Preferred Care Partners Medical Group

“PCPMG”&

WellMed Medical Management

2016 Delegation Training

Overview

Preferred Care Partners Medical Group “PCPMG” and WellMed Network of Florida, Inc. are pleased to announce we have joined

forces provide Medicare-eligible patients with high-quality, proactive patient care with a distinct focus on prevention in the South Florida

Market.

Beginning January 1, 2016 WellMed will be delegated for Utilization Management (Authorizations) & Claims payment for all

members who are assigned to a Primary Care Physician belonging to Preferred Care Partners Medical Group “PCPMG”

Member Identification

How to identify if the member is a WellMed delegated PCPMG member:

There are two key indicators to help identify PCPMG members:1.Payer ID# WELM22. WellMed is listed in the bottom right hand corner of the ID card

Your members ID card will look like the following:

It is the responsibility of every provider to verify eligibility and/or benefits for a delegated member before providing services. Always verify eligibility and/or benefits before providing services by:Logging into mypreferredprovider.com; go to “Member Inquiry”Calling Benefits & Eligibility Department at 800-587-5114 (referenced on the back of the member’s ID card)

Utilization ManagementPrior Authorizations

What is a Prior Authorization?A Prior Authorization is a formal request where a provider must receive permission before a specific procedure, treatment, or service is rendered to the member.

What is changing?Please be advised that the health plan has enhanced our current No Authorization Reference Guide “NARG”, which is included on the following slide. For any code listed on the NARG a prior authorization is not required; therefore, any codes not listed on the NARG do require prior authorization.

Effective January 1, 2016 all authorization requests must be submitted to WellMed for members belonging to a PCPMG Primary Care Physician. All participating providers are able to submit an online prior authorization request by using the secure WellMed provider portal, ePRG at https://eprg.wellmed.net or by faxing your request to 866-322-7276.

Requests which meet the ‘expedited classification’ can be called into WellMed at 877-299-7213 from 8:00am to 5:00pm (EST) Monday through Friday.

For dates of service prior to 1/1/2016 continue to send requests to Preferred Care Partners

No Authorization Reference Guide

No Authorization Reference Guide

No Authorization Reference Guide

Authorization RequestsHow to: Log into the system by going to https://eprg.wellmed.net , you can follow the basic steps outlined below to enter an online Prior Authorization request. 1. From the Menu Bar click on “Authorization or Referral” and select “Submit Prior Authorization Request”.

2. Click “Search” a second window will open to allow you to search for a Member by ID number and select the Member.

• (Note: Please make sure your pop-up blocker is disabled.)

Authorization Requests3. Once the Member is selected, the request will be prepopulated with the PCP and Member Information.

4. Select the Requesting provider information from the drop down menu. The provider(s) available for selection are the contracted providers associated with the registered user’s Tax ID number. Once the provider is selected, based on the provider specialty the following rules may apply.

• If the Requesting Provider is the Primary Care Physician (PCP), they can proceed and enter the Prior Authorization Request.

• If the Requesting Provider is a Specialist they can proceed and enter the Prior Authorization Request.• If the Requesting Provider is a Specialist with a specialty that does not require a referral from the PCP, they will

receive the following Pop-Up message.

Click on “Yes” to continue with the request. Click “No” to cancel the request.

Authorization Requests5. To select a Servicing Provider click “Search” – A new window will open allowing you to select the Specialty type and

Provider. You can search for a provider by:• Specialty Type• Provider or Group Name• A specific County in a Market• Once you have selected your search criteria click “Search”. The search results will display the providers based on

the search criteria used.• Click on the Check Mark to Select a Provider. The provider’s name, phone number and fax number (if available) will

auto-populate the prior authorization request screen.

Please Note: If you do not see the provider your request is for, please key in the provider’s last name and click “Okay”. If the provider is not found, please complete and fax a Prior Authorization Request Form to the Medical Management Department.

Authorization Requests6. The Service Type, Place of Service (POS) and Auth Type are required. Select the appropriate options that apply to the

request.7. Search for a diagnosis by ICD or diagnosis description. Once the required diagnosis is displayed, highlight and click on

the arrow to move the diagnosis to the “Selected” box. You may enter up to three (3) diagnoses.8. Click on “Choose” to select your Procedure Code(s). A pop-up window will appear for entry of the procedure code(s), number of visits/units and service group.

Entering a Procedure Code(s)Once you have clicked on “Choose” the pop-up window will appear to enter the procedure code(s), number of visits/units and service group.

Authorization Requests• Enter Procedure Code, click Filter.• Click on the procedure code and description displayed.• Enter the number of Visits or Units requested for the procedure code.• The Service Group should auto display, if there is more than one Service Group associated to the code use the drop

down option to select the Service Group that is the closest match to the procedure code.• Click “Add” to add this information to the authorization request. You will follow this process for each procedure code

added to the request up to the maximum of fifteen (15) codes.• If the procedure code does not require a prior authorization, a pop-up window will be displayed.

9. Once all procedure codes have been entered, the information will be displayed on the request.10. Clinical information can be scanned and uploaded to the request.11. Click “Submit”, the request is sent to the Medical Management Department for review.12. A web ID will be displayed notifying the user that the request has been Pended for Medical Review and the ability to print

a copy of the request for your records is available.

Authorization Requests•The printer friendly version of the Prior Authorization form includes all of the information included in the ePRG online request.

1. Authorization number, Date of request and Status2. Provider Requesting Authorization 3. Provider the patient is being referred to4. Facility where services are being rendered (if applicable)5. Patient demographics6. Patient’s Insurance details and PCP information7. Diagnosis Code & description entered8. Service Type, Place of Service and authorization type9. CPT codes and description entered10.Service Group associated to the request

Authorization RequestsViewing Approved, Pended, or Denied Requests:

Providers are able to view all Prior Authorization requests associated to the Tax ID number used at registration. PCPs are able to view all requests associated to their assigned members. You may access this information by selecting the Menu bar option “Authorization or Referral” and selecting the submenu of “View Authorizations”.  This area of the portal allows you to view the status of all Prior Authorization requests associated to a specific member or use the following filters:

• Date of Service To and From• Authorization Status • Provider and or Member ID

Please Note: When using the provider name search feature, a PCP Practice is only able to search for providers associated to the registered TIN.

Each column header allows the user to sort the data alphabetically or numerically. For example, by clicking on the column header “Referred to” the information displayed will sort alphabetically by provider name.

By clicking on an authorization line item, the requested information is displayed.

You can click on the Printer Friendly Version button to print a copy of the request for your records.

Authorization RequestsViewing Approved, Pended, or Denied Requests:

Authorization RequestsPrior Authorization Form:

Misdirected Authorization Requests

When a provider contacts Preferred Care Partners for prior authorization or hospital admission notification for a delegated member:

• If contact made via phone call or fax to Preferred Care Partners, the Intake Team will instruct the provider to call WellMed Utilization Management at 877-299-7213.

• If attempt is made via the Preferred Care Partners Provider Portal, an alert message with a hyperlink will appear that will redirect to the WellMed Provider Portal.

Claims SubmissionWhere do I submit claims for members assigned to a Primary Care Physician belonging to Preferred Care Partners Medical Group “PCPMG” & for all dates of service on or after January 1, 2016

To ensure accurate claim submission, please review your clearinghouse’s payer listing to confirm that WELM2 is listed as payer ID# for WellMed. If not, utilize the payer ID# that your specific clearinghouse has designated for WellMed. If nothing is listed notify your clearinghouse that you would like to submit claims to WellMed using payer ID# WELM2

Submit paper claims to:WellMed ClaimsP.O. Box 400066San Antonio, TX 78229

Electronic Claims:Payer ID: WELM2

What if I accidentally submit a WellMed claim to Preferred Care Partners?

If you submit a claim to Preferred Care Partners in error, the claim will be denied indicating to resubmit to the correct address/payor. You will receive a claim status message from Preferred indicating you have submitted to the wrong payer. It will then be the responsibility of the provider to resubmit the claim to WellMed.

For claims with dates of service prior to Jan. 1, 2016 continue to submit to Preferred Care Partners

Claims Status or Payment ReviewTo check the status of a claim or the date of payment, simply log in to the WellMed Provider Portal at https://eprg.wellmed.net.

Registered providers can view detailed claims information associated with their Tax ID# by using the “Member Claims Search” or the “Advance Claims Search” functions.

Misdirected Claims StatusWhen a provider contacts Preferred Care Partners directly to check claim status or verify payment date/details on delegated member:

• A customer service representative will instruct provider to call WellMed at 800-550-7691

• Using the Preferred Provider Portal: When a provider initiates a search using the Preferred Care Partners provider portal an alert message will appear stating that the member is a WellMed delegated member and will be redirected with a hyperlink to the WellMed Provider Portal

What is the fastest and most efficient way to check claims status or to review a copy of my Explanation of Payment (EOP)?

• To check the status of a claim or the date of payment, registered providers simply log into the WellMed Provider Portal at https://eprg.wellmed.net.

For dates of service prior to Jan. 1, 2016, continue to view claim status on the Preferred Care Partners Provider Portal: https://www.mypreferredprovider.com

ReimbursementAll WellMed claims payments are processed through Emdeon.

In lieu of paper checks, Emdeon issues payments on WellMed’s behalf via a virtual credit card (VCC) or electronic funds transfer (EFT) with the applicable Explanation of Payment (EOP).

If you are already signed up for electronic funds transfer (EFT) with another payer, please add WellMed to your account through the Emdeon Payment Manager at emdeon.com/epayment.

If you are not signed up for electronic funds transfer (EFT) please find steps for the enrollment process below:

Step 1:  Complete the EFT enrollment form found at http://www.emdeon.com/epayment/enrollment/enrollform.php Immediately after submitting the completed form online, the provider will receive an email asking for confirmation/acknowledgment of the electronic signature within the form.  In about 7 to 10 days, a test deposit will go into the account.  Email notification will be sent when test

deposits are available. (if you do not hear within 3 business days, please reach out to Emdeon at 866-506-2830Step 2:  Validate test deposits in applicable bank accountAfter confirming your bank account, an email notification will be sent stating “your banking is now enabled”. EFT enrollment is now complete unless there are multiple NPIs associated with yourbilling TIN.If there are multiple NPIs associated with your billing TIN, please register your additional NPIs by completing step 3 below.Step 3:  Complete Emdeon payer add/change/delete authorization form

http://www.emdeon.com/epayment/enrollment/EFTPCF.php

Claims Payment Dispute ProcessA claims payment dispute is defined as a formal written request from a provider for reconsideration of a claim already processed by WellMed

All disputes of denied claims requests for adjustments on paid claims are to be received by WellMed.

The Claim Reconsideration Request Form is recommended for each claim dispute submitted. The provider should submit a copy of the EOP, and any applicable supporting documentation. If you are not aware of your timely filing limits, please refer to your provider agreement.

Mail To: WellMed ClaimsAttn: Claims Payment Disputes P.O. Box 400066San Antonio, TX 78229 *The Claim Reconsideration Request Form can be found on WellMed Provider Portal in the Provider Resources/WellMed Florida section at https://eprg.wellmed.net

Payment disputes for dates of services prior to Jan. 1, 2016 should be sent to Preferred Care Partners.Preferred Care Partners PO Box 56-5790Miami, FL 33256-5790Phone: 1-866-725-9334Fax: 1-866-725-9337

QUESTIONS?Should you have any questions or concerns please contact your Network Management Department at

1-877-670-8432