2012 Provider Orientations

1. 2012 Provider Orientations Network Operations

2. Network Operations Staff Tulsa and Mayes Counties Oklahoma and Payne Counties Provider Contract Administrator: Jim Vogel (918) 613-0165 jim.vogel@lovelace.com Susan Berg (505) 727-0636 susan.berg@lovelace.com Provider Service Representative Jay Cleveland (405)201-5273 jay.cleveland@lovelace.com • Provider Contract Administrator: • Jim Vogel (918) 613-0165 • jim.vogel@lovelace.com • Susan Berg (505) 727-0636 • susan.berg@lovelace.com • Provider Service Representative • Sherrie Pippin (918) 237-2368 • sherrie.pippin@lovelace.com Fax Number (505) 727-9044

3. Network Operation Staff • Provider Representatives • can assist with: • - Escalated Claim Issues • - Demographic Updates • - Marketing Materials • Keeping you informed with • Lovelace updates and information • Contractors • can assist with: • - Contract Requests • Changes to Existing Contracts • Demographic Updates

4. Relationship • Lovelace has partnered with InSync Interpreter Services. • Interpretation Services through InSync includes multi-language phone support and through request, live sign language interpretation for the deaf. • Services can be accessed by contacting Customer Care at • 800-808-7363.

5. Customer Care • You can speak with a Customer Care Center Representative Monday - Friday between 8:00 am and 5:00 pm by calling • 505-727-5406 or 800-808-7363. • Customer Care can assist with: • Benefits Eligibility Claim Research • You can also access our 24-hour Interactive Voice Response (IVR) system by calling 877-480-9371 or 505-727-5378 to verify benefits or eligibility.

6. Website Resources:lovelacehealthplan.com/providers • Prior Authorization Information Grid • Eligibility, Benefit and Claim Status • Inquiry, Prior Auth, DME Forms • Online Provider Directory • Drug Formulary • Bulletins and Newsletters • Preventive Health Guidelines for • Providers • Participating Provider Application • Provider Reference Guide • Adjustment/Void Request Form • Credentialing Statewide Application • Disease Management Information • Provider Portal (coming soon)

7. Behavioral Health/Substance Abuse Outpatient Services Inpatient Services Authorization Required Admissions from 8:00 am – 5:00 pm; Phone: 505-727-5406 After hours/weekends call BH pager at 505-229-1299; late night admissions should be called in following morning • No authorization needed to see Lovelace • contracted provider • 90808, 90809 and 90814 will require PA • if more than 3 occur in a six month period • BH phone: 800-808-7363; 505-727-5747; • fax 505-727-5620 • Case Managers and Care Coordinators • Available to all members and providers • Accessing services, coordinate care and developing self-care plan

8. Healthy Steps Program • Healthy Steps Coaching: a telephonic coaching program for members living with Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Coronary Artery Disease and Asthma.  Our registered nurses support the healthcare providers’ treatment plan and give members the knowledge and tools needed to manage their condition. • Healthy Weight: A 10-week counseling program that focuses on lifestyle changes, this program is designed to help members develop the tools needed to achieve and maintain a healthy weight. • Stop Tobacco for Optimal Prevention (STOP): Individual telephone counseling to help members design a personalized program to stop tobacco use. • For more information contact Lovelace Health Steps toll free at 877-480-9368

9. LHP Case Management • Case Management is a collaboration with member/family and healthcare providers to create a plan that meets a member’s complex needs and goals. • What can Case Managers do: • - Connect members with community resources to meet needs of members • - Empower and prepare members to manage and enhance their quality of life and • health care resources • - Coordinate care and communication between providers, members • Contact Lovelace Case Management at: • Toll Free Phone: 800-808-4783 • Toll Free Fax: 877-894-4585

10. Claims Submissions Paper Claims Submission: Lovelace Health Plan PO Box 549 Buckeystown, MD 21717 Electronic Claim Submission: Lovelace Medicare Plan – 90328 Timely Filing & Follow Up Limitations: 180 days Lovelace Medicare Plan

11. Suggestions for Smoother Claims Processing • Please submit all lines of service on one claim submission at one time • Verify NPI on claim is for the individual practitioner rather than group and in the correct field • Modifiers: • Use appropriate modifiers when billing E&M and therapy codes on UB’s • LT/RT modifiers are not necessary for J-codes • J-codes should be billed with NDC • If more than one modifier applies, alpha modifier must be first, then numeric • Corrected claims should be mailed to Buckeystown claims address • Check status of claim before resubmitting multiple times to prevent duplicate denials/payments

12. Jiva Provider Portal • LHP is changing to Jiva Provider Portal The Jiva Provider Portal will be replacing the iExchange portal that’s currently in use. The Jiva portal will allow providers to request prior authorizations (PA) electronically and will provide the ability to view the PA details once a determination has been made. The Jiva portal has a target start date of December 2012. For more information and details you can call Diana Batista at 505-727-5110 or email her at Diana.Corlew@Lovelace.com (please include TIN, group name and phone number).

13. Appeals and Grievances Definitions What is an Appeal? What is a Grievance? When a provider expresses a concern regarding disputes, timeliness, or quality of health care services. • When a provider disagrees with a denial or a bundling edit on a processed claim. • Filing Limitations: • - 180 days of the initial EOP • Time: • 30 Calendar days from the date received • After 45 days, status may be checked by contacting Customer Care

14. Appeals & Grievances Necessary Documents: Ways to file: Mail: Lovelace Health Plan Attn: Provider Appeals Coordinator 4101 Indian School Rd NE Albuquerque, NM 87110 Fax: 505-727-9664 Verbal (For grievances only): Call Customer Care at 505- 727-5456 or 800-808-7363 • Cover letter with explanation • Copy of original claim or action being appealed • Explanation of Payment (EOP) • Supporting Documents • - Operative Reports • - Medical Records (required)

15. Proposed Medicare Expansion - 2013 Current Counties Proposed Counties

16. The Assist Group • The Assist Group (TAG) is a claims review service working with Lovelace Health Plan to review hospital bills for clinical correctness, billing errors and variances from industry billing practices. • If you need to contact TAG regarding an outstanding balance on a claim please contact Nadia Archuleta at 720-381-4495; email narchuleta@assistgroup.com or by mail: • The Assist Group • 300 Union Blvd. Suite 515 • Lakewood, CO, 80228

17. Lovelace Provider Portal (Coming Soon) • Self-Service Features: • Log In • Provider Home Page • Patient Inquiry / Search & Return • Patient Information (Eligibility) • PCP / Provider Information • Benefit Description – Medical • Benefit Detail • Outpatient Services • Referral Detail • Pre-Authorization Detail • Claim Center - Search & Return • Claim Detail • Provider Search & Return • Provider Information • Facility Search & Return • Facility Information • Find Inpatient Stays • Find a Patient/Result • Find Inpatient Stay Detail • Other Features: • Message Center • Update Password • Online Help

18. Cultural and Linguistic Competency Health Literacy • Health Literacy is the ability to read, understand and act on health information. Half of all adults in the United States aren’t able to understand much of what they need to know to take care of themselves and follow providers’ instructions. • Possible symptoms of low health literacy: • Asking for clarification after medical information or instructions are given • Missed appointments • Frequent errors in medication or self-care instructions, this can also be seen as non-compliance

19. Cultural and Linguistic Competency Health Literacy • How do we overcome Health Literacy Issues? • Use plain non-medical language • Ask clear, simple questions, ask patient to repeat prescription and medical information to verify patient understands care plan • Encourage questions, ask if the patient or caregiver has any questions on medications or treatment plan • Ask patient to bring prescriptions to appointments to review dosing information and verify patient is taking medication as ordered • Information regarding Health Literacy can be found at Office of Minority Health website: • www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlID=3