New Provider Orientation by HC120831111649


									              Provider Orientation


Learning Objectives

• Today you will learn:

   - Who CareCentrix is and how to work with us
   - Referral Process
      • Managed vs non-managed plans
      • Understanding the Service Authorization Form (SAF)
   - Provider Portal
      • How to submit initial authorizations, reauthorizations and add on
      • How to check authorization status
      • How to check claim status
   - Billing & Claims
      • Claim submission
      • Claims Reconsideration & Appeals
   - Contact Information and Feedback

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Home Care Benefits Management Process – “The Platform”

Program Components            Workflow

    Single Point-of-Contact       Physicians &
                                                         Discharge           Case Managers
1    to Coordinate Home-           Providers
        Based Services


                                           • Eligibility, Benefits & Authorization
2   Referral Management                    • Medical Necessity Review
                                           • Coordination of Care / Staffing

3        Management                   Home Health        DME/POS             Infusion

                                                                                       Consolidated

                                                       Claims Billing
4      Claims & Billing                                                                    Reporting
                                                                                           & Analysis
                                                    Medical Economics

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                                                                                                                            Referral Process
 Making a Referral: Service Specific Tips

                                           THH – Home Health                           DME/O&P                              Infusion

   Patient Homebound?                                                                       N/A                               N/A
Initial Auth Mandatory?**
      Re-authorization                       Plan Dependent                         Plan Dependent                     Plan Dependent
     Start of Care (SOC)                If changed, contact CCX.                If changed, contact CCX.         If changed, contact CCX.
                                      Changes must be approved by referring      Changes must be approved by   Changes must be approved by referring
                                                   physician                          referring physician                   physician

             Other                     Lab tests must be taken to                        Oxygen                  Provide height, weight,
                                        the lab specified by the              •Liter flow                        allergies, type of venous
                                             patient’s plan                   •O2 saturation w/ date             access and date/time of
                                                                                                                         next dose
                                          Routine supplies are                           CPAP                     Infusion providers must
                                      included in the cost of visit           •Sleep study or letter of          accept case “full-service”
                                                                              medical necessity                    meaning drug, skilled
                                                                              •MD order required for             nursing and supplies (per
                                                                              upgraded unit                                diem)

                                       Notify CCX immediately of                General Auth Guidelines
                                        additional supply needs
                                            -Authorization for
                                       additional supplies can be
                                         obtained through CCX
** Except for Magnolia Health Plan: DME items < $500 require no authorization
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                                                                                    Referral Process

  Making a Referral: “Managed”
    vs “Non-Managed” Plans
                             Managed (PHS+)                     Non-Managed (PHS)
Service Auth Form (SAF)     Indicates # of units           CCX will issue a “footprint”
                                authorized           authorization; SAF will indicate “0” visits
                                                      and the same “Start Date” and “Stop
  Re-authorization        Submit to CCX via portal                    Not Required
  & Add-on Services                                  -The auth number assigned during the
                                                     initial referral process will be used
 Eligibility & Benefits    CCX checks initial and               Provider Responsible
                                 ongoing             -Health Plan’s phone number for
                                                     verifying eligibility and benefits will be
                                                     included on the SAF
        Other                                           Provider is responsible for verifying
                                                          insurance plan’s authorization
                                                                                                        Managed Authorization

                                                                                      Example and Definition:

                                                                                      Managed CareCentrix referrals - You
                                                                                      should come back to the designated
                                                                                      Regional Care Center for re-authorization
                                                                                      (submit re-authorizations via the online
                                                                                      provider portal) or add-on services
                                                                                      unless defined otherwise. When
                                                                                      submitting a request for re-authorization
                                                                                      or an add-on service it is important to
                                                                                      provide the clinical justification for the

HCPC/Modifier combination                        If additional visits are needed provider
that must be used on claim                       must submit reauthorization request
                             Date of service     via online portal.
                             must fall between
                             above dates

                                                                   All paper claims must be
                                                                   sent to CareCentrix East
                                                                   Hartford CT but EDI is

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                                                              Authorization Form

                                                 Non-managed CareCentrix
                                                 referrals - You do not have to
                                                 come back to the Regional
                                                 Care Center for re-
                                                 authorization or add-on
                                                 services in which you are
                                                 contracted with CareCentrix
                                                 to provide. However, you are
                                                 expected to manage to the
                                                 patient's benefits and
                                                 authorization requirements as
                                                 stipulated by the insurance
                                                 carrier. This would include
                                                 ongoing re-verification of
                                                 eligibility and benefits.

Branch managed plans      Branch managed plans
have the same start and   have “0” units
stop date.                authorized.

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                                          Sample Fax Coversheet

Identifies in-network
supply provider for non-
routine supplies.          Make sure to use lab
                           of choice to
                           maximize member’s
Notifies you if PTA and
OTA are allowed by
member’s health plan
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Portal Training:

•   The CareCentrix portal is the way of
    submitting authorization and re-authorization
    requests to CareCentrix
     - And we’ll show you how to do that now
•   But the portal is much more than just a way
    to request an auth!
     -   View latest news & important announcements!
           •   Check the portal often to stay on top of the latest
     - Submit initial and re-auth requests
           • 24 x 7 x 365!
           • No waiting on the phone!
           • Faster auth turn-around time!
     - Check claim status
     - Check authorization status
     - Manage HomeSTAR patients
•   Please visit:

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                                                                                                              Billing & Claims

    Billing and Claims Submission
•    Format
      -   Electronic Claims submission is the preferred format (CMS 1500 forms only at present)
      -   Paper claims may be submitted on CMS 1500, UB-04
      -   Claims must be original, without erasures, strikeovers, or stickers

•    Timely filing
      -   45 days from time service was rendered
      -   Or, as determined by State law

•    *Claims must include the following*:
      -   Description of the service
      -   ICD9 Code
      -   Taxonomy number
      -   NPI number
      -   HCPC Code & Modifier as shown on your Service Authorization Form (SAF)

•    Current billing cross walk can be found at

      -   Find the CareCentrix service code and UOM (unit of measure) on your Service Authorization Form (SAF) and match to the
          above crosswalk to determine the correct HCPC/Modifier combination you must bill.

•    Coordination of Benefits (COB)
      -   Please click the PDF to the right for an overview of COB

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                                                                                                            Billing & Claims

Claims: Corrections & Appeals

• Is your payment not what you expected? Please follow our
  process for corrections and appeals:
                    •Verify that you billed the correct HCPC/Modifier combination found on your SAF, or using the
                    billing crosswalk
Self-diagnose the   •Ensure you have included all required clean-claim data elements
     Problem                 -For a complete list, please refer to and download our
                             Provider Manual or view the “Claims” section of the website

                    •Complete a Claim Reconsideration form and send to CareCentrix (see Provider Manual)
                             •Or call: 877-725-6525
                    •Claim reconsideration forms must be received within 45 days of date on EOP or as
                    required by law if longer
 Submit a Claim     •If reconsideration is not received within 45 days, your request can be denied for untimely
 Reconsideration    filing of a reconsideration
     Form           •Click PDF (at right) for a copy of the form, or go to
                    •If the payment issue is resolved in your favor, the payment will be adjusted and an
                    explanation of payment issued

                    •If payment issue cannot be resolved in your favor, you may send a claim appeal to our Appeals
                    Unit (see Provider Manual)
                    •A copy of the claim in question must be included with the CareCentrix Appeal Form
    Appeals         •Appeal must be received within 30 calendar days from the date we orally advised you or the
                    date of our communication indicating that your request for reconsideration was not be
                    resolved in your favor (or as otherwise mandated by state or federal law)
                    •Appeals received without a copy of the claim in question will be mailed back to the submitter

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                                                                                          CareCentrix Contacts
CareCentrix Contact Information: Know Where to Go
                                      Register for Portal & EDI
                   Register for the Provider Portal
           Register for EDI (electronic claims submission)

                          Portal Support           
                           EDI Support            

                   Initial Authorization Requests
                         Authorization Status
                     Re-authorization Requests
                           Add-on Services

                  Authorization Contact Numbers

                         Claim Questions
                           Claim Status
                           Appeal Status
                     Provider Resolution Team

                                Contract/Network Management
                       See Provider Manual  

                                Patient Financial Responsibility
                      Patient Services Team                      800-808-1902
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Contact Information
• Network Manager
   - Name
   - Phone
   - Email

• Network Coordinator
   - Name
   - Phone
   - Email

• We welcome your feedback!
   - Please take a moment to answer 6 quick questions and provide us your
     confidential and anonymous feedback on today’s orientation
   - Click:

     Thank you for choosing to participate in the CareCentrix provider network. We
      value the quality care you bring our patients, and will work hard to ensure that
                           your experience with us delights you.

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