Presentation on theme: "HFMA Insurance Conference “With you when it matters…” Coventry Health Care of Missouri, Inc. Provider Relations March 25, 2014."— Presentation transcript:
HFMA Insurance Conference “With you when it matters…” Coventry Health Care of Missouri, Inc. Provider Relations March 25, 2014
Living the Aetna Way will allow us to achieve our strategic goals “With you when it matters…” We put the people we serve at the center of everything we do
Health Care Reform Health Care Reform adds new information, requirements and details to an already complex business. Health Care Reform has affected every aspect of our organization. Several changes and processes have been implemented to align Coventry with current and future policies, such as: - Internal education - New benefit plans built - Communication developed for physicians, member and employer groups - Correspondence (letters and EOB/ Remittance Advices) - Finance, Actuary, and Underwriting changes have been made to address MLR requirements More information on Health Care Reform is available via the Health Care Reform link on “With you when it matters…”
What is an Exchange? The Exchange is an online market place where individual consumers and small group employers can purchase insurance coverage. Exchanges may be offered at the State or the Federal level Illinois has chosen a state partnership exchange Missouri has opted for Federal Exchange On the exchange, consumers are able to: View Subsidy eligibility Review and compare all the plans available on the exchange Enroll in health coverage “With you when it matters…”
Coventry’s Marketplace/Exchange Overview “With you when it matters…” Coventry Healthcare offers Individual coverage for the Illinois and Missouri exchanges for 2014 Three options for the marketplace: 1.Federal (FFM) – Federally-facilitated exchange where the state has no role in operation or management – Missouri 2.State Partnership (SPM) – Federal government builds infrastructure but states retain authority (network adequacy, licensure, etc.) – Illinois 3.State Base – The states create, operationalize, and maintain their own exchange All other group sales remain the same for Coventry Healthcare’s off- exchange markets
Coventry’s Marketplace/Exchange Products Missouri “With you when it matters…” 1.PPO – Eastern Missouri and Southwestern Illinois 2. Carelink from Coventry is a narrow network PPO product Missouri and Illinois counties Hospital affiliated providers: Mercy, SSM, St. Elizabeth’s, St. Anthony’s-Alton, HSHS
ICD-10 CM: 2014 Updates “With you when it matters…” Our design, development, testing and deployment are aligned for the October 1, 2014 ICD-10 compliance date. We have completed all analyses, including gap and system impact inventory, and system remediation. We have engaged the impacted areas of our company in our business assessments. We will be ready for the move from the ICD-9 codes to ICD-10 codes. The 10/1/2014 compliance date may seem far off, but the complexity of conversion requires immediate action to address the business and clinical issues associated with the transition. The ICD-10 conversion will affect nearly all provider systems and many processes. The largest impacts will likely be in clinical and financial documentation, billing and coding. It is critical not to delay planning and preparation. It is important that providers contact their billing or software vendor to understand their plans for conversion and testing.
ICD-10 CM: 2014 Updates “With you when it matters…” Coventry is a member of HIMSS and WEDI, and actively participates on many industry workgroups and task forces related to IDC-10. We did participate in the pilot; however at this time, we are not participating in the program. These industry resources will help with your planning and preparation: Centers for Medicare & Medicaid Services (CMS) Workgroup for Electronic Data Interchange (WEDI) Need to contact us? Coventry has two dedicated mailboxes for ICD-10 questions, information on ICD-10 testing, or surveys that need completed. You will receive your response within two business days. Phone:
“With you when it matters…” NIA Outpatient Imaging Program Utilized for advanced outpatient imaging management services Applies to Coventry Commercial HMO/POS, Select and PPO Members Applies to Medicare products: Advantra, Advantra PPO, and Gold Advantage Members are excluded from the Outpatient Imaging Program if they access care through: ASO, Carelink, CMR, Coventry National, First Health Network, and TotalCare
“With you when it matters…” NIA, cont. Ordering physician responsible for obtaining prior authorization for advanced radiology services Rendering facility is responsible for ensuring the prior authorization has been obtained Prior Authorization’s obtained through NIA’s website, or by phone, , option 6 Procedures requiring prior authorization: CT/CTA MRI/MRA PET Scans Nuclear Stress (MPI) CCTA Echo Stress Nuclear Cardiology Diagnostic Nuclear Medicine
“With you when it matters…” New Century Health Oncology Pathway Solution Drug Program New Century Health (“NCH”) manages the Oncology Pathway Solutions program, effective March 1, The Oncology Pathway Solutions program uses clinical guidelines based on nationally recognized, evidence- based criteria for determining medical necessity in cancer care. It streamlines the complex administrative process associated with chemotherapy pre- authorizations.
“With you when it matters…” New Century Health Prior Authorization Chemotherapeutic drugs and supporting agents will require pre-authorization prior to being administered in a physician’s office, elective inpatient, outpatient or ambulatory setting. Applies to all Coventry Medicare and Commercial members ages 18 and older. The requesting physician must complete the NCH Chemotherapy Request Form (CTR). Applies to services for Coventry Members with coverage under both fully insured and Medicare products. It does not include self-funded or Carelink products.
“With you when it matters…” New Century Health Key Features Provider portal available 24/7/365 offering: Real-time authorizations when selecting treatment care pathways Reduced documentation requirements Easily view real-time status of authorization requests Eligibility verification Fax authorization requests Supportive telephonic authorization Quick turnaround time on requests submitted via fax or phone Peer-to-peer consultation's by medical oncologists NCH is a National Comprehensive Cancer Network licensee of the Drugs and Biologics Compendia and utilizes nationally recognized evidence-based treatment guidelines
“With you when it matters…” ICORE Drug Program ICORE ensures quality care and affordability for our members. The company leads prior authorization review for drugs ordered by health care professionals in a physician office (POS 11) and outpatient facility (POS 22). The program supports a “buy and bill” reimbursement model to encourage the use of medically indicated, lower-cost options that are equal in quality and clinical outcomes. With this commitment in mind, we implemented changes to those drugs that are included in the review process with ICORE. Please see updated drug list effective March 1, 2014.
“With you when it matters…” ICORE Drugs Requiring Prior Authorization Actemra (J3262) Acthar (J0800) Botox (J0585) Euflexxa (J7323) Gel-One (J7326) Myobloc (J0587) Nplate (J2796) Orthovisc (J7324) Remicade (J1745) Supartz/Hyalgan (J7321) Synvisc/SynviscOne (J7325) Tysabri (J2323) Plans Included: All Commercial HMO, POS, PPO, Select and Medicare Advantage products Plans Excluded: Self-funded ASO/CMR Groups and Carelink/Total Care products ICORE: or Provider Hotline:
“With you when it matters…” Triad Healthcare Inc. – Quality Assurance for Pain Management Procedures Triad Healthcare, (“Triad”) a leading musculoskeletal health services company focuses on the health care needs of patients with painful spine and joint conditions. Triad administers Coventry’s quality assurance program for pain management procedures. Triad’s mission is to improve the quality of care delivered to patients with complaints of musculoskeletal pain. The new prior authorization process applies to services for CHC members with coverage under both fully insured and Medicare products. It does not include self- funded products. Triad’s medical policies, a list of CPT codes designated as pain management services requiring prior authorization and managed by Triad, along with authorization forms, are available by contacting Triad or on the Providers section of our website at chcmissouri.com. Prior authorization requests and your patient’s medical records must be submitted using any of the following methods: * Web: triadhealthcare.com/cvty * Fax: * Phone: Triad’s evidence based medical policy is available to Coventry Health Care providers at:
“With you when it matters…” Advantra’s Dual Eligible - Special Needs Plan (DE- SNP) CHC Missouri plan covers Dual Eligible (DE). DE’s are individuals who are entitled to Medicare and some level of assistance from Missouri Medicaid (MO HealthNet). Advantra DE-SNP is a Medicare replacement plan Advantra DE-SNP is NOT a Medicaid replacement plan Members must see providers who participate in both Advantra and MO HealthNet Networks to optimize their benefits Members who select us must carry and use both plans’ ID cards, Advantra DE-SNP card and MO HealthNet card Advantra DE-SNP, like Medicare, always pays first; MO HealthNet benefits wrap around our plan
“With you when it matters…” Lab Services/Providers In-Office Lab Policy Lab specimens for CHC of Missouri’s Commercial and Medicare Advantage should be sent to Quest Diagnostics in the St. Louis Metro area, or one of the approved outpatient labs for those outside of the metro area. The metro area is defined as: –In Missouri: Franklin, Jefferson, Lincoln, St. Charles, St. Francis, St. Genevieve, St. Louis City, St. Louis, Warren, Washington counties –In Illinois: Madison, Monroe, St. Clair counties Coventry Health Care reimburses in-network providers for specific lab procedures when they are preformed in office on a STAT basis only. Please refer to our provider manual for a detailed list of these labs. The provider manual is available under the provider section on
“With you when it matters…” Valuable Information Available Online at Comprehensive provider search Drug formulary (prescription coverage) Prior authorization information Medical injectable list Authorization form Prior authorization list CPT codes requiring prior authorization Network participation details Credentialing policies, criteria and provider rights related to credentialing Click “Providers” on the home page for immediate access to these valuable resources:
“With you when it matters…” Visit the “Provider Document Library” to access: Provider Manual – Includes information about claims processing, member rights and responsibilities, and other helpful resources. Complex Case Management – Informs providers about our complex case management program and how to refer patients to the program. Network News – Holds current and past issues of Network Connection, our provider newsletter. Quality Improvement Policies and Procedures – Notes quality improvement annual evaluations and medical record documentation standards. Utilization Management Policies – Displays summaries of our evaluation of new medical technology, utilization management criteria and financial incentives policy. Wellness – Highlights preventive health guidelines, clinical practice guidelines and disease management programs.
“With you when it matters…” Services & Information Available: Claim Adjustment Requests Remittance Advices Eligibility/Benefit Inquiry Resource Library Secure Messaging Member ID cards Enhanced News Authorization Request/Inquiry/Update/Appeal
“With you when it matters…” Select a Health Plan: Coventry Health Care of Missouri Carpenters’ Health and Welfare Trust Fund Coventry of Missouri (MODOT) University of Missouri Coventry Health Care of Illinois Coventry Health Care of Kansas and Preferred Health System Coventry Health Care National Network CoventryOne National Mail Handlers Benefit Plan Rural Carrier Benefit Plan
“With you when it matters…” Workers Comp on DirectProvider.com Workers Comp link added to provide access to Coventry’s Workers Comp (WC) business information Includes access to WC Bills, Pricing Sheets, Explanations of Review/ EOR’s CMS 1500 & UB-04 Bill Images If you are currently registered with DirectProvider.com for Coventry Health Plans access, just click the WORKERS’ COMP link in the left navigation bar on the home page and follow the instructions
Here are a few tips on navigating the authorization submission process: “With you when it matters…” Authorizations on DirectProvider.com Made Easy Submit the same type of clinical information that is needed when requesting the authorization via phone. Either document the information in the comment section of the authorization or attach clinical information to the authorization. Without clinical information, the authorization may be denied for lack of information. It is recommended to check member eligibility and current authorizations prior to entering a new authorization. Online help is available on DirectProvider.com for authorization as well as other key functions. If you have any questions or require technical support Coventry’s Net Support Team is available 9am-5pm Monday through Friday at (866)
“With you when it matters…” 2014 DirectProvider.com Training Sessions Authorizations & Referrals – April 4, 9, 23 at 9 a.m. Claims/Remittance Advices – April 8, 22 at 9 a.m. Workers’ Compensation – April 11 at 9 a.m. First Health/TPA Bills – April 4, 11 at 10 a.m. PCP HEDIS Reports – April 3 at 9 a.m. To register your provider office staff for DirectProvider.com training sessions please send a with the date you wish to attend to: