Community Medical Group€¦ · Greater simplicity, fewer fields Smart searches for quicker entry ... All new products will have the same benefits enhancements to existing portfolio:

© 2019 Harvard Pilgrim Health Care

Community Medical Group

September 24, 2020

2 / © 2019 Harvard Pilgrim Health Care

Today’s discussion

1. About Harvard Pilgrim

2. COVID-19

3. Provider Network Experience

4. Products and Network

5. Network Matters - Policy Updates

6. Resources and Tools


About Harvard Pilgrim


Founded by Doctors 50 years ago

3 million customers in New England and

beyond.

Commitment to service and improvement

Ready, willing and able to guide members and

providers through health care complexities

Innovative approach to population health that’s

improving health outcomes and reducing costs

Our commitment to the communities we

serve is driven by the passion of the Harvard

Pilgrim Health Care Foundation.

Who we are

ENGAGED

EMPLOYEES

THINK BIG

WORK

TOGETHER


“To improve the quality and value of health care for the

people and communities we serve”

Our Mission


COVID-19


COVID-19


Provider Information Sheet

Contains valuable information on Harvard Pilgrim’s adapted policies and

business operations, aimed at supporting our members, providers, and

employers through the COVID-19 public health emergency.


Staying Healthy & Safe

In order to stay both healthy and safe, it’s important that access to routine and preventive care is available so that easily avoidable or treatable conditions don’t become a serious health concern.

Flu vaccines • Ongoing awareness campaign to highlight the importance of keeping

vaccinations and immunizations up-to-date

Annual physicals and wellness care

• Care for existing conditions• Congestive heart failure, diabetes and other ongoing illnesses are

particularly at-risk

Mental health screening and counseling


COVID-19 Relief

Connecticut COVID-19 Relief Grant Recipients: Total $250,000

• The Hartford Foundation, COVID-19 Response Fund.• CT Food Bank, Community-based food access.• Foodshare (Bloomfield), Food pantry on wheels, meal delivery.• Town of Plymouth, Community Food Pantry.• Clifford Beers (New Haven), Supporting mental health services for youth impacted

by COVID-19.

Harvard Pilgrim provided $32 million in premium credits to all its fully-insured employer groups, as well as to Medicare Supplement members. Financial support also provided to independent directly contracted primary care physicians and community health centers.


Provider Network Experience


HPHConnect

• Faster access to transactions you use most

• Access to resource information all in one place

• Smoother search capabilities time saving templates

• Increased usability

• Easy access to information

Enhanced

Features

Auth.

Upgrade

Home

Page

Resource

Page

Log In

Full Site

Auths

Manuals



har

vard

pilg

rim

.org

/pro

vid

erp

ort

al


Good to Great

✓ A commitment to improving provider experience

✓ Fresh, intuitive design

✓ Greater simplicity, fewer fields

✓ Smart searches for quicker entry

✓ Savable Templates for frequently used requests

✓ Interactive question tool supporting Medical necessity

Authorization Upgrade


Electronic Authorization & Use

of InterQual

InterQual

Criteria

Adoption

Upgraded

Authorization

Portal

Clinical Upload

via HPHConnect

Training and

EducationElectronic

Questionnaire


New Provider Site

In our commitment to improve provider experience -

launched fully revamped provider website on Sept. 9th

➢ Features include:

- Cleaner, easy-to-navigate design- Improved filtering and search functionality- More intuitive navigability- Updated look and feel

18© 2019 Harvard Pilgrim Health Care


Network Matters – Policy Updates


News & Policy Updates


Products and Network

22 / © Harvard Pilgrim Health CareGeneral Business

Maine• Providers: 7,857

• Hospitals: 33

• PCPs 1,389

• Ancillary: 280

New Hampshire• Providers: 6,887

• Hospitals: 26

• PCPs: 1,273

• Ancillary: 300

Massachusetts• Providers: 40,205

• Hospitals: 73

• PCPs: 6,322

• Ancillary: 1,239

Connecticut• Providers: 16,547

• Hospitals: 29

• PCPs: 2,744

• Ancillary: 459

All• Providers: 78,813

• Hospitals: 182

• PCPs: 12,832

• Ancillary: 2,278

National (United)• Providers: 775,000

• Hospitals: 5,500

Medicare • Providers: 23,124

• Hospitals: 74

• PCPs: 4,781

• Counties: 20

Vermont• Providers: 2,572

• Hospitals: 10

• PCPs: 423

Rhode Island• Providers: 5,078

• Hospitals: 10

• PCPs: 681

Harvard Pilgrim Health Care

Network


Open Access HMO Plan Details

:

• Open Access HMO

– Members are not required to select a PCP

– Referrals are not required

• Covered services must be provided by contracted providers in Harvard Pilgrim’s

network within CT, MA, ME, NH, RI, and VT

– Exceptions include:

• Emergency services

• Services authorized in advance by Harvard Pilgrim

• Student coverage


PPO Plan Details

• Two levels of coverage – In-Network and Out-of-Network

• Prior approval is required for certain Out-of-Network services

• Services at the member’s in-network benefit level must be provided by:

• The Harvard Pilgrim network in: CT, MA, ME, NH, RI and VT

• The United Health Care Options network in the other 44 states

• Services at the member’s out-of-network benefit level may be provided by:

• Any provider not in the Harvard Pilgrim or UHC Options Network


Coming Soon…

New 2021 Products

FOCUS CTSM HMO NETWORK CHOICE CTSM PPO

• Narrow network HMO product

• ‘In-Network’ tier

• ‘Authorized Access’ tier

• Full/seamless New England

Network

• PCP and referrals required

• Lower PCP cost share to promote

PCP requirement.

• Two-tiered full network PPO product

• Cost share differential between T1

& T2

All new products will have the same benefits enhancements to existing portfolio:

• Unlimited visits on Chiro and Acupuncture

• Free Doctors on Demand

• Full network pharmacy offering

• Standard Wellness Offering

• Adult members will be assigned a virtual

Doctor on Demand PCP

• Pedi members will be assigned a brick

and mortar (office-based) PCP

• Members will have access to full

network.

• Full hospital, ancillary and specialty care

network

Simply Virtual*


Resources and Tools


Network Matters

HPHC Connect

Provider Call Center

Provider Manual

Payment & Medical

Policy

News & Updates

• Vendor update

• Policy changes

• Best practices

• Claims updates

• 60 day

notifications

Tools at your finger tips• 24/7 access to

eligibility, claims,

auths & referrals

• User guides

• Provider reports

• ERA

Review prior to

rendering

service

• Up-to-date

policy

information

• UM criteria

Information you

need

• Billing guidelines

• Product

information

• Pharmacy info

• Referral &

authorization

policies

• EFT

Need more help?

800-708-4414

[email protected]

Provider Tool Kit


28

Claim Review Request

✓ 1st level submit 90 days from EOP✓ 2nd level submit 90 days from

1st appeal decision letter✓ Separate form for each claim✓ Include copy of claim form

✓ Important to include rationale for

appeal vs stating only to review

Appeals accepted: filing limit, referral, duplicate claim, notice & prior Auth, contract rate, payment & clinical policy, request for additional information

Filing an Appeal is Easy

1. Submit Claim Review Form

2. Include relevant documentation

3. Submit appeal within filing limits

Reminders


[email protected]

Verronica Barrows, Sr. Provider Relations ConsultantChristina Fusick, Provider Relations ConsultantSusan Richardson, Sr. Manager, Provider Relations & Network Operations

CT Provider Relations

Contact Information

https://www.youtube.com/watch?v=CyFYePFwcGw&list=PLGy7XKCkutjTbCkhuCuS2gZMyhrsXDCK_

mailto:[email protected]


Any Questions?

https://www.youtube.com/watch?v=CyFYePFwcGw&list=PLGy7XKCkutjTbCkhuCuS2gZMyhrsXDCK_

Documents

Community Medical Group€¦ · Greater simplicity, fewer fields Smart searches for quicker entry ... All new products will have the same benefits enhancements to existing portfolio: