MyCare Ohio
Skilled Nursing Facility
Orientation
Demonstration/Pilot Area
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Health Plan Options
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Implementation Timeline
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114,000 members in 29 counties are eligible for the MyCare
Ohio program. This includes:
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Individuals 18 years and older
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Members residing in the MyCare Ohio service area
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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
older
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Persons with serious mental illness
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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
spend-down
• Individuals with third party insurance
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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
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Opt IN ID Card (Medicare & Medicaid)
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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
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Opt OUT ID Card (Medicaid Only)
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Service Packages
 Services included:
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Medical benefits
Behavioral health benefits
Home & Community Based Services
Long Term Care
Pharmacy
Dental
Vision
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e Services
 MyCare Ohio Waiver
includes:
 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.
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Determining Eligibility
 Waiver Eligibility will be determined by
government agencies
 Department on Aging
 CareStar or other vendor
 Level of care assessment evaluates the
member’s:
 Ability to perform the activities of daily
living
 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
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Transitions of Care – Nursing Facility
• NF services:
– Provider will be retained at current rate for the life of Demonstration
(42 months).
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Transitions of Care - Exceptions
During the transition period, change from the existing services or provider
can occur in any of the following circumstances:
1.
2.
3.
4.
Consumer requests a change
Significant change in consumer’s status
Provider gives appropriate notice of intent to discontinue services to a
consumer
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
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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
Counselor’s.
 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+.
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Provider Value
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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
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Provider Portal @ www.bchpohio.com
Through our main website,
providers can access:
 Provider Newsletters
 Provider and Billing
Manuals
 Provider Directory
 Announcements
 Quick Reference Guides
 Benefit Summaries for
Consumers
 Online Forms
Logon to www.bchpohio.com and become a registered provider
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On our secure portal,
providers can:
 Verify eligibility and benefits
 View provider eligibility list
 Submit and check status of
claims
 Review payment history
 Secure Contact Us
Registration is free and easy.
These services can also be handled by Buckeye Provider Services
@ 866-296-8731
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Submitting Claims to Buckeye
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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
system.
 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
866-549-8289.
All out of network non-emergent services and providers require
prior authorization.
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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
(866)-329-4701
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
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Claim Submission and Reimbursement
• Authorization is required for all services including bed hold
days
• 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.
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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
Program
Exclusions
• Buckeye will aggregate bad
debt detail
from adjudicated
claims by facility
• Buckeye will review and determine liability using the following
methodology
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.
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Claim Services
CLAIM SUBMISSION OPTIONS
Electronic Claims Submission – EDI
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More efficient, fewer errors
Faster reimbursement 5-7 days from submission
Requires EDI vendor or clearinghouse agreement
Buckeye Provider Portal
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Requires registration and username/password
Very efficient; fewer errors
No cost to provider
Faster reimbursement 5-7 days from submission
Paper Claim Submission
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Less efficient
Requires original claim forms
Average reimbursement 10-14 days from submission of clean claim
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EDI Partner
Payor ID#
Phone #’s
Emdeon
68069
(800) 845-6592
Gateway
68069
(800) 987-6720
SSI
68069
(800) 880-3032
Smart Data Solutions
68069
(651) 690-3140
Availity
68069
(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:
EDIBA@centene.com
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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
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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
field
 Type all fields completely and
 Don’t submit photocopied claim forms
correctly
(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
forms
 Include all other insurance
 Don’t submit claim forms via fax
information (policy holder, carrier
name, ID number and address) when
applicable
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EFT and ERA
 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 www.payspanhealth.com or contact them
directly at (877) 331-7154 to obtain a registration code and PIN
number.
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Thank you!