STAR+PLUS IN-SERVICE NURSING FACILITY · • Cigna STAR+PLUS currently offers STAR+PLUS services in...

STAR+PLUS IN-SERVICENURSING FACILITY

MCDTX_18_64904

AGENDA

• Cigna STAR+PLUS Company Overview• STAR+PLUS Nursing Facility Program Overview• STAR+PLUS Nursing Facility Benefits and Eligibility• Authorizations• Skilled vs. Non-Skilled Services• Non-Emergent Ambulance Services• Interacting with Cigna STAR+PLUS• Claims Process • Payment Dispute Form• Appeals• Electronic Funds Transfer• Electronic Remittance Advice• Cigna STAR+PLUS Website & Secure Provider Portal• Fraud, Waste and Abuse• Abuse, Neglect or Exploitation• Important Phone Numbers • Questions and Answers• STAR+PLUS Nursing Facility Program Overview

CIGNA COMPANY OVERVIEW

3Confidential, unpublished property of Cigna. Do not duplicate or distribute. For internal use only. Use and distribution limited solely to authorized personnel. © 2019 Cigna

Based in Nashville, Tennessee. Cigna STAR+PLUS got its start in 2012 and is now one of the country’s largest and fastest-growing coordinated care plans whose primary focus is Medicare Advantage plans. Cigna STAR+PLUS currently owns and operates Medicare Advantage plans in Alabama, Arkansas, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Mississippi, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, and Washington, D.C. as well as a national stand-alone prescription drug plan.

Our Mission Statement

Cigna is dedicated to improving the health of the communities we serve by delivering the highest quality and greatest value in healthcare benefits and services.

CIGNA STAR+PLUS COMPANY OVERVIEW (CONT.)


• Cigna STAR+PLUS currently offers STAR+PLUS services in the Tarrant SDA, Hidalgo SDA and MRSA Northeast.

• Combined, Cigna STAR+PLUS serves Members in 50 counties across the State of Texas for all three service delivery areas.

• March 1st, 2015, Cigna STAR+PLUS began serving all three Service Delivery Areas for Nursing Facility services.

CIGNA STAR+PLUS COMPANY OVERVIEW (cont.)STAR+PLUS County Coverage


Tarrant SDAMay 1, 2011 – (6 Counties)

Hidalgo SDAMarch 1, 2012 (10

Counties)

MRSA Northeast September 1, 2014 (34

Counties)

Tarrant, Denton, Johnson, Hood, Parker, and Wise.

Cameron, Duval, Hidalgo, Jim Hogg, Maverick,

McMullen, Starr, Webb, Willacy, and Zapata.

Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin,

Franklin, Grayson, Gregg, Harrison, Henderson,

Hopkins, Houston, Lamar, Marion, Montague, Morris,

Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San

Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van

Zandt and Wood.

MEDICAID STAR+PLUS PROGRAM OVERVIEW


• STAR+PLUS is a Texas Medicaid managed care program designed to coordinate and provide preventive, primary, and acute care, Long-Term Services and Supports (LTSS) to community-based and Nursing Facility residents through a managed care delivery system.

• Health and Human Services Commission (HHSC) has carved in custodial Nursing Facility services to the Managed Care Organizations (MCO). The expectation is to improve the quality of care, and to better coordinate services and healthcare needs.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Program Objectives


• Assess Member’s health risks and functional needs.

• Assist Nursing Facility Members wanting to return to the community.

• Provide competent service coordination, which includes service planning, and monitoring and coordinating acute care for members with complex or chronic health care needs.

• Improve cost effectiveness by reducing unnecessary hospitalizations and providing appropriate medical services.

STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY


• To be eligible for Nursing Facility services, a STAR+PLUS Member must meet all of the following criteria:

• A physician certifies the Member’s medical condition.

• The Member’s medical condition meets Medical Necessity (MN) requirements.

• The Member has received a Level 1 Pre-admission Screening and Resident Review

(PASRR).

• Once a Member is admitted to the facility they will receive a Minimum Data Set (MDS)

evaluation by the nursing facility to determine the Member’s Resource Utilization

Group (RUG).


STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Program Qualifications

Enrollment is required for Medicaid recipients who live in a STAR+PLUS service area and fit one or more of the following criteria:

– People who are have a physical or mental disability and qualify for supplemental security income (SSI) benefits or for elderly individuals who have Medicaid due to low income.

– People who qualify for Community-Based Alternatives (CBA) HCBS STAR+PLUS waiver services.

– People age 21 or older who can receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for HCBS STAR+PLUS waiver services.

– People age 21 or older who are receiving SSI.


STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Member Enrollment Process

• Once a Medicaid client is determined by HHSC to be eligible for STAR+PLUS, he/she will receive an enrollment packet in the mail from HHSC's administrative services contractor, MAXIMUS.

• The packet contains information about the STAR+PLUS program, instructions for completing the enrollment form, and information about the MCOs available in his/her service area.

• MAXIMUS processes STAR+PLUS applications, assists Members who are transitioning from traditional, fee-for-service Medicaid into the STAR+PLUS Program, and assists Members in selecting a MCO and process plan changes.

• Members who need assistance can contact an enrollment counselor by calling the MAXIMUS Helpline at 1-877-782-6440.

• If the member enrolls before the 15th of the month he/she will be effective the 1st of the next month. If the member enrolls after the 15th of the month he/she becomes effective the 1st of the following month (e.g. 45 days).

• The Nursing Facility will continue to provide services under the Unit Rate services.

• This applies to the types of services historically included in the DADS daily rate for nursing facility providers, such as room and board, medical supplies and equipment, personal needs items, social services and over-the-counter drugs.

• The Nursing Facility Unit Rate payment from MCOs also includes applicable nursing facility rate enhancements and professional and general liability insurance.

• Nursing Facility Unit Rates excludes Nursing Facility Add-on Services.

• Add-On services, provided by either qualified Nursing Facility employees or contracted/certified individuals, are reimbursed separately by the MCO.

• Nursing Facilities will complete and submit the Minimum Data Set (MDS) and Long Term Care Medicaid Information (LTCMI) electronically on the LTC Online Portal system at TMHP.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Unit Rate Services

11Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2018 Cigna.


STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Add-on Services

• Nursing Facility Add-on Services are the services that are provided in the facility setting by the provider or another network provider. They are not included in the Nursing Facility Unit Rate, and are including but not limited to:

– emergency dental services– physician-ordered rehabilitative services– customized power wheel chairs– augmentative communication devices

• Providers billing for add-on services must be in-network with Cigna STAR+PLUS; contracting and credentialing may be required for the respective entity. Nursing Facilities may bill claims on behalf of employed or contracted providers for therapy add-on services only.

Other Services– Physicians and other professional provider services are covered for NF residents. – Physicians need to be contracted and credentialed with Cigna STAR+PLUS. – Pharmacies are contracted through Express Scripts.

• In order to establish medical necessity for therapy requests, clinical information supporting a new onset of issues is necessary to make a determination.

• Services can be acute due to injury, illness or an exacerbation of a chronic condition, but the clinical documentation needs to demonstrate that.

• Treatment Plan indicating the frequency and length of the request.

• Documentation demonstrating if the member can progress and respond appropriately to the therapy.

• One of the most frequent reasons for denials is lack of medical information.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW Key Elements From Clinical Notes for Add-on Services


What are the turnaround times for an authorization, and how can I escalate the authorization request?

• Our standard turnaround time (TAT) is 3 business days. • TAT is calculated from the date and time of the receipt of call/fax/portal. • If the auth request comes in on Tuesday at 1pm, it is due for a determination to the

provider no later than Friday at 1pm. • 3 business days includes time obtaining the clinical, the UM nurse reviewing the

information, determining if it meets criteria and if not, sending the case to the medical director for review.

• We monitor TAT closely and if a TAT is missed, the manager has to explain why it was missed to the director.

• In life-threatening cases where a member is at risk, you can call UM and request the service be expedited. The TAT is then 1 business day.

– *Life-threatening such as swallowing issues, stroke, apnea, etc…– True emergencies can be reported to UM the next business day.

AUTHORIZATION TURNAROUND TIMES


What documentation is required for Inpatient Medical/Surgery?

• Complete ER record• Admitting orders• History and Physical• Physician Treatment Plan• OR report (if applicable)• Clinical information• Labs and imaging results• Consultations and evaluations

AUTHORIZATION REQUEST FOR INFORMATION


• Physician’s treatment plan • OR Report (if applicable)• History and Physical/progress notes• Treatment plan, physicians orders• Nutritional assessment, current weights• Laboratory and radiology reports• Therapy evaluation and weekly progress notes• Wound care assessment and treatment sheets• Discharge plan• Any other pertinent clinical information such as abnormal lab results, imaging results,

IV medications, consults, evaluations, etc.


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What documentation is required for Skilled Nursing Facility services?

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2018 Cigna.

What documentation is required for Outpatient services?

– Recent Office Visit Notes– Applicable labs and Imaging– Current orders– Current treatment plan

• Specifics are necessary in order to meet InterQual® standards

• UM Milliman and/or InterQual notes only are not acceptable. Initial clinical must be time stamped with physicians name, date and time.



What is required for discharge planning as a client transitions from a facility?

– Home health– DME– Infusion therapy– Physical therapy– Occupational therapy– Outpatient speech therapy

If discharge planning is provided by the Social Worker

– Provide Social Workers full name and phone number to:– Fax: 877-809-0787– Additional notes as needed

Note: Discharge planning is critical to ensuring the member has services they need as they transition home. We can assist in the process and supply names of in-network providers and begin the authorization process for services.



• For STAR+PLUS, the benefit allowed for our members is a non-skilled bed often known as custodial. A STAR+PLUS member can only be in a non-skilled bed.

• Under the Medicare-Medicaid Plan, skilled nursing facility bed is a benefit just as any other Medicare recipient is.

• A MMP member can be in a non- skilled bed or a skilled bed.

• If a MMP member is going to be admitted to a skilled bed, an authorization is needed.

• If a STAR+PLUS member is going to be admitted, the actual admission is not authorized, but any “add-on” services are such as therapies and customized wheelchairs.

• For Dual Eligible members needing therapies in a non-skilled bed, it is helpful for us if you note whether or not you are billing Medicare Part B or Medicaid.

SKILLED VS. NON-SKILLED


STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Non-Emergent Ambulance Services

Requests for prior authorization for non-emergent ambulance transports are submitted by the Nursing Facility. An ambulance provider may NOT request a prior authorization for non-emergent ambulance transports. The ambulance provider is ultimately responsible for ensuring that a prior authorization has been obtained prior to transport. Non-payment may result for services provided without a prior authorization or when the authorization request is denied by the MCO.


Unit Rate

Claims billed to Cigna STAR+PLUS by Nursing Facility

Billing Provider: Complete and submit Cigna STAR+PLUS Authorization Form• emergency dental services• physician-ordered rehabilitative

services• customized power wheel chairs• augmentative communication devices

Add-on Services

Complete the 3618 or 3619 forms with MDS Assessments and submit to TMHP LTC Online portal• Room and board• medical supplies and equipment• personal needs items• social services• over-the-counter drugs

Claims billed to Cigna STAR+PLUS for services provided by Nursing Facility or their subcontractors.

Claims billed to Cigna STAR+PLUS for services provided by a Cigna STAR+PLUS in-network provider


• Pre-admission Screening and Resident Review – All people who are planning to move to a partially federally funded nursing facility must undergo a

Level 1 Pre-admission Screening and Resident Review (PASSR). If the person is suspected of having a mental illness, or a diagnosis of an intellectual disability or a related condition. This includes private pay individuals. Note: If the Level 1 Screening has a positive indication of conditions for MI and/or IDD a Level 2 PASRR Assessment (face-to-face) must be conducted by the Local Authority to confirm or deny these conditions by the Local Authority.

– People are assessed to see if they need specialized services. People who are not satisfied with their PASRR determination have the right to a fair hearing to appeal the determination.

• What services are provided by Local Authority or Local Mental Health Authority? – Alternate placement services– Customized manual wheelchairs and specialized durable medical equipment– Determination of intellectual disability– Specialized therapies– Service coordination – Vocational training

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Texas Medicaid Program Benefits (Behavioral)


Value-Added Services (VAS)

• Initially, Cigna STAR+PLUS notifies new members in the Welcome Kit regarding the available value-added services and how to access them. Thereafter, Cigna STAR+PLUS sends benefit education materials to members annually, outlining the available value-added services and how to access them.

• Additional details about value-added services are available at: http://starplus.mycigna.com/. Cigna STAR+PLUS members can get assistance accessing value-added services from their Service Coordinator by calling 1-877-725-2688 or by calling Member Service at 1-877-653-0327.

• ALL services must be obtained through a in-network provider. VAS are provided to members, one per year.

NURSING FACILITY ADDITONAL BENEFITSCigna STAR+PLUS Value Added Services


NEW Texas Medicaid STAR+PLUS ID Card:

• Medicaid providers should be prepared to verify a person’s Medicaid eligibility with the new Your Texas Benefits Identification Card.

– The front of the card shows the person’s unique Medicaid ID#

– That same number is embedded in a magnetic strip on the back

– Accessible with a basic swipe-style card reader; if Provider has a card reader in his/her office

INTERACTING WITH CIGNA STAR+PLUS Member/Provider Services-Eligibility Verification


INTERACTING WITH CIGNA STAR+PLUS Texas Medicaid “Your Texas Benefits” Card

*Please note the STAR+PLUS MCO will not be listed on the card*


STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY Cigna STAR+PLUS Example ID Card for Medicaid Only Eligible Member


STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY Cigna STAR+PLUS Example ID Card for Dual Eligible Member


3 Ways to Verify Eligibility with Cigna STAR+PLUS:

1. The Cigna STAR+PLUS Provider/Member Services Department by calling 1-877-653-0331.

2. TexMedConnect - The State’s eligibility verification system.

3. The Cigna STAR+PLUS secure Provider Portal accessible through the Cigna STAR+PLUS website.

*Member eligibility can change each month. Please verify eligibility the 1st of every month.

INTERACTING WITH CIGNA STAR+PLUS Member/Provider Services – Eligibility Verification


Responsibilities of Cigna-HealthSpring’s Service Coordinator:

• Provide support to the Nursing Facility in obtaining add-on services.

• Collaborate in the creation of a plan of care.

• Participate in care plan and IDT's meetings to provide feedback on possible services with discharge planning and community placement.

• Monitor progress toward Member’s individual health goals.

• Assist the Nursing Facility with discharge planning or changes in levels of care.

• Assist the Nursing Facility by reminding members, as needed, of requirements to remit applied income to the facility.

• Assist Member or family members in transitioning our Member to a Hospice provider.

Service Coordinator contact number: 1-877-725-2688

INTERACTING WITH CIGNA STAR+PLUS Service Coordination


INTERACTING WITH CIGNA STAR+PLUS Service Coordination

• NF Members will be categorized as Level 1 Members and all Members within an NF will have the same assigned SC, who will perform a minimum of four (4) face-to-face visits yearly.

• The assigned SC will take referrals from NF Members wanting to return to the community and, when appropriate Members are identified, will develop a plan of care to transition the Member back into the community. SCs must contact the NF within 14 days once they are notified.

• Person-Centered Care is promoting a new way of thinking relating to people living in nursing facilities from task-oriented and schedule driven to focus on the person living in the facility and building relationships.


Responsibilities of the Nursing Facility:• Inviting the MCO SC to provide input for the development of the NF care plan,

subject to the member's right to refuse, by notifying the MCO SC when the interdisciplinary team is scheduled to meet

• Notifying the MCO SC within one business day of unplanned admission or discharge to a hospital or other acute facility, skilled bed, or another nursing home

• Notifying the MCO SC if a member moves into hospice care• Notifying the MCO SC within one business day of an adverse change in a

member's physical or mental condition or environment that could potentially lead to hospitalization

• When resident wants to transition from a NF to community or Section Q is marked “Yes” on the MDS

• Notifying the MCO SC within one business day of an emergency room visit• Notifying the MCO SC within 72 hours of a member's death• Notifying the MCO SC of any other important circumstances such as the relocation

of residents due to a natural disaster• Providing the MCO SC access to the facility, NF staff, and members' medical

information and records

INTERACTING WITH CIGNA STAR+PLUS (cont.)Service Coordination


• Member/Provider Services provides customer service for providers, Member’s authorized personal representatives as well as vendors, etc.

Services provided include:

– Verify eligibility, benefits and prior authorizations on file

– Assist providers to connect to the appropriate departments

– Verify claims receipt or review claims status

– Process demographic changes such as PCP on file or Member address changes

– Provide assistance with Cigna STAR+PLUS’s public website & secure Provider Portal

Contact Provider/Member Services Department at 1-877-653-0331

INTERACTING WITH Cigna STAR+PLUS Member/Provider Services


The Contracting and Provider Relations functions includes:

– Responsibility for maintaining the provider network, ensuring a sufficient number of providers are available in each County to serve the healthcare needs of Members enrolled in Cigna’s STAR+PLUS Program.

– Distribute contracting documents to Providers as well as respond to any inquiries related to contracting and credentialing requirements.

– Serve as the primary liaison with participating providers to resolve any operational challenges between the Provider and Cigna STAR+PLUS. The Nursing Facility Representative is proficient in Nursing Facility billing matters and is able to resolve billing and payment inquiries by working directly with the Cigna STAR+PLUS claims department. Providers will be notified within 10 days of any changes to your Nursing Facility Provider Representative.

INTERACTING WITH Cigna STAR+PLUS (cont.)Contracting & Provider Relations


INTERACTING WITH CIGNA STAR+PLUS Member/Provider Services-Eligibility Verification


3 Ways to Verify Eligibility with Cigna STAR+PLUS

1. The Cigna STAR+PLUS Provider/Member Services Department by calling 1-877-653-0331.

2. TexMedConnect - The State’s eligibility verification system

3. The Cigna STAR+PLUS secure Provider Portal accessible through the Cigna STAR+PLUS Website

Note: Member Eligibility can change each month. Please verify eligibility the 1st of every month.

Member Coverage Vision Care Responsibility

Dental Care Responsibility

(except emergency dental, see page 12)

If Primary Payer Is … And secondary payer is…

Cigna STAR+PLUS n/a Value Added through Cigna STAR+PLUS

Value Added through Cigna STAR+PLUS

Cigna STAR+PLUS MA-PD (Medicare) Cigna STAR+PLUS Cigna MA-PD Cigna MA-PD

Other Payer MA-PD Cigna STAR+PLUS Other Payer MA-PD Other Payer MA-PD

Traditional Medicare Cigna STAR+PLUS Medicare Medicare

CLAIMS RESPONSIBILITY FOR VISION AND DENTAL SERVICESClaims


3 ways to file a claim with Cigna STAR+PLUS

1. Electronically – (Payer ID# 52192) – via 1 of the following 3 Cigna STAR+PLUS claims clearinghouses; (1) Emdeon, (2) PayerPath, or (3) Availity.

2. Via secure Provider Portal – Submit CMS 1500 and UB04; individual claims or by batch.

3. Via TMHP State’s website – Visit the website http://www.tmhp.com/and click on ‘Providers’ in the top header. Then Click ‘Go to TexMedConnect’ in the upper right corner. TMHP claims are forwarded to Cigna STAR+PLUS.

INTERACTING WITH CIGNA STAR+PLUS (cont.)Claims


INTERACTING WITH CIGNA STAR+PLUSTexas Medicaid “Your Texas Benefits” Card

*Please note the STAR+PLUS MCO will not be listed on the card*


38

INTERACTING WITH Cigna STAR+PLUSPayment Disputes

A payment dispute is a written communication (i.e. a letter) from the Provider about a disagreement with the manner in which a claim was processed, but does not require a claim to be corrected and does not require medical records.

The Payment Dispute From can be found on our website: https://starplus.cigna.com/health-care-providers/provider-resources/forms.

Examples of when to use the payment dispute form: (this is not a complete list)

• Denial for “timely filing”, but provider has proof of timely• Denial for incorrect applied income • Denial for “RUG Level Changes” affecting payments previously

made by Cigna STAR+PLUS• Denial for “no coverage”, but member was active during the Date

of Service (DOS)• Provider not being paid at correct reimbursement rate, paid

incorrectly• Denial for incorrect modifier, CPT code, National Drug Code

(NDC) number, NPI/TIN/TPI, Place of Service (POS), Date of Service (DOS), Type of Bill (TOB), Diagnosis (DX) code, etc. and denied incorrectly

• Denial for “no active provider contract” and provider does have an active contract listed

• Denial for insufficient units, per authorization on file there’s units available, or there’s no units available due to error on our end

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2018 Cigna.

• 3 ways a Provider may appeal a previously processed claim:

1. Fax the request to Cigna STAR+PLUS at 1-877-809-0783.

2. Electronically via HSConnect Provider Portal.

3. Mail the request to:

Cigna STAR+PLUS Appeals and Complaints DepartmentPO Box 211088Bedford, TX 76095

– Requests for reconsideration must be made within 120 days from the date of remittance of the Explanation of Payment (EOP).

– Acknowledgement letter sent within 5 business days of receipt; appeal resolved within thirty (30) calendar days.

INTERACTING WITH CIGNA STAR+PLUS Appeals & Complaints


The Difference Between a Corrected Claim and an Appeal

• Claim Appeal – An appealed claim is a claim that has been previously adjudicated as a Clean Claim and the provider is appealing the disposition through written notification to the Managed Care Organization. e.g., an appeal based on a discrepancy with the amount paid to a provider; a written notification appealing the disposition on a previously adjudicated clean claim.

• Corrected Claim – A corrected claim is a claim that has already been adjudicated, whether paid or denied. A provider would submit a corrected claim if the original claim adjudicated needs to be changed. e.g., provider billed with an incorrect date of service/incorrect number of units:

– Corrected claims can be resubmitted via HSConnect, or via paper, by entering a “7” for the Resubmission code, and the original claim number as your Original Reference No on box 22 of the CMS 1500 form. The original claim number can be found on the original EOP. Follow UB04 corrected claim code as stated in the Nursing Facility Provider Manual.

– Corrected claims are considered claims reconsiderations and are not considered claims appeals.

INTERACTING WITH CIGNA STAR+PLUS Appeals & Complaints


Electronic Funds Transfer (EFT)

• Cigna STAR+PLUS contracts with Emdeon to deliver electronic funds transfer services. If you are an existing EFT customer with Emdeon and wish to add Cigna STAR+PLUS to your service, please call 1-866-506-2830, and select Option 1 to speak with an Emdeon Enrollment Representative.

– There is no cost for providers to enroll in EFT.

– If you would like to learn more or sign up for EFT, please visit Emdeon’s ePayment Web site at www.emdeonepayment.com.

INTERACTING WITH Cigna STAR+PLUSEFT


Electronic Remittance Advice (ERA)

• Providers who are able to automatically post 835 remittance data will save posting time and eliminate keying errors by taking advantage of 835 ERA file service.

ERA Enrollment Process• Download Emdeon Provider ERA Enrollment Form at the following location:

http://www.emdeon.com/resourcepdfs/ERAPSF.pdf

• Complete and submit ERA Enrollment Form via Email or Fax to Emdeon ERA Group: – Email: [email protected]– Fax: 1-615-885-3713

• Any questions related to ERA Enrollment or the ERA process in general, please call Emdeon ePayment Solutions at 1-866-506-2830 for assistance.

• NOTE: ERA enrollment for all Cigna STAR+PLUS health plans must be enrolled under Cigna STAR+PLUS Payer ID “52192”.

INTERACTING WITH CIGNA STAR+PLUS ERA


How to Complete a CMS 1500 Form

• The following slides list the minimum data required to process a claim on a CMS 1500 form.

• Providers can view a sample CMS 1500 form in Appendix J of their provider manual. However, photocopies of the form should not be used to file claims with Cigna STAR+PLUS.

*Used for add-on services

CMS 1500 Overview


How to Complete a CMS UB04 Form

• The following slides list the minimum data required to process a claim on a CMS UB04 form.

• Providers can view a sample CMS UB04 form in Appendix I of their provider manual. However, photocopies of the form should not be used to file claims with Cigna STAR+PLUS.

UB04 Overview


CLAIM FILING TIPS

• Participating Providers must submit claims within three hundred and sixty-five (365) days from the date the services were rendered for Nursing Facility unit rate services.

• Add-on Services claims must be sent to Cigna STAR+PLUS within ninety-five (95) days from the date the covered service was rendered.

• Cigna STAR+PLUS is required to process clean claims within 10 days of receipt for Nursing Facility unit rate services. Add-On Service claims are paid within 30 days.

• Providers should not collect payment from or bill Cigna STAR+PLUS members for covered services, with the exception of applied income.

• Submit claims for one Member and one Provider per claim form. Unit rate billed separate from Add-on services.

• Multiple visits rendered over several days should be itemized by date of service. If there is a break in consecutive days, bill the dates as rendered on a separate line.

• Avoid using unlisted procedure codes when possible. Submit unlisted codes only after receiving prior authorization for the specific code.



CIGNA STAR+PLUS PROVIDER WEBSITE

• The Cigna STAR+PLUS Texas Medicaid STAR+PLUS website is available at: http://starplus.cignahealthspring.com/sptxnursingclaims

• The website includes much of the information included in today’s presentation and allows providers to download numerous additional, more informative resources as well, such as:

– Nursing Facility Provider Representative Contact information– HSConnect and Change Healthcare Nursing Facility Portal Guide– Nursing Facility Quick Reference Guide– Nursing Facility Presentation– Nursing Facility Provider Manual


SECURE PROVIDER PORTAL

Providers can seek assistance with the Provider Portal by calling 1-866-952-7596.

• Secure Provider Portal is available to participating providers only.

• Providers must have a User ID & Password to access the Provider Portal. New Providers must register a User ID & Password online when accessing the Provider Portal.

• The Provider Portal allows 24-hour access and is an interactive site where participating Providers are allowed to:

– Verify Member eligibility and PCP on file

– Verify Member’s Service Coordinator – Check claim status – Request authorizations– Check authorization status – MESAVE - RUG Level & Applied

Income

Cigna STAR+PLUS SECURE PROVIDER PORTAL



FRAUD, WASTE, AND ABUSEDefinitions

Fraud: Intentional deception or misrepresentation to obtain money or products of a health care benefit program by false or fraudulent pretenses/representation.

Waste: The over-utilization of services that result in unnecessary costs.

Abuse: Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments, resulting in unnecessary costs to the Medicare program or improper payment for services that fail to meet professionally recognized standards of care or that are medically necessary.

What are the differences between Fraud, Waste and Abuse?One of the primary differences is intent and knowledge. Fraud requires the person to have intent to obtain payment and the knowledge that his or her actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge as Fraud.

FRAUD, WASTE, AND ABUSELines of Communication


Via Cigna STAR+PLUS To report suspected or detected Medicare or Medicaid program non-compliance, please contact Cigna STAR+PLUS Compliance Department . To report potential fraud, waste, or abuse please contact Cigna STAR+PLUS Benefit Integrity Unit.

Cigna STAR+PLUS Cigna STAR+PLUSAttn: Compliance Department Attn: Benefit Integrity Unit530 Great Circle Rd 500 Great Circle RoadNashville, TN 37228 Nashville, TN 37228

By phone: 1-800-230-6138, Monday through Friday, 8:00 AM to 6:00 PM CST

Via HHSC Office of Inspector General Visit http://oig.hhsc.state.tx.us/. Under the box labeled “I WANT TO” click “Report Waste, Abuse and Fraud” to complete the online form. The site tells you about the types of waste, abuse and fraud to report.

If you would rather talk to a person, call the HHSC Office of Inspector General Fraud Hotline (OIG) at 1-800-436-6184.

ABUSE, NEGLECT OR EXPLOITATION (ANE)Lines of Communication


Abuse, Neglect, or Exploitation online training is available: https://learningportal.dfps.state.tx.us/course/index.php?categoryid=22

This training is designed to meet the basic ANE training requirements for staff providing direct care in a community setting. By the end of the training, staff should be able to identify which acts constitute ANE, how to recognize ANE, understand risk factors for ANE, and what methods can be used to address ANE. Additionally, this training includes an introduction to trauma and its impact on the people we serve.

To take this course, please click on the course title and then select the "enroll me" button below the course description.

If you have questions about this course or need assistance, please email [email protected].

INTERNAL CONTACTS


INTERNAL CONTACTS Phone Number

Behavioral Health Substance Abuse Services 1-877-725-2539

Behavioral Health Crisis Hotline- Hidalgo 1-888-843-1315

Behavioral Health Crisis Hotline- Tarrant 1-877-562-4397

Claims Status Request 1-877-653-0331

Compliance Hotline 1-877-653-0331

Cigna STAR+PLUS Automated Eligibility Verification Line 1-866-467-3126

Provider/Member Services Department 1-877-653-0331

Utilization Management – Service Coordination 1-877-725-2688

Utilization Management – Concurrent Review & Skilled Nursing Facility 1-877-725-2688

Utilization Management – Home Health 1-877-725-2688

Utilization Management – Inpatient Intake 1-877-725-2688

Utilization Management – Prior Authorization 1-877-725-2688

EXTERNAL CONTACTS


EXTERNAL CONTACTS Phone Number24- Hour Health Information Line (HIL) 1-855-418-4552Automated Inquiry System (AIS), Eligibility Verification 1-800-925-9126Cigna STAR+PLUS Pharmacy 1-877-653-0331Comprehensive Care Program (CCP) 1-800-846-7470Dental (DentaQuest) – Provider Services 1-888-308-9345Dental (DentaQuest) – Member Services 1-855-418-1628Change Healthcare (formerly Emdeon) 1-800-845-6592Laboratory Services (Quest Diagnostics) 1-800-522-9235Laboratory Services (CPL) 1-800-595-1275Laboratory Services (LabCorp) 1-888-522-2677Laboratory Services (ProPath) 1-866-776-7284MAXIMUS (Medicaid Managed Care Helpline) 1-800-964-2777Medicaid Managed Care Helpline 1-866-566-8989Medicaid Managed Care Helpline TDD 1-866-222-4306Medical Transportation Program (MTP) – Tarrant SDA 1-855-687-3255Medical Transportation Program (MTP) – Hidalgo SDA and MRSA Northeast SDA 1-877-633-8747Texas Department of Family & Protective Services (TDFPS) 1-800-252-5400Vision (Superior Vision) 1-866-819-4298

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