Transcript
HMSA
QUEST Integration
Basics
Participating Provider Webinar
November 15, 2018
Agenda
IMPORTANT: Medicaid Provider Enrollment/Re-
enrollment
Introduction to QUEST Integration
HMSA Responsibilities
Provider Responsibilities
Member Rights and Responsibilities
Service Coordination
Special Health Care Needs (SHCN)
Long Term Services and Supports (LTSS)
Members “At Risk”
2
Agenda (cont.)
Verifying a Member’s Eligibility
Claims/Encounter Form Filing Information
Electronic Transactions
Cost Share
Cultural Competency
Enabling Services
Excluded providers
Administrative Information/Resources
Questions/Evaluation
3
Medicaid Provider
Enrollment / Re-enrollment
Important Announcement
Who?
Providers enrolling in Medicaid for the first time, or
Established Medicaid providers who have not re-enrolled
with Medicaid within the past 5 years
What?
Submit Medicaid Application form (DHS 1139) and other
required documents to Med-QUEST ASAP
Why?
Enhanced provider screening, credentialing and enrollment
When?
NOW! Affected providers should submit their documents
as soon as possible.
5
Submission Requirements
All providers:
Completed DHS 1139 Medicaid Provider application
Copies of Applicable Licenses/Certifications
W-9
Copy of General Excise Tax License
Copy of Certificate of Liability Insurance
Allow MQD to conduct an onsite inspection
6
Submission Requirements
Home Health Agencies, DME, Home and Community
Based Services, Hotels and Transportation providers:
Submit $500 application fee (money order or check) –
payable to:
State Director of Finance c/o Med-QUEST division
Individuals with 5% or more business ownership must
undergo fingerprinting and criminal history fitness
determination by Fieldprint.
Instructions at website:
https://www.fieldprinthawaii.com/
Not required for non-profit organizations.
7
Submission Requirements
Institutional providers (hospitals, nursing
facilities, pharmacies)
Submit $500 application fee (money order or
cashiers check) payable to:
State Director of Finance c/o Med-QUEST Division
8
Send to
Send all required documents and payment (if
applicable) to:
Med-QUEST Division
Health Care Services Branch, Provider Enrollment
601 Kamokila Blvd., Room 506A
Kapolei, HI 96707
9
Application form
DHS 1139 application form and additional
attachments for certain provider types:
https://medquest.hawaii.gov/en/plans-
providers/fee-for-service.html
Questions?
Med-QUEST (808) 692-8099 or
hcsbinquiries@dhs.hawaii.gov
10
QUEST Integration members
HMSA’s QUEST Integration members
Non-ABD (Doesn't include Aged, Blind or members with
disabilities)
ABD
(Aged, Blind or members with
disabilities)
ABD and LTSS
(Aged, Blind or members with disabilities who have additional LTSS benefits)
11
HMSA Responsibilities
Issue ID cards
Process claims
Case assistance/member education
Medical reviews (pre- and post-payment)
Home and community based services
Service Coordination
12
HMSA Responsibilities Our Partners
Magellan formerly (NIA)
Precertification of outpatient advanced imaging studies, selected
spine procedures, selected cardiac services
eviCore
Outpatient rehabilitation therapy utilization management
Beacon Health Options
Behavioral health utilization management
Service coordination involving BH
CVS
Pharmacy benefits and Medical Specialty drug management
services
13
Providers
Provider Responsibilities
Comply with Americans with Disabilities Act
(ADA)
Physical accessibility
Interpreter services
Comply with non-discriminatory requirements
Certify the accuracy, completeness, and
truthfulness of submitted data (claims, encounter
data, medical records)
Maintain confidentiality of such records
15
Provider Responsibilities (cont.)
Adhere to Standards of Care
Develop and fully and clearly discuss treatment
options or service plans with members
Meet QUEST Integration accessibility standards
for urgent/emergent care, sick visits, and routine
visits
16
PCP Responsibilities Role of the Primary Care Provider
Ongoing source for primary care, responsible for patient’s
health maintenance and disease prevention
Coordinate health care with specialists
Maintain continuity of care
Maintain patient health records
Maintain hospital admitting privileges or a written
agreement with a provider with admitting privileges
Provide EPSDT exams to eligible members
17
Work with Service Coordinator to coordinate care and
create the member’s service plan
Identify high-cost, high utilization, complex, or special
needs cases for potential service coordination
Attend or have representation at QUEST Integration
informational sessions
Fulfill PCP requirements for members transitioning to
another PCP until accepted by new PCP
Maintain accessibility standards
18
PCP Responsibilities (cont.) Role of the Primary Care Provider
Provider Grievances and Appeals
Submit Grievance or Appeal in writing to the QUEST
Integration Grievance Coordinator:
948-8224 on Oahu or 1 (800) 960-4672 toll free NI
QUEST Integration Grievance Coordinator P.O. Box 860 Honolulu, HI 96808-9988
952-7843 on Oahu or 1 (800) 440-0640 ext. 7843 toll-free NI
For more information:
https://hmsa.com/portal/provider/zav_QI.02.COM.50.htm
19
Provider Grievances
Grievance process: Dissatisfaction with our operations, activities, or
behaviors
Submit in writing to the Grievance Coordinator within 60 days of payment or episode
Include Provider’s name, address, telephone number and HMSA provider number
Include description of the grievance, including member name and member ID number, along with copies of any supporting documents
Resolution within 60 days of receiving grievance
Further recourse through Appeal
20
Provider Appeals
File appeal if:
Service requested was denied or restricted (post-
service only. Pre-service denials are considered
member appeals
Authorization for a service was terminated, suspended
or reduced
Unhappy with health care services that weren’t timely,
were unreasonably delayed, or the grievance or
appeal decision was not carried out in a timely way
21
Provider Appeals
Appeals process:
Submit written request for appeal to the Grievance Coordinator within 30 days of determination, denial, etc.
Include Provider’s name, address, telephone number and HMSA provider number
Include description of the Appeal, including member name and member ID number, along with copies of any supporting documents
Resolution within 60 days of receiving appeal
Further recourse through Arbitration
22
Provider Appeals
Appeal of Precertification
Denial Form:
https://hmsa.com/portal/provider/6050-
0010_Form_To_Appeal_A_Precertification_Denial.pdf
23
Members
Member Rights and Responsibilities
Outlined for members in QUEST Integration
Member Handbook
Outlined for providers in QUEST Integration
Provider Handbook
Member rights includes member grievance and
appeals process
Providers may act on behalf of members filing
grievances and appeals, with member written consent
25
Member Grievance and Appeals
Right to file grievance
Right to State administrative hearing
How to obtain hearing
Rules on representation
Availability of HMSA assistance in filing grievance
Right to have a provider/representative
Written consent
Toll-free numbers available
Right to receive benefits during appeal/hearing
26
Member Grievances and Appeals
Submit Grievance or Appeal verbally or in writing to
the QUEST Integration Grievance Coordinator:
948-8224 on Oahu or
1 (800) 960-4672 toll free NI QUEST Integration Grievance Coordinator P.O. Box 860 Honolulu, HI 96808-9988
952-7843 on Oahu or 1 (800) 440-0640 ext. 7843 toll-free NI
More information in QUEST Integration Member Handbook: https://hmsa.com/Media/Default/documents/member-
handbook-quest.pdf
27
Member Grievances
Dissatisfaction with our operations, activities, or behavior
Expressed verbally or in writing
• Member
• Member’s authorized representative
• Provider acting on behalf of member with member’s
written consent or written consent of member’s
authorized representative
Grievance determination letter sent within 30 days of
receiving the grievance
28
Member Grievances
State Grievance Review process available if dissatisfied
with outcome
Request for Grievance Review within 30 days of decision
Call DHS – 692-8094
Mail request to:
Med-QUEST Division Health Care Services Branch PO Box 700190 Kapolei, HI 96709-0190
State determination made within 90 calendar days from
request for review
29
Member Appeals
May file Appeal when:
Service requested was denied or restricted
Authorization for a service was terminated, suspended
or reduced
Member unhappy with health care services that
weren’t timely, were unreasonably delayed, or the
grievance or appeal decision was not carried out in a
timely way
Member disagrees with payment that was denied or
reduced
30
Member Appeals
Submitted verbally or in writing within 30 days of
adverse event. Verbal appeals must be followed
up in writing within 5 business days.
May be submitted by
Member
Member’s authorized representative
Provider acting on behalf of member with member’s
written consent or written consent of member’s
authorized representative
31
Member Appeals
32
Appeal Process
• Include member’s name, address, telephone
number and HMSA membership number, date of
the appeal
• Include account of the facts to support the
appeal and why you disagree with the decision,
along with copies of any supporting documents
• Resolution within 30 days of receiving appeal
• Right to receive benefits during appeal/hearing
• Further recourse through State Administrative
Hearing
Member Appeals
State Administrative Hearing process
Request within 30 days of appeal decision
Mail to: State of Hawaii Department of Human Services Administrative Appeals Office PO Box 339 Honolulu, HI 96809
Decision within 90 days from date of request
33
Service Coordination
- Special Health Care Needs (SHCN)
- Long Term Services and Supports (LTSS)
- Members “At Risk”
What is Service Coordination? A person-centered service delivery
system
Ensures the needs of those with
special health care needs, those
receiving long term services and
supports are met and those who are at
risk for deteriorating to nursing facility
level of care are met
35
Service coordinators assist in coordinating
services with other agencies, programs, and
community services
Special Health Care Needs (SHCN)
Patients with Special Health Care Needs (SHCN) examples:
Patients who have chronic conditions such as asthma,
diabetes, hypertension, cancer, or chronic obstructive
pulmonary disease
Patients who are outliers for emergency room utilization
Patients discharged from an acute care setting
Patients with hospital readmission within the previous 30
days
Children with Autism
Members with complex medical conditions requiring
coordination of care
36
Long-Term Services and Supports (LTSS) Patients must meet Nursing Facility Level of Care (NF LOC) on a DHS 1147
Home and community-based services (HCBS): LTSS provided to individuals to allow them to remain in their home
or community Includes Residential Settings
Institutionalized care: Skilled Nursing Facility (SNF) Intermediate Care Facility (ICF)
Self- Direction: Member employs their own provider(s) promoting
choice and independence
Individuals are mostly 65 years of older or with a disability
Most members are identified on membership card as “ABD and LTSS.”
11/14/2018 37
DHS 1147 form
Completed by either provider or
service coordinator
Only MD, DO, RN, or APRN may
complete form
Use DHS’ electronic system HILOC
if you have access
If no access to HILOC, complete
form at link below
https://medquest.hawaii.gov/en/pl
ans-providers/provider-forms.html
Search for “1147”
38
At-Risk Program
Individuals do not meet nursing facility level of care (NF LOC) on
DHS 1147
Do not need to be ABD to qualify
Assessed at risk of deteriorating to nursing facility level of care
using DHS 1147. Examples include someone who:
Lives alone and has difficulty walking
Had a recent hospital discharge
Recent traumatic event such as a stroke
Resides in own home (not home where someone is paid to care
for member such as a care home)
Services include personal assistance, meals, personal emergency
response system, adult day home/care, and skilled nursing
11/14/2018 39
Service Coordination Responsibilities of Coordinators
Support the PCP
Conduct member functional assessments
Develop and monitor a service plan based on results of
the assessment or reassessment
Coordinate and facilitate access to services with
providers, programs, and community agencies
Monitor progress with Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) requirements, as
applicable
40
Requesting Service Coordination Providers may refer any member for service coordination
Advise patient that you are making a referral to Service Coordination… this helps when we call
Refer patients for Service Coordination: fax the form at: https://hmsa.com/portal/provider/HMSA_QUEST_Integration_Service_Coordination_Referral_Form.pdf
Oahu: 944-5604
Neighbor Islands toll-free: 1 (855) 856-4176
Call HMSA to refer patients for Service Coordination:
Oahu: 948-6997
Neighbor Islands toll-free: 1 (844) 223-9856
41
Referrals
Referrals
Self referrals
Register these referrals with HMSA (requires approval)
Other specialty care requires PCP referral, but does not
require submitting a referral request to HMSA
43
• Behavioral health (OP) • Family Planning
• Refractive vision services • Well-woman exam and
mammogram
• In-state out of network referrals
• Plastic surgery services
• Off-island specialist services
How to Register a Referral
Fax the referral form
Referral form:
http://www.hmsa.com/PORTAL/PROVIDER/FM.HMSA_QUE
ST_Referral_Form.pdf
948-5648 (Oahu)
1 (800) 960-4672 (toll-free)
Register the referral online via HHIN
• Select “Submit Referrals” tab, then click on “iExchange”
Call QUEST Integration Provider Service
948-6486 (Oahu)
1 (800) 440-0640 (toll-free)
44
Precertification
Precertification (Prior Authorization)
Services requiring precertification:
https://hmsa.com/portal/provider/zav_QI.0
1.SER.50.htm
Clearly identify urgent/emergent cases for
expedited review
46
Precertification (cont.)
Unit/Partner Responsible for
HMSA Medical
Management
Medical/Surgical, LTSS,
Post-Acute Care Services,
Speech Therapy, Out of
State Referrals
Magellan (formerly NIA) Advanced imaging, Spinal
Interventional Pain
Management, Lumbar
Spine Surgery, selected
Cardiac procedures
eviCore Outpatient Rehab Therapy
47
Precertification (cont.)
Unit/Partner Responsible for
QUEST Integration
Provider Service
Travel and lodging
requests, In-state out of
network referrals,
replacement eyewear
CVS Drug
Beacon Health Options Behavioral Health
48
Precertification – HMSA Medical
Management
HMSA precertification forms available online
General
http://www.hmsa.com/PORTAL/PROVIDER/FM.Pre
certification_Request_General.pdf
Post-Acute Care Services
http://www.hmsa.com/PORTAL/PROVIDER/Precert
ification_Request_Post_Acute_Care_Services_For
m.pdf
49
Precertification – HMSA Medical
Management
HMSA – Medical Management
P. O. Box 2001
Honolulu, HI 96805-2001
(808) 944-5611
948-6464 (Oahu)
1 (800) 344-6122 (toll-free Neighbor Islands)
Monday-Friday : 7:45 a.m. - 4:30 p.m.
Access iExchange through HHIN
https://hhin.hmsa.com/
50
Precertification (Prior Authorization)
Electronic submissions accepted through HHIN
51
Precertification – Magellan
Management of:
52
MRI/MRA/MRS CT/CTA
PET CCTA
Myocardial perfusion
imaging
MUGA
Stress echocardiography Spinal interventional pain
management
Implantable cardioverter
defibrillator
Cardiac resynchronization
therapy pacemaker
Pacemaker Cardiac catheterization
Lumbar spine surgery
Precertification – Magellan
Magellan Precertification information
https://hmsa.com/portal/provider/zav_pel.aa.nia.100.htm
Does NOT include emergency room, surgery center,
observation and inpatient settings
Request Precert Online: RadMD.com
Request Precert by Phone: 1 (866) 306-9729
RadMD technical support:
RadMDSupport@MagellanHealth.com
1 (877) 807-2363 toll-free
53
Precertification - Magellan
Clinically Urgent Cases
Defined as cases that cannot be postponed for 24
hours due to severe health risks for the patient
Member information and clinical reasons for the
urgent request must be submitted. Providers receive
authorization upon completion of the call or online
request.
Clinically Urgent phone line: 1 (866) 842-1776
If using RadMD – select the “Clinically Urgent”
option to provide information on the case
54
Precertification - eviCore
Outpatient rehabilitation therapy management
Precertification information
https://hmsa.com/portal/provider/zav_pel.rt.LAN.
500.htm
Login at:
http://www.lmhealthcare.com/Providers/Landmar
kConnect.aspx
55
Precertification - eviCore
Treatment plan forms available at the website
Treatment plans may be submitted via LandmarkConnect
or by fax
1 (888) 565-4225
Questions?
1 (888) 638-7876
56
Precertification – QUEST Integration
Provider Service
In-state out of network referrals
Travel and lodging requests
Replacement eyewear
948-6486 (Oahu)
1 (800) 440-0640 (toll-free Neighbor
Islands)
948-5648 (Oahu)
1 (800) 960-4672 (toll-free Neighbor
Islands)
57
Precertification - CVS
Oral/Inhaled drugs
Drugs requiring precertification-Review Drug Formularies:
https://hmsa.com/portal/provider/zav_PHARM-
FORMULARY.htm#Nav_Formularies
1 (866) 237-5512
1 (808) 254-4414
58
Precertification - CVS
Injectable/Infused drugs
Drugs requiring precertification:
http://info.caremark.com/hmsapolicies
Note: most drugs have specific precertification request forms
Online: Access through HHIN – Preauthorization tab (NovoLogix tool)
1 (866) 237-5512
1 (808) 254-4414
59
Precertification – Beacon Health Options
Precertification of Methadone/LAAM treatment,
referrals to 0ut-of-state providers, residential
treatment
Case manager for standard behavioral health
care
Links members to resources and services
Educates member/family, serves as patient
advocate
60
Precertification – Beacon Health Options
(808) 695-7790
Oahu - (808) 695-7700 Neighbor Islands - 1 (855) 856-0578 toll free
Beacon Health Options 599 Farrington Highway, Suite 300 Kapolei, HI 96707
61
Precertification
Timeliness guidelines
Routine requests within 14 days
Urgent requests within 3 business days
If pre-certification is not obtained before the service is
provided, submit a paper claim attaching documentation for
the medical necessity
Claim will undergo medical review
Claim without documentation will be denied for no
authorization
62
EPSDT –
Early Periodic Screening
Diagnostic and Treatment
For PCPs
EPSDT – Early Periodic Screening
Diagnostic and Treatment
Mandated Federal program
Provide Medicaid-eligible infants, children and
youth with quality comprehensive health care
through primary prevention, early diagnosis
and medically necessary treatment of
conditions
For members up to 21 years of age
64
65
EPSDT Schedule
Health screening assessment schedule is in the
QUEST Integration Provider Manual:
https://hmsa.com/portal/provider/zav_qi.04.ear.50.htm
Filing Claims for EPSDT – CMS 1500
66
File claim with Preventive Medicine CPT 99381-
99385 or 99391-99395 with modifier EP in block
24D
Place “Y” in Block 24H of the CMS 1500
99392 EP Y A 1 XXX XX
Filing Claims for EPSDT
67
PCPs submit a claim and EPSDT form 8015 (or
Form 8016 for catch up visits).
Paper claim - staple EPSDT form to the claim.
Electronic claim - mail EPSDT form separately to:
HMSA QUEST Integration
P.O. Box 3520
Honolulu, HI 96811-3520
The mailed form must be received by HMSA by the time
the electronic claim processes
Filing Claims for EPSDT
Use original printed forms only, available from
ACS
Ordering EPSDT 8015 and 8016 forms:
Call ACS at 952-5570 on Oahu or 1 800-235-4378 toll
free from the Neighbor Islands
Fax request to 1 (800) 952-5595
Email request to hi.providerrelations@acs-inc.com
Only EPSDT paid if billed with office visit on the
same day
68
69
EPSDT Resources
EPSDT general information url: https://hmsa.com/portal/provider/zav_QI.04.EAR.
50.htm
Sample EPSDT form 8015 (1/10) https://hmsa.com/portal/provider/fm_form_8015_f
ront_and_back.pdf
HMSA’S Electronic
Transaction Services
11/14/2018 71
Electronic Transactions
EDI (Electronic Data Interchange). A communication system
that allows the electronic exchange of data between business
partners such as payers, providers, third party billers, and
clearinghouses.
HMSA supports the following EDI transactions:
Eligibility Verification
Claims Submission
Claim status
Electronic Funds Transfer
Electronic Remittance Advice
Report to Provider (Commercial and Medicare Advantage)
Electronic Transactions HHIN (Hawaii Healthcare Information Network)
HHIN is a free, secure HMSA portal that providers use to access
members’ plan and benefit information.
Transactions that are available on HHIN include:
Eligibility Verification
Plan Benefits
Claim Status
Precertification Requests
Fee Schedules
Report to Provider (Commercial and Akamai Advantage)
11/14/2018 72
Electronic Transactions Electronic Claims Submission
Electronic claims can be submitted two ways:
Bulk processing
Multiple claims sent in a file
Requires an electronic billing system or clearinghouse
Online electronic claim entry (eClaims)
Single claim entered and sent per file
Submitted online
Free submission
Online data edits mean fewer rejected claims
11/14/2018 73
Electronic Transactions Electronic Claims Submission
Benefits of submitting electronic claims:
Paperless
Cost and time savings
Quicker turnaround
Improved and more stable cash flow
11/14/2018 74
Electronic Transactions Electronic Claims Submission
Who can submit claims electronically?
Participating providers
Nonparticipating providers
Certain restrictions apply
System requirements:
Bulk processing
Qualified electronic billing system
Authorized Clearinghouse
Online electronic claim entry
Internet access
Web browser - Internet Explorer (v7 or higher)
11/14/2018 75
Electronic Transactions Contact Us – Outreach and Training Support
For more information about HMSA’s electronic products, to
request a new set-up, or if you need training, please
contact ETS Outreach.
ETS Outreach
(808) 948-6255 on Oahu
1 (800) 603-4672, ext. 6255 toll-free
ETSOutreach@hmsa.com
11/14/2018 76
Electronic Transactions Contact Us – Technical Support
For technical related questions and issues, please contact:
Electronic Data Interchange (EDI) Help Desk
(808) 948-6355
Toll free at 1 (800) 377-4672
edisupport@hmsa.com
HHIN Help Desk
(808) 948-6446
Toll free at 1 (800) 760-4672
hhinhelpdesk@hmsa.com
11/14/2018 77
Verifying Member
Eligibility
Verifying Member Eligibility
Check membership ID card at each visit or encounter
Access HMSA’s Hawaii Healthcare Information Network
(HHIN)
Available 24 hours, 7 days/week
Free access and support
Call QUEST Integration Provider Service
948-6486 (Oahu)
1 (800) 440-0640 (Neighbor Islands)
Monday – Friday, 7:45 a.m. to 4:30 p.m.
79
Verifying Member Eligibility
80
Verifying Member Eligibility
81
Verifying Member Eligibility
Benefit designation
NON-ABD
ABD
ABD and LTSS
82
Verifying Member Eligibility
Back of QUEST Integration ID card
83
Claims Filing
Claims/Encounter Form Processing
Common issues affecting claims processing
Patient eligibility
Precertification
Benefit status
Missing claim info
85
Claims Filing Information
Professional services billed on CMS 1500 claim form
Facility services billed on UB-04 claim form
Obtain forms from form vendor
Filing deadline is 365 days from date of service
Other insurance is always primary to QUEST Integration
Bill other insurance before QUEST Integration
Submit QUEST Integration claim with amount of other
insurance payment or copy of insurance denial notice
Paper or electronic submissions accepted
86
Claims Filing Information (cont.)
DHS Form 1147 required for LTC confinement
Only original forms (printed with red ink) accepted for
submission
Submit only 6 lines of service per claim
Font size 10 through 12
Black ink
Proofread before submitting
Billed service(s) must be documented in patient records
Use all CAPITAL letters
87
Claims Filing Information (cont.)
Do not
photocopy CMS 1500 forms
try to squeeze in more info than field can hold
use highlighters
use White-out
88
11/14/2018 89
Rejected claims
All claims undergo validation edits
Claims that fail an edit are cannot enter the processing
system
Rejection letter (Form 97) is sent to the provider
identifying the rejected claim and the reason(s) why it
rejected
Submit a new claim with the correction(s) as noted on the
rejection letter (Do not label as Resubmission)
11/14/2018 90
Claims denied for additional
information
Claims denied on a Report to Provider (RTP)
Reason for denial/requested additional information is
noted on the RTP
See instructions for Resubmitting Claims
11/14/2018 91
Resubmitting Claims
Resubmitted CMS 1500 (paper) claims require the
following:
Requirement CMS-1500
Indication of replacement
claim
Block 22 – Resubmission code “7” –
(Replacement)
Original HMSA Claim ID Block 22 – Original Ref. No. must contain
Original HMSA Claim ID
Reason for correction Block 19 – Reserved For Local Use
Include text explaining reason for
attachments (e.g. op notes, EOB)
Claims without this information will deny as a duplicate
claim
Remember to include any necessary attachments with
the resubmitted claim
11/14/2018 92
Resubmitting Claims (cont.)
Resubmitted 837P (electronic) claims require the following:
Requirement 837P
Indication of replacement
claim
Loop 2300
CLM05-3 (Claim Frequency Code) = "7"
(Replacement)
Original HMSA Claim ID Loop 2300
REF - Payer Claim Control Number
REF01 = "F8" (Original Reference Number)
REF02 = Original HMSA Claim ID
Reason for correction Loop 2300
NTE - Claim Note Segment
NTE01 = "ADD"
NTE02 = text explaining reason for correction
Optional - NTE segment at Loop 2400 line
level if more space is needed.
Submit Paper Claims to:
HMSA QUEST Integration
P.O. Box 3520
Honolulu, HI 96811-3520
93
Special Claim Submission
Procedures LTSS Providers Bill only for contracted services
94
• Adult day care • Adult day health
• Assisted living • Community care foster family
home
• Community care management • Counseling and Training
• Expanded-adult-residential care
home • Home delivered meals
• Non-medical transportation • Personal assistance (Levels I & II)
• Personal emergency response
system • Private Duty Nursing
• Respite care • Specialized medical equipment
and supplies
Special Claim Submission
Procedures LTSS Providers
Bill only for services actually rendered
Do not bill for services during a period of
hospitalization or confinement in a long term care
facility
Use appropriate codes and units
e.g., a code described as ‘per day’ must be billed by
number of days, not minutes
95
Report to Provider (RTP)
Daily claims processing, with payments run on Tuesdays
Checks mailed every Thursday
Electronic deposits may be arranged
Promptly reconcile RTP with accounts receivables
Monitor outstanding claims for follow-up as needed
96
Report to Provider (RTP)
97
Member Billings
No balance billing of QUEST Integration members
Providers accept QUEST Integration payments as
payments in full
Members may be billed for:
• Non-covered services or upgraded services; member-signed Agreement of Financial Responsibility required
• Services rendered before/after eligibility
• Primary insurance payments sent to the member or plan subscriber by the other insurance
• Cost shares
No-show fees cannot be charged to QUEST Integration members.
98
Cost Share
Amount determined by Med-QUEST
Member responsible for paying entire cost share to the
cost share provider or to HMSA
Collected by cost share provider monthly for
institutionalized members and for non-institutionalized
members receiving specific LTSS services
Providers submit collected amounts on field #29 of the
CMS 1500, or in FL 39 using value code 23 on the
UB-04 claim form
99
Cost Share (cont.)
When cost share is greater than claim charges
(e.g. mid-month admission or discharge),
provider will be invoiced for the balance that
couldn’t be collected via claim
100
Cultural
Competency
and Enabling
Services
Cultural Competency
Cultural background and values shape member views
Key cultural messages
• Members are multicultural
• Members have a right to be treated with courtesy, consideration, and respect
• Respect diversity and eliminate biases and preconceptions that can be barriers to successful delivery of health services
QUEST Integration member communications
• Easy to understand English reading level
• Available in locally spoken foreign languages
Provider foreign language capabilities
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Cultural Competency (cont.)
Outreach and care assistance to members is sensitive to
their beliefs but is aimed at improving their health
outcomes.
Myths about public assistance members:
• They’re noncompliant
• Providers have to make all the healthcare decisions
• Those with disabilities are incapable of discussing their health
• Their superstitions and beliefs are incomprehensible
• They don’t want to talk about their culture, they want to be treated like everyone else
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Cultural Competency (cont.)
HMSA identifies cross-cultural conflicts or complaints
Annual Cultural Competency staff training
Complaints and grievances are trended, analyzed and acted upon in a timely manner
Annual announcement to members to contact HMSA to report situations of lack of cultural adherence
HMSA does not assume that lack of complaints or
grievances indicates that incidents are not occurring
Avenues to identify areas for improvement:
Member communication
CAHPS survey
Member Service contacts
Provider communication
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Enabling Services
Interpreter
Transportation
Auxiliary aids for members with disabilities
Contact QUEST Integration Provider Services for arrangements
948-6486 (Oahu)
1-800-440-0640 (toll free from Neighbor Islands)
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Enabling Services
24-hour Nurse Advice Line
• Free service for HMSA QUEST Integration members
• Medical questions answered
• Advice on treatment options (home, office, ER)
• Phone number on back of member ID card
948-6486 or toll free 1 (800) 440-0640
Select 1 for Members, then Select 1 to speak to a nurse
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Excluded Providers
Excluded Provider
What is an Excluded Provider?
An individual or entity that is not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity.
Provider Responsibilities
Search Excluded Provider lists routinely (i.e., monthly) to confirm that employees or contractors are not on any list
AND
Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list
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Federal Excluded Provider Lists
(QUEST Integration & Medicare
Advantage)
11/14/2018 109
General Services Administration Excluded Parties
List System (EPLS)
https://www.sam.gov/SAM/
List of Excluded Individuals and Entities (LEIE), a
health care specific exclusion list
https://exclusions.oig.hhs.gov/
State Excluded Provider Lists (QUEST
Integration only)
Government contracting exclusion list
http://spo.hawaii.gov/for-state-county-
personnel/manual/debarment/
DHS Med-QUEST Division’s exclusion list
http://www.med-
quest.us/providers/ProviderExclusion_Reinst
atementList.html
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Administrative
Information
Medical Records Documentation
Maintained a minimum of 7 years from last entry date
For minors, maintained while a minor plus a minimum of 7 years after age of maturity
If PCP changes, transfer records to new PCP within 7 business days from receipt of records request
Records must support submitted claims
• Must be legible
• Must accurately document services provided and billed for
• Must be made available to DHS, HMSA and others as specified by DHS for audit and review purposes
Members have a right to receive copies of their medical records and request corrections
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Reporting Requirements
Member information
Report all cases of suspected child abuse to DHS Child Welfare Services Section
Report all suspected dependent adult abuse to the DHS Adult Protection Services Section
Claims/encounter data
Submit claims/encounters to document patient services
Services billed/reported must be supported by patient records
Suspected fraud and abuse by members or other providers
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Administrative
Information/Resources Provider Communications
HMSA website: hmsa.com
Provider Portal - https://hmsa.com/provider/portal
QUEST Integration section
HMSA HealthPro News
Other HMSA communications
Alerts on HHIN
https://hhin.hmsa.com/HHIN/Login/Login.aspx
114
Thank you!
Please complete the Webinar Evaluation form,
and fax it to:
948-6887 (Oahu) or
1-800-540-1668 (Neighbor Islands
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QUESTIONS?
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