Transcript Slide 1

Becoming A Provider
About Us
Health Services for Children with Special Needs (HSCSN) is a unique
health plan that provides innovative care management services and
benefits to pediatric and young adults (ages 0-26) receiving Medicaid
and Supplemental Security Income (SSI) in Washington, DC.
Each enrollee is assigned a care manager - a nurse, social worker or
other qualified professional - throughout their entire enrollment. The
HSCSN Care Manager provides coordination of care, ongoing support
and collaboration with the primary care medical home and other
specialty providers in order to successfully meet the physical, mental,
behavioral and developmental service needs of each enrollee.
HSCSN is a subsidiary of The HSC Foundation, along with The HSC
Pediatric Center, and HSC Home Care.
Department of Health Care Finance
The mission of the Department of Health Care Finance is to
improve health outcomes by providing access to
comprehensive, cost-effective and quality healthcare services
for residents of the District of Columbia.
DHCF – Summary of Services
DHCF, an agency created in FY 2009, that provides health care
services to low-income children, adults, the elderly and persons
with disabilities.
Over 200,000 District of Columbia residents (nearly one third
of all residents) receive health care services through DHCF’s
Medicaid Managed Care contracts and Alliance and Fee-forservice programs.
To become a provider with HSCSN – two different processes must
happen simultaneously.
1. Contracting – notification to the Contracting department begins the
process. You will be sent a contract along with a document that
requests other information.
2. Once you have signed your section of the contract – Contracting
notifies the Credentialing Department. Credentialing will review
the submitted documents and may contact you for additional
3. Once you have passed the credentialing process, then your
contracted will be executed by the COO of HSCSN.
4. You will then be able to start seeing our enrollees.
Initial Credentialing – Criteria, Verification and Time Limits
Interested parties may apply for participation by completing an application through the
Council for Affordable Quality Care (CAQH) at or contact the
CAQH Help Desk at (888) 599-1771.
All dental providers interested in participating with HSCSN, should contact the Quality Plan
Administrators (QPA) at (202) 722-2744.
Already a CAQH Provider
Providers who have previously obtained their CAQH ID and are interested in joining HSCSN
may submit a Provider Interest Form via electronic mail to [email protected] or
via fax to (202) 495-7536. Please be sure that CAQH has the most current and accurate
information as this will expedite the credentialing process.
Becoming a CAQH Provider
Providers who have not yet obtained a CAQH ID, complete and submit a Provider Interest
Form via electronic mail to [email protected] or via fax to (202) 495-7536.
Next Steps:
A pending file will be created and you will be notified of your CAQH ID.
Once you have been provided with a CAQH ID, you will then need to login to CAQH to
complete your provider application.
Upon completion of your application, CAQH will send you a confirmation that they have
received your data.
Notify the Credentialing department (phone or email) that your application has been
received by CAQH.
Your CAQH ID may be used by any health plan that is actively participating with CAQH.
Completed applications will be downloaded and processed within 60 days. You have the
right to be advised of your application status and may contact the Credentialing department
via phone at (202)974-4693 or in writing. Once the application process is completed, you
will be notified by certified mail of the Credentialing Committee’s decision.
Provider Services
HSCSN’s Provider Service staff is available to help your office with all Provider relation
functions including but not limited to the following:
Authorization and Claims payments;
Assisting Providers to resolve billing and other administrative problems;
Responding to Provider concerns about administrative processes;
Assisting the Department of Health Care Finance (DHCF) in notifying Providers
of DHCF initiatives; and
Responding to Provider concerns about Enrollees.
Provider Resources
Visit our website at, our online Resource Center
provides access to valuable and pertinent information. From navigation on the
home page – click Provider Resources, then Provider Services.
Provider Manual
Clinical Practice Guidelines
Provider Directory
HealthCheck Provider Education System
Provider Newsletters
Care Coordination
Care Coordination is a series of activities provided by HSCSN Care Managers to assist
enrollees in gaining access to necessary services (medical, behavioral and others),
coordinate preventative and specialty services and facilitate communication and
coordination in the medical home. Care coordination is individualized, empowering,
comprehensive, and outcome-focused.
What are the Care Manager’s role and responsibilities?
Develop a relationship with and support the enrollee and/or caregiver
Develop relationships with physicians and providers servicing enrollees
Communicate with enrollee, caregiver, treating physician(s) and providers
Assist the family with identifying their medical needs
Facilitate access and coordinating services for the enrollee (identify provider, schedule appointments, coordinate
Develop and monitor the care coordination plan
Educate enrollees and families on HSCSN benefits, resources and processes
Identify and coordinate enrollee/caregiver education needs (classes, literature, referrals)
Support the relationship between the enrollee and their providers
Connect the enrollee/caregiver with resources
Make referrals to educational advocates and attend educational meetings (with permission of enrollee/caregiver)
Assist the provider with obtaining home evaluations and/or social work assessments
Assist the provider and family to address overutilization and underutilization of services and noncompliance
Care Coordination
Working with the Care Manager – what is the role of the Provider?
Comply with EDSDT and adult preventive care requirements and guidelines
Collaborate in development of the Care Coordination Plan (review, edit, sign,
and return)
Follow the HSCSN Referral Guidelines for services requiring preauthorization
Ensure that referrals for home care, durable medical equipment and medical
supplies are complete and that services are monitored as indicated
Communicate with the HSCSN Care Manager about concerns (risks,
noncompliance, overutilization, underutilization, health education needs, etc.)
and progress
General Claims
HSCSN will process all claims through an automated system. Our goal is to pay providers
for covered services within 30 days of receipt of each completed clean claim form. Your tax
identification number is your provider ID. Please include it and the NPI on every claim to
help expedite payment.
Professional providers and Home Health Agencies are required to submit for payment of
covered services on the Centers for Medicare and Medicaid Services (CMS)-1500 Health
Insurance Claim Form and Home Health Agencies. Hospitals are required to submit for
payment of covered services on the CMS UB04. These forms are available from CMS at
Providers have the option of submitting claims electronically through EMDEON or via mail.
HSCSN’s payor ID is 37290. Claims should be mailed to:
PO Box 29055
Washington, DC 20017
General Claims
Timely Processing of Claims
In accordance with D.C. Code § 31-3132, HSCSN shall accept Network and non-Network
Provider initial Claims for Covered Services no later than one hundred and eighty (180)
days from the date of service.
Health Care Acquired Conditions
The Patient Protection and Affordable Care Act of 2010 include provisions prohibiting
Federal Financial Participation (FFP) to States for payments for health care acquired
conditions (HCACs) and other provider preventable conditions or Never Events.
HSCSN shall no longer reimburse providers for procedures relating to the following health
care acquired conditions when any of the following conditions are not present upon
admission in any inpatient setting, but subsequently acquired in that setting.
Claim payments or denials can be appealed in writing within 90 days of the denial or
General Claims
Electronic Billing
Providers now have the opportunity to submit claims electronically and check your claims
through a system called claims status link. HSCSN encourages you to sign up by visiting the
HSCSN website and follow the link:
General Claims
Coordination of Benefits
Health Services for Children with Special Needs, Inc. (HSCSN), is always the payer of
last resort when the enrollee has another insurance coverage. As a provider, you must
always submit your claims to the other insurance company first. Once you receive
an explanation of payment from them, you should file the claim with HSCSN. You
must attach a copy of the explanation of payment from the other carrier or a copy
of the letter of denial. HSCSN will coordinate the payment with the other carrier’s
payment. HSCSN will pay up to the amount that is contracted. The provider will not
receive payment for more than the charge or contracted amount when combining
the payments of both payers.
These services – DO NOT – require authorization:
•Specialty office visits (except behavioral health)
•Primary care visits
•Well woman care (including Depoprovera shots)
•Vision services (including eye glasses)
•Labs and Radiology (including X-Rays, sonograms, MRIs, CT and PET Scans)
Required Authorizations for Medical/Surgical
Intervention Services
•Rehabilitative therapies (physical, speech, occupational)
•OB Global services and services associated with pregnancy
•Home health (nursing, personal care aide and rehab therapies) and hospice care
•Durable Medical Equipment and Assistive Technology
•Supplies and Nutritional supplements
•Anesthesia for dental procedures
•Elective medical admissions (including feeding programs)
•Facility admissions - Sub-acute, Rehab, Transitional and Long Term Care
•Elective surgery (including plastic surgery), outpatient and inpatient
•Home Modification
Required Authorizations for Behavioral
and Neuropsychiatric evaluations
•Psychological testing and evaluations
•Psychotherapy, Counseling and Applied Behavioral Analysis (ABA)
•Psychotropic medication management visits
•Intensive Outpatient Programs and Day Rehabilitative services
•Partial hospitalization programs
•Sub-acute admission
•Substance Abuse treatment (inpatient and outpatient)
•Residential Treatment Facility
•Intermediate Care Facility for Mental Retardation (ICF-MR)
Home Health Services- Medical
Home health services (Skilled Nursing) must be ordered by a physician. The ordering
provider must submit a completed HSCSN Home Care Referral Form prior to service
initiation. The form will improve and expedite referrals, reviews and authorizations. The
completed HSCSN Home Care referral form can be faxed to 202-721-7190. The care
requested must be appropriate to the home setting and to the enrollee’s needs. The request
will be reviewed every 60 days within the Home Health Unit for medical necessity. The
requesting provider must review and sign the plan of care from the home care agency every
60 days to ensure that services are appropriate and continue to be medically necessary.
For Personal Care Aides – HSCSN requires an in-home assessment of the enrollee’s
personal care needs by an RN prior to the initial authorization of services and a minimum
of every 6 months for ongoing services.
Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review
Nurse if you need assistance.
Home Health Services- Behavioral
The goal of our behavioral health home care service is to work with enrollees, their families
and community providers to treat challenging behaviors that interfere with a youth's
successful functioning at home and in the community. In-home services are delivered by a
trained Behavior Specialist and a supervising licensed behavioral health professional.
The HSCSN Behavioral Health Home Services Referral Form must be submitted for all
home-based behavioral health service requests. The form will improve and expedite
referrals, reviews and authorizations. It is important that the provider supply all relevant
clinical history. The completed HSCSN Behavioral Health Home Services Referral form can
be faxed to 202-721-7190. The requests are reviewed by the Home Health Unit and referred
to an independent licensed social worker to conduct an assessment and provide
recommendations for services. Behavioral health home services are authorized based on
the recommendation. The services will be reassessed every 6 months within the Home
Health Unit for continued medical necessity.
Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review
Nurse if you need assistance.
Durable Medical Equipment (DME), Orthotics, Prosthetics and Assistive Technology
The documentation required for the authorization is dependent on the type of equipment requested. The following
are standard requirements:
Order for the Service
Certificate of Medical Necessity (CMN) or Physician Letter
A pended authorization is generated after receipt of the CMN and the physician order. Delivery confirmation
receipt from the vendor is required before an authorization can be approved. Please fax receipt to the DME Review
Nurse within 24 hours of delivery (or next business day if after hours) at 202-467-0978. Receipt should
include the following information:
of person taking possession of equipment at time of delivery;
Delivery date;
Documentation of education conducted; and
Brand name, model number, quantity, serial/identification number(s) of equipment delivered
HSCSN verifies all new and replacement durable medical equipment, prosthetics, orthotics, and assistive
technology delivered to the enrollees in the home.
Inpatient Admissions
Non-emergent (elective) medical/surgical inpatient admissions and outpatient surgical procedures
must receive prior authorization from the UM Department. The PCP or specialist should contact
the UM Department at least 3 business days prior to the scheduled admission or procedure to
obtain authorization.
All emergent/urgent inpatient admissions must be reported to the UM Department within 24
hours of the admission. Please fax admission information to 202-635-5590. The following
information is needed for the admission:
Enrollee Name
ID Number
Admitting Physician
Hospital Name and Address
Admission Date
Diagnosis and clinical information
Name and Telephone Number of Contact Person
If notification is not received within 24 hours of the admission, the day’s prior to notification will
be denied unless there are documented extenuating circumstances.
Appealing a Clinical Decision
Provider Rights to Appeal a Clinical Denial Decision
Providers have the right to:
Discuss denial decisions with the licensed clinical reviewer
Speak with the physician reviewer who issued the denial (or designee)
Obtain an explanation of appeals process, including timeframes for appeal decision
Appeal decision by submitting written comments, documents or any relevant information
To File an Appeal
There are two ways to file an Appeal:
Telephone the Utilization Review Line at 202 721-7162 Mon. – Friday 8:30am – 5:00pm
Health Services for Children with Special Needs, Inc.
1101 Vermont Avenue, NW - Suite 1200
Washington, DC 20005
Attn: Utilization Management Department - Appeals
Level of Care Criteria
The medical and behavioral criteria approved for the use by HSCSN for clinical
determinations is InterQual Level of Care Criteria. HSCSN is licensed to utilize
the criteria by McKesson Health Solutions, LLC. All InterQual criteria sets are
based on two major clinical components:
1) Severity of Illness
2) Intensity of Service
The sets are sub-grouped by body system, clinical findings, imaging findings,
laboratory findings and daily treatment protocols.
Clinical Guidelines
HSCSN encourages the use of evidence-based Clinical Practice Guidelines to
ensure that the best and most current quality of care is provided to enrollees.
HSCSN reviews all Clinical Guidelines every two years.
For a list of all clinical practice guidelines adopted and approved by HSCSN’s
Quality Council can be found on the Provider Resources page on the HSCSN
Website @
The Clinical Guidelines may also be found in your HSCSN Provider Manual on
pages 102-103.
Healthcare Effectiveness Data and
Information Set (HEDIS®)
HEDIS is a program designed and Managed by the National
Committee on Quality Assurance (NCQA). The program is designed
to measure a set of quality indicators and then be able to make
comparisons across the nation based on plan type. HSCSN posts our
results on our website and in our Provider Newsletter annually. You
as a provider may also receive information throughout the year on
your personal provider status with these measures as well as our
overall health plan status. These are tools to help us partner to
improve outcomes with the care delivery system for our enrollees.
What can HSCSN’s network physicians do?
Diabetes Care
Educate on the importance of eye exams, lipid control, blood pressure control, foot
exams, and serum glucose control. Tight management of diabetic enrollees to assist in
meeting HEDIS goals is recommended. The goals for good Diabetic Management are:
Lipid control = LDL-C < 100mg/dL
HbA1C = < 7% good control, < 8% control, > 9% poor control
BP = < 130/80 good control, < 140/90 poor control
Annual medical attention for nephropathy
Refer enrollees to ophthalmologists/optometrists at least every two years.
Encourage enrollees to have ordered labs drawn.
Contact HSCSN Care Management when enrollees cancel appointments.
Ensure that diabetic patients receive a comprehensive examination annually.
Code information on your claims to document care delivery
What can HSCSN’s network physicians do?
Monitoring of BMI and associated components of good health
In order to target Obesity and malnutrition and begin interventions as early as possible for
both of these conditions it is accepted that monitoring of BMI and tracking what percentile
and enrollee falls in is the most reliable way to date of determining where an enrollee is in
the growth cycle. HEDIS also looks for documented discussions surrounding nutrition and
exercise between the physician and caregiver or enrollee. Coding can also be used for all of
these measures to document your care
What can HSCSN’s network physicians do?
Childhood Immunizations
HEDIS looks at the Immunizations recommended by the CDC as an area of comparison for
quality care. The Childhood immunization measure most specifically counts recommended
immunizations that have been given PRIOR to the child’s second birthday. Immunizations
that have been recommended to be given prior to 24 months of age that are given after the
child’s second birthday are considered non-compliant.
Rotavirus administration is low, this may be because you must document if you are giving
the two doses or three dose vaccines. If there is no documentation it is assumed the three
dose vaccine was used and one dose was missed.
Rates of administration of the Influenza vaccine have been low in the last few years. This is
a CDC recommendation that influenza vaccines be administered to children under two
Call the HSCSN care manager to be your partner in getting enrollees in to get their
immunizations in the recommended time frame.
What can HSCSN’s network physicians do?
Timeliness of Prenatal Care and of Postpartum Care
Schedule/provide initial prenatal care as soon as pregnancy is confirmed.
Remind expectant enrollees to make appointments for prenatal care and postpartum
Educate enrollees about the importance of prenatal and postpartum care.
Contact HSCSN Care Management when enrollees cancel/fail to show up for scheduled
Alert HSCSN Care Management to any needs for outreach
Provide postpartum visits between 21 and 56 days after delivery
Global billing is a tool for your office to use for ease of billing purposes but you may
submit documentation of visits/care delivery by submitting the CPT II (Table 4) codes
to document individual visits not captured in the global billing. Codes should be used
with a zero charge as individual visit payments are already included in the global
Fraud, Waste and Abuse
Fraud - means an intentional deception or misrepresentation by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or to some other person. It includes any act that constitutes fraud under
applicable Federal or State law.
Waste - means the over-utilization of services not caused by criminally
negligent actions; waste involves the misuse of resources.
Abuse - means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and that result in an unnecessary cost to the
Medicaid program, or in reimbursement for services medically unnecessary or
that fail to meet professionally recognized standards for health care. It also
includes beneficiary practices that result in unnecessary cost to the Medicaid
Fraud, Waste and Abuse
What is your role concerning the FCA?
You are essential to your organization’s compliance with the FCA.
The codes your office/facility attaches to diagnoses and procedures, the documentation you
keep for each patient, the bills you file –even the dates you record when procedures occur
are subject to the FCA. Therefore, your work must be clear, accurate and in compliance with
all rules and regulations.
Safeguard your organization by ensuring:
You document orders in the patient’s medical record;
Services are deemed medically necessary based on patient’s needs;
Medical necessity is documented in the patient’s medical record;
All billing, coding, and reimbursement rules are followed;
Services not rendered, are credited to the patient’s account;
Accountability for your actions and acting with integrity in all circumstances.
You do not retain Medicaid funds that were improperly paid
Reporting Requirements
By law, providers must report all occurrences of sexually transmitted diseases,
communicable diseases, vaccine preventable diseases, immunizations administered,
lead levels and developmental delay in infants and children to the following
Sexually Transmitted Diseases, Communicable Diseases
Department of Health (202) 727-6408
Immunizations, Dept. of Health (Vaccine for Children)
(202) 576-7130
Lead Levels, DC Lead Registry (202) 535-1398
Developmental Delay – DC Early Intervention
(202) 727-3665 or visit
Health Insurance Portability and
Accountability Act (HIPAA)
The goals of the privacy standards are to protect the confidentiality of individually
identifiable information obtained, restricts how it can be used and disclosed and to protect
individual rights.
Access to Enrollee Records
Permitted Uses and Disclosures:
HSCSN may request Protected Health Information (PHI) for:
a) Treatment, payment or healthcare operations,
b) The healthcare operations of another covered entity or healthcare provider, if each entity has or
had a relationship with the individual who is the subject of the PHI being requested, and the
disclosure is:
For a purpose listed in the definition of healthcare operations; or
For the purposes of healthcare fraud and abuse detection or compliance.
c) Another covered entity that participates in an organized healthcare arrangement with The HSC
System for any healthcare operation activities of the organized health care arrangement.
Remember to always refer to your Provider Manual
Contract your Provider Service Representative with any questions or concerns
Refer to your important numbers (Page 5) of your Provider Manual
Notify us of any changes in your practice:
•Provider resigned
•New provider on staff
•Change of address
Read your voucher, post your payment and review the reason code description
in a timely manner.
Additional Classes
Electronic Solutions
Tuesday, October 20th, 2012
10:00 PM – 12:00 PM
1629 K. Street
Completing a CMS 1500
Thursday, October 25th, 2012
10:00 AM- 12:00 PM
1629 K. Street
Utilizing Your Provider Manual
Wednesday, November 21st, 2012 10:00 AM – 12:00 PM
1629 K. Street
Provider Orientations
2124 Martin Luther King Avenue, SE
Washington, DC 20020
Tuesday, September 11, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Tuesday, October 16, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Thursday, November 15, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Provider Orientations
HSC Pediatric Center
1731 Bunker Hill Road, NE
Washington, DC 20017
Friday, September 14, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Friday, October 19, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Tuesday, November 13, 2012
10:00 am – 1200 pm
2:00 pm- 4:00 pm
Provider Orientations
HSC Pediatric Center
1731 Bunker Hill Road, NE
Washington, DC 20017
Mandatory Annual Home Health/DME Forum
Monday, November 5, 2012
10:00 am – 1200 pm
For all Classes:
RSVP to Robert Thompson at [email protected], call
202-803-6776 or fax to 202-309-1291.