MyCare Ohio Skilled Nursing Facility Orientation

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MyCare Ohio Skilled Nursing Facility Orientation. Demonstration/Pilot Area. 2. Health Plan Options. 3. Implementation Timeline. 4. 114,000 members in 29 counties are eligible for the MyCare Ohio program. This includes: Individuals 18 years and older - PowerPoint PPT Presentation


PowerPoint Presentation

MyCare OhioSkilled Nursing Facility Orientation


2Demonstration/Pilot Area

3Health Plan Options

4Implementation Timeline

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

#Program ExclusionsThose who are not eligible for MyCare Ohio enrollment:

Individuals under age 18 yearsIndividuals with an ICF/IDD level of care served either in an ICF/ID facility or on a waiverIndividuals who are eligible for Medicaid through a delayed spend-downIndividuals with third party insurance

#Opt IN Enrollees Full duals with Buckeye

Medicare and Medicaid benefits through BuckeyeMedicare option to change plans monthlyIf member selects another MyCare MCP will be enrolled as a full dual with the new planIf 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


Opt IN ID Card (Medicare & Medicaid)#Opt OUT Enrollees Medicaid as Secondary Coverage with Buckeye

Medicaid benefits only through BuckeyeOption to change Managed Care Plans during initial 90 days of enrollmentLocked in for remainder of benefit year until annual open enrollmentMedicare benefits through other non MyCare payor including Fee for Service

Secondary claims to be submitted to Buckeye. Will be adjudicated as secondary payor


Opt OUT ID Card (Medicaid Only)

#Service PackagesServices included:

Medical benefitsBehavioral health benefitsHome & Community Based ServicesLong Term CarePharmacyDental Vision

#There are three different Service Packages available under the Integrated Care Program. The first began on May 1st, 2011. This included medical, behavioral, pharmacy, dental and vision services. Service Package II will include Long Term Care, Supportive Living, and waiver services. This will be rolling out in 2013. Service Package III includes services for members with developmental disabilities. The roll out date of this service package is to be determined. 11e ServicesMyCare Ohio Waiver includes:Ohio Home Care WaiverTransitions II Carve-Out WaiverPassport WaiverChoices WaiverAssisted Living Waiver

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

#Home and Community Based services are for individuals that are on a waiver. Waivers are designed to help members stay out of long term care facilities, and live independently in the community. The waivers that are included in Service Package II are (read bullet points).12Determining EligibilityWaiver Eligibility will be determined by government agenciesDepartment on AgingCareStar or other vendor

Level of care assessment evaluates the members:Ability to perform the activities of daily livingMental acuityLevel of impairmentLevel of need

Members 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

#In order to qualify for a waiver service, members must be determined eligible. This is not done by IlliniCare, but is done by state agencies including the Department on Aging and the Department of Rehabilitative Services. They use an assessment tool called the Determination of Need, or DON. This assesses the members ability to preform the activities of daily living, mental status, as well as the level of impairment and the level of need. The members DON score will determine what services the member can receive. Members also have to choose to receive services. They do not have to use the services made available to them. 13Transitions of Care Nursing FacilityNF services: Provider will be retained at current rate for the life of Demonstration (42 months).

#Transitions of Care - ExceptionsDuring the transition period, change from the existing services or provider can occur in any of the following circumstances:

Consumer requests a change Significant change in consumers status Provider gives appropriate notice of intent to discontinue services to a consumer Provider performance issues are identified that affect an individuals 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#

Care Manager (Accountable Point of Contact)Accountable point of contact for the Integrated Care TeamRegistered Nurses, Social Workers and Counselors. Program CoordinatorMixture 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 MembersCommunity Health WorkerProvides team support, and reaches out to members with health and preventive care informationWaiver Service CoordinatorFocuses 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+.#16Provider Value#Timely and accurate claims payment (clean claims) processed within 7-8 days of receipt75% of claims are paid within 7-10 days of receipt99% of claims are paid within 30 daysLocal dedicated resources: Care coordinators serve as an extension of physician officesEducation of providers and support staff through orientationsProvider participation on health plan committees and boardsMinimal referral requirements for physician servicesElectronic and web-based claims submissionWeb based tools for administrative functions

Value That Centene Brings to Providers

#Through our main website, providers can access:Provider NewslettersProvider and Billing ManualsProvider DirectoryAnnouncementsQuick Reference GuidesBenefit Summaries for ConsumersOnline FormsLogon to and become a registered providerProvider Portal @

#On our secure portal, providers can:

Verify eligibility and benefitsView provider eligibility listSubmit and check status of claims Review payment historySecure Contact Us

Registration is free and easy.These services can also be handled by Buckeye Provider Services@ 866-296-8731

#Submitting Claims to Buckeye#What Requires Prior Authorization?ALL SNF and LTC services require prior authorizationNew Services:Services will be based on the members 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 365 days.HCBS Care Coordinator will enter prior authorizations for each service into the system. 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 HCBS care coordination team at 866-549-8289. All out of network non-emergent services and providers require prior authorization.

#Claim ServicesTimely Filing Guidelines365 Days from the date of service180 Days if retro eligibility is an issue180 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 ClaimsProviders may submit to the following addresses:Buckeye Community Health PlanAttn: ClaimsP.O. Box 3060Farmington, MO 63640(866)-329-4701Corrected Claims, and Requests for Payment ReconsiderationProviders may submit to the following addresses:

Buckeye Community Health PlanMyCare Ohio Claim ReconsiderationP.O. Box 4000Farmington, MO 63640

#Program ExclusionsClaim Submission and ReimbursementAuthorization 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.

#Program ExclusionsBad 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 methodologyServices 5/1/14 through 9/30/14 76% of bad debtServices 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.

#Claim ServicesCLAIM SUBMISSION OPTIONSElectronic Claims Submission EDIMore efficient, fewer errors Faster reimbursement 5-7 days from submissionRequires EDI vendor or clearinghouse agreement

Buckeye Provider Portal Requires registration and username/passwordVery efficient; fewer errorsNo cost to providerFaster reimbursement 5-7 days from submission

Paper Claim SubmissionLess efficientRequires original claim formsAverage reimbursement 10-14 days from submission of clean claim

#EDI PartnerPayor ID#Phone #sEmdeon68069(800) 845-6592Gateway68069(800) 987-6720SSI68069(800) 880-3032Smart Data Solutions68069(651) 690-3140Availity68069(800) 282-4548Via the Provider Portal we can also:Receive an ANSI X12N 837 professional, institution or encounter transaction. Portal allows batch\individual claim submissionsGenerate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). Please contact:Buckeye Community Health Planc/o Centene EDI Department1-800-225-2573, extension 25525or by e-mail

#Program ExclusionsAll services must be billed to Buckeye using a 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 180 days from the date of service.Claims must be submitted to the following address:

Buckeye Community Health PlanATTN: Claims 3060Farmington, MO 63640Paper Claim format#Billing Dos and DontsProgram ExclusionsBilling Dos

Submit your claim within 90 days of the date of serviceSubmit on a proper original form CMS 1500Mail to the correct PO Box numberSubmit all claims in a 9 x 12 or larger envelopeType all fields completely and correctlyUse typed black or blue info only at 9-point font or largerInclude all other insurance information (policy holder, carrier name, ID number and address) when applicable

Billing Donts

Submit handwritten claimsUse red ink on claim formsDont circle data on claim formsDont add extraneous information to any claim form fieldDont use highlighter on any claim for fieldDont submit photocopied claim forms (no black and white claim forms)Dont submit carbon copied claim formsDont submit claim forms via fax

#EFT and ERABuckeye partners with PaySpan Health delivering electronic payments (EFTs) and remittance advices (ERAs).FREE to Buckeye ProvidersElectronic deposits for your claim payments Electronic remittance advice presented online.HIPAA Compliant

Provider Benefits with PaySpan HealthReduce accounting expenses Electronic remittance advices can be imported directly into practice management or patient accounting systemsImprove cash flow Electronic payments for faster paymentsMaintain 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 or contact them directly at (877) 331-7154 to obtain a registration code and PIN number.

#Thank you!


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