HFMA ANNUAL PAYOR PANEL 2015 “With you when it matters…” Coventry Health Care of Missouri, Inc. Provider Relations March 24, 2015

HFMA ANNUAL PAYOR PANEL 2015

“With you when it matters…”

Coventry Health Care of Missouri, Inc.

Provider RelationsMarch 24, 2015

Living the Aetna Way will

allow us to achieve our

strategic goals


We put the people we serve at the center of everything we do

Health Care Reform

Health Care Reform adds new information, requirements and details to an already complex business. Health Care Reform has affected every aspect of our organization.

Several changes and processes have been implemented to align Coventry with current and future policies, such as:

- Internal education - New benefit plans built

- Communication developed for physicians, member and employer groups- Correspondence (letters and EOB/ Remittance Advices)

- Finance, Actuary, and Underwriting changes have been made to address MLR requirements

More information on Health Care Reform is available via the Health Care Reform link on www.chcmo.coventryhealthcare.com


What is an Exchange?

The Exchange is an online market place where individual consumers and small group employers can purchase insurance coverage.

• Exchanges may be offered at the State or the Federal level• Illinois has chosen a state partnership exchange• Missouri has opted for Federal Exchange

• On the exchange, consumers are able to:• View Subsidy eligibility• Review and compare all the plans available on the exchange• Enroll in health coverage


Coventry’s Marketplace/Exchange Overview


• Coventry Healthcare offers Individual coverage for the Illinois and Missouri exchanges for 2015• Three options for the marketplace:

1. Federal (FFM) – Federally-facilitated exchange where the state has no role in operation or management – Missouri

2. State Partnership (SPM) – Federal government builds infrastructure but states retain authority (network adequacy, licensure, etc.) – Illinois

3. State Base – The states create, operationalize, and maintain their own exchange

• All other group sales remain the same for Coventry Healthcare’s off-exchange markets

Coventry’s Marketplace/Exchange ProductsMissouri


1. Coventry One PPO – Eastern Missouri and Southwestern Illinois

2. Coventry One Carelink from Coventry is a narrow network PPO product• Missouri and Illinois counties• Hospital affiliated providers: Mercy, SSM, St. Elizabeth’s,

St. Anthony’s-Alton, HSHS

3. Coventry One FocusedCare is a narrow network PPO product• Missouri and Illinois counties• Hospital affiliated providers: BJC Healthcare(all facilities)• St. Elizabeth Hospital-Belleville, IL. (HSHS)• St. Anthony’s Medical Center, St. Louis, MO.

ICD-10 CM: 2015 Updates


• Our design, development, testing and deployment are aligned for the October 1, 2015 ICD-10 compliance date. We have completed all analyses, including gap and system impact inventory, and system remediation. We have engaged the impacted areas of our company in our business assessments. We will be ready for the move from the ICD-9 codes to ICD-10 codes.

• The 10/1/2015 compliance date may seem far off, but the complexity of conversion requires immediate action to address the business and clinical issues associated with the transition. The ICD-10 conversion will affect nearly all provider systems and many processes. The largest impacts will likely be in clinical and financial documentation, billing and coding. It is critical not to delay planning and preparation. It is important that providers contact their billing or software vendor to understand their plans for conversion and testing.

ICD-10 CM: 2015 Updates


• Coventry is a member of HIMSS and WEDI, and actively participates on many industry workgroups and task forces related to IDC-10. We did participate in the pilot; however at this time, we are not participating in the program.

• These industry resources will help with your planning and preparation:• Centers for Medicare & Medicaid Services (CMS)• Workgroup for Electronic Data Interchange (WEDI)

• Need to contact us? Coventry has two dedicated mailboxes for ICD-10 questions, information on ICD-10 testing, or surveys that need completed. You will receive your response within two business days. This info may be found on www.directprovider.com too.

Email: [email protected]: 412-604-5566


NIAOutpatient Imaging Program

• Utilized for advanced outpatient imaging management services

• Applies to Coventry Commercial HMO/POS, Select and PPO Members

• Applies to Medicare products: Advantra, Advantra PPO, and Gold Advantage

• Members are excluded from the Outpatient Imaging Program if they access care through: ASO, Carelink, FocusedCare, CMR, Coventry National, First Health Network, and TotalCare


NIA, cont.• Ordering physician responsible for obtaining prior authorization for

advanced radiology services

• Rendering facility is responsible for ensuring the prior authorization has been obtained

• Prior Authorization’s obtained through NIA’s website, www.RadMD.com, or by phone, 800.546.4603, option 6

Procedures requiring prior authorization:

• CT/CTA• MRI/MRA• PET Scans

• Nuclear Stress (MPI)

• CCTA• Echo Stress

• Nuclear Cardiology• Diagnostic Nuclear Medicine


New Century HealthOncology Pathway Solution Drug Program

New Century Health (“NCH”) manages the Oncology Pathway Solutions program. The Oncology Pathway Solutions program uses clinical guidelines based on nationally recognized, evidence-based criteria for determining medical necessity in cancer care. It streamlines the complex administrative process

associated with chemotherapy pre-authorizations.


New Century Health Prior Authorization

• Chemotherapeutic drugs and supporting agents will require pre-authorization prior to being administered in a physician’s office, elective inpatient, outpatient or ambulatory setting.

• Applies to all Coventry Medicare and Commercial members ages 18 and older.

• The requesting physician must complete the NCH Chemotherapy Request Form (CTR).

• Applies to services for Coventry Members with coverage under both fully insured and Medicare products. It does not include self-funded or Carelink products.


New Century Health Key Features• Provider portal available 24/7/365 offering:

• Real-time authorizations when selecting treatment care pathways

• Reduced documentation requirements• Easily view real-time status of authorization requests• Eligibility verification

• Fax authorization requests 877-624-8602• Supportive telephonic authorization 877-624-8601• Quick turnaround time on requests submitted via fax or phone• Peer-to-peer consultation's by medical oncologists• NCH is a National Comprehensive Cancer Network licensee of

the Drugs and Biologics Compendia and utilizes nationally recognized evidence-based treatment guidelines


ICOREDrug Program

ICORE –Changes coming to Injectable Drug Management Program.Beginning May 1, 2015 ICORE Healthcare LLC will no longer manage high cost injectable drugs for Coventry Health Care of Missouri, Illinois, and Kansas members. Instead, you can call Coventry’s Health Services Department at the number on the back of the member’s ID card. This change doesn’t impact any authorizations you already have from ICORE. If you need a new one on or after April 30, 2015, call Health Services. You can call us if you need to change an existing authorization.


MedSolutionsCHC-MO & CHC-IL utilizes MedSolutions, Inc. to manage the authorization process for outpatient radiation oncology services for Commercial and Medicare members. Prior authorization is required (except for the initial consultation) when any one of the following modalities is utilized:

• 3D Conformal • SRS/SBRT • Brachytherapy

• IMRT • Hyperthermia

• Proton Beam Therapy • Neutron Beam Therapy

Requests will receive a response within two business days once complete clinical information is received, or as required by Federal or State regulations. When radiation oncology services are required in less than 48 hours due to a medically urgent condition, please call for authorization. MedSolutions will expedite the review process.


MedSolutionsThe physician ordering the treatment is responsible for obtaining prior authorization for radiation oncology services. The rendering facility must ensure that prior authorization is obtained. Payment to the treating physician and rendering facility will be denied for procedures performed without necessary authorization; the member cannot be balance-billed for such procedures.

When requesting prior authorization for radiation oncology services, please have the following information available:• Patient demographic information, including member ID and date of birth • Cancer or condition being treated (including the diagnosis code) • Procedure codes expecting to be billed (including CPT® codes and total units for each) • Dates and results of biopsies and/or procedures • Anatomic site(s) to be treated • Intent of the treatment • Approximate size of the anticipated target volume • Patient’s prior history • Number of fractions planned • A checklist of required information is accessible at www.medsolutions.com/documents


MedSolutions

Prior Authorization Process

There are three ways to obtain prior authorization for radiation therapy treatment from MedSolutions:• Web Portal - complete the internet-based submission form by logging on to

the secure website at www.medsolutionsonline.com. MedSolutions strongly recommends use of the web portal as a time efficient tool to enable prompt review of your request. The MedSolutions website cannot be used for retrospective or expedited registration requests. Those requests must be processed by calling MedSolutions.

• Call - to request an authorization call toll-free 1-888-693-3211. • Fax - complete the appropriate form and include the pertinent


Triad Healthcare Inc. – Quality Assurance for Pain Management Procedures

• Triad Healthcare, (“Triad”) a leading musculoskeletal health services company focuses on the health care needs of patients with painful spine and joint conditions. Triad administers Coventry’s quality assurance program for pain management procedures. Triad’s mission is to improve the quality of care delivered to patients with complaints of musculoskeletal pain.

• The new prior authorization process applies to services for CHC members with coverage under both fully insured and Medicare products. It does not include self-funded products. Triad’s medical policies, a list of CPT codes designated as pain management services requiring prior authorization and managed by Triad, along with authorization forms, are available by contacting Triad or on the Providers section of our website at chcmissouri.com. Prior authorization requests and your patient’s medical records must be submitted using any of the following methods:

* Web: triadhealthcare.com/cvty * Fax: 888-229-5680 * Phone: 888-584-8742• Triad’s evidence based medical policy is available to Coventry Health Care

providers at: http://www.triadhealthcareinc.com/providers/policies.aspx.


Advantra’s Dual Eligible - Special Needs Plan (DE- SNP)

CHC Missouri plan covers Dual Eligible (DE).

DE’s are individuals who are entitled to Medicare and some level of assistance from Missouri Medicaid (MO HealthNet).

• Advantra DE-SNP is a Medicare replacement plan

• Advantra DE-SNP is NOT a Medicaid replacement plan

• Members must see providers who participate in both Advantra and MO HealthNet Networks to optimize their benefits

• Members who select us must carry and use both plans’ ID cards, Advantra DE-SNP card and MO HealthNet card

• Advantra DE-SNP, like Medicare, always pays first; MO HealthNet benefits wrap around our plan


Lab Services/Providers In-Office Lab Policy

• Lab specimens for CHC of Missouri’s Commercial and Medicare Advantage should be sent to Quest Diagnostics in the St. Louis Metro area, or one of the approved outpatient labs for those outside of the metro area. The metro area is defined as:

– In Missouri: Franklin, Jefferson, Lincoln, St. Charles, St. Francis, St. Genevieve, St. Louis City, St. Louis, Warren, Washington counties

– In Illinois: Madison, Monroe, St. Clair counties

• Coventry Health Care reimburses in-network providers for specific lab procedures when they are preformed in office on a STAT basis only. Please refer to our provider manual for a detailed list of these labs. The provider manual is available under the provider section on www.chcmisssouri.com.


Valuable Information Available Online atwww.chcmissouri.com

• Comprehensive provider search• Drug formulary (prescription

coverage)• Prior authorization information• Medical injectable list• Authorization form

• Prior authorization list• CPT codes requiring prior

authorization• Network participation details• Credentialing policies, criteria

and provider rights related to credentialing

Click “Providers” on the home page for immediate access to these valuable resources:


Visit the “Provider Document Library” to access:

• Provider Manual – Includes information about claims processing, member rights and responsibilities, and other helpful resources.

• Complex Case Management – Informs providers about our complex case management program and how to refer patients to the program.

• Network News – Holds current and past issues of Network Connection, our provider newsletter.

• Quality Improvement Policies and Procedures – Notes quality improvement annual evaluations and medical record documentation standards.

• Utilization Management Policies – Displays summaries of our evaluation of new medical technology, utilization management criteria and financial incentives policy.

• Wellness – Highlights preventive health guidelines, clinical practice guidelines and disease management programs.


www.DirectProvider.com

Services & Information Available:• Claim Adjustment Requests• Remittance Advices• Eligibility/Benefit Inquiry• Resource Library• Secure Messaging• Member ID cards• Enhanced News• Authorization Request/Inquiry/Update/Appeal


www.DirectProvider.comSelect a Health Plan:

Coventry Health Care of Missouri

Carpenters’ Health and Welfare Trust Fund

Coventry of Missouri (MODOT)

University of Missouri

Coventry Health Care of Illinois

Coventry Health Care of Kansas and Preferred Health System

Coventry Health Care National Network

CoventryOne National

Mail Handlers Benefit Plan

Rural Carrier Benefit Plan


Workers Comp on DirectProvider.com

• Workers Comp link added to provide access to Coventry’s Workers Comp (WC) business information

• Includes access to WC Bills, Pricing Sheets, Explanations of Review/ EOR’s CMS 1500 & UB-04 Bill Images

• If you are currently registered with DirectProvider.com for Coventry Health Plans access, just click the WORKERS’ COMP link in the left navigation bar on the home page and follow the instructions

Here are a few tips on navigating the authorization submission process:


Authorizations on DirectProvider.com Made Easy

• Submit the same type of clinical information that is needed when requesting the authorization via phone. Either document the information in the comment section of the authorization or attach clinical information to the authorization.

• Without clinical information, the authorization may be denied for lack of information.

• It is recommended to check member eligibility and current authorizations prior to entering a new authorization.

• Online help is available on DirectProvider.com for authorization as well as other key functions. If you have any questions or require technical support Coventry’s Net Support Team is available 9am-5pm Monday through Friday at (866) 629- 3975.


2015 DirectProvider.com Training

Authorizations & Referrals Claims/Remittance Advices Administrator Registration Interactive Webinars

To register your provider office staff for DirectProvider.com training sessions please go to Directprovider.com and view the

NEWS section on Directprovider.com and choose the link Direct Provider Training Announcement for any of the

trainings listed above.

QUESTIONS


Documents

HFMA ANNUAL PAYOR PANEL 2015 “With you when it matters…” Coventry Health Care of Missouri, Inc. Provider Relations March 24, 2015