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AAHAM Third Party Payer Meeting November 14, 2014.

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Presentation on theme: "AAHAM Third Party Payer Meeting November 14, 2014."— Presentation transcript:

1 AAHAM Third Party Payer Meeting November 14, 2014

2 Agenda Martin’s Point Health Care Generations Advantage US Family Health Plan 2014 Payment Updates Pre-Authorizations Claims Update Living Healthy Programs Web Resources Additional Updates Customer Service

3 Martin’s Point Health Care Not-for-profit, health care organization with experience in clinical patient care and health plan administration. Nine Health Care Centers in Maine and New Hampshire and two health plans: –Martin’s Point Generations Advantage –Martin’s Point US Family Health Plan

4 Generations Advantage Highest Rated Medicare Advantage Plan in Maine! 30, 817 members Effective 1/1/14 – Generations Advantage Group – PPO Plan – Three Medicare Advantage plans in ME and NH –Prime-ME and NH (HMO-POS) –Select-ME and NH (PPO) –Value-ME only (HMO)

5 Generations Advantage Annual Physical and Eye Exams Covered at $0 Copay Benefit summaries available online at:

6 Martin’s Point US Family Health Plan Unique TRICARE ® Prime option - Consistently earns high ratings for quality and member satisfaction. 43, 719 members January 2014 – Expansion of USFHP PCP Network in Greater Portland HMO style of benefit with office copay. Benefit summaries online at:

7 National Recognition for Quality and Member Satisfaction

8 PlanStates2013 Status2014 Status Generations Advantage Prime HMO/POS ME, NHExcellent Generations Advantage Select PPO ME, NHAccreditedExcellent US Family Health Plan HMO MEExcellent US Family Health Plan HMO MA, NH, NY, PA, VT Commendable

9 Welcome, New Health Plan Medical Director: Ines Vigil MD, MPH, MBA

10 PCP Payment Model PCP Payment Model Reports were sent in October Be sure to check your progress toward 2014 goals to maximize payments 2015 updates to the model will be announced in December

11 Payment Updates Generations Advantage allowances will be updated on 1/1/15 consistent with Medicare –Payment rates continue to reflect 2% sequestration reduction US Family Health Plan allowances will be updated on 4/1/15

12 Payment Updates New claim editing software in January Further alignment with original Medicare claim processing rules More consistency and efficiency in our billing processes and yours Local Coverage Determination (LCD) rules will be applied based on state specific rules. (ME and NH) Please visit for more details.

13 Pre-Authorization Requirements Pre-authorization requirements available online at: Be sure to review our latest pre-authorization protocols, summary documents and CPT/HCPCs code-level search tools for each plan Requirements are usually updated in July and January each year

14 Claims Update Claim adjustment and void requests may now be submitted electronically /837 transaction(after the original claim has been paid or denied). Exceptions: To process claim adjustments pertaining to COB, EOB, timely filing and medical documentation, we must have a completed Claim Adjustment Request Form (online at and a paper copy of your adjusted claim with the corrected/additional info. When submitting claim adjustments, include all lines from the original claim which are still correct, not just the new or corrected lines. The adjusted claim will replace the original claim in its entirety. All payments on the original claim will be reversed.

15 Claims Update Contact one of our clearinghouse/EDI vendors to request direct delivery of Electronic Remittance Advice (ERA/835) files. Emdeon Business Services: Emdeon Business Services: 1-800-845-6592, Martin’s Point Payor ID: 53275 Office AllyOffice Ally: 1-866-575-4120, Martin’s Point Payor ID: MPHC1 Relay Health:Relay Health: 1-866-735-2963, Martin’s Point Payor ID: MPHC2 We’ll send test 835s to make sure everything is working correctly. Electronic Fund Transfers (EFTs) are also available. Application form online at Technical questions about 835s or EFTs? Please contact:

16 Living Healthy Programs Free for all members. Augments the care provided by our network physicians. Extra help with understanding and managing health conditions Custom education, guidance and resources to help your patients: –Fully understand the conditions that you diagnose –Take the medications you prescribe and follow the treatment plans you recommend

17 Living Healthy Programs May benefit members who: –Have complex, chronic or multiple medical conditions –Have experienced a critical event that has precipitated a need for rehabilitation –Need help navigating the healthcare system –Are in an un-safe home environment –Are struggling with medication or health care costs –Lack family support or transportation

18 Living Healthy Programs Wellness Coaching: to manage weight, reduce cholesterol/blood pressure, start or increase exercise, stop smoking, manage stress and improve nutrition Disease Management: to better understand Heart Failure, CAD, Hypertension, COPD, Diabetes and Asthma Care Management: to manage transitions of care, identify local resources and support groups, maximize plan benefits, manage follow-up care at home To refer a patient, please call 1-866-800-8833

19 Web Resources Please

20 Additional Updates The Point: Please share your email address with us today if you would like to receive the electronic version of our quarterly provider newsletter. ICD-10: We will transition to ICD-10 on October 1, 2015 Tele-health: We are now offering in-home, tele-monitoring services for high-risk heart failure patients. –Data automatically transmitted to and reviewed by RNs. –If there are any measurements outside the predetermined parameters, provider will receive a detailed report via fax. –Questions? Call 1-855-335-8951, weekdays, 9am and 5:30pm

21 Additional Updates E-Rx: Martin’s Point pharmacies now accept electronic prescriptions! Search for us under the following names from within your Electronic Medical Records (EMR) system: –“Martins Pt. Mail Order Pharmacy Maine” (for US Family Health Plan members only) –“Martins Pt. Portland Clinic Maine Pharmacy” –“Martins Pt. Portsmouth Clinic New Hampshire Pharmacy” Provider Satisfaction Survey: We will be sending you a provider satisfaction survey in January. Your responses are critically important to our continued efforts to make it easier for you to do business with us. Thank you in advance for taking a few minutes to complete and return this survey!

22 Customer Service Provider Inquiry: –1-888-732-7364 Network Management: –1-800-348-9804 Health Management: –1-866-800-8833 (to refer a member to one of our Living Healthy Programs) –1-888-339-7982 (for pre-authorization requests) Web:

23 Thank you!

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