An Educational Presentation Presented by: Avesis October 2011 Prepared For: Kentucky Eye Medical Providers & Staff

Kentucky Eye Medical Introductions

Kentucky Eye Medical Locations  Executive Offices in Baltimore, MD  Operations located in Phoenix, AZ Phone: (855) Eligibility Claims Member Services  Southeast regional office in Atlanta, GA Phone: (855) Provider Services Prior Approvals

Kentucky Eye Medical Eye Medical & Routine Vision Avesis Medicaid Eye Medical and Routine Vision Plans in Kentucky Providing Eye Medical and Routine Vision Services for Medicaid Members enrolled in:

Kentucky Eye Medical Points of Contact  Nichole Mitchell Director of Government Services (800) x296  Lornetta Gordon Roebuck Provider Services (800) x293  Dana Linton Provider Services (800) x130

Kentucky Eye Medical Avesis Vision Advisory Board  Committee of licensed Kentucky licensed Ophthalmologists and Optometrists  Act in an advisory capacity to WellCare and Avesis in all matters pertaining to the Medicaid Program in Kentucky  Help to ensure quality communications between Kentucky provider community, Avesis and WellCare  Forum for providers to submit recommendations and feedback regarding the program and its administration

Kentucky Eye Medical Eligibility

Kentucky Eye Medical Eligibility  It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month.  Please note that verification of benefits or eligibility is not a guarantee of payment: actual payment is based on the terms and conditions of the plan in force once the claim is received.

Kentucky Eye Medical Eligibility You may obtain eligibility verification four ways: 1.IVR – Please bear in mind that this only provides you with information as to whether or not the Member has coverage with the CMO on the date of service for our Medicaid Members. It does not provide utilization data (whether or not the Member has utilized their benefit) 2.Website – Choose the “coverage slice” that is applicable to the date of service for which you are seeking eligibility. Choose “View Usage” to view the Members utilization history. 3.Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. 4.Fax – You may utilize the form found on the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.

Kentucky Eye Medical Fax Eligibility Verification

Kentucky Eye Medical Benefits

Kentucky Eye Medical Benefits Overview Effective November 1, 2011, Avesis will administer a Full Eye Medical and Routine Vision Program for Members enrolled in WellCare of Kentucky. Coverage will include office visits consisting of routine vision and eye medical diagnosis, medical and surgical services, medically necessary contact lenses, when applicable, and spectacle frames and lens materials required to correct visual acuity.

Kentucky Eye Medical Benefits Overview  Covered Services Covered services will be paid according to the plan fee schedule  Non-Covered Services Non-Covered Services may be the responsibility of the Member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered

Kentucky Eye Medical Benefits Overview  There are two Medicaid programs under WellCare Kentucky: Global Choices Family Choice  Benefits for children (Members ages 20 and under) are the same in each of the plans  Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled. There are NO materials benefits for adults enrolled in either program.

Kentucky Eye Medical The Global Choices Program Global Choices is the benefit plan for most Kentucky Medicaid Members. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).

Kentucky Eye Medical Benefits for Global Choices  Global Choices benefits include but are not limited to: Adults and children limited to 1 eye exam per Member per provider per calendar year Eyewear limited to children under 21 Materials limited to $200 per calendar year. Maximum paid for one pair of glasses is $150.

Kentucky Eye Medical The Family Choices Program Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. Some benefit limits can be increased if the service is medically necessary (requires prior approval).

Kentucky Eye Medical Benefits for Family Choices  Family Choices benefits include but are not limited to: Children limited to 1 eye exam per Member per provider per calendar year Eyewear limited to children under 21 $400 limit per calendar year Maximum paid for one pair of glasses is $150

Kentucky Eye Medical General Benefits  Benefit Exception/EPSDT Process Benefit exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity Benefits are either exhausted or not a covered benefit Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days.  Emergency Services Members seeking emergency services may need to be referred back to WellCare Kentucky for medical benefits

Kentucky Eye Medical Prior Authorization

Kentucky Eye Medical Avesis Prior Approval Requirements  Avesis does not currently require prior authorization for ophthalmological services covered under the Avesis Kentucky Medicaid program.  Facility authorizations must be obtained through WellCare when required. Please contact WellCare Utilization Management Department via fax at (877) 431 – 0950 for further assistance.

Kentucky Eye Medical Claims

Kentucky Eye Medical Claim Submission Claims may be submitted one of three ways:  Through your practice management software using a clearinghouse  The Avesis payer identification number is  On a CMS1500 claim form - please submit to the following address: Avesis Vision Claims PO Box 7777 Phoenix, AZ – 7777  Utilizing our website at

Kentucky Eye Medical Claims Follow-up Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways: You may check claim status on the Avesis website at You may contact our provider services department at (855) to check claim status

Kentucky Eye Medical Corrected Claims Submission If you are missing information (i.e. modifiers, claim lines, etc.) you may refile the claim on the web for payment If you have submitted incorrect information (wrong code, wrong diagnosis, etc) you will need to submit a corrected claim. To submit a corrected claim: Please write corrected claim on the top of the CMS 1500 claim form in blue or black ink. The scanner does not read red ink Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out.

Kentucky Eye Medical Avesis Claims Payment  Check runs weekly (each Friday)  CLEAN CLAIMS processed and adjudicated within 15 business days  Claims submitted one of three ways: Electronically (EMC payer ID# 87098) Manually entered on Paper form  Electronic Funds Transfer available

Kentucky Eye Medical Electronic Funds Transfer Agreement

Kentucky Eye Medical Avesis Web Portal

Kentucky Eye Medical Web Portal

Kentucky Eye Medical Claims

Kentucky Eye Medical Submit HCFA Claim

Kentucky Eye Medical Submit HCFA Claim

Kentucky Eye Medical Medical Records Review

Kentucky Eye Medical Avesis Review Process  Avesis conducts medical record reviews for our provider networks  Your office will be contacted to furnish a list of charts for review  After the visit, your office will be sent a letter regarding the findings of our review

Kentucky Eye Medical Provider Services

Kentucky Eye Medical Services to Providers  Avesis is primary for Provider Services for both our commercial and Medicaid products.  Avesis has toll free phones staffed by experienced and knowledgeable representatives for all of our products  Regional meetings and training sessions scheduled for providers

Kentucky Eye Medical Additional Assistance  Schedule a conference call  Schedule a web demo  Schedule an onsite visit

Kentucky Eye Medical Committed to Technology 24/7 Access to information:  Web Based Eligibility Claims submission Claims status  Interactive Voice Response (IVR) Eligibility Benefits

Kentucky Eye Medical Thank You For Your Time Questions? We at Avesis look forward to working with you and your team.