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Hospital Orientation. May 2014. Conducted by: Yvonne Flores.
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Hospital Orientation May 2014 • Conducted by: Yvonne Flores The information in this document is confidential and should not be disclosed outside of Prestige Health Choice. It may not be reproduced in whole, or in part, nor may any of the information contained therein be disclosed without the prior consent of the directors of Prestige Health Choice.
Prestige Health Choice • Who we are • At Prestige Health Choice, we don’t just want to build a better health plan – we want to make getting care a priority. We believe that every person deserves respect and quality care. That’s our promise – and we’re working to deliver on that promise every day. • What makes us different • Prestige is owned in part by Community Health Centers (Federally Qualified Health Centers – FQHCs). These non-profit health centers and their doctors share our mission to improve the health of our members. Many of these centers have served their communities for over forty years, giving care to patients who need it the most. Our doctor-owners serve over 350,000 Floridians – most of whom have no insurance.
Medicaid Overview • Prestige serves both adults and children eligible to participate in Florida’s Medicaid Program. • In addition to traditional Medicaid coverage, additional coverage* includes: • Adult Dental Services • Adult Vision Services • Adult Hearing Services • Over-the-Counter Vitamins, Medicines and Health Supplies *Coverage is subject to change • No Co-Payments, Coinsurance or Deductibles.
Member Identification and Eligibility Verification • Prestige Health Choice member eligibility varies by month. Therefore, each participating provider is responsible for verifying member eligibility with Prestige before providing services. Eligibility may be verified by visiting the Provider Portal of Prestige Health Choice’s website at www.prestigehealthchoice.com, via the Availity Portal at www.availity.net or by calling Provider Services at 1-800-617-5727. • If you have questions or need assistance you can contact the Availity support team at 1-800-282-4548 or you may email them at email@example.com • Please note that the presentation of a Prestige Health Choice ID card is not sole proof that a person is currently enrolled in Prestige. For example, when a member becomes ineligible for Medicaid, the member does not return the Prestige Health Choice membership card. Providers should request a picture ID to verify that the person presenting is the person named on the ID card. Services may be delayed being rendered, if the provider suspects the presenting person is not the card owner and no other ID can be provided, except for emergent situations. If providers suspect a non-eligible person is using a member’s ID card, please report the occurrence to Prestige Health Choice’s Fraud and Abuse Hotline at 1-866-833-9718. .
Claims Overview • Prestige Health Choice will reimburse providers for the delivery of covered services as follows: • 1. Claims are considered received on the date the claims are received by Prestige. • 2. Providers must mail or electronically transfer (submit) the claim to Prestige Health Choice within the time frame allowed by their contract. • Electronic Claims Submission • Providers have the option of submitting claims electronically through Electronic Data Interchange (EDI). The advantages of electronic claims submission are as follows: • Facilitated, expedient claims payment • Acknowledged receipt of claims electronically (through EMDEON -formerly known as WebMD and ProxyMed) • Improved claims tracking • Improved claims status reporting • Improved turnaround time for timely reimbursement • Eliminated paper • Improved cost effectiveness
Claim Submission Protocol • Prestige Health Choice monitors encounter data submissions for accuracy, timeliness and completeness through claims processing edits and through network provider profiling activities. Encounters can be rejected or denied for inaccurate, untimely and incomplete information. Network providers will be notified of the rejection via a remittance advice and are expected to resubmit corrected information to Prestige in the allowed timeframe listed in the providers’ contract. Network providers may also be subject to sanctioning by Prestige for failure to submit accurate Encounter data in a timely manner. • Verification that all required fields are completed on the UB-04 forms or its successor. • Verification that all Diagnosis and Procedure Codes are valid for the date of service. • Verification of member eligibility for services under Prestige during the time period in which services were provided. • Verification that the services were provided by a participating provider or that the “out of plan” provider has received authorization to provide services to the eligible member. • Verify service being performed is a covered service and that member has not exhausted their benefits. • Verification that the provider is eligible to participate with the Medicaid Program at the time of service. • Verification that an authorization has been given for services that require prior authorization by PHC. • Verification of whether there is Medicare coverage or any other third-party resources and, if so, verification that PHC is the payer of last resort” on all claims submitted to PHC.
Provider Portal • Prestige is pleased to offer a number of online services to our providers through Availity at www.prestigehealthchoice.com. • This self-service site requires registration. • How to register: • You will need to click on: http://www.availity.com/providers/registration-details/ • Click on: • “Start Registration.” • Complete the registration process using this sign-up process • Availity will provide Security verification and assign your user name • You will be asked to crate a password • Once you've completed the registration process, you will be able utilize the website. If you need assistance, please call 1-800-Availity. • Services Available: • Eligibility and Benefits • Claim Status • Authorization Submission and Inquiry • Report Inquiry
Utilization Management Overview • Prior Authorization • The most up to date listing of services requiring Prior Authorization will be maintained in the Provider Portal at www.prestigehealthchoice.com. You may also request a listing by contacting Provider Services at • 1-800-617-5727. • Providers may request Prior Authorization by contacting Utilization Management at 1-855-371-8074 or by sending a fax request for authorization to 1-855-236-9285.
Notification of Admission • Facilities should fax the member demographic sheet and their contact information to 305-994-0059 to notify Prestige of an inpatient admission. The case will be pended for clinical review and all clinical information is to be faxed to our Utilization Management line at 305-994-0060. • **Please note faxing clinical information does not constitute as notification and we must have the business office notification in order to process. • Please be advised that elective admissions for pre-certification must be previously approved through our Prior Authorization department at 1-855-371-8074 or fax 1-855-236-9285.
Provider Appeals/Provider Complaint • Provider Complaint System 1-800-617-5727 • You may dispute Prestige Health Choice’s policies, procedures, or any aspects of Prestige Health Choice administrative functions, including proposed actions, claims, billing disputes, and service authorizations. • You may contact Prestige Health Choice via telephone, email, regular mail or may request an in- person meeting using the contact methods listed below. • Please call Provider Services at 1-800-617-5727, or send a written complaint to: • Prestige Health Choice • Attn: Provider Complaints Coordinator • P.O. Box 7366 • London, KY 40742 • Fax 1-855-358-5853 • You may file a written complaint within forty-five (45) calendar days for issues not related to claims. Within three (3) business days of receipt, Prestige Health Choice will notify you (either verbally or in writing) that the complaint was received and provide an expected date of resolution.
Provider Appeals/Provider Complaint – Cont. • Prestige will thoroughly investigate the complaint and keep you informed of any delays in resolution with an update at least every fifteen (15) calendar days. All complaints will be resolved within ninety (90) calendar days. Once a resolution has been determined, Prestige will notify you of the resolution within three (3) business days of the resolution. • Because Prestige Health Choice takes your concerns seriously, all complaints are tracked and presented bi-annually to the Quality of Service Committee, in addition to being reported to the Agency, as required. • Appeals on Behalf of the Member • “An appeal may be filed orally or in writing within thirty (30) calendar days of the enrollee’s receipt of the notice of action. • To file an appeal on behalf of the member, please send to Prestige Health Choice Appeal and Grievance Department at: • Prestige Health Choice • Appeal and Grievance DepartmentP.O. Box 7368London, KY 40742 • Fax: 1-855-358-5847
Yvonne Flores • Regional Manager, Hospital Contracting • Tampa Gulf, Central & North Florida • Cell 786-473-8402 • Email: firstname.lastname@example.org
Thank you for your participation! • We look forward to working with you!