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2012 Provider Orientations

2012 Provider Orientations. Network Operations. Agenda. Introduction to Networks Operations General Updates Claims Information JIVA Program The Assist Group – TAG Provider Portal Proposed Medicare Expansion Centennial Care Cultural Competency.

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2012 Provider Orientations

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  1. 2012 Provider Orientations Network Operations

  2. Agenda • Introduction to Networks Operations • General Updates • Claims Information • JIVA Program • The Assist Group – TAG • Provider Portal • Proposed Medicare Expansion • Centennial Care • Cultural Competency

  3. Provider Representatives can assist with: • - Escalated Claim Issues • - Demographic Updates • - Marketing Materials • - Keeping you informed with Lovelace updates and information • Contractors can assist with: • - Contract Requests • - Changes to Existing Contracts

  4. CIGNA • Lovelace/CIGNA relationship ceasedas of July 1, 2012 • To continue a CIGNA contract please contact any of the following • CIGNA representatives: • - Brandon: 303-729-8938 • - Rochelle: 303-305-0812 • - Pam: 303-305-0852 • - Debbie: 303-305-0719 • Cigna claims projects with dates of service prior to July 1, 2012 should be submitted to Lovelace through December 31, 2012

  5. Relationships • LHP’s preferred laboratory is: • Quest Laboratories • Phone: 866-MYQUEST or 866-697-8378 • Web:www.questdiagnostics.com/home.html • Lovelace has partnered with InSync Interpreter Services. Interpretation Services through InSync includes multi-language phone support and through request, live sign language interpretation for the deaf. • Services can be accessed by contacting Customer Care or InSync (866-501-2002). • Lovelace Salud! has an exclusive contract with Superior Medical Transportation (505-341-0042) • CareCentrix is the exclusive contractor for Network for DME and Home Health (800-866-6127); (800-700-2085, Fax). • Lovelace Health Plan coordinates with Optum Health (d.b.a. United Resources Network) to offer our members access to United Resources Network’s transplant resource services. Please call the Prior Authorization Department.

  6. Customer Care Center • You can speak with a Customer Care Center Representative Monday - Friday between 8:00 am and 5:00 pm by calling • 505-727-5406 or 800-808-7363. • Customer Care can assist with: • - Benefits - Eligibility - Claim Research • You can also access our 24-hour Interactive Voice Response (IVR) system by calling 877-480-9371 or 505-727-5378 to verify benefits or eligibility.

  7. IBAC Dedicated Service Unit • A dedicated unit has been created for members enrolled in the State of New Mexico, Albuquerque Public Schools and New Mexico Retiree Health Care Authority (NMRHCA) health plans. • To ensure your call is routed to the Dedicated Service Unit, please listen to the prompts to make the appropriate selection as they have recently changed.

  8. Website Resourceslovelacehealthplan.com/providers • Prior Authorization Information Grid • Eligibility, Benefit and Claim Status Inquiry, Prior Auth, DME Forms • Online Provider Directory • Drug Formulary • Bulletins and Newsletters • Preventive Health Guidelines for Providers • Participating Provider Application • Provider Reference Guide • Adjustment/Void Request Form • Credentialing Statewide Application • Disease Management Information • Provider Portal • (coming soon)

  9. What is HealthLink? • Telephone and web-based referral service that matches prospective patients with participating providers • Available 24-hours a day by calling 505-898-3030 • Online at www.lovelace.com/healthlink • No charge service to callers or providers • Member can be connected to the provider’s office to set an appointment

  10. Lovelace One-Call • A registered nurse is available 24/7 to assist you in finding a bed for a Lovelace member. If we are unable to place our member in a Lovelace hospital, we will assist in finding an appropriate transfer. • Direct Inpatient Admissions: • (888-727-7646) • Admissions to: Lovelace Medical Center, Lovelace Women’s Hospital, • Lovelace Westside Hospital, Lovelace Rehabilitation Hospital • CV STAT – Cardiovascular Emergency referrals and transports: • (866-287-8280) • Admission to: Heart Hospital of New Mexico at Lovelace Medical Center • Neonatal Intensive Care Unit at Lovelace Women’s Hospital: • (888-687-6428)

  11. Healthy Steps Programs • Healthy Steps Coaching: Health coaches share information on a variety of health issues, helps members understand and monitor personal health needs and work more closely with their doctors. The program also offers coaching for members with chronic conditions like diabetes, asthma, heart or lung disease. • Healthy Weight: A 10-week counseling program that focuses on lifestyle changes, this program is designed to help members develop the tools needed to achieve and maintain a healthy weight. • Stop Tobacco for Optimal Prevention (STOP): Individual telephone counseling to help members design a personalized program to stop tobacco use.

  12. Healthy Steps Programs • Baby Love: A prenatal education program to help expectant moms have a healthy pregnancy and give the best possible start in life for their baby. Members receive pregnancy and childbirth information by mail and have 24/7 access to a nurse by calling 505-727-BABY. • Healthy Trails: A health education and exam program designed to help parents track growth and development of their children from birth through their 18th birthday. • For more information contact Lovelace Health Steps at 505-727-5344 or • toll free at 877-480-9368.

  13. LHP Case Management • Case Management is a collaboration with member/family and healthcare providers to create a plan that meets a member’s complex needs and goals. • What can Case Managers do: • - Connect members with community resources to meet needs of members • - Empower and prepare members to manage and enhance their quality of life and health care resources • - Coordinate care and communication between providers, members • Contact Lovelace Case Management at: • Phone: 505-727-5168; Toll Free Phone: 800-808-7363 • Fax: 505-727-5272; Toll Free Fax: 877-894-4585

  14. Claims Submission Paper Claims Submission: Lovelace Health Plan PO Box 549 Buckeystown, MD 21717 Electronic Claim Submission: LHP Commercial/Medicare – 90328 LHP Medicaid/SCI – SX159 Timely Filing & Follow Up Limitations: - 180 days for Commercial and Lovelace Senior Plan Products - 90 days for Lovelace Salud and Lovelace SCI Products

  15. Suggestions for smoother claim processing • Please submit all lines of service on one claim submission at one time • Verify NPI on claim is for the individual practitioner rather than group and in the correct field • Modifiers: • Use appropriate modifiers when billing E&M and therapy codes on UB’s • LT/RT modifiers are not necessary for J-codes • J-codes should be billed with NDC • If more than one modifier applies, alpha modifier must be first, then numeric • Corrected claims should be mailed to Buckeystown claims address • Check status of claim before resubmitting multiple times to prevent duplicate denials/payments

  16. Jiva Provider Portal • LHP is changing to Jiva Provider Portal • The Jiva Provider Portal will be replacing the iExchange portal that’s currently in use. The Jiva portal will allow providers to request prior authorizations (PA) electronically and will provide the ability to view the PA details once a determination has been made. • The Jiva portal has a target start date of December 2012. • Provider training will begin in November 2012 for current iExchange users and ongoing training will be provided on case by case basis. • For more information and details you can call Diana Batista at 505-727-5110 or email her at Diana.Corlew@Lovelace.com (please include TIN, group name and phone number).

  17. Appeals and Grievances Definitions What is an Appeal? What is a Grievance? When a provider expresses a concern regarding disputes, timeliness, or quality of health care services. • When a provider disagrees with a denial or a bundling edit on a processed claim. • Filing Limitations: • - 180 days of the initial EOP for all lines of business • Turnaround Time: • 30 Calendar days from the date received • After 45 days, status may be checked by contacting Customer Care

  18. Appeals & Grievances Necessary Documents: Ways to File: Mail: Lovelace Health Plan Attn: Provider Appeals Coordinator 4101 Indian School Rd NE Albuquerque, NM 87110 Fax: 505-727-9664 Verbal (For grievances only): Call Customer Care at 505- 727-5456 or 800-808-7363 • Cover letter with explanation • Copy of original claim or action being appealed • Explanation of Payment (EOP) • Supporting Documents • - Operative Reports • - Medical Records (required)

  19. Behavioral Health/Substance Abuse Outpatient Services Inpatient Services Authorization Required Admissions from 8:00 am – 5:00 pm; Phone: 505-727-5406 After hours/weekends call BH pager at 505-229-1299; late night admissions should be called in following morning • No authorization needed to see Lovelace contracted provider • 90808, 90809 and 90814 will require PA if more than 3 occur in a six month period • BH phone: 800-808-7363; 505-727-5747; fax 505-727-5620 • Case Managers and Care Coordinators • Available to all members and providers • Accessing services, coordinate care and developing self-care plan • Healthy Balance Program • Available to Medicare members only • Annual in-home BH Wellness Assessment • Free to member

  20. Proposed HMO Medicare Expansion Proposed Current * Highlighted counties represented are Individual plan member counties. Employer Group plans are statewide.

  21. Proposed New Medicare PPO Service Area * Highlighted counties represented are Individual plan member counties. Employer Group plans are statewide.

  22. The Assist Group • The Assist Group (TAG) is a claims review service working with Lovelace Health Plan to review hospital bills for clinical correctness, billing errors and variances from industry billing practices. • If you need to contact TAG regarding an outstanding balance on a claim please contact Nadia Archuleta at 720-381-4495; email narchuleta@assistgroup.com or by mail: • The Assist Group • 300 Union Blvd. Suite 515 • Lakewood, CO, 80228

  23. Lovelace Provider Portal(Coming Soon) • Self-Service Features: • Log In • Provider Home Page • Patient Inquiry / Search & Return • Patient Information (Eligibility) • PCP / Provider Information • Other Insurance • Benefit Description – Medical • Benefit Detail • Outpatient Services • Referral Detail • Pre-Authorization Detail • Claim Center - Search & Return • Claim Detail • Provider Search & Return • Provider Information • Facility Search & Return • Facility Information • Find Inpatient Stays • Find a Patient/Result • Find Inpatient Stay Detail • Other Features: • Message Center • Update Password • Online Help

  24. Centennial Care • Centennial Care is a redesign of the New Mexico’s current Medicaid program to combine all components - Salud, Coordination of Long Term Services, State Coverage Insurance (SCI), Children’s Health Insurance Program (CHIP) and Fee for Service Medicaid - into a single global program • Minimize the number of Managed Care Organizations from 7 to a smaller undetermined number • The request for proposal (RFP) will go out in September 2012 • Contracts will be awarded in December 2012 • There will then be a full year of preparation (during which time members and health plans will prepare for a January 2014 “Go Live” date)

  25. Centennial Care • New Mexico Human Services Department has several ways for people to submit suggestions and ideas for the Centennial Care waiver: • Website: www.hsd.state.nm.us/medicaid.modernization • Email: medicaid.comments@state.nm.us • Phone: 1-855-830-5252 • Mail: Centennial Care Comments – Human Services Department P.O. Box 2348, Santa Fe, NM 87504 • Waiver document can be accessed in the in the “Waiver Documents” section http://www.hsd.state.nm.us/Medicaid%20Modernization/index.html

  26. Cultural and Linguistic Competency Health Literacy • Health Literacy is the ability to read, understand and act on health information. Half of all adults in the United States aren’t able to understand much of what they need to know to take care of themselves and follow providers’ instructions. • Possible symptoms of low health literacy: • Asking for clarification after medical information or instructions are given • Missed appointments • Frequent errors in medication or self-care instructions, this can also be seen as non-compliance

  27. Cultural and Linguistic Competency Health Literacy • How do we overcome Health Literacy Issues? • Use plain non-medical language • Ask clear, simple questions, ask patient to repeat prescription and medical information to verify patient understands care plan • Encourage questions, ask if the patient or caregiver has any questions on medications or treatment plan • Ask patient to bring prescriptions to appointments to review dosing information and verify patient is taking medication as ordered • Information regarding Health Literacy • can be found at Office of Minority Health website: • www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlID=3

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