NorthernBridges Provider Network Training Billing Procedures

1. NorthernBridges Provider Network Training Billing Procedures Presented By: Provider Network Staff NorthernBridges

2. Role of the Provider Network Development Department • Create a network of providers to deliver the array of services that address the needs of the members served, and as are required by the State of Wisconsin.

3. Governing Documents • Contract – with Rate and Special Services Letter • Provider Handbook • Provider Handbook - Billing Supplement • Other resources: www.northernbridges.com

4. Participants • Wisconsin DHS • MCO – NorthernBridges • Members Served • Residential Facility Providers • Family Care Services Providers • Vestica Healthcare (software) • Vestica TPA (claims adjudication)

5. NorthernBridges Functions • Administration • Enrollment • Care Management • Care Managers – IDT’s • Provider Network • Finance • Quality Management

6. NB Enrollment and Care Planning Process

7. NB Claims Submission and Appeal Process

8. Provider Payment Process • Become a Contracted Provider (Contract + Rate Sheet) • Members Enrolled (NB Enrollment) • Care Managers Assigned (NB care Mgmt.) • Member Service Plan Developed (NB Care Mgmt.) • Authorization Letters Received • Services Provided • Claims Submitted • Claims Adjudicated and Paid

9. NB Authorization Letter

10. NB Authorization Letter • Contains what you need to Bill • Authorization Number • Member name and Member ID • Service Codes and Modifier(s) • Quantity • Service dates • Also: Care Manager(s) contact information

11. Claims Submission Methods • US Mail • Residential Facilities Billing Form • Family Care Services Billing Form • Forms are available on the NB web site • Electronic • Residential – Through SFTP (Secure File Transfer Protocol) Site • Family Care Services – Through Vestica WPS (Web Provider Services)

12. US Mail • Submit Correct Billing Form • Data Entry Key • Use HIPAA Compliant Codes for Contracted and Authorized Services

13. Forms • Authorization Number • Member Name , DoB, Gender • Member Number (with or without 2 digit suffix) • NPI (medical providers only) • HIPAA Compliant code • Modifiers • Dates of Service • Contracted Rates

14. Residential Facility Electronic Billing • Send an e-mail to Vestica at CISdept@vestica.com • Response from Vestica providing assistance in setting up SFTP site • Use HIPAA Compliant Codes for Contracted and Authorized Services

16. Family Care Services Electronic Billing • Mail your FIRST Family Care Services claim to Vestica • Receive Remittance from Vestica with WPS setup information attached • Contact Vestica and follow instructions to access and use WPS • Use HIPAA Compliant Codes for Contracted and Authorized Services

18. Cutoff and Payment Dates • Cutoff and payment are 7th and 21st of every month • Claims received by the 7th are paid on the 21st • Claims received by the 21st are paid on the 7th • Claims must be “clean”

19. When to Contact the Provider Network Staff • After application to become a provider • Upon provider observation regarding a member “change of condition” • Provider or member comments, complaints or quality concerns of any kind • Rates Clarification • Out of network provider situations

20. Provider Network Directory • Tool to assist care managers in finding providers for specific services • Assures adequacy of network and array of providers within the network • Always changing – keep your information current – including full array of services you provide • State uses information to assure adequacy of network prior to certification

21. Members and IDT’s Have Access to Provider Network Directory • The internal provider network directory shall be updated on a regular basis and available online (in development stages currently) to the Care Management teams. • The paper copy provided to members will be updated regularly on the website but can also be printed out in hardcopy at anytime.

22. Service Authorization ProcessControlled by NB Care Managers • Service Authorizations must be completed for all services for any of the following reasons: • to start service • stop service • decrease service • increase service • for a one time cost • or if there is a change in the number of units of service provided and the member agrees with the decision

23. New Service Request from Existing Provider • Providers send NB a letter or e-mail indicating new service to be considered for addition to the contract • Provider qualification will be considered in making the decision to include the provider in the network and to extend a contract with the provider. • Contract must be fully amended with new: • Rate and Special Services Letter and • Authorization Letter prior to services being delivered by the provider.

24. Provider Request for AdditionalServices • The following standards must be met: • Service is a Family Care Benefit • Service not currently available in the network or falls within the any willing provider category • Provider meets all credentialing criteria including insurance requirements • Service ensure health and safety of member • Positive referrals • Willing to accept our payment rates, sign and adhere to contract • Submit any other material requested by the NorthernBridges

25. Communication and Reporting Requirements What to Expect of Providers • Providers are to communicate any significant change of condition to NB Care Management, such as: • If member’s legal status changes, e.g. guardian appointed, Power of Attorney activated or deactivated or decisional capacity is questioned. • If there is a plan to use physical or chemical restraints with a member. If there is use of emergency restraints. The restrictive measures policy is provided to all providers with their contract packet. • If there is allegation/suspicion of abuse or neglect.

26. Communication and Reporting Requirements – What's Expected of Providers • If there is any significant change in health status, i.e. weight loss, increased confusion, frequent falls. • If member requires an ER, Urgent Care or emergency clinic visit or is admitted to the hospital. • If there is a need to change a service or add a new service. • If there is a new diagnosis of chronic condition or new medical treatment initiated.

27. Important Things to Remember • All services must be authorized by NorthernBridges team • Services/goods to members must be authorized prior to delivery and regardless of primary payer source. • The IDT develops services plan which specifies every authorized service. • NorthernBridges will not pay for goods and services before enrollment or after disenrollment.

28. Important Things to Remember • Rates for FC Services will be the same in all counties • A weighted average of your 2008 services in all counties was used to establish the new rate • Using this method your revenue would remain the same

29. Important Things to Remember • Providers may request new or additional services or extensions of existing authorizations for service by contacting the care manager. A request, however, does not imply that a change will occur. • In case of emergent need for service authorization a 24 hour authorization phone line will be available. • Providers can not seek payment from members when reimbursement is denied because the service was not authorized.

30. Room and Board Payment Responsibility • NorthernBridges shall require that members living in substitute care settings, (CBRF’s, RCAC’s, and AFH’s), pay the appropriate room and board rate to NB. • NB will invoice members for Room and Board • Providers will submit claims for Residential Services and Room and Board – The total $’s will remain the same. • Work is currently taking place to develop a consistent residential rate setting methodology, both for room and board and residential services. • Billing must reflect the two separate residential line items

31. Program Integrity Related to Billing/Claims • Inflation of bills for services or equipment or supplies provided • Double billing • Improper coding • Embezzlement and theft

32. Resources • www.northernbridges.com • Residential Facility Claims Forms and “keys” • Family Care Services Claim Forms and “keys” • Provider Handbook and Billing Supplement • Frequently Asked Questions Re: Billing • Provider Directory (ASAP)

33. NB Provider Network Staff • Rita Mueller - Provider Network Manager, 715-934-2266 ext. 1113 • rmueller@northernbridges.net • Sarah Benson – Provider Network Developer, 715-934-2266 ext. 1125 • sbenson@northernbridges.net • Glenn Taylor – Provider Network Developer, 715-934-2266 ext. 1129 • gtaylor@northernbridges.net