hmsa quest integration basics

HMSA

QUEST Integration

Basics

Participating Provider Webinar

November 15, 2018

Agenda

IMPORTANT: Medicaid Provider Enrollment/Re-

enrollment

Introduction to QUEST Integration

HMSA Responsibilities

Provider Responsibilities

Member Rights and Responsibilities

Service Coordination

Special Health Care Needs (SHCN)

Long Term Services and Supports (LTSS)

Members “At Risk”

2

Agenda (cont.)

Verifying a Member’s Eligibility

Claims/Encounter Form Filing Information

Electronic Transactions

Cost Share

Cultural Competency

Enabling Services

Excluded providers

Administrative Information/Resources

Questions/Evaluation

3

Medicaid Provider

Enrollment / Re-enrollment

Important Announcement

Who?

Providers enrolling in Medicaid for the first time, or

Established Medicaid providers who have not re-enrolled

with Medicaid within the past 5 years

What?

Submit Medicaid Application form (DHS 1139) and other

required documents to Med-QUEST ASAP

Why?

Enhanced provider screening, credentialing and enrollment

When?

NOW! Affected providers should submit their documents

as soon as possible.

5

Submission Requirements

All providers:

Completed DHS 1139 Medicaid Provider application

Copies of Applicable Licenses/Certifications

W-9

Copy of General Excise Tax License

Copy of Certificate of Liability Insurance

Allow MQD to conduct an onsite inspection

6


Home Health Agencies, DME, Home and Community

Based Services, Hotels and Transportation providers:

Submit $500 application fee (money order or check) –

payable to:

State Director of Finance c/o Med-QUEST division

Individuals with 5% or more business ownership must

undergo fingerprinting and criminal history fitness

determination by Fieldprint.

Instructions at website:

https://www.fieldprinthawaii.com/

Not required for non-profit organizations.

7


Institutional providers (hospitals, nursing

facilities, pharmacies)

Submit $500 application fee (money order or

cashiers check) payable to:

State Director of Finance c/o Med-QUEST Division

8

Send to

Send all required documents and payment (if

applicable) to:

Med-QUEST Division

Health Care Services Branch, Provider Enrollment

601 Kamokila Blvd., Room 506A

Kapolei, HI 96707

9

Application form

DHS 1139 application form and additional

attachments for certain provider types:

https://medquest.hawaii.gov/en/plans-

providers/fee-for-service.html

Questions?

Med-QUEST (808) 692-8099 or

[email protected]

10

QUEST Integration members

HMSA’s QUEST Integration members

Non-ABD (Doesn't include Aged, Blind or members with

disabilities)

ABD

(Aged, Blind or members with

disabilities)

ABD and LTSS

(Aged, Blind or members with disabilities who have additional LTSS benefits)

11

HMSA Responsibilities

Issue ID cards

Process claims

Case assistance/member education

Medical reviews (pre- and post-payment)

Home and community based services


12

HMSA Responsibilities Our Partners

Magellan formerly (NIA)

Precertification of outpatient advanced imaging studies, selected

spine procedures, selected cardiac services

eviCore

Outpatient rehabilitation therapy utilization management

Beacon Health Options

Behavioral health utilization management

Service coordination involving BH

CVS

Pharmacy benefits and Medical Specialty drug management

services

13

Providers


Comply with Americans with Disabilities Act

(ADA)

Physical accessibility

Interpreter services

Comply with non-discriminatory requirements

Certify the accuracy, completeness, and

truthfulness of submitted data (claims, encounter

data, medical records)

Maintain confidentiality of such records

15

Provider Responsibilities (cont.)

Adhere to Standards of Care

Develop and fully and clearly discuss treatment

options or service plans with members

Meet QUEST Integration accessibility standards

for urgent/emergent care, sick visits, and routine

visits

16

PCP Responsibilities Role of the Primary Care Provider

Ongoing source for primary care, responsible for patient’s

health maintenance and disease prevention

Coordinate health care with specialists

Maintain continuity of care

Maintain patient health records

Maintain hospital admitting privileges or a written

agreement with a provider with admitting privileges

Provide EPSDT exams to eligible members

17

Work with Service Coordinator to coordinate care and

create the member’s service plan

Identify high-cost, high utilization, complex, or special

needs cases for potential service coordination

Attend or have representation at QUEST Integration

informational sessions

Fulfill PCP requirements for members transitioning to

another PCP until accepted by new PCP

Maintain accessibility standards

18

PCP Responsibilities (cont.) Role of the Primary Care Provider

Provider Grievances and Appeals

Submit Grievance or Appeal in writing to the QUEST

Integration Grievance Coordinator:

948-8224 on Oahu or 1 (800) 960-4672 toll free NI

QUEST Integration Grievance Coordinator P.O. Box 860 Honolulu, HI 96808-9988

952-7843 on Oahu or 1 (800) 440-0640 ext. 7843 toll-free NI

For more information:

https://hmsa.com/portal/provider/zav_QI.02.COM.50.htm

19

Provider Grievances

Grievance process: Dissatisfaction with our operations, activities, or

behaviors

Submit in writing to the Grievance Coordinator within 60 days of payment or episode

Include Provider’s name, address, telephone number and HMSA provider number

Include description of the grievance, including member name and member ID number, along with copies of any supporting documents

Resolution within 60 days of receiving grievance

Further recourse through Appeal

20

Provider Appeals

File appeal if:

Service requested was denied or restricted (post-

service only. Pre-service denials are considered

member appeals

Authorization for a service was terminated, suspended

or reduced

Unhappy with health care services that weren’t timely,

were unreasonably delayed, or the grievance or

appeal decision was not carried out in a timely way

21

Provider Appeals

Appeals process:

Submit written request for appeal to the Grievance Coordinator within 30 days of determination, denial, etc.

Include Provider’s name, address, telephone number and HMSA provider number

Include description of the Appeal, including member name and member ID number, along with copies of any supporting documents

Resolution within 60 days of receiving appeal

Further recourse through Arbitration

22

Provider Appeals

Appeal of Precertification

Denial Form:

https://hmsa.com/portal/provider/6050-

0010_Form_To_Appeal_A_Precertification_Denial.pdf

23

Members

Member Rights and Responsibilities

Outlined for members in QUEST Integration

Member Handbook

Outlined for providers in QUEST Integration

Provider Handbook

Member rights includes member grievance and

appeals process

Providers may act on behalf of members filing

grievances and appeals, with member written consent

25

Member Grievance and Appeals

Right to file grievance

Right to State administrative hearing

How to obtain hearing

Rules on representation

Availability of HMSA assistance in filing grievance

Right to have a provider/representative

Written consent

Toll-free numbers available

Right to receive benefits during appeal/hearing

26

Member Grievances and Appeals

Submit Grievance or Appeal verbally or in writing to

the QUEST Integration Grievance Coordinator:

948-8224 on Oahu or

1 (800) 960-4672 toll free NI QUEST Integration Grievance Coordinator P.O. Box 860 Honolulu, HI 96808-9988

952-7843 on Oahu or 1 (800) 440-0640 ext. 7843 toll-free NI

More information in QUEST Integration Member Handbook: https://hmsa.com/Media/Default/documents/member-

handbook-quest.pdf

27

Member Grievances

Dissatisfaction with our operations, activities, or behavior

Expressed verbally or in writing

• Member

• Member’s authorized representative

• Provider acting on behalf of member with member’s

written consent or written consent of member’s

authorized representative

Grievance determination letter sent within 30 days of

receiving the grievance

28

Member Grievances

State Grievance Review process available if dissatisfied

with outcome

Request for Grievance Review within 30 days of decision

Call DHS – 692-8094

Mail request to:

Med-QUEST Division Health Care Services Branch PO Box 700190 Kapolei, HI 96709-0190

State determination made within 90 calendar days from

request for review

29

Member Appeals

May file Appeal when:

Service requested was denied or restricted

Authorization for a service was terminated, suspended

or reduced

Member unhappy with health care services that

weren’t timely, were unreasonably delayed, or the

grievance or appeal decision was not carried out in a

timely way

Member disagrees with payment that was denied or

reduced

30

Member Appeals

Submitted verbally or in writing within 30 days of

adverse event. Verbal appeals must be followed

up in writing within 5 business days.

May be submitted by

Member

Member’s authorized representative

Provider acting on behalf of member with member’s

written consent or written consent of member’s

authorized representative

31

Member Appeals

32

Appeal Process

• Include member’s name, address, telephone

number and HMSA membership number, date of

the appeal

• Include account of the facts to support the

appeal and why you disagree with the decision,

along with copies of any supporting documents

• Resolution within 30 days of receiving appeal

• Right to receive benefits during appeal/hearing

• Further recourse through State Administrative

Hearing

Member Appeals

State Administrative Hearing process

Request within 30 days of appeal decision

Mail to: State of Hawaii Department of Human Services Administrative Appeals Office PO Box 339 Honolulu, HI 96809

Decision within 90 days from date of request

33


- Special Health Care Needs (SHCN)

- Long Term Services and Supports (LTSS)

- Members “At Risk”

What is Service Coordination? A person-centered service delivery

system

Ensures the needs of those with

special health care needs, those

receiving long term services and

supports are met and those who are at

risk for deteriorating to nursing facility

level of care are met

35

Service coordinators assist in coordinating

services with other agencies, programs, and

community services

Special Health Care Needs (SHCN)

Patients with Special Health Care Needs (SHCN) examples:

Patients who have chronic conditions such as asthma,

diabetes, hypertension, cancer, or chronic obstructive

pulmonary disease

Patients who are outliers for emergency room utilization

Patients discharged from an acute care setting

Patients with hospital readmission within the previous 30

days

Children with Autism

Members with complex medical conditions requiring

coordination of care

36

Long-Term Services and Supports (LTSS) Patients must meet Nursing Facility Level of Care (NF LOC) on a DHS 1147

Home and community-based services (HCBS): LTSS provided to individuals to allow them to remain in their home

or community Includes Residential Settings

Institutionalized care: Skilled Nursing Facility (SNF) Intermediate Care Facility (ICF)

Self- Direction: Member employs their own provider(s) promoting

choice and independence

Individuals are mostly 65 years of older or with a disability

Most members are identified on membership card as “ABD and LTSS.”

11/14/2018 37

DHS 1147 form

Completed by either provider or

service coordinator

Only MD, DO, RN, or APRN may

complete form

Use DHS’ electronic system HILOC

if you have access

If no access to HILOC, complete

form at link below

https://medquest.hawaii.gov/en/pl

ans-providers/provider-forms.html

Search for “1147”

38

At-Risk Program

Individuals do not meet nursing facility level of care (NF LOC) on

DHS 1147

Do not need to be ABD to qualify

Assessed at risk of deteriorating to nursing facility level of care

using DHS 1147. Examples include someone who:

Lives alone and has difficulty walking

Had a recent hospital discharge

Recent traumatic event such as a stroke

Resides in own home (not home where someone is paid to care

for member such as a care home)

Services include personal assistance, meals, personal emergency

response system, adult day home/care, and skilled nursing

11/14/2018 39

Service Coordination Responsibilities of Coordinators

Support the PCP

Conduct member functional assessments

Develop and monitor a service plan based on results of

the assessment or reassessment

Coordinate and facilitate access to services with

providers, programs, and community agencies

Monitor progress with Early and Periodic Screening,

Diagnostic and Treatment (EPSDT) requirements, as

applicable

40

Requesting Service Coordination Providers may refer any member for service coordination

Advise patient that you are making a referral to Service Coordination… this helps when we call

Refer patients for Service Coordination: fax the form at: https://hmsa.com/portal/provider/HMSA_QUEST_Integration_Service_Coordination_Referral_Form.pdf

Oahu: 944-5604

Neighbor Islands toll-free: 1 (855) 856-4176

Call HMSA to refer patients for Service Coordination:

Oahu: 948-6997

Neighbor Islands toll-free: 1 (844) 223-9856

41

Referrals

Referrals

Self referrals

Register these referrals with HMSA (requires approval)

Other specialty care requires PCP referral, but does not

require submitting a referral request to HMSA

43

• Behavioral health (OP) • Family Planning

• Refractive vision services • Well-woman exam and

mammogram

• In-state out of network referrals

• Plastic surgery services

• Off-island specialist services

How to Register a Referral

Fax the referral form

Referral form:

http://www.hmsa.com/PORTAL/PROVIDER/FM.HMSA_QUE

ST_Referral_Form.pdf

948-5648 (Oahu)

1 (800) 960-4672 (toll-free)

Register the referral online via HHIN

• Select “Submit Referrals” tab, then click on “iExchange”

Call QUEST Integration Provider Service

948-6486 (Oahu)

1 (800) 440-0640 (toll-free)

44

Precertification

Precertification (Prior Authorization)

Services requiring precertification:

https://hmsa.com/portal/provider/zav_QI.0

1.SER.50.htm

Clearly identify urgent/emergent cases for

expedited review

46

Precertification (cont.)

Unit/Partner Responsible for

HMSA Medical

Management

Medical/Surgical, LTSS,

Post-Acute Care Services,

Speech Therapy, Out of

State Referrals

Magellan (formerly NIA) Advanced imaging, Spinal

Interventional Pain

Management, Lumbar

Spine Surgery, selected

Cardiac procedures

eviCore Outpatient Rehab Therapy

47

Precertification (cont.)

Unit/Partner Responsible for

QUEST Integration

Provider Service

Travel and lodging

requests, In-state out of

network referrals,

replacement eyewear

CVS Drug

Beacon Health Options Behavioral Health

48

Precertification – HMSA Medical

Management

HMSA precertification forms available online

General

http://www.hmsa.com/PORTAL/PROVIDER/FM.Pre

certification_Request_General.pdf

Post-Acute Care Services

http://www.hmsa.com/PORTAL/PROVIDER/Precert

ification_Request_Post_Acute_Care_Services_For

m.pdf

49

Precertification – HMSA Medical

Management

HMSA – Medical Management

P. O. Box 2001

Honolulu, HI 96805-2001

(808) 944-5611

948-6464 (Oahu)

1 (800) 344-6122 (toll-free Neighbor Islands)

Monday-Friday : 7:45 a.m. - 4:30 p.m.

Access iExchange through HHIN

https://hhin.hmsa.com/

50

Precertification (Prior Authorization)

Electronic submissions accepted through HHIN

51

Precertification – Magellan

Management of:

52

MRI/MRA/MRS CT/CTA

PET CCTA

Myocardial perfusion

imaging

MUGA

Stress echocardiography Spinal interventional pain

management

Implantable cardioverter

defibrillator

Cardiac resynchronization

therapy pacemaker

Pacemaker Cardiac catheterization

Lumbar spine surgery

Precertification – Magellan

Magellan Precertification information

https://hmsa.com/portal/provider/zav_pel.aa.nia.100.htm

Does NOT include emergency room, surgery center,

observation and inpatient settings

Request Precert Online: RadMD.com

Request Precert by Phone: 1 (866) 306-9729

RadMD technical support:

[email protected]

1 (877) 807-2363 toll-free

53

Precertification - Magellan

Clinically Urgent Cases

Defined as cases that cannot be postponed for 24

hours due to severe health risks for the patient

Member information and clinical reasons for the

urgent request must be submitted. Providers receive

authorization upon completion of the call or online

request.

Clinically Urgent phone line: 1 (866) 842-1776

If using RadMD – select the “Clinically Urgent”

option to provide information on the case

54

Precertification - eviCore

Outpatient rehabilitation therapy management

Precertification information

https://hmsa.com/portal/provider/zav_pel.rt.LAN.

500.htm

Login at:

http://www.lmhealthcare.com/Providers/Landmar

kConnect.aspx

55

Precertification - eviCore

Treatment plan forms available at the website

Treatment plans may be submitted via LandmarkConnect

or by fax

1 (888) 565-4225

Questions?

1 (888) 638-7876

56

Precertification – QUEST Integration

Provider Service

In-state out of network referrals

Travel and lodging requests

Replacement eyewear

948-6486 (Oahu)

1 (800) 440-0640 (toll-free Neighbor

Islands)

948-5648 (Oahu)

1 (800) 960-4672 (toll-free Neighbor

Islands)

57

Precertification - CVS

Oral/Inhaled drugs

Drugs requiring precertification-Review Drug Formularies:

https://hmsa.com/portal/provider/zav_PHARM-

FORMULARY.htm#Nav_Formularies

1 (866) 237-5512

1 (808) 254-4414

58

Precertification - CVS

Injectable/Infused drugs

Drugs requiring precertification:

http://info.caremark.com/hmsapolicies

Note: most drugs have specific precertification request forms

Online: Access through HHIN – Preauthorization tab (NovoLogix tool)

1 (866) 237-5512

1 (808) 254-4414

59

Precertification – Beacon Health Options

Precertification of Methadone/LAAM treatment,

referrals to 0ut-of-state providers, residential

treatment

Case manager for standard behavioral health

care

Links members to resources and services

Educates member/family, serves as patient

advocate

60

Precertification – Beacon Health Options

(808) 695-7790

Oahu - (808) 695-7700 Neighbor Islands - 1 (855) 856-0578 toll free

Beacon Health Options 599 Farrington Highway, Suite 300 Kapolei, HI 96707

61

Precertification

Timeliness guidelines

Routine requests within 14 days

Urgent requests within 3 business days

If pre-certification is not obtained before the service is

provided, submit a paper claim attaching documentation for

the medical necessity

Claim will undergo medical review

Claim without documentation will be denied for no

authorization

62

EPSDT –

Early Periodic Screening

Diagnostic and Treatment

For PCPs

EPSDT – Early Periodic Screening

Diagnostic and Treatment

Mandated Federal program

Provide Medicaid-eligible infants, children and

youth with quality comprehensive health care

through primary prevention, early diagnosis

and medically necessary treatment of

conditions

For members up to 21 years of age

64

65

EPSDT Schedule

Health screening assessment schedule is in the

QUEST Integration Provider Manual:

https://hmsa.com/portal/provider/zav_qi.04.ear.50.htm

Filing Claims for EPSDT – CMS 1500

66

File claim with Preventive Medicine CPT 99381-

99385 or 99391-99395 with modifier EP in block

24D

Place “Y” in Block 24H of the CMS 1500

99392 EP Y A 1 XXX XX

Filing Claims for EPSDT

67

PCPs submit a claim and EPSDT form 8015 (or

Form 8016 for catch up visits).

Paper claim - staple EPSDT form to the claim.

Electronic claim - mail EPSDT form separately to:

HMSA QUEST Integration

P.O. Box 3520


The mailed form must be received by HMSA by the time

the electronic claim processes

Filing Claims for EPSDT

Use original printed forms only, available from

ACS

Ordering EPSDT 8015 and 8016 forms:

Call ACS at 952-5570 on Oahu or 1 800-235-4378 toll

free from the Neighbor Islands

Fax request to 1 (800) 952-5595

Email request to [email protected]

Only EPSDT paid if billed with office visit on the

same day

68

69

EPSDT Resources

EPSDT general information url: https://hmsa.com/portal/provider/zav_QI.04.EAR.

50.htm

Sample EPSDT form 8015 (1/10) https://hmsa.com/portal/provider/fm_form_8015_f

ront_and_back.pdf

HMSA’S Electronic

Transaction Services

11/14/2018 71

Electronic Transactions

EDI (Electronic Data Interchange). A communication system

that allows the electronic exchange of data between business

partners such as payers, providers, third party billers, and

clearinghouses.

HMSA supports the following EDI transactions:

Eligibility Verification

Claims Submission

Claim status

Electronic Funds Transfer

Electronic Remittance Advice

Report to Provider (Commercial and Medicare Advantage)

Electronic Transactions HHIN (Hawaii Healthcare Information Network)

HHIN is a free, secure HMSA portal that providers use to access

members’ plan and benefit information.

Transactions that are available on HHIN include:

Eligibility Verification

Plan Benefits

Claim Status

Precertification Requests

Fee Schedules

Report to Provider (Commercial and Akamai Advantage)

11/14/2018 72

Electronic Transactions Electronic Claims Submission

Electronic claims can be submitted two ways:

Bulk processing

Multiple claims sent in a file

Requires an electronic billing system or clearinghouse

Online electronic claim entry (eClaims)

Single claim entered and sent per file

Submitted online

Free submission

Online data edits mean fewer rejected claims

11/14/2018 73


Benefits of submitting electronic claims:

Paperless

Cost and time savings

Quicker turnaround

Improved and more stable cash flow

11/14/2018 74


Who can submit claims electronically?

Participating providers

Nonparticipating providers

Certain restrictions apply

System requirements:

Bulk processing

Qualified electronic billing system

Authorized Clearinghouse

Online electronic claim entry

Internet access

Web browser - Internet Explorer (v7 or higher)

11/14/2018 75

Electronic Transactions Contact Us – Outreach and Training Support

For more information about HMSA’s electronic products, to

request a new set-up, or if you need training, please

contact ETS Outreach.

ETS Outreach

(808) 948-6255 on Oahu

1 (800) 603-4672, ext. 6255 toll-free

[email protected]

11/14/2018 76

Electronic Transactions Contact Us – Technical Support

For technical related questions and issues, please contact:

Electronic Data Interchange (EDI) Help Desk

(808) 948-6355

Toll free at 1 (800) 377-4672

[email protected]

HHIN Help Desk

(808) 948-6446

Toll free at 1 (800) 760-4672

[email protected]

11/14/2018 77

Verifying Member

Eligibility

Verifying Member Eligibility

Check membership ID card at each visit or encounter

Access HMSA’s Hawaii Healthcare Information Network

(HHIN)

Available 24 hours, 7 days/week

Free access and support

Call QUEST Integration Provider Service

948-6486 (Oahu)

1 (800) 440-0640 (Neighbor Islands)

Monday – Friday, 7:45 a.m. to 4:30 p.m.

79


80


81


Benefit designation

NON-ABD

ABD

ABD and LTSS

82


Back of QUEST Integration ID card

83

Claims Filing

Claims/Encounter Form Processing

Common issues affecting claims processing

Patient eligibility

Precertification

Benefit status

Missing claim info

85

Claims Filing Information

Professional services billed on CMS 1500 claim form

Facility services billed on UB-04 claim form

Obtain forms from form vendor

Filing deadline is 365 days from date of service

Other insurance is always primary to QUEST Integration

Bill other insurance before QUEST Integration

Submit QUEST Integration claim with amount of other

insurance payment or copy of insurance denial notice

Paper or electronic submissions accepted

86

Claims Filing Information (cont.)

DHS Form 1147 required for LTC confinement

Only original forms (printed with red ink) accepted for

submission

Submit only 6 lines of service per claim

Font size 10 through 12

Black ink

Proofread before submitting

Billed service(s) must be documented in patient records

Use all CAPITAL letters

87

Claims Filing Information (cont.)

Do not

photocopy CMS 1500 forms

try to squeeze in more info than field can hold

use highlighters

use White-out

88

11/14/2018 89

Rejected claims

All claims undergo validation edits

Claims that fail an edit are cannot enter the processing

system

Rejection letter (Form 97) is sent to the provider

identifying the rejected claim and the reason(s) why it

rejected

Submit a new claim with the correction(s) as noted on the

rejection letter (Do not label as Resubmission)

11/14/2018 90

Claims denied for additional

information

Claims denied on a Report to Provider (RTP)

Reason for denial/requested additional information is

noted on the RTP

See instructions for Resubmitting Claims

11/14/2018 91

Resubmitting Claims

Resubmitted CMS 1500 (paper) claims require the

following:

Requirement CMS-1500

Indication of replacement

claim

Block 22 – Resubmission code “7” –

(Replacement)

Original HMSA Claim ID Block 22 – Original Ref. No. must contain

Original HMSA Claim ID

Reason for correction Block 19 – Reserved For Local Use

Include text explaining reason for

attachments (e.g. op notes, EOB)

Claims without this information will deny as a duplicate

claim

Remember to include any necessary attachments with

the resubmitted claim

11/14/2018 92

Resubmitting Claims (cont.)

Resubmitted 837P (electronic) claims require the following:

Requirement 837P

Indication of replacement

claim

Loop 2300

CLM05-3 (Claim Frequency Code) = "7"

(Replacement)

Original HMSA Claim ID Loop 2300

REF - Payer Claim Control Number

REF01 = "F8" (Original Reference Number)

REF02 = Original HMSA Claim ID

Reason for correction Loop 2300

NTE - Claim Note Segment

NTE01 = "ADD"

NTE02 = text explaining reason for correction

Optional - NTE segment at Loop 2400 line

level if more space is needed.

Submit Paper Claims to:

HMSA QUEST Integration

P.O. Box 3520


93

Special Claim Submission

Procedures LTSS Providers Bill only for contracted services

94

• Adult day care • Adult day health

• Assisted living • Community care foster family

home

• Community care management • Counseling and Training

• Expanded-adult-residential care

home • Home delivered meals

• Non-medical transportation • Personal assistance (Levels I & II)

• Personal emergency response

system • Private Duty Nursing

• Respite care • Specialized medical equipment

and supplies

Special Claim Submission

Procedures LTSS Providers

Bill only for services actually rendered

Do not bill for services during a period of

hospitalization or confinement in a long term care

facility

Use appropriate codes and units

e.g., a code described as ‘per day’ must be billed by

number of days, not minutes

95

Report to Provider (RTP)

Daily claims processing, with payments run on Tuesdays

Checks mailed every Thursday

Electronic deposits may be arranged

Promptly reconcile RTP with accounts receivables

Monitor outstanding claims for follow-up as needed

96

Report to Provider (RTP)

97

Member Billings

No balance billing of QUEST Integration members

Providers accept QUEST Integration payments as

payments in full

Members may be billed for:

• Non-covered services or upgraded services; member-signed Agreement of Financial Responsibility required

• Services rendered before/after eligibility

• Primary insurance payments sent to the member or plan subscriber by the other insurance

• Cost shares

No-show fees cannot be charged to QUEST Integration members.

98

Cost Share

Amount determined by Med-QUEST

Member responsible for paying entire cost share to the

cost share provider or to HMSA

Collected by cost share provider monthly for

institutionalized members and for non-institutionalized

members receiving specific LTSS services

Providers submit collected amounts on field #29 of the

CMS 1500, or in FL 39 using value code 23 on the

UB-04 claim form

99

Cost Share (cont.)

When cost share is greater than claim charges

(e.g. mid-month admission or discharge),

provider will be invoiced for the balance that

couldn’t be collected via claim

100

Cultural

Competency

and Enabling

Services

Cultural Competency

Cultural background and values shape member views

Key cultural messages

• Members are multicultural

• Members have a right to be treated with courtesy, consideration, and respect

• Respect diversity and eliminate biases and preconceptions that can be barriers to successful delivery of health services

QUEST Integration member communications

• Easy to understand English reading level

• Available in locally spoken foreign languages

Provider foreign language capabilities

102

Cultural Competency (cont.)

Outreach and care assistance to members is sensitive to

their beliefs but is aimed at improving their health

outcomes.

Myths about public assistance members:

• They’re noncompliant

• Providers have to make all the healthcare decisions

• Those with disabilities are incapable of discussing their health

• Their superstitions and beliefs are incomprehensible

• They don’t want to talk about their culture, they want to be treated like everyone else

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Cultural Competency (cont.)

HMSA identifies cross-cultural conflicts or complaints

Annual Cultural Competency staff training

Complaints and grievances are trended, analyzed and acted upon in a timely manner

Annual announcement to members to contact HMSA to report situations of lack of cultural adherence

HMSA does not assume that lack of complaints or

grievances indicates that incidents are not occurring

Avenues to identify areas for improvement:

Member communication

CAHPS survey

Member Service contacts

Provider communication

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Enabling Services

Interpreter

Transportation

Auxiliary aids for members with disabilities

Contact QUEST Integration Provider Services for arrangements

948-6486 (Oahu)

1-800-440-0640 (toll free from Neighbor Islands)

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Enabling Services

24-hour Nurse Advice Line

• Free service for HMSA QUEST Integration members

• Medical questions answered

• Advice on treatment options (home, office, ER)

• Phone number on back of member ID card

948-6486 or toll free 1 (800) 440-0640

Select 1 for Members, then Select 1 to speak to a nurse

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Excluded Providers

Excluded Provider

What is an Excluded Provider?

An individual or entity that is not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity.


Search Excluded Provider lists routinely (i.e., monthly) to confirm that employees or contractors are not on any list

AND

Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list

108

Federal Excluded Provider Lists

(QUEST Integration & Medicare

Advantage)

11/14/2018 109

General Services Administration Excluded Parties

List System (EPLS)

https://www.sam.gov/SAM/

List of Excluded Individuals and Entities (LEIE), a

health care specific exclusion list

https://exclusions.oig.hhs.gov/

State Excluded Provider Lists (QUEST

Integration only)

Government contracting exclusion list

http://spo.hawaii.gov/for-state-county-

personnel/manual/debarment/

DHS Med-QUEST Division’s exclusion list

http://www.med-

quest.us/providers/ProviderExclusion_Reinst

atementList.html

110

Administrative

Information

Medical Records Documentation

Maintained a minimum of 7 years from last entry date

For minors, maintained while a minor plus a minimum of 7 years after age of maturity

If PCP changes, transfer records to new PCP within 7 business days from receipt of records request

Records must support submitted claims

• Must be legible

• Must accurately document services provided and billed for

• Must be made available to DHS, HMSA and others as specified by DHS for audit and review purposes

Members have a right to receive copies of their medical records and request corrections

112

Reporting Requirements

Member information

Report all cases of suspected child abuse to DHS Child Welfare Services Section

Report all suspected dependent adult abuse to the DHS Adult Protection Services Section

Claims/encounter data

Submit claims/encounters to document patient services

Services billed/reported must be supported by patient records

Suspected fraud and abuse by members or other providers

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Administrative

Information/Resources Provider Communications

HMSA website: hmsa.com

Provider Portal - https://hmsa.com/provider/portal

QUEST Integration section

HMSA HealthPro News

Other HMSA communications

Alerts on HHIN

https://hhin.hmsa.com/HHIN/Login/Login.aspx

114

Thank you!

Please complete the Webinar Evaluation form,

and fax it to:

948-6887 (Oahu) or

1-800-540-1668 (Neighbor Islands

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116

QUESTIONS?

hmsa quest integration basics

Documents