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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: [email protected]
JJ Jackson, Credentialing AssistantPhone: 661.716.3471
Email: [email protected]
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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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