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Alta Bates Medical Group Transition Orientation Meeting June 2010

Alta Bates Medical Group Transition Orientation Meeting June 2010. Introduction. Alta Bates Medical Group will begin contracting with Brown & Toland Physician Services Organization (Brown & Toland) for management services beginning July 1, 2010

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Alta Bates Medical Group Transition Orientation Meeting June 2010

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  1. Alta Bates Medical Group Transition Orientation Meeting June 2010

  2. Introduction • Alta Bates Medical Group will begin contracting • with Brown & Toland Physician Services Organization (Brown & Toland) for management services beginning July 1, 2010 • Services include: claims processing, eligibility, authorization requests, customer service • ABMG C.A.R.E. to replace Sutter Connect Online for ABMG patients • Visit www.altabatesmd.com for information on transition

  3. Brown & Toland Departments Overview • ABMG C.A.R.E. IT Service Desk • Customer Service Support • Eligibility • Claims • Referral Services

  4. ABMG C.A.R.E. IT Service Desk Responsible for providing technical support for ABMG C.A.R.E.

  5. ABMG C.A.R.E. IT Service Desk is your contact for: • ABMG C.A.R.E. account problems • Citrix installation and use • Data missing or incorrect in ABMG C.A.R.E. • Reporting error messages

  6. ABMG C.A.R.E. IT Service Desk Hours of Service • Direct Phone Support: • Monday- Friday 7:00AM to 6:00 PM • Off Hours Support: • Monday- Friday 6:00 PM to 10:00 PM • Weekends: • Saturday & Sunday 6:00 AM to 5:00 PM

  7. ABMG C.A.R.E. IT Service Desk Planned System Downtime • Weekly back-up run • Saturday 5:00 PM through Sunday 9:00AM • Monthly maintenance window • Third Saturday of each month

  8. ABMG C.A.R.E. IT Service Desk Contact Information • Phone • 510.350.4410 • Email • servicedesk@altabatesmd.com

  9. Customer Service Support Responsible for call center operations and your main point of contact to Brown & Toland

  10. Customer Service Support • Staff functions • Call center operations • ABMG website customer emails • ABMG customer correspondence • Provider dispute unit • Telephone directory • Main line for Customer service, referral services, ABMG C.A.R.E. IT Service Desk

  11. Customer Service Support • Hours of Service: • Monday to Thursday 8:00 AM – 5:00 PM • Friday 9:00 AM- 5:00 PM • Closed weekends and ABMG holidays • Contact information: • Telephone 866.681.0737 • Fax 510.457.3436 • Email: customercare@altabatesmd.com

  12. Eligibility Responsible for creating and maintaining members’ HMO information

  13. How Eligibility is Updated • Electronic files sent monthly by health plan • Through ABMG C.A.R.E., Electronic Verification Requests (EVRs) submitted by physician offices or through ABMG Customer Service

  14. Verifying Eligibility through ABMG C.A.R.E. Use ABMG C.A.R.E. to verify eligibility information on member

  15. If Member Eligibility is Not Available or Incorrect Use ABMG C.A.R.E. “Messaging” function to submit a new EVR request

  16. If Member Eligibility is Not Available or Incorrect

  17. EVR Request Turn Around Times • Emergent/Senior- 24 Hours • Urgent- 48 Hours • Standard- 5 Business Days

  18. Eligibility Maintains the Following HMO Plans for ABMG • Aetna- AA • Blue Cross/Calcare-CC • Blue Shield- OO • Cigna- CI • Health Net/Health Net Seniority Plus- HH • Pacificare/Secure Horizons- XX

  19. Members Responsibility to Notify Health Plans • Name Change • Address Change • Primary Care Physician Change

  20. Questions regarding Eligibility Contact Customer Service 1.866.681.0737 Monday-Thursday 8:00AM to 5:00 PM Friday 9:00 AM to 5:00 PM Email: customercare@altabatesmd.com

  21. Claims Responsible for processing claims submitted for ABMG members

  22. Payer ID Effective for Date(s) of Service July 1, 2010 Payer ID Name: ABMG (DOS 07/01/10 and after) Payer ID: A0701 Please notify Practice Management Systems of the new Payer ID

  23. Electronic Claims Submission Submit claims electronically through preferred clearinghouses Emdeon www.emdeon.com Capario www.capario.com

  24. Paper Claims Submission Submit paper claims to: Alta Bates Medical Group P.O. Box 649010 San Francisco, CA 94164-0910

  25. Checking Claim Status Use ABMG C.A.R.E. to check claim status

  26. Claims Turn Around Times Turnaround times for non-pended claims are 5-15 business days Ancillary and Institutional claims will be processed within 45 days Adjustments will be processed within 10-15 business days

  27. Claims Adjustment Requests Contact Customer Service 1.866.681.0737 Monday-Thursday 8:00AM to 5:00 PM Friday 9:00 AM to 5:00 PM Email: customercare@altabatesmd.com For large volume requests, contact your Provider Relations Representative

  28. Proof of Timely Filing • Supporting documentation required: • Proof claim was submitted and to which entity • Include date of submission for specific • DOS

  29. Referral Services Responsible for processing prior authorization requests through ABMG C.A.R.E.

  30. Referral Services • Use ABMG C.A.R.E. to: • Submit requests for prior authorizations • Submit requests for referrals to ABMG specialists • View status of authorization requests

  31. Referral Services Use ABMG C.A.R.E. for prior authorization requests and referrals to ABMG specialists

  32. Referral Services Use ABMG C.A.R.E. to view status of authorization requests

  33. Prior Authorization List The Joint ABMG/SEBMF Utilization Management Committee has voted to make the following changes in authorization requirements in order to make the process more streamlined and to assure consistency after ABMG's MSO transition effective July 1, 2010. 

  34. Prior Authorization List • Procedures that no longer require authorization: • Echocardiograms • ENG's (with or without caloric testing) performed in the office • Fluoroscopy • Hysterosalpingograms • Office based wound care

  35. Prior Authorization List • Procedures that do require authorization: • Coronary sinus angiogramsThe complete list of Authorization requirements is posted to our Transition Page at www.altabatesmd.com. 

  36. 13 Authorization Types in ABMG C.A.R.E. Specialist Referrals Ambulance Diagnostic Testing DME/Orthotics/Prosthetics Drugs Requiring Authorization Home Care Services Hospital Admission Infertility Outpatient Rehab Outpatient Surgery Outpatient/Office Services Transplant Outpatient Vaccine Requiring Authorization

  37. Paper Authorization Requests 1. Complete Prior Authorization Request Form 2. Print or type legibly 3. Attach all relevant clinical information 4. Fax form and all relevant information to 866.681.1952

  38. Authorization Request Turn Around Times CommercialUrgent: 72 hoursRoutine: 5 business days Retrospective: 30 calendar daysSeniorUrgent: 72 hoursRoutine: 14 calendar days Authorization turnaround times are compliant with ICE standards.

  39. Open Authorizations • If you have an authorization that was issued prior to 7/1/10, it will be honored for the period of time stated on the authorization. • However, to effectively manage the continuity of care, we ask that you please enter any open authorizations that were issued prior to 7/1/10 into ABMG Care, after 7/1/10. • If you prefer, you may fax a copy of the authorization to us at 1.866.681.1952. • In no event should you delay patient care due to an open authorization not being in ABMG C.A.R.E..

  40. Case Management ABMG Case Management process has not changed.  ABMG will continue to provide case management services to our members.

  41. Thank you! • Visit www.altabatesmd.com • Copies of Transition training presentations • ABMG C.A.R.E. Computer Based Training • ABMG C.A.R.E. Enrollment form and/or online registration • Claims and Payer ID information • Prior Authorization by Authorization Type • FAQs

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