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2020 Individual Plans

Provider Training

050851 (03-05-2020)

© 2018 LifeWise. Proprietary and Confidential.

Contents

1. Evolent Health 2. Network changes 3. ID cards 4. Primary Care Provider

Assignment 5. Medical and payment policies6. Evolent secure site 7. Online tools and forms

a) Eligibility and benefitsb) Prior authorizationc) Claimsd) Appeals e) EFT (InstaMed)

8. Evolent directory 9. Training guides and resources

Evolent Health + Network Changes PROVIDER TRAINING DECK

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Evolent Health • LifeWise partnered with Evolent Health to support administrative functions for individual

plans starting January 1, 2020.

• The market landscape for the WA State Health Benefit Exchange is evolving. This partnership allows us to offer customers access to healthcare and our health plans at a more affordable price.

Customer Service

Enrollment & Billing

Member Fulfillment Claims Complaints &

Appeals

Payment Reconciliation

Utilization Management

Case Management

Provider Reimbursement

© 2018 LifeWise. Proprietary and Confidential.

Network Changes • LifeWise Primary is the new network for the Individual market.

• LifeWise Primary offers new exclusive provider organization (EPO) plans and new provider networks in 33 Washington counties.

• Major hospital systems: Swedish Medical Center, Providence Health, CHI Franciscan

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ID Cards

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Primary Care Provider Assignment • LifeWise members are required to have an assigned primary care provider (PCP).

• If a member doesn’t have a PCP on record, LifeWise will choose one for them using the steps and criteria below.

If the member… We’ll assign…Has a designated PCP on record in the Individual Signature network

The designated PCP on file

Doesn’t have a PCP on file but has seen the same PCP more than once in the past 12 months and that PCP is in LifeWise Primary

The PCP found in claims history

Hasn’t seen a PCP in the past 12 months but an enrolled family member has a designated PCP/care center in the LifeWise Primary network

The enrolled family member’s PCP or care center

Lives within 10 miles of a preferred provider A PCP from the preferred provider

Doesn’t live within 10 miles of a preferred provider The nearest in-network PCP accepting new patients

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Primary Care Provider Assignment

• Members can change PCPs at any point during the plan year effective the first of the following month.

• There isn’t a limit on the number of times a member can change their PCP assignment.

Who’s considered a PCP?Internist Family practice provider

Pediatrician Geriatric practice provider

Gynecologist/Obstetrician Naturopath

Nurse practitioner Physician assistant

Medical + Payment Policies PROVIDER TRAINING DECK

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Medical and Payment Policies

• There are 37 new medical policies for our Individual plans.

• Evolent uses InterQual® criteria when reviewing certain services. The criteria is available on the LifeWise website.

• You can view the new policies on the LifeWise website on the medical policy page and on the provider secure website.

• Payment policies will stay the same. We’ll use existing LifeWise payment policies for our Individual plans.

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Medical Policies – LifeWise Website

© 2018 LifeWise. Proprietary and Confidential.

Medical Policies – LifeWise Website

© 2018 LifeWise. Proprietary and Confidential.

Medical Policies – LifeWise Website

© 2018 LifeWise. Proprietary and Confidential.

Medical Policies – Secure Site

LifeWise Secure Site + Online Tools PROVIDER TRAINING DECK

© 2018 LifeWise. Proprietary and Confidential.

LifeWise Secure Site

There’s a separate, secure website for Individual health plans managed by Evolent with the information and tools you need to serve LifeWise patients with an Individual health plan:

• Eligibility and benefits lookup tool

• Prior authorization code list and submission tool (Identifi)

• Prior authorization submission form (fax option)

• Claims submission tool (HCFA 1500 only) available Spring 2020 (exact date TBD)

• Claims list, status lookup, and explanation of payment details

• Medical policies

• PCP roster

• Appeal form (clinical)

• Contact information for customer service and medical management

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Secure Site Access

In OneHealthPort (OHP) click on the LifeWise Health Plan of Washington icon.

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Secure Site Access

• After you click on the LifeWise Health Plan of Washington icon, click the “2020 Individual Plans” button at the top of the page.

• This takes you to the secure website managed by Evolent.

• If you’re looking for Individual plan information for years prior to 2020, click the “2019 Plans” button.

© 2018 LifeWise. Proprietary and Confidential.

Eligibility and Benefits• There’s a new tool available on the provider secure site to look up eligibility and benefits.

• Providers should NOT enter the member’s alpha prefix when searching for eligibility and benefits.

• Providers can also call the customer service number on the back of the member ID card to check eligibility and benefits.

• Read our guide on how to use the new tool.

© 2018 LifeWise. Proprietary and Confidential.

Prior Authorization Process

• There’s a new code list for Individual plans starting 1/1/20 that you can view the new on the LifeWise website and on the provider secure site.

• You have two ways to submit prior authorizations:1. Online using Evolent’s prior authorization submission tool, Identifi, available on the provider

secure site.2. Fax a new prior authorization submission form available on the LifeWise website under “Forms”

and on the provider secure site starting 1/1/20 to 888-613-1497.

• Individual market health plans aren’t using eviCore for outpatient prior authorizations.

• Individual plans are using AIM Specialty Health for imaging prior authorizations.

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Prior Authorization Process Getting started:• Providers aren’t required to register with Identifi to start using it. • Once you sign into your OneHealthPort account on/after January 1, 2020 and click to access the new

LifeWise 2020 Individual Plan secure site, you’ll be granted access to Identifi within 1-5 business days and will receive a confirmation email once your access is granted. There aren’t any additional steps you need to take.

• If you need to submit a prior authorization during the 1-5 day waiting period, you can fax your submission or call our utilization management team directly.

Resources: • For questions about Identifi, our utilization management staff can answer questions beginning on

1/1/2020 at our customer service line, 800-817-3056. • You can also look at our step-by-step guide on how to use Identifi.

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Prior Authorization Request Tool (Identifi) + Form

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Prior Authorization Request Form (LifeWise website)

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Prior Authorization Process – 2019-2020

• We understand there may have been patients with existing/approved prior authorizations in 2019 for services in 2020.

• Our medical management team tracked these cases and followed the below protocol for prior authorizations spanning the plan years:

If the serving provider in 2020 is in network and the benefit is covered then we honor the 2019 prior authorization.

If the serving provider in 2020 is now out of network, the serving provider needs to submit a new prior authorization using the new code list. LifeWise faxes back the provider if a new prior authorization is needed.

© 2018 LifeWise. Proprietary and Confidential.

Claims

• Evolent adjudicates all 2020 claims for Individual plans.

• You may notice slight differences in allowed amounts when compared to LifeWise due to rounding, edits, or fee schedule update timing, among other factors.

• You have two ways to submit claims:

Continue to submit claims electronically as you do today.

For paper claims, continue to use the industry standard claims form and mail it to the new PO Box :

Claims mailing address: LifeWise Health Plan of WAP.O. Box 21552Eagan, MN 55121

• If you accidently mail a claim to the commercial PO Box, LifeWise will forward it to Evolent.

• Claim sequence start with the calendar year “2020” and there’s a “T” in the center of the claim number (or a “M” when entered manually)

© 2018 LifeWise. Proprietary and Confidential.

Claims – Electronic HCFA 1500 submission

• There’s an option to submit HCFA (CMS 1500) claims through an online tool on the Evolent secure site, however this function won’t be live until Spring 2020 (exact date TBD).

• You can sign up for Office Ally, a full-service clearinghouse offering a web-based service where providers can submit claims to Participating Payers (Premera included) at no cost. Office Ally’s online claim entry allows you to create CMS1500, UB04, and ADA claims on their website; or you can use your existing software to create and submit claims electronically.

• You can also submit a paper claim. • You can check the status of any of your submitted claims and receive a claims list for each of your

patients using available tools on the Evolent secure site. • Read our guide on how to use the Evolent claims tools on the secure site.

© 2018 LifeWise. Proprietary and Confidential.

Claims – Secure Site

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Claims – LifeWise Website

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Appeals

• To submit a clinical appeal on behalf of a patient (prior auth denial): Submit an appeal form by fax to 844-990-0262. The new form is on the provider

secure site and the LifeWise website under “Forms”. You can also start an appeal by calling customer service at 800-817-3056.

• To submit an appeal on a claim: Call customer service at 800-817-3056 and they’ll instruct you on how to submit an

appeal letter.

• To request a peer-to-peer review, call customer service at 800-817-3056 and they’ll connect you with an Evolent medical director.

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Appeals Form – Secure Site

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Appeals Form – LifeWise Website

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Electronic Fund Transfers (EFT)

InstaMed delivers all EFT payments for our LifeWise Primary plans.

Already have InstaMed? New to InstaMed?Great! You’ll automatically receive EFT payments for our 2020 Individual plan claims.

You have 2 simple ways to sign up:

1. Online: www.instamed.com/eraeft2. Paper: Complete this online form fax

it to 877-755-3392.

© 2018 LifeWise. Proprietary and Confidential.

Explanation of Payment

• To the right is an example of an EOP for our 2020 Individual plans.

• For EFTs, you need to sign up for InstaMed if you aren’t already signed up.

• You can also access EOP statements on the secure site under “claims.”

• Read our guide on accessing EOPs on the secure site.

© 2018 LifeWise. Proprietary and Confidential.

Explanation of Payment – Secure Site

Contact Information + Resources PROVIDER TRAINING DECK

© 2018 LifeWise. Proprietary and Confidential.

Contact Information LifeWise Health Plan of Washington 2020 Individual Plan

Phone Fax Mailing Address/EmailCustomer service 800-817-3056Utilization (care) management 844-996-0333 888-613-1497AIM 866-666-0776EDI/InstaMed 866-467-8263 877-755-3392 –Support@Instamed.comProvider relations 877-342-5258, option 4Pharmacy services 888-261-1756Claims

800-817-3056

LifeWise Health Plan of Washington PO Box 21552 Eagan, MN, 55121

Level 1 appeals LifeWise Health Plan of Washington PO Box 21552 Eagan, MN, 55121

Level 2 appeals 844-990-0262

Member AppealsPO Box 91102Seattle, WA 98111-9202

© 2018 LifeWise. Proprietary and Confidential.

Resources External training guides for Evolent tools:These will be available on the LifeWise website and on the Evolent secure site in December.

• Eligibility and benefits lookup

• Claims (submission and list/status lookup)

• Prior authorization request submission using Identifi

• PCP Roster lookup

Other Resources: Regular updates on provider news under “Company Updates”

Provider News (LifeWise)

Forms and Documents:Medical policies:

• 2020 InterQual criteria

• 2020 Individual plan medical policies

Prior Authorizations:

• 2020 prior authorization code list

• 2020 prior authorization submission form

Appeals:

• 2020 appeal form