Transcript Cigna HealthSprings Provider Training 2014
TX HealthSpring Medicare Program Training
January 1, 2014—Go Live
Agenda
Overview of Plans Medicare Plans & Benefits Member ID Cards Complaints and Appeals Questions
Overview of Plans – High Level
Cigna-HealthSpring offers 13 Medicare Advantage dental plans that have been filed as part of their Texas market with CMS. HealthSpring categorizes the plans by Contract ID.
All Medicare plans are effective 1/1/2014 All Medicare plans operate on a calendar year January 2014 – December 2014 Some of the Medicare plans have out-of-network benefits Some of the Medicare plans have co-insurance
None of the Medicare plans require authorization or UM review
Overview of Plans
What types of dental plans are offered?
HealthSpring’s Medicare Advantage dental plans are similar to commercial insurance plans. There are 4 different benefit sets that members can choose to buy based on where they live: Preventive Plan Preventive + Out-of-Network Plan Preventive & Comprehensive Plan Preventive & Comprehensive Optional Supplemental Plan
Overview of Plans
The plans with the same benefits are rolled up into the same exhibits in the ORM. The subgroup names are listed below by plan category: Preventive Plans TX HS Preferred Advantage Medicare TX HS Preferred AR Medicare Preventive + Out-of-Network Plan TX HS Preferred Advantage Medicare (50% Co-Ins) Preventive & Comprehensive Plan TX HS Preferred TotalCare Medicare Preventive & Comprehensive Optional Supplemental Plans TX HS Preferred TX/AR Medicare (Opt Supp) HS Preferred AR Medicare (Opt Supp)
Preventive Plan
DentaQuest Subgroups: TX HS Preferred Advantage Medicare, TX HS Preferred AR Medicare
Covered Plans and Counties:
H4528-001 Cigna-HealthSpring Preferred (HMO) Service Area: Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise, TX H2165-018 Cigna-HealthSpring Preferred (HMO) Service Area: Cherokee, Grayson, Gregg, Hale, Henderson, Hockley, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt, Wood, TX H4513-009 Cigna-HealthSpring Advantage (HMO) Service Area: Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb, TX H4528-016 Cigna-HealthSpring Advantage (HMO) Service Area: Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise, TX H6972-001 Cigna-HealthSpring Preferred (HMO) Service Area: Yell, Sebastian, Scott, Pope, Logan, Johnson, Franklin, Crawford, Conway, AR
Preventive Benefits
Code D0120 D0140 D0150 D0210
Description Periodic Oral Evaluation Limited Oral Evaluation Comprehensive Oral Evaluation - new or established Frequency one every 6 months
Preventive Dental Benefits Diagnostic
One per Calendar year(s) Per patient One per Calendar year(s) per patient. One every 36 months per provider per tax id number Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months
Co-Pay $0 $0 $0 $0 D0220 D0230 D0272 D0274 D0330
Intraoral - Periapical first film Intraoral - Periapical each additional film Bitewing, two films Bitewing, four films Panoramic Film
D1110 Prophylaxis - Adult
One every Calendar Year One every Calendar Year One every Calendar Year One every Calendar Year One of (D0210 or D0330) every 36 months
Preventive one every 6 months $0 $0 $0 $0 $0 $0
Preventive + OON Benefits Plan
DentaQuest Subgroup: TX HS Preferred Advantage Medicare (50% Co-Ins)
Covered Plans and Counties:
H7787-001 Cigna-HealthSpring Preferred (PPO) Service Area:
Cherokee, Collin, Dallas, Denton, Grayson, Gregg, Hale, Henderson, Hockley, Johnson, Kaufman, Lubbock, Rockwall, Smith, Tarrant, Rains, Rusk, Upshur, Van Zandt, Wood
H7787-002 Cigna-HealthSpring Advantage (PPO) Service Area:
Cherokee, Collin, Dallas, Denton, Grayson, Gregg, Hale, Henderson, Hockley, Johnson, Kaufman, Lubbock, Rockwall, Smith, Tarrant, Rains, Rusk, Upshur, Van Zandt, Wood
Preventive + OON Benefits
Preventive Dental Benefits Code
Description
D0120 D0140 D0150
Periodic Oral Evaluation Limited Oral Evaluation Comprehensive Oral Evaluation - new or established Frequency
Diagnostic
one every 6 months One per Calendar year(s) Per patient One per Calendar year(s) per patient. One every 36 months per provider per tax id number
Co-Pay $0 $0 $0
Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months
D0210 $0 D0220 D0230 D0272 D0274 D0330
Intraoral - Periapical first film Intraoral - Periapical each additional film Bitewing, two films Bitewing, four films Panoramic Film
D1110 Prophylaxis - Adult
One every Calendar Year One every Calendar Year One every Calendar Year One every Calendar Year One of (D0210 or D0330) every 36 months
Preventive one every 6 months
• Members have the option of going Out-of-Network to receive the preventive services on this plan. If members receive services from a non-participating (Out-of-Network) dentist they will be responsible for 50% of the dentist’s charges for services (50% co-insurance).
$0 $0 $0 $0 $0 $0
Preventive & Comprehensive Plan
DentaQuest Subgroup: TX HS Preferred TotalCare Medicare
Covered Plan and Counties:
H4513-001 Cigna-HealthSpring Preferred (HMO) Service Area:
Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb
H4513-010 Cigna-HealthSpring TotalCare (HMO SNP) Service Area:
Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb
H4528-002 Cigna-HealthSpring TotalCare (HMO SNP) Service Area:
Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise
H2165-019 Cigna-HealthSpring TotalCare (HMO SNP) Service Area:
Cherokee, Grayson, Gregg, Hale, Henderson, Hockley, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt, Wood
Preventive & Comprehensive Plan Benefits
Code
Description
D0120 D0140 D0150 D0210 D0220 D0230 D0272 D0274 D0330
Periodic Oral Evaluation Limited Oral Evaluation Comprehensive Oral Evaluation - new or established Intraoral - Complete Series (including bitewings) Intraoral - Periapical first film Intraoral - Periapical each additional film Bitewing, two films Bitewing, four films Panoramic Film
Preventive Dental Benefits
Frequency
Diagnostic
one every 6 months One per Calendar year(s) Per patient One per Calendar year(s) per patient. One every 36 months per provider per tax id number One of (D0210 or D0330) every 36 months One every Calendar Year One every Calendar Year One every Calendar Year One every Calendar Year One of (D0210 or D0330) every 36 months
Preventive one every 6 months D1110
•
Prophylaxis - Adult
Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $1,000 towards comprehensive services including: • Restorative care • Periodontics • • Prosthodontics Oral surgery
Co-Pay $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
• • Diagnostic and preventive services above do not count towards annual coverage limit.
Full list of covered codes can be found in the ORM.
Optional Supplemental Benefits Plan: Preventive & Comprehensive
DentaQuest Subgroups: TX HS Preferred TX/AR Medicare (Opt Supp), TX HS Preferred AR Medicare (Opt Supp)
Covered Plan and Counties:
H2676-001 Cigna-HealthSpring Preferred (PPO) Service Area: Bowie, Cass, Titus, TX and Miller, AR
H4871-001 Cigna-HealthSpring Preferred (PPO) Service Area:
Howard, AR
•
Optional Supplemental Benefits
Code D1110
• Description
D0120 D0140 D0150 D0210 D0220 D0230 D0272 D0274 D0330
Periodic Oral Evaluation Limited Oral Evaluation Comprehensive Oral Evaluation - new or established Intraoral - Complete Series (including bitewings) Intraoral - Periapical first film Intraoral - Periapical each additional film Bitewing, two films Bitewing, four films Panoramic Film
Prophylaxis - Adult Preventive Dental Benefits
Frequency
Diagnostic
one every 6 months One per Calendar year(s) Per patient One per Calendar year(s) per patient. One every 36 months per provider per tax id number One of (D0210 or D0330) every 36 months One every Calendar Year One every Calendar Year One every Calendar Year One every Calendar Year One of (D0210 or D0330) every 36 months
Preventive one every 6 months
Members can decide to opt up to an enhanced dental benefit package at any time during the year.
Co-Pay $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $800 towards comprehensive services including: • Restorative care • Periodontics • • Prosthodontics Oral surgery
Optional Supplemental Benefits Continued…
•
Diagnostic and preventive services above do not count towards annual coverage limit.
• Full list of covered codes can be found in the ORM. •
Members have the option of going Out-of-Network to receive services on these plans. If members receive services from a non-participating (Out-of-Network) dentist they will be responsible for 50% of the dentist’s charges for services (50% co-insurance).
•
Both in and out-of-network services apply to the annual maximum of $800.
ID Cards & Welcome Letters
The DentaQuest ID card will be printed at the bottom of the Member Welcome Letter.
The ID card will include the HealthSpring product name & the DentaQuest subgroup name. The purpose of this is to ensure that all parties know the name of the plans (member, provider, DQ staff, HS staff).
Example: HealthSpring product name: H2165019 - Cigna-HealthSpring TotalCare (HMO SNP) DentaQuest subgroup name: TX HealthSpring Preferred TotalCare Medicare If a member has been active < 89 days they are considered “reinstated”. Reinstated members will only receive a new ID card/welcome letter. If lapse in coverage is > 90 days, they are treated as new members. New members receive an ID card/welcome letter, member handbook & EOC document.
Sample ID Cards
Member/Provider Services
DentaQuest is Primary for Member Services
DentaQuest HealthSpring Medicare Member Services 855-343-7341 For reference: HealthSpring Medicare Member Services 866-288-1573
DentaQuest is Primary for Provider Services
888-308-9345 (Dedicated TX MCO Line)
Member Complaints & Appeals
DentaQuest will not handle HealthSpring Medicare member complaints.
HealthSpring members should contact HealthSpring member services to file a complaint.
DentaQuest will not handle HealthSpring Medicare member appeals.
HealthSpring members should contact HealthSpring member services to file an appeal.
Provider Complaints & Appeals
DentaQuest will handle HealthSpring Medicare provider complaints and appeals.