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600 - TRICARE

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					    Health Net Federal Services
             (HNFS)
        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
  relationships

• Coordination via monthly meetings ensure
  successful implementation of MTF and HNFS
  goals
TSC – BCAC Flow




  •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
  issues
Communication
 – Use team approach, instead of “Us” versus
   “Them”
    • 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
                          •Authorization/Referrals
•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
Pamphlets
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

             TRICARE
Communications and Customer Service
            Conference
              August 2005
Overview

•   Introduction
•   myTRICARE.com functionality
•   BCAC and DCAO access to myTRICARE.com®
•   What’s available for a BCAC and DCAO
•   North Region service contacts
•   Closing remarks/questions
Introduction
•   PGBA, LLC is a subsidiary company of
    BlueCross BlueShield of South Carolina
•   Subcontractor for claims processing,
    claims customer service, fiscal
    management and information system
    technologies
     • 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
                                                     Regions
What’s available at myTRICARE?
TRICARE North Region Tools

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



•    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
Functionality?

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


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
Functionality?

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
 Functionality?




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


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



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



• To check claim
  status:
   - Sponsor’s SSN
   - Patient’s date of
      birth
   - Provider’s Tax ID
      (optional)
   - Date of service
Claim Summary



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



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



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


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


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

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

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

• To view answers to
  your questions in
  your secure mailbox
   - Select PGBA
     Answer
   - Search mail by
     subject
   - Save mail to Old
     Mail folder
   - Move mail to
     Deleted Mail
     folder
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
    day
•   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?

				
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