1. 7/7/09 Presented By: Provider Network Staff NorthernBridges

2. Role of the Provider Network Development Department Create a network of providers to deliver the array of services that address the needs of the members served, and as are required by the State of Wisconsin.

3. Governing Documents Contract – with Rate and Special Services Letter Provider Handbook Provider Handbook - Billing Supplement Other resources: www.northernbridges.com

4. Participants Wisconsin DHS MCO – NorthernBridges Members Served Residential Facility Providers Family Care Services Providers Vestica Healthcare (software) NB/ Vestica TPA (claims adjudication)

5. NorthernBridges Functions Administration Enrollment Care Management Care Managers – IDT’s Provider Network Finance Quality Management

6. Provider Payment Process 1. Become a Contracted Provider (Contract + Rate Sheet) 2. Members Enrolled (NB Enrollment) 3. Care Managers Assigned (NB care Mgmt.) 4. Member Service Plan Developed (NB Care Mgmt.) 5. Authorization Letters Received by Provider 6. Services Provided 7. Claims Submitted 8. Claims Adjudicated and Paid

7. Two Types of Providers and Forms Residential Facility Providers - Residential Form All residences Respite providers who serve members in respite provider’s home Family Care Services Providers – Services Form All other services Respite providers who care for members in member’s home

8. NB Authorization Letter

9. Contains what you need to Bill Authorization Number Member name and Member ID Service Codes and Modifier(s) Quantity Service dates Care Manager(s) contact information Does not contain your contracted rate Contracted rate for each code / service is on the rate sheet you received with contract

10. Residential Form and Key Review handouts Complete Residential claims correctly using “key” and authorization letter Mail to: NB Claims Processing PO Box 309 Thiensville, WI 53092

11. Services Form and Key Review handout Complete Services claims correctly using “key” and authorization letter Mail to: NB Claims Processing PO Box 309 Thiensville, WI 53092

12. Claims Submission Methods US Mail Residential Facilities Billing Form Family Care Services Billing Form Forms are available on the NB web site Electronic Residential – Through SFTP (Secure File Transfer Protocol) Site Family Care Services – Through Vestica WPS (Web Provider Services)

13. US Mail 1. Submit Correct Billing Form 2. Data Entry Key 3. Use HIPAA Compliant Codes for Contracted and Authorized Services

14. Forms Authorization Number (authorization letter) Member Name, DoB, Gender Member Number (on authorization letter) NPI (medical providers only) Type of Bill (see codes on key) HIPAA Compliant code + Modifiers (if any) Dates of Service Contracted Rates and Totals

15. Residential Facility Electronic Billing 1. Send an e-mail to Vestica at CISdept@vestica.com 2. Response from Vestica providing assistance in setting up SFTP site 3. Use HIPAA Compliant Codes for Contracted and Authorized Services

17. Family Care Services Electronic Billing 1. Mail your FIRST Family Care Services claim to Vestica 2. Receive Remittance from Vestica with WPS setup information attached 3. Contact Vestica and follow instructions to access and use WPS 4. Use HIPAA Compliant Codes for Contracted and Authorized Services

19. Diagnosis Codes - Required for WPS Claims In diagnosis code field – default is V68. 9 In service line item point to box: 1

20. Claims Processing and Payment Claims are processed twice per month (approximately the end of first and third week.) All claims received are paid within 30 days Call 800 508 6967 for status of claims Claims must be “clean”

21. Room and Board Payment Responsibility NorthernBridges shall require that members living in substitute care settings, (CBRF’s, RCAC’s, and AFH’s), pay the appropriate room and board rate to NB. NB will invoice members for Room and Board Providers will submit claims for Residential Services and Room and Board – The total $’s will remain the same. Work is currently taking place to develop a consistent residential rate setting methodology, both for room and board and residential services. Billing must reflect the two separate residential line items

22. Provider Network Directory Tool to assist care managers in finding providers for specific services Assures adequacy of network and array of providers within the network Always changing – keep your information current – including full array of services you provide State uses information to assure adequacy of network prior to certification

23. Members and IDT’s Have Access to Provider Network Directory The internal provider network directory shall be updated on a regular basis and available online to the Care Management teams. The paper copy provided to members will be updated regularly on the website but can also be printed out in hardcopy at anytime.

24. When to Contact the Provider Network Staff After application to become a provider Upon provider observation regarding a member “change of condition” Provider or member comments, complaints or quality concerns of any kind Rates Clarification Out of network provider situations

25. Service Authorization Process Controlled by NB Care Managers Service Authorizations must be completed for all services for any of the following reasons: to start service stop service decrease service increase service for a one time cost or if there is a change in the number of units of service provided and the member agrees with the decision

26. Communication and Reporting Requirements What to Expect of Providers Providers are to communicate any significant change of condition to NB Care Management, such as: If member’s legal status changes, e.g. guardian appointed, Power of Attorney activated or deactivated or decisional capacity is questioned. If there is a plan to use physical or chemical restraints with a member. If there is use of emergency restraints. The restrictive measures policy is provided to all providers with their contract packet. If there is allegation/suspicion of abuse or neglect.

27. Important Things to Remember All services must be authorized by NorthernBridges team Services/goods to members must be authorized prior to delivery and regardless of primary payer source. The care managers and IDT develop services plans that specify every authorized service. NorthernBridges will not pay for goods and services before enrollment or after disenrollment.

28. Important Things to Remember Rates for FC Services will be the same in all counties A weighted average of your 2008 services in all counties was used to establish the new rate Using this method your revenue would remain the same

29. Important Things to Remember Providers may request new or additional services or extensions of existing authorizations for service by contacting the care manager. A request, however, does not imply that a change will occur. In case of emergent need for service authorization a 24 hour authorization phone line will be available. Providers can not seek payment from members when reimbursement is denied because the service was not authorized.

30. Program Integrity Related to Billing/Claims Inflation of bills for services or equipment or supplies provided Double billing Improper coding Embezzlement and theft

31. Resources www.northernbridges.com Residential Facility Claims Forms and “keys” Family Care Services Claim Forms and “keys” Provider Handbook and Billing Supplement Frequently Asked Questions Re: Billing Provider Directory

32. NB Provider Network Staff Rita Mueller - Provider Network Manager, 715-934-2266 ext. 1113 rmueller@northernbridges.net Sarah Benson – Provider Network Developer, 715-934-2266 ext. 1125 sbenson@northernbridges.net Krista – Love-Frels - Provider Network Developer klovefrels@northernbridges.net 715 934 2266 X 1127 klovefrels@northernbridges.net Glenn Taylor – Provider Network Developer, 715-934-2266 ext. 1129 gtaylor@northernbridges.net