1. MAPAM Payer Conference 5/17/18
BMCHP

2. Agenda
BMCHP overview
Plan programs in 2018
Member ID review
Eligibility Verification
Authorizations
Claims
BMCHP Clinical Vendors
ACO Plans
Provider Network
Community Partner Program
Questions
ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are rewarded for value – improving total cost of care and outcomes – not volume
The primary focus is on improving patient outcomes by:
Promoting healthy behaviors
Expanding population health management programs, and
Improving data exchange between payers and providers

3. Service Members via 4 Programs in MA and NH
Who we are
BMCHP is a non-profit managed care organization committed to providing the highest quality healthcare coverage to underserved populations.
Service Members via 4 Programs in MA and NH 
MassHealth
NH Medicaid (under the trade name Well Sense Health Plan)
MA Qualified Health Plan
MA Senior Care Options*
*( Available in Barnstable, Bristol, Hamden Plymouth & Suffolk County)
ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are rewarded for value – improving total cost of care and outcomes – not volume
The primary focus is on improving patient outcomes by:
Promoting healthy behaviors
Expanding population health management programs, and
Improving data exchange between payers and providers

4. BMCHP MassHealth Plans include:
BMCHP MassHealth MCO – Primary Care within the BMCHP MCO Network.
BMCHP Community Alliance ACO – Primary Care within the BMCHP Community Alliance ACO Network.
BMCHP Mercy Alliance ACO – Primary Care within the BMCHP Mercy Alliance ACO Network.
BMCHP Signature Alliance ACO – Primary Care within the BMCHP Signature Alliance ACO Network.
BMCHP Southcoast Alliance ACO – Primary Care within the BMCHP Southcoast Alliance ACO.
BMCHP’s full network of MassHealth contracted facilities, specialists and ancillary services is available for all above Plans

5. Additional BMCHP Plans include:
ConnectorCare – BMCHP’s full network of ConnectorCare contracted facilities, primary care, specialists and ancillary services is available.
Qualified Health Plans - BMCHP’s full network of Qualified Health Plan contracted facilities, primary care, specialists and ancillary services is available.
Senior Care Options - BMCHP’s full network of Senior Care Options contracted facilities, primary care, specialists and ancillary services is available.

6. Member ID Card - MH MCO
Member ID Cards begin with a “B” for MassHealth MCO Plan
Products include:
MassHealth Standard (Including Special Kids Special Care)
Family Assistance
CarePlus

7. Member ID Card - MH ACO
Member ID Cards begin with a number for MassHealth ACO Plans
PCP Site logo will be included in the upper right corner
Products include:
MassHealth Standard
Family Assistance
CarePlus

8. Member ID Card – MH ACO continued
ACO Member ID’s will have new number sequencing according to the ACO they are assigned to, as shown below:
ACO
Prefix
ID Numbering Scheme (note: the 00 is the suffix for all Subscribers and will be on the ID Card)
COMMUNITY ALLIANCE 2
2#########00   
MERCY ALLIANCE 3
3#########00
SIGNATURE ALLIANCE 4
4#########00
SOUTHCOAST ALLIANCE 5
5#########00

9. Member ID Card - ConnectorCare
Member ID Cards begin with a “C” for ConnectorCare Plan
Products include:
ConnectorCare Plan Type I
ConnectorCare Plan Type II
ConnectorCare Plan Type III

10. Member ID Card – QHP Silver
Member ID Cards begin with a “C” for Qualified Health Plan Silver
Products include:
QHP Silver A
QHP Silver A II
QHP Silver B
QHP Silver B II

11. Member ID Card – QHP Metallic
Member ID Cards begin with a “C” for our Qualified Health Plan members
Products include:
QHP Bronze
QHP Gold
QHP Platinum

12. Member ID Card - SCO
ID Cards begin with the number “1” for our Senior Care Options members
Products include:
Members with MassHealth Standard only
HMO-SNP for members also enrolled with Medicare A and B, dually eligible

13. Member Eligibility
Please check Member eligibility on the date of service - before delivering services and daily for inpatient admissions
For ConnectorCare/QHP Members you are not able to verify eligibility via EVS, you must verify eligibility with the QHP Plans directly.
MH (including CarePlus):
MASSEVS: Recipient Eligibility Verification System (most accurate method of verification for MH members)
BMC HealthNet Plan: Secure Provider Portal: or
ConnectorCare/QHP:
BMC HealthNet Plan: (most accurate method of verification for ConnectorCare/QHP members)
Secure Provider Portal: or
Senior Care Options:
BMC HealthNet Plan: Secure Provider Portal: or
Note: eligibility for SCO members changes on the first of the month, however we still recommend that you verify eligibility prior to the date of service. Member panel reports are not an accurate method for verifying eligibility. These reports are only intended to inform you of the member’s assigned to your panel.

15. Find a Doctor, Hospital, or Pharmacy 
Make sure to select the right plan type when searching doctors and hospitals to see a list of available doctors for that plan. Not sure which plan type you have? Check your Member ID card or contact the Member Services Department.

16. What services need referrals (if any) and/or Prior Authorization?
BMCHP does not require referrals. We do, however, have Prior Authorization requirements for select services which are outlined in the Prior Authorization (PA) Matrix and the PA look up tools at:

17. Services Requiring Prior Authorization
Prior Authorization is required for the following services:
Inpatient care (non-emergent)
Select outpatient procedures
High end outpatient radiology
Home Health care
Durable medical equipment, prosthetics, orthotics and supplies
Physical, occupational and speech therapy (outpatient)
Genetic testing
Transplants
Select Behavioral health services
All non-emergent out of network services

19. Claims and Filing Limits
To expedite payment, we strongly encourage you to submit claims electronically and only submit paper claims when necessary
Filing Limits:
MassHealth (including Care Plus) days
ConnectorCare/QHP days
Senior Care Options days
*Coordination of Benefits and other party liability rules apply
Electronic Claims:
Emdeon, Caprio, Gateway EDI, Allscripts / Payerpath Payer ID: 13337
Relay Health: Professional Claims Payer ID: 3818
Relay Health: Facility Claims Payer ID: 2921
The SSI Group Payer ID: 0515
Submit online via BMCHP Secure Provider Portal
Paper Claims Mailing Address: Boston Medical Center HealthNet Plan
P.O. Box 55282
Boston, MA

20. HealthTrio
Remember to use HealthTrio Connect, our online provider portal - your first and primary tool for working with BMC HealthNet Plan
Once you are set up with your secure login and password, you’ll have access to the following functions and more:
Verifying member eligibility
Viewing claims status with enhanced detail information, including claims that are pending adjudication
Submitting claims
Submitting online prior authorization requests
Viewing the status of authorization requests submitted by fax, phone, online or postal mail
Downloading useful reports such as PCP Panel, Quality Reports (EPSDT, Diabetes & Asthma Treatment reports) Daily Inpatient Census, ER Frequent Users, and many others

21. Who are the Plan’s Clinical Vendors?
Beacon Health Strategies
Behavioral Health
Available 24/7 for members and providers.
Manages inpatient and outpatient behavioral health and substance use services, and will be contracting on behalf of the ACO for BH Community Partner services.
Prior authorization may be required for certain services.
Northwood
Durable Medical Equipment, Prosthetics, and Orthotics
Manages durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) network.      
Prior authorization is required for all DMEPOS dispensed and billed by a DMEPOS supplier. 
EnvisionRx Options
Pharmacy Benefits
Prior authorization may be required for certain medications.
eviCore
High End Radiology
Manages outpatient non-emergency high end radiology  (MRI, CT, PET, Nuclear Cardiology)
AxisPoint Health
Nurse Advice Line
Available 24/7 for members
An audio health library of recorded information, by topic, can be accessed through the advice line

22. What are the benefits and protections for members who are being shifted to the new ACO model?
The core covered benefits will be the same for both ACO and MCO members. There may, however, be additional services or programs offered by each ACO. ACO members have the same protections and rights under the ACO program as they currently have under the MCO Program.

23. Billing, Eligibility Verification and Prior Authorization for ACO
There are no changes to the way you will bill for the services rendered to members enrolled in our ACO model
BMCHP will continue to use the same eligibility verification system.
We also have not changed any respective prior authorization requirements or processes at this time.

24. Where will ACO Members receive care?
Members will have a PCP in the ACO and must use that PCP for all primary care. Primary Care providers may only enroll in one ACO.
The PCP will make efforts to direct members to specialists and other providers within the ACO or with whom there is an established relationship.
However, members may go to any contracted specialist/other provider within the BMCHP network – subject to the specialist/provider obtaining a prior authorization for the service, if applicable.

25. ACOs and MCOs will contract with Community Partners for the purposes of integrated care delivery
Create opportunity for ACOs and MCOs to leverage the expertise and capabilities of existing community-based organizations serving populations with BH and LTSS needs
BH CPs will provide comprehensive care management including outreach & engagement, assessment, medication reconciliation, care transitions, health & wellness coaching as well as connections to social services and community resources
LTSS CPs will provide LTSS care coordination including outreach & engagement, care planning, care transitions, health & wellness coaching as well as connections to social services and community resources

26. Questions? Thank you! Provider Relations