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MMA Training Deck
Florida 2014 Provider Orientation Module 1: Overview ©WellCare 2014. FL_021914 All About WellCare WellCare Health Plans, Inc. Company Snapshot Founded in 1985 in Tampa, Fla. • Approximately 3.3 million members nationwide. • 176,000 contracted health care providers. • 67,000 contracted pharmacies. Serving 1.8 million Medicaid members, including: • Aged, Blind and Disabled (ABD). • Children’s Health Insurance Program (CHIP). • Family Health Plus (FHP). • Supplemental Security Income (SSI). • Temporary Assistance for Needy Families (TANF). Medicaid, Medicare Advantage & Medicare Part D PDP Medicare Advantage & Medicare Part D PDP Medicare Part D PDP (49 states & D.C.) Medicare Supplement (40 states) *Map and Statistics as of February 12, 2014 Serving 1.5 million Medicare members, including: • 290,000 Medicare Advantage members. • 1.2 million Prescription Drug Plan members. • 50,000 Medicare Supplement policyholders. p2 WellCare Health Plans, Inc. Company Snapshot Serving the full spectrum of member needs • Dual-eligible populations (Medicare and Medicaid). • Managed Long Term Care. Spearheading efforts to sustain the social safety net • The WellCare Community Foundation. • Advocacy Programs. • Creation of Public-Private Partnerships. Significant contributor to the national economy Medicaid, Medicare Advantage & Medicare Part D PDP Medicare Advantage & Medicare Part D PDP Medicare Part D PDP (49 states & D.C.) Medicare Supplement (40 states) *Map and Statistics as of February 12, 2014 • A FORTUNE 500 company. • Ranked #16 in the nation on the Barron’s 500. • Approximately 5,800 associates nationwide. • Offices in all states where the company provides managed care. p3 WellCare Health Plans, Inc. Vision To be the leader in government-sponsored health care programs in partnership with the members, providers, government customers and communities we serve. Mission • Enhance our members' health and quality of life • Partner with providers and government customers to provide quality, costeffective health care solutions • Create a rewarding and enriching environment for our associates Core Values • Partnership • Integrity • Accountability • Teamwork As of June 30, 2013 p4 Our Mission to Serve Emphasis on lower income populations and value-focused benefit design At WellCare, our members are our reason for being. We work each day to enhance our members’ health and quality of life. Communication among members and providers to improve outcomes Focus on preventive care including regular doctor visits Community-based solutions to close gaps in the social safety net As of June 30, 2013 p5 Company History & Growth Medicaid and Medicare Advantage Plans As of June 30, 2013 State Began Operations Florida 1985 Connecticut 1998 New York 1998 Illinois 2004 Louisiana 2004 Georgia 2006 Missouri 2006 Ohio 2007 New Jersey 2008 Texas 2008 Hawaii 2009 Kentucky 2011 California 2012 Arizona 2013 South Carolina 2013 Arkansas 2014 Mississippi 2014 Tennessee 2014 p6 What We Do Reduce Cost and Improve Quality and Access for Government Health Programs by: • • • Providing managed care services targeted to government-sponsored health care programs, focusing on Medicaid, Medicare and Prescription Drug Plans. Serving a variety of people including families; children; and the aged, blind and disabled; includes a focus on low-income, dual-eligible populations. Improving quality of care, increasing health care access and improving outcomes for members. • Relieving providers of administrative work and hassles. • Providing cost savings for government customers and taxpayers. As of June 30, 2013 Medicaid Managed Long Term Care DualEligible Members WellCare Prescription Drug Plans Medicare Advantage p7 WellCare’s Integrated Care Model Pharmacy Management Disease Management Home and Communitybased Care Mental Health Therapy Case Management Transportation Specialists Primary Care Optical Members & Caregivers Dental Community-Based Social Services Integrated Care Management and Coordination of Care can: • Enhance quality of life for members and family caregivers • Provide value to state customers and members • Significantly decrease inpatient readmissions • Reduce over-utilization across multiple segments • Reduce non-emergency ground transportation costs • Reduce inpatient bed days As of June 30, 2013 p8 Serving Florida WellCare’s economic impact on the state of Florida is approximately $768 million* annually. Jackson Walton Washington Bay Gadsden Nassau Leon Hamilton Madison Liberty Wakulla Suwannee Calhoun Gulf Franklin Columbia • Serves approximately 593,000 members across the state. Okaloosa In Florida, WellCare: Holmes Taylor Lafayette Dixie Baker Duval Union Clay Bradford Saint Johns Gilchrist Alachua Putnam Flagler • Has a local presence with 20 office locations. Levy Marion Volusia • Employs approximately 3,300 people. Hernando Lake Sumter Citrus Seminole Orange Pasco Hillsborough Pinellas • Earned the Governor’s Top Job Producer Award for Floridaheadquartered companies in 2012. Osceola Polk Brevard Indian River Manatee Hardee Saint Lucie Highlands Desoto Martin Charlotte Glades Lee • Is one of 15 Florida-based Fortune 500 companies. Hendry Palm Beach Broward Collier Miami-Dade Counties with WellCare offices Monroe *Based on a 2011 study commissioned by WellCare and conducted by James V. Koch, Ph.D., Economics, Board of Visitors Professor of Economics and President Emeritus at Old Dominion University. As of June 30, 2013 Monroe p9 Florida Medicaid Presence (Pre-MMA) WellCare serves approximately 474,000* Medicaid members across the state. Santa Rosa Holmes Okaloosa Jackson Walton Washington Nassau Gadsden Leon Liberty Gulf Wakulla Madison Columbia Calhoun Bay Hamilton Suwannee Taylor Union Cla y Alachua Putnam Franklin Dixie Florida Medicaid Presence: Duva l Baker Flagler Levy Marion Volusia • Since 2007, the largest Medicaid provider in the state Citrus • Only Medicaid provider offering plans statewide Hillsborough Lake Sumter Hernand o Pasco Orange Osceola Pinellas Indian River Manatee • Only Medicaid HMO in 14 counties Polk Hardee Highlands St. Lucie Desoto Martin *Includes approximately 12,000 dual-eligible members Charlotte Medicaid plans available statewide Lee Glades Hendry Browar d Collier Monroe As of June 30, 2013 Palm Beach Dade p 10 Florida Healthy Kids Presence WellCare serves approximately 84,000 Florida Healthy Kids members across the state. Santa Rosa Jackson Walton • The Florida Healthy Kids program is part of Florida KidCare, the State of Florida’s high-quality, low-cost health insurance for children. Washington Nassau Gadsden Calhoun Bay Leon Liberty Gulf Wakulla Madison Hamilton Columbia Florida Healthy Kids: Holmes Okaloosa Suwannee Taylor Union Cla y Alachua Putnam Franklin Dixie Duva l Baker Flagler Levy Marion Volusia • The Florida Healthy Kids program is for children ages 5 through 18. Citrus WellCare’s Florida Healthy Kids Presence: Hillsborough Lake Sumter Hernand o Pasco Orange Osceola Pinellas • Plans offered in 65 of Florida’s 67 counties through WellCare’s Staywell Kids and HealthEase Kids plans Polk Indian River Manatee Hardee Highlands Desoto Martin Charlotte • Offers plans in more counties than any other health plan • Serves more Florida Healthy Kids participants than any other health plan As of June 30, 2013 St. Lucie Lee Glades Hendry Palm Beach FHK plans available Browar d Collier Monroe Dade p 11 Florida Medicare Presence WellCare serves approximately 119,000* Medicare members across the state. Santa Rosa Holmes Okaloosa Jackson Walton Washington Calhoun Bay • Serve approximately 80,000 Medicare Advantage members. Leon Liberty Gulf Wakulla Madison Hamilton Columbia Florida Medicare Presence: Nassau Gadsden Suwannee Taylor Duva l Baker Union Cla y Franklin Alachua Dixie Putnam Flagler • Serve approximately 39,000 Medicare Prescription Drug Plan members. Levy Marion Volusia Lake Citrus • Approximately one-third of WellCare’s Medicare members in Florida are also eligible for Medicaid. Sumter Hernand o Pasco Osceola Pinellas • All Medicare plans offer a Pay-forPerformance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. • Medicare PDP available statewide. *Includes approximately 12,000 dual-eligible members As of June 30, 2013 Orange Hillsborough Polk Indian River Manatee Hardee Highlands St. Lucie Desoto Martin Charlotte Lee Medicare Advantage & PDP plans available Glades Hendry Palm Beach Browar d Collier Medicare PDP plans available Monroe Dade p 12 Health Care Access in Florida WellCare is committed to continually improving the quality of care and service that we provide to our members. Access* Provider Access (approximately): • 4,000 primary care providers • 16,200 specialists • 1,000 behavioral health and substance abuse providers Facilities Access (approximate by number of locations): • 200 hospitals • 120 community mental health center locations • Contracted with 37 of the state’s 43 federally qualified health centers Geographic Access: • One primary care provider within 30 minutes or less for urban counties and 30 minutes or less for rural counties. • One hospital within 30 minutes or less for urban counties and 30 minutes or less for rural counties. * Data as of 2/12/14 As of June 30, 2013 p 13 Health Care Quality in Florida WellCare is committed to continually improving the quality of care and service that we provide to our members. Quality People: • Company-wide, WellCare has increased its quality improvement staff by 50 percent. • Focused on prevention, wellness, chronic disease management and patient-centered medical home alignment. • An enhanced case management model helps to more effectively serve the most medically complex members. o The model leverages both field-based and telephonic resources using statespecific, multi-disciplinary care teams. Process: • The National Committee for Quality Assurance (NCQA) awarded WellCare’s Florida Medicare and Medicaid plans an accreditation status of Commendable in 2013. Technology: • Company-wide, more than $60 million has been invested for information technology and integrated, electronic case management to support quality. As of June 30, 2013 p 14 Community Relations and Focused Giving WellCare strives to help our members, and their communities, lead better and healthier lives. The WellCare Community Foundation, our employee volunteerism and community relations efforts help to support this mission. The WellCare Community Foundation Established in 2010, it is a non-profit, private foundation with a mission to foster and promote the health, wellbeing and quality of life for the poor, distressed and other medically underserved populations – including, those who are elderly, young and indigent – and the communities in which they live. Employee Volunteerism In Florida, WellCare supports the work of community organizations, including: American Diabetes Association American Heart Association Big Brothers and Big Sisters Boys & Girls Clubs Black Infant Health Practice Initiative Children’s Home Society of Florida WellCare encourages volunteerism to support children and seniors, and those who are low-income or underserved. Employees work in their local communities to raise muchneeded funds and to support organizations that offer valuable support to those in need. Crisis Center of Tampa Bay Community Relations Habitat for Humanity The Community Relations program educates and advocates for WellCare members and the community. Through it, we proactively facilitate communications with providers, members and the community to inform, educate, address health issues and encourage preventive health care. Eckerd Youth Alternatives The Family Café Feeding America MacDonald Training Center Metropolitan Ministries National Alliance on Mental Illness Nathaniel’s Hope PARC As of June 30, 2013 p 15 Overview of Florida’s Plans Program Overview WellCare is contracted with the Agency for Health Care Administration (AHCA) to provide Medicaid managed care services and Florida Healthy Kids Corporation (FHKC) to provide health insurance for children ages 5 through 18 who are not eligible for Medicaid. • For more information on Medicaid assistance and eligibility requirements, refer to the Agency’s website at http://ahca.myflorida.com. • For more information on the Healthy Kids program and eligibility requirements, refer to the FHKC’s website at https://healthykids.org. As of June 30, 2013 p 17 Program Overview - continued HealthEase Kids/Staywell Kids: • Provides affordable health coverage to children across the state and is a part of the Florida Healthy Kids (FHK) program • FHK is a public/private partnership that provides comprehensive health insurance for school-age children in the state of FL. • Eligibility for the Healthy Kids program is determined by Florida KidCare and includes: • Uninsured, ages 5 through 18 • U.S. citizen or qualified alien • Not the dependent of a State employee • Applicant child without access to employer-sponsored insurance, or it exceeds 5% of family income; has not voluntarily lost employer coverage within the last 6 months of applying; and/or is ineligible for Medicaid or the Children’s Medical Services Network (CMSN) As of June 30, 2013 p 18 Florida Managed Medical Assistance Overview Region 1 Santa Rosa Holmes Okaloosa Walton Region 2 Jackson Washington Leon Liberty Gulf Wakulla Madison Hamilton Suwannee Taylor Columbia Bay The Florida Legislature created a new program called “Statewide Medicaid Managed Care.” Nassau Gadsden Calhoun Duval Baker Union Clay Alachua Putnam Franklin Dixie Region 4 Flagler Levy Marion In response, AHCA has changed how some individuals receive health care in Medicaid. Region 3 Lake Citrus Sumte Hernandor Region 7 Orange Pasco Region 5 Osceola Pinellas One of the two components that make up Medicaid Managed Care is the Florida Managed Medical Assistance (MMA) program. Volusia Hillsborough Region 6 Polk Indian River Manatee Hardee Highlands DeSoto Charlotte Lee The MMA program will be in all areas of the state. The state is divided into 11 regions. Each region will have a certain number of managed care plans from which members can choose. St. Lucie Martin Region 9 Glades Hendry Region 8 Palm Beach Broward Collier Region 10 Monroe Dade Region 11 Reference: AHCA http://ahca.myflorida.com/Medicaid/statewide_mc As of June 30, 2013 p 19 Florida Managed Medical Assistance Overview - continued Region 1 Santa Rosa Holmes Okaloosa Walton Region 2 Jackson Washington • Leon Liberty Gulf Wakulla Madison Hamilton Suwannee Taylor Columbia Bay Goals of the MMA program: Nassau Gadsden Calhoun Union Alachua Dixie Emphasize patient centered care and active patient participation • Provide a choice of the best managed care plans to meet recipients’ needs Putnam Flagler Levy Marion Volusia Lake Citrus Sumte Hernandor Region 7 Orange Pasco Region 5 Osceola Pinellas • Coordinate fully integrated health care in different health care settings Region 4 Clay Franklin Region 3 • Duval Baker Hillsborough Region 6 Polk Indian River Manatee Hardee Highlands DeSoto Charlotte Support innovations in service delivery, reimbursement methodologies, plan quality and plan accountability. Lee St. Lucie Martin Region 9 Glades Hendry Region 8 Palm Beach Broward Collier Region 10 Monroe Dade Region 11 Reference: AHCA http://ahca.myflorida.com/Medicaid/statewide_mc As of June 30, 2013 p 20 Florida Managed Medical Assistance Overview - continued WellCare is expected to serve approximately 530,000* Medicaid members in 57 of 67 counties, across 8 regions. Staywell Regions: Santa Rosa Holmes Okaloosa Walton Region 2 Jackson Washington Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union Liberty Gulf Wakulla Madison Hamilton Suwannee Taylor Union Region 4 Clay Alachua Dixie Duval Baker Franklin Putnam Flagler Levy Marion Volusia Region 3 Lake Citrus Sumter Hernando Region 5 Region 5: Pasco and Pinellas Region 7 Orange Pasco Osceola Pinellas Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia. Bay Leon Columbia Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla and Washington Nassau Gadsden Calhoun Hillsborough Region 6 Region 6: Hardee, Highlands, Hillsborough, Manatee, and Polk Polk Indian River Manatee Hardee Highlands DeSoto Charlotte Region 7: Brevard, Orange, Osceola, and Seminole Lee Martin Glades Hendry Region 8 Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Region 11: Miami-Dade and Monroe St. Lucie Palm Beach Broward Collier Monroe Dade Region 11 *Includes approximately 12,000 dual-eligible members As of June 30, 2013 p 21 HealthEase/Staywell Name Change • WellCare was selected to continue to provide Medicaid services in your county in Florida under the new Managed Medical Assistance (MMA) program. • The HealthEase and Staywell plans will be combined into a single Staywell brand under MMA. WellCare will be operating the new MMA program only under the brand Staywell. • There is no impact to your contract with WellCare or to your claims. This includes past, current, and future claims. • There is no impact to your patients. Your patients who are WellCare members, will have a Staywell member ID card. • The authorization process will remain the same. p 22 Florida Staywell Medicaid Eligibility The following Medicaid recipients are required to enroll in MMA: • Low-income families with children • Children with chronic conditions • Children in foster care • Children in adoption subsidy • Pregnant women • Medically needy recipients* • Recipients who are elderly, blind or disabled (excluding the developmentally disabled population) • Individuals with full Medicaid and Medicare coverage (where Medicaid is a secondary payer) will enroll in 2015 Largest new mandatory populations are medically needy.* *Pending CMS approval The MMA program will NOT change Medicare benefits. Reference: AHCA http://ahca.myflorida.com/Medicaid/statewide_mc As of June 30, 2013 p 23 WellCare Special Needs Plans Dual Special Needs Plans (D-SNPs) for dual-eligible individuals are specially designed Medicare Advantage plans that include prescription drug coverage and other benefits for members who have Medicare and Medicaid. Depending on the level of the member’s Medicaid, WellCare offers the following D-SNP plans: Liberty: • To be eligible for this plan, potential enrollees must qualify for Medicare Parts A and B and also qualify for Medicaid benefits as a QMB or a QMB Plus. • Members who are enrolled in this plan are not responsible for any cost share. Access: • To be eligible for this plan, potential enrollees must be eligible for one of the Medicare Savings Programs: SLMB+ or FBDE (Full Benefit Dual-Eligibility). • Members who are enrolled in this plan are protected from Medicare Part A and Part B deductibles, co-pays, and co-insurance by their state Medicaid Agency. Select: • To be eligible for this plan, potential enrollees must be eligible for one of the Medicare Savings Programs: QI-1, QDWI, or SLMB. • Members’ cost-sharing in this plan is determined by their level of Medicaid eligibility. p 24 Serving Florida: Medicaid WellCare serves Florida members through the following Medicaid plans. 2014 PLAN OFFERINGS All plans offer a Pay for Performance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. Staywell and HealthEase EXPANDED BENEFITS & INCENTIVES • (Pre-MMA) • • • • Over-the-Counter Items - $300 a year for over-the-counter drugs and supplies–that’s $25 dollars a month for items like diapers, sunscreen, aspirin, vitamins and more–more than 100 items to choose from, mailed right to the member’s home Free baby stroller–To qualify expectant mothers must attend at least six (6) prenatal doctor visits before the birth of their baby Free maternity education booklet–tips to help mothers stay well while they are pregnant Free 24-hour, 7-day-a-week health advice when calling a Personal Health Advisor Free flu shots p 25 Serving Florida: Medicaid - continued WellCare serves Florida members through the following Medicaid plans. All plans offer a Pay for Performance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. 2014 PLAN OFFERINGS Staywell (Post-MMA) EXPANDED BENEFITS & INCENTIVES • No Copays; Co-payments are waived for non-pregnant adults for all services except non-emergency care received in an emergency room and chiropractic services. • Unlimited Primary Care Provider (PCP) Visits • Up to $25/month free over-the-counter (OTC) items delivered to homes • Vision and Dental coverage • Higher Outpatient Hospital Services Limit ($2,500 for outpatient hospital services) • Alternative Therapies (Art, Pet, Equine)* • Doctor Home Visits*; Home Health Visits*; and Nutritional Counseling* • Extra Health and Wellness Services (Hearing exam, Vaccines, Circumcisions etc.) * • Food and Lodging for Care that Requires Travel and an Overnight Stay* • Meals Program* Beginning October 1, 2014: • Healthy Rewards Card, members can earn up to $50 by participating in the Healthy Rewards Program • Prenatal rewards program; and unlimited Prenatal and Postpartum visits *Prior Authorization Required p 26 Serving Florida: CHIP WellCare serves Florida members through the following CHIP plans. All plans offer a Pay for Performance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. 2014 PLAN OFFERINGS Staywell Kids and HealthEase Kids EXPANDED BENEFITS & INCENTIVES • $0 primary care doctor office visits • $180 in free over-the-counter (OTC) items each year (up to $10 each month) delivered to homes • Prescription medications for $5 • Free well-child care • Free immunizations • Free annual/school physicals • Free 24-hour emergency care and personal health advisor available 24/7 • Up to $100 for hypoallergenic bedding to avoid asthma triggers • Boys and Girls Club membership for members ages 6-18 during the school year p 27 Serving Florida: Medicare WellCare serves Florida members through the following Medicare plans. All plans offer a Pay for Performance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. 2014 PLAN OFFERINGS Choice Plan (HMO-POS) ($46-54.60 monthly premium) Value Plan(HMO and HMO-POS) ($0 monthly premium) Advance Plan (HMO) ($0 monthly premium) Essential Plan (HMO) ($0 monthly premium) EXPANDED BENEFITS & INCENTIVES • • • • $0-15 primary care physician visits; $25-35 specialist visits Includes Point of Service (POS) option Prescription coverage included Dental, vision, hearing and fitness membership coverage included • • • • $0-15 primary care physician visits; $0-35 specialist visits Includes Point of Service (POS) option for certain areas Prescription coverage included Dental, vision, hearing and fitness membership coverage included for certain areas • $0-primary care physician visits; $20 specialist visits • Dental, vision, hearing and fitness membership coverage included • • • • • $0 primary care physician visits; $0-35 specialist visits Includes Point of Service (POS) option for certain areas Over-the-Counter allowance for certain areas Prescription coverage included Dental, vision, and hearing coverage included for certain areas p 28 Serving Florida: Medicare - continued WellCare serves Florida members through the following Medicare plans. All plans offer a Pay for Performance program that promotes the timely completion of health care and preventive services, and improves the quality of care for eligible members. 2014 PLAN OFFERINGS Dividend Plan (HMO) ($0 monthly premium) Liberty Plan (HMO SNP) ($0 monthly premium) Access Plan (HMO SNP) ($0 monthly premium) Select Plan (HMO SNP) ($0 monthly premium) EXPANDED BENEFITS & INCENTIVES • $0 primary care physician visits; $0-35 specialist visits • Reimburses some or all of the member’s monthly Medicare Part B premium • Includes Point of Service (POS) option for certain areas • Prescription coverage included • Dental, vision, hearing and fitness membership coverage for certain areas • Dual-eligible plan with little or no out-of-pocket costs • $0 primary care physician visits; $0 specialist visits • Prescription coverage included • Proactive disease and case management model • Dental, vision, hearing, fitness membership, and transportation coverage • Over-the-counter allowance for certain areas • Dual-eligible plan with little or no out-of-pocket costs • $0 primary care physician visits; $0 specialist visits • Prescription coverage included • Dental, vision, hearing, fitness membership, and transportation coverage • Over-the-counter allowance for certain areas • Dual-eligible plan with little or no out-of-pocket costs • $0 primary care physician visits; $0 specialist visits • Prescription coverage included • Dental, vision, hearing, fitness membership, and transportation coverage p 29 Member Identification Cards The purpose of the member identification card is to identify plan members and facilitate their interactions with physicians and other health care providers. Information found on the member identification card includes: • Member Name • Identification Number • Primary Care Physician’s Name and Telephone Number • Co-payment Information • Health Plan Contact Information • Claims Filing Address Possession of the member identification card does not guarantee eligibility or coverage. The physician or provider is responsible for ascertaining the current eligibility of the cardholder. p 30 HealthEase/Staywell Member ID Cards Note: HealthEase members who transition to Staywell will receive a new Member ID Card. p 31 HealthEase Kids/Staywell Kids ID Cards p 32 WellCare Medicare Advantage ID Card WellCare ID Card template remains the same for all Medicare Advantage plans; however, plan name and specifics will vary. Possession of the member identification card does not guarantee eligibility or coverage. The physician or provider is responsible for ascertaining the current eligibility of the cardholder. p 33 WellCare’s Resources WellCare Resources Providers have access to a variety of easy-to-use reference materials on our website The information on our website is the most up-to-date and should be referenced often, including: • Resource Guides related to claims, authorizations, electronic funds transfer and how to contact us • Provider Manual • Clinical Practice Guidelines and Clinical Coverage Guidelines • Provider and Pharmacy look-up • Quick Reference Guide that provides contact information for specific departments and authorization information • Provider Education • Provider Directory p 35 WellCare Resources - continued Additional services through the website include: • Eligibility, Benefit and Co-payment Information • Corrected Claim Submission (Single) • Inpatient Log • Referral Generation (for PCP’s only) • Authorization Request and Status • Preferred Drug Listings • Single Claim Submission (Single) • Provider Newsletters • Claim Status • Reports feature (includes access to care gap reports and membership reports) • Claim Inquiry www.florida.wellcare.com p 36 WellCare Resources - continued By registering for our secure, online Provider Portal, providers have access to: • Member eligibility and co-pay information • Authorization requests • Claims status and inquiry • Provider training • A WellCare specific message inbox Provider Relations representatives are also available to assist with many requests. Contact your local market office for assistance. p 37 Provider Training WellCare Providers will receive ongoing training and education monthly, quarterly, and annually through the following activities: • Online training available on the provider portal (Wellcare.com) • Onsite visit training conducted by Provider Relations staff and field quality specialists • Webcasts that allow the opportunity to interact and ask questions • Website articles and provider newsletters • Periodic amendments to the provider manual • Self-Study programs p 38 Provider Training - continued WellCare provides ongoing provider training that includes: • Alcohol and substance abuse screening training • WellCare’s enrollment and credentialing requirements and processes • Training that promotes proper nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and early intervention services • Claims submission and payment process including explanation of common claims submission errors and how to avoid those errors • Abuse, Neglect, and exploitation of vulnerable adults • Critical Incident requirements • Other ongoing education opportunities p 39 Cultural Competency The purpose of the Cultural Competency program is to ensure: • WellCare meets the unique diverse needs of all members • Associates of WellCare value diversity within the organization • Members in need of linguistic services have adequate communication support WellCare is committed to ensuring that its staff and its provider partners, as well as its policies and infrastructure, are attuned to meeting the diverse needs of all members. The delivery of culturally competent health care and services requires health care providers and/or their staff to possess a set of attitudes, skills, behaviors and policies which enable the organization and staff to work effectively in cross-cultural situations. p 40 Cultural Competency - Continued The components of WellCare’s Cultural Competency Program include: • Data Analysis • Community-Based Support • Diversity and Language Abilities of WellCare staff • Diversity of Provider Network • Linguistic Services • Electronic Media • Provider Education p 41 Hearing-Impaired, Interpreter, and Sign Language Services Valid hearing-impaired, interpreter, and sign language services are available at no-charge to WellCare members who currently have an active plan. PCP’s should coordinate these services for WellCare members and contact Customer Service at the following number(s): HealthEase: 1-800-278-0656 HealthEase Healthy Kids: 1-800-278-8178 Staywell: 1-866-334-7927 Staywell Healthy Kids: 1-866-698-5437 TTY/TDD: 1-877-247-6272 • Valid Interpreter appointments include: Medical (PCP, Specialist, hospital); Ancillary (Dental, Vision, Hearing, Behavioral Health); and Therapy (Physical, Occupational, Speech) • Requests should be made at least 3 business days in advance and can not be made more than 30 days in advance of the scheduled appointment date • After requests have been made, an appointment confirmation by phone will occur between 3 business days up to 3 weeks, depending on the date the interpreter is needed for the appointment. • If interpreter services need to be cancelled, please contact Customer Service. There will be no charge to cancel scheduled interpreter services. p 42 WellCare Member Transportation (Pre-MMA in Non-Reform Pilot Counties) Staywell and HealthEase members are eligible for non-emergent transportation to doctor appointments. Transportation is coordinated through the Commission for the Transportation Disadvantaged. Transportation providers and guidelines vary by county. Members may contact Customer Service to inquire about scheduling transportation to and from medical appointments at Staywell 1-866-334-7927 or HealthEase 1-800-2780656. To assist a member online: 1) Access the FL Transportation Link. 2) Select the appropriate county where the member resides. 3) Provide the member the contact phone number listed. If the county has a Subcontracted Transportation Provider (STP) listed on the right-hand side, please provide contact information from that section. Note: All non-emergency ambulance transportation services require an authorization. Please refer to the Quick Reference Guide for appropriate contact information. p 43 WellCare Member Transportation (Post-MMA and Current Reform Pilot Counties) Staywell members are eligible for non-emergent transportation to doctor appointments. Transportation is coordinated through our vendor, Medical Transportation Management (MTM), Inc. Members, and providers on behalf of the member, may inquire about scheduling transportation to and from medical appointments by calling: Medical Transportation Management: 1-866-591-4066, or Staywell Customer Service: 1-866-334-7927 Members should have the following information available when scheduling transportation: 1) Medicaid ID number 2) Name of doctor or facility 3) Address and phone number of doctor or facility p 44 Additional Resources… • Review the Provider Manual for more detailed information about provider requirements • Refer to the Provider Resource Guide on WellCare’s website as your one-stop-shop Member Claims Credentialing guidesProvider to theand most common transactions with WellCare, including: Administrative Guidelines o Registering for, and WellCare’s Provider Portal for and member eligibility and Utilization Management andhow to use, Quality Improvement Appeals Grievances Case & Disease Management co-pay information, authorization requests, claims status and inquiry, provider news Delegated Entities Compliance Pharmacy Services and more; o How to file a claim via paper, electronically or via WellCare’s Direct Data Entry; o How to file a grievance; and o How to file an appeal. • Refer to the Quick Reference Guide for authorization requirements, addresses and phone numbers for key departments. • Refer to the Clinical Practice Guidelines and Clinical Coverage Guidelines to determine medical necessity, criteria for coverage of a procedure or technology, and best practice recommendations based on available clinical outcomes and scientific evidence. • Contact your Provider Relations representative to schedule an in-service meeting. p 45 Florida 2014 Provider Orientation Module 2: Eligibility and Benefits ©WellCare 2014. FL_020314 Enrollment and Eligibility Enrollment Voluntary Enrollment: A Medicaid recipient who is not mandated to enroll in a Managed Care Plan but chooses to do so State Mandated Enrollment: The Agency automatically assigns enrollees required to be in a Managed Care Plan who did not voluntarily choose one Acceptance Must Be Without: • Consideration of applicant’s health condition. • Regard to color, gender, race, religious belief, national origin or handicap p 48 Disenrollment Voluntary Disenrollment: A member chooses to disenroll from the Plan Involuntary Disenrollment: A member may be involuntarily disenrolled for reasons, such as: • Member is deceased or moves from the service area • Member loses his/her eligibility or entitlement from Medicaid • Fraud – An intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person (Example: Fraudulent use of the enrollee Identification (ID) card or Falsification of prescriptions by an enrollee.) • Non-compliance - An enrollee not following his/her providers instructions. (Examples: Not coming to his/her appointment or not taking his/her medication as instructed by the provider. p 49 How Can I Verify Member Eligibility? • A member’s eligibility status can change at anytime. • Providers should request and copy the member’s identification card and additional proof of identification, such as a photo ID, and file them in the medical record. • Eligibility should be verified at each visit. • Eligibility can be verified via the FLMMIS portal. https://home.flmmis.com/home • Eligibility status is also available by accessing the Plan website at www.florida.wellcare.com or by using our Interactive Voice Response (IVR) system. • Membership listing/panel report mailed out on a monthly basis to all Primary Care Physicians. Providers can access their membership report through florida.wellcare.com. • Verification is based on the data available at the time of the request. p 50 Covered Services and Benefits Staywell and HealthEase Standard Benefits (Pre-MMA) The following standard benefits* are currently available to Staywell and HealthEase members: Advanced nurse practitioner services Early intervention services Licensed midwife services Ambulatory surgical centers Emergency Medical Services Nursing facility services Assistive care services Family Planning services Physician services Federally qualified health center services Child health checkups (well-child Freestanding dialysis center checkups) services Birth center services Chiropractic services Podiatry services Rural health clinic services Hearing services Substance Abuse Home health services Therapy services—occupational, physical, respiratory and speech Hospice services Transportation Dental Hospital services—inpatient and outpatient Durable medical equipment and medical supplies Independent lab services Transplant services—organ and bone marrow Vision services (medically necessary) Community behavioral health services County health department clinic services The MMA program will NOT change Medicare benefits. *Benefit offerings may vary by plan. p 52 Staywell and HealthEase Expanded Benefits* and Special Programs (Pre-MMA) The following expanded benefits* and special programs are currently available to Staywell and HealthEase members: Program Description Over the Counter (OTC) Benefit Staywell will offer a $25 OTC medication allowance per household each month for items like diapers, sunscreen, aspirin, vitamins and more–more than 100 items to choose from, mailed right to your home Free Baby Stroller or Playpen By attending prenatal appointments, members are rewarded with a stroller or portable playpen that is delivered to their home. Mommy and Baby Matters Booklet Free maternity education booklet–tips to help you stay well while you are pregnant Influenza Vaccine All persons aged 6 months and older are covered for an annual vaccination. Personal Health Advisor Free 24-hour, 7-day-a-week health advice *Benefit offerings may vary by plan. p 53 Staywell (Post-MMA) Standard Benefits The following standard benefits* are currently available to Staywell MMA members: Advanced registered nurse practitioner services Laboratory and imaging services Ambulatory surgical treatment center services Medical supplies, equipment, prostheses, and orthoses Chiropractic services Mental health services Dental services Nursing care Hearing services Optometric Services Emergency Medical Services Podiatry Services Family planning services and supplies Physical, occupational, respiratory, and speech therapy services Early periodic screening diagnosis and treatment services for recipients under age 21 Prescription drugs Home health agency services Rural health clinic services Hospice services Substance abuse treatment services Hospital services - inpatient and outpatient Transportation to covered services The MMA program will NOT change Medicare benefits. *Benefit offerings may vary by plan. p 54 Staywell (Post-MMA) Expanded Benefits* and Special Programs The following expanded benefits* and special programs are available to Staywell MMA members: Program Description Co-payment Waiver Co-payments are waived for non-pregnant adults for all services except emergency department and chiropractic services. Unlimited Primary Care Provider Visits To support our quality initiatives, Staywell promotes the use of preventive care including well child visits and check-ups, and enhances overall access to care; Staywell will provide all enrollees with unlimited visits to their primary care provider (PCP). We believe that this is essential to our enrollees receiving the services they need and demonstrates our commitment to ongoing quality improvement. Home Health Visits for NonPregnant Adults Members receive four (4) Personal care Home Health visits by nurses and/or aides per day, per recipient. Personal Care Home visits provide medically necessary assistance with activities of daily living (ADL) and age appropriate instrumental activities of daily living (IADL) that enable the recipient to accomplish tasks that they would normally be able to do for themselves if they did not have a medical condition or disability. Skilled interventions that may be performed only by a licensed health professional are not considered personal care services. *Benefit offerings may vary by plan. p 55 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Outpatient Hospital Outpatient hospital services are preventive, diagnostic, therapeutic or palliative care, and service items provided in an outpatient setting. The services must be provided under the direction of a licensed physician or dentist. Medicaid reimburses licensed, Medicaid-participating hospitals for outpatient services. Medicaid reimbursement includes medical supplies, nursing care, therapeutic services, and pharmacy services. Primary care services provided in an outpatient hospital setting, hospital-owned clinic, or satellite facility are not considered outpatient hospital services and are not reimbursable under the Florida Medicaid (Title XIX) Outpatient Hospital Reimbursement Plan. Perinatal Visits Staywell reimburses for prenatal and perinatal services rendered by licensed, Medicaid-participating doctors of allopathic or osteopathic medicine. Services may be rendered as necessary to support the health and wellbeing of women and her child during pregnancy and in the period immediately after birth. Unlimited prenatal visits Unlimited post-partum visits in the 4 week post-partum period Medicaid currently offers ten prenatal visits per recipient, per pregnancy. Four additional visits may be reimbursed for high risk pregnancies. Two medically necessary postpartum visits per recipient, per pregnancy *Benefit offerings may vary by plan. p 56 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Physician Home Visit Staywell covers services provided by Physicians and Advance Practice Nurse Practitioners evaluating and treating acute and chronic medical problems in the home setting. In-home care for persons who are frail, homebound and unable to travel to a physician's office Evaluation and coordination of home health, therapy and other services as needed. Over the Counter (OTC) Benefit Staywell will offer a $25 OTC medication allowance per household each month. Hypoallergenic Bedding Members who meet criteria for asthma are offered an allowance to purchase hypoallergenic bedding, including bed linens, cushions, mattress protectors and pillow coverings. Lodging and Food for Services Requiring an Overnight Stay Costs of lodging and food associated with a non-emergent medical procedure, specialist visit or hospitalization, where overnight travel is required, will be covered. Meals Program SSI and dually eligible members discharged within two weeks from an inpatient facility can receive 10 meals for post-acute nutritional support. *Benefit offerings may vary by plan. p 57 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Circumcisions To be eligible for coverage the male patient must be age 0 to 3-months of age. Nutritional counseling Coverage includes assessment, hands-on care, and guidance to caregivers and enrollees with respect to nutrition. This service teaches caregivers and enrollees to follow dietary specifications that are essential to the enrollee’s health and physical functioning, to prepare and eat nutritionally appropriate meals and promote better health through improved nutrition. This service may include instructions on shopping for quality food and food preparation. Pneumonia Vaccine Pneumococcal conjugate vaccine (PCV13) will be covered for all children younger than 5 years old and for adults with certain risk factors. Children 2 years or older who are at high risk of pneumococcal disease will also receive the pneumococcal polysaccharide vaccine (PPSV23). *Benefit offerings may vary by plan. p 58 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Shingles Vaccine Staywell covers vaccination of shingles for members ages 60 and older. Coverage includes one vaccination every six years. Not covered for the following individuals: a person who has ever had a life-threatening or severe allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine. Tell your doctor if you have any severe allergies. • a person who has a weakened immune system because of • HIV/AIDS or another disease that affects the immune system, • treatment with drugs that affect the immune system, such as steroids, • cancer treatment such as radiation or chemotherapy, • cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma • women who are or might be pregnant *Benefit offerings may vary by plan. p 59 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Influenza Vaccine All persons aged 6 months and older are covered for an annual vaccination. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to the following persons (no hierarchy is implied by order of listing): • are aged 6 months through 4 years (59 months); • are aged 50 years and older; • have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus); • are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus); • are or will be pregnant during the influenza season; • are aged 6 months through 18 years and receiving long-term aspirin therapy and who therefore might be at risk for experiencing Reye syndrome after influenza virus infection; • are residents of nursing homes and other chronic-care facilities; • are American Indians/Alaska Natives; • are morbidly obese (body-mass index is 40 or greater); • caregivers of children aged younger than 5 years and adults aged 50 years and older, with particular emphasis on vaccinating contacts of children aged younger than 6 months; and • caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza. *Benefit offerings may vary by plan. p 60 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Smoking Cessation Members will be offered a health coach who will provide telephonic outreach and support. Support can also include bupropion or Chantix tablets and nicotine replacement therapy, multi-modal communication and other resources. Expanded Adult Dental Benefits Adults can receive preventative dental care services, including oral exams and cleanings every six months as well as annual x-rays, with no copay to members 21 and older, and pregnant women. Children are covered under a standard benefit package. Expanded Vision Benefits Members 21 and older can apply a $100 allowance toward any frame, contact lenses or upgrades. Hearing Services Staywell will provide coverage for one hearing evaluation for the purpose of determining hearing aid candidacy, per eligible, every two years from the date of the last evaluation. Healthy Rewards Card Members can earn up to $50 by participating in Staywell's Healthy Rewards Program. The incentive program allows members to be rewarded with a reloadable Visa debit card for completing specific preventive health, wellness and engagement milestones. Enrollee Discount Card Members will receive monthly discounts from pre-selected retailers. Members can receive the discount card after completion of certain healthy behaviors. *Benefit offerings may vary by plan. p 61 Staywell (Post-MMA) Expanded Benefits* and Special Programs - continued Program Description Art Therapy Provides therapy coverage for SSI children, adults, and dually eligible enrollees who are identified by care management criteria for cancer treatment, emotional abuse, and post-traumatic stress disorders (PTSD) and other chronic conditions based on medical necessity. Pet Therapy Provides therapy coverage for SSI children, adults, and dually eligible enrollees who are identified by utilization management criteria for cancer treatment, emotional abuse, cerebral palsy, autism, and other chronic conditions based on medical necessity. Equine Therapy SSI children, adults and dually eligible members who meet utilization management criteria for cerebral palsy and autism can receive 10 free riding sessions per year. Free Baby Stroller or Playpen By attending prenatal appointments, members are rewarded with a stroller or portable playpen that is delivered to their home. Free Cell Phone Staywell will offer a free cell phone to members who are engaged in a care management and do not have a telephone. *Benefit offerings may vary by plan. p 62 Staywell Kids and HealthEase Kids Standard Benefits The Florida Healthy Kids Corporation is a non-profit organization established in 1990 by the State of Florida to provide affordable healthcare coverage for uninsured children ages 5 through 18. The following standard benefits* are available to Staywell Kids and HealthEase Kids members: Well-Child Care and School Physicals Diagnostic Testing Office Visits for Minor Illnesses, Accident Care (PCP) Therapies - Outpatient Physical, Occupational, Respiratory and Speech Specialist Office Visit (if referred by PCP) Anesthesia Services Hospital Inpatient Medical and Surgical Care Home Health Services Emergency Services Durable Medical Equipment and Prosthetic Devices Prenatal Care and Delivery Routine Vision and Hearing Screening (PCP) Pharmacy Coverage Refractions/Corrective Lenses Behavioral Health Services Chiropractic Services Outpatient Services Organ Transplants Inpatient Services OTC Program($15 per family per month) *Benefit offerings may vary by plan. p 63 Staywell Kids and HealthEase Kids Expanded Benefits* and Special Programs The following expanded benefits* and special programs are available to Staywell Kids and HealthEase Kids members: Program Description No Copay for physician services $0 co-payments for primary care provider (PCP) and urgent care visits Over the Counter (OTC) Benefit $15 OTC medication allowance per household each month for items like diapers, sunscreen, aspirin, vitamins and more–more than 100 items to choose from, mailed right to your home Mommy and Baby Matters Booklet Free maternity education booklet–tips to help you stay well while you are pregnant Nurse Advice Hotline Free 24-hour, 7-day-a-week health advice Boys and Girls Club Membership Free membership to the Boys and Girls Club for members ages 6-18. Hypoallergenic Bedding Members who meet criteria for asthma are offered an allowance to purchase hypoallergenic bedding, including bed linens, cushions, mattress protectors and pillow coverings. *Benefit offerings may vary by plan. p 64 How to Access Expanded Benefits and Special Programs For more information on how to access Expanded Benefits and Special Programs: • Review the Plan’s Summary of Benefits; • Visit our website at: https://florida.wellcare.com/; or • Contact our customer service line: HealthEase: 1-800-278-0656 HealthEase Kids: 1-800-278-8178 Staywell: 1-866-334-7927 Staywell Kids: 1-866-698-KIDS TTY/TDD (All Plans): 1-877-247-6272 Monday - Friday, 7 a.m. to 7 p.m. Eastern p 65 Florida 2014 Provider Orientation Module 3: Rights and Responsibilities ©WellCare 2014. FL_020314 Provider Responsibilities Provider Responsibilities All participating providers are responsible for adhering to the Participation Agreement and the Provider Manual. The Provider Manual supplements the Agreement and provides information on requirements such as: • Provider Billing and Address change • Access and availability, including after-hours coverage • Credentialing and Re-credentialing requirements • Assisting members with special health care needs, including mental, developmental and physical disabilities and/or environmental risk factors • Claims and Encounter data submission • Specific medical records requirements as well as accuracy of, record retention timeframes and Advance Directive and Living Wills documentation • Mandatory participation in Quality Improvement projects and medical record review activities such as HEDIS® • Adhering to WellCare’s compliance requirements, including provider training and safeguarding member confidentiality in compliance with HIPAA For more information on provider rights and responsibilities, refer to the Provider Manual. p 68 Primary Care Provider Responsibilities • Coordinate, monitor and supervise the delivery of primary care services to each member • See members for an initial office visit and assessment within the first 90 days of enrollment in WellCare • Coordinate, monitor and supervise the delivery of medically necessary primary and preventive care services to each member, including EPSDT services for members under the age of 21 • Maintain a ratio of members to full-time equivalent (FTE) providers as indicated in the Provider Manual • Provide appropriate referrals of potentially eligible women, infants and children to the WIC program for nutritional assistance p 69 Primary Care Provider Responsibilities continued • Provide access to WellCare to examine the primary care offices, books, records and operations of any related organization or entity • Submit an encounter for each visit where the provider sees the member or the member receives a HEDIS® service • Ensure members utilize network providers • Comply with and participate in corrective action and performance improvement plan(s) p 70 Americans with Disabilities Act Participating WellCare providers must meet the requirements of all applicable state and federal laws and regulations including the Americans with Disabilities Act (ADA). The Americans with Disabilities Act prohibits discrimination and guarantees that everyone with disabilities are offered the same opportunities as everyone else to participate in the mainstream of American life, including access to care. For more information regarding the ADA, visit their website: http://www.ada.gov/ada_intro.htm p 71 Access and Availability Standards Type of Appointment Access Standard Urgent Within one (1) day of the request Sick Within one (1) week of the request Well Care Visit Within one (1) month of the request In-office waiting times for primary care visits, specialty and urgent care, optometry services, and lab and x-ray services shall not exceed 30 minutes. p 72 Access and Availability Standards – continued PCPs must provide or arrange for coverage of services, consultation or approval for referrals 24 hours a day, seven days a week. To ensure accessibility and availability, PCPs must provide one of the following: • A 24-hour answering service that connects the member to someone who can render a clinical decision or reach the PCP; • An answering system with the option to page the physician for a return call within a maximum of 30 minutes; or • An advice nurse with access to the PCP or on-call physician within a maximum of 30 minutes. p 73 Immunizations Medicaid Members: • The Vaccines for Children (VFC) Program provides vaccines at no charge to providers. Providers should use VFC stock when providing vaccines to Medicaid members. • WellCare pays providers an administration fee. Providers must file a claim with WellCare to receive payment for the administration fee. p 74 Immunizations - continued MediKids Members: • Provider must use private stock vaccines. MediKids members do not qualify for the VFC program. • WellCare pays providers an administration fee. Providers must file a claim with WellCare to receive payment for the administration fee and file a claim with Medicaid fee-for-service for the cost of the vaccine. p 75 Immunizations - continued Healthy Kids Members: • All primary care physicians must provide all covered immunizations to members and be enrolled with the Florida State Health Online Tracking System (SHOTS), Florida’s statewide online immunization registry. To register for Florida SHOTS, please visit: http://www.flshots.com • Provider must use private stock vaccines. Healthy Kids members do not qualify for the VFC program. • WellCare pays providers an administration fee and for the cost of the vaccine. Providers must file a claim with WellCare to receive payment for both. p 76 Advance Directives Members have the right to control decisions relating to their medical care, including the decision to have withheld or taken away the medical or surgical means or procedures to prolong their life. Each WellCare member should receive information regarding living will and advance directives. This allows them to designate another person to make a decision should they become mentally or physically unable to do so. WellCare provides information on advance directives in the Member Handbook. p 77 Advance Directives - continued Information regarding living will and advance directives should be made available in provider offices and discussed with the members. Completed forms should be documented and filed in members’ medical records. Case Managers will discuss advance directives with each member during the initial Health and Functional Assessment. A provider shall not, as a condition of treatment, require a member to execute or waive an advance directive. p 78 Members with Special Health Care Needs Members with Special Health Care Needs face physical, mental or environmental challenges daily that place at risk their health and ability to fully function in society. Factors include: • individuals with mental retardation or related conditions • individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders • individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes • children/adolescents and adults with certain environmental risk factors such as homelessness or family problems p 79 Members with Special Health Care Needs - continued Providers should: • Assess members and develop plans of care for those members determined to need courses of treatment or regular care • Coordinate treatment plans with members, family and/or specialists caring for members • Allow the members needing a course of treatment or regular care monitoring to have direct access through standing authorization or approved visits, as appropriate for the member’s condition or needs • Develop a plan of care that adheres to community standards and any applicable sponsoring government agency quality assurance and utilization review standards p 80 Members with Special Health Care Needs - continued Providers should: • Coordinate with WellCare to ensure that each member has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the member • Coordinate services with other third party organizations to prevent duplication of services and share results on identification and assessment of the member’s needs • Ensure that members requiring specialized medical care over a prolonged period of time have access to a specialty care provider • Ensure the member’s privacy is protected as appropriate during the coordination process. p 81 Abuse, Neglect and Exploitation • Providers are responsible for the screening and identification of children and vulnerable adults who are abused neglected or exploited. Providers are also required to report the identification of members who fall into those categories. • Suspected cases of abuse, neglect and/or exploitation must be reported to the State’s Adult Protective Services Unit. • Adult Protective Services (APS) are services designed to protect elders and vulnerable adults from abuse, neglect or exploitation. p 82 Abuse, Neglect and Exploitation continued • The Department of Elder Affairs (DOEA) and the Florida Department of Children and Families (DCF) have defined processes for ensuring victims of abuse, neglect or exploitation in need of home and community-based services are referred to the appropriate resources, tracked and served in a timely manner. • Training regarding Abuse, Neglect, and Exploitation is on our website at https://florida.wellcare.com/provider/Provider_Training_and_Education. • To report suspected abuse, neglect or exploitation of children or vulnerable adults, providers should call the Florida Abuse Hotline at 1-800-96-ABUSE (1-800-962-2873) (TDD 1-800-453-5145). If you see a child or vulnerable adult in immediate danger, call 911. This toll free number is available 24 hours a day. p 83 Alcohol and Substance Abuse Training WellCare offers annual alcohol and substance abuse screening training to all providers. All PCP’s are required to screen WellCare members for signs of alcohol or substance abuse as part of prevention evaluation at the following times: • Initial contact with a newly enrolled member • Routine physical examinations • Initial prenatal contact • When the member evidences serious over-utilization of medical, surgical, trauma, or emergency services • When documentation of emergency room visits suggests the need p 84 Member Rights & Responsibilities Staywell Medicaid Member Rights Member rights are outlined in the Member Handbook, which is mailed to all newly enrolled members. Staywell Medicaid Member rights include, but are not limited to: • To get details about what the plan covers and how to use its services and plan providers • To have their privacy protected • To talk openly about care needed for their health, no matter the cost or benefit coverage • To freely talk about care options and risks involved • To have this information shared in a way they understand p 86 Staywell Medicaid Member Rights – continued Member rights are outlined in the Member Handbook, which is mailed to all newly enrolled members. Staywell Medicaid Member rights include, but are not limited to: • To know what to do for their health after they leave the hospital or provider’s office • To suggest ways the plan can improve • To file complaints or appeals about the plan or the care it provides • To have all health plan staff members observe their rights • To use these rights no matter what their sex, age, race, ethnic, economic, educational or religious background • To participate with practitioners in making decisions about their health care p 87 Staywell Medicaid Member Rights – continued Member rights are outlined in the Member Handbook, which is mailed to all newly enrolled members. Staywell Medicaid Member rights include, but are not limited to: • To a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage • To receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand • To participate in decisions regarding health care, including the right to refuse treatment • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation p 88 Staywell Medicaid Member Rights – continued Member rights are outlined in the Member Handbook, which is mailed to all newly enrolled members. Staywell Medicaid Member rights include, but are not limited to: • To ask for and receive a copy of medical records, and ask that they be amended or corrected o Requests must be received in writing from the member or the person chosen to represent him/her o The records will be provided at no cost o The records will be sent within 14 days of receipt of the request The full list of member rights is in the Provider Manual. p 89 Staywell Medicaid Member Responsibilities StayWell Medicaid Members are responsible for: • Knowing how WellCare works by reading the Member Handbook • Carrying their Plan card and Medicaid Gold Card with them at all times and to present their cards prior to receiving services • Being on time for appointments • Cancelling and rescheduling appointments prior to missing their scheduled appointment • Respecting providers, staff and other patients p 90 Staywell Medicaid Member Responsibilities continued StayWell Medicaid Members are responsible for: • Asking questions if they do not understand medical advice provided • Helping to set treatment goals that they agree to with their provider • Ensuring their provider has previous medical records, or access to previous records • Informing WellCare within 48 hours, or as soon as they can, if they are in a hospital or go to an emergency room The full list of member responsibilities is in the Provider Manual. p 91 HealthEase Kids and Staywell Kids Member Rights HealthEase Kids and Staywell Kids members have the right to: • Timely and appropriate care • Receive information about the organization, its services its practitioners and provider and member rights and responsibilities • Participate with practitioners in making decisions about their health care • A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage • Make recommendations regarding the organization’s’ member rights and responsibilities; • Be treated with courtesy and respect, with appreciation of individual dignity, and protection of privacy p 92 HealthEase Kids and Staywell Kids Member Rights - continued HealthEase Kids and Staywell Kids members have the right to: • A prompt and reasonable response to questions and requests • Know who is providing medical services and who is responsible for their care • Know what patient support services are available, including whether an interpreter is available if the member does not speak English • Know what rules and regulations apply to their conduct • Get information concerning diagnosis, planned course of treatment, alternatives, risks and prognosis and the plan cannot keep the health care provider from giving the information to the member p 93 HealthEase Kids and Staywell Kids Member Rights - continued HealthEase Kids and Staywell Kids members have the right to: • Refuse any treatment; except as otherwise provided by law • Not be responsible for the plan’s debts in the event of bankruptcy • Not be held liable for covered services for which the plan does not pay the provider, and the provider cannot hold the member responsible for any unpaid amounts due to the provider other than a co-payment • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation • Make complaints and appeals without discrimination and expect problems to be fairly examined and appropriately addressed p 94 HealthEase Kids and Staywell Kids Member Rights - continued HealthEase Kids and Staywell Kids members have the right to: • Review and comment about their personal health information and review medical records and/or changes to personally identifiable health information; • Protection against unauthorized disclosure of their personal health information; • Approve the release of any information beyond Staywell Kids or HealthEase Kids; • Have information used for research or performance measurement limited in that all data will be combined; and • Authorize the use of their individually identifiable health information for any purpose The full list of HealthEase Kids and Staywell Kids member rights is available in the Provider Manual. p 95 HealthEase Kids and Staywell Kids Member Responsibilities HealthEase Kids and Staywell Kids members are responsible for: • Following plans and instructions for care that they have agreed to with their practitioners • Understanding their health problems and participating in developing mutually agreed-upon treatment goals to the degree possible • Keeping appointments and, when unable to do so, to notify their health care provider or the health care facility • Providing to the health care provider accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to health to the best of their knowledge p 96 HealthEase Kids and Staywell Kids Member Responsibilities - continued HealthEase Kids and Staywell Kids members are responsible for: • Reporting unexpected changes in their condition to the health care provider • Following the treatment plan recommended by the health care provider • Reporting to the health provider whether they understand a course of treatment and what is expected of them • Their actions if they refuse treatment or do not follow the health care provider’s instructions p 97 HealthEase Kids and Staywell Kids Member Responsibilities - continued HealthEase Kids and Staywell Kids Members are responsible for: • Ensure that co-pays are paid as promptly as possible; and • Follow health care facility rules and regulations affecting patient care and conduct. The full list of HealthEase Kids and Staywell Kids member responsibilities is available in the Provider Manual. p 98 Florida 2014 Provider Orientation Module 4: Member Care and Quality ©WellCare 2014. FL_020314 Quality Improvement Quality Improvement Program • WellCare’s Quality Improvement (QI) Program activities include, but are not limited to: o Monitoring clinical indicators and outcomes o Monitoring appropriateness of care o Quality studies o Healthcare Effectiveness Data and Information Set (HEDIS®) measures o Medical records audits o Providers are contractually responsible for participating in QI projects and medical record review activities p 101 Quality Improvement Program - continued • HEDIS® is a mandatory process that occurs annually. It is an opportunity for WellCare and its providers to demonstrate the quality and consistency of care that is available to members • For more information on WellCare’s Quality Improvement Program, refer to the Provider Manual p 102 Patient Centered Medical Homes: Benefits to Members Patient Centered Medical Homes (PCMH) follow a care delivery model in which WellCare members’ treatments are more effectively coordinated by their primary care providers. The objective is to have a centralized setting that allows providers to partner with the patient and when necessary, the family. Some examples of PCMH benefits are: • Better health outcomes to members because they are guided by their Primary Care Physician • Members will get appropriate care when they need it because their PCP works with them to ensure specialists, medications, lab tests, and treatments are a coordinated part of the care plan • Fosters a strong physician-patient relationship that emphasizes proactive care coordination • Helps increase quality of care, lower costs, reduce health disparities, and achieve better health outcomes p 103 Patient Centered Medical Homes: Incentives • WellCare supports the efforts of providers as they transition into PCMH through an incentive program. • Incentives are based on the accreditation standards used by the National Committee for Quality Assurance (NCQA) to recognize the practice and/or the physicians as a PCMH. • The level of support is determined by the level of proficiency in the PCMH practice related to infrastructure capabilities and performance on HEDIS ® and STARs metrics. p 104 Patient Centered Medical Homes: Incentives continued PCMH incentives may include: • Value-based Payment (VBP) Incentives for practices that support and promote the delivery of high-value primary and preventive services • Rewards based on three standards: 1. Establishment as a PCMH via NCQA accreditation 2. Providing PCMH services such as enhanced access and care plan oversight 3. Meeting selected quality metrics • Embedded Case Management for high volume of WellCare members • IT support may be provided p 105 Staywell Medicaid Provider Directory: Online Member Feedback Staywell Medicaid members have the opportunity to provide feedback about their provider. There are five questions: 1. How easy was it to get a regular appointment? 2. How well did the provider listen and answer questions? 3. How well did the provider explain things in a way that was easy to understand? 4. Did the staff treat you with courtesy and respect? 5. How likely are you to recommend this provider to a friend? p 106 Staywell Medicaid Provider Directory: Online Member Feedback - continued • All five questions will be scored on a five point scale, and the online directory will display the average score for each provider. • Members can only provide feedback once per provider every 30 days. • Scores are calculated from the latest nine months’ worth of data. • All data is retained and stored for at least seven years. • Your Provider Relations Representative will discuss negative scores with you. p 107 Medical Records • Member medical records must be timely, legible, current, detailed and organized to permit effective and confidential patient care and quality review. • Complete medical records include medical charts, prescription files, hospital records, provider specialist reports, consultant and other health care professionals’ findings, appointment records, and other documentation sufficient to disclose the quantity, quality, appropriateness, and timeliness of services provided under the contract. • The medical record shall be signed and dated by the provider of service. p 108 Medical Records - continued • Confidentiality of member information must be maintained at all times. Records are to be stored securely with access granted to authorized-personnel only. • Access to records should be granted to WellCare, or its representatives without a fee to the extent permitted by state and federal law. • Information from the medical records reviews may be used in the re-credentialing process as well as quality activities. • The full list of medical record requirements is in the Provider Manual in Section 3: Quality Improvement, pg. 42-46. p 109 HEDIS ® Requirements The Healthcare Effectiveness Data and Information Set (HEDIS®) is used to measure performance on important dimensions of care and service. • HEDIS® is a mandatory process that occurs annually. • WellCare has a Network Improvement Plan (NIP) in place to monitor all provider’s medical utilization and quality of care. • Every month, your Provider Relations Representative will distribute HEDIS® reports indicating preventative visits that should be scheduled for your assigned members. • Lists of your patients who have frequent emergency room visits will also be provided. • In addition, utilization reports reviewing inpatient, outpatient, emergency room, professional and pharmacy costs will be available to all Primary Care Physicians. p 110 HEDIS® Overview HEDIS® consists of a set of performance measures utilized by more than 90% of American health plans that compare how well a plan performs in these areas: • Quality of care • Access to care • Member satisfaction with the health plan and doctors HEDIS ® can also help you Identify non-compliant members to ensure they receive preventive screenings Understand how you compare with other plan providers as well with the national average p 111 HEDIS® Overview What You Can Do: Encourage your patients to schedule preventive exams Remind your patients to follow up with ordered tests Complete outreach calls to noncompliant members p 112 HEDIS® Tools The Patient Quality Opportunity section of the Provider Portal gives real-time, member-specific information regarding care gaps the member may have. This will promote timely completion of health care preventive services and improve the quality of care for members. p 113 HEDIS® Tools - continued Providers also have the ability to view reports related to their members' utilization and quality, including readmissions/ER visits and HEDIS® measures. You may access up-to-date information about members via the secure online Provider Portal. p 114 HEDIS® Tools - continued • Providers have the ability to view reports to benchmark themselves (or other provider groups) against quality, cost and utilization metrics. • You can also use the information in these reports to compare against appropriate peer groups. • Quality of care measures will include selected measures from quality programs. • Cost and utilization information will be adjusted for case-mix and patient-mix using population-based and episode-based groups. p 115 HEDIS® Tools - continued Reports include: • Performance Summary • Quality Analysis • Population-based Cost Analysis • Population-based Utilization Analysis • Episode-based Cost Analysis and Episode-based Utilization Analysis To access any of these tools, please go to https://florida.wellcare.com/provider/default. p 116 Covered Services – CHCUP / EPSDT • Providers are sent a monthly membership list which specifies the health assessment for eligible children who have not had an encounter within 120 days of joining WellCare or are not in compliance with the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program • Any provider who provides EPSDT services are responsible for: o Monitoring, tracking and following up with members: Who have not had a health assessment screening Who miss appointments to assist them in obtaining an appointment To ensure they receive the necessary medical services o Ensuring members receive the proper referrals to treat any conditions or problems identified during the health assessment o Assisting members with transition to other appropriate care for children who age-out of EPSDT services p 117 Covered Services – CHCUP / EPSDT continued • The Provider’s compliance with member monitoring, tracking and follow-up will be assessed through random medical record review audits conducted by WellCare’s Quality Improvement department. • Corrective action plans will be required for providers who are below 80% compliance with all elements of the medical record review. • Refer to the Pediatric Preventive Health Care Guidelines for more information on EPSDT Covered Services and the periodicity schedule. p 118 Child Health Services and Check-ups Available Services: Eligible children and young adults should have a health check-up at: Regular physical exams birth Growth Measurements Immunizations (shots) 2-4 days for newborns discharged in less than 48 hours after delivery Vision and hearing screenings 2 months Other important tests and services 4 months Referral for diagnosis and treatment, if necessary 6 months 9 months 12 months 15 months 18 months 24 months 30 months Yearly from ages 3-20 p 119 Health Information Exchange WellCare is dedicated to improving the health and quality of life of our members and actively supports the statewide implementation of the Florida Health Information Exchange (HIE). The HIE means the secure electronic information infrastructure created by the State of Florida for sharing health information among health care organizations and offers health care providers the functionality to support meaningful use and a high level of patient-centered care. p 120 Health Information Exchange - continued WellCare’s goal is to support providers in connecting with the Florida HIE. The HIE is a secure, interoperable network in which participating providers with certified electronic health record (EHR) technology can use to locate and share needed patient information and send Direct Secure Messages (DSM) with each other which results in improved coordination of care among physician practices, hospitals, labs, and across the various health systems. Please visit https://www.florida-hie.net to obtain more information on this program and guidance on how you can make the HIE connection. p 121 Case Management and Disease Management Interdisciplinary Care Team An Interdisciplinary Care Team (ICT) is made up of a group of individuals with diverse training and backgrounds who collaborate to solve patient problems and ensure the member’s needs are met. The ICT is made up of both community and WellCare team members, and is an integrated part of Staywell’s iREACH Care Management Model. p 123 Staywell Medicaid iREACH Care Management Model iREACH • Identify our enrollees in the community. • Reach them where they live. • Understand how they prefer to Engage with the health care system. • Facilitate their Access to Care. • Help them when they need us. The iREACH care management model integrates behavioral health and medical services using in-house behavioral health specialists who fully participate in our interdisciplinary care coordination teams and work alongside registered nurses, social workers and other professionals to serve each of the target populations that are included in the MMA program. p 124 Staywell Medicaid iREACH Care Management Model - continued p 125 Staywell Medicaid iREACH Care Management Model - continued Approximate % Population Case Management Category - Description 1% Level 4 - Complex Case Management In-person case management for multiple chronic conditions and high-need transitional care 2% Level 3 - Medium Complexity Chronic Case Management Long-term and short-term telephonic case management 12% Level 2 - Low Complexity Chronic Case Management & Health Coaching Single disease management (i.e., smoking cessation, weight management) – Alere 85% Level 1 - Wellness Engagement & Education Telephonic, paper, web, health fairs, etc. p 126 Staywell Medicaid iREACH Care Management Model - continued Evidenced Based Disease Management Programs • • Innovative and evidence based approaches to disease management. Engaged Alere for their innovative disease management programs and ability to monitor outcomes. • Disease Management Programs – Cancer, Asthma and Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Coronary Artery Disease (CAD) and Hypertension, Depression, Diabetes and HIV • • • Alere – Diabetes, Asthma and COPD, CAD and Hypertension, CHF eviti – Oncology for cancer solutions Internal – Depression, HIV, Hemophilia, other • Offering additional programs to promote and incentivize healthy behaviors such as maternity management, doula program, healthy rewards, and enhanced benefits. p 127 Community Outreach WellCare has collaborative community partnerships with community resources. Community resources for our members include and are available for: • Referrals from WellCare Care Managers for community based services • Assistance in coordinating care and post-discharge services to facilitate a smooth transfer of the member to the appropriate level of care • Community Behavioral Health services • Assistance with substance abuse and domestic violence • Community Health Workers and Member Engagement who contact the newly enrolled member to conduct a Health Risk Assessment and refer to case management services if necessary p 128 Member Engagement WellCare utilizes a number of engagement strategies to establish a relationship with our members: • Engagement begins with notification of member enrollment. Notice of enrollment triggers an attempt to reach the member by phone to complete the health risk assessment (HRA) and to educate the member about plan benefits. • A total of eight attempts are made to contact the member. • If the member can not be reached by telephone, the member’s name and address is referred to the Community Health Worker (CHW) assigned to the member’s zip code. • Community Health Workers then make every attempt to connect with the member and conduct a face-to-face session to complete the HRA. This interview whether telephonic or in person is a critical step to engaging members in their own health management. Our telephonic team and CHW’s are trained in behavioral interviewing techniques which promote maximum engagement of the member. p 129 Assessments for WellCare Members • A Health Risk Assessment (HRA) is completed with the member within the first 90 days of enrollment. • In the event that the HRA identifies a member who requires a more comprehensive assessment, the member is electronically referred to our Case Management program. Comprehensive Assessments address the following areas: Health Status Clinical Medical History Medications and allergies Activities of Daily Living Durable Medical Equipment Mental Health and psychosocial issues Socio-Economic Life Planning Activities Ethnic, Cultural, Spiritual, Linguistic, and Literacy p 130 Assessments for WellCare Members continued • Case Managers are either Licensed Registered Nurses or Social Workers. • Upon completion of the more Comprehensive Assessment, a care plan is developed with input from the member, the provider and the case manager. The care plan is available for providers to view via the Provider Portal. • Case Managers collaborate with the provider to ensure the most successful care plan is developed and implemented to affect positive outcomes for the member. p 131 Case Management: How it Works The types of cases targeted by our Case Management program include, but are not limited to the following members: • Complex care needs requiring coordination of multiple outpatient services • Transplants • Frequent inpatient admissions and readmissions • Prolonged or debilitating illness or injuries Our Disease Management program assists WellCare members with a number of conditions. p 132 Case Management: Member Referrals Our case management program identifies potential participants by: • Referrals from physicians • Self-referrals from members • Pharmacy and medical claims data • Overutilization of clinical services p 133 Disease Management • Disease management is a component of Staywell’s Medicaid iREACH Care Management program. • Clinically trained Disease Managers support members with targeted chronic conditions. • At Staywell Medicaid, our primary role is to give our members the education and tools that they need to take control of their health. • We identify members with chronic diseases and provide education and health coaching to empower them to make behavior changes and self-manage their condition(s). p 134 Disease Management - continued • To support members’ relationships with their providers, WellCare will provide the Disease Management care plan through our Provider Portal. • WellCare’s physician engagement strategies are designed to give providers feedback and information about their patients’ progress as well as any care gaps or risk management issues. p 135 Disease Management - continued The Disease Management Program targets the following conditions: • Asthma • Coronary Artery Disease (CAD)/Hypertension • Chronic Obstructive Pulmonary Disease (COPD) • HIV/AIDS • Cancer • Congestive Heart Failure (CHF) • Diabetes • Hypertension • Depression p 136 Behavioral Health Behavioral Health Integration Strategy Key Components of Behavioral Health Integration: • One Plan Structure - holistic approach to medical and behavioral health care • Member-Centric Approach to Care - develop services and programs that are responsive to health care needs of the members we serve • Patient Medical and Behavioral Health Homes - integration of medical and behavioral care in the community, including special populations • Commitment to Community Services - partnership with providers, advocates and stakeholders p 138 Behavioral Health Integration Strategy continued Key Components of Behavioral Health Integration – continued: • Use of Best Practices - that are proven to promote recovery and resiliency • Data Integration - use of data from all components of care to measure performance and drive clinical decisions • Pay for Performance - move toward quality driven utilization management models and alignment of financial incentives • Care Coordination - improve coordination and communication between medical and behavioral health providers p 139 Behavioral Health Integration Strategy Medical/Behavioral Integration Primary Focus: • Comprehensive physical and behavioral health screening • Engagement of consumers at multiple levels of care (e.g., program design, selfmanagement, care plan development) • Shared development of care plans addressing physical and behavioral health • Clinical Advisory Council - participation from behavioral and medical clinical leaders in development, implementation and evaluation of health integration strategies p 140 Behavioral Health Integration Strategy Medical/Behavioral Integration - continued Primary Focus - continued: • Transparency in care management - sharing data with stakeholders that show outcomes and performance • Ongoing training and education of medical and behavioral health providers • Standardized protocols and evidence-based guidelines that can be tailored to the needs of the members we serve • Reduction of avoidable emergency and inpatient utilization by supporting the development and use of a wide range of community based services p 141 Behavioral Health Integration Strategy – Utilization Management Process Elements of Utilization Management (UM) Process and Community Involvement: • We will begin by formulating a policy with the input of the Clinical Advisory Board and other stakeholders. • We will then implement the policy and measure its effectiveness through outcomes data and performance information. • Based on that, it will be revised and new policies will be formulated as needed. • This will be an ongoing process that leads to continuous quality improvement. p 142 Behavioral Health Integration Strategy – Utilization Management Process - continued Optimal Outcomes for Consumers, Members and Their Families Best Practices Formulate Policy Revise BH Market ADVISORY COUNCILS Communications Information Education & Training Project Management Implement Measure Performance -Data -Information p 143 Behavioral Health Integration Strategy – Utilization Management Process - continued Focus on Outlier Management: • Rather than require an authorization for all services provided, WellCare will focus on the high-utilizers at both the provider and member levels. • Using claims data, we will evaluate the utilization patterns of our providers and members. o For those that fall outside the norm, we will target additional services such as intensive case management and provider consultation. o An example of an outlier member may be a member who has had 3 inpatient hospitalizations within one month when the average is 1 hospitalization. In this case, we may refer the member to intensive case management so that a care plan can be developed in consultation with the treating providers. p 144 Behavioral Health Integration Strategy – Utilization Management Process - continued Outlier Management – continued: Data can be analyzed by hospital, provider, consumer/member, level of care, etc., for the earliest possible identification of outlier results. Outliers are targeted for additional services, such as intensive Case Management or provider consultation. p 145 Behavioral Health Services • Members do not need a referral for behavioral health services, and WellCare does not require a Prior Authorization for standard outpatient services. • Community Mental Health Services that are subject to the State of Florida Handbooks do not require Prior Authorization, simply a case registration, but will require concurrent review at set points to facilitate good clinical outcomes. • PCPs may provide any clinically appropriate behavioral health services within the scope of their practice. p 146 Behavioral Health Services - continued • WellCare strongly encourages open communication and collaboration between PCPs and behavioral health providers, including, but not limited to: o Behavioral health providers are required to submit, with the member’s or member’s legal guardian’s consent, an initial and quarterly summary report of the member’s behavioral health status to the PCP. o Behavioral health providers should communicate with the member’s PCP upon discharge from inpatient hospitalization. o If a member’s medical or behavioral condition changes, WellCare expects both the PCP and behavioral health provider to communicate those changes with each other, especially any changes in medications that need to be discussed and/or coordinated. • For more information on WellCare’s Behavioral Health program, refer to the Provider Manual and the Quick Reference Guide. p 147 Behavioral Health • All provisions contained within the Manual are applicable to medical and behavioral health providers unless otherwise noted in the Behavioral Health section of the Provider Manual. • Coordination and continuity of care between behavioral health care providers and medical care providers is critical to positively influencing member outcomes. • All members receiving inpatient psychiatric services must be scheduled for outpatient follow-up and/or continuing treatment prior to discharge, and the outpatient treatment must occur within 7 days from the date of discharge. p 148 Behavioral Health - continued • Behavioral health providers are required to: o Use the DSM-IV multi-axial classification when assessing member for behavioral health services and document the DSM-IV diagnosis and assessment/outcome information in the member’s medical record; o Contact the member within 24 hours of a missed appointment to reschedule the missed appointment; and o Submit, with the member’s or member’s legal guardian’s consent, a summary report of the member’s behavioral health status quarterly, at a minimum, to the PCP. • For more information on behavioral health, refer to the Provider Manual and the Quick Reference Guide. p 149 Behavioral Health Access and Availability Type of Appointment Access Standard BH Provider – Urgent Within one (1) day of the request BH Provider – Sick Care Within one (1) week of the request BH Provider – Well Care Visit Within one (1) month of the request All members receiving inpatient psychiatric services must be scheduled for psychiatric outpatient follow-up and/or continuing treatment, prior to discharge, which includes the specific time, date, place, and name of the provider to be seen. The outpatient treatment must occur within seven days from the date of discharge. In the event that a member misses an appointment, the behavioral health provider must contact the member within 24 hours to reschedule. p 150 Florida 2014 Provider Orientation Module 5: Authorizations ©WellCare 2014. FL_020314 Florida 2014 Provider Orientation Module 5: Authorizations ©WellCare 2014. FL_020314 Utilization Management Utilization Management (UM) WellCare’s Utilization Management (UM) program includes review processes such as: • Notifications • Referrals • Prior Authorization • Concurrent Review and/or Retrospective Review p 154 Utilization Management (UM) - continued Prior Authorization • WellCare requires prior authorization for elective or non-emergency services as designated by WellCare • Reasons for requiring authorization may include: o Review for medical necessity o Appropriateness of rendering provider o Appropriateness of setting o Case and Disease Management considerations p 155 Utilization Management (UM) - continued Prior Authorization - continued • Decision timeframes are determined by NCQA requirements, contractual requirements or a combination of both. Please see the Provider Manual for decision timeframes. • Prior authorizations may be requested via fax, phone or online via the secure Provider Portal. • For more information on prior authorizations, and the information necessary to include in your request, refer to the Provider Manual and the Quick Reference Guide. p 156 Medical Necessity To be medically necessary or a medical necessity, a covered benefit shall meet the following conditions: • Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; • Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs; • Be consistent with generally accepted professional medical standards as determined by the program, and not experimental or investigational; p 157 Medical Necessity - continued To be medically necessary or a medical necessity, a covered benefit shall meet the following conditions: • Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. For inpatient hospital services, services could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. p 158 Medical Necessity - continued The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service. In accordance with 42 CFR 440.230, each medically necessary service must be sufficient in amount, duration, and scope to reasonably achieve its purpose. p 159 Authorizations Standard: WellCare will provide a service authorization decision as expeditiously as the member’s health condition requires and within state-established timeframe which will not exceed 7 calendar days. WellCare will fax an authorization response to the provider fax number(s) included on the authorization request form. An extension on the authorization decision may be granted for an additional 7 calendar days if the member or provider requests an extension, or if WellCare justifies a need for additional information and the extension is in the member’s best interest. p 160 Authorizations - continued Expedited: In the event the provider indicates, or WellCare determines, that following the standard time frame could seriously jeopardize the member’s life or health, WellCare will make an expedited authorization determination no later than 48 hours after receipt of the request. An extension on the authorization decision may be granted for an additional two business days if the member or provider requests an extension, or if WellCare justifies a need for additional information and the extension is in the members’ best interest. p 161 Authorizations - continued Expedited - continued: Requests for expedited decisions for prior authorization should be requested by telephone, not fax or WellCare’s secure, online Provider Portal. Members and providers may file a verbal request for an expedited decision. p 162 Authorizations - continued Urgent Concurrent (Inpatient): An authorization decision for services that are ongoing at the time of the request, and that are considered to be urgent in nature, will be made by the end of the following calendar day of receipt of the request. An extension on the authorization decision may be granted for an additional 48 hours. p 163 Authorizations - continued Emergency/Urgent Care and Post Stabilization Services: Emergency Services are not subjected to prior authorization requirements and are available to members 24 hours a day, seven days a week. Urgent care services should be provided within one day. Post-Stabilization services are services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or improve, or resolve the member’s condition. Post-Stabilization services are covered without prior authorization up to the point WellCare is notified that the member’s condition has stabilized. p 164 Authorizations - continued Post Service (Retroactive): An authorization decision for services which have already been rendered will be processed within 30 calendar days of receipt of the request. An extension on the authorization decision may be granted for an additional 15 calendar days if the member or provider requests an extension, or if WellCare justifies a need for additional information and the extension is in the member’s best interest. p 165 Authorizations - continued Service Authorization Decisions: Type of Request Decision Extension on Decision Standard Pre-service 7 calendar days 7 calendar days Expedited Pre-service 48 hours 2 business days Urgent Concurrent (Inpatient) 24 hours 48 hours Post Service (Retroactive) 30 calendar days 15 calendar days p 166 Authorization Examples In this example, the requesting provider was authorized physical therapy three times per week for four weeks between the timeframe of December 6, 2012 and February 5, 2013. Keep in mind that the authorization is no longer valid when either the units run out or the timeframe expires – whichever comes first. p 167 Authorization Examples - continued In this case, the requesting provider was authorized 1 unit of code S9131 to evaluate the need for a wheelchair. The timeframe to complete this service is from December 13, 2012 through December 27, 2012 and the diagnosis code to use is 715.9. p 168 Authorization Examples - continued In this case, the requesting provider was authorized 1280 units of code T1019. In this case, each unit is for 15 minutes. Therefore, 1280 units is equal to 350 hours. This code is authorized for 5 hours per day, 5 days per week between the period of January 1, 2013 and March 31, 2013. The provider was also authorized one unit of T1030 effective 3/1/2013. The diagnosis code to be used is 715.09. p 169 Authorization Examples - continued In this authorization, the requesting provider was authorized two units of code T1030 to be used between December 6, 2012 and March 31, 2013. p 170 Authorization Examples - continued In this authorization, the requesting provider requested a benefit that is not a covered service. p 171 Utilization Management (UM) - continued Concurrent Review: • Concurrent Review is initiated as soon as WellCare is notified of a member’s admission to a hospital, long term acute care, skilled nursing facility or acute rehabilitation facility. • Subsequent reviews are based on the severity of the individual case. • Providers are required to submit notification and clinical information on the next business day after the admission, as well as upon request from WellCare’s Concurrent Review team. o Failure to submit necessary documentation may result in non-payment. p 172 Utilization Management (UM) - continued Concurrent Review - continued • Discharge planning begins upon admission and is designed to identify the member’s post-hospital needs. o The attending physician, hospital discharge planner, PCP, ancillary providers and/or community resources are required to coordinate care and post-discharge services to ensure the member receives the appropriate level of care. • Transitional Care Management identifies members in the hospital and/or recently discharged who are at risk for hospital readmission. o The member is contacted by a WellCare Care Manager to assist the member in reducing avoidable readmissions and/or offer Case/Disease Management. p 173 Utilization Management (UM) - continued Refer to the Provider Manual for additional information including, but not limited to: • Criteria for UM decisions • Decision timeframes for service authorizations • Non-covered services and procedures • Special requirements for payment of services for abortions, sterilizations and hysterectomies • Reconsideration for adverse determination (i.e., appeal) • Proposed Actions • Members with Special Health Care Needs • Second Medical Opinion • Forms for authorizations, prenatal notifications and more p 174 Utilization Management (UM) - continued • Forms are available to assist you in gathering all pertinent information to enable WellCare to provide a timely response to your request. Forms are located on our website. • For more information on UM and Case/Disease Management, refer to the Provider Manual. • For more information on authorizations and/or how to contact UM, CM and/or DM, refer to the Quick Reference Guide. p 175 Transition of Care • During the first 90 days of enrollment, authorization is not required for certain members with previously approved services by the state or another managed care plan. • WellCare will continue to be responsible for the costs of continuation of such medically necessary Covered Services: o Without any form of prior approval, and o Without regard to whether such services are being provided within or outside WellCare’s network o Until such time as WellCare can reasonably transfer the member to a service and/or network provider without impeding service delivery that might be harmful to the member’s health p 176 Transition of Care - continued • Notification to WellCare is necessary to properly document these services and determine any necessary follow-up care. • When relinquishing members, WellCare will cooperate with the receiving health plan regarding the course of on-going care with a specialist or other provider. p 177 Florida 2014 Provider Orientation Module 6: Compliance ©WellCare 2014. FL_020314 WellCare’s Compliance Program WellCare’s Compliance Program All providers, including provider employees and sub-contractors, their employees and delegated entities are required to comply with WellCare’s compliance program requirements. • WellCare’s compliance requirements include, but are not limited to: o Provider training requirements o Limitations on provider marketing o Code of Conduct and Business Ethics o Fraud, Waste and Abuse (FWA) o Americans with Disabilities Act (ADA) o Medical records retention and documentation o HIPAA Privacy and Security Training o Cultural Competency Training p 180 WellCare’s Compliance Program - continued • Report Suspected Fraud, Waste and Abuse by calling the WellCare FWA Hotline at (866) 678-8355. • For more information on WellCare’s Compliance program and specific compliance requirements, refer to the Provider Manual. p 181 Provider Education and Outreach Guidelines Providers may: • Display state-approved health-plan specific materials in-office; • Announce a new affiliation with a health plan; • Make available and/or distribute marketing materials as long as the provider and/or the facility distributes or makes available marketing materials for all Managed Care Plans with which the provider participates; and • Co-sponsor events such as health fairs and advertise indirectly with a health plan via television, radio, posters, fliers and print advertisement. p 182 Provider Education and Outreach Guidelines continued Providers are prohibited from: • Verbally, or in writing, comparing benefits or providers networks among health plans, other than to confirm their participation in a health plan’s network; • Furnishing lists of their Medicaid patients to any health plan with which they contract, or any other entity; • Furnishing health plans’ membership lists to the health plan, such as WellCare, or any other entity; and • Assisting with health plan enrollment All subcontractors and providers must submit any marketing or information materials which refer to WellCare by name to the Department for approval prior to disseminating the materials. p 183 Provider-Based Marketing Activities Providers may: • Make available and/or distribute marketing materials as long as the provider and/or the facility distributes or makes available marketing materials for all Managed Care Plans o If a provider agrees it must accept future requests from other Managed Care Plans with which it participates. • Display posters or other materials in common areas such as the provider’s waiting room p 184 Provider-Based Marketing Activities continued Providers may assist members with the following: • Provide an objective assessment of his/her needs and potential options to meet those needs; • Engage in discussions with recipients should a recipient seek advice Providers must remain neutral when assisting with enrollment decisions. p 185 Provider-Based Marketing Activities continued Providers are prohibited from: • Offering marketing/appointment forms • Making phone calls or direct, urge or attempt to persuade recipients to enroll in the Managed Care Plan based on financial or any other interests of the provider • Mailing marketing materials on behalf of the Managed Care Plan • Offering anything of value to induce recipients/enrollees to select them as their provider • Offering inducements to persuade recipients to enroll in the Managed Care Plan p 186 Provider-Based Marketing Activities continued Providers are prohibited from: • Conducting health screening as a marketing activity • Accepting compensation directly or indirectly from the Managed Care Plan for marketing activities • Distributing marketing materials within an exam room setting • Furnishing to the Managed Care Plan lists of their Medicaid patients or the membership of any Managed Care Plan For more information on Provider Based Marketing Activities and specific affiliation information, refer to the Provider Manual. p 187 Florida 2014 Provider Orientation Module 7: Billing, Payment, and Encounters ©WellCare 2014. FL_021914 Provider Validation & Registration Medicaid ID Registration Process p 190 National Provider Identifier (NPI) & Medicaid ID Validation Per MMA guidelines, WellCare’s front-end claims validation process is now modeled after AHCA’s encounter validation process. • When a claim or encounter is submitted to WellCare, the Billing and/or Rendering NPI(s) will be validated against AHCAs Provider Master List (PML). o If any of the NPI(s), within a given claim, are not recognized on the PML, the claim will reject and payment cannot be processed for the services rendered. This new edit will be fully disclosed to each provider at least 60 days prior to deployment of the new validation process. Training will also be offered to provide as much support as possible during this transition. o These edits are necessary to ensure that the provider(s) submitting claims data, are not only eligible to care for our members, but also possess an active Florida Medicaid ID. p 191 National Provider Identifier (NPI) & Medicaid ID Validation - continued • A simple search by both NPI and Name can be performed to see if a valid and active record appears on AHCA’s PML. o If after searching the PML by both NPI and Name, it is determined that the provider does not have a Medicaid ID, WellCare can obtain one on their behalf. These Medicaid ID(s) are not fully enrolled (a/k/a Fee For Service or FFS); When applicable, they are subject to the required Level 2 background screenings. o If the provider’s information is incorrect on the PML, and the record is active, providers may correct or update their information (see slide 8). p 192 Provider Registration WellCare can register providers for Medicaid ID(s) in two ways: 1. Mass Registration: • Most common method • Automated process with a one business day turnaround • Provider must meet certain requirements to use this method 2. Manual Registration: • Two-page form is prepared and mailed to AHCA • Takes 10-14 business days for AHCA to process • Used when a provider does not meet the Mass Registration requirements p 193 Provider Registration – Common Errors AHCA requires key data elements to register for a Medicaid ID. Common errors include: Individual Providers: Individual providers must be registered using: Individual or Type 1 NPI; License number; and, Social Security Number (Tax IDs for individuals are not permitted). Group Providers: If a group needs to be registered, or a provider owns a group practice, they must be registered using: Group or Type 2 NPI; Tax ID for the group; License number (if applicable); and, CLIA (if applicable). p 194 Providers Not Required to Obtain an NPI • Providers who provide medical care services are required to obtain an NPI. • AHCA does not require atypical providers to obtain an NPI; however, many do as a personal preference or choice. Examples of atypical providers include: Assistive Care Services (some, not all, are atypical) Medical Foster Care/Personal Care Provider Billing Agents Non-Profit Transportation Case Management Agency Private Transportation Multi-Load Private Transport Taxicab Company Government/Municipal Transportation Social Worker/Case manager Non-Emergency Transport Home and Community-based Services Waiver (HCBS)* *HCBS Waiver providers rendering Traumatic Brain and Spinal Cord Injury, or Cystic Fibrosis services are the exception and are required to obtain an NPI. p 195 Remediating Records on the PML Providers should contact the following to resolve issues with records: NPI is not on PML: • Provider Relations Representative o If provider does not wish to become fully-enrolled (FFS) with AHCA • AHCA, if provider wishes to become fully-enrolled (FFS) with AHCA o https://portal.flmmis.com/FLPublic/Provider_Enrollment/tabId/50/Default. aspx Inaccurate FFS Provider Records: • Log in to the FLMMIS Provider Portal - http://home.flmmis.com; or, • Call AHCA’s Provider Enrollment at 1-800-289-7799 Option 4. p 196 Claims and Encounters Claims Overview Claims may be submitted in one of the following formats: • Electronic Claims Submission (EDI) • Paper – CMS 1500 Form and UB-04 All par providers must submit claims (initial, corrected, and voided) within 180 days from the date of service, unless contract states otherwise. IMPORTANT: Plan members cannot be billed for services denied due to untimely filing submission. For dual eligible members, providers shall accept WellCare’s payment as payment in full. Prior to submitting a claim to WellCare, providers must identify whether another payer has primary responsibility for payment of a claim. • To prevent delays of processing always include the other carrier’s explanation of benefits. p 198 Claims Overview: Member Billing Guidelines continued WellCare members cannot be billed for: Hold Harmless Dual Eligible Members • Dual Eligible members, whose Medicare Part A and B member expenses are identified and paid for at the amounts provided for by Florida Medicaid, shall not be billed for such Medicare Part A and B member expenses; regardless of whether the amount a provider receives is less than the allowed Medicare amount or provider charges are reduced due to limitations on additional reimbursement provided by Florida Medicaid. Missed Appointments • Providers shall not charge WellCare members for missed appointments. p 199 Fee For Service Claims Process Overview Claims Verification Claim Submission • Front end Service Provided • Paper Claim Created • Electronic OR provider validation • SNIP edits Rejection If the claim is rejected, the provider will receive notice in the same manner the claim was submitted If the claim passes all SNIP edits, rules, and validations, it will proceed into WellCare's system Entered in WellCare’s System Acceptance Adjudication Claims Processing Payment OR Denial Provider will receive notice via the EOP p 200 Third Party Vendor Encounter Process Overview Encounter Created Electronic • SNIP • Front end validation OR Rejection If the encounter is rejected, you will receive a response file in the same manner the encounter was submitted Entered in WellCare’s System Service Provided Encounter Submission Encounter Verification Acceptance If your encounter passes all SNIP edits, rules, and validations, it will proceed into WellCare's system Encounter Processing System (EPS) Processes and sends encounters to the state p 201 Claims Submission Requirements • Paper and electronic claims should include all necessary, completed, correct and compliant data including: o Current CPT and ICD-9 (or its successor) codes o Tax ID o NPI number for Billing, Rendering, and/or Attending providers All NPIs must be registered with AHCA for Medicaid reimbursement o Provider and/or practice name(s) that match those on the W-9 or Group Roster initially submitted to WellCare o Correct taxonomy code Must be distinct and consistent with provider record on AHCA’s Master Provider List o A preauthorization number, if applicable p 202 Claims Submission Requirements - continued • WellCare encourages providers to submit claims electronically via Electronic Data Interchange (EDI) or Direct Data Entry (DDE). Both are less costly than paper and, in most instances, allow for quicker claims processing. • All claims and encounter transactions are validated for transaction integrity based on the Strategic National Implementation Process (SNIP) guidelines. • For more information on claims submission requirements and timeframes, refer to the Provider Manual or the Provider Resource Guide. p 203 Encounter/Claims Changes for MMA The Statewide FL MMA Program introduces stricter state Service Level Agreements (SLA), which focus on: • Timeliness of Submission • Completeness • Accuracy of Encounters Submitted AHCA may impose financial sanctions for non-compliance with the following: • Health Plan must maintain the following: o Complete – submit 95% of covered services o Accurate – 95% of encounter lines must pass edits. • Health Plan must submit encounter(s) within 7 days of successful processing. As a result, WellCare, must enforce stronger Front End edits on the PreAdjudication as well as on the initial steps in the life of a claim/encounter. • Soft-edit warnings will begin the end of January 2014 • Hard-edit rejections will start May 1, 2014 p 204 Encounter Data Submission • Unless otherwise stated in the Agreement, vendors and providers should submit complete and accurate encounter files to WellCare. o Resubmission: Encounters, initially rejected by WellCare, must be fully remediated and resubmitted within 7 calendar days from the date the provider receives the notification/response file from WellCare. • Encounters may be submitted electronically via: o WellCare’s preferred clearinghouse, RelayHealth o WellCare’s Secure FTP (SFTP) process o Direct Data Entry (DDE) • For more information on Encounter Data submission requirements and methods, refer to the Provider Manual. p 205 Clean Claim vs. Non-Clean Claim What is a “Clean Claim”? A claim received by WellCare for adjudication • Adjudication: claims processing – either payment or denial – after the validation of eligibility, and checking for errors; to include: • In the nationally-accepted HIPAA format • In compliance with standard coding guidelines • Requires no further information or adjustment by the biller in order to be processed and paid by WellCare o WellCare validates all incoming claims and encounter data claims using the SNIP and Business rule edits/ validation edit process Each line of business has its own specific SNIP level(s) p 206 Rejection vs. Denial What is the difference between a rejection and a denial? • Rejection – is when the claim data did not pass the "front-end" edit process. The provider needs to correct the data and resubmit a new claim. • Denial – is when a claim failed the adjudication system. If the claim needs to be corrected, a corrected claim can be submitted by the provider. p 207 Encounters Provider Validation Why is an Encounters Provider Validation Important to Providers? • AHCA requires all providers, who render services to Florida Medicaid members, to obtain a FL Medicaid ID. • In order for AHCA’s encounters system to accept a claim/encounter it must create a unique cross reference. o A distinct record is created with an NPI, Taxonomy, and Zip-code combination. • NPI Taxonomy Zip 1477599975 282N00000X 32885-0242 1477599975 207R00000X 32885-9903 WellCare’s encounters provider validation process adheres to AHCA’s guidelines. o If a unique record cannot be found on AHCA’s Provider Master List (PML), the claim/encounter will reject. o An appropriate EDI notification will be sent back to the submitter citing the reason for rejection. p 208 SNIP What is SNIP and what does it mean to providers? SNIP stands for Strategic National Implementation Process (SNIP) • It is software used to validate the accuracy and completeness of claims. • The SNIP level(s) that WellCare uses for this validation varies and is in accordance to federal and state requirements. • This process, along with front-end business rules and validation, is to determine “clean claims”. • Once a claim is validated by the SNIP process, and passes business rule requirements, it then proceeds into WellCare’s system for adjudication. p 209 SNIP Level 1 Transaction Syntax Errors – EDI syntax • This level verifies submission of a valid EDI syntax for each type of transaction. o An EDI syntax is the structure of transaction type • This is also referred to as Integrity Testing Common Errors: • The data elements are too long, too short, or have invalid entries o Date or time invalid o Characters used instead of Numerical (vice versa) • Field ‘Name’ is missing on the Reject Response Transaction when reject response is “R” p 210 SNIP Level 2 HIPAA syntax errors • This level will verify that the transaction sets adhere to HIPAA Implementation Guides • This level is also referred to as Requirement Testing Common Errors: • Invalid Address Information in Billing Provider Address • Employer Identification Number (EIN) is invalid • All Legacy IDs on claims should be removed: o Legacy numbers include Provider IDs, Medicaid and Medicare IDs, UPIN and State License numbers. • Rendering Provider's first name is required p 211 SNIP Level 3 Financial Balancing • This level validates the transactions submitted for balanced field totals and financial balancing of claims Common Errors: • Total charge amount for services does not equal sum of lines charges • Service line payment amount failed to balance against adjusted line amount • COB claim failed to balance: paid amount did not equal adjusted charge amount p 212 SNIP Level 4 Situation Testing • This level will test specific inter-segment situations as defined in the implementation guide: if A occurs, then B must be populated Common Errors: • Missing NPI for Billing, Rendering and/or Attending Providers (unless Atypical provider) o NPIs must be a valid 10 digit number. • No taxonomy information to accompany the submitted NPI for either the Rendering or Bill-To Provider. o Taxonomy should correspond with record on AHCA’s Master Provider List. • The “patient reason for visit” is required on unscheduled outpatient visits. • Subscriber Primary ID is required when subscriber is the patient. p 213 SNIP Level 5 External Code Set Testing • Testing is for valid Implementation Guide-specific code set values and other code sets adopted as HIPAA standards • This level of testing will not only validate the code sets but also make sure the usage is appropriate for any particular transaction and appropriate with the coding guidelines that apply to the specific code set Common Errors: • National Drug Code (NDC) is missing or invalid • Validates CPT (ex. 99212) • ICD-9-CM Diagnosis code is invalid in Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information • CPT Procedure Code is invalid in Line Adjudication Information and Dental Service • Point of Origin for Admission or Status codes Box 15 (UB-04) • DRG code is invalid in Diagnosis Related Group (DRG) Information p 214 SNIP Level 6 Product Types or Line of Services • This level is intended for specialized testing required by certain health care specialties Common Errors: • Service Facility Location Name is required. • Ambulance Transport Information is required on ambulance claims. • Attending Provider Name is required. p 215 SNIP Level 7 Custom Health Plan Edits • This level is intended for specific Business Requirements by the Health Plan that is not covered within the WEDI SNIP and the Implementation Guide. Common Errors: • Service Location Address contains a PO Box Address • POA indicator missing or invalid. o Valid indicators are y, n, u, w (POA indicator of "u" not allowed with primary diagnosis) p 216 SNIP Rejection Letter Example We can identify this as a SNIP rejection letter based on the rejection code(s) that are given in the letter as seen here highlighted. All SNIP rejections will have an alpha character, generally a “W” in the rejection code. Most common SNIP Rejections: • Invalid character or data element • Missing/invalid data elements (i.e., member information, CPT, diagnosis codes, zip codes, NPI, and NDC) p 217 Paper Rejection Letter Most common Paper Rejections: Hand-written • No Data Elements should be hand written on claim form with the exceptions of “Encounters”, “2nd Submissions”, and “Corrected Claim” on the top of the form. Missing required information • Tax Identification number or NPI number missing • Service line dates invalid Non Compliant CMS Claim Forms • Out dated non compliant CMS claim forms p 218 Explanation of Payment Explanation of Payment (EOP) is a statement sent to the provider from WellCare which documents payment for covered services rendered to WellCare members. An EOP includes: • The Payee (Provider), Member, and the Payer (WellCare) • The service(s) rendered, including date of service, description of service, person or place that provided the service, and the name of the member/patient. • The provider’s fee and the allowable amount. • The dollar amount the member is responsible for (includes co-payments and deductibles). • A brief explanation of any claims that were denied and appeal information. • Adjustment reasons and codes • Coordination of Benefits (COB) information. p 219 How to Submit Corrected Institutional Claims Electronically: For Institutional claims, the original WellCare claim number for the claim adjusting or voiding in the REF*F8 (loop and segment) for any 7 (Replacement for prior claim) or 8 (Void/Cancel of prior claim) in the standard 837 layout. *These codes are not intended for use on original claim submission or rejected claims. EXAMPLE: Paper: For Institutional claims, the original WellCare claim number and bill frequency code per industry standards must be included. EXAMPLE: Box 4 - Type of Bill: The third character represents the “Frequency Code” Box 64 – Houses the prior claim number p 220 How to Submit Corrected Professional Claims Electronically: Professional claims, must have the Frequency Code marked appropriately as 7 (Replacement for prior claim) or 8 (Void/Cancel of prior claim) in the standard 837 layout. *These codes are not intended for use on original claim submission or rejected claims. EXAMPLE: Paper: The original WellCare claim number and bill frequency code per industry standards must be included. Enter the appropriate Bill Frequency Code left justified in the lefthanded side of Box 22. EXAMPLE: Any missing, incomplete, or invalid information in any field may cause the claim to reject. Please Note: If you handwrite, stamp, or type “Corrected Claim” on the claim form – without entering the appropriate Frequency Code “7” or “8”, along with the Original Reference Number as indicated above – the claim will be considered a first-time claim submission and will reject as a duplicate affecting adjudication. p 221 Corrected Claims Transactions The Correction or Void Process involves two transactions: 1. The original claim will be negated – paid or zero payment (zero net amount due to a co-payment, coinsurance or deductible) – and noted “Payment lost/voided/missed.” This process will deduct the payment for this claim, or zero net amount if applicable. 2. The corrected or voided claim will be processed with the newly submitted information and noted “Adjusted per corrected bill.” This process will pay out the newly calculated amount on this corrected or voided claim with a new claim number. The Payment Reversal for this process may generate a negative amount, which will be seen on a later EOP than the EOP that is sent for the newly submitted corrected claim. p 222 Overpayment Recovery Overpayment Recovery examples: • Overpayment from a member’s coordination of benefits • Retroactive member termination • Inappropriate coding • Duplication of payments • Non-authorized services • Erroneous contract or fee schedule reimbursement • Non-covered benefit(s) • Providers deemed ineligible by AHCA p 223 Overpayment Recovery - continued • WellCare strives for 100% payment quality, but recognizes that a small percent of financial overpayments will occur while processing claims. Inappropriate payments will be quickly identified and corrected. • Overpayment Recovery will be limited to twelve (12) months from the date of service for professional claims (CMS-1500) and thirty (30) months from the date of service for institutional claims (UB-04). • These time frames do not apply if a provider has been convicted of fraudulent or abusive billing. In this case, there is no deadline for recovery from the provider. p 224 Overpayment Recovery - continued • The standard request notification for Overpayment Recovery provides fortyfive (45) days to send in the refund, contact WellCare for further information, or to dispute the overpayment. • Failure to respond within the timeframe will constitute acceptance of the terms in the letter and will result in offset of future payments. p 225 Overpayment Recovery - continued If an overpayment has been independently identified, the following options are available: A. Send corrected claims to WellCare (please refer to the Corrected Claim section in the Provider Manual). B. Send a refund and explanation of the overpayment to: WellCare Health Plans, Inc. ATTN: Recovery Department PO Box 31584 Tampa, FL 33631-3584 C. Contact Provider Services to against future payments. For contacting Provider Services, Reference Guide which may WellCare website at: arrange an off-set more information on refer to the Quick be found on the https://florida.wellcare.com/provider/resources p 226 Encounter Trainings To help reduce issues for our providers and to answer technical questions, WellCare will provide training webinars* which will include the following topics: • Encounters 101 – General submission and Naming Conventions • Remediating Rejections and Reading Response Files (999, 277CA, 277U) • Submitting Void and Replace Claim/Encounter Transactions • Q&A Dates for these trainings will be communicated soon. Look for more updates from your Provider Representative in the near future. * Webinars may be posted on Provider Portal alongside other FL-MMA specific resources. p 227 Electronic Funds Transfer / Electronic Remittance Advice Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) • WellCare partners with PaySpan Health to offer providers electronic funds transfer (EFT) and Electronic Remittance Advice (ERA). o This service is offered at no charge to providers; and is a secure, quick way to electronically settle claims. o PaySpan Health breaks down the barriers to electronic claim settlement with an innovative solution for EFTs and ERAs. o Using this free service, providers can take advantage of EFTs and ERAs to settle claims electronically, without making an investment in expensive EDI software. o Following a fast online enrollment, providers are able to receive ERAs and import the information directly into their practice management or patient accounting system, eliminating the need to re-key remittance data from paper advices. p 229 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) PaySpan Health offers providers a complete solution for claims payment management. • Using PaySpan Health, EFTs are routed to the bank account(s) chosen by the provider. • Providers can manage multiple payers, choose among common and proprietary formats for ERAs, easily reconcile payments with claims, and take advantage of claim and remittance retrieval and reporting. PaySpan Health can be reached at • providersupport@payspanhealth.com, • 1-877-331-7154 or at • https://www.payspanhealth.com/ p 230 Benefits of EFT and ERA • Faster deposits to provider accounts • Convenient • Reduces paper handling • Easy tracking and reconciling of payments with flexible reports - providers are able to design their own reports and run them at any time • Many options for viewing and receiving remittance details • HIPAA-compliant data files • Reduces accounting expenses – ERAs can be imported directly into practice management or patient accounting systems, eliminating the need for manual re-keying • Multiple practices and accounts can be supported p 231 Benefits of EFT and ERA - continued • Maintains control over bank accounts – Providers keep TOTAL control over the destination of claim payment funds. Multiple practices and accounts are supported. • Matches payments to advices quickly – Providers can associate electronic payments with electronic remittance advices quickly and easily. • Manages multiple payers – Reuse enrollment information to connect with multiple payers. Assign different payers to different bank accounts, as desired. • Improves cash flow – Electronic payments mean faster payments, leading to improved cash flow. • Did we mention – there’s no cost to the provider to use it! p 232 Registering for EFT/ERA Registering for PaySpan Health is quick and easy. 1. To begin, contact PaySpan Health by calling 877-331-7154 or emailing providersupport@payspanhealth.com. • A registration letter will be mailed to the provider. • The provider should complete the form and send it back to PaySpan at the fax number or email address on the form. • A unique registration code along with enrollment instructions will be emailed to the provider. 2. Go to www.payspanhealth.com 3. Click the “Register Now” button p 233 Registering for EFT/ERA - continued 4. Enter your registration code and click Submit. 5. Enter your practice information and follow the prompts through the remaining steps. 6. You will need: • Your vendor/provider identification number and TIN • A valid email address • Bank routing number and account number p 234 EFT/ERA Security The security of your data is paramount to PaySpan Health and WellCare. PaySpan Health has developed a rigid infrastructure to ensure data integrity and security. • Data Security - Ensuring the security of data is central to the design of the Security Network. • Physical Security - Proximity card readers are used throughout Production Centers to control access based on job function. Cameras monitor and record all activity at all hours. • Account Management - Support Center staff track all jobs and ensure that all transactions are processed accurately and efficiently. p 235 EFT/ERA Security - continued • Quality Assurance Procedures - The Quality Control function ensures that electronic transactions match standards approved by clients and that printed documents meet banking and postal standards. • HIPAA Competence - PaySpan is committed to meeting the requirements set forth in the HIPAA Privacy and Security Standards for the secure transmission, use, and management of protected health information. • Audits - PaySpan issues reports that may assist providers in evaluating the internal controls of PaySpan Services. p 236 Disputes and Resolution Claims Disputes Providers have the right to file a dispute regarding provider payment or contractual issues. The claims disputes process addresses claim issues related to untimely filing, incidental procedures, bundling, unlisted procedure codes, non-covered codes, etc. Please include the following documentation with your dispute: • Date(s) of service • Member name • Member WellCare ID number and/or date of birth • Provider name • Provider Tax ID/TIN • Total billed charges • Provider’s statement explaining the reason for the dispute and • Supporting documentation when necessary (e.g. proof of timely filing, medical records). The dispute can be submitted via mail, fax, or web. p 238 WellCare’s Provider Solution Resolution • Dedicated personnel receive and process provider complaints. The Provider Solutions team will work closely with customer service and the Provider Resolution staff to quickly address and resolve all issues. • Providers have 45 calendar days to file a written complaint for issues that are not claims related. • WellCare will notify the provider (verbally or in writing) within three business days of receipt of a complaint, that the complaint has been received and the expected date of resolution. • Each provider complaint is thoroughly investigated. p 239 WellCare’s Provider Solution Resolution continued • We will document why a complaint is unresolved after 15 calendar days of receipt and provide written notice of the status to the provider every 15 calendar days thereafter. • WellCare will resolve all complaints within 90 calendar days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three business days of resolution. • WellCare executives, who have the authority to require corrective action, are involved in the provider complaint process. p 240 Florida 2014 Provider Orientation Module 8: Appeals and Grievances ©WellCare 2014. FL_020314 Appeals • Providers have the right to file an appeal regarding provider payment or contractual issues. • Providers may act on behalf of the member with the member’s written consent. • WellCare will review the case for medical necessity and conformity to WellCare guidelines. • Appeals may be denied if: o Appeal was not filed within the applicable timeframe, or o Lacks necessary documentation p 242 Appeals - continued • When submitting an appeal: o Supply specific, pertinent documentation that supports the appeal. o Include all medical records that apply to the service. o Submit the appeal and accompanying documentation to the address on the Quick Reference Guide. • Upon review of the appeal, WellCare will either reverse or affirm the original decision and notify the provider. p 243 Appeals - continued Additional items to note: • Medicaid Members have the right to request a Medicaid Fair Hearing (MFH), in addition to and at the same time as, pursuing appeals resolution via WellCare. Benefits continue while the appeal and MFH are pending (does not apply to Healthy Kids). • HealthEase/Staywell Medicaid members may submit a request for review of their action and appeal to the Beneficiary Assistance Program (BAP) after completing WellCare’s appeals process. • Healthease/Staywell Kids members should submit their request for review of their action and appeal to the Subscriber Assistance Program (SAP) after completing WellCare’s appeals process. p 244 Appeals - continued Florida Timeframes For a Provider Appeal: • Providers have 90 calendar days from the original UM decision or claim denial to file a provider appeal.. • WellCare has 60 calendar days to review the case for medical necessity and conformity to WellCare Guidelines. • Provider must send supporting documentation which must be received within 60 calendar days of the denial to re-open the case. • If all of the relevant information is received, WellCare will make a determination within 60 calendar days. p 245 Appeals - continued Florida Timeframes For a Member Appeal: • Members, the Member’s Representative, or the Provider acting on behalf of a member have 30 calendar days to file verbally or in writing within the date of receipt of the notice of the action. o If the Appeal was filed verbally via WellCare’s Customer Service, the request must be followed up with a written, signed appeal request to WellCare within 10 calendar days of the verbal filing (except when a expedited resolution has been requested). • WellCare shall acknowledge in writing within 5 business days of receipt of appeal except in the case of an expedited request. p 246 Appeals - continued Florida Timeframes For a Member Appeal: WellCare must make a determination from the receipt of the request on a member appeal and notify the appropriate party within the following timeframes: o Expedited Request: 72 Hours o Standard Pre-Service Request: 30 Calendar Days o Retrospective Request: 30 Calendar Days p 247 Grievances • Providers have the right to file a written complaint for issues that are non-claims related within established timeframes. • WellCare will provide written resolution to the provider within established timeframes. Extensions may be requested by WellCare and/or the provider. • Providers may act on behalf of the member with the member’s written consent. • In the event a member is dissatisfied with the grievance decision reached by WellCare, the member, or the provider acting on behalf of the member, may request a Medicaid Fair Hearing (MFH) *does not apply to Healthy Kids. • For more information on provider appeals and grievances, including submission and determination timeframes, and how to submit, refer to the Provider Manual and the Quick Reference Guide. p 248 Grievances - continued Current Grievance Timeframes • Providers must file a complaint for issues that are non-claims related no later than 45 calendar days from the date the provider becomes aware of the issue generating the complaint. • A verbal or written notice will be sent to the provider filing the grievance within 10 business days acknowledging receipt of the complaint and the expected date of resolution. • WellCare will provide written resolution to the provider within 45 calendar days from the date the complaint is received by WellCare. p 249 Grievances - continued Grievance Timeframes for MMA • Providers must file a complaint for issues that are non-claims related no later than 45 calendar days from the date the provider becomes aware of the issue generating the complaint. • A verbal or written notice will be sent to the provider filing the grievance within 3 business days acknowledging receipt of the complaint and the expected date of resolution. • WellCare will provide written resolution to the provider within 90 calendar days from the date the complaint is received by WellCare. p 250 Grievances - continued For Unresolved Complaints • WellCare will document why a complaint is unresolved after fifteen (15) calendar days of receipt and provide written notice of the status to the provider every fifteen (15) calendar days thereafter; • WellCare will resolve all complaints within ninety (90) calendar days of receipt • WellCare will provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution. p 251 Florida 2014 Provider Orientation Module 9: Pharmacy ©WellCare 2014. FL_020314 Pharmacy To ensure members receive the most out of their pharmacy benefit, please consider the following guidelines when prescribing: • Follow national standards of care guidelines for treating conditions; • Prescribe drugs on WellCare’s Preferred Drug List (PDL); • Prescribe generic drugs when therapeutic equivalent drugs are available within a therapeutic class; and • Evaluate medication profiles for appropriateness and duplication of therapy p 253 Pharmacy - continued WellCare has pharmaceutical utilization management (UM) tools that are used to optimize the pharmacy program. These UM tools are described in detail in the Provider Manual including: • Preferred Drug List (PDL) • Coverage Determination Review process • Mandatory Generic Policy • Step Therapy (ST) • Quantity Level Limit (QL) • Age Limit • Pharmacy Lock-In Program • Network Improvement Program (NIP) • Exactus Pharmacy Solutions p 254 Pharmacy - continued Important Note for MMA Providers: Under the MMA program, Staywell will adopt the Agency’s Medicaid Preferred Drug List (PDL) and provide all prescription drugs and dosage forms listed therein. Access the PDL on the Provider Portal or through the AHCA website at: http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/fmpdl.shtml p 255 Pharmacy - continued The Provider Manual includes additional information on: • Non-covered drugs and/or drug categories that are excluded from the Medicaid benefit; • Over-the-counter (OTC) items listed on the PDL which require a prescription; All other OTC items offered as an expanded benefit by WellCare do not require a prescription. • Requesting additions and exceptions to the PDL through the Coverage Determination Review process, including information on: o How to submit a coverage determination request o When a coverage determination is required, including, but not limited to: Most self-injectable and infusion medications Drugs not listed on the PDL Drugs listed on the PDL but still require a prior authorization Brand name drugs when a generic exists p 256 Pharmacy - continued The Provider Manual includes additional information on: • Requesting an appeal of a coverage determination decision • 24-hour pharmacy access • For more information on WellCare’s pharmacy program, refer to the Provider Manual, the Quick Reference Guide, and the website for appropriate forms, documents and contact information. https://florida.wellcare.com/provider/resources p 257
