An Educational Presentation

1. An Educational Presentation Prepared For: Kentucky Eye Medical Providers & Staff Presented by: Avesis October 2011

2. Introductions

3. Locations • Executive Offices in Baltimore, MD • Operations located in Phoenix, AZ Phone: (855) 469-3368 • Eligibility • Claims • Member Services • Southeast regional office in Atlanta, GA Phone: (855) 469-3368 • Provider Services • Prior Approvals

4. Eye Medical & Routine Vision Avesis Medicaid Eye Medical and Routine Vision Plans in Kentucky Providing Eye Medical and Routine Vision Services for Medicaid Members enrolled in:

5. Points of Contact • Nichole MitchellDirector of Government Servicesnmitchell@avesis.com(800) 522-0258 x296 • Lornetta Gordon RoebuckProvider Serviceslgordon@avesis.com(800) 522-0258 x293 • Dana LintonProvider Servicesdlinton@avesis.com(800) 522-0258 x130

6. Avesis Vision Advisory Board • Committee of licensed Kentucky licensed Ophthalmologists and Optometrists • Act in an advisory capacity to WellCare and Avesis in all matters pertaining to the Medicaid Program in Kentucky • Help to ensure quality communications between Kentucky provider community, Avesis and WellCare • Forum for providers to submit recommendations and feedback regarding the program and its administration

7. Eligibility

8. Eligibility • It is strongly encouraged that you verify eligibility for each Member’s appointment the business day prior to rendering services unless the next business day is the first day of a new month. • Please note that verification of benefits or eligibility is not a guarantee of payment: actual payment is based on the terms and conditions of the plan in force once the claim is received.

9. Eligibility You may obtain eligibility verification four ways: IVR – Please bear in mind that this only provides you with information as to whether or not the Member has coverage with the CMO on the date of service for our Medicaid Members. It does not provide utilization data (whether or not the Member has utilized their benefit) Website – Choose the “coverage slice” that is applicable to the date of service for which you are seeking eligibility. Choose “View Usage” to view the Members utilization history. Customer Service – Customer service is able to provide you with both eligibility confirmation as well as utilization data. Fax – You may utilize the form found on the following slide for eligibility confirmation. This form will provide you with both eligibility confirmation and utilization data.

10. Fax Eligibility Verification

11. Benefits

12. Benefits Overview Effective November 1, 2011, Avesis will administer a Full Eye Medical and Routine Vision Program for Members enrolled in WellCare of Kentucky. Coverage will include office visits consisting of routine vision and eye medical diagnosis, medical and surgical services, medically necessary contact lenses, when applicable, and spectacle frames and lens materials required to correct visual acuity.

13. Benefits Overview • Covered Services • Covered services will be paid according to the plan fee schedule • Non-Covered Services • Non-Covered Services may be the responsibility of the Member if and only if the Member is notified of and agrees to financial responsibility prior to services being rendered

14. Benefits Overview • There are two Medicaid programs under WellCare Kentucky: • Global Choices • Family Choice • Benefits for children (Members ages 20 and under) are the same in each of the plans • Benefits for adults (Members ages 21 and over) vary according to the program in which the Member is enrolled. There are NO materials benefits for adults enrolled in either program.

15. The Global Choices Program Global Choices is the benefit plan for most Kentucky Medicaid Members. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Some service limits can be increased if the service is medically necessary (requires prior approval).

16. Benefits for Global Choices • Global Choices benefits include but are not limited to: • Adults and children limited to 1 eye exam per Member per provider per calendar year • Eyewear limited to children under 21 • Materials limited to $200 per calendar year. Maximum paid for one pair of glasses is $150.

17. The Family Choices Program Family Choices is the Kentucky Medicaid benefit plan for most children. This plan covers basic medical, dental and vision services. There are no co-pays for any ophthalmological or vision services for WellCare Kentucky Members enrolled in Global choices. Kentucky Children’s Health Insurance Program (KCHIP) is part of the Family Choices Plan. Some benefit limits can be increased if the service is medically necessary (requires prior approval).

18. Benefits for Family Choices • Family Choices benefits include but are not limited to: • Children limited to 1 eye exam per Member per provider per calendar year • Eyewear limited to children under 21 • $400 limit per calendar year • Maximum paid for one pair of glasses is $150

19. General Benefits • Benefit Exception/EPSDT Process • Benefit exception occurs when a provider contacts Avesis requesting services that are non-covered for medical necessity • Benefits are either exhausted or not a covered benefit • Requests will be reviewed by Utilization Management and a decision will be made with in two (2) business days. • Emergency Services • Members seeking emergency services may need to be referred back to WellCare Kentucky for medical benefits

20. Prior Authorization

21. Avesis Prior Approval Requirements • Avesis does not currently require prior authorization for ophthalmological services covered under the Avesis Kentucky Medicaid program. • Facility authorizations must be obtained through WellCare when required. Please contact WellCare Utilization Management Department via fax at(877) 431 – 0950 for further assistance.

22. Claims

23. Claim Submission Claims may be submitted one of three ways: • Through your practice management software using a clearinghouse • The Avesis payer identification number is 87098 • On a CMS1500 claim form - please submit to the following address: Avesis Vision ClaimsPO Box 7777Phoenix, AZ 85011 – 7777 • Utilizing our website at www.avesis.com

24. Claims Follow-up Providers receive remittance advices detailing claims both paid and denied. If you believe you have not received status on a claim, you may check the status of submitted claims two ways: • You may check claim status on the Avesis website at www.avesis.com • You may contact our provider services department at (855) 469-3368 to check claim status

25. Corrected Claims Submission • If you are missing information (i.e. modifiers, claim lines, etc.) you may refile the claim on the web for payment • If you have submitted incorrect information (wrong code, wrong diagnosis, etc) you will need to submit a corrected claim. To submit a corrected claim: • Please write corrected claim on the top of the CMS 1500 claim form in blue or black ink. The scanner does not read red ink • Please do not highlight notes on the claim in blue or green highlighter. The scanner reads these colors as black so what ever they highlight is blacked out.

26. Avesis Claims Payment • Check runs weekly (each Friday) • CLEAN CLAIMS processed and adjudicated within 15 business days • Claims submitted one of three ways: • Electronically (EMC payer ID# 87098) • Manually entered on www.avesis.com • Paper form • Electronic Funds Transfer available

27. Electronic Funds Transfer Agreement

28. Avesis Web Portal

29. Web Portal

30. Claims

31. Submit HCFA Claim

32. Submit HCFA Claim

33. Medical Records Review

34. Avesis Review Process • Avesis conducts medical record reviews for our provider networks • Your office will be contacted to furnish a list of charts for review • After the visit, your office will be sent a letter regarding the findings of our review

35. Provider Services

36. Services to Providers • Avesis is primary for Provider Services for both our commercial and Medicaid products. • Avesis has toll free phones staffed by experienced and knowledgeable representatives for all of our products • Regional meetings and training sessions scheduled for providers

37. Additional Assistance • Schedule a conference call • Schedule a web demo • Schedule an onsite visit

38. Committed to Technology 24/7 Access to information: • Web Based • Eligibility • Claims submission • Claims status • Interactive Voice Response (IVR) • Eligibility • Benefits

39. Thank You For Your TimeQuestions? We at Avesis look forward to working with you and your team.