PASSPORT HEALTH PLAN HOSPITAL WORKSHOP NOVEMBER 2005

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PASSPORT HEALTH PLAN HOSPITAL WORKSHOPNOVEMBER
2005
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WELCOME
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AGENDA

• Welcome and Introductions Jeri Cross
• Passport Health Plan
• Whats New?
  Carmen Williams
• Claims Billing
  Carmen Williams
• Utilization Management Helen Homberger
• BREAK
• Passport Advantage
• Overview
  Marcelline Coots
• Eligibility ID Cards
  Marcelline Coots
• Claims,Billing Reimbursement Pam
  Norris/Linda Young
• Utilization Management Helen
  Homberger
• Questions Answers Provider
  Relations

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PROVIDER RELATIONS

• Becky Bowman [phone]
• Dell Fraze [phone]
• Kim Miller [phone]
• Jason Mingus [phone]
• Kim Richards-Farley [phone]
• Vonda Sickles [phone]
• Julia Walls [phone]
• Carmen Williams [phone]
• Jeri Cross, Manager [phone]

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IMPORTANT CONTACT INFORMATION

• Provider Services
• [phone]
• Provider Relations (General)
• [phone]
•   
• IVR Phone Number
• [phone] Option 1
•  
• Provider Claims Service Unit (PCSU)
• [phone] Option 2
•  

• Passport Health Plan Web Site
• www.passporthealthplan.com
•  
• Passport Health Plan Provider Manual
• http//www.passporthealthplan.com/providercenter/
  providercom/index.asp

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WHATS NEW?

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REMITTANCE ADVICE ENHANCEMENTS

• Effective March 2005, the Payment Reduction
  Summary of the Remittance Advice includes
• Original date of service
• Check date
• Check number

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ELECTRONIC REMITTANCE ADVICE (ERA)

• To register, please contact Emdeon (formerly
  WebMD) or HDX Clearinghouses.
• Emdeon [phone]
• HDX Clearinghouse [phone]

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BEHAVIORAL HEALTH DRUGS

• Effective November 1, 2005
• Pharmacies will submit behavioral health
  prescriptions through PHPs pharmacy benefit
  manager, PerformRx.

All of the information in this workshop is
confidential. Please do not reproduce without the
express written permission of Passport Health
Plan and/or Passport Advantage.
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DENIED CLAIMS REPORT

• Designed to help reduce denied claims and assist
  the Plan to identify opportunities for improving
  our claim processing system and procedures.
• Mailed to providers when 50 or more claims are
  denied in full within a monthly reporting period.
• Includes number of original claims processed,
  breakdown of denials by category, and denial rate
  for each category, etc.

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CLAIMS ADDRESSES

• New and corrected paper claims
• Passport Health Plan
• Attn Claims Unit
• P.O. Box 7114
• London, KY 40742
• Requests for claims reconsideration or
  recoupment
• Passport Health Plan
• Attn Reconsideration
• 305 West Broadway
• Louisville, KY 40202
• When medical records are requested for claim
  processing
• Passport Health Plan
• Attn Medical Records
• 200 Stevens Drive
• Philadelphia, PA 19113

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CLAIMS ADDRESSES

• Family Planning
• AmeriHealth Family Planning
• Attn Claims
• PO Box 42476
• 1901 Market Street, 29th Floor
• Philadelphia, PA 19101-2476

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ELECTRONIC CLAIMS SUBMISSION

• PHP has partnered with Emdeon (formerly WebMD)
  and HDX clearinghouses. Providers may also
  contact their own vendor.
• Emdeon Sales Department [phone].
• PHPs electronic payer identification number is
  61129.
• Family Planning claims must be submitted to
  AmeriHealth HMO.
• Family planning claims submitted to PHP will
  result in a denial stating Z06 or Z14 carrier
  of service-AmeriHealth Inc.

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PREVENTING DENIALS

• Duplicate claim
• Eligibility
• Timely filing
• Invalid diagnosis
• EOB incomplete

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DUPLICATE CLAIM

• Corrected or Resubmitted claims must be sent to
  PHP on paper, with either corrected or
  resubmitted noted on the claim as appropriate.
• Claims that originally denied for missing/invalid
  information or for inappropriate coding should be
  submitted as a corrected claim. In addition to
  writing CORRECTED CLAIM, the corrected
  information should be circled to easily identify
  the corrected information.
• Claims that have been denied for additional
  information should be submitted as a paper claim.
  RESUBMITTED CLAIM should be written on the
  form and the new information should be attached.
• It is important to remember that these claims are
  scanned as part of the resubmission process. Red
  ink and /or highlighted text is not readable. We
  ask that you please use BLUE or BLACK ink only.

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PLASTIC KYHEALTH / MEDICAID ID CARD

• All state Medicaid cards are plastic.
• This card replaces the paper card previously used
  in the past by Medicaid recipients.

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ID CARD KYHEALTH (Medicaid)
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PHP ID CARD

• PHP members will continue to receive PHP ID
  cards. Please note, that the plastic state
  Medicaid cards do NOT reflect PHP membership.
• PHP members are encouraged to carry the plastic
  state Medicaid ID card in addition to the PHP ID
  card.
• Verify eligibility prior to providing services to
  PHP members.

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PHP ID CARD
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4 STEPS FOR VERIFYING MEMBER ELIGIBILITY

• Ask to see the PHP ID card.
• Ask to see the plastic Medicaid ID card.
• Ask to see a picture ID.
• Check eligibility online or by phone.www.passport
  healthplan.com(800) 578-0775

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TIMELY FILING

• Original Claim Filing 180 days
• For Correction of Claims 2 years

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TIMELY FILING

• Retroactive Enrollment
• For members who are retroactively enrolled in
  PHP by DMS, the deadline for claim submission is
  based on the date of notification of enrollment,
  not the date the service is rendered.
• EOBs from Primary Insurers
  If beyond 180 days of
  the DOS, claims with an EOB from the primary
  insurer must be submitted within 60 days of the
  date of the primary insurers EOB.
• EOBs from Medicare Part A
  If beyond 180 days of
  the DOS, claims with an EOB from Medicare Part A
  only must be submitted within 180 days of the
  date of the EOB.

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INVALID DIAGNOSIS
Diagnosis invalid/missing 4th or 5th digit
If a claim denies for this reason, add a valid
diagnosis code and resubmit a paper claim as a
Corrected Claim with the corrected diagnosis
code circled.
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EOB ILLEGIBLE/INCOMPLETE

• EOB copies must be clear and legible. Light
  copies will not scan.
• Remark code pages must be included.

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Passport Health PlanUtilizationManagement
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UTILIZATION MANAGEMENT

• Goal
• Purpose
• Staffing
• RNs
• Intake Coordinators
• Medical Directors

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UTILIZATION MANAGEMENT

• Referrals
• Prior Authorization
• Review Criteria
• - Milliman USA Care Guidelines
• - InterQual Level of Care Rehab Criteria
• - Medical Policies
• Retrospective Review

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UTILIZATION MANAGEMENT

• Denials
• - Administrative
• - Medical
• Appeals
• - Administrative
• - Medical
• Member
• Provider
• -Expedited

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number is
• [phone]
• Hours of operation are
• Monday Friday 800 am- 530 pm except
  designated holidays and weekends
• Send medical necessity and administrative appeals
  to
• Passport Health Plan
• Attn Appeals Coordinator
• 305 W. Broadway, 3rd floor
• Louisville, KY 40202

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iEXCHANGE WEB
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WHAT IS iEXCHANGE WEB?

• iEXCHANGE Web
• Allows physicians, facilities and healthcare
  providers to perform healthcare transactions with
  health plans using the Internet.
• Implementing electronic authorization for
  maternity admissions at select facilities 4th
  quarter 2005.
• Additional providers and admission types planned
  for 2006.
• Providers receive auto-approvals based on the
  health plans clinical and business rules.
• Call Becky Murphy, Provider Training Specialist,
  at [phone] for more information.
  

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CASE MANAGEMENT
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CASE MANAGEMENT

• What is Case Management?
• Goal
• Purpose
• Benefits
• Staffing
• RNs
• Social Workers

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CASE MANAGEMENT

• How can Case Managers help?
• Coordinate care with PCPs and specialists
• Identify and provide availability of needed
  medical and social services
• Identify and address social medical problems
• Work with community partners on members behalf

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CASE MANAGEMENT

• Case Management achievement results
• 85 satisfaction with usefulness of services has
  been demonstrated on provider survey
• 90 member satisfaction demonstrated on case
  management satisfaction survey
• 98 member health improvement and quality of life
  reported

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number is
• [phone] ext. 7915
• Hours of operation are
• Monday Friday 800 am-500 pm except
  designated holidays and weekends

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HEALTH AND DISEASE MANAGEMENT
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ASTHMA AND DIABETES DISEASE MANAGEMENT

• Program design
• Member Identification
• Staffing
• Member interventions
• Provider interventions

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ASTHMA AND DIABETES DISEASE MANAGEMENT

• Contact Information
• Kay Vance, RN 585-8311 Asthma
• Amy Vissing, RN 585-8307 Asthma
• Linda Reed, RN 585-7074 Diabetes

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MOMMY AND ME PERINATAL HEALTH PROGRAM

• Program design
• Member Identification
• Staffing
• Member interventions
• Provider interventions

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MOMMY AND ME PERINATAL HEALTH PROGRAM

• Contact Information
• Joni Connelly 585-7973
• Holly Dutcher 585-8358
• Sharon Owens 585-7330
• Lace Houston 585-7957
• Carmen Borges 585-8225
• Lorayne Donald 585-7908
• Melanie Hodoh 585-8309

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BREAK
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PASSPORTADVANTAGE
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MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS
(MA-PDs) and PRESCRIPTION DRUG PLANS (PDPs)

• MA-PDs cover Medicare Parts A, B, and D.
• PDPs cover Part D prescription drug coverage
  only.
• There are 16 MA-PDs and PDPs in the region.

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SPECIAL NEEDS PLAN (SNP)

• Passport Advantage is an SNP the only one in our
  region!
• Serves dual-eligible members Medicaid
  recipients entitled to Medicare Part A and
  enrolled in Medicare Part B.
• Passport Advantage is a MA-PD SNP for
  approximately 12,000 dual-eligible PHP/PAD
  members.

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PASSPORT ADVANTAGE SPECIAL NEEDS PLAN
Members Eligible to Participate
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WHAT PASSPORT ADVANTAGE OFFERS

• Passport Advantage Offers members
• Same prescription drugs they have under
• Passport Health Plan
• Same doctors they see under Medicare
• Same pharmacies they go to now
• 0 monthly plan premium
• Only expense 1.00 (generic)/3.00(brand-name)
  co-pay (per prescription)

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KEY DATES

• Important Dates for Passport Advantage
• 11/15/05 member applications can be received
  and processed
• 11/15/05 Passport Advantage website goes live
  www.passporthealthplan.com
• 1/1/06 Passport Advantage operations begin

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PAD ELIGIBILITY
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PASSPORT ADVANTAGE CLAIMS, BILLING
REIMBURSEMENT
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ELECTRONIC DATA INTERCHANGE (EDI)

• The Passport Advantage electronic payer
  identification numbers are 12B86 (Facility) and
  SX154 (Professional).
• Providers may contract directly with Zirmed or
  another electronic clearinghouse or vendor to
  submit claims to Emdeon (formerly WebMD).
• Assigned Passport Advantage provider numbers must
  be used. These numbers will be distributed in the
  near future.

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CLAIMS ADDRESSES

• New and corrected paper claims
• Passport Advantage
• P O Box 69325
• Harrisburg, PA 17106-9325
• Requests for claims reconsideration or
  recoupment
• Passport Advantage
• Attn PCSU
• 305 West Broadway
• Louisville, KY 40202
• Correspondence can be mailed to
• Passport Advantage
• Attn PCSU
• 305 West Broadway
• Louisville, KY 40202

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TIMELY FILING GUIDELINES

• Original claims must be submitted to the Plan
  within 180 calendar days from the date services
  were rendered or compensable items were provided.
• Resubmission of previously denied claims with
  corrections and requests for adjustments must be
  submitted within two (2) years of the process
  date.

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BILLING REQUIREMENTS

• UB-92
• CMS-1500

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CLINICAL EDITS

• January 1, 2006
• Claim Check (McKesson)
• Future
• NCCI

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REIMBURSEMENT METHODOLOGY

• Will use Medicare Claim Payment Methodology
• Will use 2006 rates
• Contracted providers receive 103 of the Medicare
  Fee Schedule
• Continue to report cost reports to CMS

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BENEFIT STRUCTURE

• Apply Medicare benefit period concept for Part A
  services
• Apply 2006 Medicare deductible, co-insurance and
  copayment amounts except no Part B deductible
• Apply 2006 Medicare day limits for Part A
  services
• Apply 3-day prior hospitalization requirement for
  Skilled Nursing Facility admissions

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CODES AND MODIFIERS

• Use all required codes and modifiers
• Passport Advantage will use CMS policies for
• Valid/invalid codes
• Multiple surgery reduction
• Global period for surgery
• Place of service differential
• Non-physician practitioner reduction

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CLAIM PAYMENT SCHEDULE

• Payment will be generated weekly on
• Wednesdays.

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CLAIM CROSS-OVER PROCESS

• Passport Advantage claim cross-over files are
  sent daily to Passport Health Plan for secondary
  processing.
• Behavioral Health and Skilled Nursing Facility
  claims must be sent to DMS for secondary
  processing.

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IMPORTANT CONTACT INFORMATION

• Provider Claims Service Unit (PCSU)
• [phone]
• Provider Relations (General)
• [phone]
• Utilization Management
• [phone]
• Emdeon (formerly WebMD)
• [phone]
• Passport Advantage Website
• Access to Passport Advantage website will be
  provided through a link on www.passporthealthplan.
  com Passport Advantage has its own homepage,
  with specific content for Medicare providers.

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PASSPORT ADVANTAGE UTILIZATION MANAGEMENT
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UTILIZATION MANAGEMENT

• Goal
• Purpose
• Staffing
• RNs
• Intake Coordinators
• Medical Directors

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UTILIZATION MANAGEMENT

• No Referrals
• Prior Authorization for specific services
• Review Criteria
• - InterQual Level of Care Criteria
• - Medical Policies
• Retrospective Review

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UTILIZATION MANAGEMENT

• Denials
• -Medical
• Appeals
• - Member
• - Provider

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IMPORTANT CONTACT INFORMATION

• Toll Free telephone number is
• [phone]
• Hours of operation are
• Monday Friday 800 am- 530 pmexcept
  designated holidays and weekends
• Appeals must be mailed to
• Passport Advantage Plan
• Attn Appeals Coordinator
• 305 West Broadway, 3rd floor
• Louisville, KY 40202

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PASSPORT ADVANTAGE CASE MANAGEMENT
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CASE MANAGEMENT

• What is Case Management?
• Goal
• Purpose
• Who benefits from Case Management
• Staffing
• RNs
• Social Workers

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CASE MANAGEMENT

• How can Case Managers help?
• Coordinate care with practitioners and
  specialists
• Identify and provide availability of needed
  medical and social services
• Identify and address social medical problems
• Coordinate with community partners on members
  behalf

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CASE MANAGEMENT

• Case Management achievement results
• 85 satisfaction with usefulness of services has
  been demonstrated on provider survey
• 90 member satisfaction demonstrated on case
  management satisfaction survey
• 98 member health improvement and quality of life
  reported

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number is
• [phone] ext. 7915
• Hours of operation are
• Monday Friday 800 am- 500 pm except
  designated holidays and weekends

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BEHAVIORAL HEALTHCARE COORDINATION
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BEHAVIORAL HEALTHCARE COORDINATION

• What is Behavioral Health Care Coordination?
• Goal
• Purpose
• Benefits
• Staffing
• RNS
• Social Workers

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BEHAVIORAL HEALTHCARE COORDINATION

• Member identification
• - Health Risk Assessment upon
  enrollment
• - Provider referrals
• - Member referrals
• - Facility referrals
• - Internal Plan referrals

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BEHAVIORAL HEALTHCARE COORDINATION

• How Can Behavioral Heath Care Coordination Help?
• Promote collaborative practice among all
  disciplines to assure continuity of care and high
  quality services
• Coordinate with community partners on members
  behalf

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BEHAVIORAL HEALTHCARE COORDINATION

• No referrals required
• Prior authorized services include
• Behavioral health and substance abuse inpatient
  admissions
• Home health services

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number is
• [phone]
• Hours of operation are
• Monday Friday 800 am - 500 pm except
  designated holidays and weekends

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• PASSPORT ADVANTAGE DISEASE MANAGEMENT

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PASSPORT ADVANTAGE DISEASE MANAGEMENT

• Diabetes
• Coronary Artery Disease (CAD)
• Chronic Obstructive Pulmonary Disease (COPD)

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PASSPORT ADVANTAGE DISEASE MANAGEMENT

• Program design
• Member Identification
• Staffing
• Member interventions
• Provider interventions

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QUESTIONS ANSWERS
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WORKSHOP SURVEY

• In your packet is the workshop survey, please
  take a moment to complete.