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Agenda
I. YourCare Background Information
II. Organizational Strengths & Priorities
III. New Information and What’s Changing
IV. Operational Updates
V. Questions and Answers
Background Information
• Monroe Plan Established In 1970
• Not-For-Profit 501(c)(6) / IPA Look-Alike with 210 employees (Buffalo, Rochester, Binghamton)
• Current Professional Network is Approximately 10,000 Practitioners in the Buffalo, Rochester, and Southern Tier Regions
• Provider of Care Management Services for Health Homes in the Rochester and Finger Lakes Region
• Effective August 1, 2015 MPMC will be Sole Member of Univera Community Health a Not-For- Profit 501(c)(3) and NYS Designated Article 44 / Prepaid Health Services Plan (PHSP) Serving the Medicaid Managed Care and Child Health Plus Populations. The Health Plan’s new name is YourCare Health Plan
• Future Expansion into Basic Health Plan, January 1,2016
• Future Expansion To Rochester and Finger Lakes Region Effective January 1, 2016
• Enrollment @ 06/01/2015 (YourCare Region):
Total Membership 53,687 (4 Counties) Medicaid Managed Care 50,403 Child Health Plus 3,284
Strengths & Philosophies • Expertise in working with the Safety Net population and provider network
• Historical market leader with value based integrated delivery network (IDN) capitation and risk agreements with large multi-specialty hospital systems, FQHC’s, and other high volume practices
• Leader in the delivery of enhanced provider network services to support practitioner offices
• Coding analysis program, quality performance payments, education and outreach
• Data Analytics and Reporting Capabilities • Financial, Utilization, and Risk Management Reporting
• Dedicated Call Center to Provider Network
• Dedicated case and disease management • Unique to SN populations
Operational Interfaces and Structure
Provider Relations & Contracting
Clinical / UM
Claims Adjudication, Adjustments, & Benefit
Management
Health
Informatics
YourCare Health Plan
Provider/Member Services (Enrollment &
Call Center)
Practice Outreach and Education
Immediate Changes August 1st
• HMO Name – Changing from UCH to YourCare Health Plan
• YourCare Health Plan Home Office • Moving from Univera Healthcare Corporate Office on Park Club
Lane to 6400 Sheridan Drive, Suite 120.
• Professional Contracts and Provider Relations • Current professional contracts remain valid
• Provider Relations team
• Hospital and Other Ancillary Contracts • Same as above on agreements
• Facility Contracting Team is in place with YourCare Health Plan
Immediate Changes August 1st
• Member ID Cards – Changing effective August 1st
• YourCare Option will use Medicaid CIN numbers
• Child Health Plus will use new numeric ID
• ID card will be issued to members on or around July 20th
Immediate Changes August 1st
• Claims Submissions and Payment • No longer using Facets platform
• New Claims submission on or after August 1st
• Regardless of date of service
• Any Claim adjustments after August 1st
• Clearinghouse (EDI) • Smart Data Solutions (SDS)
• Payer ID (New) • 15003
• Paper Claims and Other Mail Submissions YourCare Medical Claims
P.O. Box 21455
Eagan, MN 55121
• VestaCare Electronic Funds Transfer (EFT) • To register follow: https://www.vestacare.net/jsp/eftlink/monroeplans
• Link and registration instructions at: www.yourcarehealthplan.com
Utilization Management
• Prior Authorization and Referral Requirements
• Unchanged requirements from current
• Clear Coverage will no longer be in place
• Status available on our website
• Inpatient / Outpatient reviews by YourCare
• HEALTHeNET
• Referral capability will commence around
September 2015
• Other functionality in place
• Claim adjustments via form on our website
Customer Service
• Customer Operations Center • Dedicated provider and member call center
• Monday-Thursday, 8am-5pm (closing 12-1pm)
• Friday, 9am-5pm (closing 12-1pm)
• Triage support line in effect when close
• Full contact sheet for all departments and functions in your
handout
• Enrollment • To enroll for YourCare Option and Child Health Plus
• (800) 683-3781
• Health plan FE on hand
Benefit Managers
• Dental (Healthplex) remains same
• Claims, contracting, service
• Radiology (eviCore) remains same
• Authorizations
• Sleep Management, Radiation Therapy
• Pharmacy (ESI) is changing from current
• Formularies, Specialty medical drug management, etc.
• Behavioral Health (Beacon) will be new to YourCare
• Contracting, credentialing, claims and service
• Neo-Nate Management (Progeny) remains same
• Credentialing, PFM, Claims, Service
• Intakes handled by YourCare
• VestaCare (EFT)
• Electronic payments and remittances
• EDI Vendor (SDS) Smart Data Solutions
Credentialing
• Providers in process • Newly credentialing or re-credentialing in process with UCH, there is no change
• New credentialing • Contact us
• Initial provider data form (name, address, email, NPI, etc.)
• Source verification 60 days
• Full Credentialing 60-90 days
• Re- Credentialing • Due on November 1st, YourCare completes process
• Prior to November 1st, UCH completes process
• 5 month turnaround cycle
• Emergency Credentialing • Completed application (CAQH)
• Formal written request • Approval based on patient access needs
• 48 hr. turnaround
• Nurse Practitioner • Full credentialing process
• Listed as PCP (Pending meeting requirements)
Provider File Maintenance
• Provider Data • Initial information for groups
• Initial practitioner roster
• Provider Demographics • General demographic information
• Participation changes
• Practitioner enrollment
• Initial request form (name, address, email, NPI, etc.)
• Initial credentialing request
• Non Credentialed Practitioner • PA, NP, Hospitalist, Locum Tenant, Anesthesiologist, pathologist, etc.
• Practitioner Termination • Request form
• Indicates termination reason
• Practitioner Rosters • Monthly basis for larger systems
• Quarterly basis for everyone
• Credentialing/PFM point of contact
Website • Provider Portal
• Super User account / registration
• Account management at office level
• Membership eligibility
• Claim status
• Authorization status
• Remittances
• Fee Schedules
• Benefits
• Appeals/Grievances
• Member enrollment department • YourCare Option and Child Health Plus
• (800) 683-3781
• Marketing Materials • Call your PR representative
Website: https://www.yourcarehealthplan.com