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