Real Time Claims Adjudication Now Available on Provider ... · coinsurance at the time of checkout based on the ... • Cranial Orthosis for Plagiocephaly • 2060 E. Ninth StreetDME

Volume 2/Issue 4 • 4th Quarter 2009

MUTUAL MUTUAL MUTUAL NEWSNEWSNEWS

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This material is considered part of the Provider Manual Medical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

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Coordination of Benefi ts Reminders ..............................2Thank You for Your Feedback ........................................2H1N1 (Swine Flu) Vaccine Coverage ..........................3Securing Advanced Authorization .................................3Post-Licensure Requirement Changes for Network

Behavioral Health Practitioners ..................................4

Fighting Fraud, Promoting Integrity ..............................4 Corporate Medical Policies ............................................5Coming Soon: 2010 Provider Manual ............................6EFT and eRA Simplify the Payment Process ..................6 Company Contact Information ......................................7 Sign Up Now! Provider ePortal ......................................8

Coordination of Benefi ts RemindersThank You for Your Feedback

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Real Time Claims Adjudication Real Time Claims Adjudication Real Time Claims Adjudication Real Time Claims Adjudication Real Time Claims Adjudication Real Time Claims Adjudication Now Available on Provider ePortalNow Available on Provider ePortalNow Available on Provider ePortalNow Available on Provider ePortalNow Available on Provider ePortalNow Available on Provider ePortal

As well as real time claims submission, providers can contact system support staff and link to various patient communication documents by using RTCA. A user guide which provides detailed information for utilizing RTCA can be found by clicking the Administrative link in the RTCA section of the Provider ePortal at MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com.

If you have not yet registered for the Provider ePortal, visit the Provider section of our Web sites for a demo explaining the features, functions and benefi ts of using this service.

Medical Mutual of Ohio® and its Family of Companies understand the challenge the provider community faces in relation to industry-wide trends associated with the fi nancing of health care.

To address those concerns we are proud to announce the launch of a Web-based solution that allows providers to submit claims for immediate adjudication while the patient checks out of the offi ce.

CLAIMSCLAIMSCLAIMS

ADMINISTRATIONADMINISTRATIONADMINISTRATION

NOTENOTENOTE::: It is It is It is recommended that providers notify members ofrecommended that providers notify members ofrecommended that providers notify members ofthe use of Real Time Claims Adjudication at the time they the use of Real Time Claims Adjudication at the time they the use of Real Time Claims Adjudication at the time they Schedule appointments. Schedule appointments. Schedule appointments.

Submit Professional ClaimsSubmit Professional ClaimsSubmit Professional Claims

Claims Real Time AdjudicationClaims Real Time AdjudicationClaims Real Time Adjudication

Offi ce NoticeOffi ce NoticeOffi ce Notice

Contact InfoContact InfoContact Info

Real Time Claims AdjudicationReal Time Claims AdjudicationReal Time Claims AdjudicationReal Time Claims AdjudicationReal Time Claims AdjudicationReal Time Claims Adjudication

Our Real Time Claims Adjudication (RTCA) system, available within the Claims section of the Provider ePortal, provides:

Claims adjudicated in real-time, barring any benefi t • questions or a need for medical review An immediate response detailing the status of the • patient’s claimA preliminary Explanation of Benefi ts (EOB) • detailing the patient’s liability related to that visitOption to collect the patient’s deductible and • coinsurance at the time of checkout based on the amounts noted on the EOBOpportunity for patients to care for their fi nancial • obligations in a timely manner saving the offi ce staff administrative burdens related to the collections process

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A preliminary Explanation of Benefi ts (EOB) •

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Coordination of Benefi ts Reminders

Primary & Secondary CarriersWhen the Company is the secondary carrier, we will pay the balance remaining after the primary carrier makes payment, as long as this amount does not exceed the Company’s normal payment (what the Company would have paid in the absence of other insurance), less applicable copayments and deductibles. Exceptions to this method are Medicare primary and a small number of specialty groups that require non-standard coordination of benefi ts processing. A list of these exception groups is available upon request.

Electronic SubmissionThe Company currently accepts electronic submissions of commercial Coordination of Benefi ts (COB) for professional and institutional claims. A paper Explanation of Benefi ts is not required when commercial COB claims are electronically submitted.Contact your local contracting representative for additional information or a copy of commercial COB electronic claim submission specifi cations.

800/782-5869 or 216/687-7630216/687-2696Cost Center 51272060 East Ninth StreetCleveland, OH 44115-1355

PHONE:FAX:

MAIL:

800/782-5869 or 216/687-7630PHONE:

Contact the Coordination of Benefi ts Unit

Thank You for Your FeedbackThank You for Your FeedbackThank You for Your FeedbackThank You for Your FeedbackThank You for Your FeedbackThank You for Your FeedbackMedical Mutual and its Family of Companies would like to thank those providers who participated in our External Stakeholders Survey.

The Company asked providers, Covered Persons, vendors and other stakeholders to contribute feedback regarding their current partnership with us, how key issues and trends currently affect them and their offi ce, how well we have met their needs and what we can do to improve, anticipate and adapt to future industry changes.

Your responses are essential in helping us determine where our weaknesses and strengths are in health care service. Further, your recommendations assist us to provide prompt, effective and quality support throughout our entire organization in meeting your needs and better formulating our strategic plan for coming years.

Thank you for evaluating our position, giving us the opportunity to better support both providers and Covered Persons in our continued commitment as health care partners. Our extended appreciation for your time in identifying additional resources we can make available and effectively communicating possibilities for improvement.

If you have further recommendations, we encourage you toshare them with us through your local contracting representative.

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The Company will be covering the administration of the H1N1 vaccine for all Covered Persons unless otherwise directed by the plan sponsor. The Company will reimburse the administration of the vaccine, with no out-of-pocket expense when services are rendered by a network provider.

The codes to be used for billing the administration of the H1N1 vaccine are 90470 and G9141.

The federal government will be supplying the vaccine to health care providers at no charge. Covered Persons cannot be billed for the vaccine.

H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)Vaccine CoverageVaccine CoverageVaccine Coverage

H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)H1N1 (Swine Flu)Vaccine CoverageVaccine CoverageVaccine Coverage

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The Care Management Prior Approval and Investigational Services list easily identifi es services requiring prior approval and those considered investigational. Instructions necessary for submitting information before the date of service are included.

For the most current listing, the Company recommends providers routinely check the Prior Approval and Investigational Services, in the Provider, Tools & Resources, Care Management section of the Web sites MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com.

The Care Management Prior

Securing Securing Securing Securing Securing Securing Advanced Advanced Advanced AuthorizationAuthorizationAuthorization

*Cosmetic/Reconstructive

Procedures

*Devices/ Durable Medical Equipment

(DME)

CATEGORY DETAILS SUBMIT TO

*Injectables

Abdominoplasty/Panniculectomy •Blepharoplasty, Brow Lift and Blepharoptosis Repair •Breast Reconstruction and Related Procedures •Mastopexy •Otoplasty •Reduction Mammaplasty •Rhinoplasty •Surgical Treatment of Gynecomastia •

Abatacept (Orencia) •Adalimumab (Humira) •Botulinum Toxin Type A and B •Etanercept (Enbrel) •Growth Stimulating Drugs •Infl iximab (Remicade) •Rituximab (Rituxan) •Synagis (Palivizumab) and RSV IVIG Respirgam •Viscosupplementation Injections (Orthovisc, Synvisc, •

Hyalgan, Eufl exxa)

Artifi cial Anal Sphincter for Treatment of Fecal • Incontinence

Artifi cial Intervertebral Disc Replacement - Cervical •Bone Anchored Hearing Device (BAHA) •Bone Growth Stimulation: Electrical and Ultrasonic •Cochlear Implant •Conductive Garment for Delivery of TENS and NMES •Continuous Glucose Monitoring •Cranial Orthosis for Plagiocephaly •DME Misc Items (HCPCS Code E1399) >$249.00 •Gastric Electrical Stimulation for Treatment of •

GastroparesisHigh Frequency Chest Wall Oscillation System •INR Monitoring System •Interspinous Process Decompression System (X-STOP) •Knee Braces (Custom Fabricated) •Mechanical Insuffl ation-Exsuffl ationTherapy •Motorized Wheelchairs and Power Accessories •Negative Pressure Wound Therapy, Vacuum-assisted •

Closure DevicePneumatic Compression Device •Power Operated Vehicles •Pressure Reducing Support Surfaces •Pulse Oximeter (home use) •Wearable Cardioverter Defi brillator (WED) •

PCAT# 1182

Prior Approval and Investigational ServicesPrior Approval and Investigational Services

*Corporate Medical Policies (CMP) are regularly reviewed, updated, added or withdrawn and therefore, subject to change. For current CMPs consult the provider section of MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com.

Requests may be mailed to:Medical ReviewCC: 01-6A-3982

2060 E. Ninth StreetCleveland, OH 44115

Fax: 800/516-2583Fax: 877/321-6664Fax: 216/687-2616

Prior Approval Form

Requests may be mailed to:Medical ReviewCC: 01-6A-3982

2060 E. Ninth StreetCleveland, OH 44115

Fax: 800/516-2583Fax: 877/321-6664Fax: 216/687-2616

Prior Approval Form

Requests may be mailed to:Medical ReviewCC: 01-6A-3982

2060 E. Ninth StreetCleveland, OH 44115

Fax: 800/516-2583Fax: 877/321-6664Fax: 216/687-2616

Prior Approval Form

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The previous requirement for post-licensure experience was 12 months for Psychologists and 24 months for Social Workers and Counselors.

If you need more information about these changes please contact your local contracting representative.

The post-licensure experience requirement for all network behavioral health practitioners has been eliminated, effective immediately. This applies to:

Psychologists (doctorate level)• Independent Social Workers• Licensed Independent Social Workers• Licensed Clinical Social Workers• Professional Clinical Counselors• Licensed Professional Clinical Counselors• Licensed Mental Health Counselors•

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Post-Licensure Requirement Changes for Post-Licensure Requirement Changes for Post-Licensure Requirement Changes for Network Behavioral Health PractitionersNetwork Behavioral Health PractitionersNetwork Behavioral Health Practitioners

Fighting Fraud, Promoting IntegrityFighting Fraud, Promoting IntegrityFighting Fraud, Promoting IntegrityEliminating health care fraud, such as upcoding, unbundling, billing for non-rendered services, intentional duplicate billing, or misrepresenting non-covered services as medically necessary, is integral in ensuring our Covered Persons receive services from premium health care professionals.

To promote the highest degree of integrity and ethical behavior, the Company maintains an active fraud, waste and abuse program including:

Detection of questionable activity through • analysis of data.Educating Covered Persons to review their • Explanation of Benefi ts and report any irregular items or potential fraud.Compliance Connection• , a web based tool and 24-hour hotline for anonymous reporting of questionable activity or activity that interferes with the safe, legal, ethical or orderly conduct of everyday business.

Trained staff to seek criminal, civil and • administrative remedies for the benefi t of the Company and its clients.Established relationships with National Health • Care Anti-Fraud Association, law enforcement and other regulatory agencies.

To report a concern or questionable activity, click on the Compliance Connection link on the bottom of the homepage of MedMutual.com, ConsumersLife.com or CarolinaCarePlan.com, or call the fraud hotline at 800/553-1000.

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Educating Covered Persons to review their • Explanation of Benefi ts and report any irregular

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The National Health Care Anti-Fraud Association, a private-public partnership against health care fraud, estimates conservatively that $68 billion was lost in health care fraud in 2007.

Insurance Fraud in the U.S.Insurance Fraud in the U.S.Insurance Fraud in the U.S.Insurance Fraud in the U.S.Insurance Fraud in the U.S.Insurance Fraud in the U.S.

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The following list includes Corporate Medical Policies (CMPs) developed or revised July 1 to August 31, 2009. To permit easy identifi cation, “New” or “Revised” notations are included with policies added or updated within the last 30 days on the CMP page of all Company Web sites.

CMPs are regularly reviewed, updated, added or withdrawn and subject to change. For the most current list, consult the Provider, Tools & Resources,Care Management section ofMedMutual.com, ConsumersLife.com or CarolinaCarePlan.com.

Corporate Medical Policies Updates July-August 2009

Policy Number Title 94022 Bone Mineral Density Studies

94051 Pneumatic Compression Device

95003 Surgical Treatment of Gynecomastia (Male)

95020 Continuous Passive Motion Exercise Device

200002 Autonomic Nervous System Testing

200204 Heart Transplantation

200205 Heart-Lung Transplantation

200206 Lung Transplantation

200207 Liver Transplantation

200211 Screening and Diagnosis of Breast Cancer Breast

200231 Air Ambulance Transportation

200305 Negative Pressure Wound Therapy

2003-C Electrical Stimulation for Treatment of Dysphagia

200401 Bone-Anchored Hearing Aid

200407 In Utero Fetal Surgery

2004-E Fecal DNA Testing for Screening of Colorectal Cancer

200507 Doppler Velocimetry

200509 Rhinoplasty

2005-J Vertebral Axial Decompression

2005-P Laboratory Testing for Detection of Heart Transplant Rejection

200612 Mechanical Insuffl ation-Exsuffl ation Therapy

200705 Conductive Garment for Delivery of Transcutaneous Electrical Nerve

Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES)

200902 Robotic Surgical Systems - New

200908 Thoracic Electrical Bioimpedance - New

2009-B Electromagnetic Navigational Bronchoscopy - New

2009-C Anal Fistula Plug - New

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REVISION 2010

PROVIDER MANUAL

Consumers Life Insurance CompanyCarolina Care Plan

and its Family of Companies

Consumers Life Insurance CompanyCarolina Care Plan

Carolina Care Plan

and its Family of Companies

and its Family of Companies

and its Family of Companies

PROFESSIONAL

INSTITUTIONAL

The Company is in the process of updating and enhancing the professional and institutional Provider Manual, which will be available online early next year.

To save you and your offi ce time and to facilitate easy navigation, the 2010 Provider Manual will include interactive links to take you directly to required forms, Web locations, contact information and other electronic features. The manual will also include search functionality allowing you to readily locate specifi c data relevant to you.

New and revised topics will be clearly annotated to help identify pertinent information that has been updated since the last edition.

Look for communications early next quarter directing you to our Web sites, MedMutual.com, ConsumersLife.com and CarolinaCarePlan.com, as we release the new professional and institutional Provider Manual.

The Company is in the process of updating and enhancing

Coming Soon: 2010 Provider Manual

Immediate Access to Deposits Through Electronic Funds Transfer

Receive Claim Payments electronically through • direct deposit.

Have online access to a history of deposits and view • an itemized claim statement.

Valuable time savings for staff and easier • reconciliation of payments with bank statements.

Reduce paper in the offi ce and eliminate the risk of • paper checks being lost or stolen in the mail.

Valuable time savings for staff and easier • reconciliation of payments with bank statements.

Have online access to a history of deposits and view •

Receive Claim Payments electronically through Receive Claim Payments electronically through • direct deposit.

Reduce paper in the offi ce and eliminate the risk of •

Reduce Paperwork with Electronic Remittance Advice Statements

Generated in real time with e-mail notifi cation of • each electronic deposit.

Downloadable Excel• ® statements for analysis and trend information.

Search functions within eRA statements provide • quick access to specifi c information.

Two-year rolling history of eRA statements.•

•

Downloadable Excel•

Generated in real time with e-mail notifi cation of Generated in real time with e-mail notifi cation of •

Two-year rolling history of eRA statements.•

EFT and eRA Simplify the Payment Process

To enroll in EFT and eRA sign up for the Provider ePortal on our Web sites!

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Medical Mutual of Ohio® and Its Family of Companies

Network

Medical Mutual of Ohio®

2060 East Ninth StreetCleveland, OH 44115-1355Visit MedMutual.com

Carolina Care Plan®

201 Executive Center DriveColumbia, SC 29210-8406Visit CarolinaCarePlan.com

Consumers Life®

1899 Powers Ferry Road, Suite 400Atlanta, GA 30339-5619Visit ConsumersLife.Com

Consumers Life®

630 West Carmel Drive, Suite 275Carmel, IN 46032-2515Visit ConsumersLife.Com

Behavioral Health: 800/233-2058 (GA, IN, PA)

800/258-3186 (OH)

800/877-6003 (SC)

Care Management Prior Approval:800/258-3035 (GA, IN, PA)

800/258-2873 or 800/338-4114 (OH)

800/258-3021 (SC)

Case Management: 800/529-5697 (GA, IN, PA)

800/258-3175 (OH)

800/590-2583 (SC)

Provider Inquiry: 800/362-1279 (GA, IN, OH, PA)

800/315-3143 (SC)

Contracting Offi ces:Cincinnati, OH800/589-2583

Cleveland, OH800/625-2583

Columbus, OH800/235-4026

Toledo, OH888/258-3482

Atlanta, GA800/677-8028

Carmel, IN888/636-3622

Columbia, SC800/868-6734

This material is considered part of the Provider ManualMutual News, Volume 2, Issue 4, 4th Quarter 2009

Published by the Provider Communications Department • 2060 E. Ninth Street, Cleveland, OH 44115-1355Medical Mutual of Ohio, Consumers Life Insurance Company and Carolina Care Plan

PRSRT STDU.S. POSTAGE

PAIDCLEVELAND OH PERMIT NO. 1992060 East Ninth Street • Cleveland OH 44115-1355

X7902 R12/09 • PCAT # 1300

MedMutual.com ConsumersLife.com CarolinaCarePlan.com

An electronic alternative for:An electronic alternative for:

Sign Up Sign Up Sign Up Now!Now!Now!

ProviderProvider ePortal ePortal ePortal ePortal

Looking up Fee Schedules • Electronic Remittance Advice (eRA) • Real Time Claims Adjudication (RTCA)• Quick access to your demographic information • Mutual News and other provider publications via e-mail• Direct reimbursement through Electronic Funds Transfer (EFT) •

Electronic Remittance Advice (eRA) • Looking up Fee Schedules •

Real Time Claims Adjudication (RTCA)• •

Mutual News and other provider publications via e-mail• Direct reimbursement through Electronic Funds Transfer (EFT) •