2016 CCQP Spring Workshop Slide Deck

Christiana Care Quality Partners
Spring Workshop
April 28th, 2016
Welcome!
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Make sure you sign in!
Practice Transformation Companies
Bathrooms
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Getting back to your car
Questions
Thanks
Introductions
Overview of Quality Partners
Douglas P. Azar
Senior Vice President of Operations, Medical Group of Christiana Care
Executive Director, Christiana Care Quality Partners and Quality Partners ACO
DISCLAIMER
This presentation is not intended to be all inclusive.
All information is fully delineated in the Provider Guide
(Provider Manual) which may be amended from time
to time by written correspondence and can be found
online at www.NaviNet.net.
MEMBERS
MEMBERSHIP IDENTIFICATION
Each member is issued an identification
card similar to this example.
TPA member identification cards are
green marbled in color.
Contact the applicable Customer Service
Team at the telephone number indicated
on the reverse side of the member’s
identification card, to verify benefits and
coverage prior to rendering services.
SAMPLE
Sample ID cards are located at
www.NaviNet.net or via the Provider
Guide (Provider Manual).
MEMBER COST SHARING
• A member’s financial liability for certain covered
services may be determined by reviewing the
member’s Schedule of Benefits located on the
Provider Service Center www.navinet.net or by
reviewing the Health Plan’s Explanation of Payment
(EOP).
MEDICAL
MANAGEMENT
REQUIRES COORDINATION
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Hospice Election
• Facilities are required to notify the Health Plan’s Home Health/Hospice
Network immediately upon a member’s decision to invoke their
hospice benefit.
Infusion Therapy Services
• Providers are encouraged to refer to their agreement for specific
information regarding the inclusion/exclusion of infusion therapy
services.
Personal Care Facility (PCF)
• Medicare/Health Plan standards do not consider a PCF an
institutionalized facility.
Laboratory and Radiology Services
Mental Health and Substance Abuse Services
HOME INFUSION
Contact the Home Health Network to initiate a request for
precertification / notification at (877) 466-3001
Mon. – Fri. 8:30am to 5:00 pm.
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Home Solutions – 800.447.4879
BioScrip – 877.409.2301
BioTek reMEDys – 877.246.9104
Pentec Health – 800.223.4376
PRECERTIFICATION PROCESS
• Who is responsible for obtaining precertification?
• Ordering physician
• What services require precertification?
• A complete listing is available by visiting
www.navinet.net
• How do I obtain a precertification?
• Simply complete the prior authorization form
• Fax to Geisinger Health Options
REQUIRES PRECERTIFICATION
The following require precertification by the Health Plan:
• Planned inpatient admission, including rehabilitation
admissions. Planned admission require pre-certification no
less than two (2) business days prior to date of admission. No
more than thirty (30) business days prior to the date of
admission.
• Skilled level of care admissions
• Home Health/Hospice Services by Home Health Provider
• Outpatient rehabilitative services (PT/OT/ST)
• Observation Services expected to exceed 23 hours require the
Participating Provider to initiate a request for precertification.
OUTPATIENT REHAB
Contact the Outpatient Rehabilitative Therapy Network to
initiate a request for precertification / notification at (800) 2709981 or (570) 271-5301 Mon. – Fri. 8:30am to 5:00pm.
Rehabilitation Benefits: (CCHS )
 30 sessions for Physical Therapy/Occupational Therapy
(combined) per Plan Year
 30 sessions for Speech Therapy per Plan Year
 36 sessions for Cardiac Therapy per Plan Year (combined
with inpatient)
OUTPATIENT REHAB
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Outpatient Rehabilitative Therapy
• Facility Outpatient Rehabilitative Therapy Services Providers
(Outpatient Rehab. Providers) are required to initiate the request for
precertification/notification through the Outpatient Rehabilitative
Therapy Network.
 Visits one (1) through twelve (12) will be automatically approved by
the Health Plan.
 Providers should utilize the Outpatient Rehab Services Form A, to
provide notification of services so the Health Plan can track
member visit accumulation.
 Visits 13 -30, the requesting PT/OT/ST provider should submit
appropriate plan of care.
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Therapy services and plan of care should meet all medical necessity
criteria.
OUTPATIENT REHAB FORM
PHARMACY
PRESCRIPTION DRUG COVERAGE
Outpatient Prescription Drug Coverage includes the use of a
Formulary and Participating Pharmacies
• The Health Plan offers prescription benefit levels which may generate
member cost sharing contingent upon the type of medication prescribed.
• Requesting approval for non-Formulary medications or Formulary
medications requiring
prior authorization, designated in the Formulary by an
t
asterisk (*) or t ( ) next to the medication name, is the responsibility of the
prescribing physician.
• Non-Formulary exception process or prior authorization can be initiated by
contacting the Pharmacy Department.
• Effective July 1, 2015 a change was made to add new prior authorization
requirements for certain medical drugs that previously did not require
authorization. Please check online for the most up to date prior authorization
information.
Geisinger Health Plan Pharmacy Department
(800) 988-4861 or (570) 271-5673
SPECIALTY PHARMACY DRUG PROGRAM
(OPTIONAL)
• The Health Plan is able to purchase certain drugs at discounted
rates through select Pharmacy Vendors passing savings on to
Members, employers and Participating Physicians.
• The use of this Drug Program eliminates your need to purchase
these drugs, thereby reducing your out-of-pocket expenses and
eliminating the need for you to submit medication claims to the
Health Plan.
• This program allows Participating Physicians two options:
• continue to “buy and bill” certain medications as usual at new
contracted rates, or
• utilize the Specialty Pharmacy Drug Program.
• More information on this Program along with the request form, can
be found on www.navinet.net.
CLAIM SUBMISSION
REQUIREMENTS
CLAIM SUBMISSION REQUIREMENTS
Timely Filing
• Initial submission of any claim must be received by the Health
Plan:
• within 120 days from the date of service for outpatient
claims; or
• within 120 days from the date of discharge for inpatient
claims.
• Any claim which the Health Plan has previously paid or denied
may be resubmitted and must be received by the Health Plan
for reconsideration:
• within 60 days from the date indicated on the EOP from the
Health Plan that the claim was paid or denied.
CLAIM SUBMISSION REQUIREMENTS
All services rendered should be reported:
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Using a UB04 or CMS1500 claim form or in an electronic
format
Include summarization by revenue code, which may
include CPT-4® and/or HCPCS procedural codes with
applicable modifiers
Include the then current ICD-9-CM diagnosis coding to the
highest level of specificity, as applicable, for all services
and procedures
Include NPI number in Box 33a of the CMS1500 Claim
Form (Refer to Provider Guide for further instructions)
CLAIM SUBMISSION REQUIREMENTS
OUTPATIENT REHABILITATION
• Outpatient Rehab. Providers are required to utilize the
applicable modifiers;
GP – services delivered under a physical therapy plan of care
GO – services delivered under an occupational therapy plan of care
GN – services delivered under a speech-language pathology plan of care
• Physical medicine/rehabilitation encounter based CPT® codes
(i.e. 92507, 97001, 97003) are designed to be reported with
one (1) unit per date of service regardless of the length of
visit/treatment time.
CLAIM SUBMISSION REQUIREMENTS
ANESTHESIA – ORAL SURGERY
• Providers should report one of the Dental CDT codes
when performing anesthesia for dental surgery services.
• Providers are required to report the applicable modifiers
when reporting anesthesia services ( AA, AD, QK, QX, QZ,
QY).
• When reporting anesthesia administration services,
the time reported should represent the continuous
actual presence of the anesthesiologist or CRNA. The
elapsed time (minutes) in Block 24G of the CMS 1500
Claim Form or electronic equivalent.
BILLING INFORMATION - MODIFIERS
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50 modifier – bilateral procedures
• Number of units = 1
• Reimbursement calculated using 150% of the Health Plan payment
schedule unless multiple surgery reduction applies
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80, 81, or 82 modifiers – assistant surgeons
• Reimbursement for PAs, CNS, and/or nurse practitioners (NP). Will be
13.6% of the physician allowed amount.
• When reporting such services, the following information must be on the
claim:
• Name of supervising physician in field 31 of the CMS 1500 form.
• Modifier AS must be submitted for these services.
• Do not submit 80, 81, or 82 to represent a non-physician assistant at
surgery.
BILLING INFORMATION - MODIFIERS
 59 Modifier – Distinct Procedural Service - used to identify
procedures/services, other than E/M services, that are not
normally reported together, but are appropriate under the
circumstances. Documentation must support a different
session, different procedure or surgery, different site or
organ system, separate incision/excision, separate lesion, or
separate injury (or area of injury in extensive injuries) not
ordinarily encountered or performed on the same day by
the same individual.
• Documentation must accompany the claim
BILLING INFORMATION - MODIFIERS
• 25 modifier - used to report a significant, separately
identifiable E & M service performed by the same provider on
the same day of the procedure or other service.
• Use 25 modifier when the E/M service is separate from
that required for the procedure and is a clearly
documented, distinct and significantly identifiable service
was rendered.
• Use 25 modifier on an E/M service on the same day as
procedure, the E/M service must have the key elements
(history, examination, medical decision making) well
documented.
BILLING INFORMATION - MODIFIERS
Example :
Patient presents for new onset of knee pain.
Provider examines the knee and “works up” the complaint to rule in/out possible
causes. Decision for treatment is a corticosteroid injection, which is performed at the
same visit.
Billed services are 99213-25 and 20610.
 This is a payable mod 25 service. Patient presents with a new problem to the
provider for which the exam and medical decision making were required to
determine if a procedure was necessary and would be tolerated versus
conservative treatment or specialist work-up.
 The exam and medical decision making was not the pre-procedural evaluation that
is considered to be included in the minor procedure and therefore, the mod 25
service was “above and beyond” that which is included in the procedure itself.
BILLING INFORMATION - MODIFIERS
 The modifier 25 modifier definition states “significant and
separately identifiable.” This refers to whether or not the
nature and amount of E/M services provided exceeded that
needed for performance of the procedure alone.
 Documentation should accompany the claim.
 Claims can be submitted initially with notes via paper
 Claims can be appealed after initial denial via online CRRF
BILLING INFORMATION - MODIFIERS
25 modifier exceptions
• When billing a vaccine and E/M combination, if modifier 25 is
on the E/M service in combination with a vaccine
administration service, there will not be an edit applied. This
decision was made in conjunction when the new NCCI edit
surfaced. There could potentially be an edit however if there
is another service performed besides the E/M and vaccine
admin such as a lesion removal or joint injection, etc.
• Claims for allergy testing that fall into range of 95004-95079
and are billed with an E/M code will not pend for Modifier
25. Allergy claims for other services such as immunotherapy,
shots, injections, etc. that are billed with an E/M code that do
not fall into the category listed above will hit the modifier 25
edit.
CLAIM EDIT
• Geisinger’ s claim edit software edits for correct coding,
Medicare based CCI edits and industry standard Mutually
Exclusive and Incidental edits. These are usually based on CPT
guidelines and Medical/Organizational recommendations.
• It is not a mirror image of CMS CCI. The Health Plan applies
edits similar to that of Medicare in regards to modifier usage.
However, the option is that Medicare assumes proper
modifier usage and audits on the back end.
The Health Plan requires this documentation on the front end.
Modifier usage does not override the edit. The payments are
then made based on the contractual agreement.
CLAIM EDIT
• Modifier 25 notes submission
– Can be submitted initially with a paper claim
– Can be submitted after the initial denial via the online
CRRF process
• Please utilize the Secure Email feature on www.navinet.net
for claim edit denial clarifications or to request a claim edit
rationale.
• Requests for the claim edit rationale must be received by the
Health Plan within 60 day from the date indicated on the
initial Health Plan EOP.
CRRF
CLAIM RESEARCH REQUEST FORM
(CRRF)
CRRF Tips
• CRRF may be submitted electronically through NaviNet
• Only submit one claim per CRRF form
• Include claim number and date of service
• Check the appropriate boxes (i.e. COB or Claim Edit)
• Requests must be received (60) days from the date
indicated on the EOP
• Health Plan has 45 days to review and process CRRFs
CLAIM RESEARCH REQUEST FORM (CRRF)
When to use a CRRF
• UA Denials (Failure to Precert Services) – Only when there is a
compelling reason why the provider failed to precert and the
dispute is within timely filing guidelines.
• Claim Edit Denials – Be sure to check the claim edit box on the
CRRF form and attach supporting documentation.
• Timely Filing Denials – Only when there is a compelling
reason for why the provider failed to submit timely.
• When information on a PAID CLAIM needs to be corrected.
For example:
Late charges, Incorrect diagnosis, Incorrect procedure code,
Incorrect revenue code, Incorrect modifier, Invalid Member ID,
Location code.
CLAIM RESEARCH REQUEST FORM (CRRF)
When NOT to use a CRRF
• Non Participating Provider
• Claim Retractions – Providers should initiate through
Customer Service or Secured Message via Web.
• When information on a DENIED CLAIM needs to be corrected.
Providers should resubmit the corrected claim through their
normal claims submission process.
• P2 or XX Denials – Questions related to provider contracts or
fee schedules should be directed to your provider relations
representative.
• Timely Filing Denials if no compelling reason exists. (COB
claims are not subject to timely filing)
• Utilization/Authorization Denials – if no compelling reason exists.
CLAIM RESEARCH REQUEST FORM
(CRRF)
CLAIM RESEARCH REQUEST FORM
(CRRF)
PRIMARY CARE PAY FOR
VALUE
PAY FOR VALUE
• Fiscal Year 2017 – Pay for Value Manual is finalized
• Member Health Alerts
– Available via NaviNet
– Data refreshed monthly
– Three month lookout
• Contact Quality Partners:
– Assistance with the remediation process
– To obtain your member panel
– To receive non-MHA related reports
• Pharmacological Care
• Medication Adherence
ELECTRONIC CAPABILITIES
INSTAMED
• Electronic Remittance
• Direct Deposit
**For those providers not registered: After June 2016
Geisinger Health Plan will no longer send payments in the
form of paper checks. Payments will be sent through the
mail in the form of Claim Payment Cards**
REGISTER
www.instamed.com/eraeft
(866) 945-7990
NAVINET
• Eligibility and benefits inquiry
• Claims
– Claim status inquiry
– Remittance advice inquiry
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Resource Center
Member Health Alerts
Network Facility Search
Prior Authorization Forms and Information
Secure Messaging
SECURE MESSAGING
COMMUNICATIONS
COMMUNICATIONS
• Geisinger Health Plan and Quality Partners have
developed a user friendly handout to help you
identify your key contacts at the Health Plan and
Quality Partners, such as:
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Claims/Customer Service Department
Medical Management
Provider Relations
• The Who To Call Card is included in your packet and
will be located on the website.
COMMUNICATIONS
Forms and Publications
Located at www.navinet.net within the Resource Center tab.
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The Provider Guide ( Provider Manual )
• An essential part of the contract between Geisinger
Health Plan and Quality Partners
Operations Bulletins
• Geisinger’s method to communicate important time
sensitive information
Briefly
• Quarterly newsletter providing useful Geisinger Health Plan news and
information about changes which affect Participating Providers
These Forms and Publications are mailed to the participating providers and
accessible online through NaviNet.
COMMUNICATIONS
Forms and Publications
Located at www.christianacare.org/qualitypartners.
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CCQP Newsletter
Board and Committees
Provider Manual
Credentialing Provider Application Packet
Primary Care Pay for Value Manual
Link to Geisinger Health Plan Provider Directory
CRRF Form
FAQ’s
PROVIDER RELATIONS
• Your Provider Relations Representative is available to assist
you with any of the following issues:
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On-Site education offered to your staff
Fee Schedules
Contract/Provider Manual Questions
Pay for Value information
Ongoing/Unresolved Issues
Demographic changes (i.e., change in
office locations, addition and/or
termination of a physician, change in Tax identification
number)
PROVIDER RELATIONS
The Quality Partners Provider Relations team
is available to answer any questions you may
have:
Martin Weitzman
Provider Relations Representative
302-623-0363
[email protected]
Angela Williams
Provider Relations Representative
302-623-0357
[email protected]
NOTIFICATION
Christiana Care Quality Partners must be notified in
writing in advance of the following demographic or
business changes:
•Addition or departure of a provider
•Tax identification number change
•Location closure/addition
•Ownership or business name change
•Remittance address change
PACKET CONTENT REVIEW
Electronic versions of the materials included in
today’s packets will be available online.
Please visit:
www.christianacare.org/qualitypartners
THANK YOU FOR YOUR
PARTICIPATION!
QUESTIONS?