KanCare All MCO Training Fall 2019 - kmap-state-ks.us

1 KanCare All MCO TrainingFall 2019 Welcome, Introductions & Agenda Welcome Introductions Aetna Better health of Kansas Sunflower health Plan United HealthCare Agenda for the day Morning MCO Specific Sessions 8:30 to 11:15 8:30 -9:15 United Healthcare or Sunflower 9:30 10:15 Sunflower or United Healthcare 10:30 11:15 Aetna General Session 1:00 pm to 4:00 pm Break out tables for each MCO and Ombudsman All day 2 Recent Policy ChangesPolicy Changes All providers are required to have a kmap ID number to receive payment Bulletin 19110 -45 days after 7/1/19, Pharmacy claims will deny if prescribing doesn t have kmap Bulletin 19088 FQHC/RHC Enrollment effective 7/1 Bulletin 19119 -General All policies effective 7/1 Fluoride treatments covered in Local health Departments Bulletin 19085 effective 8/1/19 Bariatric policy changes Bulletin 19125 RHC/FQHC effective 7/1/19 with dates of service on or after Place of Service 13 will be allowed for RHC/FQHC for the following procedure codes.

2 Bulletin 190873 OneCare Kansas 4 Kansas The term OneCare Kansas refers to a new Medicaid option to provide coordination of physical and behavioral health care with long term services and supports for people with chronic Kansas expands upon medical home models to include links to community and social Kansas focuses on the whole person and all his or her needs to manage his or her conditions and be as healthy as the caregivers involved in a OneCare Kansas member s health communicate with one another so that all of a patient's needs are addressed in a comprehensive Kansas is intended for people with certain chronic conditions, like diabetes, asthma, or mental illness. These people must be KanCaremembers.

3 They can be members who also receive Medicare along with Kansas Frequently Asked Questions6 OneCare Kansas Frequently Asked Questions 7 OneCare Kansas Frequently Asked Questions8 OneCare Kansas Frequently Asked Questions9 Who is Assigned to a MCO? The majority of Medicaid beneficiaries will be assigned to one of the 3 KanCare Managed care Organizations (MCO) Examples of populations excluded: Qualified Medicare Beneficiary (QMB) only members Low Income Beneficiary (LMB) only members Emergency care for Immigrants (SOBRA) members Tuberculosis (TB) Only members MediKanmembersClaims for members in these categories will be submitted to Kansas Medical Assistance Program ( kmap ) for : If a member has retro-eligibility which exceeds 90 days, there may be months where the member does not have an MCO assignment.

4 Claims for those months would be billed to kmap . 10 Member Eligibility and MCO Assignment? Options kmap Website MCO Websites EDI transactions (270/271 transactions) kmap Automated Voice Response System (AVRS) kmap Provider Services Call Center MCO Provider Services Call Center Important items to look for: Which MCO is the member assigned to? Is the member in the lock -in program? Does the member have other insurance? It is important providers check the MCO specific website for member Third Party Liability (TPL)/Coordination of Benefit (COB) information Does the member have a spenddown amount, client obligation or patient liability? 11 MCO Provider Services All 3 MCO s have self service tools on their Websites, Provider Services Call Centers, and Provider Relations staff to assist you with any question regarding how a claim was processed.

5 When reaching out for assistance please make sure you have the following information: The MCO claim number The members Medicaid ID # The date of service on the claim Total billed charges The Tax ID # or NPI for the provider Provider Contact InformationIf working with one of our call centers or Provider Relations staff, please make sure you note in your file the name of the person you spoke with and the date and time of the call. 12 Eligibility Verification13 Eligibility verification can be accessed from the Provider page. The Eligibility tab appears on the menu bar at the top of the page and the Eligibility Verification link is found below the provider information. Eligibility Verification Continued14 Beneficiary eligibility can be searched in three different ways.

6 And/or Date of and Date of BirthWaiver Member and Third-Party Liability Example15 Nursing Facility Member16 Unmet SpenddownAmount Example17 Locked-in Member18 Member Third Party Liability Information AetnaProviders may obtain member TPL/COB information by calling Member Services Department at 855-221-5656, (TTY: 711) or online via our secure provider portalLog into Aetna Better health of Kansas secure provider Member s policy start and stop date, COB Primary payer information and other payer details are available19 Member Third Party Liability Information Sunflower Log into Sunflower SecureProviderPortal and click on the Eligibility tab Enter Medicaid Member ID and Date of Birth Click the Green box Check Eligibility On the left click the Coordination of Benefits tab for COB detailsProviders may also call Customer Service Center at 1-877-644-462320 Member Third Party Liability Information United HealthCareProviders may obtain the following member TPL/COB information online using LINK eligibility function via Member s policy start and stop date.

7 COB Primary payer information and other payer details are availableProvider s other options is to contact our Provider Services Call Center 1-877-542-9235 to obtain TPL/COB information for a member. 21 Provider Directory22 Provider Directory -Search23 Provider Directory -Detail24 How to Verify Coverage of a Service or Supply? MCOs provide the same benefits required under kmap . There are several ways to determine if a service is a covered benefit: kmap Website Procedure code look up tool Fee schedules kmap Provider Manuals MCO Provider Manuals, Administration Guides, or Quick Reference guides MCO Provider Services Call Center25 kmap Reference Codes26 The kmap Reference Codes page has links to search by procedure, NDC, and diagnosis codes.

8 There are additional reference links to fee schedules, tables, and pricing. Reference Codes ContinuedProcedure code search27 Reference Codes Continued28 Once a HCPCS code link is clicked, a box (similar to the one below) will open automatically with information on that particular procedure Codes Continued29 Once a NDC code link is clicked, a box will open automatically with information on that particular SearchReference Codes Continued30 Once a diagnosis code link is clicked, a box will open automatically with information on that particular diagnosis as shown SearchCoding Modifiers31 The Coding Modifiers Table is located in the Helpful Information section of the Provider page. Historical and current versions are available.

9 Click the link and the Coding Modifier Table document will open. Each MCO determines which services and supplies require a prior authorization (PA) for their members. Each MCO will have a unique list of services requiring a PA. A provider can validate whether services require a PA by using the following: MCO Website MCO Provider Services Call Center MCO Provider Manuals or Admin guides Retro-Eligibility and Prior Authorization Each MCO has a process in place for providers to follow when the member was not eligible at the time of the service, preventing a provider from obtaining a PAHow to Determine if a Service Requires Prior Authorization? 32 AetnaOnline: Go to for Providers / Resources / Prior AuthorizationoClick on the online prior authorization search tooloEnter up to 6 CPT or HCPCS codes Phone: Call the Aetna Better health of KS PA request line 1-855-221-5656oProvide the PA representative with the code/codesoPA representative will review the PA requirements How to Determine if a Service Requires Prior Authorization?

10 33 Sunflower How to Determine if a Service Requires Prior Authorization? 34 Online Prior Authorization Prescreen tooloAnswer a few questions about the service being rendered. oEnter CPT code to validate authorization requirement No: No Pre-authorization required for all providers. Yes: Pre-authorization required for all providers. Maybe: Pre-authorization is required for non-participating providers only Prior authorization should be requested 14 calendar days prior to the scheduled service delivery date or as soon as the need for service is identified including weekdays, weekends and holidays. Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information.