North Carolina Health Insurance Institute

Greensboro, NC
October 4-5, 2012
North Carolina Health Insurance Institute
About MedCost
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Over 29 years of experience providing employers
throughout the Carolinas with the best access to the best
health care through our PPO network and health
management programs.
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Based in Winston-Salem, NC, and provider owned by
Carolinas HealthCare System and Wake Forest Baptist
Health
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Serve both self-funded and fully-insured plans nationally
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MedCost Objective
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Design managed care programs that bring value to all of
our partners– providers, claim administrators, employers,
and members.
– Provide employers with a flexible and cost effective health
care option allowing market diversity
– Retain freedom of choice and ease of access to providers
– Offer programs that focus on the highest standards of quality
and member care
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Products and Services
PPO
Network
Over 3,200 employer groups representing over 600,000 covered lives
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Health Management
Utilization Management
Case Management
SmartStarts Maternity Management
Personal Care Management Nurse Coaching
Over 250,000 covered lives
Claim Administrators
Over 100 payer organizations, including MedCost Benefit Services, a wholly‐owned subsidiary of MedCost, LLC
MedCost Preferred PPO
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A Preferred Provider Organization (PPO) is a network of
selected health care providers, including physicians,
hospitals, home health agencies, and other ancillary
providers
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MedCost Preferred is the largest independent PPO in the
Carolinas
– A network of more than 40,000 healthcare providers marketed
to employers by Third Party Administrators (TPAs) and
insurance companies
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A PPO is a network of providers and not an insurance plan
Plan design will vary by individual employer group
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Online Resource Tools
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No registration required
– Provider Manual
– Provider Directory
– Listing of claim administrator Web Sites for Online Claim Status
– Provider Connection Newsletter- Formal notification of Policy
and Procedure changes within MedCost
– Monthly Educational Teleconference
– Electronic Claim Submission Information
– Legislative News
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www.medcost.com
Click on Physicians & Providers
www.medcost.com
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Online Resource Tools
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Registration required- requires one Account Administrator to set up
unlimited staff accounts
– Reference Guide
– Claims Repricing Inquiry
– Provider Claim Activity Report
www.medcost.com
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Click on Physicians & Providers
Web Applications Reference Guide
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Reference Guide
– Verify employer group names, group numbers, Utilization
Management information, and claim administrator
information.
– Verify effective or termination date of an employer group.
– Obtain eligibility phone numbers.
www.medcost.com
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Click on Physicians & Providers
Web Applications Reference Guide
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Reference Guide
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Claims Repricing Inquiry
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Claims Repricing Inquiry
– Verify receipt of claims and repricing.
– View messages from MedCost regarding claims needing
additional information.
– Connect to more than 50 claim administrators with online
resources and contact information.
– Submit additional claim information needed by MedCost so
that non-repriced claims can be updated and released to the
payer for payment consideration.
www.medcost.com
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Click on Physicians & Providers
Web Applications Claims Repricing Inquiry
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Claims Repricing Inquiry
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Claims Repricing Inquiry
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Claims Repricing Inquiry
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Claims Repricing Inquiry
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Claims Repricing Inquiry
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Claims Repricing Inquiry
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Provider Claim Activity Report
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Provider Claim Activity Report
– Create a detailed report of repriced and non-repriced claims for
a date range of up to 31 days.
– Sort, save or format report in MS Excel; report is also available
in PDF format.
– View notes regarding why a claim is in a non-repriced status.
– Identify claim administrator name and contact information for
follow up on payment status of repriced claims.
– Claims processed by MedCost today are available via our
Web site on the next business day.
www.medcost.com
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Click on Physicians & Providers
Web Applications Provider Claim Activity Report
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Provider Claim Activity Report
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Provider Claim Activity Report
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MedCost Credentialing
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CAQH Providers – Advantages of Participation
– No Fee
– Standard Application
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Universal Provider Datasource®
– Quarterly Updates
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Update attestation statement
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Verification of file accuracy
– CAQH Web site at www.CAQH.org
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MedCost Credentialing
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Access To Provider Application
– Authorization granted to MedCost
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New Practices who have been accepted for recruitment
– MedCost Provider Notification Form
– North Carolina provider requirement- attestation
statement
– Submit CAQH ID by [email protected]
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MedCost Credentialing
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Non-CAQH Providers
– Submit Application
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Email- [email protected]
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Fax- (336) 970-2139
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Mail- MedCost, LLC
Attn: Credentialing Department
P.O. Box 25347
Winston-Salem, NC 27114-5347
MedCost Credentialing
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Claims Filing
– Do not submit claims until you receive notification that the provider
is in network with an effective date
– Notification that credentialing is complete is not the effective date;
a separate notification will be sent to provider via US Mail.
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Physicians Completing Residency
– Residency completion within 90 days
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MedCost Re-credentialing
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Participating providers are re-credentialed every three (3) years
Advanced notification sent to providers
– Avoid network disruption/termination and claims processed as out
of network
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Recredentialing is considered to be complete unless otherwise
notified.
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Adding a New Provider to your Practice
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To add a Provider to a practice already participating in the
MedCost Preferred Network:
– Go to www.medcost.com
– Click on Physicians & Providers portal
– Select “Join Our PPO Network”
– Select “Participating Practice Wishing to Add a New Provider” and
complete the form
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Demographic Changes
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Notify MedCost of any changes in demographic information
prior to the effective date of the change.
– Ensures claims are processed correctly and promptly.
– Ensures most current information is provided to patients and
claim administrators.
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Go online to www.medcost.com, select the “Physicians &
Providers” portal, select “Demographic Changes, and
complete the form.
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Fax written notification of any changes to (336) 970-2199.
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MedCost Health Management
Web Application
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Health Management Web Application
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Online Certification for MedCost Health Management
– Available at www.medcost.com
• requires registration and password
• designate an Account Administrator who can then establish staff
accounts for others needing access
– Client Query - allows you to enter a company name or group number
to identify if MedCost handles utilization review. If the company has
outpatient review, it allows you to access a list of outpatient procedures
requiring certification.
– Certification Status Query - allows you to enter a MedCost
certification number or patient demographic to verify if the patient’s
service has been certified.
– Online Web Certification - allows you to initiate a certification,
review an established certification, or complete a concurrent review.
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Health Management Web Application
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Health Management Web Application
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Health Management Web Application
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MedCost Customer Service
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Customer Service Contact Center
– 800-824-7406
– Call to verify provider participation status
– Call for other general administration questions
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Conclusion
Thank You for Attending
We Appreciate Your Participation in the
MedCost PPO Network
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