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MSMA Insurance Conference

Coventry Health Care of Missouri, Inc.

Provider Relations April 24, 2014

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Living the Aetna Way will allow us to achieve our strategic goals

We put the people we serve at the center of everything we do

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Health Care Reform

Health Care Reform adds new information, requirements and details to an already complex business. Health Care Reform has affected every aspect of our organization. Several changes and processes have been implemented to align Coventry with current and future policies, such as: - Internal education - New benefit plans built - Communication developed for physicians, member and employer groups - Correspondence (letters and EOB/ Remittance Advices) - Finance, Actuary, and Underwriting changes have been made to address MLR requirements More information on Health Care Reform is available via the Health Care Reform link on

www.chcmo.coventryhealthcare.com

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What is an Exchange?

The Exchange is an online market place where individual consumers and small group employers can purchase insurance coverage.

• Exchanges may be offered at the State or the Federal level • Illinois has chosen a state partnership exchange • Missouri has opted for Federal Exchange • On the exchange, consumers are able to: • View Subsidy eligibility • • Review and compare all the plans available on the exchange Enroll in health coverage

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Coventry’s Marketplace/Exchange Products Missouri

1. CoventryOne PPO – Eastern Missouri and Southwestern Illinois 2. Coventry One Carelink from Coventry is a narrow network PPO product • Missouri and Illinois counties • Hospital affiliated providers: Mercy, SSM, St. Elizabeth’s, St. Anthony’s-Alton, HSHS

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ICD-10 CM: 2014 Updates

• • Our design, development, testing and deployment are aligned for the October 1, 2015 ICD-10 compliance date. We have completed all analyses, including gap and system impact inventory, and system remediation. We have engaged the impacted areas of our company in our business assessments. We will be ready for the move from the ICD-9 codes to ICD-10 codes. The 10/1/2015 compliance date may seem far off, but the complexity of conversion requires immediate action to address the business and clinical issues associated with the transition. The ICD-10 conversion will affect nearly all provider systems and many processes. The largest impacts will likely be in clinical and financial documentation, billing and coding. It is critical not to delay planning and preparation. It is important that providers contact their billing or software vendor to understand their plans for conversion and testing.

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ICD-10 CM: 2014 Updates

• • • Coventry is a member of HIMSS and WEDI, and actively participates on many industry workgroups and task forces related to IDC-10. We did participate in the pilot; however at this time, we are not participating in the program.

These industry resources will help with your planning and preparation: • Centers for Medicare & Medicaid Services (CMS) • Workgroup for Electronic Data Interchange (WEDI) Need to contact us? Coventry has two dedicated mailboxes for ICD-10 questions, information on ICD-10 testing, or surveys that need completed. You will receive your response within two business days.

Email: [email protected]

Phone: 412-604-5566

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NIA

Outpatient Imaging Program

• Utilized for advanced outpatient imaging management services • Applies to Coventry Commercial HMO/POS, Select and PPO Members • Applies to Medicare products: Advantra, Advantra PPO, and Gold Advantage • Members are

excluded

from the Outpatient Imaging Program if they access care through: ASO, Carelink, CMR, Coventry National, First Health Network, and TotalCare

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• • •

NIA, cont.

Ordering physician responsible for obtaining prior authorization for advanced radiology services Rendering facility is responsible for ensuring the prior authorization has been obtained Prior Authorization’s obtained through NIA’s website,

www.RadMD.com

,

or by phone, 800.546.4603, option 6

Procedures requiring prior authorization:

•CT/CTA •MRI/MRA •PET Scans •Nuclear Stress (MPI) •CCTA •Echo Stress •Nuclear Cardiology •Diagnostic Nuclear Medicine

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New Century Health Oncology Pathway Solution Drug Program

New Century Health (“NCH”) manages the Oncology Pathway Solutions program, effective March 1, 2014. The Oncology Pathway Solutions program uses clinical guidelines based on nationally recognized, evidence based criteria for determining medical necessity in cancer care. It streamlines the complex administrative process associated with chemotherapy pre authorizations.

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New Century Health Prior Authorization

• • • • Chemotherapeutic drugs and supporting agents will require pre-authorization prior to being administered in a physician’s office, elective inpatient, outpatient or ambulatory setting. Applies to all Coventry Medicare and Commercial members ages 18 and older. The requesting physician must complete the NCH Chemotherapy Request Form (CTR).

Applies to services for Coventry Members with coverage under both fully insured and Medicare products. It does not include self-funded or Carelink products.

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• • • • • •

New Century Health Key Features

Provider portal available 24/7/365 offering: • Real-time authorizations when selecting treatment care pathways • • • Reduced documentation requirements Easily view real-time status of authorization requests Eligibility verification Fax authorization requests 877-624-8602 Supportive telephonic authorization 877-624-8601 Quick turnaround time on requests submitted via fax or phone Peer-to-peer consultation's by medical oncologists NCH is a National Comprehensive Cancer Network licensee of the Drugs and Biologics Compendia and utilizes nationally recognized evidence-based treatment guidelines

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ICORE

Drug Program ICORE ensures quality care and affordability for our members. The company leads prior authorization review for drugs ordered by health care professionals in a physician office (POS 11) and outpatient facility (POS 22). The program supports a “buy and bill” reimbursement model to encourage the use of medically indicated, lower-cost options that are equal in quality and clinical outcomes. With this commitment in mind, we implemented changes to those drugs that are included in the review process with ICORE. Please see updated drug list effective March 1, 2014.

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ICORE Drugs Requiring Prior Authorization

Actemra (J3262) Acthar (J0800) Botox (J0585) Euflexxa (J7323) Gel-One (J7326) Myobloc (J0587) Nplate (J2796) Orthovisc (J7324) Remicade (J1745) Supartz/Hyalgan (J7321) Synvisc/SynviscOne (J7325) Tysabri (J2323)

Plans Included:

All Commercial HMO, POS, PPO, Select and Medicare Advantage products

Plans Excluded:

Self-funded ASO/CMR Groups and Carelink/Total Care products ICORE: 800-424-4157 or www.ICOREhealthcare.com

Provider Hotline: 800-755-5242

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• • •

Triad Healthcare Inc. – Quality Assurance for Pain Management Procedures

Triad Healthcare, (“Triad”) a leading musculoskeletal health services company focuses on the health care needs of patients with painful spine and joint conditions. Triad administers Coventry’s quality assurance program for pain management procedures. Triad’s mission is to improve the quality of care delivered to patients with complaints of musculoskeletal pain. The new prior authorization process applies to services for CHC members with coverage under both fully insured and Medicare products. It does not include self funded products. Triad’s medical policies, a list of CPT codes designated as pain management services requiring prior authorization and managed by Triad, along with authorization forms, are available by contacting Triad or on the Providers section of our website at chcmissouri.com. Prior authorization requests and your patient’s medical records must be submitted using any of the following methods: * Web: triadhealthcare.com/cvty * Fax: 888-229-5680 * Phone: 888-584-8742 Triad’s evidence based medical policy is available to Coventry Health Care providers at: http://www.triadhealthcareinc.com/providers/policies.aspx.

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Advantra’s Dual Eligible - Special Needs Plan (DE- SNP)

CHC Missouri

plan covers Dual Eligible (DE). DE’s are individuals who are entitled to Medicare and some level of assistance from

Missouri Medicaid (MO HealthNet).

• • •

Advantra DE-SNP is a Medicare replacement plan Advantra DE-SNP is NOT a Medicaid replacement plan Members must see providers who participate in both Advantra and MO HealthNet Networks to optimize their benefits

•

Members who select us must carry and use both plans’ ID cards, Advantra DE-SNP card and MO HealthNet card

•

Advantra DE-SNP, like Medicare, always pays first; MO HealthNet benefits wrap around our plan

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Lab Services/Providers In-Office Lab Policy

• • Lab specimens for CHC of Missouri’s Commercial and Medicare Advantage should be sent to Quest Diagnostics in the St. Louis Metro area, or one of the approved outpatient labs for those outside of the metro area. The metro area is defined as: – –

In Missouri:

Franklin, Jefferson, Lincoln, St. Charles, St. Francis, St. Genevieve, St. Louis City, St. Louis, Warren, Washington counties

In Illinois:

Madison, Monroe, St. Clair counties Coventry Health Care reimburses in-network providers for specific lab procedures when they are preformed in office on a STAT basis only. Please refer to our provider manual for a detailed list of these labs. The provider manual is available under the provider section on www.chcmisssouri.com.

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Valuable Information Available Online at www.chcmissouri.com

Click “Providers” on the home page for immediate access to these valuable resources: • Comprehensive provider search • Drug formulary (prescription coverage) • Prior authorization information • Medical injectable list • Authorization form • Prior authorization list • CPT codes requiring prior authorization • Network participation details • Credentialing policies, criteria and provider rights related to credentialing

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Visit the “Provider Document Library” to access:

• • • • • •

Provider Manual –

Includes information about claims processing, member rights and responsibilities, and other helpful resources.

Complex Case Management –

Informs providers about our complex case management program and how to refer patients to the program.

Network News –

Holds current and past issues of Network Connection, our provider newsletter.

Quality Improvement Policies and Procedures –

Notes quality improvement annual evaluations and medical record documentation standards.

Utilization Management Policies –

Displays summaries of our evaluation of new medical technology, utilization management criteria and financial incentives policy.

Wellness –

Highlights preventive health guidelines, clinical practice guidelines and disease management programs.

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www.DirectProvider.com

Services & Information Available:

• Claim Adjustment Requests • Remittance Advices • Eligibility/Benefit Inquiry • Resource Library • Secure Messaging • Member ID cards • Enhanced News • Authorization Request/Inquiry/Update/Appeal

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www.DirectProvider.com

Select a Health Plan:

 Coventry Health Care of Missouri  Carpenters’ Health and Welfare Trust Fund  Coventry of Missouri (MODOT)  University of Missouri  Coventry Health Care of Illinois  Coventry Health Care of Kansas and Preferred Health System  Coventry Health Care National Network  CoventryOne National  Mail Handlers Benefit Plan  Rural Carrier Benefit Plan

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Authorizations on DirectProvider.com Made Easy

Here are a few tips on navigating the authorization submission process:

• Submit the same type of clinical information that is needed when requesting the authorization via phone. Either document the information in the comment section of the authorization or attach clinical information to the authorization.

• Without clinical information, the authorization may be denied for lack of information.

• It is recommended to check member eligibility and current authorizations prior to entering a new authorization.

• Online help is available on DirectProvider.com for authorization as well as other key functions. If you have any questions or require technical support Coventry’s Net Support Team is available 9am-5pm Monday through Friday at (866) 629- 3975.

COVENTRY HEALTH CARE DIRECTPROVIDER.COM TRAINING

ADMINISTRATOR

REGISTRATION COST ESTIMATION (TN ONLY) * May 7th at 10am PST

* May 6th at 9am PST * May 16th at 10am PST MANAGE ACCOUNT & MSG CENTER * May 6th at 10am PST * May 16th at 11am PST

AUTHORIZATIONS & REFERRALS * May 7th at 9am PST * May 16th at 9am PST * May 30th at 9am PST

ELIGIBILITY & ID CARDS * May 15th at 9am PST * May 29th at 9am PST

CLAIMS/REMITTANCE ADVICES * May 13th at 9am PST * May 27th at 9am PST FIRST HEALTH/TPA BILLS * May 30th at 10am PST

RESOURCE LIBRARY & NEWS * May 27th at 10am PST

PCP HEDIS REPORTS * May 8th at 9am PST

CN PPO FS & CLIENT LISTING * May 13th at 10am PST

To register your provider office staff for DirectProvider.com training sessions please send a email with the date you wish to attend to: [email protected].

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QUESTIONS