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MSMA Insurance Conference

MSMA Insurance Conference. April 24, 2014 Columbia, MO. HealthCare USA Overview. MO HealthNet Managed Medicaid Plan Subsidiary of Coventry and Aetna 60% market share Operational since 1995 250,000 + members in Missouri Robust Statewide Network NCQA Accredited.

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MSMA Insurance Conference

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  1. MSMA Insurance Conference April 24, 2014 Columbia, MO

  2. HealthCare USA Overview • MO HealthNet Managed Medicaid Plan • Subsidiary of Coventry and Aetna • 60% market share • Operational since 1995 • 250,000 + members in Missouri • Robust Statewide Network • NCQA Accredited

  3. Who Is Your Provider Relations Representative? • All HealthCare USA providers are assigned a Provider Relations Representative • Current listing is available at www.hcusa.org

  4. Eligibility Verification Options • MO HealthNet Options: • ARU line 573-635-8908 • www.emomed.com • Medifax • HCUSA Options: • www.directprovider.com • Emdeon Office Product • Interactive Voice Response • 800-295-6888 • Member Services 800-566-6444

  5. Eligibility and Claims System • HealthCare USA Members receive a HCUSA ID card with their HCUSA member ID and MO HealthNet member ID number. • HealthCare USA accepts claims filed with either the MO HealthNet member ID or HealthCare USA member ID. • Some Western MO HealthCare USA members have a CMPCN logo on the back of their ID card.

  6. Newborn Eligibility • Timely filing is 90 days from date of enrollment within HealthCare USA’s system. • Claims must be filed under the newborn’s name and ID number. • Contact Claims Customer Service if your claim denies for untimely filing and you believe it was submitted within 90 days of the member’s enrollment.

  7. Provider Communication • Provider Visits • Provider Newsletters • Provider Newsflashes • Provider Mailings • www.hcusa.org • www.directprovider.com

  8. HealthCare USA Web Site www.hcusa.org • Online Provider Search • www.directprovider.com • Provider Forms • Authorization Directory • Provider Manual • Provider Communication • EFT, ERA, EDI Information • ICD 10 status updates

  9. CMS 1500 Claim FormUpdate • On January 6, 2014, HealthCare USA began accepting the revised CMS 1500 paper claim form, version 2/12. • HCUSA continues to accept and process paper claims submitted on the version 08/05

  10. ICD-10 • Quarterly updates including FAQ are available at www.hcusa.org • Providers can submit their questions to: 5010ICD10Inq@cvty.com

  11. www.DirectProvider.com • Member Eligibility • Member ID Cards (view and print) • ME Code • PCP Assignment • COB Information • HEDIS - Reminders - Gaps in Care • Remittance Advices • EFT Registration • Claim Inquiry/Adjustment Requests • Authorization Submissions, Edit & View • News • Resource Library - Provider Manual/forms - InterQual Smart Sheets

  12. Direct Provider Online Authorizations

  13. DirectProvider.com Training Options • Take a Tour • Online Tutorials available 24/7 • Includes Registration, HEDIS Reports, Resource Library, Remittance Advices, Claim Inquiry • Webinar Training • Quarterly dates & times available at www.hcusa.org and www.directprovider.com • Email trainingnetworkmanagement@cvty.comto register • User Guide • In “News” and help on www.directprovider.com • Net Support 866-629-3975 • Available 7:00am - 5:00pm

  14. EFTand ERA No More Checks and Remits in the Mail! • Request EFT via www.directprovider.com • Available to participating and non-participating providers • Remits available online through www.directprovider.comand/or ERAs • Providers choosing EFTs must access remittance advices online • Email notification when a new Remittance Advice is available

  15. Provider Customer ServicePhone: 800-295-6888 • Claims Processing • Remittance Advices • Claims Payment • Claim Adjudication Information • Provider Number • Check Reissue • Timely Filing/Adjustments • Recovery • Verisk claim edits • i-Health claim edits • Negative Remits • Coordination of Benefits

  16. Customer Service Performance Goals

  17. TopClaimDenials • Primary Carrier Liability • Services Not Authorized • Duplicate Claim • Member Not Effective • Untimely Filing

  18. ClaimsSubmission • Electronic claims submission for original or corrected claims • Emdeon, Payor ID# 25133 • Submit using the patient’s HealthCare USA member ID or MO HealthNetID number • Timely filing is 90 days for original claims and the timely adjustment period is 180 days from the initial remit date. • Corrected claims must be received within 180 days from original remit date • Paper Claims P.O. Box 7629 London, KY 40742-7629 Corrected claims must be clearly identified as “corrected”

  19. Altered Claims & COB Altered claims • Paper claims containing white out, strikeovers, or handwritten information must be initialed. • Please…. Coordination of Benefits (COB) • HealthCare USA is the payer of last resort, in most instances • Providers have 90 days from the date of the primary carrier EOB for HealthCare USA to receive the claim • Primary Insurance Verification

  20. HEDIS Healthcare Effectiveness Data and Information Set • HEDIS Quick Reference Billing Guide • 2013 Results • Chart audits • Administrative vs Hybrid data collection

  21. HEDIS Postpartum Visit Postpartum Care Data Collection Incentive Pilot • Report 59430 postpartum visit code for services performed from the 21-56 day post-delivery HEDIS timeframe • Incentive is paid quarterly by a separate paper check and will be sent by mail or delivered by your provider relations representative • Missed opportunity report

  22. AffordableCareActPrimary Care Rate Increase • Effective January 1, 2013 • Eligible providers must complete the HCUSA or MO HealthNet attestation form which is located at www.hcusa.org and return to HealthCare USA • Payments for services furnished by certain primary care physicians including vaccine administration under the VFC program • Claims reprocessing - 2013 and 2014 dates of service

  23. ProviderAppealReconsiderationForm • Appeal vs. Reconsideration • Fillable Form • www.hcusa.org

  24. ProviderAppeals Formal mechanism allowing the Provider the right to appeal the health plan’s decision. Submission Timeframe: Appeals must be received within 180 days of the action taken by HealthCare USA, giving rise to the appeal. Decision Responses (via fax or mail) • Pre-service: within 30 calendar days • Post service: within 60 calendar dates • Note: The appeal decision is the FINAL decision

  25. ProviderComplaints Dissatisfaction or dispute with policies, procedures, claims, denials, or any aspect of health plan functions Submission Timeframe: Complaints must be received within one (1) year of the date of the incident, remit date or date of notice of action that caused the complaint. Decision Responses (via fax or mail) • Pre-service: within 30 calendar days • Post service: within 60 calendar dates

  26. KeyContactNumbersforProviders HealthCare USA: • Prior Authorization 800-882-9666 • Provider Customer Service 800-295-6888 • Provider Relations – Western 866-613-5001 • Provider Relations - Central 800-625-7602 • Provider Relations - Eastern 800-213-7792 • Member Services 800-566-6444

  27. Just Look For Me…Doc Bear

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