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Oregon Health Plan (Medicaid), Medicare and Commercial Members

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Oregon Health Plan (Medicaid), Medicare and Commercial Members 2016 Provider Workshop Presented by Moda Health Agenda • Moda Networks • OEBB & PEBB Plan Changes • Credentialing • Primary Care Support • Prior Authorizations updates • Ensuring Accurate Claims • Risk Adjustment • Contacting Moda Health Moda Networks Total membership 266,403 42,269 46,763 Commercial Medicare Medicaid - EOCCO Northern Coast membership 10,165 3,971 Commercial Medicare Southern Coast membership 8,191 1,328 Commercial Medicare Southern Valley membership 22,478 4,527 Commercial Medicare Eastern Oregon membership 46,763 19,108 3,745 Commercial Medicare Medicaid - EOCCO Portland Metro membership 92,245 9,878 Commercial Medicare The Gorge membership 4,194 827 Commercial Medicare Central Oregon membership 21,943 2,660 Commercial Medicare Willamette Valley membership 37,891 4,649 Commercial Medicare West Central Valley membership 32,935 6,776 Commercial Medicare 2017 Network overview Affinity (Individual plans) Medicare Advantage Beacon (Individual plans) EOCCO (Medicaid) Connexus (Large and small group employer plans) Summit Synergy (Large and small group (Large and small group employer plans) employer plans) 2017 Individual Network lineup Clackamas, Clatsop, Columbia, Coos, Curry, Beacon Hood River, Jackson, Josephine, Marion, Select Western Oregon Multnomah, Polk, Wasco, counties Washington and Yamhill counties Affinity Baker, Grant, Gilliam, Harney, Lake, Malheur, Eastern Oregon Morrow, Sherman, counties Umatilla, Union, Wallowa and Wheeler counties Beacon Network Effective January 1, 2017 What is different? • Smaller geography • Clinically integrated network, which includes nine health system partners and their referring providers • Simplified plan design options (1 bronze, 3 silver and 3 gold) • PCP selection is required Beacon Network 1. Adventist Health 4 2. Asante 6 3. Bay Area Hospital 8 1 5 4. Columbia Memorial Hospital 9 7 5. Mid-Columbia Medical Center 6. Oregon Health & Science University (OHSU) 7. Salem Health 8. Tuality Healthcare 9. Willamette Valley 3 Medical Center 2 2 Affinity Network Effective January 1, 2017 What is different? • Replaces Beacon Network in Eastern Oregon • Mirrors EOCCO & Summit Network geography • PCP selection is required Affinity Network 1. Blue Mountain Hospital District 2. CHI St. Anthony Hospital 3 2 10 3. Good Shepherd 7 4 4. Grande Ronde Hospital 5. Harney District Hospital 8 6. Lake Health District 1 7. Morrow County Health District 8. Saint Alphonsus – Baker City 9. Saint Alphonsus – Ontario 5 10. Wallowa Memorial Hospital 9 6 2017 Employer group network lineup Small group Large group Connexus Connexus Statewide Statewide Synergy Synergy Western Oregon counties Western Oregon counties Summit Summit Eastern Oregon counties Eastern Oregon counties Synergy/Summit networks Partnership between Moda Health and Providers to achieve Triple Aim goals Better Better Better health care value Key tenets Population health management Provider/payer business model characterized by partnership Sharing risk, data and best practices PCPCH support Synergy Network 1. Adventist Health 4 2. Asante 17 16 8 5 3. Bay Area Hospital 1 1 7 4. Columbia Memorial Hospital 13 5. Legacy Health 10 12 11 11 15 6. Mercy Medical Center 11 7. Mid-Columbia Medical Center 15 8. Oregon Health & 9 Science University (OHSU) 15 9. PeaceHealth 10. Salem Health 3 6 11. Samaritan Health Services 12. Santiam Hospital 2 13. Silverton Hospital 2 14 14. Sky Lakes Medical Center 15. St. Charles Health System 16. Tillamook Regional Medical Center 17. Tuality Healthcare Summit Network 1. Blue Mountain Hospital District 2. CHI St. Anthony Hospital 3 2 10 3. Good Shepherd 7 4 4. Grande Ronde Hospital 5. Harney District Hospital 8 6. Lake Health District 1 7. Morrow County Health District 9 8. Saint Alphonsus – Baker City 9. Saint Alphonsus – Ontario 5 10. Wallowa Memorial Hospital 6 Discontinued networks Rose City Network • Discontinued as of 12/31/16 Community Care Network • Discontinued as of 12/31/16 OEBB Plan changes OEBB Medical plan changes • Travel network is changing to First Health Network effective October 1, 2016 • Synergy Network expanded into Crook, Deschutes, Douglas and Jefferson counties • As a reminder, Synergy/Summit members must choose a Moda Medical Home for primary care and preventive services OEBB Vision plan changes Plan options have been consolidated and renamed Opal Pearl Quartz $600 benefit $400 benefit $250 benefit max max max PEBB Plan changes PEBB Plan changes • Marion County (through the YMCA) http://theyonline.org/programs- services/ymcas-diabetes-prevention-program Diabetes • Polk County (through the YMCA) http://theyonline.org/programs- Prevention services/ymcas-diabetes-prevention-program Program • All Eastern Oregon counties (through CCNO) http://www.ccno.org/index.cfm?fuseaction=d ep_intro&dept_id=11 PEBB Plan changes PEBB is expanding Synergy into the following counties for 1/1/17: • Hood River • Jackson • Josephine • Klamath • Deschutes • Jefferson • Crook • Douglas • Coos • Curry Credentialing Medversant technologies • Effective 4/25/2016, credentialing applications for Moda are processed Credentialing is now through Medversant an online process • To use ProviderSource™, simply go to via Medversant modahealth.providersource.com and Technologies follow the steps to submit your ProviderSource™ information platform • For general credentialing questions, you may continue to contact Moda Health Credentialing Department directly at 855-801-2993, or modahealth.com/medical/ credentialing/overview Credentialing modahealth.com/medical/credentialing/overview Moda Primary Care Support What is Passport to Health? Innovative healthcare program Provides support Targets high-risk with health members conditions Program varies based on employer group Email [email protected] to learn more Who has a Passport to Health Program? Program name Employer group Engagement level Healthy Foundations City of Portland High Salem Health Passport to Health PCC Structurals High Comprehensive OEBB Coordinated Care (C3) Moderate PEBB Program Passport to Health engagement Online tools Health style Patient-centered Access to Concierge Face-to-face assessment primary care home a health clinical community-based integration advocate services care team Primary care transformation 2017 OHA Patient-Centered Primary Care Home revisions • The Oregon Health Authority’s Patient-Centered Primary Care Home program works with stakeholders across Oregon to set standards for what high-quality, patient-centered primary care looks like. • New criteria effective January 2017 • PCPCH Medical Home tiering expanded to 5 levels • Further differentiates advanced Medical Home practices • Payment structure for additional tiers will be communicated to participating Synergy, Summit, and EOCCO certified Medical Home providers • *More information can be found at www.oregon.gov/oha/pcpch/Pages/index.aspx CPC+ • Moda Health and EOCCO were each selected as a payer partner in the Comprehensive Primary Care Plus Program (CPC+). • Comprehensive Primary Care Plus (CPC+) is a national advanced primary care Medical Home model that aims to strengthen primary care through: • Multi-payer payment reform • Care delivery transformation • Multi-payer payment redesign will give practices greater financial resources and flexibility to make investments to achieve better care, smarter spending and healthier people. Key tenets include: • Care management fee • Quality incentive • Alternate payment model for advanced practices, beginning in 2018 • Details related to Moda and EOCCO’s CPC+ program will be communicated to participating practices as soon as the CMS practice selection process is complete. • Program is effective January 1, 2017 Prior authorization updates MagellanRx • MagellanRx reviews injectable medication prior authorization Moda has partnered requests performed in an outpatient with MagellanRx to assist facility, a patient’s home, or in a in medical pharmacy physician’s office management through the provider • To register with MagellanRx and submit prior authorization requests administered injectable or re-authorizations, please visit medication program www.magellanrx.com More information on the MagellanRX injectable medication program can be found at www.modahealth.com/medical/injectables/ MagellanRx updates Effective October 1, 2016, Moda is expanding its claim check program for injectable and/or infusion medications: Bendeka Nucala • Applies to all fully insured Cinqair Onivyde Commercial membership • Select ASO, Medicare Darzalex Portrazza Advantage, PERS Medicare and non-Medicare membership Empliciti Tecentriq Kanuma We will expand this initiative to cover and include specialty and injectable medications in the future Ensuring accurate claims Provider Integrity Program (PIP) This program is designed to review healthcare claims that may represent questionable or abusive billing practices PIP examines and flags potential claims daily prior to payment Captures license status and provider records Clinical editing TruClaim • TruClaim is a rigorous daily audit to detect and avoid claims billed inaccurately Applies clinical logic edits if a claim is billed inaccurately. For example: a modifier is missing, wrong modifier was attached or primary code if the provider only bills with an add-on code National Drug Codes (NDC) Policy Effective September 1, 2015: Complete NDC information is required on all professionally administered medication claims billed to Moda for the Oregon Health Plan (Medicaid), Medicare and Commercial Members. Required:
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