Quarterly Provider Office Staff Meeting Summary - June 2021
In the Quarterly Provider Office Staff Meeting held on June 9, 2021, key areas discussed included introductions, department processes review, upcoming plans, and a question session. The meeting emphasized collaboration among physicians, hospitals, and health plans for the benefit of patients. Key staff members and their roles were introduced, and important announcements were made regarding contracting new providers and updates on contracted health plans. Contracted providers were instructed to utilize the EZ-NET portal for claim and authorization inquiries.
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Quarterly Provider Office Staff Meeting June 9, 2021 2Q21 Physicians, Hospitals and Health Plans working together for the patient
Agenda Introductions Overview Department Process Review Coming Soon Questions
Introductions Sonya Araiza, CEO Michael Swartout, MD Medical Director Carl Constantine, MD Associate Medical Director Veronica Vasquez, CIO/COO Linda Viles, CFO Dione Webster, Director of Operations, Payer Risk Management (Provider Relations, Contracting, Customer Service) Anastajia Navarro, Contracting/Provider Relations Supervisor Lisa Macias, Supervisor, Customer Service Lisa Tran, Provider Relations Brandee Ball, Contracting/Provider Relations Coordinator Arlene Prado, Contracting Coordinator Kimberly Baldwin, BSN, RN, Director of Health Services Brianne Rodriguez, RN, Manager, Utilization Management Linda Lopez, Supervisor, Case Management Jamie Schaub, Supervisor, Utilization Management Stephanie Eugenio, Controller Bret Trubey, MBA, Financial Analyst Octavio Campos, Director of Claims Robin Grimm, RN, Manager, Quality Management Traci Mackey, Credentialing & Compliance Supervisor Andrea Barrios, EDI Supervisor Armina Nina Huzbasic, Manager, IT Apps & Analytics Anissa Campos, IT Applications Manager, Clinical Programs Karen Sauer, Marketing
Message from Sonya Araiza, CEO
Contracting New Providers CV and Letters of Interest (LOIs) to be sent to DL- Contracting@identitymso.com LOI must include office location and hours, provider degree, provider specialty and limitations, if any Provider Status Change (i.e., leave of absence, terminations, demographic changes, tax ID change, etc.) Send to DL-Contracting@identitymso.com
Contracted Health Plans Commercial Plans: Aetna Anthem Blue Cross Blue Shield (including TRIO product) Health Net United Healthcare Senior Plans: Alignment Anthem Blue Cross Blue Shield Central Health Plan Humana SCAN United Healthcare
Customer Service Contracted providers are to use EZ-NET portal for claim and auth inquiries prior to Customer Service outreach Customer Service documents calls; incident remains open until resolution is made Telephone Numbers: Provider Line: (805) 604-3308 Member Line: (805) 604-3332 Customer Service Center Hours: Monday-Thursday 8a-5p; Friday 9a-5p Customer Service Support: Authorizations - Authorization extensions; submit request via email to DL- DL-CustomerService@identitymso.com (only applicable to authorizations not yet expired and not previously been extended) Claims - direction on who to bill; claim status Eligibility Eligibility should be reviewed through the health plan websites directly. Member adds or issues should be reported to Customer Service. Member bills - Customer Service team to obtain copies of member bills and forwards to IPA Provider Relations team to work with provider to resolve issue (incident remains open until resolution is made) Provider network questions
Provider Relations The Provider Relations team provides support to educate the network on policies/procedures, perform office training, assist providers with EZ-NET set up and work as a liaison between IPA Departments for escalated issues or trends. Email: DL-ProviderRelations@identitymso.com Your PR Team: Lisa Tran & Brandee Ball VCIPA Website & Provider Portal: The site contains important memos, network information, provider rosters, UM guidelines, COVID-19 information, Health Plan website links, clearing house information, fee schedule & payment policies, various forms, provider manual, etc. Website: www.valleycareipa.com Log in information: User: Password: vcprovider vcipa EZ-NET: Quick link is available on the Valley Care Website Each employee needs unique log-on For access, email DL-ProviderRelations@identitymso.com Provides status of claims, authorizations and for PCPs to submit referral requests
Primary Care Physicians, Specialty Network, Urgent Care & After Hour Care Provider rosters can be found on the Valley Care IPA website. PCP: https://valleycareipa.com/valley-care-ipa-primary-care-physicians.html Specialty Network: https://valleycareipa.com/valley-care-ipa-specialty-care- physicians.html Urgent Care Locations: Valley Care IPA has 10 contracted urgent care locations available to members. For the most current list, please visit the website at: https://valleycareipa.com/affiliated-health-plans-and-hospitals.html#urgent-care- centers After Hours Care: Members can obtain after hours care through an affiliated urgent care or a hospital emergency room. Participating hospitals with Valley Care IPA are: Community Memorial Hospital, Ventura County Medical Center, Santa Paula Hospital, St. John s Regional Medical Center & St. John s Pleasant Valley Hospital
Laboratory & Radiology Providers Laboratory: Valley Care IPA s capitated laboratory is Quest Diagnostics. For a current listing of Quest draw sites, please visit the website at: https://valleycareipa.com/laboratories.html Radiology: Valley Care IPA is capitated with two different radiology providers. County of Ventura (for members assigned to a County Primary Care Physicians) 1. County PCPs are identified in the system as having VCMC after provider s last name (i.e., Lyons (VCMC), Morgan) and can be identified as such on the provider roster Beverly Radiology aka RadNet (for members not assigned to a County Primary Care Physicians For a current listing of radiology locations, please visit the website at: https://valleycareipa.com/radiology-valley-care-ipa.html 2.
Behavioral Health Reminder Valley Care IPA is only delegated to manage Anthem Blue Cross Senior members for behavioral health needs. All other members should be directed to their health plan.
Referral/Authorization Process All routine referrals go through the PCP for submission into the EZ-NET system, with exception of the following: Continuation of DME, Oxygen, Tertiary Care, Home Health, Total OB or Behavioral Health (these can be submitted directly to the IPA via fax at (805) 278-6815) Urgent & STAT referrals must be called into the UM Department: (805) 918-4179 Urgents must be called in by PCP; STATs can be called in by specialist or PCP PCP & specialist upload all supporting documentation into the EZ-NET system County County providers are entered as an internal referral and most are auto-approved upon submission priority status 0 in EZNET (REMINDER: County PCPs are identified in system as having VCMC after their last name; some County providers excluded from internal referral) new document will be available and shared soon identifying County providers included in the Internal Referral Program Contracted providers can view authorization status by logging into the EZ-NET system IMPORTANT: Providers are encouraged to review submitted referrals daily for potential pends and additional information requests. The UM team no longer places call outs for additional information.
Referral/Authorization Process contd If change requests are needed on an existing referral, the Authorization Inquiry Form must be used and submitted directly to the UM team via fax for processing at (805) 278-6815. This form is on the VCIPA website. Inquiries can be submitted by PCP and specialty offices; please avoid submitting multiple inquiries for same issue by same office staff. Turn around time is 2 business days. If needed sooner than that, provider should call the urgent/STAT Huntline. Contracted specialists are required to obtain authorizations for continuing care prior to services being rendered. Requests must be sent to the PCP to submit to the IPA via EZ-NET. PCPs are required to submit the specialist requests to the IPA via EZ-NET within 2-business days of receipt. Specialists should be checking EZ-NET 2-days after submission to PCP to ensure auth was entered. If not entered, specialist to follow up with PCP office. If PCP office is unresponsive, please advise DL-ProviderRelations@identitymso.com.
Referral/Authorization General Rules Members seen in the ER require PCP follow up prior to being referred back to an attending specialist. If need is urgent or STAT in nature, those referral requests need to be called into the Urgent/STAT Huntline. Otherwise, PCP to see member, then submit for referral as indicated. PCPs must sign ALL referral submissions/notes (electronic signatures accepted) If a member is out of network and PCP is wanting to refer back into network, a chart note signed by the PCP is required when submitting for the referral. This will avoid cancelled referrals. Submission of a referral to a specialist requires PCP signature
Referral/Authorization Turn Around Times Referral processing timeframes are as follows: Routine: Commercial: 5 days business days 45 days if missing information to make a decision Senior: 14 calendar days Urgent: 72 hours (medically urgent indications only; not scheduling reasons) STAT: 24 hours Drugs: 24 hours It is recommended to schedule member once authorization is approved. Once a referral has been finalized, it s set to fax out to the requesting provider, rendering provider and member s PCP (and facility, if one exists on the auth). Faxes are generated every three (3) hours. Real-time status can be obtained via the EZ-NET system.
Utilization Review/Authorization Tips Attach documentation that supports the authorization request (upload via EZ-NET) Diagnosis entered must support the service being requested Referral Form is complete and identifies what is being requested and why Submit authorizations with turn-around-times considered; upgrading the request to urgent status due to scheduling purposes is not appropriate Pended auths viewable in EZ-NET for quicker response time; the sooner we receive the needed information, the sooner your request will be processed. The IPA began faxing a daily pend reports to the requesting provider please be sure to review this report and submit responses timely to avoid cancellation. Information requested should be uploaded to the referral in EZ- NET. Prevent Cancelled Authorizations! Be sure physician has signed and all required elements are provided with supporting documentation!
Urgent/STAT Requests Expedited/urgent reviews will be performed for sensitive situations when the routine review timeframe could seriously jeopardize the life or health of the member s ability to regain maximum function. Examples: 1. Member s need for treatment is imminent due to the emergent or urgent nature of the illness, injury or condition requiring the treatment 2. Member has a life or limb threatening condition 3. Routine review would seriously jeopardize the life or health of the member or would jeopardize the member s ability to regain maximum function
Urgent/STAT Huntline Urgent/STAT Line: (805) 918-4179 Not to be used for inquiries on referral status, provider to use EZ-NET for auth and claim status The Urgent/STAT Huntline is often used as a direct line to Utilization Review that is not the purpose of this phone line Callers without Urgent or STAT authorization requests will be directed back to Customer Service for appropriate call handling Messages left on the Urgent/STAT line are transcribed into an email for the UM Coordinators within 10 minutes of the message being left.
Direct Referral Program Valley Care IPA has several specialties on the Direct Referral Program. What this means is a Primary Care Physician can submit for an authorization for a provider specialty on the Direct Referral Guideline for the specified type of service and the authorization will auto-approve upon submission Direct Referral Guidelines can be found under the Provider Portal on the Valley Care IPA website Be sure when submitting referral for a provider under the Direct Referral Program that you flag the referral with Priority Status 0
Case Management Inpatient concurrent review of: Hospital Admissions Skilled Nursing Facility Admissions Durable Medical Equipment (DME) Authorization Reviews Transition Care Measures Coordinate discharge needs with Care Coordination Participates in Interdisciplinary Team Meetings with the Health Plans and Medical Directors to address gaps in care and follow up needs
Care Coordination Care Coordination Team: Doug McClatchey, RN Liza Torres, MA, Health Coach Joanna Cardenas, Social Worker Care Coordination follows member outpatient to address: Gaps in Care Chronic Disease Management Healthcare Navigation PCP Coordination Hours of operation are M-F 8a-5p Care Coordination Referrals may be received via fax, secure email, shared electronic medical record (EMR), telephonically by providers, care managers, payer sources or direct member referral. Direct Line: (805) 918-5299 Direct Fax: (805) 856-0385 Email: carecoordinationvc@identitymso.com
Quality Management Responsible for writing denial letter language per MDR Investigates appeals & grievances Health Plan audits Compliance
Quality Management contd Commercial Non-Emergent Medical Appointment Access Standards Appointment Type Time-Elapsed Standards Urgent Care appointments that do not require prior authorization (PCP) Must offer the appointment within 48 hours of request Urgent Care appointments with SCP that require prior authorization Must offer the appointment within 96 hours of request Non-Urgent Care appointments for Primary Care (PCP) Must offer the appointment within 10 business days of the request Non-Urgent Care appointments with Specialists Physicians (SCP) Must offer the appointment within 15 business days of the request Non-Urgent Care appointment with non-physician mental health provider Within 10 business days of the request Non-Urgent Care appointments for ancillary services (for diagnosis or treatment of injury, illness or other health condition) Must offer appointment within 15 business days of the request In-office wait time for scheduled appointments (PCP and SCP) Not to exceed 15 minutes First prenatal visit Well-child visit Wellness check Within 10 business days of request Within 10 business days of request Within 30 calendar days of request
Quality Management contd Senior Non-Emergent Medical Appointment Access Standards Appointment Type Urgent Care appointments that do not require prior authorization (PCP) Time-Elapsed Standards Must offer the appointment within 48 hours of request Urgent Care appointments with SCP that require prior authorization Must offer the appointment within 96 hours of request Urgent Care appointment with non-physician mental health provider Within 10 business days of request. Non-Urgent Care appointments for Primary Care (PCP) Must offer the appointment within 10 business days of the request Non-Urgent Care appointments with Specialists Physicians (SCP) Must offer the appointment within 15 business days of the request Non-Urgent Care appointment with non-physician mental health provider Within 10 business days of the request Non-Urgent Care appointments for ancillary services (for diagnosis or treatment of injury, illness or other health condition) Must offer appointment within 15 business days of the request In-office wait time for scheduled appointments (PCP and SCP) Not to exceed 30 minutes Wellness check Within 30 calendar days of request
Quality Management contd Behavioral Health Emergent & Non-Emergent Appointment Access Standards Appointment Type Non-Urgent appointments for with a mental health care provider Time-Elapsed Standards Must offer the appointment within 10 business days of the request Non-Urgent Care appointments with a non-physician mental health care provider Must offer the appointment within 100 business days of the request Urgent Care appointments Must offer the appointment within 48 hours of request Access to Care for Non-Life Threatening Emergency Within 6 hours Access to Life-Threatening Emergency Care Immediately Access to Follow Up Care after Hospitalization for mental illness One follow-up encounter with a mental health provider within 7 calendar days after discharge Plus One follow-up encounter with a mental health provider within 30 calendar days after discharge
Quality Management contd Additional Access Standards AFTER HOURS ACCESS STANDARD Emergency Care Call 911 or go to the nearest emergency room. Urgent Care Call the provider s office 24 hours a day, 7 days a week. Expect a call back from a provider within 30 minutes. Telephone Access TELEPHONE RESPONSE STANDARD Telephone answer time at provider s office Answer calls within 60 seconds Telephone call back during normal business hours for non-urgent issues Call patients back within 1 business day
Claims Claim status, payment information and/or denials can be viewed by a contracted provider via the EZ-NET system. Standard claims processing timeframe is 60-days, but IPA processes 98% of clean claims within 30 days. Providers are encouraged to submit claims electronically via Office Ally: Clearinghouse: www.OfficeAlly.com Payer ID: VCIPA Contact Information: info@OfficeAlly.com / telephone (866) 575- 4120 Practice may use alternate clearinghouse, but must use payer ID VCIPA to route claims to Valley Care IPA for processing.
Claims New Document Upload Process Contracted providers now have the capability to upload supporting documentation for claims via the EZ-NET system. If your office is interested in doing this, please reach out to DL- ProviderRelations@identitymso.com for access and training. NOTE: Claim submissions cannot be done via EZ-NET; they must continue to be submitted trough electronically through your clearing house or via paper. WHAT SUBJECT NOTE SHOULD PROVIDERS USE?
Claims Virtual Examiner Implementation In an effort to enforce False Claim Act and identify claims abuse, CMS implemented the use of Correct Coding Initiative edits into claims processing for all Medicaid and Medicare Managed Care Plans. As a result of the increased audits, the U. S. Attorney s Office is currently prosecuting both civil and criminal cases under the False Claims Act and HIPAA healthcare fraud regulations. To ensure compliance with CCI initiatives, Valley Care IPA is implementing software solution to increase regulatory oversight of medical claims processing and payments. One of the goals of our compliance program is to focus on areas under government inspection and review. When investigating fraud and abuse, federal and state agents are looking at the following areas: unbundling, up-coding, medically unnecessary services, duplicate billing and billing for services not rendered. CCI Edits, NCCI Edits, CMS HCPC Edits, CMS - Mutually Exclusive and Column 1 / Column 2 Coding Edits, CMS Medicare Carriers Manual, AMA Physicians Current Procedural Terminology (CPT) Edits, Medically Unlikely Events (MUE s) While many provider offices will not be affected by this, there are some of you that will be. Provider Relations will be reaching out to the offices that have been flagged to affect the most.
Claims Service Facility Location Requirement Per Medicare Claims Processing Manual, Chapter 26, Valley Care IPA has implemented the requirement of Box 32 being populated on the CMS-1500 claim form for services payable under the physician fee schedule and anesthesia services. Valley Care has begun rejecting claims that are received without the required elements. If you have any questions on this requirement, please contact Provider Relations at dl-providerrelations@identitymso.com.
Finance Claims payments All claim payments are processed by ECHO Health, Inc. www.providerpayments.com Available documents: RA 1099s EOB Payment Options contact ECHO to change payment method @ (866) 686-3260 Virtual Credit Card (default payment) EFT Paper check MPX (formerly MedPay) Printable check (e-check) Capitated Provider Payments ACH electronic payments have been implemented, if questions, please contact Provider Relations at dl-ProviderRelations@identitymso.com.
New Members Welcome Letters are mailed to members new to IPA. They are encouraged to contact their PCP to be seen within 90-days of enrollment Members are directed to the IPA Website for important information (i.e., provider rosters, urgent care facilities, lab and radiology locations, etc.) New Member Packets are available upon request for members without internet or computer access If member requires coordination of care for a previously established specialty provider, provider is to contact the UM team and the UM team works directly with the Plan to facilitate coverage PCP assignment changes or demographic changes should be made directly with health plan
Incentives/Quality Program Annual Wellness Visits (AWV) Senior (MA) members scheduled for AWV Newly Enrolled Member Comm & MA New members seen within ninety (90) days of enrollment HCC Recapture Senior (MA) members HCC codes are recaptured Quarterly/Monthly Reports Member and Progress reports distributed to each location Care Gaps Comm & MA CAHPS Survey New Monthly Webex PCP & Specialists Getting needed care Care Coordination Doctor/Patient Conversations Onboarding new members
Specialist Submissions via EZ-NET The Valley Care IPA Board of Directors has recently approved removing the requirement of specialty follow up services and procedures needing to go through the Primary Care Physician for sign off and submission. What this means is specialty providers will be able to submit for services directly to the IPA via EZ-NET, rather than going through the PCP as the gatekeeper. Provider Relations will be reaching out to all contracted specialty offices to grant them submission access and train on the new process. We anticipate this to go-live August 1, 2021.
Annual Model of Care (MOC) Training NEED TO COMPLETE
Marketing Health Plan News Aetna Alignment Anthem Blue Cross Blue Shield Central Health Health Net Humana SCAN United Healthcare Medicare 101 In-Services
Health Education, Community Health Centers & Social Services Health Education: Valley Care IPA partners with various community centers that offer health education Community Health Centers & Social Services: Camarillo Healthcare District (adult daycare, sponsored and private pay): https://www.camhealth.com/ or (805) 388-1952 Senior Concerns (currently virtual only; align seniors with care giving, meals on wheels): https://www.seniorconcerns.org/ or (805) 497-0189 Focus on Seniors: (805) 322-8822 Ventura County Homecare Association: http://vchainc.org/ or (805) 363-2533 Alzheimer Association (AA): https://www.alz.org/cacentralcoast or (805) 494-5200 American Red Cross (ARC): https://www.redcross.org/local/california/central- california/about-us/locations/pacific-coast.html?CID=organic_gmb_listings or (805) 987-1514 Cancer Support Community: https://www.cancersupportvvsb.org/ or (805) 379-4777 Social Services: Adult daycare, health and awareness, food share (weekly), reasonably priced senior lunches ($2-5), health fairs throughout the year, coordinate DME services and assisted living, supportive nursing services, health education for debilitating diseases and how to function through these, ARC helps with re-housing during disasters, AA offers respite care, etc. Transportation is offered through Camarillo Healthcare District via bus
Starbucks Drawing Question #1! How should you request an authorization extension?
Starbucks Drawing Question #2! Where should you check first when needing authorization status?
Starbucks Drawing Question #3! How should requested information for pended authorizations and claims be submitted?
