Spring 2014 PacificSource Provider Workshop Idaho
Presented by: The PacificSource Provider Service Team
PacificSource Community Health Plans, Inc. is an HMO/PPO plan with a Medicare contract.
Y0021_PR2385_Plan Approved 04082014
Agenda
• Organizational Updates o NCQA o Locums Tenens o HEDIS o ICD 10
• Commercial o Healthcare Reform - Exchange
• Medicare • PacificSource Websites
o InTouch Provider Portal
Organizational Updates
Organizational Updates
Idaho Provider Service Team
Southwest Idaho - Saint Alphonsus Health System [email protected] (208) 780-2060
Northern Idaho - St. Luke’s Health Services [email protected] (208) 333-1517
Eastern Idaho [email protected] (208) 780-2065
PacificSource Total Membership
Total Membership: 259,323
Commercial Membership: 169,582
Medicare Membership: 37,736
Medicaid Membership: 52,005
Organizational Updates
Current Membership for Idaho
Total Membership: 47,685 Covered Lives
Commercial Membership: 27,038
Medicare Membership: 20,647
Organizational Updates
Organizational Updates
National Committee for
Quality Assurance (NCQA)
Organizational Updates
PacificSource and NCQA • PacificSource began the accreditation
process in January of 2013. • Anticipate seeing PacificSource Health
Plans on the NCQA website in May or June. • We would like to thank you for your
patience and assistance.
Organizational Updates
Examples of NCQA requirements • Required information on all rosters:
o Effective and termination dates for all licensure
o Provider directory enhancements −Hospital affiliation
−Board certification
−Language spoken
• PacificSource is required to notify members 30 days in advance of a provider leaving a practice.
Organizational Updates
Provider Changes • Provider groups shall use their best efforts
to notify PacificSource and/or their IPA promptly and in advance of the addition or termination of a provider. o We need notification from providers at least 45-
60 days prior.
Organizational Updates
Locum Tenens
Organizational Updates
Locum Tenens Policy • For Locum Tenens providing coverage for 60 or
fewer consecutive days, we will require: o A Locum Tenens application
o Current DEA certificate
o Copy of professional liability coverage
Organizational Updates
Locum Tenens Policy • For Locum Tenens providing coverage for longer
than 60 consecutive days, we will require: o A full and complete practitioner credentialing
application.
• Locum Tenens must be credentialed prior to being paid under the absent provider’s contract.
• This policy applies to all PacificSource lines of business.
Organizational Updates
Billing for Locum Tenens • Each healthcare provider or supplier who is
rendering the service, must be listed in box 31 of the CMS 1500 form.
• PacificSource does not permit incident-to-billing.
• Claims billed prior to the locum tenens credentialing approval will be denied as provider write-off.
Organizational Updates
HEDIS
What is HEDIS? • Healthcare Effectiveness Data and Information
Set • Required by CMS • Required for NCQA certification for any line of
business • PacificSource does HEDIS for Commercial and
Medicare • Set of standardized performance measures
Organizational Updates
HEDIS continued • Measure data sources: Admin (medical and
Rx claims), Hybrid (patient chart), and Survey • Measure Domains – Effectiveness of care,
Access, Availability, Cost of Care, Use of Services, and Health Plan Descriptive Info
• Measurement Year – Most look at care in most recent calendar year. Some look back >2 yrs
• HEDIS is a major data source for Medicare 5 Star Program and NCQA certification
Organizational Updates
HEDIS continued • HEDIS medical record measures assess
compliance with accepted prevention and chronic condition guidelines.
• Some measures are calculated using claims data, some use medical record documentation, some use both.
• Many of the measure results are influenced or controlled by physicians.
• Members are randomly selected for medical record portion of HEDIS audits.
Organizational Updates
HEDIS continued • Information for HEDIS audit completion will
either be requested directly by PacificSource or on our behalf by our vendors: Outcomes Health for Commercial and Verisk for Medicare.
• Any questions regarding the HEDIS audit should be directed to: o Provider Network (800) 624-6052 ext 2580 o Outcomes Health (855) 767-2650 o Verisk Health (877) 489-8437
Organizational Updates
Organizational Updates
Billing Updates
Organizational Updates
New CMS 1500 Form (Rev 02/12) The CMS 1500 form has been updated to align with 5010 837P and accommodate ICD-10 reporting.
Changes on the form include: • Fields 8, 9b, 9c, 11b, and 30 • Other fields were changed to
reflect usage. • 12 lines now available for
diagnosis codes.
Organizational Updates
New CMS 1500 Form • Effective April 1, 2014, PacificSource Medicare
is only accepting claims billed using the revised form (02/12). This includes corrected claims that were previously submitted on the (08/05) version.
• PacificSource Health Plans will continue to accept both versions, however we highly encourage providers to use the updated version.
Organizational Updates
ICD-10 • Implementation pushed to October 1,
2015 (at the earliest). • PacificSource has completed:
o System upgrades
o Impact assessments
o Translation Mapping ICD-9 to ICD-10
o End to end testing with several large health systems
Organizational Updates
Has your organization begun ICD-10 planning?
Yes, 76.8%
No, 23.2%
151 People Surveyed • Yes – 116
• No – 35
• Skipped Question – 16
Organizational Updates
Please estimate how much of the planning process your organization has completed.
47%
36%
13%
4% Answer Options
Response Percent
Response Count
0-25% 46.8% 51
25-50% 35.8% 39
50-75% 12.8% 14
75-100% 4.6% 5
ICD-10 Tip and Tricks • AAPC crosswalk from ICD-9 to ICD-10
http://www.aapc.com/ICD-10/crosswalks/pdf-documents.aspx.
• Visit AAPC for more helpful tools, such as: o Searchable databases
o Educational webinars
o Educational articles
o ICD-10 conversion issues and trends
Organizational Updates
ICD-10 Resources • If you have questions regarding
PacificSource and ICD-10, please email [email protected].
• Visit CMS’s website for another great resource on the ICD-10 transition: cms.gov/ICD10.
• If you are interested in end-to-end testing with us, please complete our brief survey at SurveyMonkey.com/s/T3CTNL6.
Organizational Updates
Commercial Updates
Commercial Updates
Commercial Updates
PacificSource Administrators (PSA) • Effective April 1, 2014, PSA claims will be
payable via EFT. • If you are already set up to receive EFT
and/or ERA, you do not need to do anything. • New EFT enrollees will now be getting
payments for commercial, Medicare, and PSA members.
• Updated EFT/835 enrollment form now available on our website.
Commercial Updates
Dedicated Provider Customer Service Phone Number
(855) 896-5208 *Benefit questions, claims inquiries, etc.
Healthcare Reform
Healthcare Reform – Your Health Idaho
ACA Employer Mandate Changed • Although mandate was effective in 2014,
the enforcement was delayed until 2015.
• Under the final rules, businesses now have even more time to comply. o Large groups (100+) have until 2015 to
comply.
o Mid-size groups (50-99) have until 2016 to comply
Healthcare Reform
Pediatric Vision Benefit • Members through 18 years of age.
• Licensed ophthalmologist or optometrist
• One vision exam per year* including refraction
• One pair of non-collection glasses (lenses and frames) per year*
• Contact lens services and materials per year* *Benefits/frequencies are per calendar or per plan year. Limits on hardware also apply.
Healthcare Reform
Oregon
PSN
SmartHealth
Prime
Idaho
PSN
SmartHealth
SmartAlliance
BrightIdea
Montana
PSN
SmartHealth
Healthcare Reform Networks
TIER
3
TIER
2
TIE
R 1
SmartHealth Contracted Providers
PSN Providers
Non-participating Providers
Healthcare Reform SmartHealth Network Northern & Eastern Counties
Healthcare Reform
TIE
R 2
TIE
R 1
St. Alphonsus MDs and Hospitals Independent providers part of St. Alphonsus Alliance
Non-participating providers
SmartAlliance Network Treasure Valley
Healthcare Reform
TIER
2
TIER
1 St. Luke’s
MD’s and Hospitals Independent BrightPath providers
Non-participating providers
BrightPath Network Treasure & Magic Valley
Becoming a contracted provider:
• BrightPath (Southwest Idaho) o Contract and credentialing completed by BrightPath o For any contract questions, please contact BrightPath at
(877) 814-5505 or http://yourbrightpath.com/
• SmartAlliance (Southwest Idaho) o Contracting completed by the Saint Alphonsus Health
Alliance o For any contract questions, please contact their provider
network committee at (208) 367-8698
Healthcare Reform
Becoming a contracted provider:
• SmartHealth (Northern and Eastern Idaho) o Contracting completed by PacificSource o For any contract questions, please contact
Provider Network at: (800) 624-6052 or [email protected].
• PSN o Contract and credentialing completed by IPN o Contact (208) 333-1513 or visit their website at
http://ipnmd.com/ipn/.
Healthcare Reform
Nominate a Provider
Nominate a Provider
Healthcare Reform
2013 vs 2014
G = Commercial group coverage N = Individual policy GE = Group Exchange NE = Nongroup Exchange (individual member)
Medicare Updates
Medicare Updates
Risk-Adjustment Chart Review • Please remember that Medicare Advantage
providers must participate in our risk-adjustment chart review.
• The reviews are conducted by Altegra Health, a PacificSource Medicare vendor.
• Data validation is submitted to CMS for a portion of risk-adjustment payment.
Medicare Updates
Risk-Adjustment Chart Review • Chart reviews may be requested
throughout the year as we prepare for our CMS submissions, which are due in January, March, and September.
• Provider offices are notified of chart requests in writing and by phone.
• Applies to Medicare Advantage products only.
Medicare Updates
Outbound Member Call Program • PacificSource Medicare has partnered with Eliza, a
vendor, to develop and implement a targeted member outreach effort.
• Part of our Medicare 5-star program.
• Call topic examples include: o Preventive screening reminders o Diabetes care o Heart health o Post-hospital discharge o Medication Adherence
Medicare Updates
Outbound Member Call Program • Purpose is to improve the overall health
and satisfaction of our members.
• Member questions should be directed to our Medicare Customer Service Department at (888) 863-3637.
Medicare Updates
Post payment review • As part of a CMS requirement, PacificSource
Medicare will begin conducting post payment audits May 1, 2014.
• Audits will focus primarily on: o Medical necessity
o Proper utilization
o Appropriateness of services
o Accuracy of claims submitted
Medicare Updates
Post payment review • Providers selected for audit will be notified in
writing.
• Notifications will include:
o type of audit
o applicable claims
o required documentation
o due date
Medicare Updates
Post payment review • If records are not received, we will request refunds
on the claims until records are received.
Note: records will be obtained electronically if EHR access has been granted.
• Future audits may focus on the overuse of modifiers billed 59 and 25.
Medicare Updates
2014 CMS OPPS Changes • Outpatient Lab Tests o Packaged – Bill Type 13x − When performed on same date as primary service − Ordered by same practitioner who ordered
primary service o Not Packaged – Bill Type 14x − The only service performed on that date − Ordered for purpose separate from the primary
procedure and ordered by different provider
Medicare Updates
CMS OPPS Changes Scenario A • Patient scheduled for eye surgery by an ophthalmologist • On same date of service patient received unrelated lab tests
ordered by cardiologist. • Payment for the lab tests not packaged; hospital reimbursed
separately for each service.
Scenario B • Patient scheduled for eye surgery by an ophthalmologist • Ophthalmologist orders lab tests as a part of preoperative testing. • Tests performed on the same date of service as the eye procedure. • Payment for the lab tests packaged into payment for the surgical
procedure under OPPS.
Medicare Updates
2014 CMS OPPS Changes • G0463
o Applies to CAH and Acute hospitals o Applies to hospitals reimbursed based off
of OPPS only.
oReplaces E&M codes 99201-99205 and 99221-99215
Medicare Updates
2014 CMS OPPS Changes
• CMS Bundling o Drugs, biologicals, and radiopharmaceuticals
that function as supplies when used in a diagnostic test or procedure
o Drugs and biologicals that function as supplies or devices when used in a surgical procedure
o Clinical diagnostic laboratory tests (except molecular pathology) when provided on the same date of service as another service
o Procedures described by add-on codes o Device removal procedures
Medicare Updates
Referral vs. Authorization
• A “referral” is the process by which the member's primary care provider (PCP) directs a member to obtain care for covered services from other health professionals in an office setting.
Please note: The referral must be submitted directly to PacificSource Medicare by the PCP.
• A “Prior authorization” is defined as a request for a specific service that requires a review to determine medical necessity. Services that require prior authorization are outlined on our website at www.Medicare.Pacificsource.com.
Medicare Updates
Referrals required for Essentials Plans (HMO) • Referrals are not required for the following:
o Urgent care/Emergent Care o Chiropractic/Physical Therapy o Routine women’s healthcare (mammograms) o Routine colonoscopies o Routine Eye Exam o Flu shots o Pneumonia vaccinations o Diabetes self-management training o Kidney dialysis
Medicare Updates
Referral Scenarios: Question: When is a referral needed?
Answer: Before seeing an in-network specialty provider*, a member must obtain a referral from his or her PCP. If additional services from another specialty provider are needed, the PCP will coordinate a referral to the appropriate specialist.
Question: What if the member had a previously scheduled office visit before becoming eligible with PacificSource Medicare?
Answer: In this situation, a referral from the member’s PCP is still required. * Requests to see an out-of-network provider must be submitted via the prior authorization process and are not considered a referral.
Medicare Updates
Referral Scenarios: Question: Is an approved referral request limited to the specialist designated by the member’s PCP? Answer: No. The approved referral covers services from any provider that practices in the same group and has the same specialty as the provider approved on the request.
Question: How will I know my referral request has been approved? Answer: Notification method is determined on how the request is submitted.
o Faxed requests: the determination notice will be mailed and/or faxed to the referring provider and specialist.
o Online requests: the determination notice will be viewable on InTouch.
Medicare Updates
Referral Scenarios:
Question: Do facilities billing for urgent care services on a UB-04 claim form require a referral?
Answer: No. Referrals are not required for services rendered in an urgent care setting when billed accordingly.
Question: Does follow-up care for specialty services, as a result of an urgent care or emergency room visit, require a referral from the member’s PCP?
Answer: Yes. A referral is required from a PCP for follow-up services provided outside of an urgent care or emergency room setting.
Medicare Updates
Health Services Update • Urgent Preauthorization and Referral
Requests o Two methods for submitting Urgent Requests: − PacificSource Medicare Authorization and Referral
Request Form Clearly annotate on the request form that you are submitting an
“urgent request”
− Via In-Touch Ensure you choose “yes” under Urgent Request
o In order to expedite processing, call our Health Services after you submit the request
Medicare Updates
Vision Benefits • Routine Services
o No prior authorization is required for routine (refractive) eye exams
o Limited to one exam every 2 years o Hardware/contacts- $100 every 2 years
• Medical Services o Referral is required, no prior authorization is required o One pair of glasses or contacts after each cataract
surgery including intraocular lens
Medicare Updates
PacificSource.com
PacificSource.com
Organizational Updates
Provider Bulletin
Organizational Updates
Provider Bulletin • PacificSource has combined our two
provider newsletters; CommunityCare (Medicare and Medicaid) and Provider Bulletin (Commercial).
• Beginning with the Spring 2014 edition, providers can expect to see topics related to all lines of business in the Provider Bulletin.
Organizational Updates
Provider Bulletin • The Provider Bulletin will be distributed
quarterly to those who have opted in to receive the newsletter as well as those who were on the distribution to receive the CommunityCare newsletter.
• Current and past newsletter editions may be found on any of our three websites.
PacificSource.com
PacificSource.com
PacificSource.com
Medicare.PacificSource.com
Medicare.PacificSource.com
Medicare.PacificSource.com
Medicare.PacificSource.com
InTouch Provider Portal
InTouch Provider Portal
InTouch Provider Portal InTouch for Providers • Secure, interactive website for providers o Commercial and Medicare Advantage members o Online eligibility o View and submit referral and preauthorization
requests o Online claim status o Explanation of payment
• Point of service direct o Access real-time patient liability information
and your actual charges for each procedure billed
InTouch Provider Portal
InTouch – OneHealthPort • InTouch for Providers is accessed through
OneHealthPort.
• OneHealthPort is a web portal that provides access to secure health plan websites with a single user ID and password.
• If you are already an OneHealthPort user, you do not need to register again to access InTouch.
InTouch Provider Portal
InTouch – OneHealthPort • Register for OneHealthPort via their website:
www.OneHealthPort.com/Register/Index.php.
• Providers who need to use “Forgot My Password” or “Forgot My UserID” links can find them on the OneHealthPort sign in page.
• For questions or assistance with the registration process, please contact:
OneHealthPort’s Help Desk: (800) 973-4797
InTouch Provider Portal
InTouch Provider Portal
InTouch Provider Portal
InTouch Provider Portal
InTouch Provider Portal
03/01/1938 03/01/1938 03/01/1938
The search feature returns active member records only. Referral requests for terminated members must be submitted to PacificSource via fax.
InTouch Provider Portal
Not all PacificSource plans require referrals. Please reference the member’s ID card to verify if referral requirements apply.
InTouch Provider Portal
Populate the online referral form with the appropriate referral information. Fields marked with an asterisk* are required.
InTouch Provider Portal
Submitting supporting documentation online speeds up the processing time for requests.
InTouch Provider Portal
Once the referral is generated, the requesting provider and the referred to provider will be able to view and track the referral request via InTouch.
InTouch Provider Portal Example of referral approval
Online Pharmacy Prior Authorization Requests • Effective April 1, 2014, providers can now
submit pharmacy prior authorization requests online via the InTouch web portal.
• This includes requests for both Commercial and Medicare members.
Organizational Updates
Organizational Updates
Organizational Updates
Organizational Updates
Organizational Updates
InTouch Provider Portal
Explanation of Payments (EOPs) can also be found by selecting the “Billing” tab on the InTouch home page.
InTouch Provider Portal
EOP Schedule • EFT delivery - Wednesday • Paper EOPs - mailed
Wednesday • InTouch EOP delivery -
Thursday • Holidays will delay delivery • EOPs are available for two
years
Thank you!
Questions?
