unitedhealthcare community plan of new jersey...unitedhealthcare community plan of new jersey...

UnitedHealthcare Community Plan of New Jersey Provider Orientation: Managed Long Term Services and Supports (MLTSS)

Agenda

• Introduction to UnitedHealthcare Community Plan • MLTSS Program • Prior Authorization Requirements • Utilization Management • Critical Incident Reporting • Unable to Contact/Open Care Opportunities • Claims Submission and Appeals • Claims Billing Tips • Credentialing, Re-Credentialing, Criminal Background Checks and

Demographic Changes • Provider Advocates and Other Resources • Link Training • Important Provider Training Concepts • Overview: UnitedHealthcare Dual Complete ONE • Questions

PCA -1- 002643-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

3

Introduction to UnitedHealthcare Community Plan

4

• Health benefits company of UnitedHealth Group • Optum is the service side

• One of four UnitedHealthcare businesses

• Serves more than five million members of government health care

programs in 24 states and the District of Columbia

• Network: 3,319 hospitals and 512,032 providers* • Medicaid Managed Long Term Services and Supports (MLTSS) in 11 states

• Pioneered 24/7 bilingual Member Services Helpline

• Emphasizes preventive health and education

• Developed the Personal Care Model *These numbers were valid as of the date on this presentation and may have changed.

UnitedHealthcare Community Plan


UnitedHealthcare Community Plan of New Jersey

Licensed in all 21 counties for New Jersey FamilyCare and Medicaid

• 485,000 Medicaid members • 5,200 MLTSS members • 14,000 physicians • 3,479 PCPs • 10,686 specialists • 52 hospitals • 1,500 dentists

Fully Integrated Dual Eligible Special Needs Plans (FIDE SNP) in 10 counties (Dual Complete ONE)

Atlantic, Bergen, Burlington, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Union

• 7,000 members Many community health & wellness events

5


6

Personal Care Model

The Personal Care Model is a holistic approach to care for members who have chronic conditions and complex needs. Benefits include: • Focused outreach • Comprehensive needs assessment including clinical and socioeconomic

needs • Comprehensive treatment plan • Health education activities • Member evaluation that stratifies members according to diagnosis and

severity of the member’s medical and psychosocial conditions Member Referrals To refer a member for Personal Care Model services, please call 877-704-8871.


Member ID Cards

To verify member eligibility, please call 888-702-2168 or go to UnitedHealthcareOnline.com.

7 PCA -1- 002643-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Care Provider Website

UHCCommunityPlan.com provides a convenient way to work with us. Using this website, you can: • Review benefits and coverage limits • Submit claims • Check claim status • Access capitation rosters • View your panel roster • Access remittance advice and review recoveries • Review your preventive health measures report • Submit demographic profile changes


HIPAA Guidelines and PHI

Care provider are expected to follow Health Insurance Portability and Accountability Act (HIPAA) guidelines, which were developed to: • Improve the portability and continuity of health benefits • Help ensure greater accountability for health care fraud • Standardize both medical and non-medical codes across the health care

industry

Among other types of acceptable disclosures, providers are permitted to disclose protected health information (PHI) to health plans for the purpose of quality assurance, quality improvement, and accreditation activities. No authorization is needed from the patient when both the care provider and health plan had a relationship with the patient and the information relates to that relationship.


10

MLTSS Program

MLTSS Overview

• As of July 1, 2014, members who were part of the following waiver programs were automatically enrolled in the MLTSS waiver program:

• AIDS Community Care Alternatives Program (ACCAP) • Community Resources for People with Disabilities (CRPD) • Traumatic Brain Injury (TBI) • Global Options (GO) for Long-Term Care Program

• Previously, these members had their services coordinated by different agencies. Now, their benefits have moved from fee-for-service Medicaid to managed care to help improve coordination of services.

Please note the Community Care Waiver (CCW) is not part of MLTSS.


MLTSS Benefits

MLTSS benefits include a member’s long-term care needs, such as: • Personal care • Respite • Care management • Home and vehicle modifications • Home-delivered meals • Personal emergency response systems • Mental health and addiction services • Assisted living • Community residential services • Nursing home care


Assisted Living Changes

• Any service that was included in your assisted living per diem remains included in your assisted living per diem.

• You will receive separate reimbursement when billing UnitedHealthcare for any service for which you received separate reimbursement ‒ in addition to your assisted living per diem ‒ under Medicaid fee-for-service.

• There are no changes to the procedures you follow for a member entering assisted living who is not currently approved for Medicaid but will be applying for Medicaid coverage.

• UnitedHealthcare is not responsible for any payment to assisted living or other MLTSS providers until the member is enrolled with UnitedHealthcare.

• There is no retroactive enrollment for members who are newly enrolled to Medicaid. Assignment to a managed care organization takes place prospectively.


MLTSS Covered Services

14

MLTSS Service MLTSS Code Modifier Unit Adult Family Care S5140 Per diem Assisted Living ALR T2031 Per diem Assisted Living ALP T2031 U2 Per diem Assisted Living CPCH T2031 U1 Per diem TBI Behavioral Management Individual H0004 Per 15 min. TBI Behavioral Management Group H0004 HQ Per 15 min. Caregiver/Participant Training S5111 Per diem Chore Services S5120 Per 15 min. Chore Services S5121 Per diem Cognitive Therapy Individual* 97532* U4* Per 15 min. Cognitive Therapy Group* 97532* U5* Per 15 min. Community Residential Services (low) T2033 Per diem Community Residential Services (medium) T2033 TF Per diem Community Residential Services (high) T2033 TG Per diem

* For cognitive therapy, the codes T2013 (individual) and T2013 HQ (group) should be used for dates of service between July 1, 2014, and Oct. 31, 2014. For dates of service on or after Nov. 1, 2014, please use the cognitive therapy codes listed above.


MLTSS Covered Services (cont’d.)

15

MLTSS Service MLTSS Code Modifier Unit Community Transition Services T2038 Per service Community Transition Services Administration T2038 U6 Per service

Home-Based Supportive Care Individual S5130 Per 15 min. Home-Based Supportive Care Group S5130 HQ Per 15 min. Home Delivered Meals S5170 Per meal Medication Monitoring Monthly S5185 Per month Medication Monitoring Initial Setup T1505 Per service Occupational Therapy Individual Habilitation 97535 U2 Per 15 min.

Occupational Therapy Group Habilitation 97535 U3 Per 15 min. Occupational Therapy Individual Rehabilitation 97535 U4 Per 15 min.

Occupational Therapy Group Rehabilitation 97535 U5 Per 15 min.

PERS Initial Setup S5160 Per month PERS Monthly, Standard Unit S5161 Per month PERS Monthly, Standard Unit with Fall Detection S5161 U4 Per month



16

MLTSS Service MLTSS Code Modifier Unit PERS Monthly, Cellular Unit S5161 U1 Per month PERS Monthly, Cellular Unit with Fall Detection S5161 U2 Per month PERS Monthly, Mobile Unit with or without Fall Detection

S5161 U3 Per month

Personal Care Services Individual T1019 Per 15 min. Personal Care Services Group T1019 HQ Per 15 min. Personal Care Services Live-In T1020 Per diem Personal Care Services Nursing assessment T1001 Per visit Personal Care Services Nursing re-assessment T1001 76 Per visit Physical Therapy Individual Habilitation 97110 U2 Per 15 min. Physical Therapy Group Habilitation 97110 U3 Per 15 min. Physical Therapy Individual Rehabilitation 97110 U4 Per 15 min. Physical Therapy Group Rehabilitation 97110 U5 Per 15 min. Private Duty Nursing 21+ RN T1002 UA Per 15 min. Private Duty Nursing 21+ LPN T1003 UA Per 15 min. Private Duty Nursing under 21 RN T1002 EP Per 15 min. Private Duty Nursing under 21 LPN T1003 EP Per 15 min.



17

MLTSS Service MLTSS Code Modifier Unit Residential Modifications S5165 Per service Residential Modifications Evaluation T1028 Per service Respite (non-hospice) in the Home T1005 Per 15 min. Respite (non-hospice) in Assisted Living S5151 Per diem Social Day Care S5102 U3 Per diem Speech Therapy Individual Habilitation 92507 U3 Per diem* Speech Therapy Group Habilitation 92508 U3 Per diem* Speech Therapy Individual Rehabilitation 92507 U4 Per diem* Speech Therapy Group Rehabilitation 92508 U4 Per diem* Structured Day Program S5100 Per 15 min. Supportive Day Services T2021 Per 15 min. Vehicle Modifications T2039 Per service Vehicle Modifications Evaluation T2039 U7 Per service

* The speech therapy unit of measure for dates of service between July 1, 2014, and Oct. 31, 2014, is per 15 minutes. For dates of service on or after Nov. 1, 2014, the unit of measure is per diem.


Description of Units

• Per diem – One unit equals once per day; only one unit can be billed per date of service.

• Per service – One unit equals one service (e.g., one Personal Emergency Response System installation setup would be one unit of service).

• Per meal – One meal equals one unit of service. • Per month – One unit equals one unit of service; only one unit can be

billed per month. • Per hour – One unit equals one hour of service. • Per 15 min. – One unit equals 15 minutes of service.


Home-Based Supportive Care – Non-Accredited Care Providers

If you are a home-based supportive care provider who is not accredited, during the continuity of care time period you may bill the following codes for home-based supportive care services provided to UnitedHealthcare Community Plan of New Jersey members: • S5130 U1 – individual • S5130 U2 – group These codes will expire on July 1, 2017.


Member Liability

• Members who receive services in an assisted living facility or through adult family care may have member liability.

• The explanation of benefits will reflect whether member responsibility is applicable.

• If a member has member liability, it is the care provider’s responsibility to collect payment from the member.

• Any payment due to the provider will be less any member liability if applicable.


21

Prior Authorization Requirements

Prior Authorization Requirements

Prior authorization is required for all MLTSS services ‒ regardless of whether the care provider participates with UnitedHealthcare Community Plan of New Jersey. Please view the complete prior authorization list for Medicaid and MLTSS at UHCCommunityPlan.com under Billing & Reference Guides. To request prior authorization, please call 800-262-0305. All members receiving MLTSS services will receive a face-to-face assessment for evaluation of needs from one of our care managers.


When a New Authorization is Required

Here are examples to show when a new prior authorization must be requested for a member: • During the authorized timeframe the member transfers to a new agency, then

transfers back to the original agency: The agency must request a new authorization to resume services for the member.

• The member goes on vacation, then returns to the same agency: The agency does not need to request a new authorization to resume services, but must notify us that the member is on vacation to avoid an “unable to contact” issue resulting in a critical incident. The care provider should not bill for services while the member is on vacation.

• The member enters a hospital or skilled nursing facility for less than 30 days, then returns home to the same agency: The agency does not need to request a new authorization to resume services but must notify us. The member may require a face-to-face assessment.

• The member enters a hospital or skilled nursing facility for 30 days or more, then returns home to the same agency: The agency must request a new authorization for services. The agency can continue to service the member at the previously approved hours until a face-to-face assessment is completed.


Utilization Management

24

Utilization Management Appeals

Claim appeals based on UnitedHealthcare Community Plan’s adverse determination regarding medical necessity, experimental or investigational services should be processed under the Utilization Management appeal process within 90 days from receipt of the original Utilization Management denial letter. Stage 1 Utilization Management appeals should include: • Copy of the original Utilization Management denial letter • Copy of the member’s medical record • Additional information that supports the need for medical necessity on the

denied date of services. Utilization Management appeals should be mailed to:

UnitedHealthcare Community Plan Attention: Utilization Management Appeals Coordinator P.O. Box 31364 Salt Lake City, UT 84131


26

Critical Incident Reporting

What Is a Critical Incident?

• A critical incident is any event or situation that has harmed or has the potential to harm a member, such as: o Abuse/neglect o Exploitation o Serious injury o Missing person o Medical errors o Suicide attempt o Any other incident that may cause harm to the member

• For a full list of reportable critical incidents required by the state, go to UHCCommunityplan.com > For Health Care Professionals > Select your state = New Jersey > Provider Administrative Manual.

• Critical incident reporting is important to help ensure the health and safety of our members.

• Any critical incidents involving one of our members must be reported within 24 hours of discovery of the incident. o May be submitted verbally, but must be followed up with a written report within

48 hours. 27 PCA -1- 002643-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Reporting Critical Incidents to UnitedHealthcare Community Plan If a critical incident is discovered, you are required to take steps within one business day to prevent further harm to all members and respond to any of their emergency needs. Then, report the critical incident to the state agency, if appropriate, BEFORE reporting it to UnitedHealthcare Community Plan of New Jersey. • All critical incidents should be reported to UnitedHealthcare Community Plan of

New Jersey. o To report a critical incident to UnitedHealthcare Community Plan of New Jersey, please call

888-702-2168 or complete the Critical Incident Reporting Form and fax it to 855-216-6408 within 24 hours of discovery of the incident. The form is available at UHCCommunityPlan.com > For Health Care Professionals > Select your state – New Jersey > Provider Forms.

• Any verbal notification must be followed by a written report describing the incident and what the care provider did to resolve it. There is no required format for the report. Fax the report to 855-216-6408.

• Participating providers must conduct an internal critical incident investigation and submit a written report within 30 calendar days after the date of the incident advising of the root cause and what steps were taken to prevent such an incident from reoccurring. There is no required format for the report. Fax the report to 855-216-6408.


Reporting Critical Incidents to the State

Immediately report to the appropriate agency including 911, any knowledge of or reasonable suspicion of:

• Report abuse, neglect or exploitation of adults to New Jersey Adult

Protective Services at 800-792-8820. • Report abuse, neglect or exploitation of members residing in nursing

homes to the New Jersey Office of the Ombudsman for the Institutionalized Elderly at 877-582-6995.

• Report brutality, abuse or neglect of children to the Division of Child Protection and Permanency (formerly the Division of Youth and family Services) at 877-652-2873.

• Report abuse, neglect or exploitation of children residing in pediatric nursing facilities to the Division of Child Protection and Permanency at 877-652-2873.


Unable to Contact and Open Care Opportunities

Unable to Contact

If an MLTSS member is absent, without notification, from any program or service offered and the MLTSS care provider is unable to identify their location using the contact information available, the member is considered “unable to contact.” MLTSS care providers must take the following steps to investigate and report “unable to contact” events: 1.Immediately contact the member using contact information on file. 2.If no response, immediately contact the member’s emergency contact. 3.If unsuccessful, immediately notify the member’s MLTSS care manager.


Open Care Opportunities

For MLTSS members, an open care opportunity is the difference between the number of hours or services scheduled in a member’s plan of care and the hours or services that are actually delivered to that member. • If there is an open care opportunity, the care provider must contact the

member immediately to acknowledge and explain the open care opportunity and provide an alternate plan to resolve it. The care provider must also notify the member’s MLTSS care manager about any open care opportunities.

• When care providers know about an upcoming open care opportunity, they must contact the member before the scheduled service to advise them that the regular caregiver will be unavailable. The member may choose to receive the service from a substitute caregiver, at an alternative time from the regular caregiver or from an alternate caregiver from the member’s informal support system.


33

Claims Submission and Appeals

Electronic Claims Submission

Electronic Submission (Use Payer ID 86047) Electronic Data Interchange (EDI) Support Services provides support for all electronic transactions involving claims, electronic remittances and eligibility. For more information, please contact EDI Support at 800-210-8315 or [email protected]. If you do not have office software and would like to submit claims directly at no cost, submission can be done through Office Ally ‒ a secure, HIPAA-compliant solution that offers: • Direct connectivity • No installation, transaction or support fees for care providers • Ease of use for both batch and single claims • 24-hour customer support You can enroll at OfficeAlly.com. To learn more, please contact 866-575-4120 or [email protected].


Electronic Payments & Statements (EPS) With EPS, you receive electronic funds transfer (EFT) for claim payments, plus your explanations of benefits (EOBs) are delivered online. Regardless of your practice size or claims volume, EPS can provide faster payment, easier reconciliation and less paper. • Users receive payments and EOBs five to seven days faster than with paper. • View payments or EOBs for the last three months, or search a 13-month archive. • Claim adjustments will not be deducted from your account.

To enroll online, please go to myservices.optumhealthpaymentservices.com. Here’s what you’ll need: • Bank account information for direct deposit • A voided check or a bank letter to verify bank account information • A copy of your practice’s W-9 form

You can download the EPS Paper Enrollment Form at UnitedHealthcareOnline.com > Claims & Payments > Electronic Payments & Statements (EPS) and mail or fax it to the contact listed in the form instructions.

If you plan to route payments to accounts based on your national provider identifier (NPI), please call for enrollment assistance.

If you have questions or need help with EPS enrollment, please call 866-842-3278, option 5.


835 Electronic Remittance Advice

If you receive 835 Electronic Remittance Advice (ERA) through a vendor, please ask them to enroll you for the 835 through OptumInsight. Once we receive the request from your clearinghouse or EDI vendor, it takes about 30 days to set up delivery of the 835 ERA.


Claim Submission – Coordination of Benefits

New Jersey FamilyCare Managed Care Contract Guidance: Coordination of Benefits for Medicaid Managed Care Members, effective January 2016 This guidance covers coordination of benefits/explanation of benefits (EOB) for Medicaid Managed Care members with Medicare Parts A and B, Supplemental or Medicare Advantage coverage and/or members with Third Party Liability (TPL) coverage. 1. Medicaid Managed Care members with Medicare Parts A and B who have Medicare

Supplemental do not require EOBs or denial for the following Medicaid services: A. State plan services:

• Medical Day Care • Personal Care Assistance - including Personal Preference Program

B. MLTSS Waiver services:

• Adult family care • Assisted living • Chore service • Community transition services • Home-based supportive care • Home-delivered meals • Medical day care

• Non-medical transport • Nursing home custodial care • Personal care assistance, including Personal Preference Program • Residential modifications • Respite • Social day care • Vehicle modifications


Claim Submission – Coordination of Benefits; continued

2. The Managed Care Organization will follow the Exceptions to the Cost Avoidance Rule outlined in the New Jersey FamilyCare contract, effective January 2015 (Article 8.7 F 2,3) for the specified State Plan and MLTSS Waiver Services for Medicaid Managed Care members with a Medicare Part A and Part B who also have a Medicare Advantage Plan and/or TPL.

8.7 F: Exceptions to the Cost Avoidance Rule:

• If the Contractor knows that the third party will neither pay for nor provide the covered service, and the service is medically necessary, the Contractor shall neither deny payment for the service nor require a written denial from the third party.

• If the Contractor does not know whether a particular service is covered by the third party, and the service is medically necessary, the Contractor shall contact the third party and determine whether or not such service is covered rather than requiring the enrollee to do so. Further, the Contractor shall require the provider or subcontractor to bill the third party if coverage is available.

A. State plan services* B. MLTSS Waiver services*

*A full listing of these services can be found on slide #37


Claim Submission – Coordination of Benefits; continued

3. For all other Medicaid State Plan and Waivers services included in New Jersey

FamilyCare member’s benefit package an EOB is required. • If you receive an EOB indicating that the service is not covered by the primary insurer,

the NJ FamilyCare Managed Care Organization will pay for the service as the primary payer. A new EOB should not be required for subsequent claims during the calendar year for the same payer, care provider, and member and service code.

• Services paid by a third party carrier may become a non-paid service if the member’s benefits are exhausted. If this happens, the care provider should submit an EOB stating the benefit is exhausted before the managed care organization pays for the service.


How Dual Eligible Special Needs Plans (DSNP) Claims Process

• If the service provided is covered by Medicare, the normal coordination of benefits occurs, as noted in the previous slides.

• The claim will process against the member’s DSNP ID then automatically move to the member’s Medicaid ID and complete processing.

• You will see two claims on your EOB for the service; one where it processed under the DSNP ID, and one where it processed under the Medicaid ID.

• If the service provided is not a covered service for Medicare, the claim

processes against the member’s DNSP ID and denies as “not a covered service”, then automatically moves to the member’s Medicaid ID and completes processing. • You will see two claims on your EOB for the service, one where it processed

under the DSNP ID and one where it processed under the Medicaid ID.


Claim Payment Appeals Process

Please follow the claim payment appeals process to resolve billing, payment or other administrative disputes such as:

• Lost or incomplete claim forms or electronic submissions • Requests for additional explanation as to services or treatment

rendered by a care provider • Inappropriate or unapproved services initiated by care providers • Any other reason for billing disputes

Claim payment disputes do not require any action by the member.


Claims Payment Appeals Submission ‒ Informal Appeals

Please submit the Paper Claim Reconsideration Form, available at UnitedHealthcareOnline.com > Tools & Resources > Forms, for the following claim appeals only: • Previously denied for additional information to process claim • Resubmission as a corrected claim • Resubmission with prior authorization information • Resubmission because it was a bundled claim • Previously denied/closed as exceeding timely filing

Please submit the form with a copy of the claim in question and any supporting documentation within 90 days from receipt of the EOB/provider remittance advice (PRA) to: UnitedHealthcare Community Plan

Attention: Claim Administrative Appeals P.O. Box 5250 Kingston, NY 12402-5250

You can also submit claim appeals at UnitedHealthcareOnline.com or by calling 888-702-2168.

Submission of an informal appeal does not replace the submission of a formal claim payment appeal.


Claims Payment Appeals Submission ‒ Formal Appeals

Formal appeals must be submitted to UnitedHealthcare Community Plan using the NJ Provider Appeal Form available at UnitedHealthcareOnline.com > Tools & Resources > Forms. • If a care provider submits a claim payment appeal using this form within

90 days following receipt of the EOB/PRA and we uphold the claim payment denial, the care provider has the right to file an external claims arbitration request using MAXIMUS, the state’s arbitration organization.

• If a care provider does not submit the original claim payment appeal on the State’s HCAPPA form, the care provider does not have the right to a claims arbitration. However, the appeal will be processed by UnitedHealthcare Community Plan of New Jersey as an informal claim payment appeal.

• The HCAPPA form can be found on the State’s website. • If we uphold a claim payment denial on an informal claim payment

appeal, there is no second level of appeal and claim payment decisions will be final.

43


44

Claims Billing Tips

Multiple Therapies and the correct use of Modifier 59 • The use of Modifier 59 applies only to HCPC codes 92507, 92508,

97110 and 97532 when billing more than one therapy on the same date of service.

• HCPC code 97535 never requires modifier 59 regardless of whether any other therapy codes are billed with it. (i.e. 92507, 92508, 97532 or 97110)

• Claims billed with modifier 59 on the wrong code or on a code that is not applicable can cause claim payment denials and errors.

• The information referenced regarding the correct use of modifier 59 was derived from the CMS policy regarding multiple therapies. Additional information as well as the source information can be found at www.cms.gov.

• Additional information regarding the use of modifier 59 can also be found in the below documents:

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/ncci_modifier_59.pdf http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/medicaid-ncci-faqs-update-11/14.pdf


http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/ncci_modifier_59.pdf

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/ncci_modifier_59.pdf

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/medicaid-ncci-faqs-update-11/14.pdf

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/medicaid-ncci-faqs-update-11/14.pdf

Multiple Therapies and the correct use of Modifier 59 continued

46

If… Then…

If you bill HCPC code 92507 with 92508, 97532 and/or 97110 on the same date of service,

Then codes 92508, 97532 and/or 97110 must have modifier 59 billed. This would apply to both the individual and group codes. HCPC code 92507 would not have modifier 59 unless you billed 92507 for both individual and group. If you billed 92507 for both individual and group, modifier 59 is needed on the 92507 group code.

If you bill HCPC code 92508 with either 97532 and/or 97110 on the same date of service,

Then codes 97532 and/or 97110 must have modifier 59 billed. This would apply to both the individual and group codes. HCPC code 92508 would not have modifier 59 unless you billed 92508 for both individual and group. If you billed 92508 for both individual and group, modifier 59 is needed on the 92508 group code.

If you bill HCPC code 92507 both individual and group with no other therapy code on the same date of service,

Then you must have modifier 59 billed with 92507 group. HCPC code 92507 individual would not have modifier 59.

If you bill HCPC code 92508 both individual and group with no other therapy code on the same date of service,

Then you must have modifier 59 billed with 92508 group. HCPC code 92508 individual would not have modifier 59.

If you bill HCPC codes 97532 and/or 97110 on the same date of service,

Neither code requires modifier 59 to be billed regardless of whether you billed both individual and group.


15-Minute Unit Conversion

For every one hour of personal care services or home-based supportive care services performed, you should bill four units.

For every half hour of personal care services or home-based supportive care services performed, you should bill two units.

47

Example 1:

Six hours of services provided would be billed as 24 units

Example 2:

4.5 hours of services provided would be billed as 18 units


Sample: Incorrect Per Diem Claim

48

The following example shows a per diem claim billed incorrectly.

The date range is listed for multiple dates of service.

The number of units billed exceeds one unit. In addition, the number of units does not match the number of days represented in the date range

billed on the line.


Sample: Correct Per Diem Claim

49

The following example shows the correct way to bill a per diem claim.

The date range should be for one date of service per line.

Each line should be billed with one unit to represent one date of

service.

Provider should bill their billed charges for each date of service.


Sample: Incorrect Claim for Multiple Shifts on the Same Day

The following example shows a claim billed incorrectly when more than one aide is providing services on the same date of service.


Sample: Correct Claim for Multiple Shifts on the Same Day

The following example shows the correct way to bill a claim when more than one aide is providing services on the same date of service. Each date of service must be billed on its own line.


Sample: Incorrect Monthly Billing Claim

The following example shows a claim billed incorrectly when billing for a service that spans a month.


Sample: Correct Monthly Billing Claim

The following example shows the correct way to bill a claim when billing for a service that spans a month.


54

Credentialing, Criminal Background Checks and Demographic Changes

Credentialing

UnitedHealthcare Community Plan of New Jersey Credentialing Requirements: 1. Complete Component Application

a) Component Attestation section must be signed and dated 2. Complete Demographic Update Information Sheet 3. Provide copy of declaration sheet and/or certificate of insurance for

current professional malpractice and comprehensive general liability insurance policies

4. Provide W-9 Form 5. Provide current and/or renewed license from the Division of Consumer

Affairs 6. Provide current Medicaid and/or Medicare numbers 7. Provide certificate of accreditation from the following, if applicable:

• Community Health Accreditation Program • Commission on Accreditation for Home Care, Inc. • The Joint Commission • National Association for Home Care/Home Care University


Re-Credentialing

UnitedHealthcare Community Plan of New Jersey Re-Credentialing Requirements: 1. Review and update the pre-filled Component Application with any

applicable changes. 2. Sign and date the Component Attestation page. 3. Return the application with the following current documents to the

address or fax number listed on the cover letter. • Copy of current state license from the Division of Consumer Affairs • Copy of certificates of accreditation, if applicable (e.g., Community

Health Accreditation Program) • Copy of declaration sheet and/or certificate of insurance for current

professional malpractice and comprehensive general liability insurance policies


Care Provider Disclosures

• Care providers must submit certain disclosure statements to participate with UnitedHealthcare Community Plan of New Jersey, as described in the state contract.

• UnitedHealthcare Community Plan of New Jersey collects and maintains these disclosures.

• To view the disclosures, please visit UHCCommunityPlan.com > For Health Care Professionals > Select your state – New Jersey > Provider Forms > Group Disclosure of Ownership and Control of Interest Form OR Individual Disclosure of Ownership and Control of Interest Form.


Criminal Background Checks

All employees and/or agents of a provider or subcontractor and all providers who provide direct care must have a criminal background check as required by federal and state law. All contracted care providers must conduct criminal background checks on all prospective employees or providers who have direct physical access to MLTSS members.


Demographic Changes

All demographic changes must be sent to UnitedHealthcare Community Plan of New Jersey using any of the following methods: Fax: 877-382-9298 Mail: UnitedHealthcare

Attn: Adrienne Collins P.O. Box 1276 Sharon Hill, PA 19079

Email: [email protected]


60

Provider Advocates and Other Resources

61

Your Provider Advocates

• Serve as your primary contact • Act as a navigational specialist to help you deal with all areas of

UnitedHealthcare Community Plan • Communicate with your practice about critical programs and processes

within UnitedHealthcare Community Plan • Specialize in issue resolution

Provider Advocates:

Estelle Adams-Wright • Phone: 763-283-2546 • Email: [email protected] • Works with all MLTSS providers except

nursing home/skilled nursing facilities, medical/social day care, and licensed home care agencies and health service firms

Monica Harris • Phone: 952-406-6941 • Email: [email protected] • Works with licensed home care

agencies and health service firms Sharon Hopson

• Phone: 952-202-2964 • Email: [email protected] • Works with social day care providers


62

Key Contact List

UnitedHealthcare Community Plan website (newsletters, bulletins, forms): UHCCommunityPlan.com UnitedHealthcare provider website (claims, eligibility): UnitedHealthcareOnline.com Provider Services for MLTSS: Call 888-702-2168 Prior Authorization/Intake for MLTSS: Call 800-262-0305 Health Services: Call 888-362-3368 or fax 800-766-2597 To identify a Care Manager for MLTSS: Call 800-645-9409 Member Services: Call 800-941-4647 (TTY:711); TTY/TDD call 800-852-7897 NurseLine: Call 888-433-1904 Demographic Changes: Fax 877-382-9298 Credentialing Center: Fax 877-620-3782 or email [email protected] Medications requiring prior authorization: Call 800-310-6826 or fax 866-940-7328 Prescription Solutions for pharmacy specialty injectibles: Fax 800-853-3844


State MTLSS Training Materials

MTLSS Resources for Providers: • MLTSS Provider Frequently Asked Questions (FAQs)

• Comprehensive Medicaid Waiver

• Essential Elements for Providers Participating in MLTSS: Video or Presentation MTLSS Resources for Members: • MLTSS FAQs • FAQs for Dual Eligible Special Needs Plans (D-SNP) and MLTSS Consumers • NJ FamilyCare Managed Care Health Plans and Member Handbooks • Program of All-inclusive Care for the Elderly (PACE) • MLTSS: The Choice is Yours Presentation


http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Provider_FAQs.pdf

http://www.state.nj.us/humanservices/dmahs/home/waiver.html

http://www.youtube.com/watch?v=snJBaEqR8g4

http://www.state.nj.us/humanservices/dmahs/home/Essential_Elements_for_Providers_Participating_in_MLTSS.pdf

http://www.state.nj.us/humanservices/dmahs/home/Consumer_FAQs.pdf

http://www.state.nj.us/humanservices/dmahs/home/FAQ_D-SNP_MLTSS.pdf

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/hmo/

http://www.state.nj.us/humanservices/doas/services/pace/index.html

http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Consumer_Slide_Presentation.pdf

Link Training

64

Link Overview

65

* Based on ongoing usability studies using keystroke-level modeling when comparing Link to UnitedHealthcareOnline.com and Optum Cloud Dashboard.

• Link is your gateway to UnitedHealthcare's online tools. • It replaced Optum Cloud Dashboard. Link includes many of the same

applications as Optum Cloud Dashboard, but with a new interface that can help make your work measurably faster and easier.*

• Use Link to check member eligibility and benefits, manage claims and submit claim reconsideration requests.

• With Link, you can quickly move between UnitedHealthcare applications and websites, and even customize your screen to put your most common tasks just one click away.

• Later this year, we’ll introduce enhanced applications and additional features to help make your transactions with us even faster.


Sign In to UnitedHealthcareOnline.com to Access Link


Use Your Optum ID

67

If you can’t remember your Optum ID or password, click on Sign In, then Forgot Username or Forgot Password. If you don’t have an Optum ID yet, please register for one by clicking Register Now.


What’s on Link?

Applications on Link include: • Eligibility & Benefits • Claims Management • Claims Reconsideration

Access other UnitedHealthcare websites: • UnitedHealthcareOnline.com • UHCWest.com • UHCCommunityPlan.com • And more


69

Eligibility & Benefits Application Use the Eligibility & Benefits application to check member eligibility and review detailed benefits information. You may also submit referrals, notifications and prior authorization requests using this application.

Features include: • Search for covered members. • View prior authorization/advance notification requirements, cost share

amounts and benefit coverage details. • Submit and check status of referrals. • View preventive care opportunities information for UnitedHealthcare

Medicare Solutions and UnitedHealthcare Community Plan members. • View detailed benefits information for multiple plans. • See coverage details and limits specific to each benefit plan. • Export or print data.


70

Claims Management Application With the Claims Management application, you can get the most up-to-date claims status and payment information quickly and conveniently. Claims processed within the last two years are available.

Features include: • Search for claim submissions and access claim summaries and details

for multiple UnitedHealthcare plans in a single application. • View payment information, remark codes and their descriptions. • Submit additional information requested on pended claims. • Submit appeals (only available in certain states). • View Explanations of Benefits (EOBs) and letters for UnitedHealthcare

Commercial benefit plans. • Select a claim for reconsideration. • Flag claims for future viewing.


71

Claims Reconsideration Application

Use the Claims Reconsideration application to quickly look up processed claims and submit paid or denied claims as reconsiderations with or without attachments. You will receive a ticket number and can check the status of your submission online.

Features include: • Search for paid or denied claims. • Receive instant printable confirmation of completed claim

reconsideration requests. • Search for a claim reconsideration request to check its status or view its

history. • Update previously submitted reconsideration requests. • If you selected a claim for reconsideration in the Claims Management

application, it will appear as a draft that can be completed and submitted in the Claims Reconsideration application.


72

Link Resources To learn more about Link, please visit the Link resources page at UnitedHealthcareOnline.com > Quick Links > Link: Learn More.


Link Resources (cont.)


74

Important Provider Training Concepts

75

Online Resources

Online resources are available to assist you with providing services to UnitedHealthcare Community Plan members, including the following topics: Cultural Competency - Resources for providing culturally competent care to a growing number of patients • UHCCommunityPlan.com > For Health Care Professionals > Select your

state – New Jersey > Cultural Competency Library Community Resources - Resources to assist you in providing care to diverse patient populations • UHCCommunityPlan.com > For Health Care Professionals > Select your

state – New Jersey > Provider Education > Managed Long-Term Care Services and Supports (MLTSS)


76

Options Counseling Options Counseling is an interactive process where individuals receive guidance to make informed choices about long-term supports based on their assessed needs. • Directed by the UnitedHealthcare member or their authorized

representative • May include other people that the member chooses • Options counseling includes the following steps:

• Personal interview to discover strengths, values and preferences of the individual and the utilization of screenings for public programs.

• Facilitated decision support process that explores resources and service options to help the member weigh pros and cons

• Action steps geared toward a goal or a long term support plan, assistance in applying for and accessing support options when requested

• Quality assurance and follow-up to ensure supports and decisions are working


Options Counseling (cont.)

• For people of all income levels, but targeted for those with immediate concerns, such as:

• Those at greatest risk for institutionalization • Individuals looking to transition from long-term care facilities

• Helps ensure members are educated on the full range of LTSS and offered a choice of care (institutional/home- and community-based services) and option to choose MLTSS or Programs of All-Inclusive Care for the Elderly (PACE), if available.

Every UnitedHealthcare MLTSS Care Manager has passed the State’s Options Counseling training program.


78

Overview: UnitedHealthcare Dual

Complete ONE

79

Overview: UnitedHealthcare Dual Complete ONE

Effective Jan. 1, 2016, UnitedHealthcare Community Plan of New Jersey expanded the service area for our UnitedHealthcare Dual Complete ONE plan, also known as HMO Special Needs Plan (SNP). Fast Facts About UnitedHealthcare Dual Complete ONE: • A Fully Integrated Dual Eligible Special Needs Plan • Better integrates coordination of care for members enrolled in

both Medicaid & Medicare in New Jersey • Participating UnitedHealthcare Community Plan care providers

may participate for this benefit plan upon contract agreement • Reimbursement is based on your UnitedHealthcare Community

Plan network agreement • Single claim submission


80

Details: UnitedHealthcare Dual Complete ONE • Medicare and Medicaid enrollment aligned under single

Managed Care Organization • Managed Long-Term Services & Supports (MLTSS) alignment is

phased: • In 2015, Institutional MLTSS members became eligible to enroll in Dual-

Eligible Special Needs Plans (DSNP) • In 2016, In addition to Institutional MLTSS members, Home- and

Community-Based Services MLTSS members are also eligible to enroll in DSNP

• $0 premium and cost-sharing, including Part D copays • Part D “Extra Help” covers Part D premium • Medicaid covers all Medicare cost sharing on behalf of members • Additional Medicaid benefits offered at $0 copay • Additional Medicaid-only drugs covered beyond Part D

Members enrolled in UnitedHealthcare Dual Complete ONE should not

be balance billed for any covered benefit.


81

2016 Service Area 2016 UnitedHealthcare Dual Complete ONE Service Area includes the following counties:

• Atlantic • Bergen • Burlington • Essex • Hudson • Mercer • Monmouth • Morris • Ocean • Union

2015 counties

2016

expansion


82

Member ID Cards

UnitedHealthcare Dual Complete ONE members have a single ID card for both their Medicare benefits (Parts A, B and D) and their New Jersey FamilyCare Medicaid benefits. For 2016, both the Medicare and Medicaid

IDs are on the card.

• Medicare ID should be used for claim submission, including prescriptions.

• UnitedHealthcare links members’ Medicare and Medicaid IDs systematically.

• Claims first process under the Medicare eligibility and will automatically

process under Medicaid for additional coverage.


83

Benefit Overview • Medicare is the primary

payer for most acute services and drugs.

• Medicaid covers

Medicare cost-sharing and has predominate responsibility for long-term care services.

• Medicaid provides additional coverage beyond Medicare limits, for screenings, durable medical equipment, inpatient services and hospice services.

• Medicaid provides additional benefits.

Medicare • Acute visits • Physician services • Skilled nursing facility • Acute home health • Durable medical

equipment • Part D drugs

Medicaid • Medicare premiums • Medicare cost-sharing • Long-term care/waivers • Long-term home health • supplies • Other acute care &

drugs • Additional drug

coverage • Additional coverage

beyond Medicare limits


84

UnitedHealthcare Dual Complete ONE (HMO SNP) Benefit Structure Medicare

Parts A, B & D

• Acute Visits • Physician

Services • Skilled Nursing

Facility • Acute Home

Health • Durable Medical

Equipment • Drug coverage

2016 Supplemental Medicare

• Over-the-counter catalog

• Routine transportation

• Personal Emergency Response System (PERS)

• Nurseline

Standard Medicaid (FamilyCare A)

• Medicare cost share covered for all members, including Part D copays

• Additional coverage beyond Medicare limits

• Vision exam & eyewear credit

• Hearing exam & hearing aid

• Routine transportation

• Comprehensive dental

• Medical Day Care • Private Duty

Nursing • Acupuncture

Medicaid MLTSS

•Adult family care •Assisted living services •Assisted living programs •Caregiver/participant training

•Chore services •Community residential services

•Community transition services

•Home based supportive care

•Home delivered meals •Medication dispensing device

•Residential modifications •Respite care •Social adult day care •Structured day program •Supported day services •TBI behavioral management

•Non-medical transportation •Vehicle modifications •Behavioral health services


Contact Information

85

For more information about UnitedHealthcare Dual Complete ONE, please consult the following resources: • Go to UHCCommunityPlan.com > For Health Care

Professionals > New Jersey for information about UnitedHealthcare Community Plan (Medicaid & D-SNP) To check eligibility, submit claims and appeals, and for other UnitedHealthcare resources for Medicare and Commercial plans, visit UnitedHealthcareonline.com.

• Call Provider Services at 888-362-3368. • Contact Your Network Account Manager. PCA -1- 002643-07202016-08052016 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

86

Thank You


unitedhealthcare community plan of new jersey...unitedhealthcare community plan of new jersey...

Documents