spring 2013 provider workshop cog - pacificsource › provider › 2014-ihcc...new cms 1500 form...

Spring 2014 PacificSource Provider Workshop Lewiston

Presented by:

The PacificSource Provider Service Team

Agenda

• Organizational Updates

o NCQA

o Locums Tenens

o HEDIS

o ICD 10

• Commercial

o Healthcare Reform - Exchange

• PacificSource Websites

o InTouch Provider Portal

Organizational Updates


Idaho Provider Service Team

Southwest Idaho - Saint Alphonsus Health System [email protected] (208) 780-2060

Northern Idaho - St. Luke’s Health Services [email protected] (208) 333-1517

Eastern Idaho [email protected] (208) 780-2065

PacificSource Total Membership

Total Membership: 259,323

Commercial Membership: 169,582

Medicare Membership: 37,736

Medicaid Membership: 52,005


Current Membership for Idaho

Total Membership: 47,685 Covered Lives

Commercial Membership: 27,038

Medicare Membership: 20,647



National Committee for

Quality Assurance

(NCQA)


PacificSource and NCQA

• PacificSource began the accreditation process in January of 2013.

• Anticipate seeing PacificSource Health Plans on the NCQA website in May or June.

• We would like to thank you for your patience and assistance.


Examples of NCQA requirements

• Required information on all rosters:

o Effective and termination dates for all licensure

o Provider directory enhancements

−Hospital affiliation

−Board certification

−Language spoken

• PacificSource is required to notify members 30 days in advance of a provider leaving a practice.


Provider Changes

• Provider groups shall use their best efforts to notify PacificSource and/or their IPA promptly and in advance of the addition or termination of a provider.

o We need notification from providers at least 45-60 days prior.


Locum Tenens


Locum Tenens Policy

• For Locum Tenens providing coverage for 60 or fewer consecutive days, we will require:

o A Locum Tenens application

o Current DEA certificate

o Copy of professional liability coverage


Locum Tenens Policy

• For Locum Tenens providing coverage for longer than 60 consecutive days, we will require:

o A full and complete practitioner credentialing application.

• Locum Tenens must be credentialed prior to being paid under the absent provider’s contract.

• This policy applies to all PacificSource lines of business.


Billing for Locum Tenens

• Each healthcare provider or supplier who is rendering the service, must be listed in box 31 of the CMS 1500 form.

• PacificSource does not permit incident-to-billing.

• Claims billed prior to the locum tenens credentialing approval will be denied as provider write-off.


HEDIS

What is HEDIS?

• Healthcare Effectiveness Data and Information Set

• Required by CMS

• Required for NCQA certification for any line of business

• PacificSource does HEDIS for Commercial and Medicare

• Set of standardized performance measures


HEDIS continued

• Measure data sources: Admin (medical and Rx claims), Hybrid (patient chart), and Survey

• Measure Domains – Effectiveness of care, Access, Availability, Cost of Care, Use of Services, and Health Plan Descriptive Info

• Measurement Year – Most look at care in most recent calendar year. Some look back >2 yrs

• HEDIS is a major data source for Medicare 5 Star Program and NCQA certification


HEDIS continued

• HEDIS medical record measures assess compliance with accepted prevention and chronic condition guidelines.

• Some measures are calculated using claims data, some use medical record documentation, some use both.

• Many of the measure results are influenced or controlled by physicians.

• Members are randomly selected for medical record portion of HEDIS audits.


HEDIS continued

• Information for HEDIS audit completion will either be requested directly by PacificSource or on our behalf by our vendors: Outcomes Health for Commercial and Verisk for Medicare.

• Any questions regarding the HEDIS audit should be directed to:

o Provider Network (800) 624-6052 ext 2580

o Outcomes Health (855) 767-2650

o Verisk Health (877) 489-8437



Billing Updates


New CMS 1500 Form

(Rev 02/12)

The CMS 1500 form has been updated to align with 5010 837P and accommodate ICD-10 reporting.

Changes on the form include:

• Fields 8, 9b, 9c, 11b, and 30

• Other fields were changed to reflect usage.

• 12 lines now available for diagnosis codes.


New CMS 1500 Form

• Effective April 1, 2014, PacificSource Medicare is only accepting claims billed using the revised form (02/12). This includes corrected claims that were previously submitted on the (08/05) version.

• PacificSource Health Plans will continue to accept both versions, however we highly encourage providers to use the updated version.


ICD-10 • Implementation pushed to October 1,

2015 (at the earliest).

• PacificSource has completed:

o System upgrades

o Impact assessments

o Translation Mapping ICD-9 to ICD-10

o End to end testing with several large health systems


Has your organization begun ICD-10 planning?

Yes, 76.8%

No, 23.2%

151 People Surveyed • Yes – 116

• No – 35

• Skipped Question – 16


Please estimate how much of the planning process your organization has completed.

47%

36%

13%

4% Answer Options

Response Percent

Response Count

0-25% 46.8% 51

25-50% 35.8% 39

50-75% 12.8% 14

75-100% 4.6% 5

ICD-10 Tip and Tricks

• AAPC crosswalk from ICD-9 to ICD-10 http://www.aapc.com/ICD-10/crosswalks/pdf-

documents.aspx.

• Visit AAPC for more helpful tools, such as:

o Searchable databases

o Educational webinars

o Educational articles

o ICD-10 conversion issues and trends


http://www.aapc.com/ICD-10/crosswalks/pdf-documents.aspx





ICD-10 Resources

• If you have questions regarding PacificSource and ICD-10, please email [email protected].

• Visit CMS’s website for another great resource on the ICD-10 transition: cms.gov/ICD10.

• If you are interested in end-to-end testing with us, please complete our brief survey at SurveyMonkey.com/s/T3CTNL6.


mailto:[email protected]

http://www.cms.gov/ICD10

http://www.surveymonkey.com/s/T3CTNL6

Commercial Updates

Commercial Updates

Commercial Updates

PacificSource Administrators (PSA)

• Effective April 1, 2014, PSA claims will be payable via EFT.

• If you are already set up to receive EFT and/or ERA, you do not need to do anything.

• New EFT enrollees will now be getting payments for commercial, Medicare, and PSA members.

• Updated EFT/835 enrollment form now available on our website.

Commercial Updates

Dedicated Provider

Customer Service Phone Number

(855) 896-5208 *Benefit questions, claims inquiries, etc.

Healthcare Reform

Healthcare Reform –

Your Health Idaho

ACA Employer Mandate Changed

• Although mandate was effective in 2014, the enforcement was delayed until 2015.

• Under the final rules, businesses now have even more time to comply.

o Large groups (100+) have until 2015 to comply.

o Mid-size groups (50-99) have until 2016 to comply

Healthcare Reform

Pediatric Vision Benefit

• Members through 18 years of age.

• Licensed ophthalmologist or optometrist

• One vision exam per year* including refraction

• One pair of non-collection glasses (lenses and frames) per year*

• Contact lens services and materials per year*

*Benefits/frequencies are per calendar or per plan year. Limits on hardware also apply.

Healthcare Reform

Oregon

PSN

SmartHealth

Prime

Idaho

PSN

SmartHealth

SmartAlliance

BrightIdea

Montana

PSN

SmartHealth

Healthcare Reform

Networks

TIE

R 3

TIE

R 2

TIE

R 1

SmartHealth Contracted Providers

PSN

Providers

Non-participating Providers

Healthcare Reform

SmartHealth Network Northern & Eastern Counties

Healthcare Reform

TIE

R 2

TIE

R 1

St. Alphonsus MDs and Hospitals

Independent providers part of St. Alphonsus Alliance

Non-participating providers

SmartAlliance Network Treasure Valley

Healthcare Reform

TIE

R 2

TIE

R 1

St. Luke’s MD’s and Hospitals

Independent BrightPath providers

Non-participating providers

BrightPath Network Treasure & Magic Valley

Becoming a contracted provider:

• BrightPath (Southwest Idaho)

o Contract and credentialing completed by BrightPath

o For any contract questions, please contact BrightPath at (877) 814-5505 or http://yourbrightpath.com/

• SmartAlliance (Southwest Idaho)

o Contracting completed by the Saint Alphonsus Health Alliance

o For any contract questions, please contact their provider network committee at (208) 367-8698

Healthcare Reform

http://yourbrightpath.com/



Becoming a contracted provider:

• SmartHealth (Northern and Eastern Idaho)

o Contracting completed by PacificSource

o For any contract questions, please contact Provider Network at: (800) 624-6052 or [email protected].

• PSN

o Contract and credentialing completed by IPN

o Contact (208) 333-1513 or visit their website at http://ipnmd.com/ipn/.

Healthcare Reform

mailto:[email protected]

http://ipnmd.com/ipn/



Nominate a Provider

Healthcare Reform

2013 vs 2014

G = Commercial group coverage

N = Individual policy

GE = Group Exchange

NE = Nongroup Exchange (individual member)

PacificSource Websites

PacificSource.com

PacificSource.com


Provider Bulletin


Provider Bulletin

• PacificSource has combined our two provider newsletters; CommunityCare (Medicare and Medicaid) and Provider Bulletin (Commercial).

• Beginning with the Spring 2014 edition, providers can expect to see topics related to all lines of business in the Provider Bulletin.


Provider Bulletin

• The Provider Bulletin will be distributed quarterly to those who have opted in to receive the newsletter as well as those who were on the distribution to receive the CommunityCare newsletter.

• Current and past newsletter editions may be found on any of our three websites.

PacificSource.com

InTouch Provider Portal



InTouch for Providers

• Secure, interactive website for providers

o Commercial and Medicare Advantage members

o Online eligibility

o View and submit referral and preauthorization requests

o Online claim status

o Explanation of payment

• Point of service direct

o Access real-time patient liability information and your actual charges for each procedure billed


InTouch – OneHealthPort

• InTouch for Providers is accessed through OneHealthPort.

• OneHealthPort is a web portal that provides access to secure health plan websites with a single user ID and password.

• If you are already an OneHealthPort user, you do not need to register again to access InTouch.


InTouch – OneHealthPort

• Register for OneHealthPort via their website: www.OneHealthPort.com/Register/Index.php.

• Providers who need to use “Forgot My Password” or “Forgot My UserID” links can find them on the OneHealthPort sign in page.

• For questions or assistance with the registration process, please contact:

OneHealthPort’s Help Desk:

(800) 973-4797


03/01/1938 03/01/1938 03/01/1938

The search feature returns active member records only. Referral requests for terminated members must be submitted to PacificSource via fax.


Not all PacificSource plans require referrals. Please reference the member’s ID card to verify if referral requirements apply.


Populate the online referral form with the appropriate referral information. Fields marked with an asterisk* are required.


Submitting supporting documentation online speeds up the processing time for requests.


Once the referral is generated, the requesting provider and the referred to provider will be able to view and track the referral request via InTouch.


Example of referral approval

Online Pharmacy Prior Authorization Requests

• Effective April 1, 2014, providers can now submit pharmacy prior authorization requests online via the InTouch web portal.

• This includes requests for both Commercial and Medicare members.



Explanation of Payments (EOPs) can also be found by selecting the “Billing” tab on the InTouch home page.


EOP Schedule • EFT delivery - Wednesday

• Paper EOPs - mailed Wednesday

• InTouch EOP delivery - Thursday

• Holidays will delay delivery

• EOPs are available for two years

Thank you!

Questions?

spring 2013 provider workshop cog - pacificsource › provider › 2014-ihcc...new cms 1500 form...

Documents