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Empire Plan Provider Orientation
Objectives
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Welcome and Introductions Overview of ValueOptions ValueOptions & Empire Plan Partnership Overview of Operational Areas Clinical Operations Claims & Payment Overview Tools, Resources and Communications Contacts and Helpful Links Questions and Answers
ValueOptions Overview
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Founded in 1983 Committed to principles of recovery and
resiliency Diverse client base – covering 32 million lives
Commercial Division Employer Groups Health Plans
Federal Division Public Sector Division
ValueOptions’ National Presence
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Shared Commercial and Public Program/ Medicaid Membership
Commercial Membership Only
Regional support, EAP staff and corporate support offices
Major service centers
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Empire Plan
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On January 1, 2014, ValueOptions began to administer the Empire Plan Mental Health and Substance Abuse Program
The Empire Plan is the largest state employer in the country
and covers over one million lives
For your clinical and claims questions, continue to contact 877.7.NYSHIP (877.769.7447) Option 3 and you will be connected with ValueOptions.
Empire Plan
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Providers already participating with the ValueOptions network • Providers should confirm network participation
status prior to seeing an Empire Plan enrollee. • If you are concerned about your participation
status, contact the Provider Services line at 800.235.3149.
Empire Plan
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Providers identified as having an Empire Plan enrollee in care, but who are not currently participating with ValueOptions • Complete and sign the Practitioner Data Form and
Agreement and returned it to the address or fax provided.
Overview of Operational Areas: National Network Services
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Provider Relations Ensuring that members’ behavioral health care needs are met
through a geographically and clinically robust network whose providers are readily available;
Ensuring the maintenance of network composition by engaging in assertive retention strategies;
Engaging in timely and appropriate recruitment; Engaging in professional, consistent, and educative
communications with our provider community and staff.
Provider Credentialing Completion of Credentialing Application required for
network participation.
Overview of Operational Areas: National Network Services, cont’d.
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Provider Re-credentialing Online re-credentialing process via ProviderConnect
Every 3 years Notification
Telephonic message via Provider Pulse about 4 months prior to due date that application is available
Follow up email or fax approximately 1 week later with instructions for accessing application (Provider Data Sheet)
15 and 30 day reminder notices Failure to respond to the request will result in disenrollment
from the network Completing the Online re-credentialing application
Prepopulated – just need to verify and update information Attach updated license, certification and malpractice
information Electronically sign the application Once signed it is automatically submitted
Overview of Operational Areas: National Network Services, cont’d.
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Provider Contracting ValueOptions Provider Agreements.
Questions about Contracting and Credentialing?
Call 800.235.3149
(8 a.m. – 8 p.m. ET)
ValueOptions’ Quality Management
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Quality Management Program Oversight is provided by Medical Director.
Key Quality Indicators include but are not limited to: Satisfaction Survey measures. Access and Availability of Services – geographic access;
phone statistics; appointment availability; etc. Complaints and Grievances tracking and reporting. Patient Safety – (adverse incidents and quality of care). Coordination of Care. Quality Improvement Activities/Projects. Compliance with URAC Standards. Compliance with NCQA Standards.
ValueOptions’ Quality Management cont’d.
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Ongoing Quality Improvement Activities (QIAs) Clinical QIAs
Ambulatory Follow-up Time in the Community – Depression Management Risk Tracking – Referral for Urgent and Emergent
Treatment
Service QIAs Average Speed of Answer of the Phone Line Provider Satisfaction with Utilization Management
Customer Service Philosophy
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ValueOptions Customer Service philosophy lies in our commitment to provide our members and providers with the most accurate and informed benefit, eligibility, claims, and certification information in the most effective, efficient, and compassionate manner.
ValueOptions puts our members’ needs and concerns first and is committed to resolving inquiries promptly without the need to re-contact.
We value our members’ questions and concerns and place member satisfaction at the heart of our Customer Service philosophy.
Key Areas of Expertise
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Clinical Operations: Care Management Paradigm
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Clinical Operations: Referral Assistance
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Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management. Member referral process:
Emergencies are followed until disposition Urgent referrals are offered appointments within 48 hours
and are called to ensure appointment is kept Providers can contact ValueOptions for referral assistance
if needed Providers should contact ValueOptions 24 hours a
day/seven (7) days a week if members require higher level of care or increased visit frequency
Care Management staff will assist with referral to inpatient or specialty programs
Utilization Management Process
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Inpatient Inpatient and higher level of care requests are completed
telephonically by calling 1-877-7-NYSHIP (1-877-769-7447), Option 3.
ValueOptions Staff are available 24 hours a day/ seven (7) days a week
Outpatient Enhanced Outpatient Care Model
Empire plan enrollees will no longer require prior authorization of routine outpatient mental health and substance abuse services, with the exception of psychological testing, outpatient electroconvulsive therapy, and transcranial magnetic stimulation.
Utilization Management Process, cont’d.
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Discharge Reviews
Providers can complete discharge reviews via ProviderConnect or call the assigned CCM
Providers should contact ValueOptions if they need assistance scheduling discharge appointments
Providers should make every effort to schedule a discharge appointment within one to two days of discharge, but in all cases within seven (7) days.
Clinical Resources for Providers
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Clinical information is available at www.valueoptions.com
ValueOptions Medical Necessity criteria
Treatment Practice guidelines
PCP consult line 9 am to 5 pm (Eastern Time)
877.241.5575
Intensive Case Management Services
Claims & Payment Overview
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Claims should be submitted to ValueOptions at:
ValueOptions P.O Box 1800
Latham, New York 12110
Claims questions should be directed to ValueOptions at 1-877-7-NYSHIP (877.769.7447), Option 3 between 8 AM and 8 PM ET, Monday through Friday.
Electronic Claims Submission
Advantages: • It’s better, faster, and cheaper! • Reduced Paper Files. • Reduced Labor and Postage Expenses. • Reduced potential of error or mishandling. • Faster claims processing improves cash flow.
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ValueOptions EDI
Accepts claims files from any Practice Management System that outputs HIPAA formatted 837P or 837I files, as well as from EDI claims submission vendors
Offers Direct Claims Submission to providers without own software, or who wish to submit certain claims outside their batch files
Claims are processed immediately, and you are provided the claim number
You may submit batch claims files or Direct Claims interchangeably
Never charges for electronic claims submission
Additional claims resources available at http://www.valueoptions.com/providers/Provider_Connect.htm
Dedicated Helpdesk 888.247.9311 (8am to 6pm ET) for EDI issues
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Tools, Resources and Communications
ValueOptions Website
ProviderConnect®
PaySpan Health®
Training Opportunities
Communication Channels
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ValueOptions.com
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ValueOptions.com
Network Specific
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ValueOptions.com
Network Specific
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ProviderConnect
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ProviderConnect
Role-Based Security in ProviderConnect
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New level of ProviderConnect access to enhance security as required by HIPAA guidelines
Level of ProviderConnect access defined by role
Roles defined by user type and/or VO business rules
Users assigned roles with access to certain functions i.e. claims
User Types: Super User, Managed User (managed by Super User),
Standard User
PaySpan® Health
A tool enabling you to: • Receive payments automatically • Receive email notifications immediately upon payment • View your remittance advice online • Download an 835 file to use for auto-posting purposes • Visit the PaySpan Health website at
www.payspanhealth.com
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Up to the Minute Communications
Provider PulseSM Messages
Fax and Email Communications
Provider Mailings
Constant Contact Alerts
Monthly Valued Provider eNewsletter
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Provider Contacts
Clinical and Claims Customer Service
877.7.NYSHIP (1.877.769.7447) Option 3
Provider Relations, Credentialing and Contracting Questions:
800.235-3149 (8 am - 8 pm ET Monday – Friday)
Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk):
888.247-9311 (8 am - 6 pm ET Monday - Friday) or [email protected]
For PaySpan Registration Provider Support contact: 877.331-7154 [email protected]
Provider Support is available from 8am to 8pm Eastern time, Monday through Friday.
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Helpful Links
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Network-specific website for the Empire Plan • http://www.valueoptions.com/providers/Network/Empire.htm
ProviderConnect Login • https://www.valueoptions.com/pc/eProvider/providerLogin.do
ProviderConnect User Guide • http://www.valueoptions.com/providers/ProviderConnect/ProviderCo
nnect_External_Users_Guide3.pdf
ProviderConnect Training Video Tutorials • http://www.valueoptions.com/providers/How-To.htm
