April 24, 2014
Columbia, MO
HealthCare USA Overview
• MO HealthNet Managed
Medicaid Plan
• Subsidiary of Coventry and
Aetna
• 60% market share
• Operational since 1995
• 250,000 + members in Missouri
• Robust Statewide Network
• NCQA Accredited
Who Is Your Provider Relations
Representative?
• All HealthCare USA
providers are assigned a
Provider Relations
Representative
• Current listing is available
at www.hcusa.org
Eligibility Verification Options
MO HealthNet Options:
• ARU line 573-635-8908
• www.emomed.com
• Medifax
HCUSA Options:
• www.directprovider.com
• Emdeon Office Product
• Interactive Voice Response
800-295-6888
• Member Services 800-566-6444
Eligibility and Claims System
• HealthCare USA Members
receive a HCUSA ID card
with their HCUSA member
ID and MO HealthNet
member ID number.
• HealthCare USA accepts
claims filed with either the
MO HealthNet member ID
or HealthCare USA
member ID.
• Some Western MO
HealthCare USA members
have a CMPCN logo on the
back of their ID card.
Newborn Eligibility
• Timely filing is 90 days from
date of enrollment within
HealthCare USA’s system.
• Claims must be filed under the
newborn’s name and ID
number.
• Contact Claims Customer
Service if your claim denies for
untimely filing and you
believe it was submitted
within 90 days of the
member’s enrollment.
Provider Communication
• Provider Visits
• Provider Newsletters
• Provider Newsflashes
• Provider Mailings
• www.hcusa.org
• www.directprovider.com
HealthCare USA Web Site
www.hcusa.org
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Online Provider Search
www.directprovider.com
Provider Forms
Authorization Directory
Provider Manual
Provider Communication
EFT, ERA, EDI Information
ICD 10 status updates
CMS 1500 Claim Form
Update
• On January 6, 2014, HealthCare USA
began accepting the revised CMS 1500
paper claim form, version 2/12.
• HCUSA continues to accept and process
paper claims submitted on the version
08/05
ICD-10
• Quarterly updates including FAQ are available at
www.hcusa.org
• Providers can submit their questions to:
5010ICD10Inq@cvty.com
www.DirectProvider.com
• Member Eligibility
• Remittance Advices
• Member ID Cards
• EFT Registration
• ME Code
• Claim Inquiry/Adjustment
Requests
(view and print)
• PCP Assignment
• COB Information
• Authorization Submissions,
Edit & View
• HEDIS
• News
- Reminders
- Gaps in Care
• Resource Library
- Provider Manual/forms
- InterQual Smart Sheets
Direct Provider
Online Authorizations
DirectProvider.com
Training Options
• Take a Tour
• Online Tutorials available 24/7
• Includes Registration, HEDIS Reports, Resource Library, Remittance
Advices, Claim Inquiry
• Webinar Training
• Quarterly dates & times available at www.hcusa.org
and www.directprovider.com
• Email trainingnetworkmanagement@cvty.com to register
• User Guide
• In “News” and help on www.directprovider.com
• Net Support 866-629-3975
• Available 7:00am - 5:00pm
EFT and ERA
No More Checks and Remits in the Mail!
• Request EFT via www.directprovider.com
• Available to participating and non-participating providers
• Remits available online through www.directprovider.com
and/or ERAs
• Providers choosing EFTs must access remittance advices online
• Email notification when a new Remittance Advice is available
Provider Customer Service
Phone: 800-295-6888
• Claims Processing
• Timely Filing/Adjustments
• Remittance Advices
• Recovery
• Claims Payment
• Verisk claim edits
• Claim Adjudication
Information
• i-Health claim edits
• Provider Number
• Check Reissue
• Negative Remits
• Coordination of Benefits
Customer Service Performance
Goals
Item
Standard Goals
1Q 2014 Results
ASA
< 30 seconds
7.3 seconds
Abandonment Rate
< 3%
0.6%
Call Quality
>= 97%
98.6%
Processed in 15 Days
92%
93.8%
Processed in 30 Days
99%
99.6%
EDI Submission
70%
92%
Auto Adjudication
80%
80.1%
Top Claim Denials
• Primary Carrier
Liability
• Services Not
Authorized
• Duplicate Claim
• Member Not Effective
• Untimely Filing
Claims Submission
• Electronic claims submission for original or corrected claims
–
Emdeon, Payor ID# 25133
• Submit using the patient’s HealthCare USA member ID or MO
HealthNet ID number
• Timely filing is 90 days for original claims and the timely
adjustment period is 180 days from the initial remit date.
• Corrected claims must be received within 180 days from original
remit date
• Paper Claims
P.O. Box 7629
London, KY 40742-7629
Corrected claims must be clearly identified as “corrected”
Altered Claims & COB
Altered claims
• Paper claims containing white out, strikeovers, or
handwritten information must be initialed.
•
Please….
Coordination of Benefits (COB)
• HealthCare USA is the payer of last resort, in most instances
• Providers have 90 days from the date of the primary carrier
EOB for HealthCare USA to receive the claim
• Primary Insurance Verification
HEDIS
Healthcare Effectiveness
Data and Information Set
• HEDIS Quick Reference
Billing Guide
• 2013 Results
• Chart audits
• Administrative vs Hybrid
data collection
HEDIS Postpartum Visit
Postpartum Care Data Collection Incentive Pilot
• Report 59430 postpartum visit code for services performed
from the 21-56 day post-delivery HEDIS timeframe
• Incentive is paid quarterly by a separate paper check and will
be sent by mail or delivered by your provider relations
representative
• Missed opportunity report
Affordable Care Act
Primary Care Rate Increase
• Effective January 1, 2013
• Eligible providers must complete the HCUSA or MO HealthNet
attestation form which is located at www.hcusa.org and return to
HealthCare USA
• Payments for services furnished by certain primary care physicians
including vaccine administration under the VFC program
• Claims reprocessing - 2013 and 2014 dates of service
Provider Appeal
Reconsideration Form
• Appeal vs.
Reconsideration
• Fillable Form
• www.hcusa.org
Provider Appeals
Formal mechanism allowing the Provider the right to appeal the
health plan’s decision.
Submission Timeframe:
Appeals must be received within 180 days of the action
taken by HealthCare USA, giving rise to the appeal.
Decision Responses (via fax or mail)
• Pre-service: within 30 calendar days
• Post service: within 60 calendar dates
• Note: The appeal decision is the FINAL decision
Provider Complaints
Dissatisfaction or dispute with policies, procedures, claims, denials, or
any aspect of health plan functions
Submission Timeframe: Complaints must be received within one (1)
year of the date of the incident, remit date or date of notice of action
that caused the complaint.
Decision Responses (via fax or mail)
• Pre-service: within 30 calendar days
• Post service: within 60 calendar dates
Key Contact Numbers
for Providers
HealthCare USA:
• Prior Authorization
800-882-9666
• Provider Customer Service
800-295-6888
• Provider Relations – Western
866-613-5001
• Provider Relations - Central
800-625-7602
• Provider Relations - Eastern
800-213-7792
• Member Services
800-566-6444
Just Look For Me…
Doc Bear