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10/20/2015
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2015 CFC Procedure Manual:
INSURANCEEI TRAINING PROGRAM AT THE UNIVERSITY OF ILLINOIS
OCTOBER 2015
Today’s Presenters
Chelsea Guillen EI Ombudsman
EI Training Program
Ann FreiburgInterim Part C Coordinator
DHS
Today’s Moderators
Alissa Jones Research Specialist
Early Intervention Training Program
Susan ConnorDirector
Early Intervention Training Program
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A. SunnyB. Partly cloudyC. CloudyD. RainyE. Snowy
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Post Session Survey & Certificate
Post Webinar Survey
CFC Managers will provide list of participants to EITP at conclusion of webinars
Certificate will be sent within 5 business days after webinar
Importance of insurance use
History of saving Early Intervention $10-$12 million annually. Allowing additional families to be served.
Assists families with protections from surprise costs for services for their child.
Economical plan to help parents use their own resources wisely. Enhances advantages for Early Intervention providers within their
business model and shows fiscal feasibility to becoming an Early Intervention Provider.
System of payments & fees
All families should receive the Notice of System of Payments and Fees & the Family Participation Fees Program Fact Sheet
System of payments & fees
All families should receive the Notice of System of Payments and Fees & the Family Participation Fees
Program Fact Sheet This should be provided at:
Intake Each annual IFSP
No insurance
Use Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC to determine families potential eligibility for public benefits
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No insurance
Use Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC to determine families potential eligibility for public benefits
Potentially eligible families, encouraged,but not required, to apply for public benefits (AllKids)
No insurance
Use Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC to determine families potential eligibility for public benefits
Potentially eligible Families, encouraged, but not required, to apply for public benefits (all kids)
Check with the family periodically if they apply
No insurance
Use Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC to determine families potential eligibility for public benefits
Potentially eligible Families, encouraged, but not required, to apply for public benefits (all kids)
Check with the family periodically if they apply Remind family to report any changes in income
or family status
Public benefits only
Obtain copy of AllKids card or print PA 42
Public benefits only
Obtain copy of AllKids card or print PA 42
Family may have MCO- see list in 10.1.5
Public benefits only
Obtain copy of AllKids card or print PA 42
Family may have MCO- see list in 10.1.5
If family is enrolled with All Kids, Ensure the family has been provided the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits
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Public benefits only
Obtain copy of AllKids card or print PA 42Family may have MCO- see list in 10.1.5 If family is enrolled with all kids, Ensure the family
has been provided the Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits
No benefit verification needed- indicate “no private insurance” on authorizations
Public & private insurance
Ensure the family signed the: Consent to Use Private
Insurance/Healthcare Plan Benefits & Assignment of Rights and the
Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits
appropriately based on their private insurance plan.
Public & private insurance
Ensure the family signed the: Consent to Use Private Insurance/Healthcare Plan
Benefits & Assignment of Rights and the
Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits
appropriately based on their private insurance plan. Submit the normal benefits verification outlined in 10.4
Private insurance
Families whose children are enrolled under private insurance plans that are not Employer Self-Fundedmust allow use of their benefits to assist in meeting the costs of covered EI services and Assistive Technology (AT) devices.
Private insurance
Families whose children are enrolled in Employer Self-Funded plans must provide informed consent prior to use of the plan to assist in meeting the costs of covered EI services and AT devices.
Private insurance
Perform benefits verification (BV) as
outlined in 10.4
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Private insurance
Perform benefits verification as outlined in 10.4
BV process will tell you whether plan is self funded or
not
Private insurance
Perform benefits verification (BV) as
outlined in 10.4
If employer self-funded, families complete both consent section and assignment of rights
BV process will tell you whether plan is self
funded or not
Private insurance
Perform benefits verification (BV) as
outlined in 10.4
If employer self-funded, families complete both consent section and assignment of rights
BV process will tell you whether plan is self
funded or not
If NOT employer self-funded, families only need to complete
assignment of rights
Audience PollHelping families understand the implications of using their private insurance is not a role of the service coordinatorA. TrueB. False
Private insurance
Family must be fully informed of ramifications of waivers, exemptions, and Family Fees based on the results of the BV process and provider choice options.
Private insurance
Family must be fully informed of ramifications of waivers, exemptions, and Family Fees based on the results of the BV process and provider choice options.
Notice of System of Payments and Fees can be used to help families understand private insurance prerequisites
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Reminders:
EI service providers are required to follow authorizations for services, including insurance usage, waivers, exemptions, etc. and bill appropriately following policies and procedures.
Reminders:
EI service providers are required to follow authorizations for services, including insurance usage, waivers, exemptions, etc. and bill appropriately following policies and procedures.
NOTE: The following services are the exception to insurance billing: Developmental Therapists, Translators/Interpreters, Deaf Mentors, and Physicians providing only medical diagnostics and Transportation providers.
BV process for private insurance
Submitting a Benefits Verification Request:Copy front and back of the card
BV process for private insurance
Submitting a Benefits Verification Request:Copy front and back of the cardSubmit copy of insurance card with the CFC
Fax Cover Sheet for Insurance Benefits Verification Requests/Updates form to the CBO
BV process for private insurance
Submitting a Benefits Verification Request:Copy front and back of the cardSubmit copy of insurance card with the CFC Fax Cover
Sheet for Insurance Benefits Verification Requests/Updates form to the CBO
CBO will verify benefits and provide results to the CFC within 5 working days to assist the family and CFC in determining if the plan is Employer Self-Funded or not.
BV process for private insurance
Submitting a Benefits Verification Request: Copy front and back of the card Submit copy of insurance card with the CFC Fax Cover Sheet for
Insurance Benefits Verification Requests/Updates form to the CBO CBO will verify benefits and provide results to the CFC within 5
working days to assist the family and CFC in determining if the plan is Employer Self-Funded or not.
CBO BV process does not replace the more comprehensive BV the rendering provider must perform with the insurance plan. providers who fail to perform their own BV risk non-payment for services rendered
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Private insuranceEmployer self-funded
If CBO BV results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
Private insuranceEmployer self-funded
If CBO BV results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
Family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights
Private insuranceEmployer self-funded
If CBO BV results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
Family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights
For families who consent, ensure any authorizations indicate “Private Insurance-Bill”, following outlined processes for waivers or exemptions.
Private insuranceEmployer self-funded
If CBO BV results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights
For families who consent, ensure any authorizations indicate “Private Insurance-Bill”, following outlined processes for waivers or exemptions.
For families who decline, ensure authorizations indicate “Private Insurance-Declined” as appropriate.
Private insuranceEmployer self-funded
If CBO B V results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights
For families who consent, ensure any authorizations indicate “PrivateInsurance-Bill”, following outlined processes for waivers or exemptions.
For families who decline, ensure authorizations indicate “Private Insurance-Declined” as appropriate.
Non-employer self-funded
If the family does not have an Employer Self-Funded plan, work with the family to determine Provider Choice based on the results of the Benefits Verification.
Private insuranceEmployer self-funded
If CBO B V results indicate Employer Self-Funded plan, immediately contact the family to obtain informed consent for use of the plan for EI services.
family must complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rights
For families who consent, ensure any authorizations indicate “Private Insurance-Bill”, following outlined processes for waivers or exemptions.
For families who decline, ensure authorizations indicate “Private Insurance-Declined” as appropriate.
Non-employer self-funded
If the family does not have an Employer Self-Funded plan, work with the family to determine Provider Choice based on the results of the Benefits Verification.
Have the family complete a Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Rightsindicating they assign billing rights to EI.
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Check for understanding/questions
Audience Poll
I think about the following when listening to insurance webinars:A. What should I have for lunch?B. Why won’t they stop talking?C. When can I go home?D. All of the aboveE. None of the above, because I am giving
this my full attention
Waiver procedures: General guidelines
Completely fill out form; missing information can result in denial of request and need for resubmission
Waiver procedures: General guidelines
Completely fill out form; missing information can result in denial of request and need for resubmission
CBO will process information within 10 working days
Waiver procedures: General guidelines
Completely fill out form; missing information can result in denial of request and need for resubmission
CBO will process information within 10 working days
Maintain all documentation in child’s permanent file
Waiver procedures: General guidelines
Assist the family in finding a provider based on the allowances of the benefit plan
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Waiver procedures: General guidelines
Assist the family in finding a provider based on the allowances of the benefit plan
If waiver is issued and later an available, in-network provider is identified, work with family to make switch
Waiver procedures: General guidelines
Assist the family in finding a provider based on the allowances of the benefit plan
If waiver is issued and later an available, in-network provider is identified, work with family to make switch
Waivers are renewed annually, based on IFSP year. This may not correspond with family’s benefit year
Waiver procedures: Pre-billing waiver
CBO informs SC if there is a need for a pre-billing waiver due to finding no enrolled EI providers or an unobtainable required PCP referral.
Waiver procedures: Pre-billing waiver
CBO informs SC if there is a need for a pre-billing waiver due to finding no enrolled EI providers or an unobtainable required PCP referral.
CBO will work with the SC to issue a pre-billing waiver to the service provider.
Waiver procedures: Pre-billing waiver
If provider is not known, CBO will issue a pre-billing waiver for the discipline. The SC must inform their CBO Insurance Processor when a
payee/provider is identified. The CBO will re-issue the pre-billing waiver in the individual
payee/provider’s name for the records. The CFC must send a copy of the pre-billing waiver to the
provider. No provider should perform services without the waiver process being completed and a waiver in hand for their records.
Pre-billing waiver
If BV limits provider choice & SC has contacted all providers on list without finding one who is available to accept referral within 15 days, the SC must submit a pre-billing waiver request after ensuring family is aware of ramifications of going outside their insurance plan benefits
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Pre-billing waiver If BV limits provider choice &
SC has contacted all providers on list without finding one who is available to accept referral within 15 days, the SC must submit a pre-billing waiver request after ensuring family is aware of ramifications of going outside their insurance plan benefits
Pre-billing waiver Complete waiver request section of the CFC Fax Cover
Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Insurance Waiver Request form and appropriate case documentation if: A provider is not available The provider is not enrolled The family would have to travel more than 15 miles/30
minutes to reach provider [for team recommended center-based services]
Case Documentation For a waiver request, CBO looks for a few key items in the case
notes. Documentation should contain the following information: The full name of the office or facility contacted – no abbreviations. The name of the person you spoke with – first name is enough. The phone number called with area code. The result of the conversation – Can they take the case? If not, why
not? (Just a summary) If more than one provider or facility is listed on the BV, the SC is
expected to contact all of the listed providers.
Pre-billing waiver
Complete waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update,the Pre-Billing Insurance Waiver Requestform and appropriate case documentation if: A provider is not available The provider is not enrolled The family would have to travel more
than 15 miles/30 minutes to reach provider [for team recommended center-based services]
NOTE: If the CBO is aware that there are no insurance-enrolled, EI credentialed providers at the time of the benefits verification, a pre-billing waiver will be issued.
Post-billing waiver
If the provider bills private insurance and receives information that the service: is not covered, or the maximum sessions have been exhausted so no benefits
can be paid, the provider must submit the claim along with the insurance
claim and EOB/notice. CBO will issue a post-billing waiver for the remainder of the
plan year.
Audience Poll
Post billing waivers can be issued before a provider has a claim or response from the insurance companyA. TrueB. False
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Check for understanding/questions
Exemptions
If the family has chosen, or the SC becomes aware of a need for an exemption to using private insurance, the SC should submit that request by indicating exemption request on the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates as soon as possible.
Exemptions The current exemption request may be necessary based on:
an Individually Purchased/Non-Group Plan; a plan that has a Lifetime Cap (limits) that EI services may
exceed or exhaust if the plan is used for EI; and the family has a Tax Savings Plan (such as a Health Savings
Account or Health Reimbursement Account) that is automatically withdrawing funds when claims are submitted to the health plan AND the family agrees they do not want the Tax Savings Account accessed by EI.
Exemptions
In June 2013, Illinois law began providing certain assurances for non self-funded plans
Exemptions
In June 2013, Illinois law began providing certain assurances for non self-funded plans
If a family’s plan is not consistent with these assurances, contact your EI specialist to begin investigation. This may lead to an exemption
ExemptionsFor tax savings plan,
the SC must also submit the completed CFC Tax Savings Account Information Sheet to let CBO know the contact information for the tax savings plan account.
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Exemptions
For tax savings plan, the SC must also submit the completed CFC Tax Savings Account Information Sheet to let CBO know the contact information for the tax savings plan account. Families may decline the exemption for tax
savings plan as long as they are well informed of the consequences of their decision.
Exemptions For tax savings plan, the SC must also submit the completed CFC
Tax Savings Account Information Sheet to give CBO the contact information for the tax savings plan account. Families may decline the exemption for tax savings plan as
long as they are well informed of the consequences of their decision.
If the family does request EI to utilize the tax savings account to pay for EI services, have the family sign the Acknowledgement to Decline Exemption for Tax Savings Account form and submit to the CBO with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updatesindicating “other” as the required attachments in Section 4 of the form.
Check for understanding/questions
Insurance Changes
When the status of private insurance changes the CFC must act immediately to ensure continuance of services and reimbursement to providers by ensuring the following occur:
Insurance Changes
When the status of private insurance changes the CFC must act immediately to ensure continuance of services and reimbursement to providers by ensuring the following occur:Check monthly to ensure all coverage is the same.
Being mindful of major plan year changes, e.g. end of calendar year or fiscal year. A provider might discover the update first. If so, take appropriate actions immediately when informed.
Insurance Changes When the status of private insurance changes the CFC must act
immediately to ensure continuance of services and reimbursement to providers by ensuring the following occur:Check monthly to ensure all coverage is the same. Being
mindful of major plan year changes, e.g. end of calendar year or fiscal year. A provider might discover the update first. If so, take appropriate actions immediately when informed.
Use the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates and complete the Change/Update section on an active child with an IFSP.
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Insurance changes
Families obtaining insurance for first time and families changing private plans both receive a 45-day exception to insurance billing, beginning the day the CBO receives the request from the CFC
Insurance changes
Families obtaining insurance for first time and families changing private plans both receive a 45-day exception to insurance billing, beginning the day the CBO receives the request from the CFC
As soon as the results of the BV are received by the CFC, or the 45-days are over, services must be delivered in the manner matching the BV results, including need for a waiver or exemption.
Insurance changes
Families obtaining insurance for first time and families changing private plans both receive a 45-day exception to insurance billing, beginning the day the CBO receives the request from the CFC
As soon as the results of the BV are received by the CFC, or the 45-days are over, services must be delivered in the manner matching the BV results, including need for a waiver or exemption.
If family does not have the new card yet, the CFC must complete the CFC Change of Insurance Notification form along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates to assist the CBO in processing the benefits verification request.
Insurance changes
Families changing from private benefits to having no private benefits will have services billed to EI, potentially impacting their Family Fee
Insurance changesFamilies changing from private benefits to
having no private benefits will have services billed to EI potentially impacting their Family Fee
Again, submit the update request to the CBO adjusting Cornerstone only when the CFC receives confirmation of lapse date from CBO.
Insurance changes Families changing from private benefits to having no
private benefits will have services billed to EI potentially impacting their Family Fee
Again, submit the update request to the CBO adjusting Cornerstone only when the CFC receives confirmation of lapse date from CBO.
After receiving the confirmation, the SC must adjust the authorizations to “No Private Insurance” and send new authorizations to all direct service providers to correctly reflect the insurance status.
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Insurance changes Families changing from private benefits to having no private
benefits will have services billed to EI potentially impacting their Family Fee
Again, submit the update request to the CBO adjusting Cornerstone only when the CFC receives confirmation of lapse date from CBO.
After receiving the confirmation, the SC must adjust the authorizations to “No Private Insurance” and send new authorizations to all direct service providers to correctly reflect the insurance status.
The SC should recommend that families who lack private benefits research options such as All Kids or coverage available under the Affordable Care Act with www.getcovered.illinois.gov.
Last Audience Poll
The following word(s) can be made from the word “insurance”:A. SureB. RainsC. NineD. All of the aboveE. None of the above
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Questions/support needs
Post Session Survey & Certificate
Post Webinar Survey https://www.surveymonkey.com/r/CFCwebinarInsurance
Survey link will be emailed to all managers AFTER the webinarSurvey will close at midnight on SundayCertificate will be sent within 5 business days after webinar
Ann Freiburg: [email protected] Guillen: [email protected]