1. 2019 IHCP 1st Quarter Workshop
MDwise 2019 Updates

2. Prior Authorization (PA) Claims Provider Portal Provider Relations
Agenda
Updates
Eligibility
Prior Authorization (PA)
Claims
Provider Portal
Provider Relations
Transportation
Resources
Questions
We will go over MDwise updates, our eligibility and PA processes, filing claims and a new form to assist in adjusting claims, our provider relations department and Provider portal, transportation updates and close out with some useful resources and a time for questions.

3. MDwise restructured its Delivery System model to:
Updates
MDwise restructured 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.
MDwise will restructured its delivery system model to work as a single network, MDwise Excel. This has reduced the number of contact you must work with to get issues reviewed or to have questions answered. Our claim submission and prior authorization process have been streamlined to reduce administrative redundancy. If you have not yet contracted with MDwise Excel, we will review what is required to become an in-network provider.

4. 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)?
Eligibility must be verified each time a member is in office for a visit. Previously, you had to check two portals for eligibility to confirm the delivery system. That is no longer the process. IHCP eligibility and Program can be verified by visiting the IHCP Provider Healthcare Portal. All MDwise members are now MDwise Excel. If you would like to review a members PMP or eligibility history, you will use the MDwise Provider portal. Once eligibility is verified, (switch slides)
Provider Healthcare Portal
MDwise Provider Portal
IHCP Program
Delivery System: MDwise Excel
MCE
Assigned PMP History
Assigned PMP

5. One standard authorization list
Prior Authorization
One standard authorization list
One point of contact for all authorization requests
Go to MDwise.org for most up-to-date version of PA lists
MDwise.org
Providers
Forms
Prior Authorization
Verifying requirement for authorization is the next step. MDwise now has one PA list that includes both Hoosier Healthwise and Healthy Indiana Plan. Behavioral Health services have their own authorization guide. The PA lists are housed on the Prior Authorization Forms page. If you are reviewing services with dates of service prior to 1/1/19, these authorization guides are housed on the same page under the archived Authorization Lists link.

6. 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.

7. 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 received a 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 reference the PA quick contact guide on our website.

8. 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, a written appeal can be filed within 33 calendar days of receiving the PA 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.

9. Pharmacy Prior Authorizations
For all requests and questions regarding Pharmacy PA, contact the Pharmacy Benefit Manager (PBM), MedImpact.
Pharmacy Benefit Manager (PBM):
MedImpact:
Pharmacy Resources:
Pharmacy authorizations are submitted to the Pharmacy Benefit Manager, or PBM. Please contact the PBM with pharmacy PA questions.

10. Hoosier Healthwise & Healthy Indiana Plan
Claims
Claim Submission is date of service driven - date of service 1/1/19
Electronic Submission
Provider Customer Service Unit
Claims inquiries
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
Hoosier Healthwise
Healthy Indiana Plan
Payer ID: 3519M
Payer ID: 3135M
Also new this year, MDwise has brought claim processing in house, allowing us to have one claim submission address and one 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. Delivery system submission information can be found on the archived Quick Contact Guide on the Provider Contact Information Page.

11. Claims Claim Timelines: Claim Submission: Claim Adjustment Process
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.*
Claim Adjustment Process
Providers can adjust a claim by submitting the adjustment form and supporting documentation within 90 days of the explanation of benefits (EOB).
Disputes
60 days from the date of the EOB OR 60 days from the date of your claim adjustment response.
*Reference BT for more information
Claim submission timelines remain unchanged for contracted providers. For non contracted provider, we are mirroring the state change made in bulletin BT Providers who are not contracted with MDwise Excel will have 180 days to file claims. To assist in the one-to-one match in our claims system, we are asking providers to include their taxonomy in box 24J on the CMS 1500 form.
If you receive a claim denial, MDwise is adding in a new step to adjust your claim prior to filing a formal dispute. If you receive a response from your claim adjustment form submission that you still disagree with, a formal claim dispute can be filed 60 days after the decision date from your claim adjustment.

12. Claim Adjustment Request Form
Claims
Claim Adjustment Request Form
Request for payment reconsideration for a paid or denied claim
To be used before Claim Dispute process
Use form:
To have claim reconsidered for payment if denied in error
If claim paid at inappropriate rate
To submit attachments missing from original claim submission
All claim adjustment inquiries and requests must be made to MDwise within 90 calendar days of the most current MDwise EOP.
Form cannot be used if claim has already been disputed
Adjustment Form must be complete and include all documentation to be considered
The claim adjustment form process MUST be used prior to filing a claim dispute. This process allows you to submit attachments that may have been omitted in your original filing. You can also ask that a claim that denied for PA, but has a PA on file, be re-reviewed, or if you feel a payment is incorrect, the claim pricing can be researched.
The claim adjustment form must be completed in full and sent within 90 calendar days of the date of the current EOP. Any submission outside of the 90 days will not be considered.

13. Claim Adjustment Request Form
Claims
Claim Adjustment Request Form
Again, be sure to complete the form and select the reason for requesting adjustment. Also, be sure to submit your supporting documentation to the claims address or fax number on the next page.

14. Claim Adjustment Request Form
Claims
Claim Adjustment Request Form
Send completed Provider Claim Adjustment Request Form with a copy of the claim form and/or any supporting documentation to:
Or fax to:
For questions regarding the Provider Claims Adjustment Process, call the Provider Customer Service Unit at
This address is exclusively for Claim Adjustment Form submission. A notification of receipt will be sent back using the same format of submission, within 10 days of receipt.
For questions, please contact the Provider Customer Service Unit, or PCSU, at
If you are unsure of the status of your claim… (switch slides)

15. MDwise Provider Portal
You can begin by looking up the claim in the MDwise Provider Portal. All Providers, contracted and non-contracted, have access to the MDwise provider portal to view claim status and member eligibility. To access the MDwise provider Portal, Go to the Provider page at MDwise.org, and select the Log In quick link on the top right.

16. Provider Portal
Use the main log in to access all claims dates of service
The sign in page will give you two portal options: You will use the Valence portal to access claims with dates of service 1/1/17 to 12/31/18. You will use only the MDwise Provider Portal to access claims with dates of service 1/1/19 and forward. The MDwise Provider Portal will become your exclusive access to claims and eligibility information starting [enter date]. This will house all claims dates of service 2015 and forward.
Use the Valence portal for dates of service 1/1/17-12/31/18

17. 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. Remember, starting [enter date] this will be your exclusive portal for all MDwise claims.

18. 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
Care Management/Disease Management (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.

19. Provider Relations - Contracting
Providers not currently participating as MDwise Excel need to contract to continue to see MDwise members.
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
Provider not currently contracted with MDwise Excel can submit a contract inquiry form located on our Provider Forms page of our website.
If you are not seeking a MDwise Excel contract but wish to see MDwise members, we need to submit 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.

20. 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:
The Provider page has many educational avenues for you and your office staff including enrollment, claim adjustment, prior authorization lists and contact information, and a map to identify your Provider Representative.

21. Provider Relations – Territory Map1 2 5 3 4 9
Your dedicated Provider Representative is available to review provider and facility enrollments, go over Quality metrics and to educate your office on any updates. If you would like to schedule a time to review any of these items, please reach out to your dedicated territory Rep. Remember, the Provider Customer Service Unit is now your first contact for all claim issues with dates of service 1/1/19 and forward. That number again is 6 8 7

22. Provider Relations – Contact Information
Representative
Territory
Phone
Paulette Means
Region 1
Jinny Hibbert (Interim)
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)
Here is the contact list for all of our Provider Representatives. If you are a DME or ABA provider, please reach out to the Representative in you respective region. For behavioral health, Nichole young covers CMHC’s, OTP’s, IMD’s and residential providers. All other BH providers should contact their territory reps.
Our final item to review is MDwise Transportation.

23. MDwise non-emergent transportation vendor is now Southeastrans.
To schedule a non-emergent medical transport (NEMT) ride:
Southeastrans Web Portal
MDwise Customer Service:
Follow the call tree for the appropriate extension
To become a MDwise Transportation vendor:
Kristy Swoveland, Provider Relations Manager or
Andrew Tomys, Corporate Network Development Manager or

24. 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.

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