Download presentation
Presentation is loading. Please wait.
1
Johns Hopkins Advantage MD
Provider Education Seminar Presented by: Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
2
Johns Hopkins HealthCare
Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
3
Hopkins Health Advantage, Inc.
Johns Hopkins Advantage MD Johns Hopkins Advantage MD Plus Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
4
What is Medicare Advantage?
A Medicare Advantage plan option is available to Medicare eligibles who elect a health plan option for their Part A, Part B and potentially Part D benefits Run by private insurance companies contracted with Medicare If an individual joins a Medicare Advantage plan, he/she: Is still in Medicare with all rights and protections MA plans are approved by CMS Medicare pays the plan every month for care Still gets Part A and Part B covered services Must have both Part A and B to join a MA plan May have to select from a network of doctors/hospitals May have prescription drug coverage included May get extra benefits such as vision or dental It is optional! 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
5
What is Medicare Advantage?
Part of and Approved by Medicare Run by Private Insurance Companies Various Plan Types May Cover Extra Benefits Part C Characteristics Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
6
Medicare Advantage in Maryland
Maryland has seen a Medicare Advantage growth rate similar to that of the rest of the United States; however, it remains significantly under-penetrated Approximately 906,000 Medicare-eligibles Only 10% enrolled in a Medicare Advantage Plan 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
7
Medicare Advantage Enrollment Periods
Initial Enrollment Periods 7-month Period 3 months before the month the member turns 65, the month the member turns 65, 3 months after the member turns 65 Open Enrollment Period October 15 – December 7 Coverage takes effect on January 1 Special Enrollment Periods Member moves out of service area Plan leaves Medicare program or reduces service area From January 1 to February 14, members can leave plans, switch to Original Medicare, or join a Part D Plan. They may not switch MA plans during this period. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
8
Service Area Service Area is defined as a geographic area where a health plan accepts members if it limits membership based on where people live The following counties are included in the Service Area for Johns Hopkins Advantage MD: Anne Arundel County Baltimore City Baltimore County Calvert County Carroll County Howard County Montgomery County Somerset County Washington County Wicomico County Worcester County 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
9
Participating Hospitals
The following hospitals are participating with Johns Hopkins Advantage MD: - Anne Arundel Medical Center McCready Hospital - Atlantic General Hospital Mercy Medical Center - Carroll Hospital Center Meritus Medical Center - Calvert Memorial Hospital Northwest Hospital Center - Doctors Community Hospital Peninsula Regional Medical Center - Greater Baltimore Medical Center Prince Georges Hospital Center - Holy Cross Germantown Hospital Shady Grove Adventist Hospital - Holy Cross Hospital Sheppard Pratt Health System - Howard County General Hospital Sinai Hospital of Baltimore - Johns Hopkins Bayview Medical Center - St. Agnes Hospital - Johns Hopkins Hospital Suburban Hospital - Laurel Regional Hospital Washington Adventist Hospital - Levindale Hebrew Geriatric Center & Hospital Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
10
Johns Hopkins Advantage MD Plans
PPO (Preferred Provider Organization) Johns Hopkins Advantage MD Johns Hopkins Advantage MD Plus Members can self-refer to in- or out-of-network providers Participating providers should refer members to other in-network providers to decrease member out-of-pocket expense Pre-Authorization is still required for certain services 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
11
Medical Benefit Overview
Ambulance Inpatient care Behavioral health care – inpatient and outpatient Outpatient rehabilitation – includes cardiac rehab and PT/OT/ST Chiropractic care – limited spinal manipulation Outpatient substance abuse care Outpatient surgery Limited dental services Preventive care Diabetic supplies and services Skilled nursing facility Diagnostic lab and radiology Prescription drug coverage Doctors office visits Part B drugs Durable medical equipment Prosthetic devices Emergency care Renal dialysis Podiatry services - diabetes-related Urgently-needed services Hearing services - diagnose and treat hearing and balance issues Vision – Ophthalmology specialty and limited routine eye exams Home health care 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
12
Behavioral Health Benefits:
Inpatient mental health care Outpatient mental health care Outpatient substance abuse services Partial hospitalization services Pre-authorization is required for all behavioral health services To obtain pre-authorization, please contact Johns Hopkins Advantage MD at 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
13
Additional Benefits Johns Hopkins Advantage MD Plus includes the following value-added services: Limited acupuncture benefit Hearing aid services – yearly allowance Eyeglasses/contacts – yearly allowance Silver & Fit ® fitness benefit 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
14
Prescription Drug Benefit (Part D) Overview
Johns Hopkins Advantage MD uses CVS/Caremark network of pharmacies which includes over 60,000 pharmacies nationwide including most home infusion, long-term care and retail chain and independent pharmacies in Maryland. CVS-Caremark mail order pharmacy shall provide mail order requests for members. Plan’s website includes a pharmacy locator and directory for member and providers to easily locate participating pharmacies. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
15
Prescription Drug Benefit (Part D) Overview
Johns Hopkins Advantage MD utilizes a CMS approved formulary. Drugs excluded by Medicare: drugs used for cosmetic purposes, erectile dysfunction, cough and cold , vitamins (except prenatal vitamins), and over-the-counter medications. Coverage limit requirements such as prior authorization, step edits, and quantity limits are identified on plan’s formulary, available on the plan’s website at Forms and information to request Part D prior authorization, exception, appeals, or grievance are available on the website. Under certain circumstances, plan offers a temporary (transition) supply of a drug when it is not on the formulary or when it is restricted. In these circumstances both members and providers will receive a transition letter explaining the situation and provide options. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
16
Johns Hopkins Advantage MD Membership ID Card
Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
17
Johns Hopkins Advantage MD Member Eligibility
You can verify member’s eligibility, claim status and authorizations by doing one of the following: Contacting Customer Service Accessing your account after January 1, 2016 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
18
PCP Selection Selection of a Primary Care Physician is not required. Members will be encouraged to select a PCP in order to: Ensure they have a medical home upon enrollment and Facilitate coordination of care PCP names will not be on the card. You can verify the member’s PCP by: Calling Customer Service at or Accessing you account Members may be advised to contact Customer Service to update their PCP information If you are not the member’s selected PCP, you may still see the patient at the in-network benefit level PCPs will receive monthly reports in regards to their member panel. Presented by: Johns Hopkins HealthCare Provider Relations Department
19
Access Standards Service Appointment wait time (not more than):
Well Patient Four (4) weeks Specialist Routine One (1) week Urgent Twenty-four (24) hours Office Wait Time Thirty (30) minutes Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
20
Pre-Authorization For Services that require Pre-Authorization (Medical Review), you must obtain an authorization prior to rendering services Submit clinical notes and treatment plan to Utilization Management The following services require Pre-Authorization Inpatient Hospital Services Skilled Nursing Facility Cardiac and Pulmonary Rehabilitation Partial Hospitalization Home Health Services Chiropractic Services Physical, Occupational and Speech Therapy Acupuncture (only offered in Johns Hopkins Advantage MD Plus) Ambulance Durable Medical Equipment Prosthetics/Orthotics/Medical Supplies 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
21
STARS What are the Medicare STAR Ratings?
Medicare uses a STAR Rating System to measure how well Medicare Advantage and prescription drug (Part D) plans perform. Medicare reviews plan performances each year and releases new star ratings each fall. This means plan ratings change from one year to the next. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
22
STARS Medicare health plans are rated on how well they perform in five different categories: Staying Healthy: Screenings, Tests, and Vaccines Managing Chronic (Long-Term) Conditions Plan Responsiveness and Care Member Complaints, Problems Getting Services, and Choosing to Leave the Plan Health Plan Customer Service Medicare drug plans are rated on how well they perform in four different categories: Drug Plan Customer Service Member Experience with Drug Plan Drug Pricing and Patient Safety 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
23
Provider Engagement Team
Builds a collaborative relationship with both primary and specialty care providers and be the liaison between the health plan, regional care team, and the provider network. Engages providers to participate in clinical and quality based efficiency and incentive programs to support all plans and products administered by Johns Hopkins HealthCare. Disseminates and explains all quality and financial data reporting Collaborates with providers to develop and execute alternative contracting and reimbursement models to ensure value-based reimbursement. Implements bi-directional reporting between provider organizations and Johns Hopkins HealthCare. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
24
The Claims Process Providers are encouraged to submit claims electronically: Medicare Advantage Payer ID # 66003 For electronic remittance advices (835) and electronic payments: Enroll online at emdeon.com/eft; or Download the enrollment form at emdeon.com/epayment/enrollment and fax completed form to Timely filing – 180 days from date of service for all lines of business Clean claims processed within 30 days 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
25
Balance Billing Hold Harmless Code of Federal Regulations
The MA organization’s providers must not hold any enrollee liable for payment of any fees that are the legal obligation of the MA organization Code of Federal Regulations (g)(1)(i) and (i)(3)(i) When members obtain plan-covered services in a PPO plan, such as Johns Hopkins Advantage MD/Johns Hopkins Advantage MD Plus, they may not be charged or held liable for more than plan-allowed cost-sharing. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
26
Provider Payment Dispute Process
Provider Payment Disputes must submitted within 90 business days of the date of denial 1st Level Dispute (Verbal) If a provider disagrees with the way a claim was processed contact Dispute decision is processed within 30 days 2nd Level Dispute (Written) If a provider disagrees with the 1st level dispute decision, submit your 2nd level request in writing to: Johns Hopkins Advantage MD PO Box 3537 Scranton, PA 18505 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
27
Johns Hopkins HealthCare Provider Relations Department
Inquiries or complaints regarding contracting, fee schedules and credentialing should be referred to JHHC Provider Relations Dept. by: Phone Fax or Mail to: Johns Hopkins HealthCare LLC 6704 Curtis Court Glen Burnie, MD The Provider Relations Dept. will abide by all processing timelines as identified in regulatory standards. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
28
Compliance JHHC has a Compliance Department Division dedicated to Johns Hopkins Advantage MD Beginning October 1, 2015, you can reach the Medicare Compliance Department using the contact information listed below. Our hours of operation are M-F 8:00 am to 5:00 pm. Phone: Local: Toll free: Fax: Mail: 6704 Curtis Court, Glen Burnie, MD 21060 Attn: Medicare Compliance Department For 24/7 Hotline reporting use: WE-COMPLY ( ) or the Hotline at mycompliancereport.com (Access ID: JHU) 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
29
Compliance Regularly review the JHHC Provider website, HealthLINK provider portal, and the Plan’s Medicare newsletters for information from the Compliance Department. Material may range from: Informational Hotline information Helpful suggestions/tips Required plan actions Copies of the plan’s code of conduct Policies and procedures Required regulatory submissions from your practice (such as attestations) 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
30
Off Shoring of PHI Attestation Required
In the near future and annually thereafter, your office will be receiving an attestation form to complete. Forms are due back to the Compliance Office within 10 business days of receipt. Purpose of this attestation is to ensure the protection of our Plan members’ protected health information. Additional informational material will be supplied with the attestation paperwork. Your cooperation is required by the Plan in order to comply with CMS regulations. Access the Provider website for additional materials related to your responsibilities regarding this regulatory requirement. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
31
Exclusion/Debarment Medicare payment may not be made for items, services or equipment furnished or prescribed by an excluded provider, supplier, entity or employee excluded by the Department of Health and Human Services (DHHS” Office of Inspector General (OIG) or General Service Administration (GSA). You are prohibited from submitting claims for individuals who have been excluded or debarred. Listed below are the links to check for federal exclusion and debarment. DHHS OIG List of Excluded Individuals and Entities (“LEIE”): System Award Management (“SAM”) List (debarment): Checks must be performed: At time of hire, and Monthly thereafter Maintain proof of your exclusion/debarment checks for 10 years as you may be asked by the Plan or by CMS to produce them during an audit 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
32
Johns Hopkins HealthCare Website
Provider website includes: Provider Manuals Forms portal access Online Provider Directory Find participating providers on after October 1 Links Policies & Procedures Compliance Guidance 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
33
HealthLINK@Hopkins Johns Hopkins Advantage MD:
Providers already registered with HealthLINK will use their Employer Health Programs/Priority Partners login to access information 1/1/2016 – Eligibility available 2/1/2016 – Viewing authorizations available 3/1/2016 – Claims available Care Coordination reports 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
34
Updating your Information
If there are any changes in your practice, you are required to notify Johns Hopkins HealthCare Provider Relations Department by: Calling , and/or Faxing the documentation to CMS requires the Health Plan to validate provider information monthly. 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
35
Overall Educational Opportunities
Providers will receive invitations to the 2016 seminars, which will address STARS and coding Additional resources will be posted on Medicare Learning Network – Medicare Managed Care Manual – Internet Only Manuals – 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
36
IMPORTANT HIGHLIGHTS Product Names – Product Types – PCP Selection –
Johns Hopkins Advantage MD Johns Hopkins Advantage MD Plus Product Types – Both products are PPO (with in- and out-of-network benefits) PCP Selection – Encouraged, but not required Effective date – January 1, 2016 Annual Enrollment Period October 15–December 7 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
37
IMPORTANT HIGHLIGHTS Customer Service Phone number –
EDI Payer ID number – #66003 Do not bill Medicare for services covered through Johns Hopkins Advantage MD/Johns Hopkins Advantage MD Plus Submit practice changes (demographic, office hours, etc) to: JHHC Provider Relations , Phone , Fax Eligibility (1/1/16), Authorizations (2/1/16), Claims Status (3/1/16), tentatively 9/21/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018
38
Questions? Presented by: Johns Hopkins HealthCare Provider Relations Department 9/21/2018 9/21/2018
Similar presentations
© 2025 SlidePlayer.com Inc.
All rights reserved.