Welcome Annual Provider Office Manager’s Meeting

1. WelcomeAnnual Provider Office Manager’s Meeting Physicians Choice Medical Groups & Marian Health Services July 30-31, 2013

2. Agenda • Welcome/Introductions • Client Network • Health Plan/Provider Updates • Eligibility Verification Overview • Referral Management • Claims • Credentialing • Annual Provider Training • Language Assistance • Fraud, Waste and Abuse • Cultural Competency • GEMCareHealth Plan • Conclusion/Q&A

3. Hand-Out Packet Contents • Summary of Key Things to Remember A-1: Marian Health Services A-2: Physicians Choice Medical Group of SLO A-3: Physicians Choice Medical Group of Santa Maria • Utilization Review Information Form C.Claims Submission Guideline – Health Plan D.Claims Submission Guideline – IPA E. PRA Memo/Sample F. Referral/PDR Process Memo G. Language Assistance Program H. New Material – MHS Ancillary Vendor Listing

4. MCS CLIENT NETWORK

5. Blue Shield Commercial and Dignity Health Effective 1/1/2013, contract terms changed Dignity Health accepted risk for Blue Shield Commercial members enrolled with PCSLO What does this mean? If you were previously billing the IPA, continue billing the IPA. If you were previously billing Blue Shield directly, submit to MCS. MCS will process and pay these claims on DH’s behalf. 5

6. PCMG Provider Updates • Central Coast Pathology Laboratory is the capitated provider for all out-patient laboratory services. • Inclusive of anatomic and clinical pathology services • Pre-op testing • Exception of platelet function testing (bleeding time) • Effective June 1, 2013 for PCSLO • Effective September 1, 2013 for PCSM • Tertiary Services UCLA and USC are contracted with PCMG and MHS • USC University Hospital is the preferred tertiary center

7. MHS Provider Updates • Effective 2/12/2013: Marian Community Clinics officially changed their name to Pacific Central Coast Health Centers. • Effective 3/1/2013: Bariatric surgery program offered at the Weight Loss Surgery Institute of the Central Coast by Dr. David Maccabee.

8. MHS Provider Updates Effective 6/1/2013: Dignity Health bought and now owns the following centers for chemo therapy outpatient infusion services: Mission Hope Cancer Center in Santa Maria - Physician Group: Central Coast Medical Oncology Corporation Coastal Integrative Cancer Center in San Luis Obispo - Physician Group: Oncology Hematology Medical Associates of the Central Coast • Patients access and receive chemo treatment at centers. • Authorization clerks issue separate facility authorization. • No impact on patient; only affects rendering facility billing process to Plans.

9. Provider Network Updates - MCS Online Provider Network Updates are summaries of important information and available on MCS Online under Newsletters Updated monthly

10. Eligibility Verification • If a member is no longer actively enrolled or not listed in the system, the following are your options to verify eligibility and/or add new members: • MCS Online > Eligibility Verification Form or • Call Customer Service (may experience prolonged call time)

11. Eligibility Verification Form (EVF) • MCSO>Eligibility>Search Member Click onto link

12. Eligibility Verification Form (EVF) • Complete and Submit EVF online Email accessible during business day

13. EVF – Email Response • You will receive email communications from “System Configuration” as the sender, acknowledging receipt and findings. If member is found eligible, MCSO will be updated with current info, shortly thereafter.

14. Utilization/Referral Management From our staff to yours….. Thank you for being such an awesome team to work with! Friendly calls, dedication, hard work, and team efforts in streamlining patient care are recognized and much appreciated by our staff. A “high-five” to ALL of our provider offices.

15. Urgent Authorizations • Urgent authorization requests: • Goal to provide an online response within 24 hours • Based on medical necessity • Should not be submitted for scheduling reasons • Do not place an authorization request in an urgent status unless there is a truly emergent situation requiring a determination within 1 working day and have supporting documentation ready for review

16. Same Day Authorizations If you need a Same day authorization: • Submit prior authorization requests via MCS onlineas Urgent. • Call Customer Service, provide tracking number and request expedited processing. If you do not have access to MCS Online, you may fax the request. Prior to faxing: • Call customer service and inform you have a stat request. • Customer service will provide faxing instructions and walk you through process.

17. Routine Authorizations • Routine authorizations are processed within five (5) business days. • Referral submissions via fax: • Complete information including ICD-9 and CPT codes with supporting documentation.

18. Routine Authorizations – cont. • Referral submissions via MCS Online: • Avoid duplicate entries - Verify member’s authorization history on MCS Online prior to entering new entry. • Have clinical information readily available prior to submitting online (for additional note entry or via fax) • Supporting documentation should be faxed immediately after online submission with authorization tracking number indicated. • It can take up to 2 hours for your authorization request to show up on MCS Online

19. Faxing and Additional Note Box 1. Facility name; 2. indicating at patient’s request; 3. and/or clinical information supporting request Note box should be used for entering:

20. MCS Online – Fax Cover Page • When faxing Supporting Documentation, it is highly recommended to: • Utilize MCSO fax cover page or • Indicate authorization reference number • Failure to do so may result in extended delay in processing or lost fax.

21. Deferred Authorizations • If an authorization request is incomplete: • MCS Auth Clerk will place request in a “Deferred” status • MCS Auth Clerk will fax URI form daily until information is received or deadline is reached • If deferred for additional information and we do not receive a response: • Request may be denied. • Request may be placed in an extended deferred status up to 45 days, with a delay letter sent to the member. • Medicare members must have a determination within 14 calendar days.

22. Utilization Review Information Form • Utilization Review Information (URI) Form Refer to hand-out ‘B’ • Sample • Form indicating the expectation from provider office • Reminder: The effective date of an authorization will be the date a determination action is made.

23. Authorization Processing Statistics Utilization Management 2013 Statistics Volume January - June

24. MCS Online Reminders • Do not use the Specialty drop down box to select a requested provider. Results will display in and out of network providers

25. MCS Online Reminders • Always refer to the current Provider Listings for in-network providers Select appropriate network database Provider Listings are updated on a Monthly basis

26. MCS Online Reminders • Other reference material available on MCSO>Provider Resources>Provider Listings • Ancillary Providers by Health Plan - Updated quarterly • Contracted Facilities by Health Plan (PCMG only) - Updated quarterly ** Posted reference material available will be based on network database • Provider offices with access to MCSO do not receive faxed auths or PRA (EOB) will not accompany remittance checks. • Ability to download and print from MCSO.

27. MCS Online Reminders • MCS online provider representatives (Office Managers), please remember to: • Submit user requests for new staff • Consider allowing billing services user access • Notify when an employee leaves to deactivate access to your provider’s account

28. MCS Online MCSO not working properly? i.e. not displaying results, links malfunctioning, freezing up for long periods • Possible cause: Internet Explorer 10 • MCSO not compatible, programmer working on it • Troubleshoot: How can you identify what web browser you are using?

29. Identify Web Browser • Go to Command toolbar and click onto Tools icon>About Internet Explorer • Solution: Downgrade to Internet Explorer 8 or 9 or use a different web browser, i.e. Mozilla Firefox (free download) • Recommendation: Check with your IT on impact probability

30. Claims • Claims Submission Guidelines for Health Plan Payable Services (Hand-out ‘C’) • Claims Submission Guidelines for IPA Payable Services (Hand-out ‘D’)

31. Coordination of Benefits • If a member has dual coverage, the secondary… • Must use in-network providers and • Prior authorization is required to access secondary insurance coverage • This rule includes members with Medicare as primary • Having dual coverage does not mean member will have no financial responsibility. Member may have some out-of-pocket costs. • Do not collect copays from patients with Medi-Medi coverage

32. Provider Remittance Advice (PRA) • Revised PRAs - Additions and Changes Refer to hand-out ‘E’ packet for copy of memo and PRA sample explaining revisions that were applied.

33. MCSO – PRA Search • PRA search options that are available: • PRA Inbox • Search PRA>by Check Number • Search PRA > by Vendor ID (TIN)

34. MCSO - PRA Search Options • Search by check number, or if the check number is not available, you may… • Enter the your Provider’s tax ID number in the Vendor ID field and select the Date Paid range, then Search 1 2 2

35. Services Not Prior AuthorizedPDR Process (Refer to hand-out ‘F’) • PDR process allows providers to appeal a claim that has been denied and service has not been prior authorized. • Under AB1455, Providers are entitled to appeal denied claims via PDR process. • PDR are only accepted when claim has been denied • PDR submissions will be reviewed retrospectively and a determination will be made within 45 business days. • Provider will be notified of the final determination status

36. Credentialing • If recredentialing is not completed within 36 months, basis policy & procedures for termination are followed. There is no grace period. • Hospital Privileges: If a provider does not have hospital privileges, a letter indicating the name of the provider who will admit on their behalf must be in writing. If utilize a hospitalist group, the group name must be indicated.

37. Credentialing Contacts • Yolanda Herrera, Credentialing Coordinator Phone: 661.716.7156 Fax: 661.716.9156 Email: yherrera@managedcaresystems.com • JJ Jackson, Credentialing Assistant Phone: 661.716.3471 Email: jjjackson@managedcaresystems.com

38. Annual Provider Training • Annual training for Healthcare Providers as required by health plans • Cultural Competency Training for Healthcare Providers • Fraud, Waste, Abuse (FWA) • Many fines, penalties imposed on providers who fraudulently bill and accept payment from government agencies. • Encourage all in medical community to report suspected FWA

39. Annual Provider Training • All health plans are required to offer Language Assistance Refer to hand-out ‘G’ for contact information when requesting help with limited or non-English speaking members • For Language Assistance Program Provider Training, refer to MCS Online Provider Portal www.managedcaresystems.com Path to link: Provider Resources>Reference Sources>Language Assistance Program Provider Training

40. Annual Provider Training • For compliance training on Cultural Competency Training for Healthcare Providers and Fraud, Waste and Abuse Programs • Refer to MCS Online Provider Portal www.managedcaresystems.com Path to link: Provider Resources>Cultural Competency Provider Resources>Reference Sources>Fraud, Waste and Abuse Compliance Training

41. Physicians Choice Medicare Plus HMO by GEMCare Health Plan Speaker Stella Sanchez Sales Manager

42. Conclusion • A copy of our presentation will be available on MCS Online • Questions & Answers