MDwise 2019 Updates Workshop: Eligibility, Prior Authorization, Claims

1. 2019 IHCP 1st Quarter Workshop MDwise 2019 Updates

2. Agenda • Updates • Eligibility • Prior Authorization (PA) • Claims • Provider Portal • Provider Relations • Transportation • Resources • Questions

3. Updates • MDwise restructured its Delivery System model to: • Improve claim payment timeliness and accuracy • Streamline and reduce administrative redundancy for providers • Provide greater access for our members • One standard authorization list • One point of contact for all authorization requests • One claim submission address • Non-Excel Delivery System contracts • Providers not contracted with MDwise Excel must contract to stay in network.

4. Eligibility When determining eligibility, verify: • Is the member eligible for services today? • Which Indiana Health Coverage Program plan are they enrolled? • If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise? • Who is the member’s Primary Medical Provider (PMP)?

5. Prior Authorization • One standard authorization list • One point of contact for all authorization requests • Go to MDwise.org for most up-to-date version of PA lists

6. Prior Authorization You will need two key items when filing a request for Medical Prior Authorization (PA): • Universal Prior Authorization Form • Located on our website • Documentation to support the medical necessity for the service you are requesting to prior authorize: • Lab work • Medical records/physician notes • Test results • Therapy notes Tips: • Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number. • Be sure to note if PA is for a retroactive member. Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe.

7. Prior Authorization Prior Authorization Turn-Around Time • All emergency inpatient admissions require authorization within 2 business days of the admission. • Urgent prior authorizations can take up to 3 business days • Requests for non-urgent prior authorization will be resolved within 7 calendar days. • It is important to note that resolved could mean a decision to pend for additional information. • If you have not received a response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue. • PA Inquiry Line • 1-888-961-3100

8. Prior Authorization Appeals • Providers can request a prior authorization appeal on behalf of a member within 33 calendar days of receiving denial. • Providers must request an authorization appeal in writing to MDwise: MDwise Customer Service Department PO Box 441423 Indianapolis, IN 46244-1426 • MDwise will resolve an appeal within 20 business days and notify the provider and member in writing of the appeal decision including the next steps. • If you do not agree with the appeal decision, additional appeal procedure options are available.

9. Prior Authorization Pharmacy Prior Authorizations • For all requests and questions regarding Pharmacy PA, contact the Pharmacy Benefit Manager (PBM), MedImpact. • Pharmacy Benefit Manager (PBM): • MedImpact: 844-336-2677 • Pharmacy Resources: • http://www.MDwise.org/for-providers/pharmacy-resources

10. Claims • Claim Submission is date of service driven - date of service 1/1/19 • Electronic Submission • Provider Customer Service Unit • 1-833-654-9192 • Claims inquiries Please note: Paper claims must be on red/white form with black ink.

11. Claims Claim Timelines: • Claim Submission: • Primary: 90 days from the date of service • Secondary: 90 days from the date of the explanation of benefits (EOB) • Effective 1/1/19, non-contracted providers will have 180 days for claim submission.* • Claim Adjustment Process • Providers can adjust a claim by submitting the adjustment form and supporting documentation within 90 days of the explanation of benefits (EOB). • Disputes • 60 days from the date of the EOB OR 60 days from the date of your claim adjustment response. *Reference BT201829 for more information

12. Claims Claim Adjustment Request Form • Request for payment reconsideration for a paid or denied claim • To be used before Claim Dispute process • Use form: • To have claim reconsidered for payment if denied in error • If claim paid at inappropriate rate • To submit attachments missing from original claim submission • All claim adjustment inquiries and requests must be made to MDwise within 90 calendar days of the most current MDwise EOP. • Form cannot be used if claim has already been disputed • Adjustment Form must be complete and include all documentation to be considered

13. Claims Claim Adjustment Request Form

14. Claims Claim Adjustment Request Form • Send completed Provider Claim Adjustment Request Form with a copy of the claim form and/or any supporting documentation to: • MDwiseClaims@mclaren.org • Or fax to: 833-540-8649 • For questions regarding the Provider Claims Adjustment Process, call the Provider Customer Service Unit at 833-654-9192.

15. Provider Portal MDwise Provider Portal • http://www.MDwise.org/for-providers

16. Provider Portal Use the main log in to access all claims dates of service Use the Valence portal for dates of service 1/1/17-12/31/18

17. Provider Portal MDwise Provider Portal • Please note: Portal Access Requests can take up to 3 business days

18. Provider Portal MDwise Provider Portal • Member Eligibility including PMP • Claims • Quality Reports • Member Rosters • Member Health Profile • Coordinate Medical and Behavioral Health services based on paid claims • Includes physician visits, medication and ER visits • Care Management/Disease Management (CM/DM) Requests

19. Provider Relations - Contracting Providers not currently participating as MDwise Excel need to contract to continue to see MDwise members. • What is required to contract? • MDwise Excel Contract • Provider/Ancillary Enrollment Forms • W-9 • Sample Claim Providers not seeking a MDwise Excel contract are required to submit the following: • Non-Contracted Provider Set-Up Form • W-9 • Sample Claim

20. Provider Relations -Forms Provider Relations Forms • http://www.MDwise.org/for-providers/forms/provider-enrollment • Credentialing/Enrollment • MCE Enrollment Form • Enrollment Cover Sheet (until 12/31/18) • Provider Update Form • Disenroll/Re-enroll • Panel Move • Non-Contracted Set-Up Form • Required for non-contracted providers • Contract Inquiry Form Submit Forms to: • prenrollment@mdwise.org

21. Provider Relations – Territory Map 1 2 5 3 4 9 6 8 7

22. Provider Relations – Contact Information

23. Transportation MDwise non-emergent transportation vendor is now Southeastrans. • To schedule a non-emergent medical transport (NEMT) ride: • Southeastrans Web Portal • https://www.southeastrans.com/transportationproviders/indiana-providers/ • MDwise Customer Service: 1-800-356-1204 • Follow the call tree for the appropriate extension • To become a MDwise Transportation vendor: • Kristy Swoveland, Provider Relations Manager • kswoveland@Southeastrans.com or 765-602-6004 • Andrew Tomys, Corporate Network Development Manager • atomys@Southeastrans.com or 770-362-4839

24. Resources MDwise Provider Tip Sheets • http://www.mdwise.org/for-providers/tools-and-resources/additional-resources/tip-sheets/ MDwise Provider Manuals • http://www.mdwise.org/for-providers/manual-and-overview/ MDwise Provider Relations Territory Map • http://www.mdwise.org/for-providers/contact-information/ MDwise Customer Service • 1.800.356.1204 IHCP Provider Modules • Indianamedicaid.com

25. Questions