2020-2021 PROVIDER MANUAL MEDICARE ADVANTAGE - a population health company
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2020-2021
MEDICARE ADVANTAGE
PROVIDER MANUAL
a population health company
TABLE OF CONTENTS
Introduction Billing & Claims
Welcome to Physicians of Southwest Washington Co-payment & Coinsurance
2020 Medicare Advantage Contracts Claims Submission
Provider Engagement Timely & Prompt Payment
Contact Information Reimbursement
Claims Reconsideration & Dispute Process
General Information Referrals & Prior Authorizations
Identifying a Health Plan Member
Determining Eligibility and Benefits Medical Management
Non-Interference with Patient/Provider Relationship Utilization Management
Coordination of Benefits Quality Management and Incentive Program
Member Transfer Between Contracted PCP’s Care Management
Facility Admissions
Rights & Responsibilities Urgent or Emergent Services
Provider Responsibilities and Standards
Provider Engagement and Communication Compliance and Ethics
Electronic Medical Record (EMR) General Requirements
Reporting Fraud, Waste, and Abuse
Credentialing Marketing Guidelines
Credentialing Standards Confidentiality
PSW Credentialing Discretion
Credentialing Requirements for Participation
Credentialing Process
Re-Credentialing
Decision Making Process & Provider Notification
Credentialing Non-Compliance
mission statement
The mission of Physicians of Southwest Washington is to support the physician-patient
relationship in the independent practice of medicine through fair contracting, responsible
resource utilization and prudently adopted innovations in health care delivery. PSW is
committed to quality improvement, clinical integration and meaningful measures of value.
INTRODUCTION A Population Health Company Welcome This Provider Manual is intended for practices who hold a Physicians of Southwest Washington (“PSW”) Provider Agreement to deliver quality health care services to members enrolled in PSW contracted Medicare Advantage (“MA”) health plans. Providers and practice staff are encouraged to reference this document which has been developed to provide information and assistance regarding PSW’s Provider Agreement requirements, policies and procedures as well as the responsibilities of being a contracted provider. The Provider Manual is an extension of the Provider Agreement (“Agreement”) between PSW and its provider network participants, including, but not limited to: physicians, providers, hospitals, and ancillary health care providers (hereinafter collectively and/or individually referred to as “Provider(s)”). In accordance with the Agreement, participating Providers must abide by all applicable provisions of this Manual. PSW reserves the right to make changes to the Provider Manual and will do so in accordance with Section 2.05 of the Provider Agreement. About PSW An independent physician association based in Olympia, WA, Physicians of Southwest Washington (PSW) is the leading healthcare resource in the South Puget Sound region for physicians and practices. Formed in 1995 by primary care and specialist physicians with a goal to shape the future of regional healthcare by providing continuity of health plan access and maximizing quality of patient care. Today, PSW is a diversified organization with twenty-four years of proven success in managing full risk health plan contracts, implementing Accountable Care models and delivering management services. As a delegated entity with Medicare Advantage health plans, PSW provides key services to nearly 1,000 healthcare providers and the approximate 5,000 patients they serve. These services include claims processing, provider credentialing, contracting, and care management. In 2016, PSW launched NW Momentum Health Partners ACO, LLC, to participate in the CMS Next Generation ACO model of care. The Next Generation ACO Model supports Medicare beneficiary lives through active care coordination and services with the goal of improving quality, reducing expenditures and enhancing the patient and provider experience. We look forward to working with you and your patients in 2020.
INTRODUCTION
PSW Medicare Advantage Contracts
PSW understands the best healthcare is accomplished by working in partnership with providers, patients
and payers. PSW is proud of its network of more than 1000 providers and facilities, whose active
engagement is a cornerstone of our success.
2020 Medicare Advantage Health Plan Partners
PSW manages fully-delegated Medicare Advantage contracts on behalf of its network. This means, we have
responsibility for all operational aspects of our Medicare Advantage contracts including:
Care Management | Utilization Management | Medical Directors | Claims Processing | Provider Contracting
Credentialing | Quality Reporting | Financial | Ability to Enroll Patients
PSW is your local resource for these plans. For questions regarding your Premera and Humana members,
contact us 360-943-4337.
Practice Resources
Our staff is available to provide training, education and materials on any operational processes outlined in
this Manual. To stay up-to-date on contract changes, prior authorizations or other news, be sure to take
advantage of the following resources located electronically in the Provider Portal at:
pswipa.com/provider | [password] PSW2019
Claims Information | Event Calendar | Provider Quality Reporting | Prior Authorization Forms
PCP Change Forms | Quality Guides
PSW Health Plan Agents
PSW licensed agents can answer questions on Medicare, Medicare Advantage and specific PSW health
plans. Free one-on-one consultations are available Monday-Friday, 8:30am - 4:30pm. No appointment
needed and no obligation.
Provider Engagement and Communication
PSW keeps providers and practices engaged by sharing data, performance metrics on quality measures and
approved key initiatives. This is accomplished through customized reporting, Value Based Workshops,
continuing education opportunities and individual meetings at provider practices as needed.
Distribution of all reports, is facilitated via Box.com. If you are a primary care provider and have not received
access to your Box.com account, please contact 360-943-4337, ext 101.
CONTACT US
DEPARTMENT CONTACT INFORMATION
AUTHORIZATION & NOTIFICATION PHONE: 360.786.8690
FAX: 360.786.8751
CLAIMS PHONE: 360.943.4337 option 2
FAX: 360.754.4324
claimsquestions@pswipa.com
CARE MANAGEMENT PHONE: 360.786.8690
FAX: 360.786.8751
careteam@pswipa.com
Monday - Friday 9am-5pm PDT
CREDENTIALING PHONE: 360.943.4337 ext 138
FAX: 360.754.4324
COMPLIANCE | FRAUD | WASTE & PHONE: 360.943.4337 option 7
ABUSE (FWA) CONCERNS PHONE: 360.743.4337 ext 119
FAX: 360.754.4324
www.pswipa.com/contact-us/compliance
(anonymous report)
HEALTH PLAN AGENTS PHONE: 360.943.4337
FAX: 360.754.4324
agentteam@pswipa.com
NETWORK OPERATIONS PHONE: 360.943.4337 ext 132
FAX: 360.754.4324
providernetwork@pswipa.com
GENERAL MEMBER INFORMATION
Identifying a PSW Member
Member identification cards, consistent with Centers for Medicare and Medicaid Services (“CMS”) standards,
are issued by the health plan to Members upon enrollment and contain basic information you will need
when providing covered services to our Members.
Member identification cards identify PSW Members, the plan type they have, and facilitate interactions with
health care providers by including details on claim submission, PCP and contact information. Below are
samples of member cards for PSW delegated health plans.
NOTE: Member ID cards list PCP name and PSW payer ID and address for claims.
2020 Contracted Plans
GENERAL MEMBER INFORMATION [continued] Determining Member Eligibility and Benefits Due to potential changes in a member’s eligibility and to ensure accurate reimbursement of services, providers are responsible for verifying a member‘s eligibility prior to providing services. Please contact the member’s health plan directly for this information. To verify a member’s eligibility, the following methods are available to all practitioners: Ask to see the Member’s ID card Verify eligibility and coverage for Humana at www.availity.com Verify eligibility and coverage for Premera at www.onehealthport.com PSW is unable to provide benefit information and any calls received will be redirected to the health plan. Coordination of Member Benefits PSW members may have other insurance coverage. PSW adheres to CMS regulations to determine the primary insurance carrier and the appropriate reimbursement process. The Provider is responsible for identifying all insurance coverage held by the Member at the time of admission or services provided. Any additional coverage information obtained by Provider (in addition to PSW delegated health plans) should be forwarded immediately by Provider to PSW. This information will help expedite payment. If the additional coverage is “primary, the claim must first be submitted by Provider to the primary carrier for payment. Non-Interference with Patient/Provider Relationship PSW encourages a strong Provider-Patient relationship, and therefore does not interfere, prohibit, or otherwise restrict Providers from freely communicating with or advising PSW Members concerning their health status, medical care or treatment options, including timely communication of clinical information. We serve as an advocate on behalf of a Member regarding care and treatment options, regardless of benefit coverage limitations. Member Change of Primary Care Provider The following guidelines apply to the transfer of a PSW delegated health plan member, upon his/her request, from one PCP to another: The Member’s decision to transfer should be strictly voluntary; The Member must not have been directly recruited by phone or in person by anyone involved with either primary care office; The Member must not have been influenced to transfer to the new PCP due to improper or incorrect information, or for medical reasons; Upon a Member’s request, the primary care office must send his/her medical records to the newly selected primary care office without charge to the Member. Member must call health plan directly and follow established PCP change process. Or, fill out the PCP change form located on the PSW Provider Portal with new PCP.
PROVIDER RIGHTS & RESPONSIBILITIES Member Appeal & Grievance Process PSW’s appeal and grievance process conforms to CMS guidelines, and applies to delegated health plan Members who are dissatisfied with the health care services received, or any aspect of the Plan. An appeal/ grievance may be filed by a Member or his/her authorized representative. Member appeals and grievances are handled by the respected health plan. However, PSW can be contacted for assistance with questions or concerns on how to submit. Humana Inc. Premera Blue Cross Medicare Advantage Plans Attn: Appeals and Grievance Department Attn: Appeals and Grievances Department PO Box 14165 P.O. Box 262527 Lexington, KY 40512-4165 Plano, TX 75026 1-800-494-2961 1-800-889-1076 Provider Responsibilities and Standards PSW contracted providers have agreed to provide care to PSW health plan enrollees. We look forward to supporting you in providing accessible, quality healthcare that meets the needs of our members. Providers are also responsible for the education and training of all individuals working within their medical practice to ensure that policies and procedures outlined in your contractual agreement and the PSW Provider Manual are followed correctly. Below are Provider rights and responsibilities in accordance with CMS requirements: To adhere to all credentialing requirements as outlined in the PSW credentialing section . To maintain participation in Medicare under Sections 1128 or 1128A of the Social Security Act. To provide services in a manner consistent with professionally recognized standards of care. Insurance in amounts deemed sufficient by PSW and delegated health plans. To maintain the requirements for Continuing Medical Education (CME). To provide Plan notification if there are any changes to your licenser status, sanctions or business information (Tax ID numbers, address, etc.). To maintain confidentiality with the Members’ records, correspondence, and discussions in accordance with state and federal laws and regulations. To maintain Members’ medical records in a form that is consistent with the requirements of state and federal laws and regulations. To maintain procedures to inform Members of follow-up care or provide training in self-care as necessary. To ensure all services are provided in a culturally competent manner. Applicable to PCP’s, to provide, coordinate, monitor, and supervise the delivery of health care services for assigned-Members and to provide appropriate referrals to participating specialists. Applicable to Specialists, communicate with member PCP to facilitate coordination of care and any additional referrals necessary. Applicable to Acute Facilities, to provide notification of all inpatient admissions as described in the Manual and have inpatient and emergency services available.
PROVIDER RIGHTS & RESPONSIBILITIES [continued] To collect the appropriate co-payment, coinsurance or deductible in accordance with the Member’s benefit plan. To provide copies of medical records to the Member upon request. Permissible fees associated with the procurement of records must only include certain labor, supplies and postage (if applicable) as defined by HHS. To provide services in a manner consistent with standards of care. To encourage a Member to participate in his or her treatment planning and course of care. To provide clear and understandable information to the Member regarding treatment options, including interpretive services for Members who are hearing impaired or whose primary language is not English. To provide Members with written information about advanced care planning, advance directives, and the right to make anatomical gifts. To meet safety standards in accordance with the Occupational Safety Health Administration, ADA, and any other regulatory requirements. To comply with PSW’s utilization management/quality improvement activities including, but not limited to: HEDIS, medical record reviews, audits and corrective action plans including participation provider access standards. To comply with PSW’s audits. To ensure that Members are not discriminated against based on race, ethnicity, national origin, religion, sex, sexual orientation, age, mental or physical disability, or source of payment. To ensure that the hours of operation are convenient for Members so services may be provided with reasonable promptness. To make an exception, as per written authorization form the Member, to allow their medical records or medical condition(s) to be disclosed to others. To maintain safe storage of inactive medical records for a minimum of ten (10) years (outlined in 42 CFR 422.504) and have them easily retrievable when needed. To allow Members to directly access all services as required by CMS, state, and federal law, including, but not limited to: screening mammography, influenza vaccination services, and in network routine women’s health. To ensure that any payment and incentive arrangements with subcontractors are specified in writing , that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards. To follow PSW processes for notifying Members of any partial or full Agreement terminations. To cooperate with and assist PSW in fulfilling its responsibility to disclose to CMS quality, performance and other indicators, as specified by CMS. To follow PSW procedures for handling grievances, appeals, and expedited appeals. To provide full disclosure to Members before providing a health service if you believe there is a substantial likelihood that a specific service will not be covered. A pre-service organization determination request (prior authorization request) should be sent to PSW Medical Management to issue formal decision to the member, explaining non-coverage. To abide by all state and federal laws, rules, regulations, and statutes. To comply with all provisions of your Agreement with PSW. To refer all services to a participating provider in PSW’s network, except as otherwise authorized by PSW.
PROVIDER RIGHTS & RESPONSIBILITIES [continued] NOTE: To the extent allowed by state law, mid-level providers are state licensed professionals who may be employed or contracted by Providers to examine and treat Members. Mid-level providers are Advanced Registered Nurse Practitioners (ARNPs) or Physician Assistants (PAs). The Member must be notified of their credentials and the possibility of not being seen by a Medical Doctor when utilizing a mid-level provider. The Provider must sign all progress notes made by PAs when billing incident-to. PSW allows ARNPs and PAs the ability to have Members assigned as his or her PCP. Listings in Provider Directories and Other Member Materials Information provided in member materials, including provider directories, is the publicly available information obtained in the credentialing process. This includes: Name Location (s) Certification Specialties Panel Status Notification to PSW of Provider Additions and Terminations PSW requires immediate notification of any provider additions or terminations to/from the practice (TIN based) associated with the contractual agreement with PSW. Failure to do so could impact reimbursement for services provided. To ensure continuity of care for members during the transition (termination or retirement) of primary care providers, PSW must be informed at least 90-days in advance (per executed Provider Agreement). This advance notice allows PSW to support the practice by informing health plans, coordinating reassignment of members and, if needed, additional communication to members.
CREDENTIALING Credentialing Standards PSW is delegated by its contracted health plans to assume all credentialing requirements for its Medicare Advantage provider network. It is a requirement to demonstrate all providers meet Washington State, federal and other regulatory or compliance requirements. Health care professionals who want to join the PSW network and be listed in our provider directory, must first successfully complete the credentialing process. PSW follows National Committee for Quality Assurance (NCQA) and CMS requirements. Non-Discrimination Credentialing and re-credentialing decisions are not based on race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or members they specialize in. Confidentiality PSW maintains mechanisms to properly limit review of confidential credentialing information. Credentialing taff or representatives must not disclose confidential provider credentialing and re-credentialing information, outside of required PSW approval committees, to any persons or entity except with the express written permission of the provider or as otherwise permitted or required by law. Initial Credentialing Process PSW seeks to process all initial credentialing requests within 90-days. We use both CAQH ProView and One health Port websites to collect credentialing data for providers. To support this goal, practices are asked to submit completed documents – including signatures – in a timely manner or as requested. To be eligible for the credentialing process, providers must complete a Washington Practitioner Application (WPA) and meet the following criteria, as applicable: A completed WPA includes a signed statement attesting to: Applicant’s current professional liability insurance policy; Limitations on ability to perform functions of the position with and without accommodation; History of loss or limitation of privileges or disciplinary activity; Absence of current, illegal drug use; History of loss of license and felony convictions; and Completeness and accuracy of the information provided. Have the requisite medical or professional education and training to practice within the scope of the provider’s license, including residency completion if applicable to practice; Verification of post-graduate education or training; Current license or certification in all states where the applicant practices without material restrictions, conditions or any other disciplinary action; Valid DEA or Controlled Substance Certificate or Acceptable Substitute, as required per practice; Medicare/Medicaid program participation eligibility; Board certification, as applicable Work history — five years; Malpractice Insurance or State-Approved Alternative, equal to or greater than the minimum amounts required and outlined in provider’s contract; Malpractice history —five years; No sanction or limitation on being licensed; No prior denials or terminations within the last 24 months; and Admitting hospital privileges or arrangements with a participating licensed provider to admit and provide facility coverage;
CREDENTIALING [continued] Provider Office Site Quality Review For newly contracted Primary Care Providers, PSW conducts initial on-site survey to ensure all health plan requirements are met. Office site standards that you must follow include: Physical accessibility, such as handicapped accessible; Physical appearance; Adequacy of waiting and examining room space; Availability of appointments; and Adequacy of treatment record keeping (e.g., secure/confidential filing system). The credentialing program applies to the following provider types: Doctor of Medicine (MD) Doctor of Osteopathy (DO) Doctor of Podiatry (DPM) Doctor of Chiropractic Medicine (DC) Doctor of Optometry (OD) Physician Assistant (PA) Nurse Practitioner (NP) Physical Therapist (PT) PSW contracted health plans are responsible for credentialing facilities. Re-Credentialing Process PSW re-credentials network providers at least every 36 months. The process locates and evaluates changes in the providers’ data, which confirms the provider’s ability to deliver healthcare services. Providers are encouraged to attest to all the data in your CAQH ProView or Provider One websites application every 120 days and maintain a complete and current application with supporting documentation, no further action is required. PSW credentialing department will access your information and follow the steps needed for re-credentialing. If the credentialing information is not current, PSW will reach out to the provider and/or practice to request updated re-credentialing application form and attestation.
BILLING & CLAIMS Claims Submissions Claims must be submitted electronically, following 5010 guidelines and using PSW’s Payer ID # 91171. Attachments cannot be accepted at this time via EDI claims, see Supporting Documentation for instructions. To ensure claims are routed to the correct entity the back of each Member ID card should be reviewed for claims mailing/EDI submission ID. See Page 6. Paper claims are only accepted when they are submitted by a member. Paper claims submitted by providers will not be processed and returned to provider for electronic submission. Questions or concerns regarding this process should be directed to the Claims Manager. Practices who have questions regarding billing electronically must contact the PSW Claims Manager for further information. Time Frame to Submit Claims Claims must be submitted and received at PSW within 365 days from the date of service. In order for a claim to be considered timely it must be a Clean Claim and received at PSW. Claims must be submitted on a timely basis; if submitted beyond timely filing guidelines, claim will be denied and provider has no formal channels of appeal. Providers may not charge a beneficiary in cases where claim was not submitted timely, except for copay/coinsurance amounts, as would have been appropriate if payment had been made. For exclusions to this rule, see Medicare Claims Processing Manual, Chapter 1 General Billing Requirements, Section 70.6- Filing Claim Where General Time Limit Expired and 70.7 Exceptions Allowing Extension of Time Limit. Corrected Claims Corrected claim must be submitted within 365 days from the date of service to be considered for payment. A corrected claim is any claim that has a change to the original claim (e.g., changes or corrections to diagnosis, procedure codes, date of service, charges, etc.). Corrected claims should be submitted following the below format: In Loop 2300, the CLM segment (claim information), CLM05-3 (claim frequency type code) must represent qualifier codes of: “7”- Replacement “8”- Void or Cancel Also in Loop 2300, the REF segment (claim information), is preferred to include the original claim number of the claim being corrected.
BILLING & CLAIMS [continued] Requirements for Complete Claims PSW may reject or deny your claim if you do not list: Member’s name, address, gender, date of birth (mm/dd/yyyy). Subscriber’s name (enter exactly as it appears on the member’s health care ID card), ID number. Rendering provider’s name, their signature or representative’s signature, address where service as r endered, “Remit to” address, phone number, NPI and federal TIN. Referring physician’s name and TIN (if applicable). Complete service information, including date of service(s), place of service(s), number of services (day/ units) rendered, current CPT and HCPCS procedure codes, with modifiers where appropriate, current ICD-10- CM diagnostic codes by specific service code to the highest level of specificity. It is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item. Charge per service and total charges. Detailed information about other insurance coverage. Information regarding job-related, auto or accident information, if available. Current NDC (National Drug Code) 11-digit number, NDC unit of measure (F2, GR, ML, UN) must be added and NDC units dispensed (must be greater than 0) for all claims submitted with drug codes. Enter the NDC information for the drug(s) administered in the 24D field of the CMS-1500 Form or the LIN03 and CTP04-05 segments of the HIPAA 837 Professional electronic form. Ambulance Providers are required to, at minimum, list street address and zip code of the pick-up/drop-off locations. All providers to indicate if they “Accept Assignment”. Supporting Documentation If there are medical records or other documents that are unable to be submitted with an electronic claim, please continue to mail or fax those specific documents. Medical records sent via encrypted CD is preferred. Mailing address for attachments: Physicians of Southwest Washington Attn: Claims Department Supporting Documentation 319 Seventh Ave SE Ste 201 Olympia, WA 98501 Fax number: 360-754-4324 Medical Record Routing Form
BILLING & CLAIMS [continued] Charging Members Members are only responsible for applicable co-payments and coinsurance associated with their benefit plans. Co-payments should be collected at the time of service. However, to determine the exact member responsibility related to the benefit plan coinsurance, if any, we recommend that claims are submitted first and refer to the appropriate Remittance Advice (RA) when billing members. Members can only be billed for assigned copay/coinsurance assigned on RA and may not be billed for additional charges. Provider are responsible for reviewing RA and refunding member within 60 days of RA if copay/coinsurance was taken and not assigned. Annual Out-of-Pocket Maximum Annual out-of-pocket maximum is the total of the member’s annual co-payment maximum (if any), as shown on the member’s Evidence of Coverage. Cost sharing for certain types of covered services may not apply toward the annual out-of-pocket maximum. Please refer to the member’s Evidence of Coverage to determine applicability to the benefit plan. When an individual member’s out-of-pocket expenses has reached the Individual annual out-of-pocket maximum, no further cost share amounts will be due by the member for those services that apply to the annual out-of-pocket maximum. Member cost share is assigned based on receipt of claims and not date of service. Additional Fees for Covered Services Providers may NOT charge additional fees for: Covered services beyond their co-payments, coinsurance, or deductible Denied services/claims due to not following PSW guidelines/protocols and/or reimbursement policies NOTE: CMS does not allow you to charge MA members for missed appointments unless the member was aware of that policy. Refunds and Overpayment Recovery Process When an overpayment is identified, PSW will recoup funds due to provider against any future claim payments due. In the situation where PSW is unable to recoup funds a formal refund request letter will be generated and mailed to provider with details of request. Provider shall have right to dispute the request. If no dispute generated provider should promptly refund PSW within 60 days. Provider may negotiate a mutually agreed upon repayment plan for certain refund on a case-by-case basis. PSW will send monthly statements/invoices to billing department with funds owed. Any refunds not under a repayment plan that are not promptly issued are subject to interest and/or maybe referred to a collection agency. Refund checks cannot not be made out to the specific health plan. PSW needs to be issued the check directly as the funds come from PSW and not the health plan any checks made out to the health plan will be returned to the provider for reinsurance to PSW. Where and who to issue refund checks to: Physicians of SW Washington Attn: Refunds Department 319 7th Avenue SE, Suite 201 Olympia, WA 98501
BILLING & CLAIMS [continued] How to file a Provider Dispute If not called out in contract, provider has 60 days from date of decision or payment to send in a dispute by completing the Provider Dispute form and sending to PSW. Form must be received by 60 days from date of decision overpayment in order to be received timely and processed, any disputes beyond 61 days will be denied as exceeding timeline. Examples of over-payments can include but not limited to: Retro eligibility, Coordination of Benefits (COB), benefit assignment, fee schedule changes. Subrogation Subrogation: We have the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness to the extent permitted under state and federal law and the member’s benefit plan. If provider has received payment from another plan or entity in relation to subrogation case you must immediately send EOB/documents to PSW for payment to be reviewed. Workers’ Compensation: Cases where an illness or injury is employment-related, workers’ compensation is primary. If you receive notification that the workers’ compensation carrier has denied a claim for services, submit the claim to us along with the worker’s compensation denial letter. PSW does not coordinate payments with workers compensation cases/claims. Coordination of Benefits (COB) Coordination of Benefits (COB) is a provision included in both member plan information and provider contracts. When two or more health plans cover a member, COB protects against double or over-payment. When PSW processes a claim, we coordinate benefits if the member has other primary coverage from another carrier or third-party payer. PSW will coordinate the benefits of the members plan with those of other plans to make certain that the total payments from all plans aren’t more than the total CMS allowable. PSW is responsible for processing claims submitted for primary or secondary payment. We use information on the claim form and in the CMS data systems to avoid making primary payments in error. Where CMS systems indicate that other insurance is primary to Medicare, PSW will not pay the claim as a primary payer and will deny it to the provider of service with instructions to bill the proper party. Providers help us to ensure that claims are paid correctly when Medicare is the secondary payer by asking members about other health insurance at their visits and by properly submitting claims with primary EOBs. Primary Submission: Show all insurance information on the claim, and then submit the claim to the primary plan first. Secondary Submission: When submitting secondary claims to us, submit the primary processing information with the submission of the secondary claim. It is important to file a claim with all insurance companies to which the member subscribes. To ensure prompt and accurate payment when PSW is the secondary carrier, we encourage you to send the secondary claims with the primary processing information as soon as you receive it. If we do not receive the EOB, and are unable to obtain the primary payment information by phone, the claim will be denied with a request for a copy of the primary EOB.
BILLING & CLAIMS [continued] Coverage Issues It’s very important that providers know whether or not a service is covered by the members Health plan. If a Medicare Advantage member receives services under the direction or authorization of a Medicare Advantage plan provider and the member hasn’t been informed in writing that he/she is liable for the cost of the services, the provider must write off these charges. The only exceptions to the above instructions are: The presence of written evidence that the provider advises the Medicare Advantage member before each and every service is received that the service isn’t covered, or Cases where the member should be expected to know that the services are not covered by his or her plan, e.g., acupuncture services and cosmetic procedures. Claim Payments Options PSW partners with Change Healthcare and ECHO Health Inc. to provide more choices in electronic payment methods to support solutions that work for your practice. The following provides information on options available: If you are a new provider with PSW all payments will default to Virtual Card Payment, you may call PSW to opt out of Virtual Card Payments and work with PSW to select how you would like to be reimbursed, other options to follow. Virtual Card Payment: Virtual cards allow your office to process our payments as credit card transactions. Virtual card payments are generally received 7-10 days earlier than paper checks since there are no print and mail delays. Your office will receive fax notifications, each containing a virtual card with a number unique to that payment transaction. Once the number is received, you simply enter the code into your office’s credit card terminal to process the payment as a regular card transaction. If the card is not processed within 60 days, the virtual transaction will be voided and a paper check will automatically be sent to your office. Transaction fees do apply to this option and will be based on your merchant inquirer relationship. EFT/ACH: You can enroll for EFT/ACH by providing your banking account information, and once your enrollment is verified begin receiving payment via electronic funds transfer (EFT). Setting up EFT is a fast and reliable method to receive payment. If you wish, each time a payment is made to you, you can elect to receive an email notification. You will need to provide a Change Healthcare payment draft number and payment amount as part of the enrollment authentication. For single payer enrollment (per payer) you can fill out the below enrollment for to set up EFT payments from PSW. For all payer enrollment (any payer enrolled with Change Healthcare) you can enroll on-line through change healthcare’s website, an administrative fee will be assessed to provider, from Change Health to manage enrollments. (PSW does not receive any of this fee).
BILLING & CLAIMS [continued]
Paper Check: Paper checks remain an option. If there are concerns with electronic payments, you must
elect to opt out of Virtual Card Services or remove your EFT enrollment to receive paper checks and paper
explanation of payments.
For all payment options above, you can log into www.providerpayments.com and access a detailed
remittance advice or EPP for each transaction. In order to register at providerpayments.com you will need to
verify your ACH Deposit and confirm your Tax ID and Deposited Amount.
* You may not register until you have received an initial payment from ECHO health.
Checking Claim Status
Providers should allow 45 days for processing of their claim before contacting PSW for claim status. PSW
offers users a self-service website www.providerpayments.com where claims details can be located once
payment has been issued. If provider has questions about processing of claim after reviewing
www.providerpayments.com the PSW claims department can assist with additional questions.
If providers have questions about www.providerpayments.com, the user guide is provided below.
Providers can learn about:
Registering New Users
Advanced Search Options
Adding New TINs
Viewing 1099s and many other subjects.
www.providerpayments.com User Guide
If you have additional questions regarding your payment options, please contact Echo Health at the
numbers listed below:
Payment Options or EFT Enrollment | 1-888-834-3511
Virtual Card Processing | 1-877-705-4230
Virtual Card Dis-Enrollment | 1-877-260-3681MEDICAL MANAGEMENT Utilization Management (UM) Referral Process Physicians of SW Washington contracted providers have referral rights. All referrals must be kept in member charts, as PSW maintains the right to audit referrals. If a PSW provider is referring to another in-network provider, all required documentation will be communicated between the two parties. PSW Health Plans are HMOs. If the provider is referring to an out-of-network provider, supplier or facility, a prior authorization request (See ‘How to Request Prior Authorization’ section) with supporting clinical documentation explaining why the member’s condition requires out-of-network treatment, must be submitted to PSW. How to Request Prior Authorization To request prior authorization for health plan members, providers must complete the PSW prior authorization form, located on our website, PSWIPA.com. The form, and all supporting clinical documentation, must be completed and submitted via fax at 360-786-8751. Supporting clinical documentation may include one or more of the following: results of face-to-face evaluations, diagnostic testing results, imaging reports, second opinions, and medical clearance for the requested procedures. Failure to provide the necessary information may result in an administrative denial. NOTE: All fields on the prior authorization form must be populated, including requested codes and correlating diagnosis. Requests must be faxed; phone requests will not be accepted, with the exception of requests for skilled nursing facilities. Types of Prior Authorization Requests and Processing Timeliness Standard Requests All standard requests will be reviewed and a decision rendered within 14 days of receipt at PSW. Medically Urgent/Expedited Requests Medically urgent or expedited requests are processed within 72 hours of receipt of request. Urgent criteria is defined as “a medical event that could jeopardize the life, health, or safety of the member or others, due to the member’s psychological state; or in the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is being requested. NOTE: Use of urgent requests should be reserved for the above definition only. Improper use of “urgent” can slow the requests of others. If an ‘urgent’ request does not meet the above criteria, it may be subject to being downgraded to a standard request. Do not request “urgent/expedited” review unless it meets the above definition.
MEDICAL MANAGEMENT [continued] Inpatient Planned Procedures Planned surgeries are reviewed and a decision rendered within the time-frames outlined above. See “Stan- dard Requests” and “Medically Urgent/Expedited Requests”. Inpatient Emergent Notification should be submitted to PSW within 24 hours of admission. A tracking number will be issued by PSW to verify receipt of the notification. NOTE: The only exceptions to 24 hour notification is in the case of emergent situations when a patient does not present information necessary to support these requests. Any inpatient notification that is not received within this timeline may be subject to claims denial. Skilled Nursing Facility Placement Skilled nursing placement requests are reviewed and a decision rendered within 24 hours of receipt of request. Long-Term Care Hospital Placement Requests for long-term care hospital usage will be reviewed and a decision rendered within 24 hours of receipt of request. In-Patient Rehabilitation Placement Requests for in-patient rehabilitation are reviewed and a decision is rendered within 24 hours of receipt of request. NOTE: Failure to submit necessary information may slow, delay, and can even result in a denial in services. Please ensure your request is complete. See section “How to Request Prior Authorization”. Clinical Decision-Making PSW follows CMS guidelines and utilizes the hierarchy of clinical decision-making to make an informed determination regarding prior authorization requests. An initial review will take place, and if the request is deemed incomplete or does not meet criteria, the request is sent to a medical director for review. All requests must be medically necessary. Clinical decision-making hierarchy: National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Health Plan Benefits Health Plan or PSW Local Medical Policy InterQual® (evidence-based criteria used for clinical decision-making)
MEDICAL MANAGEMENT [continued] Medical Necessity Medical necessity is defined as healthcare services, supplies, or equipment provided by a licensed healthcare professional that are: Appropriate and consistent with the diagnosis or treatment of the patient’s condition, illness or injury. In accordance with the standards of good medical practice consistent with evidence based and clinical practice guidelines. Not primarily for personal comfort or convenience of the member, family or provider. The most appropriate services, supplies, equipment, or level of care that can be safely and efficiently provided to the member. Furnished in a setting appropriate to the patient’s medical need and condition and, when supplied to the care of an inpatient, further mean that the member’s medical symptoms or conditions require that the services cannot be safely provided to the member as an outpatient service. Not experimental, investigation, or for research or education purposes. Approvals Upon approval of a prior authorization request, PSW will mail an authorization letter to the corresponding member, and a copy will be faxed to the requester and the member’s primary care provider. Urgent requests will receive the same documentation, with the addition of a phone call to both member and provider, verbally notifying them of the determination. Denials PSW will always act with the beneficiary’s best interest in mind. The following steps are taken on all potentially adverse determinations to reach a final decision regarding the request. 1. The initial request is reviewed by a UR Nurse. 2. In the event that the request does not meet the necessary criteria, the request is escalated to a PSW Medical Director for review. 3. In the event the reviewing PSW Medical Director determines the request does not meet CMS criteria for approval, the Medical Director will reach out to the requesting provider to offer a Peer-to-Peer meeting during a specified time frame. Any additional information that is provided verbally to the Medical Director in the Peer-to-Peer meeting must be submitted via fax before the request can be approved. 4. In the event that the requesting provider does not respond to the Peer-to-Peer request in the allotted time frame, a denial letter is issued to both member and requester. 5. Denial notification letters will state the specific reasons for the adverse determination, as well as the clinical criteria guidelines used in the decision-making process. PSW does not reward Medical Directors or other reviewing staff for making adverse determinations.
MEDICAL MANAGEMENT [continued] Appeals Only members or member representatives have the right to appeal decisions that have resulted in denials. Instructions on the process to appeal can be found on the member’s denial letter. Appeals are processed directly by the health plan. Skilled Nursing Facilities (SNF) Decision Time frames All SNF requests are reviewed and a decision rendered within 24 hours. Direct Admissions PSW has the ability to direct admit eligible members to Skilled Nursing without a qualifying 3 midnight hospital stay. This admission can be from a provider office, ER or Observation. Eligible members have a skilled need that requires direct nursing care or intensive therapies. If you have someone you believe qualifies and could benefit from a direct admit, you may call us at 360-786-8690 during business hours. Discontinuance of Skilled Stay PSW performs regular reviews of skilled members to evaluate continued need, progress and whether the services can be safely performed in a lower level of care. A Notice of Medicare Non Coverage (NOMNC) will be issued by PSW if the stay is determined to no longer be medically necessary. The NOMNC will be issued at least two days or more prior to planned last covered day. The Skilled Nursing Facility may also issue a NOMNC if they feel the patient no longer qualifies for that level of care. Once a NOMNC is issued, the member should sign the document, then the signed copy should be faxed to PSW. Expedited (Fast Track) Appeal of NOMNC The member has the right to appeal the decision made by the SNF or PSW. The member can request an expedited review by the Quality Improvement Organization (QIO) , if completed in the first 24 hours after receipt of NOMNC. When the SNF receives notification of and expedited appeal, either by the member or the QIO, the SNF should call PSW to report that an appeal has been initiated, wherein PSW will issue the required Detailed Explanation of Non-Coverage(DENC) back to the facility to provide to the member. Once the records request document from the QIO is received, the SNF should submit the records per the request document within the allotted time period required by the QIO. QIO determinations are provided to the SNF, Health Plan, the member, and PSW. Standard Appeal of NOMNC If the member fails to meet this time line, but still wishes to appeal, they must appeal directly to the Health Plan.
MEDICAL MANAGEMENT [continued] Inpatient Hospitalizations Pre-Planned Inpatient Surgeries Prior authorization is required for all pre-planned inpatient procedures. Clinical documentation should be submitted along with PSW’s prior authorization request form. Decisions will be issued according to applicable time frames for Standard or Expedited requests. Inpatient Emergent Notification PSW does not require prior authorization for Urgent/Emergent care. Clinical records are required for review and should be submitted via fax or through granted EHR access. Determination PSW’s utilization review nurse evaluates the appropriateness of admission using InterQual criteria. For pre-planned procedures, the clinical decision-making hierarchy referenced above will be followed. The member is followed through stay to assist with any discharge needs and to monitor for continued medical necessity. If a member’s care becomes custodial in nature at any point during the stay, the case is escalated to a medical director for review of continued stay and authorization may be discontinued. A Medically Unnecessary Days (MUD) letter will be issued by PSW if the stay is determined to no longer be medically necessary. The facility is notified of determination with MUD letter via fax and the member may not be held liable for remaining charges. Quality Management (QM) QM Program Activities Overseen by PSW’s Chief Medical Officer, Chief Quality Integration Officer, and the Chief Nursing Officer, the PSW QM program is designed to enhance quality scores through comprehensive collaboration with PSW’s contracted health plans and healthcare providers. The QM team manages HEDIS reporting required for CMS Medicare Advantage programs, the Quality Performance Program for Next Generation ACO, and other lines of business (Medicare, Commercial, and Public Employee Benefits) quality data collection for delegated services, in accordance with the National Committee for Quality Assurance (NCQA) in order for PSW network providers to receive value-based contract incentive payments. Improving Quality Performance Medical Records Providers are responsible for creating and maintaining complete and accurate documentation for all PSW members assessed or treated. The primary purpose of the medical record is to foster quality and continuity of care. Medical records must contain information to support completion of preventative screenings and services, diagnosis and description of member progress, responses to medications, and services. Thorough documentation within the medical record enhances provider ability to evaluate preventative health services, treatment, planning, and delivery of care.
MEDICAL MANAGEMENT [continued] PSW Medical Record Reviews In an effort to support the proactive physician-patient relationship as well as to enhance outcomes for value-based contract incentive payments, PSW performs routine chart reviews. Through secure remote EHR connection, QM staff are able to extract supplemental data from individual member charts to satisfy HEDIS reporting requirements and improve Medicare Advantage STAR ratings, Quality Program Performance, and delegated services performance for incentive payments. Electronic, remote connections do not disturb the practice setting. Frequent, routine chart reviews enable PSW to close HEDIS quality gaps and manage HCC quality initiatives as part of the estimation of healthcare utilization costs. The PSW Quality Integration Officer then provides clinical interpretation and guidance to providers and practice staff; develops and implements programs to correct deficiencies and improve outcomes. Physician Advisory Council The Physician Advisory Council (PAC) is responsible for overseeing quality and cost-effectiveness of medical care provided to PSW members and serves as a managing body over policies, procedures, and information disseminated to all PSW network providers. In an effort to support evidence-based practice guidelines the PAC reviews activities of both the Quality Management and Intensive Case Management programs. Serving as subject matter experts, members of the PAC assess clinical practice guidelines and make recommendations to improve policies, procedures, and guidelines, as well as assists PSW in other ways defined in the PAC Charter. The PAC is comprised of PSW’s Chief Executive Officer, Chief Operations Officer, Chief Medical Director, Chief Quality Integration Officer, Chief Nursing Officer, and seven physician representatives. Physician members are represented by both primary care and specialty providers in the PSW network of practices, hospitals, community-based practices, and medical groups in the PSW service area. Care Management (CM) The Care Management program is designed to support members’ coordination of services to promote cost effective and high quality care across the continuum. The care management team works with physicians and their patients to provide transitional care, chronic disease management education, and to connect patients to benefits and resources to support health care goals and needs. PSW’s patient centered approach is designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively with the aim to improve health and reduce the need for medical services. PSW Care Management Goals: Improve patient’s function health status Enhance coordination of care Eliminate duplication of services Reduce the need for unnecessary, costly medical services
MEDICAL MANAGEMENT [continued] The Care Management Department provides services uniformly to all members, including: Timely access to medical services provided to all members. Identify and promote health care benefits and community resources to optimize Member health, and promote appropriate utilization of health care services by Members. Coordinating and collaborating with primary care providers to monitor Members requiring increased healthcare coordination and/or services. Key functions of care management include, but are not limited to: Care management services to support access to community and health plan resources Complex Care Management for management of chronic disease Transitional care support across the continuum of care Remote Patient Monitoring for individuals who need assistance with management of CHF or COPD (or other chronic diseases) Access to community based resources and programs Transitional Care Management This program emphasizes achieving long term positive outcomes by assuring that patients and family caregivers have the knowledge and skills to recognize and address health care problems as they arise. The transitional care period is from 1 to 30 days post-discharge from an acute care facility or skilled nursing facility. TCM is guided by a licensed nurse, who follows patients from hospitals into their homes (or the next site of care), and uses evidence-based care-coordination to interrupt patterns of frequent acute hospitalizations and emergency department use. The nurse collaborates with physicians, nurses, social workers, discharge planners, pharmacists and other members of the healthcare team. Complex Care Management This program aims to provide support to patients and family caregivers to improve self-care in the management of chronic diseases to reduce risk of preventable declines in health status. The care management team works with your patients to provide education on disease management, coordination of community services, and education regarding when to notify the primary care provider of changes or concerns related to their health status. Social Determinates of Health (SDoH) PSW collaborates with our contracted health plans and local community to dedicate and deploy resources to support our members.
MEDICAL MANAGEMENT [continued] Responsibilities of care management include: Assisting members transition to other care, if necessary, when benefits have ended or are not part of the member’s benefit package. Working with appropriate staff members of the health care team to facilitate member care at the appropriate level, meet service needs, ensure continuity of services and decrease overall costs. Consulting with physicians and subcontracted groups to coordinate care within the network to maximize available resources for member. Working closely with the member population, the Providers and medical staff, hospital patient care staff, and hospital departments (social services, discharge planning, quality improvement, home health/hospice). Coordinating all services for a members discharge in a timely manner and with contracted Providers. Following and facilitating care coordination and population health management activities. Evaluating each case based on the member’s specific needs and local delivery system, considering age, co-morbidity, complications, progress of treatment, home environment and availability of facilities. Ensuring determinations are made in a timely, efficient manner within regulatory standards. Ensuring confidentiality of clinical and proprietary information. Working with health care providers to develop care plan goals and interventions through shared decision making. Provider responsibilities for members engaged in care management services: Educate office staff regarding care management services Support patient engagement in services Work with care management department for same day office visits as needed to reduce unnecessary use of emergency room and provide continuity of care Review care plans submitted by care management and provide feedback as needed to coordinate shared health care goals for patients. How to refer patients to care management services Provider patients who may benefit from services to include education on disease management, remote patient monitoring, or access to social determinants of health interventions.
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