Sunrise AdvantageBilling Training

December 2018

Medicare Plan Statement

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• Sunrise Advantage Plan is a Medicare Advantage Plan offering three distinct products designed to improve care for Sunrise Senior Living residents. The three products offered by Sunrise Advantage Plan are:

• Institutional/Institutional Equivalent Special Needs Plan (ISNP)–designed for residents who functionally and medically meet a nursing facility level of care

• Chronic Condition Special Needs Plan (CSNP) – designed for individuals with a diagnosis of Dementia

• Medicare Advantage and Prescription Drug Plan (MAPD)• We are a Senior Living owned plan, with strong local roots and a

commitment to the residents, families, and communities we serve.

Sunrise Senior Living Confidential & Proprietary Information 2016|

Model Benefits

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Enhanced Clinical Care – specially trained physicians working in tandem with on site nurse practitioners to address changes in condition immediately and begin treatment protocols without hospital transfer when clinically appropriate. Focus on responsiveness 24/7. Treat in place as much as possible/appropriate.

Reduced out of pocket expense – reduction in medical expense and prescription drug expense

Supplemental benefits – covered services above and beyond traditional Medicare ( dental, vision, hearing, incontinence supplies)

Care Management– We do the work so that you don’t have to…• Health Risk Assessment – completed by NP within 90 days of enrollment, at

regular intervals and with significant change of condition. Determines frequency of NP & PCP visits (weekly, monthly etc)

• Comprehensive Care Plan -created and routinely updated to address the physical, social, emotional and spiritual needs and preferences of residents and their families

• Interdisciplinary Care Team meetings – NP coordinates among providers and stakeholders to resident’s care

Sunrise Resident/Family Survey

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What they wanted more coverage for:1. Reduced out of pocket expense on medical services

2. Reduced out of pocket expense on prescription drugs

3. Coverage for incontinence supplies

4. Dental, hearing, vision all tied at 4th place

Sunrise Family/Resident SurveyHow Sunrise Advantage Responded:

1. Reduced out of pocket costs on medical services:1. $0 copay for PCP services2. $0 deductible on Part B services3. $0 coinsurance on SNF days for ISNP & CSNP4. $0 coinsurance for PT/OT/ST for ISNP & CSNP5. Reduced the out of pocket maximum from $6700 to $3400 (ISNP),

$5700 (CSNP & MAPD) * IL has $3400 for all three products6. $0 deductible for inpatient hospital services

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Sunrise Family/Resident SurveyHow Sunrise Advantage Plan Responded:

2. Reduced out of pocket spending on prescription drugs:1. $0 deductible ($450 savings)

3. Assistance paying for incontinence supplies1. $50 per month toward purchase of incontinence supplies

4. Dental/vision/hearing1. dental - $200 toward 1 cleaning, oral exam and x-ray2. vision – added routine vision exam and glaucoma exam (1 per year)

at $0, Provide $100-$270 (depends upon plan) toward glasses, contacts

3.hearing – added one routine hearing exam and fitting/evaluation for hearing aids per year at $0 copay. Provide $500-$1000 toward purchase of hearing aids every 2 or 3 years (amount and timing varies by plan)

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Claims Submissions

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• Sunrise Advantage Plan follows all Medicare guidelines in regard to timely filing requirement (12 months from date of service)

• Cannot bill future dates of service• Bill Sunrise Advantage Plan as you would bill

Medicare in 30 day increments

• Acceptable claim forms:• CMS 1500 for Professional Claims• UB04 for Facility Claims

• Claims can be submitted via paper, EZNet or EDI

• Paper Claims Mailing Address:

Sunrise Advantage PlanPO Box 908Addison, TX 75001-0908

Sunrise Senior Living Confidential & Proprietary Information 2016|

Billing Resources: EZNET

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• Functionality:• Member Eligibility Lookup• Authorization/Referral Submittal & Inquiry• Claims Submittal & Inquiry

• User Guide & Training Video available on home page: https://planprovportal.align-360.com/EZ-NET60/ConfigFiles/EZ-NET%20User%20Guide.docx

• Monthly provider trainings offered on the last Friday of each month at 12:30 PM EST

Sunrise Senior Living Confidential & Proprietary Information 2016|

Billing Resources: Electronic Billing

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• Claims can be submitted directly through our clearinghouse or through your current system. You can also receive payments electronically, but you need to sign up! Here is how:

• EDI Customer Support: 1-888-635-0009, Option 2• Website: http://exchangeedi.com/quick-links• Obtain Companion Guide and Enrollment Form from the Sunrise Advantage

Plan website

Sunrise Senior Living Confidential & Proprietary Information 2016|

Payment Schedule

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• Sunrise Advantage Plan runs a bi-weekly payment cycle• 835s, RAs and Payments will be sent within 30 days of claim

received date per Medicare requirements for all claims paid or denied with explanation of status

• *Interest will be paid if a clean claim received is not paid within 30 day time frame

• Explanation of Benefits will be provided to all members

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Sunrise Senior Living Confidential & Proprietary Information 2016|

Reminders

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• UM Department can be reached at:• Phone: 1-844-896-0628 (Option 3)• Fax: 800-779-6954

• For help, Sunrise Advantage Provider Services Representatives can be reached at:

• 1-844-896-0628 (NY-PA-VA)• 1-844-502-4149 (IL)

• Helpful provider information is always available on the Sunrise Advantage Plan website

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Sunrise Senior Living Confidential & Proprietary Information 2016|

Sunrise AdvantageBilling Training