| 2 Learning Objectives Today you will learn: - Who CareCentrix is and how to work with us - Referral Process Managed vs non-managed plans Understanding the Service Authorization Form (SAF) - Provider Portal How to submit initial authorizations, reauthorizations and add on services How to check authorization status How to check claim status - Billing & Claims Claim submission Claims Reconsideration & Appeals - Contact Information and Feedback
| 3 Physicians & Providers Claims Billing Home Health DME/POS Eligibility, Benefits & Authorization Medical Necessity Review Coordination of Care / Staffing Infusion Medical Economics Hospital Discharge Planners Case Managers Home Care Benefits Management Process – “The Platform” Consolidated Claims Reporting & Analysis Workflow Healthplan Single Point-of-Contact to Coordinate Home- Based Services Referral Management Network Management Claims & Billing Program Components 1 2 3 4
| 4 Making a Referral: Service Specific Tips THH – Home HealthDME/O&PInfusion Patient Homebound?N/A Initial Auth Mandatory?** Re-authorizationPlan Dependent Start of Care (SOC)If changed, contact CCX. Changes must be approved by referring physician OtherLab tests must be taken to the lab specified by the patient’s plan Oxygen Liter flow O 2 saturation w/ date Provide height, weight, allergies, type of venous access and date/time of next dose Routine supplies are included in the cost of visit CPAP Sleep study or letter of medical necessity MD order required for upgraded unit Infusion providers must accept case “full-service” meaning drug, skilled nursing and supplies (per diem) Notify CCX immediately of additional supply needs -Authorization for additional supplies can be obtained through CCX General Auth Guidelines Referral Process ** Except for Magnolia Health Plan: DME items < $500 require no authorization
Making a Referral: “Managed” vs “Non-Managed” Plans Managed (PHS+)Non-Managed (PHS) Service Auth Form (SAF)Indicates # of units authorized CCX will issue a “footprint” authorization; SAF will indicate “0” visits and the same “Start Date” and “Stop Date” Re-authorization & Add-on Services Submit to CCX via portalNot Required -The auth number assigned during the initial referral process will be used Eligibility & BenefitsCCX checks initial and ongoing Provider Responsible -Health Plan’s phone number for verifying eligibility and benefits will be included on the SAF OtherProvider is responsible for verifying insurance plan’s authorization requirements Referral Process
| 6 Managed Authorization From HCPC/Modifier combination that must be used on claim All paper claims must be sent to CareCentrix East Hartford CT but EDI is preferred! Date of service must fall between above dates If additional visits are needed provider must submit reauthorization request via online portal. Servicing branch Example and Definition: Managed CareCentrix referrals - You should come back to the designated Regional Care Center for re-authorization (submit re-authorizations via the online provider portal) or add-on services unless defined otherwise. When submitting a request for re-authorization or an add-on service it is important to provide the clinical justification for the request.
| 7 Non-managed Authorization Form Branch managed plans have “0” units authorized. Branch managed plans have the same start and stop date. Non-managed CareCentrix referrals - You do not have to come back to the Regional Care Center for re- authorization or add-on services in which you are contracted with CareCentrix to provide. However, you are expected to manage to the patient's benefits and authorization requirements as stipulated by the insurance carrier. This would include ongoing re-verification of eligibility and benefits.
| 8 Sample Fax Coversheet Notifies you if PTA and OTA are allowed by member’s health plan Make sure to use lab of choice to maximize member’s benefits. Identifies in-network supply provider for non- routine supplies.
| 9 Portal Training: www.carecentrixportal.comwww.carecentrixportal.com The CareCentrix portal is the way of submitting authorization and re-authorization requests to CareCentrix - And we’ll show you how to do that now But the portal is much more than just a way to request an auth! - View latest news & important announcements! Check the portal often to stay on top of the latest developments - Submit initial and re-auth requests 24 x 7 x 365! No waiting on the phone! Faster auth turn-around time! - Check claim status - Check authorization status - Manage HomeSTAR patients Please visit: www.carecentrixportal.com
| 10 Billing and Claims Submission Format - Electronic Claims submission is the preferred format (CMS 1500 forms only at present) - Paper claims may be submitted on CMS 1500, UB-04 - Claims must be original, without erasures, strikeovers, or stickers Timely filing - 45 days from time service was rendered - Or, as determined by State law *Claims must include the following*: - Description of the service - ICD9 Code - Taxonomy number - NPI number - HCPC Code & Modifier as shown on your Service Authorization Form (SAF) Current billing cross walk can be found at www.carecentrixportal.comwww.carecentrixportal.com - Find the CareCentrix service code and UOM (unit of measure) on your Service Authorization Form (SAF) and match to the above crosswalk to determine the correct HCPC/Modifier combination you must bill. Coordination of Benefits (COB) - Please click the PDF to the right for an overview of COB Billing & Claims
| 11 Claims: Corrections & Appeals Is your payment not what you expected? Please follow our process for corrections and appeals: Billing & Claims Self-diagnose the Problem Submit a Claim Reconsideration Form Appeals Verify that you billed the correct HCPC/Modifier combination found on your SAF, or using the billing crosswalk Ensure you have included all required clean-claim data elements -For a complete list, please refer to www.carecentrixportal.com and download our Provider Manual or view the “Claims” section of the websitewww.carecentrixportal.com Complete a Claim Reconsideration form and send to CareCentrix (see Provider Manual) Or call: 877-725-6525 Claim reconsideration forms must be received within 45 days of date on EOP or as required by law if longer If reconsideration is not received within 45 days, your request can be denied for untimely filing of a reconsideration Click PDF (at right) for a copy of the form, or go to www.carecentrixportal.comwww.carecentrixportal.com If the payment issue is resolved in your favor, the payment will be adjusted and an explanation of payment issued If payment issue cannot be resolved in your favor, you may send a claim appeal to our Appeals Unit (see Provider Manual) A copy of the claim in question must be included with the CareCentrix Appeal Form Appeal must be received within 30 calendar days from the date we orally advised you or the date of our communication indicating that your request for reconsideration was not be resolved in your favor (or as otherwise mandated by state or federal law) Appeals received without a copy of the claim in question will be mailed back to the submitter
| 12 CareCentrix Contact Information: Know Where to Go CareCentrix Contacts
| 13 Contact Information Network Manager - Name - Phone - Email Network Coordinator - Name - Phone - Email We welcome your feedback! - Please take a moment to answer 6 quick questions and provide us your confidential and anonymous feedback on today’s orientation - Click: http://www.surveymonkey.com/s/8SL8MLDhttp://www.surveymonkey.com/s/8SL8MLD Thank you for choosing to participate in the CareCentrix provider network. We value the quality care you bring our patients, and will work hard to ensure that your experience with us delights you.