SutterSelect Administrative Manual August 2014

Transcription

SutterSelect
Administrative Manual
August 2014
Introduction
This SutterSelect Administrative Manual has been prepared as a resource for providers who are caring for members
of SutterSelect health plans. The Manual includes information about requesting prior certification, how to submit
claims, and a guide to using the SutterSelect Provider website. Please refer to the Table of Contents for a complete
listing of the sections enclosed in this Manual. This Manual may be updated as needed. Visit our website at
http://sutterselect.tpa.com for the most up-to-date information.
We hope that you find this Manual to be a valuable tool and thank you for helping to deliver quality health care to our
members.
SutterSelect Administrative Manual
i
Table of Contents
Introduction�� i
Table of Contents��ii
Background�� 1
SutterSelect Products��1
SutterSelect Provider Network��1
About UMR��1
Plan Design and Options�� 2
EPO or EPO Plus Option��2
PPO Option��2
Pharmacy�� 12
Preferred Product List (PPL)��12
Medication Reviews��12
Prior Authorization ��12
Pharmacy Network��12
Mail Order Pharmacy��12
Behavioral Health�� 13
Contact Information��13
Emergency Care��13
Online Benefits and Claim Inquiry�� 14
Member ID Cards��3
Home Page....................................................................... 14
Provider Login��15
Reset Password ��15
Navigating the Website ��16
Prior Certification�� 4
Provider Directories�� 17
Eligibility�� 3
UMR Care Management Certification Requests��4
Referrals to Specialists��4
Responsibility and Member Penalty��4
Prior Certification Request Form.................................... 5
SutterSelect EPO, EPO Plus and PPO Tier 1 Provider
Information��17
Quick Reference List�� 18
Clinical Management�� 6
Contact Information��6
Utilization Management��6
Case Management��6
Disease Management��7
Nurse Advice Line��7
Claims�� 8
Claims Submission Guidelines��8
Claims Inquiries��9
Claims Submission Address��9
Timely Filing��9
Coordination of Benefits ��9
Subrogation��9
Provider Remittance Advice��10
RA Field Explanations��11
ii
Background
SutterSelect is Sutter Health’s self-funded medical plan, developed to take the place of an outside insurance company.
Self-funding allows Sutter Health affiliates to deliver consistent medical plan coverage from year to year through
a stable, predictable medical plan. In turn, affiliates can design benefit plans, wellness programs and more with
employees and their families in mind.
SutterSelect Products
SutterSelect manages EPO and PPO self-funded medical plans for its customers. Product descriptions are detailed in
the Plan Design section on page 2.
SutterSelect Provider Network
The SutterSelect provider network includes more than 8,000 physicians, and is comprised predominately of Sutter
Health providers. Additionally, the PPO plan offers in-network providers from the broader HealthSmart Preferred
(formerly known as Interplan Health Group) network inside of California or the PHCS Healthy Directions network
outside of California.
About UMR
Sutter Health has partnered with UMR to administer the plan. UMR is the largest employee benefits third-party
administrator in the United States and is fully compliant with HIPAA requirements for health data security. The
organization serves more than 1,400 clients and more than 2 million plan members, processing over 65 million
claims each year. UMR is a subsidiary of UnitedHealthcare, a UnitedHealth Group company.
Pharmacy benefits management is provided through UMR’s service organization, OptumRx. The OptumRx
pharmacy network includes a national network of more than 67,000 community pharmacies and also offers a mail
order prescription service.
UMR is the primary contact for provider and member information and assistance with SutterSelect.
The illustration on the following page provides information about the SutterSelect medical plan options.
1
Plan Design and Options
Plan Design
EPO or EPO Plus Option
PPO Option
In-network benefits only. No coverage
for out-of-network services, except
emergencies.
In-network and out-of-network
benefits through three coverage tiers.
Out-of-pocket costs depend on which
tier (and provider network) accessed.
Able to choose a different tier each
time care is needed.
Primary Care Physician
Designation
No Primary Care Physician
requirement.*
No Primary Care Physician
requirement.
See any network provider for office
visits, including specialists.
See any network provider for office
visits, including specialists.
Network
Uses the SutterSelect network,
comprised predominantly of Sutter
Health providers.
Network access depends on tier.
Choices include SutterSelect network,
comprised predominantly of Sutter
Health providers (Tier 1), or a broader
network (Tier 2) and out-of-network
(Tier 3), which is not available for all
plans.
Costs
The lower cost medical option in terms
of monthly premium costs and out-ofpockets costs.
Higher premium cost option due to
flexibility in choosing providers. Outof-pocket expenses are higher under
Tiers 2 or 3.
*The Sutter Health Central Valley and Sacramento Sierra Region EPO plan options have a primary care physician
requirement.
2
Eligibility
It is important to verify eligibility prior to rendering services. Eligibility rules vary by plan and employer.
Eligibility can be verified by two methods:
•
Telephone: Call SutterSelect Customer Service at 866-868-2703.
Provider service representatives are available from 7:00 a.m. – 6:00 p.m. Pacific Time, Monday –
Friday.
•
Online: http://sutterselect.tpa.com.
The website provides access to eligibility information 24 hours a day, seven days a week.
Member ID Cards
Important key information and resources are highlighted on the below sample identification card. Cards may differ
slightly between plans or plan options.
Front of ID Card
Plan name
(benefits and coverage may vary
between SutterSelect plans)
Plan option
Member’s ID card will list copay
amounts for their plan option
UMR is the SutterSelect
third party administrator
Back of ID Card
Call UMR Care Management
for prior certification
866-895-3378
Claims submission information
EDI # 39026
UMR, PO Box 30541
Salt Lake City, UT 84130-0541
Provider Customer Service
866-868-2703
http://sutterselect.tpa.com
• Eligibility and claims
• Provider network directory
• General inquiries
3
Prior Certification
To obtain a prior certification determination, call the telephone number listed on the back of the member’s ID card.
A list of services requiring prior certification is available in the member’s Health Plan Summary Plan Description
(SPD). The SPD for a member can be viewed online by logging on to the provider website at
http://sutterselect.tpa.com. Most plans utilize the SutterSelect standard list of services which require prior
certification; however, a few Plans utilize a custom version. Please call SutterSelect Customer Service at 866-868-2703
or logon to http://sutterselect.tpa.com for details. Emergency services may be authorized or certified after care is
delivered. Most service requests will require submission of medical records to establish medical necessity. Requests
are also reviewed to assure they meet benefit criteria as defined by the Plan.
UMR Care Management Certification Requests
•
Telephone: Call the number on the back of the member identification card to request certification prior to
the scheduled procedure or service, in order to allow for fact gathering and independent medical review, if
necessary. Hours of operation: 7:00 a.m. – 6:00 p.m. Pacific Time, Monday – Friday.
•
Fax: Complete the request form (a sample of the form is on the next page) and fax with pertinent medical
records to 866-754-9428.
•
Online: An online request form can be completed at http://sutterselect.tpa.com. From the “MyMenu” tab on
the left side of the screen select “Get preauthorization” to begin the online process.
Request Response
• UMR Care Management will contact your office via telephone or letter with the certification number, if
approved.
•
If more information is needed, you will be contacted for requested records needed to make the medical
necessity determination.
•
If the request is denied, you and the member will receive a written notice, including appeal rights and
process.
•
Request turnaround time frames:
o Concurrent Urgent – 24 hours
o Pre-service Urgent – 72 hours
o Pre-service Non-urgent – 15 days
o Post-service – 30 days
Referrals to Specialists
Most SutterSelect plans offer the ability for members to see any provider within the network, including specialists,
without a referral. Refer to the member ID card to determine if the member’s plan has a Primary Care Physician
(PCP) designation, in which case specialty care must be coordinated through the PCP listed on the card.
Responsibility and Member Penalty
Providers need to submit requests for prior certification on behalf of members. Failure to obtain prior certification
will result in a financial penalty for the member. This penalty does not apply to emergency services.
Emergency service is any otherwise covered service that a prudent layperson with an average knowledge of health
and medicine would seek if he/she was having serious symptoms and believed that without immediate treatment his/
her health would be put in serious danger, his/her bodily functions, organs or part would become seriously damaged
or would seriously malfunction.
4
prior certification request
Requesting Provider Information
Patient Information
Provider Name
Patient Name
Tax ID Number
Date of Birth
Provider Specialty
Address
Address
City, State & Zip
City, State & Zip
Phone #
Contact Name
Member ID #
Phone #
Fax #
Group #
diagnosis
Current Diagnosis
ICD-9 Code(s)
Comments
Complete the applicable section below.
office services
Referred to Provider Name
Number of Visits Requested
Inpatient or outpatient services
Facility Name
Facility TIN (Optional)
Address
Phone #
City, State & Zip
Fax #
Date of Procedure
Estimated Length of Stay (Inpatient Only)
Procedure
CPT Code(s)
other services
Referred to Provider Name
Type of Service
Number/Frequency of Services
Code(s)
Comments
Medical documentation is required.
Please fax completed form to 866-754-9428.
5
Clinical Management
SutterSelect contracts with UMR Care Management, to provide telephonic clinical management programs. There is
no fee to patients or providers for these programs.
Clinical Management services include:
•
Utilization Management
•
Case Management
•
Disease Management*
•
Health Information
•
Independent Medical Review
Contact Information
•
Telephone: Call 866-895-3378, 5:30 a.m. – 7:00 p.m. Pacific Time, Monday – Friday
Utilization Management
Prior Certification Review
The prior certification review process is outlined in the Prior Certification section on page 4.
Concurrent Review
Concurrent review provides review of medical necessity and level of care for members while they are accessing
services in the hospital inpatient, acute rehabilitation, skilled nursing facility or home health setting.
Independent Medical Review (IMR)
IMR provides clinical review and determinations for medical necessity by independent clinical reviewers. IMR also
manages the appeals process and investigational treatment requests.
Case Management
Case Management provides authorization, discharge planning and care coordination for complex and high dollar
cases including organ/tissue transplants and high risk neonates. Care and benefits are coordinated across the
continuum of care.
* Disease management services are provided by Sutter Care Management for the Sutter Health Central Valley and Sacramento Sierra Regions
and Sutter Health Support Services Plans. Call 800-544-1808, 9:00 a.m. – 4:30 p.m. Pacific Time, Monday – Friday or email
[email protected] for information.
6
Clinical Management
Disease Management
Patients are invited to enroll in disease management programs based on claims data. Disease management case
managers provide telephonic and written education and self-management tools to patients with chronic disease
including:
•
Asthma
•
Chronic Obstructive Pulmonary Disease (COPD)
•
Congestive Heart Failure (CHF)
•
Coronary Artery Disease (CAD)
•
Diabetes
•
Depression
•
Hypertension
Disease management services for the Sutter Health Central Valley and Sacramento Sierra Regions and Sutter Health
Plans are provided by Sutter Care Management. Call 800-544-1808, 9:00 a.m. – 4:30 p.m. Pacific Time, Monday –
Friday or email [email protected] for information.
Nurse Advice Line
NurseLineSM is an advice line for members to speak to a registered nurse regarding medical questions, information,
education and health-related concerns. It can be accessed 24 hours a day, seven days a week by calling 866-868-1320.
7
Claims
Providers are encouraged to submit claims via electronic claims submission. UMR’s EDI Claim Payer ID Number is
39026. If you wish to obtain more information about electronic claims submission, please call UMR at 866-868-2703.
Claims Submission Guidelines
All paper claims should be submitted on a standard HCFA/CMS 1500 form or UB, as applicable, and contain the
following information:
UB Forms
• Provider Name, Address and Telephone Number
• Patient Control Number
• Type of Bill
• Federal Tax ID Number
• Statement Covers Period
• Patient’s Name
• Patient’s Address
• Patient’s Birth Date
• Patient’s Gender
• Patient’s Marital Status
• Admission Date/Start of Care
• Admission Hour
• Type of Admission
• Discharge Hour
• Occurrence Span Code and Dates
• Revenue Code
• Revenue/HCPC/CPT Description
• HCPCS Rates
• Service Date
• Service Units
• Total Charges
• Non-Covered Charges
• Payer Identification
• Provider Number
• Release of Information
• Assignments of Benefits Cert. Information
• Prior Payments
• Insured’s Name
• Patient’s Relationship to Insured
• Group Name
• Insurance Group Number
• Employment Status Code
• Principal Diagnosis Code
• Admitting Diagnosis
• Principal Procedure Code and Date
• Attending/Referring Physician NPI
• Provider Representative Signature
• Date
HCFA/CMS 1500 Forms
• Patient’s full name (as printed on Health Plan ID
card)
• Patient’s date of birth
• Policyholder/subscriber, Insurance Name and ID #
(include any suffix numbers shown on the card to
assist with dependent coverage verification)
• Diagnosis (ICD-9-CM code is required)
• Date(s) of service
• CPT-4 procedure codes with description and
modifier, if applicable
• Name should be shown of PA, FNP, rendering
provider
• Referring physician’s name, if applicable
• NPI
• Federal Tax ID Number
• Information on other insurance coverage
• Prior certification number, if applicable
• Signature of provider rendering service
8
Claims
Claims Inquiries
Claims inquiries should be directed to SutterSelect’s Customer Service Line at 866-868-2703.
Claims Submission Address
UMR
PO BOX 30541
SALT LAKE CITY UT 84130-0541
Timely Filing
Complete claims are to be submitted to the third-party administrator, UMR, as soon as possible after services
are received, but no later than six months from the date of service. A complete claim means that the Plan has all
information that is necessary to process the claim. Claims received after the timely filing period has expired will not
be considered for payment.
Coordination of Benefits
Coordination of benefits (COB) applies whenever a member has health coverage under more than one plan. The
purpose of coordinating benefits is to pay for covered expenses, but not to result in total benefits that are greater than
the covered expenses incurred.
The order of benefit determination rules determine which plan will pay first (primary plan). The primary plan pays
without regard to the possibility that another plan may cover some expenses. A secondary plan pays for covered
expenses after the primary plan has processed the claim, and will reduce the benefits it pays so that the total payment
between the primary plan and secondary plan does not exceed the covered expenses incurred. Up to 100 percent of
charges incurred may be paid between both plans.
Subrogation
Claims identified as possibly accident related may pend for additional information. When these claims are identified,
a questionnaire is generated to the member asking if they received treatment for an injury or illness that may be
accident related. The member must complete and return the questionnaire by mail or fax. The member can also
respond to the inquiry by calling SutterSelect Customer Service or online at http://sutterselect.tpa.com. If there is an
indication that the claim was for an illness or injury that was not caused by another person or party, the claim(s) will
be reprocessed. If there is an indication that the claim was for an illness or injury that was caused by another person
or party UMR will reprocess the claim(s) and pursue the plan’s right of reimbursement of the medical bills paid by
the plan.
Failure by the member to return the completed questionnaire will result in denial of the claim(s).
9
Claims
Provider Remittance Advice
UMR produces weekly check runs. Provider Remittance Advices (RA) and member Explanations of Benefits (EOB)
are an integral part of finalization of the patient/physician experience. To help familiarize you with the Remittance
Advice that your office will receive, below is a key to explain each field in detail. Claim specific details are also
available to you by logging on to http://sutterselect.tpa.com.
10
Claims
RA Field Explanations
1. Remittance Advice for Period Ending: Last day of the week for the period covering claims listed on this
particular remittance advice.
2. Identifying Plan Header: Header that identifies organizational plan that patients are associated with. Header
includes name, address and return telephone number.
3. Plan Name: The plan name that patients are associated with.
4. Employer Name: The company name the patients are associated with.
5. Provider Name and Address: The provider’s name and address.
6. Federal Tax ID No.: The provider’s federal tax ID number.
7. Dates From/To: Displays the first date of service through the last date of service for the services performed.
8. Service Code: CPT/HCPCS procedure code. (Hospital charges display as 00000.)
9. Charged Amount: Total amount charged per service. (Hospital per diem charges will display on one line with
one total charge amount.)
10. Allowed Amount: Total amount of charge considered for payment.
11. Deductible: The portion of the charge applied to the patient’s deductible, if applicable.
12. Co-pay: The portion of the charge applied to the patient’s co-pay, if applicable.
13. Coinsurance: The portion of the charges applied to the patient’s coinsurance, if applicable.
14. Discount Managed Care Adjust: Includes the amount of the provider’s negotiated discount and the amount
not allowed per contracted fees. (Difference between the actual charge amount and the contracted allowable
amount.)
15. Ineligible: Amount not allowed due to plan provisions.
16. Withheld: The portion of the approved charge that is withheld based upon negotiated rates.
17. OC: Number of occurrences per line of service.
18. ANSI Code: American Standard Institute (ANSI) code provides reason why charges are not allowed.
19. Paid: Amount paid to provider per line of service. (This amount may differ from amounts paid on EOB due to
withhold amounts.)
20. Patient Responsibility: Amount the patient is responsible for paying per line of service.
21. Employee: The employee’s name. (Last name, first name, middle initial.)
22. Patient: The patient’s name. (Last name, first name, middle initial.)
23. Cert No.: The employee’s health plan identification number.
24. Account Number: The patient’s account number, submitted by the provider of service.
25. Claim Number: The internal claim control number.
26. Total: Total amounts per column.
27. The Primary Insurance Paid: If applicable, displays the total amount the patient’s primary insurance paid on the
claim.
28. Subtotal: Subtotals for columns if pages follow.
29. Provider Total: Total combined amounts for each provider, displayed on final page.
30. CP Number: Banking source code (specific to each customer).
31. Internal Number: Ten-digit internal sequence number matching remittance advice to the appropriate payment
check.
32. Plan Administrator Website Address
11
Pharmacy
OptumRx is the prescription benefits administrator for SutterSelect plan members. If you have questions or need
assistance getting prescriptions for members, you can contact OptumRx customer service, 24 hours a day, seven days
a week via:
•
Telephone: Call the OptumRx customer service center at 877-559-2955.
•
Online: www.optumrx.com
o Click the “Enter Website” link.
Preferred Product List (PPL)
SutterSelect uses a Preferred Product List (PPL) instead of a formulary. The PPL is updated twice per year. To find out
what drugs are on the PPL, contact OptumRx via telephone or check the SutterSelect provider website at
http://sutterselect.tpa.com and click the “OptumRx Preferred Product List” link under the MyTools tab.
Medication Reviews
The physicians and pharmacists who serve on the OptumRx Pharmacy & Therapeutics (P&T) Committee are
responsible for reviewing all new medications as they come to market. With each agent, they consider whether a
medication should be covered under the prescription benefit. In addition, they may recommend quantity limits and
prior authorization to ensure appropriate use.
When making a recommendation, the P&T Committee focuses on the medication’s overall health benefit as well as
the cost. The P&T Committee will consider FDA recommendations, manufacturer package labeling instructions, and
published clinical recommendations, such as the Journal of the American Medical Association (JAMA).
Prior Authorization
Contact the OptumRx prior authorization department at 866-565-7723 to begin the prior authorization process.
Pharmacy Network
The OptumRx pharmacy network includes more than 64,000 retail pharmacies nationwide. For specific information
call the customer service center or use the pharmacy finder link on the website.
•
Telephone: Call the OptumRx customer service center at 877-559-2955
•
Online: www.optumrx.com
o Click the “Enter Website” link.
Mail Order Pharmacy*
The Mail Order Program allows a member’s prescription products to be ordered through the mail service pharmacy.
Using mail order offers plan members the advantage of obtaining up to a 90-day supply of prescription products.
* The Sutter Health Central Valley Region SutterSelect mail order pharmacy program is administered through the Memorial Medical Center
Outpatient Pharmacy.
12
Behavioral Health
Optum (formerly known as United Behavioral Health) administers the Mental Health, Substance Abuse and
Chemical Dependency benefits for all SutterSelect plans.
Peninsula Coastal Region SutterSelect plan members have a second choice for Mental Health, Substance Abuse and
Chemical Dependency benefits through the SutterSelect Behavioral Health network of providers.
Call for authorization before providing inpatient or outpatient mental health or substance abuse services.
Contact Information for Optum
•
Telephone: Call Optum customer service at 855-809-2012, 24 hours a day, seven days a week.
Contact Information for SutterSelect Behavioral Health (Peninsula Coastal Region
Plan members only)
•
Telephone: Call SutterSelect Behavioral Health at 855-729-4390, 24 hours a day, seven days a week.
Emergency Care
If the member needs emergency services, you do not need to obtain prior authorization from the behavioral health
carrier prior to providing emergency care. However, you must notify the carrier within 24 hours and once emergency
care has ended, call the carrier to get authorization to provide any additional services.
13
Online Benefits and Claim Inquiry
Access information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week
by going to http://sutterselect.tpa.com. Logging on to this website provides you and your office the following:
•
Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to
whom payment was made.
•
Eligibility and benefits information, including patient specific plan information, claim submission details,
prior certification requirements and member benefit levels.
•
Contact phone numbers and an email notification form to contact a member of the UMR team with your
questions.
If you have questions or problems related to the website, please contact the UMR technical support team at
866-922-8266.
Home Page
Click: “Provider”
14
Provider Login
If you do not already have a username and logon, click “New user? Register here.” to complete the registration process
using your name and password.
Reset Password
Should you forget your password, you can select the “Forgot username or password?” option to change it.
15
Navigating the Website
You can view an online video tutorial to learn about site navigation and available features.
16
Provider Directories
Which Network a provider belongs to will determine how much a member will need to pay for certain services.
To obtain the highest level of benefits under this Plan, members need to see an in-network provider, however
SutterSelect does not limit a member’s right to choose his or her own provider or medical care. If a medical expense
is not a Covered Expense under the medical benefit plan, or is subject to a limitation or exclusion, a member still has
the right and privilege to receive such medical service at his or her own personal expense.
To find out which network a provider belongs to, please refer to the Provider Directory or call the toll free number
that is listed on the back of the member’s identification card. The participation status of providers may change from
time to time.
SutterSelect EPO, EPO Plus and PPO Tier 1 Provider Information
•
Telephone: Call the SutterSelect Customer Service Line at 866-868-2703.
•
Online: Available at http://sutterselect.tpa.com. Providers must login to view the information.
To find a mental health provider in the Optum network, go to www.liveandworkwell.com and enter the access code
“healthy.”
17
Quick Reference List
SutterSelect
866-868-2703
Customer Service
7:00 a.m. – 6:00 p.m. PST
(Providers)
Monday – Friday
Eligibility Verification
Benefit Inquiries
Claim Inquiries
Prior Certification
Provider Appeals
Pharmacy Information
Website
Benefit Inquiries
Claim Status
Eligibility Verification
Provider Directories
Claim Submission
UMR
PO Box 30541
Salt Lake City, UT
84130-0541
EDI Claim Payer ID: 39026
Care Management
866-895-3378
Utilization Review/Prior Certification
SutterSelect
Customer Service
(Members)
866-868-1320 or
18

SutterSelect Administrative Manual August 2014

Transcription

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