6/10/2019

Johns Hopkins US Family Health Plan (USFHP)

Presented by: Johns Hopkins HealthCare Provider Relations Department 2020

Johns Hopkins HealthCare LLC

6/10/2019

Agenda• Welcome to JHHC• Johns Hopkins HealthCare Website• USFHP Product Overview• New for 2020• Referrals and Preauthorization• Claims and Appeals• Health Care Performance Measures• Resources and Important Information

Welcome to JHHC

Johns Hopkins HealthCare LLC (JHHC) provides health care services for four health plans:• Priority Partners Managed Care Organization (PPMCO)• Johns Hopkins Employer Health Programs (EHP)• Johns Hopkins US Family Health Plan (USFHP)• Johns Hopkins Advantage MD (HMO and PPO)

Johns Hopkins HealthCare Websitewww.jhhc.com>For Providers

Provider website includes:

• Provider manuals• Forms• HealthLINK@Hopkins portal access• Provider directory Find participating providers

• Policies and procedures• Prior authorization tool

Johns Hopkins HealthCare Websitewww.jhhc.com> For Providers

Provider Website Reviewwww.jhhc.com> For Providers > Resources & Guidelines

Referrals and Preauthorizationwww.jhhc.com> For Providers > Resources & Guidelines >

USFHP > Outpatient Referral Guidelines (2020)

USFHP Product Overview

Johns Hopkins US Family Health Plan (USFHP) is a health care choice for eligible beneficiaries under the Department of Defense’s TRICARE Prime program.

USFHP Product OverviewHealth care is provided to:• Active duty family members• Activated National Guard and Reserved family

members• Retirees and their family members• Certain grandfathered beneficiaries who are age 65

and older

USFHP Product Overview

For members who have coverage under both USFHP and Medicare:• Medicare cannot be billed for services that are covered by

USFHP.• Members who have coverage under both USFHP and

Medicare may only use Medicare benefits for non-covered USFHP services, such as chiropractic care or end-stage renal disease.

USFHP Product Overview

• Members filing Medicare claims or members that have claims filed on their behalf are in violation of the conditions of participation for USFHP and are subject to disenrollment.

• Members utilizing Medicare for benefits covered under USFHP are subject to disenrollment

USFHP Product OverviewJohns Hopkins USFHP offers programs and services to help members better manage their health.Prescription coverage: USFHP utilizes the TRICARE pharmacy formulary for prescription drug benefits. The USFHP pharmacy and formulary can be viewed here. Walgreens is the network pharmacy for USFHP.Dental care: USFHP members take advantage of two free dental cleanings per year and discounted dental benefits administered through United Concordia Companies, Inc. (UCCI) and its Concordia Advantage. Members can call UCCI customer service at 800-332-0366.

USFHP Product OverviewVision care: One free eye exam each year from a plan provider.

Health Coaching: One-on-one health coaching gives members the opportunity to work with a personal health coach to help them meet their health goals. Members can call800-957-9760 for more information.

Care management program: This program offers tools and ongoing support that members need to better understand and manage their health. Members can call 800-557-6916 for more information.

USFHP Product Overview

Pregnancy resources: Various programs for expectant moms including care management and the Partners with Mom program. For additional information about these programs, members should call customer service at 800-808-7347.

USFHP Product Overview

Vision care discounts: Include lenses, frames, and LASIK eye surgery performed by Johns Hopkins doctors.

Cosmetic procedures: Discounts on selected cosmetic procedures performed by Johns Hopkins doctors.

Fertility treatment: Discounts on selected fertility treatment services performed by Johns Hopkins doctors.

Hearing Aid Discount: Includes hearing exam, hearing aid, and follow-up visits throughTruHearing.

USFHP Product OverviewMember ID Card

Front Back

USFHP Product Overview

New for 2020

USFHP - New for 2020Changes to Pharmacy Copays Prescription drug copays will change for many US Family Health Plan (USFHP) members beginning January 1, 2020. The new copay increases are listed below:

• Mail-Order Pharmacy (Home Delivery) – 90-day supplyGeneric drug copay: increase from $7 to $10Brand-name drug copay: increase from $24 to $29Non-formulary* drugs: increase from $53 to $60

• Walgreens Pharmacy – 30-day supplyGeneric drug copay: increase from $11 to $13Brand-name copay: increase from $28 to $33Non-formulary copay: increase from $53 to $60

*Non-formulary means that the drug is not on TRICARE’s list of fully covered medications.

2020 TRICARE Prime Out-of-Pocket Expenses

**When TRICARE Prime enrollees self refer to specialty or non-emergent inpatient care without a referral from a network provider, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.

**When TRICARE Prime enrollees self refer to specialty or non-emergent inpatient care without a referral from a network provider, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.

2020 TRICARE Prime Out-of-Pocket Expenses

Referral and Preauthorization

Referrals• Do not need to be sent to the plan• Can be sent directly to the specialist• Specialist will enter the referring provider’s NPI number in

box 17b of the CMS 1500 form• Include the referring provider’s NPI on the script/referral that

is sent to the specialist.

Referral and PreauthorizationPreauthorization:Authorization from the insurance plan for a scheduled service (not requiring additional clinical documentation).

Medical Review:Review process in which a nurse reviewer or medical director reviews the medical necessity for a scheduled procedure.Information must be faxed with the request and clinical documentation.

Referral and Preauthorization

Medical Review (cont.):For a list of services that require a referral, preauthorization or medical review, please refer to the Outpatient Referral and Preauthorization Guidelines at www.jhhc.com -> For Providers -> Resources &Guidelines -> USFHP -> Outpatient Referral Guidelines (2020).

Claims and Appeals Process

Claims AddressUS Family Health Plan Attn: Claims DepartmentP.O. Box 830479Birmingham, AL 35283

AppealsAddressUS Family Health Plan Attn: Appeals Department

7231 Parkway Drive, Suite 100Hanover, MD 21076

Claims and Appeals ProcessClaims• Must be submitted on CMS 1500 or UB-04 forms• Specialist or ancillary providers must include referring

provider’s NPI in Box 17b of the CMS 1500 form• Rendering provider’s NPI must be in Box 24J of CMS 1500

form• Submission must be within 180 calendar days of the date of

service

Claims and Appeals ProcessClaims (cont.)Payment disputes:• Timely filling• Care not coordinated by PCP• Authorization not on file• Member not eligible at time of service• Incorrect coding• Medical necessity appeals• Must be submitted within 90 business days of the date of

denial

Claims and Appeals Process

Payment DisputesSubmit payment disputes with the Provider Claims/ Payment Dispute and Correspondence Submission Form located at jhhc.com > Download FormsMedical NecessitySubmit medical necessity appeals with the Provider Appeal Submission Form, located online at jhhc.com > DownloadForms

Claims and Appeals ProcessElectronic Data Interchange (EDI)For additional information on EDI, please send an email request to edi@jhhc.com. EDI Payor ID #52123Balance Billing• Participating providers cannot balance bill a member for a

covered service.• A participating provider cannot balance bill a member for a

non-covered service unless the member has signed a specific acknowledgment of financial responsibility.

• The Acknowledgement and Financial Responsibility form can be found at jhhc.com > Download Forms.

HealthLINK@HopkinsHealthLINK@Hopkins is a secure, online web portal where registered providers can check:• Eligibility• Claims• Authorization & referrals status• Plan-specific reports and moreRegistrationTo register for a HealthLINK@Hopkins account, go to www.jhhc.com or contact your Network Manager. If you need assistance, contact Provider Relations at 888-895-4998.

Health Care Performance MeasuresHealthcare Effectiveness Data and Information Set (HEDIS®)HEDIS® is a widely used set of health care performance measures that is developed and maintained by the National Committee for Quality Assurance (NCQA).Examples of HEDIS® measures are:• Comprehensive Diabetes Care• Childhood Immunizations• Yearly Well Child Exams for children ages 3-6• Yearly Adolescent Well Care ExamsFor detailed information about HEDIS®, please go to www.ncqa.org or read our Quality Measures Tip Sheet.

Health Care Performance MeasuresConsumer Assessment Health Plan Surveys (CAHPS®)CAHPS® 5.0H is a member satisfaction survey whose objective is to capture information about consumer-reported experiences with healthcare.• The focus of the survey is to measure how well plans are meeting

member expectations• Determine which areas of service have the greatest effect on overall

member satisfaction• Identify areas of opportunity for improvement.The survey is conducted according to NCQA protocol by an NCQA certified vendor.

Health Care Performance MeasuresHealth LiteracyThere are many reasons health plan members, patients and caregivers may struggle to understand health information. JHHC has structured its goals to meet its mission to provide quality health care and develop new methods to improve the health of its patient community and set standards of excellence in patient care. For more information on health literacy tools for improved communication, visit the Agency for Healthcare Research and Qualitywebsite.

Updating Your InformationYou are required to notify JHHC’s Provider Relations department of any demographic changes to your practice.

Provider Relations (For demographic changes, contract status and fee schedule questions):

Email: ProviderChanges@jhhc.com

CMS requires the Health Plan to validate provider information on a quarterlybasis.

Important Contact InformationMedical Management410-424-4480 or 800-261-2421410-424-46030 Fax(Referrals not needing Medical Review)Inpatient410-424-4894 FaxOutpatient Medical Review410-762-5205 FaxDME410-762-5250

United Concordia866-851-7576Behavioral Health Services410-424-4845410-424-4839 FaxProvider Relations (Contracts, fee schedules, and demographic changes)

410-762-5385 or 888-895-4998410-424-4604 FaxFraud and Abuse410-424-4996

Important Contact Information

Presented by:6/10/2019Presented by: Johns Hopkins HealthCare Provider Relations Department

Provider Relations 888-895-4998

Thank you