acc: access kp provider training - kaiser...
TRANSCRIPT
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Jun-16
Presented by: Colorado Access
ACC: Access KP Provider
Training
ACC: Access KP Overview
• ACC: Access KP is a new Colorado Medicaid initiative run in
partnership with the State of Colorado Department of Health Care
Policy and Financing, Colorado Access, and Kaiser Permanente. It
is scheduled to launch July 1, 2016
• ACC: Access KP focuses on whole person care and brings Kaiser
Permanente care coordination to participating members.
• ACC: Access KP is unique to Medicaid members in RCCO region 3
(Adams, Arapahoe, and Douglas County) of the ACC program.
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How is ACC: Access KP different?
• The initiative was designed to cover most primary care and some
specialty care.
• The initiative consists of about 2,000 CPT codes for which Kaiser
Permanente will be financially responsible.
• Only KP contracted providers can bill Kaiser Permanente for
covered services provided to ACC: Access KP members.
• Medicaid covered services not among the covered primary and
specialty services will continue to be billed directly to the State.
• ACC: Access KP members will need to obtain services from KP
physicians or from KP contracted providers with a prior
authorization.
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ACC: Access KP Benefits
• ACC: Access KP members have the SAME benefits as ACC Medicaid.
• Most primary care and some specialty care will be covered by ACC: Access KP, with additional benefits covered by Medicaid as wraparound services.
• Members will continue to access behavioral health services through their BHO.
• Wraparound services include, but are not limited to the following:
Dental Services
Behavioral Health Organization (BHO) Services
Pharmacy
Home Heath Services
Hospital/Inpatient Services
• All eligibility criteria must be met in order to receive these services. For more information about these benefits, please contact your Colorado Access RCCO Contract Manager.
• ACC: Access KP members should discuss access to all covered services with their KP provider.
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Let’s Recap
• ACC: Access KP is only for Region 3 ACC clients assigned
to Kaiser Permanente
Kaiser Permanente may still be a PCMP for ACC clients in all
regions, except for Region 3
• Benefits are the same as ACC Medicaid
• ACC: Access KP includes services contained in the 2,000
CPT code list
• Services not in the 2,000 CPT code list are called
wraparound services
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Member Enrollment
• There will be a one-time passive enrollment into ACC: Access KP.
• All ACC Region 3 (Adams, Arapahoe, and Douglas County) Medicaid
clients who are attributed to Kaiser Permanente as their Primary
Care Medical Provider (PCMP) will be enrolled.
• The initial enrollment is estimated to be about 26,000 Medicaid
clients.
• ACC: Medicare Medicaid Program (ACC: MMP) clients will not be
enrolled in ACC: Access KP but will be able to select Kaiser
Permanente as a PCMP.
• Clients who have health coverage in addition to Medicaid (i.e.
Medicare, commercial insurance) will not be enrolled into the
initiative.
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How will Members Opt-out?
• ACC: Access KP clients will receive a notification
letter at least 30 days prior to the start of the
program.
• After enrollment, clients will have 90 days to
disenroll for any reason. After 90 days, the client
must wait until their open enrollment period to
change. Clients may change their health plan once
a year.
• ACC: Access KP members can call HealthColorado,
303-839-2120 to opt out.
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Let’s Recap
• 26,000 Region 3 members assigned to Kaiser Permanente
will be passively enrolled into ACC: Access KP
Individuals with third party insurance and/or enrolled in the
ACC: MMP will be excluded
• To disenroll, members call HealthColorado within the:
First 30 days after receiving the passive enrollment letter
First 90 days of enrollment (e.g. July, August, September)
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Services Provided by Non-KP Providers
• Only KP contracted providers can bill KP for ACC: Access KP
members.
• A prior referral and authorization from Kaiser Permanente is
required for all covered services provided to ACC: Access KP
members.
• Without Prior Authorization, claims for covered services will
be denied.
• All prior authorizations need to be submitted to Kaiser
Permanente Utilization Management for thorough review.
• If a member prefers to continue receiving covered services
from a non-KP contracted provider, they should opt out of
ACC: Access KP.
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Referrals
• Providers should always check the eligibility portal before
providing services.
• ACC: Access KP members should be directed to a Kaiser
Permanente provider.
• If covered services are provided without an authorization
from Kaiser Permanente - claims will be denied for
payment by both Medicaid and Kaiser Permanente.
• If ACC: Access KP members do not wish to seek services
from a Kaiser Permanente provider they should opt-out
of the program.
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ACC: Access KP Members and FQHCs
• ACC: Access KP members accessing services at an
FQHC should not be referred to a specialist by the
FQHC.
• The FQHC should have the member call KP and set
up an appointment with their primary care provider
to obtain a referral for specialist services from a KP
specialist or KP contract specialist.
• Members who wish to receive services from non-KP
contracted specialists should opt out of the
program.
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Let’s Recap
• Providers should always check the eligibility portal before
providing services.
• Only KP contracted providers can bill KP for covered
services (in the 2,000 CPT code list) that are provided to
ACC: Access KP members.
Any provider can bill Medicaid for wraparound services
• KP contracted providers must obtain a referral and
authorization from KP for all covered services provided to
ACC: Access KP member.
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Member Identification
• ACC: Access KP members will be identifiable in two ways:
1. ACC: Access KP ID card (see example below)
2. State Web Portal (see example on next slide)
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Web Portal Member Identification
• The State Web Portal can be accessed at:
https://sp0.hcpf.state.co.us/Mercury/login.aspx
• Instructions for obtaining eligibility information from the State Web Portal
can be accessed at:
https://www.colorado.gov/pacific/sites/default/files/EligibilityUserGuide_11252014.pdf
• The State web portal will appear as follows, indicating that the KP member is
enrolled in the ACC: Access KP program;
Please note: Providers will need to scroll to the bottom of the eligibility response
to see the Prepaid Health Plan field, identifying ACC: Access KP Members
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Eligibility Response Comparison
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(All regions, except Region 3)(All regions, except Region 3)
Let’s Recap
• Medicaid clients who have Kaiser Permanente as
their provider will have different eligibility
responses
Regular ACC with Kaiser as PCMP
ACC: Access KP
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Covered Services
• The list of the ACC: Access KP covered CPT codes will be available
at the following website:
www.kp.providers.coaccess.com
• ACC: Access KP covered services will most commonly occur in a
primary or specialty care setting.
• Some examples include:
99203- OFFICE/OUTPATIENT VISIT NEW
76815- OB US LIMITED FETUS(S)
74177- CT ABD & PELV W/CONTRAST
92083- VISUAL FIELD EXAMINATION(S)
99195- PHLEBOTOMY
81001- URINALYSIS AUTO W/SCOPE
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Billing for Services
• If the codes are on the 2,000 CPT list, bill KP directly
for these services. With a valid prior authorization,
the provider will be reimbursed by Kaiser Permanente.
• If the codes are not on the 2,000 CPT list, bill
Medicaid.
• Hospitals and FQHC’s should continue to bill the state
directly.
• Claims submitted by non-KP contracted providers for
the covered services will be denied by KP and
Medicaid.
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Billing for Services (cont.)
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Billing Exemptions: Hospital Billing
• Hospitals using a CMS 1450 (UB-04) claim form should continue to bill
Medicaid as usual.
• Non-hospital employed physicians submitting a CMS 1500 claim form with
Hospital as the place-of-service should submit claims for covered services
to Kaiser Permanente.
Claims submitted using a CMS 1500 with Hospital as the place-of-
service will not require a prior authorization.
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Billing Exemptions: Family Planning Services
• Family planning services included in the 2,000 CPT
codes, will be paid by KP, without prior
authorization.
• Any provider can bill KP for family planning
services provided to an ACC: Access KP member, as
long as the services are billed with the FP
modifier.
• All other family planning services not included in
the 2,000 CPT codes should continue to be billed
directly to the State.
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Denied Claims
• If KP is billed and the claim is denied, follow the KP
claims dispute process.
• If Medicaid is billed and the claim is denied, follow
the Medicaid claims dispute process.
• Colorado Access does not have the authority to
override a denial.
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Billing Medicaid Patients
• If a provider receives a denial from Kaiser
Permanente or the state for a service covered by
Medicaid, the provider cannot bill the member.
• Colorado Medicaid’s rules for billing Medicaid
clients apply to Medicaid members in the ACC:
Access KP program.
• In general, billing Medicaid members is not
permissible due to federal and state regulations.
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Let’s Recap• Hospitals and FQHC’s should continue to bill the state directly.
• Claims submitted by non-KP contracted providers for ACC:
Access KP covered services will be denied by KP and Medicaid.
• Prior Authorization Exemptions: Hospital POS on CMS 1500
claims and Family Planning services billed with an FP modifier.
• Providers cannot bill the member, if a claim is denied.
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Member Contact Information
• ACC: Access KP members may contact Kaiser Permanente Member
Services with questions about benefits, providers, etc.
303-338-3800 or
1-800-632-9700
• ACC: Access KP members may also continue to contact their
Regional Care Collaborative Organization (RCCO), Colorado
Access, with questions.
303-368-0037 or
1-855-267-2095
• For disenrollment, members may contact HealthColorado.
303-839-2120
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Additional Resources
Visit www.kp.providers.coaccess.com (click Provider
Training, then Program Information) to find:
• Cheat Sheet
• Fact Sheet
• Webinar Information & Slides
• CPT Code List
• Frequently Asked Questions (under Who to Contact)
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Provider Contact Information
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Dan Obarski
Colorado Access
Kaiser Permanente
Questions or Concerns?
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Thank You!