1. New PROVIDER ORIENTATION

2. WELCOME TO New PROVIDER Orientation
Congratulations on becoming a patient of the CareCentrix family! Our role in Provider Operations is to be your advocate as you work with CareCentrix. Please feel free to contact your Provider Operations team should you have additional questions after reviewing this new provider orientation!

3. Agenda Who is CareCentrix and how does CareCentrix benefit providers?
Review the home care benefits management workflow
Review the steps of the referral process and getting authorizations/pre-certifications
Review the requirements of meeting start of care (SOC)
Review the steps of the claim submission process and getting paid
Review CareCentrix contact information
Review provider performance metrics
Questions?

4. CareCentrix

5. CareCentrix Who is CareCentrix? Nation’s leading home care network
A healthcare delivery system that performs utilization management functions for ancillary care and specialty pharmacy services for commercial, and managed Medicare and Medicaid plans
Privately owned since 2008, founded in 1996
Network: Over 8,000 credentialed provider locations of home health, durable medical equipment, infusion and behavioral health
Accreditation: Full URAC accreditation in health utilization management
Customers: CIGNA/CIGNA West, Health Net, Florida Blue, Horizon Blue Cross Blue Shield of New Jersey, Aetna and Cofinity
National footprint: 24/7 service in all 50 states
How does CareCentrix benefit the provider?
Single Point-of Contact: CareCentrix integrates the full spectrum of services - network management, referrals, care coordination, utilization management, and reimbursement consolidation
Focus on relieving provider from the burden of collecting patient cost share

6. Home care benefits management workflow

7. Homecare benefits management workflow
Physicians
Hospital Discharge Planners
Case Managers
CCX Providers
CareCentrix 
Infusion Provider & Ambulatory Infusion Suites
Home Health Provider
DME/OP Provider
Claims Billing

8. Authorizations/ Pre-certifications
The Referral Process & Getting an Authorization
Requests for service, whether for the initial start of care or reauthorization for continued care, must be requested prior to the service being provided. If a provider fails to request an authorization/pre-certification prior to providing services, the services performed may not be reimbursable and are not billable to the patient.

9. The referral process: service specific tips
THH – Home Health
DME/O&P
Infusion
Required to be Homebound?
Varies by plan/product type.
N/A
Initial Auth Required?
Yes for non-BlueCard services*
Re-auth Required?
Plan Dependent
Start of Care (SOC) Changes
Provider must make CareCentrix aware & update on
Miscellaneous
Lab tests must be taken to the lab specified by the patient’s plan
Routine supplies are included in the cost of visit
If additional supplies are needed, CareCentrix will authorize.
Oxygen
Liter flow
O2 saturation w/ date
CPAP
Sleep study or letter of medical necessity
MD order required for upgraded unit
Provide height, weight, allergies, type of venous access, and next scheduled dose
Infusion providers must accept case “full-service” which includes drug, skilled nursing and supplies (per diem)
- Please note these are service specific tips, however all providers should reference the provider manual, the provider agreement and the health plan policies for guidance on the referral process.
* BlueCard requirements for precert vary by HomePlan. Please refer to BlueCard training.

10. Sample referral instruction sheet
Read your fax coversheet. It will tell you the patient ’s plan type, including how to check eligibility and benefits and whether reauthorization is needed.
Identifies the lab of choice per the health plan
Notifies you if PTA and OTA are allowed by patient ’s health plan

11. Important Authorization Information
Coordination of Benefits (COB)
Please click the PDF to the right for an overview of COB
Authorizations of services is NOT a guarantee of payment
Payment of services rendered is subject to the patient’s eligibility and coverage on the date of service, the medical necessity of the services rendered, the applicable payer’s payment policies, including but not limited to, applicable the payer’s claim coding and bundling rules, and compliance with the Provider’s contract with CareCentrix. Refer to the Provider Manual for more information regarding authorizations.
Provider is ultimately responsible for eligibility benefit and payer source verification.
Providers must in every instance, whether receiving a referral from CareCentrix or a primary referral source, verify eligibility and benefits with the patient’s Health Plan prior to providing any service, equipment or supply item.
Providers should maintain documentation to evidence this verification of eligibility and benefits.
CareCentrix does not conduct electronic eligibility and benefit verification transactions, but our health plan customers do.
Eligibility and benefit verification and service authorization are not a guarantee of payment for services such as, but not limited to, items provided when the patient is not eligible or there is no available benefit. Providers are responsible for ensuring that they maintain, and have available upon request, all documentation necessary to support the services rendered, including but not limited to, the medical necessity of such services.

12. Eligibility Tips Health Plan Website Patient Plan Type Contact Phone
Aetna
Navinet
PPO patient
HMO patient
(888)
(800)
Cigna
Cigna Web Portal
Florida Blue
Blue Card
Availity
State, Local and FEP
BlueCard
(877)
(800) 676-BLUE(2583)
Horizon NJ
General/Medicare Advantage/SHBP
(800)
FEP
(800)
Pfizer
(888)
Merck
(877)
Labor Funds
(888)

13. Start of Care
Missed starts of care (MSOC) can create dissatisfaction, put patients at risk, and can result in readmissions or delayed discharges

14. Start of Care (SOC)
A start of care (SOC) date is set by the ordering physician or discharge planner.
When accepting a case, consider your ability to service the patient and meet their needs.
Notify CareCentrix immediately if you must delay the start of care or if you are unable to continue the case. Refer to page 26 of the Provider Manual for start of care delays and referral turn backs.
Changes to the patient’s start of care date must be approved by the referring physician. You are required to obtain the orders needed to prevent a delay in the start of care.
For most items and services, the CareCentrix Service Validation team will confirm that the care was provided by the SOC via an outbound phone call to the patient.
Provider performance is measured on various metrics, including compliance with SOC date and number of missed starts of care.

15. Claim Submission and Payment
Clean claims must be submitted electronically within 60 days of the date of service (or, as determined by applicable law) and must include the CareCentrix HCPCS Code & Modifiers.

16. CLAIM SUBMISSION AND PAYMENT
The Referral Process
(Getting an Authorization)
Visit the Patient
The Claim Submission Process

17. The claims submission process
Timely filing
60 days from time service was rendered (or, as determined by applicable law or plan mandate)
Providers must submit a clean claim within timely filing period, non clean claims submitted within the timely filing period therefore reject
Substitution of Services
Example: If a provider is granted auth for RN visits, an LPN may be used but providers must bill CCX for LPN not RN. The same applies for the substitution of PTAs and OTAs.
*Important Note Horizon does not allow for PTA or OTA/COTA. Providers should always bill the services that were rendered at the appropriate contracted rate.
Providers may NOT disclose contracted pricing
Providers do not collect copays/deductibles from patients. CareCentrix will collect the copays and deductibles from the patient.
Click here to review the provider manual for clean claim submission requirements.

18. The Claim Submission Process
CareCentrix offers a billing crosswalk to identify the CareCentrix internal service code to the HCPC code on the provider’s fee schedule. Current billing cross walk can be found at
To use the billing crosswalk, locate the CareCentrix service code and UOM (unit of measure) as shown on your Service Authorization Form (SAF) and match to the above crosswalk to determine the correct HCPCS/Modifier combination you must bill.
Claims must include the following:
Description of the service
ICD9 and/or ICD-10 Code(beginning on 10/1/2015)
Taxonomy number (provider’s and referring physician)
NPI number
If billed with HCPCS and modifiers not consistent with the HCPCS and modifiers on the SAF the claim could be denied
Refer to the Provider Manual for a complete list of clean claim submission requirements.

19. If your claim was rejected
Rejected claim
If your claim was rejected
(You received a rejection letter from CareCentrix)
Correct the claim for the issue(s) identified and resubmit the claim as an
Original Claim via an 837 submission or on a CMS1500/UB04 form.
(Do not submit the claim as a Corrected Claim, Claim Reconsideration,
or Claim Appeal)
Please resubmit the claim to CareCentrix as quickly as possible; claims must still be received within 60 days* from the date of service (or as indicated by State law) to be timely.

20. Denied claim If your claim was denied
(You received and explanation of payment (EOP) from CareCentrix)
And you agree with the denial reason given by CareCentrix, correct the claim for the issue(s) identified and resubmit the claim as a Corrected Claim.
(Do not submit the claim as a Claim Reconsideration or Claim Appeal).
“Corrected” marking must be clearly visible in large font and cannot obstruct any data elements on claim
Please resubmit the claim timely to expedite the payment process. Claims can be submitted electronically or sent to: PO Box 7779 London, KY

21. If your claim was denied
Denied claim
If your claim was denied
(You received and explanation of payment (EOP) from CareCentrix)
And you disagree with the denial reason given by CareCentrix, complete the Claim Reconsideration Form
(CLICK HERE FOR CLAIM RECONSIDERATION FORM) and mail it to the address on the form.
(Do not make changes to the original claim. Claim Reconsideration Forms should only be used if you believe your initial claim was 100% accurate)
Claim Reconsideration Forms must be received within 45 days of the date of an EOP, or as required by law, if longer.

22. Claim appeals If your Claim Reconsideration
request was denied you may submit a claim appeal
Complete the Claim Appeal Form
(CLICK HERE FOR CLAIM APPEAL FORM) and mail it to the address on the form.
(Do not make any changes to the original claim. Claim Appeals should only be used if you have received an EOP from a Claim Reconsideration)
Claim Appeal Forms must be received within 30 days of the date of a Claim Reconsideration EOP
Note: Corrected claims, reconsiderations, and appeals can be submitted electronically for claims processed through our Claims 2.0 platform.

23. What is claims 2.0?
We listened to your feedback! The 2.0 platform includes several new features that came from provider requests.
These enhancements include:
More detailed claim status updates via the Provider Portal
Improved technology that checks your claim for completeness
Claims reconciliation tools that provide you with detailed claims reporting information
The Claims 2.0 training can be found under the Education Center on the CareCentrix Provider Portal :

24. Contact us
Know where to go

25. Register for Portal Access & EDI Claims Submission
Contact us
Register for Portal Access & EDI Claims Submission
Register for Portal Access
Register for EDI Claims Submission
Support
Portal Support
EDI Support
Authorizations
Initial Authorization Requests
Re-Authorization Requests
Add-on Requests
Authorization Status
Edit an Authorization
Authorization Contact Numbers
Aetna FL:
BCBS FL: –Inquiries -
All Other Plans:
Claims
Claims Status
Claims Questions
Phone:
Appeal Status
Claims Support Team
Contract/Network Management
Provider Manual
Patient Financial Responsibility
Patient Services Team
Phone:

26. Things to remember

27. Things to remember Provider Performance Metrics
100% portal compliance
100% EDI compliance
Claim denial rate of 7% or less
No quality of care concerns
Case acceptance rate, no turn-backs
Monitor these to avoid becoming non-compliant.
Providers may NOT use the CareCentrix name in any media without prior approval.
Timely filing
60 days from time service was rendered (or, as determined by State law)

28. THANK YOU