Early Intervention Services Provider Orientation and Training Effective

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Early Intervention Services Provider Orientation and Training Effective 12/1/2018

Early Intervention Services Provider Orientation and Training Effective 12/1/2018

Agenda • Member Identification & Eligibility Verification • Provider Portal/Availity • EIS Services Workflow

Agenda • Member Identification & Eligibility Verification • Provider Portal/Availity • EIS Services Workflow • Prior Authorization • Claims Submission • Provider Refund Guidelines • Provider Appeals • Reporting Abuse • Rapid Response Outreach Team • Integrated Care Management • Quality Measures & Healthy Behaviors Program • Resources & Contact Info • Joining the Prestige Network Prestige Health Choice 2

Member Identification Prestige Health Choice Member ID Card Prestige Health Choice 3

Member Identification Prestige Health Choice Member ID Card Prestige Health Choice 3

Member Eligibility Verification Prestige Health Choice member eligibility varies by month. Therefore, each provider

Member Eligibility Verification Prestige Health Choice member eligibility varies by month. Therefore, each provider is responsible for verifying the member’s current eligibility with Prestige before providing services. Eligibility may be verified via: • The Availity portal at www. availity. com • The Florida Medicaid portal at https: //portal. flmmis. com/FLPortal/Eligibility/tab. Id/68/Default. aspx • Calling Prestige Member Services at 1 -855 -355 -9800 Please note that the presentation of a Prestige member ID card is not sole proof that a person is currently enrolled in Prestige. For example, when a member becomes ineligible for Medicaid, the member does not return the Prestige membership card. If you suspect an ineligible person is using a member’s ID card, please report the occurrence to Prestige’s Fraud and Abuse Hotline at 1 -866 -833 -9718. Prestige Health Choice 4

Provider Portal Prestige is pleased to offer a number of online services to our

Provider Portal Prestige is pleased to offer a number of online services to our providers through Availity at www. prestigehealthchoice. com or www. availity. com. This self-service site requires registration and you must have a valid NPI number. How to register You will start by clicking on: www. availity. com/providers/registration-details/ Then click on Start Registration. 1. Complete the registration process using this sign-up process. 2. Availity will provide security verification and assign your user name. 3. You will be asked to create a password. Once you've completed the registration process, you will be able utilize the website. Here are the services available: • • Eligibility and benefits Claim status Authorization submission and inquiry Report inquiry If you need assistance, please call 1 -800 -Availity. Prestige Health Choice 5

EIS Services Workflow 1. During the MDT meeting, the EIS Service Coordinator will call

EIS Services Workflow 1. During the MDT meeting, the EIS Service Coordinator will call the Prestige Care Manager, Ledayne Martinez, at 1 -855 -464 -8812, ext. 305 -102 -1163 to participate by assessing any medical needs and coordinating care. 2. The EIS Service Coordinator sends the member’s completed IFSP to the Prestige Care Manager at the designated Prestige EIS fax number: 833 -669 -7675. Each child’s completed IFSP should be sent in a single faxed transmission. Please make sure all the pages of the IFSP are sent together. Do not send IFSPs for more than one member at a time, as it will be included in the member’s record. 3. Routine case review will occur with the EIS Service Coordinator and Prestige Care Manager to ensure collaboration of efforts with ongoing care. 4. For IFSP reviews (at least every 6 months), the EIS Service Coordinator will send the member’s updated IFSP to the Prestige Care Manager at the designated Prestige EIS fax number: 833 -669 -7675. To reach out to the designated Prestige Care Management team, send your email to DLPHCPHCEISCM@Prestige. Health. Choice. com. Prestige Health Choice 6

Prestige Care Management The Prestige EIS Care Manager will provide coordination for medical care,

Prestige Care Management The Prestige EIS Care Manager will provide coordination for medical care, such as: • Diagnoses-related information and referrals • Connection to Medicaid transportation • Well-child appointments & EPSDT • Education about our Healthy Behaviors programs where members earn gift certificates

Prior Authorization All services included on the EIS and TCM fee schedules DO NOT

Prior Authorization All services included on the EIS and TCM fee schedules DO NOT require prior authorization. For physical therapy, occupational therapy and speech therapy, evaluations DO NOT require prior authorization for participating or non-participating providers. All other services outside of the EIS fee schedule DO REQUIRE prior authorization for participating or non-participating providers. If services outside of the current EIS fee schedule are recommended, the Prestige EIS CM can educate on how to request authorization for services. Providers can request prior authorization in two different ways. 1. Submit the prior authorization request in Availity. 2. Complete Prestige’s Prior Authorization Request Form found on our website at: http: //www. prestigehealthchoice. com/pdf/provider/resources/prior-authorizationrequest-form. pdf then fax the request form to 1 -855 -236 -9285. Prestige follows all timeliness requirements for prior authorization requests, which include responding in 7 days for a standard request and in 2 days for an expedited request. For authorization info not available on the portal, call Utilization Management at 1 -855 -371 -8074. Prestige Health Choice 8

What to Do if You Disagree with a Utilization Managementt. Determination If a provider

What to Do if You Disagree with a Utilization Managementt. Determination If a provider receives an adverse determination, the provider has three (3) business days from the time of the verbal, or confirmed fax, determination notification to request a peer-to-peer discussion by calling Utilization Management at 1 -855 -371 -8074. If you still disagree with our decision after the peer-to-peer discussion, you have the right to file an appeal. More information on how to file an appeal is available later in this training. Prestige Health Choice 9

Claims Submission Initial Claim Submission Guidelines All claims must be billed on a CMS

Claims Submission Initial Claim Submission Guidelines All claims must be billed on a CMS 1500 for submission to Prestige for payment. For line by line instruction on how to complete a claim form (CMS 1500), go to AHCA’s website at this link: http: //ahca. myflorida. com/medicaid/review/Reimbursement/RH_08_080701_CMS 1500_ver 1_4. pdf. You can submit your claims 2 ways: • Electronic Claim Submission: Prestige Health Choice Payer ID # 77003 • Paper Claims Submission: Prestige Health Choice P. O. Box 7367 London, KY 40742 Timeframe for Claim Submission: 180 days from the date of service (unless your contract specifies otherwise). Prestige Health Choice 10

Claims Submission (cont. ) Corrected/Void Claim Submission Guidelines Prestige does not accept handwritten notes

Claims Submission (cont. ) Corrected/Void Claim Submission Guidelines Prestige does not accept handwritten notes on resubmitted claims as indicators of a corrected claim. To submit a corrected/void claim: 1. Use one of the following resubmission or frequency codes to indicate that the claim is a corrected, replacement, or voided claim: • 7 = Replacement of prior claim • 8 = Void prior claim 2. Include the resubmission or frequency code and previous claim number in the correct location(s) on your claim (see next page for details) *Note a claim number can only be corrected one time. If multiple corrected claims are submitted for the same claim number, they will be denied. Be sure to use the most recent claim number when submitting a corrected claim. Prestige Health Choice 11

Claims Submission (cont. ) Corrected Claim Submission Guidelines (cont. ) This grid shows the

Claims Submission (cont. ) Corrected Claim Submission Guidelines (cont. ) This grid shows the correct location for the resubmission or frequency code and the previous claim number, based on paper or electronic submission: Prestige Health Choice 12

Claims Submission (cont. ) Corrected Claim Submission Guidelines (cont) 3. When submitting a corrected

Claims Submission (cont. ) Corrected Claim Submission Guidelines (cont) 3. When submitting a corrected claim you must ensure that your corrected claim contains a valid Member ID and Billing Provider Tax ID that match the original claim. 4. If the Member ID or Billing Provider Tax ID need to be corrected, the procedure is to VOID the original claim (using resubmission or frequency code 8) and to submit a new, clean claim using the correct Member ID and/or Billing Provider Tax ID. Timeframe for Corrected/Void Claim Submission: 180 days from previous claim Remittance Advice (RA) date (unless contract specifies otherwise) Prestige Health Choice 13

Claims Submission (cont. ) Tips to Avoid Claim Denials: 1. Verify the member’s eligibility

Claims Submission (cont. ) Tips to Avoid Claim Denials: 1. Verify the member’s eligibility before each visit. 2. Bill with the member’s ID, name, and DOB exactly as they appear on the member’s ID card. 3. Ensure that the servicing, billing, and ROPA (when required) providers have active Medicaid IDs. 4. When needed, obtain prior authorization before services are rendered. Use the instructions included in this training (slide 8). 5. If prior authorization was obtained, please include the authorization in Box 23 of the claim form. For claims questions regarding how to bill a service, please reach out to the Local Early Steps office. Prestige Health Choice 14

Provider Refund Guidelines Prestige makes every effort to ensure provider claims are processed accurately,

Provider Refund Guidelines Prestige makes every effort to ensure provider claims are processed accurately, but understands that sometimes an overpayment /incorrect payment may be made to a provider. Here are some reasons for an overpayment: an error in a provider contract or fee schedule reimbursement, duplication of a payment, inappropriate /inaccurate coding, and member eligibility. Should a provider identify that an overpayment has been made, the provider must return the improper payment or overpayment to the health plan. This payment should be returned to the health plan as soon as possible, and no later than 60 days from the date of discovery. Providers should return these funds to Prestige by following the refund process listed below: • For a single claim, please complete page 1 of the Provider Claim Refund Form (see next slide). • For multiple claims associated with the return payment, please complete pages 1 and 2 of the Provider Claim Refund Form, or you can attach your own to page 1. Please ensure that your spreadsheet contains the pertinent fields from the Provider Claim Refund Form for proper processing of your refund check. Submit the completed form and your refund check by mail to the following address: Prestige Health Choice Attention: Provider Refund Check Unit P. O. Box 7367 London, KY 40742 A copy of the Provider Claim Refund Form is available at www. prestigehealthchoice. com. If you have any questions, contact Provider Services at 1 -800 -617 -5727. Prestige Health Choice 15

Provider Refund Guidelines - continued Provider Claim Refund Form Prestige Health Choice 16

Provider Refund Guidelines - continued Provider Claim Refund Form Prestige Health Choice 16

Provider Refund Guidelines Provider Guideline: Submitting a Refund Check to the Health Plan for

Provider Refund Guidelines Provider Guideline: Submitting a Refund Check to the Health Plan for a Prestige Identified Overpayment When Prestige identifies that a claim has been overpaid, an overpayment notification will be mailed to the provider. Providers must submit a refund, or contest the overpayment, within 40 days. When submitting a refund, providers should complete the Refund form on the previous slide, and return the original overpayment notification with their refund. If contesting an overpayment request, follow the instructions provided on the overpayment notification, and be sure to include all pertinent documentation with your inquiry. Prestige Health Choice 17

Provider Appeals Prestige Health Choice maintains a provider appeals system that allows the provider

Provider Appeals Prestige Health Choice maintains a provider appeals system that allows the provider to dispute Prestige’s policies, procedures, or any aspect of our administrative functions, including proposed actions, claims, billing disputes, and authorizations. Appeals are reviewed and resolved by the Provider Appeals department. Should a provider disagree with an authorization or claims decision, the provider may participate in the Provider Appeal process. Some examples could include: • I submitted an authorization request that was denied, had my Peer to Peer review denied, and would like to appeal that decision • I had a claim denied due to lack of authorization • I had a claim denied for reasons other than authorization or I disagree with the payment amount. These include, but are not limited to the following: • • • Untimely filing Billing edits Benefit limitations Unlisted procedure codes/non-covered codes Fee schedule/reimbursement rates Provider contract questions/concerns Prestige Health Choice 18

How to Submit a Provider Appeal 1. Download the Provider Appeal Form at www.

How to Submit a Provider Appeal 1. Download the Provider Appeal Form at www. prestigehealthchoice. com. 2. Submit the completed Provider Appeal Form via mail or fax: Mail: Prestige Provider Appeals Dept. PO Box 7366 London, KY 40742 Fax: 1 -855 -358 -5853 3. If the appeal is of clinical nature, provide supporting documentation (including medical records and additional information to support the clinical decision). Please only attach the relevant additional medical records required to support your case. Medical records submissions must be limited to 300 pages. 4. If the appeal is of a claims nature, please include all relevant information to support your appeal, including but not limited to fee schedules, copy of contract, Remittance Advice, calculations, or other information to support the request. 5. A provider has 180 days from the clinical decision or claims payment date to submit an appeal. All appeals past that date will be administratively upheld. 6. Prestige will send an acknowledgement letter within three (3) business days to inform you that we have received your appeal. 7. Prestige will resolve all provider appeals within 60 days. Prestige Health Choice 19

Joining Prestige’s Provider Network Prestige Health Choice Medicaid provider eligibility All providers must be

Joining Prestige’s Provider Network Prestige Health Choice Medicaid provider eligibility All providers must be a part of the Medicaid program prior to joining Prestige’s network and have an active enrolled Medicaid number as a condition to being paid for services rendered. Provider Credentialing and Re-credentialing (when required) When credentialing is required by AHCA, the initial credentialing process may take up to 60 days after receiving a complete application form and supporting documentation in the Prestige credentialing department. If there is missing and/or incomplete information, provider will receive notification. Once the time included in the notification expires or within 10 business days from the date the credentialing process started, the credentialing application will be discontinued. Re-credentialing process occurs every three (3) years and starts at least 90 days prior to the credentials expiration date. Several attempts will be made prior to the credentialing expiration date to obtain the application and/or any missing documentation (as applicable). Unless the provider has been terminated for cause, Prestige Health Choice members who are in active treatment will be allowed to continue care with a terminated treating provider through completion of treatment. The provider manual is available at www. prestigehealthchoice. com and it has additional, specific information for your reference. You can also contact Provider Services at 1 -800 -617 -5727. Prestige Health Choice 20

Reporting Abuse, Neglect and Exploitation All participating and direct service providers are required to

Reporting Abuse, Neglect and Exploitation All participating and direct service providers are required to report suspected cases of abuse, neglect, or exploitation of children or vulnerable adults to the Department of Children and Families’ Central Abuse Hotline in accordance with s. 39. 201 and Chapter 415, F. S. Report online at https: //reportabuse. dcf. state. fl. us/ Report by phone: 1 -800 -962 -2873 If a child or adult is seriously injured or in imminent danger, call 911 immediately. Prestige Health Choice 21

Rapid Response and Outreach Team A valuable resource available to each Prestige member is

Rapid Response and Outreach Team A valuable resource available to each Prestige member is the Rapid Response & Outreach Team (RROT). The unit offers unique services to address the needs of our members. • The RROT is a call center with dedicated nonclinical care connectors and nurses readily available to service our members in a very personalized way. • Both members and providers may call for assistance. • The RROT does triage and supports the member to ensure they receive what they need. This team refers to the appropriate Prestige program to support member’s health. • The RROT coordinates with all other departments within Prestige to promptly resolve member issues. To contact the RROT please call 1 -855 -371 -8072. Prestige Health Choice 22

Rapid Response and Outreach Team (cont. ) When the Rapid Response care connector talks

Rapid Response and Outreach Team (cont. ) When the Rapid Response care connector talks with a member’s parent or guardian, the following services are offered: • Locate a PCP or patient-centered medical home or specialist provider when needed. • Assists members with scheduling PCP/pediatrician office visits, including the Well. Child and Child Health Check-Up (CHCUP) appointments for a comprehensive examination, immunizations, assessments for nutrition, dental, vision & hearing, and labs with lead screening. • • • Arrange transportation services when needed. Arrange interpreter services when needed. Address care gaps or preventive services when needed. Identify and connect to behavioral health and vision services. Mail Educational Well Child materials to the parents or guardians. Assist with any other services needed by the member, including pharmacy needs. Prestige Health Choice 23

Integrated Care Management Pediatric preventive health care: Focused on adherence to EPSDT program guidelines

Integrated Care Management Pediatric preventive health care: Focused on adherence to EPSDT program guidelines and health of pediatric enrollees. Episodic care management: Focused on enrollees, both adult and pediatric, with short-term and/or intermittent behavioral or physical health needs. Bright Start® (maternity) program: Focused on pregnant enrollees during their prenatal to postpartum care period. To refer an enrollee, please contact Bright Start at 1 -855 -371 -8076. Complex and chronic care management: Focused on enrollees identified with complex behavioral, psychosocial, and physical health needs. Provide care coordination and health coaching of enrollees with such chronic conditions as asthma, diabetes, and chronic obstructive pulmonary disease. To refer an enrollee please contact the RROT at 1 -855 -371 -8072. Prestige Health Choice 24

Quality Measures & Healthy Behavior Programs Prestige is focused on providing quality care to

Quality Measures & Healthy Behavior Programs Prestige is focused on providing quality care to our members. Below are just some of the measures we use to evaluate our effectiveness. • Provide children access to primary care practitioners • Provide childhood immunizations (targets children 2 years of age) And for the two areas below, we have Healthy Behavior programs where members can earn gift cards for up to $50, depending on the program. More to come on this initiative! • Provide well child visits (specifically in the first 15 months of life) • Provide lead screening in children (targets children 2 years of age) Prestige Health Choice 25

Resources & Contact Information Providers may access Prestige Health Choice’s website at www. prestigehealthchoice.

Resources & Contact Information Providers may access Prestige Health Choice’s website at www. prestigehealthchoice. com. Provider Services 1 -800 -617 -5727 Vaccines for Children (VFC) 1 -800 -483 -2543 Rapid Response Outreach Team 1 -855 -371 -8072 Immunization Registry (SHOTS) 1 -877 -888 -SHOT Authorizations 1 -855 -371 -8074 Healthy Start program 1 -800 -451 -BABY Member Services 1 -855 -355 -9800 WIC and Nutritional Service 1 -800 -342 -3556 Member Services TTY/TDD (hearing impaired) 1 -855 -358 -5856 Coastal Care (Home health, infusion, DME) 1 -855 -481 -0505 QUEST (Laboratory) 1 -866 -697 -8378 Perform. Rx (Pharmacy) 1 -855 -371 -3963 Premier Eye Care 1 -855 -371 -3961 Hear. USA (Audiology and hearing aids) Optum (Behavioral Health) 1 -855 -371 -3967 1 -800 -731 -3277 Access 2 Care (transportation services) 1 -855 -371 -3968 Prior Authorization: Availity or the Prior Authorization Request Form is on our website at: http: //www. prestigehealthchoice. com/pdf/provider/r esources/prior-authorization-request-form. pdf then fax the form to 1 -855 -236 -9285 Prestige Dedicated CM: Ledayne Martinez, at 1 -855464 -8812, ext. 305 -102 -1163 Prestige EIS CM: fax # 833 -669 -7675, email DLPHCPHCEISCM@Prestige. Health. Choice. com Paper Claims: Prestige, P. O. Box 7367, London, KY 40742 Electronic claims: Change Healthcare, Prestige Payor ID #77003 Prestige Health Choice 26

Questions? Prestige Health Choice 27

Questions? Prestige Health Choice 27