"Reconsider Provider Contract Denial"
Provider Newsletter January 2009 In This Issue... Providers and Members Members No Longer Assigned to OB PCP Working Together During Pregnancy 2 Updated Provider Manual Appointment Standards for Mercy Care recently updated the Provider Manual. Foster Children 3 Please go to www.MercyCarePlan.com to review the manual. If you need Important Message the Provider Manual in another format, please contact your Provider Services from Merck 4 Representative. Mercy Care will continue to update the Provider Manual, as Pharmacy Update 4 appropriate, and will alert you to changes online or in subsequent newsletters. Coordination of Benefits 5 Appointment Standards Dental Corner 6 Mercy Care has established appointment standards, in accordance with the Arizona New CMS Reporting Health Care Cost Containment System (AHCCCS), to promote timely appointments Requirements 7 and accessibility. Providers are required to meet the appointment standards set forth in their contract and the Provider Manual. Don’t Wait for Prior Authorization! 8 Mercy Care also monitors members for excessive no shows. Members are expected to keep their appointments and providers are expected to have appropriate CMS Bans Physician appointment availability. Signature Stamps on All Medical Records 11 How can you help? • Make sure you know and are able to keep the required appointment standards. Personal Health (Minimum standards are noted in the Appointment Availability Standards table). Information (PHI) • Document missed or cancelled appointments. Notification 12 • Send reminders to members about their appointments. Changes to • Notify Member Services through the Provider Assistance Program of a member who Albuterol Inhalers 12 continually misses appointments. (Instead of removing the member from your panel for missed appointments, please consider the use of our Provider Assistance Program.) • Cooperate with the Mercy Care Provider Services Department when they are conducting accessibility audits. Audits can occur during site visits or by contacting your office by telephone. Appointment Availability Standards Emergency Preventive & Wait Time in Provider Type Urgent Care High Risk Services Routine Care Office Standard PCP Same day Within 24 hrs. Within 21 days Less than 45 min. Specialty Within 24 hrs. Within 3 days Within 45 days Less than 45 min. Referrals Within 3 days Dental Care Within 24 hrs. Within 45 days Less than 45 min. of request 2nd trimester- 3 trimester- rd Within 3 days of Maternity Immediate within 14 days within 7 days of identification of Less than 45 min. of request request high risk status Within 30 days Behavioral Within 24 hrs. of referral or Less than 45 min. Health screening Not Urgent/ Less than 1 hour Not Emergency before or after Transportation appointment ...Continued on Page 2 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 1 Provider Newsletter A Missed Appointment is a Missed Opportunity! Mercy Care identifies members who are reported for consistently missing scheduled appointments and follows up with them. Follow up may include a letter, outreach call, case management referral or reassignment. Participating Health Providers (PHPs) are required to document missed appointments in the member’s record. You may use our Provider Assistance Program to report Mercy Care members who consistently miss appointments and have not responded to the education provided by your office to keep their appointments. Please be sure to include the following information in your documentation: The member’s name and ID number Dates of missed appointments Address and current home or telephone number provided to you by the member Efforts made to contact and educate the member If the member is pregnant, expected date of delivery Other pertinent information As a reminder, providers electing to remove members from their panel must first notify the member and provide at least a 30-day notice to both the member and Mercy Care. Mercy Care is committed to helping reduce no-show rates. Please let your Provider Services Representative know how we can assist your practice with this important issue. Members No Longer Assigned to OB PCP During Pregnancy Effective February 1, 2009, Mercy Care will assign pregnant members to a Primary Care Physician (PCP) and authorize services to an obstetrician (OB), rather than assign the member to an OB. Pregnant members will receive their routine care through their PCP. However, if a member chooses to have an OB as their PCP during their pregnancy, they may be assigned to an OB as a PCP and receive all of their medical care though their OB. Pregnant members assigned to an OB PCP as of February 1, 2009, will not be impacted by this change. 2 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter Mercy Care Serves Many Counties! Mercy Care Mercy Care Plan Effective October 1, 2008, Mercy Care Plan has an AHCCCS acute care contract in the Acute following counties: Cochise, Graham, Greenlee, Maricopa, and Pima (capped). Mercy Care Plan Continues to serve members in Maricopa County. Long Term Care The acute care contract changes did not impact Mercy Care Plan’s contract with the Mercy Care Plan Division of Developmental Disabilities. Mercy Care Plan continues to serve members Developmental Disabilities with developmental disabilities in the following counties: Cochise, Gila, Graham, Greenlee, LaPaz, Maricopa, Pima, Pinal, and Yuma. Mercy Care Advantage Mercy Care Advantage continues to serve members in the following counties: (Medicare Advantage Prescription Maricopa, Pima and Santa Cruz. Drug Special Needs Plan) Mercy Healthcare Group Mercy Healthcare Group continues to serve members in the following counties: (Coverage for small businesses Cochise, Coconino, Gila, Graham, Greenlee, Maricopa, Pima, Pinal, Santa Cruz, with 2-50 employees) Yavapai and Yuma. Appointment Standards for Foster Children On September 26, 2008, a new law went into effect that requires staff and contractors of the Arizona Department of Economic Security to make every reasonable effort to not remove a child who is placed in out-of-home care (foster care) from school during regular school hours for appointments, visitations or activities not related to school. The intent of this new law is to minimize interference with the foster child’s learning and disruptions to the child’s school schedule. Your office may receive more requests than usual for children’s healthcare appointments to be scheduled before or after school hours due to this new requirement. The Division of Developmental Disabilities encourages your office to work with foster caregivers to schedule appointments before or after regular school hours for the children and youth in foster care. www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 3 Provider Newsletter Pharmacy Update Incentives for Electronic Prescribing Did you know that thousands of medication errors occur each year? By using electronic prescribing (e-prescribing) you can help reduce this number while increasing quality. According to the Department of Health and Human Services, starting in 2009, and during the next four years, Medicare will provide incentive payments to eligible professionals who are successful electronic prescribers. Eligible professionals will receive a two-percent incentive payment in 2009 and 2010; a one-percent incentive payment in 2011 and 2012; and a one-half percent incentive payment in 2013. Mercy Care is collaborating with AHCCCS and other Medicaid health plans to support the AHCCCS initiative to increase the number of e-prescribing participants. We appreciate your participation! To learn how to participate in this program, go to www.cms.hhs.gov/pqri. Billing Members is Important Prohibited Message from Mercy Care frequently Merck identifies inappropriate billing of Mercy Care Plan members, A recent message from Merck a violation of the AHCCCS indicates that they have been rules and regulations. As a working diligently to restore market reminder, if a member presents availability of the HIB-containing as a Mercy Care Plan member, vaccines, PedvaxHIB® and the member may not be billed Comvax®. Merck’s goal was to for covered services, including return these vaccines to market in copayment, coinsurance or the fourth quarter of 2008. However, the company recently identified the deductibles for primary benefits. Instead, all providers are need for an additional manufacturing required to bill the primary insurance first and bill Mercy change that will require a regulatory Care Plan for any copayment, coinsurance or deductibles. filing. Because of this, Merck is The following Arizona Administrative Codes apply to Mercy revising their projected market return Care Plan members: in the U.S. to mid-2009. • R9-22-702 (Mercy Care Plan Acute) • R9-28-701.10 (MCP Long Term Care), defers to R9-22-702 4 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter Coordination of Benefits Mercy Care Plan is the payer of last resort when coordinating medical and dental benefits. Upon the receipt of payment or denial by the other insurer, you should submit your claim to Mercy Care Plan, enclosing a complete and legible copy of the remittance advice or EOB from the other insurer. • Secondary claims should be submitted within 60 days from the printed date on the primary insurer's EOB or remittance and within 180 days from the date of service. • If you have not received a payment or denial from the primary within 180 days, then you must file an initial claim with Mercy Care. • All claims with EOBs should be submitted and processed within 365 days (one year) from the Date of Service*. * Mercy Care Plan may reconsider payment of claims which have been denied for untimely filing in situations where it is evident that the provider made an effort to determine the extent of liability. What Happens When... A member is enrolled in both Mercy Care Advantage (MCA) and MCP? MCA is the primary payer and MCP is secondary if there is no other insurance involved. In accordance with the Balanced Budget Act of 1997 and your contract: • “For Members covered by Medicare or other insurance, unless otherwise required by Plan Contract, Mercy Care shall pay the lesser of: (1) the copayment, coinsurance and deductible amount for the Covered Services as reported on the explanation of benefits; or (2) the difference between the fee schedule amount under this Agreement and the amount paid to PHP by Medicare or other third party source for the Covered Services.” • For medical or dental services requiring a prior authorization, if Mercy Care Plan is paying as secondary, prior authorization is not required. When coordinating pharmacy benefits, Mercy Care Plan pays as secondary and prior authorization is required according to the member’s benefits. Mercy Care Advantage Deductibles, copayment and coinsurance updates Effective January 1, 2009, Medicare will update deductibles, copayment and coinsurance. Below is a summary of the January 1, 2009 information: Service Copay/Coinsurance Preventive Services 20% Diabetic Supplies 20% Inpatient Hospital – Days 1 - 60 $1024.00 per admit deductible Inpatient Hospital – Days 61 – 90 $238.00 per day Inpatient Hospital – Days 91 – 151 $476.00 per day Physician Services No PA 20% Surgical/Outpatient 20% Skilled Nursing Facilities Days 21-100: $133.50 per day www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 5 Provider Newsletter Dental Corner Help with Dental Claims and Resubmissions Mercy Care Plan routinely reviews claims for our dental network and has identified some opportunities to improve timeliness and accuracy of payment. We continue to review our system and make system updates. You can improve timeliness and accuracy of your payments by keeping in mind these helpful tips: • All dental claims must be billed on the current ADA form with the correct tax ID and NPI. All codes for the same date of service must be billed on the same form. • New claims must be submitted within 180 days or the claim will be denied for timely filing. • Single digit tooth numbers must be billed as a single digit, i.e., 1, 2, 3, etc. If a zero is placed in front of the single digit (01, 02, 03), the claim will deny for invalid tooth number. • A “D” must be placed before any dental code, i.e., D7230, not 7230 or 07230. Incorrectly billed codes will result in a claim denial. • RESUBMISSIONS must clearly state “RESUBMISSION” in black ink on the front of the claim and all supporting documentation. • When filing RESUBMISSIONS, all lines from the original claim must be rebilled. Remittance Advices are provided with each payment. By working the Remittance Advice each week, you will prevent potential issues from accumulating. • Mercy Care encourages providers to informally resolve any payment issues through the Claims department or through their Provider Services Representative before filing a formal claim dispute. Providers have the right to file a claim dispute if it is believed that the claim was incorrectly paid or denied. • Claim disputes must be filed within 365 days from the date of service or 60 days from the last adverse action. You can find additional information at www.MercyCarePlan.com. 6 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter Prior Authorization Reminders New CMS Reporting Requirements As a contractor with the Centers for Medicare and Medicaid Services (CMS), Mercy Care Advantage must meet all CMS reporting requirements. In many cases, we depend on our Participating Health Providers (PHPs) to report the data. Mercy Care Advantage would like to alert you to three new Medicare reporting requirements. 1. Present on Admission Flag - Effective October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) requires that all UB-04 claims include a Present on Admission (POA) indicator. 2. Effective January 1, 2009, "Never Events" (Serious Reportable Adverse Events) must be submitted on each claim form. "Never Events" are hospital-acquired conditions that must be submitted on each claim form. 3. Effective May 1, 2010, Mercy Care Advantage must begin reporting "Never Events" to CMS, based on 2009 data. "Never Events" include surgeries identified as 1) done on wrong body part; 2) on wrong patient; 3) with wrong procedure; 4) with foreign object left in body; 5) with post-op death, and total surgeries resulting in specific conditions. Mercy Care Advantage will send additional information to affected providers in the near future. You may refer to the CMS website at www.cms.hhs.gov for additional information. Mercy Healthcare Group Healthcare Group of Arizona (HCGA) recently made changes to benefit packages. Go to: www.healthcaregroupaz.com/classic-active9108.pdf to find more information about copayments by benefit package. Claim Dispute Process for MCP Mercy Care Plan trends and analyzes claims dispute data on a regular basis. We would like to remind you of a few key actions you can take to promote accurate and timely claims payment on initial submission. • The correct claim form must be submitted for each type of service (CMS 1500, UB-04 or ADA). Claims forms, along with detailed instructions on how to complete them, can be found on the Mercy Care Plan website at http://www.MercyCarePlan.com. The document name is Provider Claims Toolkit. • Correct procedure and diagnosis coding must be used. Refer to your ICD-9, CPT, and HCPCS codes. • Codes entered on the claim must correspond to the actual services provided, as evidenced in the member’s medical record. • Services rendered must coincide with the terms of your contract with Mercy Care, covered benefits and your registered Category of Service with AHCCCS. • Correct Coding Initiatives (CCI) must be followed. • Claims must be submitted within 180 days of the date of service or they will be denied for timely filing. Please refer to the article, “Coordination of Benefits – Medical Claims” for more information on submitting secondary claims. • All resubmissions and reconsiderations should be clearly noted. • Resubmissions or reconsiderations must be mailed to Mercy Care. Resubmissions and reconsiderations cannot be accepted via EDI. If you have any questions, please contact your provider services representative. www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 7 Provider Newsletter Don’t Wait Prior Authorization for Prior Prior Authorization Contacts Authorization! Mercy Care requires prior authorization for selected acute outpatient services and planned hospital admissions. You may If you have a prior authorization request submit your requests for prior authorization by fax, phone or online that is urgent, you don’t at www.MercyCarePlan.com. You may also review our prior have to wait! Call Mercy authorization requirements online. Please refer to the table below Care Prior Authorization for contact information. Department and speak to a prior authorization representative. Questions about covered services, referrals or the need for authorization should Outpatient requests Fax - (602) 659-1655 (Phoenix) or be directed to the Prior (800) 217-9345 (Toll Free) and elective surgeries Authorization Department. Call - (602) 263-3000 or (800) 624-3879 Prior authorization is not MCP Provider Web Portal required for emergency www.MercyCarePlan.com services. Inpatient Hospital Fax - (602) 659-1963 (Phoenix) or (866) 300-3926 (Toll Free) Pharmacy Fax - (800) 854-7614 (Toll Free) Dental Fax - (602) 659-1655 (Phoenix) or (800) 217-9345 (Toll Free) (Use the “Dental Prior Authorization Request” form on the Mercy Care website and fax to Mercy Care Plan.) Urgent Requests Prior Authorization Representative Call - (602) 263-3000 or (800) 624-3879 Use Express Code: 622 Routine Requests Prior Authorization Representative Call - (602) 263-3000 or (800) 624-3879 Use Express Code: 622 8 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter Types of Prior Authorization Prior Requests Authorization Mercy Care will respond to your requests for prior authorization within the following timelines: Checklist To expedite request Types of Requests for prior authorization, • Responded to within three (3) working days upon receipt please have the following of the request. information available when • An urgent request is appropriate for a non-life threatening calling or requesting a prior condition, which if not treated promptly, will result in a Urgent worsened or more complicated patient condition. authorization: Request • An urgent request may be changed to a routine request, if the urgent request does not meet criteria for urgent. Member name The member and provider will be notified of the change of type of request and the new time frames to process Member ID number that request. CPT code/HCPC code of the Routine • Responded to within 14 calendar days upon receipt of intended service(s) Request request. ICD9 code(s) • If MCP requires more clinical documentation to make a decision on the prior authorization request, MCP will extend the time frames up to 14 more calendar days after Referring physician name the request. Extension Facility name or place of service • MCP will notify the provider and member of this extension and the documentation MCP requires to make a decision. If MCP does not receive this information Date of service (if applicable) within the time frame, MCP will deny the request on the Pertinent information to support date that the time frame expires. request for service www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 9 Provider Newsletter Correction to Correction to Provider Spring Newsletter Changes and Relevant Article on PEDS Forms Tool As previously communicated, Mercy Care created a “Provider Change Form” for participating providers. The Provider Change In the Spring 2008 Newsletter Form is designed to simplify the notification process when changes article titled, “PEDS Tool Aids in occur at your practice. Mercy Care must be notified in advance of Developmental Assessment,” Mercy any demographic and panel changes. Our previous communication Care reminded you of the importance stated that Mercy Care must be notified at least 30 days prior to the of PEDS tool in the screening, triage change. The notification timeline, in accordance with the terms and surveillance for developmental and of the provider contract, requires a 90 day notification period, behavioral problems in children ages not 30 days. Please make a note of this important requirement. birth to eight years of age. Here are Participating Health Providers (PHPs) terminating their contract some recent updates that supersede any must continuing treating assigned members through the 90-day previous messages on the PEDS tool: termination period, unless the members are safely transferred prior • The billing provider must complete to the termination date. Any new providers to the practice must be formal training in the use of the PEDS credentialed and loaded in our system to allow reimbursement. tool prior to providing services. The Provider Change Form is located on our website at: • The PEDS tool is especially helpful www.MercyCarePlan.com. when conducting formal developmental For information on where to send notification of changes, please screening during primary care EPSDT refer to the Provider Record Updates table below. For more visits and is a required assessment for information, please contact your Provider Services Representative NICU graduates. directly. • MCP providers can be reimbursed for the PEDS evaluation, for members who Provider Record Updates were born January 1, 2006, or after Type of Notification Time to and are NICU graduates, by billing CPT Send to Change Requirements Process code 96110 with an ‘EP’ modifier. Demographic The Arizona chapter of the American Changes Academy of Pediatrics (AAP) provides Must mail updated W-9 Individual or group and Provider Change Form Provider online and in-office PEDS tool training. 60 days name which identifies the change Services Mercy Care Plan encourages all Tax ID number and effective date participating providers to become Address certified in the use of the PEDS tool. Staffing changes Fax (602) 263-3034 or mail Please note that there is no fee for including Provider Change Form which Provider 90 days the online training, which is a service physicians leaving identifies the change and Services the practice effective date of the Arizona chapter of the AAP. If you have any questions, you can Fax (602) 263-3034 or mail Network contact AzAAP via email at Adding new office Provider Change Form which Development 90 days locations identifies the change and email@example.com or by effective date & Contracting phone at 602-265-1950. Fax (602) 263-3034 or For in-office training, please Adding new mail “Participating Health Network Minimum contact Janiece Doran-Slovak at physicians to Provider Form, Attachment Development of 90 days current contract C” describing change and & Contracting firstname.lastname@example.org or effective date 602-316-6768. 10 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter CMS Bans Physician Signature Stamps on All Medical Records According to “Report on Medicare Compliance,” CMS has now stated that all providers and suppliers must stop using physician signature stamps. In an MLN Matters article (SE0829) released July 29, CMS states, “Stamped signatures are not acceptable on any medical record.” The article states that Transmittal 248 was issued to bar the use of signature stamps. “Medicare will [only] accept handwritten, electronic signatures or facsimiles of original written or electronic signatures,” says the article. This includes progress notes, orders and treatment plans. The reason for this crackdown is CMS’s longstanding concern over abuse of signature stamps. “CMS has identified problems of noncompliance with existing statutes, regulations, rules and other systemic problems relating to standards of practice for a valid physician’s signature on medical orders and related medical documents,” the article states. Because the transmittal, issued March 28, revised the program integrity manual section on medical reviews, all claims are affected. Any documentation signed by a physician signature stamp will be null and void, so in the eyes of an auditor, the documentation might as well be nonexistent. To avoid rejection of medical records, please verify documentation with original signatures. To view the MLN Matters article, visit AIS’s Government Resources at the Compliance Channel; click on “CMS’s MLN Articles.” Educational Update: Physician Meetings Upcoming Provider Meetings Mercy Care Plan is happy to announce that we will be scheduling provider meetings during the months of March, June and September of 2009 in Pima and Maricopa Counties. Office manager meetings will be scheduled for April of 2009 for both counties as well. Further details regarding these meetings, including agendas, will be sent to you as these meetings approach. Mercy Care hopes to see you at these meetings. We look forward to having interactive sessions with our providers to enhance communication and further education. www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com 11 Personal Health Information (PHI) Notification In accordance with HIPAA, Mercy Care protects a member’s personal health information through a variety of ways. Providers are required to do the same. If a member’s personal health information is lost or stolen, as in the case of a stolen laptop, please inform Mercy Care within 48 hours. Please contact Mercy Care and report this information to your Provider Services Representative. You can reach Mercy Care at (602) 263-3000. Changes to Albuterol Inhalers As of January 1, 2009, all generic Albuterol inhalers with the CFC propellant are no longer available or dispensed at any pharmacy. Albuterol brand inhalers with the new HFA propellant are now available. All members must be converted to the branded Albuterol HFA inhalers. Branded Albuterol HFA inhalers available through Medicaid include: ProAir HFA, Proventil HFA, Ventolin HFA. Branded Mercy Care Plan Albuterol HFA inhalers available through Medicare 4350 E. Cotton Center Blvd. Bldg. D are Proventil HFA and ProAir HFA. Visit www. Phoenix, AZ 85040 MercyCarePlan.com for frequently asked questions on the changes and usage of HFA inhalers. 12 www.MercyCarePlan.com • www.MercyCareAdvantage.com • www.MercyHealthcareGroup.com Provider Newsletter