5/7/2012. Provider Q&A

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Provider Q&A

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1. What is the statewide expansion of Physical Health Managed

Care?

Effective July 1, 2012, the Department of Health and Human Services (DHHS) is expanding the physical health managed care program statewide. DHHS is contracting with two health plans to manage physical health services; one health plan is AmeriHealth Nebraska, Inc.

2. What is the new product name?

AmeriHealth Nebraska Inc. (ANI) will be operating under the name of ―Arbor Health Plan.‖

3. What counties is the plan targeting?

DHHS Nebraska is expanding to counties not currently served by Physical Health Managed Care. Therefore, Arbor Health Plan will be targeting the 83 counties not currently serviced by Physical Health Managed Care.

4. Does the plan have a website?

Y es. The website address is www.arborhealthplan.com and it will be updated with provider resources on an ongoing basis.

5. How will I be paid? (FFS or capitation)

All physician reimbursement is based on the Medicaid Fee Schedule. We will reimburse providers for telemedicine in conformance with the DHHS telemedicine regulations.

6. What clearing house do you participate with?

Emdeon. Emdeon is currently preparing for Arbor Health Plan claims transactions and is available for provider calls at 877-363-3666.

7. Where will I send my claims for payment?

Electronic Claims Submission (EDI)

If you would like to transmit claims electronically, contact your EDI software vendor, and be prepared to specify Arbor Health Plan’s payer ID # 52312, or, call Emdeon's customer service at 877-363-3666. Paper claims should be sent to:

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8. Can I receive payments through EFT?

Yes.

Electronic Funds Transfer (EFT) EFT simplifies the payment process by:  Providing fast, easy and secure payments  Reducing paper

 Eliminating checks lost in the mail

 Not requiring you to change your preferred banking partner

Y ou will be able to enroll through our EFT partner, Emdeon Business Services and complete an Enrollment and Authorization Form, or call 866-506-2830 to enroll in EFT.

Electronic Remittance Advice (ERA)

For information about, or to sign up to receive Electronic Remittance Advice (ERA), call Emdeon's customer service at 877-363-3666. We will include further details and information during our provider orientation and workshops.

9. How often will I get paid, what is the payment cycle?

Our payment cycle is weekly.

10. What is the average turnaround time on clean claims

payment?

Our average time period for paying clean claims is less than 30 days.

11. What are the timely filing requirements?

Original invoices must be submitted to the Plan within 365 calendar days from the date services were rendered or compensable items were provided.

Re-submission of previously denied claims with corrections and requests for adjustments must be submitted within 90 calendar days from the date services were rendered or compensable items were provided.

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12. Where do I send paper claims?

Paper claims should be sent to:

P.O. Box 7336 London, KY 40742.

13. What is the timely filing period for appeals?

Any request for an adjustment to payment or appeal of a payment or denial must be made within ninety (90) days following the date of the original payment or denial. Provider

appeals information is outlined in the Provider Handbook which will be available early April.

14. What hospitals participate with Arbor Health Plan?

Arbor Health Plan will contract with hospitals including tertiary care centers, to provide adequate service in the coverage area.

15. What reference labs participate with Arbor Health Plan?

Negotiations are underway for agreements with several reference labs in the service area.

16. What services will need prior approval?

Services Requiring Authorization

 All out-of-network services (except emergency services)  Air ambulance

 In-patient services

o All inpatient hospital admissions, including medical, surgical and rehabilitation o Obstetrical admissions/newborn deliveries exceeding 48 hours after vaginal

delivery and 96 hours after caesarean section o In-patient medical detoxification

o Elective transfers for inpatient and/or outpatient services between acute care facilities

o Long-term care initial placement if still enrolled with the plan o Services Requiring Authorization Continued.

 Home-based services

o Home health care (after 12 visits) o Skilled nursing visits (after 6 visits)

o Private duty nursing (extended nursing services) o Home health extended services

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o Enteral feedings, including related DME  Therapy and related services

o Speech therapy, occupational therapy and physical therapy (after 12 visits for each modality)

o Chiropractic care o Cardiac rehabilitation

 Transplants, including transplant evaluations  All DME rentals

 DME purchases for billed charges $500 and over, including prosthetics and orthotics  Diapers/pull-ups (ages 3 through 20) who qualify:

o For quantities over 200 per month for either or both o Brand-specific diapers

o If supplied by a DME provider  Hyperbaric oxygen

 Implants (over $500)

 Medications – 17-P and all infusion/injectable medications listed on the Nebraska Medicaid Practitioner Fee Schedule for injectables with amounts of $250 or greater; infusion/injectable medications not listed on the Medicaid Fee Schedule for

injectables are not covered by Arbor Health Plan  Surgical services that may be considered cosmetic  Cochlear implantation

 Gastric bypass/vertical band gastroplasty  Hysterectomy

 Pain Management – external infusion pumps, spinal cord neurostimulators, implantable infusion pumps, radiofrequency ablation and nerve blocks  Radiology Services* o CT scan o PET scan o MRI o MRA o MRS o SPECT scan

o Nuclear cardiac imaging

 All unlisted and miscellaneous codes.

*Emergency room, Observation Care and inpatient imaging procedures do not require Prior Authorization

Providers will be able to submit prior authorization of inpatient and outpatient services electronically in addition to the fax and phone submission.

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18. If I have questions, who do or where do I call?

Y ou may contact our provider services team at our toll free number, 888-738-0004, for assistance with any questions about Arbor Health Plan. In the very near future, we will provide a one page reference guide with important contact information and contact numbers, and we will have this available on our website.

19. Will I be assigned a Provider Representative? How often will

I see them?

A Provider Network Account Executive (AE) will be your representative for the Plan. AEs will work with you as frequently as you would like.

At a minimum, AEs plan to meet in person with providers as follows:

 If you are a PCP the AE will meet with you at least quarterly, or as requested.  If you are a Specialist the AE will meet with you every six months, or as requested.  Hospital/Ancillary providers the AE will meet annually.

 Y ou may request a site visit at any time to address any questions and/or concerns with the Plan.

20. How will Arbor Health Plan communicate with providers?

Communications to Arbor Health Plan providers occur through on-site orientations for newly contracted providers, routine site visits, provider workshops, letters to specific providers, the provider handbook, the provider web site, and provider newsletters. We held provider workshops the week of March 19th_{. Arbor Health Plan will update this questions} and answers document with feedback from providers.

Additionally, Arbor Health Plan will conduct an annual provider satisfaction survey to assess satisfaction.

21. Who is your Medical Director?

We are currently working to identify a Medical Director for Arbor Health Plan.

22. Are there practice guidelines that I have to follow?

We recognize the practice guidelines identified by NQCA and referenced as HEDIS measures. Information may be accessed at www.ncqa.com . Arbor Health Plan offers several condition management programs to address the expected high-incidence conditions for which there are evidence-based protocols that have been shown to improve health outcomes. The following programs are available for Arbor Health Plan members;

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and Heart Failure. Our programs promote the use of the below nationally-accepted guidelines in the delivery of health care services:

Condition

Clinical Evidence-Based Guidelines

Diabetes  American Diabetes Association: Clinical Practice Recommendations 2010 http://care.diabetesjournals.org/content/33/Supplement_1

Heart Failure

 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults

http://circ.ahajournals.org/cgi/content/full/119/14e/e391

 Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease

http://ahajournals.org/cgi/content/full/115/21/2761

Asthma

 Global Initiative for Asthma (GINA) 2009

http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&int Id=60  National Institute of Health (NIH) 2009

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

COPD

 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008.

http://www.goldcopd.com/guidelineitem.as p?l1= 2&l2=1&int Id=989

Obesity

 National Heart, Lung, and Blood Institute: Obesity Education Initiative: the Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults

 http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf

 American Academy of Pediatrics endorsed: Expert Committee

Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity: Summary; Sarah E. Barlow;

Pediatrics, 2007120; S164;

 www.aap.pediatrics.aapublications.org Pregnancy

 Institute for Clinical Systems Improvement: Routine Prenatal Care, 14th ed. July 2010

http://www.icsi.org/prenatal_care_4/prenatal_care_routine_ful_version_2.html

23. If I am currently credentialed with BCBSNE do I have to go

through the re-credentialing process?

No. If you are currently credentialed with BCBSNE you need only complete a short one page application form so the Plan may obtain additional data required by the State. This

application was mailed with your new contractual agreement. You may return it with your contract or return it to the Plan via fax at 855-282-8340 or e-mail it to

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24. What is your credentialing process?

Arbor Health Plan works with the Council for Affordable Quality Healthcare (CAQH) to offer our providers the Universal Provider Datasource that simplifies and streamlines the data collection process for credentialing and recredentialing.

Through CAQH, you provide credentialing information to a single repository, via a secure Internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. Arbor Health Plan’s goal is to have all of our providers enrolled with CAQH.

There is no charge to providers to submit applications and participate in CAQH.

If you participate with CAQH you do not need to complete a full application for our Plan, just provide your CAQH provider ID # and name(s) and complete our one page check list, and authorize our Plan to obtain information from CAQH, and either fax or e-mail this form to our credentialing department as noted in (23.)

If you are unable to enroll with CAQH a full paper application form must be completed and submitted to the Plan. Y ou may contact our credentialing team at 888-738-0004 to obtain the complete application and for assistance.

We provide all credentialing information, forms and applications on our website at

www.arborhealthplan.com under provider resources, credentialing. You may contact the credentialing team at 888-738-0004 for assistance.

25. Do you require Physician Assistants (PA) and Advanced

Registered Nurse Practitioners (ARNP) to be credentialed with

the Plan?

Y es.

26. Can PAs and ARNPs treat Arbor Health Plan patients?

Y es. ARNPs and PAs when practicing under the supervision of a physician specializing in Family Practice, General Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology may also qualify as a PCP under the Nebraska DHHS contract.

27. Do you contract at the individual or group level?

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28. Will the Plan require referrals to specialists?

No. Referrals to specialists will not be required for participating providers.

29. Will you pay for radiology done in my office?

Y es we pay for medically necessary radiology performed in a provider office.

30. How do we request assistance with care management issues?

Y ou will be able to contact our care managers directly. Contact information will be provided during the provider orientation process.

31. What are the basic benefits that will be provided by Arbor

Health Plan?

The following physical health services represent a minimum benefit package that must be provided by the Managed Care Organization (MCO) to enrollees:

 Inpatient hospital services  Outpatient hospital

 Clinical and anatomical laboratory services including the administration of blood draws completed in the physician office or outpatient clinic for MH/SA diagnosis  Radiology services

 Health Check (EPSDT) services and outreach including missed appointments or lack of follow up

 Physician services, including nurse practitioner service, certified nurse midwife services, physician assistant services, clinic administered injections/medications, and anesthesia services including CRNA

 Home health agency services  Private duty nursing services

 Therapy services (physical therapy, occupational therapy, and speech pathology and audiology)

 Durable medical equipment and medical supplies, including hearing aids, orthotics, prosthetics and nutritional supplements

 Podiatry services  Chiropractic services

 Emergency Medical Transportation  Vision services

 Free Standing Birth Center Services.

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 Adult preventative visits  Parenting Classes

 24x7 Nurse Hotline

 WeeCare Diaper Program (tied to AmeriHealth Nebraska’s maternity program)  Lamaze classes

 Rapid Response Team.

Hospital specific additional questions:

32. Are there penalties for the Hospital for not getting a prior

approval for an inpatient admission?

Unless emergent, services will be denied.

33. Will your nurses do concurrent review on site or

telephonically?

Arbor Health Plan nurses will conduct concurrent review telephonically. Please contact our concurrent Review Staff at 866-729-0076.

34. What is the time requirement for calling in an inpatient

admission?

The Plan must be notified of an inpatient admission within one (1) business day.

35. Do you do retrospective reviews on inpatient/outpatient

services?

Arbor Health Plan conducts retrospective reviews on a case by case basis if there is a reason prior authorization could not be requested.

36. How will Hospital providers be paid?

Hospital reimbursement will be by DRG.

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37. When will the provider manual be finished?

The Arbor Health Plan provider manual is complete and can be accessed on our website at

www.arborhealthplan.com/provider/.

38. Will pharmacy NDCs be required?

We will follow Nebraska requirements and expect that Physician Administered, outpatient drugs be billed with both the NDC code and appropriate HCPCS code. Payment is calculated via the HCPCS code according to the NE Medicaid Fee schedule. Determination of available NDC is made using the CMS NDC-HCPCS crosswalk file which is updated on a quarterly basis. The CMS cross-walk file can be found at the following link:

http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a19_2010aspfiles.asp#TopOfPage

39. What edits will they be using Medicaid or Medicare NCCI or

something else?

Arbor Health Plan claim payment policies are based on guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), National Correct Coding Initiative, the American Medical Association (AMA), State regulatory agencies and medical specialty professional societies. In making claim payment determinations, Arbor Health Plan also uses coding terminology and methodologies that are based on accepted industry standards, including the Healthcare Common Procedure Coding System (HCPCS) manual, the Current Procedural Terminology (CPT®) codebook and the International Statistical Classification of Diseases and Related Health Problems (ICD) manual. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefit design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding Arbor Health Plan’s claim payment policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, Arbor Health Plan will use reasonable discretion in interpreting and applying payment policy to health care services provided in a particular case. Other factors affecting reimbursement may supplement, modify or in some cases, supersede claim payment policies. These factors may include, but are not limited to: legislative or regulatory mandates, the provider contract, and/or the member’s eligibility to receive the health care services.

40. What are the rules surrounding observation, overlapping

claims (such as same day and 3 day) and Condition Code 44?

Observation services are those services furnished by a hospital on the hospital premises,

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reimbursed. When a patient receives hospital observation services and is thereafter admitted as an inpatient of the same hospital, the hospital observation services are included in the hospital's payment for the inpatient services.

41. Will retrospective authorizations be considered?

Arbor Health Plan conducts retrospective reviews on a case by case basis and depends in part on whether there is a reason prior authorization could not be requested.

42. What DRG system will be used? And what version?

Arbor will utilize the Nebraska Medicaid payment methodology which is AP DRG version 27.

43. What quality measures will you monitor?

We monitor standard measures associated with HEDIS, along with member satisfaction, utilization metrics and service measures (e.g. phone answer time, appointment availability, etc.). For providers, the focus is on HEDIS measures, utilization and appointment

availability/after-hours coverage.

44. How long will the credentialing process take?

We are currently able to credential a physician within 7 days, provided we have all of the necessary information. We can also expedite credentialing for select urgent cases.

Additionally, we will approve services from an out-of-network provider on a case-by-case basis while credentialing is in process.

45. Is Arbor Health Plan required by the Nebraska Network

Adequacy Act to treat a provider as participating providers

even if they do not sign a contract?

No. Providers who do not contract with Arbor Health Plan will not be reimbursed for services provided unless the services were prior authorized by Arbor Health Plan.

46. Do RHC’s bill UB or 1500? Can RHCs submit claims to the

state for encounters?

Arbor Health Plan requests Rural Health Clinics bill using the standard CMS-1450 format or the 837I electronic format. Services included in the Rural Health Clinic Encounter as well as payable exceptions are both billed to Arbor Health Plan and can be billed on the

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47. Will RHCs submit all claims for Arbor Health Plan members to

Arbor Health Plan regardless of the reason for the visit?

All services that are covered by the Managed Care Organization per Nebraska Medicaid should be billed to Arbor Health Plan. Excluded services should be billed to the state or the state’s sub-contracted vendor. The following is a list of excluded services:

 Pharmacy services

 Nursing Facility services — custodial level of care  ICF/MR services

 Home- and Community-based Waiver services

 School-based services covered under Medicaid in Public Schools  Optional Targeted Case-Management services

 Mental Health and Substance Abuse services (except those delivered by non-Behavioral Health professionals)

 Dental services

 Non-home health agency approved Personal Assistance services  Hospice

 Non-emergency Transportation

48. Will you have a billing manual?

Y es. Arbor Health Plan will have a billing manual. It will be available on our website at www.arborhealthplan.com

49. How are RHC’s reimbursed?

RHCs associated with Critical Access Hospitals less than 50 beds will continue to be reimbursed based upon 100 percent of billed charges.

Independent and provider-based RHCs associated with hospitals having greater than 50 beds will continue to be reimbursed based upon their PPS rate. All claims will be submitted to Arbor Health Plan. Arbor Health Plan will accept all RHC claims on a UB

50. Will more specific reimbursement language be included in

Arbor Health Plan RHC contracts?

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51. Will there be referral or authorization requirements for urgent

care clinics? (if so, what are the administrative authorization

processes)

We do not require a referral or authorization for urgent care services from a participating provider. Urgent care from a non-participating provider will need to be authorized – however, the provider can obtain the authorization retrospectively. Please reference Q.41 above.

52. If a member moves to another county and is seen by another

PCP or Urgent Care facility will the claim be denied?

Since managed care and assignment to a particular PCP is unfamiliar to Nebraska Medicaid Enrollees in our service area, Arbor Health Plan will support a period of adjustment. During this time, Primary Care Practitioners will not be required to obtain authorization prior to treating a member of our Plan who is assigned to another Practice. Notification that the adjustment period is ending will be communicated to both our members and provider network no less than 60 days before discontinuation. The above statements regarding how we handle urgent care apply. Additionally, we do not require authorization or referral for emergency medical care. Emergency medical care can be provided by either a participating or non-participating provider.

53. How do you handle retro eligibility?

Managed Care enrollment is prospective only. Enrollees will have regular Fee-for-Service Medicaid during the period of retro eligibility and the provider must verify managed care eligibility before rendering the service via [email protected] or call 402-471-9461 or 866-498-4357.

54. If a patient comes into our office and the physician identified

is not one of our physicians and the patient wants to change

PCP offices what should we do to ensure payment?

The physician’s office may assist the member to call and request the PCP change – the office cannot request it on their own. If it is a one-time visit, the office may call the UM line to request approval to see the member. Additionally, the urgent care comments above will apply, including the ability to retrospectively request approval for urgent care situations.

55. Will out-of-network providers be paid if not in network?

Out-of-network providers will be paid for emergency medical care. They will not be paid for routine or urgent care that is delivered unless they have authorization to provide the