Embed Size (px)
Citation preview
HMSA New Provider Orientation
HMSA Provider Services Training
September 2018
Agenda
Module 1 - Welcome to HMSA
Module 2 - Tools and Resources
Module 3 - Claims Filing
Module 4 - Programs
2 2/5/2019
Module I – Welcome to HMSA!
3
HMSA – “Who We Are”
How HMSA Supports Providers
Provider Services Specialized Teams
2/5/2019
About HMSA
Nonprofit, Founded in 1938
Member-Focused, Community-Focused
Independent Licensee Blue Cross Blue Shield
National Committee for Quality Assurance (NCQA)
Accreditation
HMSA Foundation – Improve Well-Being of Communities
2/5/2019 4
Access and Affordability
2/5/2019 5
Source: 2017 HMSA Annual Report
Premium Dollar
93 cents of every dollar
collected goes directly to
paying for our members’ care.
How HMSA Supports Providers
Provider Business Operations:
Direct Payment to Participating Providers
Electronic Claims Filing
Electronic Fund Transfer
HHIN – Internet Tool
Web-Based Provider Portal
6
2/5/2019
2/5/2019
HMSA Contact List
Support Oahu Neighbor Islands
Customer Relations - PPO/HMO, Medicare Advantage - Routine Questions, Claims Status &
Benefits
948-6330 1 (800) 790-4672
QUEST Integration Provider Service
948-6486 1 (800) 440-0640
BlueCard Tele-Service - Out of State BCBS Members
948-6280 1 (800) 648-3190
Federal Employee Program (FEP) 948-6281 1 (800) 966-6198
Provider Data Administration - Address, Payee Changes, etc.
952-7847 1 (800) 603-4672 Ext. 7847
2/5/2019 7
HMSA Provider Support
Provider Service Field Associates
Claims Issues Not Resolved Through Customer Relations
Reimbursement Issues
Payment & Medical Policy Coordination
Provider Contracts
2/5/2019 8
HMSA Provider Support
Provider Data Administration
Registering New Providers
Updates to Provider Data Additional Location
Address Changes
Payee Changes
Re-Credentialing
9 2/5/2019
HMSA Provider Support
Provider Research and Correspondence Responds to Written Provider Inquiries
Contracting & Facility Relations Work w/Providers - Contract Language & Terms Facility Contracting Manage Facility Relationships
2/5/2019 10
Module 2 – HMSA Tools & Resources
11
Provider Portal (Newsletters, Training Modules, etc.) Electronic Support – HHIN (Eligibility, Claims Status, etc.); HMSA Online Care (Tele-Health)
Engagement – Coreo, Sharecare
Preauthorization – HHIN, iExchange, Magellan, eviCore, CVS
2/5/2019
HMSA’s Provider Portal https://hmsa.com/providers
2/5/2019 12
HHIN Hawaii Healthcare Information Network
HMSA’s Secure Provider Website
24/7 Access Member Plan & Benefit Information
HHIN Transactions Include: Eligibility Verification & Plan Benefits
Claim Status
Report to Provider
Preauthorization Requests Thru iExchange
Fee Schedules
Claim Submission Using Direct Data Entry
2/5/2019 13
HMSA’s Online Care ® Connect Via Web or Phone!
Web-Based System Available To Anyone In Hawaii 24/7, 365 Days A Year
Real-Time Healthcare Services Online
Connects Patients w/Healthcare Providers Via Secure Videoconferencing & Web Chat
Confidential & Secure Conversations Data Encrypted - Fully HIPAA & DoD Compliant
2/5/2019 14
HMSA’s Online Care ®
Benefits for Providers
Secure & Confidential Patient Information Kept Secure
E-Prescribing Send Rx Electronically to Pharmacy
Integrated Claims No Copayments /No Additional Claims
Direct Reimbursement Payments Paid Directly Deposited Weekly To Bank Account
Telehealth Now Schedule & Initiate Online Care Visits
2/5/2019 15
Coreo™
Specialized tool to quickly and easily manage patient panels
and performance on quality measures
Supports PCPs participating in Payment Transformation
Integrates claims, EHR, lab and hospital data in a single
platform
Empowers PCPs and their staff to better understand patient
populations and opportunities for improved care
Monitoring Performance on Quality
Measures
Monitoring Provider Panels (Attribution)
19 2/5/2019
Sharecare RealAge Assessment
Commercial Members 18 & Older
Complete Assessment at Least Once During the Measurement Year
How Fast Aging Based on Lifestyle & Medical History
HMSA Members Create Account at https://hmsa.sharecare.com
20 2/5/2019
Sharecare Find a Doctor Tool New!
Enhanced Provider Profile
Comprehensive Platform to Promote Practice & Improve Patient Outcomes
Ability to Add Video/Q&A Content
2/5/2019 21
Precertification/Preauthorization Which Services Require It?
HMSA Medical
QUEST Integration
Medicare Advantage
BlueCard
Note: See “Preauthorization Requests” section on Contact List
2/5/2019 22
Online Preauthorization Requests - HHIN
2/5/2019 23
iExchange (Medical/Surgical/DME)
Secure, Web-Based, Preauthorization Tool
Accessible via HHIN
Managed by HMSA
Available 24/7; Except for Maintenance
Upload Clinical Notes Quickly
Online Status Updates; Save Phone Calls
Recently Added:
Supportive Care (Benefit for Late-Stage Diseases) Inpatient Admission Reviews
2/5/2019 24
Magellan Preauthorization (Formerly National Imaging Associates)
HMSA’s Radiology Management Partner 20+ Years Experience NCQA Certified for Utilization Management
HMSA Retains: Claims Adjudication Functions Oversight Magellan’s Utilization Management
Magellan Preauthorization Not Required For: Emergency Room Observation Inpatient Procedures (exception: scheduled IP spine
surgery requires preauthorization)
2/5/2019 25
Magellan Preauthorization Management
MRI/MRA/MRS
PET Scans
Pacemaker
Lumbar Spine Surgery
Stress Echocardiography
Myocardial Perfusion Imaging
Implantable Cardioverter Defibrillator
CT/CTA
CCTA
MUGA
Cardiac Catheterization
Spinal Interventional Pain Management
Cardiac Resynchronization Therapy Pacemaker
26 2/5/2019
Magellan Preauthorization Clinically Urgent Cases
Cannot Postpone 24 Hours Due to Severe Health Risk for Patient
Dedicated Urgent Phone Line: 1 (866) 842-1776 OR
Log On RadMD – Select “Clinically Urgent Indication”
Must Provide Case Information & Reason Clinically Urgent for Automatic Approval
Receive Preauthorization Number Before Call Ends
2/5/2019 27
eviCore Preauthorization Rehabilitation Services
HMSA Covers…
Medically Necessary Visits Only
Medical Necessity Determined by Ongoing Patient Assessment
Not “What the Doctor Ordered” But What Patient Needs to Return to Basic Function
Note: See “Preauthorization Requests” section on Contact List
2/5/2019 28
CVS Preauthorization of Specialty Drugs
Manages Preauthorization Of:
Medical Specialty Drugs –
Injectable/Infusible
Pharmacy Specialty Drugs –
Oral/Inhaled
2/5/2019 29
CVS Preauthorization Medical Specialty Drugs
Contact List Link to Medical Specialty Drugs Requiring Precertification NovoLogix Training Video
Submit online (NovoLogix) Accessed Through HHIN View Status of Requests
Submit Via Fax
Request Via Phone
30 2/5/2019
CVS Preauthorization
Pharmacy Specialty Drugs
Review HMSA Drug Formularies for Drugs Requiring Precertification
Request Via Phone or Fax
2/5/2019 31
Beacon Health Options Behavioral Health
Concurrent review/precertification of:
Acute Inpatient services
Residential Treatment services
Partial Hospitalization Program
Methadone Treatment for QUEST Integration Members
Intensive Outpatient Program
2/5/2019 32
Beacon Health Options Behavioral Health
Also provides:
Quality Improvement – member and provider interventions
Case Management – Intensive case management, care coordination, case consultation
Benefit predetermination
PCP Toolkit
Psychiatric Decision Support
Behavioral Health Referrals
2/5/2019 33
Module 3 – HMSA Claims Filing
34
Check Eligibility
Interactive Claims Filing Tool
Claims Filing Requirements
Claims Filing “Tips for Success”
2/5/2019
HHIN
Membership Connection
QUEST Integration Provider Service
Blue Card
Federal Employee Program (FEP)
Verify Eligibility For Every Encounter
2/5/2019 35
Professional Claims – CMS 1500
Provider Portal Basic Claims Filing – CMS 1500 Claims Form
CMS 1500 Interactive Training Tool Color Coded Blocks
Short Description - Click Block Number
Must Use Internet Explorer Web Browser
Links Listed on HMSA Contact List
2/5/2019 36
CMS 1500 Claims Filing Guidelines
Use Current Original Claim Form
No Photocopies – For Original Claim Submissions
List of Form Vendors - HMSA Contact List
Double Check: Member Numbers, Procedure Codes & Diagnosis Codes
File Claims Promptly – Within 1 Year From Date of Service
AVOID Delays - Use Correct HMSA 10-Digit Provider Number for Practice Location
37 2/5/2019
CMS 1500 Claims Filing Tips
No Highlighters or White-Out Negatively Affects Claim Scanning Process
Ensure Required & Conditionally Required Fields are Complete
Type or Computer Generate Using Minimum Size 10 Font
Use Dark Ink Replace Ink/Toner As Type Begins Fading
38 2/5/2019
Electronic Data Interchange (EDI)
Communication System That Allows Electronic Data Exchange Between Business Partners
Electronic Transactions HMSA Supports:
Electronic Claims Submission (837)
Electronic Eligibility Verification (270, 271)
Electronic Claim status (276)
Electronic Remittance Advice (835)
Electronic Report to Provider (eRTP)
Electronic Funds Transfer (EFT)
2/5/2019 39
Module 4 – HMSA Programs
40
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
QUEST Integration
Medicare Advantage
2/5/2019
Module 4 - HMSA Programs Cont.
41
BlueCard
Primary Care Payment Transformation
Primary Care Performance Measures
2/5/2019
PREFERRED PROVIDER ORGANIZATION (PPO) Member Sees Doctor of Their Choice
No Referral Necessary for Specialist Care
Select Participating Providers for Lowest Out-Of-Pocket Cost
If Non-Participating Provider Renders Services
Member Pays Provider in Full
HMSA’s Benefit Payment Made to Patient
2/5/2019 42
HEALTH MAINTENANCE ORGANIZATION (HMO)
PCP Coordinates Care
Most Services Must be Referred by PCP
Referrals https://hmsa.com/help-center/seeing-specialists-and-other-providers-when-you-are-an-hmo-member/
2/5/2019 43
Members Select a HMO Health Center and a Primary Care Provider (PCP) within that Health Center
HMO Membership Card
Member’s Name
Member’s ID Number
HMO Health Center
PCP’s Name
Coverage Code (Benefits)
2/5/2019 44
HMO – Referral Hierarchy
1 • Provider in Patient’s HMO Health Center
2 • Other HMSA HMO Participating Provider
3 • HMSA Participating Provider
4
• Non-Participating HMSA Provider (If Approved by HMSA Administrative Review)
2/5/2019 45
HMO-Referrals
2/5/2019 46
• Services Not Referred By PCP - Member Pays Full Amount
• No Referral Required: • Emergencies • Urgent Care • OP Mental Health • Vision Exams • Annual Gyn exam (by
HMO Referral provider)
HMSA Care Management Support
Applies to PPO, HMO & Medicare Advantage Plans
Preventive Care Pathway Management
Episode and Disease Condition Care Pathway Management
Late-Stage Care Management
Event-Driven Interventions
Hospital Discharge follow-up
Emergency room follow-up
Complex Case Management
2/5/2019 47
HMSA QUEST INTEGRATION PLAN Quest Integration Members
HMSA’s QUEST Integration Members
Non-ABD
(Does Not Include Aged,
Blind or Members with
Disabilities)
ABD
(Aged, Blind or Members with
Disabilities)
ABD and LTSS
(Aged, Blind or Members with
Disabilities Who Have Additional LTSS Benefits)
48 2/5/2019
Verifying Member Eligibility
49 2/5/2019
QUEST Integration Service Coordination
Person-Centered Service Delivery System
Ensures Needs Met For Those: With Special Health Care Needs Receiving Long Term Services & Support (LTSS)
Service Coordinators Assist: Coordinating Services w/Other Agencies, Programs,
& Community Services Relieving Provider’s Staff
Service Coordination Referral – call QUEST Integration Provider Service
50 2/5/2019
QUEST Integration Service Coordination Process
Patient Referred For Service Coordination
Service Coordinators Meet With Patient
Assessment Done - Determine Patient’s Needs
Plan Created & Sent to Patient & PCP
Service Coordinator Arranges Services for Patient
51 2/5/2019
QUEST Integration Member Billing
No Balance Billing
Providers Accept QI Payments as Payment in Full
Cannot Charge QI Members No-Show Fees
QI Members Can Be Billed For: Non-Covered Services or Upgraded Services
(Member-Signed Financial Agreement Statement Required)
Services Rendered Before/After Eligibility
Primary Insurance Payments Sent to Member or Plan Subscriber by Other Insurance
Cost Shares
52 2/5/2019
HMSA’s Medicare Advantage Plans
Oahu Plans Neighbor Island Plans
Akamai Advantage® Complete or Complete Plus (PPO)
Akamai Advantage® Standard or Standard Plus (PPO)
Essential Advantage (HMO)
2/5/2019 53
All Islands
Akamai Advantage Dual Care
Why Choose Medicare Advantage?
Comprehensive Benefits – All Original Medicare Benefits Plus More
Financial Protection – Maximum Out-of-Pocket Limit
Predictable Costs
2/5/2019 54
Essential Advantage (HMO)
HMSA’s Medicare Advantage Managed Care (HMO) Plan
Doctors In Hawaii Pacific Health Network
Available On Oahu Only
Lower Cost Option Than Akamai Advantage (PPO) Plans
2/5/2019 55
Akamai Advantage Dual Care Plan
Eligibility - Must Be Eligible Medicare & Medicaid May Be: Qualified Medicare Beneficiary (QMB) Only OR QMB Plus Dual Eligibility Status
May Have: HMSA Akamai Advantage & HMSA QUEST Integration
OR HMSA Akamai Advantage & Another Health Plan’s
QUEST Integration
2/5/2019 56
Akamai Advantage Dual Care Plan
Claims Submission
Primary Plan - Akamai Advantage Dual Care
Secondary Plan – Member’s QUEST Integration Plan
2/5/2019 57
Akamai Advantage Dual Care Membership Card
Plan Name – Front Top Right Corner
No Member Premium - After Low Income Subsidy
58 2/5/2019
Akamai Advantage Dual Care Model of Care
Each Dual Care Member Assigned an HMSA Care Manager:
Access To Medical, Behavioral Health, & Social Services
Care Coordination
Transition of Care Across Health Care Settings, Providers, & Health Services
Improve Health Outcomes
2/5/2019 59
Dual Care Member
Health Risk Assessment
Interdisciplinary Care Team
Individualized Care Plan
Akamai Advantage Dual Care Model of Care
60 2/5/2019
EXCLUDED PROVIDERS
HMSA’s QUEST Integration & Medicare Advantage Plans
2/5/2019 61
Excluded Providers
Individual/Entity Not Allowed to Receive Reimbursement for Providing Medicare/Medicaid Services
Provider Responsible Search Excluded Provider Lists:
Routinely (i.e., monthly) – Confirm Employees or Contractors Not On Any List
Prior To Hiring Staff – Confirm Potential Employees or Contractors Not On Any List
62 2/5/2019
BlueCard Program
Out of State Blue Cross Blue Shield Members Can Obtain Healthcare Benefits From HMSA’s Provider Network
Claims Filed to HMSA
HMSA Sole Contact for Claims Payment, Adjustments, & Issue Resolution
Payment Based on HMSA Eligible Charges
Benefits, Policies, Precertification Determined By Plan Member Enrolled In (i.e. BCBS of Arizona)
2/5/2019 63
BlueCard Program – Identify Members
3-Character Alpha Prefix: Key to Identifying Member’s Plan
Make Copies Front & Back of Membership Cards
Blue Card ID Cards Have Suitcase Logo
2/5/2019 64
BlueCard Program
Eligibility - Providers Submit Electronic Eligibility Inquiry or Call 1-800-676-BLUE (2583)
Preauthorization – Online or by phone - See HMSA Contact List
2/5/2019 65
PRIMARY CARE PROVIDER (PCP) PAYMENT TRANSFORMATION
PCP Engagement and Performance
2/5/2019 66
Payment Transformation Key Goals
Māhie 2020 - Maximize Value to Members, Providers, & Employers
Improve Member Experience & Quality of Care Better Health & Well-Being
PCPs Practice Medicine Their Way
Achieve Triple Aim: Access, Cost, & Quality
Build New Value-Based Sustainable Model of Care
2/5/2019 67
Payment Transformation Key Concepts
Move From Volume-Based To Value-Based Reimbursement
Alignment w/CMS Initiatives (i.e. MACRA, CPC+, MSSP)
Help PCP Manage Whole Patient Populations & Promote Health & Wellness
Per Member Per Month (PMPM) Payments for PCP’s Attributed Patients
68 2/5/2019
Global Base PMPM Payment Included Services
All PCP Services Including:
Office Visits, Newborn Care
Procedures
Labs, EKGs, TB & Other Tests
Injectable Drugs Administered By PCP
Administration Of Vaccine
Vaccine Cost Will be Paid FFS
69 2/5/2019
Services Not Included in Global Payment PMPM Calculation
Services not included in PMPM; Still Paid FFS:
All Immunizations
Member Claims For: BCBSA Federal Employee Plan (FEP)
Other Blue Cross Blue Shield Association Plans
QUEST Integration Aged, Blind & Disabled
70 2/5/2019
PMPM Payment
New PCPs May Not Meet Minimum Member Months Requirements
Will Receive Base PMPM Rate Based On:
Medical Group Rate - If PCP Belongs To Medical Group OR
Network Average Base PMPM Band Rate Based On PCP Type (i.e. Adult, Pediatric)
71 2/5/2019
Primary Care Payment Transformation Requirements
72
Participating Providers Must:
Participate In All HMSA Lines of Business
Be Credentialed As Primary Care Provider (PCP)
Contract w/One Physician Organization
Learn HMSA Payment Transformation on HMSA’s Provider Portal
2/5/2019
PRIMARY CARE PERFORMANCE MEASURES
2/5/2019 73
Global Payment
All PCP Services Including:
Office visits
Procedures
Labs, EKGs, TB & other tests
Injectable drugs administered by PCP
Administration of vaccines
Vaccine cost will be paid FFS
Services Excluded From Global Payment
Services not included in PMPM; still paid FFS:
All Immunization serums
All facility-based services billed with appropriate POS codes
Member claims For:
BCBSA Federal Employee Plan (FEP)
Other Blue Cross Blue Shield Association Plans
QUEST Integration Aged, Blind & Disabled
Performance (Quality) Requirements & Compensation
Signed Payment Transformation Program Amendment to Participating Agreement
Measure Scoring Thresholds
Minimum Threshold = 40% of Max Payment Potential for the Measure
Target Threshold = 100% of Max Payment Potential for the Measure
76 2/5/2019
Mahalo!
2/5/2019 77
Living healthy and enjoying life to the fullest. That’s what we’re striving for.
