CPAN Guide 1 Network Services Provided to our

CPAN Guide 1

Network Services Provided to our Partners 2

Management Services § Services Provided Ø Contract Facilitation Ø Case Management Ø Credentialing Ø Claims Management Ø Quality Improvement Programs and Standards Ø Mycare Ohio Updates and Assistance 3

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

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

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

Credentialing • 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 kbess@cpanohio. com (513) 777 -2371, Extension 1012 7

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: claims@cpanohio. com Kim Reeves, Executive Director of Network Services 513 -777 -2371, ext. 1010 8

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 jcoyle@cpanohio. com (513) 777 -2371, Extension 1015 9

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

SUBMIT A PRE-CERT REQUEST Review the list of Documents on the Pre-cert Referral Request Form Submit Pre-cert Requests: Submit with all Pre-cert Requests: Pre-cert Request Form Clinical Documents Listed precert@cpanohio. com FAX NUMBER: 513 -777 -2372 SCANNING IS PREFERRED 11 CPAN HOURS OF OPERATION: 8 AM – 5 PM

HOW TO COMPLETE A PRECERT First Facility Contact person must Complete Insurance Benefit Verification. Second Fax the following information to the CPAN Case Management Office @ 513. 777 -2372 as soon as possible or scan to precert@cpanohio. com: Date for Admit This must be done prior to submitting case to CPAN’s Precertification Department Name of admitting facility, contact person and Facility MD to follow. Important: The benefit verification is completed by the facility contact person or someone at the facility. This step is not completed by CPAN. Discharge plan, short term vs. long term resident & secondary payer Do not send x-rays, labs etc. unless pertinent to admitting documentation 12 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

PRECERT TRIAGE Clinical Documentation PRECERT PROCESS SEND PRECERT IN ASAP • Submit with CPAN Pre-cert Fax Cover Sheet • CPAN care coordinator will provide a verbal confirmation that your case was received. 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 MANAGE EXPECTATIONS • 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. PROCESSSING REFERRALS • Cases are prioritized based on the anticipated admit date and second on date/time received STATUS UPDATE • Case managers on consistently on the phone with hospitals/payers. Return calls will be based on case calls pending 13 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

NEXT REVIEW DATE How to submit an Update to CPAN 14

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: reviews@cpanohio. com FAX NUMBER: 513 -777 -2372 SCANNING IS PREFERRED 15 CPAN HOURS OF OPERATION: 8 AM – 5 PM

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 16

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 17

Hip Fracture (Open Repair) – 16 -28 Days Total Knee Replacement – 6 – 9 Days CHF Exacerbation 9 – 16 Days CVA 8 – 21 days Chronic Renal Failure 10 – 17 Days Arthroplasty 7 – 11 Days Community Acquired Pneumonia 8 – 14 Days COPD Exacerbation 7 – 14 Days Cellulitis 8 – 15 Days Chronic Renal Failure – 10 – 17 Days 18 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.

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 19 guardian / POA?

Claims 20

CLAIMS/BILLING CPAN does not provide billing services to our partners. We provide billing templates that provide the provider with information to format claims. q Initial Billing Notice - faxed to your facility after a case has been processed for pre-cert authorization q Final Billing Notice – faxed to your facility after the resident discharges. q Care. Source – 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 Care. Source cases submitted through CPAN 21

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