2/28/2012):
Provider Orientation
Welcome!
Learning Objectives
• Today you will learn:
- Who CareCentrix is and how to work with us
- Referral Process
• Managed vs non-managed plans
• Understanding the Service Authorization Form (SAF)
- Provider Portal
• How to submit initial authorizations, reauthorizations and add on
services
• How to check authorization status
• How to check claim status
- Billing & Claims
• Claim submission
• Claims Reconsideration & Appeals
- Contact Information and Feedback
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Home Care Benefits Management Process – “The Platform”
Program Components
1
Single Point-of-Contact
to Coordinate HomeBased Services
Workflow
Physicians &
Providers
Hospital
Discharge
Planners
Case Managers

2
Referral Management
3
Network
Management
• Eligibility, Benefits & Authorization
• Medical Necessity Review

• Coordination of Care / Staffing
Home Health
DME/POS

4
Claims & Billing
Infusion
Healthplan
Consolidated
Claims
Claims Billing
Medical Economics
Reporting
& Analysis
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Referral Process
Making a Referral: Service Specific Tips
THH – Home Health
DME/O&P
Infusion
N/A
N/A
Plan Dependent
Plan Dependent
Plan Dependent
If changed, contact CCX.
If changed, contact CCX.
If changed, contact CCX.
Changes must be approved by referring
physician
Changes must be approved by
referring physician
Changes must be approved by referring
physician
Patient Homebound?
Initial Auth Mandatory?**
Re-authorization
Start of Care (SOC)
Other
Lab tests must be taken to
the lab specified by the
patient’s plan
Oxygen
•Liter flow
•O2 saturation w/ date
Provide height, weight,
allergies, type of venous
access and date/time of
next dose
Routine supplies are
included in the cost of visit
CPAP
•Sleep study or letter of
medical necessity
•MD order required for
upgraded unit
Infusion providers must
accept case “full-service”
meaning drug, skilled
nursing and supplies (per
diem)
Notify CCX immediately of
additional supply needs
-Authorization for
additional supplies can be
obtained through CCX
** Except for Magnolia Health Plan: DME items < $500 require no authorization
General Auth Guidelines
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Referral Process
Making a Referral: “Managed”
vs “Non-Managed” Plans
Managed (PHS+)
Non-Managed (PHS)
Service Auth Form (SAF)
Indicates # of units
authorized
CCX will issue a “footprint”
authorization; SAF will indicate “0” visits
and the same “Start Date” and “Stop
Date”
Re-authorization
& Add-on Services
Submit to CCX via portal
Not Required
-The auth number assigned during the
initial referral process will be used
Eligibility & Benefits
CCX checks initial and
ongoing
Provider Responsible
-Health Plan’s phone number for
verifying eligibility and benefits will be
included on the SAF
Other
Provider is responsible for verifying
insurance plan’s authorization
requirements
Managed Authorization
From
Example and Definition:
Servicing
branch
HCPC/Modifier combination
that must be used on claim
Date of service
must fall between
above dates
Managed CareCentrix referrals - You
should come back to the designated
Regional Care Center for re-authorization
(submit re-authorizations via the online
provider portal) or add-on services
unless defined otherwise. When
submitting a request for re-authorization
or an add-on service it is important to
provide the clinical justification for the
request.
If additional visits are needed provider
must submit reauthorization request
via online portal.
All paper claims must be
sent to CareCentrix East
Hartford CT but EDI is
preferred!
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Non-managed
Authorization Form
Non-managed CareCentrix
referrals - You do not have to
come back to the Regional
Care Center for reauthorization or add-on
services in which you are
contracted with CareCentrix
to provide. However, you are
expected to manage to the
patient's benefits and
authorization requirements as
stipulated by the insurance
carrier. This would include
ongoing re-verification of
eligibility and benefits.
Branch managed plans
have the same start and
stop date.
Branch managed plans
have “0” units
authorized.
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Sample Fax Coversheet
Identifies in-network
supply provider for nonroutine supplies.
Notifies you if PTA and
OTA are allowed by
member’s health plan
Make sure to use lab
of choice to
maximize member’s
benefits.
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Portal Training: www.carecentrixportal.com
•
•
The CareCentrix portal is the way of
submitting authorization and re-authorization
requests to CareCentrix
- And we’ll show you how to do that now
But the portal is much more than just a way
to request an auth!
-
View latest news & important announcements!
•
Check the portal often to stay on top of the latest
developments
- Submit initial and re-auth requests
• 24 x 7 x 365!
• No waiting on the phone!
• Faster auth turn-around time!
•
- Check claim status
- Check authorization status
- Manage HomeSTAR patients
Please visit: www.carecentrixportal.com
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Billing & Claims
Billing and Claims Submission
•
Format
•
Timely filing
•
*Claims must include the following*:
•
Current billing cross walk can be found at www.carecentrixportal.com
-
-
-
•
Electronic Claims submission is the preferred format (CMS 1500 forms only at present)
Paper claims may be submitted on CMS 1500, UB-04
Claims must be original, without erasures, strikeovers, or stickers
45 days from time service was rendered
Or, as determined by State law
Description of the service
ICD9 Code
Taxonomy number
NPI number
HCPC Code & Modifier as shown on your Service Authorization Form (SAF)
Find the CareCentrix service code and UOM (unit of measure) on your Service Authorization Form (SAF) and match to the
above crosswalk to determine the correct HCPC/Modifier combination you must bill.
Coordination of Benefits (COB)
-
Please click the PDF to the right for an overview of COB
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Billing & Claims
Claims: Corrections & Appeals
• Is your payment not what you expected? Please follow our
process for corrections and appeals:
Self-diagnose the
Problem
Submit a Claim
Reconsideration
Form
Appeals
•Verify that you billed the correct HCPC/Modifier combination found on your SAF, or using the
billing crosswalk
•Ensure you have included all required clean-claim data elements
-For a complete list, please refer to www.carecentrixportal.com and download our
Provider Manual or view the “Claims” section of the website
•Complete a Claim Reconsideration form and send to CareCentrix (see Provider Manual)
•Or call: 877-725-6525
•Claim reconsideration forms must be received within 45 days of date on EOP or as
required by law if longer
•If reconsideration is not received within 45 days, your request can be denied for untimely
filing of a reconsideration
•Click PDF (at right) for a copy of the form, or go to www.carecentrixportal.com
•If the payment issue is resolved in your favor, the payment will be adjusted and an
explanation of payment issued
•If payment issue cannot be resolved in your favor, you may send a claim appeal to our Appeals
Unit (see Provider Manual)
•A copy of the claim in question must be included with the CareCentrix Appeal Form
•Appeal must be received within 30 calendar days from the date we orally advised you or the
date of our communication indicating that your request for reconsideration was not be
resolved in your favor (or as otherwise mandated by state or federal law)
•Appeals received without a copy of the claim in question will be mailed back to the submitter
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CareCentrix Contacts
CareCentrix Contact Information: Know Where to Go
Register for Portal & EDI
Register for the Provider Portal
www.carecentrixportal.com
Register for EDI (electronic claims submission)
Support
Portal Support
EDI Support
Portalinfo@carecentrix.com
EDISupport@carecentrix.com
Authorizations
Initial Authorization Requests
Authorization Status
Re-authorization Requests
Add-on Services
www.carecentrixportal.com
Authorization Contact Numbers
Claims
Claim Questions
Claim Status
Appeal Status
Provider Resolution Team
www.carecentrixportal.com
877-725-6525
Contract/Network Management
See Provider Manual
www.carecentrixportal.com
Patient Financial Responsibility
Patient Services Team
800-808-1902
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Contact Information
• Network Manager
- Name
- Phone
- Email
• Network Coordinator
- Name
- Phone
- Email
• We welcome your feedback!
- Please take a moment to answer 6 quick questions and provide us your
confidential and anonymous feedback on today’s orientation
- Click: http://www.surveymonkey.com/s/8SL8MLD
Thank you for choosing to participate in the CareCentrix provider network. We
value the quality care you bring our patients, and will work hard to ensure that
your experience with us delights you.
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