PRESORTED STANDARD U.S. POSTAGE PAID SALT LAKE CITY, UTAH PERMIT NO. 4621 PROVID R N WS 560 East 200 South | Salt Lake City, UT 84102-2004 A PEHP PROVIDER RELATIONS PUBLICATION SPRING 2015
PROVID R N WS A PEHP PROVIDER RELATIONS PUBLICATION SPRING 2015 Contact List EDI Please note: The contact numbers for Case Management, Preauthorization and Customer Service are not the same. Case Management PEHP WeeCare NOW ...... 801-366-7755 or 800-753-7490 ...... 801-366-7400 or 855-366-7400 Are You Customer Service/ Provider Relations Filing Claims Pre-authorization (outpatient) Electronically? ...... 801-366-7557 or 800-677-0457 ...... 801-366-7555 or 800-765-7347 Glenda Lowe ...... 801-366-7496 or 800-950-4877 If Not, EDI Helpdesk Client Liaison [email protected] What ...... 801-366-7544 or 800-753-7818 Chantel Lomax ...... 801-366-7507 or 800-753-7407 Are You Inpatient Preauthorization Provider Relations Specialist [email protected] Waiting ...... 801-366-7755 or 800-753-7490 Angel Macas ...... 801-366-7721 or 800-753-7721 For? Provider Relations Specialist [email protected] Inpatient Mental Health & Substance Abuse Authorization Wendy Philbrick ...... 801-366-7753 or 800-753-7753 Provider Relations Specialist [email protected] Blomquist Hale Consulting Group (BHCG) Canyons School District Selena Johnson ...... 801-366-7511 or 800-753-7311 Jordan School District Provider Data Specialist [email protected] ...... 801-262-9619 or 800-926-9619 Jackie Smith ...... 801-366-7795 or 800-753-7595 Wellness Program Provider Relations Analyst [email protected] ...... 801-366-7300 or 855-366-7300 Laurel Rodriguez ...... 801-366-7350 or 800-753-7350 PEHP Healthy Utah...... 801-366-7300 or 855-366-7300 Provider Relations Manager [email protected]
PEHP Waist Aweigh ...... 801-366-7300 or 855-366-7300 Cortney Larson ...... 801-366-7715 or 800-753-7715 Director of Provider Relations [email protected] ICD-10 Code PEHP Healthy PEHP QuitLine...... 855-366-7500 INSIDE PEHP Website Tips for Utah Is On ...... www.pehp.org MORE USEFUL NEWS PEHP Quitline ...... www.pehp.quitlogix.org Transition The Move 4/17/15 & INFORMATION FOR » PAGE 6 » PAGE 7 PROVIDER PARTNERS PROVIDER NEWS PROVIDER NEWS
COVER STORY: EDI / EFT Requirement Member Watch: Billing In this issue 2-3 EDI / EFT When Lab Testing Requirement Reminder Hurts Your Patients 3 Avoiding Paperless yet? any of your PEHP must be met for coverage for Rejections for EDI patients are getting genetic testing; in addition, Claims M Reminder: Claims Should be Submitted Electronically stuck with large unexpected many genetic tests are not 3 When Lab n case you’ve forgotten, PEHP claim submissions. medical bills due to provider covered. Failure to obtain Testing Hurts Your no longer accepts paper medical Please be aware, a few offices sending laboratory preauthorization for a test Patients Iclaims. These claims are required exceptions for paper claims test(s) to out-of-network leaves a member at risk of 4 Billing: to be submitted via Electronic Data are allowed. They are: laboratories and due to having no coverage or having Rendering and/ Interchange (EDI). » Out of network and/or requests for non-covered the claim paid at out-of- or Incident-to If your office is already submitting claims contracted out of state genetic testing. network benefits, leaving Services EDI, but aren’t getting through to us, providers; We often see claims where them with large financial contact our EDI helpdesk or your Provider 4 Appeals » Providers not contracted obligations. Relations Specialist. We will need to know the billed amounts are over Process Change with any PEHP Networks; your TIN, providers in the group and the 500% above what PEHP Covered genetic tests should 5 Headaches: clearinghouse being utilized. » Claims that require medical allows for the service. This be sent to participating Invasive records – Note: This does providers. A complete list Not currently set up? Contact your practice can leave your patients, our Procedures Policy not include COB claims; or of participating genetic management software; clearinghouse or members, with balance bills ICD-10 is for thousands of dollars. laboratories can be found on 6 UHIN to get started. » If PEHP is the tertiary payer. you don’t have a login, contact your Forthcoming our website at www.pehp.org, Coming Soon!! PEHP will have a claims Additionally, as of January 1, 2015, PEHP Your patients trust you and Provider Relations Specialist. under the specialty “Genetic 7 Enhancements tool online through the secured portion of requires all contracted providers to sign your staff to check for prior If you haven’t signed up for either Laboratory.” Even genetic to Code Auditing our website which will enable providers to up for Electronic Funds Transfer (EFT). authorization requirements function, we encourage you to do it tests covered under the Tool submit their claims electronically. The tool Your office can simply sign up by logging and to send their tests is designed to support individual claim in with your User ID and Password to the as soon as possible to keep your office Affordable Care Act require Spring to laboratories that are 7 submissions and is not designed for batch secured provider portion on pehp.org. If moving smoothly! pre-authorization and may Announcement contracted with their PEHP not be paid if they are directed from PEHP plan so that they are protected to a non-contracted genetic Wellness from balance billing and with laboratory. 8 Group Benefit Avoiding Rejections for EDI Claims the assurance that the services Changes ver find yourself spending is associated with the wrong TPN/ » Check claim information ordered will be covered. We have also seen a large countless hours dealing with clearinghouse Members often feel upset and increase of medically 8 Dual PEHP › DOS (Date of Service) – DOS unnecessary toxicology Coverage rejections of your EDI claims? misled by both the providers E » Claim submitted prematurely must be accurate (no post- testing. As a result, several of Because of avoidable errors, PEHP and PEHP when they are put 9 PEHP’s (COBA) dating) the non-contracted toxicology rejects 4% of electronic claims per day. in these situations. Preauthorization How to prevent your claims from Rendering NPI labs have no out-of-network List Let us offer some guidance to help get › The two categories of being rejected: benefits. your claims through the first time! › Verify CPT codes are valid, as laboratory testing that are 10 2015 » Check eligibility prior to We encourage your office to Education Fair A few top reasons claims get rejected: well as modifiers hurting your patients the Flyer submission most are genetic testing and direct medically necessary Invalid Subscriber ID We encourage you to check your services to contracted » Verify DOB toxicology lab work. 11 Provider › claims prior to submission to providers so members have a Relations Reps » Incorrect DOB (Date of Birth) › Ensure the ID number is avoid the pitfalls of rejected claims All genetic tests require better healthcare experience preauthorization. 12 Contact List » NPI has not been associated with a accurate (i.e. 13 digits; starts and to have them accepted in a and are better protected TPN (Trading Partner Number) or with 1741000) timely manner! PEHP has clinical policies that financially. PAGE 2 PAGE 3 Billing Rendering and/or Incident-to Services EHP’s Financial Assurance PEHP follows CMS’s “incident-to” PDepartment is committed to guidelines for physician extenders. Summary of Guidelines identifying fraud, waste and abuse A physician can bill an incident-to A summary of the guideline includes the and provider education when service when billing for auxiliary following: needed. personnel. » Services or supplies as an integral, though During several random audits, the CMS states auxiliary personnel incidental, part of the physician’s personal Financial Assurance Department include nurses, technicians, or professional services in the course of has identified many provider offices diagnosis or treatment of an illness. that are not correctly following the certified nurse midwives, clinical Centers for Medicare and Medicaid psychologists, clinical social » The physician MUST initiate the care but Services (CMS) “incident-to” workers, physician assistants, nurse need not render a service at each instance guidelines and are not billing claims practitioners, and clinical nurse of billing. under the correct rendering provider. specialists. » The physician must remain actively involved in the care of the patient’s condition. For a complete listing of guidelines, we invite you to visit CMS’s website to learn more at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Refer to Chapter 15, section 60.
Appeals Process Clinical Policies Expediting Turnaround Time Headaches: Invasive Procedures s of April 1, 2015, PEHP has made a determination made by the Benefit EHP now considers trigger Policy Excerpt point injections and occipital change to our appeals process. Resolution Department, the provider will P A nerve blocks experimental be given instructions on how to appeal We’re confident this change will speed up and investigational for the our disputed claims/appeals turnaround DID YOU the determination to PEHP’s Executive treatment of cervicogenic DID YOU time. Review Committee. KNOW? headache, occipital neuralgia, KNOW? If a provider wishes to dispute any To dispute or appeal a claim, inquires cluster headache, chronic Contracted determinations made to a claim, the daily headache, and migraine You can call should be sent to: your Provider providers provider must continue to dispute the headache because their Relations have the determination within 180 days after the PEHP Appeals and Policy Management effectiveness for these indications Specialist responsibility Department claim was processed. has not been established. if you’ve to file the claim P.O. Box 3836 within 12 All disputed claims will first be reviewed To find the full policy, login to misplaced months from by our Benefits Resolution Department Salt Lake City, Utah 84110-3836 the secured provider site and your login information, the DOS. 15 before they can be appealed to our By fax: 801-320-0541 click on “Clinical Policies” on the months if the forgotten it or Executive Review Committee. Our complete claims dispute and appeals left hand side. claim is for simply locked COB. We will not require a form to be process can be found on our website at: We encourage you to stay up to yourself out. completed for the initial review. https://www.pehp.org/providers/claims- date on our policies by regularly If a provider disagrees with the and-billing/appeals checking them out online! PAGE 4 PAGE 5 ICD-10 Coding Code Auditing Pointers for Web Tool Enhancements e are happy to inform you that Trouble-Free Wenhancements have been done on Advantages of the Tool our web-based code auditing reference » Reduces administrative costs! tool. Providers can now enter more claim › Fewer “front line calls” Transition information on this tool, including the claim › Less provider appeals › Reduces reprocessing of claims ctober will be here before you DX, number of units billed and the patient’s know it! You’ll be pleased to age. Providers are encouraged to use this tool » Easy to use! Provides an immediate response know that PEHP is right on track to review PEHP’s coding rationale regarding › O to provider inquiries related to the claims payments online. for the ICD-10 implementation. To keep evaluation of code combinations our provider community in the loop, The tool is available through the secured during the processing of claims below are things we’ve recently tested: portion of our website; therefore, a login is › Enables providers to pre-screen a claim required. If you do not have one or need more and/or review the rationale for a claim Claims Intake » information on how to navigate our website denial Adjudication » and this tool, contact your Provider Relations » Available 24 days, 7 times a week on Specialist. » Financial Outcomes PEHP’s website We encourage your office to take advantage of » Report Capabilities Testing Inquiries » Used by internal personnel for consistent Interested in testing with us? this useful tool, to have a better understanding communication with provider To better assist your office with this Contact our EDI Department (801-366- of the coding rules and edits that are in place. transition trouble-free, we would like to 7544) or PEHP’s Project Manager, Lance offer a few key pointers: Toms ([email protected]) PEHP Wellness » Dual use of ICD-9 and ICD-10 will not Currently testing, but have questions? be accepted for the same claim. Contact PEHP’s Project Manager, Lance PEHP Healthy Utah Navigates Online » If the dates of service span the Toms or PEHP’s EDI Manager, Terri Airmet implementation date of Oct. 1, 2015, the ([email protected]) pring is a season for new to access benefits such as health coaching claim will need to be split. beginnings, transformation, and and weight management tools from DID YOU growth. . . . making it a perfect PEHP Waist Aweigh. Support PEHP For DOS on inpatient claims that will S KNOW? » › Examples: time for change. As of March 2015 PEHP WeeCare – a prenatal and Postpartum span 10/01/15, PEHP will take the » Laterality (Right, Left, Bilateral, members can access wellness resources program for expectant mothers. PEHP PEHP for admit date as determination for ICD-9 PROVIDERS Unilateral) previously found at HealthyUtah.org on Healthy Utah is an exclusive wellness or ICD-10. the PEHP website! PEHP simplified by is a secured » Anatomical locations benefit for eligible PEHP members and DID YOU online provider » DX criteria for preauthorization will be providing members with one website, their spouses. » Trimester KNOW? site which based upon date of service established one account, and one login to remember. Through PEHP Healthy Utah members For benefits, allows you to in the preauthorization. If establishing » Type of diabetes PEHP consolidated all insured member easily and cost and their eligible spouse are offered status of an a preauthorization for services to be Known complications or health benefits in one convenient place at effectively access » a variety of programs, services, and appeal or resources and rendered post 10/01/15, the DX code comorbidities www.pehp.org. resources to help them get and stay well preauthorizations information that should be coded in ICD-10. » Description of severity, acute or Why the change? Merging online – including rebates for good health and and/or complicated claim can simplify and » PEHP will only accept codes that are chronic or other known parameters, resources from the Healthy Utah website improvements. expedite your etc. makes it easier for your patients to questions, call reported to the highest character and We appreciate our providers and hope Customer Service organization’s take full advantage of their health and daily tasks. specificity available and consistent If you have any other questions that your office will promote these useful at 801-366-7555. with ICD-10 coding guidelines and regarding ICD-10, please visit the CMS wellness benefits. services to help improve patients quality recommendations from CMS. or AMA websites. Help your patients by encouraging them of life.
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Group Benefit Changes PEHP Pharmacy State Moves to One OOPM very year our groups make Ebenefit changes to their plans. This year, the State of Utah will be making some significant changes to their Traditional Plan deductibles and maximum out-of- pocket benefits. To become compliant with future Affordable Care Act (ACA) out-of-pocket maximum requirements, the State of Utah (and other groups) are rolling up separate out-of-pocket maximum categories such as pharmacy into one out-of-pocket maximum. As a result, the annual deductible PEHP’s Preauthorization Updates has increased from $250/$500 to EHP chooses specific prescription drugs Drugs REMOVED from List $350/$700 and the medical out- Pand specialty medications to require of-pocket maximum has changed preauthorization. These specific prescription Drug Name Effective Date from $2,500/$5,000/$7,500 with drugs and specialty medications are chosen Zenatane March 1, 2015 other out-of-pocket categories because of: Claravis March 1, 2015 to $3,000/$6,000/$9,000 with the high potential for adverse reactions, » Myorisan March 1, 2015 one combined out-of-pocket contraindications, misuse, and safety maximum. issues; Sotret March 1, 2015 DID YOU March 1, 2015 We invite you to verify coverage » the opportunity to use first line therapy; Adderall XR KNOW? online or to call if you have Daytrana March 1, 2015 cost. PEHP’s specific benefit questions. » Stratter March 1, 2015 Disease To begin, obtain preauthorization forms at DID YOU Management www.pehp.org. Choose Providers/Provider Vyvanse March 1, 2015 KNOW? Program takes Login and enter your superuser ID and Access to a big picture PEHP Dual Coverage password. Drugs ADDED to List current policies, approach to fee schedule(s), your patients’ Questions? Contact your Provider Relations Drug Name Effective Date preauthorization health, Allow Time for the Dual Process Specialist or call Customer Service at 801- Erwinaze March 1, 2015 forms can incorporating roviders do not not always be paid on end, please allow time for 366-7555 or 800-765-7347. Members may call Viekira Pak March 1, 2015 be obtained everything need to submit the the same day, but always the dual to process. Customer Service for status of the provider’s by logging from wellness secondary coverage within a couple days request. P If you haven’t received PEHP’s Preferred Drug List is updated into PEHP to pharmacy to to PEHP when the prime from each other. a response on the dual Approval or denial will be communicated for Providers education, to several times a year and contains the most is PEHP as well. We will to the provider’s office. Preauthorization secured site. complex care To avoid unnecessary coverage, prior to current preauthorization list, in addition to process under the dual does not guarantee payment and coverage management. claim submissions on submitting the claim, other lists that affect pharmacy choices. coverage automatically. your end and numerous check online or call is subject to eligibility, benefit coverage, and The dual coverage may duplicate denials on our Customer Service. preauthorization requirements. Find it at www.pehp.org.
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Provider Relations Representatives To provide optimal service to PEHP providers, each Provider Relations Representative is assigned a specific area to manage. This assignment is based on the physical locations of the providers. If you are unsure who your representative is, please call PEHP at 800-365-8772 or 801-366-7700.
SERVICE AREA #1 SERVICE AREA #2 Chantel Lomax Wendy Philbrick Provider Relations Specialist Provider Relations Specialist Phone: 801-366-7507 or 800-753-7407 Phone: 801-366-7753 or 800-753-7753 Come join us for a day of learning, with topics for just about every interest: Fax: 801-245-7507 Fax: 801-245-7753 E-mail: [email protected] E-mail: [email protected] Continuing favorites like Privacy & Security and Payer Panel will be back, along with In-State Cities In-State Counties In-State Cities timely new topics. Draper (84020), Holladay (84117, 84121 & 84124), Box Elder, Cache, Davis, Murray (84107, 84123 & Get ready for ICD-10 with a variety of classes for different readiness levels and needs, Midvale (84047), Salt Lake City, Sandy (84070, 84090, Morgan, Rich, Summit, 84157) including: 84091, 84092, 84093 & 84094) Weber A ground-floor ICD-10 overview Out-of-State Out-of-State o Colorado Arizona, Idaho o An “ask the experts” session o An overview of ICD-10 changes to injury coding SERVICE AREA #3 SERVICE AREA #4 Come for the exciting educational sessions; stay for great networking opportunities, face time Angel Macas Glenda Lowe with vendors, and fantastic prizes! Clinicians and clinical staff, administrators, office Provider Relations Specialist Client Liaison managers, billers, and coders will all find valuable information in these sessions. Phone: 801-366-7721 or 800-753-7721 Phone: 801-366-7496 or 435-673-6300 Fax: 801-245-7721 or 800-950-4877 Don’t miss this chance to catch so much expertise under one roof! E-mail: [email protected] Fax: 435-634-0654 In-State Counties In-State Cities E-mail: [email protected] Fair Dates and Locations: Time (All Locations) Carbon, Daggett, Herriman (84065 & 84096), In-State Counties Out-of-State Cities Duchesne, Emery, Juab, Kearns (84118), Magna Beaver, Garfield, Grand, Las Vegas, Nevada Provo – Wednesday, April 15 Registration 8:00 AM – 8:30 AM Millard, Sanpete, Tooele, (84044), Riverton (84065, Iron, Kane, Piute, Mesquite, Nevada Utah Valley Convention Center Breakouts 8:30 AM – 3:30 PM Uintah, Utah, Wasatch 84095 & 84096), South San Juan, Sevier, 220 W Center St. *Prize drawing at 3:45 PM- must be present to win* Out-of-State Jordan (84065 & 84095), Washington, Wayne Wyoming Taylorsville (84084, 84118 Layton – Tuesday, April 21 & 84119), West Jordan Davis Conference Center (84084 & 84088), 1651 N 700 W West Valley (84119, 84120 & 84128) MAILING ADDRESSES Salt Lake City – Tuesday, April 28 Service Area #4 Glenda Lowe South Towne Exposition Center SERVICE AREA #5 9575 S State St. Selena Johnson URS/PEHP Provider Data Specialist 166 North 100 East #9 St. George, UT 84770 St. George – Thursday, April 30 Phone: 801-366-7511 or 800-753-7311 1424 E Foremaster Dr. Fax: 801-245-7511 All Other Service Areas & Representatives E-mail: [email protected] PEHP Out-of-State 560 East 200 South All states other than those listed above Salt Lake City, UT 84102 This education series is a joint effort of many organizations from your Utah healthcare community.
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