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Blue Cross Community
Health PlansSM (BCCHP) and Blue Cross
Community MMAI
(Medicare-Medicaid)SM
Provider Orientation Jan. 1, 2018
What You Will Learn?
2
Highlights: BCCHP & MMAI
Member Criteria
Enrollment Process
Care Coordination
Contact and Inquiries Process
Required Provider Training
Appeals & Grievances
Reporting Critical Incidents
Eligibility/benefits
Benefit preauthorization
Claim submission
Service Delivery Models
Providers Duties & Responsibilities
Highlights: BCCHP/MMAI
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The Blue Cross Community Health Plans (BCCHP) refers to the delivery of
integrated and quality managed care. This program is designed to help improve
member health through care coordination while preventing unnecessary health
care costs.
• Seniors and Adults with disabilities who are Medicaid eligible but not eligible
for Medicare.
• Non-Disabled Children and Adults (NDCA);
• ACA Expansion Adults
• Children with Disabilities;
• Managed Long Term Services and Support (MLTSS)
The Medicare Medicaid Alignment Initiative (MMAI) is a demonstration plan of the
Illinois Department of Healthcare and Family Services (HFS) and the Centers for
Medicare & Medicaid Services (CMS) designed to improve health care for
seniors and person with disabilities.
Medicare-Medicaid Plan provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an
independent licensee of the Blue Cross and Blue Shield Association. HCSC is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits
of both programs to enrollees. Enrollment in HCSC’s plan depends on contract renewal.
Blue Cross Community Health Plans (BCCHP)
Blue Cross Community MMAI
These service delivery models were developed to help provide:
• Better care coordination
• Improved preventive care
• Enhanced quality of care
• Integration of physical and behavioral health
• Rebalancing from institutional to community care
• Education and self-sufficiency
• Community support for member ongoing needs
• Managed costs without compromising quality or
access to care
The Blue Cross Blue Shield of Illinois Medicaid product also known as
Blue Cross Community Health Plans is now available throughout the
state of Illinois, servicing 102 counties.
The Blue Cross Blue Shield of Illinois Medicare-Medicaid product also
known as Medicare Medicaid Alignment Initiative (MMAI) is available in
the following counties: Cook, DuPage, Kankakee, Kane, Lake and Will. If
you have additional questions please contact your Provider Network
Consultant. (Starting on slide 35)
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Blue Cross Community Health Plans
Effective Jan. 1, 2018
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Member Criteria
• Medicaid eligible
• Seniors and adults (19+ years of age) with
disabilities
• Parents / guardians living with and caring
for children (age 19 or younger), mothers
and babies
• ACA expansion: low income members,
ages 19-64
• MLTSS members who elected to opt out of
MMAI.
• Includes Medicaid waiver members
Medicare Medicaid Alignment Initiative
Effective Since March 1, 2014
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Member Criteria
• Age 21 or older
• Entitled to Medicare Part A
• Enrolled in Medicare Part B and Part D
• Enrolled in Medicaid Aid to the Aged, Blind
and Disabled (ABD)
• Living in the community or nursing facility
• Includes Medicaid waiver members
Additional Coverage Eligibility
• Additional coverage may be available to those that qualify for the following
Medicaid Waivers:
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Persons with Disabilities
Elderly
HIV/AIDS
Supportive Living Facilities
Brain Injury
Waiver Services Include
• Adult Day Service/Transportation
• Behavioral Services
• Day Habilitation
• Personal Emergency Response System/PERS
• Home Health Aide
• Home Delivered Meals
• Home Modification
• Homemaker/Personal Assistant Services
• Nursing: Intermittent and Skilled
• Prevocational Services
• Physical/Occupational/Speech Therapy
• Respite Care
• Specialized Medical Equipment/Supplies
• Supported Employment
• Supportive Living Facilities
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Eligibility for the Medicaid Waivers is determined by one of two
state agencies - Illinois Department of Aging (IDoA) or Department
of Rehabilitation Services (DRS). To qualify for waiver services,
members will need to work with a state agency to complete the
Determination of Need Assessment (DON). Once a member
becomes eligible, a DON score is assigned to determine the level of
need. The member is then enrolled in the waiver program.
The State of Illinois –
Client Enrollment Services (ICES)
Processes all enrollments and disenrollments
Ensures unbiased education and information about health plans
Assists members in the enrollment process
www.enrollhfs.illinois.gov
877-912-8880
Monday to Friday 8 a.m. – 7 p.m., Saturday 9 a.m. – 3 p.m.
Free interpretation services
Enrollment for Medicaid
Best advice: For enrollment information, encourage your patients to contact ICES as soon as
possible. If they cannot make this call, a family member or friend can call on their behalf. See the
ICES website for more information on how this can be done.
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• Enrollment into a health plan is mandatory for BCCHP members. Members
select a plan or the state automatically enrolls the member if they do not select a
plan.
• Existing members can stay with their current participating plan or they will have
90 days from Jan. 1, 2018, to select another Managed Care Organization
(MCO). If they want to change plans during that time, they may do so by calling
the Illinois Client Enrollment Services (ICES).
• After 90 days, BCCHP members are locked into their chosen or assigned health
plan for one year.
• Open Enrollment: After the initial enrollment period, and once every 12 months
thereafter, members will have a 30-day period in which they are allowed to
change health plans. Members will be notified no later than 40 days prior to the
member’s anniversary date by ICES. If no plan is selected, the State re-enrolls
the member in their current health plan. Members will be locked into that plan for
the next 12 months.
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Enrollment Process – BCCHP
Enrollment Process - MMAI
• Enrollment is voluntary for a 90-day period. Members select a plan of their choice.
• The State will notify members via letter to indicate when the 90-day period begins. At end of the 90-
day period, passive enrollment begins. Members who have not chosen a plan will be automatically
assigned a plan by the State.
• Members can switch plans or opt out of MMAI at any time on a monthly basis. If the choice to enroll
is made by the 12th of the month, enrollment will be effective the first of the following month.
Enrollment requests received after the 12th of the month will be effective the first of the second
month following the request.
• MMAI member with Long Term Services and Supports (LTSS) Medicaid Waivers may choose to
opt-out from the Medicare side of MMAI. As for Medicaid services, waiver members are required to
remain enrolled with a managed care organization to continue to receive those services.
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Program Foundations: Philosophy
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Considers Individual
• Preferences
• Cultural needs
• Linguistic needs
• Potential to self direct care
Health System Navigation
• Communication
• Collaboration
• Alignment
Health Care Delivery
• Connected
• Unified
• Multidimensional
Inclusive/Multidisciplinary
• Member
• Family/Authorized
representatives
• Providers
• Caregivers
• Community resources
Right To
• Be treated with respect and dignity
• Privacy
• Be offered treatment
options/alternatives
• Participate in health care decisions
• Refuse treatment
• Be free from restraint/seclusion
• Have access to medical records; may
amend/correct
• Receive information in an easily
understood format
Comprehensive in Scope
• Cognitive needs
• Psychosocial and Behavioral
needs
• Physical needs
• Functional
Person
Centered
Integrated
Coordinated Holistic
Enrollee Rights
Team Based
Care Coordination • Members will be assigned a Care Coordinator who leads an Interdisciplinary Care Team and coordinates care
between all providers and services.
• A risk assessment (health screening) will be completed for each BCCHP and MMAI member within 60 days of
enrollment.
• If you are treating a member who has not completed a Health Risk Screening (HRS) please encourage them
to do so by calling 855-334-4780. Please note that translation services are available for those who call to
complete the HRS.
• Members will be assigned a risk level (i.e., low, moderate, high) based on results from the HRS.
• The intensity of care coordination involvement is as follows:
• Low risk: prevention and wellness messaging and condition-specific education materials along with
monthly surveillance monitoring using claims data; support is primarily telephonic.
• Moderate risk: members are provided with problem solving interventions, and monthly surveillance
monitoring using claims data. Support is both telephonic and face-to-face.
• High risk: intensive care management for reasons such as addressing acute and chronic health needs,
behavioral health needs, or addressing lack of social support. Members are contacted every 90 days;
support is both telephonic and face-to-face. All Special Needs Children are categorized as high risk.
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Transition of Care
• BCBSIL will help facilitate transition of care when a member needs assistance in
moving from one level of care to another or from one provider to another.
• Transition of care protocols are applicable when a member is displaced by physician
de-participation or is displaced by termination of a provider contract.
• The Care Coordinator facilitates selection of an in-network provider for the member.
• Members in the first trimester of pregnancy may request assistance to continue with
established provider for a defined time. Our Customer Service team may assist with
such requests.
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BCCHP transition of care period: 90 days
MMAI transition of care period: 180 days
Eligibility and Benefit Determination
• An eligibility and benefits inquiry should be completed to confirm membership and to
verify coverage prior to rendering services to a member. Coverage decisions for claim
payment are always subject to all terms, conditions, limitations and exclusions of the
applicable benefit plan.
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How to Check Eligibility and Benefits:
Electronic Transactions:
You may use your current web portal or existing
Practice Management Systems (PMS) vendors.
Telephone Transactions:
877-860-2837 BCCHP
877-723-7702 MMAI
Hours: Monday to Friday, 8 a.m. to 8 p.m.
Eligibility and Benefits Determination
• Information to have ready when calling for eligibility and benefits:
• Provider’s NPI number and Tax ID number
• Patient’s BCBSIL identification number
• Patient’s date of birth
• For benefit inquiries: Type of service being rendered, CPT® code(s) and place of treatment
• Status of provider that will render services: (contracted or non-contracted)
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CPT copyright 2016 American Medical Association (AMA).
All rights reserved. CPT is a registered trademark of the
AMA.
Member Identification Card
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MMAI-Member Card Group Number – HMM00002
Group Number – HMM00004
Medicaid Member Card
Group Number – HMM00004
MLTSS Member Card
• 24/7 access to nurse hotline
• $30 every 3 months for over the counter items
• Gift cards to buy health care items if you complete certain preventive measures
• Extra dental care for adults
• Pregnancy and healthy kids
• Special Beginnings Program - Pregnant women who enroll and remain in the Special Beginnings program until after deliver are eligible for either a crib or a car seat for attending prenatal care; the diaper program is an incentive for attending post-partum care. For more information, please contact Care Coordination at 888-421-7781.
• Transportation to appointments, pharmacy, medical equipment provider and Women Infant and Children’s offices
• Vision - $40 toward a pair of upgraded eyeglass frames every 2 years
• Mobile Crisis Response Services
• Translation services (written and verbal)
• In-house chaplain services
• Community Health Workers Program
• Long Term Services and Supports (LTSS) support center
• Transition of Care Team
Additional Benefits
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Dental, Vision, Pharmacy and Transportation Contact Information
• DentaQuest Customer Service Phone Number: 888-286-2447
• Provider Relations Phone Number: 888-281-2076
• Provider Website: http://www.dentaquest.com/dentists/ DentaQuest
Prime Therapeutics
• Davis Vision Customer Service Phone: 800-283-9374
• Provider Relations Phone Number: 800-584-3140
• Provider Website:https://www.davisvision.com/become-a-provider/
Davis Vision
• LogistiCare Customer Service Phone Number: 844-544-1393
• Provider Relations Phone Number: 877-917-4149
• Provider Website: http://www.logisticare.com/drive-with-logisticare/
LogistiCare
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• Prime Therapeutics Customer Service
Phone Number: 855-457-0173
• Provider Relations Phone Number: 800-821-4795
• Provider Website:
https://primetherapeutics.com/en/resources/pharmacists.html
Benefit Preauthorization
• Benefit preauthorization is the process of determining whether the proposed treatment or service meets the
definition of “medical necessity” as set forth in the member’s benefit plan, by contacting BCBSIL for prior
approval of services.
• Primary Care Physicians (PCPs) do not need to obtain benefit preauthorization for referrals to contracted
specialists.
• Benefit preauthorization is not required for emergency and urgent care services.
• Members can self-refer to in-network providers for routine Obstetrical/Gynecological services.
• All services rendered by non-contracted providers require benefit preauthorization and appropriate
medical referral to be considered for reimbursement.
• Approved referrals to non-contracted providers are valid for one visit within six months from the date the
request is entered into our system.
• Review our provider manual for a complete list of services requiring prior authorization.
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Please note that the fact that a guideline is available for any given treatment, or that a service has been preauthorized, is not a guarantee of payment. Benefits
will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of
coverage applicable on the date services were rendered. If you have any questions, please call the number on the back of the member’s ID card.
Preauthorization Tools
iExchange® (iExchange)—supports direct submission and provides online approval of benefits for inpatient
admissions, as well as select outpatient and pharmacy services 24 hours a day, seven days a week – with the
exception of every third Sunday of the month when the system will be unavailable from 11 a.m. to 3 p.m. (CT).
iExchange is accessible to physicians, professional providers and facilities contracted with BCBSIL.
Please visit our website for additional resources and requirements to sign up for iExchange.
https://www.bcbsil.com/provider/education/iexchange.html
eviCore: Blue Cross Community Health Plans (BCCHP) has contracted with eviCore, an independent specialty
medical benefits management company, to provide utilization management services for pre-service authorization.
Please visit eviCore website for a listing of categories of service and specific codes requiring authorization by
eviCore.
eviCore contact information: Phone: 800-575-4517
Email: [email protected]
Website: https://www.evicore.com/healthplan/bcbsil_m
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Electronic Claim Submission
• Electronic submission of claims helps optimize the flow of information between providers and
health plans. Claims may be submitted via the web portal or existing Practice Management
Systems (PMS) vendors. Please select from the following vendors for detailed information on
claim submission and other e-Commerce transactions:
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Payer ID for Electronic Submissions
• Facility Claims (UB-04): MCDIL*
• Professional Claims (CMS-1500): MCDIL*
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange
services to medical professionals. Availity provides administrative services to BCBSIL.
*If you use a practice management/hospital information system or billing services, and/or a clearinghouse other than Availity or
Passport/Experian contact your vendor for the correct Payer ID to use on electronic claim submitted.
Paper Claim Submission
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Paper claims should be sent to:
Blue Cross Community Health Plans
P.O. Box 3418
c/o Provider Services
Scranton, PA 18505
Rejected and Denied Claims
REJECTED CLAIMS
A rejection is a claim that never makes it into
the MCO’s claim system, usually because the
information is not complete or it is inaccurate
Rejected claims that are not
resolved/resubmitted correctly by the provider
may later be rejected for timely filing by the
MCO should they be corrected
DENIED CLAIMS
A denied claim is one that was successfully
received but could not be adjudicated for
payment
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Common Denials:
Duplicate claims
No authorization on file
Claim not submitted within the
timely filing guidelines
Member not on the patient credit file
Member not eligible on the date of
service
Common Rejections:
Incorrect RIN/Member ID#
Missing Diagnosis
Missing or Incorrect TIN or NPI
Missing Taxonomy Code
Claim Disputes
Providers may dispute a claims payment decision by requesting a
claims review. Providers may contact BCBSIL at 877-860-2837
regarding claim disputes.
BCBSIL must be notified in writing within 60 days of receipt of payment.
Unless the provider disputes a claim(s) payment within the time frame
indicated above, prior payment of the disputed claim(s) shall be
considered final payment in full and will not be further reviewed by
BCBSIL.
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Mail claim disputes to:
Blue Cross Community Health Plans
Claim Disputes
c/o Provider Services
P.O. Box 3418
Scranton, PA 18505
Paper Claim Submission
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Paper claims should be sent to:
Blue Cross Community MMAI
P.O. Box 4168
c/o Provider Services
Scranton, PA 18505
Claim Resources
• Illinois Medicaid Program Advanced Cloud Technology (IMPACT)
• As of July 2015, all Medicaid providers seeking to serve or are currently serving Medicaid members are
required to enroll with HFS in the IMPACT provider enrollment system. Please visit the IMPACT provider
enrollment website, IMPACT.Illinois.gov, to complete the enrollment process.
• Items required for enrollment:
• National Provider Identifier (NPI) number
• A certified W-9 tax form on file with the comptroller
• Taxonomy number
• Licensures or certifications, as applicable
• Other information verified by IMPACT such as criminal background check, Drug Enforcement Agency
number, sanctions, vital statistics, provider basic information, driver’s license/State ID, vehicle
identification, and Safety Training certificate
• Valid email address and a supported browser
• If you have any questions, please contact the IMPACT Project Team either by phone at 877-782-5565
(select option #1) or by email at [email protected].
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Provider Training • It is a CMS and State of Illinois requirement for BCBSIL to make available training on specified topics for
BCCHP & MMAI contracted providers. These trainings are mandatory in order to comply with the terms of
your provider contract. Please have your staff participate in the BCBSIL online training.
• To access the BCCHP & MMAI provider training tutorials, visit the Network Participation/Provider Training
Requirements and Resources section on our website at bcbsil.com/provider/network/bc_community.html.
• BCBSIL Online Training Tutorials* –
• Model of Care/Medical Home (Person Centered Practice)
• Combating Medicare Parts C & D Fraud, Waste and Abuse
• Abuse, Neglect, Exploitation/Critical Incidents
• Cultural Competency
• Americans with Disabilities Act (ADA)/Independent Living
• Medicare Parts C & D General Compliance Training (only MMAI providers)
• ADA Site Compliance Survey
*Alternative option for compliance training completion: You may complete the online attestation of training
completion which certifies that your practice has completed the annual BCCHP & MMAI compliance training from
another government contracted Managed Care Organization (MCO).
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Brainshark
Appeals and Grievances
A member has a right to Medical Appeals and Grievances:
Appeals are defined as dissatisfaction with an organization determination
Grievances are defined as dissatisfaction with health care services
An expedited reconsideration appeal may occur if proposed or continued services
pertain to a medical condition that may seriously jeopardize the life or health of a
member or if the member has received emergency services and remains hospitalized.
All appeals and grievances must be resolved within a specified
time frame.
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Reporting Incidents of
Abuse, Neglect and Exploitation
• It is important to report abuse, neglect and exploitation to the appropriate authorities to
ensure the health safety and well being of vulnerable adults and children.
• Please call 855-334-4780 to inform Blue Cross Community Health Plans and MMAI of
the report.
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Reporting Critical Incidents of
Abuse, Neglect and Exploitation
• Mandated Reporters
• Mandated reporters can be employees of facilities, community agencies and certain professionals; they
are required by law to report abuse, neglect and exploitation. These professionals include: doctors,
nurses, psychologists, dentists, social service workers, law enforcement personnel.
• Voluntary Reporters
• Everyone is encouraged, even when not required, to report any suspected abuse, neglect and
exploitation. It is not necessary to provide your name, should you wish to remain anonymous. No matter
who reports, the identity of the reporter is not disclosed without the written permission of the reporter or by
order of a court.
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How to Report a Critical Incident
• Report critical incidents related to BCCHP & MMAI members
• By calling 855-334-4780 .
• Please have the name and id of the member
• Provide a brief synopsis of what occurred
• Provide the steps taken to ensure the safety of the
member
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Providers Duties & Responsibilities
Notice of Change: Provide the HMO at least (90) days in advance of any changes to the practice/facility. These changes include the
following:
• Change of address
• Change of phone number
• Closing practice to new patients
• Addition or termination of practice provider
• Change in after-hours emergency services
• Substantial change in weekly hours of operation
Access and Availability: Appointment availability and access guidelines should be used to help ensure our members have timely access
to Medical Care and Behavioral Health Care, for routine and preventive care, urgent care, emergent urgent care – life threatening/non-life
threatening and prenatal care.
In addition, your practice shall make necessary and appropriate arrangements to ensure that Medically Necessary Covered Services are
readily available to members 24 hours a day, seven (7) days a week. In addition, your practice shall maintain a 24-hour answering service
and assure that each Practice Provider provides a 24-hour answering arrangement, including a 24-hour on-call arrangement for all
members, voicemail alone is not acceptable to meet this requirement. For more information, please reference the provider manual -
bcbsil.com/provider/standards/manual.html.
.
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Provider Network Contact Information
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Manager, Medicaid Provider Network: Region 1
James McNeal 312-653-0562
Medical Provider Network Consultants
Sandra Hopson
815-639-1558
Stacy Poehlman
815-639-7124
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information
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Manager, Medicaid Provider Network: Region 2
Lauren Bowman 217-479-6242
Medical Provider Network Consultants
Allison Scott
217-243-0152
Candace Peters
Phone number will be provided later
Chris McCorkle
217-479-6869
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information
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Manager, Medicaid Provider Network: Region 2
Lisa Kugler 217-479-6263
Medical Provider Network Consultants
Amy Phillips
217-862-7087
Bradley Adams
217-277-4276
Grace Mabry
217-221-4139
Jennifer Lipscomb
217-479-6793
Josh Warren
217-228-6140
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information
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Manager, Medicaid Provider Network: Region 3
Shawn Dunas
Medical Provider Network Consultants
Yomeko Sumrall
618-222-6397
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information
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Manager, Medicaid Provider Network Region 4 and 5
Dara Clark
312-653-3327
Medical Provider Network Consultants
Ratna Soni
312-653-2317
Tammy Smith White
312-653-3530
Beverly Jones
312-653-9115
Linda Tolbert
312-653-3306
Sheda Brown
312-653-8742
Marina Bazan
312-653-6389
Dave Rockafellow
312-653-6131
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information Manager, Medicaid Network Development Regions 1, 4 and 5
Shanquinnell Bullock, LCPC
312-653-2494
Group email account Provider Phone Line
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Provider Network Consultants
Beverley Domaleczny (SUPR)
312-653-6435
Marian E. Brown (LTSS)
312-653-4762
Juanita Harris (CMHC)
312-653-1401
Mary Love (BH)
312-653-4100
Thomas Edwards (LTSS)
312-653-4423
Group email account Provider Phone Line
[email protected] 855-653-8126
Provider Network Contact Information
Manager, Ancillary Medicaid Network Development
Regions 1, 4, and 5
Kimmyatta Thurmon 312-653-4859
Group email account Provider Phone Line
[email protected] 855-653-8126
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Provider Network Consultants
James Butler (SLF, Dialysis, DME)
312-653-3249
Jesus Rocha (Long Term Care)
312-653-4749
Jimmy Perez (Home Health and Hospice)
312-653-5081
Thank you for participating!
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Blue Review: bcbsil.com/provider/standards/manual.html
As a reminder visit the Blue Cross Community Health Plans
section of our website at bcbsil.com/provider/network/medicaid_index.html.
Sign up to have the Blue Review emailed to
you. Fill out the “Subscribe to the Monthly
Blue Review Email Newsletter”
Rev. 5/16/18
View the PNC Contact lists, starting on slide 35!