1. CPAN Guide

2. Services Provided to our Partners
Network Services
Services Provided to our Partners

3. A provider owned network of skilled nursing facilities
Management Services
Services Provided
Contract Facilitation
Case Management
Credentialing
Claims Management
Quality Improvement Programs and Standards
Mycare Ohio Updates and Assistance

4. A provider owned network of skilled nursing facilities
CPAN Contracts
GATEWAY – Medicare Advantage
MULTIPLAN – PPO network
ANTHEM – Facility Specific
PARAMOUNT ADVANTAGE – MEDICARE ADVANTAGE (SPECIFIC REGIONS), MEDICAID HMO
UNITED HEALTH CARE (Corporate Specific)
Aetna Mycare Ohio Plan – Medicare Advantage and Medicaid
HUMANA – Medicare HMO, commercial
Medicare HMO, Commercial and Evercare Community
MEDICAL MUTUAL OF OHIO– Commercial, Medicare HMO
MOLINA – Medicaid HMO, Medicare HMO, Mycare Plan
BUCKEYE – Medicaid HMO, Medicare HMO, Mycare Plan
CARESOURCE – Medicaid HMO, Medicare HMO, Mycare Plan(delegated credentialing)

5. Case Management Initial Pre-cert Authorization
CPAT Program - Hospitals
CPAN facilitates pre-cert for all referrals from our contracts and case management agreements for direct contracts. Our case manager’s will contact the facility directly with the authorization or determination. The authorization will be provided in written form on the initial billing notice that is faxed to the facility after the authorization is provided.
Partners participate in the comprehensive post acute transition program with participating hospital partners throughout the state. The program is designed to reduce the time barriers related to managed care patients discharging from the hospital to the skilled nursing facility. CPAN will communicate the program to our partners in the specific markets

6. Case Management Concurrent Review Discharge Planning
CPAN submits updates to payers on your behalf. CPAN case managers will provide the facility with their next review date and required clinical documents after the initial pre-cert authorization is provided.
CPAN concurrent case managers will be assigned by payor.
Discharge Planning – CPAN case manager will collaborates with partner on appropriate discharge plan according to the payer specific skilled guidelines. The case manager will provide you with guidance on each case.

7. Karla Bess, Credentialing Specialist
CPAN processes all credentialing request for each payer contract that we provide. CPAN has been granted Delegating Credentialing Status with several payers that allows providers to move quickly onto those contracts.
All credentialing documents and application must be completed with the appropriate information to start the process per payer guidelines. The credentialing process varies per payer and may take up to 90 days to get through the review and loaded onto contracts.
The credentialing specialist will mail out effective date letters to each partner as you are loaded onto the contracts. You may contact CPAN’s credentialing department to inquiry about the status of a specific contract.
Submit Re-credentialing Request from payers directly to CPAN:
Karla Bess, Credentialing Specialist
(513) , Extension 1012

8. Kim Reeves, Executive Director of Network Services
Claims Management
CPAN does not process claims on behalf of our partners.
CPAN provides the template for appropriate billing practice per patient/case. Initial and Final Billing Notices are faxed to the facility point person after pre-cert authorization is given and upon patient discharge.
CPAN can make a recommendation to a billing service company if a Partner needs assistance with Mycare Ohio Claims or Billing Processes/Issues
CPAN can assist the facility with claims and billing issues.
To initiate contract from CPAN regarding Claims and Billing Issues, please send EOB/Claims to:
Kim Reeves, Executive Director of Network Services
, ext. 1010

9. Quality Improvement Program
CPAN runs a Quality Performance Program that focuses on minimizes Hospital Readmissions.
CPAN’s Director of Quality Improvement will contact the facility after orientation to set up a training for the appropriate staff members to educate on the QI Program.
The Program has been endorsed by ODA as 1 of their 3 programs providers must participate for licensure requirements.
Please direct all questions or request for training for the Readmission to Hospital QI Program to:
Jen Coyle, Director of QI
(513) , Extension 1015

10. How to submit a referral to CPAN
Pre-cert Process
How to submit a referral to CPAN

11. SUBMIT A PRE-CERT REQUEST
Review the list of Documents on the
Pre-cert Referral Request Form
Submit with all Pre-cert Requests:
Pre-cert Request Form
Clinical Documents Listed
Submit Pre-cert Requests:
FAX NUMBER:
SCANNING IS PREFERRED
CPAN HOURS OF OPERATION:
8AM – 5PM

12. HOW TO COMPLETE A PRECERT
First
Facility Contact person must Complete Insurance Benefit Verification .
This must be done prior to submitting case to CPAN’s Precertification Department
Important: The benefit verification is completed by the facility contact person or someone at the facility. This step is not completed by CPAN.
Second
Fax the following information to the CPAN Case Management as soon as possible or scan to
Date for Admit
Name of admitting facility, contact person and Facility MD to follow.
Discharge plan, short term vs. long term resident & secondary payer
Do not send x-rays, labs etc. unless pertinent to admitting documentation
Notes
Hospital demographic/face sheet
Past 3-4 days of MD Progress notes, if available
PT & OT evaluations & recent therapy progress notes (within the pas 24 hours)
List of current medications & stop dates for any IV antibiotic
Wound Measurements, staging & current treatment & if wound vac is in use

13. Clinical Documentation
PRECERT TRIAGE
PRECERT PROCESS
Clinical Documentation
Submit with CPAN Pre-cert Fax Cover Sheet
CPAN care coordinator will provide a verbal confirmation that your case was received.
SEND PRECERT IN ASAP
Communicate to the hospital d/c planner what a realistic time frame will be. i.e. a case submitted on a Friday afternoon for a Sunday admit will likely not even be reviewed by the payer until Monday.
MANAGE EXPECTATIONS
Cases are prioritized based on the anticipated admit date and second on date/time received
PROCESSSING REFERRALS
Case managers on consistently on the phone with hospitals/payers. Return calls will be based on case calls pending
STATUS UPDATE
One of the largest factors in an untimely pre-cert is based on the lack of appropriate/complete clinical documentation received. The following list of documents require more detail and review prior to submitting the case for pre-cert:
Therapy Evaluation & Notes- Therapy Notes must be dated within 24 hours of the case review by the payer Example: SNF submits case to CPAN on Friday afternoon, the Payer doesn’t review the case until Monday. The therapy notes have to be within 24 hours of Monday, not Friday..
Wound Assessment-Current wound assessment with treatment frequency.
IV Meds.-medication dosage and most importantly the stop date. Confirm they are to continue after discharge.
Hospital Face Sheet
Hospital H & P
Current List of Medications

14. How to submit an Update to CPAN
NEXT REVIEW DATE
How to submit an Update to CPAN

15. CPAN HOURS OF OPERATION:
SUBMIT AN UPDATE
Review the list of Documents on the
NEXT REVIEW DATE FORM
Submit for all Updates:
Payer Specific Form
Discharge Planning Worksheet
Clinical documents requested
Submit updates to:
FAX NUMBER:
SCANNING IS PREFERRED
CPAN HOURS OF OPERATION:
8AM – 5PM

16. Next Review Date DOCUMENTATION REQUESTED:
Narrative Nurse’s Notes - (last 7 days), MAR’s, TAR’s
Therapy Notes updated on specific Insurance form – recent within 24 hours
Levels of care
Change of condition
Minute Logs - essential for Medicaid-substantiate level of payment or per diems.
Patient Education
Discharge Plan

17. Next Review Date
CPAN provides the SNF with their next review date after the pre-cert authorization is obtained.
This information is faxed to your SNF CPAN Point Person and should be distributed to the appropriate person(s).
The packet will include the following information you will need for your NRD:
Next Review Date
Discharge Planning Worksheet
Payer specific form that must be completed
Timeliness-review needs to be done on required date or potential payment issues.
No physician order sheets

18. Hip Fracture (Open Repair) – 16-28 Days
Arthroplasty
7 – 11 Days
Total Knee Replacement – 6 – 9 Days
Community Acquired Pneumonia 8 – 14 Days
CHF Exacerbation
9 – 16 Days
COPD Exacerbation 7 – 14 Days
CVA
8 – 21 days
Cellulitis
8 – 15 Days
Chronic Renal Failure
10 – 17 Days
Chronic Renal Failure – 10 – 17 Days
Length of Stay Guide
Use this as a guide to help you determine the estimated length of stay for your residents.
This is the guideline that all payers are using when determining the length of stay.

19. INITIAL DISCHARGE ASSESSMENT
Where is the resident planning to discharge to?
What are the barriers if any may there be to discharging to that next environment?
What could be an acceptable alternate discharge plan if barriers exist?
Are the resident’s goals realistic?
What support systems are available to the resident at discharge?
Is the resident making their own decisions or is there a guardian / POA?

20. Claims

21. CLAIMS/BILLING
CPAN does not provide billing services to our partners. We provide billing templates that provide the provider with information to format claims.
Initial Billing Notice - faxed to your facility after a case has been processed for pre-cert authorization
Final Billing Notice – faxed to your facility after the resident discharges.
CareSource – Caresource is the only payer that requires you to submit your claims with CPAN’S Tax ID. CPAN will provide this information on each billing notice for CareSource cases submitted through CPAN

22. CLAIMS/BILLING SUPPORT
When Claim does not pay or pays wrong:
1st: Call MCO’s customer service to find out problem and see if it can be fixed. Get specifics.
Be aware of timely filling issues.
Appeal claim if necessary
Utilize MCO’s websites
What Can CPAN do for you:
Resolve Rate Issues
Resolve authorization issues: number or length of stay
Change in level problems
Get claim processed at Provider Relations level.
Who to contact in CPAN about billing issues:
Send claim/billing issues to:
A CPAN representative will follow up once a status update has been obtained from the payer.