7/7/09 presented by: provider network staff northernbridges
TRANSCRIPT
7/7/09 Presented By:Provider Network Staff
NorthernBridges
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.
Governing DocumentsContract – with Rate and Special Services Letter
Provider Handbook
Provider Handbook - Billing Supplement
Other resources: www.northernbridges.com
ParticipantsWisconsin DHSMCO – NorthernBridgesMembers ServedResidential Facility ProvidersFamily Care Services ProvidersVestica Healthcare (software)NB/ Vestica TPA (claims adjudication)
NorthernBridges Functions
AdministrationEnrollmentCare Management
Care Managers – IDT’sProvider Network FinanceQuality Management
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 Provider6. Services Provided7. Claims Submitted8. Claims Adjudicated and Paid
Two Types of Providers and Forms
Residential Facility Providers - Residential FormAll residences Respite providers who serve members in respite
provider’s homeFamily Care Services Providers – Services
FormAll other servicesRespite providers who care for members in
member’s home
NB Authorization Letter
NB Authorization LetterContains what you need to Bill
Authorization NumberMember name and Member IDService Codes and Modifier(s)QuantityService datesCare Manager(s) contact information
Does not contain your contracted rateContracted rate for each code / service is
on the rate sheet you received with contract
Residential Form and Key
Review handoutsComplete Residential claims correctly using
“key” and authorization letterMail to:
NB Claims Processing PO Box 309Thiensville, WI 53092
Services Form and Key
Review handoutComplete Services claims correctly using
“key” and authorization letterMail to:
NB Claims Processing PO Box 309Thiensville, WI 53092
Claims Submission Methods
US MailResidential Facilities Billing FormFamily Care Services Billing Form
Forms are available on the NB web site
ElectronicResidential – Through SFTP (Secure File Transfer
Protocol) SiteFamily Care Services – Through Vestica WPS
(Web Provider Services)
US Mail
1. Submit Correct Billing Form
2. Data Entry Key
3. Use HIPAA Compliant Codes for Contracted and Authorized Services
FormsAuthorization Number (authorization letter)Member Name , DoB, GenderMember Number (on authorization letter)NPI (medical providers only)Type of Bill (see codes on key)HIPAA Compliant code + Modifiers (if any)Dates of ServiceContracted Rates and Totals
Residential Facility Electronic Billing
1. Send an e-mail to Vestica at [email protected]
2. Response from Vestica providing assistance in setting up SFTP site
3. Use HIPAA Compliant Codes for Contracted and Authorized Services
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
Diagnosis Codes - Required for WPS Claims
In diagnosis code field – default is V68 . 9
In service line item point to box: 1
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”
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 BoardProviders 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
Provider Network DirectoryTool to assist care managers in finding
providers for specific servicesAssures adequacy of network and array of
providers within the networkAlways changing – keep your information
current – including full array of services you provide
State uses information to assure adequacy of network prior to certification
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.
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
Service Authorization ProcessControlled by NB Care Managers
Service Authorizations must be completed for all services for any of the following reasons:to start servicestop servicedecrease serviceincrease servicefor a one time costor if there is a change in the number of units of
service provided and the member agrees with the decision
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.
Important Things to RememberAll services must be authorized by
NorthernBridges teamServices/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.
Important Things to RememberRates 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
Important Things to RememberProviders 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.
Program Integrity Related to Billing/Claims
Inflation of bills for services or equipment or supplies provided
Double billing
Improper coding
Embezzlement and theft
Resources
www.northernbridges.com
Residential Facility Claims Forms and “keys”Family Care Services Claim Forms and
“keys”Provider Handbook and Billing SupplementFrequently Asked Questions Re: Billing
Provider Directory
NB Provider Network StaffRita Mueller - Provider Network Manager, 715-934-2266 ext. 1113
Sarah Benson – Provider Network Developer, 715-934-2266 ext. 1125 [email protected]
Krista – Love-Frels - Provider Network Developer [email protected] 715 934 2266 X 1127
Glenn Taylor – Provider Network Developer, 715-934-2266 ext. 1129 [email protected]