Dec 10, 2018 CHOICE & HHAeXchange
HHAX Implementation CHOICE transitions to HHAeXchange as of October 8, 2018 with Wave 1. Wave 2 went live Oct 25, 2018 All Wave 3 providers will be required to accept/deny cases through HHAeXchange – Dec 15, 2018: HHAeXchange Enterprise Providers – Jan 19, 2019: Portal or Non-HHAeXchange providers 2 CONFIDENTIAL Discussion Draft
End to End Process Claims can be sent to ChangeHealth (CHOICE’s clearinghouse) HHAX receives Provider enters Provider submits Provider can log Claims processed CHOICE creates authorization; Provider accepts/ services via EVV 837i files for 835 file into Provider by CHOICE’s authorization case placed with denies case or manually via adjudication via a generated Portal to review system a provider Provider Portal UB04 835 Claims can be sent to provider’s clearinghouse 3 CONFIDENTIAL Discussion Draft
Member Placement Process Current Future: HHAX Contract Administration currently sends referrals VNSNY CHOICE will send referrals to Providers through the HHAeXchange provider portal as opposed to the VNSNY to Providers through the VNSNY placement Placement portal. portal Providers will accept or decline referrals directly through Providers accept and decline referrals through HHAeXchange provider portal. VNSNY placement portal Providers will continue to have 20 minutes to accept/decline a referral. Providers have 20 minutes to accept or decline a If referrals time out on portal, providers can request referral. additional time by reaching out to CHOICE via a – If referrals time out, providers can request communication note. additional time – Referral types processed through the HHAeXchange portal include HHA, PCA, Consumer Direct and vendor – Contract Admin works with you to extend changes the time as necessary. – On occasion referrals will be broadcasted to multi- providers. 4 CONFIDENTIAL Discussion Draft
AUTHORIZATIONS 5 CONFIDENTIAL Discussion Draft
Authorization Process Current Future: HHAX No authorization number is required for All referrals will be assigned an authorization number placement of referrals through OPS by Contract Provider is responsible to: Administration – Verify member information using V# - V# indicates LOB V8 = MLTC V7= MAP or Total V6= FIDA The authorization will be for 180 days or as specified Universal Billing codes will replace service type codes on referrals Total Bucket = Provider is required to manage hours based on authorization of full 180 days. The units authorized should span the full length of the delivery of care dates. Services to member ends upon the ‘end date ’ in authorization even if member shows as ‘Active’ in HHAX 30 days after the authorization end date, the authorization – will drop from the Provider’s view Change in schedule does not warrant a new authorization 6 CONFIDENTIAL Discussion Draft
Member Authorization Ends & Disenrollment Authorization Ends – A member should only receive authorized services based on the start of care and end of care – If a member shows ‘end of care dates’ in queue, but the authorization dates have lapsed, send a communication note – CHOICE will coordinate with nursing staff based on the member’s medical necessity. Disenrollment – The member, though inactive, may not immediately drop from the provider’s list. Therefore, it is critical the auth end date be the source of truth for authorized services. 7 CONFIDENTIAL Discussion Draft
Plan of Care It is the responsibility of the LHCSA to maintain the POC. – Enterprise providers must maintain the POC in HHAX – For all other providers, maintain the POC outside of HHAX – 1 Personal Care Task is required If member refuses, refusal must be documented It is at the discretion of VNSNY CHOICE to request member POC details at any time for audit purposes Nursing Services Nursing services can be viewable in HHAeXchange but no authorization is included 8 CONFIDENTIAL Discussion Draft
COMMUNICATION NOTES 9 CONFIDENTIAL Discussion Draft
Communication Providers are required to use communication notes in HHAX to communicate with VNSNY CHOICE. Scenarios for communication notes – Member demographic information must be updated – Reauthorization – Questions regarding order – Interruption of Care (black out dates used) – Member death Travel Time and Over Time requests are required to be submitted via an appeal to Grievance & Appeals 10 CONFIDENTIAL Discussion Draft
Service Interruptions (Black Out Dates) Black-out dates are utilized in HHAX if there is an interruption of care (ex: patient is hospitalized, on vacation, etc.) – VNSNYC CHOICE will black out dates in HHAX for up to 15 days – Provider is notified via an automated HHAX communication note that the dates have been blacked out. – CHOICE Care Management will resume service once member returns home – Provider is notified via an automated HHAX communication note to resume service 11 CONFIDENTIAL Discussion Draft
VISIT CONFIRMATIONS 12 CONFIDENTIAL Discussion Draft
Timesheets All providers contracted with VNSNY CHOICE must maintain timesheets outside of HHAeXchange. During an audit, VNSNY expects providers to show proof of in order to validate services rendered. 13 CONFIDENTIAL Discussion Draft
BILLING 14 CONFIDENTIAL Discussion Draft
Submitting Claims for Payment As a contracted provider, there are 3 ways to submit a claim: 1. HHAeXchange generates 837i 3 rd Party Mgmt. System generates 837i 2. 3. Provider directly bills CHOICE Electronically • CHOICE Clearing House: Change Health • Provider’s clearinghouse Manually • Mailing address on following slide Upon go-live date, CHOICE expects providers to be prepared to bill using one of the outlined options 15 CONFIDENTIAL Discussion Draft
Claims Process Prior authorization is required for all services covered by MLTC, MAP and FIDA. Unless otherwise described by your VNSNY CHOICE Provider Contract, VNSNY CHOICE requires submission on Form CMS1450 (UB-04) for all PCA/HHA Claims. As of 4/1/2018 VNSNY CHOICE is compliant with Universal Billing Code Guidance as outlined by New York State and The Department of Health Electronic billing is preferred, will facilitate payment, and will allow you to track your claims online. Please call the VNSNY CHOICE Provider Call Center for additional details on how to register. Otherwise Paper Claims can be mailed to – MLTC and MAP Claims PO Box 4498 Scranton, PA 08505 – FIDA Claims PO Box 3715 Scranton, PA 08505 16 CONFIDENTIAL Discussion Draft
Claims Process Cont. Expect a 30-45 day turnaround time for payment Once the claim is submitted, log in to the provider portal to check on the status and outcomes. – The Provider Portal will facilitate the correction and any necessary communication – Use of the Provider Portal is not contingent on the claims submission type 17 CONFIDENTIAL Discussion Draft
GRIEVANCE & APPEALS 18 CONFIDENTIAL Discussion Draft
Grievance & Appeals Providers may file appeals disputing a denial issued as a result of a utilization management decision, a claims denial (ie: no authorization; provider not contracted to perform services; submit claim to primary carrier) or if they disagree with the amount paid on a previously processed claim. All appeals must be filed in writing and must include all relevant information, including medical records, if applicable. The address to submit appeals is: VNSNY CHOICE Health Plans Grievance and Appeals P.O. Box 445 Elmsford, NY 10523 19 CONFIDENTIAL Discussion Draft
Grievance & Appeals Cont. Timeframe for Filing Appeal: 60 calendar days from the date of the denial/initial determination, unless the provider’s contract allows for additional time to file. Acknowledgment Letter Timeframe: Within 15 business Days from receipt of the appeal, Grievance and Appeals will send a written acknowledgment letter. Resolution Timeframe: Within 60 calendar days from receipt of the appeal. Appeals that involve a medical necessity, experimental or investigational decisions may be further appealed through the State’s external appeal process. Some facilities also have the right to file an appeal with a Dispute Resolution Entity. Please refer to your provider contract to determine if this right applies to you. 20 CONFIDENTIAL Discussion Draft
Contact Information Follow up questions to today’s webinar? Email: hhaxquestions@vnsny.org Looking for HHAX materials, please visit our site: http://vnsnychoice.org/health-professionals Questions regarding claims set up? Network Development is actively reaching out to review your billing plan and any outstanding questions Question regarding claims status, denial or payment? Provider Call Center: 1-866-783-0222 21 CONFIDENTIAL Discussion Draft
Recommend
More recommend
