Managed Provider Relations Overview Geralyn D. Molinari Director,
Managed Provider Relations Overview Geralyn D. Molinari Director, Managed Provider Relations Unit Office of Managed Health Care Division of Medical Assistance and Health Services Department of Human Services June 2018 1 Presentation Topics
Provider Relations Overview Authorization and Claims Processing Continuity of Care MCO Reporting for Provider Inquiries Resources 2
Overview Managed Provider Relations Addresses provider inquiries and/or complaints as it relates to Managed Care Organization (MCO) contracting, credentialing, reimbursement, authorizations and appeals, and conducts complaint resolution tracking/reporting Provides education and outreach for MCO contracting, credentialing, claims submission, authorization, appeals process, eligibility verification, TPL, MLTSS transition and other Medicaid program changes Addresses stakeholder inquiries related to the network credentialing process, network access, and payment compliance.
3 Managed Care Organization Provider Relations Unit Requirements creating an annual provider manual and preparing updates as necessary; offering provider education and outreach, and provide a call center for claims troubleshooting for providers establish process for claims and utilization appeals assign Provider representative or contact to address Provider contract
4 Managed Care Organization Network Requirements Establish network of providers to serve needs of enrolled members Certify that provider network meets standards of the MCO contract Establish network of MLTSS service providers, which plans are currently doing 5
Managed Care Organization Claim Submission Requirements Capture and adjudicate all claims submitted by providers Support NJs NJ Family Cares encounter data reporting requirements Comply with "Health Claims Authorization, Processing and Payment Act (HCAPPA) for all Medical Services Ensure Coordination of Benefits (exhaust all other sources of payment before NJ Family Care pays) 6
Prior Authorization Parameters Prior authorization decisions for non-emergency services shall be made within 14 calendar days Prior authorization denials and limitations must be provided in writing in accordance with the Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352. Source: Health Claims Authorization Processing and Payment Act, P.L. 2005, c.352. 7
Claim Submission Requirements MCO claims are considered timely when submitted by providers within 180 days of the date of service as per (HCAPPA) P.L. 2005, c.352 8 Claim Submission Requirements with Explanation of Benefits Providers are to submit Coordination of Benefits (COB) claims within 60 days from the date of primary insurers Explanation of Benefits (EOB)
or 180 days from the dates of service, whichever is later. 9 Claim Denials Claims may get denied for a variety of reasons and it is important to supply the plan with as much information as possible when appealing a decision. 10
Continuity of Care Continuity of Care Definition: The plan of care for an enrollee that should assure progress without unreasonable interruption The Contractor shall ensure continuity of care and full access to primary, behavioral, specialty, MLTSS and ancillary care as required under this contract and access to full administrative programs and support services offered by the Contractor for all its lines of business and/or otherwise required under this contract. Source: Article 2.B of the July 2017 NJ FamilyCare Managed Care Contract
Prior Authorization Guidelines for MLTSS New Member no existing Plan of Care Member transitions to MCO with existing Plan of Care for LTC MCO must prior-authorize service
MCO must honor continuity of care parameter of contract Provider must be in Network MCO and Provider must set up with MCO and/or have a single SCA or join network. Approved case agreement to serve services as per existing plan member will be reimbursed until new plan of care established 13
Provider Relations Inquiry Process Provider and Member must submit claim detail for follow-up. Providers must submit detail indicating that MCO was contacted prior to outreach to OMHC OMHC will review and reach out to the MCO on behalf of the Provider if applicable. All inquiries sent to MCO are logged in Sharepoint database MCO are requested to respond to member and/ or Provider within 10 business days and forward copy of communication to OMHC OMHC completes inquiry upon receipt of detail indicating that MCO contract guidelines were
followed. Claim inquiries are closed upon receipt of claim number and amount and /or letter to Provider. MCO Reporting Process MCO Contract Quarterly Report (Table 3C) includes all inquires submitted to MCO by OMHC OMHC prepares Quarterly Report to MCO to ensure all inquiries are resolved. Summary of operational concerns are included in report Policy Guidance and /or contract updates developed based on issues presented by Providers and Stakeholder groups
State Resource for Managed Care Providers: Office of Managed Health Care (OMHC) Managed Provider Relations Unit Access Below is link http://www.state.nj.us/humanservices/dmahs/home/mltss_resources.html Form is located by clicking on highlight
DMAHS Provider Relations Inquiry Information Provider Relations Inquiry Request form single case Provider Relations Inquiry Request form multiple cases Email detail via secure email to [email protected] Separate emails should be sent for individual MCOs. Multiple cases must include excel summary of information.
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