CIMS- HBR

1. CIMS- HBR

2. New Medicaid Dedicated Service Team • BlueChoice HealthPlan Medicaid began a new Provider Relations Team in April specifically for our Medicaid Provider Network. If your practice has not been visited, give us a call. • We are there to support you- do not hesitate to reach out to your designated PR Rep for assistance!!

3. n w o t e g r o e G o f u a e B t r BlueChoice HealthPlan Medicaid Provider Education Territory Map Provider Representatives Pee Dee Donna Thompson 803-264-3196 donna.o.thompson@bcbssc.com - 23 46 North Carolina Cherokee 42 39 11 G York r Spartanburg e Pickens e 37 n Karen Phillips 803-382-5778 Karen.phillips@wellpoint.com v i 12 l Oconee l 44 29 13 e M a r l b o r o 04 Chester Lancaster 30 Union Chesterfield 35 Anderson 20 28 Laurens Dillon 36 17 Darlington 01 Fairfield Kershaw 16 31 Newberry Abbeville Marion 24 Greenwood 21 Lee 34 41 40 Florence 43 26 33 32 Saluda Richland McCormick 19 Sumter Lexington Horry Edgefield 09 14 45 02 Calhoun Clarendon 22 Williamsburg 38 Aiken Orangeburg 06 05 08 Georgia Barnwell Bamberg Provider Representatives Dorchester Berkeley 15 Allendale 18 Upstate 03 25 Colleton Edwina Sanders-Lisbon 803-382-5125 Edwina.sanders-lisbon@wellpoint.com - Hampton LowCountry Charleston 10 07 27 Midlands Jon Keith 803-382-5085 Jon.keith@bluechoicesc.com Jasper

4. Contacting BlueChoice HealthPlan Medicaid Remember that all contact information for BlueChoice HealthPlan Medicaid is different than our commercial product BlueChoice HealthPlan. Website: www.BlueChoiceSCMedicaid.com Customer Care Center: (verify eligibility, benefits, claims status, general questions, etc.) Voice: 866-757-8286 Monday to Friday: 8 a.m. to 6 p.m. Fax: 912-233-4010 or 912-235-3246 TTY: 866-773-9634 24-Hour Nurseline Voice: 866-577-9710 TTY: 800-368-4424 Utilization Management (Prior Auth and Hospital/Facility Admission Notification): Voice: 866-902-1689 Monday to Friday: 8 a.m. to 5 p.m. Fax: 800-823-5520 Case Management (CareCoordination and WIC Information): Voice: 877-833-5736 Monday to Friday: 8 a.m. to 5 p.m. Fax: 866-406-2808 24 hours a day, 7 days a week WIC: 800-868-0404 ExpressScripts, Inc. (Pharmacy Benefits) Voice: 800-470-0933 Monday to Friday: 8 a.m. to 9 p.m. Fax: 866-807-6241 Saturday to Sunday: 8 a.m. to 6 p.m.

5. Verifying Eligibility Checking eligibility is critical for every visit since each member has 90 days to switch plans after assignment and can lose eligibility at any time of the year based on a change in their status. Member ID card Customer Care Center: 1-866-757-8286 www.BlueChoiceSCMedicaid.com SC Point of Sale (POS) device SC Medicaid IVRS SC https://portal.scmedicaid.com/

6. Identification Card In addition to this BlueChoice HealthPlan Medicaid ID Card, members are also required to carry their SC DHHS-issued Healthy Connections ID card.

7. Claim Submission Claim Filing LimitsAll providers are allowed 365 days to submit claims. Electronic Data Interchange (Payer ID 00403)Preferred and fastest way to submit your claims.For set up and questions call 1-800-470-9630. Hard Copy Claim Submission, Corrected Claims and Correspondence If you need to file a hard copy claim, submit a corrected claim, file an appeal or submit any type of for correspondence please mail to: BlueChoice HealthPlan Medicaid ATTN: Medicaid Claims PO Box 100124 Columbia, SC 29202-3124

8. Timely Filing, Re-submissions, and Appeals Original Claims Original claims must be submitted within 365 days of the date of service Corrected ClaimsCorrected claims must be received within 90 days from the process date to be considered for payment. Corrected claims must be submitted with the Claim Follow Up form. AppealsAppeals must be received within 90 days from the process date to be considered for review. Appeals must be submitted with the Provider Dispute Resolution form

9. ER Diversion and Clinic Days • ER Diversion Demonstration Project • Participants include 3 hospitals with highest ER utilization in 3 regions; 12 primary care groups surrounding those facilities and all urgent and minor care clinics. • Project began 3/1/13 and will run to 12/31/13 • Mail out to all members in Project area with information on place of care ( urgent versus ER), 24/7 nurse call line with refrigerator magnets and listings of urgent/minor care in their neighborhood. • Providers receive monthly listings of their assigned membership utilizing ER services • Excellent provider feedback and action • Clinic Days- HEDIS Project • Two Pediatric practices to participate in this new project to facilitate improvement in specific HEDIS measure scores. • Well Child Visits to be targeted during these events to be held in July • We will schedule all our members on Gaps in Care reports for visits during event. Gift cards to be presented to members and Provider incentive to practice.

10. ER Utilization Report

11. First Quarter ER Diversion Results

12. Gaps in Care Reports

13. What is a Patient-Centered Medical Home? • The Patient Centered Medical Home (PCMH is a model of care designed to strengthen the physician-patient relationship by moving from episodic (reactive) care to coordinated (proactive) care, while establishing on ongoing relationship with a physician-led care team. • In a PCMH, the care team is responsible for providing all the patient’s healthcare needs, including appropriate referral to other qualified physicians as needed. Emphasis is placed on open scheduling, expanded hours, and strong communication between patients, physicians and staff.

14. Why PCMH?? • So why take the plunge? Following are six reasons to consider implementing the PCMH Model: • National recognition • Increased reimbursement • Reduction in Hospital Admission Rates • Reduction in ER Visits • Improved staff satisfaction in PCMH practices • Improved patient health outcomes

15. BlueChoice HealthPlan Innovation Specialists • Guide practices through the NCQA Recognition and PCMH transformation • Perform baseline assessments with each practice to gauge readiness and identify gaps • Develop “road maps” for each practice on their individual needs and abilities • Build PCMH transformation team within the practice • Provide education on the NCQA PCMH Recognition standards • Develop tools and resources to assist practices with the NCQA documentation requirements- P&P, reports, mechanisms for performance monitoring, etc.

16. BlueChoice HealthPlan Innovation Specialists (2) • Provide continued support to practices after NCQA Recognition. • Identify key drivers for performance improvement • Organize learning opportunities from national experts • Provide meaningful feedback on performance and solutions for barriers.

17. PCMH Incentives – Medicaid As RHC’s begin to apply for NCQA certification as a Patient Centered Medical Home, they become eligible to receive quarterly reimbursement from BlueChoice HealthPlan Medicaid based upon their certification level. The incentive is paid out as a per member per month payment for each eligible member assigned to the practice. • Application Level $.50 PMPM • Level One Certification $1.00 PMPM • Level Two Certification $1.50 PMPM • Level Three Certification $2.00 PMPM

18. Questions?? Any Questions may be directed to: Judi Ryder Senior Director Network Management 803 264-2068 Judi.ryder@bluechoicesc.com