October 2, 2018 CHOICE & HHAeXchange · 2018-10-04 · HHA Exchange provider portal. Providers will...
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October 2, 2018 CHOICE & HHAeXchange
Transcript of October 2, 2018 CHOICE & HHAeXchange · 2018-10-04 · HHA Exchange provider portal. Providers will...
October 2, 2018
CHOICE & HHAeXchange
2CONFIDENTIAL Discussion Draft
CHOICE transitions to HHAeXchange as of October 8, 2018.
All Wave 1 providers will be required to accept/deny cases through HHAeXchange starting on this date.
CHOICE will roll out 2 additional waves of providers through the end of the calendar year.
HHAX Implementation
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End to End Process
CHOICE creates authorization
HHAX receives authorization &
places with a provider
Provider accepts/denies case
Provider enters services via EVV or manually via Provider Portal
Services are reviewed in
Prebilling
Clear Prebilling?
837i - Sent for adjudication
Provider required to fix in
HHAeXchange
Claims & 835 file generated
No
Yes
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Member Placement Process
Current Contract Administration currently sends referrals
to Providers through the VNSNY placement portal
Providers accept and decline referrals through VNSNY placement portal
Providers have 20 minutes to accept or decline a referral.
– If referrals time out, providers can request additional time
– Contract Admin works with you to extend the time as necessary.
Future: HHAX CHOICE Care Management and Contract Administration will
send referrals to Providers through the HHA Exchange provider portal as opposed to the VNSNY Placement portal.
Providers will accept or decline referrals directly through HHA Exchange provider portal.
Providers will continue to have 20 minutes to accept/decline a referral.
If referrals time out on portal, providers can continue to request additional time by reaching out to Contract Administration.
– Referral types processed through the HHA Exchange portal include HHA, PCA, Consumer Direct and vendor changes
– On occasion referrals will be broadcasted to multi-providers
– Contract Admin will continue to oversee and manage case acceptance process.
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AUTHORIZATIONS
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Authorization Process
Current No authorization number is required for
placement of referrals through OPS by Contract Administration
Future: HHAX All referrals will be assigned an authorization number
Provider is responsible to:– Verify member information using V# - V# indicates LOB
The authorization will be for 180 days or as specified
Universal Billing codes will replace service type codes on referrals
Total Bucket = Provider to manage hours based on authorization of full 180 days. The units authorized should span the full length of the delivery of care dates.
*Services to member ends upon the ‘end date’ in authorization even if member shows as ‘Active’ in HHAX
Reauthorization required? Send a communication note to Contract Administration
and CA will notify Care Management of request
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Authorization Ends– A member should only receive authorized services based on the start
of care and end of care dates. – If a member shows in queue but the authorization dates have lapsed,
send a communication note to Contract Admin requesting an updated authorization
– Contract Admin will coordinate with nursing staff based on member medical necessity.
Disenrollment– The member, though inactive, may not immediately drop from the
provider list. Therefore it is critical the auth end date be the source of truth for authorized services.
Member Authorization Ends & Disenrollment
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It is the responsibility of the LHCSA to maintain the POC.– Enterprise providers must maintain the POC in HHAX– For all other providers, maintain the POC outside of HHAX
It is at the discretion of VNSNY CHOICE to request member POC details at any time for audit purposes
Plan of Care
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COMMUNICATION NOTES
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Providers are required to use communication notes in HHAX to communicate with VNSNY CHOICE. – Follow existing protocols as outlined in Contract Admin’s SLAs.
Contract Admin Service Level Agreements) SLAs will remain the same:– For Urgent Communications: Responses are required within Same Business
Day– For Non-Urgent Communications: Responses are required within 24-48 hours
unless otherwise specified.
Scenarios for communication notes– Member demographic information must be updated– Questions regarding order – Request ‘Travel Time’– Request ‘Over Time’– Interruption of Care (black out dates used)– Member death
Communication
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A request for Travel Time due to missed visit by member
Mark visit as ‘missed’ & OMIG reason code
Send Travel Time request to Contract Admin
Contract Admin will coordinate with nursing staff for either an approval or denial of Travel Time
After the request has been processed by Contract Admin, an approval/denial note will be sent back to the Provider via HHAX portal.
Travel Time
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Over Time is to be used only for emergency situations requiring special accommodation (i.e. member hospitalization)
A request for Over Time:
Send communication note requesting over time and reason for over time ask
Contract Admin will coordinate with nursing staff for an approval/denial
Contract Admin will send back a communication note notifying of decision and associated auth information (if applicable).
Over Time
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Service Interruptions (Black Out Dates)
Black-out dates are utilized in HHAX if there is an interruption of care (ex: patient is hospitalized, on vacation, etc…)– Contract Admin blacks out dates in HHAX for up to 15 days– Provider is notified via an automated HHAX communication note that
the dates have been blacked out.– Contract Admin will be notified by CHOICE Care Management to
resume service once member returns home– Contract Admin will update existing authorization in HHAX to resume
service– Provider is notified via an automated HHAX communication note to
resume service
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VISIT CONFIRMATIONS
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Manual visit confirmations require a timesheet (see slide 16)
All providers contracted with VNSNY CHOICE must maintain timesheets outside of HHAeXchange.
During an audit, VNSNY expects providers to show proof of timesheets in order to validate services rendered.
Timesheets
Missed Visits
If a visit is missed due to member no-show– Mark off ‘missed visit’ in HHAX to allow services to pass PreBilling– Indicate the missed visit reason using OMIG reasons and the action
taken
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Provider Portal Entry: Replacement of Duty Sheet
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PREBILLING
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Prebilling will stop any service entered by a provider from ‘going out the door’ if it does not align with the authorized services and/or number of hours.
Example of Prebilling Issue:
Overlapping shifts: an aide enters in two services with overlapping times. This is not allowed by CHOICE and will sit in prebilling until corrected.
Mutual Cases: the appropriate modifier must be present on the authorization to allow this exception. If the modifier is incorrect, send a communication note requesting correction.
Have a Prebilling issue?
Contact: [email protected]
What is PreBilling?
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BILLING
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Original/Corrected Claims
Sent to VNSNY CHOICE for adjudication. Contact the Provider Call Center within the first 2 weeks for status of claim after HHAeXchange has resubmitted the claims.
835s are received
Upload remittance
Claims Process – Original & Corrected Claims
Need additional help to resolve a claims issue?
Call CHOICE Provider Call Center: 1-866-783-0222
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Claim Process – Resubmitting a Claim
Un-bill the visit (if on the same day AND before overnight process). If visits were invoiced on the same day and need to be corrected:
1. Navigate to Billing >Invoice Search > By Visit2. Select either Delete Visit or Delete Visit and Confirmation3. Make corrections (such as Service Date, Service Code, Hours)4. Generate new Invoice
Rebill the Visit (for the next day AND overnight process occurred; 835s have been sent). Providers cannot un-bill billed claims. Wait to receives the 835 and complete:
1. Un-post payment (if applicable)2. Indicate the date of service to be rebilled on spreadsheet form (include
TRN) and include the Service Code and Schedule Start/End Time3. Request rebilling by creating a ticket with the spreadsheet and send to
[email protected]. Support emails
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GRIEVANCE & APPEALS
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Providers may file appeals disputing a denial issued as a result of a utilization management decision, a claims denial (ie: no authorization; provider not contracted to perform services; submit claim to primary carrier) or if they disagree with the amount paid on a previously processed claim.
All appeals must be filed in writing and must include all relevant information, including medical records, if applicable. The address to submit appeals is:
VNSNY CHOICE Health Plans
Grievance and Appeals
P.O. Box 445
Elmsford, NY 10523
Grievance & Appeals
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Timeframe for Filing Appeal:
60 calendar days from the date of the denial/initial determination, unless the provider’s contract allows for additional time to file.
Acknowledgment Letter Timeframe:
Within 15 business Days from receipt of the appeal, Grievance and Appeals will send a written acknowledgment letter.
Resolution Timeframe:
Within 60 calendar days from receipt of the appeal.
Appeals that involve a medical necessity, experimental or investigational decisions may be further appealed through the State’s external appeal process.
Some facilities also have the right to file an appeal with a Dispute Resolution Entity. Please refer to your provider contract to determine if this right applies to you.
Grievance & Appeals Cont.
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Contact Information
Follow up questions to today’s webinar?
Email: [email protected]
Looking for HHAX materials, please visit our site:
http://vnsnychoice.org/health-professionals
Questions regarding 837 claims denial/payment?
Provider Call Center: 1-866-783-0222
