Presentation on theme: "Developed by the Florida Agency for Health Care Administration (AHCA)"— Presentation transcript:
1Developed by the Florida Agency for Health Care Administration (AHCA) Provider and Dedicated Provider TrainingStatewide Medicaid Managed Care (SMMC)Managed Medical Assistance (MMA) ProgramDeveloped by the Florida Agency for Health Care Administration(AHCA)
2Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance Program (MMA) The Florida Medicaid program is implementing a new system through which Medicaid enrollees will receive services. This program is called the Statewide Medicaid Managed Care Managed Medical Assistance program.The Managed Medical Assistance program is comprised of several types of managed care plansHealth Maintenance OrganizationsProvider Service NetworksChildren’s Medical Services NetworkMost Medicaid recipients must enroll in the MMA program
3Who is NOT required to participate? The following individuals are NOT required to enroll, although they may enroll if they choose to:Medicaid recipients who have other creditable health care coverage, excluding MedicarePersons eligible for refugee assistanceMedicaid recipients who are residents of a developmental disability centerMedicaid recipients enrolled in the developmental disabilities home and community based services waiver or Medicaid recipients waiting for waiver servicesWho is NOT eligible to participate?The following individuals are NOT eligible to enroll:Women who are eligible only for family planning servicesWomen who are eligible through the breast and cervical cancer services programPersons who are eligible for emergency Medicaid for aliensChildren receiving services in a prescribed pediatric extended care center
6What region am I in? Region Counties 1 Escambia, Okaloosa, Santa Rosa, and Walton2Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and Washington3Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union4Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia5Pasco and Pinellas6Hardee, Highlands, Hillsborough, Manatee, and Polk7Brevard, Orange, Osceola, and Seminole8Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota9Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie10Broward11Miami-Dade and Monroe
7When will recipients be notified and be required to enroll? Approximately 60 days prior to each region’s start date, eligible Medicaid recipients will receive a letter with enrollment information, including information on how to enrollEligible recipients who must enroll will have a minimum of 30 days from the date they receive their welcome letter to choose from the plans available in their region.90 Days to Change PlansAfter joining a plan, recipients will have 90 days to choose a different plan in their regionAfter 90 days, recipients will be locked in and cannot change plans without a state approved good cause reason or until their annual open enrollment.
9What are MMA Specialty Plans? Five companies were selected to provide specialty plans that will serve populations with a distinct diagnosis or chronic condition. These plans are tailored to meet the specific needs of the specialty population.Information on each specialty plan will be available in the choice counseling information provided in each region that the specialty plans are available.What do recipients have to do to choose an MMA plan?Choice counselors are available to assist recipients in selecting a plan that best meets their needs. This assistance will be provided by phone, however in-person visits are also available for recipients by request.Recipients can also enroll at the following website:
10Can I change my MMA plan once I make a selection? Recipients are encouraged to work with a choice counselor to choose the managed care plan that best meets their needs.After joining a plan, the recipient has 90 days to change to another plan offered within their region.After the 90-day deadline, recipients may only change plans for good cause reasons.After the initial 12-month period, recipients may change plans during an open enrollment period.
11Managed Medical Assistance Services Minimum Required Covered Services: Managed Medical Assistance PlansAdvanced registered nurse practitioner servicesMedical supplies, equipment, prostheses and orthosesAmbulatory surgical treatment center servicesMental health servicesBirthing center servicesNursing careChiropractic servicesOptical services and suppliesDental servicesOptometrist servicesEarly periodic screenings diagnosis and treatment services for recipients under age 21Physical, occupational, respiratory, and speech therapyEmergency servicesPhysician services, including physician assistant servicesFamily planning services and supplies (some exceptions)Podiatric servicesHealthy Start Services (some exceptions)Prescription drugsHearing servicesRenal dialysis servicesHome health agency servicesRespiratory equipment and suppliesHospice servicesRural health clinic servicesHospital inpatient servicesSubstance abuse treatment servicesHospital outpatient servicesTransportation to access covered servicesLaboratory and imaging services
13Will my MMA plan continue the services I am receiving now? The new MMA plan is required to authorize and pay for existing services for up to 60 days, OR until the enrollee’s primary care practitioner or behavioral health provider reviews the enrollee’s treatment plan.The SMMC Program does not/is not:The program does not limit medically necessary services.The program is not linked to changes in the Medicare program and does not change Medicare benefits or choicesThe program is not linked to National Health Care Reform, or the Affordable Care Act passed by the U.S. CongressIt does not contain mandates for individuals to purchase insurance.It does not contain mandates for employers to purchase insurance.It does not expand Medicaid coverage or cost the state or federal government any additional money.
16Discontinued Programs Will a recipient’s health plan continue the services recipients are currently receiving?The new MMA plan is required to authorize and pay for existing services for up to 60 days, OR until the enrollee’s primary care practitioner or behavioral health provider reviews the enrollee’s treatment plan.The Managed Care Plan and subcontractor shall reimburse non-participating providers at the rate they received for services rendered to the enrollee immediately prior to the enrollee transitioning for a minimum of thirty (30) days, unless said provider agrees to an alternative rate.Discontinued ProgramsOnce the MMA program is implemented, some programs that were previously part of the Medicaid program will be discontinued.This includes the following programs:MediPassPrepaid Mental Health Program (PMHP)Prepaid Dental Health Plan (PDHP)
17REGIONSService Level Agreement - SLA1234567891011At least XXX percent of required participating specialists, by region are accepting new Medicaid enrollees90%85%No more than XXX percent of enrollee specialty care utilization, by region shall occur with non-participating providers, excluding continuity of care periods. Hospital based specialists are not included in this standard8%10%For all electronically submitted claims for services, the Managed Care Plan agrees to pay the claim or notify the provider or designee that the claim is denied or contested within fifteen (15) calendar days after receipt of a non-nursing facility/non-hospice claim. The Managed Care Plan agrees the notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.15 daysFor all non-electronically submitted claims for services, the Managed Care Plan agrees to pay the claim or notify the provider or designee that the claim is denied or contested within twenty (20) calendar days after receipt of the claim. The Managed Care Plan agrees the notification to the provider of a contested claim shall include an itemized list of additional information or documents necessary to process the claim.20 daysThe Managed Care Plan agrees to pay fifty percent (50%) of all clean claims submitted within seven (7) calendar days.50% in 7 daysThe Managed Care Plan agrees to pay seventy percent (70%) of all clean claims submitted within ten (10) calendar days.70% in 10 daysThe Managed Care Plan agrees to pay ninety percent (90%) of all clean claims submitted within twenty (20) calendar days.90% in 20 days
18How Can I Verify Member Eligibility? A member’s eligibility status can change at anytimeProviders should request and copy the member’s identification card and additional proof of identification, such as a photo ID, and file them in the medical record.Eligibility should be verified at each visit.Eligibility can be verified via the FLMMIS portal. https://home.flmmis.com/homeVerification is based on the data available at the time of the request.
19Transition of CareDuring the first 90 days of enrollment, authorization is not required for certain members with previously approved services by the state or another managed care plan.CAC will continue to be responsible for the costs of continuation of such medically necessary Covered Services:Without any form of prior approval, andWithout regard to whether such services are being provided within or outside the CAC network,Until such time as CAC or the Plan can reasonably transfer the member to a service and/or network provider without impeding service delivery that might be harmful to the member’s health.Notification to the Plan or CAC is necessary to properly document these services and determine any necessary follow-up care.When relinquishing members, the Plan will cooperate with the receiving health plan regarding the course of on-going care with a specialist or other provider
20Abuse, Neglect and Exploitation Providers are responsible for the screening and identification of children and vulnerable adults who are abused, neglected or exploited. Providers are also required to report the identification of members who fall into those categories.Suspected cases of abuse, neglect and/or exploitation must be reported to the State’s Adult Protective Services Unit.Adult Protective Services (APS) are services designed to protect elders and vulnerable adults from abuse, neglect or exploitationThe Department of Elder Affairs (DOEA) and the Florida Department of Children and Families (DCF) have defined processes for ensuring victims of abuse, neglect or exploitation in need of home and community-based services are referred to the appropriate resources, tracked and served in a timely manner.To report suspected abuse, neglect or exploitation of children or vulnerable adults, providers should call the Florida Abuse Hotline at ABUSE ( ) (TDD ). If you see a child or vulnerable adult in immediate danger, call 911. this toll free number is available 24 hours a day.
21Medicaid Member Rights FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIESFlorida Law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of the patients. All providers are required to post this summary in their offices. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows:A patient has the right to be treated with courtesy and respect, withappreciation of his individual dignity, and with protection of his need for privacy.A patient has the right to a prompt and reasonable response to questions and requests.A patient has the right to know who is providing medical services and who isresponsible for his care.A patient has the right to know what patient support services are available, including whether an interpreter is available if he does not speak English.A patient has the right to know what rules and regulations apply to his conduct.A patient has the right to be given by his health care provider, information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis.
22Medicaid Member Rights - continued A patient has the right to refuse any treatment, except as otherwise provided by law.A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his care.A patient who is eligible for Medicare has the right to know upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and , upon request, to have the charges explained.A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap or source of payment.A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.A patient has the right to know if medical treatment is for purposes of experimental research and to give his consent or refusal to participate in such experimental research.
23Medicaid Member Rights - continued A patient has the right to confidential handling of medical records and, except when required by law, patients are given the opportunity to approve or refuse their release.A patient has the right to express grievances regarding any violation of his rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him and to the appropriate state licensing agency.A patient is responsible for providing to his health care provider to the best of his knowledge , accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters related to his health.A patient is responsible for reporting unexpected changes in his condition to his health care provider.A patient is responsible for reporting to his health care provider whether he comprehends a contemplated course of action and what is expected of him.A patient is responsible for following the treatment plan recommended by his health care provider.A patient is responsible for keeping appointments and when he is unable to do so for any reason, for notifying the health care provider or health care facility.A patient is responsible for his actions if he refuses treatment or does not follow the health care provider’s instructions.A patient is responsible for assuring that the financial obligations of his health care are fulfilled as promptly as possible.
24Quality Improvement Program Quality Improvement (QI) Program activities include, but are not limited to:Monitoring clinical indicators and outcomesMonitoring appropriateness of careQuality studiesMedical records auditsProviders are contractually responsible for participating in QI projects and medical record review activities
25Medical RecordsMember medical records must be timely, legible, current, detailed and organized to permit effective and confidential patient care and quality review.Complete medical records include medical charts, prescription files, hospital records, provider specialist reports, consultant and other health care professionals’ findings, appointment records, and other documentation sufficient to disclose the quantity, quality, appropriateness, and timeliness of services provided under the contract.The medical record shall be signed and dated by the provider of service.Confidentiality of member information must be maintained at all times. Records are to be stored securely with access granted to authorized personnel only.Access to records should be granted to CAC or the Plan, or its representatives without a fee as required in the Practitioner Agreement.Information from the medical records reviews may be used in the re- credentialing process as well as quality activities.
26Health Information Exchange Sponsor Health Plans are dedicated to improving the health and quality of life of our members and actively support the statewide implementation of the Florida Health Information Exchange (HIE) The HIE means the secure electronic information infrastructure created by the State of Florida for sharing health information among health care organizations and offers health care providers the functionality to support meaningful use and a high level of patient-centered care. The HIE is a secure, interoperable network in which participating providers with certified electronic health record (EHR) technology can locate and share needed patient information and send Direct Secure Messages (DSM) with each other which results in improved coordination of care among health care practitioners. Please visit https://www.florida-hie.net to obtain more information on this program and guidance on how you can make the HIE connection.
27Utilization Management (UM) Utilization Management (UM) program includes review processes such as:NotificationsPrior authorizationsConcurrent review and/or retrospective reviewPrior AuthorizationPrior authorization is not typically required for chiropractic services.Prior authorization for medical necessity review is required when the plan visit limits are reached.
28Medical NecessityTo be medically necessary or a medical necessity, a covered benefit shall meet the following conditions:Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;Be consistent with generally accepted professional medical standards as determined by the program and not experimental or investigational;Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; andBe furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.In accordance with 42 CFR , each medically necessary service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
29AuthorizationsStandard: The Plan will provide a service authorization decision as expeditiously as the member’s health condition requires and within state-established timeframe which will not exceed 7 calendar days. The Plan will fax an authorization response to the provider fax number(s) included on the authorization request form. Expedited: In the event the provider indicates, or CAC determines, that following the standard time frame could seriously jeopardize the member’s life or health, CAC will make an expedited authorization determination for an additional 48 hours of the request. Requests for expedited decisions for prior authorization should be requested by telephone, not fax. Providers may file a verbal request for an expedited decision. Urgent Concurrent: An authorization decision for services that are ongoing at the time of the request, and that are considered to be urgent in nature, will be made by the end of the following calendar day of receipt of the request
30Authorizations - continued Emergency/Urgent Care and Post Stabilization Services: Emergency services are not subjected to prior authorization requirements and are available to members 24 hours a day, seven days a week. Urgent care services should be provided within one day. Service Authorization Decisions:
31National Provider Identifier (NPI) & Medicaid ID Validation Per MMA guidelines, the front-end claims verification process is now modeled after AHCA’s encounter validation process.When a claim or encounter is submitted to the Plan, the billing and/or rendering NPI(s) will be validated against AHCAs Provider Master List (PML)If any of the NPI(s) within a given claim are not recognized on the PML, the claim will reject and payment cannot be processed for the services rendered.This new edit will be fully disclosed to each provider at least 60 days prior to deployment of the new validation process.Training will also be offered to provide as much support as possible during this transitionThese edits are necessary to ensure that the provider(s) submitting claims data, are not only eligible to care for our members, but also possess an active Florida Medicaid ID.A simple search by both NPI and Name can be performed to see if a valid and active record appears on the AHCA’s PMLIf after searching the PML by both NPI and Name, it is determined that the provider does not have a Medicaid ID, the Plan can obtain one on their behalf.These Medicaid ID(s) are not fully enrolled (a/k/a Fee for Service or FFS)When applicable, they are subject to the required Level 2 background screenings.If the provider’s information is incorrect on the PML, and the record is active, providers may correct or update their information.
32Provider Registration – Common Errors AHCA required key data elements to register for a Medicaid ID.Common errors include:Individual Providers: Individual providers must be registered using:Individual or Type 1 NPI;License number; and, ‘Social Security Number (Tax IDs for individuals are not permittedGroup Providers: If a group needs to be registered, or a provider owns agroup practice, they must be registered using:Group or Type 2 NPI;Tax ID for the group;License number (if applicable); and,CLIA (if applicable).
33Remediating Records on the PML Providers should contact the following to resolve issues with records:NPI is not on PML:Provider Relations RepresentativeIf provider does not wish to become fully –enrolled (FFS) with AHCAAHCA, if provider wishes to become fully-enrolled (FFS) with AHCAhttps://portal.flmmis.com/FLPublic/Provider_Enrollment/tabld/50/Default.aspxInaccurate FFS Provider Records:Log in to the FLNNIS Provider Portal – or,Call AHCA’s Provider Enrollment at Option 4.
34Claims OverviewClaims may be submitted in one of the following formats:Electronic Claims Submission (EDI)Paper – CMS 1500 Form (02/12)https://portal.flmmis.com/FLPublic/Provider_Enrollment/tabld/50/Default.aspxAll par providers must submit claims (initial, corrected, and voided) according to the provisions in the practitioner agreement.For dual eligible members, providers shall accept CAC or the Plan payment as payment in full.Prior to submitting a claim, providers must identify whether another payer has primary responsibility for payment of a claim.To prevent delays of processing always include the other carriers explanation of benefits.IMPORTANT: Plan members cannot be billed for services denied due to untimely filing submission.
35Claims Overview: Member Billing Guidelines Plan members cannot be billed for:Hold Harmless Dual Eligible MembersDual eligible members whose Medicare Part A and B members expenses are identified and paid for at the amount provided by Florida Medicaid, shall not be billed for such Medicare Part A and B members expenses; regardless of whether the amount a provider receives is less than the allowed Medicare amount or provider charges are reduced due to limitations on additional reimbursement provided by Florida Medicaid.Missed AppointmentsProviders shall not charge Plan members for missed appointments.
36Claims Submission Requirements Paper and electronic claims should include all necessary, completed, correct and compliant data including:Current CPT and ICD-9 (or its successor) codesTax IDNPI number for Billing, Rendering and/or Attending providersAll NPIs must be registered with AHCA for Medicaid reimbursementProvider and/or practice name(s) that match those on the W-9 or Group Roster initially submitted to CACCorrect taxonomy codeMust be distinct and consistent with provider record on ACHA’s Master Provider ListCAC encourages providers to submit claims electronically via Electronic Data Interchange (EDI) or Direct Data Entry (DDE). Both are less costly than paper.All claims and encounter transactions are validated for transaction integrity based on the Strategic National Implementation Process (SNIP) guidelinesFor more information on claims submission requirements and timeframes, refer to the Provider Manual or the Member Plan.
37Encounter/Claims Changes for MMA The Statewide FL MMA Program introduces stricter state Service Level Agreements (SLA), which focus on:Timeliness of SubmissionCompletenessAccuracy of Encounters SubmittedAHCA may impose financial sanctions for non-compliance with the following:Health Plans must maintain the following:Complete – submit 100% of covered servicesAccurate – 95% of encounter lines must pass editsHealth Plan must submit encounter(s) within 7 days of successful processing.As a result, CAC and the Plan must enforce stronger Front End edits on the Pre- adjudication as well as on the initial steps in the life of a claim/encounter.Soft-edit warnings will begin the end of [ Month, Year]Hard- edit rejections will start [Month, Year]
38Appeals When submitting an appeal: Providers have the right to file an appeal regarding provider payment or contractual issues.Providers may act on behalf of the member with the member’s written consent.CAC/ClaimXpress will review the case for medical necessity and conformity to the Plan’s guidelines.Appeals may be denied if:Appeal was not filed within the applicable timeframe, orLacks necessary documentationWhen submitting an appeal:Supply specific, pertinent documentation that supports the appeal.Include all medical records that apply to the serviceSubmit the appeal and accompanying documentation to the address on the Quick Reference Guide.Upon review of the appeal, the Plan will either reverse or affirm the original decision and notify the provider.
39Appeals - continued Florida Timeframes For a Provider Appeal: Providers have ninety (90) calendar days from the original UM decision or claim denial to file a provider appeal.The Plan has sixty (60) calendar days to review the case for medical necessity and conformity to Plan guidelinesProvider must send supporting documentation which must be received within sixty (60) calendar days of the denial to re-open the case.If all the relevant information is received, the Plan will make a determination within sixty (60) calendar days
40GrievancesProviders have the right to file a written complaint for issues that are non- claims related within established timeframes.The Plan will provide written resolution to the provider within established timeframes. Extensions may be requested by the Plan and/or the provider.Providers may act on behalf of the member with the member’s written consent.In the event a member is dissatisfied with the grievance decision reached by the Plan, the member, or the provider acting on behalf of the member, may request to Medicaid Fair Hearing (MFH) *does not apply to Pediatric plans.For more information on provider appeals and grievances, including submission and determination timeframes, and how to submit, refer to the Provider Manual and the Quick Reference Guide.
41Grievances – continued Current Grievance TimeframesProviders must file a complaint for issues that are non-claims related not later than forty-five (45) calendar days from the date the provider becomes aware of the issue generating the complaint.A verbal or written notice will be sent to the provider filing the grievance within ten (10) business days acknowledging receipt of the complaint and the expected date of resolution.The Plan will provide written resolution to the provider within forty-five (45) calendar days from the date the complaint is received by the Plan.Grievance Timeframes for MMAProviders must file a complaint for issues that are non-claims related no later than forty-five (45) calendar days from the date the provider becomes aware of the issue generating the complaint.A verbal or written notice will be sent to the provider filing the grievance within three (3) business days acknowledging receipt of the complaint and the expected date of resolution.The Plan will provide written resolution to the provider within ninety (90) calendar days from the date the complaint is received by the Plan.
45Developed by the Florida Agency for Health Care Administration (AHCA) Congratulations!You have completed this training regarding theStatewide Medicaid Managed Care (SMMC)Managed Medical Assistance (MMA) ProgramDeveloped by the Florida Agency for Health Care Administration(AHCA)