provider bulletin - evergreen health health provider bulletin • april 2014 ... capacity i oversee...

EVERGREEN HEALTH PROVIDER BULLETIN • APRIL 2014 | 1

Provider Bulletin APRIL 2014 • Volume 1, Issue 1

Welcome to the Evergreen Health network! THANK YOU FOR JOINING US IN PUTTING MARYLANDERS’ HEALTH FIRST.

Peter Beilenson, MD, MPHFounder & CEO, Evergreen Health

We are honored that you have chosen to be in our provider network and pledge to be the easiest insurance carrier to work with in the market. Evergreen Health is Maryland’s first nonprofit health care Co-op, built by local doctors to bring better health care, greater accessibility, increased efficiency, and better service to Maryland’s providers and patients. We are excited to be here and look forward to developing a relationship with you. Our provider relations team is always happy to assist you at 443-475-0105.

You can also visit us online at www.evergreenmd.org/ providers to access your forms and contact us with questions.

Sincerely,

TABLE OF CONTENTS

A Letter from the CMO 2

Provider Payment Options 3

Fraud, Waste, and Abuse 3

Quick Reference Guide 4-5

Provider Claims Reference Guide 6

Provider Portal 7

Coverage Determination & Utilization Management 7

Quality Corner 8

ICD-10 Implementation 8

Evergreen Health Industry Partners 9

Important Phone Numbers 9

Evergreen Health’s Provider Bulletin is published biannually for providers.


CHOLESTEROL GUIDELINES: The new cholesterol guidelines (American College of Cardiology and the American Heart Association cholesterol treatment guidelines, released November, 2013) dismantle the imperative to treat to lipid target levels, and emphasize the importance of making decisions with an appreciation of absolute risk. This is a radical change. For those with known cardiovascular disease, the new recommendation is to treat all adults, regardless of LDL choles-terol level. For prevention, the new guidelines recommend treating for those with an LDL cholesterol level of 70 mg per deciliter or higher for those with diabetes or a 10 year risk of cardiovascular disease of 7.5% or more as estimated on the basis of a new equation.

HYPERTENSION GUIDELINES: The JNC 8 was released February, 2014 and highlight new blood pressure treatment thresholds. Unlike prior guidelines, these are (mostly) evidence based. If you are older than 60 years, the new guideline is to treat for a blood pressure goal of < 150/90 mm Hg (old recommen-dation was to start medication at 140/90 or >). For those 30-60 years of age, the goal is a blood pressure < 140/90 mm Hg (the systolic recommendation is expert opinion but the diastolic is evidence based). For patients who have kidney disease and diabetes, the goal is 140/90 mm Hg. For medications, non-African American patients should be started on an ACE inhibitor, ARB, Calcium channel blocker or thiazide diuretic. African American patients should be started first on a Calcium channel blocker or thiazide diuretic.

We are thrilled that you are a participating provider in Evergreen Health’s network. I am responsible for Evergreen Health’s Clinical Services Department. In that capacity I oversee our provider network and act as a liaison between you and our organization. I also manage our credentialing process, quality efforts, utilization management, case management, and behavioral health. My overall goal as Chief Medical Officer is to improve the health of our members and support the delivery of high quality health care. To that end, on our website we have posted our Clinical Practice Guidelines and Reference Material for your convenience. I’d like to highlight 2 new and important clinical guidelines: cholesterol guidelines and hypertension guidelines (see sidebar at right). Please note that a recent review in JAMA (Krumholz, 2014) pointed out that the guidelines are “evidence-based recommendations, not iron clad rules.” They are not substitutes for clinical judgment. In the cholesterol guidelines, where the risk estimation is paramount, the authors point that the estimated 10-year risk should be the start of the clinician–patient discussion; patient preference should be addressed and the conversation should not automatically lead to statin initiation. These guidelines and other important documents can be viewed online at www.evergreenmd.org/providers. I look forward to working with you. If I can ever be of assistance, please don’t hesitate to contact me at [email protected].

Alex Blum, MD, MPHChief Medical Officer, Evergreen Health

Go to www.evergreenmd.org/providers to access your forms and contact us with questions.

A LETTER FROM

EVERGREEN HEALTH’S

Chief Medical Officer


Provider Payment OptionsEvergreen Health is excited to offer you a number of payment options through our electronic payment vendor, ECHO Health. Below is a summary of the payment options available.

1. Direct ACH/EFT payments – Contact Direct ACH: 855-475-0990

2. QuicRemit Payment – Contact QuicRemit: 877-705-4230 QuicRemit is a paperless system that pays providers faster through their credit card terminals. A virtual “Debit Card” is printed on the Explanation of Provider Payment (EPP) and by dialing in the card number the money is deposited immediately.

3. Simplicity EFT/ERA - Contact ECHO: 888-834-3511

4. Optum Electronic Payment System (EPS) Payment – Contact Optum Health: 866-802-8588 The Optum Network is also utilized through the ECHO relationship. The Optum Network is another way to electronically and paperlessly pay providers without the credit card routing.

5. Paper

FOR MORE INFORMATION ABOUT PAYMENT OPTIONS GO TO: www.evergreenmd.org/providerpayment

Fraud, Waste, and Abuse At Evergreen Health, we believe that preventing insurance fraud, waste and abuse is part of our goal to provide high quality health care to our members. Nationwide, insurance fraud, waste and abuse costs are estimated to be over $80 billion dollars per year and that increases the costs of health insurance and health care services for all of us. Insurance fraud is not only expensive, it is a crime.

WHAT IS INSURANCE FRAUD? In Maryland, insurance fraud includes fraud committed by members, providers, brokers or employees. Fraud can be committed by completing an enrollment application with false information, submitting a falsified claim, or enrolling as a member when you are not eligible for health insurance coverage. To prevent insurance fraud, Evergreen Health asks that everyone—employees, providers, brokers, and members—be vigilant in reporting suspected insurance fraud.

TO SEND A REPORT BY PHONE: Call the Evergreen Health Reporting Hotline at 855-490-1549.

TO SEND A REPORT BY EMAIL: [email protected] Please note that a report filed by email cannot be guaranteed to be anonymous since the email address of the sender will appear on the message transmitted to Evergreen Health, however we will keep such information confidential.

CONTACT BY U.S. MAIL: Send a letter with a description of the suspected fraudulent activity and all available details to: Chief Compliance Officer, Evergreen Health Cooperative Inc., 3000 Falls Road, Suite 1, Baltimore, MD 21211

To learn more about Fraud, Waste, and Abuse or to file a report go to: www.evergreenmd.org/fraud-waste-and-abuse

Evergreen Health Partner Benefits

We have shortened our pre-authorization list.

Turnaround time is 24 hours for expedited prior authorization and within 48 business hours for routine prior authorization.

We pride ourselves on excellent customer service for our providers and members.

We have systems in place to pay claims in a timely manner and ensure you are paid for the care you provide ASAP.

We have a provider relations team that is available by phone, email, and fax and ready to educate you and your staff about Evergreen Health.

Our credentialing process is provider- friendly.

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SAMPLE MEMBER ID CARDFront (Individual) Back Front (Small Group)

PROVIDER CUSTOMER SERVICE 855-729-0077

PROVIDER RELATIONS 443-475-0105

PRIOR AUTHORIZATION 855-776-8839

MEMBER TTY 800-735-2258

VERIFY ELIGIBILITY AND CHECK CLAIMS STATUS

855-729-0077 www.evergreenmd.org/providerportal

NUMBER TO CALL IF MEMBER PRESENTS WITHOUT A CARD 855-475-0990

PROVIDER CLAIMS ADDRESS

Evergreen Health Claims Processing CenterP.O. Box 2907Clinton, IA 52733-2907EMDEON: PAYOR ID 45319

PREFERRED LAB VENDOR LabCorp

PREFERRED RADIOLOGY VENDORS

Advanced Radiology, P.A.American Radiology Associates, P.A.Clinical Radiologists Medical Imaging, P.A.Community Radiology Associates, Inc.Drs. Korsower & Pion Radiology, P.A.

IMPORTANT INFORMATION

Quick Reference Guide2014


VENDOR NAME SERVICE PROVIDEDPROVIDER PHONE NUMBER

PROVIDER & MEMBER CLAIMS ADDRESS

BLOCK VISIONRoutine Vision < 19 HSA & Platinum plans: adult eye exam only

866-819-4298939 Elkridge Landing Road Suite 200Linthicum, MD 21090

DENTAQUEST Dental < age 19 (select plans offer dental) 800-334-6277 PO Box 399

Mequon, WI 53092

VALUEOPTIONSMental Health/ Substance Abuse Treatment Services

855-816-7622 P.O. Box 383Latham, NY 12110

CATAMARAN Retail, Mail Pharmacy, Specialty 855-577-6516

CatamaranP.O. Box 5216Lisle, IL 60532-5216

ADMINISTRATIVE APPEALS CLINICAL APPEALS

Evergreen Health Claims Processing CenterP.O. Box 2907Clinton, IA 52733-2907

Evergreen HealthHealthCare Management Dept.P.O. Box 83301Lancaster, PA 17608-3301

PRIOR AUTHORIZATIONS GUIDELINES*

• Facility admissions—acute, rehab, LTAC, SNF, Hospice• Organ transplant, including evaluation• Inpatient mental health and substance abuse• Partial hospitalization• Intensive outpatient services• Substance abuse treatment, including residential services• Ambulatory surgeries• Observation after 24 hours• Diagnostic radiology (PETs, MRIs, MRAs)• Nuclear cardiology• IMRT

• Air ambulance• Chiropractic services (after the first ten visits)• Podiatry (after the first ten visits)• Proton beam therapy• Infertility services• Home health services (PT/OT/ST/RN/Hospice)• Prosthetics and orthodics• Out of service area requests• Genetic testing• Rehab services• Infusion services• Medical injectables• DME—rental for more than 3 months or >$1000

* LIST IS NOT INCLUSIVE OF ALL PROCEDURES. PROVIDER SHOULD CALL 855-776-8839 TO VERIFY ELIGIBILITY, BENEFITS AND PRIOR AUTHORIZATION STATUS BEFORE SERVICES ARE RENDERED.

CALL: 855-776-8839 OR FAX: 877-411-4917

VENDOR INFORMATION


HOW DO I VERIFY MEMBER ELIGIBILITY AND BENEFITS?

BY PHONE: Call Provider Services at 855-729-0077 to verify eligibility via an automated line. Alternatively, a provider may speak with a Provider Services Representative to verify benefits.

ONLINE: Evergreen Health providers have access to an online eligibility verification system. Go to www.evergreenmd.org/ providerportal.

Note that each member is issued a member identification (ID) card. The Member ID card contains member and provider information, including the member’s identification number, plan code, and co-payment amounts.

Since changes do occur with eligibility, the card alone does not guarantee member eligibility.

WHERE DO I SUBMIT A CLAIM?

ELECTRONIC: Evergreen Health’s clearinghouse is Emdeon. The payor ID is 45319. Providers interested in using Emdeon should contact their customer service office and ask them how to enroll. The Emdeon number is 866-924-4634.

PAPER: Paper claims must be submitted on the most current CMS 1500 or UB04 forms. All information must fit properly in the blocks provided.

WHAT IS THE ADDRESS FOR SUBMITTING A CLAIM?

Evergreen HealthClaims Processing CenterP.O. Box 2907Clinton, IA 52733-2907

HOW MANY DAYS DO I HAVE TO SUBMIT A CLAIM?

Per Maryland law, claims must be submitted to Evergreen Health within one hundred eighty (180) calendar days from the date of service.

WHAT HAPPENS IF I SUBMIT MY CLAIM AFTER 180 DAYS?

Claims submitted beyond the timely filing limit are generally rejected. If the claim is rejected, and there exists proof via an Explanation of Benefits (EOB) that the claim was submitted to Evergreen Health within the

timely filing requirements, a request for reconsideration may be made by filing an administrative claims appeal. For electronic claims, Evergreen Health must receive a clearinghouse confirmation showing that Evergreen Health successfully accepted the claim. Print-outs from billing systems are not acceptable documentation.

HOW DO I FILE A CLAIM APPEAL?

A claim appeal should be sent to the address listed below within ninety (90) working days of the denial as indicated on the Explanation of Benefits. Please send a written request outlining reasons for appeal with all neces-sary documentation to the Evergreen Health Claims Processing Center.

At a minimum, the appeal should include a copy of the claim and the Explanation of Benefits. A provider appeal must include a clearly expressed desire for re-evaluation, with an indication as to why the denial was believed to have been issued incorrectly. If Evergreen Health receives only an Explanation of Benefits with items circled, this will not constitute a dispute and will be handled as a correspon-dence. Evergreen Health will make a decision on the appeal within thirty (30) calendar days of receipt of the appeal.

All appeals should be sent to the following address:

Evergreen Health Claims Processing Center P.O. Box 2907 Clinton, IA 52733-2907

Claim denials that are overturned on appeal will be paid within thirty (30) calendar days of the decision. Evergreen Health will not take any punitive action against the provider for utilizing the provider appeal process.

CAN I REPORT MULTIPLE SERVICES FOR ONE PROVIDER?

No. If more than one provider in your practice renders services for a given member, separate claims must be submitted for each provider.

WHAT CODING GUIDELINES DOES EVERGREEN HEALTH UTILIZE WHEN PROCESSING CLAIMS?

Evergreen Health follows NCCI (National Correct Coding Initiative) guidelines and utilizes the Claim Check software. ICD-9 (future ICD-10), CPT, and HCPCS codes

in the medical record must match what is being requested for authorization and what is billed to Evergreen Health.

WHAT ARE EVERGREEN HEALTH’S GUIDELINES FOR CLEAN CLAIM ATTACHMENTS?

Per Maryland’s clean claims legislation adopted under COMAR 31.10.11, uniform claims submission requirements must be followed. Any of the required fields that are not used for claims processing must be reported on the online Semi-Annual Maryland Insurance Administration Claims Data Filing Form. This clean claims legislation requires Evergreen Health to identify the Standard Required Attachments to claims. The following describes circumstances under which the identified attachment is required for submission with the claim:

• An Explanation of Benefits statement from a primary commercial payer if Evergreen Health is secondary.

• A Medicare remittance notice, if Medicare is primary and Evergreen Health is secondary.

• Information related to an audit, if a pattern of fraud, improper billing, or coding is demonstrated.

• Invoices will need to be sent on observation claims that are >24 hrs. (units)

WHAT IS THE TURNAROUND TIME FOR CLEAN CLAIMS BEING PAID?

Clean claims will be paid within 30 days of receipt, in accordance with Maryland law. To inquire about claims status, contact the Claims Department or check the provider portal at www.evergreenmd.org/providerportal

CONTACT THE EVERGREEN HEALTH CLAIMS PROCESSING CENTER?

The phone number is 855-729-0077. The hours of operation are Monday – Friday, 8:00-5:00 EST.

Provider Claims Reference Guide

To find out what labs are reimbursed when performed in the office setting go to: www.evergreenmd.org/providers


Coverage Determination AND UTILIZATION MANAGEMENT DECISIONS

At Evergreen Health, health care coverage and medical necessity decisions are based on applicable federal and state regulations, clinical policies and/or guidelines and utilization management (UM) decision-making criteria that are objective and based on medical evidence. Here are some additional details on the resources used during the decisions processes:

• We use the applicable definitions in the member-

specific document to determine coverage.

• In making medical necessity decisions, we use

nationally developed decision-making criteria

and/or internal criteria which have been developed

in conjunction with network practitioners.

Please note that UM decision-making at Evergreen Health is based only on the appropriateness of care and service and the existence of coverage. We do not offer financial incentives to physicians to encourage underutilization of care or services, or encourage barriers to care and service. Practitioners or others are not rewarded for issuing denials of coverage.

The medical necessity and coverage determination process is focused on ensuring that Evergreen Health members receive the most appropriate care based on applicable law, evidence based medicine and their benefit plan design.

In order to assist in the management of health care for Evergreen Health members, practitioners and physicians may obtain a copy of specific UM clinical criteria or discuss utilization management decisions.

Practitioners may call to discuss a Utilization Management decision or process with the UM staff or a physician reviewer or request a copy of Evergreen Health’s Clinical Criteria by calling 855-475-0990, Monday through Friday between the hours of 8:00 a.m. to 7:00 p.m. If you are calling after normal business hours, please leave a message on the confidential voicemail and a designated UM staff person will return your call.

Sign in to theEvergreen Health Provider Portal.The Evergreen Health self-service portal brings you better and more personalized service.

GO TO: www.evergreenmd.org/providerportal

USE THE NEW PORTAL TO:

• Update your account profile

• Check the status of claims

• Check eligibility history

• Send messages and inquiries to various departments

• Download a provider directory


UPDATE: On April 1st, President Barack Obama signed the “Protecting Access to Medicare Act of 2014,” which creates a one-year patch for the Sustainable Growth Rate (SGR) and also included a one year delay in the conversion to ICD 10.

WHY WE NEED TO UPDATE TO ICD 10: The ICD system allows tracking and payment for every medical procedure. But the current ICD 9 coding system is now four decades old, and it does not meet the needs of our modern medical systems.

One clear example of this is the number of codes for procedures: ICD-9 only offers about 4,000 codes for procedures while ICD-10 has about 72,000.

Without enough codes, health outcome data is not as accurate. Cardiologists, for example, can’t differentiate between the dozens of different kinds of implants now commonly used to open clogged arteries. And without the data, comparison studies cannot determine head to head success rates of those various stents. In addition, ICD 10 should help speed the processing of claims, because payers will get more detailed information.

As of the publishing of this newsletter, the implementation is delayed until October of 2015. We will keep you updated on any new information as we receive it.

QUALITY

CORNER

Evergreen Health promotes the use of clinical practice guidelines to:

• Define clear goals of care based on the best available scientific evidence

• Reduce variation in care and outcomes

• Provide a more rational basis for clinical management of some conditions

• Comply with accreditation standards and regulatory expectations

A detailed summary of the clinical and preventive health guidelines is available for your reference on www.evergreenmd.org/providers. If you prefer a hard copy, call 855-475-0990 and we will mail it to you.

Evergreen Health has adopted evidence-based clinical practice and preventive health guidelines as roadmaps for healthcare decision-making targeting specific clinical circumstances.

ICD-10 Implementation Delayed until 2015

ICD -10 includes over 72,000 codes for very specific medical events. For example, W5803XA is the code in case your patient is crushed by an alligator.

Crushed by an alligator?

There’s a code for that!(ICD-10) W5803XA


PROVIDER RELATIONS

[email protected]

MEMBER SERVICES

[email protected]

SALES & ENROLLMENT

FOR INDIVIDUALS & FAMILIES

443-839-0585

[email protected]

OUTREACH & COMMUNITY RELATIONS

[email protected]

CORPORATE OFFICES

[email protected]

FRAUD, WASTE & ABUSE REPORTING:

[email protected]

EVERGREENMD.ORG

CALL US 443-475-0990 HABLAMOS ESPAÑOL. LLAME AL 443-839-0753

If you have questions, comments, or concerns, we want to hear from you!

Evergreen Health Industry PartnersAt Evergreen Health, we’re proud to partner with Catamaran, ValueOptions, Block Vision, and DentaQuest to bring members comprehensive health coverage from industry leaders.

Catamaran provides retail and mail order pharmacy benefits to Evergreen Health members. They are also Evergreen Health’s exclusive vendor for specialty medications. The formulary can be found at www.evergreenmd.org/formulary. To obtain prior authorization for medications, call Catamaran at 855-577-6516.

Block Vision provides pediatric vision coverage for patients under the age of 19. For some Evergreen Health plans, a routine vision exam is covered for adults. Call 866-819-4289.

ValueOptions providers both mental health and substance abuse treatment services to members at any time, with no need for a physician referral. Call 855-816-7622.

IMPORTANT PHONE NUMBERS

Members should contact the Evergreen Health member services phone number on the front of their card for questions about their vision, dental or behavioral health benefits or to get assistance locating a provider.

Members should call Catamaran directly for any pharmacy related questions at 855-577-6516.

For those plans that include dental coverage, DentaQuest is the administrator of dental benefits. Call 855-816-7622.

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