Specialty Care Provider Orientation - MetroPlus Health Plan

Specialty Care Provider OrientationRevised: February 1, 2013

Orientation Topics• MetroPlus Overview• MetroPlus Product Lines• New Managed Care Benefits• MetroPlus Medicare• Member Eligibility Verification• Specialty Referrals• Access to Care Guidelines• HIV Testing• Model of Care for MedicareSpecial Needs Plans (SNPs)• Quality Management• MetroPlus Fraud and AbusePrevention Program• Required Authorizations• Pharmacy/Prescriptions• Laboratory Services &Approved In-Office Lab Tests• Claims• Notification of Changes• MetroPlus Website & ProviderPortal• Care Management• Smoking Cessation• Transportation Services• Key Points to Remember• HHC Facility Referral ContactList1

MetroPlus Overview• MetroPlus is a Prepaid Health Services Plan (PHSP) licensed tooperate in:­ Manhattan­ Brooklyn­ Queens­ Bronx• In 2012, MetroPlus was again rated the #1 Medicaid Managed Carehealth plan in NYC along with being rated #1 in New York State.­ Based on indicators chosen by the New York State Department ofHealth (NYSDOH) and published in the Consumer’s Guide toMedicaid Managed Care in NYC• MetroPlus, which began operations in 1985, is a wholly ownedsubsidiary of New York City Health and Hospitals Corporation (HHC)2

MetroPlus Product Lines• Medicaid Managed Care (MMC)• Child Health Plus (CHP)• Family Health Plus (FHP)• Medicaid HIV Special Needs Plan, Partnership in Care (SNP)• MetroPlus Platinum Plan (HMO)• MetroPlus Advantage Plan (HMO SNP)• MetroPlus Select Plan (HMO SNP)• MetroPlus Medicare Partnership in Care Plan (HMO SNP)• MetroPlus Gold• MetroPlus Managed Long Term Care3

New Managed Care BenefitsMedicaid Managed Care Marketing• Medicaid Managed Care Plan marketing representatives can onlyenroll uninsured people into their plans• Plan Marketing Representatives cannot enroll Fee for Service (FFS)Medicaid recipients; this is also true for MetroPlus HIV SNPMarketing Reps­ If you have a patient who is in FFS Medicaid and wants to enrollin a Medicaid Managed Care Plan, please instruct them to callNY Medicaid CHOICE at 800-505-5678• As a result of these changes, MetroPlus HIV SNP MarketingRepresentatives are no longer located in the HHC HIV clinics; theymay be able to conduct workshops/educational activities• In addition to enrolling the uninsured, Plans are expected toconcentrate on retaining current members4

New Managed Care Benefits con’tPersonal Care/Home Attendant Services• Personal Care/Home Attendant Services are part of the MedicaidManaged Care benefit package• MetroPlus now provides these services to MetroPlus MedicaidManaged Care and Medicaid HIV Special Needs members• Personal Care Services must:­ Be ordered by the member’s PCP­ Be medically necessary­ Provide some or total assistance with personal hygiene, dressing,feeding, assisting in preparing meals and housekeeping­ Be important to keep the member healthy and safe in their ownhome• The Personal Care Services must be provided by an agency thathas a contract with MetroPlus5

New Managed Care Benefits con’tPersonal Care Services• To request authorization for Personal Care Services for a MetroPlusmember, complete the following forms which are posted on theProvider Orientation tab of the MetroPlus portal:­ Fax to MetroPlus Personal Care Team­ M-11Q Medical Request for Home Care6

New Managed Care Benefits con’tRestricted Recipients• Medicaid consumers in the Restricted Recipients Program are required to enroll in aMedicaid Managed Care Plan• Restricted Recipients are individuals with a pattern of misusing or abusing benefitpackage services and are restricted to one or more providers to receive their services­ Restrictions include PCPs, specialists, dentists, podiatrists, hospitals,pharmacies, and durable medical equipment (DME) vendors• Plans are responsible for enforcing the restrictions and assessing the members todetermine if the restrictions should remain in place• Plans must also identify the need for restrictions for their members• Rosters contain a two-digit code field to identify restricted members and it will includetheir specific restrictions• MetroPlus Restricted Recipients have an “R” on their ID card• Providers must verify member eligibility before every encounter and identify anyrestrictions­ If a member is restricted to a particular doctor, the member cannot be seen byanother doctor without a prior authorization; claims without an auth will be denied­ If a member is restricted to an HHC facility, a prior authorization is required forvisits to another HHC facility7

MetroPlus Medicare• Beneficiaries must live in the MetroPlus service area and cannot have End-Stage Renal Disease (ESRD) at the time of enrollment• MetroPlus Medicare Plans­ MetroPlus Platinum Plan (HMO) for those eligible for Medicare Parts Aand B­ MetroPlus Advantage Plan (HMO SNP) for those eligible for MedicareParts A and B and for NY State Medicaid­ Medicare Select Plan (HMO SNP) for those eligible for Medicare Parts Aand B and for NY State Full Medicaid­ MetroPlus Medicare Partnership in Care Plan (HMO SNP) for thoseeligible for Medicare Parts A and B and living with HIV/AIDS­ MetroPlus Choice Plan (HMO) for those eligible for Medicare Parts A andB who already have creditable prescription drug coverage; this plan doesnot have prescription drug coverage• For more information, visit MetroPlus website, www.MetroPlus.org, log intothe Provider Portal or call our Medicare Customer Services at 866-986-03568

MetroPlus Managed Long Term CareMetroPlus managed Long Term Care is a health care plan especially designed for people21 years or older, who live in Brooklyn, Manhattan, the Bronx or Queens who needlong term care services and have Medicaid. MetroPlus Managed Long Term Careoffers the assistance members need to live safely at home.Members Are Eligible if they are…• 21 years old or older• Eligible for Medicaid• Living in the Bronx, Brooklyn, Manhattan or Queens• In need of long term care of nursing home-level care• Able to remain in their home without jeopardizing their health or safety• In need of long term care services for at least four months from the time of enrollmentMetroPlus Manage Long Term Care will help members obtain the services we do notdirectly cover to make sure they receive the care needed.To find out more about what is and isn’t covered by MetroPlus Managed Long TermCare, please check our Member Handbook or call us at (855)-355-MLTC(TYY: 1-800-881-2812)9

Member Eligibility Verification• Members’ coverage and PCP must be verified before every encounter• Step 1: Ask to see their MetroPlus Member ID Card and a Photo ID• Step 2: Check member’s eligibility using one of these methods­ MetroPlus Provider Portal: http://public.metroplus.org­ MetroPlus Fax Recall (receive fax confirmation): call 800-303-9626and follow prompts for Fax Recall­ EMEVS web site: www.emedny.org for Medicaid, FHP, MedicaidHIV SNP, MetroPlus Advantage and MetroPlus Select members­ EMEVS verification line: call 800-997-1111, enter the MetroPlusProvider Number 01529762 and the Plan Code 092­ MetroPlus Customer Services: 800-303-962610

Specialty Referrals• MetroPlus does not require the submission of referral forms• PCPs use their own written correspondence method for conveyingindications for referral and relevant medical history or test results toSpecialists• Specialists are expected to provide PCPs with consultation reports11

Access to Care• MetroPlus Members must secure appointments within the followingtime guidelinesEmergency CareUrgent Medical or Behavioral ProblemNon-Urgent “Sick” VisitWell-Child Care VisitsRoutine Non-Urgent, Preventive or Well Child VisitAdult Baseline and Routine PhysicalAdult Baseline and Routine Physical for HIV SNP MembersInitial Family Planning VisitIn-plan Behavioral Health or Substance Abuse Follow-up Visit(Pursuant to Emergency or Hospital Discharge)In-plan Non-urgent Behavioral Health VisitSpecialist Referrals (Non-urgent)Health Assessment of Ability to WorkImmediately upon presentationWithin 24 hours of requestWithin 48-72 hours of request, asclinically indicatedWithin 4 weeks of requestWithin 4 weeks of requestWithin 12 weeks of enrollmentWithin 4 weeks of enrollmentWithin 2 weeks of requestWithin 5 calendar days of request, oras clinically indicatedWithin 2 weeks of requestWithin 4-6 weeks of requestWithin 10 calendar days of request12

Access to Care: Initial Prenatal Care &Newborns• MetroPlus Members must secure appointments within the followingtime guidelinesInitial Prenatal Visit First TrimesterWithin 3 weeks of requestInitial Prenatal Visit Second Trimester Within 2 weeks of requestInitial Prenatal Visit Third TrimesterWithin 1 week of requestInitial Primary Care Provider (PCP) Visit forNewbornsInitial Newborn Visit for HIV SNP MembersWithin 2 weeks of hospital dischargeWithin 48 hours of hospital discharge13

HIV Testing• HIV testing must be offered to all people between the ages of 13and 64 receiving­ primary care services from a physician, physician assistant,nurse practitioner or midwife,­ care in the emergency room­ or care as an inpatient in a hospital• Prenatal care providers should provide HIV counseling to allpregnant women as early as possible in their pregnancy­ A repeat third trimester test, preferably at 34 - 36 weeks, shouldbe recommended to all pregnant women who tested negativeearly in prenatal care14

Model of Care Requirements forMedicare SNPs• CMS requires Special Needs Plans (SNPs) to have an evidencedbasedmodel of care which outlines how the Plan will provide care tomeet the specialized needs of SNP enrollees• The Model of Care requires SNPs to:­ Have an appropriate network of providers and specialists­ Conduct an initial assessment and an annual reassessment ofthe individual’s physical, psychosocial and functional needs foreach enrolled individual­ Develop a plan that identifies goals and objectives for thatindividual under the SNP­ Use an interdisciplinary team in the management of care15 15

MetroPlus Model of Care con’t• Develop a plan of care for each member under the SNP thatidentifies goals and objectives for that individual­ Plan of care developed by MetroPlus Care Manager incollaboration with PCP, behavioral health experts, socialservices experts and the member­ MetroPlus will share the plan of care with the member’s PCP fortheir review and comment16 16

MetroPlus Model of Care con’t• Use an interdisciplinary team in the management and coordinationof the member’s care­ PCP, care managers, behavioral health, social services and themember• Work with physicians, other providers and the member to coordinatecare­ Patient/family education­ Self management of chronic disease­ Preventive care­ Discharge planning• The exchange of information between the provider, MetroPlus andthe member is critical17 17

Quality Management• MetroPlus is committed to providing comprehensive, patient-centered,quality health care­ MetroPlus strives to establish a coordinated, cost effective medicaldelivery system which is timely and appropriate for Member needs• MetroPlus collects and analyzes data for HEDIS and QARR annually­ Quality Assurance Reporting Requirements (QARR) for CHP, FHPand Medicaid products­ Healthcare Effectiveness Data and Information Set (HEDIS) forMedicare products­ Providers are required to assist with collecting data as needed• Quality of Care­ MetroPlus uses QARR and HEDIS results to identifyaccomplishments and areas for improvement­ If there is an area for improvement, MetroPlus collaborates withproviders to develop and implement quality improvement projects18

MetroPlus Fraud and Abuse PreventionProgram• MetroPlus is committed to preventing fraud, waste and abuse by members,providers and employees­ Examples for members include overutilization of ER services,oversupply of controlled substances, prescriptions or DME, doctorshopping, pharmacy shopping, inappropriate medication combinations,prescription forgeries and member card loaning or sharing• Providers are encouraged to report suspected fraud, abuse, questionableand illegal activities to MetroPlus• MetroPlus has the following reporting mechanisms in place:­ MetroPlus Compliance Hotline: Call 888-245-7247; you can give yourname or report anonymously­ Corporate Compliance Officer: Contact Dennis Norton,MetroPlus Corporate Compliance Officer, at 212-908-8550 ormetropluscomplianceofficer@nychhc.org­ Provider Services: Contact your MetroPlus Provider ServicesRepresentative19

MetroPlus Fraud and Abuse PreventionProgram con’t• MetroPlus Special Investigations Unit (SIU)­ MetroPlus has a dedicated SIU that is responsible for performingprovider-based fraud and abuse audits and investigations­ The SIU accepts tips, referrals and allegations of fraud or abusefrom a variety of internal and external sources­ Some examples of the fraudulent and abusive activities that theSIU audits and investigates for are: double billing, upcoding,overutilization, lack of medical necessity, unbundling, billing forservices not rendered, billing for services without a license, etc.20

Required Authorizations• You must call MetroPlus Customer Services at 800-303-9626 to obtain prior authorization and/orverification of benefits for the following services:­ Services provided by a Non-Participating Provider­ All Ambulatory Surgical Procedures scheduled at non-HHC facilities­ Behavioral Health and Substance Abuse Services• Authorization required for inpatient services• Authorization for outpatient services required for Medicaid and HIV SNP members over60 visits/year­ Inpatient Admissions, Home Health Care, Skilled Nursing Facility Care, Durable MedicalEquipment, Personal Care, Erectile Dysfunction Treatments, Potentially Cosmetic Procedures­ Physical Therapy, Occupational Therapy and Speech Therapy• MetroPlus members enrolled in Medicare Advantage, Child Health Plus, MetroPlusGold and “exempt” Medicaid and Family Health Plus members who are children 0 – 20years of age and/or members with developmental disabilities will not be subject to themandated benefit limit of twenty (20) visits per specialty type per calendar year, but willstill require authorization for services after visit number twenty.• For all other non-exempt Medicaid and Family Health Plus members, there is a benefitlimit of 20 visits per specialty type per calendar year. There is no means or opportunity torequest an approval or an authorization that will allow for additional visits to be approved.21

Pharmacy/Prescriptions• Effective October 1, 2011, MetroPlus took over responsibility formanaging pharmacy benefits for our Medicaid Managed Care(including HIV SNP) and Family Health Plus members; this benefitwas previously provided by Fee for Service Medicaid• MetroPlus transitioned to a new Pharmacy Benefit Manager (PBM),CVS Caremark, effective October 1, 2011, and as of this date CVSCaremark manages Medicaid (including HIV SNP) and FHPmembers• Effective January 1, 2012, MetroPlus transitioned from informed Rxto CVS Caremark for its remaining lines of business which areMetroPlus' Child Health Plus, Medicare Advantage and MetroPlusGold22

Pharmacy/Prescriptions con’t• MetroPlus formularies are available on the MetroPlus website,www.metroplus.org­ Medicaid/Family Health Plus/HIV SNP formulary was added alongwith a Quick Reference Guide­ MetroPlus also has formularies for Child Health Plus, MetroPlusMedicare and MetroPlus Gold• Some covered drugs have additional requirements or limits oncoverage, including prior authorization, quantity limits and step therapy• For drugs that require prior authorizations­ Call CVS Caremark at 877-433-7643• For members who require specialty drugs­ Call CVS Caremark’s Specialty Guideline Management (SGM)Program at 866-814-550623

Laboratory Services & Approved In-OfficeLab Tests• LabCorp is MetroPlus’ preferred lab partner­ A full list of participating labs can be found on www.metroplus.org• MetroPlus established a list of approved in-office lab tests:­ In order to perform in-office lab testing, the location must have aClinical Laboratory Improvement Act (CLIA) certificate­ Providers may bill one draw fee per patient (CPT Code 36415 or36416) per day; providers paid under a capitated arrangement willbe reimbursed for in-office lab services in their monthly capitationpayment­ All other lab tests must be referred to a MetroPlus participatingreference laboratory; for any lab test not available at an in-networklaboratory, call MetroPlus Utilization Management at 800-303-9626to obtain an out-of-network prior authorization­ Any claims from a provider for tests other than the list of approvedtests will be denied; remember that MetroPlus members cannot bebilled for these services24

ClaimsClaims Submission• Claims must be submitted detailing all services rendered for everyencounter within 90 days of the date of service or discharge­ This applies regardless of whether the provider is paid on acapitated or fee-for-service methodology• Please allow 30 days from claim submission date to receive payment• Claims for all members can be submitted electronically usingMetroPlus Emdeon Payer ID# 13265• Paper claims must be submitted on CMS 1500 or UB-04 forms­ Send paper claims for Medicaid, CHP, FHP and MetroPlus Goldto: MetroPlus Health Plan, P.O. Box 1966, New York, NY 10116-1966­ Send paper claims for MetroPlus Medicare to: MetroPlus HealthPlan, P.O. Box 381508, Birmingham, AL 35238-150825

Claims con’tClaim Status & Appeals• Check Claim Status­ MetroPlus Provider Portal: http://public.metroplus.org­ MetroPlus Customer Services: 800-303-9626• If you disagree with a claim payment determination, you have theright to appeal. You must explain the reason for the appeal andinclude all pertinent information as well as a copy of the original claim.­ In writing:MetroPlus Health PlanClaims Department160 Water Street, 3rd FloorNew York, New York 10038­ By phone: 800-303-9626­ By fax: 212-908-878926

Notification of Changes in Your Practice• Always notify MetroPlus about the following changes:­ Change of address­ Change in Tax ID Number­ Change of providers in group practice­ New sites or closed sites­ Change in practice name/ownership­ Extended leave of absence• Submit changes to Provider Services­ By phone: 800-303-9626­ By fax: 212-908-8885­ In writing to:MetroPlus Health PlanProvider Services160 Water Street, 3rd FloorNew York, NY 1003827

MetroPlus Website & Provider Portal• Visit www.MetroPlus.org to access information 24/7­ Provider Manual, Provider Newsletters­ Formularies, Benefits­ Provider Search, Provider Directory (PDF)• Once you register, you can access the Provider Portal to­ Check member eligibility­ Check the status of submitted claims­ Access Provider orientation and clinical guidelines­ PCPs can access membership rosters­ Obtain MetroPlus reports via the Report Delivery System (RDS)• Membership reports• Utilization reports• Provider Performance Profiles• Diagnosis Code lists• To register, go to www.MetroPlus.org28

Care Management• MetroPlus’ goal is to promote wellness and improve the healthstatus of members• MetroPlus Care Management services include:­ Care Management Programs­ Member outreach­ Member health and education materials­ Health education classes­ Provider health education seminars29

Care ManagementCare Management Programs• AsthmaPlus• Behavioral Health• Complex Case Management/Healthy Heart/Disabilities• DiabetesCare• Domestic Violence• MetroPlus Medicare• MetroMom• Partnership in Care, for people living with HIV/AIDS• Smoking Cessation• Supplemental Security Income (SSI)• Providers may refer any member by calling Care Management at800-579-979830

Smoking Cessation Counseling• Every provider should be an effective advocate for smokingcessation• Free smoking cessation resources include:­ MetroPlus Smoking Cessation Information Line: 800-579-9798­ New York State Toll-free Smokers’ Quit line: 866-697-848731

Transportation Services• Providers are responsible for distributing MetroCards or cash toreimburse members of the following plans for public transportation:­ Medicaid Managed Care­ Medicaid HIV Special Needs Plan• Providers must register to participate for reimbursement in the PublicTransportation Automated System (PTAR) available on:www.nyc.gov/html/hra/html/partners/serv_ptar.shtml32

Key Points to Remember• Check eligibility for each visit• Always check Prior Authorization Requirements• Submit claims for all services rendered on every encounter• Notify MetroPlus as soon as possible of any changes in yourpractice, including extended leave of absence• Call MetroPlus Provider Services at 800-303-9626 with anyquestions33

HHC Facility Referral Contact List• Bellevue Hospital­ Phone 212-562-1011­ Fax 212-562-1035• Coney Island Hospital­ Phone 718-616-4817, 4815 or 4393­ Fax 718-616-4717• Elmhurst Hospital­ Phone 718-334-5970­ Fax 718-334-1866• Harlem Hospital Center­ Phone 212-939-8028­ Fax 212-939-8048• Kings County Hospital Center­ Phone 718-245-3080 or 718-245-3081­ Fax 718-245-342834

HHC Facility Referral Contact List• Lincoln Hospital­ Phone 718-579-4658 or 718-579-5551­ Fax 718-579-5510• Metropolitan Hospital­ Phone 212-423-6491­ Fax 212-423-7017• North Bronx Health Network (Jacobi Medical Center & North CentralBronx Hospital)­ Phone 718-519-4940­ Fax 718-519-3707• Queens Hospital­ Phone 718-883-2202­ Fax 718-883-6252• Woodhull Hospital­ Phone 718-963-8444­ Fax 718-630-3165 (with authorization if necessary)35