MyCare Ohio Skilled Nursing Facility

Orientation

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Demonstration/Pilot Area

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Health Plan Options

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Implementation Timeline

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114,000 members in 29 counties are eligible for the MyCare Ohio program. This includes:

• Individuals 18 years and older

• Members residing in the MyCare Ohio service area • Individuals entitled to benefits under Medicare Part

A enrolled under Medicare Parts B and D, and receive full Medicaid benefits.

• Adults with disabilities and persons 65 years and older

• Persons with serious mental illness

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Program Exclusions

Those who are not eligible for MyCare Ohio enrollment:

• Individuals under age 18 years

• Individuals residing outside the MyCare Ohio service area

• Individuals with an ICF/IDD level of care served either in an ICF/ID facility or on a waiver

• Individuals who are eligible for Medicaid through a delayed spend-down

• Individuals with third party insurance

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Opt IN Enrollees

Full duals with Buckeye

Medicare and Medicaid benefits through Buckeye – Medicare – option to change plans monthly – If member selects another MyCare MCP will be

enrolled as a full dual with the new plan – If member selects a plan outside the MyCare network,

member retains Medicaid benefits with Buckeye. One claim submitted to Buckeye.

– Will be adjudicated for both Medicare and Medicaid with one submission.

– Will generate two payments

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Opt IN ID Card (Medicare & Medicaid)

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Opt OUT Enrollees

Medicaid as Secondary Coverage with Buckeye

Medicaid benefits only through Buckeye – Option to change Managed Care Plans during initial 90

days of enrollment – Locked in for remainder of benefit year until annual

open enrollment – Medicare benefits through other non MyCare payor

including Fee for Service Secondary claims to be submitted to Buckeye.

– Will be adjudicated as secondary payor

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Opt OUT ID Card (Medicaid Only)

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Service Packages

Services included: Medical benefits Behavioral health benefits Home & Community Based Services Long Term Care Pharmacy Dental Vision

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e Services

MyCare Ohio Waiver includes: Ohio Home Care Waiver Transitions II Carve-Out Waiver Passport Waiver Choices Waiver Assisted Living Waiver

Enrollees who are eligible for waiver will have access to all of the services included in the MyCare Ohio Waiver.

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Determining Eligibility Waiver Eligibility will be determined by

government agencies Department on Aging CareStar or other vendor

Level of care assessment evaluates the member’s: Ability to perform the activities of daily

living Mental acuity Level of impairment Level of need

Member’s level of care determination will determine which services the member

is eligible to receive. Skilled, Intermediate, Intermediate/Mental Retardation-Developmental Disabilities /

Protective or None

Member has choice to receive services

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Transitions of Care – Nursing Facility

• NF services: – Provider will be retained at current rate for the life of Demonstration

(42 months).

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Transitions of Care - Exceptions

During the transition period, change from the existing services or provider can occur in any of the following circumstances: 1. Consumer requests a change 2. Significant change in consumer’s status 3. Provider gives appropriate notice of intent to discontinue services to a

consumer 4. Provider performance issues are identified that affect an individual’s

health & welfare Plan-initiated change in service provider can only occur after an in-home assessment and development of a plan for the transition to a new provider

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Care Manager (Accountable Point of Contact) Accountable point of contact for the Integrated

Care Team Registered Nurses, Social Workers and

Counselor’s.

Program Coordinator Mixture of licensed/certification professionals.

Focused on the physical, psychological and social welfare of the member.

The Integrated Care Team Works Together with the Member to Find the Best Health Solutions for Members

Community Health Worker Provides team support, and reaches out to members with health and preventive

care information

Waiver Service Coordinator Focuses on Buckeye members that receive services through a home and

community-based services waiver. Partnership with the Area Agency on Aging (AAA) for member age 60+.

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Provider Value

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Timely and accurate claims payment (clean claims) processed

within 7-8 days of receipt

75% of claims are paid within 7-10 days of receipt

99% of claims are paid within 30 days

Local dedicated resources: Care coordinators serve as an extension of physician offices

Education of providers and support staff through orientations

Provider participation on health plan committees and boards

Minimal referral requirements for physician services

Electronic and web-based claims submission

Web based tools for administrative functions

Value That Centene Brings to Providers

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Through our main website, providers can access:

Provider Newsletters

Provider and Billing Manuals

Provider Directory

Announcements

Quick Reference Guides

Benefit Summaries for Consumers

Online Forms

Logon to www.bchpohio.com and become a registered provider

Provider Portal @ www.bchpohio.com

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On our secure portal, providers can:

Verify eligibility and benefits View provider eligibility list Submit and check status of

claims Review payment history Secure Contact Us

Registration is free and easy. These services can also be handled by Buckeye Provider Services

@ 866-296-8731

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Submitting Claims to Buckeye

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What Requires Prior Authorization?

ALL SNF and LTC services require prior authorization

New Services: Services will be based on the member’s

care plan. Care Coordinator will be in contact with

both the member and provider. Once services are approved, prior

authorization will be entered into the system by Care Coordinator.

Care Coordinator will contact service providers with a prior authorization number, confirming service can now take place.

Existing Services: Services that are currently in place for

member will remain for the life of the demonstration (42 months) .

Providers will receive a notice from Buckeye explaining transition process, and members identified as currently in facility or LTC.

If you have questions if a service is authorized for the member, contact the MyCare care coordination team at 866-549-8289.

All out of network non-emergent services and providers require prior authorization.

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Claim Services

Timely Filing Guidelines

365 Days from the date of service 180 Days to submit a corrected claim, request a reconsideration of payment, or to file a

claim dispute

*Please refer to our provider or billing manual online for more detailed information*

Paper Claims Providers may submit to the following addresses:

Buckeye Community Health Plan

Attn: Claims P.O. Box 3060

Farmington, MO 63640 (866)-329-4701

Corrected Claims, and Requests for Payment Reconsideration – Providers may submit to the following addresses:

Buckeye Community Health Plan

MyCare Ohio Claim Reconsideration P.O. Box 4000

Farmington, MO 63640

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Program Exclusions

Claim Submission and Reimbursement

• Authorization is required for all services including bed hold days

• Buckeye will accept standard Medicare and Medicaid billing codes RUGS etc. No payor specific codes required

• Buckeye will reimburse based upon current Medicare & Medicaid fee schedules including bed hold days

• Bed hold days policy will be consistent with current regulatory policies and rates (Buckeye has current rates including occupancy variances)

• Inpatient hospice – Buckeye will reimburse hospice provider who will in turn reimburse SNF for room & board.

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Program Exclusions

Bad Debt Policy

• Bad Debt – applies to member liability for skilled level of care days 21-100 of single stay

• Buckeye will not require SNF to file annual bad debt report • Buckeye will aggregate bad debt detail from adjudicated

claims by facility

• Buckeye will review and determine liability using the following methodology

Services 5/1/14 through 9/30/14 – 76% of bad debt Services 10/1/4 through 12/31/14 – 65% of bad debt • Reimbursement will be paid as a lump sum payment in the 2nd

quarter of each year.

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Claim Services

CLAIM SUBMISSION OPTIONS Electronic Claims Submission – EDI • More efficient, fewer errors • Faster reimbursement 5-7 days from submission • Requires EDI vendor or clearinghouse agreement

Buckeye Provider Portal • Requires registration and username/password • Very efficient; fewer errors • No cost to provider • Faster reimbursement 5-7 days from submission

Paper Claim Submission • Less efficient • Requires original claim forms • Average reimbursement 10-14 days from submission of clean claim

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EDI Partner Payor ID# Phone #’s

Emdeon 68069 (800) 845-6592

Gateway 68069 (800) 987-6720

SSI 68069 (800) 880-3032

Smart Data Solutions 68069 (651) 690-3140

Availity 68069 (800) 282-4548

Via the Provider Portal we can also: Receive an ANSI X12N 837 professional, institution or encounter transaction. Portal

allows batch\individual claim submissions Generate an ANSI X12N 835 electronic remittance advice known as an Explanation of

Payment (EOP). Please contact:

Buckeye Community Health Plan c/o Centene EDI Department

1-800-225-2573, extension 25525 or by e-mail at:

EDIBA@centene.com

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Program Exclusions

All services must be billed to Buckeye using either a UB04 or CMS 1500 form.

Forms cannot be filled out by hand. Must be completed using computer

software or a typewriter.

All claims must be submitted within 365 days from the date of service.

Claims must be submitted to the following address:

Buckeye Community Health Plan

ATTN: Claims 3060 Farmington, MO 63640

Paper Claim format

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Billing – Dos and Don’ts

Program Exclusions

Billing – Dos

Submit your claim within 365 days of the date of service

Submit on a proper original form – UB04 or CMS 1500

Mail to the correct PO Box number

Submit all claims in a 9” x 12” or larger envelope

Type all fields completely and correctly

Use typed black or blue info only at 9-point font or larger

Include all other insurance information (policy holder, carrier name, ID number and address) when applicable

Billing – Don’ts

Submit handwritten claims

Use red ink on claim forms

Don’t circle data on claim forms

Don’t add extraneous information to any claim form field

Don’t use highlighter on any claim for field

Don’t submit photocopied claim forms (no black and white claim forms)

Don’t submit carbon copied claim forms

Don’t submit claim forms via fax

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EFT and ERA Buckeye partners with PaySpan Health delivering electronic payments (EFTs) and

remittance advices (ERAs). FREE to Buckeye Providers Electronic deposits for your claim payments Electronic remittance advice presented online. HIPAA Compliant

Provider Benefits with PaySpan Health

Reduce accounting expenses – Electronic remittance advices can be imported directly into practice management or patient accounting systems

Improve cash flow – Electronic payments for faster payments Maintain control over bank accounts – You keep TOTAL control over the destination of

claim payment funds. Multiple practices and accounts are supported. Match payments to advice quickly – You can associate electronic payments with

electronic remittance advices quickly and easily. Manage multiple Payers – Reuse enrollment information to connect with multiple

Payers. Assign different Payers to different bank accounts, as desired.

For more information visit www.payspanhealth.com or contact them directly at (877) 331-7154 to obtain a registration code and PIN

number.

Thank you!