 12-1pm)

• Triage support line in effect when close

• Full contact sheet for all departments and functions in your

handout

• Enrollment • To enroll for YourCare Option and Child Health Plus

• (800) 683-3781

• Health plan FE on hand

Benefit Managers

• Dental (Healthplex) remains same

• Claims, contracting, service

• Radiology (eviCore) remains same

• Authorizations

• Sleep Management, Radiation Therapy

• Pharmacy (ESI) is changing from current

• Formularies, Specialty medical drug management, etc.

• Behavioral Health (Beacon) will be new to YourCare

• Contracting, credentialing, claims and service

• Neo-Nate Management (Progeny) remains same

• Credentialing, PFM, Claims, Service

• Intakes handled by YourCare

• VestaCare (EFT)

• Electronic payments and remittances

• EDI Vendor (SDS) Smart Data Solutions

Credentialing

• Providers in process • Newly credentialing or re-credentialing in process with UCH, there is no change

• New credentialing • Contact us

• Initial provider data form (name, address, email, NPI, etc.)

• Source verification 60 days

• Full Credentialing 60-90 days

• Re- Credentialing • Due on November 1st, YourCare completes process

• Prior to November 1st, UCH completes process

• 5 month turnaround cycle

• Emergency Credentialing • Completed application (CAQH)

• Formal written request • Approval based on patient access needs

• 48 hr. turnaround

• Nurse Practitioner • Full credentialing process

• Listed as PCP (Pending meeting requirements)

Provider File Maintenance

• Provider Data • Initial information for groups

• Initial practitioner roster

• Provider Demographics • General demographic information

• Participation changes

• Practitioner enrollment

• Initial request form (name, address, email, NPI, etc.)

• Initial credentialing request

• Non Credentialed Practitioner • PA, NP, Hospitalist, Locum Tenant, Anesthesiologist, pathologist, etc.

• Practitioner Termination • Request form

• Indicates termination reason

• Practitioner Rosters • Monthly basis for larger systems

• Quarterly basis for everyone

• Credentialing/PFM point of contact

Website • Provider Portal

• Super User account / registration

• Account management at office level

• Membership eligibility

• Claim status

• Authorization status

• Remittances

• Fee Schedules

• Benefits

• Appeals/Grievances

• Member enrollment department • YourCare Option and Child Health Plus

• (800) 683-3781

• Marketing Materials • Call your PR representative

Website: https://www.yourcarehealthplan.com

Q&A

Let’s talk…

Thanks for attending and we look forward to continuing working with your office and welcome to the YourCare Health Plan family.

Provider Relations Team Tina Burns

•(716) 565-6732 Sheri Bezinque

•(716) 565-6733 Chris Retamar

•(585) 453-8543 Mario Macias

•(585) 256-8451