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Virginia Premier CompleteCare Provider Resource Guide.
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Virginia Premier CompleteCare Provider Resource Guide
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Transcript of Virginia Premier CompleteCare Provider Resource Guide.
Virginia Premier CompleteCare
Provider Resource Guide
Virginia Commonwealth University Health System Health Plan Division
Info in this Resource Guide
• Our Clearinghouses• Checking Eligibility• Getting an Authorization• Getting Help with Claims• Claims Submission• Scheduling Transportation• Contact Information• LTSS Authorization Information
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Virginia Commonwealth University Health System Health Plan Division
Our Clearinghouses
• Christina Chewning Phone: 813-363-5255 [email protected]
• Jennifer Nethery Phone: 800-981-8601 • [email protected]
Providers can go through either one of these clearinghouses to submit claims to us electronically.
We participate with:
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Virginia Commonwealth University Health System Health Plan Division
Checking Eligibility
• Please contact our Member Services call center to check a member’s eligibility.
• You can reach us at 1-855-338-6467.• A member’s eligibility must be checked through
Virginia Premier and not through CMS or DMAS.• If you have the Members Medicaid Number, you
may determine in which Health Plan the beneficiary has enrolled through the DMAS website
Call us!
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Virginia Commonwealth University Health System Health Plan Division
Checking Eligibility
• You can use our provider portal to check a Member’s eligibility
• The provider portal can be found here:https://www.vapremier.com/providers/provider-portals/
• Contact Provider Services to get signed up today! You can reach them at [email protected] or by calling our Provider Services line at 1-855-338-6467
• A member’s eligibility must be checked through Virginia Premier and not through CMS or DMAS.
Use our Provider Portal!
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Virginia Commonwealth University Health System Health Plan Division
Getting an Authorization
• Our Medical Management team is standing by to assist you with getting an authorization
• They can be reached at 1-888-251-3063• We also welcome your faxed authorization requests.
The authorization form can be found on our website and the fax number is 1-800-827-7192
Call us!
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Virginia Commonwealth University Health System Health Plan Division
Getting Help with Claims
• Our Customer Service Team is standing by to assist you with any claim issues you may be having
• Call us at 1-855-338-6467• Your Provider Service Representative or your regional
Long Term Services and Supports Manager can also help you with any issues that you may have
• You can reach them at [email protected] or by calling our Provider Services line at 1-855-338-6467
Call us!
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Virginia Commonwealth University Health System Health Plan Division
Getting Help with Claims
• You can use our provider portal to check the status of your claim
• The provider portal can be found here:https://www.vapremier.com/providers/provider-portals/
• Contact Provider Services to get signed up today!
• You can reach them at [email protected] or by calling our Provider Services line at 1-855-338-6467
Use our Provider Portal!
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Virginia Commonwealth University Health System Health Plan Division
Online Claims Submission
There are several ways!
• You can enter your claim using our provider portal or using one of our clearinghouses – Availity or RelayHealth
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Virginia Commonwealth University Health System Health Plan Division
Paper Claims Submission
Primary Care ProvidersCCC by Virginia PremierP.O. Box 4468Richmond, VA 23220-0207
Specialty ProvidersCCC by Virginia PremierP.O. Box 4468Richmond, VA 23220-0208
Hospital ClaimsCCC by Virginia PremierP.O. Box 4468Richmond, VA 23220-0120
Claims AppealsCCC by Virginia PremierP.O. Box 4468Richmond, VA 23220-0307
Transportation ClaimsCCC by Virginia PremierP. O. Box 4468Richmond, Virginia 23220-5287
Paper Claims should be submitted to the following addresses:
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Virginia Commonwealth University Health System Health Plan Division
Scheduling Transportation
• Please contact our Member Services call center to get help with scheduling transportation.
• You can reach us at 1-855-338-6467.
Call us!
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Virginia Commonwealth University Health System Health Plan Division
Contact Information
• 1-855-338-6467
Member Services
• 1-855-338-6467
Claims Customer Service
• 1-888-251-3063
Organizational Determinations
• 1-855-338-6467
Provider Services
• 1-855-338-6467
Case Management
Our Call Centers
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Service Facilitation / Consumer Directed Services
Virginia Commonwealth University Health System Health Plan Division
LTSS Authorizations
• All LTSS services shall require prior authorization and approval of services is based on the DMAS screening tools and criteria and LOC assessment and score if applicable.
• The PAS team should send all screening documents (UAI, DMAS-97 and DMAS-96) to Virginia Premier CompleteCare. The pre-authorization process allows Virginia Premier CompleteCare to:– Verify the member’s eligibility– Determine the services required to meet the Member’s need– Contact the member to review their chosen model of care delivery and agency preference if
they have selected to have agency directed care or adult day health care– Honor all prior authorizations or plans of care (POC)– Make sure that the chosen provider is in the Virginia Premier CompleteCare network– Evaluate the medical necessity criteria for the service– Update the members POC
Call Care Manager (1-855-338-6467)
Fax Forms (1-877-739-1363)
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Virginia Commonwealth University Health System Health Plan Division
Consumer Directed• If consumer directed care is selected, the Pre-Admission Screener
(PAS) must complete the DMAS-95 Addendum (DMAS-95A) and submit that to Virginia Premier along with the other screening tools once completed
• If the PAS does not complete the DMAS-95A at the time of screening and Virginia Premier’s care manager determines that the member desires to have consumer direction, the service facilitator will complete the DMAS 95A
• Virginia Premier’s care manager will contact one of its network service facilitators to schedule an in-home comprehensive assessment with the member which is documented on the DMAS-99
• To avoid duplication, Virginia Premier’s care manager will collaborate with the service facilitator to attend this face-to-face assessment and incorporate information into Virginia Premier’s initial member face-to-face assessment.
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Virginia Commonwealth University Health System Health Plan Division
Service Facilitator• The service facilitator will assist the member in completing their required forms for
PPL and all information associated with employing their attendant• The member will have follow up visits from the service facilitator and Virginia Premier
at 30, 60 and 90 days after the initial assessment to monitor the member’s ability to hire and maintain attendants and monitor the plan of care and level of services that are being given
• The member will have at least quarterly face-to-face visits with a reassessment every 6 months that is done by the service facilitator in collaboration with Virginia Premier’s care manager
• At the time of the reassessment, Virginia Premier will provide additional authorizations as needed.
• The service facilitator will be part of the member’s ICT• The DMAS 97 A/B must be completed annually and when there is a significant
change in the needs of the member• Virginia Premier’s care manager will complete the annual DMAS 99 C• Authorizations are valid for 180 days• Members may keep their service facilitator if out of network for 180 days of
enrollment or until their authorization expires. Virginia Premier will work with the service facilitator and member to avoid any disruption in care
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Virginia Commonwealth University Health System Health Plan Division
Authorizations and Care Management
Call (888) 251-3063
Fax
(877) 739-1363
To speak to a Care Manager
(855) 338-6497
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Virginia Commonwealth University Health System Health Plan Division
Thank You!
Thank you for participating with
VAPremier CompleteCare!
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