Welcome to Harvard Pilgrim

Transcription

1 Welcome to Harvard Pilgrim

2 Objectives At the close of this session, you should Be able to locate and use information about Harvard Pilgrim s diverse product portfolio Understand Harvard Pilgrim s administrative requirements for contracted providers Understand Harvard Pilgrim s Administrative Simplification agenda and recognize its importance for Providers Be able to locate Harvard Pilgrim s online tools and resources to assist you in daily business activities Recognize that this presentation does not replace materials contained in the Provider Manual 2

3 HPHC Product Portfolio

4 Provider Manual Product Portfolio Individual guides to product offerings, grouped by product type Describe: Sample card stock Member cost sharing Related Policies 4

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7 Product Portfolio - Regional HMO Best Buy Connector Limited Networks Tiered Networks Tiered Copayments Core Coverage (MA & NH) POS Best Buy 7

8 Product Portfolio - Regional PPO Best Buy Independence Plan Dirigo Choice Core Coverage (ME) Health Plans, Inc. (HPI) an HPHC affiliate HPHC products and administrative services available through HPI 8

9 Product Portfolio Senior Products Medicare Supplement A medigap plan Enhance Medicare Wrap 9

10 Product Portfolio - National Choice and Choice Plus offered through Passport Connect SM, an alliance between UnitedHealthcare and Harvard Pilgrim Health Care 10

11 Product Portfolio National Choice Plus and Options PPO jointly offered by Harvard Pilgrim Health Care and UnitedHealthcare For fully insured and selfinsured employers with 150 or more eligible employees 11

12 Product Portfolio National Student Insurance Plan, offered by Harvard Pilgrim Health Care, and administered by UnitedHealthcare StudentResources, to students of fully insured colleges and universities in Harvard Pilgrim s service area 12

13 Administrative Requirements

14 Member Eligibility & Plans Check member ID card Front for plan, ID number, copay & deductible info Back for provider service info and claim submission address Verify eligibility 3 times When scheduling an appointment At the time of service When billing Verify eligibility electronically via HPHConnect, EDI-Direct, NEHEN or NEHENNet 14

15 Notification/Authorization & Referrals Notification required for inpatient admissions and outpatient therapy services (facility notifies) Notification/Authorization required for outpatient advanced imaging procedures (ordering physician notifies NIA) Prior authorization required for selected procedures, services & items (see the Provider Manual) Specialty care referrals required for HMO & POS members using in-network benefits 15

16 Billing & Reimbursement Payment policies 90-day filing limit from date of service Review requirements in the Provider Manual prior to rendering service Claims submission both electronic & paper NPI number, as contracted, required Complete, clean claims key to reducing denials Claims submission address/payor ID on member ID card Provider changes HPHC Provider Change Form to submit changes in demographic or billing information 16

17 Best Practices

18 What Providers Want Fast and accurate claims payments Information to guide their business Intuitive tools to assist with self-service Solutions for their issues, not just answers to questions Access to people who can help them 18

19 Harvard Pilgrim s Administrative Simplification Agenda Directed effort to decrease amount of administrative claim denials experienced by the Harvard Pilgrim provider network Collaboration between Harvard Pilgrim and individual providers to More fully understand provider behaviors that lead to administrative denials Recognize differences in provider infrastructures Mitigate or eliminate root causes through consultation, training and education Increase percentage of first time submissions paid Decrease need for resubmissions, appeals or reprocessing of claims that were previously paid 19

20 What Harvard Pilgrim Is Doing Providing responsive, well informed provider service Reliable, predictable experiences for our providers Understandable, timely, accurate information Engaging provider in face-to-face, onsite education Consulting with providers on effective management of their accounts receivable Working with providers to help integrate ebusiness activities/enhanced e-transaction capabilities into their daily routine Increase e-transaction utilization Decrease overall A/R cycle time 20

21 Measures of Success Increased percentage of first time claim submissions paid Decreased volume of claims denied for administrative reasons Decreased volume of administrative appeals received Decreased volume of phone calls and faxes Increased provider satisfaction with more timely payment 21

22 Tools for Reducing Administrative Denials Electronic eligibility verification Online referral, notification and authorization submission EDI claim submission Online claim status inquiry Provider Analytics Provider Manual Network Matters 22

23 Self-Service and Best Practices Reduce Outstanding Account Receivables Claim Status Eligibility Referral/Auth/NIA Policies Provider Claim Reports Scheduling & Patient Visit Eligibility & collect co-pay Referral/Auth/NIA Make a referral Policies Electronic Claim Remittance Advice Auto post remittance Claim Submission Eligibility Referral/Auth/NIA Submit Claim Policies Work In-Process or Rejected Claims Response Report/ File Claim Status Eligibility Referral/Auth/NIA Policies 23

24 Provider Analytics A tool provided by Harvard Pilgrim Health Care to help providers monitor and manage the claims activity at their practices Available to registered users of HPHConnect Produced monthly and available the Monday on or following the 10 th of the month Monthly view refreshed each month 24

25 Online Tools & Resources

26 Harvard Pilgrim For Providers THE place for all the latest information 26

27 E-Transactions Resources Information to get you started Companion Guides for testing and setup of electronic transactions Learn about the transactions that HPHC can accept electronically Contact information 27

28 HPHConnect Home Page 28

29 HPHConnect Resources Registration instructions User Guides & Quick Reference tools Frequently Asked Questions 29

30 News Center Be sure to sign up for Network Matters. 30

31 Office Support Key Contacts directory can also be downloaded 31

32 Products 32

33 Provider Manual Updates published monthly Highlights of updates published in Network Matters 33

34 Summary

35 Next Steps Signup online to receive Network Matters electronically Register for HPHConnect for Providers To request additional training on various topics to meet your needs for conducting business with Harvard Pilgrim, 35

36 Questions?