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Provider Manual November 2020 Contact Information

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Provider Manual November 2020 Contact Information OHSU HEALTH SERVICES Provider Manual November 2020 Contact Information Customer Service P: 844-827-6572 Hours 7:30 a.m. – 5:30 p.m. weekdays Medical Referrals and Prior P: 844-931-1774 Authorization F: 833-949-1887 Pharmacy Prior Authorization F: 503-346-8351 Voluntary Sterilization F: 833-949-1556 Form Submission EviCore – Radiology, P: 844-303-8451 Cardiology & www.eviCore.com Advanced Imaging www.eviCore.com/provider#ReferenceGuidelines Magellan Rx – Specialty P: 800-424-8114 Pharmacy www.icorehealthcare.com Provider Relations P:503-418-7750 F:503-346-8041 [email protected] Care Integration & P: 844-827-6572 Coordination [email protected] Contracting P:503-418-7750 F: 503-346-8041 [email protected] OHSU Health Website www.ohsu.edu/healthshare Provider Portal Tax ID number driven • Eligibility & Benefits • PCP History • Referral Inquiry • Claim Status Medical Claim Submission OHSU Health Services PO Box 40384 Portland, OR 97240 To submit claims electronically, please use Payer ID: 13350 If you would like information on billing claims electronically, please contact our Electronic Data Interchange department at [email protected] Voluntary Sterilization F: 833-949-1556 Form Submission Must be submitted with PA otherwise will be denied. WWW.OHSU.EDU Table of Contents Welcome 5 MEMBERS 6 How to become an OHSU Health Services Member 6 Coordinated Care Organizations (CCOs) 6 Oregon Health Plan (OHP) Eligibility 6 Oregon Health Plan Member’s Rights and Responsibilities 6 Member Rights 7 Applying for the Oregon Health Plan 8 Member Responsibilities 10 Verifying Plan Enrollment for Oregon Health Plan 10 PCP ASSIGNMENT AND SELECTION 11 Assigning a PCP to OHSU Health Services Members 11 Changing PCP 10 Member Rosters 10 MEMBER COMPLAINTS 12 Resolving Complaints with a Provider or Facility 12 Restraint and Seclusion 12 BENEFITS 14 Oregon Health Plan Covered Services 14 Sterilizations and Hysterectomies 15 Telehealth 16 Skilled Nursing Facility Care 16 Palliative and Hospice Care 17 Mental Health and Substance Use Services 17 Tobacco Cessation 17 Health Related Services 18 Oregon Health Plan Non-Covered Services 18 Care Coordination and Integration Services 22 Access to Care 23 Physical Access 23 Appointment Availability and Standard Schedule Procedures 23 Follow Up on Missed Appointments 24 24 Hour Telephone Access 25 3 Table of Contents Quality Management Program 26 Medical Records 28 OHSU Health Services Access to Records 29 Third Party Access to Records 29 Confidentiality 30 Interpreter Services 31 Special Healthcare Needs Members 32 Medical Transportation for OHP Members 32 Health Promotion Materials 33 Provider Relations & Contracting 34 Provider Rights 35 Provider Termination of Member Care 36 CLAIMS 38 Submitting Claims 38 Medicaid Provider ID Number 39 National Correct Coding Initiative (NCCI) Edits 39 Claims Appeals 39 Member Billing 40 Coordination of Benefits 41 Calculating Coordination of Benefits 41 Hysterectomy and Sterilization 41 Vaccines For Children (VFC) Billing 42 Locum Tenens Claims and Payments 42 Fraud, Waste and Abuse 42 Referral and Authorizations 42 Referrals 42 Referrals after a PCP change 43 Retroactive referrals 44 Referral process for PCPs 45 Referral process for specialists and ancillary providers 46 Referral for members with Special Health Care Needs (SHCN) 47 Authorizations 48 eviCore 50 WWW.OHSU.EDU 4 Table of Contents Inpatient admissions 50 Urgent and emergent admissions 50 Concurrent review 51 Retroactive outpatient authorization request 51 Retroactive inpatient authorization requests 51 Obstetrical admissions 51 Readmission (DRG hospitals) 52 Second opinions 52 Monitoring Appropriate Utilization 54 PHARMACY PROGRAM 55 Using the Formulary 55 Contracted Pharmacies 55 Prior Authorization Process 55 Injectables and High Cost Medication through Specialty Pharmacies 56 5 OHSU HEALTH SERVICES | PROVIDER MANUAL Welcome In 2019, OHSU Health partnered with Moda Health operating as an Integrated Delivery System (IDS) under Health Share of Oregon, a Coordinated Care Organization (CCO) certified by the Oregon Health Authority (OHA) to serve OHP (Medicaid) enrollees in Clackamas, Multnomah and Washington Counties. OHSU Health Services administers over 41,000 Medicaid lives. The OHSU Health Services network includes over 1,000 referral specialists and four hospital systems in the tri-county service area. OHSU Health Services administrative staff supports our Providers with medical case management, care coordination, health related services, pharmacy, compliance oversight, delegated credentialing, and quality improvement services. Moda Health performs most administrative functions such as: medical claims processing, customer service, PCP assignments, provider directory, finance / accounting, prior authorizations, grievances and appeals, and compliance and Fraud, Waste & Abuse (FWA). All of the partners within OHSU Health Services work to help ensure a focus on providing safe, effective, efficient, patient-centered (culturally appropriate and linguistically sensitive), timely and equitable standards of care. OHSU Health Services reflects the Institute for Healthcare Improvement’s (IHI) Quadruple Aim Initiative Health Equity, which seeks to: • Improve the member’s experience of care • Improve the health of populations • Reduce the per capita cost of care • Improve Health Equity More information about IHI’s Quadruple Aim Initiative Health Equity can be found at http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four- points-to-help-set-your-strategy. WWW.OHSU.EDU 6 Members Individuals become members of OHSU Health by enrolling in the Health Share of Oregon CCO and choosing OHSU Health Services or by stating their Provider preference. Coordinated Care Organizations (CCOs) The Oregon Health Plan CCOs were developed by the State to provide better health (OHP) is the Oregon and better care at lower costs for all Oregonians. Through Medicaid program an integrated model, CCOs provide locally managed care emphasizing prevention, chronic disease management, and administered by the educating members who may be high-utilizers in need of Health Systems Division additional assistance. OHSU Health Services administers (HSD) of the State of OHP benefits through Health Share of Oregon. Oregon. HSD extended Oregon Health Plan (OHP) Eligibility Medicaid eligibility to all state residents with OHP Eligibility is determined by a simple screening and application process managed by Oregon Health Authority. % incomes up to 138 of OHP members must meet income and residency requirements the federal poverty level but may also qualify based upon age and disability status. (FPL), as well as children OHP member’s eligibility effective dates are retroactively whose family income is granted to the recipient’s application date. Adult recipients are eligible for six months and must reapply prior to the % up to 300 of the FPL. conclusion of each six-month period. Children must reapply every 12 months. If recipients do not reapply before their eligibility ends, their OHP eligibility terminates until they reapply. Member eligibility effective dates and application For more information about renewal dates are available in the CIM6 portal located Health Share of Oregon please visit: https://cim6.phtech.com/cim/login?CFID=3073&CFTO- www.healthshareoregon.org KEN=67BBFFC8-5BB6-4E12-BBD58D62CD07C486 Oregon Health Plan Member’s Rights and Responsibilities OHSU Health Services members receive their rights and responsibilities statement in their member handbook at onboarding and with each revision of the handbook. Members and participating Providers can access the handbook via the Health Share of Oregon website www.healthshareoregon.org and the OHSU Health Services website www.ohsu.edu/healthshare. 7 OHSU HEALTH SERVICES | PROVIDER MANUAL Member Rights: OREGON HEALTH PLAN MEMBER’S RIGHTS AND RESPONSIBILITIES • Be treated with dignity, respect and privacy • Be treated by participating Providers the same as other people seeking health care benefits to which they are OHSU Health Services entitled, and to be encouraged to work with your care members receive their rights team, including Providers and community resources and responsibilities statement appropriate to your needs in their member handbook • To be free from discrimination in receiving benefits and at onboarding and with each services to which you are entitled revision of the handbook. • To receive equal access for both males and females under Members and participating 18 years of age to appropriate treatment, services and Providers can access the facilities. This includes homeless youth and those in gangs, as required by ORS 417.270 handbook via the Health Share of Oregon website • Choose a Primary Care Provider (PCP), Primary Care Dentist (PCD), mental health Provider or service site, www.healthshareoregon.org and to make changes to these as permitted in the Health and OHSU Health Services Share’s administrative policies www.ohsu.edu/healthshare. • Get behavioral health or family planning services without a referral from a PCP or other participating Provider • Have a friend, family member, or advocate with you during appointments and other times as needed within clinical guidelines • Be actively involved in the development of your treatment plan; to talk honestly with your Provider about appropriate or medically necessary treatment choices for your conditions, regardless of the cost or benefit coverage • Be told information about your
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