NEW PROVIDER ORIENTATION WELCOME TO NEW PROVIDER ORIENTATION

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NEW PROVIDER ORIENTATION

NEW PROVIDER ORIENTATION

WELCOME TO NEW PROVIDER ORIENTATION Congratulations on becoming a part of the Care. Centrix

WELCOME TO NEW PROVIDER ORIENTATION Congratulations on becoming a part of the Care. Centrix family! Our role in Provider Operations is to be your advocate as you work with Care. Centrix. Please feel free to contact your Provider Operations team should you have additional questions after reviewing this new provider orientation! 2

AGENDA Who is Care. Centrix and how does Care. Centrix benefit providers? Review the

AGENDA Who is Care. Centrix and how does Care. Centrix benefit providers? Review the home care benefits management workflow Review the steps of the referral process and getting authorizations/precertifications Review the requirements of meeting start of care (SOC) Review the steps of the claim submission process and getting paid Review Care. Centrix contact information Review provider performance metrics Questions? 3

CARECENTRIX

CARECENTRIX

CARECENTRIX Who is Care. Centrix? Nation’s leading home care network A healthcare delivery system

CARECENTRIX Who is Care. Centrix? Nation’s leading home care network A healthcare delivery system that performs utilization management functions for ancillary care and specialty pharmacy services for commercial, and managed Medicare and Medicaid plans Privately owned since 2008, founded in 1996 Network: Over 8, 000 credentialed provider locations of home health, durable medical equipment, infusion and behavioral health Accreditation: Full URAC accreditation in health utilization management Customers: CIGNA/CIGNA West, Health Net, Florida Blue, Horizon Blue Cross Blue Shield of New Jersey, Aetna and Cofinity National footprint: 24/7 service in all 50 states How does Care. Centrix benefit the provider? Single Point-of Contact: Care. Centrix integrates the full spectrum of services - network management, referrals, care coordination, utilization management, and reimbursement consolidation Focus on relieving provider from the burden of collecting patient cost share 5

HOME CARE BENEFITS MANAGEMENT WORKFLOW

HOME CARE BENEFITS MANAGEMENT WORKFLOW

HOMECARE BENEFITS MANAGEMENT WORKFLOW Physicians Hospital Discharge Planners Case Managers Care. Centrix Home Health

HOMECARE BENEFITS MANAGEMENT WORKFLOW Physicians Hospital Discharge Planners Case Managers Care. Centrix Home Health Provider CCX Providers Infusion Provider & Ambulatory Infusion Suites DME/OP Provider Claims Billing 7

AUTHORIZATIONS/ PRE-CERTIFICATIONS The Referral Process & Getting an Authorization Requests for service, whether for

AUTHORIZATIONS/ PRE-CERTIFICATIONS The Referral Process & Getting an Authorization Requests for service, whether for the initial start of care or reauthorization for continued care, must be requested prior to the service being provided. If a provider fails to request an authorization/precertification prior to providing services, the services performed may not be reimbursable and are not billable to the patient.

THE REFERRAL PROCESS: SERVICE SPECIFIC TIPS THH – Home Health DME/O&P Infusion Required to

THE REFERRAL PROCESS: SERVICE SPECIFIC TIPS THH – Home Health DME/O&P Infusion Required to be Homebound? Varies by plan/product type. N/A Initial Auth Required? Yes for non-Blue. Card services* Re-auth Required? Plan Dependent Start of Care (SOC) Changes Provider must make Care. Centrix aware & update on www. carecentrixportal. com Miscellaneous Lab tests must be taken to the lab specified by the patient’s plan Routine supplies are included in the cost of visit If additional supplies are needed, Care. Centrix will authorize. Oxygen Provide height, weight, allergies, type of venous access, and next scheduled dose Infusion providers must accept case “full-service” which includes drug, skilled nursing and supplies (per diem) • Liter flow • O 2 saturation w/ date CPAP • Sleep study or letter of medical necessity • MD order required for upgraded unit - Please note these are service specific tips, however all providers should reference the provider manual, the provider agreement and the health plan policies for guidance on the referral process. * Blue. Card requirements for precert vary by Home. Plan. Please refer to Blue. Card training. 9

SAMPLE REFERRAL INSTRUCTION SHEET Read your fax coversheet. It will tell you the patient

SAMPLE REFERRAL INSTRUCTION SHEET Read your fax coversheet. It will tell you the patient ’s plan type, including how to check eligibility and benefits and whether reauthorization is needed. Identifies the lab of choice per the health plan Notifies you if PTA and OTA are allowed by patient ’s health plan 10

IMPORTANT AUTHORIZATION INFORMATION Coordination of Benefits (COB) Please click the PDF to the right

IMPORTANT AUTHORIZATION INFORMATION Coordination of Benefits (COB) Please click the PDF to the right for an overview of COB Authorizations of services is NOT a guarantee of payment Payment of services rendered is subject to the patient’s eligibility and coverage on the date of service, the medical necessity of the services rendered, the applicable payer’s payment policies, including but not limited to, applicable the payer’s claim coding and bundling rules, and compliance with the Provider’s contract with Care. Centrix. Refer to the Provider Manual for more information regarding authorizations. Provider is ultimately responsible for eligibility benefit and payer source verification. Providers must in every instance, whether receiving a referral from Care. Centrix or a primary referral source, verify eligibility and benefits with the patient’s Health Plan prior to providing any service, equipment or supply item. Providers should maintain documentation to evidence this verification of eligibility and benefits. Care. Centrix does not conduct electronic eligibility and benefit verification transactions, but our health plan customers do. Eligibility and benefit verification and service authorization are not a guarantee of payment for services such as, but not limited to, items provided when the patient is not eligible or there is no available benefit. Providers are responsible for ensuring that they maintain, and have available upon request, all documentation necessary to support the services rendered, including but not limited to, the medical necessity of such services. 11

ELIGIBILITY TIPS Health Plan Website Patient Plan Type Contact Phone Aetna Navinet www. navinet.

ELIGIBILITY TIPS Health Plan Website Patient Plan Type Contact Phone Aetna Navinet www. navinet. com PPO patient HMO patient (888) 632 -3862 (800) 624 -0756 Cigna Web Portal www. cignaforhcp. com Florida Blue Card Availity www. availity. com State, Local and FEP Blue. Card (877) 352 -2583 (800) 676 -BLUE(2583) Horizon NJ Navinet www. navinet. com General/Medicare Advantage/SHBP (800) 624 -1110 FEP (800) 624 -5078 Pfizer (888) 340 -5001 Merck (877) 663 -7258 Labor Funds (888) 456 -7910 12

START OF CARE Missed starts of care (MSOC) can create dissatisfaction, put patients at

START OF CARE Missed starts of care (MSOC) can create dissatisfaction, put patients at risk, and can result in readmissions or delayed discharges

START OF CARE (SOC) A start of care (SOC) date is set by the

START OF CARE (SOC) A start of care (SOC) date is set by the ordering physician or discharge planner. When accepting a case, consider your ability to service the patient and meet their needs. Notify Care. Centrix immediately if you must delay the start of care or if you are unable to continue the case. Refer to page 26 of the Provider Manual for start of care delays and referral turn backs. Changes to the patient’s start of care date must be approved by the referring physician. You are required to obtain the orders needed to prevent a delay in the start of care. For most items and services, the Care. Centrix Service Validation team will confirm that the care was provided by the SOC via an outbound phone call to the patient. Provider performance is measured on various metrics, including compliance with SOC date and number of missed starts of care. 14

CLAIM SUBMISSION AND PAYMENT Clean claims must be submitted electronically within 60 days of

CLAIM SUBMISSION AND PAYMENT Clean claims must be submitted electronically within 60 days of the date of service (or, as determined by applicable law) and must include the Care. Centrix HCPCS Code & Modifiers.

CLAIM SUBMISSION AND PAYMENT The Referral Process (Getting an Authorization) Visit the Patient The

CLAIM SUBMISSION AND PAYMENT The Referral Process (Getting an Authorization) Visit the Patient The Claim Submission Process 16

THE CLAIMS SUBMISSION PROCESS Timely filing 60 days from time service was rendered (or,

THE CLAIMS SUBMISSION PROCESS Timely filing 60 days from time service was rendered (or, as determined by applicable law or plan mandate) Providers must submit a clean claim within timely filing period, non clean claims submitted within the timely filing period therefore reject Substitution of Services Example: If a provider is granted auth for RN visits, an LPN may be used but providers must bill CCX for LPN not RN. The same applies for the substitution of PTAs and OTAs. *Important Note Horizon does not allow for PTA or OTA/COTA. Providers should always bill the services that were rendered at the appropriate contracted rate. Providers may NOT disclose contracted pricing Providers do not collect copays/deductibles from patients. Care. Centrix will collect the copays and deductibles from the patient. Click here to review the provider manual for clean claim submission requirements. 17

THE CLAIM SUBMISSION PROCESS Care. Centrix offers a billing crosswalk to identify the Care.

THE CLAIM SUBMISSION PROCESS Care. Centrix offers a billing crosswalk to identify the Care. Centrix internal service code to the HCPC code on the provider’s fee schedule. Current billing cross walk can be found at www. carecentrixportal. com To use the billing crosswalk, locate the Care. Centrix service code and UOM (unit of measure) as shown on your Service Authorization Form (SAF) and match to the above crosswalk to determine the correct HCPCS/Modifier combination you must bill. Claims must include the following: Description of the service ICD 9 and/or ICD-10 Code(beginning on 10/1/2015) Taxonomy number (provider’s and referring physician) NPI number If billed with HCPCS and modifiers not consistent with the HCPCS and modifiers on the SAF the claim could be denied Refer to the Provider Manual for a complete list of clean claim submission requirements. 18

REJECTED CLAIM If your claim was rejected (You received a rejection letter from Care.

REJECTED CLAIM If your claim was rejected (You received a rejection letter from Care. Centrix) Correct the claim for the issue(s) identified and resubmit the claim as an Original Claim via an 837 submission or on a CMS 1500/UB 04 form. (Do not submit the claim as a Corrected Claim, Claim Reconsideration, or Claim Appeal) Please resubmit the claim to Care. Centrix as quickly as possible; claims must still be received within 60 days* from the date of service (or as indicated by State law) to be timely. 19

DENIED CLAIM If your claim was denied (You received and explanation of payment (EOP)

DENIED CLAIM If your claim was denied (You received and explanation of payment (EOP) from Care. Centrix) And you agree with the denial reason given by Care. Centrix, correct the claim for the issue(s) identified and resubmit the claim as a Corrected Claim. (Do not submit the claim as a Claim Reconsideration or Claim Appeal). “Corrected” marking must be clearly visible in large font and cannot obstruct any data elements on claim Please resubmit the claim timely to expedite the payment process. Claims can be submitted electronically or sent to: PO Box 7779 London, KY 40742 20

DENIED CLAIM If your claim was denied (You received and explanation of payment (EOP)

DENIED CLAIM If your claim was denied (You received and explanation of payment (EOP) from Care. Centrix) And you disagree with the denial reason given by Care. Centrix, complete the Claim Reconsideration Form (CLICK HERE FOR CLAIM RECONSIDERATION FORM) and mail it to the address on the form. (Do not make changes to the original claim. Claim Reconsideration Forms should only be used if you believe your initial claim was 100% accurate) Claim Reconsideration Forms must be received within 45 days of the date of an EOP, or as required by law, if longer. 21

CLAIM APPEALS If your Claim Reconsideration request was denied you may submit a claim

CLAIM APPEALS If your Claim Reconsideration request was denied you may submit a claim appeal Complete the Claim Appeal Form (CLICK HERE FOR CLAIM APPEAL FORM) and mail it to the address on the form. (Do not make any changes to the original claim. Claim Appeals should only be used if you have received an EOP from a Claim Reconsideration) Claim Appeal Forms must be received within 30 days of the date of a Claim Reconsideration EOP Note: Corrected claims, reconsiderations, and appeals can be submitted electronically for claims processed through our Claims 2. 0 platform. 22

WHAT IS CLAIMS 2. 0? We listened to your feedback! The 2. 0 platform

WHAT IS CLAIMS 2. 0? We listened to your feedback! The 2. 0 platform includes several new features that came from provider requests. These enhancements include: • More detailed claim status updates via the Provider Portal • Improved technology that checks your claim for completeness • Claims reconciliation tools that provide you with detailed claims reporting information • The Claims 2. 0 training can be found under the Education Center on the Care. Centrix Provider Portal : www. carecentrixportal. com/Provider. Portal/home. Page. do 23

CONTACT US Know where to go

CONTACT US Know where to go

CONTACT US Register for Portal Access & EDI Claims Submission Register for Portal Access

CONTACT US Register for Portal Access & EDI Claims Submission Register for Portal Access Register for EDI Claims Submission Support Portal Support EDI Support Authorizations Initial Authorization Requests Re-Authorization Requests Add-on Requests Authorization Status Edit an Authorization Contact Numbers Claims Status Claims Questions Appeal Status Claims Support Team Contract/Network Management Provider Manual Patient Financial Responsibility Patient Services Team www. Care. Centrix. Portal. com [email protected] Centrix. com [email protected] Centrix. com www. Care. Centrix. Portal. com Aetna FL: 888 -999 -9641 BCBS FL: 877 -561 -9910 –Inquiries FLBlue. Auth. [email protected] com All Other Plans: 877 -466 -0164 www. Care. Centrix. Portal. com Phone: 877 -725 -6525 www. Care. Centrix. Portal. com Phone: 800 -808 -1902 25

THINGS TO REMEMBER

THINGS TO REMEMBER

THINGS TO REMEMBER Provider Performance Metrics 100% portal compliance 100% EDI compliance Claim denial

THINGS TO REMEMBER Provider Performance Metrics 100% portal compliance 100% EDI compliance Claim denial rate of 7% or less No quality of care concerns Case acceptance rate, no turn-backs Monitor these to avoid becoming non-compliant. Providers may NOT use the Care. Centrix name in any media without prior approval. Timely filing 60 days from time service was rendered (or, as determined by State law) 27

THANK YOU

THANK YOU