CCNV 2CCNV 2ndnd Annual Client Annual Client Conference Conference

““Managed Care Organizations and NPI Managed Care Organizations and NPI Procedures” Procedures”

Evelyn Pena-Morton, BAEvelyn Pena-Morton, BADirector of ContractingDirector of Contracting

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Managed Care OrganizationsManaged Care Organizations

• Who are they?

– Any CCNV Master Network Agreement negotiated on behalf of the centers

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Managed Care OrganizationsManaged Care Organizations

– Currently CCNV has 30 master network agreements

– Includes 22 delegated credentialing agreements

– Our contracts include an average of 75,000 enrollees, generating substantial revenue for the health centers

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CCNV COMMERCIAL AGREEMENTS CCNV COMMERCIAL AGREEMENTS 8 Direct Commercial Agreements8 Direct Commercial Agreements

• Aetna

• Corvel

• Optima

• CCN

• Southern Health

• United Healthcare/MAMSI

• Health Net Federal Services

• Unicare

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CCNV MEDICAID AGREEMENTS CCNV MEDICAID AGREEMENTS

5 Medicaid Agreements

• AMERIGROUP • CenVANet• Optima Medicaid• Southern Health / Care Net• Virginia Premier

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CCNV MEDICARE ADVANTAGECCNV MEDICARE ADVANTAGE

3 Medicare Advantage Participation Agreements

• Humana Choice Care PPO• Optima Medicare Advantage• Pyramid Today’s Option

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CCNV DENTAL AGREEMENTSCCNV DENTAL AGREEMENTS

4 Dental Agreements

• Aetna• Dental Benefits Providers• Delta Dental• Doral

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CCNV NETWORK AGREEMENTS CCNV NETWORK AGREEMENTS

7 Network Participation Agreements

– 4Most Health Network – Galaxy Health Network – Gateway Health Alliance/Halifax PHO– National Capital Preferred Provider Organization

(NCPPO)– Three Rivers Provider Network– Virginia Health Network/Great West Healthcare, Inc. – Wellmont/Highlands Physicians (SWVA centers

only)

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Other CCNV agreementsOther CCNV agreements

3 Other agreements

• Virginia Coordinated Care (VCC)

• Mid-Atlantic Health Solutions

• Veterans Administration (VA)

NPI ProceduresNPI Procedures

CCNV Network CCNV Network ContractsContracts

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NPI ProceduresNPI Procedures

Organization (Entity Type1)– Medical Center – Pharmacy

Individual Provider (Entity Type 2)– (MD, DO, PA, NP, LCSW, Dentist, Pharmacist, ect.) – Center site must be his/her primary location

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NPI ProceduresNPI Procedures

Direct Commercial Payors – Will use the both entity and provider NPI’s for

billing

CCNV Participating Network’s– Are currently collecting from CCNV all entity

and provider NPI’s– These are being passed on to their

commercial payors

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NPI ProceduresNPI Procedures

Medicaid– Requires the entity and provider NPI for

billing purposes

Dental – Requires the both entity and provider

NPI for billing purposes

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Other CCNV agreements NPI Other CCNV agreements NPI ProceduresProcedures

Virginia Coordinated Care (VCC) • Uses Virginia Premier as their administrator

for payment.• Requires the entity and provider NPI

Veterans Administration • NPI numbers are included with invoice as

provided by contract

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CCNV Contracting NPI ProcedureCCNV Contracting NPI Procedure

• CCNV sent provider and entity NPI numbers to all contracted payor organizations in July 2006

• For newly credentialed providers who have been accepted by the CCNV Board of Directors, the demographic spread sheet is updated to include NPI numbers

• For non-delegated agreements the NPI numbers are included in the applications

• CCNV continues to respond to requests for NPI information going forward