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Guiding You Through Administrative Processes
2006 Provider Forum
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Agenda
Welcome and IntroductionsOverview of ValueOptionsOverview of New York State PlansCustomer Service and ClaimsClinical OperationsQuality ManagementLocal and National Provider RelationsContact InformationQuestions and Answers
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National Service Presence
Consolidated Commercial Claims in Latham, NYConsolidated Employer Customer Service in Dallas, TXConsolidated Health Plan Customer Service in Troy, NYEAP Center of Excellence established in Durham, NCIT Center of Excellence located in Reston, VANetwork Operations Center of Excellence established in Virginia Beach, VADedicated Empire Team in Troy, NYNYC Service Center servicing GHI, CHCS and Great West in New York City,
NY
National HeadquartersESD Service CenterHPD Service CenterCenter of ExcellencePSD Service CenterFederal Service Center
Co-located Facilities
NCQA Accreditation
URAC Utilization ManagementAccreditation
For All Service Centers
URAC Case ManagementAccreditation
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Annual 2005 Provider Satisfaction Survey
Highlights of the Survey:
Overall Satisfaction: The majority of providers are satisfied (87%) with ValueOptionsUse of Handbook: 33% of providers have read or looked through the ValueOptions Provider HandbookUse of Newsletter: Approximately 80% of the providers have read or looked through the ValueOptions newsletterUse of Website: About 44% of the providers use the website and 74% of those providers said it is easy to find informationAvailability: Overall for all disciplines, 94% of providers are open to see new patients
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New York State Empire Plan Service Center
Utilization Review Accreditation Commission (URAC) certified
ValueOptions (Administrator) and GHI (Insurer)ValueOptions manages both the Mental Health and
Substance Abuse benefitsCustomer Service number: 800-446-3995
New York State Empire PlanOver 1 Million covered commercial members and retirees
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New York City Service Center
ValueOptions pays the claims
ValueOptions pays the claims for CPPSuffolk Health Plan and VidaCare claims are paid by Royal
ValueOptions pays the claims
GHI-BMP: GHI pays the claimsGHI Medicare: ValueOptions pays the claims
Great-West Healthcare
(866) 714-2960
Community Premier Plus, Suffolk Health Plan, VidaCare(800) 922-3626
GHI-Family Health Plus
(866) 801-5367
Liberty Health Advantage
(866) 635-3468
GHI-BMP(866) 271-6403
GHI-Medicare Choice PPO
(866) 318-7595
New York City Service CenterOver 3.5 Million Covered Commercial/Medicare/Medicaid members and retirees
Utilization Review Accredited Committee (URAC) certifiedValueOptions manages both the Mental Health and Substance Abuse benefits
Customer Service and Claims
Committed to your service needs …
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The New Customer Service Plan
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Customer Service
Designed to handle routine issues.
Available 24/7.TeleConnect
ConsiderationsAdvantagesOptions
Designed to handle routine issues.
Available 24/7.ProviderConnect
5 business days for a response.
Documentation of question and resolution.
Available 8-5 during business days.
Expert service from a live person who specializes in complex issues.
Customer Service Professionals
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ProviderConnect Enhancements
Increased convenience & decreased administrative processes
ProviderConnect (Provider Online Services)• View authorization letters, access your provider
practice profile and submit demographic changes online
• Eligibility verification, and download forms• View authorization summary and detail • Benefit status • Request Authorizations – Pilot Program Underway
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Technology Enhancements (Web)
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Customer Service – ghi.com
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A Winning Formula
TeleConnectProviderConnect
+ +Customer Service
• Web-based self-service
• Available Anytime
• Phone-based self-service
• Available Anytime –
• Expert assistance
• Normal business hours
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The Winner is…
More time to spend with patientsMore time to see new patientsReduced workload for administrative staffLess paperwork
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Claims
Our Focus
• Tips on avoiding administrative claim denials –no one likes them!
• Health Insurance Portability and Accountability Act (HIPAA)
• Scanning by means of Optical Character Recognition (OCR) technology allows for a more automated process of capturing information
• Electronic claims – the key to quicker payment
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Claims – Administrative Claim Denials
22%
27%12%
19%
20%
No Authorization
Other Carrier EOB
Duplicate
Submit to MedicalCarrierMissing Information
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Optical Character Recognition
Tips for reducing turnaround time and improved quality:• Use original red claim forms
• Use machine print and black ink
• Print claim data within the defined boxes on the claim form. Use all capital letters
• Use a laser printer for best results
• Use white correction tape for corrections
• Use an 8-digit date format (e.g., 10212000) and fixed width font (Courier for example)
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Electronic Claims Filing
Are you sending paper claims?
Is your cash flow not flowing the wayyou would like?
Are you buried in paper work or backbilling that needs to be done?
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Electronic Claims Submission
Advantages:
Better, Faster and More EfficientReduced Paper FilesReduced potential of error or mishandlingFaster claims processing improves cash flow
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ELECTRONIC CLAIMS FILING
ValueOptions Software, Clearinghouse, orMedical Practice System can submit claims to ValueOptions directly.
•Practice Management System Vendors and Billing Services can submit claims to GHI via Emideon Business Services (formerly WebMD Business Services)•Practice Management System Vendors and BillingServices can submit claims “directly” to GHI
ValueOptions offers FREE EDI softwareEDI software can be downloaded on www.valueoptions.comRuns on Windows 98 or above ValueOptions offers Single Claim Submission, directly on our website, for smaller volume Providers
Contact Dedicated Helpdesk for EDI issues at 888-247-9311 (8am to 6pm EST)
•Contact a GHI EDI Representative at (212) 615-4EMC (212-615-4362).
Electronic Payer ID FHC &Affiliates•GHI 7-digit provider number•Electronic Payer ID 13551
HIPAA compliant files simplify the electronic transfer of data
•HIPAA compliant files simplify the electronic transfer of data
VALUEOPTIONSEmpire & GHI/BMP
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Customer Service and Claims…
Creating new choices for our providers today and tomorrow.
Clinical OperationsHelping meet members’ care needs ...
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Clinical Operations (continued)
Used for requesting medication management services only (90862 or 90805)Note: Medication management with psychotherapy (90807) is requested via an ORF
Used for more complex outpatient mental health casesIncludes provider rating scale of current risk to self/others and 12 functional impairments – rating scale 0 (none) – 3 (severe)Complete only if requested
Used for requesting routine outpatient mental health treatment Includes provider rating scale of current risk to self/others and 12 functional impairments – rating scale 0 (none) – 3 (severe)
Used as a guide for completing telephonic reviews of inpatient and higher levels of careIncludes provider rating scale of current risk to self/others and 12 functional impairments – rating scale 0 (none) – 3 (severe)ASAM Dimensions
Medication Management
Registration Form
Outpatient Review Form
(ORF2)
Outpatient Registration Form
(ORF1)
Inpatient Treatment Report (ITR)
Review/Authorization Request Process
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Clinical Operations (continued)
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Clinical Operations (continued)
Outpatient Mental Health Authorization Process• Member “pass through” visits:
– Empire Plan – 10 visits per member/per provider/per lifetime
– GHI-BMP – 10 visits per member/per provider/per year– Community Premier Plus – 20 visits/per member/per
provider/per year
• Start Date: Prior authorization is required for all visits beyond the initial “pass through” visits. Please indicate your requested start date on the ORF – we will consider up to 30 days before or after the date the form was received in our office
• End Date: All outpatient mental health authorizations end on December 31st of the current calendar year
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Clinical Operations (continued)
OPMH Authorization Process (continued)• Number of Visits: It will be important for you to monitor
the number of visits authorized and utilized. We are unable to authorize retrospective outpatient visits.
• There is no change in the mailing/fax process for Empire Plan and NYC Service Center treatment requests!
New York City ORF Fax Number:1-212-560-7778
New York City Mailing Address:P.O BOX 1884
New York, NY 10116
Empire Plan ORF Mailing Address:
ValueOptions Empire Plan433 River Street, Suite 200
Troy, NY 12180-2259
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Clinical Operations (continued)
Outpatient Chemical Dependency Review Process –Empire Service Center• Automated phone attendant for outpatient chemical dependency
(OPCD) programs at 1-800-446-3995• Register clinic level of care less than 9 hours per week (x228990)• Register an evaluation only visit (x228991)• Request an extension of an end date for a current authorization
(x228992)• Confirm a discharge (x228993)• Register for the Family Treatment Benefit (x228994)
If you are seeking authorization for an intensive or structured outpatient chemical dependency program (i.e., 9 or more hours ofservice per week, with a minimum of at least 3 hours per day), contact the care manager assigned to your agency during regular businesshours.
Quality ManagementCommitted to working with you toward continuous improvement …
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Clinical Quality Initiatives
Increasing Family Involvement in Adolescent Outpatient Treatment
• Focuses on adolescents who have recently been hospitalized
• Outreach to parents• Outreach to providers• Goal: to involve family in outpatient
treatment within first 90 days afterdischarge
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Clinical Quality Initiatives (continued)
Substance Abuse: Engagement in Treatment• Focuses on Alcohol and other Dependence
Treatment• Outreach to members and providers• Goal: 1st visit within 14 days after initial diagnosis
and at least 2 visits within 30 days thereafter
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Ambulatory Follow-Up – HEDIS/QARR
• Over the past three years, ValueOptions has implemented an intensive and focused approach to ensuring that members receive timely follow-up care after inpatient psychiatric hospitalization.
• Ambulatory Follow-up Team (AFT) follows the progress of the member throughout their inpatient episode and determines whether appropriate arrangements have been made for follow-up ambulatory care.
• Once discharged, members receive reminder calls about their appointment and, if they identify barriers (e.g., transportation, scheduling conflicts, etc), are provided assistance.
• The AFT contacts providers after the scheduled appointment time to confirm that the member actually attended.
• By continuously monitoring claims-based reports throughout the measurement year, ValueOptions identifies cases where claims have not been submitted and works with providers to ensure proper and timely filing.
• Perform tracking and trending analyses to identify providers whose performance is substandard with regard to timely follow-up care.
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Coordination of Care
Coordination of Care between Behavioral Health and Primary Care Physicians (PCPs)
Therapist
Physician
Psychiatrist
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Depression Management
New Program for NYS Empire Plan members
Dedicated toll-free line (877)-7NYSHIP
Additional resources for your recently diagnosed patients
Opportunity for Referrals
Provider Relations/ Network Operations
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All changes regarding your provider demographic information orTax Identification Number must be submitted in writing. Please go to www.valueoptions.com and click on the ‘forms’ section
• Forms: Current downloadable forms on the website• Change of Address • W-9 forms
• For Other inquiries, such as: • Credentialing/re-credentialing issues• Application status updates• Comments or concerns regarding ValueOptions’ policies and
proceduresPlease contact us at 800-397-1630
National Network Operations
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Continuous Program of Provider Education
ValueOptions Newsletters
valueoptions.com
ProviderForums
Annual revision toProvider Handbooks
Representationat Trade shows
Visits to key facilities
E-Pub
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Key Achievements - Provider Satisfaction
Access to Providers• Accepting ValueOptions’
members - 94% are currently accepting new ValueOptions patients. Availability of routine appointment - 96% of the providers say they have routine appointments for existing patients available within 2 weeks.
• New York State Empire Plan –ValueOptions, requires 7 days for routine appointments.
Improved Provider Access
92 95 96 94
0102030405060708090
100
Perc
enta
ge
2003 2004 2005 2006
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Provider Database Accuracy Audit Results
98%
98%
100%
October 2005
98%99.30%98%Phone Number
98%95.30%98%Address
100%100%100%Discipline
May2006
May2005
October 2004
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National Provider Identifier
NPI is a step to promote, improve and simplify all electronic transactions. The standard Provider Identifier will ensure that each provider has one unique identifier to be used in transactions with all health plans.
All providers are required to acquire and be using their unique identifier by May 2007.
Providers can apply for NPI 3 ways:• Web–based application, visit: http://nppes.cms.hhs.gov. • Paper application can also be found on
http://nppes.cms.hhs.gov.• Contact CMS for a copy of the application or any questions at
800-465-3203 or TTY 800-692-2362.
ValueOptions will be compliant with this requirement by May 2007. For more information on ValueOptions readiness, please visit: www.valueoptions.com/news
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Provider Relations: Email Address and Helpline
866-477-9741NewYorkRegion@valueoptions
.com
800-235-3149Empireproviderrelations@
valueoptions.com
New York City Service Center
NY State Empire Plan
Thank you!
Please remember to complete your evaluation form.
