Paramount AdvantageParamount Advantage

Physician Orientation

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Overview Paramount Advantage

• Toledo-based Ohio Managed Care Plan (MCP)

• Established 1993

• Provides health care coverage to

– Covered Families and Children (CFC)

– Aged, Blind, or Disabled (ABD)

• All counties in the State of Ohio

• Member of ProMedica

• Accredited by NCQA (National Committee for Quality Assurance}

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Overview Paramount Advantage

• As of 5-1-13, serving 94,437 Covered Families and

Children (CFC) members in NW Ohio

• Highest overall member satisfaction rating

of all Medicaid care coordination plans in Ohio since

1995

• Highest ranked plan in the State of Ohio by

NCQA/Consumers Report in 2009, 2010, and 2012

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Member Identification Card

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Front Back

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Website Resources

– Provider Manual – provider source for detailed information

Paramount Advantage Provider Manual

ALSO…………………….

– Provider News &

Bulletins

– Network Newsletters

– Provider Directory

– Product Information

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Claims Submission

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HCFA 1500 Form

Required for all claim submissions Within 365 days from the date of service

Electronic Claims Submission Contact ECS Helpline 855-803-6777

to become a submitter

Mail

P.O. Box 497, Toledo OH 43697-0497 Attention: Claims Department

Medicaid Provider Numbers

Effective July 1, 2013

0077190 (CFC)

0077188 (ABD)

(CMHC) Community Mental Health Centers

(ODADAS) Ohio Department of Alcohol and

Drug Addiction Services

Bill Ohio Medicaid

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Electronic Claims Submission

• Providers are encouraged to submit routine claims electronically

• For questions related to electronic claims submissions, contact our Electronic Claims Submissions Coordinator:

Phone: 855-803-6777

Email: PHCECSHelpDesk@promedica.org

• HIPPA compliant Electronic Vendors/Clearinghouses List

Provider Manual Page 8.1

• Example of Electronic Claims Report

Provider Manual Page 8.2

• How to review rejected claim reports for correction and resubmission.

Provider Manual Page 8.3

Paramount AdvantageParamount Advantage

Home Health CareHome Health Care

Home Health ServicesObjectives

• Provide Paramount members with home health care services per member benefit

• Encourage utilization of home health services when a plan

of treatment is identified as appropriate for in-home care services

• Provide two post-partum home health care visits to

Paramount Advantage mothers of normal newborns

– For assessment of parenting skills and education as needed

• Provide two post-discharge home health visits to all newborns who havereceived care in the NICU whether or not infant has skilled health care needs

– For assessment of infant progress, parenting skills, and education as need

Home Health ServicesOrdering Care

• Home health services may be ordered by the PCP,

OB/GYN or a par specialist who is actively treating the

member

• The ordering physician is responsible for sending/communicating the referral to the designated In-Plan agency

• The in-plan home health agency is responsible for assessing the needs of the patient and contacting Paramount for authorization

– Agency faxes Home Health Care (HHC) Admission Notification Form to

Paramount

Paramount Utilization Case Management Contact Information:

Phone 800-891-2525 Fax 866-214-2024

FORMS referenced for home health care may be found at www.paramounthealthcare.com

Home Health ServicesAuthorization

• The Paramount Utilization Case Manager U/CM will verify eligibility andbenefits

• Home health care services will be approved if criteria/guidelines met using the InterQual® Alternate Level of Care Guidelines

• The U/CM Coordinator specifies:

– The time span

– Services approved

– Next review date

• The Home Health Agency will receive via fax of completed HHC AdmissionNotification Form

– Authorization number

– Next review date

Home Health ServicesOther Services that May be Authorized

• Home Health Aides

– May be covered if medically appropriate as per plan benefit

• Pharmaceuticals and related supplies

– May be covered if the member has prescription drug

coverage through Paramount and/or if covered under

the medical benefit

• Out-of-Plan Services

– Covered for urgent or immediate post hospitalization care only

Home Health ServicesConcurrent Review/Updating Authorization

• Authorization of additional home care services

– Home health agency must provide clinical information, progress report, and

number and type of visits

• The Review Worksheet is faxed to Paramount by the home health agency on the review date specified by the U/CM Coordinator

• U/CM Coordinator reviews the information to determine if the requested services are appropriate and necessary

– The Case may be discussed with the Associate Medical Director

• Should services be denied, provider and member notification will be in accordance with Paramount U/CM procedures

Home Health ServicesOn Hold Notification & Discharge Notification

• If member is admitted to a facility while receiving home care services

– Agency sends an On Hold Notification Form

– If the member is inpatient on the 60th day after admission to home care, the agency will close the episode of care on that date

• When a member is discharged from home care services

– Agency is asked to fax HHC Discharge Notification Form to Paramount

– Agency to include a final summary of the number and types of services provided

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Prior Authorization Requirements

• Some procedures, diagnostic services and drugs require Prior Authorization for Paramount Advantage membersPrior Authorization List

• Prior Authorization is obtained by contacting Utilization Management

Phone 800-891-2520

Fax 866-214-2024

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Outpatient Imaging ServicesPrior Authorization

• Imaging scans requiring prior authorization include: – Elective MRI, CT Scans, CTA Coronary Arteries, & Nuclear Cardiology

– The ordering physician or facility performing the imaging procedure should submit

the prior authorization request

• Submitting the prior authorization, two options:• Clear Coverage™ - Web-based prior authorization tool

or

• Fax 866 214 2024

Imaging Fax Form available at:

Outpatient Imaging Prior Authorization Fax Request Form

– Medical Documentation to be submitted with the fax request:

• Medical / Clinical History

• Current signs & symptoms

• Results of any pertinent testing

• Consults or other treatment

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Outpatient Imaging Services (continued)

Prior Authorization

• A few more things you need to know:– Paramount will send return fax with authorization number within 5 working

days

– If denied, provider has right to request reconsideration (ORC 1751.82)

– “Stat” tests - ALWAYS address patient needs first & prior authorize the next

business day

– Approval authorizations will be available for viewing in Provider Direct

– Authorizations are generally valid for a 3-month period

– Location 21(inpatient) or location 23 (ER)

do not require PA

Provider Manual Pages 4.3-4.5

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Web-based Prior Authorization ToolMcKesson’s Clear Coverage™

• May be used to prior authorize CT, CTA of Coronary Arteries, MRI, MRA, and Nuclear Cardiology

• Automates authorization process

• Provides an instant determination

• Utilizes InterQual® Criteria sets for

medical necessity determinations

• New users may obtain a login online

at www.paramounthealthcare.com

• Clear Coverage Login Request

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Electronic Payment & Remittance ServicesEmdeon™

• Paramount is contracted with Emdeon

to deliver Electronic Funds Transfer (EFT) services and Electronic Remittance Advice (ERA) files in PDF image format

• Enrollment is simple:

– Call 1 866 506 2830 and select Option 1

– Visit www.emdeon.com/eft

• Payment remittance data is delivered electronically via Emdeon payment manager by which each remittance can be viewed and printed

• Existing Electronic Fund Transfer customers with Emdeon may add Paramount: Call 866 506 2830 Option 2

Provider Manual Page 8.12

• Click to add text

– Second level

• Third level

– Fourth level

» Fifth level

• Submit

Provider Data Change Form

for all provider change

requests

Provider Data Change Form

• Fax 800-891-2542

• Mail

Provider Relations Department,

Paramount

P.O. Box 928

Toledo, OH 43697

Provider Changes

Claim Adjustments & Coding Review RequestsOne Form

• Paramount utilizes one form for adjustments and appeals

– Claim Adjustment/Coding Review Request Form may be found at Claim Adjustment Coding Review Request Form

– In late 2013 submission of adjustment requests will be availableelectronically through the Paramount website

• Coding Review Requests require a copy of the EOP and any of

the following:

CPT coded chart notes

CPT coded operative notes or

CPT coded diagnostic reports

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Provider DirectParamount’s Interactive Website

• Secure online access to health plan information for our members

• Eliminates calls to Paramount for our providers

• Connect from anywhere, day or night

• Fully compliant with all HIPAA privacy standards

• To obtain access, complete

Provider Direct Login Request Form available at

Provider Direct Login Request Form

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Behavioral Health ServicesOutpatient

• Role of Behavioral Health Coordinator

– Facilitates & coordinates appropriate use of benefits and referrals as required to:

• Publicly funded community BH system including CMHCS & ODADAS

certified Medicaid providers

• Members may self-refer to these agencies

• Paramount Advantage

– Required to make arrangements for services outside community

network

– Must maintain an Advantage provider panel

• Members may self-refer to par Advantage providers with no prior

authorization required

– Financially responsible for long-acting injectable second generation antipsychotic drugs (e.g., Risperdal, Invega, Zyprexa)

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Behavioral Health Services (continued)

Outpatient

• Not covered by Paramount

– Outpatient detoxification

– Methadone maintenance

– Marriage counseling

• Member Liability

– No liability (may not be billed) when a par Advantage provider provides a service requiring PA for which the provider does notobtain a PA.

– Member responsible (may be billed) for non-covered services

– A signed waiver meeting state guidelines must be obtained to bill an

Advantage member

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Who to Call at ParamountDEPARTMENT ASSISTANCE AVAILABLE PHONE FAX

Credentialing• New Provider Applications

• Recredentialing Questions

800-891-2542 855-896-0854

Member Services

• Member Questions

• PCP Change Requests

• Interpreter Services

800-462-3589

888-740-5670 TTY

888-740-0222

Provider Inquiry8:30AM – 12N

1:00PM – 5:00PM

Monday – Friday

• Member Benefits & Eligibility

• Claim Status Inquiries

• Claim Processing Issues

• Claim Adjustment

855-522-9076 855-448-4705

Provider Relations

Representatives

• Education - Provider & Office Staff

• Contract Issues

• Orientations/Webinars

• New Product Participation Requests

• Representative Office Visit Requests

800-891-2542

855-896-0854(Toledo)

855-448-4707 (Cincinnati, Cleveland,

Columbus)

Utilization/Case Management

8:00AM – 6:00PM

Monday-Friday

• Obtaining In-Plan & Out-of-Plan

Prior Authorizations800-891-2520 866-214-2024

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Thank you for your attention…

Questions??