Health Partners Plans Provider Orientation - PowerPoint Presentation

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Health Partners Plans

Provider Orientation

and Training

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Training Requirement

DHS now requires the MCO’s to ensure their providers attend at least one MCO sponsored training during the course of the year. By attending this session you fulfill that requirement. Please complete the attestation located at the end of this presentation.

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Agenda

Introduction to Health Partners PlansLines of BusinessLab and Other Benefit CarriersOnline Tools Member Identification CardsReferral ProcessKey Departments and ServicesEmergency Department Use InformationProvider Practice Information and HPP ProgramsEncounter DataAccess, Appointment Standards and Telephone availabilityMaternity ServicesIdentification of Potential or Actual Abuse

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Agenda (continued)

Information on Reportable ConditionsInfection ControlCultural CompetencySpecial NeedsSpecial HIV/AIDS ServicesMember Rights and ResponsibilitiesFalse Claims Act / FWARecipient Restriction ProgramComplaints and Grievances / DHS Fair HearingsBalance Billing / Dual EligiblesPractice ChangesPlan Contacts and Resources

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Introduction

Health Partners Plans is one of a few hospital-owned health maintenance organizations. We were founded by four local teaching hospitals and helps residents of Southeastern and Central Pennsylvania lead healthier lives through innovations and services that improve access to high-quality care.Today, we are owned by:Aria HealthEinstein Medical Center Episcopal Hospital Hahnemann University HospitalSt. Christopher’s Hospital for ChildrenTemple University Hospital

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Key Facts

Health Partners Plans was founded in the Commonwealth of Pennsylvania more than 30 years ago. We are among the nation’s top 15 Medicaid MCO’s, as ranked by the National Committee for Quality Assurance (NCQA).Has been ranked number one in membership satisfaction in Southeastern Pennsylvania for 14 of the last 15 years.Nationally recognized for its innovative approach to health care and has a proven track record in creating life-changing programs that improve health outcomes.As the recipient of the first Multicultural Health Care Distinction award, Health Partners Plans was literally the first plan in the nation to be accredited by the NCQA for outreach and services that help improve health outcomes in diverse communities.

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Lines of Business

Graphic/Image

Health Partners (Medicaid) Provides free health coverage for children, teens, and adults who qualify. Members are eligible for all benefits covered under the Pennsylvania Department of Human Services (DHS) Medical Assistance Program.KidzPartners (CHIP) Provides health coverage for uninsured children and teens up to age 19 who qualify and are not eligible for Medical Assistance. Members are eligible for all benefits covered under the Pennsylvania Insurance Department (PID).Health Partners Medicare (Medicare Advantage) Provides health coverage for Original Medicare (Part A & Part B), Part C (Medicare Advantage) and Part D (prescription drug coverage). Members are eligible for all benefits covered under the Department of Centers for Medicare & Medicaid Services (CMS).

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Laboratory and other Benefit Carriers

Laboratory Quest Diagnostics Dental Carrier Avesis 1-800-952-6674Vision Carrier Superior Vision 1-800-879-6901

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Medicaid, Medicare, CHIP

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Other Benefit Carriers

Behavioral Health Health Partners (Medicaid) – Philadelphia County. Community Behavioral Health (1-888-545-2600) – Bucks County. Magellan Behavioral Health (1-877-769-9784) – Chester County. Community Care Behavioral Health (1-886-622-4228) – Delaware County. Magellan (1-888-207-2911) – Montgomery County. Magellan (1-877-769-9782)KidzPartners (CHIP) – Magellan Behavioral Health (1-800-424-3702)Health Partners Medicare – Magellan Behavioral Health (1-800-424-3702)

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HPP Provider Website

Website offers access to:HP Connect NaviNetHPP UniversityOnline directoryProvider manualOnline formularyClinical informationProvider newsletter and much more….

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www.healthpartnersplans.com/providers

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HPP Provider Portals

Our provider portals, HP Connect and NaviNet offers convenient and secure access to important information 24 hours a day.While we currently offer two portals, each portal provides unique functionality that is important to your office. The following chart will show how we are transitioning current HP Connect features over to NaviNet.Contact your office’s current administrator to register.Provider Portals

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All Lines of Business

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HPP Portals

FeaturesNaviNetHP CONNECTMember eligibilityXMember benefitsXClaims statusXRequest claims reconsiderations comingXRequest AuthorizationscomingXPatient roster reportsXProvider Performance Reports (QCP Report Card) XCare Gap ReportsXChronic Care Management Program (CCMP) Diagnosis Documentation X

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You can access these documents by clicking on the Practice Documents option under the Workflow menu.   If you are not registered with NaviNet, go to www.navinet.net to register for a new account and click on “Providers: Sign up for NaviNet” in the upper right corner. If you do not have access to the Practice Documents transactions, please speak with your NaviNet Security Officer.

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NaviNet

Please

call our Provider Helpline at 1-888-991-9023 if you have any questions or need more information

about new

features.

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HPP University

Health Partners Plans University is a series of online educational offerings targeted to the needs of various HPP audiences. You can explore interactive presentations designed specifically for HPP providers. Your colleagues and practice staff can also take advantage of these online learning opportunities.www.healthpartnersplans.com/providers/resources/hpp-university

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Introduction to our plans and services available to our membersFrequently asked questionsAn overview of member enrollment and eligibility guidelinesBenefit summaries for all lines of business An introduction to Health Partners Plans’ Utilization Management team and the guidelines and criteria used by the department.Quality management standards used at Health Partners PlansProvider practice standards and guidelinesBilling and reimbursementAppeals, Complaints and Grievances

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Provider Manual Overview

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Identification Cards 2017

Health Partners (Medicaid)(9 digit ID Number)

KidzPartners (CHIP)(10 digit ID Number)

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Identification Cards 2017

Health Partners (Medicare)(7 digit ID Number)

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Referrals

Referrals are not required for any Health Partners Plans line of business! Our members are permitted to “self-refer” for specialist care. When coordinating care, the PCP should direct members to a specialist who the PCP believes can best assist with the care needed. In return, it is extremely important for specialists to continue to keep a patient’s assigned PCP informed of all care they render to the patient.

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Encounter Data

Member EncountersHealth Partners Plans PCPs, specialists, Ambulatory Surgical Centers, ancillary and allied health providers must provide encounter data for professional services on properly completed CMS-1500 forms or electronic submission in an ASC X12N 837P format for each encounter with a Health Partners Plans member.EPSDT Encounter - Providers should report the appropriate level Evaluation and Management CPT code, plus CPT code EP Modifier and all immunization CPT codes to properly report an EPSDT claim.

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EPSDT Standards

EPSDT stands for Early and Periodic Screening, Diagnosis and TreatmentEPSDT standards are comprised of routine care, screenings, services and treatment that allow members under the age of 21 the ease to receive the recommended services set forth by the American Academy of Pediatrics’ Guidelines.Following an EPSDT screen, if the screening Provider suspects developmental delay and the child is not receiving services at the time of screening, s/he is required to refer the child (not over five years of age) through CONNECT, 1-800-692-7288, for appropriate eligibility determination for Early Intervention Program services. 

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Medicaid only

For

more information on EPSDT,

visit

our

web site

or

call the EPSDT Hotline at 1-866-500-4571.

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Lead Screening Requirements for all Children

All Medicaid children must have a minimum of two screenings by the age of 5 as part of the Early and Periodic Screening, Diagnosis and Treatment(EPSDT) well child screenings, regardless of the individual child’s risk factors. Please refer to the recommendations set forth in the EPSDT Periodicity schedule. EPSDT Periodicity ScheduleAll Children’s Health Insurance Program (CHIP) members should follow the same schedule.

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Claims Filing Instructions

Electronic:Payer ID Number: 80142Claims Clearing House: Change Healthcare (formerly Emdeon)EFT Payments and Remittances: ECHO Health , Inc.EDI Support: EDI@hpplans.comTimely filing deadlines:Initial Submissions: 180-days from Date of Service or Discharge DateReconsiderations: 180-days from HPP’s original Explanation of Payment (EOP)TPL: 60-days from (EOP)

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Health Partners (Medicaid ) and Health Partners Medicare:P.O. Box 1220 Philadelphia, PA 19105-1220

KidzPartners:

P.O

. Box 1230

Philadelphia, PA 19105-1220

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Claims Reconsideration

Providers can request a reconsideration determination for a claim that a provider believes was paid incorrectly or denied inappropriately.Three options to request a reconsideration of a claim:Submit requests through the provider portal, HP Connect.Rapid Reconsideration. Call to speak with a claims reconsiderationspecialist who can reprocess a claim (or confirm a denial) – Monday to Friday, 8:30a.m. to 5 p.m., by calling 1-888-991-9023 , Option #1. Submit written requests to: Health Partners PlansAttention: Claim Reconsiderations Department901 Market Street, Suite 500Philadelphia, PA 19107

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Utilization Management

Providing Appropriate Medical Care for MembersAt Health Partners Plans, we are committed to providing our members with the most appropriate medical care for their specific situations. To achieve this goal, our utilization management decisions are based on medical necessity, appropriateness of care and service, the existence of coverage  and whether an item is medically necessary or considered a medical item. This means Health Partners Plans does not provide financial incentives for utilization management decision makers that encourage denials of coverage or service or decisions that result in underutilization.

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Prior Authorization Process

Providers should obtain prior authorization at least seven days in advance for elective (non-emergent) procedures and services. Your request will be processed according to state and federal regulations. Failure to comply with this guideline may result in the medically non-urgent services being delayed.

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Prior Authorization Process

For elective admissions and transfers to non-participating facilities, the PCP, referring specialist or hospital must call the Health Partners Plans Inpatient Services department at 1-866-500-4571.We also offer the convenience of submitting authorization requests around the clock via HP Connect, our secure provider portal at www.HealthPartnersPlans.comMore detailed information can be found in the Utilization Management section of our provider manual at www.HealthPartnersPlans.com

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Emergency Care

Emergency care and post-stabilization services in emergency rooms and emergency admissions are covered services for both participating and non-participating facilities, with no distinction for in- or out-of-area services. Emergency care and post-stabilization services do not require prior authorization. Health Partners Plans must comply according to our HealthChoices Agreement pertaining to coverage and payment of Medically Necessary Emergency Services.Medicaid Members are not responsible for any payments.

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Non-par follow-up specialty care for an emergency is covered by Health Partners, but our staff will contact the member to arrange for services to be provided in-network, whenever possible. Access to PCP care is vitally important to maintaining the health of our members and, when possible, steering them away from the use of emergency rooms when their condition can more appropriately be managed in a PCP office environment. A PCP is required to provide access to care as outlined in the Access and Appointment Standards section of the manual. In addition, a PCP must be accessible 24/7. This information applies all lines of business.

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Emergency Care (continued)

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Healthcare Management

Clinical Care Programs ensures our members receive high-quality care and provides programs through the following units:Accordant Health ServicesBaby PartnersComplex Case ManagementDisease ManagementFit Kids ProgramHealthy Kids ProgramMember IncentivesOptum Care PlusSpecial Needs UnitMedicare DSNPMedicare AdvantageOptum OncologyCOPD Program

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Contact:

215-845-4765

Practitioners

can refer to any

program.

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Extra Benefits

YMCA Fitness ProgramAnnual gym membership covered;$2 copay for each of first 12 visits for members 18 and older (Medicaid). No visit requirement for Medicare. Weight Watchers 50 weekly visits covered yearly; program requirements apply;$2 weekly meeting fee

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All Lines of Business

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Access, Appointment Standards and Telephone Availability

Access

, Appointment Standards and Telephone Availability Criteria PCPSpecialistRoutine Office Visits Within 10 days Within 10 DaysRoutine Physical Within 3 weeks N/APreventive Care Within 3 weeks N/AUrgent Care Within 24 hours Within 24 hours of referralEmergency Care Immediately and/or refer to ER Immediately upon referralFirst Newborn Visit Within 2 weeks N/APatient with HIV Infection Within 7 days of enrollment for any member known to be HIV positive unless the member is already in active care with a PCP or specialist regarding HIV status

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All Lines of Business

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Access

, Appointment Standards and Telephone Availability Criteria PCPSpecialistEPSDT Within 45 days of enrollment unless the member is already under the care of a PCP and the member is current with screenings and immunizations N/ASSI Recipient Within 45 days of enrollment unless the enrollee is already in active care with a PCP/specialist N/AOffice Wait Time 30 minutes, or up to one hour if urgent situation arises 30 minutes, or up to one hour if urgent situation arises Weekly Office Hours At least 20 hours per site At least 20 hours per site Maximum Appointment per Hour 6 N/A

All PCPs must be available to members for consultation regarding an emergency medical condition 24 hours a day, seven days a week.

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All Lines of Business

Access, Appointment Standards and

Telephone Availability (continued)

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Administrative Procedures Regarding Patient Access

Guidelines and ProceduresWhile maintaining patient confidentiality, the practice should attempt to notify the patient of missed appointments and the need to reschedule. Such attempts are recorded in the patient record. The attempts must include at least one telephonic outreach.The office has procedures for notifying patients of the need for preventive health services, such as various tests, studies, and physical examination as recommended for the appropriate age group. Notifications are recorded in the patient record.

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All Lines of Business

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Maternity Services

Members who are confirmed to be pregnant are not subject to limitations on the number of services or copayments. Members are eligible for comprehensive medical, dental, vision and pharmacy coverage with no copayments or visit limits during the term of their pregnancy and until the end of their postpartum care.These services include expanded nutritional counseling and smoking cessation services. However, services not ordinarily covered under a pregnant member’s benefit package are not covered, even while pregnant.

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Medicaid

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Direct Access

Women are permitted direct access to women’s health specialists for routine and preventive health care services without being required to obtain a referral or prior authorization as a condition to receiving such services. Women’s health specialists include, but are not limited to gynecologists or certified nurse midwives. Pregnant members and newborns If a new member is pregnant and already receiving care from an out-of-network OB-GYN specialist at the time of enrollment, she may continue to receive services from that specialist throughout the pregnancy and delivery-related postpartum care. This coverage period may also be extended if Health Partners Plans' Medical Director finds that the postpartum care is related to the delivery.

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All Lines of Business

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Determination of Abuse or Neglect

Upon notification by the County Children and Youth Agency system, Health Partners Plans must ensure its members receive proper services when under evaluation as possible victims of child abuse and /or neglect and who present for physical examinations for determination or abuse or neglect. HPP staff who are designated as mandated reporters, as defined by the Pennsylvania Family Support Alliance, must report suspected child abuse to the appropriate authorities. Section 11 of the HPP Provider Manual stipulates that providers must report abuse, neglect and/or domestic violence.

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Mental Health and Substance Abuse Treatment

Under HealthChoices, all Medical Assistance members, regardless of the health plan/MCO to which they belong, receive mental health and substance abuse treatment through the behavioral health managed care organization (BHMCO) assigned to their county of residence.PCPs who identify a Health Partners (Medicaid) member in need of behavioral health services should direct the member to call his or her county's BHMCO. The BHMCO will conduct an intake assessment and refer the member to the appropriate level of care.

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Criteria

The Pennsylvania Department of Human Services (DHS) publishes and maintains behavioral health "Medical Necessity Criteria" for the Pennsylvania HealthChoices program. If you are interested in learning more about this criteria, visit the HealthChoices Behavioral Health Services Guidelines for Mental Health Medical Necessity Criteria.

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Reportable Conditions

All providers ̶ including labs, practitioners and facilities ̶ are required to appropriately report in accordance with 28 PA Code Chapter 27 reported conditions to PA/county/municipal health departments. For complete information about this requirement please refer to Chapter 27 of the PA Code.Here is the link with details about how and what to report. Access the Health Information Portal to report a disease. Health Information Portalwww.pacode.com/secure/data/028/028toc.html

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All Lines of Business

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Infection Control

Mandatory Requirements Recommended Standards Infectious material is separated from other trash and disposed of appropriately Medical instruments used on patients are disposable or properly disinfected and/or sterilized after each use Needles and sharps are disposed of directly into rigid, sealed container(s) that cannot be pierced and are properly labeled Standard precautions are reviewed with staff and documented annually The practice site has an OSHA manual Hand washing facilities or antiseptic Hand sanitizers are available in each exam room

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All Lines of Business

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Pay-For-Performance Program

Each year, Health Partners Plans develops Pay-for-Performance (P4P) incentives for our providers, based on specific initiatives that improve the health outcomes of our members. While ultimately benefiting our members, these incentives also offer an opportunity to increase revenue to your office.We encourage you to become familiar with our pay-for-performance programs and take advantage of every opportunity available to get patients in for appropriate treatment. For more detailed information or a copy of the manual outlining the changes and details of the QCP, contact your Network Account Manager or the Provider Helpline @ 1-888-991-9023.

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Members with Special Needs

Treating individuals with

disabilitiesOur Special Needs Unit (SNU) serves as a link between members, physicians, agencies, community services and Health Partners Plans.Case management activities focus on both long-term and short-term goals that help members who require extra assistance getting care for their illnesses, disabilities, or other special needs to achieve and maintain the maximum benefit from their medical treatment plan.

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Medicaid only

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Members with Special Needs

Referrals to the SNU are accepted from all sources including primary care physicians, community and hospital social workers, discharge planners and members themselves. SNU staff is available to help address specific needs of our member population.Special needs sensitivityFor those with hearing disabilities or language barriers, interpreters should be considered as an option to minimize or eliminate any potential miscommunication between provider and patient.

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Medicaid only

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It is required that all members have access to quality health care and we rely on our providers to ensure that our members have barrier-free access to our quality network.Our Special Needs Unit (SNU) can be reached at 215-967-4690 for any guidance or assistance in locating interpreter services.

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Members with Special Needs

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Special HIV/AIDS Services

Case Management Services. Any Health Partners (Medicaid) member diagnosed as being HIV infected are eligible for HIV/AIDS case management provided by the Center of Excellence (COE), regardless of whether that member is assigned to the COE for primary care services. To be reimbursed, HIV or AIDS must be a primary or secondary diagnosis for each service.COE is a participating provider or group of providers that offers special medical and social expertise to HIV/AIDS patients and are a recognized provider of coordinated medical and social services to patients with HIV/AIDS and has agreed to provide special services as outlined in their COE agreement.Siblings can also be assigned to these providers as their PCP.

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Cultural and Linguistic Requirements and Services

Low English proficiency, also known as Limited English Proficiency (LEP), affects more than 23 million Americans. Research has found that people with LEP encounter barriers to quality health care and are less likely to see their PCP, seek preventive care or use public health services. They are more likely to seek care in the ER, and receive far fewer services once seen in the ER than English-speaking patients.

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All Lines of Business

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Providing adequate interpreter and translation services to people seeking care is mandated by Federal law.These mandates are found in Title VI of the Civil Rights Act of 1964, Title I & II of the Americans with Disabilities Act, and PA Code Title 55. Every patient with LEP is entitled to professional interpretation and translation services.For medical appointments, family members should never be used to interpret, nor should untrained office staff who are bilingual.

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All Lines of Business

Cultural and Linguistic Requirements

and Services

Slide48

Professional interpretation and translation services are necessary to ensure that patients are provided with quality care that they can understand, question and engage with their doctor.If you would like information regarding where your staff can receive training to become a certified medical interpreter or information about scheduling interpreter services for your patients, contact our Special Needs Unit at 215-967-4690.To schedule to have an interpreter meet one of your patients at the office for an appointment, you can contact Quantum directly at 215-627-5521.  They have interpreters available 24 hours a day, 7 days a week. www.quantumtranslations.com.

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All Lines of Business

Cultural and Linguistic Requirements

and Services

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Members Rights and Responsibilities

Health Partners members have the right to know about their rights and responsibilities. Exercising these rights will not negatively affect the way they are treated by Health Partners Plans, its participating providers or other state agencies. Members have the right to take an active part in decisions about their health care and/or care plan without feeling as though Health Partners Plans or its providers are restraining, secluding or retaliating against them.

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Slide50

Health Partners Plans statement of Member Rights and Responsibilities are provided to our members. A list is made available to providers. You can find this list located in the Provider Manual. Member Rights and Responsibilities Section 14

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Members Rights and Responsibilities

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Medical Assistance Provider Self-Audit Protocol / FWA

False Claims Act / Self-Auditing & ReportingAs you know, identifying and reporting fraud, waste, and abuse is everyone’s responsibility. HPP takes this very seriously and holds all employees, members and providers accountable for reporting all concerns of fraud, waste and abuse.Our providers are responsible for auditing themselves and reporting any findings that would have resulted in an overpayment or underpayment to them. You can find self-auditing protocols on the Pennsylvania Department of Public Welfare website at: www.dhs.state.pa.us/learnaboutdhs/fraudandabuse/medicalassistanceproviderselfauditprotocol/

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Recipient Restriction ProgramMedicaid only

Program Description The Recipient Restriction is a program of DHS’s Bureau of Program Integrity (BPI), also referred to as “lock-in” program (requirement of DHS).Participants are MEDICAID members only.Identifies patterns of misutilization of benefits.Recipients may be restricted to a physician, a pharmacy, or both (physician and pharmacy) upon BPI approval.

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Program Goals

Encourage members to efficiently manage their health care needs, obtaining only required services and medications through proper care coordination.Establish a relationship with both a provider and pharmacy for the best medical management.Provide safeguards against inappropriate use of Medicaid services under the Medical Assistance (MA) program.For more information about the Recipient Restriction Program, contact the pharmacy department at, 215 991-4300 or email: PharmacyRecipientRestriction@hpplans.com

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False Claims Act

The False Claims Act is the most important tool U.S. taxpayers have to recover the billions of dollars stolen through fraud by U.S. government contractors, including providers, every year.Under the False Claims Act, those who knowingly submit or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim.If you wish to report fraud or suspicious activity, please call the Special Investigation Unit Hotline at 1-866-HP-SIU4U.

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Complaints, Grievances and Appeals

When Health Partners Plans denies, decreases, or approves a service or item different than the service or item requested because it is not medically necessary, a written grievance may be filed by the member, member's legal representative, or healthcare provider or other member's representative (with the appropriate written consent of the member) to request that Health Partners Plans reconsider its decision. For more information on the complaint, grievance and appeal process refer to our provider manual or contact Health Partners Plans at 1- 888-991-9023.

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Member Information about Fair Hearings

Department of Human Services Fair HearingsIn some cases members can ask the Department of Human Services to hold a hearing because they are unhappy about or do not agree with something HPP did or did not do. These hearings are called “fair hearings.” Members can ask for a fair hearing at the same time they file a complaint or grievance or can ask for a fair hearing after HPP decides the members first or second level complaint or grievance.For more information, consult the Member Handbook’s “Help With Problems” section.

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Balance Billing Dual Eligible MembersMedicare / Medicaid

Partially Dual Eligible members are responsible for their appropriate cost share amounts, as defined by their benefit package and should be billed accordingly.  Fully Dual Eligible members are not directly responsible for their appropriate cost share amounts. These charges are payable by Medicaid Fee-For-Service.

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Practice Changes

The Network Management department must be immediately notified in writing when any of the following occurs:Additions/deletions of providersChange in payee informationChange in hours of operationProvider practice name changeChange in practice ownershipTelephone number changeSite relocationChange in patient age restrictionsTax ID change (must be accompanied by W9)Please send all updates to credentialing@hpplans.com or via fax at 1-215-967-4473.

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All Lines of Business

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Plan Contacts and resources

Benefits and eligibility – 24 hour Helpline1-888-991-9023, prompt 3Claims inquires and claims reconsiderations1-888-991-9023, prompt 1 Authorizations – utilization management1-888-991-9023, prompt 2Radiology authorizations, PT/OT/ST and other expanded servicesEviCore 1-888-693-3211 Provider Services Helpline1-888-991-9023, prompt 4ECHO Health – electronic funds transfer and remittance advice1-888-834-3511

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Plan Contacts and resources

Provider Landing Pagehttp://www.healthpartnersplans.com/providersProvider Manualhttp://www.healthpartnersplans.com/providers/resources/provider-manualHP (Provider Portal)http://www.healthpartnersplans.com/providers/provider-portalHealth Partners Plans Universityhttp://www.healthpartnersplans.com/providers/resources/hpp-universityProvider Directoryhttp://www.healthpartnersplans.com/providers/resources/provider-directoryOnline Formularyhttp://www.healthpartnersplans.com/providers/resources/formularyECHO Healthhttp://View.echohealthinc.com

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In Closing

Thank you for your participation in the Health Partners Plans provider network and for your commitment to our members health care needs! Attestation If you reviewed the training materials electronically, please complete the provider attestation by accessing the following link: https://www.healthpartnersplans.com/providers/provider-education-attestationIf the link has been disabled, please copy the URL into your browser. If you requested a paper copy of the training materials, please complete the attestation form sent along with your materials. Fax to Lisa Mallory at 215 967-9249 or email ProviderEducation@hpplans.com

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Questions?

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Thanks for participating!