BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.
CHOICES Webinar
July 2011
Sandata EVV Updates
Sandata has created a Training Path Checklist for each functional area (i.e. Billing, Scheduling, etc.). It is available in the Training Library
Changed the title “Time Management” to “Scheduling”
Added arrows and other visual components to better highlight
items in screen shots
Reorganized materials so there are fewer clicks to access job aids, quick reference checklists, and other materials in the Training Library
2
Important Electronic Voice Verification Reminder
All visits should be scheduled according to the authorization in Electronic Voice Verification (EVV)
Visit should not be canceled for any reason If a visit cannot be made, the scheduled visit should go to “missed”
status and a reason code should be entered at that time To receive a new authorization for a “missed” visit, please contact
the Care Coordination support center at 1-888-747-8955
3
Home Modification Requirements and Policy
Effective May 31, 2011, VSHP Home Modification Inspectors will perform the following tasks:
– Evaluate member’s home to determine needed modifications – Draft report documenting needed home modifications – Submit report to Home Modification Coordinator for distribution to
potential providers for bids – Review bids and make appropriate recommendation
The winning bid is not shared with non-winning contractors The Bidder Tool is available for provider assistance with the
bidding process. This tool is intended for informational use only; it is not required
Bid Request Forms are available on the company website, bcbst.com
Providers notified via email of approved bids
4
Adult Day Care (ADC) License Requirements
On May 25, 2011, the Bureau of TennCare notified all unlicensed ADC providers that moving forward, a license is required prior to providing services to members.
A grace period until Dec. 31, 2011, has been granted to all
Nursing Facility providers and to contracted ADC providers currently providing services to enrollees who were previously participating under the Waiver program prior to the transition.
All other providers must obtain an ADC license from the
Department of Health and Human Services or a Mental Retardation Adult Habilitation Day Facility license from the Department of Mental Health prior to providing ADC services to members, even if contracted with VSHP.
5
Transportation for Adult Day Care Services (ADC)
Transportation to and from an ADC is not reimbursed by VSHP The provider may offer transportation to participants if needed, but
VSHP will not reimburse these charges VSHP must provide Non-Emergency Transportation Service to
members receiving ADC services only if: 1. Due to network inadequacy, the member requires transportation
due to distance constraints; or 2. It was deemed an overall cost effective alternative as indicated in
TennCare Rules 2.11.1.8.1 and 2.6.5.2.6
Only in theses two instances will transportation be considered reimbursable by VSHP
Assistive Technology vs. Durable Medical Equipment
Examples of Assistive Technology (AT) include – Grabbers – Grab Bars – Devices to help zip up or down
Durable Medical Equipment (DME) items, such as wheelchairs, are not considered AT and should not be considered part of the member’s CHOICES benefits
If a member is in need of DME, an authorization should be
requested from CareCentrix® by calling 1-888-571-6022 VSHP will not reimburse items considered to be DME if filed under
the member’s CHOICES benefits 7
Inpatient Respite and In-Home Respite
Inpatient Respite services for CHOICES members can be billed via the CHOICES Web Portal on bcbst.com or via normal claims submission procedures
In-Home Respite services for CHOICES members should only be scheduled and billed through the Sandata EVV system
8
Billing Codes and Modifiers for HCBS Services
Please remember when billing for services, the appropriate modifier and HCPCS code is used
9
Service HCPCS Revenue Code Modifier
Adult Day Care S5100 0570
Assistive Technology T2029 0590 U4
Attendant Care S5125 0570
Home Delivered Meals S5170 0590
Homemaker Services S5130 0570 U1
In-Home Respite S5150 0660
Inpatient Respite S5151 0660
Minor Home Mods S5165 0590
Personal Care Visits T1019 0570
PERS – Installation S5160 0590
PERS – Monthly Fee S5161 0590
Pest Control S5121 0590 U1
Personal Emergency Response System (PERS) Policy and Member Hospitalized
10
Contact the Care Coordination Support Center as soon as you become aware a member has been hospitalized
PERS providers may leave their equipment in the member’s home
and resume monitoring once the member is discharged home If the member is permanently institutionalized, the PERS provider
may retrieve the equipment at this time PERS should not charge the member or VSHP for monitoring while
the member is inpatient
Notification to VSHP when Member is Hospitalized
Contact the Care Coordination Support Center as soon as you become aware that a member has been hospitalized
Many times, you know of a member’s hospitalization before the Care Coordinator
Area Agencies on Aging and Disability (AAAD) Credentialing, Site Visits, Attestation Forms
Effective July 1, 2011, VSHP will no longer use the AAAD to credential providers
The assigned Network Representative will conduct all initial site
visits and recredentialing site visits AT, Minor Home Modifications and Pest Control providers will only
require the initial site visit for credentialing purposes Nursing Facilities will continue to be recredentialed every three
years All other provider types will be recredentialed on an annual basis
12
AAAD – Credentialing, Site Visits, Attestation Forms
Legislation passed by Congress in 2005 requires that VSHP “ensures organization complies with federal and state laws that detect and prevent Fraud, Waste and Abuse in federal health care programs.”
Attestation form is required once per year
Providers may receive the form via email, fax or in person during the annual site visit performed by the Network Representative
Please sign and return to your Network Representative
13
Pre-Admission Evaluation: Who to Contact and When
A new Pre-Admission Evaluation (PAE) is required when the level of care changes
Enter the Medicaid Only Payor Date
(MOPD) into TN Pre-Admission Evaluation System (TPAES)
To verify eligibility, send a copy of
the most recent PAE to your Network Representative
Enhanced Rates for Nursing Facility Services
To receive enhanced rates for nursing facility services, authorization is required from Care Coordination
For level 1 and level 2 services that do not involve enhanced
services, the PAE serves as the authorization Please do not contact Utilization Management for these
authorizations
15
Support Center Changes in Care Coordination and the POD Unit
Beginning June 1, 2011, Support Center new hours are 7 a.m. to 5 p.m. (CT)
The Support Center also modified its structure to provide additional resources
Each CHOICES Member has a Care Coordination team known as a POD
Each POD consists of the Care Coordinator, Assistant Care Coordinator and Care Coordinator Assistant and is responsible for coordinating the initial services and extending authorizations
The VSHP Care Coordination team has also established a Provider Inquiry Specialist team to assist providers in resolving claims-related issues
Each provider has been assigned a Provider Inquiry Specialist who will be contacting you soon 16
Claims Submissions & Remittance Advices
Submit all claims as quickly as possible to avoid any delays in payment
Work your remittance advice as soon as it is received
Timely filing has been extended to July 31, 2011. Please remember to submit your claims to avoid timely filing denials.
Critical Incidents
Providers are required to notify VSHP within 24 hours of discovery of a Critical Incident.
Phone number for reporting – 1-888-747-8955
If the initial report is made verbally, the written Critical Incident Report form must be faxed to (615) 396-8589.
18
Critical Incidents
A follow-up report of the provider’s investigation and the actions taken must be submitted as soon as possible (ASAP) and within 30 days.
The report must include: – The findings of the provider’s investigations – Actions taken in response to the specific incident to ensure the safety and
well-being of the member – Actions provider will take to ensure there is no recurrence of the same issue
In ALL circumstances, providers must provide a written status report within 30 days if for some reason they are unable to complete their investigation.
The status report must include: – The reason for the delay and – The timeframe when the report will be completed and submitted.
A delayed follow-up report should be a rare occurrence
19
CHOICES Information Available on bcbst.com
20
Select “More”
CHOICES Information Available on bcbst.com
21
Scroll down to the BlueCare/TennCareSelect section and select “more”
CHOICES Information Available on bcbst.com
22
Scroll down and select “more” under the CHOICES section on the right side of the page
CHOICES Information Available on bcbst.com
23
The CHOICES Section now appears
CHOICES Provider Referral Process
CHOICES members have a right to choose HCBS Providers that are within the network. However, the member may request assistance from the Care Coordinator or Support Center to choose a provider when necessary.
Therefore, when a HCBS service (e.g. Personal Assistant, Attendant Care, Home Maker Services) is approved by VSHP, the Care Coordinator or Support Center must provide the member with the most current copy of the VSHP Provider Directory or verbal listing of providers in order to allow the member to choose a provider.
The Care Coordinator shall assist in the members’ selection of providers to ascertain that the member receives their home care needs.
The Care Coordination Supervisor monitors the process to make certain the provider selection is managed appropriately.
24
CHOICES Provider Referral Process
The Care Coordinator will follow the steps outlined below: – Print a copy of the provider directory available online at www.bcbst.com/
weekly to assure there is an up-to-date copy of the provider directory with them at all times when visiting members’ homes.
– Allow the member to select a provider that is within their region or county. – If member needs or requests assistance, assists the member to select a
provider. – To ensure that providers are selected fairly and consistently, the care
coordinator rotates providers alphabetically within the region or county. Example: Ms. Boone wants her care coordinator to assist with selecting a provider for her Personal
Assistant Care. The Care Coordinator also had to assist Ms. Wilhite today who lives in the same county and for the same service.
The provider directory lists the agencies in Shelby County: – Alpha and Omega Home Care – Freedom Home Care – Zest of Life Home Care
– The Care Coordinator chose Alpha and Omega Home Care for Ms. Wilhite, so she must choose Freedom Home Care for Ms. Boone.
25
CHOICES Provider Referral Process
If the Support Center receives a request for assistance with locating a provider they must also choose providers alphabetically. The Support Center staff follows the steps outlined below:
– Retrieves the provider directory from www.bcbst.com/ and allows the member to select a provider within his/her region or county. If member needs or requests assistance, the Support Center assists them to select a provider.
– To ensure providers are selected fairly and consistently, the Support Center rotates providers alphabetically within the region or county. Example: Ms. Boone wants her care coordinator to assist with selecting a provider for her Personal
Assistant Care. The Care Coordinator had to assist Ms. Wilhite today who lives in the same county and for the same service.
The provider directory lists the agencies in Shelby County: – Alpha and Omega Home Care – Freedom Home Care – Zest of Life Home Care
– The Associate Care Coordinator chose Alpha and Omega Home Care for Ms. Wilhite, so she must choose Freedom Home Care for Ms. Boone.
26
Locating a Participating Provider on bcbst.com
27
Select “Health Tools” and then “Find a Doctor”
Locating a Participating Provider on bcbst.com
28
Locating a Participating Provider on bcbst.com
Always use the online Provider Directory – it is the most current directory of contracted providers. The hard copy Provider Directories are out-of-date as soon as they are printed.
Search for CHOICES Providers as explained in the previous slide. Failure to do so will yield unfavorable results when searching for providers.
29
BlueAccess
BlueAccess is available to all providers on bcbst.com and vshptn.com
Register and obtain your shared secret
BlueAccess allows you to view:
– Benefit limits – Authorizations – Access to the web portal – Review remittance advices – Obtain member-specific information
For additional information on BlueAccess, please contact your
Network Representative
Important Numbers
Handouts are available with additional important phone numbers
Network Representative contacts:
East Grand Region: Buffy Bass-Douglas Phone: (423) 535-3856 Email: [email protected] Middle Grand Region: Nathan Key Phone: (615) 760-8707 Email: [email protected] West Grand Region: Sheldon House Phone: (901) 544-2170 Email: [email protected]
Important Numbers
Care Coordination: Phone: 1-888-747-8955 Fax: (615) 386-8589 Email: [email protected] ***Beginning June 1, 2011, Care Coordination’s new hours of
operation are 7 a.m. – 5 p.m. (CT).***
BlueCare® Provider Service: Phone: 1-800-468-9736
TennCareSelect Provider Service: Phone: 1-800-276-1978
Automated Eligibility Line:
Phone: 1-800-543-8607