OHSU Health Services OHSU Health Provider Training Services

OHSU Health. Services OHSU Health Provider Training Services Network Pricing Methodologies DATE: December 16 th, 2019 DATE: November 5 th, 2019 PRESENTED BY: Dorane Brower, Chief Administrative Officer, OHSU Health Services Plan Services

Topics 2 • OHSU Health Services • • • – Who We Are Moda Health’s Experience in Medicaid PCP assignments Claim Submission Referral & Medical Authorization Process DMAP Provider Enrollment Appeals & Grievances Provider Portal Care Integration and Coordination Pharmacy Website Contact Us

OHSU Health Services- Who We Are Operating as an Integrated Delivery System (IDS) under Health Share of Oregon, a Coordinated Care Organization OHSU Health Legacy Health Pacific Source Kaiser Permanente Providence Care. Oregon Health & Services Primary Care & Primary Care Behavioral Health ✔ ✔ ✔ Specialty Care & Hospitals ✔ ✔ ✔ Specialty Behavioral Health ✔ ✔ ✔ Non Emergent Medical Transportation ✔ ✔ ✔ Dental Advantage Dental ● Care. Oregon Dental ● Kaiser Permanente ● ODS ● Willamette Dental Group OHSU Health Services is responsible for all CCO requirements and reporting up to Health Share. This is a delegated function from the CCO. 3 Source: “Presentation_OHSU Health Share_Comm Teams Meet”

OHSU Health Services- Who We Are OHSU Health Services is a partnership between OHSU Health and Moda Health Membership Outline 2019: 41, 000 Medicaid lives administered by Tuality Health Alliance and Care Oregon 2020: 41, 000 Medicaid lives will be administered by OHSU Health Services 4 • OHSU Health Systems will actively manage all case management, care coordination, flex services and pharmacy (OHSU’s PBM), compliance oversight and provider relations (credentialing and contracting) • Moda Health performs most administrative functions • Medical claims processing • Customer Service • Enrollment and PCP assignments • Finance and Accounting • IT Services • Provider Directory and Network Adequacy Analysis • Provider Services (claim status, change in PCP, etc. ) • Compliance and Fraud, Waste and Abuse expertise

Moda Health’s Experience in Medicaid We’re committed to partnering for heathier communities • We have deep experience in standing up and operating a successful Medicaid program Operating MCO and DCO since 1994 The value, services and infrastructure that we bring to OHSU Health Services: • Transparency • Medicaid claims processing • Customer Service • Enrollment and PCP assignments • Finance and Accounting • IT Services • Provider Directory and Network Adequacy Analysis • Compliance and Fraud, Waste and Abuse expertise • • 5 Eastern Oregon Coordinated Care Organization (EOCCO) • • EOCCO received its first contract from the Oregon Health Authority in 2012 to administer Medicaid services in Eastern Oregon (all 12 counties). Moda Health is an equity owner of EOCCO Administering ~ 51, 000 Medicaid lives Success in meeting quality metrics Operating with the global budget framework of 3. 4% Implementation of value based payment models Enhanced PCPCH payments

PCP Assignments 6 6

PCP Assignments • Newly enrolled members are unassigned for the first 30 days to allow time for members to choose their own PCP • If no PCP selection is made, OHSU Health Services will auto-assign a PCP for the member – Assignment will be based on geographic location and/or any claim history the member may previously have with a PCP • Requests can be made by member, member’s family member, member’s caseworker, or by PCP on member’s behalf • Forms can be found on OHSU Health Services website • A list of participating PCP can be found on the Provider Directory on OHSU Health Services website 7

Claim Submission 8 8

Claims Submission • To ensure accurate & timely processing of claims: – Check member’s eligibility prior to each visit for each member in accordance (OAR 410 -120 -1140) – Verify the service performed is a covered service via the Prioritized List of Covered Services & the Prior Authorization list on OHSU Health Services Website – Provider is a registered DMAP provider – Applicable referral &/or authorization has been approved prior to services rendered – Submit claims to the appropriate claims address – Standard timely filing is 120 days from the date of service • Medicaid is payment in full • Claims are paid on a weekly basis 9 We process at least 90% of all clean claims within 30 days and 99% within 90 days. We currently exceed the requirements for processing

Claim Submission Claims received electronically are typically processed more expediently than paper claims. Electronic Claims: Claims received electronically are typically processed more expediently than paper claims To submit claims electronically, please use Payer ID: 13350 If you would like information on billing claims electronically, please contact our Electronic Data Interchange department at edigroup@modahealth. com 10 Submit Medical Claims: OHSU Health Services PO Box 40384 Portland, OR 97240

Referral & Authorization Process 11 11

Transition of Care • Starting 1/1/2020 though 3/31/2020 OHSU Health Services will honor Prior Authorization for all members for 90 days for physical health and pharmacy • Health Related Service will be considered as part of the care coordination process – Services are submitted to OHSU Health via an authorization form – The review is handled via the Case Management team • OHSU Health Services will continue to have discussions with Health Share around the Transition of Care requirements that best fit our members 12

Referrals • Referrals will be waived for the first 90 days (1/1/2020 – 3/31/2020) • Beginning 4/1/2020 referrals are not required for members within the first 30 days of coverage • Referrals are valid for 180 days or the until the number of visits as been meet (whichever comes first) Referrals are required for: • Services that are below-the-line, non-funded or unlisted on DMAP’s Prioritized List of Covered services • Request for out-of-network specialist & ancillary providers • PCP to PCP referrals outside of call share 13 Submit referrals to OHSU Health Services: Fax: 833 -949 -1887 Phone: 844 -931 -1774

Referrals • Referrals are not required for people with Special Health Care Needs (SCHN) or for OB/GYN, Orthopedic services and/or immunizations for in or out-of-network services – Individuals who have high health care needs, multiple chronic conditions, mental illness or substance use disorders and either have functional disabilities, or live with health or social conditions that place them at risk of developing functional disabilities (for example, serious chronic illnesses or certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care) 14 Submit referrals to OHSU Health Services: Fax: 833 -949 -1887 Phone: 844 -931 -1774

Medical Prior Authorizations • Authorization forms can be found on the OHSU Health Services website • The provider must be DMAP registered • Out-of-network providers must have a valid referral on file before authorization request can be processed • Retroactive request after 90 days from the date of service will not be accepted nor approved • Authorizations are not required if OHSU Health Services is secondary, unless the primary policy doesn’t allow the service • In-network DME requires prior authorization when total billed charges on the claim is over $150. 00 For members who transition between IDS’ under Health Share, OHSU Health Services will honor prior authorizations from other IDS partners for the first 90 days (beginning 1/1/20 through 3/31/2020) for physical health and pharmacy. Submit authorization (along with chart notes) request to OHSU Health Services: 15 Fax: (833) 949 -1887 Phone: (844) 931 -1774

Medical Prior Authorizations Understanding expedited vs. priority PA requests Expedited authorization decisions will be made no later than 72 hours after the receipt of the request for services that: • Seriously jeopardize the member’s life, health or ability to attain, maintain or regain maximum function Standard authorization requests, the standard timeframe will apply • 14 calendar days of receipt of the request Priority authorization: request is made within two working days of receipt of the request for: 16 • Example: admission to skilled nursing facility pending • Member’s life, health, or ability to attain, maintain or regain maximum function is not being questioned

Prior Authorizations- In House Review Radiology, Cardiology & Advanced Imaging • OHSU Health Services will manually process PA’s for the first 60 days – After this time period, evi. Core will process all radiology, cardiology and advanced imaging prior authorizations. • Only specific codes will require a PA during this timeframe (see table on the right) • Standard ultrasounds & routine OB ultrasounds do not require prior-authorization 17 Beginning 1/1/2020 – 2/29/2020* Codes Requiring a PA: CPT 77047 73706 70545 70549 75574 75635 78816 MRI Breast, no contrast CT angio LE MRA head w/s contrast MRA head w/contrast MRA neck w/s contrast CTA abdominal aorta PET, Tumor imaging * After 2/29/2020, all radiology, cardiology and advanced imaging prior authorizations will be process by evi. Core

Evi. Core Radiology, Cardiology & Advanced Imaging Beginning 3/1/2020 and forward • Reviews & prior authorizations for radiology, cardiology & advanced imaging – Standard ultrasounds & routine OB ultrasounds do not require priorauthorization • Codes are incorporated on the evi. Core prior authorization list on the OHSU Health Services website • Criteria can be found on evi. Core website – https: //www. evicore. com/provider#Reference. Guidelines • Retro authorizations are allowed up to 90 days from the date of service • Prior authorizations will be submitted directly to evi. Core Contacting evi. Core: Phone: (844) 303 -8451 18 Web: www. evi. Core. com

Prior Authorizations- In House Review Specialty Pharmacy, reviews & authorizes selected chemotherapy & specialty drugs Beginning 1/1/2020 and forward Beginning 1/1/2020 – 2/29/2020 OHSU Health Services will manually process PA’s that will be required through Magellan Rx **All codes requiring a PA are incorporated on the prior authorization list on the OHSU Health Services website. • These prior authorizations will be reviewed in house: J 3398 J 3490 J 9015 Codes are listed on website** Luxturna Zolgensma Zulresso Proleukin Agents for the treatment of hemophilia and other bleeding disorders Please review OHSU Health Services website for a full list. 19

Magellan Rx will process prior-authorizations for specialty pharmacy, selected chemotherapy and specialty drugs Beginning 3/1/2020 and forward Codes are incorporated on the Magellan Rx prior authorization list on the OHSU Health Services website (list will be added January -February 2020 or earlier) Prior authorizations will be submitted directly to Magellan Rx Contact Magellan Rx Specialty Pharmacy: Phone: 800 -424 -8114 Web: www. icorehealthcare. com 20

Hysterectomies • Hysterectomies performed for the sole purpose of sterilization are not covered • Prior authorization is required for all hysterectomies except radical hysterectomies – A properly completed Hysterectomy Consent form is required for all hysterectomies at the time of prior authorization request • Do not use the Consent to Sterilization form (DMAP 742 A or B) for hysterectomies Oregon law requires an informed consent be obtained from any individual seeking voluntary sterilization (tubal ligation or vasectomy) or a hysterectomy – This form is available on the OHSU Health Services website – Please send the form to 833 -949 -1556 – If the form is not received with the prior authorization, we will deny the authorization until the form is received 21

Voluntary Sterilization • Consent for voluntary sterilization must be an informed choice • Ages 15 years or older who are mentally competent to give informed consent with at least 30 days but not more than 180 days must pass between the date of the written consent and the date of the sterilization • The member must sign and date the consent form before it is signed and dated by the person obtaining the consent – The person obtaining the consent must sign the consent form anytime after the client has signed but before the sterilization is performed Consent forms are required at the time of prior-authorization request – Not required if the procedure caused sterilization but the purpose of the procedure is something other than sterilization – The form can be found on OHSU Health Services website 22 – Please send the form to 833 -949 -1556 with authorization request

DMAP Provider Enrollment 23 23

DMAP Provider Enrollment • All rendering, billing providers & facilities must be DMAP registered in order to get paid for the services for seeing OHSU Health Service’s members • All attending providers • All prescribing physician & pharmacies • Enrollment is for 3 years or until the license expires/lapses • Typically 30 -60 days for provider to become enrolled once application is received 24

DMAP Provider Enrollment • 25 Can also verify via MMIS • If shows valid in MMIS but not on our spreadsheet then most likely will show up on next week’s file

Appeals and Grievances 26 26

Member Grievances • A complaint is an expression of dissatisfaction to OHSU Health Services or a provider about any matter that does not involve a denial, limitation, reduction or termination of a requested covered service – Examples include, but not limited to, access to providers, waiting times, demeanor of medical care personnel, quality of care & adequacy of facilities • Providers are encouraged to resolve complaints, problems & concerns brought to them by their OHSU Health Services patients but if you cannot resolve a complaint yourself, please inform the member that we have a formal complaint procedure • There is no timeline for when a grievance can to be filed • Forms can be found on OHSU Health Services website • OHSU Health Services will reach out to you to for assistance in resolving grievances. – Please respond as quickly as possible as there are short turnaround times required for these grievances. 27

Member Appeals • An appeal is a request by an OHSU Health Services member or his/her representative to review an OHSU Health Services decision to deny, limit, reduce or terminate a requested covered service or to deny a claim payment • A member appeal can be submitted to OHSU Health Services by a member or a provider, on the member’s behalf • The member’s written consent is required • The appeal must be requested within 60 days of the date on the member’s Notice of Action letter & must be in received in writing • If the appeal decision upholds the denial, the member is informed of the right to request an administrative hearing through OHA 28

Member Appeals • OHSU Health Services appeal staff facilitates the member complaint & appeal process & • Written appeals can be sent to: seeks input from appropriate parties to reach OHSU Health Services a decision about the complaints & appeals Attn: Appeals Unit The appeal staff sends a written resolution to PO Box 40384 the member or his/her representative within 5 Portland, OR 97240 days of receipt of a complaint & within 14 days of receipt for an appeal (with possible extensions) • Forms can be found on OHSU Health Services website 29 Fax: 503 -412 -4003 Attention: Appeals Unit

Provider Appeals • Initial applicant provider & participating providers have 60 calendar days following the receipt of the medical director’s letter of the OHSU Health Services decision to take adverse action against the provider’s or practitioners participating status • A written request would be mailed to the medical director by certified mail • If a provider has a question regarding claims status, member eligibility, payment methodology, medical policy or third-party issues, please send a written request to: OHSU Health Services Attn: Appeals Unit PO Box 40384 Portland, OR 97240 30

Provider Portal 31 31

Provider Portal • Please use the following website: Moda Health Benefit Tracker • In the portal, you can validate the following: – Eligibility & benefits – PCP history – Referral inquiry – Claims status • Tax Identification Number driven 32

Provider Portal 33

Provider Portal: Eligibility Jane Doe AB 123 C 4 D OHSU Health IDS OHSU Health 34

Provider Portal; Claims 35

Provider Portal: PCP 36

Provider Portal: Referrals 37

Care Integration and Coordination 38 38

CCO 2. 0 – Five Primary Areas of Action Focus Behavioral Health and Dental Health Integration Value-Based Payments Care Coordination and Integration 39 Social Determinants of Health Information and Technology – Data Integration

Care Integration and Coordination Team Community Outreach Specialist Integrated Community Care Manager (RN/SW) (CHW) Health Engagement Specialist OHSU Health Plan Member Care Integration Specialist Panel Coordinator Clinical Pharmacist 41

Care Integration and Coordination Team CICP Director Maggie Klein West Side Integrated Community Care Managers (RN/SW)(3) CICP Manager Vacant Core Integrated Community Care Managers (RN/SW)(3) Health Engagement Specialists (2) 42 Pharmacist (1) Health Engagement Specialists (2) Care Integration Specialists (2) Panel Coordinators+ East Side Integrated Community Care Managers (RN/SW)(3) Health Engagement Specialists (3) Care Integration Specialists (2) Panel Coordinators+ Wellness Promotion All Regions and Outreach Supervisor Cristela Daniel-Valdez Community Outreach Specialists (2) Clinical Integration Specialist – Foster Program (1 -TBD)

Health Plan Member Populations Differentiated High Risk Rising Risk Care Coordination Wellness Promotion 43

Health Plan Member Populations Defined High Risk • Members with multiple, ongoing and complex medical or behavioral issues and social concerns • Managed by Multi-disciplinary Integrated Care Team • Integrated Community Care Managers (ICCM - RN) have lead – if Behavioral ICCM – SW have lead • Members with acute, time-limited medical needs or new onset conditions • Medical Condition or Social Situation • Less Intense Care Integration and Coordination Rising Risk • Care Integration Specialists or Health Engagement Specialists have lead – ICCM RN/SW as needed Care Coordination • Members with single (or non-complicated) conditions • Members with specific needs due to Social Determinants of Health • General Care and Service/Need Coordination • Care Integration Specialists have lead – Community Outreach Specialists (CHW/THW) as needed • Members who are healthy to provide wellness support and preventive services • Community-based Education programs and services • Foster Children Coordination Wellness Promotion • First Tooth (Dental Program) 44 • Wellness Supervisor, Care Integration Specialist – Foster Care, and Community Outreach Specialists

Pharmacy 46 46

Pharmacy How can I access the pharmacy formulary? – Beginning January 1 st 2020, the OHSU Health formulary will be available at https: //www. ohsu. edu/healthshare – Prior to January 1 st 2020, the existing THA formulary can be referenced at https: //tualityhealthalliance. org/ Google Chrome is the preferred browser to navigate the formulary URL search tool. 47

Pharmacy How do I submit pharmacy authorization requests? – Beginning January 1 st 2020, pharmacy authorization requests for OHSU Health Services members should be sent to OHSU PBM Services – Prior to January 1 st 2020, requests should be sent to the member’s current Medicaid insurer – OHSU Health pharmacy authorization request forms are located at https: //www. ohsu. edu/healthshare and via the Cover. My. Meds Portal – A completed form and supporting clinical documentation is required for authorization review – The fax number for OHSU PBM Services is 503 -346 -8351 What number should I call with questions about pharmacy claims or authorization requests? – Contact OHSU Health at 844 -827 -6572 and select option “ 1” – Provider services are available Monday-Friday 8 am-5 pm 48

Pharmacy Will active pharmacy authorizations on-file with the member’s previous Medicaid insurer be valid after January 1 st? – Active pharmacy authorizations obtained from the member’s previous Medicaid insurer prior to January 1 st 2020 will be honored for up to 90 days during the transition period – A pharmacy authorization request will need to be submitted to OHSU PBM Services to ensure continued coverage prior to the transition period ending Where can I locate pharmacy clinical coverage guidelines ? – Pharmacy prior authorization and step therapy clinical coverage guidelines can be found at https: //www. ohsu. edu/healthshare and upon request 49

Pharmacy How are mental health medications covered for OHSU Health members ? – Medications used for treatment of mental health conditions are covered by the Oregon Health Authority – These medications will appear as “Non-Formulary” on the formulary URL search tool as coverage is not through OHSU Health Services What pharmacies are in-network? – Most major pharmacy chains aside from CVS and Walgreens are in-network – Beginning January 1 st 2020, a pharmacy locator tool will be available at https: //www. ohsu. edu/healthshare 50

Website 51 51

Website 52 https: //www. ohsu. edu/healthshare

Contact Us Primary point of contact for OHSU Health Services is Customer Service Phone 844 -827 -6572 Hours of Operation: 7: 30 a. m. to 5: 30 p. m. , Weekdays 53 Provider Relations Representative Noah Pietz 503 -265 -4786 noah. pietz@modahealth. com Manager, Medicaid Services Kayla Jones 503 -412 -4015 kayla. jones@modahealth. com

Questions? 54