provider orientation welcome! updates (2/28/2012): cob appeals rcc auth phone #s
TRANSCRIPT
Provider Orientation
Welcome!
Updates (2/28/2012):COBAppealsRCC Auth Phone #s
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Learning Objectives
• Today you will learn:
- Who CareCentrix is and how to work with us- Referral Process
• Managed vs non-managed plans• Understanding the Service Authorization Form (SAF)
- Provider Portal• How to submit initial authorizations, reauthorizations and add on
services• How to check authorization status• How to check claim status
- Billing & Claims• Claim submission• Claims Reconsideration & Appeals
- Contact Information and Feedback
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Physicians & Providers
Claims Billing
Home Health DME/POS
• Eligibility, Benefits & Authorization• Medical Necessity Review• Coordination of Care / Staffing
Infusion
Medical Economics
Hospital Discharge Planners
Case Managers
Home Care Benefits Management Process – “The Platform”
Consolidated Claims
Reporting & Analysis
Workflow
Healthplan
Single Point-of-Contact to Coordinate Home-
Based Services
Referral Management
Network Management
Claims & Billing
Program Components
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Making a Referral: Service Specific Tips
THH – Home Health DME/O&P Infusion
Patient Homebound? N/A N/A
Initial Auth Mandatory?**
Re-authorization Plan Dependent Plan Dependent Plan Dependent
Start of Care (SOC) If changed, contact CCX. Changes must be approved by referring
physician
If changed, contact CCX. Changes must be approved by
referring physician
If changed, contact CCX. Changes must be approved by referring
physician
Other Lab tests must be taken to the lab specified by the
patient’s plan
Oxygen•Liter flow •O2 saturation w/ date
Provide height, weight, allergies, type of venous access and date/time of
next dose
Routine supplies are included in the cost of visit
CPAP•Sleep study or letter of medical necessity•MD order required for upgraded unit
Infusion providers must accept case “full-service”
meaning drug, skilled nursing and supplies (per
diem)
Notify CCX immediately of additional supply needs
-Authorization for additional supplies can be
obtained through CCX
General Auth Guidelines
Microsoft Excel Worksheet
Referral Process
Microsoft Excel Worksheet
** Except for Magnolia Health Plan: DME items < $500 require no authorization
Making a Referral: “Managed” vs “Non-Managed” Plans
Managed (PHS+) Non-Managed (PHS)
Service Auth Form (SAF) Indicates # of units authorized
CCX will issue a “footprint” authorization; SAF will indicate “0” visits
and the same “Start Date” and “Stop Date”
Re-authorization & Add-on Services
Submit to CCX via portal Not Required -The auth number assigned during the initial referral process will be used
Eligibility & Benefits CCX checks initial and ongoing
Provider Responsible-Health Plan’s phone number for verifying eligibility and benefits will be included on the SAF
Other Provider is responsible for verifying insurance plan’s authorization
requirements
Referral Process
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Managed Authorization From
HCPC/Modifier combination that must be used on claim
All paper claims must be sent to CareCentrix East Hartford CT but EDI is preferred!
Date of service must fall between above dates
If additional visits are needed provider must submit reauthorization request via online portal.
Servicing branch
Example and Definition:
Managed CareCentrix referrals - You should come back to the designated Regional Care Center for re-authorization (submit re-authorizations via the online provider portal) or add-on services unless defined otherwise. When submitting a request for re-authorization or an add-on service it is important to provide the clinical justification for the request.
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Non-managed Authorization Form
Branch managed plans have “0” units authorized.
Branch managed plans have the same start and stop date.
Non-managed CareCentrix referrals - You do not have to come back to the Regional Care Center for re-authorization or add-on services in which you are contracted with CareCentrix to provide. However, you are expected to manage to the patient's benefits and authorization requirements as stipulated by the insurance carrier. This would include ongoing re-verification of eligibility and benefits.
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Sample Fax Coversheet
Notifies you if PTA and OTA are allowed by member’s health plan
Make sure to use lab of choice to maximize member’s benefits.
Identifies in-network supply provider for non-routine supplies.
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Portal Training: www.carecentrixportal.com
• The CareCentrix portal is the way of submitting authorization and re-authorization requests to CareCentrix- And we’ll show you how to do that now
• But the portal is much more than just a way to request an auth!
- View latest news & important announcements!• Check the portal often to stay on top of the latest
developments
- Submit initial and re-auth requests• 24 x 7 x 365!• No waiting on the phone!• Faster auth turn-around time!
- Check claim status- Check authorization status- Manage HomeSTAR patients
• Please visit: www.carecentrixportal.com
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Billing and Claims Submission• Format
- Electronic Claims submission is the preferred format (CMS 1500 forms only at present)- Paper claims may be submitted on CMS 1500, UB-04- Claims must be original, without erasures, strikeovers, or stickers
• Timely filing- 45 days from time service was rendered- Or, as determined by State law
• *Claims must include the following*:- Description of the service- ICD9 Code- Taxonomy number - NPI number- HCPC Code & Modifier as shown on your Service Authorization Form (SAF)
• Current billing cross walk can be found at www.carecentrixportal.com
- Find the CareCentrix service code and UOM (unit of measure) on your Service Authorization Form (SAF) and match to the above crosswalk to determine the correct HCPC/Modifier combination you must bill.
• Coordination of Benefits (COB)- Please click the PDF to the right for an overview of COB
Billing & Claims
Adobe Acrobat Document
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Claims: Corrections & Appeals
• Is your payment not what you expected? Please follow our process for corrections and appeals:
Billing & Claims
Self-diagnose the Problem
Submit a Claim Reconsideration
Form
Appeals
•Verify that you billed the correct HCPC/Modifier combination found on your SAF, or using the billing crosswalk •Ensure you have included all required clean-claim data elements
-For a complete list, please refer to www.carecentrixportal.com and download our Provider Manual or view the “Claims” section of the website
•Complete a Claim Reconsideration form and send to CareCentrix (see Provider Manual)•Or call: 877-725-6525
•Claim reconsideration forms must be received within 45 days of date on EOP or as required by law if longer•If reconsideration is not received within 45 days, your request can be denied for untimely filing of a reconsideration•Click PDF (at right) for a copy of the form, or go to www.carecentrixportal.com•If the payment issue is resolved in your favor, the payment will be adjusted and an explanation of payment issued
•If payment issue cannot be resolved in your favor, you may send a claim appeal to our Appeals Unit (see Provider Manual)•A copy of the claim in question must be included with the CareCentrix Appeal Form•Appeal must be received within 30 calendar days from the date we orally advised you or the date of our communication indicating that your request for reconsideration was not be resolved in your favor (or as otherwise mandated by state or federal law)•Appeals received without a copy of the claim in question will be mailed back to the submitter
Adobe Acrobat Document
Adobe Acrobat Document
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Register for the Provider PortalRegister for EDI (electronic claims submission)
Portal Support [email protected]
EDI Support [email protected]
Initial Authorization RequestsAuthorization Status
Re-authorization RequestsAdd-on Services
Authorization Contact Numbers
Claim QuestionsClaim Status
Appeal StatusProvider Resolution Team
See Provider Manual www.carecentrixportal.com
Patient Services Team 800-808-1902
Contract/Network Management
Patient Financial Responsibility
877-725-6525
Register for Portal & EDI
Support
Authorizations
Claims
www.carecentrixportal.com
www.carecentrixportal.com
www.carecentrixportal.com
CareCentrix Contact Information: Know Where to GoCareCentrix Contacts
Adobe Acrobat Document
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Contact Information
• Network Manager- Name- Phone- Email
• Network Coordinator- Name- Phone- Email
• We welcome your feedback! - Please take a moment to answer 6 quick questions and provide us your
confidential and anonymous feedback on today’s orientation- Click: http://www.surveymonkey.com/s/8SL8MLD
Thank you for choosing to participate in the CareCentrix provider network. We value the quality care you bring our patients, and will work hard to ensure that
your experience with us delights you.