PASSPORT HEALTH PLAN DME

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PASSPORT HEALTH PLAN DME HOME HEALTH
WORKSHOPNOVEMBER 2005
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WELCOME
3
AGENDA

• Welcome and Introductions Jeri Cross
• Passport Health Plan
• Whats New?
  Kim Richards-Farley
• Claims Billing
  Kim Richards-Farley
• Utilization Management Randy Simmons
• BREAK
• Passport Advantage
• Overview
  Marcelline Coots
• Eligibility ID Cards
  Marcelline Coots
• Claims,Billing Reimbursement Pam
  Norris/Linda Young
• Utilization Management Randy
  Simmons
• 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 began submitting behavioral health
  prescriptions through PHPs pharmacy benefit
  manager, PerformRx.

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DENIED CLAIMS REPORT

• Designed to help reduce denied claims by
  assisting the Plan in identifying opportunities
  for improving our claim processing system and
  procedures as well as allowing providers to
  recognize and correct billing errors.
• 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

• Passport Advantage
• P.O. Box 69325
• Harrisburg, PA 17106-9325

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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.

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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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DMEHOME HEALTHHOME INFUSION
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DME
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DURABLE MEDICAL EQUIPMENT

• Purpose
• Goal
• Prior Authorization is required for
• DME services greater than 500.00.
• Rental and/or purchase of DME items with a
  billable amount of 500.00 or greater for a one
  month supply.
• All items requiring customization or accessories.
• Rentals and/or purchase of DME items with a
  billable less than 500.00 do not require
  authorization.

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IMPORTANT CONTACT INFORMATION

• Hours of operation for DME staff are
• Monday Friday 800 am 430 pm
• (except designated holidays and weekends)
• The DME area receives request for service via fax
  at
• [phone]

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HOME HEALTH
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HOME HEALTH

• Purpose
• Goal
• Prior Authorization is required by
• Calling Utilization Management at [phone].
  
• Subsequent requests should be faxed to (502)
  585-7990.

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number for Home Health
  prior authorization is
• [phone]
• Hours of operation are
• Monday Friday 800am 430pm
• (except on holidays and weekends)
• Requests for continued service for Home
  Health should be sent via fax to [phone].

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HOME INFUSION
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HOME INFUSION

• Purpose
• Goal
• Prior Authorization is required by
• Calling Utilization Management at [phone].
  
• Subsequent requests should be faxed to (502)
  585-7990.

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IMPORTANT CONTACT INFORMATION

• Hours of operation for Home Infusion are
• Monday Friday 800 am 430 pm
• (except designated holidays and weekends)
• Requests for continued service for Home
  Infusion should be sent via fax to [phone].

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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 Passport Advantage applications
  accepted for dual-eligible Passport Health Plan
  members not included in the one time enrollment
• 11/15/05 Passport Advantage web site 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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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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CLAIM PAYMENT SCHEDULE

• Payment will be generated weekly on Wednesdays.

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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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IMPORTANT CONTACT INFORMATION

• Provider Claims Service Unit (PCSU)
• [phone]
• Provider Relations (General)
• [phone]
• Utilization Management
• [phone]
• Emdeon (formerly WebMD)
• [phone]
• Passport Advantage Web site
• 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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• DURABLE MEDICAL EQUIPMENT HOME HEALTH
• HOME INFUSION

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• DME

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DURABLE MEDICAL EQUIPMENT

• Purpose
• Goal
• Prior Authorization is required for
• DME services greater than 500.00.
• Rental and/or purchase of DME items with a
  billable amount of 500.00 or greater for a
  months supply.
• All items requiring customization or accessories.
• Rentals and/or purchase of DME items with a
  billable less than 500.00 do not require
  authorization.

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IMPORTANT CONTACT INFORMATION

• Hours of operation for DME staff are
• Monday Friday 800 am 430 pm
• (except designated holidays and weekends)
• The DME area receives request for service via fax
  at
• [phone]

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• HOME HEALTH

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HOME HEALTH

• Purpose
• Goal
• Prior Authorization is required by
• Calling Utilization Management at [phone].
  
• Subsequent requests should be faxed to (502)
  585-7990.

63
IMPORTANT CONTACT INFORMATION

• Toll-free telephone number Home Health prior
  authorization is
• [phone]
• Hours of operation are
• Monday Friday 800am 430pm
• (except on holidays and weekends)
• Requests for continued service for Home
  Health should be sent via fax to [phone].

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HOME INFUSION
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HOME INFUSION

• Purpose
• Goal
• Prior Authorization is required by
• Calling Utilization Management at [phone].
  
• Subsequent requests should be faxed to (502)
  585-7990.

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IMPORTANT CONTACT INFORMATION

• Toll-free telephone number for Home Infusion
  prior authorization is
• [phone]
• Hours of operation are
• Monday Friday 800am 430pm
• (except on holidays and weekends)
• Requests for continued service for Home
  Infusion should be sent via fax to [phone].

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PHARMACY

• Pharmacy benefits under Medicare
• Part B
• -billed by a medical provider on a CMS 1500
  send to PAD
• Part D
• -billed by Pharmacy send to PerformRx

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PHARMACY

• CO-PAYMENTS
• 1.00 for each prescription of a generic drug.
• 3.00 for each prescription of a brand drug.
• Once the member and the Medicare program (or
  certain other payers) have paid 3,600 toward the
  drug benefit in a calendar year, the member will
  not have to pay additional co-payments for the
  rest of that calendar year.

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PHARMACY

• Formulary
• To view the Passport Advantage formulary,
  visit our web site at www.passporthealthplan.com
  and link to the Passport Advantage formulary. To
  request a copy of the formulary, please contact
  the Plans PBM at [phone].

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CLOSING REMARKS

• Provider Identification Numbers
• Provider Manuals
• On-line 12/01/2005
• Will send notification when CDs/Hardcopies
  are available
• EFT/ERA
• Website

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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.