"05 - July 2009 Newsletter"
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