1 Welcome Annual Provider Office Manager’s Meeting Physicians Choice Medical Groups & Marian...

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WelcomeAnnual Provider Office

Manager’s Meeting

Physicians Choice Medical Groups

&

Marian Health Services

July 30-31, 2013

Agenda

Welcome/Introductions Client Network Health Plan/Provider

Updates Eligibility Verification

Overview Referral Management

Claims Credentialing Annual Provider Training

Language Assistance Fraud, Waste and Abuse Cultural Competency

GEMCare Health Plan Conclusion/Q&A

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Hand-Out Packet Contents

A. Summary of Key Things to Remember A-1: Marian Health Services

A-2: Physicians Choice Medical Group of SLO

A-3: Physicians Choice Medical Group of Santa Maria

B. Utilization Review Information Form

C. Claims Submission Guideline – Health Plan

D. Claims Submission Guideline – IPA

E. PRA Memo/Sample

F. Referral/PDR Process Memo

G. Language Assistance Program

H. New Material – MHS Ancillary Vendor Listing 3

MCS CLIENT NETWORK

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Blue Shield Commercial and Dignity Health Effective 1/1/2013, contract terms changed Dignity Health accepted risk for Blue Shield

Commercial members enrolled with PCSLO

What does this mean? If you were previously billing the IPA,

continue billing the IPA. If you were previously billing Blue Shield

directly, submit to MCS. MCS will process and pay these claims on DH’s behalf.

PCMG Provider Updates

Central Coast Pathology Laboratory is the capitated provider for all out-patient laboratory services. Inclusive of anatomic and clinical pathology services Pre-op testing Exception of platelet function testing (bleeding time)

Effective June 1, 2013 for PCSLO Effective September 1, 2013 for PCSM

Tertiary ServicesUCLA and USC are contracted with PCMG and MHS

USC University Hospital is the preferred tertiary center

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MHS Provider Updates

Effective 2/12/2013:Marian Community Clinics officially changed their name to Pacific Central Coast Health Centers.

Effective 3/1/2013:

Bariatric surgery program offered at the Weight Loss Surgery Institute of the Central Coast by Dr. David Maccabee.

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MHS Provider Updates

Effective 6/1/2013:

Dignity Health bought and now owns the following centers for chemo therapy outpatient infusion services:

Mission Hope Cancer Center in Santa Maria - Physician Group: Central Coast Medical Oncology Corporation

Coastal Integrative Cancer Center in San Luis Obispo - Physician Group: Oncology Hematology Medical Associates of the Central Coast

Patients access and receive chemo treatment at centers.Authorization clerks issue separate facility authorization.No impact on patient; only affects rendering facility billing process to Plans.

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Provider Network Updates - MCS Online

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Updated monthly

Provider Network Updates are summaries of important informationand available on MCS Online under Newsletters

Eligibility Verification

If a member is no longer actively enrolled or not listed in the system, the following are your options to verify eligibility and/or add new members:

1. MCS Online > Eligibility Verification Form or

2. Call Customer Service (may experience prolonged call time)

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Eligibility Verification Form (EVF)

MCSO>Eligibility>Search Member

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Click onto link

Eligibility Verification Form (EVF)

Complete and Submit EVF online

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Email accessible during business day

EVF – Email Response

You will receive email communications from “System Configuration” as the sender, acknowledging receipt and findings. If member is found eligible, MCSO will be updated with current info, shortly thereafter.

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Utilization/Referral Management

From our staff to yours…..

Thank you for being such an awesome team to work with!

Friendly calls, dedication, hard work, and team efforts in streamlining patient care are recognized and much appreciated by our staff. A “high-five” to ALL of our provider offices.

Urgent Authorizations

Urgent authorization requests: Goal to provide an online response within 24

hours Based on medical necessity Should not be submitted for scheduling

reasons Do not place an authorization request in an

urgent status unless there is a truly emergent situation requiring a determination within 1 working day and have supporting documentation ready for review

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Same Day Authorizations

If you need a Same day authorization: Submit prior authorization requests via MCS

online as Urgent. Call Customer Service, provide tracking number

and request expedited processing.

If you do not have access to MCS Online, you may fax the request. Prior to faxing:

Call customer service and inform you have a stat request.

Customer service will provide faxing instructions and walk you through process.

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Routine Authorizations

Routine authorizations are processed within five (5) business days.

Referral submissions via fax: Complete information including ICD-9 and CPT

codes with supporting documentation.

Routine Authorizations – cont.

Referral submissions via MCS Online:

Avoid duplicate entries - Verify member’s authorization history on MCS Online prior to entering new entry.

Have clinical information readily available prior to submitting online (for additional note entry or via fax)

Supporting documentation should be faxed immediately after online submission with authorization tracking number indicated.

It can take up to 2 hours for your authorization request to show up on MCS Online

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Faxing and Additional Note Box

1. Facility name; 2. indicating at patient’s request; 3. and/or clinical information supporting request

Note box should be usedfor entering:

MCS Online – Fax Cover Page

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When faxing Supporting Documentation, it is highly recommended to:

Utilize MCSO fax cover page or Indicate authorization reference number

Failure to do so may result in extended delay in processing or lost fax.

Deferred Authorizations

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If an authorization request is incomplete: MCS Auth Clerk will place request in a “Deferred” status MCS Auth Clerk will fax URI form daily until information

is received or deadline is reached

If deferred for additional information and we do not receive a response: Request may be denied. Request may be placed in an extended deferred

status up to 45 days, with a delay letter sent to the member.

Medicare members must have a determination within 14 calendar days.

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Utilization Review Information Form Utilization Review Information (URI) Form

Refer to hand-out ‘B’ Sample Form indicating the expectation from provider office

Reminder:The effective date of an authorization will be the date a

determination action is made.

Authorization Processing Statistics

Utilization Management 2013 Statistics VolumeJanuary - June

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Medical Group

Monthly Auth

Average

Daily Auth

Average

% Online Auth

Submission

Denial Rate

Modification Rate

Urgent Auths

Average Turnaround

Time

PCSM 1,858 88 89% 2% 2% 5.5% 1.30 days

PCSLO 1, 385 66 74% 1.5% 3% 7.5% 1.73 days

DHCC 1,140 54 59% 2% 1.5% 8.25% 1.48 days

MCS Online Reminders

Do not use the Specialty drop down box to select a requested provider.

24Results will display in and out of network providers

MCS Online Reminders

Always refer to the current Provider Listings for in-network providers

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Select appropriate network database

Provider Listings are updated on a Monthly basis

MCS Online Reminders

Other reference material available on

MCSO>Provider Resources>Provider Listings Ancillary Providers by Health Plan

- Updated quarterly Contracted Facilities by Health Plan (PCMG only)

- Updated quarterly** Posted reference material available will be based on network database

Provider offices with access to MCSO do not receive faxed auths or PRA (EOB) will not accompany remittance checks. Ability to download and print from MCSO.

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MCS Online Reminders

MCS online provider representatives (Office Managers), please remember to:

Submit user requests for new staff Consider allowing billing services user access Notify when an employee leaves to deactivate

access to your provider’s account

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MCS Online

MCSO not working properly?

i.e. not displaying results, links malfunctioning, freezing up for long periods

Possible cause: Internet Explorer 10 MCSO not compatible, programmer working on it

Troubleshoot: How can you identify what web browser you are using?

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Identify Web Browser

Go to Command toolbar and click onto Tools icon>About Internet Explorer

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Solution: Downgrade to Internet Explorer 8 or 9 or use a different web browser, i.e. Mozilla Firefox (free download)

Recommendation: Check with your IT on impact probability

Claims

Claims Submission Guidelines for Health Plan Payable Services (Hand-out ‘C’)

Claims Submission Guidelines for IPA Payable Services (Hand-out ‘D’)

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Coordination of Benefits

If a member has dual coverage, the secondary… Must use in-network providers and Prior authorization is required to access secondary

insurance coverage This rule includes members with Medicare as primary

Having dual coverage does not mean member will have no financial responsibility. Member may have some out-of-pocket costs.

Do not collect copays from patients with Medi-Medi coverage

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Provider Remittance Advice (PRA)

Revised PRAs - Additions and Changes

Refer to hand-out ‘E’ packet for copy of memo and PRA sample explaining revisions that were applied.

MCSO – PRA Search

PRA search options that are available: PRA Inbox Search PRA>by Check Number Search PRA > by Vendor ID (TIN)

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MCSO - PRA Search Options

1. Search by check number, or if the check number is not available, you may…

2. Enter the your Provider’s tax ID number in the Vendor ID field and select the Date Paid range, then Search

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Services Not Prior AuthorizedPDR Process (Refer to hand-out ‘F’) PDR process allows providers to appeal a claim that

has been denied and service has not been prior authorized.

Under AB1455, Providers are entitled to appeal denied claims via PDR process.

PDR are only accepted when claim has been denied PDR submissions will be reviewed retrospectively and

a determination will be made within 45 business days. Provider will be notified of the final determination status

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Credentialing

If recredentialing is not completed within 36 months, basis policy & procedures for termination are followed. There is no grace period.

Hospital Privileges: If a provider does not have hospital privileges, a letter indicating the name of the provider who will admit on their behalf must be in writing. If utilize a hospitalist group, the group name must be indicated.

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Credentialing Contacts

Yolanda Herrera, Credentialing CoordinatorPhone: 661.716.7156

Fax: 661.716.9156

Email: yherrera@managedcaresystems.com

JJ Jackson, Credentialing AssistantPhone: 661.716.3471

Email: jjjackson@managedcaresystems.com

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Annual Provider Training

Annual training for Healthcare Providers as required by health plans Cultural Competency Training for Healthcare

Providers Fraud, Waste, Abuse (FWA) Many fines, penalties imposed on providers who

fraudulently bill and accept payment from government agencies.

Encourage all in medical community to report suspected FWA

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Annual Provider Training

All health plans are required to offer Language AssistanceRefer to hand-out ‘G’ for contact information when requesting help with limited or non-English speaking members

For Language Assistance Program Provider Training, refer to MCS Online Provider Portalwww.managedcaresystems.com

Path to link:

Provider Resources>Reference Sources>Language Assistance Program Provider Training

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Annual Provider Training

For compliance training on Cultural Competency Training for Healthcare Providers and Fraud, Waste and Abuse Programs

Refer to MCS Online Provider Portalwww.managedcaresystems.com

Path to link:

Provider Resources>Cultural Competency

Provider Resources>Reference Sources>Fraud, Waste and Abuse Compliance Training

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Physicians Choice Medicare Plus HMO by GEMCare Health Plan

Speaker

Stella Sanchez

Sales Manager

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Conclusion

A copy of our presentation will be available on MCS Online

Questions & Answers

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