05 - July 2009 Newsletter by laurarichert

VIEWS: 21 PAGES: 6

									                                           A PUBLICATION FOR
                                                    HEALTHCARE USA PROVIDERS


                                        NEWSLETTER      This newsletter is also available on our Web site: www.hcusa.org




                                                                            July 2009 Newsletter Volume 14, No. 5

                                            GENERAL NEWS
                                              AGEMENT


           SERVICE AREA EXPANSION                                                           H1N1 FLU
               PERRY COUNTY                                                                 UPDATE

HealthCare USA has expanded its service area into               HealthCare USA posted an update regarding H1N1
Perry County for Eastern Missouri. We are pleased               Flu with important information to the Web site at
to welcome Perry County Memorial Hospital and its               (www.hcusa.org). Please note HealthCare USA has
affiliated clinics to our statewide provider network.           made arrangements to cover both Tamiflu and
                                                                Relenza as recommended by the CDC for H1N1 Flu.

      MO HEALTHNET CONTRACT AWARD                               Providers, parents and members can access key
                                                                information regarding H1N1 Flu and other important
We are pleased to announce HealthCare USA has                   health and wellness topics via the KidsHealth link on
been awarded a new three-year contract with MO                  our Web site.
HealthNet which becomes effective October 1, 2009.
Thank you to all the providers who submitted letters
of support which we submitted as part of the bidding
process. We truly appreciate the collaborative nature
of the relationships we have developed with you in
the 14 years we have been doing business in the
State of Missouri.


        2009 FALL PROVIDER SEMINARS                                         JULY 2009 EDITION
                                                                      In this issue, you will find helpful
In order to help providers understand key changes in                  information on the following:
the new MO HealthNet contract, HealthCare USA will                      1. General News
be hosting provider seminars in all three regions
                                                                        2. Quality Spotlight
across Missouri.      Look for announcements and
details in our next newsletter.                                         3. Member Services
                                                                        4. Claims Corner
                                                                        5. Provider Relations




                                                                                                                  Page 1 of 6
                                          QUALITY SPOTLIGHT


                                    FOCUS ON PREVENTIVE HEALTH CARE

HealthCare USA and MHNet continue to work in               Providers Role: Talk to parents about the necessity
collaboration on a number of preventative behavioral       of continuous monitoring. Parent and/or caregiver
health programs. We recognize that many Primary            education about the importance of follow up care has
Care Physicians are the first line to identify and treat   been shown to have a positive impact on adherence
many mental/behavioral health concerns that affect         to follow up appointments and improved outcomes of
our members. We have developed our preventative            care. While educating parents may address one
mental health outreach efforts with this in mind. We       barrier to care, some parents may be resistant to
need your assistance to improve member                     regular appointments because of time constraints,
participation.                                             transportation issues and other barriers. Please
                                                           contact us if assistance to schedule an appointment,
Below is a brief description of our ADHD preventative      transportation or other barriers are identified.
behavioral health program: a collaborative effort
between HealthCare USA and MHNet.                          Our Role: Early identification of members receiving
                                                           medication management for ADHD followed by
                                                           educational materials and encouragement to
   Attention Deficit Hyperactivity Disorder                complete follow up appointments. We will offer
   Preventative Behavioral Health Program                  referrals to community resources and/or support
                                                           groups in addition to offering referrals to an in-
The National Institute of Mental Health (NIMH)             network behavioral health practitioner for those not
reports that attention deficit hyperactivity disorder      already in family or individual therapy. We will work
(ADHD) is the most commonly diagnosed disorder of          with the member to resolve barriers to completion of
children. It is estimated to effect 3-5% of school age     follow-up care.
children, or, on average, at least one child in every
classroom. For children who receive ADHD services          Your support for this program is important to us.
through HCUSA, we actively encourage their parents
to access available assistance and resources for           Please visit the website www.mhnet.com for more
treating a child with ADHD. Offering enhanced and          detailed information and to see other preventative
comprehensive services to children with ADHD as            health programs offered.       Additional member
well as their parents increases the efficacy of            education materials may be viewed and downloaded
treatment. This program is developed to promote            at    HealthCare    USA’s    KidsHealth   website:
early identification and increased member follow up        www.kidshealth.com
with the prescribing physician to ensure effectiveness
of their medication. Specific measures below:
                                                               MENTAL HEALTH SERVICES & BENEFITS
        Initiation Phase: Members ages 6-12 with an
ambulatory prescription dispensed for ADHD                 Providers should contact MHNet directly at 1-800-
medication to have one follow-up visit with                377-9096 to verify available mental health and
prescribing provider during the 30-day initiation          substance abuse (MH/SA) benefits and to access
period.                                                    MHNet network providers.

        Continuation and Maintenance Phase:                When making a referral for MH/SA services,
Members ages 6-12 who remained on ADHD                     providers should encourage members to sign a
medication for at least 210 days and who, in addition      Universal Consent Form to allow for communication
to the visit in the initiation phase, have at least 2      between the member’s primary care provider (PCP)
follow-ups visits with a provider within 270 days or 9     and mental health provider.
months after the initiation phase.



                                                                                                  Page 2 of 6
                                          MEMBER SERVICES



                                           BACK TO SCHOOL FAIRS


For close to a year HealthCare USA has been
planning our health and back to school events in all
three regions.

Last summer HealthCare USA hosted several
successful events from Kansas City to St. Louis.
Children’s services such as school and sports
physicals, lead testing, child identification, haircuts
and dental, speech, vision and hearing screenings
were offered. Food, fun and activities kept children
entertained while parents and grandparents took           The following are confirmed fairs, locations and
advantage of services such as mammograms, HIV             dates:
testing and total lipid panels.
                                                             Western
At the end of each event, children received a                § July 25, Truman Career and Technical
backpack filled with school supplies to start them off         Center; 9 a.m.-3 p.m.
on the right foot. And, best of all, services were
                                                             Eastern
offered at no charge!
                                                             § Aug. 1, The Dream Center, St. Louis (north);
                                                                10 a.m.-2 p.m.
What we need now are a few dedicated providers
                                                             § Aug. 8, Lyon-Blow Middle School (south);
who would be willing to volunteer their time and talent
                                                                10 a.m.-2 p.m.
at our events.
                                                             Central
If you are interested, please contact Daphne Terrill,        § Aug. 8, Union Hill Baptist Church, Callaway
1-314-444-7270 (St. Louis area); Julie Graves, 1-               County/Holts Summit, 10 a.m.-2 p.m.
816-460-4464 (Kansas City area); or Peggy                    § Aug. 15, Calvary Baptist Church, Columbia,
Thoenen, 1-573-681-5230 (Jefferson City and central             9 a.m.-2 p.m.
area).

Let’s help those less fortunate get a jump start on the      We are also co-sponsoring events with
2009-2010 school year!                                       community agencies in several other counties:
                                                             §   July 10, St. Peters, St. Charles County; 9-2
                                                             §   July 17, Troy/Wentzville, Lincoln County; 10-2
     IMPORTANT CONTACT INFORMATION
                                                             §   July 24, Union, Franklin County; 10-2
                                                             §   July 25, Ralls County, 12-3.
   Member Services:            1-800-566-6444                §   Aug. 7 Hillsboro, Jefferson County; 10-2
   Case Management                                           §   Aug. 15, Pike County, Bowling Green
          Requests:            1-800-882-9666                    Fairgrounds, 10-2
   Pre-Authorization Requests: 1-800-882-9666




                                                                                                Page 3 of 6
                                             MEMBER SERVICES



                                     MEMBER RIGHTS AND RESPONSIBILITIES

Member Rights
                                                             •   SERVICES,            FROM          OUT-OF-NETWORK
•   Each member is guaranteed the RIGHT TO BE
                                                                 PROVIDERS
    TREATED WITH RESPECT and with due
                                                             •   Each member will be PROVIDED WITH THE EXTENT
    consideration for his or her dignity and privacy;
                                                                 TO WHICH, AND HOW, AFTER-HOURS AND
•   Each member is guaranteed the RIGHT TO RECEIVE
                                                                 EMERGENCY          COVERAGE         ARE     PROVIDED
    INFORMATION ON AVAILABLE TREATMENT
                                                                 including:
    OPTIONS AND ALTERNATIVES, presented in a
                                                             •   What constitutes emergency medical condition,
    manner appropriate to the member’s condition and
                                                                 emergency services, and post stabilization services
    ability to understand
                                                             •   The fact that prior authorization is not required for
•   Each member is guaranteed the RIGHT TO
                                                                 emergency services
    PARTICIPATE IN DECISIONS REGARDING HIS OR
    HER HEALTH CARE, including the right to refuse           •   The process and procedures for obtaining emergency
    treatment and the freedom of choice among network            services, including the 911 telephone system or its
    providers                                                    local equivalent
•   Each member is guaranteed the RIGHT TO BE FREE           •   The locations of any emergency settings and other
    FROM ANY FORM OF RESTRAINT OR SECLUSION                      locations at which providers and hospitals furnish
    used as a means of coercion, discipline, convenience,        emergency services and post stabilization services
    or retaliation                                           •   The fact that the member has the right to use any
•   Each member is guaranteed the RIGHT TO                       hospital or other setting for emergency care.
    REQUEST AND RECEIVE A COPY OF HIS OR HER                 •   Each member will be PROVIDED THE POST
    MEDICAL RECORDS, and to request that they be                 STABILIZATION CARE SERVICES RULES
    amended or corrected                                     •   Each member will be PROVIDED THE POLICY ON
•   Each member is FREE TO EXERCISE HIS OR HER                   REFERRALS FOR SPECIALTY CARE and for other
    RIGHTS, and that the exercise of those rights does           benefits not furnished by the enrollee’s primary care
    not adversely affect the way the health plan and its         provider
    providers the state agency treat the member              •   Each member will be PROVIDED COST SHARING
•   Each member will be PROVIDED WITH NAMES,                     INFORMATION, if any, and
    LOCATIONS, TELEPHONE NUMBERS, AND ANY                    •   Each member will be PROVIDED INFORMATION ON
    NON-ENGLISH          LANGUAGES          SPOKEN      BY       HOW AND WHERE TO ACCESS ANY BENEFITS
    CURRENT CONTRACTED PROVIDERS in the                          that are available
    enrollee’s service area, including identification of
    providers that are not accepting new patients            Member Responsibilities
•   Each       member     will   be     PROVIDED      WITH
    INFORMATION ON GRIEVANCE AND FAIR                        •   Each member must PROVIDE, TO THE EXTENT
    HEARING PROCEDURES                                           POSSIBLE,    INFORMATION         NEEDED BY
•   Each member will be PROVIDED WITH THE                        PROVIDERS in caring for the member
    AMOUNT, DURATION, AND SCOPE OF BENEFITS                  •   Each member must CONTACT THEIR PRIMARY
    AVAILABLE UNDER THE CONTRACT to which they                   CARE PROVIDER AS THEIR FIRST POINT OF
    are entitled                                                 CONTACT when needing medical care
•   Each       member     will   be     PROVIDED      WITH   •   Each member must FOLLOW APPOINTMENT
    INFORMATION ON HOW TO OBTAIN BENEFITS,                       SCHEDULING PROCESSES and
    INCLUDING AUTHORIZATION REQUIREMENTS
                                                             •   Each member must FOLLOW INSTRUCTIONS
•   Each member will be PROVIDED WITH THE EXTENT
    TO WHICH, AND HOW, THEY MAY OBTAIN                           AND GUIDELINES GIVEN BY PROVIDERS
    BENEFITS INCLUDING FAMILY PLANNING


                                                                                              Page 4 of 6
                                              CLAIMS CORNER


             CLAIM CHECK INQUIRIES                            COORDINATION OF BENEFITS RECOVERIES

A claim inquiry may be submitted to the Customer            HealthCare USA has partnered with Health Management
Service Organization along with notes, documentation        Systems (HMS) to administer Coordination of Benefits
and specific details for the provider’s concern or reason   (COB) because we are required by State contract to
for request of review. The claim inquiry will be reviewed   ensure that Medicaid is secondary to all other insurance
by our medical claim review nurse (MCRN). The               coverage. If HMS identifies that HCUSA paid a claim for a
provider will receive a response to the inquiry in the      member who has other insurance coverage, HMS invoices
                                                            the primary carrier. When the primary carrier reimburses
form of a Remittance Advice (RA). The claim will either
                                                            us, we apply their reimbursement to the claim that we
be reprocessed to pay or denied again.
                                                            originally paid.
These inquiries should be attached to your claim and        These reimbursements are reflected on your Remittance
directed to:                                                Advice, initially as a backout and then as a reprocessed
               HealthCare USA                               claim. There will be no change in allowed amount;
               ATTN: Claim Inquiry                          therefore, your payment has not been affected by the
               P.O. Box 7090                                posting of the other carrier’s reimbursement. If you have
               London, KY 40742-7090                        questions regarding any COB recovery on your
                                                            Remittance Advice, please contact Claims Customer
If the claim is upheld by the MCRN, the provider can        Service.
initiate a complaint using HealthCare USA’s Provider
Complaint, Grievance and Appeal process. Providers
should send in the claim and a letter from the physician
stating why they disagree. The letter along with the
                                                                         BILL ABOVE LIST UPDATE
notes and documentation can be directed to:
                HealthCare USA                              The HealthCare USA Bill Above List was updated to add
                ATTN: Appeals                               several adult immunization code. The updated list was
                P.O. Box 7091                               mailed to capitated PCP providers with the June capitation
                London, KY 40742-7091                       checks and summaries. Please visit
                                                            www.directprovider.com or contact your provider relations
                                                            representative if you did not receive the updated copy.
 CODING CHANGES FOR EYE EXAMS, CONTACT
  LENS EVALUATIONS AND NON-STANDARD
                LENSES

Please review the Optometrist and Optician Service                      IMPORTANT INFORMATION
Bulletin Volume 31, Number 41 which was posted to the
MO HealthNet Web site:                                          Claims Customer Service:        1-800-295-6888
(http://dss.mo.gov/mhd/providers/pdf/bulletin31-                EDI Claim Submission:
41_2009apr22.pdf).
                                                                        Gateway EDI Payor ID =          00550
HealthCare USA updated our claims systems to                            Emdeon Payor ID =               25143
require the new coding as described in this bulletin.
Claims submitted with the invalid optical S-codes for
dates of service on or after June 15, 2009 will not be
allowed for payment.


                                                                                             Page 5 of 6
                                           PROVIDER RELATIONS


         PROVIDER ACCESS GUIDELINES                              PROVIDER MANUAL UPDATE -- SECTION II, F
                                                                       PARTICIPATING HOSPITALS
Scheduling Appointments and Waiting Times
The following access and availability standards must be        Please be advised page 8 of the HealthCare USA
provided by all participating providers:                       Provider Manual has been updated to reflect the
MEDICAL SERVICES                                               termination of the HCA Midwest Health Systems
                                        ACCESS/                hospitals. Please visit our website at www.hcusa.org
APPOINTMENT TYPE                        APPOINTMENT            to download a copy of the replacement page or
                                        STANDARD               contact Provider Relations at 1-800-213-7792 ext.
Emergent                                Immediately            7240.
Urgent care appointments for illness
injuries which require care
immediately, but do not constitute
emergencies, (e.g., high temperature,   Within 24 hours          PROVIDER MANUAL UPDATE -- SECTION VIII
persistent vomiting or diarrhea,                                CLAIMS AND REIMBURSEMENT PROCEDURES
symptoms which are sudden or
severe onset but which do not require
emergency room services)                                       It is not necessary to submit corrected claims with all
Routine care, with symptoms,            Within 1 week or 5     original claim lines. Your corrected claim should be
appointments (e.g., persistent rash,    business days,         clearly identified as “corrected” and we will reprocess
recurring high grade temperature,       whichever is           the original claim lines with the changes on your
nonspecific pain , fever)               earlier                corrected claim.
Routine care appointments without
                                        Within 30 calendar
symptoms (e.g., well child, routine                            In turn, your corrected claim will process as
                                        days of request
physical exams)                                                “duplicate.”
MATERNITY CARE
CATEGORY (INITIAL
                             ACCESS/
                                                                     CONTACTING PROVIDER RELATIONS
PRE-NATAL CARE
                             APPOINTMENT STANDARD
SERVICES                                                       HealthCare USA maintains a strong commitment to
Members within their first   Within 7 calendar days of first   meeting the needs of our providers. In order to
trimester                    request                           accomplish this, a provider relations representative is
Members within their         Within 7 calendar days of first   assigned to both primary and specialty care providers in
second trimester             request                           certain geographic areas. This process allows each
Members within their third   Within 3 calendar days of first   office to become familiar with its representative and
trimester                    request                           form a solid working relationship.
                             Within 3 calendar days of
                             identification of high-risk       Your provider relations representative visits or phones
Members identified with      factors by HealthCare
                                                               you to ensure that your day-to-day experience with
high-risk pregnancies        USA or maternity care
                                                               HealthCare USA and our members is smooth. We are
                             provider or immediately if an
                             emergency exists                  available to meet with office staff or providers upon your
                                                               request.
MENTAL HEALTH AND SUBSTANCE ABUSE
SERVICES                                                       To contact your local provider relations representative,
                     ACCESS/                                   please call HealthCare USA at:
CATEGORY
                     APPOINTMENT STANDARD
Emergent                     Immediately                       Central Missouri – 1-800-625-7602
Aftercare appointments       Within 1 week or 5                Eastern Missouri – 1-800-213-7792
                             business days after               Western Missouri – 1-866-613-5001
                             hospital discharge,
                             whichever is earlier.



                                                                                                Page 6 of 6

								
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