SutterSelect Administrative Manual - UMR

SutterSelect Administrative ManualAPRIL 2020

SutterSelect Administrative Manual | i

This SutterSelect Administrative Manual has been prepared as a resource for providers who are caring for members of SutterSelect-administered health plans. The Manual includes information about requesting prior certification, how to submit claims, and a guide to using the SutterSelect Provider website. Please refer to the Table of Contents for a complete listing of the sections enclosed in this Manual. This Manual may be updated as needed. Visit our website at sutterselect.tpa.com for the most up-to-date information.

We hope that you find this Manual to be a valuable tool and thank you for helping to deliver quality health care to our members.

Introduction

http://sutterselect.tpa.com

SutterSelect Administrative Manual | ii

Table of Contents

BackgroundSutterSelect Products ..................................................... 1

SutterSelect Provider Network ...................................... 1

SutterSelect Vendors ...................................................... 1

Plan Designs and OptionsEPO Plus ........................................................................... 2

PPO ................................................................................... 2

Sutter Health Options PPO ............................................. 2

Sutter Health National EPO ............................................ 2

Sutter Health National PPO ............................................ 2

EligibilityMember ID Cards ............................................................ 3

Prior CertificationUMR Care Management Certification Requests .......... 4

Request Response .......................................................... 4

Referrals to Specialists ................................................... 4

Responsibility and Member Penalty .............................. 4

Clinical ManagementContact Information ........................................................ 5

Utilization Management .................................................. 5

Case Management .......................................................... 5

Nurse Advice Line ............................................................ 5

ClaimsClaims Submission Guidelines ...................................... 6

Claims Inquiries ............................................................... 7

Claims Submission Address .......................................... 7

Timely Filing ..................................................................... 7

Coordination of Benefits ................................................ 7

Provider Remittance Advice ........................................... 8

RA Field Explanations ..................................................... 9

PharmacyDrug Formulary .............................................................. 10

Medication Reviews ...................................................... 10

Prior Authorization ....................................................... 10

Pharmacy Network ........................................................ 10

Mail Order Pharmacy .................................................... 10

Specialty Pharmacy ...................................................... 10

Behavioral HealthContact Information .......................................................11

Emergency Care .............................................................11

Online Benefits and Claim InquiryHome Page .....................................................................12 Provider Login .................................................................13

Reset Password .............................................................13 Navigating the Website .................................................14

Provider DirectoriesSutterSelect Provider Information ................................15

Quick Reference List ��16

SutterSelect Administrative Manual | 1

Background

SutterSelect is Sutter Health’s self-funded medical plan, developed to take the place of an outside insurance company. Self-funding allows Sutter Health affiliates to deliver consistent medical plan coverage from year to year through a stable, predictable medical plan. In turn, affiliates can design benefit plans, wellness programs and more with employees and their families in mind.

SutterSelect ProductsSutterSelect manages the self-funded medical plans for its customers. Product descriptions are detailed in the Plan Design section on page 2.

SutterSelect Provider NetworkThe SutterSelect provider network includes nearly 7,500 physicians. Additionally, the PPO plan option offers in-network providers from the UnitedHealthcare Choice Plus provider network. The Sutter Health Options PPO plan utilizes the UnitedHealthcare Options PPO network. The Sutter Health National plan utilizes the UnitedHealthcare Choice Plus provider network.

SutterSelect VendorsSutter Health partners with UMR to administer the plan. UMR is the largest employee benefits third-party administrator in the United States and is fully compliant with HIPAA requirements for health data security. The organization serves more than 1,700 clients and more than 2.5 million plan members, processing over 32 million claims each year. UMR is a UnitedHealthcare company.

UMR is the primary contact for provider and member information and assistance with SutterSelect.

Express Scripts® is the pharmacy benefit manager (PBM) for SutterSelect. Express Scripts administers the outpatient pharmacy benefit for our members, including retail, mail order, specialty prescription drugs, and prior authorization/appeal requests for drugs.

Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for SutterSelect plans, excluding Sutter Health Options PPO and Sutter Health National. UMR administers the Mental Health, Substance Abuse and Chemical Dependency benefits for Sutter Health Options PPO and Sutter Health National.

The illustration on the following page provides information about the SutterSelect medical plan options.


Plan Designs and Options

Plan Design Network Costs

EPO Plus In-network benefits only. No coverage for out-of-network services, except emergencies.

Uses the SutterSelect provider network.

The lower cost medical option in terms of monthly premium costs and out-of-pockets costs.

PPO In-network benefits only. No coverage for out-of-network services, except emergencies.

Out-of-pocket costs depend on which tier (and provider network) is accessed.

Able to choose from Tier 1 or Tier 2 each time care is needed.

Network access depends on tier. Choices include SutterSelect provider network (Tier 1), or UnitedHealthcare Choice Plus provider network (Tier 2).

Higher premium cost option due to flexibility in choosing providers. Out-of-pocket expenses are higher under Tier 2.

Sutter Health Options PPO*

In-network and out-of-network benefits.

Out-of-pocket costs depend on which tier is accessed.

Able to choose a different tier each time care is needed.

Network access depends on tier. Choices include the UnitedHealthcare Options PPO provider network (Tier 1), or out-of-network (Tier 2).

Out-of-pocket expenses are higher under Tier 2.

Sutter Health National EPO*

In-network benefits only. No coverage for out-of-network services, except emergencies.

Uses the UnitedHealthcare Choice Plus provider network.

The lower cost medical option in terms of monthly premium costs and out-of-pockets costs.

Sutter Health National PPO*

In-network and out-of- network benefits.

Out-of-pocket costs depend on which tier is accessed.

Able to choose a different tier each time care is needed.

Network access depends on tier. Choices include the UnitedHealthcare Choice Plus provider network (Tier 1), or out-of-network (Tier 2).

Out-of-pocket expenses are higher under Tier 2.

*Plan available only in certain geographic areas.


Eligibility

Back of ID Card

Front of ID Card

Plan name (benefits and coverage may vary

between SutterSelect plans)

UMR is the SutterSelect third party administrator

Provider Customer Service 866-868-2703

sutterselect.tpa.com

• Eligibility and claims • Provider network directory • General inquiries

Member’s ID card will list copay amounts for their

plan option (PPO ID card will show Tier

information)

Call UMR Care Management for prior certification

866-895-3378

Claims submission information EDI # 39026

UMR, PO Box 30541 Salt Lake City, UT 84130-0541

It is important to verify eligibility prior to rendering services. Eligibility rules vary by plan and employer.

Eligibility can be verified by two methods:

• Telephone: Call SutterSelect Customer Service at 866-868-2703. Provider service representatives are available from 7:00 a.m. – 6:00 p.m. Pacific Time, Monday – Friday.

• Online: sutterselect.tpa.com The website provides access to eligibility information 24 hours a day, seven days a week.

Member ID CardsImportant key information and resources are highlighted on the below sample identification card. Cards may differ slightly between plans or plan options.




Prior Certification

To obtain a prior certification determination, call the telephone number listed on the back of the member’s ID card. A list of services requiring prior certification is available under the Prior Certifications button on the provider website homepage. The list is also available in the member’s Health Plan Summary Plan Description (SPD). The SPD for a member can be viewed online by logging on to the provider website at sutterselect.tpa.com. Emergency services may be authorized or certified after care is delivered. Most service requests will require submission of medical records to establish medical necessity. Requests are also reviewed to assure they meet benefit criteria as defined by the Plan.

UMR Care Management Certification Requests • Telephone: Call the number on the back of the member identification card to request certification prior to

the scheduled procedure or service, in order to allow for fact gathering and independent medical review, if necessary. Hours of operation: 7:00 a.m. – 6:00 p.m. Pacific Time, Monday – Friday.

• Fax: Complete the request form (available at sutterselect.tpa.com) and fax with pertinent medical records to 866-754-9428.

• Online: An online request form can be completed at sutterselect.tpa.com. From the “Provider” tab on the left side of the screen select “Get preauthorization” to begin the online process.

Request Response • UMR Care Management will contact your office via telephone or letter with the certification number, if approved.

• If more information is needed, you will be contacted for requested records needed to make the medical necessity determination.

• If the request is denied, you and the member will receive a written notice, including appeal rights and process.

• Request turnaround time frames:

– Concurrent Urgent – 24 to 48 hours

– Pre-service Non-urgent – 15 days

– Pre-service Urgent – 72 hours

– Post-service – 30 days

Referrals to SpecialistsSutterSelect plans offer the ability for members to see any provider within the network, including specialists, without a referral.

Responsibility and Member PenaltyProviders need to submit requests for prior certification on behalf of members. Failure to obtain prior certification will result in a financial penalty for the member. This penalty does not apply to emergency services.

Emergency service is any otherwise covered service that a prudent layperson with an average knowledge of health and medicine would seek if he/she was having serious symptoms and believed that without immediate treatment his/her health would be put in serious danger, his/her bodily functions, organs or part would become seriously damaged or would seriously malfunction.





Clinical Management

SutterSelect contracts with UMR Care Management to provide telephonic clinical management programs. There is no fee to patients or providers for these programs.

Clinical Management services include:

• Utilization Management

• Case Management

• Health Information

• Independent Medical Review

Contact Information • Telephone: Call 866-895-3378, 5:30 a.m. – 7:00 p.m. Pacific Time, Monday – Friday

Utilization ManagementPrior Certification ReviewThe prior certification review process is outlined in the Prior Certification section on page 4.

Concurrent ReviewConcurrent review provides review of medical necessity and level of care for members while they are accessing services in the hospital inpatient, acute rehabilitation, skilled nursing facility or home health setting.

Independent Medical Review (IMR)IMR provides clinical review and determinations for medical necessity by independent clinical reviewers. IMR also manages the appeals process and investigational treatment requests.

Case ManagementCase Management provides authorization, discharge planning and care coordination for complex and high dollar cases including organ/tissue transplants and high risk neonates. Care and benefits are coordinated across the continuum of care.

Nurse Advice LineNurseLineSM is an advice line for members to speak to a registered nurse regarding medical questions, information, education and health-related concerns. It can be accessed 24 hours a day, seven days a week by calling 866-868-1320. A Nurse Chat feature is also available online to members.


Claims

UB Forms • Provider Name, Address and Telephone Number

• Patient Control Number

• Type of Bill

• Federal Tax ID Number

• Statement Covers Period

• Patient’s Name

• Patient’s Address

• Patient’s Birth Date

• Patient’s Gender

• Patient’s Marital Status

• Admission Date/Start of Care

• Admission Hour

• Type of Admission

• Discharge Hour

• Occurrence Span Code and Dates

• Revenue Code

• Revenue/HCPC/CPT Description

• HCPCS Rates

• Service Date

• Service Units

• Total Charges

• Non-Covered Charges

• Payer Identification

• Provider Number

• Release of Information

• Assignments of Benefits Cert. Information

• Prior Payments

• Insured’s Name

• Patient’s Relationship to Insured

• Group Name

• Insurance Group Number

• Employment Status Code

• Principal Diagnosis Code

• Admitting Diagnosis

• Principal Procedure Code and Date

• Attending/Referring Physician NPI

• Provider Representative Signature

• Date

CMS 1500 Forms • Patient’s full name (as printed on Health Plan

ID card)

• Patient’s date of birth

• Policyholder/subscriber, Insurance Name and ID # (include any suffix numbers shown on the card to assist with dependent coverage verification)

• Diagnosis (ICD-10-CM code is required)

• Date(s) of service

• CPT-4 procedure codes with description and modifier, if applicable

• Name should be shown of PA, FNP, rendering provider

• Referring physician’s name, if applicable

• NPI

• Federal Tax ID Number

• Information on other insurance coverage

• Prior certification number, if applicable

• Signature of provider rendering service

Providers are encouraged to submit claims via electronic claims submission. UMR’s EDI Claim Payer ID Number is 39026. If you wish to obtain more information about electronic claims submission, please call UMR at 866-868-2703.

Claims Submission GuidelinesAll paper claims should be submitted on a standard CMS 1500 form or UB, as applicable, and contain the following information:


Claims

Claims InquiriesClaims inquiries should be directed to SutterSelect’s Customer Service Line at 866-868-2703.

Claims Submission AddressUMR PO BOX 30541 SALT LAKE CITY UT 84130-0541

Timely FilingComplete claims are to be submitted to the third-party administrator, UMR, as soon as possible after services are received, but no later than six months from the date of service. A complete claim means that the Plan has all information that is necessary to process the claim. Claims received after the timely filing period has expired will not be considered for payment.

Coordination of Benefits Coordination of benefits (COB) applies whenever a member has health coverage under more than one plan. The purpose of coordinating benefits is to pay for covered expenses, but not to result in total benefits that are greater than the covered expenses incurred.

The order of benefit determination rules determine which plan will pay first (primary plan). The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays for covered expenses after the primary plan has processed the claim, and will reduce the benefits it pays so that the total payment between the primary plan and secondary plan does not exceed the covered expenses incurred. Up to 100 percent of charges incurred may be paid between both plans.


Claims

Provider Remittance AdviceUMR produces weekly check runs. Provider Remittance Advices (RA) and member Explanations of Benefits (EOB) are an integral part of finalization of the patient/physician experience. To help familiarize you with the Remittance Advice that your office will receive, below is a key to explain each field in detail. Claim specific details are also available to you by logging on to sutterselect.tpa.com.

27

26

24 25

21 22

1

2

3

5

4

6

10 14

23

18 19 20

32

8 12 16

29

3130

7 11 159 13 17

28



Claims

RA Field Explanations1. Remittance Advice for Period Ending: Last day of the week for the period covering claims listed on this particular

remittance advice.

2. Identifying Plan Header: Header that identifies organizational plan that patients are associated with. Header includes name, address and return telephone number.

3. Plan Name: The plan name that patients are associated with.

4. Employer Name: The company name the patients are associated with.

5. Provider Name and Address: The provider’s name and address.

6. Federal Tax ID No.: The provider’s federal tax ID number.

7. Dates From/To: Displays the first date of service through the last date of service for the services performed.

8. Service Code: CPT/HCPCS procedure code. (Hospital charges display as 00000.)

9. Charged Amount: Total amount charged per service. (Hospital per diem charges will display on one line with one total charge amount.)

10. Allowed Amount: Total amount of charge considered for payment.

11. Deductible: The portion of the charge applied to the patient’s deductible, if applicable.

12. Co-pay: The portion of the charge applied to the patient’s co-pay, if applicable.

13. Coinsurance: The portion of the charges applied to the patient’s coinsurance, if applicable.

14. Discount Managed Care Adjust: Includes the amount of the provider’s negotiated discount and the amount not allowed per contracted fees. (Difference between the actual charge amount and the contracted allowable amount.)

15. Ineligible: Amount not allowed due to plan provisions.

16. Withheld: The portion of the approved charge that is withheld based upon negotiated rates.

17. OC: Number of occurrences per line of service.

18. ANSI Code: American Standard Institute (ANSI) code provides reason why charges are not allowed.

19. Paid: Amount paid to provider per line of service. (This amount may differ from amounts paid on EOB due to withhold amounts.)

20. Patient Responsibility: Amount the patient is responsible for paying per line of service.

21. Employee: The employee’s name. (Last name, first name, middle initial.)

22. Patient: The patient’s name. (Last name, first name, middle initial.)

23. Cert No�: The employee’s health plan identification number.

24. Account Number: The patient’s account number, submitted by the provider of service.

25. Claim Number: The internal claim control number.

26. Total: Total amounts per column.

27. The Primary Insurance Paid: If applicable, displays the total amount the patient’s primary insurance paid on the claim.

28. Subtotal: Subtotals for columns if pages follow.

29. Provider Total: Total combined amounts for each provider, displayed on final page.

30. CP Number: Banking source code (specific to each customer).

31. Internal Number: Ten-digit internal sequence number matching remittance advice to the appropriate payment check.

32. Plan Administrator Website Address


Pharmacy

Express Scripts is the prescription benefits administrator for SutterSelect plan members. If you have questions or need assistance getting prescriptions for members, you can contact Express Scripts customer service, 24 hours a day, seven days a week via:

• Telephone: Call the Express Scripts customer service center at 877-787-8660

• Online: express-scripts.com/sutterselect

Drug FormularyThe SutterSelect Formulary is a list of drugs covered by the plan. The formulary is developed and maintained by Express Scripts and approved by a committee comprised of independent physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication’s safety, effectiveness and associated clinical outcomes. To find out what drugs are on the formulary, contact Express Scripts via telephone or check their website at express-scripts.com/sutterselect and click the “Formulary” link.

Prior Authorization Contact Express Scripts for prior authorization at 877-787-8660. Providers must submit a prior authorization request through Express Scripts online portal at esrx.com/pa or at covermymeds.com (registration required).

Pharmacy NetworkThe Express Scripts pharmacy network includes most retail pharmacies nationwide. For specific information call the customer service center or use the pharmacy locator link on the website.

• Telephone: Call the Express Scripts customer service center at 877-787-8660

• Online: express-scripts.com/sutterselect

Mail Order PharmacyThe Mail Order Program is administered by Express Scripts. The program allows a member’s prescription products to be ordered through the mail service pharmacy. Using mail order offers plan members the advantage of obtaining up to a 90-day supply of prescription products.

• Telephone: Call 877-787-8660, 7 days a week, 24 hours a day.

Specialty PharmacyAccredo® is Express Scripts specialty pharmacy. Specialty prescription drugs treat complex health conditions, such as hepatitis C and rheumatoid arthritis and may include self-injectables, oral drugs, drugs with special storage needs, and drugs with additional monitoring. Contact Accredo at 877-787-8660 for more information.

http://express-scripts.com/sutterselect


http://esrx.com/PA

http://covermymeds.com



Behavioral Health

Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for the SutterSelect plans, excluding Sutter Health Options PPO and Sutter Health National plans. UMR administers the Mental Health, Substance Abuse and Chemical Dependency benefits for for Sutter Health Options PPO and Sutter Health National plans.

Call for authorization before providing inpatient or outpatient mental health or substance abuse services.

Contact Information • Call Optum customer service at 855-809-2012, 24 hours a day, seven days a week.

• Call UMR customer service at 866-868-2703, 7:00 a.m – 6:00 pm. PT Monday – Friday.

Emergency CareIf the member needs emergency services, you do not need to obtain prior authorization from the behavioral health carrier prior to providing emergency care. However, you must notify the carrier within 24 hours and once emergency care has ended, call the carrier to get authorization to provide any additional services.


Online Benefits and Claim Inquiry

Access information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week by going to sutterselect.tpa.com. Logging on to this website provides you and your office the following:

• Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to whom payment was made

• Eligibility and benefits information, including patient specific plan information, claim submission details, prior certification requirements and member benefit levels

• Contact phone numbers and an email notification form to contact a member of the UMR team with your questions

If you have questions or problems related to the website, please contact the UMR technical support team at 866-922-8266.

Home PageClick: “Provider”




Provider LoginIf you do not already have a username and logon, click “New user? Register here.” to complete the registration process using your name and password.

Reset Password Should you forget your password, you can select the “Forgot username or password?” option to change it.



Navigating the Website You can view an online video tutorial to learn about site navigation and available features.


Provider Directories

To obtain the highest level of benefits under this Plan, members need to see an in-network provider, however SutterSelect does not limit a member’s right to choose his or her own provider or medical care. If a medical expense is not a Covered Expense under the medical benefit plan, or is subject to a limitation or exclusion, a member still has the right and privilege to receive such medical service at his or her own personal expense.

To find out which network a provider belongs to, please refer to the Provider Directory or call the toll free number that is listed on the back of the member’s identification card. The participation status of providers may change from time to time.

SutterSelect Provider Information • Telephone: Call the SutterSelect Customer Service Line at 866-868-2703.

• Online: Available at sutterselect.tpa.com.

• To find a mental health provider in the Optum network, go to liveandworkwell.com and enter the access code “healthy.” Sutter Health Options PPO and Sutter Health National plans access mental health providers through the applicable UnitedHealthcare directory.


www.liveandworkwell.com


SutterSelect Customer Service Providers866-868-2703 7:00 a.m. – 6:00 p.m. PT Monday – Friday

• Eligibility Verification • Benefit Inquiries • Claim Inquiries • Prior Certification • Provider Appeals

Pharmacy877-787-8660 or express-scripts.com/sutterselect

• Drug Formulary • Pharmacy Network

Websitesutterselect.tpa.com

• Benefit Inquiries • Claim Status • Eligibility Verification • Provider Directories

Quick Reference List

Claim SubmissionEDI Claim Payer ID: 39026

UMR PO Box 30541 Salt Lake City, UT 84130-0541

Care Management866-895-3378

• Utilization Review/Prior Certification

SutterSelect Customer Service Members866-868-1320 or sutterselect.tpa.com

Optum* Behavioral Health855-809-2012 or liveandworkwell.com access code healthy

• Prior Certification • Provider Directory

*Sutter Health Options PPO and Sutter Health National plans are administered by UMR, 866-868-2703�

SSP-20-002




http://liveandworkwell.com

Documents

SutterSelect Administrative Manual - UMR