Provider Relations and Credentialing Updates
CHAMPS Enrollment reminder for all providers and facilities, with instructions provided for reactivation if necessary. The UPHP Credentialing Department has implemented CAQH ProView to streamline credentialing processes, reducing paperwork. Important MDHHS links are shared for notifications and information. Details on the Medicaid Doula Benefit covered services and provider criteria are outlined for reference.
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UPHP Provider In-Service October 25, 2023
Provider Relations & Credentialing Updates Sarah Dobson, Provider Relations Manager
CHAMPS Enrollment Reminder: all providers and facilities must be enrolled in CHAMPS Any questions regarding enrollment/reactivation: ProviderEnrollment@Michigan.gov 1-800-292-2550 Reoccurring issue: Members trying to fill prescriptions at pharmacies Pharmacy declining refill Check CHAMPS Enrollment If the provider s participation became inactive, will need to be reactivated
CAQH Proview Provider Data UPHP Credentialing Department has contracted with the Council for Affordable Quality Healthcare (CAQH) Now fully implemented Collect provider data Streamline credentialing Eliminate as much paperwork and redundant processes as possible Credentialing Team has been able to access provider information and collect updates via CAQH Goal Provider Relations Department to streamline the process of collecting updates from CAQH Download files saves on provider outreach
Important MDHHS Links/Information ListServ Email Notifications Michigan Dept of Health & Human Services (govdelivery.com) Bulletins 2023 Medicaid Policy Bulletins (michigan.gov) Fee Schedule Information Specific to Different Providers (michigan.gov) MDHHS Provider Manual MedicaidProviderManual.pdf (state.mi.us)
Medicaid Doula Benefit Covered Services A maximum of six total visits during the prenatal and postpartum periods and one visit for attendance at labor and delivery will be covered. Additional visits may be requested by prior authorization
Doula - Provider Criteria Doula must be: At least 18 years of age Possess a high school diploma or equivalent Complete an MDHHS approved doula training program MDHHS has assembled a Doula Advisory Counsel that will be comprised of doulas and will be making future decisions about what programs are to be added to the list of accepted programs. Approved programs are on the doula initiative website https://www.michigan.gov/Doula
Doula - Credentialing Requirements Enroll in Community Health Automated Medicaid Processing System (CHAMPS) for participation with Michigan Medicaid Complete an approved doula training program Be on the MDHHS Doula Registry Professional liability insurance Pass sanction screening checks NPI and Tax ID/SSN to bill under
Doula UPHP Contracting and Credentialing Contact Provider Relations and request to contract Contracting contact: UPHPProviderRelations@uphp.com Provider Relations will: Collect provider information Finalize a contract Supply a credentialing application Credentialing will process the application for enrollment into the network Credentialing contact: Credentialing@uphp.com Questions about member eligibility or number of visits available can be directed to Customer Service at 906-225-7500.
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Overview Sarah Dobson, Provider Relations Manager
CAHPS Survey Overview Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey sent out to UPHP members annually Experience with Provider Offices Experience with Health Plan Comprehensive results of survey are evaluated Where are we excelling Where can we improve
UPHP CAHPS Taskforce Results reviewed by UPHP CAHPS Taskforce Chief Operating Officer Customer Service Manager Credentialing Manager Strategic Initiatives Manager Clinical Coordinator Quality Management Provider Relations Manager Government Programs Liaison Review and implement activities and interventions on how to improve CAHPS scores
CAHPS Survey Overview Different factors can affect scores Response rates How many members completed each year How often members received care Interventions from the CAHPS Taskforce More educational information to provide to provider offices Social media Provider network review
Best Practices: Pharmacy and Medical Pharmacy Prior Authorizations Rachael Prusi, PharmD, MSGH Director of Pharmacy
Objectives Medicaid and Medicare Part D Formulary Pages How to use the Searchable Formulary Prior Authorization/Coverage Determination Forms Request for Information Medicaid Carve Out Information Cover My Meds for PA Medical Pharmacy 24
www.uphp.com 25
Medicaid Formulary 1 2 3 27
Medicare Formulary 1 2 3 4 30
Provider Forms 1 3 2 4 31
Page 1 of 5 33
Magellans Request for Additional Information When you receive a Notice of Prior Authorization Determination it is important to respond in a timely manner. The request is asking for additional information to make a clinical determination. The patient information and medication you requested are included on the notice. Return this form to Magellan at the listed fax number to facilitate completion of your prior authorization request. 34
Medicaid Carve Out Information https://michigan.magellanrx.com/provider/ The Michigan Preferred Drug List Summary Document will list drugs that are carve outs. Drugs that are carve outs mean the authorization and coverage is through MDHHS. A pharmacy would bill FFS at point of sate even though the member is a UPHP member. Contact FFS MagellanRx (prior authorization): 1-877-864- 9014 35
Medicaid Medical Pharmacy Prior Authorization Medical Pharmacy Drugs are drugs that are administered in a healthcare setting (J Codes, Q Codes, etc) Authorization for these codes must be obtained before services are rendered Retrospective requests will not be reviewed Authorization for out of network rendering providers must be obtained prior to review of medical pharmacy requests 38
Medicaid Medical Pharmacy Prior Authorization A prior authorization is NOT required for medications administered during: Emergency room visits Observation room setting DRG related payment for inpatient admissions Requests can be submitted via the provider portal! 39
Take Aways Use the UPHP online formularies Call with questions Respond to requests for information in a timely manner Use CoverMyMeds at your own risk Medical pharmacy requests can be submitted via the portal 40
Medical Director and Pharmacy Department Medical Director Pharmacists Pharmacy Assistants Nadine Hatch Chris Nelson Michael Mlsna, MD Rachael Prusi, PharmD, MSGH, UPHP Pharmacy Director Don Moisio, PharmD, RPh Abby Wales, PharmD UPHP Pharmacy 906-232-1628 41
10 Minute Break
Cotiviti Provider Intelligence Supporting Redeterimination Lindsey Havel, BSN, RN Clinical Services Manager Quality Management
Redetermination The Michigan Department of Health and Human Services (MDHHS) must annually re-determine if members continue to be eligible for Medicaid benefits. This is called redetermination, or renewal. During the Public Health Emergency (PHE), the annual review was paused. It will now resume on a monthly rotation. Redetermination month will be the same month that benefits became effective. The redetermination process includes a full review of all areas that determine member eligibility for benefits. UPHP Medicaid Renewals: link for members to MIBridges to update contact information! Medicaid Renewals Infographic print and hand out this resource to your Michigan Medicaid members!
Cotivti Provider Intelligence UPHP offers all primary care provider clinics a web- based population health management tool called Cotiviti Provider Intelligence. Provider Intelligence combines Cotiviti s: Industry-leading risk adjustment and predictive modeling Evidence-based clinical quality rules Healthcare utilization metrics Claims-based HEDIS measures to enable payers and providers to manage risk and target opportunities for improving healthcare results. Users can easily stratify and segment populations, access member-level detail (e.g., conditions, comorbidities, clinical events, gaps in care, prescription compliance), and evaluate efficiency.
