providernews - INTotal Health

PROVIDERNEWS
Second Quarter 2015 • www.intotalhealth.org •
Help Medicaid Members
Exercise Their Right to Choose!
TABLE OF CONTENTS
1 Help Medicaid Members Exercise Their
Right to Choose!
2 Expedite Your Corrected Claims and
Reconsiderations
2 Medicaid Member Billing Rules
. 3 Update Your Directory Information
.
3 . Provider Satisfaction Survey Results
4 Formulary Changes Effective June 15
. 4 INTotal Health’s Preparation for ICD-10
4 Correct Code for Dental Varnish
. 5 Welcome Back Amy Robards!
5 Additions to the Provider Relations
Team
6 Provider Education Resource Now
Available Online
O
pen Enrollment in Northern Virginia begins July 1 and continues
through Aug 31. This is the time when Medicaid enrollees can
exercise their right to choose a health plan.
Do you or your staff have questions about the Medicaid enrollment
process? We can help explain the following:
• How to switch MCOs
• Where patients can apply for Medicaid
• The number to call to apply or switch MCOs over the telephone
We can provide you with paper Medicaid applications and locations to
submit them as well as information about how to apply online. We can
even come to your office and answer patient questions.
Call us at 1.800.231.8076. We’re here to help!
Open Enrollment Highlight:
INTotal Health Medicaid
Bus Tour — We’re coming to a city near you!
Our Fun Bus will tour different cities throughout Northern Virginia
during Open Enrollment. The stops will include fun family events where
our on-site staff will answer questions about the Medicaid enrollment
process and INTotal Health. We will also have:
• Fun, interactive games and activities for the kids
• Healthy snacks
• Lots of information for adults
• Free giveaway items
If you’d like us to stop by your office, let us know. Help
us help your patients to exercise their right to choose a
health plan.
Expedite Your Corrected Claims
and Reconsiderations
T
o ensure your corrected claims and
reconsiderations are processed timely, please
attach the corrected claims/reconsideration
request form to your claim resubmissions. For your
convenience, you will now have the ability to download
the form online at https://provider.intotalhealth.org. Also
remember to indicate the appropriate frequency code on
your corrected claims as explained below:
A corrected CMS-1500 should be submitted with the
form, appropriate resubmission code (value of 7) in Box
22, the original claim number and a copy of the original
Explanation of Payment (EOP). EDI 837P data should
be sent in the 2300 Loop, segment CLM05 (value of 7)
along with an additional loop in the 2300 loop, segment
REF*F8* with the original claim number for which the
corrected claim is being submitted.
A corrected UB-04 should be submitted with the form,
appropriate resubmission code in the third digit of the bill
type (for corrected claim, this will be 7), the original claim
number in Box 64 of the paper claim, and a copy of the
original EOP. EDI 837I data should be sent in the 2300
Loop, segment CLM05 (with value of 7) along with an
additional loop in the 2300 loop, segment REF*F8* with
the original claim number for which the corrected claim is
being submitted.
If a corrected claim is submitted without this information,
the claim will be processed as a first-time claim and may
M
INTotal Health
PO Box 5448
Richmond, VA 23220-5448
This process is for correcting denied claims only, not
correcting claims rejected by the clearinghouse.
Providers do have an option to file a formal Appeal with
the Health Plan and can use the downloadable Provider
Payment Appeal form located online at:
http://bit.ly/1GcsFI8.
Additional information on Corrected Claims,
Reconsiderations, and Payment Appeals may be found
in your Provider Manual located at: http://provider.
intotalhealth.org/uploads/files/2014_Provider_Manual.pdf
link or by calling Provider Relations at 1.800.231.8076.
Medicaid Member Billing Rules
edicaid members may never be billed for balance
amounts above the contracted amount paid for
covered services other than co-pays for FAMIS
members. Providers are not allowed to balance bill a
Medicaid member for:
• Failure to follow pre-authorization requirements
• Failure to submit a claim in a timely manner, including
claims not received by us
• Submission of an incomplete or incorrect claim
• Failure to submit a corrected claim within the timely filing
resubmission period
• Failure to appeal a medical necessity review decision
within 30 days of a coverage denial notice
• Failure to appeal a claim payment within the 90-day
administrative payment appeal period
• Errors made in claims preparation, claim submission, or
the appeal process
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deny as a duplicate. Corrected claims must be received
within 180 days from the date of service (or per the timely
filing provisions in the provider contract) and mailed to:
If you choose to provide our members with services
that are not covered by INTotal Health or that have
been denied as not medically necessary, you must
tell the member before providing the service that the
cost of non-covered services will be charged to them.
Also, before providing the service, you must get written
acknowledgement signed by you and the member stating
that the member:
1. Requests the service and
2. Will be responsible for payment of non-covered
services.
Additional information may be found in your Provider
Manual at: http://provider.intotalhealth.org/uploads/
files/2014_Provider_Manual.pdf or by calling Provider
Relations at 1.800.231.8076.
Update Your Directory Information
• Call Provider Relations at 1.800.231.8076, or
• Complete our Provider Data Update Form by visiting
http://provider.intotalhealth.org/ and clicking the
following links: Provider Resources & Documents, Forms,
and then Provider Data Update Form.
You may fill out the form online, and then print and either
fax or mail to us at:
INTotal Health,
Attention, Provider Data Team
3190 Fairview Park Drive, Suite 900
Falls Church, VA 22042
Fax: 1.888.881.6166
W
e want to ensure our Provider Directory
accurately reflects our providers’ demographic
information — including yours! If you have not
updated your practice information in the last six months,
or if you have moved, opened a new office, or have any
other change to your information, please let us know by
doing one of the following:
Thank you for taking the time to update your current
information.
Provider Satisfaction Survey Results
W
e conduct surveys to find out how we’re doing
in meeting your needs and to learn how we
can continue to improve. Our 2014 results
show that 83 percent of providers surveyed are satisfied
with INTotal Health. In addition, nine in ten of survey
respondents said they would recommend our health
plan to other providers. We received our highest ratings
in the areas of Claims Processing and Communication &
Technology. We also received overall positive scores for
quality service provided by our Provider Relations and
Provider Service Center Representatives.
We recently added a Director of Pharmacy who updates
our online formulary once a quarter. We have worked
to streamline our pre-authorization request processes
and have improved our turnaround time by 46 percent.
We’ve also added a Certified Credentialing Professional
and partnered with a Credentialing Verification
Organization, resulting in a 50 percent improvement in
our credentialing turnaround time.
We are actively conducting outreach to increase member
engagement in wellness programs. Our initiatives
include a monthly focus on the Healthcare Effectiveness
Data and Information Set (HEDIS) measures and we’re
reminding members of important preventive care exams.
In the past year, we’ve increased functionality of our
website (www.intotalhealth.org) to include online claims
submission, online panel rosters, and important news
such as drug recalls. We also launched our Facebook
and Twitter applications as another way to connect
with providers, community partners, and members.
Our survey results also identified areas of opportunity
including ease of obtaining drug formulary information
and pre-authorizations, improving the re-credentialing
process, and increasing member understanding of
preventative
care and
wellness
programs.
We always appreciate your feedback, so please do not
wait for next year’s survey to share your thoughts. Please
contact Provider Services at 1.855.323.5588, Provider
Relations at 1.800.231.8076, or submit your ideas via our
website. Thank you for your continued partnership in
optimizing the health and well-being of the members we
serve!
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Formulary Changes Effective June 15
W
e update our formulary quarterly and post changes on our website: www.intotalhealth.org. To request
prior authorization of any of the drugs on our formulary that require it, fax us a completed Caremark Prior
Authorization Form located at the following: http://bit.ly/1FkpPNi. The formulary changes are listed below and on
www.intotalhealth.org:
Products added with a quantity
limit (QL):
• Striverdi AER Respimat
Products added to Specialty:
• Triumeq
Products added to Specialty with
prior authorization (PA):
• Sovaldi
• Harvoni
Products removed from formulary:
• Premphase
• Prempro
• Serevent Diskus
• Tazorac cream and gel
• Elidel cream
• Pred-Mild suspension
• Betoptic-S suspension
• Zyvox tablets
• Oxycodone 20mg tab
• Oxycodone 30mg tab
• Ortho Tri-Cyclen Lo
• Fexofenadine suspension and
tablets
• Cetirizine chewable tablets
Product changes:
• Suboxone Film – now PA and QL
(3/day)
• Buprenorphine/naloxone SL tablets
– now PA and QL (3/day)
• Lidocaine patch – now PA and QL
(2/day)
• Blood glucose monitoring test
strips (Freestyle and Precision
products are formulary) – now QL
(100/30 days)
• Fentanyl Patches – maximum total
dose of 200mcg/hr
INTotal Health’s Preparation for ICD-10
I
Please remember:
• ICD-10-CM is the diagnosis code set that will replace ICD9-CM Volumes 1 and 2 and will be used to bill for diagnosis
codes in all clinical settings. ICD-10-PCS is the procedure
code set that will replace ICD-9-CM Volume 3 and will be
used to bill for hospital inpatient procedures.
• Upgrading to ICD-10 is not optional; the Centers for
Medicare and Medicaid Services (CMS) require that all
healthcare payers, providers and clearinghouses make the
transition to the new codes effective Oct. 1, 2015.
•
The original form is red and white
CD-10 (International Classification of Diseases, 10th
Edition) codes will go into effect on Oct. 1, 2015. The
INTotal Health team’s preparation for the implementation
includes in-depth testing. It is important to remember that
for dates of service starting on Oct. 1, 2015, only claims
coded with ICD-10 can be accepted. ICD-9 codes will no
longer be accepted for dates of service after Oct. 1. If you
have a claim that includes dates of service both before
and after Oct. 1, 2015, you will need to submit two claims.
One claim form will not be able to accommodate both
ICD-9 and 10 codes. Additional information regarding
ICD-10 coding may be found on the Centers for Medicare
& Medicaid Services (CMS) website (www.cms.gov/ICD10)
and the American Medical Association website
(www.ama-assn.org).
ICD-10 codes will not replace Current Procedural
Terminology (CPT) or Healthcare Common Procedure
Coding System (HCPCS) codes.
If you have any additional questions, please contact
Provider Services or your Provider Relations
representative.
T
he correct code for Dental Varnish is now 99188. D1206 will no longer be accepted for dates of
service on or after March 1, 2015.
4⊳
Welcome Back Amy Robards!
A
my Robards returns to INTotal Health as the Director of Operations.
Robards has a wealth of healthcare leadership experience, including
claims operations, call centers, benefit administration, provider
data, project and vendor management, process improvement and system
implementation gained in her years at INTotal and in organizations including
Anthem, WellPoint (Lumenos), Amisys, and United Health.
Additions to the Provider Relations Team
V
icki Thompson joins the Provider Relations team as the Manager of PR. She comes to
INTotal Health with more than 10 years of experience in managed care working with
United Healthcare, MAMSI and HealthSouth. Thompson’s previous roles have included
management positions in provider relations, contracting, and network development. This
background will be an asset as she works with the Northern Virginia Provider Relations team
to assess our current network needs and strengthen relationships with our provider network.
L
ili Elling is the newest Provider Relations Representative to join the PR team. Most recently, she
worked as a Patient and Community Relations Specialist at the University of North Carolina,
School of Pediatric Dentistry where she helped patients and their families receive dental care
and establish relations with dental providers throughout the state. Elling has also worked as an
Information Specialist for the National Institute on Aging and the Alzheimer’s disease Education
and Referral Center where she supported a bilingual information clearinghouse for the elderly
and Alzheimer’s patients and families. She has a Bachelor’s degree in Public Relations from the
University of Panama in Panama City, Panama.
Welcome to
Your New Role
⊲5
NON PROFIT
U.S. POSTAGE PAID
PERMIT #2469
MERRIFIELD, VA
T
Provider Education Resource
Now Available Online
he new Provider Education Resource on www.intotalhealth.org allows INTotal Health providers the ability to
view the updated INTotal Provider Orientation online at their convenience. This presentation gives a complete
overview of INTotal Health, including member benefits, billing instructions, reference tools, and forms. Check it
out today!
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