choices webinar - bcbst.com...the provider directory lists the agencies in shelby county: – alpha...

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.

CHOICES Webinar

July 2011

Sandata EVV Updates

Sandata has created a Training Path Checklist for each functional area (i.e. Billing, Scheduling, etc.). It is available in the Training Library

Changed the title “Time Management” to “Scheduling”

Added arrows and other visual components to better highlight

items in screen shots

Reorganized materials so there are fewer clicks to access job aids, quick reference checklists, and other materials in the Training Library

2

Important Electronic Voice Verification Reminder

All visits should be scheduled according to the authorization in Electronic Voice Verification (EVV)

Visit should not be canceled for any reason If a visit cannot be made, the scheduled visit should go to “missed”

status and a reason code should be entered at that time To receive a new authorization for a “missed” visit, please contact

the Care Coordination support center at 1-888-747-8955

3

Home Modification Requirements and Policy

Effective May 31, 2011, VSHP Home Modification Inspectors will perform the following tasks:

– Evaluate member’s home to determine needed modifications – Draft report documenting needed home modifications – Submit report to Home Modification Coordinator for distribution to

potential providers for bids – Review bids and make appropriate recommendation

The winning bid is not shared with non-winning contractors The Bidder Tool is available for provider assistance with the

bidding process. This tool is intended for informational use only; it is not required

Bid Request Forms are available on the company website, bcbst.com

Providers notified via email of approved bids

4

Adult Day Care (ADC) License Requirements

On May 25, 2011, the Bureau of TennCare notified all unlicensed ADC providers that moving forward, a license is required prior to providing services to members.

A grace period until Dec. 31, 2011, has been granted to all

Nursing Facility providers and to contracted ADC providers currently providing services to enrollees who were previously participating under the Waiver program prior to the transition.

All other providers must obtain an ADC license from the

Department of Health and Human Services or a Mental Retardation Adult Habilitation Day Facility license from the Department of Mental Health prior to providing ADC services to members, even if contracted with VSHP.

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Transportation for Adult Day Care Services (ADC)

Transportation to and from an ADC is not reimbursed by VSHP The provider may offer transportation to participants if needed, but

VSHP will not reimburse these charges VSHP must provide Non-Emergency Transportation Service to

members receiving ADC services only if: 1. Due to network inadequacy, the member requires transportation

due to distance constraints; or 2. It was deemed an overall cost effective alternative as indicated in

TennCare Rules 2.11.1.8.1 and 2.6.5.2.6

Only in theses two instances will transportation be considered reimbursable by VSHP

Assistive Technology vs. Durable Medical Equipment

Examples of Assistive Technology (AT) include – Grabbers – Grab Bars – Devices to help zip up or down

Durable Medical Equipment (DME) items, such as wheelchairs, are not considered AT and should not be considered part of the member’s CHOICES benefits

If a member is in need of DME, an authorization should be

requested from CareCentrix® by calling 1-888-571-6022 VSHP will not reimburse items considered to be DME if filed under

the member’s CHOICES benefits 7

Inpatient Respite and In-Home Respite

Inpatient Respite services for CHOICES members can be billed via the CHOICES Web Portal on bcbst.com or via normal claims submission procedures

In-Home Respite services for CHOICES members should only be scheduled and billed through the Sandata EVV system

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Billing Codes and Modifiers for HCBS Services

Please remember when billing for services, the appropriate modifier and HCPCS code is used

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Service HCPCS Revenue Code Modifier

Adult Day Care S5100 0570

Assistive Technology T2029 0590 U4

Attendant Care S5125 0570

Home Delivered Meals S5170 0590

Homemaker Services S5130 0570 U1

In-Home Respite S5150 0660

Inpatient Respite S5151 0660

Minor Home Mods S5165 0590

Personal Care Visits T1019 0570

PERS – Installation S5160 0590

PERS – Monthly Fee S5161 0590

Pest Control S5121 0590 U1

Personal Emergency Response System (PERS) Policy and Member Hospitalized

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Contact the Care Coordination Support Center as soon as you become aware a member has been hospitalized

PERS providers may leave their equipment in the member’s home

and resume monitoring once the member is discharged home If the member is permanently institutionalized, the PERS provider

may retrieve the equipment at this time PERS should not charge the member or VSHP for monitoring while

the member is inpatient

Notification to VSHP when Member is Hospitalized

Contact the Care Coordination Support Center as soon as you become aware that a member has been hospitalized

Many times, you know of a member’s hospitalization before the Care Coordinator

Area Agencies on Aging and Disability (AAAD) Credentialing, Site Visits, Attestation Forms

Effective July 1, 2011, VSHP will no longer use the AAAD to credential providers

The assigned Network Representative will conduct all initial site

visits and recredentialing site visits AT, Minor Home Modifications and Pest Control providers will only

require the initial site visit for credentialing purposes Nursing Facilities will continue to be recredentialed every three

years All other provider types will be recredentialed on an annual basis

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AAAD – Credentialing, Site Visits, Attestation Forms

Legislation passed by Congress in 2005 requires that VSHP “ensures organization complies with federal and state laws that detect and prevent Fraud, Waste and Abuse in federal health care programs.”

Attestation form is required once per year

Providers may receive the form via email, fax or in person during the annual site visit performed by the Network Representative

Please sign and return to your Network Representative

13

Pre-Admission Evaluation: Who to Contact and When

A new Pre-Admission Evaluation (PAE) is required when the level of care changes

Enter the Medicaid Only Payor Date

(MOPD) into TN Pre-Admission Evaluation System (TPAES)

To verify eligibility, send a copy of

the most recent PAE to your Network Representative

Enhanced Rates for Nursing Facility Services

To receive enhanced rates for nursing facility services, authorization is required from Care Coordination

For level 1 and level 2 services that do not involve enhanced

services, the PAE serves as the authorization Please do not contact Utilization Management for these

authorizations

15

Support Center Changes in Care Coordination and the POD Unit

Beginning June 1, 2011, Support Center new hours are 7 a.m. to 5 p.m. (CT)

The Support Center also modified its structure to provide additional resources

Each CHOICES Member has a Care Coordination team known as a POD

Each POD consists of the Care Coordinator, Assistant Care Coordinator and Care Coordinator Assistant and is responsible for coordinating the initial services and extending authorizations

The VSHP Care Coordination team has also established a Provider Inquiry Specialist team to assist providers in resolving claims-related issues

Each provider has been assigned a Provider Inquiry Specialist who will be contacting you soon 16

Claims Submissions & Remittance Advices

Submit all claims as quickly as possible to avoid any delays in payment

Work your remittance advice as soon as it is received

Timely filing has been extended to July 31, 2011. Please remember to submit your claims to avoid timely filing denials.

Critical Incidents

Providers are required to notify VSHP within 24 hours of discovery of a Critical Incident.

Phone number for reporting – 1-888-747-8955

If the initial report is made verbally, the written Critical Incident Report form must be faxed to (615) 396-8589.

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Critical Incidents

A follow-up report of the provider’s investigation and the actions taken must be submitted as soon as possible (ASAP) and within 30 days.

The report must include: – The findings of the provider’s investigations – Actions taken in response to the specific incident to ensure the safety and

well-being of the member – Actions provider will take to ensure there is no recurrence of the same issue

In ALL circumstances, providers must provide a written status report within 30 days if for some reason they are unable to complete their investigation.

The status report must include: – The reason for the delay and – The timeframe when the report will be completed and submitted.

A delayed follow-up report should be a rare occurrence

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CHOICES Information Available on bcbst.com

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Select “More”


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Scroll down to the BlueCare/TennCareSelect section and select “more”


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Scroll down and select “more” under the CHOICES section on the right side of the page


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The CHOICES Section now appears

CHOICES Provider Referral Process

CHOICES members have a right to choose HCBS Providers that are within the network. However, the member may request assistance from the Care Coordinator or Support Center to choose a provider when necessary.

Therefore, when a HCBS service (e.g. Personal Assistant, Attendant Care, Home Maker Services) is approved by VSHP, the Care Coordinator or Support Center must provide the member with the most current copy of the VSHP Provider Directory or verbal listing of providers in order to allow the member to choose a provider.

The Care Coordinator shall assist in the members’ selection of providers to ascertain that the member receives their home care needs.

The Care Coordination Supervisor monitors the process to make certain the provider selection is managed appropriately.

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The Care Coordinator will follow the steps outlined below: – Print a copy of the provider directory available online at www.bcbst.com/

weekly to assure there is an up-to-date copy of the provider directory with them at all times when visiting members’ homes.

– Allow the member to select a provider that is within their region or county. – If member needs or requests assistance, assists the member to select a

provider. – To ensure that providers are selected fairly and consistently, the care

coordinator rotates providers alphabetically within the region or county. Example: Ms. Boone wants her care coordinator to assist with selecting a provider for her Personal

Assistant Care. The Care Coordinator also had to assist Ms. Wilhite today who lives in the same county and for the same service.

The provider directory lists the agencies in Shelby County: – Alpha and Omega Home Care – Freedom Home Care – Zest of Life Home Care

– The Care Coordinator chose Alpha and Omega Home Care for Ms. Wilhite, so she must choose Freedom Home Care for Ms. Boone.

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If the Support Center receives a request for assistance with locating a provider they must also choose providers alphabetically. The Support Center staff follows the steps outlined below:

– Retrieves the provider directory from www.bcbst.com/ and allows the member to select a provider within his/her region or county. If member needs or requests assistance, the Support Center assists them to select a provider.

– To ensure providers are selected fairly and consistently, the Support Center rotates providers alphabetically within the region or county. Example: Ms. Boone wants her care coordinator to assist with selecting a provider for her Personal

Assistant Care. The Care Coordinator had to assist Ms. Wilhite today who lives in the same county and for the same service.

The provider directory lists the agencies in Shelby County: – Alpha and Omega Home Care – Freedom Home Care – Zest of Life Home Care

– The Associate Care Coordinator chose Alpha and Omega Home Care for Ms. Wilhite, so she must choose Freedom Home Care for Ms. Boone.

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Locating a Participating Provider on bcbst.com

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Select “Health Tools” and then “Find a Doctor”


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Always use the online Provider Directory – it is the most current directory of contracted providers. The hard copy Provider Directories are out-of-date as soon as they are printed.

Search for CHOICES Providers as explained in the previous slide. Failure to do so will yield unfavorable results when searching for providers.

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BlueAccess

BlueAccess is available to all providers on bcbst.com and vshptn.com

Register and obtain your shared secret

BlueAccess allows you to view:

– Benefit limits – Authorizations – Access to the web portal – Review remittance advices – Obtain member-specific information

For additional information on BlueAccess, please contact your

Network Representative

Important Numbers

Handouts are available with additional important phone numbers

Network Representative contacts:

East Grand Region: Buffy Bass-Douglas Phone: (423) 535-3856 Email: [email protected] Middle Grand Region: Nathan Key Phone: (615) 760-8707 Email: [email protected] West Grand Region: Sheldon House Phone: (901) 544-2170 Email: [email protected]

Important Numbers

Care Coordination: Phone: 1-888-747-8955 Fax: (615) 386-8589 Email: [email protected] ***Beginning June 1, 2011, Care Coordination’s new hours of

operation are 7 a.m. – 5 p.m. (CT).***

BlueCare® Provider Service: Phone: 1-800-468-9736

TennCareSelect Provider Service: Phone: 1-800-276-1978

Automated Eligibility Line:

Phone: 1-800-543-8607

choices webinar - bcbst.com...the provider directory lists the agencies in shelby county: – alpha...

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