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An Administrative
Orientation for Providers for
Oscar Health Insurance
Objectives
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Overview of ValueOptions
Overview of ValueOptions & Oscar Partnership
Overview of Operational Areas
Clinical Operations
Claims & Payment Overview
Tools, Resources and Communications
Contacts and Helpful Links
Questions and Answers
ValueOptions
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Founded in 1983
Largest independent behavioral health company
Serving over 32 million members; contracts with 20 health plans
More than 50 Medicaid contracts in 14 states
Committed to principles of recovery and resiliency
Diverse client base
• Commercial Division - Employer Groups, Health Plans
• Federal Division
• Public Sector Division
ValueOptions’ National Presence
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Shared Commercial and Public Program/
Medicaid Membership
Commercial Membership Only
Regional support, EAP staff and corporate
support offices
Major service
centers
ValueOptions and Oscar Partnership
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Effective January 1, 2014, ValueOptions will begin to manage the Oscar Health Insurance Mental Health and Substance Abuse benefit.
ValueOptions will provide Mental Health and Substance Abuse services to members enrolled in Oscar Health Insurance.
Service areas include Manhattan, Brooklyn, Bronx, Queens, Staten Island, Rockland County, Westchester County, Nassau County and Suffolk County
Operational Areas:
National Network Services
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Provider Relations
Ensures members’ behavioral health care needs are met
through a geographically and clinically robust network of
providers
Ensures maintenance of network composition by engaging in
assertive retention strategies;
Engages in timely and appropriate recruitment
Engages in professional, consistent, and educative
communications with provider community and staff
Provider Credentialing
Completion of Credentialing Application required for
network participation
Operational Areas:
National Network Services (cont’d.)
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Provider Recredentialing (every three years)
Notifications
4 months prior to due date (telephonic), 1 week later
(email/fax), 15 and 30 days prior to due date
Failure to respond to requests will result in disenrollment from
the network
Process
Complete online, prepopulated recredentialing application
Attach updated license, certification and malpractice
information
Electronically sign the application (once signed, it is
automatically submitted)
Operational Areas:
National Network Services (cont’d.)
Provider Contracting
ValueOptions Provider Agreements
Questions about Contracting and Credentialing?
Call 1-800-235-3149
8:00 a.m. – 5:00 p.m. ET /
8:00 a.m. – 8:00 p.m. ET on 1/1/14
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Quality Management Program Oversight provided by Regional
Medical Director/CMO Commercial Division and Director of Quality
Management
Key Quality Indicators include but are not limited to:
Satisfaction Survey measures
Access/Availability of Services – geographic access, phone
statistics, appointment availability, etc.
Complaints/Grievances - tracking and reporting
Patient Safety – adverse incidents and quality of care
Coordination of Care
Quality Improvement Activities/Projects
Accredited with URAC and NCQA
Standards
Operational Areas:
Quality Management
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ValueOptions’ Quality Management cont’d.
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Ongoing Quality Improvement Activities (QIAs)
Clinical QIAs
Ambulatory Follow-up and Increasing Rate of
Psychiatric Evaluations for Members Diagnosed with
Moderate or Severe Depression and in Outpatient
Treatment with a Non-Prescribing Behavioral Health
Practitioner
Service QIAs
Average Speed of Answer
Operational Areas: Customer Service
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ValueOptions Customer Service philosophy lies in our commitment
to provide our members and providers with the most accurate and
informed benefit, eligibility, claims, and certification information in
the most effective, efficient, and compassionate manner.
ValueOptions puts our members’ needs and concerns first and is
committed to resolving inquiries promptly without the need to
make a re-contact.
We value our members’ questions and concerns and place
member satisfaction at the heart of our Customer Service
philosophy.
Operational Areas:
Customer Service (cont’d)
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Transition Benefits
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If a new member joins Oscar Health and is in an
ongoing course of treatment with a non-
participating provider, the member may elect to
continue treatment with the non-participating
provider for a period up to 60 days, if provider:
• accepts Oscar Health’s fee schedule
• continues to follow their policies and procedures,
and
• provides ValueOptions with necessary medical
information pertaining to the member’s care.
Operational Areas: Care Management
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Operational Areas: Care Management and
Referral Assistance
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Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management.
Member referral process:
Emergencies are followed until disposition
Urgent referrals are offered appointments within 48 hours and are called to ensure appointment is kept
Providers can contact ValueOptions for referral assistance if needed
Providers should contact ValueOptions 24 hours a day/seven (7) days a week if members require higher level of care or increased visit frequency
Care Management staff will assist with referral to inpatient or specialty programs
Operational Areas:
Utilization Management
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Inpatient
Inpatient and higher level of care requests are completed
telephonically by calling the number on the back of the member’s
Identification card
ValueOptions Staff are available 24 hours a day/ seven (7) days a
week or via ProviderConnect
Outpatient
Since pass through or registration no longer applies to outpatient
services impacted by federal parity, authorization cannot be required.
However:
It is important to check benefits and authorization requirements on each member via the web or by calling the number on the member’s identification card
Services must be medically necessary and provided using evidence based on practices specific to the member’s condition
Operational Areas:
Utilization Management (cont’d.)
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Discharge Reviews
Providers can complete discharge reviews via
ProviderConnect or call the assigned CCM
Providers should contact ValueOptions if they need assistance
scheduling discharge appointments
Providers should make every effort to schedule a discharge
appointment within one to two days of discharge, but in all
cases within seven (7) days.
Clinical Resources for Providers
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Clinical information is available at www.valueoptions.com
ValueOptions Medical Necessity criteria
Changes to Substance Use Medical Necessity Criteria
Treatment Practice guidelines
PCP consult line 9 am to 5 pm (Eastern Time)
877-241-5575
Intensive Case Management Services
Claims & Payment Overview
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Claims for services rendered by participating providers with dates
of service on or after January 1, 2014 should be submitted to
ValueOptions at:
ValueOptions
P.O Box 1347
Latham, New York 12110
Claims questions on or after January 1, 2014 should be directed to
ValueOptions at 877-759-5722 between 8 AM and 6 PM ET,
Monday through Friday, or send inquiry through ProviderConnect.
Member Premium Payments
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Failure by member to pay premiums could impact provider
payments
Providers can contact ValueOptions to request member premium
status at 877-759-5722 from 8 am – 6 pm ET
Electronic Claims Submission
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• Advantages:
• It’s better, faster, and cheaper!
• Reduced Paper Files.
• Reduced Labor and Postage Expenses.
• Reduced potential of error or mishandling.
• Faster claims processing improves cash flow.
Authorizations on ProviderConnect
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• Providers can submit and review authorizations
online through ProviderConnect
• Authorization letters showing approval for services
available only on ProviderConnect
• Providers can access authorization within 24-48
hours of a decision
• To obtain authorizations, providers need to register
for ProviderConnect
• Additional training on topic available in Video
section of Valueoptions.com
Tools, Resources and Communications
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3
• ValueOptions Website
• ProviderConnect®
• PaySpan Health®
• Training Opportunities
• Communication Channels
ValueOptions.com
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ProviderConnectSM – Provider Online Services
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Role-Based Security in ProviderConnect
New level of ProviderConnect access to enhance security as
required by HIPAA guidelines
Level of ProviderConnect access defined by role
Roles defined by user type and/or VO business rules
Users assigned roles with access to certain functions
i.e. claims
User Types: Super User, Managed User (managed by Super User),
Standard User
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PaySpan® Health
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A tool enabling you to:
• Receive payments automatically
• Receive email notifications immediately upon payment
• View your remittance advice online
• Download an 835 file to use for auto-posting purposes
• Visit the PaySpan Health website at
www.payspanhealth.com
Training Opportunities
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CEQuick
Training Webinars (New regulations, updates,
ProviderConnect, etc.)
• An Overview of ProviderConnect
Tue, Jan 14, 2014 3:00 PM - 4:00 PM EST
https://www2.gotomeeting.com/register/885170650
Video Tutorial Library
• http://www.valueoptions.com/providers/How-To.htm
Up to the Minute Communications
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Provider PulseSM Messages
Fax and Email Communications
Provider Mailings
Constant Contact Alerts
Monthly Valued Provider eNewsletter
Provider Contacts
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0
Customer Service
(877) 759-5722 (8 am - 6 pm ET Monday – Friday/8 am-8pm starting 1/1/14)
Provider Relations, Credentialing and Contracting Questions:
(800) 235-3149 (8 am - 5 pm ET Monday – Friday/ 8 am – 8pm starting 1/1/14)
Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk):
(877) 759-5722 (8 am - 6 pm ET Monday - Friday) or [email protected]
ProviderConnect (EDI Help Desk)
(888) 247-9311
For PaySpan Registration Provider Support contact:
(877) 331-7154
Provider Support is available from 8am to 8pm Eastern time,
Monday through Friday.
Helpful Links
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Network-specific website for Oscar Health
Insurance
• Provider Frequently Asked Questions
• Presentation
http://www.valueoptions.com/providers/Network/Ne
w_York_City_Health_Plans.htm#oscar
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Questions?
