Kentucky Spirit Health Plan a Subsidiary of Centene Corporation Home Health Association Educational Presentation Febru

1. Kentucky Spirit Health Plan a Subsidiary of Centene Corporation Home Health Association Educational Presentation February 2012

2. AGENDA • Kentucky Spirit Design • Member Eligibility • Web Based Tools & Web Portal • Medical Management Prior Authorization • Retro Review/Authorization • Cenpatico STRS • Claims • Reconsideration

3. KENTUCKY SPIRIT DESIGN ●Ensure care is delivered in the best setting to achieve an optimal outcome ● Improve access to all necessary healthcare services ● Encourage quality, continuity, and appropriateness of medical care ● Provide medical coverage in a cost-effective manner ● Understand that our Members and Providers have Rights and Responsibilities and enforcing them as appropriate

4. MEMBER ELIGIBILITY VERIFICATION Verify member eligibility monthly by using use one of the following methods: Log on to the secure provider portal at www.KentuckySpiritHealth.com You can search by date of service and member name and date of birth, or member Medicaid ID and date of birth. Through the State’s Kentucky Health Net Call our automated member eligibility IVR system, 1-866-643-3153 from any touch tone phone and follow the appropriate menu options 4. Call Kentucky Spirit Health Plan Provider Services from 8:00 a.m. to 6:00 p.m. Monday through Friday EST (excluding holidays)

5. WEB-BASED TOOLS - PROVIDER PORTAL

6. WEB-BASED TOOLS Logon to www.KentuckySpiritHealth.com to access: Provider Newsletters Provider and Billing Manuals Provider Directory Announcements Quick Reference Guides Benefit Summaries for Consumers Updates to the State’s Medicaid Program Online Forms

7. Provider Secure Portal Through our secure portal, providers can: ● Verify eligibility and benefits View eligibility list View and submit authorizations Submit and check status of claims Review payment history Secure Contact Us Benefits of the Secure Portal: No waiting No time limits Registration is free and easy

8. PRIOR AUTHORIZATION Authorization requests may be done electronically on our Provider Portal – The Provider Portal is the fastest, most efficient option for prior auth requests Or by telephone 1-866-643-3153 Or by fax 1-855-252-0567

9. PRIOR AUTH NEEDED? Convenient code look up tool located at www.kentuckyspirithealth.com will instantly let you know if you need a pre-authorization for a: specific procedure medication or revenue code Kentucky Spirit Health Plan has adopted utilization review criteria developed by McKesson InterQual® products to determine medical necessity for healthcare services.

10. MEDICAL MANAGEMENT - PRIOR AUTHORIZATION

11. HOME HEALTH SERVICES REQUIRING PRIOR AUTHORIZATION Skilled Nursing Services, Home Health Aide, Medical Social Services, Home Infusions Occupational, Physical, or Speech Therapy, and Wound Therapy All supplies that are $500 or greater per line item or exceeds benefit maximum Enteral & Parenteral Nutrition that are $500 or greater 270 Disposable Medical Supplies 279 Nutritional Supplement 420 Physical Therapy 430 Occupational Therapy 440 Speech Therapy 550 Nursing 560 Medical Social Services 570 Home Health Aide Revenue Code 270 & 279 will require HCPC code

12. DURABLE MEDICAL EQUIPMENT (DME) REQUIRING PREAUTHORIZATION Apnea Monitor Bi-Pap Bili-Lights Bone Growth Stimulator C-pap Neuro Stimulator Wound Vacuum Rental Items with purchase price of ≥ $500 Rental items with rental ≥ $250 if no purchase price Purchase Items with price of ≥ $500

13. RETRO REVIEW A retro review/authorization may be obtained due to extenuating circumstances as listed below: Member was unconscious at presentation Member did not have their Medicaid card or otherwise indicated Medicaid coverage Services authorized by another payer who subsequently determined member was not eligible at the time of services Member received retro-eligibility from Department of Medicaid Services. Requests for retrospective review must be submitted promptly. A decision will be made within 30 calendar days following receipt of the request (not to exceed 180 calendar days from the date of service).

14. Cenpatico’s Specialty Therapy and Rehabilitative Services (STRS)

15. EPSTD SPECIAL SERVICES Therapy services are authorized through Cenpatico’s Specialty Therapy and Rehabilitative Services (STRS) Submit requests using the Outpatient Treatment Request (OTR) form to Cenpatico Submit EPSTD Special Services on a UB04 Form Revenue codes: 420 Physical Therapy 430 Occupational Therapy 440 Speech Therapy

16. PHARMACY BENEFIT MANAGER

17. COVERED DRUGS Pharmacy Benefit Manager Some drugs on the Kentucky Spirit Health Plan PDL require a PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Biopharmaceuticals Most biopharmaceuticals and injectables billed for more than $250 require a PA to be approved for payment PA requirements are programmed specific to the drug *** National Drug Code (NDC) must be billed in the appropriate fields on all claim forms as required by the state for pricing Physician Injectible Drugs and for Outpatient Hospitals and Renal Dialysis Centers per the Deficit Reduction Action (DRA) of 2005.

18. CLAIMS

19. TOP DENIAL REASONS Duplicate Claim Service Authorization Not On File Medical Records/Consent Form Required Resubmit with Correct Modifier Procedure Mutually Exclusive/Unbundling Service Non-Covered – (Incorrect Claim Form)

20. ELECTRONIC TRANSMISSION Faster processing turn around time Less costly than submitting paper claims Five clearinghouses for EDI submission We can: Receive an ANSI X12N 837 professional, institution or encounter transaction. Generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). Clearing Houses: Payor ID: Emdeon 68067 Availity 68067 Gateway EDI 68067 ClaimRemedi 68067 Relay Health 68067 Please contact: Kentucky Spirit Health Plan c/o Centene EDI Department 1-800-225-2573, extension 25525 or by e-mail at: EDIBA@centene.com

21. EDI Rejections Periodically claims may reject on the front end and will not make it in the Kentucky Spirit claims system. These claims are reported on a 997 Rejection Acknowledgement Report from your EDI vendor. Please ensure that you receive and review the rejections from your current clearinghouse following each claims submission.

22. CLAIMS In general, Kentucky Spirit Health Plan follows the CMS (Centers for Medicare & Medicaid Services) Submitted claims are required to comply with “clean claims” criteria. Kentucky Spirit Health Plan has a claim payment cycle that produces a payment to providers each week on Thursday Your EOP may show a list of claims that were received and paid, pending or denied. If not processed, this is notification that your claims have been received and do not require resubmission

23. UB 04 CLAIM FORM Must have: Provider name (as noted on current W9 form) National Provider Identifier (NPI) Tax Identification Number (TIN) Taxonomy code Physical location address (as noted on current W9 form) Billing name and address All Diagnosis Codes are to their highest number of digits available (4th or 5th digit). Principle Diagnosis billed reflects an allowed Principle Diagnosis as defined in the current volume of ICD9 CM, or ICD10 CM for the date of service billed

24. CLAIMS TIMELY FILING Providers must submit all original claims (first time claims) within three hundred and sixty five (365) calendar days of the date of service When Kentucky Spirit Health Plan is the secondary payer, claims must be received within ninety (90) calendar days of the final determination of the primary payer. COB claims may be submitted electronically. All requests for reconsideration or claim disputes must be received within 24 months from the original date of notification of payment or denial.

25. HCI – Health Care Insight HealthCare Insight (HCI) - a claims review process to help identify incorrect coded claims For example: Unbundled and fragmented services Pricing that include follow-up visits will be tracked for duplicate claim payment.

26. RECONSIDERATION Use correct form or a cover letter, indicating what is incorrect or needs to be adjusted Corrected claims should be marked as a corrected claim to avoid being considered as a duplicate submission List the original claim number on an adjustment request Include the member’s name, ID num-ber, claim number and date A claim dispute is to be used only when a provider has received an unsatisfactory response to a request for reconsideration.

27. Electronic Funds Transfer (EFT) Electronic Remittance Advice (ERA) Free service – No fees to use the service Eliminate re-keying of remittance data – can be imported directly into Practice Management or Patient Accounting Systems Maintain control over bank accounts – Control over the destination of claim payment funds - multiple practices and accounts are supported Match payments to advices quickly – Providers can associate electronic payments with electronic remittance advices quickly and easily Pursue secondary billings faster – Accelerates the revenue life cycle Improve cash flow – Faster payments, leading to improvements in cash flow Connect with multiple payers – Quickly connect with any payers that are using PaySpan Health to settle claims Contact PaySpan Health 1-800-733-0908

28. OUR COMMITMENT TO YOU Kentucky Spirit Health Plan is committed to working with the Home Health Agencies to develop a long-term partnership in serving Kentucky Medicaid beneficiaries Visit the Kentucky Spirit website for a listing of the Provider Relations Specialist in your County.

29. Thank you for your time Questions?