Provider-Led Arkansas Shared Savings Entity (PASSE) provider orientation

Table of contents

• PASSE Program — overview

• Covered services and excluded services

• About us

• Provider network participation

• Benefit service partners

• Pharmacy services

• Availity Portal — eligibility/benefits, prior authorizations (PAs), claims Provider roles and responsibilities

• Provider communications

• Quick Reference Guide — key contact information

• Provider manual and additional resources

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PASSE Program —overview

PASSE Program

What is the purpose of the PASSE model?

• To improve the health of Arkansans who need intensive levels of specialized care due to behavioral health (BH) issues or developmental/intellectual disabilities

• To link providers of physical health care with specialty providers of BH and developmental/intellectual disabilities services

• To coordinate care for all community-based services for these individuals

• To allow flexibility in the array of services offered

• To increase the number of service providers available in the community to the population covered

• To reduce cost of care by coordinating and providing appropriate and preventive care

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PASSE Program (cont.)

Who is served by the PASSE entities?

PASSE enrollment population includes only:

• Individuals receiving services through a developmental disability (DD) waiver.

• Individuals on the DD waiver waitlist and receiving state plan services.

• Individuals who are in private DD intermediate care facilities.

• Individuals who have a BH diagnosis and have received an independent assessment that determines they need services in Tiers 2 or 3.

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Care coordination

• Responsible for bringing together all plans of care for a member

• Ensures member access to all behavioral and medical services

• Seeks to maximize efficiency in service delivery

• Serves as liaison between member, providers and the health plan

• Serves as general advocate for members’ needs

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Care coordination — DHS defined metrics

• Caseload — 90 percent of care coordinators with a case load < 50

• Initial outreach — 75 percent of members contacted within 15 days of attribution to Summit Community Care

• Hospital follow-up — 50 percent of members contacted within seven days of discharge from ER or hospital or inpatient psychiatric facility

• Monthly contact — 75 percent of members with successful monthly contact by care coordinator

• Quarterly contact — 75 percent of members with successful face-to-face meeting quarterly with assigned care coordinator

• PCP assignment — > 80 percent of members will have assigned PCP

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Covered services

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Community & Employment Supports

Respite Supplemental Support Consultation

Supported Employment Adaptive Equipment Crisis Intervention

Supported Living Specialized Medical Supplies

Community Transition Services Environmental Modifications

Arkansas Community Independence Services

Supportive Employment Planned Respite Behavior Assistance

Peer Support Emergency Respite Crisis Intervention

Family Support Partners Therapeutic Host Home Mobile Crisis Intervention

Child & Youth Support Services

Community Reintegration Program

Individual Life Skills Development

Therapeutic Communities Supportive Housing Partial Hospitalization

Adult Rehabilitation Day Treatment

Supportive Life Skills Group Life Skills Development

State Plan Services

Personal Care Physician Specialists Family Planning

Primary Care Physician Pharmacy Inpatient Psychiatric

Durable Medical Equipment Hospital Services Outpatient Behavioral Health Counseling Occupational Therapy Physical Therapy

Speech Therapy Nursing Services

Excluded services

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The following services will be available to PASSE members, but the service provider will continue to bill the Arkansas Medicaid program directly for these services.• Dental benefits (For assistance with dental benefits, refer to the state

vendor MCNA Dental at 1-844-341-6292.)• School-based services provided by school employees• Nonemergency medical transportation (For assistance scheduling

transportation, refer to the State vendor NET at 1-888-987-1200).

Members needing assistance securing any of these services through the Arkansas Medicaid program can contact their assigned care coordinator.

Expanded services

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Summit Community Care removed certain limitations from the current Medicaid benefits:• Annual limits on physician visits — For adults 21 and older, the limitation of

12 visits per calendar year no longer applies.• Annual prescriptions — No annual limit; the limitation of six prescriptions

per month no longer applies.• Outpatient hospital — For adults 21 and older, the limitation of $500 per

year for outpatient laboratory, radiology and machine test procedures no longer applies. (Advanced imaging and diagnostics may require PA.)

• Specialty referrals — Authorization for referrals to specialty physicians is no longer required.

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About us

About us

Summit Community Care is a joint venture comprised of the Arkansas Provider Coalition, LLC (APC) and Anthem Partnership Holding Company, LLC (Anthem), a wholly owned subsidiary of Anthem, Inc.

Arkansas Provider Coalition is comprised of 75 provider investors across the state and maintains 51 percent ownership in Summit Community Care.

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Leadership

• Jason Miller — Plan President

• Daniel Bell, M.D. — Medical Director

• Dan Johnson — Chief Financial Officer

• Brenda Tompkins— Director II, Healthcare Management Service (HCMS)

• Stephanie Martin — Clinical Quality Director

• Stephanie Carpenter — Compliance Director

• Jeff Allen — Director, Network Relations

• Jessica Anderson — President, Care Coordination (APC)

• Tiffany Parkhurst — Director of Operations, Care Coordination (APC)

• Ashley Hubbard — DD Director, Care Coordination (APC)

• Shelly Evans — Behavioral Health Director, Care Coordination (APC)

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Provider network participation

Provider network participation — joining the network

Network participation request

• Our contracting and credentialing process is easy. Download the required documents by selecting Join our Network under the Provider tab on our website at www.summitcommunitycare.com/provider. Email completed documents to Providers@SummitCommunityCare.com.

The credentialing process

• Provider Relations will contact you to discuss submitted documents and next steps to execute a participation agreement.

Provider setup

• Following successful completion of any credentialing requirements and counter-signature of the participation agreement, you'll be configured in our system and listed in the Provider Directory.

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http://www.summitcommunitycare.com/provider

Provider network participation — updating information

Updating demographic or other practice information is easy!

Complete the Practice Profile Update Form on our website and email it to Providers@SummitCommunityCare.com or submit it via fax to 1-844-839-9308.

You can find the form by:

• Selecting the Resources tab at the top of the homepage.

• Selecting Forms.

• Selecting + next to Other Forms.

• Selecting Practice Profile Form to open the document.

The form is also available at: https://provider.summitcommunitycare.com/docs/inline/ARAR_CAID_PracticeProfileUpdateForm.pdf.

Note: Any updates to billing information will require a W-9.

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https://provider.summitcommunitycare.com/docs/inline/ARAR_CAID_PracticeProfileUpdateForm.pdf

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Benefits service partners

Benefits service partners

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Benefits service partner Contact information

Pharmacy services ― effective October 1, 2019IngenioRx

www.ingenio-rx.comSpecialty pharmacy phone: 833-262-1726 (24 hours/7 days a week) Fax: 833-263-2871

Vision and medical eye care servicesEyeMed

www.eyemedinfocus.comDedicated Summit Community Care line:833-279-4364

http://www.ingenio-rx.com/http://portal.eyemedvisioncare.com/wps/portal/em/eyemed/providers

Pharmacy management information

Need up-to-date pharmacy information?

• Log in to our provider website to access our formulary, PA forms, Preferred Drug List (PDL) and process information (https://provider.summitcommunitycare.com/arkansas-provider/pharmacy).

Have questions about the formulary or need a paper copy?

• Call our Pharmacy department at 1-844-462-0022. Pharmacy technicians are available Monday-Friday from 8 a.m-8 p.m. and Saturday from 10 a.m.-2 p.m. Eastern time.

• Our Member Services representatives serve as advocates for our members. To reach Member Services, call 1-844-405-4295.

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https://provider.summitcommunitycare.com/arkansas-provider/pharmacy

Pharmacy ― Preferred Drug List (PDL)

• Summit Community Care will maintain a Preferred Drug List (PDL) that is at least equivalent to the standard benefits of the state.https://provider.summitcommunitycare.com/arkansas-provider/pharmacy.

• If a generic equivalent drug is not available, a new brand-name drug rated as P (priority) by the FDA will be added to the formulary. Coverage may be subject to prior authorization to ensure medical necessity for specific therapies.

• For formulary drugs requiring prior authorization, a decision will be provided in a timely manner to adversely affect the member’s health. Decisions are made within 24 hours of receipt of the request to comply with federal regulations. If we are missing necessary clinical information that is critical to the review, the service will be denied.

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https://provider.summitcommunitycare.com/arkansas-provider/pharmacy

Pharmacy prior authorization

Providers are strongly encouraged to write prescriptions for preferred products as listed on the PDL. If for medical reasons a member cannot use a preferred product, providers are required to contact Pharmacy Services to obtain prior authorization in one of the following ways:• To initiate PA electronically, to go

https://www.covermymeds.com/main/partners/anthem.• To initiate a PA telephonically, call 1-844-462-0022 and respond Pharmacy at

the main menu. Select option 2 to verbally request a PA.• To initiate a PA via fax, send the Medication Prior Authorization Form to Summit

Community Care Retail Pharmacy at 1-844-429-7761. The Medication Prior Authorization Form can be found athttps://provider.summitcommunitycare.com/arkansas-provider/pharmacy.

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https://www.covermymeds.com/main/partners/anthemhttps://provider.summitcommunitycare.com/arkansas-provider/pharmacy

Pharmacy issued DME/medical soft goods

DME and certain medical soft goods such as diabetic supplies (test strips, meters, insulin pumps), nebulizers and syringes are covered under the medical versus pharmacy benefit and must be billed directly to Summit Community Care.

Providers billing under the medical benefit must be registered with the Arkansas Medicaid program as a DME provider and must maintain a Participating Provider Agreement directly with Summit Community Care. If the pharmacy has any questions about whether they are a contracted DME provider, please have them contact Providers@SummitCommunityCare.com. Pharmacies wanting to submit DME claims to Summit Community Care can register with Availity at https://www.availity.com and/or submit paper claims to the address on the back of the member’s ID card.

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https://www.availity.com/

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Availity — secure provider website

Our provider website and our secure provider website — Availity Portal

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Provider website: https://www.summitcommunitycare.com/provider

Availity Portal: https://www.availity.com

Our provider website is available 24/7 regardless of participation status – registration and a login are not required for access. The following tools are available:• Claims forms• Critical Incident Form and process• Prior authorization tool• Provider manual• Clinical Practice Guidelines• News and announcements• Provider Directory• Fraud, waste and abuse resources• PDL• Steps to become an in-network provider

Registration and login are required for access to: • Prior authorization tool• Patient360 (provider facing)• Multiple eligibility and benefits inquiry• Provider Online Reporting Tool (POR)• PCP member panel listings • Interactive Care Reviewer (ICR)• Pharmacy authorizations (pharmacy

benefits)• Claims dispute submission • Claims inquiry• Medical appeal authorization submission

https://www.summitcommunitycare.com/providerhttps://www.availity.com/

Availity Portal

Availity Portal is a secure website to access your Summit Community Care online tools and resources. It provides access to real-time information and instant responses in a consistent format regardless of the payer.

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Functionality available on Availity Summit Community Care applications in Payer Spaces on Availity

Eligibility and benefits Remittance inquiry

Member ID card Claims status listing

Claims status inquiry Clear Claim Connection

Claims submission Patient360

Medical claim attachments Prior authorization tool

Claim disputes Maternity HEDIS®

Authorization requests and inquiries

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Availity Portal (cont.)

• Providers are required to register to access Availity (https://www.availity.com).• Multiple resources and trainings about site navigation are available. • Specific Summit Community Care training and general Availity training is

available through Help & Training. Select Get Trained to access the Availity Learning Center.

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https://www.availity.com/

Billing guidelines/NPI versus Medicaid ID

Providers must bill according to how the provider is registered with the Arkansas Medicaid program; only use an NPI if it is registered for a given provider service type.

Even if a provider maintains an NPI, if the NPI is not registered with the Arkansas Medicaid program, the provider should not include the NPI on the claims submission.

If a provider renders services for which they do not have an NPI registered with the Arkansas Medicaid program (i.e., atypical providers), the provider should bill for those services using only their Arkansas Medicaid provider ID number.

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Billing guidelines/NPI versus Medicaid ID (cont.)

Availity registration allows all providers to set up an Express Entry, which streamlines any data entry requirements.

Atypical providers may register for claims submission of their atypical services without entering an NPI. For reference on completing an Express Entry in Availity as an atypical provider, please see the May 10, 2019, Atypical Provider Claims & Billing Instructions update listed on the Summit Community Care website at https://provider.summitcommunitycare.com/arkansas-provider/archives .

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https://provider.summitcommunitycare.com/arkansas-provider/archives

Availity — Express Entry

• Once logged into Availity, select Express Entry through My Providers.

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Availity — Express Entry (cont.)

• Select Add Provider.

• In the drop-down menu, select the arrow next to Select Organization. (This is the payer.)

• Only available options will be listed.

• If multiple options exist, the provider will be loaded into the selected organization.

Note: A separate process exists for copying providers from one organization to another.

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Availity — Express Entry (cont.)

• For providers with an NPI registered with the Arkansas Medicaid program, enter NPI and select Add Provider.

• For atypical providers, once you have selected the organization, select This provider is not required to have an NPI.

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Availity — Express Entry (cont.)

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For atypical providers:

• The Manage Express Entry screen will load, which does not request your NPI.

• The Payer Assigned Provider Identifier is the provider’s Arkansas Medicaid provider ID.

PCP selection

• A member must select a PCP or Summit Community Care will assign one.

• A member may see any PCP in the Summit Community Care provider network. Members may not select a PCP unless the PCP is listed as accepting new members in the Provider Directory.

• If a member requests a change in PCP assignment, the change will be made within 24 hours from the time the request was made.• Members can change their PCP at any time. • Members may select a PCP from the Provider Directory or call

Member Services at 1-844-405-4295.• A member may see a specialty provider without a referral.

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Member ID cards

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• Members will receive a Summit Community Care member ID card.• Ask your patients for their new Summit Community Care member ID cards.

Providers may also access the member’s Summit Community Care ID number in Availity by checking eligibility using the member’s existing Medicaid ID number. Claims submissions must include the Summit Community Care member’s ID number.

• Assigned PCP is not on the member ID card.• Local office address is on the front, and paper claims submission address is on

the back.

SAMPLE

PCP member listing tool

The PCP member listing tool is available in Availity for providers to research and download a complete list of past and current members assigned to their specific provider, group or independent practice association. • PCP member listings include data captured at the close of

business on the previous day.• PCP member listings and reports are accessible via the POR

application in Availity under Payer Spaces. • Following initial registration in Availity, an additional registration

within POR is required to access the PCP member listing.

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Prior authorizations

Planned/elective admissions

Providers must receive prior approval at least 72 hours prior to the admission or scheduled procedure to ensure the proposed care is a covered benefit, medically necessary and performed at the appropriate level of care. Authorizations can be submitted via:• Availity: https://www.availity.com• Fax:

• Inpatient physical health (IP PH): 1-844-815-4711• Outpatient physical health (OP PH): 1-844-858-0824• Behavioral health (IP BH): 1-877-434-7578

• Phone: 1-844-462-0022

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https://www.availity.com/

Planned/elective admissions (cont.)

• Failure to comply with notification rules will result in an administrative denial.

• A medical necessity review will be conducted using applicable nationally recognized clinical criteria.

• If needed, additional supporting documentation may be requested to determine if the request is medically necessary.

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PA for inpatient admissions

All inpatient admissions, both elective and emergent, require PA. PA with supporting documentation is required for:• Planned/elective admission.• Inpatient surgery.• Skilled nursing facilities (limited rehabilitation stays).• Acute rehabilitation.• Acute crisis unit.• Residential levels of care.

Note: Providers are required to submit either the Physical or Behavioral Health Precertification Form within 24 hours of making an emergent inpatient admission.

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PA for inpatient admissions (cont.)

Notification is required for the following services; however, for these services, clinical information is not needed since they do not require a medical necessity review:• Observation: Only needed for nonparticipating facilities• OB deliveries: Medical necessity review required for anything over a 48-hour

stay for vaginal delivery and over a 72-hour stay for a Cesarean section delivery

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PA for inpatient admissions (cont.)

Emergent inpatient admissions require notification within one business day following admission. Authorizations can be submitted via:• Availity: https://www.availity.com• Fax:

• IP PH: 1-844-815-4711• OP PH: 1-844-858-0824• IP BH: 1-877-434-7578• OP BH: 1-800-505-1193

• Phone: 1-844-462-0022

Failure to comply with notification rules will result in an administrative denial. All medical emergent inpatient hospital admissions will be reviewed within one business day of the facility notification to Summit Community Care.

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https://www.availity.com/

PA ― outpatient services

PA is required for the following:• Certain BH levels of care*• Out-of-network (OON) services • Outpatient services*• Outpatient DME purchases and rentals*• Specialty drugs transplant services*• Certain diagnostic Imaging*

* As outlined in the prior authorization tool on our website (https://provider.summitcommunitycare.com/arkansas-provider/prior-authorization-lookup).

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https://provider.summitcommunitycare.com/arkansas-provider/prior-authorization-lookup

PA – waiver services

• Revised model for the Community Employment & Supports (CES) waiver services currently in development and configuration.

• Identify distinction between waiver waitlist and true waiver members as benefits will differ.

• CES waiver services should be requested in conjunction with care coordinator and, as much as possible, during the person centered service planning meeting.

• Currently, requests can be sent to Ashley Hubbard, DD Director, (Ashley.Hubbard@SummitCommunityCare.com) or to Utilization Management via fax at 1-844-815-4715 ― for waiver services only.

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Authorization review time frames

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Expedited PA request Time frame for decision

Standard authorization request As expeditiously as required by the enrollee’s/member’s condition, not to exceed two business days

Expedited prior authorization request* As expeditiously as required by the enrollee’s/member’s condition, not to exceed one business day

Final determinations will be communicated to the facility.

Summit Community Care’s failure to meet these requirements will result in the requested service being deemed approved. Services must be a covered benefit.

Note: Expedited requests will be completed when “following the standard time frame could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function” (Code of Federal Regulations Title 42 §438.210).

Denial management (medical necessity)

• Outpatient: If medical necessity requirements are not met, the case is forwarded to the medical director for review. Additional clinical can also be submitted to support the request. If a denial is issued, the provider may request peer review for reconsideration, to be completed within two business days of the issuance of the denial.

• Inpatient: If medical necessity requirements are not met, the case is forwarded to the medical director for review. Paper or peer review may be requested by the provider. If denial is issued after paper review, peer-to-peer reconsideration can be requested, to be completed within two business days of the issuance of the denial.

If denials are upheld and peer-to-peer reconsideration timeline is exhausted, the case may move to the Medical Appeals process.

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Patient360

Patient360 is a real-time dashboard that gives a picture of a patient’s health and treatment history to help facilitate coordination of the member’s care.

Patient360 includes but is not limited to: • Demographic information. • Authorization details. • Care summaries. • Pharmacy information. • Claims details.• Care management activities.

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Patient360 (cont.)

To access Patient360: • Log in to our secure provider website at https://www.availity.com.• Select Payer Spaces/Summit Community Care.• Choose Patient360 on the Application tab.• Enter a specific member’s information.

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https://www.availity.com/

Clear Claim Connection

Use Clear Claim Connection™ for guidance when you submit a claim.

This tool is available under Payer Spaces in the Availity Portal and can help determine whether procedure codes and modifiers will likely pay for your patient’s diagnosis.

Clear Claim Connection contains editing features that will determine the validity of items like diagnosis codes or revenue codes. If the codes are not valid, it will produce an edit showing such.

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Disclaimer: Clear Claim Connection does not guarantee coverage under a member’s benefit plan. Member benefit plans vary in coverage, and some plans

may not provide coverage for certain services.

Claim submission

We accept paper claims, but we encourage you to submit claims on our website or by electronic data interchange (EDI):• Summit Community Care does not accept faxed or hand-written claims.• Submit both CMS-1500 and UB-04 claims on Availity. • Submit 837 batch files and receive reports through Availity at no cost. You must

register for this service first. For more detail, review the EDI Availity guide on the Summit Community Care website.

• Use a clearinghouse via EDI. Using our electronic tool reduces claims/payment processing expenses and offers:• Faster processing than paper and enhanced claims tracking.• HIPAA-compliant submissions.• Reduced claim rejections and adjudication turnaround time.

• There is a filing limit of 365 days from the date of service. It’s your responsibility to ensure electronic claims are completed and submitted without rejection.

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Claim submission resources

The Summit Community Care provider website has many claim resources available.

• EDI Quick Start Guide —This is the EDI connection and services start-up guide. It contains information to get you started with submitting EDI transactions to Availity, from registration to ongoing support.

• https://www.summitcommunitycare.com/provider > Education and Training > Tutorials

• Availity Health Information Network EDI Guide (Availity EDI Guide) — This guide communicates Availity-specific requirements and other information that supplements requirements and information already provided in standard EDI and HIPAA communications.

• https://provider.summitcommunitycare.com/docs/ARAR_CAID_AvailityEDIGuide.pdf

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https://www.summitcommunitycare.com/providerhttps://provider.summitcommunitycare.com/docs/ARAR_CAID_AvailityEDIGuide.pdf

Claim submission resources (cont.)

• EDI — Availity is your partner for all electronic data and transactions. Availity is an intelligent EDI gateway for multiple payers and will be the single EDI connection for Summit Community Care.

• https://provider.summitcommunitycare.com/arkansas-provider/electronic-data-interchange

• Finding tools on Availity — This page provides quick steps to many of the tools you need, such as eligibility and benefits inquiry, claims submission, claims status inquiry, and authorizations.

• https://provider.summitcommunitycare.com/arkansas-provider/learn-about-Availity

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https://provider.summitcommunitycare.com/arkansas-provider/electronic-data-interchangehttps://provider.summitcommunitycare.com/arkansas-provider/learn-about-Availity

Corrected claim submission

When submitting a professional or facility claim, under the Claim Information screen, providers must select Billing Frequency. To submit a corrected claim, providers should select 7 — Corrected Claim and in the additional box that appears, enter the claim ID (control number) for the claim to be corrected.

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Third-party liability (TPL)

• For dual-eligible members with Medicare and Medicaid coverage, Summit Community Care maintains a Medicare Bypass List that identifies service codes for which no TPL information will be required. Summit Community Care also maintains a Commercial Insurance Bypass List for those members who are dual-eligible with Commercial insurance and Medicaid coverage.

• When billing for dual-eligible members for services not included on one of our TPL bypass lists, the provider must bill the primary insurer and obtain documentation of the primary payer’s action for submission to Summit Community Care as the secondary insurer.

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TPL (cont.)

• When submitting claims for services not included on the TPL bypass list, Summit Community Care requires TPL verification. Providers may submit any of the following as verification of the primary insurance adjudication decision:

• Certificate of Benefits from the primary insurer

• Denial letter or EOP showing no payment from the primary insurer

• EOP showing payment to the provider from the primary insurer

• Documentation of the primary insurance denial via the Certificate of Benefits or EOP with no payment will satisfy the TPL requirements for one year from the date of the denial or letter.

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TPL (cont.)

• Methods for submitting required TPL documentation:

• For new claims submissions, providers may forward the required TPL documentation as follows:

• Submit a Claim Correspondence Form, a copy of your EOP and the supporting documentation to:

Claim Correspondence

Summit Community Care

P.O. Box 62429

Virginia Beach, VA 23466-2429

• Submit an electronic claim through the Availity Portal and use the medical attachments functionality to attach a copy of your EOP and the supporting documentation.

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Third-party liability (cont.)

• For information on using the medical attachments functionality via the Availity Portal, select Find Help under the Help & Trainings link on the top right-hand side of the Availity homepage. Then, search for medical attachments and select any of the available instructional materials.

Note: For new claims submissions, the following is an example: The provider receives a Certificate of Denial dated January 1, 2019. The provider can use that Certificate of Denial through December 31, 2019. The provider would select Yes, indicating primary insurance was billed using the denial date of January 1, 2019, and enter a $0.00 payment amount (for this example).

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Proper coding

• Summit Community Care uses the coding guidelines, definitions and direction provided in the CPT® manual to process claims and can only accept HIPAA-compliant codes.

• Refer to the current CPT manual on the CMS website for appropriate codes according to levels of service.

• For complete details on claims submissions and billing, consult the provider manual by visiting www.summitcommunitycare.com/provider > Provider Tools & Resources > Provider Manuals and Guides.

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http://www.summitcommunitycare.com/provider

Electronic payment services

Providers will need to enroll for electronic funds transfer (EFT) through CAQH EnrollHub in order to receive payments. It can take up to five weeks to start receiving electronic payments. When enrolling, select Amerigroup then Summit Community Care from the drop down.

Providers who enroll for EFT will be able to:• Route EFTs to the bank account of their choice.• Receive electronic remittance advice (ERA) and import the information directly into their

patient management or patient accounting system.• Use the electronic files to create custom reports in your office at anytime.

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Type of electronic payment Website

ERAs only https://www.availity.com

EFTs only https://solutions.caqh.org/bpas/Default.aspx

EDI-Availity Client Services number 1-800-282-4548

https://www.availity.com/https://solutions.caqh.org/bpas/Default.aspx

EFT — CAQH

To prevent any delays associated with printing and mailing paper checks, Summit Community Care recommends all providers enroll with EFT as quickly as possible to receive electronic payments.

When selecting a Payer, please select the following line: Amerigroup/Blue Simply Healthcare/Summit Community Care.

• Phone: 1-844-815-9763

• Email: efthelp@enrollhub.caqh.org

• Help Desk hours:

• Monday-Thursday, 7 a.m.-9 p.m. Eastern time

• Friday, 7 a.m.-7 p.m. Eastern time

EFT — enrolling for EFT only

• Select Register Now.

• Enter your contact information and choose a username and password.

• Enter your practice details.

• Select a payer — Providers enrolling for EFT for Summit Community Care should select the line that references Amerigroup/Healthy Blue/Simply Healthcare/Summit Community Care; do not select the payer line for Anthem.

Note: It is recommended that providers enroll in EFT at the TIN level, versus enrolling at the NPI level.

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ERA

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Users in your organization who need access to view online remittances should contact their Availity administrator to assign them to the claims role within the Availity Portal.• Electronic payment services — ERA only

• https://www.availity.com• ERA – Availity support

• EDI – Availity Client Services number: 1-800-282-4548

Note: Recommendation is to enroll at TIN versus NPI level.

https://www.availity.com/

Remittance Inquiry

• You will be able to view/receive remittance information through Availity.• Providers will receive daily remits Monday-Friday. You can view remittances

from 15 months back to 7 days into the future. The images can be saved to the user’s PC or they can be printed out.

• From the Availity Portal homepage, select Payer Spaces > Summit Community Care > Applications. The Remittance Inquiry application will appear as an option. Choose Remittance Inquiry to gain access to the Remittance Inquiry functionality.

• Choose your organization and tax ID number. If the administrator previously loaded NPIs, select your NPI from the Express Entry drop-down menu. Otherwise, enter an NPI number in the allotted box.

• You can choose from one of three search options: • EFT number• Check number• Date range

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Remittance Inquiry (cont.)

You have the option to sort your results by:• Provider name.• Issue date.• Check/EFT number.• Patient or claim.

If you need an image of the remittance for your files, select the View Remittance link associated with each remit and then Print or Save. • Contact your administrator if you do not see this tool to request claims status

access. If you don’t know who the administrator is for your organization, log in to Availity and select My Administrators.

• For questions or additional registration assistance, contact Availity Client Services at 1-800-AVAILITY (1-800-282-4548) Monday-Friday from 7 a.m.-6:30 p.m., Central time.

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Rejected versus denied claims

• There are two types of notices you may get in response to your claim submission, rejected or denied. • Rejected claims do not enter the adjudication system because they have

missing or incorrect information.• Denied claims go through the adjudication process but are denied for

payment.• You can find claims status information on the website or by calling Provider

Services.• If you need to appeal a claim decision, please submit a copy of the EOP, letter

of explanation and supporting documentation.• If your claim is administratively denied, you may file an appeal. As part of the

appeal, you must demonstrate that you notified or attempted to notify Summit Community Care within the established time frame and that the services are medically necessary.

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Claim status inquiries

Claims status is available through the Availity Portal or by calling Provider Services.• Availity Portal:

• Submit a 276/277 EDI transaction using the new payer ID PASSE. • Tip: If a claims status transaction is not submitted with the new payer

ID PASSE, the claim will not be found. Providers will need to correct the payer ID and resubmit the transaction.

• Perform a claim status inquiry by selecting Claim Status Inquiry and selecting the Summit Community Care payer from the drop-down menu.• Tip: Start from an eligibility and benefits response (patient card) and

then select Claims, then Claim Status Inquiry (or Claims and Payments).

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Claim status inquiries (cont.)

• Provider Services:• Call 1-844-462-0022, Monday-Friday, 8 a.m.-5 p.m.• For questions related to the Availity Portal, call 1-800-AVAILITY

(1-800-282-4548).• Online: From the Availity Portal, Help & Training > My Support Tickets.

For more claims help and training, select Help & Training, then Get Trained and search for Claim Status Inquiry — Training Demo.

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Claim payment disputes

To learn how to submit a claim payment dispute using Availity, sign up for a scheduled webinar or listen to a recorded session:

• Log in to the Availity Portal > Help & Training > Get Trained.

• Search the catalog for the term appeal to find a listing of the scheduled webinars. Select the date that you wish to register for and then select Enroll in the top right-hand corner.

• Recorded sessions: When you search for the term appeal, you’ll see the On-Demand and Training Demo courses at the bottom of the search results. Select the course and then select Enroll.

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Claim payment disputes (cont.)

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The provider payment dispute process consists of two internal steps and a third external step. You will not be penalized for filing a claim payment dispute, and no action is required by the member. • Reconsideration (within 90 days of EOP): This is the first step in the provider

payment dispute process. The reconsideration represents your initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step.

• Appeal (reply with 30 days): This is the second step in the provider payment dispute process. If you disagree with the outcome of the reconsideration, you may request an additional review as a claim payment appeal.

• State Fair Hearing: Arkansas Medicaid supports an external review process if you have exhausted both steps in the payment dispute process but still disagree with the outcome.

Note: Providers should complete both the dispute and/or appeal defined herein prior to filing for a state fair hearing with Arkansas Medicaid.

Claim payment disputes (cont.)

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To file a claim payment dispute: • Verbally (reconsiderations only): Call Provider Services at 1-844-462-0022. • Online (reconsiderations and claim payment appeals): Use the secure

provider Availity payment appeal tool. Through the Availity Portal, you can upload supporting documentation and will receive immediate acknowledgement of your submission.

• In writing (reconsiderations and claim payment appeals): Mail all required documentation (see next slide for more details), including the Claim Payment Appeal Form or the Reconsideration Form, to:

Payment Dispute Unit Summit Community Care P.O. Box 62429 Virginia Beach, VA 23466-2429

Claim payment disputes (cont.)

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Submit reconsiderations on the Reconsideration Form or written claim payment appeals on the Claim Payment Appeal Form. To access these forms, visit Other Forms at https://provider.summitcommunitycare.com/arkansas-provider/forms.

Required documentation for claims payment disputes Summit Community Care requires the following information when submitting a claim payment dispute (reconsideration or claim payment appeal): • Your name, address, phone number, email address, TIN and NPI (or Arkansas

Medicaid ID number, whichever number is registered with Arkansas Medicaid) • Member’s name and their Summit Community Care or Medicaid ID number• A listing of disputed claims, which should include the Summit Community Care

claim ID number(s) and the date(s) of service(s) • All supporting statements and documentation

https://provider.summitcommunitycare.com/arkansas-provider/forms

• Grievance: A grievance is your expressed dissatisfaction about any matter except a payment dispute or a proposed adverse medical action. A grievance can be submitted either by a member or a physician, hospital, facility or other health care professional licensed to provide health care services.

• Claims appeals: Provider appeals are for issues with reimbursement(s) to health care providers for medical services that have already been provided.

• Medical appeals: There are separate and distinct appeal processes for our members and providers that depend on the services denied or terminated. Refer to the denial letter issued to determine the correct appeals process. Written correspondence should be sent to:

Grievances and Medical AppealsP.O. Box 61599Virginia Beach, VA 23455-2429

Grievances and appeals

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Provider roles and responsibilities

Provider roles and responsibilities

• To provide preventive health screenings• To comply with Americans with Disabilities Act standards and not discriminate

against members with mental, developmental and physical disabilities• To not discriminate on the grounds of age, race, color, religion, sex, national origin

or any of the protected classes that fall under federal law• To provide notification of changes in billing address, name, etc. • To educate members on advance directives• To comply with HIPAA recordkeeping standards for medical records• To provide preventive care services recommended to all members• To identify BH needs• To document fraud, waste and abuse• To meet access standards (e.g., wheelchair accessibility)• To provide after-hours access and flexible appointment availability

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Access and availability

Appointment standards:• You must arrange to provide care as expeditiously as the member’s health condition

requires and according to each of the following appointment standards:

This standard does not apply to appointments for:• Routine physical examinations.• Regularly scheduled visits to monitor a chronic medical condition if the schedule calls for

visits less frequently than once every 30 days.• Routine specialty services (e.g., dermatology, allergy care).

74 Please review the provider manual for all additional standards including BH practitioner standards.

Appointment purpose Time frame

Emergency services Immediately

Urgent medical condition Within 24 hours of request

Routine primary care services Within 21 calendar days

Balance billing

Billing the member:• Providers cannot request or accept payments from Medicaid recipients, their

families or others on behalf of the recipient for any of the following: • Base rate changes• Missed appointments• The difference between insurance allowed amounts and usual/customary

charges (provider contract reductions)• If health services are determined to be experimental, investigative or not

medically necessary, providers may not bill the subscriber unless the provider gives the subscriber written notification of noncoverage immediately before the health services are performed and the subscriber agrees in writing to be responsible for the health services.

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Interpreter services

Use an interpreter, when necessary, to ensure your patient understands all his or her options and is able to make informed decisions. Free interpreter services are available to Summit Community Care members 24 hours a day, 7 days a week, with over 170 languages.

Call 1-844-405-4295 for:• Interpreter services.• Telephonic interpreter services.• In-person interpreter services for case management.

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24/7 NurseLine

• Members can call the 24/7 NurseLine for health advice seven days a week, 365 days a year at 1-844-405-4295.

• RNs answer members’ questions and assist members in deciding how to take care of health problems.

• If medical care is needed, nurses can help a member decide where to go.

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Cultural competency

We are committed to fostering cultural competency within our company and provider networks. Cultural competency can enable you to: • Acknowledge the importance of culture and linguistic differences.• Recognize the cultural factors that shape personal and professional behavior.• Enhance support of diverse patients by incorporating cultural insights into your practice

where appropriate. • Strive to expand cultural knowledge.

Cultural barriers between you and your patients can:• Impact your patient’s level of comfort and fear of what you might find upon examination. • Result in differences in understanding of our health care system.• Cause a fear of rejection of your patient’s personal health beliefs.• Impact your patient’s expectation of you and of treatment.

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Cultural competency (cont.)

MyDiversePatients.com features robust educational resources to help support you in addressing these disparities. On the site, you will find:• Continuing medical education learning experiences about disparities, potential

contributing factors and opportunities for you to enhance care.• Real-life stories about diverse patients and the unique challenges they face.• Tips and techniques for working with diverse patients to promote improvement

in health outcomes.

While there’s no single, easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends one patient at a time.

Accelerate your journey to becoming your patients’ trusted health care partner by visiting the site today.

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MyDiversePatients.comMyDiversePatients.com

Fraud, waste and abuse

If you suspect a provider (e.g., provider group, hospital, doctor, dentist, counselor, medical supply company, etc.) or any member (a person who receives benefits) has committed fraud, waste or abuse, you have the right to report it.

No individual who reports violations or suspected fraud and abuse will be retaliated against for doing so. The name of the person reporting the incident and his or her callback number will be kept in strict confidence by investigators.

You can report your concerns by:• Visiting our website and completing the Report Waste, Fraud and Abuse form.• Calling Provider Services at 1-844-462-0022.• Calling our Special Investigations Unit fraud hotline at 1-877-660-7890.

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Provider communications

Provider communications

• The provider manual is a key support resource for:

• PA requirements.• An overview of covered services.• The member eligibility verification process.• Member benefits.• Access and availability standards.• The grievances and appeals process.• Members’ rights and responsibilities.

• Providers are notified about any business changes and important updates through a variety of communications, including:

• In-person visits.• Bulletins.• Newsletters.• Letters and fliers.

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Provider communications (cont.)

• If you would like to be added to our email distribution list, please email us at Providers@SummitCommunityCare.com.

• Our distribution methods include in-person, email, fax, mail and/or posting on our provider website.

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Provider Services

Summit Community Care Provider Services and the provider website should be your primary go-to for all the information you need.

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Provider Services

• Provider Services supports your inquiries about a variety of topics including but not limited to member eligibility and benefits, claims and authorization status, as well as authorizations and claims issues.

Provider website

• Our provider website is available 24/7 to all providers and gives providers access to member eligibility and benefits, and claims and authorization submissions and status.

Your support system and staff

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We support you through many different departments as you provide care to our members:

Our Provider Relations staff serves the following functions:

• Provider Services• Care Coordination team• Our Medical Management staff• Our Provider Relations team

• Provides education and training• Engages providers in quality initiatives• Builds and maintains the provider

network

Call Provider Services at 1-844-462-0022 for assistance with claim issues, member enrollment and general inquiries.

You can always contact your local Provider Relations representative with any questions you may have.

Provider Relations assignments by county

8686

Louisiana — Melba Mississippi — LashondaMissouri — ClaytonOklahoma — NikkiTennessee — LashondaTexas — MelbaNon-border States — Raymond

Provider Relations assignments — systems

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• Jeff “JP” Perez• Jeffrey.Perez@SummitCommunityCare.com• 501-303-9762

• Clayton Saunders• Clayton.Saunders@SummitCommunityCare.com • 501-304-0632

• Lashonda Mills• Lashonda.Mills@SummitCommunityCare.com • 501-304-8018

• Demesia Watts • Demesia.Watts@SummitCommunityCare.com • 501-904-3931

Provider Relations assignments — systems (cont.)

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• Nikki Khotsyphom• Nikki.Khotsyphom@SummitCommunityCare.com • 501-516-1233

• Laketha Jamison• Laketha.Jamison@SummitCommunityCare.com • 501-519-4769

• Raymond Liszewski• Raymond.Liszewski@SummitCommunityCare.com • 501-904-3941

• Melba Royal• Melba.Royal@SummitCommunityCare.com• 501-353-9122

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Provider manual and

Quick Reference Guide

Provider manual

The provider manual is available on our website and includes additional education materials, including but not limited to:

• Information regarding members and benefits.

• Processes and procedures governing provider interaction with Summit Community Care.

• Greater detail on topics covered in this provider orientation.

Link: https://provider.summitcommunitycare.com/docs/inline/ARAR_CAID_ProviderManual.pdf

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https://provider.summitcommunitycare.com/docs/inline/ARAR_CAID_ProviderManual.pdf

Quick reference ― key contact information

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Service Phone number

Provider Services/Member Services1-844-462-0022 1-844-405-4295

Behavioral health services 1-844-462-0022

PA 1-844-462-0022

24/7 NurseLine 1-844-405-4295

Pharmacy services — member/provider 1-844-462-0022

IngenioRx — effective October 1, 2019 833-262-1726

Interpreter/translation services 1-844-405-4295 (TTY 711)

Fraud, waste and abuse 1-800-422-6641

Availity Portal (https://www.availity.com) 1-800-282-4548

https://www.availity.com/

Quick reference ― key contact information (cont.)

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Service Phone number/website

Availity client services 1-800-282-4548

EFT — CAQH1-844-815-9763

https://solutions.caqh.org/bpas/Default.aspx

Electronic claims submission and ERA https://www.availity.com

Paper claims: Summit Community CareP.O. Box 61010Virginia Beach, VA 23466-1010

365 calendar days from the Date of Service

Transportation (NET) 1-888-987-1200

Grievance and Medical Appeals: Summit Community CareP. O. Box 62429Virginia Beach, VA 23455-2429

60 calendar days from Summit Community Care’s notification postmark date

https://solutions.caqh.org/bpas/Default.aspxhttps://www.availity.com/

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Additional resources

Additional resources

The following tutorials and documents, as well as others, are available today on our provider website:

• Availity overview presentation

• ICR presentation

• Claims Payment Refund Form

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ARPEC-0552-20 February 2020