Insurance Case Management for Service Coordinators and Providers

1. Insurance: NYEIS Case Management and Functionality for Service Coordinators and Providers Presented by: EI Learning Network at Just Kids Early Childhood Learning Center 1

2. Welcome and Course Overview 2

3. Training Resources • Handouts and Material Used During Training • Participant Slide Packet • Participant Training Packet • All training handouts, course evaluation, and helpful resources • Includes NYEIS User Manual, Unit 1: Getting Started, Accessing NYEIS, Pages 8-11 • Insurance Tool Kit for Service Coordinators 3

4. Today’s Topics 4

5. Purpose of This Training • Provide service coordinators, municipal staff and providers with the information and tools to effectively obtain and collect insurance information from families with children receiving early intervention services • Demonstrate how to add and edit in NYEIS insurance data through live web-based presentations • Provide additional resources that can be accessed to ensure successful billing and claiming 5

6. Unit 1 Accessing NYEIS 6

7. Accessing NYEIS (U-1) • Live NYEIS Web Demonstration • What Is the NYEIS Web-Based System? 7

8. Accessing NYEIS (U-1 cont’d) • Optional: Live NYEIS Demonstration • How to Log Into NYEIS Through the Password Secure Health Commerce System Portal 8

10. Accessing NYEIS (U-1 cont’d) Live NYEIS Demonstration • How to Access Insurance Information in the Child’s NYEIS Integrated Case Home Page 10

12. Accessing NYEIS (U-1 cont’d) Live NYEIS Demonstration • How to Find and Navigate the Child’s Health Insurance Information in NYEIS 12

14. Accessing NYEIS (U-1 cont’d) Live NYEIS Demonstration • Important Information About Using Web-Based NYEIS 14

16. Unit 2 Obtaining/Collecting Insurance Information 16

17. Obtaining/Collecting Insurance Information (U-2) • Service Coordinators’ responsibilities for collection and documentation of third party insurance information expanded due to April 2013 PHL changes • NYSDOH provides an Insurance Tool Kit for Service Coordinators that includes standard forms and templates to assist with this process • Insurance Tool Kit information is posted on the NYSDOH web page: http://www.health.ny.gov/community/infants_children/early_intervention/memoranda.htm 17

18. Obtaining/Collecting Insurance Information (U-2 cont’d) Meeting the Parent(s)/Guardian(s) • Initial Home Visit (First Step) • Initial Service Coordinator Responsibilities • Discuss with family whytheir insurance information MUST be collected and explain the protections afforded to them under insurance law. 18

19. Obtaining/Collecting Insurance Information (U-2 cont’d) PLACEHOLDER (#6) Live NYEIS Web Demonstration • Collecting Insurance Information from the Parent Using Form A of the Insurance Tool Kit • Request and review all active health insurance cards. • Ask the child’s family to verify the child’s gender, date of birth and correct spelling of the child’s first and last name. 19

21. Obtaining/Collecting Insurance Information (U-2 cont’d) The Initial Service Coordinator will: • Obtain insurance information and appropriate releases – mail required forms to the insurance company • Confirm insurance company billing and claiming address • Verify billing and claiming address in NYEIS • Enter insurance company/policy information into NYEIS on the child’s insurance pages • Ask the family for correct information if Early Intervention records and insurance records do not match 21

22. Obtaining/Collecting Insurance Information (cont’d) Live NYEIS Web Demonstration How to: • Access Insurance Company Information in NYEIS • Verify Billing and Claiming Address in NYEIS • Enter Insurance Company/Policy Information into NYEIS on Child’s Insurance Pages 22

26. Verifying Insurance Information (U-2 cont’d) If Parent Declines to Provide Insurance Information – • Complete “Notice of Parent Declination to Provide Insurance Information” Form B • Mail copy of form to service provider(s) and municipality • Document the declination in NYEIS on the child’s home page under the cluster labeled “Insurance Information” • Changes are updated in NYEIS and sent to providers 26

27. Obtaining/Collecting Insurance Information (U-2 cont’d) • Live NYEIS Web Demonstration • How to Document Parent Refusal to Provide Insurance Information 27

30. Obtaining/Collecting Insurance Information (U-2 cont’d) • Important: Service Coordinator Collection of Additional Insurance Information • Inform families that non-regulated commercial insurance can only be billed with written parental consent • Encourage families to inform service coordinators of any changes in their insurance information • Inform providers about the child’s insurance coverage • Assist parent, if child is uninsured, in identifying and applying to eligible benefit programs • Mail all providers a copy of the child’s completed “Collection of Insurance Information”Form A (third party insurance information) 30

31. Obtaining/Collecting Insurance Information (U-2 cont’d) Parent Consent • Provide and discuss with parent the “Dear Parent” letter for regulated or non-regulated insurance • Parent provides written consent to use non-regulated insurance for payment of EIP services • Complete “Consent to Bill Non-Regulated Insurance”Form F, if appropriate • Mail copies to EIP providers and upload to NYEIS 31

32. Obtaining/Collecting Insurance Information (U-2 cont’d) • What is Regulated and Non-Regulated? • Regulated insurance plans are overseen by the New York State Department of Financial Services and are subject to New York State Insurance Law with regard to the Early Intervention Program. • Non-Regulated insurance plans are NOT overseen by the New York State Department of Financial Services and are NOT subject to New York State Insurance Law with regard to the Early Intervention Program. • For a list of NYS Regulated and Non-Regulated insurance plans refer to the Insurance Tool Kit for Service Coordinators and • https://support.eibilling.com/KB/a131/regulated-insurers-list.aspx 32

33. Obtaining/Collecting Insurance Information (U-2 cont’d) • Determining if an Insurance Plan is Regulated or Non-Regulated by NYS Insurance Law • Plans that are issued or written outside of New York State are NOT regulated by NYS Insurance Law • Blue Cross/Blue Shield plans that are issued or written outside of NYS are NOT NYS regulated insurance, even though the claims are sent to the local address for processing • Health Saving Plans, Health Spending Accounts, Flex Spending Accounts, and Health Reimbursement Accounts are NOT insurance health plans • Self-funded plans are NOT regulated by NYS Insurance Law (except if listed on the NYS Regulated Health Insurance Providers List) 33

34. Unit 3 Verifying Insurance Information 34

35. Verifying Insurance Information (U-3) • Complete “Authorization to Release Health Information” Form C and “Request for Coverage Information” Form D and mail to the insurer • Give/mail copies of above completed forms to providers • Enter above information into NYEIS or give to the municipality for children in KIDS • Document ALL efforts to obtain accurate insurance information in the child’s record 35

36. Verifying Insurance Information (U-3 cont’d) Live NYEIS Web Demonstration • Entering Information from Authorization to Release Health Information (Form C) and Request for Coverage Information (Form D) into NYEIS 36

38. Verifying Insurance Information (U-3 cont’d) • Is Insurance Regulated or Non-Regulated? See Tool Kit Items 15 & 16 • Directly contact the insurer to verify family’s individual insurance plan • Refer to “List of NYS Regulated Insurers” • Refer to “List of Non-Regulated Insurance Plans” • Review Family Insurance ID Card for possible Regulated/Non-Regulated designation 38

39. Verifying Insurance Information (U-3 cont’d) • Determining Regulated or Non-Regulated: What to Watch For • Many regulated insurers issue self-funded plans • Some plans may be administeredoutside of New York State, but still be regulated 39

40. Verifying Insurance Information (U-3 cont’d) • Complete/update “Collection of Insurance Information” Form A • Submit Form A to municipality for children whose records reside in KIDS legacy data system – or – • Enter insurance information directly into NYEIS verifying regulated or non-regulated • Mail completed Form A to providers and upload into NYEIS: Child’s Integrated Case Home Page • Inform Service Providers that Insurance Information is in NYEIS 40

41. Verifying Insurance Information (U-3 cont’d) Written Referral/Scripts • Written Referrals and Scripts are two distinct documents serving separate purposes • The script may be used [as a written referral] • Best Practice – Treat separately and pursue both • Note in the child’s record all efforts to obtain documents 41

42. Verifying Insurance Information (U-3 cont’d) Written Referral/Scripts (cont’d) • Medicaid required information for a script MUST be contained in the written referral. 42

43. Verifying Insurance Information (U-3 cont’d) Scripts/Orders • Commercial insurance companies MAY REQUIRE a medical order or script in order to document medical necessity for a service to be covered • NOTE: The script above IS NOT the same script required for delivery of some selected EI Services (e.g., OT, PT, etc.) • However, this script MAY BE USED to meet the need for the order required in EIP regulations if it contains ALL the required elements under regulation for an order 43

44. Verify Insurance Information (U-3 cont’d) Written Referral • SC must collect written referral from families who have commercial insurance coverage for services covered under their plan • PHL requires families to supply the municipality with a written referral from the primary care provider familiar with the medical condition of the child to support medical necessity • The written referral DOES NOT apply to: • Service Coordination and Special Education Services • Families with Medicaid and Medicaid Managed Care Insurance 44

45. Verifying Insurance Information (U-3 cont’d) Written Referral • OSC completes, with the family, Form E, “Written Referral from Primary Health Care Practitioner” • Fill-in the top portion of the form and list services from the child’s IFSP in the boxes at the bottom of the form • With parent consent, OSC contacts the PHCP to assist parent in obtaining Form E or to make follow-up calls • Update family’s insurance information on Insurance Tool Kit Form A, “Collection of Insurance Information” at each IFSP meeting 45

46. Verifying Insurance Information (U-3 cont’d) Written Referral • Once Form E is signed and returned by PCP, the OSC: • Submits Form E to the municipality for children in KIDS, or • Documents receipt of information in comment field on the child’s insurance page in NYEIS, and scans signed referral as an attachment to the child’s NYEIS integrated case home page • Mails copy of written referral form to child’s provider(s) • Files written referral form in child’s record 46

47. Verifying Insurance Information (U-3 cont’d) Live NYEIS Web Demonstration • Document Information from Form E, Written Referral from Primary Health Care Practitioner into NYEIS 47

49. Verifying Insurance Information (U-3 cont’d) Written Referral Important Notes • The written referral does not need to be obtained before EI services begin • Services MUST NOT be delayed if written referral cannot be obtained from the PCP • The written referral can be used for claims at the time of billing- Medicaid OPRA requirement • Child’s file MUST contain documentation of attempts to obtain written referral • Commercial insurance continues to be billed 49

50. Verifying Insurance Information (U-3 cont’d) Important Insurance InformationTypes of Different Insurance Coverage for EI Services • Commercial Insurance - Regulated or Non Regulated • Primary Insurance • Secondary Insurance • Child Health Plus • Medicaid • Medicaid Managed Care 50