MDwise 2019 Updates Updates Eligibility Prior Authorization PA Claims Provider Portal Provider Relations Transportation Resources Questions Agenda MDwise restructured its Delivery System model to ID: 751304
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Slide1
2019 IHCP 1st Quarter Workshop
MDwise 2019 UpdatesSlide2
Updates
EligibilityPrior Authorization (PA)Claims
Provider Portal
Provider RelationsTransportationResourcesQuestions
AgendaSlide3
MDwise restructured its Delivery System model to:
Improve claim payment timeliness and accuracyStreamline and reduce administrative redundancy for providersProvide greater access for our members
One standard authorization list
One point of contact for all authorization requestsOne claim submission address Non-Excel Delivery System contractsProviders not contracted with MDwise Excel must contract to stay in network.
UpdatesSlide4
Eligibility
When determining eligibility, verify:
Is the member eligible for services today?
Which Indiana Health Coverage Program plan are they enrolled?
If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise?
Who is the member’s Primary Medical Provider (PMP)?
Provider Healthcare Portal
MDwise Provider Portal
IHCP Program
Delivery System: MDwise Excel
MCE
Assigned PMP HistoryAssigned PMPDelivery System: MDwise ExcelSlide5
One standard authorization list
One point of contact for all authorization requestsGo to MDwise.org for most up-to-date version of PA lists
Prior AuthorizationSlide6
You will need two key items when filing a request for Medical Prior Authorization (PA):
Universal Prior Authorization Form
Located on our website
Documentation to support the medical necessity for the service you are requesting to prior authorize:
Lab work
Medical records/physician notes
Test results
Therapy notes
Tips:
Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number.
Be sure to note if PA is for a retroactive member.
Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe. Prior AuthorizationSlide7
Prior Authorization Turn-Around Time
All emergency inpatient admissions require authorization within 2 business days of the admission.Urgent prior authorizations can take up to 3 business days
Requests for non-urgent prior authorization will be resolved within 7 calendar days.
It is important to note that resolved could mean a decision to pend for additional information.If you have not received a response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue.
PA Inquiry Line
1-888-961-3100
Prior AuthorizationSlide8
Appeals
Providers can request a prior authorization appeal on behalf of a member within 33 calendar days of receiving denial.Providers must request an authorization appeal in writing to MDwise:
MDwise Customer Service Department PO Box 441423 Indianapolis, IN 46244-1426
MDwise will resolve an appeal within 20 business days and notify the provider and member in writing of the appeal decision including the next steps.
If you do not agree with the appeal decision, additional appeal procedure options are available.
Prior AuthorizationSlide9
Pharmacy Prior Authorizations
For all requests and questions regarding Pharmacy PA, contact the Pharmacy Benefit Manager (PBM), MedImpact.Pharmacy Benefit Manager (PBM):
MedImpact: 844-336-2677
Pharmacy Resources:http://www.MDwise.org/for-providers/pharmacy-resources
Prior AuthorizationSlide10
Claim Submission is date of service driven - date of service 1/1/19
Electronic Submission
Provider Customer Service Unit
1-833-654-9192Claims inquiriesPlease note: Paper claims must be on red/white form with black ink.
Claims
Hoosier Healthwise & Healthy Indiana Plan
MDwise/McLaren Health Plans
P.O. Box 1575
Flint, MI 48501
Hoosier Healthwise
Healthy Indiana Plan
Payer ID: 3519MPayer ID: 3135MSlide11
Claim Timelines:Claim Submission:
Primary: 90 days from the date of serviceSecondary: 90 days from the date of the explanation of benefits (EOB)Effective 1/1/19, non-contracted providers will have 180 days for claim submission.*
Claim Adjustment Process
Providers can adjust a claim by submitting the adjustment form and supporting documentation within 90 days of the explanation of benefits (EOB).Disputes60 days from the date of the EOB OR 60 days from the date of your claim adjustment response.
*Reference BT201829 for more information
ClaimsSlide12
Claim Adjustment Request FormRequest for payment reconsideration for a paid or denied claim
To be used before Claim Dispute processUse form:To have claim reconsidered for payment if denied in errorIf claim paid at inappropriate rate
To submit attachments missing from original claim submission
All claim adjustment inquiries and requests must be made to MDwise within 90 calendar days of the most current MDwise EOP.Form cannot be used if claim has already been disputedAdjustment Form must be complete and include all documentation to be considered
Claims Slide13
Claims
Claim Adjustment Request FormSlide14
Claim Adjustment Request Form
Send completed Provider Claim Adjustment Request Form with a copy of the claim form and/or any supporting documentation to:MDwiseClaims@mclaren.orgOr fax to: 833-540-8649
For questions regarding the Provider Claims Adjustment Process, call the Provider Customer Service Unit at 833-654-9192.
ClaimsSlide15
MDwise Provider Portal
http://www.MDwise.org/for-providers
Provider PortalSlide16
Provider Portal
Use the main log in to access all claims dates of service
Use the Valence portal for dates of service 1/1/17-12/31/18Slide17
MDwise Provider PortalPlease note: Portal Access Requests can take up to 3 business days
Provider PortalSlide18
MDwise Provider Portal
Member Eligibility including PMP ClaimsQuality ReportsMember Rosters
Member Health Profile
Coordinate Medical and Behavioral Health services based on paid claims Includes physician visits, medication and ER visitsCare Management/Disease Management (CM/DM) Requests
Provider PortalSlide19
Providers not currently participating as MDwise Excel need to contract to continue to see MDwise members.
What is required to contract?MDwise Excel ContractProvider/Ancillary Enrollment Forms
W-9
Sample ClaimProviders not seeking a MDwise Excel contract are required to submit the following:Non-Contracted Provider Set-Up FormW-9Sample Claim
Provider Relations - ContractingSlide20
Provider Relations Forms
http://www.MDwise.org/for-providers/forms/provider-enrollmentCredentialing/Enrollment
MCE Enrollment Form
Enrollment Cover Sheet (until 12/31/18)Provider Update FormDisenroll/Re-enrollPanel MoveNon-Contracted Set-Up FormRequired for non-contracted providers
Contract Inquiry FormSubmit Forms to:
prenrollment@mdwise.org
Provider Relations -FormsSlide21
Provider Relations – Territory Map
1
6
4
3
5
2
8
9
7Slide22
Provider Relations – Contact Information
Representative
Territory
Phone
Email
Paulette Means
Region 1
317-822-7490
pmeans@mdwise.org
Jinny Hibbert (Interim)
Region 2jhibbert@mdwise.org Michelle PhillipsRegion 3,
Hospice, Home Health
317-983-7819
mphillips@mdwise.org
Jamaal Wade
Region 4
317-822-7276
jwade@mdwise.org
David Hoover
Region 5
317-983-7823
dhoover@mdwise.org
Tonya Trout
Region 6
317-308-7329
ttrout@mdwise.org
Rebecca Church
Region 7
317-308-7371
rchurch@mdwise.org
Sean O’Brien
Region 8
317-308-7344
sobrien@mdwise.org
Whitney Burnes
Region 9
317-308-7345
wburnes@mdwise.org
Nichole Young
Behavioral Health
(CMHC, OTP, IMD or Residential)
317-822-7509
nyoung@mdwise.orgSlide23
MDwise non-emergent transportation vendor is now
Southeastrans. To schedule a non-emergent medical transport (NEMT) ride:Southeastrans Web Portalhttps://www.southeastrans.com/transportationproviders/indiana-providers/
MDwise Customer Service: 1-800-356-1204Follow the call tree for the appropriate extensionTo become a MDwise Transportation vendor:Kristy Swoveland, Provider Relations Manager
kswoveland@Southeastrans.com or 765-602-6004Andrew Tomys, Corporate Network Development Manager
atomys@Southeastrans.com
or 770-362-4839
TransportationSlide24
MDwise Provider Tip Sheets
http://www.mdwise.org/for-providers/tools-and-resources/additional-resources/tip-sheets/MDwise Provider Manuals
http://www.mdwise.org/for-providers/manual-and-overview/
MDwise Provider Relations Territory Map http://www.mdwise.org/for-providers/contact-information/
MDwise Customer Service1.800.356.1204
IHCP Provider Modules
Indianamedicaid.com
ResourcesSlide25
Questions