April 24, 2014 Columbia, MO
HealthCare USA Overview • MO HealthNet Managed Medicaid Plan • Subsidiary of Coventry and Aetna • 60% market share • Operational since 1995 • 250,000 + members in Missouri • Robust Statewide Network • NCQA Accredited
Who Is Your Provider Relations Representative? • All HealthCare USA providers are assigned a Provider Relations Representative • Current listing is available at www.hcusa.org
Eligibility Verification Options MO HealthNet Options: • ARU line 573-635-8908 • www.emomed.com • Medifax HCUSA Options:
• www.directprovider.com • Emdeon Office Product • Interactive Voice Response 800-295-6888 • Member Services 800-566-6444
Eligibility and Claims System • HealthCare USA Members receive a HCUSA ID card with their HCUSA member ID and MO HealthNet member ID number. • HealthCare USA accepts claims filed with either the MO HealthNet member ID or HealthCare USA member ID. • Some Western MO HealthCare USA members have a CMPCN logo on the back of their ID card.
Newborn Eligibility • Timely filing is 90 days from date of enrollment within HealthCare USA’s system. • Claims must be filed under the newborn’s name and ID number. • Contact Claims Customer Service if your claim denies for untimely filing and you believe it was submitted within 90 days of the member’s enrollment.
Provider Communication • Provider Visits • Provider Newsletters • Provider Newsflashes • Provider Mailings • www.hcusa.org • www.directprovider.com
HealthCare USA Web Site www.hcusa.org • • • • • • • •
Online Provider Search www.directprovider.com Provider Forms Authorization Directory Provider Manual Provider Communication EFT, ERA, EDI Information ICD 10 status updates
CMS 1500 Claim Form Update • On January 6, 2014, HealthCare USA began accepting the revised CMS 1500 paper claim form, version 2/12. • HCUSA continues to accept and process paper claims submitted on the version 08/05
ICD-10 • Quarterly updates including FAQ are available at www.hcusa.org • Providers can submit their questions to:
[email protected]
www.DirectProvider.com • Member Eligibility
• Remittance Advices
• Member ID Cards
• EFT Registration
• ME Code
• Claim Inquiry/Adjustment Requests
(view and print)
• PCP Assignment • COB Information
• Authorization Submissions, Edit & View
• HEDIS
• News
- Reminders
- Gaps in Care
• Resource Library
- Provider Manual/forms - InterQual Smart Sheets
Direct Provider Online Authorizations
DirectProvider.com Training Options • Take a Tour
• Online Tutorials available 24/7 • Includes Registration, HEDIS Reports, Resource Library, Remittance Advices, Claim Inquiry
• Webinar Training • Quarterly dates & times available at www.hcusa.org and www.directprovider.com • Email
[email protected] to register
• User Guide • In “News” and help on www.directprovider.com
• Net Support 866-629-3975 • Available 7:00am - 5:00pm
EFT and ERA No More Checks and Remits in the Mail! • Request EFT via www.directprovider.com • Available to participating and non-participating providers • Remits available online through www.directprovider.com and/or ERAs • Providers choosing EFTs must access remittance advices online • Email notification when a new Remittance Advice is available
Provider Customer Service Phone: 800-295-6888 • Claims Processing
• Timely Filing/Adjustments
• Remittance Advices
• Recovery
• Claims Payment
• Verisk claim edits
• Claim Adjudication Information
• i-Health claim edits
• Provider Number • Check Reissue
• Negative Remits • Coordination of Benefits
Customer Service Performance Goals Item
Standard Goals
1Q 2014 Results
ASA
< 30 seconds
7.3 seconds
Abandonment Rate
< 3%
0.6%
Call Quality
>= 97%
98.6%
Processed in 15 Days
92%
93.8%
Processed in 30 Days
99%
99.6%
EDI Submission
70%
92%
Auto Adjudication
80%
80.1%
Top Claim Denials • Primary Carrier Liability • Services Not Authorized • Duplicate Claim • Member Not Effective • Untimely Filing
Claims Submission • Electronic claims submission for original or corrected claims –
Emdeon, Payor ID# 25133
• Submit using the patient’s HealthCare USA member ID or MO HealthNet ID number • Timely filing is 90 days for original claims and the timely adjustment period is 180 days from the initial remit date. • Corrected claims must be received within 180 days from original remit date • Paper Claims P.O. Box 7629 London, KY 40742-7629 Corrected claims must be clearly identified as “corrected”
Altered Claims & COB Altered claims • Paper claims containing white out, strikeovers, or handwritten information must be initialed.
•
Please….
Coordination of Benefits (COB) • HealthCare USA is the payer of last resort, in most instances • Providers have 90 days from the date of the primary carrier EOB for HealthCare USA to receive the claim • Primary Insurance Verification
HEDIS Healthcare Effectiveness Data and Information Set • HEDIS Quick Reference Billing Guide • 2013 Results • Chart audits • Administrative vs Hybrid data collection
HEDIS Postpartum Visit Postpartum Care Data Collection Incentive Pilot • Report 59430 postpartum visit code for services performed from the 21-56 day post-delivery HEDIS timeframe • Incentive is paid quarterly by a separate paper check and will be sent by mail or delivered by your provider relations representative • Missed opportunity report
Affordable Care Act
Primary Care Rate Increase • Effective January 1, 2013 • Eligible providers must complete the HCUSA or MO HealthNet attestation form which is located at www.hcusa.org and return to HealthCare USA • Payments for services furnished by certain primary care physicians including vaccine administration under the VFC program • Claims reprocessing - 2013 and 2014 dates of service
Provider Appeal Reconsideration Form • Appeal vs. Reconsideration • Fillable Form • www.hcusa.org
Provider Appeals Formal mechanism allowing the Provider the right to appeal the health plan’s decision. Submission Timeframe: Appeals must be received within 180 days of the action taken by HealthCare USA, giving rise to the appeal.
Decision Responses (via fax or mail) • Pre-service: within 30 calendar days • Post service: within 60 calendar dates • Note: The appeal decision is the FINAL decision
Provider Complaints Dissatisfaction or dispute with policies, procedures, claims, denials, or any aspect of health plan functions Submission Timeframe: Complaints must be received within one (1) year of the date of the incident, remit date or date of notice of action that caused the complaint.
Decision Responses (via fax or mail) • Pre-service: within 30 calendar days • Post service: within 60 calendar dates
Key Contact Numbers for Providers HealthCare USA: • Prior Authorization
800-882-9666
• Provider Customer Service
800-295-6888
• Provider Relations – Western
866-613-5001
• Provider Relations - Central
800-625-7602
• Provider Relations - Eastern
800-213-7792
• Member Services
800-566-6444
Just Look For Me… Doc Bear
