CHPW PRESENTATION
2016 Updates and Refresher Course
About
CHPW
In 1992, Washington’s local Community Health Centers voted to create a
not-for-profit managed care company —
Community Health Plan of Washington
.
Our plan membership grew from 14,000 members in 1993 to over 300,000
currently.
Our network includes:
•
21 Community Health Centers that operate more than 125 clinic sites
•
More than 2,600
primary care providers
•
More than 14,000 contracted medical specialists
CHPW
Lines of Businesses
Washington Apple Health, continues to expand coverage in 2016 to individuals and families who have incomes below 138% of the Federal Poverty Level (FPL).
Our affordable Medicare Advantage HMO plans provide members valuable extended coverage and services.
Together with our valued and committed contracted Providers, Community Health Plan of Washington is serving many members with Washington Apple Health!
CHPW serves Washington Apple Health members statewide except in the following nine counties:
Clallam, Columbia, Garfield, Jefferson, Klickitat, Lincoln, Mason, Skamania, Whitman
http://www.hca.wa.gov/medicaid/Pages/index.aspx
For more information on WA Apple Health, go to:
Preventive care is CHPW’s focus. CHPW covers 100% of the following services:
• Bone Mass Measurements
• Colorectal Screening Exams
• Immunizations
• Mammograms
• Pap Smears and Pelvic Exams
• Prostate Cancer Screenings
The following slides covers our plan types and benefit highlights; for more information visit our Medicare Advantage (MA) website at:
Medicare Advantage (MA) Plan Options:
CHPW MA Plans vary by service area
(county).
To enroll, member must reside in one of
our service areas.
Note:
Plan
014
in 2016 was Plan 005 in
prior years.
Plans and Benefit Highlights:
Plan Highlights
$0 primary care copay
$40 specialty care copay
$0 copay for diabetic supplies
Up to $100 every two years for supplemental eyewear
Up to $500 per year for supplemental dental services
$0 copay for acupuncture visit
Plan Highlights
$0 monthly premium
Up to $100 every two years for supplemental eyewear
Up to $900 per year for supplemental dental services
$0 copay for acupuncture visit
Plan Highlights
$0 primary care copay
$40 specialty care copay
$0 copay for diabetic supplies
Plans and Benefit Highlights:
Plan Highlights
$0 primary care copay
$40 specialty care copay
$0 copay for diabetic supplies
Up to $100 every two years for supplemental eyewear
Up to $500 per year for supplemental dental services
Plan Highlights
$10 primary care copay
$45 specialty care copay
$0 copay for diabetic supplies
Up to $100 every two years for supplemental eyewear Up to $250 every year for supplemental dental with optional rider
Vision
Service Plan (VSP)
Community HealthFirst™ Medicare Advantage has vision benefits through VSP:VSP administers the Plan and Vision Benefits on behalf of CHPW, including:
• Claims processing
• Quality
• Credentialing
• OON provider services
• Data/reporting
CHPW’s Washington Health Benefit Exchange Plan
Bronze metal plan will be discontinued on December 31, 2015; CHPW will not offer Bronze plans in 2016. Other updates and changes are as follows:
• Gold and Silver metal plans will be renewed effective on January 1, 2016 in the 14 county service area only
• Silver plans with Cost Sharing Reduction (CSR) have different copays and coinsurance amounts in 2016
Community
HealthEssentials
Plus
2016
Plan Changes
Important facts:
• CHPW partnered with First Choice Health (FCH) to serve as the Preferred Provider Organization (PPO) network and Third Party Administrator (TPA) for Community HealthEssentials commercial products.
• November 1, 2015 - Open Enrollment Begins for 2016
• January 1, 2016 - 2016 coverage begins
• January 31, 2016 - Open Enrollment Ends for 2016
Community
HealthEssentials
Plus
2016
Plan Changes
Contact Guide
WA Apple Health (Medicaid) and Community HealthFirst (Medicare Advantage) Customer Service: 800 440-1561 (Apple Health)
Customer Service: 800 942-0247 (Medicare Advantage)
Medical Management: 800 336-5231
Email: customercare@chpw.org
Website: www.chwp.org
Community HealthEssentials (Health Exchange) Administered by First Choice
Customer Service: 800 930-0132
Medical Management: 800 808-0450
Website: www.fchn.com
Contact Guide
Provider Relations Contacts:
Carmen Switzer– Provider Relations Administrator (Eastern WA) – also covering: Providence Health System (Professional), DME, HME and Ancillary state-wide.
Email:carmen.switzer@chpw.org
Phone: 206 613-8827
Carol Wallingford – Provider Relations Representative (Eastern WA)
Email:carol.wallingford@chpw.org
Phone: 206 652-7229
Douglas Sheldon – Provider Relations Administrator (Western WA) – also covering: Providence Health Systems (Facility) state-wide.
Email:douglas.sheldon@chpw.org
Contact Guide
Appeals & Grievances:Provider and Member appeals and grievances may be mailed, faxed or emailed for all lines of businesses:
Address: 720 Olive Way, Ste 300 – Seattle, WA 98101 Fax: 206 613-8984
Email: appealsgrievances@chpw.org
Claims Investigative Unit (CIU)
After attempts to resolve issues through Customer Service have been exhausted and to address complicated and escalated claims issues, as outlined on CHPW’s contact guide, Providers could contact the CIU directly:
Email: cs.claimsdistribution@chpw.org
Contact Guide
CredentialingFor credentialing status, Provider could contact:
Phone: 206 613-8977
Email: provider.credentialing@chpw.org
Provider Data Services (PDS)
Contact PDS for the following:
• Add New Providers
• Provider Terminations
• Provider/Clinic/Facility Address Adds/Changes/Terminations
• Tax ID Updates & Changes
Contact Guide
Electronic Data Interchange (EDI)CHPW supports several Electronic Transactions, i.e., 270, 271, 276, 834, 835 and 837. To enroll or inquire:
Email: edi.support@chpw.org
Provider Relations welcomes input and suggestions from Providers. If you have ideas that might improve our Contract Guide; to make it more user friendly, etc., please do not
hesitate to contact:
CHPW Provider Directory
To access our Provider Directory, including
Mental and Behavioral Health
Providers, please go to:
http://chpw.org/provider-search/
From website: Steps to find a Mental or Behavioral Health Provider:
Uncheck this box and click here:
Enter Zip, City or County here and enter Behavioral or Mental here:
Timely
Filing
&
Claims
Submission
Timely Filing = 365 days from Date of Service
Questions/ Claims Status:
WA Apple Health Customer Service 1 (800) 440-1561
Where to Send Claims
Medicare Advantage Customer Service 1 (800) 942-0247 Paper Claims: CHPW Claims PO Box 269002 Plano TX, 75026-9002
Electronic Claims Submission: Availity Payor ID: CHPWA
E
lectronic
Transactions
CHPW supports the following Electronic Transactions:270: Eligibility, coverage or benefit inquiry
271: Eligibility, coverage or benefit information
276: Health care claim status report
277: Health care information status notification
834: Benefit enrollment and maintenance
835: Health care claim payment advice
837: Health care claim
ACH payments: Automated clearing house (ACH) payments are electronic payments often referred to as direct deposit or electronic funds transfer (EFT).
Plan Authorized Referral
CHPW requires a Plan Authorized Referral as follows:
• Non-Par Specialist will always require a Plan Authorized Referral.
• Contracted Primary Care Provider/Clinic – member presents to your clinic, and they are not assigned to your organization, including an Urgent Care (billed with POS 11) or After Hours clinic – your group would need to request a Plan Authorized Referral from CHPW prior to rendering services.
• Non-Par Primary Care Provider/Clinic will always require a Plan Authorized Referral from CHPW.
The CHITA form is what should be used to submit a request for a Plan Authorized Referral – fax to
Apple Health (206) 613-8873 or Medicare Advantage (206) 652-7065. Preferred method to request a Plan Authorized Referral is through our Care Management Portal (JIVA).
Note: CHPW does not issue retro-referrals, thus a referral must be obtained prior to rendering the service. If not obtained, claims will deny correctly. Providers have appeal rights; however, if
Plan Authorized Referral
http://chpw.org/for-providers/documents-and-tools/
For other forms and tools, please go to
www.chpw.org:
From the Home Page: Click “For Providers
Click “Forms and Tools”
or copy/paste the following link to your browser:
Prior Authorization (PA) Requests
Providers could request Prior Authorizations one of two ways as follows:
•
Complete and submit a CHPW Prior Auth form via fax to:
--Apple Health (Medicaid) 206 613-8873
--Community HealthFirst (Medicare Advantage) 206 652-7065
•
Submit requests through CHPW’s care management portal (JIVA)
Prior Authorization (PA) Requests
Question: Customer service advises the provider that a prior authorization is not required. What is the most useful information to document or note in your system in the event a PA denial is received?• Request a call Reference number.
• Document the date and time.
The above information should be included in your appeal.
State in your appeal that you were advised by CSR that a PA for the attached denial was not required and include call reference number, date and time. CHPW will pull the call script and if the call supports your appeal, the denial may be overturned.
Prior Authorization (PA) Requests
Question: What is CHPW’s standard response time for PA requests?CHPW follows Medicare and Medicaid guidelines as follows:
Medicaid (Apple Health)
Standard PA Requests: 5 days – 14 days Urgent PA Requests: 24hrs - 72hrs
Medicare Advantage (Community HealthFirst)
Standard PA Requests: 14 days – 28 days Urgent PA Requests: 72hrs – 14 days
Turnaround times are extended if additional information is required. CHPW’s policy is to readily request additional information after the initial request is received. To avoid
Prior Authorization (PA) Lists
Question: Is CHPW able to update their prior authorization list to include pharmacy J codes?
CHPW’s PA list includes which drugs require a prior authorization.
CHPW’s code driven prior authorization list is another source; however, is not a complete list and was designed to be a provider “help list”. CHPW recommends that providers use the hard copy PA list as a primary tool found here: http://chpw.org/for-providers/documents-and-tools
If the drug in question is related to a drug on the hard copy PA list and the code is not found on the code driven PA list, a prior authorization request is suggested.
Please note that providers will be more familiar with specific drugs than CHPW Customer Service Reps, thus it is best to submit a PA request if you are uncertain if it requires a PA.
Prior Authorization (PA) Requests
Providers could request Prior Authorizations one of two ways as follows:
•
Complete and submit a CHPW Prior Auth form via fax to:
--Apple Health (Medicaid) 206 613-8873
--Community HealthFirst (Medicare Advantage) 206 652-7065
•
Submit requests through CHPW’s care management portal (JIVA)
To access CHPW’s PA List and Code Look Up List, go to:
www.chpw.org -- from Home Page, go to:
• For Providers
• Prior Authorizations
http://chpw.org/for-providers/prior-authorization-and-medical-review/
To access CHPW’s PA List and Code Look Up List, go to:
www.chpw.org -- from Home Page, go to:
• For Providers
• Prior Authorizations
http://chpw.org/for-providers/prior-authorization-and-medical-review/
Prior Authorization Form
http://chpw.org/for-providers/documents-and-tools/
For other forms and tools, please go to
www.chpw.org:
From the Home Page: Click “For Providers
Click “Forms and Tools”
or copy/paste the following link to your browser:
PA Summary of Changes
http://chpw.org/for-providers/documents-and-tools/
For other forms and tools, please go to www.chpw.org:
From the Home Page: Click “For Providers
Click “Forms and Tools”
or copy/paste the following link to your browser:
PA Summary of Changes
http://chpw.org/for-providers/documents-and-tools/
For other forms and tools, please go to www.chpw.org:
From the Home Page: Click “For Providers
Click “Forms and Tools”
or copy/paste the following link to your browser:
Balance
Billing
Providers may not bill members for co-payments, coinsurances, deductibles or covered
services for the following lines of businesses:
Washington Apple Health
MA Special Needs Plan (014)
Balance
Billing
• Providers must accept payment by CHPW as payment in full.• Balance billing is not permitted unless the provider and member fully complete and sign an HCA 13-879 form--Agreement to Pay for Healthcare Services. See WAC and HCA Memo in final bullet below for additional information.
• Services must be rendered within 90 days from signing the HCA 13-879 form, otherwise a new form must be completed and signed.
• The HCA 13-879 form must be translated into the member’s primary language if he or she has limited English proficiency, and if necessary, an interpreter must be provided for the member. If an interpreter is used to complete and sign the form, the
Balance
Billing
Special Needs Plan (SNP)
SNP members should not be billed, as they are dual covered by Medicare and Medicaid.
When a member presents to your clinic or hospital with a CHPW Medicare Advantage ID card with a Group 014 plan type, the member should be registered in your billing system as follows:
• Community HealthFirst™ as primary • Medicaid (DSHS FFS) as secondary
Provider
Portals
Health Information Portal (HIP)
Registered users have access to the following information:
• Eligibility and Benefit Details
• Member Rosters
• View Referrals & Authorizations
• View Claim Status
Once registered, providers can access HIP through a single sign-in at:
• OneHealthPort, or
Provider
Portals
CHPW JIVA Care Management Portal
The portal is the preferred method for you to submit and track all Care Management requests.
Request or check the status of the following:
• Eligibility/Referrals/Prior Authorizations
• Notify CHPW of Inpatient Admissions
To register for JIVA, contact:
Access
Standards
Primary
Care
&
Pediatric
Primary Care
• Schedule routine/preventive visits within 30 calendar days.
• Schedule an urgent visit within 24 hours.
• Schedule transitional care visit within 7 calendar days after discharge from
inpatient/institutional care facility.
Behavioral
&
Mental Health
• Provide non-life threatening emergency care within 6hrs.
• Schedule transitional care visit within 7 calendar days after discharge from
inpatient/institutional care facility.
• Schedule an urgent care visit within 48 hours.
Specialty
Access
Community Health Plan of Washington wants to know if our providers are experiencing barriers with referring to Specialist.
If our providers need assistance with Specialty access, please go to www.chpw.org, click For Providers, Tools and Resources and click on the following on-line form:
Specialty Access Assistance Request
The on-line form will give you the opportunity to answer the following questions:
• What specialty or specialties are you having access issues with?
• In your opinion, what is causing the issue(s)?
Culturally and Linguistic Appropriate
Service (CLAS)
CHPW supports providers in meeting CLAS standards and meets them ourselves by:
1. Training on key items, like the standards and tools we recommend for good care.
2. Resources to use with CHPW members in need of language assistance. 3. How to gain additional resources on CLAS and culturally competent care.
A complete training program on CLAS standards could be found here:
http://chpw.org/for-providers/training/. This is a mandatory training program for providers.
Language Assistance
CHPW interpretation services are available:
– Apple Health: The Health Care Authority’s vendor provides this service at (800) 535-7358.
– Medicare: CHPW provides this service at (866) 998-0338 with the following log in:
• Enter Account Number: 14767
• Enter PIN Number: 0044
Provider Training and Education Programs
Community Health Plan of Washington offers on-line Provider Orientation and Training programs. Some programs are mandatory and others are optional. Following are some of our training programs:
Green Initiative
CHPW is working on creating a culture of environmental responsibility; an enterprise-wide strategy to reduce paper and encourage more self-service among CHPW Staff, Providers, and Members.
How Provider’s can help:
• If you receive 835’s, you could request that CHPW turn off paper remittance advices. If you are not enrolled to receive 835’s,
please go to: http://chpw.org/resources/multipayer_era_835_enrollment.pdf
• Many providers prefer auto-recoupments who also receive refund letter requests from CHPW. If you receive refund letters and you have no use for them, you could request that CHPW turn off the submission of refund letters.
Green Initiative
Please email your Provider Relations contact directly or Provider.Relations@chpw.org to make your “green” request today! With your request, please share your ideas on how we can be more environmentally responsible.
A forest area the size of 20 football fields will be lost for paper production use alone. In the last year, logging in the Southeastern U.S. resulted in a loss of land about the size of New Jersey (5 million acres). In fact, the area of natural pine forest there has declined in size from 72 million acres in 1953 to 33 million acres in 1999. This is where most of the trees used to make paper come from (an astonishing 26% of the world's supply, to be exact), and it's clearly in critical danger.
Thank you to our Providers who have
already sent in your requests to
If your patient would like to:
• Determine eligibility for healthcare coverage
with CHPW, or
• Change their health plan to CHPW.
….your team could use the Plan Change Form and fax the completed form to 206 652-7087 for
processing.
For a copy of this form , please contact your Provider Relations Administrator or
Representative directly; or email
