Post on 30-Sep-2018
HMSA QUEST Integration Plan
Par Provider Information Webinar
May 24,2017
Agenda
Excluded Providers
Member Cost Share
Service Coordination
Referrals and Pre-certifications
EPSDT
QUEST Integration Fee Schedules (HHIN)
Contact information
Q & A
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QUEST Integration members
HMSA’s QUEST Integration members
Non-ABD (Doesn't include Aged, Blind or members with
disabilities)
ABD
(Aged, Blind or members with
disabilities)
ABD and LTSS
(Aged, Blind or members with
disabilities who have additional LTSS benefits)
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Excluded Providers
Excluded Providers
What is an Excluded Provider?
Individual or Entity who is not allowed to receive reimbursement for providing Medicare or Medicaid services
HMSA is required to immediately terminate the Excluded Provider and/or affiliated provider (owners, agents or managing employees) from the provider network
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Excluded Providers
QUEST Integration Provider Responsibilities
Search Excluded Provider lists routinely (i.e. monthly) to confirm that employees or contractors are not on any list AND
Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list
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Federal Excluded Provider Lists
6/5/2017 7
• General Services Administration Excluded Parties List System (EPLS)
• https://www.sam.gov/index.html/#1#1#1
• List of Excluded Individuals and Entities (LEIE), a health care specific exclusion list
• https://exclusions.oig.hhs.gov/
State Excluded Provider Lists
Government contracting exclusion list
http://spo.hawaii.gov/for-state-county-personnel/manual/debarment/
DHS Med-QUEST Division’s exclusion list
http://www.med-quest.us/providers/ProviderExclusion_ReinstatementList.html
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Service Coordination
Service Coordination
A person-centered service delivery system
Ensures the needs of those with special health care needs and those receiving long term services and supports are met
Service coordinators assist in coordinating services with other agencies, programs, and community services
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Service Coordination
Who is eligible?
QUEST Integration members with Special Health Care Needs (SHCN). May include:
Patients with chronic conditions such as asthma, diabetes, hypertension, cancer, or COPD
Patients who are outliers for emergency room utilization
Patients being discharged from an acute care setting
Patients with hospital readmission within the previous 30 days
Children with autism
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Service Coordination Responsibilities of Coordinators
Support the PCP
Conduct member functional assessments
Develop and monitor a service plan based on results of the assessment or reassessment
Coordinate and facilitate access to services with providers, programs, and community agencies
Monitoring progress with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. As applicable
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Requesting Service Coordination Fax the form at:
https://hmsa.com/portal/provider/HMSA_QUEST_Integration_Service_Coordination_Referral_Form.pdf
Oahu fax: 944-5604
Neighbor Islands toll-free fax: 1(855) 856-4176
May also call HMSA
Oahu: 948-6997
Neighbor Islands toll-free: 1 (844) 223-9856
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Member Cost Share
What is Cost Share?
Members who do not meet Medicaid financial eligibility requirements
Cost Share amount determined by Med-QUEST
Members responsible for paying their Cost Share monthly
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Providers who collect Cost Share
• Nursing Facilities • Skilled or private duty nursing
• Hospital Wait-listed • Community Care Foster Family Homes
• Personal Assistance • Expanded Adult Residential Care Homes
• Adult Day Health • Respite Care
• Adult Day Care
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Identifying members who have Cost Share
HMSA Service Coordinator contact providers to discuss cost share amounts to collected
Service Coordinators send copy of Member’s Cost Share Agreement to the provider
Providers may check the Med-QUEST eligibility website: hiweb.statemedicaid.us
Providers may also call QUEST Integration Provider Service at 948-6486 (Oahu) or 1 (800) 440-0640 toll free Neighbor Islands
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Entering Cost Share amounts collected
on Claims
Cost Share amounts must be entered on claims
submitted by these providers
UB-04: Use Value Code 23 in Form Locator 39
CMS 1500: Enter cost share amount in Block 29
Use equivalent fields for electronic claims
Cost Share process
Med-QUEST
Division (MQD) determines
member’s cost share amount
HMSA Service Coordinator meets with member to:
1. Explain their cost share responsibility
2. Have member sign Cost Share agreement
HMSA sends copy of agreement to
provider
Payment made to provider
HMSA payment is reduced by the
amount of the cost share
Provider files claim to HMSA indicating Cost Share amount
collected
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Cost Share
If member’s Cost Share exceeds the claim amount, HMSA sends provider an invoice asking them to send the balance to:
HMSA Attn: F & A Disbursements P. O. Box 860 Honolulu, HI 96808
Providers may opt to have invoice amounts deducted from future Reports to Provider
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Cost Share
Cost Share amounts are applied to claims submitted by designated providers
Retroactive changes to Cost Share result in reprocessing of claims to reflect current cost share amounts
Referrals
Referrals
Self referrals
All other specialty care requires PCP referral
Register these referrals with HMSA
Plastic surgery services
Off - island specialist services
In-state out of network referrals
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• Behavioral health (OP) • Family Planning
• Refractive vision services • Well-woman exam and mammogram
How to Register a Referral
Referral form is at: http://www.hmsa.com/PORTAL/PROVIDER/FM.HMSA_QUEST_Referral_Form.pdf
Fax the referral form 948-5648 (Oahu) 1 (800) 960-4672 (toll-free)
Register the referral online via HHIN Select “Submit Referrals” tab, then click on “iExchange”
Call QUEST Integration Provider Service 948-6486 (Oahu) 1 (800) 440-0640 (toll-free)
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Precertification
Precertification (Prior Authorization)
List of QUEST Integration services requiring pre-certification: https://hmsa.com/portal/provider/zav_QI.01.SER.50.htm
Clearly identify urgent/emergent cases for expedited review
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Precertification (cont.)
Unit/Partner Responsible for
HMSA Medical Management
Medical/Surgical, LTSS, Post-Acute Care Services, Speech Therapy, Out of State Referrals
National Imaging Associates (NIA)
Advanced imaging, Spinal Interventional Pain Management, Lumbar Spine Surgery, selected Cardiac procedures
eviCore Outpatient Rehab Therapy
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Precertification (cont.)
Unit/Partner Responsible for
QUEST Integration Provider Service
Travel and lodging requests, In-state out of network referrals
CVS Drug
Beacon Health Options Behavioral Health
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Precertification – HMSA Medical
Management
HMSA precertification forms available online
General http://www.hmsa.com/PORTAL/PROVIDER/FM.Precertification_Request_General.pdf
Post-Acute Care Services http://www.hmsa.com/PORTAL/PROVIDER/Precertification_Request_Post_Acute_Care_Services_Form.pdf
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Precertification – HMSA Medical
Management
Mail to: HMSA – Medical Management P. O. Box 2001 Honolulu, HI 96805-2001
Fax: 1 (808) 944-5611
Phone: 948-6464 (Oahu) 1 (800) 344-6122 (toll-free Neighbor Islands) Monday-Friday : 7:45 a.m. - 4:30 p.m.
Online: Access iExchange through HHIN or Cozeva
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Precertification (Prior Authorization)
Electronic submissions accepted through HHIN
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Click on “Preauthorization” tab. Then click on “iExchange (HMSA Medical).” To request access to HHIN – call (808) 948-6255
How to Access iExchange using Cozeva
Use Firefox or Internet Explorer browser
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Click dropdown arrow for “Inbox” and select “Req Authorizations”
The window below appears. Click the button to continue to iExchange
How to Access iExchange using Cozeva
The iExchange window appears. Select “Inpatient” or “Other” to start your type of request
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Note: May have to disable popups to view iExchange
Precertification - NIA
Management of:
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MRI/MRA/MRS CT/CTA
PET CCTA
Myocardial perfusion imaging
MUGA
Stress echocardiography
Spinal interventional pain management
Implantable cardioverter defibrillator
Cardiac resynchronization therapy pacemaker
Pacemaker Cardiac catheterization
Lumbar spine surgery
Precertification - NIA
Radiology management Quick Reference Guide: https://hmsa.com/portal/provider/zav_pel.aa.rad.400.htm
NIA FAQ: https://hmsa.com/portal/provider/HMSA_Medical_Specialty_Solutions_Program_NIA_Magellan_FAQs.pdf
Does NOT include emergency room, surgery center, observation and inpatient settings
Online: RadMD.com
Phone: 1 (866) 306-9729
Clinically Urgent Cases: 1 (866) 842-1776
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Precertification - eviCore
Formerly known as Landmark Healthcare
Login at: http://www.lmhealthcare.com/Providers/LandmarkConnect.aspx
Treatment plan forms available at the website
Treatment plans may be submitted via LandmarkConnect or by fax
Fax: 1 (888) 565-4225
Questions: 1 (888) 638-7876
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Precertification – QUEST Integration
Provider Service
Phone: 948-6486 (Oahu)
1 (800) 440-0640 (toll-free Neighbor Islands
Fax: 948-5648 (Oahu)
1 (800) 960-4672 toll-free Neighbor Islands
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Precertification - CVS
Oral/Inhaled drugs
Drugs requiring precertification-Review Drug Formularies: https://hmsa.com/portal/provider/zav_IN.PHARM-FORMULARY.htm#Nav_Formularies
Fax: 1 (866) 237-5512
Phone: 1 (808) 254-4414
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Omit
Precertification - CVS
Injectable/Infused drugs
Drugs requiring precertification: http://info.caremark.com/hmsapolicies Note: most drugs have specific precertification request forms
Online: Access through HHIN – Preauthorization tab (NovoLogix tool)
Fax: 1 (866) 237-5512
Phone: 1 (808) 254-4414
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Precertification – Beacon Health Options
For BH referrals to 0ut-of-state providers, Residential Treatment, Methadone/LAAM treatment
Fax: (808) 695-7790
Phone: Oahu - (808) 695-7700
Neighbor Islands - 1 (855) 856-0578 toll-free
Mail: Beacon Health Options
599 Farrington Highway, Suite 300
Kapolei, HI 96707
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Precertification
Timeliness guidelines
Routine requests within 14 days
Urgent requests within 3 business days
If precertification is not obtained before the service is provided, submit a paper claim attaching documentation for the medical necessity
Claim will undergo medical review
Claim without documentation will be denied for no authorization
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EPSDT –
Early Periodic Screening
Diagnostic and Treatment
For PCPs
EPSDT – Early Periodic Screening
Diagnostic and Treatment
Provide Medicaid-eligible infants, children and youth with quality comprehensive health care through primary prevention, early diagnosis and medically necessary treatment of conditions
For children up to 21 years of age
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EPSDT Schedule
Health Screening Assessment schedule is at the Med-QUEST website: http://www.med-quest.us/PDFs/EPSDT/Info%20on%20Hawaii%27s%20Medicaid%20EPSDT%20Program%20_Overview_.pdf
Filing Claims for EPSDT – CMS 1500
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File claim with Preventive Medicine CPT 99381-99385 or 99391-99395 with modifier EP in block 24.d
Place “Y” in Block 24.h of the CMS 1500
99392 EP Y A 1 XXX XX
Filing Claims for EPSDT
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PCPs submit EPSDT form 8015 (or Form 8016 for catch up visits).
Paper claim - staple EPSDT form to the claim.
Electronic claim - mail EPSDT form separately to: HMSA QUEST Integration P.O. Box 3520 Honolulu, HI 96811-3520
The mailed form must be received by HMSA by the time the electronic claim processes
Filing Claims for EPSDT
Must use original printed forms only. No copies.
Ordering EPSDT 8015 and 8016 forms:
Call ACS at (808) 952-5570 on Oahu or 800-235-4378 toll free from the Neighbor Islands
Fax request to (800) 952-5595
Email request to hi.providerrelations@acs-inc.com
Only EPSDT Paid if Billed with Office Visit on the Same Day
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EPSDT Resources
EPSDT general information url: https://hmsa.com/portal/provider/zav_QI.04.EAR.50.htm
Sample EPSDT form 8015 (1/10) https://hmsa.com/portal/provider/fm_form_8015_front_and_back.pdf
Fee schedules
(Professional)
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Fee Schedules
Participating Providers Accept Eligible Charge as payment in full for covered
services
Payment based on the Eligible Charge, less applicable copayments, deductibles, and payment from third parties*
* PCPs in HMSA’s Payment Transformation Program have an alternate
reimbursement methodology
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Fee Schedules
Fee schedules are available on HHIN
Under “QUEST Integration,” click on the “Fee Schedules” tab on the left side of the home page
Note: If an eligible charge is stated in your provider agreement, terms of the agreement supersede the fee listed in HHIN
Fee Schedules
Fee schedules on HHIN separated into Non-QUEST and QUEST sections
Separate fee schedules for non-ABD and ABD members
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Resources
Provider Communications
Provider Portal - https://hmsa.com/portal/provider/
QUEST Provider Handbook
Communication Archive - HealthPro News
QUEST Integration Provider Service
Phone: 948-6486 (Oahu) or 1 (800) 440-0640 toll free Neighbor Islands
Fax: 948-5648 (Oahu) or 1 (800) 960-4672 from the Neighbor Islands
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Thank you!
Questions?
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