Transcript EXPANDED UHC PowerPoint Template
UnitedHealthcare Community Plan Provider Orientation Presentation
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Overview: UnitedHealthcare Community Plan
• • • •
UnitedHealth Group
More than 85M individuals served worldwide 172,000 employees worldwide #14 on Fortune 500 12 MLTSS markets • • • • • Employer & Individual Medicare & Retirement Community & State Military & Veterans Optum 3 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
New Jersey
Founded as Managed Healthcare Systems of New Jersey (MHS) in 1995.
Operated as AmeriChoice of New Jersey from 1998 – 2010.
Acquired by UnitedHealth Group (UHG) in 2002.
Re-branded as UnitedHealthcare Community Plan in January 2011.
Licensed in all 21 counties for NJ FamilyCare/Medicaid • 4 counties for DSNP • • • ~ 1 in 8 New Jersey residents ~ 490,000 NJ Family Care members DSNP in 4 counties • Community Involvement & Investment • • • 150 Health Education events 50 health fairs 100 community outreach events with various community-based and faith-based organizations throughout NJ 4 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
MLTSS Statistics
• 3,500 members / 5,000 State Plan PCA • 65% at home • 25% in assisted living • 10% in NF • > 4,000 F2F assessments • > 100k claims (99.5% electronic within 15 days) • Place of service • Dx code • EOB • 60 : 1 member to care manager ratio for HCBS 5 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Continuity of Care
• All State approved services will be authorized until the member is assessed by his/her care manager • Once the member is assessed a new service plan will be created with corresponding authorizations where necessary • All MLTSS requests prior to 7/1/14 are the responsibility of the State • The State is providing prior authorization files to UHC that contain the services that members receive under FFS prior to 7/1/14 • UHC is responsible for services once the individual’s Medicaid eligibility is confirmed AND is enrolled in managed care .
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Long Term Care Team
• UHC has a dedicated unit to provide customer service for MLTSS members • All members receiving MLTSS services will receive a face to face assessment for evaluation of needs • Providers/members are provided with a direct line for contacting their Care Manager (800) 645-9409 • Members can reach a nurse 24x7 by calling Member Services or the Nurseline at 888-433-1904 .
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Critical Incident Reporting
What is a Critical Incident?
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Unexpected death of a member; Missing person or Unable to Contact; Inaccessible for initial on-site meeting; Theft with law enforcement involvement; Severe injury or fall resulting in the need for medical treatment; Medical or psychiatric emergency, including suicide attempt; Medication error resulting in serious consequences; Inappropriate or unprofessional conduct by a provider/agency involving the member; Suspected or evidenced physical or mental Abuse, (including seclusion and restraints, both physical and chemical); Sexual abuse and/or suspected sexual abuse; Neglect/Mistreatment, including self-neglect, caregiver overwhelmed, environmental; Exploitation, including financial, theft, destruction of property; Failure of a member’s Back-up Plan; Elopement/wandering from home or facility; Eviction/loss of home; Facility closure, with direct impact to member’s health and welfare; Media involvement or the potential for media involvement; Cancellation of utilities; Natural disaster, with direct impact to member’s health and welfare; Other, Explain : 9 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
How do I report a Critical Incident to UHCCP of NJ and what are my responsibilities?
Providers are expected to assist the member immediately and then report to the State agency if appropriate BEFORE reporting to the MCO via the Call Center.
• Critical Incidents can be reported to the UnitedHealthcare by contacting the Call Center at (888) 702-2168 or by completing the Critical Incident form and faxing it to (855) 216-6408 within 24 hours of discovery of the incident. • The form can be found on the UnitedHealthcare Community Plan of NJ web site:
www.UHCCommunityPlan.com
• Any verbal notification must be followed up with a written report describing the incident and what the provider did to resolve the incident. There is no required format for the report. It should be faxed to (855) 216-6408.
• Participating providers must conduct an internal investigation and submit a written report advising of the root cause(s) of the incident and what steps were put in place to prevent such an incident from reoccurring. There is no required format for the report. It should be faxed to (855) 216-6408.
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Who else do I need to report a Critical Incident to?
Immediately report to the appropriate agency including 911, any knowledge of or reasonable suspicion of: • Abuse, neglect, or exploitation of adult member to the State’s Adult Protective Service office (APS) at 1-800-792-8820; • Abuse, neglect, or exploitation of members residing in Nursing Home to the State's Office of the Ombudsman for the Institutionalized Elderly (O.O.I.E.) at 1-877-585-6995; • Brutality, abuse or neglect of members who are children to the Division of Child Protection and Permanency, DCP&P, (formerly the Division of Youth and family Services, DYFS) DYFS Hotline at 1-877-NJABUSE (652-2873); • Abuse, neglect, and exploitation of members who are children residing in Pediatric Nursing Facilities to Division of Child Protection and Permanency, DC&P, (formerly the Division of Youth and family Services, DYFS), DYFS Hotline at 1-877-NJABUSE (652-2873); or 11 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Critical Incident Reporting Form page 2 13 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Critical Incident Reporting Form page 3 14 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Unable to Contact & Gaps in Care
Unable to Contact
Unable to Contact
shall be defined as an MLTSS Member who is absent, without notification, from any program or service offered and MLTSS provider is unable to identify the location of the Member using contact information available. In the event that an MLTSS Member is unable to be contacted, MLTSS providers must take the following steps in investigating and reporting unable to contact events: 1. Immediate outreach to the client using contact information on file. 2. If no response, immediate outreach to emergency contact(s) for Member. 3. If unsuccessful to the above, immediately notify the Member’s MLTSS Care Manager.
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Gaps in Care
Gap in Care -
the difference between the number of hours or services scheduled in a Member’s plan of care and the hours or services that are actually delivered to that Member. When a provider is aware of an upcoming gap in care, it is required to contact the Member before the scheduled service to advise him/her that the regular caregiver will be unavailable, that the Member may choose to receive the service from a back-up substitute caregiver, at an alternative time from the regular caregiver or from an alternate caregiver from the Member’s informal support system. Whenever there is a gap in services, the provider must contact the Member immediately, acknowledging the gap and provide an explanation as to the reason for the gap, and the alternative plan being created to resolve the particular gap and any likely future gaps. The provider must also notify the Member’s MLTSS Care Manager of any gaps.
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NJ MLTSS ID Card
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MLTSS Benefits
• • • • • • • • • • MLTSS benefits include a member’s long-term care needs, such as: Personal care Respite Care management Home and vehicle modifications Home-delivered meals Personal emergency response systems Mental health and addiction services Assisted living Community residential services Nursing home care 20 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
MLTSS Covered Services MLTSS Service
Adult Family Care Assisted Living ALR Assisted Living ALP Assisted Living CPCH TBI Behavioral Management Individual TBI Behavioral Management Group Caregiver/Participant Training Chore Services Chore Services Cognitive Therapy Individual* Cognitive Therapy Group* Community Residential Services (low) Community Residential Services (medium) Community Residential Services (high)
MLTSS Code
S5140 T2031 T2031 T2031 H0004 H0004 S5111 S5120 S5121 97532* 97532* T2033 T2033 T2033
Modifier
U2 U1 HQ U4* U5* TF TG
Unit
Per diem Per diem Per diem Per diem Per 15 min.
Per 15 min.
Per diem Per 15 min.
Per diem Per 15 min.
Per 15 min.
Per diem Per diem Per diem
* For cognitive therapy, the codes T2013 (individual) and T2013 HQ (group) should be used for dates of service between July 1, 2014, and Oct. 31, 2014. For dates of service on or after Nov. 1, 2014, please use the cognitive therapy codes listed above.
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MLTSS Covered Services (cont’d.) MLTSS Service
Community Transition Services Community Transition Services Administration Home-Based Supportive Care Individual Home-Based Supportive Care Group Home Delivered Meals Medication Monitoring Monthly Medication Monitoring Initial Setup Occupational Therapy Individual Habilitation Occupational Therapy Group Habilitation Occupational Therapy Individual Rehabilitation Occupational Therapy Group Rehabilitation PERS Initial Setup PERS Monthly, Standard Unit
MLTSS Code
T2038 T2038 S5130 S5130 S5170 S5185 T1505 97535 97535 97535 97535 S5160 S5161
Modifier
U6
Unit
Per service Per service HQ U2 U3 U4 U5 Per 15 min.
Per 15 min.
Per meal Per month Per service Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Per month Per month 22 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
MLTSS Covered Services (cont’d.) MLTSS Service
PERS Monthly, Cellular Unit PERS Monthly, Cellular Unit with Fall Detection PERS Monthly, Mobile Unit with or without Fall Detection Personal Care Services Individual Personal Care Services Group Personal Care Services Live-In Physical Therapy Individual Habilitation Physical Therapy Group Habilitation Physical Therapy Individual Rehabilitation Physical Therapy Group Rehabilitation Private Duty Nursing 21+ RN Private Duty Nursing 21+ LPN Private Duty Nursing under 21 RN Private Duty Nursing under 21 LPN
MLTSS Code
S5161 S5161 S5161 T1019 T1019 T1020 97110 97110 97110 97110 T1002 T1003 T1002 T1003
Modifier
U1 U2
Unit
Per month Per month U3 HQ U2 U3 U4 U5 UA UA EP EP Per month Per 15 min.
Per 15 min.
Per diem Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
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MLTSS Covered Services (cont’d.) MLTSS Service
Residential Modifications Residential Modifications Evaluation Respite (non-hospice) in the Home Respite (non-hospice) in Assisted Living Social Day Care Speech Therapy Individual Habilitation Speech Therapy Group Habilitation Speech Therapy Individual Rehabilitation Speech Therapy Group Rehabilitation Structured Day Program Supportive Day Services Vehicle Modifications Vehicle Modifications Evaluation
MLTSS Code
S5165 T1028 T1005 S5151 S5102 92507 92508 92507 92508 S5100 T2021 T2039 T2039
Modifier
U3 U3 U3 U4 U4 U7
Unit
Per service Per service Per 15 min.
Per diem Per diem Per diem* Per diem* Per diem* Per diem* Per 15 min.
Per 15 min.
Per service Per service
* The speech therapy unit of measure for dates of service between July 1, 2014, and Oct. 31, 2014, is per 15 minutes. For dates of service on or after Nov. 1, 2014, the unit of measure is per diem.
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Description of Units
• • • • • • Per diem – One unit equals once per day; only one unit can be billed per date of service.
Per service – One unit equals one service (e.g., one PERS installation setup would be one unit of service).
Per meal – One meal equals one unit of service.
Per month – One unit equals one unit of service; only one unit can be billed per month.
Per hour – One unit equals one hour of service.
Per 15 min. – One unit equals 15 minutes of service.
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Home-Based Supportive Care – Non-Accredited Care Providers
If you are a home-based supportive care provider who is not accredited, during the continuity of care time period you may bill the following codes for home-based supportive care services provided to UnitedHealthcare Community Plan of • • New Jersey members: S5130 U1 – individual S5130 U2 – group These codes will expire on July 1, 2015.
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Prior Authorization Requirements
Prior authorization is required for all MLTSS services ‒ regardless of whether the care provider participates with UnitedHealthcare Community Plan of New Jersey.
Please view the complete prior authorization list for Medicaid and MLTSS at UHCCommunityPlan.com under Billing & Reference Guides.
To request prior authorization, please call 800-262-0305.
All members receiving MLTSS services will receive a face-to face assessment for evaluation of needs.
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When New Authorization Is Required
• • •
Here are examples to illustrate when a new prior authorization must be requested
•
after a care provider receives authorization to provide services for a member:
During the authorized timeframe the member transfers to a new agency, then transfers back to the original agency: The agency must obtain a new authorization to resume services for the member. The member goes on vacation, then returns to the same agency: The agency does not need a new authorization to resume services, but must notify us that the member is on vacation to avoid an “unable to contact” issue resulting in a critical incident. The care provider should not bill for services while the member is on vacation.
The member enters a hospital or skilled nursing facility for less than 30 days, then returns home to the same agency: The agency does not need a new authorization to resume services, but must notify us. The member may require a face-to-face assessment. The member enters a hospital or skilled nursing facility for 30 days or more, then returns home to the same agency: The agency must get a new authorization for services. The agency can continue to service the member at the previously approved hours until a face-to-face assessment is completed.
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Utilization Management Appeals
Claim appeals based on UnitedHealthcare Community Plan’s adverse determination regarding medical necessity, experimental or investigational services should be processed under the Utilization Management appeal process
within 90 days from receipt of the original Utilization Management denial letter.
• • • Stage 1 Utilization Management appeals should include: Copy of the original Utilization Management denial letter Copy of the member’s medical record Additional information that supports the need for medical necessity on the denied date of services.
Utilization Management Appeals should be mailed to: UnitedHealthcare Community Plan Attention: Utilization Management Appeals Coordinator P.O. Box 31364 Salt Lake City, UT 84131 29 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Electronic Claims Submission
Electronic Submission
(Use Payer ID 86047) Electronic Data Interchange (EDI) Support Services provides support for all electronic transactions involving claims, electronic remittances and eligibility. For more information, please contact EDI Support at 800-210-8315 or [email protected]. If you do not have office software and would like to submit claims directly
at no cost,
submission can be done through Office Ally ‒ a secure, HIPAA-compliant solution that • • • • offers: Direct connectivity No installation, transaction or support fees for care providers Easy to use for both batch and single claims 24-hour customer support You can enroll at officeally.com. To learn more, please contact 866-575-4120 or [email protected].
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Electronic Payments & Statements (EPS)
With EPS, you receive electronic funds transfer (EFT) for claim payments, plus your explanations of benefits (EOBs) are delivered online. No matter what your practice size • • • or claims volume is, EPS means faster payment, easier reconciliation and less paper. Users receive payments and EOBs five to seven days faster than with paper.
View payments or EOBs for the last three months, or search a 13-month archive.
Claim adjustments will not be deducted from your account.
• • •
To enroll online, please go to myservices.optumhealthpaymentservices.com.
Here’s what you’ll need: Bank account information for direct deposit Either a voided check or a bank letter to verify bank account information A copy of your practice’s W-9 form If you prefer, you can download the EPS Paper Enrollment Form at UnitedHealthcareOnline.com > Claims & Payments > Electronic Payments & Statements (EPS) and mail or fax it to the contact listed in the form instructions. If you plan to route payments to accounts based on your national provider identifier (NPI), please call for enrollment assistance.
If you have questions or need help with EPS enrollment, please call 866-842-3278, option 5.
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Claim Payment Appeals Process
Please follow the claim payment appeals process to resolve billing, payment or other administrative disputes such as: • • Lost or incomplete claim forms or electronic submissions Requests for additional explanation as to services or treatment rendered by a care provider • • Inappropriate or unapproved services initiated by care providers Any other reason for billing disputes Claim payment disputes do not require any action by the member.
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Claims Payment Appeals Submission ‒ Informal Appeals
Please submit the Paper Claim Reconsideration Form available at UnitedHealthcareOnline.com > Tools & Resources > Forms. This form can
only
be • • • • • used for the following claim appeals: Previously denied for additional information to process claim.
Resubmission as a corrected claim Resubmission with prior authorization information Resubmission because it was a bundled claim Previously denied/closed as exceeding timely filing Please submit the form with a copy of the claim in question and any supporting documentation
within 90 days
from receipt of the EOB/provider remittance advice (PRA) to: UnitedHealthcare Community Plan Attention: Claim Administrative Appeals P.O. Box 5250 Kingston, NY 12402-5250 You can also submit claim appeals at UnitedHealthcareOnline.com or by calling 888-702-2168.
Submission of an informal appeal does not replace the submission of a Formal Claim Payment Appeal.
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Claims Payment Appeals Submission ‒ Formal Appeals
Formal appeals must be submitted to UnitedHealthcare Community Plan using the NJ Provider Appeal Form available at UnitedHealthcareOnline.com > Tools & Resources > Forms.
• • • If a care provider submits a claim payment appeal using this form
within 90 days
following receipt of the EOB/PRA and we uphold the claim payment denial, the provider has the right to file an external claims arbitration using MAXIMUS, the state’s arbitration organization.
If a care provider does not submit the original claim payment appeal on an HCAPPA form, the provider does not have the right to claims arbitration. However, the appeal will be processed by UnitedHealthcare Community Plan of New Jersey as an informal claim payment appeal.
If we uphold a claim payment denial on an informal claim payment appeal, there is no second level of appeal and claim payment decisions will be final.
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Credentialing
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Re-Credentialing
UnitedHealthcare Community Plan of New Jersey Re-Credentialing Requirements: 1.
2.
3.
Review and update the pre-filled Component Application with any applicable changes.
Sign and date the Component Attestation page.
Return the application with the following current documents to the address or fax number listed on the cover letter.
• Copy of current state license from the Division of Consumer Affairs • Copy of certificates of accreditation, if applicable (e.g., Community Health Accreditation Program) • Copy of declaration sheet and/or certificate of insurance for current professional malpractice
and
comprehensive general liability insurance policies 36 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Demographic Changes
All demographic changes must be sent to UnitedHealthcare Community Plan of New Jersey using any of the following methods:
Fax:
877-382-9298
Mail:
UnitedHealthcare Attn: Adrienne Collins P.O. Box 1276 Sharon Hill, PA 19079
Email:
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Your Provider Advocates
• • • • Serve as your primary contact Act as a navigational specialist to help you deal with all areas of UnitedHealthcare Community Plan Communicate with your practice about critical programs and processes within UnitedHealthcare Community Plan Specialize in issue resolution 38 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
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Hospice R&B Contracting
• Contract Amendments • Originally sent out to participating providers in November 2012. • Reimbursement is an averaged per diem rate since our payment system cannot accommodate the 300+ individual facility rates established by the State of NJ.
• Cannot be retroactive. Must have a future effective date.
• Single Case Agreements • To reimburse providers for room board until contract amendments become effective.
• To establish rates for non-participating providers .
• All new provider contracts have the R&B code included.
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Hospice R&B Authorization
• Hospice providers need to call in the notice of admit for hospice,
not the facility
, even when the member has Federal Medicare as primary.
• In order for hospice providers to be reimbursed, all authorizations must be under the hospice provider and
not the facility.
• Hospice R&B
does not
require authorization for members with Medicaid
only
.
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Hospice R&B Billing
• The hospice R&B codes are Rev Code 658/HCPCS code T2046. You must bill both codes on your claim.
• Single Case Agreements • Must be extended each time the authorization is extended • Claims can be submitted on paper or via the web portal with a copy of the fully executed agreement attached.
• Required if you are non-participating or your contract has not yet been amended to include a rate for the R&B code.
• If there is still a need for either an amendment or a single case agreement please contact me.
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Contact Information
For questions related to CHHA and/or Hospice contracting:
Angela Turner [email protected]
856-423-2063
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CHHA and Hospice Service Model
• A copy of the service model was sent out in October of 2014.
• Our team of Market Service Agents is trained to handle claims issues.
• • • E-mail issues to [email protected]. Automated response from mailbox with forms and instructions.
Agent will respond in approx. 72 hours and will contact you with questions and follow up.
• The agent responding to the mailbox submission may not be the agent assigned to resolve the issue.
• Work with the agent through to resolution. If you do not respond to requests for information the issue will be closed.
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Optum Cloud Dashboard
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Claim Project Submission
• To request reconsideration for
19 or fewer
claims the provider must have documentation of a call reference number from Provider Services.
•
20+ claims
for the
same issue
are considered claim projects (13+ for Oxford Commercial), and those can be referred to the MSA box without previous Provider Services review.
• Providers who have access to the web portal are encouraged to submit their projects there, but the service team is happy to submit projects for those providers who are unable to submit via the portal.
• Claim projects
must
be separated by denial code or payment dispute reason.
• Claim projects that have multiple root causes are considered accounts receivable dumps, and will be rejected.
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Reminder: Key Contact List Web Portal (newsletters, bulletins, forms) Provider Portal (claims, eligibility) – www.UHCCommunityPlan.com
www.unitedhealthcareonline.com
Provider Services Line for MLTSS Prior Auth/Intake for MLTSS -
(888) 702-2168 (800) 262-0305
Health Services
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To Identify Care Manager for MLTSS Member Services 24 Hour/Help Line Demographic Change Fax
–
Credentialing Center Fax/E-mail
–
Provider Advocates – Estelle Adams- Wright Monica Harris
(888) 362-3368 or Fax: (800) 766-2597 (800) 645-9409 (800) 941-4647 (TTY:711) TTY/TDD at (800) 852-7897 (877) 382-9298 (877) 620-3782 or [email protected]
(732) 623-1953 E-mail: [email protected]
(732) 623- 1066 E-mail: [email protected]
Medications requiring prior authorization
(800) 310-6826 Fax: (866) 940-7328
Prescription Solutions (PSI) for Pharmacy specialty injectables
- Fax: (800) 853-3844 47 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Links to State Training Materials
Resources for Providers:
MLTSS Provider Communications : http://www.state.nj.us/humanservices/dmahs/home/AL_CRS_Administrators_Letter.pdf
MLTSS Provider Frequently Asked Questions (FAQs) : http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Provider_FAQs.pdf
The Comprehensive Medicaid Waiver: http://www.state.nj.us/humanservices/dmahs/home/waiver.html
Resources for Consumers:
MLTSS Consumer Communications : http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Consumer_Communications.pdf
MLTSS Frequently Asked Questions (FAQs) : http://www.state.nj.us/humanservices/dmahs/home/Consumer_FAQs.pdf
Frequently Asked Questions (FAQs) for Dual Eligible Special Needs Plans (D-SNP) and MLTSS Consumers : http://www.state.nj.us/humanservices/dmahs/home/FAQ_D-SNP_MLTSS.pdf
NJ FamilyCare Managed Care Health Plans : http://www.state.nj.us/humanservices/dmahs/clients/medicaid/hmo/ Program of All-inclusive Care for the Elderly (PACE) : http://www.state.nj.us/humanservices/doas/services/pace/index.html
The Comprehensive Medicaid Waiver : http://www.state.nj.us/humanservices/dmahs/home/waiver.html
Slide Presentations:
MLTSS: The Choice is Yours : http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Consumer_Slide_Presentation.pdf
Essential Elements for Providers Participating in MLTSS: https://www.youtube.com/watch?v=snJBaEqR8g4&feature=youtu.be
Draft of HCBS Crosswalk: http://www.state.nj.us/humanservices/dmahs/home/Essential_Elements_for_Providers_Participating_in_MLTSS.pdf
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