Presentation on theme: "MN AAHAM Conference March 12, 2015"— Presentation transcript:
1 MN AAHAM Conference March 12, 2015 Elizabeth NelsonCheryl Wilson
2 Contents HealthPartners specific question Provider inquires Additional informationQ & A
3 Provider InquiriesHealthPartners (HP) Question:Q:Is there a specific way HealthPartners would like to handle credits where they need to recoup or we need to refund HealthPartners?
4 HealthPartners Credit/Recoup Question HealthPartners preference is to use a Payment Adjustment Form (PAF) which can be submitted by the provider, in which case HP will adjust the claim and recoup monies from current or future payments.This type of recoupment is done electronically through our claims system through a void and replacement and not requiring a manual refund request.However, if this not an option HP will do a manual refund request by sending a letter to the provider requesting that the provider submit a refund check back to the health plan.Further questions direct to Eric Johnson and Pam Huseby
5 Provider Inquiries Q: HealthPartners (HP) Question MN Care Tax is an issue when sending secondary’s. (This came up in thecontext of this discussion; why doesn’t HP have to give us an EOB with lineby line COB that can be sent to patients secondary insurances? BCBS,Humana and Medica do all this all the time and in order for us to get ourSecondary claim paid we have to manipulate the payment to cover eachbilled line. Doesn’t the AUC have regulations for EOB’s)
6 HealthPartners COB Question HealthPartners sends remits with line by line COB detail.HealthPartners Remits are electronic and can be accessed by utilizing HealthPartners Provider portal:Reminder – Providers and billing staff receive remits from the health plan. The members receive explanation of benefits (EOB’s) which do not contain line by line detail.
7 Provider Inquiries Q: A: All Payor Question I have a question for all payers – Do any of the payers want/allow the Medicare condition codes when sending replacement or void claims? Example: DO – Change to service dates, D1 – Change to charges.A:Yes, HP does allow and would like the condition codes to be submitted when applicable.Condition codes D1 –D9 are only valid on “institutional claims”.Reminder: Institutional claims – references hospitals and other institutional medical facilities i.e. inpatient, ASC and residential. These condition codes do not apply to Professional and clinics.Further questions – direct to Faye Ostroot
8 Provider Inquiries Q: A: All Payor Question I would like to ask a question to the Payers who have Medicare Advantage plans. If providers cannot use the Medicare ABN for notifying a patient prior to receiving a service that may not be covered, what is the correct notification to use to a patient with a MAP plan? Is it the patient’s responsibility to know what is covered and what is not covered?A:The Centers for Medicare and Medicaid (CMS) requires notification of non-coverage to Medicare Advantage and Medicare Cost plan members prior to the service(s) being rendered.In accordance with Chapter 4 of the Medicare Managed Care Manual and per language in HealthPartners contract agreements, providers are responsible for determining whether services are covered for HealthPartners Freedom (Cost) and Minnesota Senior Health Options (MSHO) members prior to rendering a service or referring to a non-contracted provider.Effective March 1, 2015, providers are required to follow the process outlined in the HealthPartners Administrative policy, Advance Notice of Non-coverage for Medicare Member (HealthPartners Fast Facts Article: February 2015 Special Edition)Summary Notes: It is not the patient responsibility to know what is covered and not covered. It is the providers responsibility. The process is outlined in HP’s Administrative Program. Please see the specific administration policy.Processes to follow:Contact HP Member ServicesReview HP Medicare coverage policies and any other coverage documentationWhen the item is covered by HP and doesn’t require PA: No further steps are necessary and the service may be provided.When the item or service is never covered by HP and Medicare and is listed as an exclusion in the member’s health documents: Providers must obtain the member’s written consent prior to rendering any non-covered service or item.If still unclear if service or item is covered – please follow the PA for Medicare Products policy found in the HP Admin Manual (there is a link to the policy that we are handing out.
9 Additional Information High Tech Diagnostic Imaging (HTDI) Decision Support (DS)In accordance with the HTDI policy, HealthPartners providers are required to have a DS solution in place.Providers may select the health plan sponsored DS solution – Medicalis, or may “Build Your Own” DS solution.The Diagnostic Imaging Provider Notification Program provides guidance on HTDI services such as CT, MRI, MRA, PET and Nuclear Cardiology as well as providing notification when DS is not required.Accurate communication of information between ordering and rendering providers is essential.By improving the quality of the order, better patient care will be achieved through use of treatments and imaging modalities that are consistent with evidence-based medicine and reduces unnecessary exposure to radiation.HealthPartners recognizes the value of decision support for high tech diagnostic imaging services. In alignment with the Triple AIM, HealthPartners implemented a Diagnostic Imaging Decision Support Program. (February 2007 enhancements to the program were implemented May 2014) The intent of the program is to encourage a collaborative approach to patient care through the ordering provider, ensuring that the right exam at the right time is being appropriately ordered for the patient.
10 Additional Information Epidural Steroid Injection (ESI) Decision Support (DS)Decision Support for Epidural Steroid Injections (ESI) for Low Back PainCurrently HealthPartners manages ESIs through preferred and non-preferred spine injection networks.Through feedback from members and designated Medical Spine Centers, we identified a need to reassess our current approach to this procedureAs a result, HealthPartners will be implementing a decision support tool for low back ESIs with an anticipated launch date of July 1, 2015This will provide a means to assess treatment options that support long-term functional improvement for the patientMore information will be available in the May edition of HealthPartners Fast Facts newsletter
11 Additional Information Health Insurance Exchange Grace Period InformationHealthPartners will begin reporting Health Insurance Exchange Grace Period information in the Eligibility Response (eligibility tool) as of March 26, 2015Please review our Fast Facts news letter, March 2015 edition, article page 1 for further detailsLink to view the: Health Care Eligibility Inquiry and Response ( 270/271) Best PracticeLink to view the: AUC Best Practices to Meet Requirements for Health Insurance Exchange Grace Period Notifications (per 45 CRF (d)(2)271 response (code) identifying an active member receiving the Advanced Premium Tax Credit (APTC) federal subsidy, and is within the Health Insurance Exchange grace period, which is a 3 month grace period before they can be term’d.*allowing APTC enrollees a three month grace period before terminating coverage due to nonpayment of premiums*; *Note: In order for the APTC enrollees to be eligible for the three month grace period, the enrollees must also have previously paid at least one full month's premium during the benefit year.*the Qualified Health Plan issuer (QHP - insurer) must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period, regardless of whether the enrollee subsequently pays the premium for the first month of the grace period or not. The QHP may pend claims for services rendered to the enrollee in the second and third months of the grace period;*the QHP must notify providers that may be affected by the enrollee’s premium payment grace period that an enrollee has lapsed in his or her payment of premiums. The notice may be exchanged via automated electronic processes, and must indicate there is a possibility that the issuer may deny payment of claims incurred during the second and third months of the grace period if the enrollee exhausts the grace period without paying the premiums in full.
12 Additional Information Contact information please visit:Under “Help Center” on the left side of the pageClick on “More HealthPartners contacts” PDFWeb support for the provider portalElectronic Commerce DepartmentMonday - Friday 8:00 – 4:00 CSTorFast Facts NewsletterPlease sign up for the delivery if you are still receiving the postal mailed paper copyPlease be sure to read each edition for updates and change noticesThank you!