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PASSPORT HEALTH PLAN HOSPITAL WORKSHOP NOVEMBER 2005

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Passport Health Plan Web Site. www.passporthealthplan.com. Passport Health Plan ... PHP has partnered with Emdeon (formerly WebMD) and HDX clearinghouses. ... – PowerPoint PPT presentation

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Title: PASSPORT HEALTH PLAN HOSPITAL WORKSHOP NOVEMBER 2005


1
PASSPORT HEALTH PLAN HOSPITAL WORKSHOPNOVEMBER
2005
2
WELCOME
3
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

4
PROVIDER RELATIONS
  • Becky Bowman (502) 585-7971
  • Dell Fraze (502) 585-8245
  • Kim Miller (502) 585-8246
  • Jason Mingus (502) 585-7951
  • Kim Richards-Farley (502) 585-8348
  • Vonda Sickles (502) 585-7902
  • Julia Walls (502) 585-7920
  • Carmen Williams (502) 585-7988
  • Jeri Cross, Manager (502) 585-8356

5
IMPORTANT CONTACT INFORMATION
  • Provider Services
  • (800) 578-0775
  • Provider Relations (General)
  • (502) 585-7943
  •   
  • IVR Phone Number
  • (800) 578-0775 Option 1
  •  
  • Provider Claims Service Unit (PCSU)
  • (800) 578-0775 Option 2
  •  
  • Passport Health Plan Web Site
  • www.passporthealthplan.com
  •  
  • Passport Health Plan Provider Manual
  • http//www.passporthealthplan.com/providercenter/
    providercom/index.asp

6
WHATS NEW?

7
REMITTANCE ADVICE ENHANCEMENTS
  • Effective March 2005, the Payment Reduction
    Summary of the Remittance Advice includes
  • Original date of service
  • Check date
  • Check number

8
ELECTRONIC REMITTANCE ADVICE (ERA)
  • To register, please contact Emdeon (formerly
    WebMD) or HDX Clearinghouses.
  • Emdeon (800) 845-6592
  • HDX Clearinghouse (610) 219-1825

9
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.
10
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.

11
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12
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

13
CLAIMS ADDRESSES
  • Family Planning
  • AmeriHealth Family Planning
  • Attn Claims
  • PO Box 42476
  • 1901 Market Street, 29th Floor
  • Philadelphia, PA 19101-2476

14
ELECTRONIC CLAIMS SUBMISSION
  • PHP has partnered with Emdeon (formerly WebMD)
    and HDX clearinghouses. Providers may also
    contact their own vendor.
  • Emdeon Sales Department (800) 845-6592.
  • 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.

15
PREVENTING DENIALS
  • Duplicate claim
  • Eligibility
  • Timely filing
  • Invalid diagnosis
  • EOB incomplete

16
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.

17
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.

18
ID CARD KYHEALTH (Medicaid)
19
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.

20
PHP ID CARD
21
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

22
TIMELY FILING
  • Original Claim Filing 180 days
  • For Correction of Claims 2 years

23
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.

24
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.
25
EOB ILLEGIBLE/INCOMPLETE
  • EOB copies must be clear and legible. Light
    copies will not scan.
  • Remark code pages must be included.

26
Passport Health PlanUtilizationManagement
27
UTILIZATION MANAGEMENT
  • Goal
  • Purpose
  • Staffing
  • RNs
  • Intake Coordinators
  • Medical Directors

28
UTILIZATION MANAGEMENT
  • Referrals
  • Prior Authorization
  • Review Criteria
  • - Milliman USA Care Guidelines
  • - InterQual Level of Care Rehab Criteria
  • - Medical Policies
  • Retrospective Review

29
UTILIZATION MANAGEMENT
  • Denials
  • - Administrative
  • - Medical
  • Appeals
  • - Administrative
  • - Medical
  • Member
  • Provider
  • -Expedited

30
IMPORTANT CONTACT INFORMATION
  • Toll-free telephone number is
  • (800) 578-0636
  • 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

31
iEXCHANGE WEB
32
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 (502) 585-8224 for more information.

33
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34
CASE MANAGEMENT
35
CASE MANAGEMENT
  • What is Case Management?
  • Goal
  • Purpose
  • Benefits
  • Staffing
  • RNs
  • Social Workers

36
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

37
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

38
IMPORTANT CONTACT INFORMATION
  • Toll-free telephone number is
  • (800) 578-0636 ext. 7915
  • Hours of operation are
  • Monday Friday 800 am-500 pm except
    designated holidays and weekends

39
HEALTH AND DISEASE MANAGEMENT
40
ASTHMA AND DIABETES DISEASE MANAGEMENT
  • Program design
  • Member Identification
  • Staffing
  • Member interventions
  • Provider interventions

41
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

42
MOMMY AND ME PERINATAL HEALTH PROGRAM
  • Program design
  • Member Identification
  • Staffing
  • Member interventions
  • Provider interventions

43
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

44
BREAK
45
PASSPORTADVANTAGE
46
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.

47
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.

48
PASSPORT ADVANTAGE SPECIAL NEEDS PLAN
Members Eligible to Participate
49
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)

50
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

51
PAD ELIGIBILITY
52
PASSPORT ADVANTAGE CLAIMS, BILLING
REIMBURSEMENT
53
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.

54
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

55
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.

56
BILLING REQUIREMENTS
  • UB-92
  • CMS-1500

57
CLINICAL EDITS
  • January 1, 2006
  • Claim Check (McKesson)
  • Future
  • NCCI

58
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

59
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

60
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

61
CLAIM PAYMENT SCHEDULE
  • Payment will be generated weekly on
  • Wednesdays.

62
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.

63
IMPORTANT CONTACT INFORMATION
  • Provider Claims Service Unit (PCSU)
  • (800) 578-0775
  • Provider Relations (General)
  • (502) 585-7943
  • Utilization Management
  • (800) 578-0636
  • Emdeon (formerly WebMD)
  • (800) 845-6592
  • 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.

64
PASSPORT ADVANTAGE UTILIZATION MANAGEMENT
65
UTILIZATION MANAGEMENT
  • Goal
  • Purpose
  • Staffing
  • RNs
  • Intake Coordinators
  • Medical Directors

66
UTILIZATION MANAGEMENT
  • No Referrals
  • Prior Authorization for specific services
  • Review Criteria
  • - InterQual Level of Care Criteria
  • - Medical Policies
  • Retrospective Review

67
UTILIZATION MANAGEMENT
  • Denials
  • -Medical
  • Appeals
  • - Member
  • - Provider

68
IMPORTANT CONTACT INFORMATION
  • Toll Free telephone number is
  • (800) 578-0636
  • 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

69
PASSPORT ADVANTAGE CASE MANAGEMENT
70
CASE MANAGEMENT
  • What is Case Management?
  • Goal
  • Purpose
  • Who benefits from Case Management
  • Staffing
  • RNs
  • Social Workers

71
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

72
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

73
IMPORTANT CONTACT INFORMATION
  • Toll-free telephone number is
  • (800) 578-0636 ext. 7915
  • Hours of operation are
  • Monday Friday 800 am- 500 pm except
    designated holidays and weekends

74
BEHAVIORAL HEALTHCARE COORDINATION
75
BEHAVIORAL HEALTHCARE COORDINATION
  • What is Behavioral Health Care Coordination?
  • Goal
  • Purpose
  • Benefits
  • Staffing
  • RNS
  • Social Workers

76
BEHAVIORAL HEALTHCARE COORDINATION
  • Member identification
  • - Health Risk Assessment upon
    enrollment
  • - Provider referrals
  • - Member referrals
  • - Facility referrals
  • - Internal Plan referrals

77
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

78
BEHAVIORAL HEALTHCARE COORDINATION
  • No referrals required
  • Prior authorized services include
  • Behavioral health and substance abuse inpatient
    admissions
  • Home health services

79
IMPORTANT CONTACT INFORMATION
  • Toll-free telephone number is
  • (800) 578-0636
  • Hours of operation are
  • Monday Friday 800 am - 500 pm except
    designated holidays and weekends

80
  • PASSPORT ADVANTAGE DISEASE MANAGEMENT

81
PASSPORT ADVANTAGE DISEASE MANAGEMENT
  • Diabetes
  • Coronary Artery Disease (CAD)
  • Chronic Obstructive Pulmonary Disease (COPD)

82
PASSPORT ADVANTAGE DISEASE MANAGEMENT
  • Program design
  • Member Identification
  • Staffing
  • Member interventions
  • Provider interventions

83
QUESTIONS ANSWERS
84
WORKSHOP SURVEY
  • In your packet is the workshop survey, please
    take a moment to complete.
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