Illinois Health Partners (IHP) Provider Manual Illinois Health Partners Health Partner Management Committees Midwest Physicians Administrative Services (MPAS) IHP/MPAS Administrative Directory IHP Contract Health Plan Listing Member Eligibility Eligibility Verification PCP Selection / Member Assignment IHP Plan Link Copayments Health Services Utilization Management Case Management Pre-Certification Process Office Referral Procedure Referral Turnaround Times Pre-Certification List Hospitalist Program Concurrent Review Process Out-Of-Network Care Out-Of-Area Care Quality Improvement
31
Embed
Illinois Health Partners (IHP) Provider Manual Health Partners (IHP) Provider Manual Illinois Health Partners Health Partner Management Committees Midwest Physicians Administrative
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Illinois Health Partners (IHP)
Provider Manual
Illinois Health Partners
Health Partner Management Committees
Midwest Physicians Administrative Services (MPAS)
IHP/MPAS Administrative Directory
IHP Contract Health Plan Listing
Member Eligibility
Eligibility Verification
PCP Selection / Member Assignment
IHP Plan Link
Copayments
Health Services
Utilization Management
Case Management
Pre-Certification Process
Office Referral Procedure
Referral Turnaround Times
Pre-Certification List
Hospitalist Program
Concurrent Review Process
Out-Of-Network Care
Out-Of-Area Care
Quality Improvement
Provider Reimbursement
Capitation
Sample PCP Capitation Detail Reports
Provider Office Access
Claims
Claims Submission
IHP Check Sample
IHP Explanation of Benefits (EOB) Sample
Coordination of Benefits (COB)
Credentialing
Initial Credentialing Process
Re-Credentialing Process
Medicare Advantage
Coding
Super Visit/Annual Health Assessment Process
CMS Compliance
IHP Fee for Service (FFS) Plans
Medicare/Medicaid Dual Eligible Plans
Blue Cross Blue Shield Community
Humana Gold Plus Integrated
Medicaid Humana Care Integrated
Accountable Care Organization Plans
Medicare
Blue Cross Blue Shield PPO
United Healthcare
Illinois Health Partners
Illinois Health Partners (IHP) is a network of more than 1,800 affiliated physicians throughout the
west, northwest and southwest suburbs of Chicago. This network jointly manages the health care
needs of HMO and Medicare Advantage patients in the Blue Cross Blue Shield and Humana networks.
IHP was formed in 2011 by DuPage Health Partners/DuPage Medical Group and Edward Health
Partners/Edward Health Services. In 2013, the Elmhurst Memorial Healthcare and Elmhurst Physician
Association joined IHP. The IHP network was further enhanced with the addition of Northwest
Community Health Partners in 2015. Edward Hospital, Linden Oaks, Elmhurst Hospital and
Northwest Community Hospital are IHP’s hospital partners.
Our Mission:
Delivering value through quality, access and efficiency.
Our Vision:
To be a regional provider network recognized for delivering highly efficient and coordinated care with
exceptional outcomes.
Our Physicians:
Illinois Health Partners offers a large panel of over 1,800 physicians. Included are primary care
physicians in the areas of family practice, internal medicine and pediatrics; specialists trained in 50
different areas of medicine; and three hospitals.
IHP’s Program:
IHP offers its members and providers the benefits of a multispecialty network including PCPs,
specialists and hospitals that provide state of the art, comprehensive and efficient healthcare to meet
patients’ medical needs.
IHP Structure:
IHP is dedicated to ensuring high quality and efficient care across the entire network and all its patient
populations. IHP negotiates and holds the managed care health plan contracts for the IHP network.
Under Illinois Health Partners there are currently three medical groups or “tower divisions” (DuPage
Health Partners, Edward Health Partners and Elmhurst Health Partners). In 2015, Northwest Health
Partners will be added as the fourth IHP Tower.
IHP Health Partner Management Committees
IHP strategic network decisions are made at the IHP Board and Finance/Contracting Committees.
Health Partner Management Committees have been formed to advise IHP leadership of system
activities, provide feedback on operations and make policy recommendations to IHP. The Health
Partner Management Committees meet bi-monthly to discuss IHP directives, initiatives and system
operations. Each Tower Committee has its own governance and charter that outlines the Committee
responsibilities and duties including:
UM/QI Performance oversight
Review of patient satisfaction scores
Financial report review
ACO and shared savings contract performance review of IHP providers
Review of prospective providers requesting to join the tower
Determination of bonus distribution methodology
Payout approval
Operating expense approval
Medical Director review and oversight
IHP has designated Midwest Physicians Administrative Services (MPAS) as the management
organization responsible for administering and managing the operations required to successfully
support its health plan contracts. Tower Management leadership also serves on the MPAS Operations
Committees (UM, QI, and subcommittees) to provide medical network insight, make recommendations
for administrative operations and communicate initiatives to IHP leadership, committees and network
Durable Medical Equipment (DME) / Orthotics & Prosthetics (O&P) Family Planning
Infertility
Sterilization
Termination of Pregnancy
Genetic Testing Benefit Determinations
Cosmetic Procedures
Sclerotherapy
Bariatric Surgery Consults
Clinical Trials
Acne Surgery
Dental / Oral Surgery
Hearing Aids
Transplants Drugs
Synvisc Botox
Epogen, Procrit (J0085) Xolair (J2357)
Transplant, Bariatric (including consult), Urgent and Retro requests must be submitted telephonically. Prior authorization is not required for routine labs, radiology, physician consultation (unless specified above), office visits (excluding procedures) to IHP providers. For questions, contact the UM Dept. at (630) 942-7950, select option 4. Supporting clinical must be submitted with each referral request. IHP specialists’ offices should be entering referrals for services on diagnoses for which they were consulted.
Hospitalist Services
In the IHP network, hospitalists are used to assist the PCP in care coordination for inpatient stays at
Edward, Elmhurst, Central Dupage and Advocate Good Samaritan Hospitals. Objectives of the
hospitalist program are to reduce admit length of stay, re-admissions, avoidable days, inappropriate
emergency room admissions and change one-two day stay status to observations.
Hospitalists coordinate care for all admission categories except NICU, Psychiatric, OB/GYN and
Pediatrics. During an inpatient stay, hospitalists are responsible for:
Admission of patients
Communication with the PCP to maintain continuity and quality of patient care
Providing continuous care, coordination and interpretation of test results and specialty
consultations
Conducting discharge planning and patient discharge
At least one daily visit to hospitalized patients, including medical record documentation of
the visit
Hospitalists concurrently review inpatient stays and communicate with the patient, PCP, Specialists,
health plan, staff, and patient families to ensure that care is coordinated and discharge services are
timely.
Concurrent Review Process
MPAS UM Nurses work with the hospitalists and providers to provide concurrent review
services for the BCBS HMO and the BCBS and Humana Medicare Advantage members.
Concurrent review assesses the medical necessity and appropriateness of care at the acute level.
The UM Nurses telephonically obtains relevant clinical information and/or consult with the
attending hospitalist and physicians as necessary. Concurrent reviews are performed on pre-
certification cases and cases that exceed their assigned length of stay.
UM Nurses document potential discharge needs upon admission and monitor discharge plans
throughout the patient’s stay and arrange for any required services. In addition, MPAS case
managers assist with out-of-network hospitalization reviews and communication with the
hospitalist or PCP to arrange in-network transfer as soon as medically appropriate.
Humana HMO members admitted to Edward or Elmhurst hospital are monitored by the
hospital case management RNs. The hospital case managers notify Humana upon initial
admission and provide clinical updates during the inpatient stay. Humana members that are
admitted out of network are managed by MPAS UM Nurses until such time that the member is
transferred in network or discharged from the hospital. Physicians should contact the MPAS
UM Department with any questions related to acute care.
Out-Of-Network Care
IHP providers are required to refer members to specialty physicians within the IHP network whenever
possible. Occasionally, there may be a service or treatment which cannot be provided by a physician
or contracted ancillary provider within the IHP network. In these cases, the provider is required to
obtain pre-certification. If a provider requires clarification on whether services required can be
performed by an IHP network participant, contact MPAS for assistance in identifying provider options.
The Primary Care Physician is still responsible for the management of care when a member is referred
outside the network and is expected to maintain communication with the out-of-network provider
throughout the course of treatment. After the referred treatment, the member should be brought back
into network as soon as medically possible. It is the PCP’s duty to ensure that he/she receives
consultation notes from these out-of-network providers and keeps them as a part of the patient’s
permanent medical record. The out-of-network providers should only provide those services which
were pre-certified and should not refer the patients for additional care (i.e., MRI, laboratory studies,
etc.) without first consulting an IHP PCP or specialist.
Out-Of-Area Care
If a member is out-of-area, or away from the service area, and requires urgent or emergent care:
Direct the member to contact their health plan directly for authorization of service
or treatment (health plan number is listed on the member’s insurance card).
The PCP should act in an advisory capacity with the out-of-area provider in order to stay
informed of the treatment decisions and medical care rendered to the member. In this manner,
the PCP will be in a better position to accept transfer of the patient and to coordinate care of
the patient upon return to the service area.
Most insurance carriers will only cover out-of-area emergency treatment and will not cover
any routine care out-of-area.
The out-of-area scope varies for each health plan. For some plans, there is a mileag
determination (i.e., 30 miles from PCP, 50 miles from PCP, etc.) and for other plans this
scope will involve specific counties surrounding the member’s PCP office.
Quality Improvement
IHP, through its MPAS relationship, has developed an extensive and detailed Quality Improvement
(QI) program designed to improve member healthcare and comply with health plan mandated
programs. To more efficiently coordinate all of the health plan’s programs and initiatives, IHP is
moving to a population health management philosophy. Population health management focuses on the
development of tools to assist office staff and providers with documentation requirements that will
facilitate optimal reporting of healthcare services across the entire IHP patient population.
MPAS works with providers, health plans, government agencies and health care associations to
identify guidelines for defining and achieving quality in the patient care setting. To ensure that all IHP
patients receive outstanding care, IHP tracks, measures and implements programs that assist providers
in continuously improving levels of care. Key components of the quality program include:
Identification of standards of care using evidence based medicine.
Ensuring compliance with health plans and regulatory agency standards through
monitoring provider outcomes.
Collection, analysis and reporting of outcome data.
Working collaboratively with health plans, IHP leadership and providers to develop
meaningful programs to assure patient quality at all levels of the patient care experience.
Continuous assessment of performance, identification of issues and barriers and
development of initiatives to improve care delivery programs.
The MPAS Quality Improvement department works with IHP leadership through the IHP QM/UM
committee to monitor outcomes, set network care goals and design/implement programs to improve
member health care. IHP provider participation in the quality program is key to the success of the IHP
organization. Physician and staff communication is the most important factor in improving patient
activation, outcomes and experience.
Each office is asked to identify a dedicated staff member to serve as the Quality Liaison for the
purpose of facilitating communication and implementation of the quality initiatives at the practice
level. MPAS Quality Specialists work directly with provider offices providing expertise, education
and information resources. Physicians and office staff are encouraged to contact the MPAS Quality
Department to discuss office metrics and available resources.
Capitation
Capitation (“cap”) is a prepaid method of payment for health services. Capitation is paid on a Per-
Member Per-Month (PMPM) basis and is calculated for the members assigned to each Primary Care
Physician (PCP) for that current month. Monthly cap payments reimburse the PCP for all services
provided by the PCP during that month, regardless of the number or nature of the services provided.
Each health plan provides IHP with a monthly list of effective members. Some health plans assign
members to a PCP (Humana), while others ask the member to contact the medical group and identify
their PCP choice (BCBS). PCP capitation payments vary each month according to benefit plan
copayments, age and sex of each assigned member. IHP has established a cap rate for each category of
member and provides each PCP with a monthly capitation/eligibility list indicating the rate paid for
each assigned member.
To calculate the total monthly capitation payment for each PCP, IHP calculates the average member
payment and pays each PCP the average payment multiplied by the total number of PCP patients
assigned.
Capitated physicians are paid each month based upon the established capitation rate and number of
eligible members assigned to the PCP on the 16th day of the month. Cap payments are calculated
following the eligibility receipt, and checks are mailed by the end of each month.
IHP provides each PCP with a monthly capitation report that identifies the cap rate for all members
assigned to the PCP during the current month. The total capitation paid to each PCP is based on the
average member payment times the number of members assigned for that month to the PCP. Attached
is a sample PCP cap report.
Sample Capitation-Eligibility List
PROV NAME PAT NAME BIRTH
DATE
GENDER BENEFIT PLAN NAME PCP
COPAY
MEM
NUMBER
Physician, IHP Member A 4/22/2012 F JWG20 BA 20 888888888
Physician, IHP Member B 5/9/2011 M 092/688 ELM/EDW EMPLOYEES 45 H11111111
Physician, IHP Member C 2/16/2013 F 092/688 ELM/EDW EMPLOYEES 45 H43214321
Physician, IHP Member D 10/8/2007 F 092/688 ELM/EDW EMPLOYEES 45 H12341234
Physician, IHP Member E 5/4/2011 F QNH20 BA 20 999999999
Physician, IHP Member F 6/6/2010 F QNH20 BA 20 123412341
Physician, IHP Member G 11/29/2011 F QNH20 BA 20 432143214
Physician, IHP Member H 5/19/2010 M WRQ40 BA 40 222222222
Physician, IHP Member I 9/10/2009 F QMH30 BA 30 333333333
Physician, IHP Member J 11/19/2011 F QMH30 BA 30 555555555