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Dec 10, 2018 CHOICE & HHAeXchange
Dec 10, 2018
CHOICE & HHAeXchange
2CONFIDENTIAL Discussion Draft
CHOICE transitions to HHAeXchange as of October 8, 2018 with Wave 1.
Wave 2 went live Oct 25, 2018
All Wave 3 providers will be required to accept/deny cases through HHAeXchange – Dec 15, 2018: HHAeXchange Enterprise Providers– Jan 19, 2019: Portal or Non-HHAeXchange providers
HHAX Implementation
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End to End Process
CHOICE creates authorization
HHAX receives authorization;
case placed with a provider
Provider accepts/denies case
Provider enters services via EVV or manually via Provider Portal
Provider submits 837i files for
adjudication via a UB04
Claims can be sent to
ChangeHealth (CHOICE’s
clearinghouse)
Claims can be sent to provider’s
clearinghouse
Claims processed by CHOICE’s
system
835 file generated
Provider can log into Provider
Portal to review 835
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Member Placement Process
Current Contract Administration currently sends referrals
to Providers through the VNSNY placement portal
Providers accept and decline referrals through VNSNY placement portal
Providers have 20 minutes to accept or decline a referral.
– If referrals time out, providers can request additional time
– Contract Admin works with you to extend the time as necessary.
Future: HHAX VNSNY CHOICE will send referrals to Providers through the
HHAeXchange provider portal as opposed to the VNSNY Placement portal.
Providers will accept or decline referrals directly through HHAeXchange provider portal.
Providers will continue to have 20 minutes to accept/decline a referral.
If referrals time out on portal, providers can request additional time by reaching out to CHOICE via a communication note.
– Referral types processed through the HHAeXchange portal include HHA, PCA, Consumer Direct and vendor changes
– On occasion referrals will be broadcasted to multi-providers.
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AUTHORIZATIONS
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Authorization Process
Current No authorization number is required for
placement of referrals through OPS by Contract Administration
Future: HHAX All referrals will be assigned an authorization number
Provider is responsible to:– Verify member information using V# - V# indicates LOB
V8 = MLTC V7= MAP or Total V6= FIDA
The authorization will be for 180 days or as specified
Universal Billing codes will replace service type codes on referrals
Total Bucket = Provider is required to manage hours based on authorization of full 180 days. The units authorized should span the full length of the delivery of care dates.
Services to member ends upon the ‘end date’ in authorization even if member shows as ‘Active’ in HHAX
– 30 days after the authorization end date, the authorization will drop from the Provider’s view
Change in schedule does not warrant a new authorization
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Authorization Ends– A member should only receive authorized services based on the start
of care and end of care– If a member shows ‘end of care dates’ in queue, but the authorization
dates have lapsed, send a communication note – CHOICE will coordinate with nursing staff based on the member’s
medical necessity.
Disenrollment– The member, though inactive, may not immediately drop from the
provider’s list. Therefore, it is critical the auth end date be the source of truth for authorized services.
Member Authorization Ends & Disenrollment
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It is the responsibility of the LHCSA to maintain the POC.– Enterprise providers must maintain the POC in HHAX– For all other providers, maintain the POC outside of HHAX– 1 Personal Care Task is required If member refuses, refusal must be documented
It is at the discretion of VNSNY CHOICE to request member POC details at any time for audit purposes
Nursing Services
Nursing services can be viewable in HHAeXchange but no authorization is included
Plan of Care
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COMMUNICATION NOTES
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Providers are required to use communication notes in HHAX to communicate with VNSNY CHOICE.
Scenarios for communication notes– Member demographic information must be updated– Reauthorization– Questions regarding order – Interruption of Care (black out dates used)– Member death
Travel Time and Over Time requests are required to be submitted via an appeal to Grievance & Appeals
Communication
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Service Interruptions (Black Out Dates)
Black-out dates are utilized in HHAX if there is an interruption of care (ex: patient is hospitalized, on vacation, etc.)– VNSNYC CHOICE will black out dates in HHAX for up to 15 days– Provider is notified via an automated HHAX communication note that
the dates have been blacked out.– CHOICE Care Management will resume service once member returns
home– Provider is notified via an automated HHAX communication note to
resume service
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VISIT CONFIRMATIONS
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All providers contracted with VNSNY CHOICE must maintain timesheets outside of HHAeXchange.
During an audit, VNSNY expects providers to show proof of in order to validate services rendered.
Timesheets
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BILLING
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As a contracted provider, there are 3 ways to submit a claim:1. HHAeXchange generates 837i 2. 3rd Party Mgmt. System generates 837i3. Provider directly bills CHOICE Electronically
• CHOICE Clearing House: Change Health • Provider’s clearinghouse
Manually• Mailing address on following slide
Upon go-live date, CHOICE expects providers to be prepared to bill using one of the outlined options
Submitting Claims for Payment
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Prior authorization is required for all services covered by MLTC, MAP and FIDA.
Unless otherwise described by your VNSNY CHOICE Provider Contract, VNSNY CHOICE requires submission on Form CMS1450 (UB-04) for all PCA/HHA Claims.
As of 4/1/2018 VNSNY CHOICE is compliant with Universal Billing Code Guidance as outlined by New York State and The Department of Health
Electronic billing is preferred, will facilitate payment, and will allow you to track your claims online. Please call the VNSNY CHOICE Provider Call Center for additional details on how to register.
Otherwise Paper Claims can be mailed to – MLTC and MAP Claims PO Box 4498 Scranton, PA 08505 – FIDA Claims PO Box 3715 Scranton, PA 08505
Claims Process
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Expect a 30-45 day turnaround time for payment
Once the claim is submitted, log in to the provider portal to check on the status and outcomes.– The Provider Portal will facilitate the correction and any necessary
communication– Use of the Provider Portal is not contingent on the claims submission type
Claims Process Cont.
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GRIEVANCE & APPEALS
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Providers may file appeals disputing a denial issued as a result of a utilization management decision, a claims denial (ie: no authorization; provider not contracted to perform services; submit claim to primary carrier) or if they disagree with the amount paid on a previously processed claim.
All appeals must be filed in writing and must include all relevant information, including medical records, if applicable. The address to submit appeals is:
VNSNY CHOICE Health Plans
Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523
Grievance & Appeals
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Timeframe for Filing Appeal:
60 calendar days from the date of the denial/initial determination, unless the provider’s contract allows for additional time to file.
Acknowledgment Letter Timeframe:
Within 15 business Days from receipt of the appeal, Grievance and Appeals will send a written acknowledgment letter.
Resolution Timeframe:
Within 60 calendar days from receipt of the appeal.
Appeals that involve a medical necessity, experimental or investigational decisions may be further appealed through the State’s external appeal process.
Some facilities also have the right to file an appeal with a Dispute Resolution Entity. Please refer to your provider contract to determine if this right applies to you.
Grievance & Appeals Cont.
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Contact Information
Follow up questions to today’s webinar?
Email: [email protected]
Looking for HHAX materials, please visit our site:
http://vnsnychoice.org/health-professionals
Questions regarding claims set up?Network Development is actively reaching out to review your billing plan and any outstanding questions
Question regarding claims status, denial or payment?
Provider Call Center: 1-866-783-0222
