Joyce Landers Highmark Blue Cross
Highmark Blue Cross Blue Shield WV May 15, 2014 HEALTH CARE EXCHANGE/ MARKETPLACE WHAT IS IT? The Affordable Care Act (ACA) requires that each state establish an online marketplace, referred to as a health insurance marketplace or exchange, through which qualified individuals may enroll in qualified health plan coverage. Eligible individuals that qualify for financial assistance to purchase coverage must purchase their coverage through a marketplace in order to receive the cost savings, which may include advance premium tax credit or cost-sharing reductions for those individuals who qualify. The marketplaces, or exchanges, were scheduled to permit consumers in each state to begin the plan selection and enrollment process as early as October 1, 2013 for coverage that began January 1, 2014, the date when the individual coverage mandate became effective. Health insurance marketplaces will support functions other than permitting qualified individuals to shop for qualified health plans. Consumers can also find out if they are eligible for public health programs such as Medicaid, and they can take steps to enroll in those programs. 2 Health Care Exchange Products Our Products & Formularies ACA sets the requirements for Qualified Health Plans (QHPs) in terms of metal levels, out-of-pocket maximum limits, essential health benefits and more. Health plans on the exchanges are offered in a tiered format with several plans in each tier to choose from. Plan tiers are based on metal levels that match the percentage of costs covered (the actuarial value of the plan) as follows: Bronze (60 percent) Gold (80 percent) Silver (70 percent) Platinum (90 percent) Essential health benefits must be covered under each tier. • ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health and substance use disorder services, including behavioral health treatment • prescription drugs • rehabilitative and habilitative services and devices • laboratory services • preventive and wellness services and chronic disease management • pediatric services, including oral and vision care 3 Health Care Exchange Products Helpful Tips…….. • No separate contract agreements to participate • Follows Highmark WV Commercial Network Medical Policies Authorization process Management programs Services requiring authorization 4 Highmark Member Cards Cards will look the same as other lines of business for Highmark WV. Copays will be listed but not metallic tier. NaviNet should be utilized to verify eligibility and covered benefits. 5 How will this affect you and your provider…. THE 90-DAY GRACE PERIOD The Affordable Care Act (ACA) requires a 90-day premium delinquency grace period for individuals who purchased insurance through the Health Insurance Marketplace (HIM) and received an Advanced Premium Tax Credit (APTC). Within this 30-day period, the member is placed in delinquency and the first delinquency letter is sent to the member. Claims are still being paid to providers at this point. After 60 days with no premium payment(s) made, a second delinquency letter will be sent to the member, with the future termination date if payment is not made in full. Claim payment to providers is suspended at this point. Alpha Prefixes Specific to Market Place Policies (subject to change) ZPL-On Exchange ZPI- Off Exchange If 90 days pass and the account is not paid up to date, the member's coverage will be terminated and the claims rejected for payment back to the provider. Once a member's coverage is terminated for nonpayment of premiums, he/she is responsible for claim payment to the provider. 6 7 8 PROVIDER RELATIONS REPRESENTATIVES SERVICING AREAS – January 1, 2014 MELANIE CLYDE (304) 547-2229 SHERRI DEAN (304) 424-7719 JOE LIPPOLI (304-547-2264) MARY DELAROSA (304) 347-7799 JAMIE RAY (304) 347-7792 05 Brooke 15 Hancock 26 Marshall 31 Monongalia* 35 Ohio 09 Doddridge 18 Jackson 37 Pleasants 43 Ritchie 48 Tyler 53 Wirt 52 Wetzel 54 Wood 44 Roane 02 Berkeley 12 Grant 14 Hampshire 16 Hardy 19 Jefferson 29 Mineral 33 Morgan 36 Pendleton 39 Preston 31 Monongalia* 10 Fayette 13 Greenbrier 24 McDowell 28 Mercer 32 Monroe 34 Nicholas 38 Pocahontas 41 Raleigh 45 Summers 51 Webster 55 Wyoming 03 Boone 06 Cabell 22 Lincoln 23 Logan 27 Mason 30 Mingo 40 Putnam 50 Wayne 07 Belmont, OH 15 Columbiana, OH 41 Jefferson, OH 56 Monroe, OH 05 Athens, OH 84 Washington, OH 58 Morgan, OH 61 Noble, OH 01 Allegany, MD 11 Frederick, MD 12 Garrett, MD 22 Washington , MD 03 Alleghany, VA 09 Bath, VA 11 Bland, VA 14 Buchanan, VA 23 Craig, VA 35 Giles, VA 45 Highland, VA 89 Tazewell, VA 10 Boyd, KY 64 Lawrence, KY 77 Martin, KY 98 Pike, KY 27 Gallia, OH 44 Lawrence, OH 53 Meigs, OH 30 Green, PA 26 Fayette, PA 08 Augusta, VA 22 Clarke, VA 34 Frederick, VA 53 Loudoun, VA 79 Rockingham, VA 82 Shenandoah, VA JAMI WITT-LEWIS (304) 347-7695 04 Braxton 07 Calhoun 08 Clay 11 Gilmer 20 Kanawha CINDY GORBY (304)-917-7604 01 Barbour 17 Harrison 21 Lewis 25 Marion 42 Randolph 46 Taylor 47 Tucker 49 Upshur * Melanie Clyde and Joe Lippoli share Mon County – Melanie is responsible for WVU Hospital and connected Physicians as well as Mon General and connected physicians. 9 Highmark West Virginia website www.highmarkbcbswv.com • Resource Center • Health Care Reform 10 11 NETWORK PARTICIPATION • The WVFH network is an extension of the Highmark BCBS WV PPO Network. Existing PPO providers who participate with Medicaid are offered participation with WVFH by agreeing to the amendment of the current agreement with Highmark WV • Reimbursement for covered services is 105% of West Virginia Medicaid 12 Primary Care Providers Each West Virginia Family Health member will choose a Primary Care Practice as their Patient Centered Medical Home. The PCP works in conjunction with the member to coordinate all appropriate medical care. Members are able to change PCP’s on a monthly basis if requested. 13 Referrals In certain instances, members do not require a referral from the PCP to see a network specialty care practitioner. Members may self refer for the following services: • • • • • • OB/GYN Services Family Planning Services (Family Planning services do not have to be rendered by a Network provider) Dental services Routine vision Chiropractic services (an authorization must be obtained by the chiropractic office, including the initial evaluation) Mental health/substance abuse services 14 Claims and Billing • Bill all appropriate modifiers • Bill all encounters, regardless of payment expected • Timely filing Criteria ₋ Initial Bills must be received within 12 month of date of service or payment from the primary carrier. • ₋ • All EPSDT claims and primary care services should be submitted within 60 calendar days from the date of service to permit accurate member outreach. Corrected claims or requests for review must be received within 180 days from the date of the remittance advice Claims submitted with any attachments, such as EOBs from Primary Carriers must be submitted on paper West Virginia Family Health – Claim Department P.O. Box 69319 Harrisburg, Pa. 17106 15 Claims and Billing Electronic Billing • • Electronic claims accepted through Emdeon or Relay Health Please refer to the following grid for Emdeon Payer ID’s and RelayHealth CPID’s (clearinghouse Process ID): CPID PAYER NAME PAYER ID CLAIM TYPE 45276 West Virginia Family Health (WVFH) 45276 Professional 45276 West Virginia Family Health (WVFH) 45276 institutional • • Hospital should include their West Virginia Family Health issued legacy number in your 837I submissions • Loop 2010BB REF01 with a qualifier of 'G2‘ • REF02 should be WVFH Issued ID# PCP’s and Specialists should bill under their individual NPI# 16 WVFH PROVIDER RELATIONS REPRESENTATIVES SERVICING AREAS - January 1, 2014 Melissa Johnson 304-547-2267 Melissa.johnson@highmark.com Alana DeJesus 304-347-7692 Alana.dejesus@highmark.com 05 Brooke 15 Hancock 26 Marshall 31 Monongalia 35 Ohio 52 Wetzel 09 Doddridge 02 Berkeley 12 Grant 14 Hampshire 16 Hardy 19 Jefferson 29 Mineral 33 Morgan 36 Pendleton 39 Preston 37 Pleasants 43 Ritchie 48 Tyler 01 Barbour 21 Lewis 25 Marion 17 Harrison 42 Randolph 46 Taylor 47 Tucker 49 Upshur 04 Braxton 18 Jackson 07 Calhoun 08 Clay 11 Gilmer 53 Wirt 20 Kanawha 54 Wood 44 Roane 03 Boone 06 Cabell 22 Lincoln 23 Logan 27 Mason 30 Mingo 40 Putnam 50 Wayne 10 Fayette 13 Greenbrier 24 McDowell 28 Mercer 32 Monroe 34 Nicholas 38 Pocahontas 41 Raleigh 45 Summers 51 Webster 55 Wyoming 17 West Virginia Family Health Website www.wvfh.com • Policy & Procedure Manuals • Complete Formularies • Online Provider Directory • WVFH Forms 18 ATTENTION SKILLED NURSING HOMES • Highmark has engaged the services of the Matrix Medical Network to help us complete health risk assessments for Medicare Advantage Plan beneficiaries • There is no cost to the member • Assessments help Highmark on-going commitment to quality care 19 Highmark WV Workshop Schedule June 10th Charleston Marriott Salons A&C on the 2nd floor June 11th Huntington Pullman Plaza Virginia/Maryland Rooms June 17th Bridgeport Conference Center Ballroom June 18th Wheeling Oglebay Conference Center Wilson Lodge Banquet Rooms 1, 2 and 3 20 FY 2015 Quality Blue Hospital Program Focus Streamlined to Six Components Quality Bundle • Hospital employed physician practices quality of care metrics Readmissions • Acute Care 3 and 30 day readmissions • return to ED within 7 days following acute care discharge Healthcare Associated Adverse events (HAAE) Advance Care Planning and/or Palliative Care for Complex Patients Perinatal Efficiency Measure (Medicare Spending Per Beneficiary –MSPB) • Healthcare Associated Infections (HAI): CDC-NHSN data • Venous thromboembolism • Palliative care consults for targeted populations • (POLST/POST) for SNF and LTAC discharges • Low risk birth mothers C-section rate (AHRQ IQI 33) • CMS Medicare Spending Per Beneficiary Ratio 2121 21 Measures included in the Quality Bundle: 20 CMS Star Measures C01 Breast Cancer Screening C20 Disease Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis C02 Colorectal Cancer Screening C23 Plan All-Cause Readmissions : Medicare Advantage C03 Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening D11 Use of High Risk Medication in the Elderly C04 Comprehensive Diabetes Care: LDL-Cscreening D12 Diabetes: Appropriate Treatment for Hypertension C10 Adult BMI Assessment D13 Medication Adherence for Diabetes Medication C14 Osteoporosis Management in Women who had a Fracture D14 Medication Adherence for Hypertension: Renin Angiotensin System Antagonists (RASA) C15 Comprehensive Diabetes Care: Eye exam ( retinal) performed D15 Medication Adherence for Cholesterol (Statins) C16 Comprehensive Diabetes Care : Medical attention for nephropathy C51 Annual Wellness and Initial Preventive Physical Exam Rate C17 Comprehensive Diabetes Care: HbA1c Control ( ≤9%) DMC 16 Exacerbation: Systemic Corticosteroid within Comprehensive Diabetes Care: LDL-C Control ( < 100 mg/dL) DMC17 Exacerbation: Bronchodilator within 30 days C18 Pharmacotherapy Management of COPD 14 days * Measures in blue denote Static measures Pharmacotherapy Management of COPD 22 Highmark WV Quality Blue Hospital Program Participants Current Participants Future Participants United Hospital Center Berkeley Medical Center Camden Clark Medical Center Jefferson Medical Center West Virginia University Hospital Monongalia General Fairmont General Logan General Cabell Huntington Hospital Weirton Medical Center Wheeling Hospital Bluefield Regional [FY2016] Thomas Memorial St. Francis Greenbrier Valley Medical Center Princeton Raleigh Pleasant Valley 23 THANK YOU For questions or additional information please contact: Joyce Landers Cindy Heiskell 304-347-7730 304-347-7717 joyce.landers@highmark.com cindy.heiskell@highmark.com 24
© Copyright 2024