1. 2018 IHCP Annual Workshop
MDwise 101
HHW-HIPP0579 (9/18)

2. Prior Authorization (PA) Claims Member Management
Agenda
MDwise History
Updates
Eligibility
Prior Authorization (PA)
Claims
Member Management
Provider Relations & Quality
Resources
Questions
We will go over the history of MDwise and an introduction to McLaren Health Care, some delivery system updates, our eligibility and PA processes, filing claims, how you can benefit from our Quality program, managing your members, our provider relations department and representatives, and close out with some useful resources and a time for questions.

3. 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.

4. 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.

5. 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

6. Updates
Effective 1/1/19:
MDwise is restructuring its 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, 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!

7. 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

8. 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.

9. 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.

10. 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
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.

11. Appeals Prior Authorization
Providers can request a prior authorization appeal on behalf of a member within 33 calendar days of receiving denial.
Providers must request an authorization appeal in writing to MDwise:
MDwise Customer Service Department
PO Box
Indianapolis, IN
MDwise will resolve an appeal within 20 business days and notify the provider and member in writing of the appeal decision including the next steps.
If you do not agree with the appeal decision, additional appeal procedure options are available.
If you receive an outcome to your PA that you disagree with, you are welcome to file a written appeal within 33 calendar days of receiving the denial. MDwise will resolve the appeal within 20 business days and notify you of the outcome and next steps. The appeal address is listed on this slide as well as in the PA quick contact guide.

12. Pharmacy Prior Authorizations
For all requests and questions regarding Pharmacy PA, contact the Pharmacy Benefit Manager.
MedImpact:
Pharmacy Resources:
Pharmacy authorizations are submitted to the Pharmacy Benefit Manager, or PBM, based on the members program. Please contact the appropriate PBM with pharmacy PA questions.
Next we will go over MDwise claims.

13. Hoosier Healthwise & Healthy Indiana Plan
Claims
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/McLaren Health Plans
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

14. Claims 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 BT 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….

15. Care Management Member Management
MDwise identifies care management as an integral part of medical management.
Care management involves the development and implementation of a coordinated, member-focused plan of care that meets the member’s needs and promotes optimal outcomes.
Care management objectives include:
Developing and facilitating interventions that coordinate care across the continuum of health care services
Decreasing fragmentation or duplication of services
Promoting access or utilization of appropriate resources
Next up is Member management in regards to Care and disease management. The MDwise care management team is dedicated to assisting members who may need additional attention to their healthcare. This includes facilitating contact with the member and providers, educating members on their covered benefits, and directing them toward appropriate utilization.

16. The Care Management process includes:
Member Management
The Care Management process includes:
Identification and evaluation of member’s needs
Review of clinical information
Development of goals and treatment plans including behavioral and physical health
On-going communication with the member or member’s family/caregivers
Monitoring progress and adjusting care plans accordingly
Transitioning the member through levels of case management when appropriate (i.e. goals and needs met, member coverage terminated)
(Review Slide)

17. Member Management
Please note: You will need to log in to the MDwise Provider Portal to access this form
If you know a member who could benefit from the assistance of a care manager, we ask that you complete the electronic Care Management Referral Form located on the MDwise Portal. This form can also be used for members with chronic diseases. They will be assisted by our disease management team.

18. Disease Management Member Management
MDwise members are offered disease management programs that address the following conditions in which patient self-care efforts and empowerment are significant:
Diabetes
Attention-Deficit Hyperactivity Disorder (ADHD)
Coronary artery disease (CAD)
Pervasive developmental disorder (PDD)
Chronic obstructive pulmonary disease (COPD)
Pregnancy
Asthma
Post Traumatic Stress Disorder (PTSD)
Congestive heart failure (CHF)
Chronic kidney disease (CKD)
Hypertension
Depression
The disease management department is dedicated to assisting members with specific health issues, like those listed here. Disease managers can assist in seeking medical treatment, speaking with a specialist and educating the member on living life with a chronic condition.

19. Member Management
Disease Management
Members are encouraged to actively participate in the management of their condition through disease education, self- management tools, and access to healthcare professionals.
There are several avenues by which members may be identified and referred to care managers to be evaluated for implementation of case management:
Contacting the Care Management department
Completing the electronic CM/DM Referral Form located on the MDwise Portal
(Read slide)

20. Right Choices Program (RCP)
Member Management
Right Choices Program (RCP)
The Right Choices (RCP) program was created to safeguard against unnecessary or inappropriate use of Medicaid services by identifying members who use Indiana Health Coverage Programs (IHCP) services more extensively than their peers.
MDwise considers multiple factors in enrolling a member into this program. They include, but are not limited to:
ER utilization
Pharmacy utilization
Member compliance
Outcomes of member interventions
Referrals from providers
Our care managers also work directly with members in the right choices program. This program was created to safeguard against unnecessary or inappropriate use of Medicaid services by identifying members who use IHCP services more extensively than their peers. This is determined based on claim submission or provider referral.

21. Right Choices Program (RCP)
Member Management
Right Choices Program (RCP)
The Right Choices Program is available for Hoosier Healthwise and Healthy Indiana Plan members.
MDwise members are considered candidates for restriction if they continue to misuse benefits despite efforts on the part of MDwise and its provider(s) to educate and assist the member in modifying misuse patterns.
Members that qualify are eligible for a two to five year lock-in.
In the Right Choices program, members are assigned to one primary medical provider (PMP), one pharmacy and one hospital.
The goal of this program is to ensure members receive appropriate care and to prevent members from incorrect utilization of services.
Both Hoosier Healthwise and HIP members are eligible for the RCP program. Members are locked in to one PMP, one pharmacy and one hospital, and cen visit specialists based on a referral from their PMP.

22. Member Management
If you come upon a member who could use the extra devotion of their PMP, please nominate them for RCP using the electronic form on our website. You can also call customer service and speak to a live Reprsentative.

23. Provider Relations & Quality
Provider Relations Quality Education Opportunities
MDwise can assist in:
Educating office staff by providing Provider Orientations or Re-orientations.
Troubleshooting claim issues.
Providing education on Quality and OMPP standards through office visits.
Creating and implementing projects to improve quality of care.
Providing quality performance metrics via reports.
Identifying office practices that may result in missed opportunities to provide care.
MDwise Quality is dedicated to educating the provider office on ways the office can benefit from meeting quality standards. Our quality materials provide education on NCQA, HEDIA and OMPP standards, ways to maximize a member visit to meet quality criteria, assisting in member outreach and online reports.

24. Provider Relations & Quality
Quality Resources
Network Improvement Resources
Quality Posters
HEDIS Performance
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Lead Screening
Guides and Tip Sheets
Fax Back Program
Notification of Pregnancy
EPSDT Billing
Member Access to Care
Also with Quality education is a great amount of educational documents to share with your office. Updated HEDIS and Lead screening posters and tip sheets on the fax back program and the requirements for member access to care. If you would like someone to come to your office and discuss Quality with your team, please contact you dedicate Provider Relations Representative. We will review their territories a little later in the presentation.

25. Provider Relations -Forms
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:
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.

26. Provider Relations - Contracting
Providers not currently participating as MDwise Excel will need to contract to continue to see MDwise members in 2019.
What is required to contract?
MDwise Excel Contract
Provider/Ancillary Enrollment Forms
W-9
Sample Claim
Providers not seeking a MDwise Excel contract are required to submit the following:
Non-Contracted Provider Set-Up Form
For providers contracted with a delivery system that is not MDwise Excel, you will be required to contract with Excel to continue to see MDwise members in You will be required to submit the signed contract, enrollment forms, a W-9 and a sample claim for payor set up.
If you are not seeking a MDwise Excel contract, we still need the Non-contracted provider set up form, a w-9 and a sample claim to make sure you are accurately set up in our claims system.
All of these documents are submitted to the address for processing.

27. Provider Relations – Territory Map1 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

28. Provider Relations – Contact Information
Representative
Territory
Phone
Paulette Means
Region 1
Garrett Walker
Region 2
Michelle Phillips
Region 3, Hospice, Home Health
Jamaal Wade
Region 4
David Hoover
Region 5
Tonya Trout
Region 6
Rebecca Church
Region 7
Sean O’Brien
Region 8
Whitney Burnes
Region 9
Nichole Young
Behavioral Health
(CMHC, OTP, IMD or Residential)
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.

29. MDwise Provider Portal
Resources
MDwise Provider Portal
Additional resources can be found on our website, MDwise.org. The dedicated provider page has access to the provider portal as well as educational and reference materials.

30. MDwise Provider Portal
Resources
MDwise Provider Portal
Please note: Portal Access Requests can take up to 3 business days
If you do not currently have access to the MDwise provider portal, be sure to request access by following the link on our website. Effective 1/1/19, MDwise will go back to one provider portal. This will house all claims, 2015 and forward.

31. MDwise Provider Portal
Resources
MDwise Provider Portal
Member Eligibility including PMP
Claims
Quality Reports
Member Rosters
Member Health Profile
Coordinate Medical and Behavioral Health services based on paid claims
Includes physician visits, medication and ER visits
CM/DM Requests
The provider portal also gives you access to member eligibility, quality reports as discussed earlier, member rosters for PMPs and the member Health profile which helps with member utilization.

32. MDwise Provider Tip Sheets
Resources
MDwise Provider Tip Sheets
resources/tip-sheets/
MDwise Provider Manuals
MDwise Provider Relations Territory Map
MDwise Customer Service
IHCP Provider Modules
Indianamedicaid.com
Lastly, a few links for you to tip sheets, our provider manuals, the territory map and reaching customer service.

33. Questions
I want to thank you for taking the time to listen and learn more about MDwise. Does any one have any questions?