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End of Year2017
0118.PR.P.PP 1/18
Agenda
End of Year• Prior Authorization Need to Know
• Allwell 2018
• Ambetter 2018
• MHS Website
• Patient and Provider Analytics
• Questions
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Prior Authorization
Durable Medical Equipment (DME) and Home MedicalEquipment (HME)
Providers must initiate all DME/HME needs directlythrough MHS or Ambetter from MHS web portal
Medline provides or coordinates all orders• Streamline ordering process for providers
• Track requests
• Improve response times
• Online request option through MHS portal
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Prior Authorization DME
MHS partnered with NIA to ensure that the physical, occupational and speechtherapy provided to our MHS members are consistent with nationally recognizedclinical guidelines. Effective October 1st, PT, OT and ST services no longerrequire prior authorization.
Beginning October 1st PT, OT and ST services claims are reviewed by NIApeer consultants to determine whether the services met/meet MHS policycriteria for medically necessary and medically appropriate care.
Claims may be pended requiring clinical information for post therapy review.They can be submitted the following ways:
• Records can be uploaded to RadMD.com
• Faxed to NIA at 800-784-6864
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Therapy
Pertinent therapy records including the initial evaluation, treatment notes, andrecent progress notes
Documentation such as progress notes and/or a discharge summary from arecent or concurrent episode of care
All documentation must comply with Clinical Guidelines: Record Keeping andDocumentation Standards. This includes, but not limited to the following:
• Inclusion of appropriate patient history, diagnosis, prognosis and rehabpotential
• Objective tests and measures
• Treatment goals and a plan of care including frequency and duration ofservices provided
• Additionally, these items must be updated on a regular basis and includedas part of a therapy progress note.
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Clinical Documentation Required
Allwell from MHS provides complete continuity of care to membersincluding:
• Integrated care coordination• Care management• Co-location of behavioral health expertise• Integration of pharmaceutical services with the PBM• Additional services specific to the beneficiary needs
Approach to care management facilitates the integration of:• Community resources• Health education• Disease management
Promotes access to care as beneficiaries are served through a single,locally-based multidisciplinary team including:
• RNs• Social Workers• Pharmacy Technicians• Behavioral Health Case Managers
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Allwell
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2018 Counties for Allwell
7 Counties for 2018AllenElkhartHamiltonHowardMarionSt. JosephVanderburgh
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Allwell ID Cards
PPO HMO
Medicare Advantage Claims are to be mailed to thefollowing billing address:
Allwell from MHSP.O. Box 3060
Farmington, MO 63640-3822
Participating providers have 180 days from the date ofservice to submit a timely claimAll requests for reconsideration or claim disputes must bereceived within 180 days from the original date ofnotification of payment or denialPayer ID 68069
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Time Frames and Payer ID
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Ambetter Counties for 2018
AdamsAllenBooneCassClarkDaviessDe KalbDuboisElkhartFloydFultonGibsonHamiltonHancockHarrisonHendricksHenry
HowardHuntingtonJohnsonKnoxKosciuskoLakeLaPorteMadisonMarionMarshallMiamiMontgomeryMorganPorterPoseyPulaskiShelby
St JosephStarkeSteubenTippecanoeVanderburghWarrickWellsWhitley
Ambetter is an Exclusive Provider Network (EPO)
EPO stands for "Exclusive Provider Organization" plan.
Members of an EPO, can use the doctors and hospitals withinthe EPO network, but cannot go outside the network for care.
Important Note: There are no out-of-network benefits
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What is “EPO”?
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Ambetter ID Cards
Ambetter Claims are to be mailed to the following billingaddress
Ambetter from MHS
PO Box 5010
Farmington, MO 64640-5010
Participating providers have 180 days from the date ofservice to submit a timely claimAll requests for reconsideration or claim disputes must bereceived within 180 days from the original date ofnotification of payment or denialPayer ID 68069
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Time Frame and Payer ID
Web Portal
Public WebsiteAt mhsindiana.com click on For Providers, Login and then
Login/Register
MHS Provider PortalTo access the dashboard, enter an email address and password.Once a user logs in, the dashboard will appear. Patient Analytics islocated under Welcome.
Dashboard ChangeProvider has the ability to change between Tax IDs along with Medicaid,
Ambetter and Allwell from MHS at anytime.
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MHS Welcome and ResourcesWelcome
• Multiple TINs can be managed from a single account.
• Account Managers can oversee the secure portal
accounts of their staff/office. User can be added,
disabled, and have their permissions changed.
• Reports are available here
• Patient and Provider Analytics
Quick Links
• Public link to Provider Resources
Demographic Update Tool
Preferred Drug Lists
Provider Education
And More…
• Member Management Forms
• IHCP Provider Healthcare Portal link
• Pharmacy Information
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Patient Analytics
Accessing Patient Analytics
When logging into PatientAnalytics, the user is presentedwith the Patients tab as the mainlanding page. Across the top of thescreen are the following buttons:
• View All Patients – This button willremove any filter options and displayall patients for which the user hasaccess.
• Filter Patients – By selecting thisbutton, an info window generatesallowing the user to select patientsthat fit a specific criteria.
Manage Filters: Filter the patient list by businessrules, subgroups, and physicians.
• Create PDF – Generate a .pdfdocument or printer friendly versionof the patient list.
• Export – Exports the Patient List toan Excel worksheet.
Patients Tab
1. Tabs: Allows the providers to choosebetween the Patients information andReports.
2. Logout Button: For securitypurposes, logout to protect patientinformation. Not shown, in upper righthand corner.
3. Search: Allows providers to search bythe patient’s name, Medicaid, Medicareor Marketplace ID number.
4. Filters and Export Features: Allowsusers to view all patients or filter bymultiple criteria. The users will alsohave the ability to create a PDFdocument or export a detailed patientprofile.
4a. Manage Filters: Filter thepatient list by business rules,subgroups, and physicians.
5. Timeframe: Provides the date whenclaims have been posted, followed bya link to contact for questions orconcerns.
Search Results
Patient Demographics
High Priority Care Opportunities: Displays acount of care opportunities deemed to be of thehighest importance.
Risk Score: Identifies the likelihood that thepatient will incur cost and services in the next 12months when compared to an average patient. Anaverage patient has a health of 1.0. Higher valuesindicate the patient is more likely to need servicesin the future.
IP Probability: A percentage indicating thelikelihood that a patient will have one or moreinpatient confinements in the next 12 months.
Inpatient Stays in the Last 30 Days: A metric thatcaptures the number of distinct inpatienthospitalizations in the last 30 days based onprocessed claims.
Emergency Room Visits within 90 Days: A metricthat shows the number of distinct emergency roomvisits within 90 days based on processed claims.
Subgroup: Medicaid, Medicare, or Marketplace.
Physician: Displays the provider’s name andcredentials.
Patient Profile1. Member Demographics: Displays
information about the member.
2. All Care Opportunities: The defaultlanding page for patient details. Displayscare opportunities or measures that indicateif a patient has or has not receivedtreatment for a health condition.
3. Diagnosis: Shows primary and secondarydiagnoses from claims data.
4. Procedures: Shows patient proceduresassociated with primary and secondarydiagnoses.
5. Medications: Displays a list of medicationsprescribed to the patient.
6. Lab/Observational: Shows lab values,interpretations, and trends.
7. Care Team: Allows users to view thepatient’s providers. Providers are labeledas Managing Doctor or Other Doctor.
Reports
Quality Measure Report
Monitor Quality Measures Report
• Users are able to view reports by selected grouping and filteringoptions.
Provider Analytics
Provider AnalyticsWhat is Provider Analytics?
Provider Analytics is an intelligent health platform that enables providers to make better-informeddecisions about healthcare costs and quality metrics using standardized cost, utilization and qualitydata.
Provider Analytics provides 6 dashboards including: cost, utilization and quality to help providersunderstand trend performance in key areas where they may have the opportunity to impact and improvehealth outcomes, better support patient care and provider performance in value-based arrangements.
Dashboard views:Key Performance Indicators (summary): high level summary statistics to help providers identifyspecific care management opportunities
Cost and Utilization: categorization and trending of costs and utilization of services by disease categoryand type of service
Emergency Room: cost and trending of emergency room utilization and identification of potentiallypreventable visits
Pharmacy: comparison and trending of generic vs brand cost and utilization
Quality: identification and trending of quality performance and gaps in care
VBC: Houses quarterly reports that include performance summaries and identifies number of membersneeded to meet care gap targets and potential dollars to earn
FeaturesMonthly Quality reports display easy to read gaps-in-care graph
Can be organized by HEDIS measure or provider (assigned provider, notinputted)
Loyalty display shows percentage of members in 5 engagement categories todetermine how frequently members are seeing their assigned PCP
Gaps Member Detail report allows users to create a custom report with memberdetail including: NPI, HEDIS measure, member compliance, and loyalty
Tax Identification Number (TIN) to Plan Comparison graph that displays the TIN’scompliant rate compared to the rest of the plan
Provider Analytics
Benefits:The formatting is improved, user-friendly and intuitive
Quarterly reports are available on the VBC tab
Prioritizes measures based on performance to help providers focus onmoving the needle on performance in order to optimize payout
Provides measure anchor dates which helps providers prioritize time-sensitive care gaps
Provides the number of gaps needed to close in order to meet the highestperformance target
Reports exportable to Excel
Provides a monthly view of performance against target and shows currentand potential payout.
Provider Analytics
Accessing Provider Analytics
To navigate to the Qualityand Pay for PerformanceDashboards:
1. From the Provider Portal click onthe Provider Analytics link to bedirected to the launch page.
2. Select one of the followingdashboards to get started:
• Summary
• Cost & Utilization
• Emergency Room
• Pharmacy
• Quality
• Value-Based Contract
Summary
Cost Utilization
Provider Analytics: Quality1. Quality Gaps in Care: Shows the
compliant count and rate by HEDISmeasure or provider.
2. Loyalty: Displays the number ofmembers in each of the fiveengagement categories to determinehow frequently the members arevisiting their assigned PCP. The fivecategories are PCP Exclusive,Multiple PCP, Other Exclusive, NoPCP Claims, and No Claims.
3. Tax Identification Number (TIN) toPlan Comparison: Displays the TIN’saverage compliant rate and the plan’scompliant rate as a percentage.
4. Gaps Member Detail: The build areport feature allows users to create acustom report with member detailincluding line of business, NPI, HEDISmeasure, HEDIS sub-measure,member compliance, and loyalty.
Provider Analytics: Value-BaseContract
Summary Tab: Shows the earnedand paid amount year to date,outlines the maximum, earned, andunearned bonus amounts in figuresand graphical form. The summaryincludes a measures list that displaysthe score, compliant and qualifiedcounts, targets, maximum target gap,and bonus amount.
Detail Tab: Outlines the number ofmembers needed to reach themaximum target. The selected viewsinclude members needed or dollarsmissed.
– Provider Information: Includes theparent TIN, model, member months,member panel, report period, andcontract period.
– Other Information: The user has theoption to view an affiliated TIN,product list, or definitions found in thereport.
Messaging
Secure MessagingContents of a Secure Message
• Select Subject and if applicable Member ID and Date of Birth along withyour message then click Send
• A confirmation message appears that your message successfully sent
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MHS Provider Relations Team
Questions?
