Program Exclusions
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Transcript Program Exclusions
MyCare Ohio
Skilled Nursing Facility
Orientation
Demonstration/Pilot Area
2
Health Plan Options
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Implementation Timeline
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114,000 members in 29 counties are eligible for the MyCare
Ohio program. This includes:
•
Individuals 18 years and older
•
Members residing in the MyCare Ohio service area
•
Individuals entitled to benefits under Medicare Part
A enrolled under Medicare Parts B and D, and
receive full Medicaid benefits.
•
Adults with disabilities and persons 65 years and
older
•
Persons with serious mental illness
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Program Exclusions
Those who are not eligible for MyCare Ohio enrollment:
• Individuals under age 18 years
• Individuals with an ICF/IDD level of care served either in an
ICF/ID facility or on a waiver
• Individuals who are eligible for Medicaid through a delayed
spend-down
• Individuals with third party insurance
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Opt IN Enrollees
Full duals with Buckeye
Medicare and Medicaid benefits through Buckeye
– Medicare – option to change plans monthly
– If member selects another MyCare MCP will be
enrolled as a full dual with the new plan
– If member selects a plan outside the MyCare network,
member retains Medicaid benefits with Buckeye.
One claim submitted to Buckeye.
– Will be adjudicated for both Medicare and Medicaid
with one submission.
– Will generate two payments
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Opt IN ID Card (Medicare & Medicaid)
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Opt OUT Enrollees
Medicaid as Secondary Coverage with Buckeye
Medicaid benefits only through Buckeye
– Option to change Managed Care Plans during initial 90
days of enrollment
– Locked in for remainder of benefit year until annual
open enrollment
– Medicare benefits through other non MyCare payor
including Fee for Service
Secondary claims to be submitted to Buckeye.
– Will be adjudicated as secondary payor
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Opt OUT ID Card (Medicaid Only)
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Service Packages
Services included:
Medical benefits
Behavioral health benefits
Home & Community Based Services
Long Term Care
Pharmacy
Dental
Vision
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e Services
MyCare Ohio Waiver
includes:
Ohio Home Care Waiver
Transitions II Carve-Out Waiver
Passport Waiver
Choices Waiver
Assisted Living Waiver
Enrollees who are eligible for waiver will have access to all of the services
included in the MyCare Ohio Waiver.
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Determining Eligibility
Waiver Eligibility will be determined by
government agencies
Department on Aging
CareStar or other vendor
Level of care assessment evaluates the
member’s:
Ability to perform the activities of daily
living
Mental acuity
Level of impairment
Level of need
Member’s level of care determination will determine which services the member
is eligible to receive.
Skilled, Intermediate, Intermediate/Mental Retardation-Developmental Disabilities /
Protective or None
Member has choice to receive services
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Transitions of Care – Nursing Facility
• NF services:
– Provider will be retained at current rate for the life of Demonstration
(42 months).
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Transitions of Care - Exceptions
During the transition period, change from the existing services or provider
can occur in any of the following circumstances:
1.
2.
3.
4.
Consumer requests a change
Significant change in consumer’s status
Provider gives appropriate notice of intent to discontinue services to a
consumer
Provider performance issues are identified that affect an individual’s
health & welfare
Plan-initiated change in service provider can only occur after an in-home
assessment and development of a plan for the transition to a new provider
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The Integrated Care Team Works Together with the
Member to Find the Best Health Solutions for Members
Care Manager (Accountable Point of Contact)
Accountable point of contact for the Integrated
Care Team
Registered Nurses, Social Workers and
Counselor’s.
Program Coordinator
Mixture of licensed/certification professionals.
Focused on the physical, psychological and social
welfare of the member.
Community Health Worker
Provides team support, and reaches out to members with health and preventive
care information
Waiver Service Coordinator
Focuses on Buckeye members that receive services through a home and
community-based services waiver.
Partnership with the Area Agency on Aging (AAA) for member age 60+.
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Provider Value
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Value That Centene Brings to Providers
Timely and accurate claims payment (clean claims) processed
within 7-8 days of receipt
75% of claims are paid within 7-10 days of receipt
99% of claims are paid within 30 days
Local dedicated resources: Care coordinators serve as an
extension of physician offices
Education of providers and support staff through orientations
Provider participation on health plan committees and boards
Minimal referral requirements for physician services
Electronic and web-based claims submission
Web based tools for administrative functions
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Provider Portal @ www.bchpohio.com
Through our main website,
providers can access:
Provider Newsletters
Provider and Billing
Manuals
Provider Directory
Announcements
Quick Reference Guides
Benefit Summaries for
Consumers
Online Forms
Logon to www.bchpohio.com and become a registered provider
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On our secure portal,
providers can:
Verify eligibility and benefits
View provider eligibility list
Submit and check status of
claims
Review payment history
Secure Contact Us
Registration is free and easy.
These services can also be handled by Buckeye Provider Services
@ 866-296-8731
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Submitting Claims to Buckeye
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What Requires Prior Authorization?
ALL SNF and LTC services require prior authorization
New Services:
Existing Services:
Services will be based on the member’s
care plan.
Services that are currently in place for
member will remain for 365 days.
Care Coordinator will be in contact with
both the member and provider.
HCBS Care Coordinator will enter prior
authorizations for each service into the
system.
Once services are approved, prior
authorization will be entered into the
system by Care Coordinator.
Providers will receive a notice from Buckeye
explaining transition process, and members
identified as currently in facility or LTC.
Care Coordinator will contact service
providers with a prior authorization
number, confirming service can now
take place.
If you have questions if a service is
authorized for the member, contact the
HCBS care coordination team at
866-549-8289.
All out of network non-emergent services and providers require
prior authorization.
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Claim Services
Timely Filing Guidelines
365 Days from the date of service
180 Days if retro eligibility is an issue
180 Days to submit a corrected claim, request a reconsideration of payment, or to file a
claim dispute
*Please refer to our provider or billing manual online for more detailed information*
Paper Claims
Providers may submit to the following addresses:
Buckeye Community Health Plan
Attn: Claims
P.O. Box 3060
Farmington, MO 63640
(866)-329-4701
Corrected Claims, and Requests for Payment Reconsideration
– Providers may submit to the following addresses:
Buckeye Community Health Plan
MyCare Ohio Claim Reconsideration
P.O. Box 4000
Farmington, MO 63640
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Claim Submission and Reimbursement
• Authorization is required for all services including bed hold
days
• Buckeye will accept standard Medicare and Medicaid billing
codes RUGS etc. No payor specific codes required
Program Exclusions
• Buckeye will reimburse based upon current Medicare &
Medicaid fee schedules including bed hold days
• Bed hold days policy will be consistent with current regulatory
policies and rates (Buckeye has current rates including
occupancy variances)
• Inpatient hospice – Buckeye will reimburse hospice provider
who will in turn reimburse SNF for room & board.
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Bad Debt Policy
• Bad Debt – applies to member liability for skilled level of care
days 21-100 of single stay
• Buckeye will not require SNF to file annual bad debt report
Program
Exclusions
• Buckeye will aggregate bad
debt detail
from adjudicated
claims by facility
• Buckeye will review and determine liability using the following
methodology
Services 5/1/14 through 9/30/14 – 76% of bad debt
Services 10/1/4 through 12/31/14 – 65% of bad debt
• Reimbursement will be paid as a lump sum payment in the 2nd
quarter of each year.
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Claim Services
CLAIM SUBMISSION OPTIONS
Electronic Claims Submission – EDI
•
•
•
More efficient, fewer errors
Faster reimbursement 5-7 days from submission
Requires EDI vendor or clearinghouse agreement
Buckeye Provider Portal
•
•
•
•
Requires registration and username/password
Very efficient; fewer errors
No cost to provider
Faster reimbursement 5-7 days from submission
Paper Claim Submission
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•
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Less efficient
Requires original claim forms
Average reimbursement 10-14 days from submission of clean claim
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EDI Partner
Payor ID#
Phone #’s
Emdeon
68069
(800) 845-6592
Gateway
68069
(800) 987-6720
SSI
68069
(800) 880-3032
Smart Data Solutions
68069
(651) 690-3140
Availity
68069
(800) 282-4548
Via the Provider Portal we can also:
Receive an ANSI X12N 837 professional, institution or encounter transaction. Portal
allows batch\individual claim submissions
Generate an ANSI X12N 835 electronic remittance advice known as an Explanation of
Payment (EOP).
Please contact:
Buckeye Community Health Plan
c/o Centene EDI Department
1-800-225-2573, extension 25525
or by e-mail at:
[email protected]
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Paper Claim format
All services must be billed to Buckeye using a CMS 1500 form.
Forms cannot be filled out by hand.
Must be completed using computer
software or a typewriter.
All claims must be submitted within
Program Exclusions
180 days from the date of service.
Claims must be submitted to the
following address:
Buckeye Community Health Plan
ATTN: Claims 3060
Farmington, MO 63640
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Billing – Dos and Don’ts
Billing – Dos
Billing – Don’ts
Submit your claim within 90 days of
the date of service
Submit handwritten claims
Submit on a proper original form –
CMS 1500
Don’t circle data on claim forms
Use red ink on claim forms
Don’t add extraneous information to
Mail to the correct PO Box number
any claim form field
Submit all claims in a 9” x 12” or Program Exclusions
Don’t use highlighter on any claim for
larger envelope
field
Type all fields completely and
Don’t submit photocopied claim forms
correctly
(no black and white claim forms)
Use typed black or blue info only at 9 Don’t submit carbon copied claim
point font or larger
forms
Include all other insurance
Don’t submit claim forms via fax
information (policy holder, carrier
name, ID number and address) when
applicable
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EFT and ERA
Buckeye partners with PaySpan Health delivering electronic payments (EFTs) and
remittance advices (ERAs).
FREE to Buckeye Providers
Electronic deposits for your claim payments
Electronic remittance advice presented online.
HIPAA Compliant
Provider Benefits with PaySpan Health
Reduce accounting expenses – Electronic remittance advices can be imported directly
into practice management or patient accounting systems
Improve cash flow – Electronic payments for faster payments
Maintain control over bank accounts – You keep TOTAL control over the destination of
claim payment funds. Multiple practices and accounts are supported.
Match payments to advice quickly – You can associate electronic payments with
electronic remittance advices quickly and easily.
Manage multiple Payers – Reuse enrollment information to connect with multiple
Payers. Assign different Payers to different bank accounts, as desired.
For more information visit www.payspanhealth.com or contact them
directly at (877) 331-7154 to obtain a registration code and PIN
number.
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Thank you!