WELCOME TO New PROVIDER Orientation Congratulations on becoming a part of the C areCentrix family Our role in Provider Operations is to be your advocate as you work with C areCentrix Please feel free to contact your Provider Operations team should you have additional questions after ID: 760147
Download Presentation The PPT/PDF document "New PROVIDER ORIENTATION" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
New PROVIDER ORIENTATION
Slide2WELCOME TO New PROVIDER Orientation
Congratulations on becoming a part of the CareCentrix family!Our role in Provider Operations is to be your advocate as you work with CareCentrix. Please feel free to contact your Provider Operations team should you have additional questions after reviewing this new provider orientation!
Slide3Agenda
Who is CareCentrix and how does CareCentrix benefit providers?
Review the home care benefits management workflow
Review the steps of the referral process and getting
authorizations/pre-certifications
Review
the requirements of meeting start of care (SOC)
Review
the steps of the claim submission process and getting
paid
Review
CareCentrix contact
information
Review
provider performance
metrics
Questions
?
Slide4CareCentrix
Slide5CareCentrix
Who is CareCentrix?
Nation’s leading home
care network
A healthcare delivery system that performs utilization management functions for ancillary care and specialty pharmacy services for commercial, and managed Medicare and Medicaid
plans
Privately owned since 2008, founded
in
1996
Network
: Over
8,000
credentialed
provider locations of home
h
ealth, durable medical equipment, infusion and behavioral health
Accreditation
: Full
URAC accreditation in health utilization management
Customers:
CIGNA/CIGNA West,
Health
Net, Florida Blue, Horizon Blue Cross Blue Shield of New Jersey, Aetna and Cofinity
National footprint: 24/7 service in all 50
states
How does CareCentrix benefit the provider?
Single Point-of Contact: CareCentrix integrates the full spectrum of
services - network management,
referrals, care coordination, utilization management, and reimbursement
consolidation
Focus on relieving provider from the burden of collecting patient cost share
Slide6Home care benefits management workflow
Slide7Homecare benefits management workflow
Physicians
Claims Billing
Home
Health Provider
DME/OP Provider
Infusion Provider & Ambulatory Infusion Suites
Hospital Discharge Planners
Case Managers
CCX Providers
CareCentrix
Slide8Authorizations/Pre-certifications
The Referral Process & Getting an Authorization
R
equests
for service, whether for the initial start of care or reauthorization for continued care, must be requested prior to the service being provided. If a
provider
fails to request an
authorization/pre-certification
prior to providing services,
the
services performed may not be reimbursable and are not billable to the
patient.
Slide9The referral process: service specific tips
THH – Home HealthDME/O&PInfusionRequired to be Homebound?Varies by plan/product type.N/AN/AInitial Auth Required?Yes for non-BlueCard services*Yes for non-BlueCard services*Yes for non-BlueCard services*Re-auth Required?Plan DependentPlan DependentPlan DependentStart of Care (SOC) ChangesProvider must make CareCentrix aware & update on www.carecentrixportal.com Provider must make CareCentrix aware & update on www.carecentrixportal.com Provider must make CareCentrix aware & update on www.carecentrixportal.com MiscellaneousLab tests must be taken to the lab specified by the patient’s plan Routine supplies are included in the cost of visitIf additional supplies are needed, CareCentrix will authorize.OxygenLiter flow O2 saturation w/ dateCPAPSleep study or letter of medical necessityMD order required for upgraded unit Provide height, weight, allergies, type of venous access, and next scheduled doseInfusion providers must accept case “full-service” which includes drug, skilled nursing and supplies (per diem)
- Please note these are service specific tips, however all providers should reference the provider manual, the provider agreement and the health plan policies for guidance on the referral process.
* BlueCard requirements for precert vary by HomePlan. Please refer to BlueCard training.
Slide10Sample referral instruction sheet
Read your fax coversheet. It will tell you the patient ’s plan type, including how to check eligibility and benefits and whether reauthorization is needed.
Notifies you if PTA and OTA are allowed by patient ’s health plan
Identifies the lab of choice per the health plan
Slide11Important Authorization Information
Coordination of Benefits (COB)Please click the PDF to the right for an overview of COB Authorizations of services is NOT a guarantee of paymentPayment of services rendered is subject to the patient’s eligibility and coverage on the date of service, the medical necessity of the services rendered, the applicable payer’s payment policies, including but not limited to, applicable the payer’s claim coding and bundling rules, and compliance with the Provider’s contract with CareCentrix. Refer to the Provider Manual for more information regarding authorizations. Provider is ultimately responsible for eligibility benefit and payer source verification.Providers must in every instance, whether receiving a referral from CareCentrix or a primary referral source, verify eligibility and benefits with the patient’s Health Plan prior to providing any service, equipment or supply item. Providers should maintain documentation to evidence this verification of eligibility and benefits.CareCentrix does not conduct electronic eligibility and benefit verification transactions, but our health plan customers do. Eligibility and benefit verification and service authorization are not a guarantee of payment for services such as, but not limited to, items provided when the patient is not eligible or there is no available benefit. Providers are responsible for ensuring that they maintain, and have available upon request, all documentation necessary to support the services rendered, including but not limited to, the medical necessity of such services.
Slide12Eligibility Tips
Health Plan
Website
Patient
Plan Type
Contact Phone
Aetna
Navinet
www.navinet.com
PPO patient
HMO patient
(888) 632-3862
(800) 624-0756
Cigna
Cigna Web Portal
www.cignaforhcp.com
Florida Blue
Blue
Card
Availity
www.availity.com
State, Local and FEP
BlueCard
(877) 352-2583
(800) 676-BLUE(2583)
Horizon NJ
Navinet
www.navinet.com
General/Medicare Advantage/SHBP
(800) 624-1110
FEP
(800) 624-5078
Pfizer
(888) 340-5001
Merck
(877) 663-7258
Labor Funds
(888) 456-7910
Slide13Start of Care
Missed starts of care (MSOC
) can
create dissatisfaction, put patients at risk, and can result in readmissions or delayed discharges
Slide14Start of Care (SOC)
A start of care (SOC) date is set by the ordering physician or discharge
planner.
When accepting a case, consider
your ability
to service the patient and meet their needs.
Notify CareCentrix immediately
if
you must delay the start of care or if you are unable
to continue the
case. Refer to page 26 of
the
Provider Manual
for
start of care delays and referral turn backs.
Changes to the patient’s start of care date
must be approved by
the referring physician. You are required to obtain the orders needed to
prevent a delay
in
the start
of care.
For most items and services, the
CareCentrix Service Validation team will
confirm that the care was provided by the SOC via an outbound phone call to the patient.
Provider
performance is measured on various metrics,
including compliance with SOC date and number of missed starts of care.
Slide15Claim Submission and Payment
Clean
claims must be submitted electronically within
60 days
of the date of service (or, as determined by
applicable law)
and must include the CareCentrix
HCPCS
Code &
Modifiers.
Slide16CLAIM SUBMISSION AND PAYMENT
The Claim Submission Process
The Referral Process
(Getting an Authorization)
Visit the Patient
Slide17The claims submission process
Timely filing
60
days
from time service was rendered (or, as determined by
applicable law or plan mandate)
Providers must submit a clean claim within timely filing period,
n
on clean claims submitted within the timely filing period therefore reject
Substitution of Services
Example: If a provider is granted auth for RN visits, an LPN may be used but providers must bill CCX for LPN not RN. The same
applies for the substitution of PTAs
and OTAs
.
*Important
N
ote
Horizon does not allow for PTA or OTA/COTA. Providers
should always bill the services that were
rendered at the appropriate contracted rate.
Providers
may NOT disclose contracted pricing
Providers do not
collect copays/deductibles from
patients.
CareCentrix will collect the copays and deductibles from the patient.
Click
here
to review the provider manual for clean claim submission requirements.
Slide18The Claim Submission Process
CareCentrix offers a billing crosswalk to identify the CareCentrix internal service code to the HCPC code on the provider’s fee schedule. Current billing cross walk can be found at www.carecentrixportal.comTo use the billing crosswalk, locate the CareCentrix service code and UOM (unit of measure) as shown on your Service Authorization Form (SAF) and match to the above crosswalk to determine the correct HCPCS/Modifier combination you must bill.Claims must include the following:Description of the serviceICD9 and/or ICD-10 Code(beginning on 10/1/2015)Taxonomy number (provider’s and referring physician)NPI numberIf billed with HCPCS and modifiers not consistent with the HCPCS and modifiers on the SAF the claim could be denied
Refer to the Provider Manual for a complete list of clean claim submission requirements.
Slide19If your claim was rejected (You received a rejection letter from CareCentrix)
Correct
the claim for the issue(s) identified and resubmit the claim as an Original Claim via an 837 submission or on a CMS1500/UB04 form. (Do not submit the claim as a Corrected Claim, Claim Reconsideration, or Claim Appeal)Please resubmit the claim to CareCentrix as quickly as possible; claims must still be received within 60 days* from the date of service (or as indicated by State law) to be timely.
Rejected claim
Slide20If your claim was denied(You received and explanation of payment (EOP) from CareCentrix)
And you
agree with the denial reason given by CareCentrix, correct the claim for the issue(s) identified and resubmit the claim as a Corrected Claim. (Do not submit the claim as a Claim Reconsideration or Claim Appeal).“Corrected” marking must be clearly visible in large font and cannot obstruct any data elements on claim Please resubmit the claim timely to expedite the payment process. Claims can be submitted electronically or sent to: PO Box 7779 London, KY 40742
Denied claim
Slide21If your claim was denied(You received and explanation of payment (EOP) from CareCentrix)
And you disagree with the denial reason given by CareCentrix, complete
the Claim Reconsideration Form (CLICK HERE FOR CLAIM RECONSIDERATION FORM) and mail it to the address on the form. (Do not make changes to the original claim. Claim Reconsideration Forms should only be used if you believe your initial claim was 100% accurate)Claim Reconsideration Forms must be received within 45 days of the date of an EOP, or as required by law, if longer.
Denied claim
Slide22If your Claim Reconsideration request was denied you may submit a claim appeal
Complete the
Claim Appeal Form (CLICK HERE FOR CLAIM APPEAL FORM) and mail it to the address on the form. (Do not make any changes to the original claim. Claim Appeals should only be used if you have received an EOP from a Claim Reconsideration)Claim Appeal Forms must be received within 30 days of the date of a Claim Reconsideration EOPNote: Corrected claims, reconsiderations, and appeals can be submitted electronically for claims processed through our Claims 2.0 platform.
Claim appeals
Slide23What is claims 2.0?
We listened to your feedback! The 2.0 platform includes several new features that came from provider requests.These enhancements include:More detailed claim status updates via the Provider PortalImproved technology that checks your claim for completeness Claims reconciliation tools that provide you with detailed claims reporting informationThe Claims 2.0 training can be found under the Education Center on the CareCentrix Provider Portal : www.carecentrixportal.com/ProviderPortal/homePage.do
Slide24Contact us
Know where to go
Slide25Contact us
Register for Portal Access & EDI Claims
Submission
Register for Portal Access
www.CareCentrixPortal.com
Register for EDI Claims Submission
Support
Portal Support
Portalinfo@CareCentrix.com
EDI Support
EDISupport@CareCentrix.com
Authorizations
Initial Authorization Requests
www.CareCentrixPortal.com
Re-Authorization Requests
Add-on Requests
Authorization Status
Edit an Authorization
Authorization Contact Numbers
Aetna FL: 888-999-9641
BCBS FL:
877-561-9910 –Inquiries -
FLBlueAuthInquiry@carecentrix.com
All Other Plans: 877-466-0164
Claims
Claims Status
www.CareCentrixPortal.com
Claims Questions
Phone: 877-725-6525
Appeal Status
Claims Support Team
Contract/Network Management
Provider Manual
www.CareCentrixPortal.com
Patient Financial Responsibility
Patient Services Team
Phone:
800-808-1902
Slide26Things
to
remember
Slide27Things to remember
Provider Performance Metrics
100% portal compliance
100% EDI compliance
Claim denial rate of 7% or less
No quality of care concerns
Case acceptance rate, no turn-backs
Monitor these to avoid becoming non-compliant.
Providers may NOT use the CareCentrix name in any media without prior approval.
Timely filing
60
days from time service was rendered (or, as determined by State law)
Slide28THANK
YOU