An Educational Presentation

An Educational Presentation

Presented by: Avesis

October 2011

Prepared For:

Kentucky Eye Medical Providers & Staff

Kentucky Eye Medical

Introductions


Locations

Executive Offices in Baltimore, MD

Operations located in Phoenix, AZ

Phone: (855) 469-3368

• Eligibility

• Claims

• Member Services

Southeast regional office in Atlanta, GA

Phone: (855) 469-3368

• Provider Services

• Prior Approvals


Eye Medical & Routine Vision

Avesis Medicaid Eye Medical and Routine Vision Plans in Kentucky

Providing Eye Medical and Routine Vision Services for Medicaid Members enrolled in:


Points of Contact

Nichole MitchellDirector of Government [email protected](800) 522-0258 x296

Lornetta Gordon RoebuckProvider [email protected](800) 522-0258 x293

Dana LintonProvider [email protected](800) 522-0258 x130


Avesis Vision Advisory Board

Committee of licensed Kentucky licensed Ophthalmologists and Optometrists

Act in an advisory capacity to WellCare and Avesis in all matters pertaining to the Medicaid Program in Kentucky

Help to ensure quality communications between Kentucky provider community, Avesis and WellCare

Forum for providers to submit recommendations and feedback regarding the program and its administration


Eligibility


Eligibility

It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month.

Please note that verification of benefits or eligibility is not a guarantee of payment: actual payment is based on the terms and conditions of the plan in force once the claim is received.


Eligibility

You may obtain eligibility verification four ways:

1. IVR – Please bear in mind that this only provides you with information as to whether or not the Member has coverage with the CMO on the date of service for our Medicaid Members. It does not provide utilization data (whether or not the Member has utilized their benefit)

2. Website – Choose the “coverage slice” that is applicable to the date of service for which you are seeking eligibility. Choose “View Usage” to view the Members utilization history.

3. Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data.

4. Fax – You may utilize the form found on the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.


Fax Eligibility Verification


Benefits


Benefits Overview

Effective November 1, 2011, Avesis will administer a Full Eye Medical and Routine Vision Program for Members enrolled in WellCare of Kentucky.

Coverage will include office visits consisting of routine vision and eye medical diagnosis, medical and surgical services, medically necessary contact lenses, when applicable, and spectacle frames and lens materials required to correct visual acuity.


Benefits Overview

Covered Services

• Covered services will be paid according to the plan fee schedule

Non-Covered Services

• Non-Covered Services may be the responsibility of the Member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered


Benefits Overview

There are two Medicaid programs under WellCare Kentucky:

• Global Choices

• Family Choice

Benefits for children (Members ages 20 and under) are the same in each of the plans

Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled. There are NO materials benefits for adults enrolled in either program.


The Global Choices Program

Global Choices is the benefit plan for most Kentucky Medicaid Members. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).


Benefits for Global Choices

Global Choices benefits include but are not limited to:

• Adults and children limited to 1 eye exam per Member per provider per calendar year

• Eyewear limited to children under 21

• Materials limited to $200 per calendar year. Maximum paid for one pair of glasses is $150.


The Family Choices Program

Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. Some benefit limits can be increased if the service is medically necessary (requires prior approval).


Benefits for Family Choices

Family Choices benefits include but are not limited to:

• Children limited to 1 eye exam per Member per provider per calendar year

• Eyewear limited to children under 21

• $400 limit per calendar year

• Maximum paid for one pair of glasses is $150


General Benefits

Benefit Exception/EPSDT Process

• Benefit exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity

• Benefits are either exhausted or not a covered benefit

• Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days.

Emergency Services

• Members seeking emergency services may need to be referred back to WellCare Kentucky for medical benefits


Prior Authorization


Avesis Prior Approval Requirements

Avesis does not currently require prior authorization for ophthalmological services covered under the Avesis Kentucky Medicaid program.

Facility authorizations must be obtained through WellCare when required. Please contact WellCare Utilization Management Department via fax at(877) 431 – 0950 for further assistance.


Claims


Claim Submission

Claims may be submitted one of three ways:

Through your practice management software using a clearinghouse

The Avesis payer identification number is 87098

On a CMS1500 claim form - please submit to the following address:

Avesis Vision ClaimsPO Box 7777Phoenix, AZ 85011 – 7777

Utilizing our website at www.avesis.com


Claims Follow-up

Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways:

• You may check claim status on the Avesis website at www.avesis.com

• You may contact our provider services department at (855) 469-3368 to check claim status


Corrected Claims

Submission

• If you are missing information (i.e. modifiers, claim lines, etc.) you may refile the claim on the web for payment

• If you have submitted incorrect information (wrong code, wrong diagnosis, etc) you will need to submit a corrected claim. To submit a corrected claim:

• Please write corrected claim on the top of the CMS 1500 claim form in blue or black ink. The scanner does not read red ink

• Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out.


Avesis Claims Payment

Check runs weekly (each Friday)

CLEAN CLAIMS processed and adjudicated within 15 business days

Claims submitted one of three ways:

• Electronically (EMC payer ID# 87098)

• Manually entered on www.avesis.com

• Paper form

Electronic Funds Transfer available


Electronic Funds Transfer Agreement


Avesis Web Portal


Web Portal


Claims


Submit HCFA Claim


Medical Records Review


Avesis Review Process

Avesis conducts medical record reviews for our provider networks

Your office will be contacted to furnish a list of charts for review

After the visit, your office will be sent a letter regarding the findings of our review


Provider Services


Services to Providers

Avesis is primary for Provider Services for both our commercial and Medicaid products.

Avesis has toll free phones staffed by experienced and knowledgeable representatives for all of our products

Regional meetings and training sessions scheduled for providers


Additional Assistance

Schedule a conference call

Schedule a web demo

Schedule an onsite visit


Committed to Technology

24/7 Access to information:

Web Based

• Eligibility

• Claims submission

• Claims status

Interactive Voice Response (IVR)

• Eligibility

• Benefits


Thank You For Your TimeQuestions?

We at Avesis look forward to working with you and your team.

An Educational Presentation

Documents

Transcript of An Educational Presentation