CarePlus Provider Orientation

CarePlus from
©2013 CeltiCare Health Plan of Massachusetts, Inc.™
1
CarePlus Provider Orientation
Provider Orientation Agenda:
•
•
•
•
•
Overview of CarePlus and Expansion
Populations
Provider Resources
CarePlus Benefits
Eligibility Verification and Provider
Secure Portal
Provider Access and Responsibilities
•
Specialty Partners
•
Medical Management Overview
•
Prior Authorization Requirements
•
Claims Submission
•
Credentialing and Re-credentialing
•
Quality Improvement
2
Overview of CarePlus and
Expansion Populations
3
CarePlus Overview
• The ACA now presents an opportunity for Massachusetts to
build upon the gains in health insurance coverage achieved
through state health care reform and the Waiver Programs
by expanding MassHealth coverage.
• In order to provide MassHealth coverage to this expansion
population, EOHHS has created a new Coverage Type called
MassHealth CarePlus.
4
Expansion Populations
MassHealth CarePlus covers adults ages 21-64 with incomes up to 133 percent of the
Federal Poverty Level and who are not eligible for MassHealth Standard (which covers
adults who are disabled, pregnant, or parents or caretaker relatives of dependents under
the age of 19). MassHealth CarePlus will include members who are new to subsidized
insurance as well as members transitioning from the following programs:
•
Massachusetts Health Safety Net: Low-income adults who were uninsured
•
Commonwealth Care: Individuals up to 133 percent of the FPL who were eligible for coverage through other
agencies, including the Commonwealth Health Connector Authority. (continuing till 3/31/14)
•
Medical Security Program: Individuals who received unemployment insurance benefits in the Medical Security
Program.
•
MassHealth Basic: offered coverage to certain unemployed adults.
•
MassHealth Essential: offered coverage to certain long-term unemployed unemployed adults, not eligible for
MassHealth Basic.
•
MassHealth Insurance Partnership: Individuals who received premium assistance through the Insurance
Partnership
5
Your CeltiCare Health Resources
CeltiCare Health offers our Provider Community support and resources to assist in
providing the best care possible to CeltiCare Health CarePlus Members. These resources
will be highlighted throughout this orientation, and include:
•
Provider public website housing information, tools, and resources that educate and inform:
• CeltiCare Health’s Care Management & Quality Improvement Programs
• Clinical and Payment Policies
• Prior Authorization Requirements
• Frequently Asked Questions
• Documents and Forms (Provider Manual, Provider Billing Manual, Prior Authorization Forms)
•
Provider Secured Portal that allows our Providers to access:
• Patient Benefits and Eligibility Information
• Care Gaps
• Patient Claims Information and Claim Submission
• E-Prior Authorization Requests
•
Provider Relations Specialists who support, educate, and work collaboratively with you.
•
Provider Services Representatives who answer questions about day-to-day operations.
6
Provider Resources
7
Provider Relations
CeltiCare Health's Provider Relations Department works closely with Providers to
build and strengthen relationships with our Provider community. Provider Relations
Representatives meet regularly with designated staff within their provider territories
to:
• Coordinate and conduct on-site orientation and training programs
• Assist providers with the interpretation of policies and procedures related to
reimbursement, prior authorization, clean claims submission and operational
issues
• Facilitate problem resolution and initiate Plan interdepartmental collaboration to
resolve complex provider issues
• Manage the flow of credentialing information to and from provider offices
For more information or to schedule an appointment with your designated Provider
Relations Specialist, please contact Customer Service at 1-855-678-6975
8
Provider Services
Provider Services Representatives work with your Provider Relations Specialists
to ensure that you receive the assistance you require when providing care to
CeltiCare Health Members. Contact the Provider Services Department at
1-855-678-6975. Representatives are able to:
• Answer inquiries from providers regarding claim and authorization status,
member eligibility and covered benefits
• Provide assistance regarding website registration, navigation and customerrelated inquires
• Achieve first call resolution of your issues and concerns
• Connect you to your designated Provider Relations Specialist
9
CarePlus Benefits
10
Your Responsibilities as a Provider
CeltiCare Health encourages our Providers to build positive, enduring professional relationships with
Members. We have included the following list of Provider Responsibilities so that all Providers are aware
of their responsibilities to our Members, CeltiCare Health and MassHealth. For a complete listing of
Provider Responsibilities, please refer to the CarePlus Provider Manual.
Members have the right to be treated by Providers in a manner reflecting respect for their privacy and dignity as persons, without regard to age,
gender, race, color, religion, national origin, ancestry, marital status, sexual orientation, income status, veteran status, physical or mental condition
or disability, pre-existing condition, occupation, and/or need for health care services.
Providers are required to accept CeltiCare Health Members as patients in the same manner as other health plan members are accepted.
Providers are to present all care and treatment options to Members, in a manner appropriate to Members conditions and their ability to understand,
so as to ensure the quality and continuity of care.
Providers are to be aware of and comply with the Member’s right to receive a second opinion on a medical procedure.
CeltiCare Health requires Providers to coordinate Members’ care with other providers and CeltiCare Health, as appropriate. Providers are required
to be aware of and comply with a Member’s rights to participate in decisions regarding his or her health, including the right to refuse treatment.
Providers are to inform Members 18 years of age and older, of their rights to execute Advance Directives and are required to adhere to all
requirements set forth under the Advance Directives section of the CeltiCare Health Provider Manual.
Providers are required to maintain policies and procedures to ensure the confidentiality and security of Protected Health Information in accordance
with the Health Insurance Portability and Accountability Act (HIPAA).
Providers are required to be sensitive and responsive to the linguistic, cultural, and other unique needs of Members of all minorities, whether
homeless or disabled, deaf, hard-of-hearing or deaf blind. Providers are required to assist Members with linguistic needs by providing interpreter
services, free of charge, and in accordance with Title VI of the Civil Rights Act of 1964, to Limited English Proficiency (LEP) Members, when
necessary. Interpreter services must be in compliance with all state and federal mandates.
11
CeltiCare Health CarePlus MCO Benefits
For details on these benefits and authorization requirements, please visit
the CeltiCare Health CarePlus Provider Manual. The CeltiCare Health
CarePlus MCO Benefits include:
Abortion
Ambulatory Surgery/Outpatient Hospital Care
Chiropractic Services
Dialysis
Family Planning
Hospice
Medical /Surgical Supplies
Oxygen and Respiratory Therapy
Physician (primary and specialty)
Radiology and Diagnostic Tests
Tertiary Services
Transportation (non-emergent, to out-of-state
locations at least 50 miles outside of MA
Acupuncture Treatment
Acute Inpatient Hospital Services
Audiologist
Behavioral Health Services
Dental (emergency only)
Diabetes Self-Management Training
Durable Medical Equipment
Emergency Services
Hearing Aids
Home Health
Infertility (diagnosis and treatment of
underlying medical condition)
Laboratory
Medical Nutritional Therapy
Orthotics
Prescription Drugs
Over‐the‐Counter Drugs
Podiatry
Prosthetic Services and Devices
Skilled Nursing Facility, Chronic or Rehabilitation
Therapies- Physical, Occupational, Speech and
Hospital Services (up to 100 days
Hearing
per contract year)
Tobacco Cessation Services
Transportation (emergent)
Vision Care (medical component)
Wigs
12
Non-CarePlus MCO Benefits
CeltiCare Health will educate on the process for accessing and assist in
coordinating Non-CarePlus MCO Covered Benefits provided by EOHHS.
These services include:
For services provided at either a chronic or rehabilitation hospital, or any
combination thereof, that exceeds the 100 days per contract year, the
Chronic or Rehabilitation Hospital Member will be disenrolled from CeltiCare Health , and such services will be
Services
covered by another MassHealth program. (Proper notification from CeltiCare
Health required for this disenrollment, or CeltiCare Health remains
responsible.)
Dental
Preventive and basic services for the prevention and control of dental
diseases and the maintenance of oral health for adults as described in 130
CMR 420.000.
Transportation (non-emergent to
Ambulance (land), chair car, taxi, and common carriers that generally are prein-state location or location
arranged to transport an Enrollee to and from a service that is located inwithin 50 miles of the
state or within a 50-mile radius of the Massachusetts border.
Massachusetts border)
Vision Care (non-medical
component)
The prescription and dispensing of ophthalmic materials, including eyeglasses
and other visual aids, excluding contacts.
13
Eligibility Verification and
Provider Secure Portal
14
Verification of Eligibility
Providers are required to verify Eligibility prior to providing any service.
Eligibility can be verified in the following ways:
•
Verify eligibility through our Provider Secured Portal at
www.celticarehealthplan.com;
•
Verify eligibility 24 hours a day, 7 days a week through our Interactive Voice
Response system by calling 1-855-678-6975;
•
Verify eligibility with a Provider Service Representative Monday through
Friday, 8:00 am to 5:00 pm (EST) by calling 1-855-678-6975
•
Or, verify eligibility by checking EVS at the time of each visit, as well as daily
during an inpatient hospital stays; MassHealth EVS (AVR): 1800-554-0042
www.massresources.org/masshealtheligibility_check.html
15
Verification on the Provider Portal
16
Verification on the Provider Portal
•
•
•
•
•
•
•
Overview – Patient Information,
PCP Information, Eligibility History,
Care gap information and the most
recent Medical Activity
Cost Sharing – Not Applicable for
CarePlus; there is no Patient cost
Obligation
Assessments – Health Risk
Assessment Form
Health Record - Visits,
Medications and Immunization for
the patient
Authorizations - View and create
a patient authorization
Coordination of Benefits Displays the other insurance
information for the patient
Claims – View and create claims
for a patient. Claim auditing tool
17
Secure Provider Portal
Reach out to your Provider Relations Specialist for Training on
using our Secure Provider Portal!
18
Interactive Voice Response (IVR)
The IVR provides greater access to information via voice commands and
offers the following options:
•
•
•
•
•
Check PCP demographic
information
Obtain benefit information
Check claims status
Connect to Cenpatico Behavioral
Health and NurseWise®
Verify member demographic
information
•
•
•
Obtain any pharmacy co-payment
information when checking member
eligibility (unless Member is
exempted)
Connect to medical management
and referral specialists
Connect with our vendors who
supply medically necessary
covered services
IVR Phone Number:1-855-678-6975
19
Provider Access and
Responsibilities
20
CeltiCare Health Provider Access
CeltiCare Health Providers are required to provide access to medical
services to CarePlus Members:
Primary Care Providers are required to provide Members with access to Primary Care
Services in accordance with the Member’s request for care within the following time
frames:
•
•
•
Urgent Care: Within forty-eight (48) hours of the Member’s request
Non-Urgent Symptomatic Care: Within ten (10) calendar days of the Member’s request
Non-Symptomatic Care: Within forty-five days (45) calendar days of the Member’s
request
Specialists are required to provide Members with access to Specialty Care in accordance
with the Member’s request for the care within the following time frames:
•
•
•
Urgent Care: Within forty-eight (48) hours of the Member’s request
Non-Urgent Symptomatic Care: Within thirty (30) calendar days of the Member’s request
Non-Symptomatic Care: Within sixty days (60) calendar days of the Member’s request
21
Specialty Companies
22
Specialty Companies
•
Cenpatico Behavioral Health - CeltiCare Health partners with our Behavioral Health affiliate,
Cenpatico Behavioral Health, to deliver Behavioral Health (mental health and substance use disorder)
services to our Members. For information regarding Behavioral Health Services, locating providers, or
for assistance in coordinating services for a Member, contact CeltiCare Health’s Integrated Medical
Management department from 8:00 am to 5 pm at 1-866-896-5053 www.cenpatico.com for any
Cenpatico questions. After hours use the same number and be connected with NurseWise.
•
Cenpatico Specialty Therapy Rehab Services authorizations (STRS) - CeltiCare Health offers our
members access to all covered medically necessary outpatient and home health physical, occupational
and speech therapy services through Cenpatico STRS. For more information regarding STRS services
please call 855-678-6975.
•
National Imaging Associates (NIA) - High Tech Radiology Imaging Services, 1-800-635-2873
www.radmd.com Provider Relations – Charmaine Gaymon csgaymon@magellanhealth.com
•
OptiCare – CeltiCare Health’s designated vendor for vision services 1-855-650-3794
www.opticare.com Providers that interested in participating in OptiCare can contact the OptiCare
Network Management team at networkmanagement@opticare.net
•
Univita - Home Health, DME and Home Infusion call: 1-888-914-2201, fax referrals to: 888-914-2202
https://providers.univitahealth.com, Provider Relations –Brian Vines, BVines@univitahealth.com
23
Pharmacy
US Script is CeltiCare Health’s contracted Pharmacy Benefit Manager (PBM)
responsible to provide prescription drugs and over-the-counter drugs.
Certain medications do require Prior Authorization by US Script before being
approved for coverage by CeltiCare Health. These include:
– Some preferred drugs designated as “PA” on the PDL
– Medications not listed on the CelitCare PDL
Please contact US Scripts at 1-855-688-6592 for general information and
1-866-399-0929 for Prior Authorizations, or visit them at www.usscript.com.
Detailed information on the CarePlus Preferred Drug List (PDL) can be found at:
http://www.celticarehealthplan.com/files/2013/12/PDL.pdf
AcariaHealth (Specialty Drugs) – Administers the Prior Authorization process
for Biopharmaceutical and Specialty Injectables. Call 1-855-535-1815 or visit
http://www.CeltiCareHealthPlan.com/for-providers/pharmacy/
24
Medical Management
Overview
and
Prior Authorization
Requirements
25
Medical Management Overview
Our Medical Management Team is comprised of skilled and licensed health care
professionals whose primary goal is to optimize an enrollee's health status,
sense of well-being, productivity, and access to quality health care, while at the
same time actively managing cost trends.
The Medical Management Team aims to provide services that are a covered
benefits, medically necessary, appropriate to the patient's condition, rendered in
the appropriate setting and meeting professionally recognized standards of care.
Medical Management is responsible for the Care Coordination processes of:
– Care Management
- Utilization Management
– Complex Care Management
- Disease Management
– Intensive Behavioral Health
- Wellness Initiatives
Clinical Management
– Integrated Physical & Behavioral Health Care
Please refer to CarePlus Provider Manual for full description of these programs.
26
Care Management Programs and Staff
Care Management offers our CeltiCare Health Members added value to help support and promote their
health and well-being.
•
Care Management : We help our Members address medical and behavioral situations and needs through
coordination with disease management programs, wellness initiatives, and a full range of Care Management,
Complex Care Management, and Behavioral Health Intensive Clinical Management activities.
•
Social Care Management : We assist and educate Members on available community resources, state/local
social programs (WIC, housing, transportation) and pharmacy resources.
•
Program Coordinators : We identify Members for our disease management programs, as well as, outreach
calls to early identify needs post hospitalization.
•
Member Connections : We connect Members to community and social service programs that can assist
members who are in need of food, housing, and clothing.
•
NurseWise : Registered Nurses ready to answer your health questions 24 hours a day – every day of the year.
Please contact us at 1-855-678-6975.
27
Disease Management
Nurtur* is our Disease Management Partner that provides programs at no cost to our
Members as part of our Members value-added Care Management programs. Nurtur
focuses on managing specific diseases or conditions. Disease or Health Management are
often partnered between a Care Manager and a disease management program that
provides education, tools and resources to managing chronic diseases. Coaching and
resources are available for the following conditions:
•
•
•
•
•
Asthma
Diabetes
Coronary Artery Disease
COPD
Heart Failure
•
•
•
•
•
Hyperlipidemia
Hypertension
Weight Management
Lower Back Pain – Back Pain Management
Tobacco Cessation
*Nurtur is URAC accredited - To refer Members call CeltiCare Health 1-855-678-6975
Cenpatico** Behavioral Health provides care coordination for Depression and Substance
Use conditions – To refer Members call** Cenpatico 1-866-896-5053
28
Care for Pregnant Women
Members who become pregnant are eligible for comprehensive maternity care through other
MassHealth programs. While awaiting transition to MassHealth Standard, CeltiCare Health
provides coverage to pregnant women under the CarePlus benefit.
•
Providers are required to notify CeltiCare Health Care Management Department promptly when
rendering prenatal care to a CeltiCare Health Member by calling:1-855-678-6975
• CeltiCare Health will notify MassHealth weekly based on this notification
The following services describe the coverage available to pregnant women until the point of
disenrollment from CeltiCare Health’s CarePlus Program:
•
CeltiCare Health will cover all medically necessary obstetrical and gynecological services
through delivery of the child, as well as immediate post-partum care and the follow-up
appointments within the first six weeks of delivery for the Mother.
CeltiCare Health facilitates immediate transfer of newborns to the MassHealth eligibility
process.
• Providers should regularly check the MassHealth Eligibility Verification System for newborn
eligibility and enrollment information.
29
Prior Authorization Submission Requirements
CeltiCare Health has Prior Authorization (PA) requirements on all inpatient services, some
outpatient medical procedures, some ancillary provider services such as Durable Medical
Equipment (DME) or Home Health Care, services with Out-of-Network Providers, and for
Behavioral Health Diversionary Services. For more detail about CeltiCare Health’s Prior
Authorization requirements, please visit www.celticarehealthplan.com, or refer to our
Provider Manual.
Timeliness of Provider Notification to CeltiCare Health
Providers are asked to be responsible for obtaining Prior Authorization as follows:
•
•
•
For all pre-scheduled services (i.e. standard requests) requiring prior authorization,
providers should notify the plan prior to the requested service date.
Facilities are required to notify the plan of all inpatient admissions within one (1)
business day following the admission.
Prior authorization is not required for emergent or urgent care services, or Poststabilization services. However, once the member’s emergency medical condition is
stabilized, certification for hospital admission or authorization for follow-up care is
required as stated above.
30
Prior Authorization Submission Requirements
Prior Authorization can be requested in 3 ways:
1.
Via the CeltiCare Health secure portal www.celticarehealthplan.com
2.
Fax Prior Authorization Requests to1-866-614-1950
3.
Call for Prior Authorization at 1-855-678-6975
Copies of Prior Authorization Forms can be found at:
http://www.celticarehealthplan.com/for-providers/provider-resources/documents-forms/
Failure to obtain authorization may result in an administrative denial, and Providers are
prohibited from holding a Member financially responsible.
31
Prior Authorization UM Decision Making Timeframes
Timeliness of CeltiCare Health UM Decision Making and Notifications
Plan provides Prior Authorization decisions as expeditiously as Member’s health requires:
•
For Standard Authorization Decisions - no later than 14 calendar days after receipt of the
request for services.
•
For Expedited Service Authorization Decisions - where standard timeframe could seriously
jeopardize the member’s life or health or ability to attain, maintain or regain maximum
function, Plan provides an expedited authorization decision and notice no later than 3
business days after receipt of the request.
•
A one-time extension not to exceed 14 calendar days is allowed for both standard and
expedited decisions, when requested or additional information is necessary prior to decision.
For Behavioral Health:
• Prior authorization response time requires Plan availability 24 hours/day-7days/week for any
inpatient service admission or 24-Hour Diversionary Service.
• Initial authorization for all BH emergency inpatient admissions must be made verbally within
30 minutes, and within 2 hours for non-emergency inpatient authorization and in writing within
24 hours of admission.
Please refer to the CarePlus Provider Manual for additional information.
32
Electronic PA Submission
33
NIA: Prior Authorization* for High Tech Imaging

Providers wishing to order any of the imaging services below are responsible for
obtaining authorization before these services are rendered.

Providers rendering the services should verify that the necessary authorization has
been obtained. Failure to do so may result in nonpayment of claims.

To verify an authorization:
 Visit www.RadMD.com; or
 Call the NIA dedicated toll-free phone number at 1-800-635-2873.
Outpatient Imaging Services Requiring Prior Authorization
•
•
•
•
CT/CTA
CCTA
MRI/MRA
PET
• Nuclear Cardiology /Nuclear
Stress / Myocardial Perfusion
• Stress Echo
• Echocardiography
*Only non-emergent procedures performed in an outpatient setting require authorization
with NIA
34
Claim Submissions
35
Claims Submission
•
CeltiCare Health accepts both electronic (EDI) and (red) paper claims
•
Payer Identification Numbers
68069 Medical
68068 Behavioral Health
•
Timely Filing (EDI or paper)
– All claims must be filed within 90 days of the date of service
– Claim adjustments must be received within 90 calendar days from the date of the
Explanation of Payment
•
Paper Claims – CeltiCare Health only accepts original (red) claim forms
CMS-1500 (08/05)
CMS-1450 (UB04)
36
Claims Submission
Claims may be submitted in 4 ways:
1.
The secure web portal located at http://www.celticarehealthplan.com
2.
Electronic Clearinghouse - For a listing of our Clearinghouses, please visit
our website at http://www.celticarehealthplan.com/for-providers/electronicsubmissions/edi/
3.
If you are interested in becoming a member or are an existing member of
NEHEN, contact the Centene/CeltiCare EDI Service Desk at:
ediba@centene.com or call: 1-800-225-2573 ext.25525 and begin to take
advantage of the opportunities that NEHEN has to offer.
4.
Original paper and corrected claims may be submitted to:
Claims Department
PO Box 3080
Farmington, MO 63640-3824
37
Member Grievances, Appeals & Board of Hearings
CeltiCare Health has steps in place to encourage Members and Providers to contact us so
that we may answer any questions, and address any issues or concerns that may arise
regarding the health care of our Members.
CeltiCare Health has developed the following processes to address Member Inquiries,
Grievances, Adverse Actions and Appeals:
•
•
•
•
•
Internal Inquiry
Internal Grievance
Adverse Action Notices
Internal Appeal
External Review by EOHHS Board of Hearings (BOH)
CeltiCare Health’s policies and procedures follow EOHHS’ requirements covering Grievances,
Appeals, and Board of Hearings reviews. The Grievance and Appeals Process provides
Members with options to file a grievance, two levels of appeal, expedited appeals, and
external review by the Board of Hearings (BOH) when the Member is dissatisfied with an
adverse action.
Please refer to the Provider Manual for complete details on CeltiCare Health’s
Grievance, Appeals and BOH policy and procedures.
38
Claims Appeals/Disputes Process
•
First point of contact should be to access the IVR or the web portal to check claim
status. You may also contact Provider Services at 1-855-678-6975 and follow the
prompts for claim status.
•
If you would like to request reconsideration of a claim, please submit a request in
writing within 90 days of the EOP date. A “Request for Reconsideration” must be
submitted prior to a dispute. If the request for reconsideration is denied then a
“Claim Dispute” (2nd level appeal) can be submitted.
•
A Claim Dispute must be submitted within 90 calendar days of the resolution of
your Request for Reconsideration.
CeltiCare Health
Claims Reconsiderations
PO Box 3080
Farmington, MO 63640-3824
CeltiCare Health
Claims Disputes
PO Box 3000
Farmington, MO 63640-3800
39
PaySpan Health EFT/ERA
• PaySpan Health is a secure, self-service website which can be utilized
to manage and receive electronic payment and remittance advice.
• Manage and access remittance data 24 hours a day
• For more information please contact PaySpanHealth at 800-733-0908,
www.payspanhealth.com
• Register to attend a free webinar by calling 877-331-7154 or e-mail
PaySpan at providersupport@payspanhealth.com
40
Credentialing
and
Re-Credentialing
41
Credentialing, Demographic Updates and
Re-Credentialing
•
New providers applying for participation must submit the required application
and documentation to their Provider Relations Specialist. The application and
document check list are available on our website:
http://www.celticarehealthplan.com/files/2012/05/CeltiCare_Credentialing_Che
cklist_Current_201205.pdf?8c0b62
•
CeltiCare Health will conduct an initial site visit and orientation for new
providers
•
In order to maintain a current provider profile, providers are required to notify
CeltiCare Health of any relevant changes 30 days prior to the change
•
CeltiCare Health conducts the re-credentialing process every 24 months from
the date of provider’s initial participation effective date
•
Inquiries regarding a provider’s credentialing status and demographic changes
can be resolved by contacting Provider Services at 1-855-678-6975
42
Quality Standards
43
Quality Standards
Each PCP is responsible for maintaining sufficient facilities and personnel to provide
covered physician service 24 hours a day, 365 days a year.
Coverage must consist of one of the following means:
• Answering service
• Call forwarding to covering physician(s)
• After-hours, on-call coverage
24-Hour Access of coverage requires:
• After-hours coverage be accessible using the medical office’s daytime telephone
number
• The PCP, or covering medical professional, returns all calls within 30 minutes of the
initial contact
• Connecting the caller to someone who can render a clinical decision, reach the
PCP for a clinical decision, or refer the caller to the emergency room
CeltiCare Health will monitor appointment and after-hours availability on an ongoing basis
through its Quality Improvement Program.
44
Quality Improvement Initiatives
As part of CeltiCare Health’s Quality Management and Quality Improvement
initiatives, you can expect the following activities at least annually from CeltiCare
Health:
•
•
•
•
Educating about our Provider Profiling activities to include:
– Methodology and benchmarks for standards of care
– Assessment of performance using clinical, administrative, and Member satisfaction.
– Feedback mechanisms and action plans for improvement
Establishing provider specific quality improvement goals;
Developing and establishing activities and incentives to improve patient quality of care;
Ongoing education and support in targeted areas such as issues concerning women,
peoples with disability, special populations, and areas concerning adult preventive care.
Visit CeltiCare Health’s Website for more information about our Quality
Improvement programs at www.celticarehealthplan.com/for-provider/qi-program.
45
Quality Improvement Information
http://www.celticarehealthplan.com/for-providers/qi-program
/
46
Educational Opportunities
Ongoing Education for Primary Care Providers:
• Ongoing education and training for Primary Care Providers (PCP) will occur periodically
on program topics that will include Cultural Competency, integrated care management,
and wellness initiatives, and if there is a request for refresher training on policies,
procedures, systems, or workflows.
• Additionally, training will be provided at least annually for PCPs on the Behavioral Health
and Substance Use Disorder screening tools and how to identify Behavioral Health
Service needs, including how to refer for services when needed
Ongoing Education for Specialty Providers:
• Education and training for Specialists will occur periodically to ensure their continued
understanding of and ability to abide by the requirements of the program and on topics
related to Cultural Competency, programs or initiatives CeltiCare Health is promoting
and if there is a request for refresher or quality of care issue. Additionally, targeted
periodic training, will occur regarding clinical tools and resources, Physical and
Behavioral Health Integration, and Performance improvement initiatives. Training will be
scheduled and published on the CeltiCare Health website indicating intended audiences
and modality of training.
47
Cultural Competency
•
CeltiCare Health monitors the delivery of care and services in relation to the
provision of culturally competent services through a comprehensive set of Quality
Methods that include the CAHPS Member Satisfaction Survey and Provider
Satisfaction Survey
•
Language Line medical translation services are available 24 hours a day, seven
days a week in 140 languages to assist providers and members in communicating
with each other during urgent/emergent situations, non-urgent/emergent
appointments as requested, or when there are no other translators available for the
language requested. The language line is accessed through Member Services
during regular business hours or through NurseWise, CeltiCare Health’s medical
triage advice line, after normal business hours
•
Additional information can be found at: CeltiCare Health Cultural Competency
(hyperlink) or http://www.celticarehealthplan.com/files/2013/08/2013-CulturalCompetency-Plan.pdf?8c0b62, or
•
By calling the Member Services Department at: 1-855-678-6975, Monday – Friday
8:00 am to 5:00 pm
48
Provider Assistance with Public Health Services
CeltiCare Health is partnering with EOHHS to coordinate with public health
entities regarding the provision of public health services. We need your
help in doing that by:

Complying with public health reporting requirements regarding communicable diseases and/or
diseases which are preventable by immunization as defined by Massachusetts law.

Assisting in the notification or referral of any communicable disease outbreaks involving
members to the local public health entity as defined by Massachusetts law.

Referring to the local public health entity for tuberculosis contact investigation, evaluation, and the
preventive treatment of persons with whom the Member has come into contact.

Referring Members to the local public health entity for STD/HIV contact investigation,
evaluation, and preventive treatment of persons whom the Member has come into contact.
•
Providing Serious Reportable Events (SREs) and Provider Preventable Conditions to DPH and
CeltiCare Health within 7 days of discovery, with a follow-up report within 30 days of the initial
notification; CeltiCare will inform MassHealth.
Massachusetts Department of Public Health 1-617-624-6000
49
Provider Assistance with Public Health Services
continued
 Providing all women of childbearing age with HIV counseling and offering them HIV
testing at the initial prenatal care visit. All women who are infected with HIV are
counseled about and offered treatment.
 Screening all pregnant Members for the Hepatitis B surface antigen.
 Referring Members for Women, Infant, and Children (WIC) services.
 Assisting in the coordination and follow-up of suspected or confirmed cases of
childhood lead exposure (FYI for providers, does not apply to CarePlus Members.
 Assisting in the collection and verification of race/ethnicity and primary language data.
Massachusetts Department of Public Health 1-617-624-6000
50
QUESTIONS?
Call our Provider Service Department at
1-855-678-6975
Monday through Friday, 8 a.m. to 5 p.m.
51