Network Operations

Network Operations Provider Orientation 2011

Agenda • • Introduction to Network Operations • • Lovelace Health Plan resources • • Ongoing changes • • Cultural Competency • • Questions

TerritoryAssignments NorthBehavioral Health Adolfo Martinez Christi LaPlante (505) 727-5489 (505) 727-5799 Central 1 Central 2 Julie Wohrlin Sonia Gonzales (505) 727-5138 (505) 727-5293 Southwest Southeast Leslie Pollaro Lisa Williams (505) 727-5113 (505) 727-5388

What Can YourProvider Representative Do For You? • Escalated claim issues • Provide you with marketing materials • Demographic updates • Keeping you informed • Escalated CIGNA issues • Quarterly visits • When in doubt call your PSR

Contract Administrators NorthBehavioral Health Seth Brody Christi LaPlante Central 1 & 2 SPCCentral 1 & 2 PCP Sam Williams Susan Berg Southwest /Southeast Denise Hernandez

What Can Your Contractor Do For You? • Contracting • Changes to an existing contract • Look out for new contracts in 2012

CIGNA CIGNA utilizes the Lovelace Health Plan provider network for their New Mexico Members. Lovelace Health Plan provides contract maintenance and provider servicing for CIGNA. CIGNA is your first point of contact for all CIGNA related issues. Contact Information (800) 244-6224 Claim Mailing Address: Appeal Mailing Address: Please Refer to the Back of the CIGNA Healthcare Member ID Card PO BOX 5225 Scranton, PA 18505-5225 Electronic Routing ID: 62308 Note: Lovelace does not contract on behalf of CIGNA Great West. Please reach out to your Great West contacts for further assistance.

Relationships • Lovelace’s preferred Laboratory is S.E.D. Laboratories (800) 999-LABS • Exclusive contract with CareCentrix network for DME and Home Health (800) 866-6127 (800) 700-2085 (Fax) • Lovelace Salud! has an exclusive contract with Superior Medical Transportation (505) 341-0042 • Lovelace Health Plan coordinates with Optum Health d.b.a. United Resources Network to offer our members access to United Resources Network’s transplant resource services. Please call the Prior Authorization Department.

Customer Care Center • You may contact our Customer Care Center from 8:00 AM – 5:00 PM by calling (505) 727-5406 or you may utilize our 24 hour Interactive Voice Response system by calling (877) 480-9371 or (505) 727-5378. • • Benefits • Eligibility • Claim Research Interpreter Services - Lovelace has partnered with InSync Interpreter Services. Our Customer Care Center is now equipped with American Sign Language lap tops. Please contact the Customer Care Center to coordinate services.

Website Toolslovelacehealthplan.com/providers • Prior Authorization Information Grid • Eligibility, Benefit and Claim Status • Inquiry, Prior Auth, DME Forms • Online Provider Directory • Drug Formulary • Bulletins and Newsletters • Participating Provider Application • Provider Reference Guide • Adjustment/Void Request Form • Credentialing Statewide Application • Disease Management Information

• Lovelace HealthLink is a telephone and web-based referral service designed to match prospective patients with participating providers. • • This service is available 24 hours a day, seven days a week. • • There is no charge to callers or providers. • • When a prospective patient calls Lovelace HealthLink, they will be matched with one or more health care providers who meet their desired criteria, such as medical specialty, gender, office location and other areas of interest. • • The prospective patient can be directly connected to the provider’s office to set an appointment, if desired.

For the Patient: • Following the call, a letter is generated and mailed to the prospective patient to recap the provider contact information given during the call. • Prospective patients may also view provider’s educational and professional information on the Lovelace website. • For the provider: • As a participating provider, you will receive a monthly report listing every caller that was referred to your office. • This report will have full detail on each caller so you can follow up and monitor the volume of patients who come through the Lovelace HealthLink referral line. • You may de-activate and/or temporarily change your open referral status at any time.

Lovelace Health Plan Case Management • Case Management is a collaboration with member/family, physician and other healthcare providers to implement a plan that meets the member’s complex needs and goals. • • 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 among and between providers, members and case management • Contact Lovelace Case Management at: • Phone: 505-727-5168 Toll Free Phone: 800-808-7363 • Fax: 505-727-5272 Toll Free Fax: 877-894-4585

Healthy Steps Programs Disease management Healthy Steps Coaching: for chronic conditions provides telephonic services for members living with Diabetes, COPD, CAD, CHF and Asthma. Our registered nurses support healthcare providers treatment plans and give members the knowledge and tools they need to improve their health and manage their condition. Lifestyle management Healthy Weight: is a 10 week counseling program that focuses on lifestyle change. It is designed to help members develop the knowledge and skills needed to achieve and maintain a healthy weight. STOP: Stop Tobacco for Optimal Prevention: a registered nurse provides individual telephone counseling to helpmembers set up a personalized quit program and supports members every step of the way.

Healthy Steps Programs • Maternity Management • Baby Love is a prenatal education program to help members have a healthy pregnancy and the best possible start in life for their baby. Members receive pregnancy and childbirth information by mail and have access to nurses by phone 24/7 during their pregnancy by calling (505) 727-BABY. • Contact Lovelace Healthy Steps Programs at: • Phone: 505-727-5344 Toll Free Phone: 877-480-9368 • Fax: 505-727-5389

Lovelace Health Plan Prior Authorization • Prior Authorization can be obtained: • iExchange • Fax • Phone • Contact Lovelace Health Plan Prior Authorization at:

iExchange • iExchange is a web-based tool that allows “contracted” provider offices and facilities to request authorizations electronically. • Ability to submit requests for authorization and possibly receive immediate notification of approval • Verify and monitor status of the authorization request online (pended/approved) • Services that CANNOT be submitted via iExchange:

Claim Submission Paper Claims Submission Lovelace Health Plan PO Box 549 Buckeystown, MD 21717 Electronic Claim Submission • LHP Commercial/Medicare – 90328 • LHP Medicaid/SCI – SX159 Timely Filing & Follow Up Limitations • 180 days for Commercial and the Lovelace Senior Plan Products • 90 days for Lovelace Salud and Lovelace SCI Products

Claim Forms Online Claim Forms: • Claim Adjustment Request • Claims Status Inquiry • Recoupment Inquiry Form • Appeal Request Form Visit: http://www.lovelacehealthplan.com/providers/resources-forms

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

Appeals & Grievances • When Filing an Appeal or Grievance Include the Following: • Cover Letter with Explanation • Copy of Original Claim or Action Being Appealed • Explanation of Payment (EOP) • Supporting Documents Operative Reports Medical Records (required) • Appeals and Grievances May be Filed in the Following Ways: • – Mail • Lovelace Health Plan • Attn: Provider Appeals Coordinator • PO Box 27107 • Albuquerque, NM 87125-7107 • – Fax • (505) 727-5307 • – Verbal – Customer Service • (505) 727-5456 • (800) 808-7363 • Provider will receive a response for all appeals and grievances with resolution

Behavioral HealthUtilization Management • Outpatient Behavioral Health and Substance Abuse Services • No authorization needed to see Lovelace contracted provider • Extended visits (90808, 90809, 90814, etc) require an authorization if more than 3 occur in a 6 months • Form available at: http://www.lovelacehealthplan.com/providers/prior-authorizations • Inpatient Behavioral Health and Substance Abuse Services • Authorization Required • Admissions from 8:00 to 5:00 call CCC (505) 727-5406 • After hours/week-ends call BH pager at (505) 229-1299 --- late night admissions can be called in the following morning

Behavioral Health Case Management • Behavioral Health Case Managers and Care Coordinators • Provide assistance in accessing services, coordinating care and developing a self-care plan • Available to all members • Healthy Balance Program provides an annual in-home Behavioral Health Wellness assessment at no charge to the member • Available to Medicare Members only

Behavioral Health Contacts • Behavioral Health Utilization Management staff available 8 to 5 by calling (505) 727-LOVE and asking to speak to someone in BH or (800) 808-7363 • Behavioral Health Utilization Management staff available after hours by pager at (505) 229-1299 • Behavioral Health Case Management/Care Coordination staff available 8 to 5 by calling (505) 727-5747 • • Behavioral Health fax (505) 727-5620

Healthcare Reform Update • The State is looking at Medicaid Modernization to restructure the current Salud program to make the program competitive. • If you would like to send suggestions to the State on how to improve the program or read about Medicaid Modernization: • • E-mail: Medicaid.comments@state.nm.us • • Website: www. HSD.state.nm.us/Medicaid. Modernization • State Healthcare Exchange • Every State will have a Healthcare Exchange, which will be a one-stop shop for health insurance pricing this will be maintained by either the State or Federal government. Target date to be in place is 2014 when everyone is required to have some type of health insurance.

Online Training • • Lovelace Health Plan’s website includes critical information for providers and the • provider’s office staff. Online training can be found on our website at: • http://lovelacehealthplan.com/providers/training-and-seminars • • Some on-line training includes: • Cultural and Linguistic Competency • Medicare Part D Training

Medicare Part D Training • Beginning in 2009 the annual training was required by Lovelace Health Plan and CMS for all prescribing providers and pharmacies. You can still go to the website to do the training. • Coming Soon!!!! New 2012 Training Materials!! • On Lovelace Health Plan’s website, you will find the following materials for your training: • Medicare Part D Training Presentation • Medicare Part D Training Attestation • Medicare Part D Training Certificate • Complete Attestations and Certificates should be faxed to Medicare Part D Compliance Analyst at (505)727-5510. • You can also go to www.nmchili.org to take the training for all MCO’s. • Note: Certificates received from other Managed Care Organizations (MCO) are accepted by Lovelace Health Plan.

Cultural and Linguistic Competency Benefits of effective and barrier-free communication are significant, numerous and may include the following: • Fewer missed appointments • Improved patient and family satisfaction • Earlier diagnosis and treatment • Improvement in the process for consent in urgent situations

Network Operations