UniNet Spring Updates

Transcription

1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions UniNet Spring Updates Tonya Yale March/April 2016

2 Aetna s Values Wheel 2

3 Aetna Project Update Aetna Commercial member claims may have been processed at a lower expected reimbursement 7/1/15-8/31/15. Aetna Whole Health rates were connected to Aetna s commercial rates for UniNet providers from 7/1/15-8/31/15 Project was submitted 2/26/16 included ALL UniNet providers Projects take typically days to complete but this project is very large. ETA on a completion date is not available yet All claims for UniNet providers will be reprocessed with DOS 7/1/15-8/31/15 3

4 Aetna & Coventry Newsletters Stay up to date with quarterly newsletters Aetna OfficeLinkUpdates Located on Health Care Professionals, Newsletters and News Coventry Provider News Located within the News section of or Services & Support, Providers, Announcements/News 4

5 National Precertification List (NPL) Aetna and Coventry will have one participating provider precertification list effective April 1, 2016 NPL can be found on both aetna.com and chcnebraska.com NPL is updated semi-annually in January and July No changes of where to call or submit authorization requests 5

6 Clinical Policy Bulletins Aetna and Coventry both use Aetna s Clinical Policy Bulletins View medical and pharmacy Clinical Policy Bulletins (CPBs) online through aetna.com or NaviNet: Aetna.com, Health Care Professional, Clinical Policy Bulletins NaviNet.net, Aetna Health Plan, Resources, Clinical Policy Bulletins 6

7 Observation Notifications Online Send Aetna observation notifications over 24 hours electronically Use the secure provider website on NaviNet to notify us about observations over 24 hours: From Precertification Submission, enter the patients information On the next screen, choose Medical then Outpatient Select an outpatient place of service in step 3 In step 5, be sure to include an observation CPT code. Also include the number of hours you ve been observing the patient as the time of your notification Coventry observation notifications may be entered in Directprovider.com 7

8 Provider Demographic Information Help us ensure our Medicare directories are accurate The Centers for Medicare & Medicaid Services requires that Medicare Advantage plans and Qualified Health plans maintain accurate directories. Having the most up-to-date contact information allows us to do that. Check our directories and if there are changes to be made, please let us know. Aetna updates Submit through NaviNet.net Coventry of Nebraska updates Submit to Coventry in writing by faxing to

9 Provider Office Manuals Aetna and Coventry s provider office manuals are available on our websites and keep you informed Aetna provider office manual Aetna.com, Health Care Professionals, Education & Manuals, Explore provider manuals Navinet.net, Aetna Health Plan, Resources Coventry provider office manual chcnebraka.com, Providers, Document Library, Commercial Guides/Manuals 9

10 2016 Commercial Risk Adjustment Program This Coventry Health Care program identifies patients enrolled in individual or small group plans either on or off the health insurance exchange that have or are at risk for acute and chronic conditions. We can help you manage patient care through proper medical record documentation, coding and billing. To help in these efforts, you can: Schedule health assessments for your Coventry and Aetna patients Provide medical records to our vendors: Your Home Advantage (YHA), Episource, Verisk and ArroHealth Evaluate health conditions and document them in medical records and claims 10

11 2016 Commercial Risk Adjustment Program Member Assessments Your patients can schedule a free assessment with our vendors. Or they can schedule one at your office. We ll share the information from the vendors with you to coordinate care. Prepare for record requests Our vendors will retrieve records on our behalf, so submit them upon request. This helps us identify patients with documented medical conditions that qualify for risk adjustment. Improve documentation Remember to evaluate and document the treatment of all conditions at each encounter and for each date of service. For more information, view the webinar on the Commercial Risk Adjustment program found on 11

12 Healthcare Effectiveness Data and Information Set (HEDIS) Collection Help us collect HEDIS data Our staff or a contracted representative from ArroHealth or Healthport may be contacting you soon to collect medical record information on Coventry and Aetna patients You will still get separate requests from Coventry and Aetna, since there are different claims payment systems If contacted, we ask that you provide timely access to our members medical records The representative will work with you and give you options for sending medical records 12

13 Referring In Network Help patients save and stay in network When you issue referrals or recommend a consult/procedure, refer members within their specific networks. Aetna Provider Search - Docfind Aetna.com, Find a Doctor, Select the members plan within your search Coventry Provider Search chcnebraska.com, Find a Doctor, Enter provider search, Select the members plan 13

14 Provider Specific Networks In Douglas, Sarpy & Pottawattamie counties the following high value networks exist with specific networks for members of that plan: 1. Aetna Whole Health CHI Health Accountable Care Network 2. Carelink from CoventryOne - CHI Health Alegent Creighton Health (HMO) 3. Coventry Total Care with Alegent Creighton Health (Medicare Advantra HMO) Three networks above primarily include CHI Health facilities and providers, UniNet PHO providers and facilities; and Children s Hospital and Medical Center You must participate with Coventry and Aetna through UniNet to be considered IN network for these plans 4. Carelink from CoventryOne - Methodist Health Partners (HMO) Network primarily includes Methodist PHO providers and facilities and Children s Hospital & Medical Center 5. Carelink from CoventryOne - MIPPA (POS) Network primarily includes MIPPA contracted providers, Methodist PHO facilities and Children s Hospital & Medical Center 6. Carelink from CoventryOne - Nebraska Health Network (HMO) Network primary includes Nebraska Medicine providers and facilities, Methodist PHO providers and facilities, Children s Health Network and Children s Hospital & Medical Center 14

15 Provider Specific Networks ID Cards 15

16 Digital Aetna Member ID Cards Aetna Member ID cards on a smartphone Aetna members have easy access to a copy of their most up-to-date member ID card online Please accept this as a valid proof of insurance coverage You should expect to see an increasing number of members using this technology in the future See handouts for additional information 16

17 Aetna Policy and Coding Updates Aetna clinical payment, coding and policy changes Effective 3/1/16 we will allow times per year. This frequency limit is based on a rolling year (12 months), from the time the service is first rendered. Modifier 59 Effective 6/1/16 our Modifier 59 policy will apply to facility claims. Payment for professional services Effective 8/1/16 according to Aetna policy, professional services billed by a hospital on a UB form are to be denied. 17

18 Coventry Policy and Coding Updates Coventry clinical payment, policy and coding updates The Radiation Therapy policy is effective on 3/15/16 not 10/15/15 as stated in a previous newsletter. This policy limits payment and frequency of certain radiotherapy procedures. For more information please reference the July 2015 Coventry provider news. Policy reminder: 3D Mammograms as a reminder Coventry does not cover 3D mammograms for our commercial members. 3D mammograms are covered for Medicare members. You can read more in our Clinical Policy Bulletins. 18

19 Aetna Signature Administrators (ASA) Send ASA claims to the correct payer As a reminder, you should send all claims for ASA members electronically to the payer ID listed on the member s ID card. Send paper claims only to the address listed on the ID card. Direct all ASA claim questions to the appropriate payer on the ID card. The payer will process the claims and contact Aetna as needed. Recognizing ASA members The ID card generally has two logos: Payers logo Network logo - Aetna Signature Administrators For more information, please see additional handout. 19

20 First Health Network Professional Only First Health Network Professional Only Network (PON) is a subset of the First Health Primary network. First Health Network PON is the network and not the payer First Health Network PON includes a network of physicians, ancillaries and other non-hospital provider types Reimbursement for providers is the same rate for the PON as it is for the standard First Health Network Hospital claims are reimbursed at a reference based pricing which is usually a percentage above Medicare 20

21 2016 CMS Compliance and Fraud, Waste and Abuse Training Requirements Aetna 2016 attestation site changes to NaviNet First tier, downstream and related entity (FDR)s must meet CMS compliance requirements annually Two options for completing the required training are through CMS or through NaviNet Complete your 2016 attestation on NaviNet with no limits on attesting for more than 20 tax id numbers The attestation on NaviNet is for both Coventry and Aetna Read our FDR Compliance Newsletter, a link is located within the January 2016 Aetna OfficeLink Update Additional questions can be directed to MedicareFDR@aetna.com and additional information can be found on 21

22 Coventry Trainings 22

23 Coventry Trainings chcnebraska.com

24 Aetna Trainings 24

25 Aetna Trainings aetnaeducation.com 25

26 Service Center Contact Information 26

27 Thank you Copyright 2016 Aetna Inc.

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29 Provider esolutions Digital Member ID Card Initiative Our Strategy - We have introduced Digital member ID cards to our members. The initiative is driven by several factors; growth in the broad market, acceptance of smartphones and Aetna s consumer business offering digital ID cards to members. We believe that digital ID cards are an opportunity to further promote awareness of self-service solutions. We also have the opportunity to direct members and providers to digital assets for ID cards and coverage information. The member s digital ID card is identical to their physical ID card and can be viewed, downloaded or printed by the member from Aetna Navigator, the Aetna Mobile app, or by visiting Aetna.com from a smartphone s internet browser. Members can show their digital card to their doctor. Effective in 2016, member requests for additional cards will be directed to self-service options to access a digital ID card. Certain member ID card updates will result in a plastic ID card mailed to the member, such as a name change or dependent change. When we have a member s on file, less critical ID card updates will only be applied to the digital ID card. A plastic card will be mailed if there is no on file for the member. o If a member calls Member Services and indicates they don t have access to any technology to view a digital ID or prefer to have a plastic ID card, the CSR will issue a plastic card. Our goal is to deliver a simpler, more connected experience for our members. To minimize confusion, we cannot support requests to opt-out of a digital ID card. There are some exceptions to these changes to duplicate ID card requests Certain states require us to produce and mail a physical card. Members will continue to receive plastic ID cards as they always have in the following states: Colorado Minnesota New Hampshire In addition, all Medicare and Medicaid members, Coventry members on the IDX platform and new commercial members will continue to receive plastic ID cards. At this time, our new Leap/consumer plans are the only all-digital member ID plans.

30 Communications - We ll be communicating this new digital strategy to our member and provider population throughout Provider esolutions is actively communicating this new strategy to providers. We will do so by reaching out to targeted providers through an and direct-mail campaign. In addition we will be utilizing NaviNet communication channels to help deliver this message. Our Targets - Aetna s network uses our secure provider website on NaviNet to access claims and account management transactions and tools. This includes using the eligibility and benefits transaction where providers can view or download the digital member ID. Provider communications will focus on: Reminding providers that ID cards on smartphones and self-printed, paper copies are acceptable alternatives to plastic ID cards Promotion of eligibility and digital ID cards as an alternative to physical ID cards Promotion of electronic features such as sustainability, security, ease-of-use and accuracy Direction to access digital member ID In November and December of 2015, we reached out to these providers with an campaign. We are continuing this campaign through-out 2016 with an each month. In addition, we ll send two post-cards later in 2016 to targets that we see are not utilizing the digital member ID functionality. Throughout 2016, we will also have messaging posted on NaviNet plan central. Provider access to digital member ID s - Providers can access copies of an Aetna patients member ID card right from our secure provider website and on Availity. The digital ID card is an electronic version of the Aetna member s ID card and allows provider s to easily get all of the information they need. On NaviNet, security officers are automatically enabled to access member ID cards. All other users must be enabled by their NaviNet security officer to begin accessing member ID cards. The security officer must go to Administration>Manage User Permission. They should then enable the Member ID Card functionality. Once access has been granted, the user can begin accessing member ID cards immediately

31 To access the electronic image of the member ID card on NaviNet, users must first submit an eligibility and benefits request for a member. An image of a generic ID card is displayed on the eligibility details screen. A small image displayed on the eligibility response screen is not the actual member ID card. Users should not print this small image. The user must click the image to open a copy of the member ID card. The digital version of the member ID card will open with a PDF. The digital copy of the ID card can then be downloaded to a computer as well as printed, saving time and additional work associated with card scanners and photocopying ID cards. If a member ID card does not display once the small generic image is clicked on, the user will receive the following message: The patient's ID card is not available to display. Note: The online ID card is a courtesy feature offered to assist office staff. The eligibility and benefits response provides sufficient details to determine patient benefits and coverage in absence of an ID card. Please note: only users enabled to access member ID cards will receive this message. On Availity, all users can access member ID cards. To access the digital member ID card on Availity, users must first submit an eligibility and benefits request for a member. When a successful eligibility response is returned, a link to access the ID card is displayed on the response screen. Member ID cards will display for most Aetna members A card will be generated only if the Aetna system which produces the card has the member information. Display of member ID cards is limited by the plan sponsor s request to generate/regenerate physical ID cards. ID cards may not be available for a small number of plan sponsors. If the ID card is not available, the eligibility and benefits response provides sufficient details to determine patient coverage and benefits in absence of an ID card. An eligibility and benefits inquiry can be submitted using the member s name and date-of-birth. Information displayed on electronic member ID card The information displayed on both the digital and plastic member ID card is identical. The digital ID card is generated from the same system that generates the member s physical ID card. If a change was made to a member s benefit plan, those changes may not be reflected on the electronic ID card for approximately two business days following when the updates were made within Aetna systems. Therefore, information viewed within the

32 eligibility response and what is noted on the electronic member ID card, may be different. Provider questions related to accessing electronic ID cards or technical issues with NaviNet - Users should first contact their NaviNet Security officer within their facility. If a technical question cannot be answered by the NaviNet Security Officer, they should then contact NaviNet Customer Care at Users may access the Electronic Member ID Card help document within the NaviNet support center Provider questions related to accessing electronic ID cards or technical issues with Availity - Technical questions should be directed to Availity Customer Care at Provider questions related to content displayed on the digital card - Users can access information from our online tools and resources within NaviNet. If information is not accessible from our online tools, contact the phone number listed on the member ID card.

33 Accessing member ID cards on the secure provider website on NaviNet NaviNet users have access to member ID cards electronically To access the electronic image of the member ID card, users must first submit an eligibility request for a member. When a successful eligibility response is returned, an image of a generic ID card will display on the response screen. When the image is clicked, users will be presented with a copy of the member s ID card. The copy of the ID card can then be downloaded to a local computer or network as well as printed, saving time and additional work associated with card scanners and photo-copying ID cards. Example of electronic member ID card

34 Image of member ID card displayed on eligibility response screen The small image displayed on the eligibility response screen is not the actual member ID card. Users should not print this small image. The user must click the image to open a copy of the member ID card. The electronic version of the member ID card will open with a PDF. The copy of the member ID card can then be downloaded to a local computer or network, as well as printed. NaviNet user access to member ID cards NaviNet security officers are automatically enabled to access member ID cards. All other users must be enabled by their NaviNet security officer to begin accessing member ID cards. The security officer must go to NaviNet Central > Administration and select Manage User Permissions. They should then enable the Member ID Card functionality. Once access has been granted, the user can begin accessing member ID cards immediately. Member ID cards will display for most Aetna members A member ID card will display for most members. It will be generated only if the Aetna system which produces the card has the member information. Availability of a member ID card is limited by the plan sponsor s request to generate/regenerate physical ID cards. ID cards may not be available for a small number of plan sponsors. However, the eligibility and benefits response provides sufficient details to determine patient coverage and benefits in absence of an ID card. o Member ID card does not display If a member ID card does not display electronically once the small generic image is clicked on, the user will receive the following message: The patient's ID card is not available to display. Note: The online ID card is a courtesy feature offered to assist office staff. The eligibility and benefits response provides sufficient details to determine patient benefits and coverage in absence of an ID card. Please Note: only users enabled to access member ID cards will receive this message. Electronic member ID card versus the physical member ID card

35 The information displayed on both member ID cards is identical. The electronic member ID card is generated from the same system that generates the member s physical member ID card. Discrepancies in what is viewed within the eligibility response and what is noted on the electronic member ID card If a change was made to a member s benefit plan, those changes may not be reflected on the electronic ID card for approximately two business days following when the updates were made within Aetna systems. This may occur more frequently during times of open enrollment. Questions related to accessing electronic ID cards or technical issues with NaviNet o Users should first contact their NaviNet Security officer within their facility. o If a technical question cannot be answered by the NaviNet Security Officer, they should then contact NaviNet Customer Care at Questions related to content displayed on the electronic card o Users can access information from our online tools and resources within NaviNet. o If information is not accessible from our online tools, contact the phone number listed on the member s ID card.

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37 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Quick overview Aetna Signature Administrators Aetna Signature Administrators enables us to extend our services to additional plan sponsors with preferred provider organization (PPO) plans. We have established relationships with a limited number of payers, which include leading third-party administrators and carriers. These payers meet our standard requirements and agree to follow our policies and procedures. Member ID cards have both the Aetna Signature Administrators and payer logos and list the payer s phone numbers for questions. Aetna Signature Administrators is an alternative distribution approach for our PPO product. Aetna and the payer share responsibility for servicing PPO customers. Aetna s responsibility Provide stop loss insurance coverage Handle claims pricing Direct contract with self-funded plan sponsors Provide network access services and management Resolve provider contract issues Provide case management and medical management options Payer s responsibility Handle claims processing/adjudication Provide customer service Design plans with benefits differentials to provide incentives for patients to seek care from participating physicians and facilities (generally at least 20 percent) Manage precertification using Aetna standards and approved criteria Manage appeals using Aetna-approved criteria F (10/15)

38 Payer Payer website Payer ID Allied Benefit Systems AmeriBen Assurant Health Boon-Chapman Chesterfield Resources, Inc. (Administrator for The Salvation Army) Christian Brothers Services (Made available by Allied Benefit Systems) CNIC Health Solutions, Inc. Colonial Medical Insurance Company cnicee.asp see member ID card see member ID card Continental Benefits Employee Benefit Management Services (EBMS) Government Employees Health Association (GEHA) HealthSCOPE Benefits HealthSmart Benefit Solutions, Inc. see member ID card see member ID card see member ID card INDECS What does this mean to you? Contracts Since Aetna Signature Administrators is a distribution model for the PPO product, if the contract pertains to the PPO product, then it also pertains to Aetna Signature Administrators. Medical management The payer is the provider s contact for routine medical management. The payer s patient management phone numbers can be found on the member s ID card. In some cases, utilization management and case management are performed by Aetna-owned subsidiaries ActiveHealth or American Health Holding, Inc., and the patient management phone numbers will route the provider accordingly. Claims The payer handles all claims processing. The provider should send all claims electronically to the payer ID listed on the member s ID card. If not, send paper claims to the address listed on the ID card. Claims should not be sent to Aetna.* Claims questions and rework Providers should direct all Aetna Signature Administrators claims questions to the appropriate payer on the member s ID card. The payer will process the claims and will contact Aetna if needed. Verifying member eligibility The payer s phone numbers are listed on the member s ID card. Recognizing an Aetna Signature Administrators member The ID card issued by the payer generally has two logos: - Payer s logo - Aetna Signature Administrators logo Nippon Life Benefits (NLIA) SEIU Funds Trustmark Companies (Trustmark, CoreSource, FMH CoreSource, NGS CoreSource, Starmark) (select drop-down menu on the left to view individual third-party administrator sites) see member ID card WebTPA Exception there may be additional logos when the member lives in a rental/rural network area This statement will be reflected on the back of the ID card: Aetna participating doctors and hospitals are independent providers and are neither agents nor employees of Aetna. WellSpan Population Health Services see member ID card * The single exception to this occurs when an Aetna Signature Administrators member accesses one of our Institutes of Excellence facilities for transplant. Under this scenario, the facility will continue to use the Special Case Customer Service Unit as they do currently, including the submission of claims. Aetna Signature Administrators is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates Aetna Inc F (10/15)

39 ID card standards for payers A properly forfor network providers to identify First Health patients. Certain basic information m accessing the First Health Network. The sample health benefits ID card in this document meets all of our requirements. Submit new ID cards for approval before production You must get approval of all new ID cards before production. Contact your account manager for approval. To receive your copy of the logo, please contact your account manager. Employer s Name MEMBER NUMBER: EFFECTIVE DATE: 01/01/2011 GROUP NUMBER: ###### INSURED NAME: John Doe PPO OFFICE CO-PAYMENT: $10.00 MEDICAL COVERAGE Emergency Room: $XXX Family: $XXX SAMPLE Certain providers are not included under this network arrangement. Please contact the claims administrator for information. <Administrator contact information> Contact Information: Benefits/Eligibility 800-(carrier/TPA) Provider Locator Assistance Provider Locator Website This card does not guarantee coverage. This policy provides automatic assignment of benefits to the provider. Electronic (EDI) Claims should be sent to: Client s Payor ID: ###### All claims with itemized bills including diagnosis, should be mailed to: Client/Vendor, P.O. Box 1000 Anytown, USA SAMPLE Front of card: First Health Professional Only Network logo Back of card: Contact information, including: º Benefits/Eligibility: Payor s toll-free number º First Health s provider locator assistance toll-free number: º Provider locator website address for First Health: Payor s electronic payor ID for EDI claims Payor s address for submission of all claims Medical management company name and the phone number must be included if pre-certification is required 3713 (01/2016) First Health is a brand name of First Health Group Corp., an indirect, wholly owned subsidiary of Aetna Inc First Health Group Corp.