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MHS
UPDATES
0118.PR.P.PP.2 2/18
Agenda
Therapy Guidelines
Emergency Room Physician Reimbursement
Durable Medical Equipment
HIP Waiver
Provider Updates Using the MHS Website
Member Management Forms
Patient Analytics Tool
My Health Direct
Claim Submission and Appeals Timeframes
Questions
Therapy Services – Speech,
Occupational, Physical
Therapy
Therapy Services - (Speech,
Occupational, Physical Therapy)
10/1/17 authorization is no longer required
Must follow billing guidelines (GP, GN, GO modifiers)
National Imaging Associates, Inc. (NIA) will conduct
retrospective review to evaluate medical necessity
• If requested, medical records can be uploaded to
RadMD.com or faxed to NIA at 1-800-784-6864
• Medical necessity appeals will be conducted by NIA
• Follow steps outlined in denial notification
• NIA Customer Care Associates are available to assist
providers at 1-800-424-5391
Emergency Room Physician
Reimbursement
Emergency Room Physician
Reimbursement
Effective February 1, 2018, MHS will provide reimbursement rates consistent with the complexity or severity of services rendered in the emergency room. This may result in lower levels of reimbursement for conditions charged at Level 4/Level 5 procedure codes.
Emergency Room Physician
Reimbursement
When a claim comes in with a Level 4/Level 5 ER visit and the final discharge diagnosis appearing on the bill indicates a lower level of complexity or severity, MHS will auto-adjudicate the claim to reimburse providers at a Level 3 (99283) reimbursement rate.
Providers retain the right to appeal by providing evidence for medical complexity of procedures performed
Durable & Home Medical
Equipment
Durable & Home Medical
Equipment
Members and referring providers do not need to search for a DME
provider or provider of medical supplies to service their needs.
Order is submitted directly to MHS, coordinated by Medline and
delivered to the member.
Availability via Medline’s web portal to submit orders and track
delivery.
Prior authorization required by the ordering physician for all non-
participating DME providers.
Does not apply to items provided by and billed by physician office
Exclusions applicable to specific hospital based DME/HME vendors
Durable & Home Medical
Equipment
Requests should be initiated via MHS secure portal
• Web Portal: Simply go to mhsindiana.com, log into the provider portal, and click on “Create Authorization.” Choose DME and you will be directed to the Medline portal for order entry.
• Fax Number: 1-866-346-0911
• Phone Number: 1-844-218-4932
Prior Authorization
Is Prior Authorization Needed?
• MHS website mhsindiana.com
• Quick reference guide
• Non-contracted provider services require prior authorization
HIP Changes
HIP Changes
MCE Selection Period (November 1 –December 15)
Benefit Period vs Eligibility Year
Redetermination
POWER Account Contribution Tier Payments
Tobacco Surcharge (Effective 1/1/2019)
Emergency Room Co-Pays
Chiropractic Benefits added for HIP Plus
HIP Maternity
HIP Changes
Additional Information can be found on indianamedicaid.com on IHCP Bulletin BT201776
Provider Demographic Updates
17
Provider Demographic Updates
Providers can utilize the Demographic Update Tool to update below information.
Address Changes
Demographic Changes
Update Member Assignment Limitations
Term an Existing Provider
Make a Change to an IRS Number or NPI Number
Provider Demographic Updates
Member Management Forms
Member Management Forms
Member Management Forms are now submitted via our Secure Web Portal and is listed under Quick Links as Member Management Forms.
You must be signed in the MHS Secure Web Portal to complete and submit these forms.
Member Management Forms
You will be able to submit Member Disenrollment and submit for Full Panel Add-Ons for Full Panels or for Panels that have been placed on hold.
Member Management Forms
Member Management Forms
Member Management Forms
Patient Analytic Tool
Accessing Patient Analytics
When logging into Patient Analytics, the
user is presented with the Patients tab as
the main landing page. Across the top of
the screen are the following buttons:
• View All Patients – This button will remove
any filter options and display all patients
for which the user has access
• Filter Patients – By selecting this button,
an info window generates allowing the
user to select patients that fit a specific
criteria
Manage Filters: Filter the patient list
by business rules, subgroups, and
Physicians.
• Create PDF – Generate a .pdf document
or printer friendly version of the patient list
• Export – Exports the Patient List to an
Excel worksheet
Patients Tab
1. Tabs: Allows the providers to choose
between the Patients information and
Reports
2. Logout Button: For security
purposes, logout to protect patient
information. Not shown, in upper right
hand corner
3. Search: Allows providers to search by
the patient’s name, Medicaid, Medicare
or Marketplace ID number
4. Filters and Export Features: Allows
users to view all patients or filter by
multiple criteria. The users will also
have the ability to create a PDF
document or export a detailed patient
profile
4a. Manage Filters: Filter the
patient list by business rules,
subgroups, and physicians
5. Timeframe: Provides the date when
claims have been posted, followed by
a link to contact for questions or
concerns
Search Results
Patient Demographics
High Priority Care Opportunities: Displays a
count of care opportunities deemed to be of the
highest importance
Risk Score: Identifies the likelihood that the
patient will incur cost and services in the next 12
months when compared to an average patient. An
average patient has a health of 1.0. Higher values
indicate the patient is more likely to need services
in the future
IP Probability: A percentage indicating the
likelihood that a patient will have one or more
inpatient confinements in the next 12 months
Inpatient Stays in the Last 30 Days: A metric that
captures the number of distinct inpatient
hospitalizations in the last 30 days based on
processed claims
Emergency Room Visits within 90 Days: A metric
that shows the number of distinct emergency room
visits within 90 days based on processed claims
Subgroup: Medicaid, Medicare, or Marketplace
Physician: Displays the provider’s name and
credentials
Patient Profile
1. Member Demographics: Displays
information about the member
2. All Care Opportunities: The default
landing page for patient details. Displays
care opportunities or measures that indicate
if a patient has or has not received
treatment for a health condition
3. Diagnosis: Shows primary and secondary
diagnoses from claims data
4. Procedures: Shows patient procedures
associated with primary and secondary
diagnoses
5. Medications: Displays a list of medications
prescribed to the patient
6. Lab/Observational: Shows lab values,
interpretations, and trends
7. Care Team: Allows users to view the
patient’s providers. Providers are labeled
as Managing Doctor or Other Doctor
Reports
Quality Measure Report
Monitor Quality Measures Report
• Users are able to view reports by selected grouping and filtering options
MyHealthDirect
MyHealthDirect
Claim Submission and Appeals
Timeframes
Claim Submission and Appeals
Timeframes
Claims must be received by MHS within 90 calendar days of the date of service if Contracted Provider.
Claim Corrections, Claim Appeals and Disputes must be received by MHS within 67 calendar days of the MHS EOP. (Requests received after day 67 will not be considered)
Providers must follow the dispute process.
MHS Provider Relations Team
Candace ErvinEnvolve Dental Indiana Provider
Relations 1-877-647-4848 ext. 20187 [email protected]
Chad Pratt Provider Relations Specialist –
Northeast Region1-877-647-4848 ext. 20454 [email protected]
Tawanna DanzieProvider Relations Specialist –
Northwest Region1-877-647-4848 ext. 20022 [email protected]
Jennifer GarnerProvider Relations Specialist –
Southeast Region1-877-647-4848 ext. 20149 [email protected]
Taneya Wagaman Provider Relations Specialist –
Central Region1-877-647-4848 ext. 20202 [email protected]
Katherine Gibson Provider Relations Specialist –
North Central Region1-877-647-4848 ext. 20959 [email protected]
Esther CervantesProvider Relations Specialist –
South West Region1-877-647-4848 ext. 20947
Estherling.A.PimentelCervantes@m
hsindiana.com
Mary Schermer
Behavioral Health Provider
Relations Specialist - West
Region
1-877-647-4848 ext. 20269 [email protected]
LaKisha Browder
Behavioral Health Provider
Relations Specialist - East
Region
1-877-647-4848 ext. 20224 [email protected]
Provider Network Territories
Behavioral Health Provider
Network Territories
What You Learned Today
Therapy Guidelines
Emergency Room Physician Reimbursement
Durable Medical Equipment
HIP Waiver
Provider Updates Using the MHS Website
Member Management Forms
Patient Analytics Tool
MyHealthDirect
Claim Submission and Appeals Timeframes
Questions?
42
