WORKING with CareSource
Health Partner Orientation1 How to use this PRESENTATION
This presentation is an orientation training for all of CareSource’sIndiana health partners, including those serving members of:
• Hoosier Healthwise (HHW) HHW • Healthy Indiana Plan (HIP) • Marketplace Plans (MP) • CareSource Medicare Advantage/CareSource Dual Advantage(D-SNP) HIP
We will indicate what plan(s) each slide’s information applies to with MP the tabs on the slide. MA/D - SNP
2 About CareSource PART 1
3 Our MISSION To make a lasting difference inour members' lives by improving their health and well-being.
OUR PLEDGE Make it easier for you to work with us Partner with providers to help members make healthy choices Direct communication Timely and low-hassle medical reviews Accurate and efficient claims payment
4 Health Care with HEART
MISSION FOCUSED Comprehensive, member- 31 centric health and life services. EXPERIENCED With over 31 years of service, CareSource is a leading non-profit health insurance company. 93% DEDICATED MEDICAL COST RATIO We serve over 1.8 million members through our Medicaid, Marketplace and Medicare Advantage/CareSource Dual Advantage plans and our Veterans Choice A-Z partnership with TriWest Healthcare $14.5 M Alliance. IN FOUNDATIONGRANTS
5 Our PLANS
LOW-INCOME LOW-INCOME, HEALTH MEDICARE ADULTS & UNINSURED INSURANCE ADVANTAGE CHILDREN AND ADULTS ADOLESCENTS DUAL AGES 19-64 MARKETPLACE UP TO AGE19 ELIGIBLE HOOSIER HEALTHY INDIANA MARKETPLACE MEDICARE ADVANTAGE/ HEALTHWISE PLAN DUAL ADVANTAGE(D-SNP)
Details: HHW Details: Details: Details: • For uninsured • Qualified health • Combines • Risk-based Hoosiers up to 138% managed care plan benefits of of federal poverty • Individual and Medicare and • Children up to age level
Family health Medicaid into HIP 19 • Members are insurance plans single plan • Pregnant women responsible for cost • All plans include • Adds additional sharing by making a POWER account Pediatric Dental & benefits
contribution (PAC) or Vision outside of MP by copayments. • Optional Adult Medicare and Members who make Dental, Vision & Medicaid plans a PAC receive Fitness coverage MA/D enhanced benefits - 6 SNP Our PLANS
ST. JOSEPH ELKHART LAGRANGE STEUBEN LAPORTE LAKE PORTER NOBLE DEKALB HIGHLIGHTS MARSALL STARKE KOSCIUSKO WHITLEY ALLEN We provide services for Hoosier JASPER PULASKI FULTON and in NEWTON Healthwise Healthy Indiana Plan WABASH ALL of Indiana WHITE CASS MIAMI WELLS ADAMS BENTON CARROLL HOWARD GRANT We offer our Marketplace plans in ALL of WARREN TIPPECANOE JAY CLINTON TIPTON Indiana DELAWARE HHW FOUNTAIN MADISON RANDOLPH MONTGOMERY BOONE HAMILTON We offer our MA/D-SNP plan in 18 HENRY HANCOCK WAYNE counties in Indiana (See counties PARKE HENDRICKS MARION PUTNAM VERMILLION RUSH FAYETTE UNION
where MA/D-SNP is offered on map) HIP JOHNSON SHELBY VIGO MORGAN CLAY FRANKLIN OWEN DECATUR MONROE BROWN SULLIVAN RIPLEY GREENE JENNINGS OHIO JACKSON LAWRENCE SWITZERLAND MP JEFFERSON KNOX DAVIESS MARTIN SCOTT WASHINGTON ORANGE CLARK PIKE FLOYD
DUBOIS MA/D GIBSON CRAWFORD
WARRICK PERRY HARRISON -
POSEY SPENCER SNP 7 Working with CareSource PART 2
8 Provider Network & ELIGIBILITY
CareSource members choose or are assigned a primary care provider (PCP) “DO YOU TAKE upon enrollment. CARESOURCE?” Be sure to ask to see each patient’s member When referring patients, ensure other ID card to ensure you take their plan. Be sure providers are in-network to ensure coverage. to confirm which CareSource plan the member is asking that you accept. Use our Find A Doc tool at CareSource.com to help you locate a participating CareSource NOTE: For Marketplace and HHW provider by plan. MA/D-SNP, routine Vision and Hearing services are covered through EyeMed and
OUT-OF-NETWORK TruHearing network providers. HIP For HHW/HIP, routine Vision SERVICES services are covered through Out-of-network services are NOT covered Superior Vision. MP unless they are emergency services, self- NOTE: Provider eligibility to accept referral services or prior authorized by CareSource members can be
CareSource (not applicable to Marketplace confirmed in the CareSource Provider MA/D Plans).
Portal. - 9 SNP Notification of Pregnancy
Indiana Health Coverage Programs (IHCP) recognizes that timely identification of risk factors improves birth outcomes.
The Notification of Pregnancy (NOP) form pinpoints risk factors in the earliest stages of pregnancy for women enrolled in HIP andHHW.
The NOP form may be accessed through the Provider Healthcare Portal (https://portal.indianamedicaid.com/hcp/) REIMBURSEMENT A qualified provider is eligible for a $60 reimbursement for one NOP per pregnancy completed and successfully submitted using the Provider Healthcare Portal. The submitted information is used by CareSource to determine the risk level associated with the pregnancy and establish areas of follow-up care: • Submit claim 99354-TH if you completed the NOP, but not in the 1st trimester • Submit claim 99354-TH for $70 if you completed the NOP within the 1st trimester HHW • The NOP must be submitted via the Provider Portal no more than five calendar days from the date of the the office visit on which the NOP is based • The member’s pregnancy must be less than 30 weeks’ gestation at the time of the HIP office visit on which the NOP is based. 10 ID CARDS: Medicaid Member
HOOSIER HEALTHWISE HEALTHY INDIANA PLAN
11 ID CARDS: Marketplace Member
Make sure the state matches your contracted region Marketplace dependents are indicated by the Member ID + dependent suffix (portion after the “-”) Example: 14800000000-01 (JaneDoe)
12 ID CARDS: Medicare Member
MEDICARE ADVANTAGE CARESOURCE DUAL ADVANTAGE
13 Claim SUBMISSIONS
SUBMISSION PROCESS Providers can submit claims through our secure, online Provider Portal at CareSource.com > Provider Log In. Here, providers can submit claims along with any documentation, track claim payments and more. WE ENCOURAGE ELECTRONIC CLAIM SUBMISSION • We will be partnering with ECHO Health for electronic funds transfer (EFT).* HHW • You must enroll with ECHO Health to participate. • Find the enrollment form online at www.echohealthinc.com. For questions, call ECHO Support at 1-888-485-6233. HIP EDI CLEARINGHOUSES CareSource currently accepts electronic claims through our clearinghouse, Availity.
Providers can find a list of EDI vendors online at MP www.availity.com/caresourceedivendors.
NOTES M A / • Please list your National Provider Identifier (NPI) on all claims. D - S N
• Please ensure you list the correct billing taxonomy code. P
14 Access and AVAILABILITY
As a CareSource health partner, you must ensure your practice complies with the following minimum access standards:
• Provide 24-hour availability to your CareSource patients by telephone. – Whether through an answering machine or a taped message after hours, patients should have the means to contact their PMP or back-up health partner to be triaged for care.
– It is not acceptable to use a phone message that doesn’t provide access to you or your back- HHW up health partner and only recommends an emergency room after hours. • Be available to see members at least three days per week for a minimum of 20 hours per week. • Provide members telephonic access to the PCP (or appropriate designee) HIP in English and Spanish 24/7.
Please refer to our Provider Manual at CareSource.com for a complete MP listing of Access and Availability standards. MA/D 15 - SNP Access and AVAILABILITY
Primary Care Providers (PCP’s) Medicaid Members Marketplace Members
Type of Visit Should be seen… Should be seen…
Emergency needs Immediately upon Immediately upon presentation presentation Urgent care* Not to exceed 48 hours Not to exceed 48 hours HHW
Regular and routine care Not to exceed 14 calendar Not to exceed 6 weeks days HIP
*For primary medical providers (PMPs) only: Provide 24-hour availability to your CareSource patients by telephone. Whether through an answering machine or a taped message used after hours, patients should be given the means to contact their PMP or a back-up provider to be triaged for care. It is not acceptable to use a phone MP message that does not provide access to you or your back-up provider, and only recommends emergency room use for after hours. MA/D - SNP 16 Access and AVAILABILITY
Non-PCP Specialists Medicaid Members Marketplace Members
Type of Visit Should be seen… Should be seen…
Emergency needs Immediately upon Immediately upon presentation presentation Urgent care* Not to exceed 48 hours Not to exceed 48 hours HHW
Regular and routine care Not to exceed 14 calendar Not to exceed 6 weeks days HIP
*Providers should see members as expeditiously as their condition and severity of symptoms warrant. It is expected that if a provider is unable to see the member within the designated timeframe, CareSource will facilitate an appointment with another participating provider, or a non-participating provider, when necessary. MP MA/D - SNP 17 Access and AVAILABILITY
Behavioral Health Providers Medicaid Members Marketplace Members
Type of Visit: Should be seen… Should be seen… Emergency needs Immediately upon Immediately upon presentation presentation Non-life threatening Not to exceed 6 hours Not to exceed 6 hours
emergency* HHW Urgent care* Not to exceed 48 hours Not to exceed 48 hours Initial visit for routine care Not to exceed 10 business Not to exceed 10 business days days HIP Follow-up routine care Not to exceed 30 calendar Not to exceed 30 calendar days (based on condition) days (based on condition MP For the best interest of our members, and to promote their positive health care outcomes, CareSource supports and encourages continuity of care and coordination
of care between medical care providers, as well as between physical health providers MA/D and behavioral health providers. - SNP 18 Hospice COVERAGE
Healthy Indiana Plan (HIP) members receive hospice coverage with the exception of institutional hospice which is only covered inFFS.
Hoosier Healthwise (HHW) members must be disenrolled from managed care in order to receive hospice services. The state of Indiana administers this benefit.The member must be enrolled in traditional Medicaid.
CareSource coordinates with IHCP hospice health partners to provide any information needed to complete the hospice election form for the member.
Members must fill out Medicaid Hospice Election State Form 48737 to enter hospice care.
For more details regarding hospice provider enrollment, member eligibility, HHW election/discharge, authorizations, billing and more, please refer to the IHCP “Hospice Services” Provider Reference Module. HIP
19 HIP
POWER Account
HIP Plus members are required to pay for their first $2,500 of covered services out of a Personal Wellness and Responsibility (POWER) Account. The state will contribute most of the required amount, plus members will also be responsible for making a smallcontribution to their account each month. The amount of a member's contribution amount is based on income. 20 HIP Basic COPAYMENTS
HIP Basic members are required to make the following copayments at the time services arerendered: $4 copayment for outpatient services, including office visits $75 copayment for inpatient services $4 copayment for preferred drugs
$8 copayment for non-preferred drugs
*An emergency room visit does not require a copay, unless it is non-emergent: $8 copayment for each non-emergency ER visit
No copayment is required for preventive care, including early periodic screening, diagnostic and testing Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, or family planning services. HIP
21 School-based CLINICS
• For HHW members • Support care coordination efforts between school- based clinics and primary medical providers • Coordinate health services with schools for members with individualized education plan (IEP) services • Reimburse school clinics for providing medically necessary covered services HHW Findings available on the CareSource.com Provider Portal
22 Member COMMUNICATION
Help your CareSource patients understand their insurance coverage. Encourage them to visit CareSource.com, where they can access: • MyCareSource.com member portal • Searchable online formulary and prescription cost calculator HHW • Find a Doctor/Provider tool • Evidence of coverage & schedule of benefits HIP • Member handbook • Forms
• And more MP
For more information, visit:CareSource.com/Members MA/D - 23 SNP Communicating with US
MEDICAID MARKETPLACE MA/D-SNP PROVIDER SERVICES MA: 844-679-7865 1-844-607-2831 1-866-286-9949 D-SNP: 833-230-2176
HOURS Monday – Friday Monday – Friday Monday – Friday 8 a.m. – 8p.m. EST 8 a.m. –6 p.m. EST 8 a.m. –6 p.m. EST
MEMBER MA: 844-607-2827 1-844-607-2829 1-877-806-9284 SERVICES D-SNP: 833-230-2020 Monday – Friday Monday – Friday Monday – Friday HOURS 8 a.m. –8 p.m. EST 7 a.m. – 7 p.m. EST 8 a.m.– 8 p.m. EST From Oct. 1 – Feb. 1, we areopen the same hours 7 days a week Visit our Provider Portal on CareSource.com for regular online submissions.
24 Provider Portal PART 3 CareSource PROVIDER PORTAL
SAVE TIME. SAVE MONEY. Use our secure online Provider Portal. With this tool you can:
Check member eligibility and Submit claims and verify benefit limits claim status HHW Find prior authorization Verify or update Coordination requirements of Benefits information(COB) HIP Submit and check the status of a Prior Authorization And more!
request MP
Access the Provider Portal 24 hours a day, 7 days a week, at CareSource.com >
Login > Provider Portal . MA/D -
NOTE: Submitting requests for covered services that meet criteria provides an immediate approval when submitted through theportal SNP 26 Register for the PORTAL
Go to CareSource.com. Click Providers then Provider Portal Login on the right side of the page.
Select Indiana. HHW
Click register here under Register for the Provider Portal. HIP Enter your information, including your CareSource Provider Number (located in your welcome letter). MP
Follow remaining steps to register. MA/D - SNP
27 Member ELIGIBILITY
Current HHW HIP MP D - SNP 28 Member
Past Due
10400001
Contains demographic details on the ID number entered John Lennon 1960 Abbey Road 10400001 Indianapolis, IN. 46256 Marion County 00048255 Shows genderof (317)555-5555 Male the ID entered 1/9/1940
* Program details shows the
* Marketplace only member is past due
(317)111-1111 PCP Phone Number Dr. John Doe Member’s selected PCP MP Contains primary policy holder’s information Lists copays, coinsurance amount remaining toward deductible Dental or vision services rendered while covered with our plan Indicates any benefit limits associated with plan (i.e chiropractic visits) Results of HRA’s or other clinical assessments done by CareSource 29 Member ELIGIBILITY
Current HHW HIP MP D - SNP
30 Marketplace Member FINANCIAL RESPONSIBILITY
Annual deductible, copayments or coinsurance are applicable for many covered services. It is up to you, the provider, to collect these amounts at the time of service.
Balance Billing Network providers may not balance bill CareSource members for covered services.
Balance billing is when a provider bills the patient for the difference between the provider’s charge and the allowed amount. For example, if your office visit charge is $100, and the allowed amount is $70, you may not bill CareSource members for the remaining $30. MP
31 Marketplace Member FINANCIAL RESPONSIBILITY
All Marketplace members have a 90-day grace period inwhich to make their premium payment.
• Not applicable for their initial payment • CareSource will continue to process medical claims and pay providers in those 90 days • After 30 days, CareSource will flag a member in the eligibility file and on the Provider Portal • After 30 days, CareSource will suspend pharmacybenefits
If they bring their account into good standing within the 90 days, pharmacy benefits will start again.
After 90 days past due, the member is terminated for non- payment of premium. • CareSource will retroactively terminate the member • CareSource will recover all claims paid for months two and three of delinquency MP
32 Member
Emergency Room Shows copay if not admitted members coinsurance MP
33 MP
34 BENEFITS Member Covered Services & Benefits PART 4 Covered SERVICES
HHW & HIP BENEFITSOVERVIEW ENHANCED BENEFITS
PCP and specialist office visits Life Services ER services Non-emergent transportation Inpatient hospital (additional above NET, forcertain special populations) Mental health and addictionservices Wellness & diseasemanagement Urgent care Incentives for well-care, preventive Family planning screenings, tobacco cessation,prenatal Diagnostic services (ex: lab &radiology) care and more Preventative services (routine well- Medication therapy management visits and screenings) Girl Scout membership (grades K –8) Maternity services at no cost to themember Pharmacy Vision services (except HIPBasic) Dental – no limitations on fillings For more details on each plan’s HHW or extractions (except HIPBasic) Chiropractic care – provided for covered services, visit Plus members CareSource.com. HIP
35 Services NOT COVERED
• Medically unnecessary services • Services received from a non-network provider, with specific exceptions • Experimental or investigational services with specific exceptions • Alternative or complimentarymedicine
• Cosmetic procedures orservices HHW • Assisted reproductive therapy • Maintenance therapy treatments HIP
Marketplace and MA/D-SNP only:
• Routine Vision services & eyewear not provided by anEyeMed MP provider
• Routine Hearing services & hearing aids not provided by a MA/D TruHearing provider - SNP 36 Marketplace SUPPLEMENTAL BENEFITS
SUPPLEMENTAL BENEFIT MANAGER OVERVIEW – CareSource partners with select vendors to provide expanded benefits and services including expertise in the services and broadened networks – These are exclusive relationships for the services considered – meaning our member must use a provider within the Benefit Manager’s network in order for CareSource to contribute – See caresource.com for additional detail on the benefits and additional perks available BenefitCategory Eligible Members Services BenefitOverview MemberContact
RoutineDental -All Pediatric Members (<19 years of • Member Services Preventive, 1-855-209-5281 (DentaQuest) age) • Provider network diagnostic, -Adults 19+ years of ageon Dental and • Claims adjudication restorative, Vision plans • EOBs comprehensive and medical necessary orthodontics for pediatric only RoutineHearing All MarketplaceMembers Member Services Routine hearing 1-866-202-2674 (TruHearing) Provider Network exams and Claims Adjudication hearing aids
RoutineVision -All Pediatric Members (<19 years of Member Services Routineeye exam, 1-833-337-3129 (EyeMed) age) Provider Network glasses, contacts -Adults 19+ years of ageon Dental and Claims Adjudication and other value Vision plans EOBs added services
Fitness (American Adults 18+ years of age on Dental and MemberServices No cost share fitness 1-877-771-2746 Specialty Health) Vision plans Provider Network center access,home health kits, internet tools and education
NOTE: You may refer your CareSource patients to these vendors using the numbers provided above. 37 CareSource Advantage SUPPLEMENTAL BENEFITS
SUPPLEMENTAL BENEFIT MANAGER OVERVIEW CareSource partners with the select vendors to provide expanded benefits and services including expertise in the services and broadened networks. These are exclusive relationships for the services considered – meaning our member must use a provider within the Benefit Manager’s network in order for CareSource to contribute. See CareSource.com for additional detail on the benefits and additional perks available. Benefit Category Eligible Members Services Benefit Overview Member Contact RoutineDental All Medicare Advantage • Member Services Preventive (Zero and 1-855-453-5281 (DentaQuest) members • Provider network Advantage plans), • Claims adjudication Diagnostic, restorative, • EOBs and comprehensive (Advantage only) RoutineHearing All Medicare Advantage • Member Services Routine hearing exams 1-855-205-6219 (TruHearing) members • Provider network and hearing aid fittings • Claims adjudication w/ hearing aid cost shares RoutineVision All Medicare Advantage • Member Services Routine eye exam, 1-866-248-2011 (EyeMed) members • Provider network glasses, contacts (w/ • Claims adjudication $100/$130 allowance) • EOBs and other value added services Fitness All Medicare Advantage • MemberServices No cost share fitness 1-877-427-4788 (AmericanSpecialty members • ProviderNetwork center access, home Health) health kits, internettools, & education 38 NOTE: You may refer your CareSource member patients to these vendors using the numbers provided above. CareSource Dual Advantage SUPPLEMENTAL BENEFITS
SUPPLEMENTAL BENEFIT MANAGER OVERVIEW CareSource partners with the select vendors to provide expanded benefits and services including expertise in the services and broadened networks. These are exclusive relationships for the services considered – meaning our member must use a provider within the Benefit Manager’s network in order for CareSource to contribute. See CareSource.com for additional detail on the benefits and additional perks available. Benefit Category Eligible Members Services Benefit Overview Member Contact RoutineDental All Medicare Dual Advantage • Member Services Preventive,diagnostic, 1-855-453-5281 (DentaQuest) members • Provider network restorative and • Claims adjudication comprehensive care • EOBs w/annual limits of $1000 RoutineHearing All Medicare Dual Advantage • Member Services Routine hearing exams 1-833-759-6826 (TruHearing) members • Provider network and hearing aid fittings • Claims adjudication w/a $1000 allowance per ear RoutineVision All Medicare Dual Advantage • Member Services Routine eye exam, 1-833-337-3129 (EyeMed) members • Provider network glasses, contacts (w/ • Claims adjudication $250 allowance) and • EOBs other value added services Fitness All Medicare Dual Advantage • Member Services No cost share fitness 1-877-771-2746 (AmericanSpecialty members • Facility network center access, home Health) health kits, internet tools and education
39 NOTE: You may refer your CareSource member patients to these vendors using the numbers provided above. HIP Maternity BENEFITS
Healthy Indiana Plan (HIP) Maternity: This benefit plan offers access to all benefits available under the State Plan, with no cost-sharing, to pregnant women who are enrolled in or determined eligible for HIP. During the member’s pregnancy and for a 60-day postpartum period, HIP Maternity offers enhanced benefits including vision, dental, and chiropractic services; nonemergency transportation; and enhanced smoking cessation services.
HIP Maternity does not mimic Presumptive Eligibility for Pregnant Women (PEPW) or emergency services with coverage for pregnancy, which only covers emergent and pregnancy related services. For additional information about Presumptive Eligibility benefits, visit the provider reference module.
Questions? Please contact CareSource Provider Services at 1-844-607-2831 or reach out to your Provider Engagement Specialist. HIP
40 CareSource BENEFIT INFORMATION
VISIT CARESOURCE.COM FOR MORE DETAILS: CareSource Medicaid PlanBenefits
CareSource.com > Medicaid > Benefits & Services > Medical Benefits HHW
Marketplace Plan Benefits HIP CareSource.com > Marketplace > Plan Documents
CareSource Medicare Advantage/ Dual AdvantagePlan Benefits MP
CareSource.com > Dual Advantage > Benefits & Services > MedicalBenefits MA/D - SNP 41 Prior Authorizations PART 5 Prior Authorization SERVICES
Services Requiring Prior Authorization Include HHW/HIP • Most services providedout-of-network • Purchase or rental of specified • Partial hospitalizationprograms medical supplies, durable medical equipment (DME) supplies or • Advanced diagnostic imaging through NIAMagellan (i.e. PET, MRI, appliance, as well as items exceeding MRA, CT/CTA, CCTAetc.,) $750. • Skilled nursingfacilities • Orthotics and prosthetics with a • Home infusiontherapy price exceeding $1200. • Accidental dental (reconstruction due to accident) HHW • Pain management services Marketplace • Behavioral health: Inpatient and outpatient services including alcohol • Purchase or rental of specified and substance abuse, intensive outpatient treatment, transcranial medical supplies, durable medical magnetic stimulation and SUD residential equipment (DME) supplies or appliance, as well as items exceeding HIP $500. • Orthotics and prosthetics with a price exceeding $500. NOTE: MP • Prior authorization of a service does not guarantee payment. The service must be a covered benefit in the member’s plan. Retrospective authorization is not the same as a retrospective prior authorization request. • Log in to the Provider Portal at CareSource.com to view a more comprehensive list of covered services and limitations. • Please monitor network notifications for changes that may occur to the PA list. MA/D - SNP
*This is not a comprehensive list 42 Procedure Code Tool HHW HIP MP
https://procedurelookup.caresource.com MA/D - SNP
43 Prior Authorization SUBMISSIONS
TO SUBMIT REQUESTS: MEDICAID MARKETPLACE MA/D-SNP At CareSource.com through ONLINE At CareSource.com At CareSource.com through Provider Portal through Provider Portal Provider Portal
EMAIL N/A [email protected] [email protected] HHW
PHONE 1-844-607-2831 1-866-286-9949 833-230-2176
FAX 844-432-8924 888-716-9480 844-417-6157 HIP
MAIL CareSource CareSource CareSource P.O. Box 1307 Attn: IN UtilizationManagement Attn: INUtilization P.O. Box 1307 Dayton, OH 45401-1307 MP Management Dayton, OH45401 P.O. Box 1307 Dayton, OH45401-1307 MA/D - SNP
44 Prior Authorization INFORMATION CHECKLIST
When you request authorization, be sure to include: • Provider name and NPI • Member/patient name and CareSource member ID number • Anticipated date(s) of service • Diagnosis code(s) and narrative • Procedure, treatment or service(s) requested • Number of visits requested, if applicable
• Reason for referring to an out-of-network provider if applicable HHW • Clinical information to support the medical necessity of the service (i.e. office notes, relevant lab work, trials/failures, etc.) • Inpatient service requests must include whether the service is elective, urgent or emergency,
admitting diagnosis, symptoms and plan of treatment HIP
NOTE: The IHCP universal PA form is required for all Medicaid PA requests. Note:The IHCP Universal PAform is required for all Medicaid PArequests
REFERRALS MP We do not require a referral to see a specialist. However, prior authorizations may still be required for services provided by specialists. MA/D WHERE DO I FIND MORE INFORMATION? - You can find more information in our Provider Manual, located atCareSource.com. SNP
45 Self-Referral SERVICES
CareSource includes self-referral health partners in our network. For both HHW and HIP, members may self-refer to any IHCP-enrolled provider for the services eligible for self-referral.
CareSource reimburses self- HHW MEMBERS referral services up to the May receive self-referral services from IHCP- applicable benefit limits and at enrolled self-referral health partners who are not IHCP FFS rates in the CareSource network
CareSource reimburses self- HIP MEMBERS referral services up to the • Must go to an in-network health partner; OR applicable benefit limits and at a • Receive PA from CareSource to go to an out- rate not less than the Medicare of-network health partner rate, or at 130% of Medicaid if no HHW Medicare rate Exceptions: Family planning,emergency services and routine vision services HIP 46 Self-Referral SERVICES
The following services are eligible for self-referral: • Psychiatric services • Family planning services • Diabetes self-management • Behavioral health services not provided by a psychiatrist
The following services are eligible for self-referral, but may only be provided to members receiving services through Hoosier Healthwise, HIP State Plans, HIP Plus or while receiving the additional HIP pregnancy-only benefits: Chiropractic services
Eye care services, except surgical services • Routine dental services • Podiatric services HHW
The IndianaAdministrative Code 405 IAC 5 (Hoosier Healthwise) and 405 IAC 9-7 (Healthy Indiana Plan) provide furtherdetail. HIP
47 Prior Authorization NIA MAGELLAN IMAGING
For all plans, CareSource utilizes NIA Magellan to implement a radiology benefit management program for outpatient advanced imaging services.
Procedures requiring Services NOT requiring prior authorization prior authorization NIA Magellan authorization through NIA Magellan: through NIA Magellan:
phone number: HHW • CT/CTA • Inpatient advanced • Marketplace: 1-800-424-5660 • MRI/MRA imaging services • HHW/HIP: 1-800-424-4883 • PETScan • Observation setting • Medicare Advantage:1-800-424-1741 • Myocardial Perfusion advanced imaging Imaging (MPI) services HIP • MUGA Scan • Emergency room imaging • Echocardiography services • Stress Echocardiography MP NIA Magellan Provider RelationsManager: Meghan Murphy 1-410-953-1042 | [email protected] MA/D More resources on NIAMagellan imaging may be found atCareSource.com/Providers - SNP Expedited authorizations are accepted. Register at RadMD.com
48 Care Management & Quality PART 5
48 Care MANAGEMENT
WE CAN HELP REFERRING A PATIENT You may refer a patient for care management in • Coordinate care provided by the following ways: multiple providers ONLINE : • Provide education on managing chronic conditions CareSource.com through the Provider Portal
• Assist with care transitions HHW • Reduce readmission risks PHONE: • Connect members to community-based support
1-844-607-2829 HIP organizations such as food pantries, housing, legaland FAX: employment YOU CAN HELP 844-417-6263 MP By identifying patients who may EMAIL: MA/D need individualized attention tohelp [email protected] - them manage their complex health SNP care needs. D-SNP: [email protected] 49 Disease MANAGEMENT
WE HELP OUR MEMBERS THROUGH: • The MyHealth online program for members 18+ to participate in a journey to improve their health • Newsletters with helpful tips and information to manage their disease, promote self-
management skills, and provide additional resources HHW • Coordination with outreach teams such as wellness advocates and health coaches • One-to-one care management (if they qualify) HIP NOTE: All materials are available to CareSource members in English and Spanish.
Members with specific disease conditions are identified by criteria or triggers such as emergency room visits, hospital admissions and the health assessment. Members identified MP in the Disease Management program receive help finding the appropriate level of care for their condition, and they are encouraged to actively participate in the patient-provider relationship. If you have a patient who you believe would benefit from this program and is not MA/D - currently enrolled, please call 1-844-438-9498. SNP
If a member does not wish to be enrolled in this program, they can call 1-844-438-9498 to opt out. 50 HHW HIP MP MA/D-SNP . . QUIT increase available available 800- - tobacco use and tobacco pharmacotherapy, pharmacotherapy, at1 lifestyle, lifestyle, with Quitline Quitlineaims to to obtain obtain to For cessationtobacco a healthy healthy a 51 PROGRAM: www.quitnowindiana.com on howon Tobacco Tobacco maintain includes not using tobacco products as products tobaccousing includesnot http:// remind remind of providers resources withquitting. to This information information The Indiana Indiana The assist assist 8669) or 8669) - to CESSATION help members help 784 of cessation. The The of programprovides regularhealth cessation.
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TOBACCO CESSATION TOBACCO Tobacco Cultural COMPETENCY
Health partners are expected to provide services in a culturally competent manner, including: • Removing all language barriers to service • Accommodating unique cultural, ethnic and social needs of members
• Meeting the requirements of all applicable state and HHW federal laws
RESOURCES HIP We provide cultural competency training sources in the Health Partner Manual and online at CareSource.com. MP MA/D - 52 SNP HHW
QUALITY IMPROVEMENT Initiatives HIP MP CareSource encourages you to actively participate in Centers for
Medicare & Medicaid Services (CMS) and U.S. Department of Health MA/D
and Human Services (HHS) quality improvement initiatives. - SNP
53507 Quality MEASURES
CareSource monitors member quality of care, health outcomes and satisfaction through the collection, analysis and the annual review of the Healthcare Effectiveness Data and Information Set (HEDIS®) and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®). Marketplace plans are monitored with the Qualified Health Plan (QHP) Enrollee Experience Survey. Potential quality measures include, but are not Potential CAHPS measures include: limited to: • Wellness and prevention: • Customer service − Preventative screenings (breast cancer, cervical • Getting carequickly HHW cancer and chlamydiascreenings) − Well-child care • Getting neededcare • Chronic diseasemanagement: • How well doctors communicate − Comprehensive diabetes care − Controlling high blood pressure • Ratings of all health care, healthplans,personal HIP • Behavioral health: doctors andspecialists − Follow-up after hospitalization for mentalillness QHP Enrollee ExperienceSurvey − Antidepressant medication management Provides (Marketplace): − Follow-up for childrenprescribedADHD • Access to care MP medication • Access to information − Initiation and Engagement ofAlcohol and • Care Coordination
Other Drugs • Ratings of health care, health plans, personal MA/D • Safety: doctors andspecialists - − Use of imaging studies for lower backpain SNP HEDIS is one of the most widely used means of health care measurement in the United States. HEDIS® is developed and maintained by The National Committee for Quality Assurance (NCQA). The HEDIS® tool is used by America’s health plans to measure important dimensions of care and service and allows for comparisons across health plans in meeting state and federal performance measures and national HEDIS® benchmarks. HEDIS® measures are based on evidence-based care and address the most pressing areas of care. 54 Quality RESOURCES
CareSource provides quality training for you and your teams through our Health Partner Managers and the Provider Portal. We have additional resources available through Plan ResourcesonCareSource.com. QUALITY TRAINING AND RESOURCES:
QualityOnboarding CAHPS SurveyTips HHW Training HIP Clinical Practice Coding Guides RegistryTraining MP
Clinical Practice
Clinical Practice Guideline MA/D Registry QuickTips
Information - SNP 55 Clinical Practice Registry TOOL
The CareSource Clinical Practice Registry is an online tool available to providers to IDENTIFY GAPS INCARE identify and prioritize needed health care services, screening andtestsfor their View preventive service history andeasily CareSource members. The Clinical Practice identify HEDIS® gaps in care to discuss Registry is easy to access via the secure during appointments. CareSource Provider Portal.
The registry includes, but is not limited to, HOLISTICALLY ADDRESS PATIENT CARE information on the following quality Receive alerts when CareSource members HHW measures: need tests or screenings, review member • Adult access to preventive care appointment histories and view their • Asthma prescriptions. • Breast cancer screening HIP • Cervical cancer screening • Colorectal cancer screening IMPROVE CLINICALOUTCOMES • Chlamydia screening Easily sort your CareSource members into
• Diabetes (HbA1c, eye exam, MP kidney/urine micro-albumin) actionable groups for population • Emergency room visits management.
• Lead screening MA/D • Well-care visit - SNP 56 Model of Care TRAINING
CareSource Dual Advantage providers are required to complete an initial and annual refresher training on delivering the model of care. Access the on- demand training on the Provider Portal at CareSource.com.
Please note: Providers are required to attest to completing the training after viewing. CURRICULUM INCLUDES: HEALTH RISK ASSESSMENT INTEGRATED CARE TEAM Learn the medical, cognitive, behavioral and Learn how you can work with the CareSource functional domains to be assessed. staff to support the model of care. SPECIALIZED TREATMENT PLANS PERFORMANCE & HEALTH OUTCOMES Learn about developing treatment plans Learn how CareSource will work with you to informed by health assessment results. improve model of care delivery. MA/D - SN 57 P Medical RECORDS
You must maintain medical and other records of all medical services provided to our members for seven years, in accordance with Indiana Code (IC) 16-39-7-1. HHW CareSource medical records standards are consistent, to the extent feasible, with NCQA accreditation standards for medical records. HIP STANDARDS
For full medical record standards, please see the Health MP Partner Manual. MA/D - SNP
58 Fraud, Waste &ABUSE
Help CareSource stop fraud. Contact us to report any suspected fraudulent activities:
EMAIL:
CALL: HHW 1-855-852-5558 [email protected]
MAIL: HIP FAX: CareSource 800-418-0248 Attention: Program IntegrityDepartment MP P.O. Box 1940
Dayton, OH 45401-1940 MA/D - 59 SNP Pharmacy PART 6 Pharmacy OVERVIEW
PARTNERSHIP WITH EXPRESS SCRIPTS CareSource will be working collectively with Express Scripts, our delegated pharmacy innovation partner, to manage our prescription drug costs and develop and implement plan-specific formulary or formularies. SPECIALTY DRUGS Accredo is our preferred specialty provider and can provide specialty medications directly to the member or the prescribing physician and coordinates nursing care if required. HHW E-PRESCRIBING
CareSource formulary files are available through your EMR, EHR or E-prescribing vendor. HIP RESOURCES • Authorization requirements for prescriptions may be found on your plan’s Provider pages under the Pharmacy section. MP • Formulary Search Tool and Prior Authorization lists are available on CareSource.com under Member Documents.
• Medication Therapy Management (MTM) allows pharmacists to work collaboratively with physicians to MA/D prevent or address medication-related problems, decrease member costs and improve prescription - drug adherence. SNP
61 BehavioralHEALTH
SUPPORTING MEMBERS WITH SUBSTANCE USE AND MENTAL HEALTH DISORDERS We work with resources to help health partners take action:
• Online drug formulary – our easy-to-use tool helps you facilitate care for our members in HHW all substance use clinical scenarios • Controlled medications – Buprenorphine HIP – Vivitrol – Naloxone *Some medications may require priorauthorization
• Medication Assisted Treatment (MAT) program – enables members to access MP opioid detoxification and promote maintenance • Opioid toolkit online – find resources to support you and help you find best practices in
pain management MA/D
• Controlled substance report – a tool to provide awareness of controlled substance - over-prescribing SNP • Addiction Line – allows members to speak with a CareSource staff member who can answer questions related to addiction and assist members in finding available treatment options 62 Marketplace PHARMACY BENEFITS
TIERED MEDICATION STRUCTURE The higher the tier, the higher the cost of thedrug. TIER 0 TIER 1 TIER 2 TIER 3 TIER 4 TIER 5
Available Low-cost Higher Higher Higher Higher without a genericdrugs coinsurance or coinsurance or coinsurance or coinsurance copaymentor copaymentthan copaymentthan copaymentthan than thosein coinsurance those in Tier 1 those in Tier 2 those in Tier 3 Tier 4
Includes Includesgeneric Includes Includes non- Includes Includes preventive drugs preferred preferred preferred medications medications medicationsthat medications; specialty generally may be generic medications medications classified as
drugs or single- considered specialtynon- MP or multi-source single- ormulti- preferred brand-name source brand- medications drugs name drugs
Visit the Pharmacy page at CareSource.com if you wish to access our full formulary list.
63 CareSource Advantage PHARMACY BENEFITS
TIERED MEDICATION STRUCTURE The higher the tier, the higher the cost of thedrug. TIER 1 TIER 2 TIER 3 TIER 4 TIER 5 TIER 6
Lowest costtier Highercost Highercost Highercost Highestcost $0 co-pay tier than Tier 1 than Tier 2 than Tier 3 tier Includes preferredgeneric Includes non- Includes Includes non- Includesbrand Includes popular medications preferredgeneric preferredbrand preferredbrand and generic generics drugs medications medications specialty medications MA/D - Visit the Pharmacy page at CareSource.com if you wish to access our full formulary list. SNP
64 CareSource Dual Advantage PHARMACY BENEFITS
TIERED MEDICATION STRUCTURE ONE TIER
Lowest cost tier Cost-sharing structure with coinsurance based on member LIS level; includes specialty medications limited to 30-day supply
Visit the Pharmacy page at CareSource.com if you wish to access our full formulary list. MA/D - SNP
65 Medicaid PHARMACY BENEFITS
HOOSIER HEALTHWISE PACKAGE A (STANDARD PLAN) No copays PACKAGE C (CHILDRENS PLAN) Copays apply
HEALTHY INDIANA PLAN HIP BASIC Copays apply HIP PLUS No copays STATE BASIC PLAN Copays apply STATE PLAN PLUS No copays HHW HIP 66 Provider Resources PART 7 Provider RESOURCES
Visit the CareSource.com Plan Resources page to access the following resources:
• Printable health partner manual HHW • Printable orientation slides
• Newsletters & network notifications HIP • Formularies • Covered benefits • Quick reference guides MP • And more MA/D - CareSource Provider Portal: SNP https://providerportal.caresource.com/IN 68 CareSource CONTACTS
MEDICAID MARKETPLACE MA/D-SNP PROVIDER SERVICES MA: 844-679-7865 1-844-607-2831 1-866-286-9949 D-SNP: 833-230- 2176 UTILIZATION MANAGEMENT 844-432-8924 877-716-9480 844-417-6157
FAX HHW WEBSITE CareSource.com
PROVIDER PORTAL https://providerportal.caresource.com/IN https://pwp.sciondental.com/PWP/Landing SKYGEN Dental Portal (HHW/HIP): HIP DentaQuest (Marketplace/MA/D-SNP): www.Dentaquest.com ELECTRONIC FUNDS TRANSFER (EFT) ECHO Health:1-888-485-6233
ELECTRONIC CLAIM MP SUBMISSION INCS1
CLAIM ADDRESS Attn: Claims Department, P.O. Box 3607, Dayton, OH 45401-3607 MA/D - SNP 90 days from date of 90 days from date of 90 days from date of TIMELY FILING service or discharge service or discharge service or discharge 69 HHW HIP MP MA/D - HEALTH PARTNER ENGAGEMENT Specialist SNP
CareSource Health Partner Engagement Representatives
DeniseEdick,Manager, HealthPartnerships Brian Grcevich, Health Partner Specialist– Ancillary, Associations and Dental 317-361-5872 317-296-0519 [email protected] [email protected]
Amy Williams, Team Lead, Health Partnerships 317-741-3347 Contracting Managers– Hospitals/Large Health [email protected] Systems Behavioral Health– Tenise Cornelius –North Health Partner Resolution Specialists 317-220-0861 [email protected] Angelina Warren -- North 317-658-4904 Mandy Bratton –South [email protected] 317-209-4404 [email protected] Stephanie Gates – South 317-501-6380 63You can find the most up-to-date engagement [email protected] 70 specialist information at CareSource.comContinued on nextslide HEALTH PARTNER ENGAGEMENT SPECIALIST Assignments TammyGarrett 219-221-7065 [email protected] Fanciscan Alliance
Cathy Pollick 260-403-8657 [email protected] Parkview, Lutheran, St. Joseph Regional Medical Center
SarahTinsley 317-607-4844
[email protected] HHW Union Hospital, American Health Network
MariaCrawford 317-416-6851 [email protected] HIP Indiana University, Suburban Health Organization
Sara Hall 765-256-9617 [email protected] MP Community Health Network, Eskenazi
Paula Garrett 812-447-6661 MA/D [email protected] - Deaconess, St. Vincent Health SNP
Erin Samuels 812-454-4846 You can find the most up-to-date [email protected] 71 engagement specialist KentuckyOne, Norton,Baptist Health Floyd information at CareSource.com. HHW HIP MP D - SNP
PARTNERS with Purpose
Are you contracted with all of our plans? Join us by contacting your Health Partner Engagement Specialist.
Or visit https://www.caresource.com/providers/education/become-caresource-provider/ to start the contracting process.
IN-P-0002l; Issued Date: 5/18/21 72 OMPP Approved: 5/8/21