Spring 2014 PacificSource Provider Workshop Lewiston
Presented by:
The PacificSource Provider Service Team
Agenda
• Organizational Updates
o NCQA
o Locums Tenens
o HEDIS
o ICD 10
• Commercial
o Healthcare Reform - Exchange
• PacificSource Websites
o InTouch Provider Portal
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
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 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.
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
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
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.
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
TIE
R 3
TIE
R 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
TIE
R 2
TIE
R 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
Healthcare Reform
2013 vs 2014
G = Commercial group coverage
N = Individual policy
GE = Group Exchange
NE = Nongroup Exchange (individual member)
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.
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
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.
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
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