Program Exclusions

MyCare Ohio
Skilled Nursing Facility
Demonstration/Pilot Area
Health Plan Options
Implementation Timeline
114,000 members in 29 counties are eligible for the MyCare
Ohio program. This includes:
Individuals 18 years and older
Members residing in the MyCare Ohio service area
Individuals entitled to benefits under Medicare Part
A enrolled under Medicare Parts B and D, and
receive full Medicaid benefits.
Adults with disabilities and persons 65 years and
Persons with serious mental illness
Program Exclusions
Those who are not eligible for MyCare Ohio enrollment:
• Individuals under age 18 years
• Individuals with an ICF/IDD level of care served either in an
ICF/ID facility or on a waiver
• Individuals who are eligible for Medicaid through a delayed
• Individuals with third party insurance
Opt IN Enrollees
Full duals with Buckeye
 Medicare and Medicaid benefits through Buckeye
– Medicare – option to change plans monthly
– If member selects another MyCare MCP will be
enrolled as a full dual with the new plan
– If member selects a plan outside the MyCare network,
member retains Medicaid benefits with Buckeye.
 One claim submitted to Buckeye.
– Will be adjudicated for both Medicare and Medicaid
with one submission.
– Will generate two payments
Opt IN ID Card (Medicare & Medicaid)
Opt OUT Enrollees
Medicaid as Secondary Coverage with Buckeye
 Medicaid benefits only through Buckeye
– Option to change Managed Care Plans during initial 90
days of enrollment
– Locked in for remainder of benefit year until annual
open enrollment
– Medicare benefits through other non MyCare payor
including Fee for Service
 Secondary claims to be submitted to Buckeye.
– Will be adjudicated as secondary payor
Opt OUT ID Card (Medicaid Only)
Service Packages
 Services included:
Medical benefits
Behavioral health benefits
Home & Community Based Services
Long Term Care
e Services
 MyCare Ohio Waiver
 Ohio Home Care Waiver
 Transitions II Carve-Out Waiver
 Passport Waiver
 Choices Waiver
 Assisted Living Waiver
Enrollees who are eligible for waiver will have access to all of the services
included in the MyCare Ohio Waiver.
Determining Eligibility
 Waiver Eligibility will be determined by
government agencies
 Department on Aging
 CareStar or other vendor
 Level of care assessment evaluates the
 Ability to perform the activities of daily
 Mental acuity
 Level of impairment
 Level of need
 Member’s level of care determination will determine which services the member
is eligible to receive.
 Skilled, Intermediate, Intermediate/Mental Retardation-Developmental Disabilities /
Protective or None
 Member has choice to receive services
Transitions of Care – Nursing Facility
• NF services:
– Provider will be retained at current rate for the life of Demonstration
(42 months).
Transitions of Care - Exceptions
During the transition period, change from the existing services or provider
can occur in any of the following circumstances:
Consumer requests a change
Significant change in consumer’s status
Provider gives appropriate notice of intent to discontinue services to a
Provider performance issues are identified that affect an individual’s
health & welfare
Plan-initiated change in service provider can only occur after an in-home
assessment and development of a plan for the transition to a new provider
The Integrated Care Team Works Together with the
Member to Find the Best Health Solutions for Members
 Care Manager (Accountable Point of Contact)
 Accountable point of contact for the Integrated
Care Team
 Registered Nurses, Social Workers and
 Program Coordinator
 Mixture of licensed/certification professionals.
Focused on the physical, psychological and social
welfare of the member.
 Community Health Worker
 Provides team support, and reaches out to members with health and preventive
care information
 Waiver Service Coordinator
 Focuses on Buckeye members that receive services through a home and
community-based services waiver.
 Partnership with the Area Agency on Aging (AAA) for member age 60+.
Provider Value
Value That Centene Brings to Providers
 Timely and accurate claims payment (clean claims) processed
within 7-8 days of receipt
 75% of claims are paid within 7-10 days of receipt
 99% of claims are paid within 30 days
 Local dedicated resources: Care coordinators serve as an
extension of physician offices
 Education of providers and support staff through orientations
 Provider participation on health plan committees and boards
 Minimal referral requirements for physician services
 Electronic and web-based claims submission
 Web based tools for administrative functions
Provider Portal @
Through our main website,
providers can access:
 Provider Newsletters
 Provider and Billing
 Provider Directory
 Announcements
 Quick Reference Guides
 Benefit Summaries for
 Online Forms
Logon to and become a registered provider
On our secure portal,
providers can:
 Verify eligibility and benefits
 View provider eligibility list
 Submit and check status of
 Review payment history
 Secure Contact Us
Registration is free and easy.
These services can also be handled by Buckeye Provider Services
@ 866-296-8731
Submitting Claims to Buckeye
What Requires Prior Authorization?
ALL SNF and LTC services require prior authorization
 New Services:
 Existing Services:
 Services will be based on the member’s
care plan.
 Services that are currently in place for
member will remain for 365 days.
 Care Coordinator will be in contact with
both the member and provider.
 HCBS Care Coordinator will enter prior
authorizations for each service into the
 Once services are approved, prior
authorization will be entered into the
system by Care Coordinator.
 Providers will receive a notice from Buckeye
explaining transition process, and members
identified as currently in facility or LTC.
 Care Coordinator will contact service
providers with a prior authorization
number, confirming service can now
take place.
 If you have questions if a service is
authorized for the member, contact the
HCBS care coordination team at
All out of network non-emergent services and providers require
prior authorization.
Claim Services
Timely Filing Guidelines
 365 Days from the date of service
 180 Days if retro eligibility is an issue
 180 Days to submit a corrected claim, request a reconsideration of payment, or to file a
claim dispute
*Please refer to our provider or billing manual online for more detailed information*
Paper Claims
 Providers may submit to the following addresses:
Buckeye Community Health Plan
Attn: Claims
P.O. Box 3060
Farmington, MO 63640
Corrected Claims, and Requests for Payment Reconsideration
– Providers may submit to the following addresses:
Buckeye Community Health Plan
MyCare Ohio Claim Reconsideration
P.O. Box 4000
Farmington, MO 63640
Claim Submission and Reimbursement
• Authorization is required for all services including bed hold
• Buckeye will accept standard Medicare and Medicaid billing
codes RUGS etc. No payor specific codes required
Program Exclusions
• Buckeye will reimburse based upon current Medicare &
Medicaid fee schedules including bed hold days
• Bed hold days policy will be consistent with current regulatory
policies and rates (Buckeye has current rates including
occupancy variances)
• Inpatient hospice – Buckeye will reimburse hospice provider
who will in turn reimburse SNF for room & board.
Bad Debt Policy
• Bad Debt – applies to member liability for skilled level of care
days 21-100 of single stay
• Buckeye will not require SNF to file annual bad debt report
• Buckeye will aggregate bad
debt detail
from adjudicated
claims by facility
• Buckeye will review and determine liability using the following
Services 5/1/14 through 9/30/14 – 76% of bad debt
Services 10/1/4 through 12/31/14 – 65% of bad debt
• Reimbursement will be paid as a lump sum payment in the 2nd
quarter of each year.
Claim Services
Electronic Claims Submission – EDI
More efficient, fewer errors
Faster reimbursement 5-7 days from submission
Requires EDI vendor or clearinghouse agreement
Buckeye Provider Portal
Requires registration and username/password
Very efficient; fewer errors
No cost to provider
Faster reimbursement 5-7 days from submission
Paper Claim Submission
Less efficient
Requires original claim forms
Average reimbursement 10-14 days from submission of clean claim
EDI Partner
Payor ID#
Phone #’s
(800) 845-6592
(800) 987-6720
(800) 880-3032
Smart Data Solutions
(651) 690-3140
(800) 282-4548
 Via the Provider Portal we can also:
 Receive an ANSI X12N 837 professional, institution or encounter transaction. Portal
allows batch\individual claim submissions
 Generate an ANSI X12N 835 electronic remittance advice known as an Explanation of
Payment (EOP).
Please contact:
Buckeye Community Health Plan
c/o Centene EDI Department
1-800-225-2573, extension 25525
or by e-mail at:
[email protected]
Paper Claim format
All services must be billed to Buckeye using a CMS 1500 form.
 Forms cannot be filled out by hand.
 Must be completed using computer
software or a typewriter.
 All claims must be submitted within
Program Exclusions
180 days from the date of service.
 Claims must be submitted to the
following address:
Buckeye Community Health Plan
ATTN: Claims 3060
Farmington, MO 63640
Billing – Dos and Don’ts
Billing – Dos
Billing – Don’ts
 Submit your claim within 90 days of
the date of service
 Submit handwritten claims
 Submit on a proper original form –
CMS 1500
 Don’t circle data on claim forms
 Use red ink on claim forms
 Don’t add extraneous information to
 Mail to the correct PO Box number
any claim form field
 Submit all claims in a 9” x 12” or Program Exclusions
 Don’t use highlighter on any claim for
larger envelope
 Type all fields completely and
 Don’t submit photocopied claim forms
(no black and white claim forms)
 Use typed black or blue info only at 9 Don’t submit carbon copied claim
point font or larger
 Include all other insurance
 Don’t submit claim forms via fax
information (policy holder, carrier
name, ID number and address) when
 Buckeye partners with PaySpan Health delivering electronic payments (EFTs) and
remittance advices (ERAs).
 FREE to Buckeye Providers
 Electronic deposits for your claim payments
 Electronic remittance advice presented online.
 HIPAA Compliant
Provider Benefits with PaySpan Health
 Reduce accounting expenses – Electronic remittance advices can be imported directly
into practice management or patient accounting systems
 Improve cash flow – Electronic payments for faster payments
 Maintain control over bank accounts – You keep TOTAL control over the destination of
claim payment funds. Multiple practices and accounts are supported.
 Match payments to advice quickly – You can associate electronic payments with
electronic remittance advices quickly and easily.
 Manage multiple Payers – Reuse enrollment information to connect with multiple
Payers. Assign different Payers to different bank accounts, as desired.
For more information visit or contact them
directly at (877) 331-7154 to obtain a registration code and PIN
Thank you!
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