Kansas Hospital Association

Kansas Medical Society
September 6, 2012
Welcome to Sunflower State Health Plan
Confidential and Proprietary
Presenter Contact Info
• Kent Cerneka – Vice-President, Network Development
 Phone: 314-505-6340 or [email protected]
• Lacee Allen– Manager Provider Relations
 Phone: 601-874-1874 or [email protected]
• Monica Arter – Sr. Director of Medical Management
 Phone: 314-505-6011 or [email protected]
• Teresa Dodd – Manager, Payment Excellence Team
 Phone: 314-445-0108 or [email protected]
Confidential and Proprietary
Parent Organization Overview
Headquartered in St. Louis, MO
Contract with over 130,000 providers
Fortune 500 company
Serve over 2.1 million members / 18 states
Employ over 6,000 individuals
4 LTC programs/ 12 ABD programs
Confidential and Proprietary
Core Functions
Network Development
•Since 2006, Sunflower’s parent company has built provider networks from scratch in
eight states totaling ~ 50,000 providers:
Georgia – 15, 957 providers (116 Hospitals)
South Carolina – 7,380 providers (29 Hospitals)
Mississippi – 4,232 providers (74 Hospitals)
Washington – 8,600 providers (66 Hospitals)
Illinois – 5,390 providers (54 Hospitals)
Kentucky – 12,552 providers (54 Hospitals)
Louisiana – 3,987 providers (31 Hospitals)
Missouri – 7,782 providers (72 Hospitals)
•Targeting 8,000 to 10,000 Provider Network in KS which includes Hospitals, Physicians, FQHC/RHC’s, and
Ancillary Providers
Critical Success Factors:
1.Flexible, consultative, relationship-based, partner focused
2.Dedicated resources for Kansas
–On-the-ground experienced Network Development leaders building collaborative relationships (hospitals,
physicians, CMHCs, CDDOs FQHCs, trade associations)
–Complemented by a dedicated telephonic Network Development team
3.Educate, listen and engage; Collaborate rather than mandate
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Core Functions
Provider Relations
•Dedicated, local Provider Relations Representatives
•Initial Training and Orientation within 30 days of contract effective date
 Train on Sunflower Policy and Procedures
 Train on Website and Secure Portal Functions – including registration process for Secure Portal
 Registration and Training on EFT/ERA process, EDI submission, etc.
•Orientations conducted as individual meetings, group meetings, and webinars
•Provider Summit Calls – begin approximately 30 days prior to “Go-Live” and
continue as long as there is interest
•Ongoing education
Confidential and Proprietary
Web Portal
Through the Secure Web Portal,
Providers can:
•Check Member Eligibility
•Check by CPT or HCPCs code whether prior
authorization is needed for par providers
•Submit Prior Authorization Requests
•View Patient Lists
•Submit, view and adjust claims
•View Payment History
•Member Health Record
Through the unsecure website,
Providers can access:
•Provider/Billing Manual
•Quick Reference Guides
•Prior Auth and Notification of Pregnancy
•Clinical Guidelines
•Provider Newsletters and announcements
Confidential and Proprietary
Core Functions
Medical Management
Care Management Teams
Identify and engage high-risk and non-compliant members
Identify barriers to compliance with treatment plans and goals
Facilitate communication across medical and behavioral specialties
Coordinate services, including transportation and referrals
Disease Management Teams
- NCQA/URAC Accredited Programs
Onsite Discharge Planning at high-volume facilities
Confidential and Proprietary
Core Functions
Utilization Management
•Goal is to ensure services are appropriate for the condition, provided in an
appropriate setting and meet or exceed professionally recognized standards of
•Program is based on nationally recognized, evidence-based clinical decision
support criteria
– InterQual is used to determine medical necessity review of most
•Program is overseen by a Medical Director. Only MDs can make adverse
decisions (denial or reduction of service.) MDs are available for peer to peer
Confidential and Proprietary
Core Functions
Programs and Incentives:
•Start Smart for Your Baby – education and case management program starts
during pregnancy through child’s first year of life
•Start Smart for Your Health – educational materials printed and on website.
•CentAccount – monetary awards loaded to a pre-paid debit card for healthy
behaviors. Based on claims with specific CPT Codes.
•MemberConnections and Connections Plus – community events, home visits.
Phones for members at highest risk with unreliable phone access.
Confidential and Proprietary
Core Functions
Claims Payment and Remittance
•Payer ID – 68069
 SSI, Emdeon, Gateway, Availity, Smart Data Solutions
•EFT/ERA through PaySpan Health
 Free Service and fast online enrollment
 Register for Webinars
•Payment Excellence Team (PET)
 Strongly encourages and participates in Claims Testing prior to Go-Live
Confidential and Proprietary
Claims Processing Centers
Farmington, Missouri Claims Center
 Centralized mail room
 Vertexing, OCR validation and data
 High Dollar Review
 Quality Review Team
 Claims Processing Center
 Provider Claims Call Center
Great Falls, Montana Claims Center
 Claims Processing Center
 Kansas claims to be processed here
 Provider Claims Call Center
 Kansas claims calls to be answered
Confidential and Proprietary
PET/Payment Excellence Team
Goals of the Payment Excellence Team
– Ensure claims are received, processed timely and processed correctly for all new markets
– Assist in research of benefits, payment methodology, billing requirements, etc.
– Write all new work processes for claims and answer all claims related questions
immediately after go-live
– Write the health plan’ provider billing manual
– Partner with IT to test all aspects of claims receipt and processing 45 days prior to golive
– Monitor pend volume and aging in efforts to identify ways to avoid pends and increase
auto-adjudication rate
– Partner with provider relations to help resolve key provider issues and provide claims
related education to providers and provider relations staff
– Partner with health plan and Internal Audit to review check run and increase payment
– Manage all claims related issues for a period of 3-6 months post go-live
Confidential and Proprietary
Sunflower State’s relationship with local PPO
• A PPO serving the State of Kansas and surrounding areas
• The only physician owned and operated PPO in Kansas
• Providers in the ProviDRS Care network may participate with Sunflower
by executing a Sunflower/Medicaid addendum to their ProviDRS Care
• Benefits of contracting with Sunflower State Health Plan through ProviDRS Care:
 Simple Sunflower/Medicaid addendum to ProviDRs Care contract in lieu of
review and execution of a full participation agreement
 Since you are already credentialed through ProviDRs Care, there is no
additional credentialing paperwork
Confidential and Proprietary
What to expect prior to January 1, 2013
Sunflower is emphasizing the need to complete contracts by
end of September!!!
•Member enrollment packets (including provider directory information) is targeted
for distribution at the end of October
•Ensure that we have ample time to review your contract packet, complete the
credentialing process, and upload your information into our directory systems
 Signed an LOI? You will still need to complete contracting and credentialing paperwork.
 Behavioral Health Providers already contracted with Cenpatico – addendum process
Next two weeks – Contracts approved and distributed to providers
 Provider Contract
 CAQH Credentialing documents or KS Standardized Credentialing App
 Disclosure of Ownership form (Federal requirement)
Next two months – types of communication from our contracting team
 Personal visits
 Phone calls
 Fax and/or Email
Confidential and Proprietary
Network Subcontractors
Sunflower State Provider Contracting
Vision: To join our vision provider network, OptiCare, email OptiCare at
[email protected] or go to this link: http://www.opticare.com/joinus.aspx
Pharmacy: For contact information or to join US Script’s provider network please visit us at
Behavioral Health: To join our behavioral health provider network, Cenpatico, go to this link:
http://www.cenpatico.com/providers/join-our-network/ or call 800-989-1655
Or you can contact:
Deb Burnham
Network Manager
800.989.1655, ext. 1 office | 785.633.5746 cell
Non Emergency Transportation
Amy Mueller
Manager, Network Operations
Medical Transportation Management, Inc.
Direct: (636) 695-5589
Fax: (800) 459-6224
[email protected]
Confidential and Proprietary
Confidential and Proprietary
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