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					    Health Net Federal Services
        TRICARE Service Center (TSC) &
Beneficiary Counseling & Assistance Coordinator
              (BCAC) Interaction
Who Is Health Net, Inc.

• One of the nation’s largest publicly traded managed
  health care companies (NYSE Symbol: HNT)
• Health Net’s HMO, insured PPO and government
  contracts subsidiaries provide health benefits to
  approximately 6.5 million individuals
• Comprehensive behavioral health (MHN) and
  pharmacy benefit management subsidiaries
• 20+ years delivering health care coverage
• 17+ years supporting military families through the
  delivery of both CHAMPUS and TRICARE
Health Net Federal Services Overview

• Nearly 3 million TRICARE eligible beneficiaries in the
  North Region
• Nearly 1800 associates plus our partners
• Operations in 32 states
   – 23 states and DC in TRICARE North Region
• VA business
   – National PPO Network
   – 19 Community Based Outpatient Clinics
   – National DRG Audit and Recovery Services
A Day in the Life of Health Net…

• 2,000    TRICARE Service Center walk-ins

• 2,100    Enrollment transactions

• 20,000   Phone calls to 1-877-TRICARE

• 4,200    Referral and authorization requests

• 50,000   Provider claims received
Communication & Coordination

• Communication is an essential component
  between successful HNFS, MTF and BCAC

• Coordination via monthly meetings ensure
  successful implementation of MTF and HNFS

  •Simple flow of information at all levels
  •“Open Door Policy” at TSC
  •Team approach to solve issues
  •Realize subject matter experts, from both
  HNFS and MTF; utilize their talents for certain
 – Use team approach, instead of “Us” versus
    • Successful communication occurs when HNFS and MTF
      staff view themselves as one team
    • BCAC and TSC Staff work closely together on potential
      beneficiary problems
    • Community Representative, BCAC and TSC Manager
      work to develop briefing opportunities/topics
    • Unilateral “Open Door Policy” between MTF and HNFS
    • Positive recognition of “job-well done”; highlighting
      individual and team accomplishments, often shared
      between MTF and HNFS in group settings
Role of TRICARE Service Center

• Enrollments: PCM changes, acceptance of enrollment
  fees, provide provider lists
• Claims correction: (when appropriate), EOB
  explanation, assistance with debt collection issues
• Explanation of benefits: customer interaction,
  community briefing, printed material, TFL guidance
• Authorization/Referrals: Program process education
  to beneficiaries, civilian network providers. Provide
  copies of approved ASAP/STAT/Urgent requests
TSC – What Do We Do

   TSC Associate           Community Rep.                     RMCL
Assist walk-in            Educate Network and        •Educate MTF providers
customer (Provider,       MTF Providers with:        on Authorization and
Nurses, Beneficiaries):   •Claims, Policy, Recruit   Referrals process
•Benefits; MTF/TRICARE    Assist RMCL - with any     •Work closely w/ MTF
Policies                  and all provider issues    RMC staff on Authorization
                                                     and Referrals
•Claims; Enrollment       Conduct Briefings -        •Assist Community Rep.
Payments                  (TAP, PRIME class,         On provider visits (if
                          Welcome/INDOC, etc.,)      problems with Auth/Ref)
•Authorization and        Assist TSC – Walk-in       •Facilitate CLR process
Referrals; Information    beneficiaries              with civilian providers
Working Together
           BCAC to TSC                        TSC to BCAC
•   Question on enrollment         •   MTF procedures
•   Question on Ref/Auth           •   Dental – material request
•   Covered Benefit verification   •   Potential problem patient
•   Provider Questions – Status    •   CHCS inquiry – verify if
•   Potential problem patient          patient data in MTF system
•   Dental (medical)               •   Joint briefings
•   Claims if extreme              •   Issues concerning patient
•   Joint briefings                    complaints
BCAC – Customer Service POC

BCAC/DCAO Services:
• BCAC/DCAO Priority Phone Line: 800.929.9220
• BCAC/DCAO Priority Fax Line: 888.250.4510
• BCAC/DCAO Correspondence Address:
     North Region BCAC/DCAO Support Team
     P.O. Box 870146
     Surfside Beach, SC 29587-9746
             PGBA, LLC
             Presentation For

Communications and Customer Service
              August 2005

•   Introduction
• functionality
•   BCAC and DCAO access to®
•   What’s available for a BCAC and DCAO
•   North Region service contacts
•   Closing remarks/questions
•   PGBA, LLC is a subsidiary company of
    BlueCross BlueShield of South Carolina
•   Subcontractor for claims processing,
    claims customer service, fiscal
    management and information system
     • Health Net Federal Services for
       the North Region, and
     • Humana Military Health
       Systems for the South Region
•   Our TRICARE offices are in Columbia,
    Camden, Florence and Surfside Beach,
    South Carolina
•   Health Net, partnered with PGBA, is
    delivering a new level of excellence to
    North Region customers

                                                  PGBA serves the
                                              TRICARE North and South
What’s available at myTRICARE?
TRICARE North Region Tools

• Electronic Funds
• Revenue Codes with
  Valid HCPCS Codes
• 2005 State Prevailing
  Rates Functionality
    How Does a BCAC and DCAO Gain Access to This

•    A PGBA RACF-ID with Web
     access is required for access to
     our secure Web site.
•    Select Register now located in
     the left navigation of the
     myTRICARE Web site.
How Does a BCAC and DCAO Gain Access to This

1. Select Are you a
   TRICARE government
2. Read and accept the
   terms and conditions
How Does a BCAC and DCAO Gain Access to This

3.   If you do not already have
     a PGBA RACF -ID or if you
     need to update your RACF-
     ID for access to our Web
     site, select North Region
     Government Agent
How Does a BCAC and DCAO Gain Access to This

4. Complete the form and
    return to Health Net
    Federal Services (address
    is included on the form).
 How Does a BCAC and DCAO Gain Access to This

When notified
by Health Net,
you may sign
  in with your
 ID username
and password
(your RACF-ID is
 your username)
Government Agent Secure Home Page
Obtain Patient Information

• To get patient
   - Sponsor’s SSN
   - Patient’s date of
   - Eligibility date
Patient Information

• Patient information
   - Eligibility
   - Sponsor’s Status
   - Enrollment region
   - PCM name
   - Deductible/cat
   - Other health
Check Claim Status

• To check claim
   - Sponsor’s SSN
   - Patient’s date of
   - Provider’s Tax ID
   - Date of service
Claim Summary

• View all claims for
  selected date(s) by
   - Completed
   - In process
   - Returned/
• View Details
Claim Details

• Claim details
   - Dates of service
   - Provider
   - Billed amount
   - Payment amount
   - Check number &
   - Patient’s
      (deductible, cat
      cap, OHI)
   - View/print TEOB
TRICARE Explanation of Benefits

• View detailed claim
• Print TEOB
Search for Authorizations and Referrals

• To view Auths and
   - Sponsor’s SSN
   - Patient’s date
     of birth
   - Provider’s tax
     ID (optional)
   - Date range or
Authorization and Referral Summary

• Auths and
  Referrals include:
   - Authorization
   - Dates of
   - Place of
   - Decision
   - Servicing
Authorization and Referral Details

• Auth and Referral
  Details include:
   - Requested
   - Decision reason
   - Approved
     procedure, units
     & frequency
   - Servicing
   - Referring
   - Facility
AskUs a Question

•   To AskUs a question:
     - Select AskUs on
       any page or the
       tab at the top to
       send a secure,
       question to
       customer service
     - Receive a prompt
       answer in your
myTRICARE Mailbox

• To view answers to
  your questions in
  your secure mailbox
   - Select PGBA
   - Search mail by
   - Save mail to Old
     Mail folder
   - Move mail to
     Deleted Mail
BCAC/DCAO Service Contacts
North Region General Contact Information

Address To                 FAX (Best choice)   Mail                            Type

TRICARE Claims             Not applicable      PO Box 870140                   All paper claims
                                               Surfside Beach, SC 29587-9740
TRICARE Claims             888-432-7077        PO Box 870141                   All correspondence about
    Correspondence                             Surfside Beach, SC 29587-9741          claims
Auth Appeals               888 881-3622        PO Box 870142                   To appeal an authorization for
                                               Surfside Beach, SC 29587-9742         care denial
Claims Appeals             888 458-2554        PO Box 870148                   To appeal a claim processing
                                               Surfside Beach, SC 29587-9748         denial
Enrollment                 With payment:       PO Box 870143                   New beneficiary Prime
                           888 299-4114        Surfside Beach, SC 29587-9743        enrollment or changes to
                           Without payment:                                         existing enrollment or
                           888 299-4145                                             PCM
PGBA Provider Management   888-250-4355        PO Box 870156                   Non-network provider
                                               Surfside Beach, SC 29587-9756        certification
HNFS Provider Management   888 244-4025        PO Box 870145                   Network provider contracting
                                               Surfside Beach, SC 29587-9745
North Region General Contact Information

Address To                     FAX (Best choice)   Mail                            Type

Authorizations and Referrals   888 299-4181        PO Box 870144                   Request medical authorization
                                                   Surfside Beach, SC 29587-9744   or referral to specialty care

PGBA Priority                  888-250-4510        PO Box 870146                   BCAC/DCAO, TMA and other
                                                   Surfside Beach, SC 29587-9746   priority issues

TRICARE Finance                888-432-7077        PO Box 870153                   Refund requests, recoupments,
                                                   Surfside Beach, SC 29587-9753   offsets

Program Integrity              888 881-3644        PO Box 870147                   Fraud/abuse alert and
                                                   Surfside Beach, SC 29587-9747   prevention
     Service Contacts – BCAC & DCAO

For PGBA routine BCAC service (Monday – Friday, 8 am – 5 pm Eastern and Central time zones):

PGBA Regions                                                       BCAC Phone                            BCAC FAX

TRICARE North Region Priority                         (800) 929-9220                           (888) 250-4510
PO Box 870146                                                                                  (This is the best way to send
Surfside Beach, SC 29587-9746                                                                  information!)

 Important: These numbers are reserved for BCAC use only. Please do not disclose to beneficiaries or providers.
     Priority Issues – BCAC & DCAO

Please call the following people directly only if you experience problems with PGBA routine BCAC service:

 PGBA Regions                                            BCAC Priority Person                    BCAC Priority Phone

 TRICARE North Region                             Tammy Davis, Manager                 (843) 650-6100 ext. 17722

 TRICARE South Region                                                                  (843) 736-0040

 Important: These numbers are reserved for BCAC use only. Please do not disclose to beneficiaries or providers.
Closing Remarks

•   PGBA is a customer-driven organization relentlessly focused on
    innovation and continuous improvement
•   We are proud to work with Health Net Federal Services to deliver
    outstanding service to TRICARE North Region customers
•   Advanced systems and web-transactions improve customer service
    while reducing administrative cost
•   We learn from our mistakes and improve our processes every single
•   Our mission is to make using TRICARE easy and stress-free for the
    military, their dependents and the retirees we are privileged to serve
•   Questions?