MyCare OhioSkilled 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 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 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.

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Claim Services

Timely Filing Guidelines 365 Days from the date of service 180 Days if retro eligibility is an issue 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 PlanAttn: Claims

P.O. Box 3060Farmington, MO 63640

(866)-329-4701

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

Buckeye Community Health PlanMyCare Ohio Claim Reconsideration

P.O. Box 4000Farmington, 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 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.

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Claim Services

CLAIM SUBMISSION OPTIONSElectronic 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 #’sEmdeon 68069 (800) 845-6592Gateway 68069 (800) 987-6720SSI 68069 (800) 880-3032Smart Data Solutions 68069 (651) 690-3140Availity 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 Planc/o Centene EDI Department

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

EDIBA@centene.com

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Program Exclusions

All 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 3060

Farmington, MO 63640

Paper Claim format

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Billing – Dos and Don’ts

Program Exclusions

Billing – Dos Submit your claim within 90 days of

the date of service Submit on a proper original form –

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!