PARTICIPATING PROVIDER
ORIENTATION
Keystone VIP Choice
This training program is designed to familiarize Providers with Keystone
VIP Choice. At the conclusion of the training, providers will be familiar
with Keystone VIP Choice’s Model of Care, the role of the Provider in
the Model of Care and Keystone VIP Choice’s resources available to
the Provider and Member for Keystone VIP Choice.
•
Keystone VIP Choice is a Medicare Advantage Dual Eligible Special
Needs Health Maintenance Organization. (D-SNP/HMO)
3
•
Keystone VIP Choice is a member
of the AmeriHealth Caritas Family
of Companies - the industry
leader in managing medically
complex members
•
We are expanding our
membership to continue our vision
and mission to provide healthcare
services to the underserved
•
Keystone VIP Choice enables us
to offer our existing and eligible
chronically ill Medicaid members, a
seamless transition to a Medicare
Advantage Special Needs Plan
Why Keystone VIP Choice?
As a member of AmeriHealth Caritas, Keystone VIP Choice
is uniquely qualified to provide these populations with the
coordinated care they deserve.
AmeriHealth Caritas – care is the heart of our work:
•
Nearly 5 Million Covered Lives
•
3,000+ Employees
•
NCQA-Accredited plans
Why Keystone VIP Choice?
Keystone VIP Choice is well equipped to provide high-level
customer service to members and providers.
AmeriHealth’s corporate systems and centers currently:
•
Handle more than 2.25 million member and provider calls annually in our
24/7 call centers.
•
Process an average of 2.1 million claims each month.
•
Receive more than 87 percent of provider claims electronically with
automatic adjudication rates of more than 81 percent.
Why Keystone VIP Choice?
AmeriHealth Caritas Pennsylvania (Harrisburg Area)
Keystone First (Philadelphia Area)
MDwise Hoosier Alliance (Indiana)
Select Health (South Carolina)
Based upon NCQA Health Insurance Plan Rankings 2013-2014, issued September, 2013
The success of AmeriHealth Caritas’ mission-driven programs is
evidenced by the national recognition and awards received.
The following AmeriHealth Caritas Medicaid plans have received
Commendable Accreditation for 2013-2014.
Keystone VIP Choice and Keystone First
AmeriHealth Caritas is focused on extending the services
that we provide under the Keystone First Pennsylvania
Medicaid Plan to members who have become eligible for
Medicare due to age or disability.
8
We help people get care,
stay well and build healthy
communities.
We have a special concern
for those who are poor.
Mission
Plan Overview
Plan Overview
Keystone VIP Choice is contracted to provide Medicare Hospital (A), Medical
(B) services, and Prescription Drug Coverage (Part D) services in the following
counties: Bucks, Chester, Delaware, Montgomery, or Philadelphia
Members must live in one of these counties to join the plan.
Keystone VIP Choice Enrollment
Will accept only those beneficiaries with dual Medicaid/Medicare eligibility
Summary of Keystone VIP Choice’s Benefit Package
• Ambulance Services
• Cardiac and Pulmonary Rehabilitation Services
• Catastrophic Coverage
• Chiropractic
• Dental Services
• Diabetes Program and Supplies
• Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
• Doctor Office Visits
• Durable Medical Equipment
• Emergency Care
• Hearing Services
• Home Health
• Hospice – Initial Consultation
• Inpatient Hospital Care
• Inpatient Mental Health Care
• Kidney Disease and Condition
• Out-of Network Catastrophic Coverage
• Out-of-Network Initial Coverage
• Outpatient Mental Health Care
• Outpatient Rehabilitation
• Outpatient Services/Surgery
• Outpatient Substance Abuse Care
• Pharmacy
• LTC Pharmacy
• Mail Order Prescriptions
• Out-of-Network catastrophic Prescriptions
• Outpatient Prescription Drugs
• Retail Pharmacy
• Podiatry
• Preventive Services and Wellness/Education
• Prosthetic Devices
• Skilled Nursing Facility
• Urgent Care
Supplemental Benefits with Keystone VIP Choice - Dental
DENTAL SERVICES
Preventative Dental
•
Oral Exams – 1 every 6 months
•
Cleaning – 1 every 6 months
•
Fluoride Treatment – 1 every 6 months
•
Dental x-rays – 1 every year
Comprehensive Dental
•
Non – routine services, including minor restorations (such as
fillings, simple extractions and denture repair)
•
$500.00 every two years
•
Includes coverage for minor restorations
•
Fillings, simple extractions, dentures and denture repair
11Supplemental Benefits with Keystone VIP Choice - Vision
VISION SERVICES
•
Up to one supplemental routine Eye Exam every year
•
Up to one pair of eyeglasses or contact lenses every two
years
•
$150 plan limit on eyewear every two years
Supplemental Benefits with Keystone VIP Choice - Hearing
HEARING SERVICES
•
Up to one supplemental routine Hearing Exam every
year
•
Up to one fitting evaluation for a hearing aid every three
years
•
Up to $1,000 coverage for hearing aids every three
years
Supplemental Benefits with Keystone VIP Choice – Over the
Counter Items
OVER THE COUNTER
•
Typically includes medicines or products that alleviate or
treat injuries or illness
•
No statement from a medical provider required or
documentation of a diagnosis to use the benefit
•
Up to $60 every three months
•
No roll-over quarter to quarter
Supplemental Benefits with Keystone VIP Choice – Non
Emergency Transportation
TRANSPORTATION
•
Must be Plan approved location
•
Thirty-two (32) one-way trips per year to a plan approved
location
•
Car, shuttle, van services, including non-emergent
transportation to doctor visits, preventive services,
pharmacies and fitness center
•
Authorization and scheduling rules apply
Supplemental Benefits with Keystone VIP Choice – Health and
Wellness
Gym Memberships
•
Available to Keystone VIP Choice members.
•
Members may choose which gym they would like to
belong to from local gyms.
•
Members may call member services at (800) 450-1166
to arrange for membership.
Supplemental Benefits with Keystone VIP Choice – 24/7/365 Nurse
Call Line
If members are unable to reach their PCP’s office, registered
nurses are available 24/7days to assist members through the
Nurse toll-free Call Line
Keystone VIP Choice Nurse Call Line: (888) 765-6375
Supplemental Benefits with Keystone VIP Choice – Rapid
Response and Outreach
RAPID RESPONSE AND OUTREACH TEAM
The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include:
• Contacting members • Educating members • Calling Providers • Calling Pharmacies
• Completing surveys and assessments to support special projects
Providers and Members may request RROT support directly by calling toll free at (855) 809-9203 8am-5pm Monday – Friday.
19
Member
Eligibility
Member Rights and Responsibilities
Member Rights and Responsibilities
Federal law requires that health care providers and facilities recognize member rights. Members have the right to request and receive from their health care provider, a
complete copy of the Patient’s Bill of Rights and Responsibilities.
Providers may refer to the Provider Manual for a detailed listing of the Member’s Rights and Responsibilities.
Member Welcome Packet
Keystone VIP Choice Member welcome packet includes:
Cover (Welcome) Letter
Provider & Pharmacy Directory The Plan’s Formulary
Evidence Of Coverage (EOC) document
Health Risk Assessment (HRA) and return envelope Multi-Language Insert
Notice of Privacy Practices Member grievance process
• Member materials including a summary of benefits compared to Original
Medicare and complete evidence of coverage information are accessible via
our web site at www.keystonevipchoice.com or Keystone VIP Choice member
services at (800) 450-1166.
Member PCP Selection
•
Members may select a new PCP at any point in time by
calling Keystone VIP Choice member services at
(800) 450-1166.
•
An updated card will be sent to the member each time
there is a change in eligibility or PCP.
•
Because a member may present with a card with old
information, Keystone VIP Choice encourages providers
to validate member eligibility at each visit.
Member Eligibility Verification
Member eligibility varies. Providers can verify eligibility by using the following
Provider tools:
•
Utilizing the Monthly Member Panel Roster
•
Visiting our website at
www.keystonevipchoice.com
and accessing
NaviNet
•
Calling Provider Services at: (800) 521-6007
NaviNet
What is NaviNet?
– A FREE web-based solution for providers and health plans to share critical administrative, financial and clinical data.
– America’s largest real-time healthcare communications network, securely linking providers nationwide through a single website.
Provider portal address:
– https://connect.NaviNet.net
Informational website
– www.NaviNet.net
– NaviNet Web Portal: www.navinet.net Phone: (888) 482-8057
Must be accessed via Internet Explorer v. 7.0 or above
– Older versions of IE may not work appropriately
– Not accessible via Firefox, Safari or Google Chrome
NaviNet (continued)
NaviNet Functions:
View Member Eligibility Member Rosters
View Third Party Liability Information (TPL) Claims Status & Updates
Prior Authorization HEDIS Performance
On-Line Remittance Advice Care Plans
Clinical Summary Referrals
Care Gaps
Accessing Member Eligibility via NaviNet
Providers must select Keystone VIP Choice when checking eligibility for
Keystone VIP members
Potential NaviNet Issues
Providers who do not see Keystone VIP Choice as an option on the
Plan Central page should contact NaviNet to request access. This can
occur in two ways.
1.
Click on My Account at the top of the NaviNet page
• Support Cases will be located on the left side of the screen• Providers may Open a Case or View a Case here.
2.
Send an email to NaviNet Support at
[email protected]
All Support Cases or requests submitted via email should include:
– Tax identification Number (TIN)
– NaviNet user contact name and phone number
– Group and provider NPI’s to be added or terminated
– Transaction access request (Eligibility, Referrals, Prior Authorization Management, etc.)
Accessing Member Eligibility via NaviNet
On the Keystone VIP Choice landing page, NaviNet will
provide alerts if there are issues with search functions or
availability.
Providers may also call Provider Services for Keystone VIP
Choice (800) 521-6007 to verify eligibility.
Member Eligibility via NaviNet
Monthly Panel Roster
Provider panel rosters will be available on a monthly basis to
provide PCP offices with a listing of Keystone VIP Choice
members who have chosen their practice. Member information
on the panel roster will include:
•
The member’s name, address and telephone number
•
Date of birth and age
•
Gender
•
Effective date with Keystone VIP Choice Plan
•
Keystone VIP Choice Medicare Identification number
•
State Medicaid Identification Number (if applicable)
•
Primary Language spoken
•
Medicare Plan Type (D-SNP-HMO)
Keystone VIP Choice Panel Roster
Keystone VIP Choice– A Medicare Replacement
For Keystone VIP Choice members, Keystone VIP Choice
should be entered into the provider’s billing system in the place
of Medicare Fee for Service.
If a provider has Medicare or another Medicare Advantage plan
loaded in their patient management system for an Keystone VIP
Choice member, Keystone VIP Choice will replace this plan.
The
Keystone VIP Choice
member will have Pennsylvania
Medicaid secondary to Keystone VIP Choice, even if the
member previously enrolled in Keystone First.
Provider Participation
Keystone VIP Choice Medicare Provider Eligibility
Health care providers are selected to participate in the
Keystone VIP Choice Network based on an assessment
and determination of the network's needs.
Providers must be enrolled with the Medicare program in
order to be credentialed with Keystone VIP Choice.
Provider Credentialing
•
Keystone VIP Choice is responsible for the credentialing
and re-credentialing of its provider network.
•
Hospital-based physicians are not required to be
independently credentialed if those providers serve
Keystone VIP Choice members only through the
hospital.
•
All providers credentialed by Keystone VIP Choice must
also be enrolled with the Medicare program and, as
such, must agree to comply with all pertinent Medicare
regulations.
Keystone VIP Choice Credentialing
•
Keystone VIP Choice credentialing/re-credentialing criteria and
standards are consistent with the Centers for Medicare and
Medicaid Services’ specific requirements and National Committee
for Quality Assurance (NCQA) standards. Practitioners and
facility/organizational providers are re-credentialed every three
years.
•
Keystone VIP Choice works with the Council for Affordable Quality
Healthcare (CAQH) to offer providers a Universal Provider Data
source that simplifies and streamlines the data collection process for
credentialing and re-credentialing.
•
Through CAQH, providers submit credentialing information to a
single repository, via a secure Internet site, to fulfill the credentialing
requirements of all health plans that participate with CAQH.
Keystone VIP Choice’s goal is to have all providers enrolled with
CAQH.
Medical Records Requirements
Providers are required to maintain medical records in accordance with the Provider
Manual.
Requirements include, but are not limited to:
•
Elements in the medical record are organized in a consistent manner, and the
records are kept secure;
•
Patient’s name or identification number is on each page of record;
•
All entries are dated and legible;
•
All entries are initialed or signed by the author;
•
Personal and biographical data are included in the record;
•
Current and past medical history and age-appropriate physical exam are
documented and include serious accidents, operations and illnesses;
•
Allergies and adverse reactions are prominently listed or noted as “none” or No
Known Allergies “NKA”;
•
Information regarding personal habits such as smoking and history of alcohol
use and substance abuse (or lack thereof) is recorded when pertinent to
proposed care and/or risk screening.
Access to Care
Access to Care
Keystone VIP Choice PCPs, specialists and behavioral health providers must meet standard
guidelines as outlined in the Provider Manual to help ensure that Keystone VIP Choice members have timely access to care.
Keystone VIP Choice Access Standards:
• Assure members’ accessibility to health care services
• Establish mechanisms for measuring compliance with existing standards
• Identify opportunities for the implementation of interventions for improving accessibility to health care services for members
Office Accessibility
The following areas are monitored by Keystone VIP Choice to ensure physician access standards are continually met:
• PCP office hours must be clearly posted and reviewed with members during the initial office visit.
• The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services.
A Medicare-eligible PCP must provide the coverage to Keystone VIP Choice members. 39
Provider Appointment Scheduling
Appointment Scheduling
• Keystone VIP Choice monitors access standards on an annual basis. Specialists who are serving in the PCP role (i.e. Internal Medicine, Family Practice, Pediatrics, or OB/GYN) are subject to the PCP Access Standards.
• Timely Access Standards for appointment availability for Primary Care Physicians (PCPs), Specialists and Behavioral Health providers are outlined on slide 41.
Missed Appointment Tracking
• If a member misses an appointment with a provider, the provider should document the missed appointment in the member’s medical record.
• Providers should make at least three attempts to contact the member and determine the
reason. The medical record should reflect any reasons for delays in performing the examination.
• Medical record should include any refusals by the member.
Physician Office Standards
Primary Care and Behavioral Health Provider Access Standards:
Emergent Care 24/7 Request
•
Immediately or referred to ER
Urgent Care•
Within two (2) calendar days of
request
Routine Care
•
Within 14 calendar days of request
Specialty Care Provider Access Standards:
Routine Care
•
Within 30 business days of request
Access to Care
Access to After-Hours Care
Members should have access to quality, comprehensive health care services 24 hours a day, 7 days a week.
• PCPs and behavioral health providers must have either an answering machine or an answering service for members during after-hours for non-emergent issues.
• The answering service must forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes.
• When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office’s daytime telephone number.
• For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room.
Keystone VIP Choice monitors access to after-hours care on an annual basis by conducting a survey of PCP offices after normal business hours.
Keystone VIP Choice Referrals
Keystone VIP Choice- Referrals
Services that Require Referrals
•
Specialist visits
(except Direct Access Services – see below)
•
Podiatry services
•
Chiropractic Services
•
Outpatient diagnostic procedures (unless otherwise specified)
•
Ambulatory surgery center services
•
Diabetes self-management training
Direct Access Services that Do Not Require Referral
•
Direct access to women’s specialists for routine and preventive services
•
Direct access to mammography and influenza vaccinations
•
Behavioral Health Services
Keystone VIP Choice Referrals
Keystone VIP Choice
Referrals Required
Will affect provider payments
•
Electronic submission and inquiry available on NaviNet.
•
Hard Copy forms available at www.keystonevipchoice.com.
•
Three copies must be created - Referral copies must be kept in the
member’s medical record, given to the member, and faxed or mailed to
Keystone VIP Choice.
•
“Paper” form may be faxed or mailed. Mailing may cause delay in
processing.
NaviNet Referral Submission
“Paper” Referral Form
Keystone VIP Choice Referral Inquiry
Specialists, hospitals and ancillaries can use
Referral
Inquiry
to view and retrieve referrals on NaviNet.
•
Simply log on to NaviNet (
https://Navinet.Net
) and
select
Keystone VIP Choice
from Plan Central.
•
Select Referral Inquiry and follow the steps to refer a
patient or view referrals.
•
Specialists, hospitals and ancillaries may also call
Provider Services for Keystone VIP Choice (800)
521-6007 to inquire about a referral status.
NaviNet Referral Inquiry
Care Management
Keystone VIP Choice offers a Care Management Program that is aimed at assisting
members and providers in meeting the health care needs of our members. This program includes assistance with:
• coordinating transportation • obtaining medications
• educational outreach
• developing an individual care plan for each member based on their goals.
To assist members and providers Keystone VIP Choice has created a Rapid Response Outreach Team.
Care Management
The Rapid Response and Outreach Team (RROT) consists of Care Managers (Nurses and Social Workers) who are trained to help members investigate and overcome barriers to achieve their healthcare goals. Outreach Services include:
• Contacting members • Educating members • Calling Providers • Calling Pharmacies
• Completing surveys and assessments to support special projects Providers may request RROT support directly by calling toll free at (855) 809-9203, 8 am - 5 pm, Monday through Friday.
Medical Management Components
Prior
Authorization
Utilization
Review
Case
Management
53Prior Authorization
Keystone VIP Choice requires Prior Authorization for certain services
including, but not limited to:
•
Elective / non-emergent air ambulance
•
All out of network services (except emergency services)
•
In-patient services
•
Behavioral health care (mental health and substance abuse services)
•
Home-based services
•
Therapy and related services
•
Transplants, including transplant evaluations
•
All DME rentals and rent to purchase items
•
High-Tech Outpatient Radiology Services
For a complete list of services requiring prior authorization, please
reference the Provider Manual.
Keystone VIP Choice–
The Model of Care
Keystone VIP Choice Model of Care is an Integrated Care Management
Approach to health care delivery and coordination for Dual Eligible
(Medicare/Medicaid) individuals.
The Model of Care focuses on:
•
Improving Health Outcomes
•
Access to Essential Services/Affordable Care
•
Coordination of Care through the Medical Home/Primary Care Physician
•
Access to Preventive Services
•
Seamless Transitions
The Model of Care – Structure and Roles
Each member enrolls with a Medical Home/Primary Care Physician.
The model includes care and support from health care providers, community agencies and service organizations.
A 26-question Health Risk Assessment (HRA) is used to collect: – Physical and behavioral health history
– Preventive care – Level of activity – Medication use
The assessment is mailed with the Member’s welcome packet.
Staff follow up with the Member by phone and mail to collect the data.
Members receive an annual postcard reminding them to call Keystone VIP Choice and update their HRA information.
Assessment and Plan of Care Development
Data from multiple sources is used to develop the Plan of Care:
•
Review of available claim and pharmacy history
•
Data from the Health Risk Assessment
•
Input from the member, Primary Care Physician and other providers
Interdisciplinary Care Team
Each member has an Interdisciplinary Care Team to address
his or her unique needs:
•
Primary Care Physician/Medical Home
•
Specialists – Physical & Behavioral
•
Health Plan Nurses, Medical Directors, & Pharmacists
•
Home Health Care
•
Social Workers
•
Community Mental Health Workers
•
Physical, Speech & Occupational Therapy
The PCP/Medical Home
The PCP/Medical Home plays an important role in the Interdisciplinary
Team. Key responsibilities include:
•
Assisting members in determining which services are necessary
•
Connecting members to appropriate services
•
Serving as a central communication point for the member’s care
•
Reviewing the Plan of Care sent by Keystone VIP Choice
•
Providing feedback to Keystone VIP Choice
Updates to the Plan of Care
Updates are made routinely to the Plan of Care and come from multiple
sources:
•
Member or Provider call
•
Updated HRA (annual)
•
Care Transition (hospital, nursing home)
•
Claim, Pharmacy or Utilization trigger
•
Care episode
Identifying Vulnerable Sub-Populations
Keystone VIP Choice uses several mechanisms to identify vulnerable sub-populations, including:
• Claim data is analyzed to identify members with:
• Conditions targeted for chronic care improvement, such as diabetes, heart disease, COPD and renal disease
• Health needs, such as missing preventive care or recommended condition monitoring
• Utilization of emergency room and inpatient services is reviewed to identify members with opportunities for improved outpatient management
• Predictive Risk Scores are calculated using the DxCG methodology to identify members who are at risk for future avoidable health care episodes
• Health Risk Assessment data is reviewed for triggers identifying unmet health needs or the presence of chronic conditions
Chronic Condition Improvement Programs
Keystone VIP Choice offers several Chronic Care Improvement
Programs:
•
Diabetes
•
Asthma
•
Chronic Obstructive Pulmonary Disease
•
Depression
•
Members may self refer, be referred by a provider, or are identified
through claims data analysis.
•
Members or providers may contact the Member’s Case Manager for
enrollment.
Clinical Practice Guidelines
Keystone VIP Choice’s Clinical Practice Guidelines are:
•
Adopted from nationally-recognized organizations
•
Serve as a guide to practitioners, but do not replace clinical judgment
•
Available on www.keystonevipchoice.com and via hard-copy from Provider
Services upon request
Guideline Topics:
63
– Diabetes
– Anxiety Disorder in Adults – COPD
– Preventive Health Services
– Depression
– Coronary Vascular Disease – Hypertension
Provider Focus on Preventive Services
Medicare benefits cover an annual preventive physical examination.
During each office visit, please remember to:
•
Coach the member on appropriate physical activity
•
Ask about falls and fall prevention
•
Ask and coach on smoking cessation
•
List all relevant diagnoses on the claim
•
Check to see if the member needs:
–
Cancer Screening
–
Mammography or Colonoscopy
–
Glaucoma Testing
–
Flu or Pneumonia vaccine
High Risk Medication in the Elderly
Medication alternatives should be evaluated prior to prescribing any of
the following medications to an elderly member:
Antihistamines (promethazine, cyproheptadine, diphenhydramine, hydroxyzine)
Skeletal Muscle Relaxants (cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxazone)
Oral Estrogens
CNS Stimulants (amphetamines, anorexiants, methylphenidate)
Urinary Anti-infectives (nitrofurantoin, nitrofurantoin macrocrystals, nitrofurantoin macrocrystals-monohydrate)
Narcotics (pentazocine, meperidine)
Others (dicylcomine, meprobamate, nifedipine IR, scopolamine, thioridazine, benzodiazepines, barbiturates)
Focus on Health Outcomes
Keystone VIP Choice goals include improving health outcomes for:
Diabetes Care– Hgb A,C and LDL testing/management – Diabetic retinal exam
– Nephropathy screening – Blood pressure control Cardiac Care
– LDL testing/management
– Beta-blocker treatment after heart attack Blood Pressure Control
COPD Management
– Systemic corticosteroids and bronchodilator therapy for exacerbations Decreasing the use of high-risk drugs
Focus on Seamless Transition
Everyone plays a role ensuring seamless transition:
67
Keystone VIP Choice Staff
Notify PCP/Medical Home of planned or unplanned
transition for admission and at discharge.
Contact members to verify plans, establish point of contact .
Provide Plan of Care
information to sending and receiving facility/provider, including changes at discharge.
PCP
Contact admitting physician to coordinate care.
After discharge, review and reconcile medications. After discharge from an inpatient behavioral health stay, follow up with behavioral health provider.
See the member at office visit post discharge.
Hospital
Send discharge summary/orders with medication list to Plan. Admitting Physician be available to speak with the Medical Home/PCP regarding member’s care needs.
Model of Care Evaluation
Keystone VIP Choice’s Model of Care is evaluated using several
data sources
:
Claims (medical, behavioral health, pharmacy) Authorizations
HEDIS reports
Member surveys (CAHPS, HOS) Practitioner and Facility surveys Provider workshops
Complaint and grievance analysis
Communicating the Plan of Care on Transition
The Transition Team collects and communicates information related
to a member’s transition from one health care setting to another:
69
Transition Team
With Member & Provider Input
Sends Updated Plan of Care
Medical Home/PCP Hospital/Facility/Agency Receiving the Member
Keystone VIP Choice– Claims
Keystone VIP Choice providers submit Medicare service claims
to the same address and payer id number.
•
Providers contractually have 365 days from the date of
service to submit claims.
•
Providers are encouraged to submit claims timely.
•
Resubmissions must be submitted within 90 days from the
date the original claim was processed.
Keystone VIP Choice– Claims
Providers may submit claims electronically through their current EDI
Vendor if that vendor contracts with Emdeon, or the provider may contract
directly with Emdeon.
•
Keystone VIP Choice Payer ID is 84223
•
Provider may submit Paper Claims to:
Keystone VIP Choice
Claims
P.O. Box 307
Linthicum, MD 21090-0307
Medicaid-only services and
appropriate
secondary payments (deductible,
coinsurance, etc.) should be sent to Pennsylvania Medicaid.
Electronic Data Interchange (EDI)
To transmit claims electronically, contact your EDI software vendor and provide the Keystone VIP Choice Payer ID: 84223.
– Arrange electronic claims submission through your EDI vendor or through Emdeon Provider Support at: (877) 363-3666
Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
– Simplifies the payment process by providing fast, easy and secure payments
– Reduces paper
– Eliminating checks lost in the mail
– Not requiring a change to your preferred banking partner
– Enroll through our EFT partner, Emdeon Business Services or sign up via our fast and easy links on www.keystonevipchoice.com
Keystone VIP Choice Payments and Remittance Advices
Initially, all providers will receive Keystone VIP Choice
payments and remittance advices hard copy.
Electronic Remittance Advices (ERA) and Electronic Funds
Transfer (EFT) are available. Please reference your latest
remittance advice for directions on enrolling in these
programs.
Keystone VIP Choice – Provider
Services
Provider Claims and Customer Service
Provider Services for Keystone and AmeriHealth– (800) 521-6007. Same number to reach all Pennsylvania products
Keystone Plans choose Option 1
Choose Option 1 for Keystone First. Choose Option 2 for Keystone VIP Choice.
Verify member eligibility, PCP assignment, obtain member ID # (Option 1)
Provider claims issue resolution or adjustments (Option 2)
Obtain and verify prior authorizations (Option 3)
Prescription drugs, prescription prior authorizations, and exceptions (Option 4)
Assistance in coordinating care (Option 5)
Provider Account Executives
Keystone VIP Choice prides themselves in having a provider representative
available to providers – an Account Executive.
•
Your Account Executive will provide on-site education, issue resolution, and
assistance with credentialing.
•
Keystone VIP Choice will communicate through on-site orientations, routine
site visits, provider workshops, letters, the Provider Manual, the provider
resource center on the website and provider newsletters.
•
A listing of Keystone VIP Choice Account Executives are available on our
website at www.keystonevipchoice.com
The Provider Manual
The Keystone VIP Choice Provider Manual is on our website at www.keystonevipchoice.com.
• The Provider Manual is an extension of your provider contract with Keystone VIP Choice
• Identifies key provider roles & responsibilities • Member rights & responsibilities
• The Keystone VIP Choice’s quality programs, credentialing & utilization management • Keystone VIP Choice’s Model of Care
• Claims protocols
Provider Marketing Compliance
The Centers for Medicare and Medicaid Services (CMS) is concerned with
provider marketing activities for the following reasons:
•
Providers may not be fully aware of benefits & costs and may inadvertently
misinform a member
•
Providers may confuse the member regarding their role as their health care
provider versus acting as a Keystone VIP Choice representative
•
Providers may face a conflict of interest
Acceptable Provider Marketing Practices
Examples of Acceptable Provider Marketing Practices
• Provide the names of Medicare Advantage Plan sponsors with which they contract and/or participate.
• Provide information and assistance in applying for the Low Income Subsidy (LIS).
• Make available and/or distribute Keystone VIP Choice marketing materials developed by Keystone VIP Choice.
• Refer patients to other sources of information, such as SHIPs, a Medicare Advantage plans marketing representative, the State Medicaid Office, local Social Security Office, CMS’
website at http://www.medicare.gov/ or 1-800-MEDICARE.
• Share information with patients from CMS’ website, including the “Medicare and You” Handbook or “Medicare Options Compare” (from http://www.medicare.gov), or other documents that were written by or previously approved by CMS.
Cultural and Linguistic Requirements
Our Cultural Competency program, has been built upon 14 of the national standards for Culturally and Linguistically Appropriate Services (CLAS), as set forth by the Federal Department of Health and Human Services.
As a provider of health care services who receives Federal financial payment through the Medicare and Medicaid programs, you are responsible to make arrangements for:
Standard 4 - Language assistance at no cost to patients/consumers
Standard 5 - Signage and written notices of interpreter services available at no cost Standard 6 - Use of qualified/certified interpreters and translators
Standard 7 - Translation of vital documents
Language assistance information should be at all points of contact and during all hours of operation.
Cultural and Linguistic Requirements
Providers are required to:
• Provide written and oral language assistance at no cost to Keystone VIP Choice members with limited English proficiency or other special communication needs, at all points of contact and during all hours of operation. Language access
includes the provision of competent language interpreters, upon request.
• Provide members verbal or written notice (in their preferred language or format) about their right to receive free language assistance services.
• Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents such as
patient information forms and treatment consent forms, must be made available in other languages and formats.
Available Cultural and Linguistic Services
We have an arrangement for participating Keystone VIP Choice providers to access telephonic interpretation at a discounted rate. For more information, please contact Provider Services for Keystone VIP Choice (800) 521-6007
Providers who are unable to arrange for translation services for a Limited English Proficiency (LEP), Limited Language Proficiency (LLP) or sensory impaired member should contact Member Services for Keystone VIP Choice (800) 450-1166 and a representative will help locate a professional interpreter who communicates in the member’s primary language.
Providers may request a full copy of Keystone VIP Choice‘s Cultural Competency Plan free of charge, or, access this information in the Provider Manual. For additional
information or to view the CLAS standards go to www.minorityhealth.hhs.gov. For language assistance services, contact us at (800) 521-6007 or go to
www.keystonevipchoice.com
.
Fraud, Waste and Abuse
Designed in accordance with federal rules and regulations, Keystone VIP
Choice’s compliance program is aimed at ensuring compliance with all
Medicare Advantage program requirements and preventing and detecting
activities that constitute fraud, waste and abuse.
Keystone VIP Choice has developed a Compliance and Fraud, Waste and
Abuse (FWA) online training program. The program includes:
• Compliance requirements • FWA policies and procedures • Investigation of unusual incidents • Implementation of corrective action
Keystone VIP Choice and has provider training materials available via its
website: www.keystonevipchoice.com.
Materials, which are available by contacting the Provider Network
Management team, include information regarding the following…
Fraud, Waste and Abuse
Fraud
“Fraud” is 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. The term includes any act that constitutes fraud under
applicable federal or state law. As applied to the federal health care programs
(including the Medicaid and Medicare programs), health care fraud generally
involves a person or entity’s intentional use of false statements or fraudulent
schemes (such as kickbacks) to obtain payment for, or to cause another to
obtain payment for, items or services payable under a federal health care
program. Some examples of fraud include:
•
Billing for services not furnished;
•
Soliciting, offering or receiving a kickback, bribe or rebate; or
•
Violations of the physician self-referral prohibition.
Fraud, Waste and Abuse
Waste
“Waste” means to use or expend carelessly, extravagantly, or to no purpose.
Abuse
“Abuse” is defined as provider practices that are inconsistent with generally accepted business or medical practice and that result in an unnecessary cost to the Medicaid or Medicare programs or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or
recipient practices that result in unnecessary cost to the Medicaid or Medicare programs. In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare and Medicaid programs. Some examples of abuse include:
• Charging in excess for services or supplies; • Providing medically unnecessary services; or
• Providing services that do not meet professionally recognized stand
ards.
Fraud, Waste and Abuse
False Claims Act
The Federal False Claims Act (FCA) is a federal law that applies to fraud
involving any contract or program that is federally funded, including Medicare
and Medicaid. Health care entities that violate the Federal FCA can be subject
to civil monetary penalties ranging from $5,000 to $10,000 for each false claim
submitted to the United States government or its contactors, including state
Medicaid agencies.
The Federal FCA contains a “qui tam” or whistleblower provision to encourage
individuals to report misconduct involving false claims. The qui tam provision
allows any person with actual knowledge of allegedly false claims submitted to
the government to file a lawsuit on behalf of the U.S. Government. The FCA
protects individuals who report under the qui tam provisions from retaliation that
might result from filing an action under the Act, investigating a false claim, or
providing testimony for or assistance in a federal FCA action.
Fraud, Waste and Abuse
Reporting and Preventing Fraud, Waste and Abuse
Compliance with state and federal laws and regulations is a priority of Keystone VIP Choice. If you or any entity with which you contract to provide services become concerned about or identifies potential fraud, waste or abuse, please contact:
• Keystone VIP Choice toll-free at (866) 833-9718; or you may also send an e-mail to the Medicare Compliance Officer at [email protected] to report potential FWA; or
• Inspector General: 1-800-HS-TIPS (800) 447-8477)
Report suspected Medicaid Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities by contacting:
Medicaid Fraud Control Unit
Pennsylvania Attorney General's Office 1600 Strawberry Square
Harrisburg, PA 17120 (717) 783-1481
