4/8/2014 Spring 2 0 1 4 PacificSource Provider W orkshop Montana - PDF document

4/8/2014 Spring 2 0 1 4 PacificSource Provider W orkshop Montana Presented by: Shawna Talles, Provider Service Specialist Agenda • NCQA • Locums Tenens • HEDIS • CMS 1500 Claim Form • Electronic Claims • ICD 10 • Healthcare Reform – Exchange • PacificSource Websites Organizational Updates PacificSource Total Mem bership Total Mem bership: 267,622 Covered Lives Com m ercial Mem bership: 210,631 Medicare Mem bership – OR & I D: 17,759 Medicaid Mem bership - OR: 39,232 1

4/8/2014 Organizational Updates Current Mem bership 3 0 1 Total Area Mem bership: 3,477 Exchange Mem bership: 767 Organizational Updates Current Mem bership 3 0 2 Total Area Mem bership: 6,446 Exchange Mem bership: 130 Organizational Updates Current Mem bership 3 0 3 Total Area Mem bership: 7,617 Exchange Mem bership: 1,465 2

4/8/2014 Organizational Updates Current Mem bership 3 0 4 Total Area Mem bership: 3,197 Exchange Mem bership: 1,568 Organizational Updates National Com m ittee for Quality Assurance ( NCQA) Organizational Updates 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. 3

4/8/2014 Organizational Updates Exam ples of NCQA requirem ents • 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. Organizational Updates 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. Organizational Updates Locum Tenens 4

4/8/2014 Organizational Updates 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 Organizational Updates 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. Organizational Updates 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. 5

4/8/2014 Organizational Updates HEDI S Organizational Updates W hat is HEDI S? • 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 Organizational Updates HEDI S 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 6

4/8/2014 Organizational Updates HEDI S 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. Organizational Updates HEDI S 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 Organizational Updates CMS 1 5 0 0 Claim Form 7

4/8/2014 Organizational Updates New CMS 1 5 0 0 Form ( Rev 0 2 / 1 2 ) 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. Organizational Updates Electronic vs. Paper Claim s Organizational Updates Electronic Claim s Transactions • PacificSource encourages electronic claims submission and EFT/ERA enrollment o This includes coordination of benefit (COB) claims. o Office Ally is free o Availity claims now accepted electronically. o A list of participating clearinghouses and enrollment forms are available on our website. 8

4/8/2014 Organizational Updates PacificSource Adm inistrators ( 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 and PSA members. • Updated EFT/835 enrollment form now available on our website. Organizational Updates Dedicated Provider Custom er Service Phone Num ber ( 8 5 5 ) 8 9 6 -5 2 0 8 * Benefit questions, claim s inquiries, etc. Organizational Updates I CD-1 0 9

4/8/2014 Organizational Updates I CD-1 0 • I m plem entation pushed to October 1 , 2 0 1 5 ( 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 Organizational Updates Has your organization begun I CD-1 0 planning? 151 People Surveyed No, Yes – 116 2 3 .2 % • No – 35 • Skipped Question – 16 Yes, • 7 6 .8 % Organizational Updates W hen do you anticipate starting your organization's education on I CD-1 0 ? 2% 2% Already Started – 46.4% 7% 7% Q1 2014 (Jan-Mar 2014) - 23% Q2 2014 (Apr-Jun 2014) – 22% 22% 22% 46% 46% Q3 2014 (Jul-Sep 2014) – 7% We don’t anticipate providing education on this topic. We don’t use ICD Codes – 2% 23% 23% 10

4/8/2014 Organizational Updates Please estim ate how m uch of the planning process your organization has com pleted. 4 % Answ er Response Response Options Percent Count 1 3 % 0-25% 46.8% 51 4 7 % 25-50% 35.8% 39 50-75% 12.8% 14 3 6 % 75-100% 4.6% 5 Organizational Updates I CD-1 0 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 Organizational Updates I CD-1 0 Resources • If you have questions regarding PacificSource and ICD-10, please email ICD10inquiries@pacificsource.com. • 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. 11

4/8/2014 Organizational Updates Provider Bulletin Organizational Updates 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. Organizational Updates 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. 12

4/8/2014 Organizational Updates Provider Bulletin Com m ercial Site Organizational Updates AI M Specialty Health AI M Specialty Health 13

4/8/2014 AI M Specialty Health Standardization of our • authorization process for radiology services within our service area. More than 20 years experience • effectively managing radiology services. AIM’s Safe Choices in Imaging • program focuses on increasing awareness of health and safety issues related to radiation exposure in advanced imaging procedures. AI M Specialty Health Covered Modalities • Computed Tomography Scans (CT) • Computed Tomographic Angiography (CTA) • Magnetic Resonance Imaging (MRI) • Magnetic Resonance Angiography (MRA) • Magnetic Resonance Spectroscopy (MRS) • Nuclear Cardiology (e.g., SPECT scans) • Positron Emission Tomography (PET) AI M Specialty Health Required Settings: Excluded Settings: • Hospitals (outpatient) • Inpatient Services • Free-Standing • Emergency Room Imaging Facilities • 23-hour Observation • Physician Offices • Ambulatory Surgery • Urgent Care Centers 14