sutterselect administrative manual - umr portal€¦ · · 2017-06-23sutterselect administrative...

SutterSelect Administrative Manual June 2017

SutterSelect Administrative Manual i

Introduction

This SutterSelect Administrative Manual has been prepared as a resource for providers who are caring for members of SutterSelect health plans. The Manual includes information about requesting prior certification, how to submit claims, and a guide to using the SutterSelect Provider website. Please refer to the Table of Contents for a complete listing of the sections enclosed in this Manual. This Manual may be updated as needed. Visit our website at http://sutterselect.tpa.com for the most up-to-date information.

We hope that you find this Manual to be a valuable tool and thank you for helping to deliver quality health care to our members.

SutterSelect Administrative Manual ii

Introduction �� i

Table of Contents ��ii

Background �� 1SutterSelect Products �� 1SutterSelect Provider Network �� 1About UMR �� 1

Plan Designs and Options �� 2EPO Plus �� 2PPO �� 2Options PPO �� 2

Eligibility �� 3Member ID Cards �� 3

Prior Certification �� 4 UMR Care Management Certification Requests � 4Referrals to Specialists �� 4Responsibility and Member Penalty �� 4

Clinical Management �� 5Contact Information�� 5Utilization Management �� 5Case Management �� 5Disease Management �� 6Disease Management Contact Information �� 6Nurse Advice Line �� 6

Claims �� 7Claims Submission Guidelines �� 7Claims Inquiries �� 8Claims Submission Address �� 8Timely Filing �� 8Coordination of Benefits �� 8Subrogation �� 8Provider Remittance Advice �� 9RA Field Explanations �� 10

Pharmacy �� 11Drug Formulary �� 11Medication Reviews�� 11Prior Authorization �� 11Pharmacy Network �� 11Mail Order Pharmacy �� 11

Behavioral Health �� 12Contact Information�� 12Emergency Care �� 12

Online Benefits and Claim Inquiry �� 13Home Page �� 13Provider Login �� 14Reset Password �� 14Navigating the Website �� 15

Provider Directories �� 16SutterSelect Provider Information �� 16

Quick Reference List �� 17

Table of Contents

SutterSelect Administrative Manual 1

SutterSelect is Sutter Health’s self-funded medical plan, developed to take the place of an outside insurance company. Self-funding allows Sutter Health affiliates to deliver consistent medical plan coverage from year to year through a stable, predictable medical plan. In turn, affiliates can design benefit plans, wellness programs and more with employees and their families in mind.

SutterSelect ProductsSutterSelect manages the self-funded medical plans for its customers. Product descriptions are detailed in the Plan Design section on page 2.

SutterSelect Provider NetworkThe SutterSelect provider network includes more than 7,000 physicians. Additionally, the PPO plan option offers in-network providers from the broader HealthSmart Preferred network inside of California or the PHCS Healthy Directions network outside of California. The Options PPO plan network utilizes the UnitedHealthcare Options PPO network.

SutterSelect VendorsSutter Health partners with UMR to administer the plan. UMR is the largest employee benefits third-party administrator in the United States and is fully compliant with HIPAA requirements for health data security. The organization serves more than 1,700 clients and more than 2.5 million plan members, processing over 32 million claims each year. UMR is a UnitedHealthcare company.

UMR is the primary contact for provider and member information and assistance with SutterSelect.

Pharmacy benefits management is provided through MedImpact. The MedImpact pharmacy network includes a national network of more than 67,000 community pharmacies and also offers a mail order prescription service through Prescription Solutions Program (PPS).

Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for all SutterSelect plans.

The illustration on the following page provides information about the SutterSelect medical plan options.

Background


EPO Plus PPO Options PPO

Plan Design In-network benefits only. No coverage for out-of-network services, except emergencies.

In-network benefits only. No coverage for out-of-network services, except emergencies.

Out-of-pocket costs depend on which tier (and provider network) is accessed.

Able to choose from Tier 1 or Tier 2 each time care is needed.

Plan available only in certain geographic areas.

In-network and out-of-network benefits.

Out-of-pocket costs depend on which tier is accessed.

Able to choose a different tier each time care is needed.

Network Uses the SutterSelect provider network.

Network access depends on tier. Choices include SutterSelect provider network (Tier 1), or a broader network of HealthSmart Preferred in CA and PHCS Healthy Directions outside CA (Tier 2).

Network access depends on tier. Choices include the UnitedHealthcare Options PPO provider network (Tier 1), or out-of-network (Tier 2).

Costs The lower cost medical option in terms of monthly premium costs and out-of-pockets costs.

Higher premium cost option due to flexibility in choosing providers. Out-of-pocket expenses are higher under Tier 2.

Out-of-pocket expenses are higher under Tier 2.

Plan Designs and Options


It is important to verify eligibility prior to rendering services. Eligibility rules vary by plan and employer.

Eligibility can be verified by two methods:

• Telephone: Call SutterSelect Customer Service at 866-868-2703.

Provider service representatives are available from 7:00 a.m. – 6:00 p.m. Pacific Time, Monday – Friday.

• Online: http://sutterselect.tpa.com.

The website provides access to eligibility information 24 hours a day, seven days a week.

Member ID CardsImportant key information and resources are highlighted on the below sample identification card. Cards may differ slightly between plans or plan options.

Eligibility

Back of ID Card

Front of ID CardPlan name

(benefits and coverage may vary between SutterSelect plans)

Plan option

UMR is the SutterSelect third party administrator

Provider Customer Service 866-868-2703

http://sutterselect�tpa�com

• Eligibility and claims• Provider network directory• General inquiries

Member’s ID card will list copay amounts for their plan option

Call UMR Care Management for prior certification

866-895-3378

Claims submission informationEDI # 39026

UMR, PO Box 30541 Salt Lake City, UT 84130-0541


To obtain a prior certification determination, call the telephone number listed on the back of the member’s ID card. A list of services requiring prior certification is available in the member’s Health Plan Summary Plan Description (SPD). The SPD for a member can be viewed online by logging on to the provider website at http://sutterselect.tpa.com. Emergency services may be authorized or certified after care is delivered. Most service requests will require submission of medical records to establish medical necessity. Requests are also reviewed to assure they meet benefit criteria as defined by the Plan.

UMR Care Management Certification Requests• Telephone: Call the number on the back of the member identification card to request certification prior to

the scheduled procedure or service, in order to allow for fact gathering and independent medical review, ifnecessary. Hours of operation: 7:00 a.m. – 6:00 p.m. Pacific Time, Monday – Friday.

• Fax: Complete the request form (available at http://sutterselect.tpa.com) and fax with pertinent medicalrecords to 866-754-9428.

• Online: An online request form can be completed at http://sutterselect.tpa.com. From the “Provider” tab onthe left side of the screen select “Get preauthorization” to begin the online process.

Request Response • UMR Care Management will contact your office via telephone or letter with the certification number, if

approved.

• If more information is needed, you will be contacted for requested records needed to make the medicalnecessity determination.

• If the request is denied, you and the member will receive a written notice, including appeal rights andprocess.

• Request turnaround time frames:o Concurrent Urgent – 24 to 48 hours o Pre-service Non-urgent – 15 dayso Pre-service Urgent – 72 hours o Post-service – 30 days

Referrals to SpecialistsSutterSelect plans offer the ability for members to see any provider within the network, including specialists, without a referral.

Responsibility and Member PenaltyProviders need to submit requests for prior certification on behalf of members. Failure to obtain prior certification will result in a financial penalty for the member. This penalty does not apply to emergency services.

Emergency service is any otherwise covered service that a prudent layperson with an average knowledge of health and medicine would seek if he/she was having serious symptoms and believed that without immediate treatment his/her health would be put in serious danger, his/her bodily functions, organs or part would become seriously damaged or would seriously malfunction.

Prior Certification


SutterSelect contracts with UMR Care Management, to provide telephonic clinical management programs. There is no fee to patients or providers for these programs.

Clinical Management services include:

• Utilization Management

• Case Management

• Health Information

• Independent Medical Review

Contact Information• Telephone: Call 866-895-3378, 5:30 a.m. – 7:00 p.m. Pacific Time, Monday – Friday

Utilization Management

Prior Certification ReviewThe prior certification review process is outlined in the Prior Certification section on page 4.

Concurrent ReviewConcurrent review provides review of medical necessity and level of care for members while they are accessing services in the hospital inpatient, acute rehabilitation, skilled nursing facility or home health setting.

Independent Medical Review (IMR)IMR provides clinical review and determinations for medical necessity by independent clinical reviewers. IMR also manages the appeals process and investigational treatment requests.

Case ManagementCase Management provides authorization, discharge planning and care coordination for complex and high dollar cases including organ/tissue transplants and high risk neonates. Care and benefits are coordinated across the continuum of care.

Clinical Management


Disease ManagementDisease management services are provided by the Sutter Health Department of Care Coordination Telephonic Disease Management (TDM) Program. Patients are invited to enroll in disease management programs based on claims data. A team of nurses, pharmacists, coaches, and clinical support staff reach out to patients with the below chronic conditions who have specific evidence of increased acuity of their condition, key gaps in care, or by physician or patient request. The TDM program contacts patients by letter, phone and My Health Online (MHO).

• Asthma

• Diabetes

• Heart Failure

• Hyperlipidemia

• Hypertension

Disease Management Contact Information• Telephone: Call 855-421-6831, 8:30 a.m. – 4:30 p.m. Pacific Time, Monday – Friday

• Email: [email protected]

Nurse Advice LineNurseLineSM is an advice line for members to speak to a registered nurse regarding medical questions, information, education and health-related concerns. It can be accessed 24 hours a day, seven days a week by calling 866-868-1320.

Clinical Management


Providers are encouraged to submit claims via electronic claims submission. UMR’s EDI Claim Payer ID Number is 39026. If you wish to obtain more information about electronic claims submission, please call UMR at 866-868-2703.

Claims Submission GuidelinesAll paper claims should be submitted on a standard CMS 1500 form or UB, as applicable, and contain the following information:

UB Forms• Provider Name, Address and Telephone Number• Patient Control Number• Type of Bill• Federal Tax ID Number• Statement Covers Period• Patient’s Name• Patient’s Address• Patient’s Birth Date• Patient’s Gender• Patient’s Marital Status• Admission Date/Start of Care• Admission Hour• Type of Admission• Discharge Hour• Occurrence Span Code and Dates• Revenue Code• Revenue/HCPC/CPT Description• HCPCS Rates• Service Date• Service Units• Total Charges• Non-Covered Charges• Payer Identification• Provider Number• Release of Information• Assignments of Benefits Cert. Information• Prior Payments• Insured’s Name• Patient’s Relationship to Insured• Group Name• Insurance Group Number• Employment Status Code• Principal Diagnosis Code• Admitting Diagnosis• Principal Procedure Code and Date• Attending/Referring Physician NPI• Provider Representative Signature• Date

CMS 1500 Forms• Patient’s full name (as printed on Health Plan ID

card)• Patient’s date of birth• Policyholder/subscriber, Insurance Name and ID #

(include any suffix numbers shown on the card toassist with dependent coverage verification)

• Diagnosis (ICD-10-CM code is required)• Date(s) of service• CPT-4 procedure codes with description and

modifier, if applicable• Name should be shown of PA, FNP, rendering

provider• Referring physician’s name, if applicable• NPI• Federal Tax ID Number• Information on other insurance coverage• Prior certification number, if applicable• Signature of provider rendering service

Claims


Claims InquiriesClaims inquiries should be directed to SutterSelect’s Customer Service Line at 866-868-2703.

Claims Submission AddressUMRPO BOX 30541SALT LAKE CITY UT 84130-0541

Timely FilingComplete claims are to be submitted to the third-party administrator, UMR, as soon as possible after services are received, but no later than six months from the date of service. A complete claim means that the Plan has all information that is necessary to process the claim. Claims received after the timely filing period has expired will not be considered for payment.

Coordination of Benefits Coordination of benefits (COB) applies whenever a member has health coverage under more than one plan. The purpose of coordinating benefits is to pay for covered expenses, but not to result in total benefits that are greater than the covered expenses incurred.

The order of benefit determination rules determine which plan will pay first (primary plan). The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays for covered expenses after the primary plan has processed the claim, and will reduce the benefits it pays so that the total payment between the primary plan and secondary plan does not exceed the covered expenses incurred. Up to 100 percent of charges incurred may be paid between both plans.

SubrogationClaims identified as possibly accident related may pend for additional information. When these claims are identified, a questionnaire is generated to the member asking if they received treatment for an injury or illness that may be accident related. The member must complete and return the questionnaire by mail or fax. The member can also respond to the inquiry by calling SutterSelect Customer Service or online at http://sutterselect.tpa.com. If there is an indication that the claim was for an illness or injury that was not caused by another person or party, the claim(s) will be reprocessed. If there is an indication that the claim was for an illness or injury that was caused by another person or party UMR will reprocess the claim(s) and pursue the plan’s right of reimbursement of the medical bills paid by the plan.

Failure by the member to return the completed questionnaire will result in denial of the claim(s).

Claims


Provider Remittance AdviceUMR produces weekly check runs. Provider Remittance Advices (RA) and member Explanations of Benefits (EOB) are an integral part of finalization of the patient/physician experience. To help familiarize you with the Remittance Advice that your office will receive, below is a key to explain each field in detail. Claim specific details are also available to you by logging on to http://sutterselect.tpa.com.

Claims


RA Field Explanations1. Remittance Advice for Period Ending: Last day of the week for the period covering claims listed on this

particular remittance advice.2. Identifying Plan Header: Header that identifies organizational plan that patients are associated with. Header

includes name, address and return telephone number.3. Plan Name: The plan name that patients are associated with.4. Employer Name: The company name the patients are associated with.5. Provider Name and Address: The provider’s name and address.6. Federal Tax ID No.: The provider’s federal tax ID number.7. Dates From/To: Displays the first date of service through the last date of service for the services performed.8. Service Code: CPT/HCPCS procedure code. (Hospital charges display as 00000.)9. Charged Amount: Total amount charged per service. (Hospital per diem charges will display on one line with

one total charge amount.)10. Allowed Amount: Total amount of charge considered for payment.11. Deductible: The portion of the charge applied to the patient’s deductible, if applicable.12. Co-pay: The portion of the charge applied to the patient’s co-pay, if applicable.13. Coinsurance: The portion of the charges applied to the patient’s coinsurance, if applicable.14. Discount Managed Care Adjust: Includes the amount of the provider’s negotiated discount and the amount

not allowed per contracted fees. (Difference between the actual charge amount and the contracted allowableamount.)

15. Ineligible: Amount not allowed due to plan provisions.16. Withheld: The portion of the approved charge that is withheld based upon negotiated rates.17. OC: Number of occurrences per line of service.18. ANSI Code: American Standard Institute (ANSI) code provides reason why charges are not allowed.19. Paid: Amount paid to provider per line of service. (This amount may differ from amounts paid on EOB due to

withhold amounts.)20. Patient Responsibility: Amount the patient is responsible for paying per line of service.21. Employee: The employee’s name. (Last name, first name, middle initial.)22. Patient: The patient’s name. (Last name, first name, middle initial.)23. Cert No.: The employee’s health plan identification number.24. Account Number: The patient’s account number, submitted by the provider of service.25. Claim Number: The internal claim control number.26. Total: Total amounts per column.27. The Primary Insurance Paid: If applicable, displays the total amount the patient’s primary insurance paid on the

claim.28. Subtotal: Subtotals for columns if pages follow.29. Provider Total: Total combined amounts for each provider, displayed on final page.30. CP Number: Banking source code (specific to each customer).31. Internal Number: Ten-digit internal sequence number matching remittance advice to the appropriate payment

check.32. Plan Administrator Website Address

Claims


MedImpact is the pharmacy benefits administrator for SutterSelect plan members. If you have questions or need assistance getting prescriptions for members, you can contact MedImpact customer service, 24 hours a day, seven days a week via:

• Telephone: 844-599-4064

• Online: https://mp.medimpact.com/SSP

Drug FormularyThe SutterSelect Formulary is a list of drugs covered by the plan. The Formulary was developed to meet the needs of most members based on rational drug therapies. To find out what drugs are on the formulary, contact MedImpact via telephone or check their website at https://mp.medimpact.com/SSP and click the “Formulary” link.

Medication ReviewsThe formulary is developed and maintained by a committee comprised of physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication’s safety, effectiveness and associated clinical outcomes.

Prior Authorization Contact the MedImpact prior authorization department at 844-599-4064 to begin the prior authorization process.

Pharmacy NetworkThe MedImpact pharmacy network includes more than 64,000 retail pharmacies nationwide. For specific information call the customer service center or use the pharmacy locator link on the website.

• Telephone: Call the MedImpact customer service center at 844-599-4064

• Online: https://mp.medimpact.com/SSP.

o Click the “view this site as a guest” link.

Mail Order Pharmacy*The Mail Order Program is administered by Postal Prescription Services (PPS). The program allows a member’s prescription products to be ordered through the mail service pharmacy. Using mail order offers plan members the advantage of obtaining up to a 90-day supply of prescription products.

• Telephone: Call 800-552-6694, Monday – Friday 6:00 a.m. – 6:00 p.m. or Saturday 9:00 a.m. - 2:00 p.m.Pacific Time

* The Sutter Health Central Valley Region SutterSelect mail order pharmacy program is administered through the Memorial Medical Center Outpatient Pharmacy.

Pharmacy


Optum administers the Mental Health, Substance Abuse and Chemical Dependency benefits for all SutterSelect plans.

Call for authorization before providing inpatient or outpatient mental health or substance abuse services.

Contact Information• Telephone: Call Optum customer service at 855-809-2012, 24 hours a day, seven days a week.

Emergency CareIf the member needs emergency services, you do not need to obtain prior authorization from the behavioral health carrier prior to providing emergency care. However, you must notify the carrier within 24 hours and once emergency care has ended, call the carrier to get authorization to provide any additional services.

Behavioral Health


Access information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week by going to http://sutterselect.tpa.com. Logging on to this website provides you and your office the following:

• Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and towhom payment was made.

• Eligibility and benefits information, including patient specific plan information, claim submission details,prior certification requirements and member benefit levels.

• Contact phone numbers and an email notification form to contact a member of the UMR team with yourquestions.

If you have questions or problems related to the website, please contact the UMR technical support team at 866-922-8266.

Home PageClick: “Provider”

Online Benefits and Claim Inquiry


Provider LoginIf you do not already have a username and logon, click “New user? Register here.” to complete the registration process using your name and password.

Reset Password Should you forget your password, you can select the “Forgot username or password?” option to change it.



Navigating the Website You can view an online video tutorial to learn about site navigation and available features.



To obtain the highest level of benefits under this Plan, members need to see an in-network provider, however SutterSelect does not limit a member’s right to choose his or her own provider or medical care. If a medical expense is not a Covered Expense under the medical benefit plan, or is subject to a limitation or exclusion, a member still has the right and privilege to receive such medical service at his or her own personal expense.

To find out which network a provider belongs to, please refer to the Provider Directory or call the toll free number that is listed on the back of the member’s identification card. The participation status of providers may change from time to time.

SutterSelect Provider Information

• Telephone: Call the SutterSelect Customer Service Line at 866-868-2703.

• Online: Available at http://sutterselect.tpa.com. Providers must login to view the information.

To find a mental health provider in the Optum network, go to www.liveandworkwell.com and enter the access code “healthy.”

Provider Directories


SutterSelect 866-868-2703 Eligibility VerificationCustomer Service 7:00 a.m. – 6:00 p.m. PST Benefit Inquiries(Providers) Monday – Friday Claim Inquiries

Prior CertificationProvider Appeals

Pharmacy 844-599-4064 or Drug Formularyhttps://mp.medimpact.com/ssp Pharmacy Network

Website http://sutterselect.tpa.com Benefit InquiriesClaim StatusEligibility VerificationProvider Directories

Claim Submission UMR EDI Claim Payer ID: 39026PO Box 30541Salt Lake City, UT 84130-0541

Care Management 866-895-3378 Utilization Review/Prior Certification

SutterSelect 866-868-1320 orCustomer Service http://sutterselect.tpa.com(Members)

Quick Reference List

Optum Behavioral Health

855-809-2012 orwww://liveandworkwell.comaccess code healthy

Prior CertificationProvider Directory

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