strategies for contracting with health plans for vaccine delivery, july 18, 2012. part of the 2012...

Strategies for Contracting with Health Plans for Vaccine Delivery, July 18, 2012. Part of the 2012 Webinar SeriesThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments

Part One: Strategies for Contracting with

Health Plans for Vaccine DeliveryJuly 18, 2012

Third-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health

Departments 2012 Webinar Series

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Presenters

1. Barbara Lardy, M.P.H., Senior Vice President, Clinical Affairs and Strategic Partnerships, America’s Health Insurance Plans

2. Wayne Rawlins, M.D., M.B.A, National Medical Director, Racial and Ethnic Equality Initiatives, Aetna.

3. Kate Reynolds, M.H.A., Enterprise Contract Manger, Provider Contracting and Reimbursement, WellPoint

4. Donna Dojan, M.S., National Director of Contracting Policy, Standards and Compliance, Cigna

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Webinar Agenda

1. Welcome

2. Introduction to Webinar

3. Presentations

4. Questions and Answers

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Recap: Coverage for Vaccines

1. Health plans provide first-dollar coverage (i.e. no cost sharing) for routine vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).

2. New health plans (non grandfathered plans) are required to cover all ACIP recommendations for routine vaccines beginning 2010.

3. Coverage of ACIP recommendations within one year of adoption.

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1. Incorporate practice-level improvements:

– Research acquisition options and strategies.– Understand managed care contracts.– Code appropriately for claims submission.

1. Encourage electronic claims submission processes.

2. Develop collaborative relationships with retail clinics to address vaccine financing and administrative challenges.

America’s Health Insurance Plans, 2009. Vaccine Financing. AHIP Vaccines and Immunization Roundtable Report. August.

Recap: Effective Business Practices Associated with Vaccines

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Webinar Goals

1. Provide public health entities with steps for contracting with health plans for vaccine delivery.

2. Discuss the variability that exists within states and health plans for vaccine contracting.

3. Review contracting processes of two large health plans.

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WellPoint: Contracting for Vaccines

A Step-by-Step Overviewon Behalf of AHIP

Kate Reynolds, M.H.A., Enterprise Contract Manager

Provider Contracting and ReimbursementWellPoint

Webinar One: Strategies for Contracting with Health Plans for Vaccine Delivery, July 18, 2012. Part of the 2012 Webinar SeriesThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments 8


• WellPoint (WLP) is the parent company of 14 Blue Cross Blue Shield (BCBS)

Plans in 14 states across the country: CA, CO, NV, OH, IN, KY, MO, WI, ME, NY,

CT, VA, NH and GA.

• BCBS Plans work together through the Blue Card Program, which allows

members of one state the ability to access discounts through another state’s blue

plan.

– Example: A member who lives in Missouri and has health insurance through an auto manufacturer located in Michigan, would be considered a BCBS of Michigan plan member. Through the Blue Card Program, the member would have access to Missouri health care providers and discounts. Providers would file claims to the BCBS Plan in Missouri where the provider is located. The BCBS Plan of Missouri would price the claim based on the Missouri contract with the provider in question, and would send the claim back to the BCBS Plan in Michigan to apply benefits.

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About WellPoint


1. Contact the local Network Management Contract Manager for your state via

email or phone (see the WLP contracting contact list).

2. Tell the Contract Manager you would like your local health department (LHD) to

be contracted to provide immunization services only. Ask the Contract Manager

to detail this process for their state.

3. The WLP Contract Manager will collect information from you, such as your

billing and practice addresses, National Provider Identification (NPI) number,

Tax Identification Number, telephone number, practitioners, licensure, insurance,

etc.

4. The WLP Contract Manager will likely have you complete and return an

application which reflects the above information.

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WellPoint: Contracting for Vaccines – A High-level Review


5. WLP will not typically list LHD’s in its Provider Directories, and

therefore, will not credential the LHD itself.

– Note: A few WLP states still may wish to credential either the LHD’s Medical Director or practitioners, but the majority will not require any type of credentialing.

– Note: If you are working with a state that requires credentialing, ask the Contract Manager for specifics and they will instruct you regarding how to proceed.

6. Next, the Contract Manager will send you (via regular mail or email)

the Enterprise Provider Agreement (EPA) - also known as the

contract.

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WellPoint: Contracting for Vaccines – A High-level Review (cont’d.)


7. Ask the Contract Manager to also send you the allowed amounts by network

for the most common immunization codes billed by your LHD. Note: this will

typically be sent separately since the EPA will refer to a fee schedule and

will not list the allowed amounts for each CPT code.

– Note: most WLP states do not typically negotiate allowed amounts for immunization codes.

8. Once you have reviewed the EPA, you will need to sign and complete the

signature page and return the entire Agreement (plus a w-9 form and any

application if this has not already been returned) to the Contract Manager .

9. The Contract Manager will send the contract for execution (signing) by WLP.

Typically the Vice President of Contracting for each state will sign.

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10. The Contract Manager will also assign an effective date for the EPA, which is

the same date that the LHD would be considered “In-Network”.

– Note: The effective date is typically assigned 40 – 45 days after the Contract Manager receives the signed, fully executed agreement back from the LHD. This is because the Contract Manager must work with other WLP departments to ensure the LHD is loaded into the claims system as a participating provider, and all of the products and fee schedules are set up to ensure claims will price appropriately.

11. Ask your Contract Manager to provide you with the name and contact

information of your Network Consultant, who is available to help with provider

education issues such as e-billing and claim questions.

**Note: This is a high-level review and the process may vary slightly from

plan-to-plan.

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Cigna: Contracting for Vaccines An Overview on Behalf of

AHIP

Donna Dojan, M.S., National Director

Contracting Policy, Standards and ComplianceCigna

Webinar One: Strategies for Contracting with Health Plans for Vaccine Delivery, July 18, 2012. Part of the 2012 Webinar SeriesThird-party Reimbursement for Vaccines: Effective Billing Strategies for Public Health Departments 14


The Letter of Agreement (LOA) is also known as the contract. It consists of the contract terms and details – what both parties are agreeing to do (and not to do):

1. Effective Date & Length of LOA

2. Definitions of specific terms

3. Timeframes and rules for submitting claims

4. Using Cigna Administrative Guidelines

5. Participant Eligibility

6. Services included

7. Reimbursement

8. Timeframes and Readiness15

Cigna: Contracting for Vaccines – The Letter of Agreement

Cigna: Contracting for Vaccines – The Letter of Agreement


1. Contact the point of contact: Donna Dojan (860) 226-5725.

2. Be prepared with some basic information when calling, including:– Legal Name and Address of your Agency– Tax Identification Number (TIN) and National Provider

Identification (NPI) number

3. Two copies of the LOA will be sent; sign both and return them using the instructions included. Cigna will sign and return one copy.

*Note: Will provide a note about “full contracts” and a note about “insurance companies”

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Cigna: Contracting for Vaccines – A Single Point of Contact


Q & A

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Part Two: Coding and Electronic Billing for Vaccine Delivery Webinar scheduled for August 22, 2012; 2:00 p.m. – 3:30 p.m. ET

Part Three: Navigating the Credentialing Process with Health Plans Webinar scheduled for September 19, 2012; 2:00 p.m. – 3:30 p.m. ET

Register at: http://ahip.org/Webinar/ReimbursementforVaccines/

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Save the Dates – AHIP’s 2012 Webinar Series Continues


AHIP’S ARCHIVED IMMUNIZATION PRESENTATIONS PROVIDED

FOR THE CDC BILLING PROJECT CAN BE ACCESSED AT:

HTTP://WWW.AHIP.ORG/ARCHIVED-WEBINARS-IMMUNIZATION/

THANK YOU!

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