WVFH Highlights Management and Rewards

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1 WVFH Highlights Management and Rewards Disease and Case Management - Providers and Member Referrals Welcome Call Care Management at to make referrals. Mom Matters (Maternity to Post Partum and up to a year after delivery) Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and Cardiac Services Asthma, Diabetes and Personal Care Plans Target member open care gaps Complex Case Management Available to Providers Dedicated Medical Case Management available for members Dedicated Behavioral Health Case Management available for member Operationalize the use of Risk Stratification Reports 1

2 SFY18 Withhold Measures SFY18 Withhold Measures (Final) # Measure 1 Annual Dental Visit For 2-3 Year Olds (new for 2018) 2 Adolescent Well-Care Visits 3 Initiation & Engagement of Alcohol and Other Drug Dependence Treatment Initiation 4 Follow-Up After Hospitalization for Mental Illness (Follow-Up Visit Within 7 Days of Discharge) 5 Prenatal and Postpartum Care Postpartum Care 6 Annual Monitoring for Patients on Persistent Medications Total 7 Medical Assistance With Smoking and Tobacco Use Cessation (MSC) Advising Smokers to Quit 8 Childhood Immunization Status Combo 3 9 Comprehensive Diabetes Care HbA1c testing 10 Counseling for Nutrition for Children/Adolescents All measures, with the exception of the Annual Dental Visit For 2-3 Year Olds, are remaining the same for SFY This measure replaces Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life. 2

3 WVFH Highlights Management and Rewards (cont.) 2017 Wellness and Reward Incentives (Value Adds) for Member and Provider Maternity to Post Partum - Member + Provider Incentive $200 PRSI DHHR notification by month 5 of pregnancy $50 member reward Well visit Adults and children Member $50 annually + Provider Incentive (Adolescents ages 12-21) Persistent medications management Member + Provider incentive Childhood immunization status (combo 3) Provider incentive Counseling for nutrition for children and adolescents Provider incentive Comprehensive diabetes care HbA1C test Member + Provider incentive Preventive dental care during pregnancy and 6 weeks postpartum Be Better quit line ( ) for members who are trying to quit smoking 3

4 WVFH Key Contact Claim Information WVFH Subcontractors Beacon Behavioral Health Electronic BH Payer ID: Member Information, Claims, Authorizations Contact Beacon to assist with registering for eservices access Visit Beacon online at Davis Vision In network claims must file electronically, contact UCD/Scion Dental Member Services, Dental Referrals and Authorizations contact CVS Caremark Pharmacy Request Non-Formulary Drug and Prior Authorizations contact BIN#: PCN#: ADV Group ID#: RX2340 Member ID Format: 8 digits, alphanumeric NIA Radiology Authorization Diagnostic Imaging contact Hour Nurse Line Contact Medical, Vision, and Dental Contact & Mailing Addresses: Visit us online at 4

5 WVFH Key Contact Claim Information (cont.) Claims Submission Guidelines and Identification Numbers Timely filing criteria 365 calendar days after DOS, date of primary payment, or denial of claim Include current practitioner information, including NPI Number on electronic claims Include current member information, including WVFH Member ID number WVFH accepts electronic claims through Emdeon and Relay Health CPID and Payer ID Access NaviNet for the following transactions Eligibility and Benefits Inquiry Claim Status Inquiry Referral Status Inquiry Provider Directory 5

6 Provider Servicing & Key Contact Information Provider Service Resources WVFH is doing business differently in 2017 Focus is on electronic resolution Business model is changing to self-service with more robust self-service options Take advantage of the online and telephonic tools offered Tools deliver efficient, accurate answers to routine inquiries Our provider service advocates remain available to you for inquiries that you are not able to resolve by using self-service options Use NaviNet as a primary resource for inquiries related to WVFH Questions can also be directed to WVFH Provider Services at Submit Claim Review Requests by using the dedicated Fax Line at

7 Provider Resources NaviNet Provider Services Unit Phone Fax Line for Submitting Claim Review Requests Provider Contracting & Provider Relations Marsha Swader (Director of Provider Contracting) & Evonne Allen (Director of Provider Relations) Website Provider Manual Directory (Audit Record) Bulletins Policy & Procedures 7

8 Provider Servicing & Key Contact Information (cont.) Key Contact Information President - Jason Landers jason.landers@highmark.com Director of Operations Donna Sands donna.sands@highmark.com Provider Contracting & Provider Relations Marsha Swader (Director of Provider Contracting) & Evonne Allen (Director of Provider Relations) mswader@gatewayhealthplan.com eallen@gatewayhealthplan.com Behavioral Health John Marks (Program Director) & Sheila Kelly (Case Manager) john.marks@beaconhs.com sheila.kelly@beaconhealthoptions.com 8