Special points of in- terest: Medicare Plan Update Area Network - PDF document

February 2015 ADVANTAGE HEALTH SOLUTIONS Special points of in- terest:  Medicare Plan Update Area Network Offerings:  Medicare Remits ADV 360, Commercial PHO Networks and MEDICARE ADVANTAGE online  Medicare Provider Ap- peals  Medicare Wellness Codes  ADVANTAGE 360: Medicare Retro Auths  2015 Prior Advantage Indiana Statewide Risk Auth requirements Direct Provider Contracts  SHO Claims transition www.advantageplan.com to view claims and eligibility  2015 Advantage web tools  PR contacts MEDICARE PPO:  Web resources Coming soon: Access to online claims and Eligibility 47 Indiana counties participate in Medicare PPO Commercial PHO Networks: CHA 360 FRANCISCAN ALLIANCE Community Prohealth Select Health Network St. Francis Health Network St. Vincent CMO SHO Medicare ADVANTAGE Plan Update EFFECTIVE June 1, 2014 ALL MEDICARE ADVANTAGE claims should be submitted to the following: New EDI Payor ID: 35219 or PO Box 502030 Indianapolis, IN 46250 Please contact Medicare ADVANTAGE provider services for any questions regarding the claims address/payor ID change at 1.877.660.6258

Page 2 Access Medicare Provider Remits online at: www.cmcs-indy.com/services/eservices 1. Once on the website, Provider will select the “PROVIDER” button on the left side. 2. After selecting the “PROVIDER” button, the provider will login if they have an account. If the provider does not have an account the provider will need to select “Register New User’ below the login area. 3. Once they have created the account and logged in, the provider will be able to see claims informa- tion. 4. If the provider needs assistance on the website they can call 1-888-504-5556. Coming soon : Access to Medicare online claims and eligibility @ www.advantageplan.com Medicare Provider Appeal Process Provider letterhead or individual appeal form  ………..rising Deadlines  above the service you Submit—60 days from date of Remittance Advice Decision—60 days of Receipt expect” ADVANTAGE Health Solutions, Inc. SM ATTN: Medicare Provider Appeals Provider Relations 9045 N. River Road, Suite 200 Indianapolis, IN 46240 Wellness Codes EFFECTIVE January 1, 2015 In order to remain consistent with CMS, all claims submitted with CPT Codes 99381 – 99397 for Medicare Advantage Members covered by ADVANTAGE Health Solutions, Inc. will be denied as non-covered services & members should be held harmless. EDI Payor ID: 35219 or PO Box 502030 Indianapolis, IN 46250 Please contact Medicare Advantage provider services for any questions regarding the processing of provider claims at 1.877.660.6258

Page 3 Dear Provider Partner: Advantage Health Solutions, Inc. is implementing a new Retrospective authorization policy effective November 1, 2014 . Providers must provide all relevant information necessary to authorize a service within the following timeframe:  Within 3 business days for an emergency  No later than 2 business days before service if non-emergent Retrospective authorizations after services have begun or have been completed will be considered by Advantage Health Solutions for medically necessary services only under the following circumstances: The provider followed appropriate procedures but received invalid information. For example, documentation of authorization from an incorrectly identified payor source. The provider's documentation confirms checking eligibility but was provided erroneous infor- mation. The provider's records document that the recipient refused or was physically unable to provide the recipient identification information. All authorization requests delayed due to the three circumstances above must be submitted within 30 calendar days from identifying the member’s eligibility or member’s confirmation of insurance cover- age. The request must be accompanied by evidence of the provider’s failed attempts to confirm eligi- bility (i.e. screen shots). If a claim is submitted for services that require authorization but is not ob- tained, the claim will be processed as a payment denial. The Explanation of Benefit (EOB) will include the applicable reference to denial for no authorization and includes contact information on submitting a provider dispute. If you have any questions regarding this new policy please contact Provider Relations Thank you, Provider Relations

Page 4 ADVANTAGE RISK 2015 PRIOR AUTH REQUIREMENTS Provider MUST obtain prior auth through ADVANTAGE auto authorization system  Cardiac & Pulmonary Rehab  Inpatient hospitalization  Physical Therapy (after 8 visits)  Advanced imaging: PET/SPECT & MRI’s  Occupational Therapy (after 8 visits)  Outpatient Surgery, excluding colonoscopies  Speech Therapy and endoscopies  Corrective Appliances/Prosthesis  Durable Medical Equipment > than $750  Biotech Drugs*(See Below)  Home Health Care  Wound Treatment  Home IV Therapy  Sleep Study  Hospice Care  Pain Management  Skilled Nursing Facility  Transplants  Dialysis  Tertiary/ Out of Network Services Tertiary/ Out of Network Services  Chemotherapy/radiation Behavioral Health Prior Authorizations: “Prior Authorization Behavior Health (Call phone number on back of card for  does not Prior Authorizations) guarantee payment. Authorization is required for following services:  Payment is All inpatient services,  subject to Intensive Outpatient Programs  eligibility and Electroconvulsive Therapy  benefits at the Partial Hospitalizations  time of service.” Specialty Pharmacy Prior Authorizations: * Biotech medication requests will be completed by Envison Specialty Pharmacy:  Prior Authorization Phone: 877.684.0021  Prior Authorization Fax: 330.405.8081  Visit www.advantageplan.com for a The product will then be delivered per the direction of the complete listing of specialty ordering physician* pharmacy drugs.

Page 5 TO: SHO PHO and St. Vincent CMO Providers RE: Transition of ADVANTAGE Claims & Medical Management to Cooperative Managed Care Services (CMCS) Suburban Health Organization (SHO) is moving the administration of Advantage Health Solution claims and medical management administration from ProHealth to CMCS effective 1/1/2015 . PLEASE READ BELOW CAREFULLY. Providers will remain in their SHO PHO network and/or St. Vincent CMO; only claims processing and medical management administration will move to CMCS. The following information will need to be shared with your office and billing staff and your records updated in order to receive reimbursements: CMCS Electronic Claims Submission: may be submitted as early as 12/15/14 EDI Payer ID: EMDEON 35199 Paper Claims: may be submitted as early as 12/15/14 Suburban Health Organization P.O. Box 50830 Indianapolis, IN 46250 Claims Inquiries & Customer Service Medical Management (including all authorizations and precertifi- cation-related calls): Information Ph: 1- 866-873-4516 or 1-317-596-5929 Ph: 1-317-570-9999 or 1-866-482-5254 Fax: 1-317-570-6822 Fax: 800-747-3693 Please note: Member Services at Advantage & Credentialing at Suburban Health Organization will not change. ADVANTAGE member services phone number is 800-553-8933 or 317-573-6228. If you have any questions please contact our Provider Relations Department at ADVANTAGE Health Solutions 1-877-901-2237 or by visiting www.advantageplan.com .

Page 6 Volume 1, Issue 1 ADVANTAGE Web Tools ADVANTAGE Web Tools ADVANTAGE- connect features:  Online Service Request & Provider Demographic Changes  View Network Authorization & Precert Requirements  Verify Member Benefits & Eligibility  View Claim Status The Automated Prior Auth  Access to Other Health Plan Websites Tool is available 24/7  Access to Health Guidelines & Preventative Health Information including weekends  Access to ADVANTAGE Announcements and holidays. Allows providers the ability to check medical claims and current eligibility status *Retro Automated Prior Auth Tool @ www.advantageplan.com authorizations can not be completed on This tool has been built to reduce the time and resources it takes provider of- fices to request authorizations from ADVANTAGE. line. The tool is available 24 hours a day and 7 days a week including weekends and holidays. Inter Interacti ctive V e Voice ice Response Response Allows providers the ability to check medical claims and current eligibility status The IVR is available by for members and dependents. calling 1-800-553-8933 or 317-573-6228. 1. Providers may select an automated interactive voice response and/or a faxed copy of the interactive voice response. 2. To access the IVR system, providers can call 800-553-8933 or 317-573-6228 and select option 1. 3. Be sure to have the following information handy when calling: Provider fax number, TIN, Member ID, DOB & DOS.