Download Compliance Information Credentialing Tips

Viva Voice
Fall 2011
A newsletter for V iva H ealth ® Providers.
Compliance Information
In This Issue
Page 2
What can Viva Health
e-Power do for your office?
Viva Health working on
EFT/Direct Deposit
Pages 3-5
for Viva Health Providers
Compliance has always been a cornerstone of operations at Viva Medicare Plus (Viva)
and training is a key component of ensuring compliance. Centers for Medicare and
Medicaid Services (CMS) regulations (42 CFR 422.503 and 423.504) require managed
care organizations (MAOs) like Viva to extend compliance training to all of our First
Tier and Downstream Providers.
Improvements to Medicare
Prescription Services
Laboratory Services Factoid
Update to Viva Health
& Viva Medicare Plus
Authorization List
To meet this requirement, Viva prepared Compliance Training for all First Tier and
Downstream providers. The training gives an overview of Viva’s compliance plan as
well those requirements specific to providers. The 2011 Compliance Training can be
accessed from the website for Viva providers (http://www.vivaprovider.com/Resources/Default.aspx).
Please review the Compliance Training on the Viva website. Thank you for your help, and if you have questions or
comments please e-mail or call Viva’s Provider Customer Service Department at 205-558-7474 or 800-294-7780, or
e-mail [email protected].
Credentialing Tips
Here are some tips to help expedite the credentialing
process for practitioners:
Curriculum Vitae
Have you updated your practitioner’s Curriculum Vitae
(CV)? Viva Health must obtain and verify a
practitioner’s work history as part of the credentialing
process. Listing the month and the year for each period
of employment (or lack thereof ) on his/her CV will help
the Credentialing Department process the paperwork
without delay.
Continuing Education Units (CEUs)
Please remember to include the practitioner’s CEUs with
his/her credentialing application. VIVA Health must
have documentation of CEUs for the last two (2) years.
Professional Liability History
Are you adding a new provider? If so, Viva Health must
obtain the past five (5) years of your insurance carrier(s)
coverage. In some instances, the five-year period may
include residency or fellowship years.
Accuracy Matters
Please verify, update or correct information in a
credentialing or recredentialing form. Remember to
also update the attestation page(s). The practitioner
being credentialed must be the one to verify, sign and
date the attestation.
If you have any questions regarding these tips, or about
the credentialing process in general, please call Provider
Customer Service at 205-558-7474 or 1-800-294-7780
and ask for the Credentialing Department.
2
What Can Viva Health e-Power Do for Your Office?
e-Power is a free, web-based application many Viva Health providers use at their convenience.
How can e-Power help your practice?
• Check member eligibility – providers can verify patients are currently covered by Viva. They can also
check members’ histories with Viva. Patients can be looked up a number of ways, including policy number, first and
last name or birth date.
• Check member benefits – Once a patient has been identified as a covered Viva member, providers can
review a wide range of benefits information. A member’s full Certificate of Coverage is available, as well as a Summary of Benefits, which provides copay and coinsurance information for specific services. Drug and pharmacy information can also be viewed by providers. If a member’s plan requires him or her to have a PCP, e-Power shows who
the PCP is and whether a PCP referral to a specialist is needed.
• Check referral or authorization information – e-Power allows providers to see if referrals or authorizations are in place for scheduled appointments or procedures. There are a number of different ways to use this function: all authorizations for a given provider for a given date can be reviewed, authorizations for a specific member
can be looked up, or individual authorization details can be checked. e-Power cannot be used to request or make a
referral or authorization.
• Check status of claims – Providers’ billing departments love this feature! With e-Power, they can see when
claims were received and the check number and date they were paid. If a claim is denied, reasons for the denial are
given. Providers can check claims by date range, a specific patient or provider, whichever best suits their needs.
Viva e-Power is accessed by a secure login and password. If your office does not
have this service and you would like it, please visit http://vivaprovider.com/
Epower/Default.aspx and complete the on-line form to request a login and
password. Requests must be made by participating provider offices only; Viva
cannot issue access to clearinghouses, third-party billing companies or other
entities with which we are not directly contracted. If you are applying for a
facility or ancillary provider, enter the name in the “last name” field. If you are
unsure of your Viva Health provider number, you can find it on your Viva
Health remittance/Explanation of Payment (EOP). You can also call Provider
Customer Service at 205-558-7474 or 1-800-294-7780 for your Viva provider
number or for help in applying for e-Power. Provider Customer Service can also
connect you with your Provider Services Representative to arrange an e-Power
demonstration for your office or to answer questions about it.
Logins and passwords are delivered to you by e-mail. Once you have them, go to
http://vivaprovider.com/default.aspx, click on the ePower Login link and begin.
You can now navigate Viva e-Power at your convenience.
VIVA Health Working on EFT/Direct Deposit
A number of provider offices have asked recently if Viva
Health has Electronic Fund Transfer (EFT) capability, or
“direct deposit,” in lieu of paper Explanations of Payment
and checks. We do not offer this service right now, but are
working steadily towards it. We are presently working on
a “pilot project” and hope to roll it out to more providers
later this year.
If your office is interested in EFT/Direct
Deposit, please let us know by e-mailing
Viva Provider Services at
[email protected], and
put “EFT” in the e-mail subject line.
3
Improvements to Medicare Prescription Services
Viva Health has recently changed the process for our Medicare Part D reviews for Prior Authorizations
(PAs) and Exceptions. For faster service for your Viva Medicare Plus patients, please fax these reviews
to 205-558-7506. Please include your signature, a supporting statement, and two (2) tried/failed
medications for the review. A copy of our Medicare PA and Exception forms are available on the Viva
provider website at http://vivaprovider.com/Resources/Forms.aspx. Please continue to send commercial/
group plan reviews to fax number 205-933-1232.
Laboratory Services Factoid:
Viva Health and Viva Medicare Plus (VMP) cover most in-office lab tests and
services, and we encourage you to provide those services whenever feasible. Viva
pays for in-office lab work with no additional out-of-pocket costs to Viva
Health or VMP members. This is also if you send lab work to an independent
laboratory, such as LabCorp.
However, use of hospital-based labs may result in additional copays or coinsurance for Viva Health/VMP members. These services are typically billed
by the hospital as out-patient services, which are not linked to the member’s
physician office visit and therefore require a separate copay or coinsurance
payment.
You may not have the ability to perform all lab services in your office or
have ready access to an independent laboratory; a hospital-based lab may the
only option. But if you have a choice, please consider using your in-office or
independent lab.
PCP HEDIS Reports On The Way
Viva Medicare Plus (VMP) is committed to partnering with participating Primary Care Physicians (PCPs) to deliver
high quality care to our members. This commitment takes on new significance under health reform. Specifically, Medicare Advantage plans like VMP are being graded with a star-rating system by the Centers for Medicare and Medicaid
Services (CMS) on the quality of care and customer service members receive.
VMP currently has 3.5 out of 5 stars and is one of the highest-rated Medicare Advantage plans in Alabama. Our goal
is to be a 5 star plan. To that end, we will soon be distributing a Performance Feedback Report to physicians who are
PCPs for VMP members. This report is based on 2010 HEDIS data obtained through claims or medical record reviews.
The report will include a list of patients who still need HEDIS-reported services. When you receive it, please review
and – if you concur the services are needed – contact the patient to come in for care before the end of 2011. VMP staff
will also reach out to the patients to reinforce the importance of these services. All the tests and treatment suggestions
in the patient reports are covered services for VMP members and will form the basis for the 2011 HEDIS results to be
shared with you next year. We recognize that this information may not reflect ALL services you have provided to your
patients.
Thank you for serving VMP members and partnering with us to ensure they get the care they need. If you have any
questions about this issue, or the reports when you receive them, please contact Jan Scott, Quality Improvement Manager, at 205-558-7693. You may also e-mail her at [email protected].
Update to Viva Health & Viva Medicare Plus Authorization List
From time to time Viva Health and Viva Medicare Plus make changes to the list of services that require prior authorization.
Please note the latest change to the list, below, in red.
PROCEDURES REQUIRING PRIOR AUTHORIZATION
FROM Viva Health & Viva Medicare Plus
All Viva Health members require the Primary Care Physician (PCP) and/or Specialist to contact the Medical Management
Department in advance for the following:
• All inpatient admissions, either elective or emergent (including 23 hour observations). For emergencies, Viva Health should be contacted within 24 hours of admission (or the next business day).
• All out of network, out of panel or out of area services
• All referrals from the PCP to the Specialist (only required for Viva Health “Gatekeeper” model HMO products), excluding OB/Gyn, ophthalmologist and optometrist services from participating providers
• Outpatient surgery including wound care
• Emergency Room visits for non-emergent care (within 24 hours or next business day)
• Inpatient Rehabilitation or Day Treatment (letter of medical necessity required)
• Rehabilitation Services: Physical Therapy, Occupational Therapy, and Speech Therapy
• Pain Clinic Care
• Prescriptions requiring Prior Authorization
• All ancillary services (home health, IV therapy, hospice care, durable medical equipment (DME), orthotics, prosthetics, etc.)
• All scopes performed outside the physician’s office excluding colonoscopy & EGD
• All plastic surgery, even if performed in physician’s office (copies of records, pre-op photos and letter of
medical necessity required)
• Diabetic shoes/inserts, from physician office or DME provider
• All sinus or nasal surgery (copies of records required)
• Sleep studies: C-PAP, MSLT, PSNG (copies of records listing symptoms required)
• Arteriograms
• All angiograms except CT guided
• Cardiac Catheterizations
• Cardiac Rehab, Pulmonary Rehab
• Holter monitors, if worn longer than 24 hours
• Myelograms, Discograms, and PET scans
• Orthotics
• Skilled Nursing Facility admissions
• Transplant services
• Neuropsych Testing
• DME issued in an office setting (POS 11) where billed charges exceed $500.00
Viva Health & Viva Medicare Plus Medical Management
may be reached at (205) 558-7475 or 1-800-294-7780.
Viva Medicare Plus…Among the Best!
The Centers for Medicare & Medicaid Services (CMS) conducts call center monitoring of
Medicare Part C and Part D customer service call centers throughout the year, including VIVA
Medicare Plus’s own Member Services and Pharmacy departments. This is often done by
“secret shopping;” CMS representatives call Medicare Managed Care Plans and, according to a
planned outline by CMS, ask questions of the Plans while posing as prospective members. In
July 2011, CMS shared with Medicare Managed Plans the results of their surveys.
The following measures were recently assessed:
• Interpreters provided for callers with limited proficiency or fluency in English
• Communication with hearing-impaired callers via TTY/TDD
• Accuracy of answers to plan-specific and general Medicare Part C or Part D questions
Viva Medicare Plus’s scores, compared with the average across all Medicare Part C and Part D
participants nation-wide, are shown below:
Interpreter Availabilty for Part C questions
Interpreter Availabilty for Part D questions
TTY/TTD Functionality (Part C)
TTY/TTD Functionality (Part D)
Information Accuracy (Part C)
Information Accuracy (Part D)
VIVA MEDICARE Plus Score
87%
Average Score Across All Plans
+9
79%
VIVA MEDICARE Plus Score
90%
Average Score Across All Plans
VIVA MEDICARE Plus Score
93%
Average Score Across All Plans
92%
Average Score Across All Plans
+27
65%
VIVA MEDICARE Plus Score
96%
Average Score Across All Plans
+2
94%
VIVA MEDICARE Plus Score
91%
Average Score Across All Plans
20
+24
69%
VIVA MEDICARE Plus Score
0
+12
78%
+6
85%
40
60
80
100
Needless to say, we are pleased that our dedication to superior customer service has been validated by
these results, and we are commited to continued excellent service to all our customers.
Viva Voice
PRSRT STD
A newsletter for VIVA H ealth ® Providers.
1222 14th Ave S • Birmingham, AL 35205
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