2018 IHCP Annual Workshop MDwise Claims HHW-HIPP0581 (9/18)

Agenda MDwise History Updates Contracting Eligibility Claim Submission Disputes Refunds Prior Authorization (PA) Resources Questions

2007: MDwise selected to provide care through the Healthy Indiana Plan MDwise History 1994: MDwise founded as Indiana-based nonprofit health care company Central Indiana Managed Care Organization, Inc. (CIMCO), utilizing a delivery system model 2001: CIMCO teamed up with IU Health Plan and formed into MDwise, Inc., serving more than 55,000 Hoosier Healthwise members. 2007: MDwise begins service Care Select (now Hoosier Care Connect) members 2007: MDwise selected to provide care through the Healthy Indiana Plan 2018: MDwise acquired by Michigan-based McLaren Health Care; one of Michigan’s largest integrated health systems MDwise’s history began back in 1994 when we were founded as CIMCO. From 2001 to 2014, MDwise offered medical coverage to Indiana residents through the Hoosier Healthwise, Hoosier Care Connect, formerly Care Select, HIP and Marketplace programs. Our focus shifted over the last couple of years from all 4 medical programs to just Hoosier Healthwise and HIP. And in 2017, MDwise was purchased by McLaren Health Care, a Michigan-based health system with a significant health plan operation across the state of Michigan.

Who Is McLaren Health Care? Is one of the largest integrated health care systems in Michigan Owns 15 hospitals, including Barbara Ann Karmanos, nationally renowned for their cancer care and outcomes Employs over 500 physicians Trains over 550 residents annually Has a workforce of over 20,000 Owns McLaren Health Plan, who covers over 265,000 members in Medicaid, commercial, and Medicare Supplemental markets.

MDwise – McLaren Synergies Sharing Best Practices between MDwise and McLaren Health Plan, such as: Care Management Opioid Crisis Management Effectively managing inappropriate ER utilization Streamlining Prior Authorizations Pay for Value Physician Incentive programs Claims adjudication Results are Demonstrating: Improvement in health care outcomes for our members Enhanced access for members Greater administrative efficiencies, which allow more health care dollars to be spent on the actual delivery of medical care

Updates Effective 1/1/19: MDwise is restructuring it’s Delivery System model to: Improve claim payment timeliness and accuracy Streamline and reduce administrative redundancy for providers Provide greater access for our members One standard authorization list One point of contact for all authorization requests One claim submission address Non-Excel Delivery System contracts Providers not contracted with MDwise Excel must contract to stay in network. Effective January 1, 2019, MDwise will begin operating as a single network, MDwise Excel. This will show when checking eligibility in the MDwise Portal as well as the state systems. Along with this change, MDwise delivery system contracts will expire December 31, 2018. If you are not currently contracted as a MDwise Excel provider and want to be able to see MDwise members, you will need to contract as a MDwise excel provider. Please reach out to your dedicate provider representative to begin this process. Also changing will be out claims processing, our prior authorization process and requirements, and our MDwise portal access. All of these items are covered in this presentation, so lets get started!

Contracting Effective 1/1/19: Providers not contracted with MDwise Excel must contract to stay in network.

Provider Relations Forms Contracting Provider Relations Forms http://www.MDwise.org/for-providers/forms/provider-enrollment Credentialing/Enrollment MCE Enrollment Form Enrollment Cover Sheet (until 12/31/18) Provider Update Form Disenroll/Re-enroll Panel Move Non-Contracted Set-Up Form Required for non-contracted providers Contract Inquiry Form Submit Forms to: prenrollment@mdwise.org Our final department to review is Provider Relations. Recently the Provider Relations and Quality departments merged. If you are in charge of quality or billing, you will now be working through one representative. Non-contracted provider form is required to verify that the provider is set up correctly in the provider portal.

Effective 1/1/19: Eligibility When determining eligibility, verify: Is the member eligible for services today? Which Indiana Health Coverage Program plan are they enrolled? If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise? Who is the member’s Primary Medical Provider (PMP)? Beginning in January, you will be able to utilize the state website for the members Program and MCE. The assigned network or delivery system will always be MDwise Excel. To verify a PMP, you will use the MDwise provider portal, as you do now. Provider Healthcare Portal MDwise Provider Portal IHCP Program Delivery System: MDwise Excel MCE Assigned PMP History Assigned PMP

Hoosier Healthwise & Healthy Indiana Plan Claim Submission Effective 1/1/19: Claim Submission is date of service driven. Electronic Submission Please note: Paper claims must be on red/white form with black ink. Hoosier Healthwise & Healthy Indiana Plan MDwise P.O. Box 1575 Flint, MI 48501 Effective January 1st, we will go to one claim submission address and Payer ID per program, as shown here. Please remember this is date of service driven. Claims with date of service 12/31/18 being submitted after January 1st will still need to be sent to the correct delivery system and program, as shown on the previous page. Again, for this updated claim submission information, go to MDwise.org and click on Provider contact information. Hoosier Healthwise Healthy Indiana Plan Payer ID: 3519M Payer ID: 3135M

Claim Submission Claim Timelines: Claim Submission: Primary: 90 days from the date of service Secondary: 90 days from the date of the explanation of benefits (EOB) Effective 1/1/19, non-contracted providers will have 180 days for claim submission.* MDwise Adjudication: (clean claims) Electronic Claims: 21 days Paper Claims: 30 days Claim Disputes: 60 days from the date of the explanation of benefits (EOB) Dispute Response: 30 business days from date of submission *Reference BT201829 for more information Claim submission timelines and response times are not changing in the new year. Primary claims are still due 90 days from the date of service, secondary 90 days from the date of the primary EOP. Due to state changes announced in bulletin BT201829, providers who are not contracted with MDwise Excel will have 180 days to file claims. MDwise will adjudicate all clean claims within 21 days for electronic submission, and 30 days for paper submission. If you receive a claim denial that you would like to dispute, the dispute is due within 60 days of the date of the EOB. MDwise will respond back within 30 business days with an outcome. If you would like to inquire about a claim in process, you can do so at any time. A response will be made to you within 30 business days of your submission. We do ask that you allow the full 21 or 30 days adjudication time before submitting an inquiry, to allow adequate time for the claim to be reviewed. Moving on from claims….

Secondary Insurance Submissions Claim Submission Secondary Insurance Submissions When the member has other insurance: Provider must submit claims to the other insurance carrier prior submitting to MDwise Submitting a secondary claim to MDwise Must be submitted within 90 days of the date on the EOB Claims submitted via paper must include a copy of the EOB Be sure to verify member eligibility for the date of service Effective 1/1/19: Secondary claims will be accepted via electronic submission.

Claim Submissions CMS 1500 Form MDwise follows National Uniform Claim Committee (NUCC) guidelines. Box 19 should contain typed notes Claims system is not able to pick up other writing *Box 22: Corrected or Replacement claims -*Required Box 23: Prior Authorization If you have an authorization number, please include it.

Claim Submission UB-04 Form MDwise follows National Uniform Billing Committee (NUBC) guidelines Box 80: Notes Box 4: Bill Type Include correct frequency for submission and resubmission

Claim Refund Process changing: Refunds Effective 9/15/18 Claim Refund Process changing: Provider Refund Form required along with supporting documentation Send to: MDwise, Inc. P.O. Box 441423 Indianapolis, IN 46244-1423 Refund form can be submitted without a check if you wish your claim to be offset from future payments. https://www.mdwise.org/for-providers/forms/claims

Refunds Requirements: One TIN/NPI per form and check

How do you know if you received a denial or a rejection? Disputes How do you know if you received a denial or a rejection?

Denied claims will include an EOB with a denial code. Disputes Denied claims will include an EOB with a denial code. Rejected claims are different than denied claims: Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system. Since rejected claims are not registered in the claims processing system, the provider must resubmit the claim within the claims timely filing limit. Rejected claims do not extend the timely filing limit. Contracted providers have 90 days from the date of service

Claim Dispute Process: Disputes Claim Dispute Process: Provider completes the Claims Dispute Form found at www.mdwise.org on the For Providers page, under Claim Forms. Completed form and supporting documents are sent via email: cdticket@mdwise.org Received email is routed to a Claims Dispute work queue where a ticket number will be issued and an email notification will be sent back immediately. The Claim Dispute team will review the submitted dispute and work the cases to resolution (uphold or overturn). An email notification will then be sent to the provider, referencing the dispute and ticket number, on the resolution determination.

Informal Claim Dispute Disputes Informal Claim Dispute Provider disagrees in writing with how the claim was adjudicated: Must be commenced within 60 days from the date on the Explanation of Payment (EOP) MDwise will reach a resolution and notify provider within 30 calendar days. Formal Claim Dispute Provider disagrees with 1st level resolution: Provider has 60 days from the date of the 1st level resolution MDwise will compose a panel of persons not involved with the 1st level dispute to review the 2nd level dispute. MDwise will reach a resolution and notify provider within 45 calendar days. The panel’s decision is MDwise’s final action on the claim.

Effective 1/1/19 Prior Authorization One standard authorization list One point of contact for all authorization requests Submission timelines and process will not change Go to MDwise.org for most up-to-date version of PA lists MDwise.org For Providers Forms Prior Authorization Effective January 1st, our PA guides will update. There will be one PA list per program. The PA lists will still be housed on the Prior Authorization page. The current 2017 and prior PA lists will remain on this page to allow for review after the new year. Be sure you are reviewing the correct PA guides in the new year.

Prior Authorization You will need two key items when filing a request for Medical Prior Authorization (PA): Universal Prior Authorization Form Located on our website Documentation to support the medical necessity for the service you are requesting to prior authorize: Lab work Medical records/physician notes Test results Therapy notes Tips: Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number. Be sure to note if PA is for a retroactive member. Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe. When submitting a prior authorization, always be sure your form is completely filled out and required documentation in included. IF a form is incomplete or documentation is missing, your request will be returned to you and your review timeframe will start over. Also, if you are requesting a PA for a retro active member, be sure to note this in the notes section of the form.

Prior Authorization Turn-Around Time All emergency inpatient admissions require authorization within 2 business days of the admission. Urgent prior authorizations can take up to 3 business days Requests for non-urgent prior authorization will be resolved within 7 calendar days. It is important to note that resolved could mean a decision to pend for additional information. If you have not heard response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue. PA Inquiry Line 1-888-961-3100 Turn around time for authorizations depends on the urgency of the request. Emergency requests must have a PA requested within 2 business days of the date of service; urgent requests will have an outcome within 3 business days, and a non-urgent request will have a decision made within 7 business days. If you have an inquiry on a current PA, please regerence the PA quick contact guide on our website.

Resources 1 2 5 3 4 9 If you have questions on these forms or on the contracting process for MDwise Excel, be sure to contact your dedicated Provider Relations representative for your region, as shown here. 6 8 7

Resources Representative Territory Phone Email Paulette Means Region 1 317-822-7490 pmeans@mdwise.org Garrett Walker Region 2 317-983-6088 gwalker@mdwise.org Michelle Phillips Region 3, Hospice, Home Health 317-983-7819 mphillips@mdwise.org Jamaal Wade Region 4 317-822-7276 jwade@mdwise.org David Hoover Region 5 317-983-7823 dhoover@mdwise.org Tonya Trout Region 6 317-308-7329 ttrout@mdwise.org Rebecca Church Region 7 317-308-7371 rchurch@mdwise.org Sean O’Brien Region 8 317-308-7344 sobrien@mdwise.org Whitney Burnes Region 9 317-308-7345 wburnes@mdwise.org Nichole Young Behavioral Health (CMHC, OTP, IMD or Residential) 317-822-7509 nyoung@mdwise.org Michelle Phillips, our dedicate Home Health and Hospice rep is now covering region 3 as well. If you are a DME provider, please reach out to the Representative in you respective region. Also, territory reps are now covering ABA providers as well. For behavioral health, Nichole young covers CMHC’s, OTP’s, IMD’s and residential providers. All other BH providers should contact their territory reps.

MDwise Provider Tip Sheets Resources MDwise Provider Tip Sheets http://www.mdwise.org/for-providers/tools-and-resources/additional- resources/tip-sheets/ MDwise Provider Manuals http://www.mdwise.org/for-providers/manual-and-overview/ MDwise Provider Relations Territory Map http://www.mdwise.org/for-providers/contact-information/ MDwise Customer Service 1.800.356.1204 IHCP Provider Modules Indianamedicaid.com

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