Kansas Medical Society

Kansas Medical Society

Welcome to Sunflower State Health Plan

September 6, 2012

Confidential and Proprietary 1

• Kent Cerneka – Vice-President, Network DevelopmentPhone: 314-505-6340 or [email protected]

• Lacee Allen– Manager Provider RelationsPhone: 601-874-1874 or [email protected]

• Monica Arter – Sr. Director of Medical ManagementPhone: 314-505-6011 or [email protected]

• Teresa Dodd – Manager, Payment Excellence TeamPhone: 314-445-0108 or [email protected]

Presenter Contact Info


Parent Organization Overview


– Headquartered in St. Louis, MO

– Fortune 500 company

– Employ over 6,000 individuals

• Contract with over 130,000 providers

• Serve over 2.1 million members / 18 states

• 4 LTC programs/ 12 ABD programs

Network Development•Since 2006, Sunflower’s parent company has built provider networks from scratch in eight states totaling ~ 50,000 providers:

Georgia – 15, 957 providers (116 Hospitals) Illinois – 5,390 providers (54 Hospitals)

South Carolina – 7,380 providers (29 Hospitals) Kentucky – 12,552 providers (54 Hospitals)

Mississippi – 4,232 providers (74 Hospitals) Louisiana – 3,987 providers (31 Hospitals)

Washington – 8,600 providers (66 Hospitals) Missouri – 7,782 providers (72 Hospitals)

•Targeting 8,000 to 10,000 Provider Network in KS which includes Hospitals, Physicians, FQHC/RHC’s, and Ancillary Providers

Critical Success Factors:1.Flexible, consultative, relationship-based, partner focused

2.Dedicated resources for Kansas–On-the-ground experienced Network Development leaders building collaborative relationships (hospitals, physicians, CMHCs, CDDOs FQHCs, trade associations)

–Complemented by a dedicated telephonic Network Development team

3.Educate, listen and engage; Collaborate rather than mandate

Core Functions


Provider Relations•Dedicated, local Provider Relations Representatives

•Initial Training and Orientation within 30 days of contract effective date Train on Sunflower Policy and Procedures Train on Website and Secure Portal Functions – including registration process for Secure Portal Registration and Training on EFT/ERA process, EDI submission, etc.

•Orientations conducted as individual meetings, group meetings, and webinars

•Provider Summit Calls – begin approximately 30 days prior to “Go-Live” and continue as long as there is interest

•Ongoing education

Core Functions


Web Portal

Through the Secure Web Portal, Providers can:•Check Member Eligibility•Check by CPT or HCPCs code whether prior authorization is needed for par providers•Submit Prior Authorization Requests•View Patient Lists•Submit, view and adjust claims•View Payment History•Member Health RecordThrough the unsecure website, Providers can access:•Provider/Billing Manual•Quick Reference Guides•Prior Auth and Notification of Pregnancy Forms•Clinical Guidelines•Provider Newsletters and announcements

Confidential and ProprietaryConfidential and 6

Medical Management•Care Management Teams

– Identify and engage high-risk and non-compliant members

– Identify barriers to compliance with treatment plans and goals

– Facilitate communication across medical and behavioral specialties

– Coordinate services, including transportation and referrals

•Disease Management Teams - NCQA/URAC Accredited Programs

•Onsite Discharge Planning at high-volume facilities

Core Functions


Utilization Management•Goal is to ensure services are appropriate for the condition, provided in an appropriate setting and meet or exceed professionally recognized standards of care.

•Program is based on nationally recognized, evidence-based clinical decision support criteria

– InterQual is used to determine medical necessity review of most services

•Program is overseen by a Medical Director. Only MDs can make adverse decisions (denial or reduction of service.) MDs are available for peer to peer discussions.

Core Functions


Programs and Incentives:

•Start Smart for Your Baby – education and case management program starts during pregnancy through child’s first year of life

•Start Smart for Your Health – educational materials printed and on website.

•CentAccount – monetary awards loaded to a pre-paid debit card for healthy behaviors. Based on claims with specific CPT Codes.

•MemberConnections and Connections Plus – community events, home visits. Phones for members at highest risk with unreliable phone access.

Core Functions


Claims Payment and Remittance•Payer ID – 68069

•Clearinghouses: SSI, Emdeon, Gateway, Availity, Smart Data Solutions

•EFT/ERA through PaySpan Health Free Service and fast online enrollment Register for Webinars

•Payment Excellence Team (PET) Strongly encourages and participates in Claims Testing prior to Go-Live

Core Functions


Claims Processing Centers

Farmington, Missouri Claims Center Centralized mail room Vertexing, OCR validation and data

entry High Dollar Review Quality Review Team Claims Processing Center Provider Claims Call Center

Great Falls, Montana Claims Center

Claims Processing Center

Kansas claims to be processed here

Provider Claims Call Center

Kansas claims calls to be answered here


Goals of the Payment Excellence Team– Ensure claims are received, processed timely and processed correctly for all new markets

– Assist in research of benefits, payment methodology, billing requirements, etc.

– Write all new work processes for claims and answer all claims related questions immediately after go-live

– Write the health plan’ provider billing manual

– Partner with IT to test all aspects of claims receipt and processing 45 days prior to go-live

– Monitor pend volume and aging in efforts to identify ways to avoid pends and increase auto-adjudication rate

– Partner with provider relations to help resolve key provider issues and provide claims related education to providers and provider relations staff

– Partner with health plan and Internal Audit to review check run and increase payment accuracy

– Manage all claims related issues for a period of 3-6 months post go-live

PET/Payment Excellence Team


Confidential and Proprietary

Sunflower State’s relationship with local PPO Network

• A PPO serving the State of Kansas and surrounding areas

• The only physician owned and operated PPO in Kansas

• Providers in the ProviDRS Care network may participate with Sunflower by executing a Sunflower/Medicaid addendum to their ProviDRS Care agreement

• Benefits of contracting with Sunflower State Health Plan through ProviDRS Care: Simple Sunflower/Medicaid addendum to ProviDRs Care contract in lieu of

review and execution of a full participation agreement Since you are already credentialed through ProviDRs Care, there is no

additional credentialing paperwork

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Signed an LOI? You will still need to complete contracting and credentialing paperwork. Behavioral Health Providers already contracted with Cenpatico – addendum process

Next two weeks – Contracts approved and distributed to providers Provider Contract CAQH Credentialing documents or KS Standardized Credentialing App Disclosure of Ownership form (Federal requirement)

Next two months – types of communication from our contracting team Personal visits Phone calls Fax and/or Email

Confidential and Proprietary

What to expect prior to January 1, 2013

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Sunflower is emphasizing the need to complete contracts by end of September!!!•Member enrollment packets (including provider directory information) is targeted for distribution at the end of October•Ensure that we have ample time to review your contract packet, complete the credentialing process, and upload your information into our directory systems

Network Subcontractors

• Vision: To join our vision provider network, OptiCare, email OptiCare at [email protected] or go to this link: http://www.opticare.com/joinus.aspx

• Pharmacy: For contact information or to join US Script’s provider network please visit us at http://www.usscript.com/contact.php

• Behavioral Health: To join our behavioral health provider network, Cenpatico, go to this link: http://www.cenpatico.com/providers/join-our-network/ or call 800-989-1655

Or you can contact:Deb BurnhamNetwork Manager800.989.1655, ext. 1 office | 785.633.5746 cell

• Non Emergency TransportationAmy MuellerManager, Network OperationsMedical Transportation Management, Inc.Direct: (636) 695-5589Fax: (800) [email protected]


Sunflower State Provider ContractingSunflower State Provider Contracting1-877-644-4623

http://www.sunflowerstatehealth.com

Questions?


Kansas Medical Society

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Transcript of Kansas Medical Society