Health Alliance Plan Updates

November 10, 2017

Peggy O’NeilSr. Provider Services Administrator

1

Agenda

• Prior Authorization Requirements

• Submitting Authorizations

• NDC Requirements

• Reimbursement

• Claims Appeals/Adjustments

• Medical Appeals

• Get to Know HAP Restore

• Cigna

2

Prior Authorization Requirements

3

Prior Authorization Requirements

• Always check the Prior Authorization Lists first to see if a service

requires prior authorization.

– Log in at hap.org; select Procedure Reference Lists under Quick Links.

4

Prior Authorization Lists

• Select the Services that Require Prior Authorization List.

• Changes to the list are summarized monthly and can be

found in the Summary of Changes.

5

Prior Authorization Lists

• Refer to the:

– Prior Auth Required column to see if an authorization is required

or covered.

– Key column for special notes (see the Legend at the beginning of

the document for explanation).

– Product Lines column for requirements specific to HAP products.

6

Services that Require

Prior Authorization List - Legend

7

Submitting Authorizations

– Online application - CareAffiliate

8

CareAffiliate

• You can submit authorizations online and check the status

of authorization requests too.

• Log in at hap.org and select Authorizations

9

CareAffiliate - Benefits

• Quicker approvals for prior authorization requests that

meet evidenced-based criteria

• Pre-populated authorization requests resulting in less

data entry

• Expanded character limitations within each text box to

capture more information needed to submit an

authorization

Note: authorization requests that you submit through CareCore

(eviCore) today are not affected.

10

CareAffiliate -

Training Materials

• Training manuals and tip sheets are available when you

log in at hap.org.

• Select Authorizations-CareAffiliate Help under Quick

Links.

11

CareAffiliate -

Training Materials

12

• These manuals have step-by-step instructions on entering

an authorization.

NDC Requirements

13

NDC Requirements

• Effective September 1, 2017, all claims for outpatient,

drug-related HCPCS codes and CPT codes must also

include the following information:

– NDC code of the product that was administered

– Unit of measure

– Quantity

• This information is required for CMS-1500 and UB-04

claim forms and Electronic Data Interface transactions.

• This applies to all HAP products, excluding Medicare

crossover claims and claims where HAP is not the

primary payer.

14

NDC Requirements

• Any claim without a valid NDC code will be rejected.

• You can find the list of affected codes when you log in at

hap.org and select Procedure Reference Lists under

Quick Links and look for:

– Codes that require an NDC

OR

– Services that Require Prior Authorization List or the DME Services

that Require Authorization List (NDC will be indicated in the Key

column if it is required)

15

NDC Format

• NDCs must contain a valid 11-digit number (no spaces,

hyphens or extra characters) in a 5-4-2 format.

• The first five digits identify the manufacturer of the drug

and are assigned by the Food and Drug Administration.

• The other digits, which are assigned by the manufacturer

of the drug, identify the specific product and package size.

• If an NDC is less than 11 digits, add leading zeros to the

appropriate segment to create the 5-4-2 configuration.

16

NDC format on label Convert to 5-4-2 format

4-4-2: xxxx-xxxx-xx 0xxxxxxxxxx

5-3-2: xxxxx-xxx-xx Xxxxx0xxxxx

5-4-1: xxxxx-xxxx-x Xxxxxxxxx0x

Submitting the NDC

Claim How to Submit

Electronic

claims

Follow the 5010 837 X12 standard

CMS-1500

claim form

In box 24A-24G – in the shaded portion

Enter the NDC qualifier of N4

Followed by the NDC number (see format above)

Enter one space for separation

Enter appropriate unit of measure (F2, GR, ML or UN)

Enter the quantity

UB-04

claim form

In box 43

Reimbursement

18

Reimbursement

• Log in at hap.org

• Check the appropriate Fee Schedules under Quick Links

19

Claims Appeals/Adjustments

20

Claims Appeals/Adjustments

• To eliminate duplication and ensure a more efficient, timely

means of resolution, please use one of the options below

when appealing claims.

• Important: Please do not fax claims appeals and do not

submit medical records.

21

Claims Appeals/Adjustments

1. Call HAP’s Provider Inquiry department at (866) 766-4661

• Hours: Monday through Friday from 8 a.m. to noon and 1 p.m. to 5 p.m.

• Please have the following information available when calling:

– Provider Name

– Provider NPI

– Provider Tax Identification Number (TIN)

– Member’s Name

– Date of Service

– Total Amount Billed

22

Claims Appeals/Adjustments

2. Use HAP’s online claims application for claims adjustments.

• Log in at hap.org; Select Claims; Search for claims that you wish to

appeal.

• Select from one of three options:

23

Option Use when

Appeal-

referral appeal Claims and authorizations do not match

Payment Amount-

Underpayment

You think HAP did not pay the appropriate amount for a

claim based on your contracted rates

Payment Amount-

Overpayment

You think HAP paid you too much for a claim per your

contracted rates

Include the required information in the notes section:

Reason for submitting appeal/adjustment request

Contact name

Phone number

Email address (add this in the notes field)

Note:

For any appeals that do not fall into one of the options above, please select

option 2—Payment Amount-Underpayment

If “Ineligible” displays in the column “Request Appeal,” contact Provider Inquiry

at (866) 766-4661

Medical Appeals

24

Medical Appeals Process

• Examples of denials that may be appealed:

– Referral/Pre-certifications: Failed medical appropriateness,

retroactive requests, out-of-network service, non-covered benefit .

– Admissions: Failed medical appropriateness, late notification, no

call-in.

• Appeals are defined as:

– Administrative: requests from providers to review an adverse

determination of a decision involving contract or HAP rules.

– Medical: requests from a provider to review an adverse

determination of a decision involving medical necessity.

25

Submitting Medical Appeals

• For an adverse organization determination decision made by HAP:

– Fax: (313) 664-5904

– In writing: HAP Practitioner/Provider Appeals – Mail Code 010

2850 West Grand Blvd.

Detroit, Michigan 48202

• For an adverse organization determination decision made by HAP for

psychiatric or chemical-dependency related decisions:

– Fax: (313) 664-8686

– In writing: Medical Director for Behavioral Services (Level I)

Coordinated Behavioral Health Management

2850 West Grand Blvd.

Detroit, Michigan 48202

26

Level 1 Appeals

• The practitioner/provider has sixty (60) calendar days from the date of

the denial letter to appeal HAP issued denials.* All cases that do not

contain clinical information will be denied, reconsiderations require

providers to file a Level 2 appeal.

– The table below outlines the appeal type and process to follow.

27

Appeal Type Process

Medical 1. The Medical Director, pharmacist or designated clinical staff review the

appeal. Note:

The decision maker responsible for the initial adverse determination decision

cannot review the appeal.

The decision maker may consult, as necessary, with board-certified licensed

physicians or other clinical professionals from the appropriate specialty.

1. Decisions are based on medical necessity.

Administrative 1. HAP staff reviews the appeals using HAP business rules. Note:

The decision maker responsible for the initial determination will cannot

review the appeal.

eviCore 1. eviCore processes commercial cases only.

2. Medicare claims must be submitted to HAP.

3. Appeals are processed using their contracted timeframe of 45-days.

Note: For networks with delegated utilization management agreements, Level 1 appeals should

be directed to your managed care office.

Level 2 Appeals

• The provider has sixty (60) days from receipt of the Level 1 appeal to

submit a Level 2 appeal.* All appeals will be processed within 45 days

of receipt.

• *Appeals received after 60 days from the date of the denial will not

be accepted.

• All determinations will be communicated to practitioners by mail.

• For questions regarding the appeal process, contact HAP’s Provider

Inquiry department at (866) 766-4661.28

Appeal Type Process

Medical 1. HAP medical directors and clinical leadership review appeals.

2. Clinical information is presented, reviewed, and a determination is made.

Administrative 1. Utilization management leadership and Provider Services review administrative

appeals.

2. Facts are presented and consideration is given for extenuating circumstances that

may necessitate overriding HAP policy.

Decisions from this committee are final unless provider contract dictates specific actions.

EviCore HAP processes all level 2 appeals

Get to know HAP Restore

29

Get to Know HAP Restore

• HAP’s Restore program is designed to help our members with chronic

conditions better manage their own health and make sure they’re

getting the best care possible at all times.

• HAP Restores helps in more ways than one because it’s made up of

three different, highly effective programs:

– CareTrack® Disease Management

– Restore Case Management

– Comfort & Palliative Care

• If you know of or are treating a HAP member who would benefit from

additional assistance or for more information about any of HAP’s

Restore programs, call (800) 288-2902 or email Restore@hap.org.

30

CareTrack Disease Management

• Restore CareTrack helps members manage their chronic conditions by

providing resources that encourage smart choices. The purpose is to

help them keep their prescribed treatment plans. To achieve that, a

nurse health coach works closely with each member. The CareTrack

program includes:

– Telephone coaching to give encouragement and support

– A three-month condition management teaching program

– Medication monitoring

– Monitoring for behavioral and emotional triggers relative to the treatment

plan

– Health reminders for screenings and tests

31

CareTrack Disease Management

• Members age 18 and older qualify for CareTrack if they are high risk

with any of the following conditions:

– Asthma (Members five years old and older with asthma are included)

– COPD

– Coronary Artery Disease (CAD)

– Diabetes

– Heart failure

• CareTrack also addresses the following as co-morbid conditions to the

above:

– Depression

– Hypertension

– Obesity

32

Restore Case Management

• This innovative program assists members requiring intensely focused

care coordination due to complex conditions and those transitioning

from one care setting to another.

• In order to minimize return visits to the hospital or emergency room, the

program helps these members understand the requirements of their

health status. It also helps reduce any barriers that might interfere with

the services they need.

• An RN from HAP will work closely with each member’s health care

provider to ensure the member is getting the right care when it’s

needed, including:

– Navigating through the local health care system

– Scheduling tests, procedures and appointments

– Addressing medical, therapeutic and polypharmacy issues

– Secure home care, medical supplies and durable medical equipment when

needed 33

Restore Comfort & Palliative Care

• The Restore Comfort & Palliative Care program is a pre-hospice

program for members with end-stage terminal conditions.

• It provides in-home health care services that combine both curative and

palliative treatment options.

• Members have access to care 24 hours a day, seven days a week.

• The goal is to support the member through their terminal illness, while

reducing the need for repeated emergency room visits and inpatient

hospitalizations and to eventually transition care to hospice services

when appropriate.

• To refer a member to the Comfort and Palliative Care program, call

(313) 664-8324.

34

Cigna

35

Cigna

• Cigna has a strategic alliance with HAP, which includes

ASR Health Benefits (an affiliate company of HAP), to

jointly offer medical benefit plans in select geographic

areas.

– Individuals with coverage through this strategic alliance will have an

ID card issued by Alliance Health and Life Insurance Company

(HAP), ASR Health Benefits (ASR), or Cigna (including GWH-Cigna

and “G” ID cards) that contains both company logos.

– The HAP service area is located in the following Michigan counties:

Arenac, Bay, Genesee, Huron, Jackson, Lapeer, Livingston, Iosco,

Isabella, Macomb, Monroe, Oakland, Ogemaw, Sanilac, Saginaw,

Shiawassee, St. Clair, Tuscola, Washtenaw, and Wayne.

36

Cigna Claims Submission

• Please submit all claims for these patients directly to

Cigna using Payor Code 62308.

• Any claims submitted directly to HAP will be rejected with

error code 116 – Claims Submitted to Incorrect Payor.

You will need to resubmit your claims to Cigna.

• Claims submitted to Cigna are subject to HAP and Cigna

claim edits.

37

Cigna Claims Submission-

Electronic

• Cigna strongly encourages electronic claims submission,

including coordination of benefits (COB) claims.

• There are two options to submit claims electronically:

– Post-n-Track® - The Post-n-Track Web service is available at no

cost to health care professionals that participate in the Cigna

network. To enroll in this Web service, call (860) 257-2030, or visit

Post-n-Track.com/Cigna.

– Other EDI vendors - A list of electronic data interchange (EDI)

vendors and transactions that Cigna supports is available at

Cigna.com/EDIvendors. If you have questions about transactions

submitted through your EDI vendor, please contact the vendor

directly.

38

Cigna Claims Submission-

Paper

• Find the appropriate address to submit claims on the back of the

Cigna customer’s ID card.

39

Cigna Reference Guide

• You can find a reference guide specific to HAP on Cigna’s

website. Visit:

– https://cignaforhcp.cigna.com

– Select Resources

– Select Reference Guides

– Select View Documents under Medical Reference Guides

– Select HAP Quick Reference Guide

40

Contact Information

41

Claims, Eligibility and Training

42

For Contact

• Claims status• Claims appeal status

• Provider Inquiry Department: (866) 766-4661

(Monday through Friday 8 a.m. to noon and 1 p.m. to 5 p.m.)

• Please have the following information available:

• Provider Name, NPI, Tax ID Number (TIN)

• Member’s Name• Date of Service and Total Amount Billed

• Member benefit and

coverage information

Note: For HAP Preferred refer to

the back of the member's ID card for TPA contact information

• Provider Automated Services (PAS) 24/7: (800) 801-1766

• If you can’t retrieve the benefit information or have a discrepancy with

the information provided, email: PI_benefitdiscrepancy@hap.org

(Note: If you do not receive an immediate acknowledgment of your

email, please confirm you have entered the correct email address.)

• Allow up to 24 hours (one business day) for a response

• If the patient is in the office, mark the email URGENT and allow 15-30

for a response

• Provider education training

• Provider portal access

• Password resets

• Online Authorizations—(CareAffiliate) application help

• Provider Services Department: (866) 766-4708

Utilization Management Staff

43

For HAP Department Contact Information

Admissions

Transfers

Inpatient review

Skilled nursing facility

Rehab

Admissions Team

(313) 664-8833

Outpatient authorizations and services

DME

Homecare

Home infusion

Hospice

Referral Management Team Monday – Friday

8:00 a.m. – 4:30 p.m.

(313) 664-8950

Case management Case Management Monday – Friday

8 a.m. – 5 p.m.

(800) 288-2902

Pharmacy Services Pharmacy Monday – Friday

8:00 a.m. – 4:30 p.m.

(313) 664-8940

Behavioral Health Services Coordinated Behavioral

Health Management (CBHM)

Monday – Friday

8 a.m. – 5 p.m.

(800) 444-5755

Questions?

44