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Essential Information forNew Jersey FamilyCare ProvidersGeralyn D. MolinariDirector, Managed Provider Relations UnitOffice of Managed Health CareNJ Department of Human ServicesDivision of Medical Assistance and Health Services1
Presentation Topics Overview of New Jersey Medicaid/NJ FamilyCareConfirmation of Member EligibilityProvider Relations Overview- DMAHS /OMHCBalance BillingAuthorization and Claims ProcessingContinuity of CareUtilization Appeals Provider /Stakeholder Resources2
What is Medicaid? Medicaid is a joint Federal and State program thathelps pay medical costs if individuals have limitedincome and resources or meet other requirements. Medicaid is a voluntary program. If you want toparticipate, you must know, accept and abide bythe rules and regulations New Jersey Medicaid is referred to as NJ FamilyCarein member and provider communication3
New Jersey MedicaidManaged Care ContractsThe New Jersey Department of Human Services, DMAHS, hasa contract with the following Managed Care Organizations:–––––Aetna Better Health of New JerseyAmerigroup New Jersey, Inc.Horizon NJ HealthUnitedHealthcare Community PlanWellCare Health Plans of NJ, Inc.4
Administration & OversightThe Medicaid program in New Jersey is administered and/or overseen byDepartment ofLaw & PublicSafetyDivision ofCriminalJusticeOffice of theInsuranceFraudProsecutorMedicaidFraud ControlUnit(MFCU)Department ofHumanServicesDepartment ofTreasuryDivision ofMedicalAssistanceand HealthServices(DMAHS)Office of theStateComptrollerMedicaidFraud Division(MFD)Managed CareOrganizations(MCO)5
CONFIRMATION OF MEMBERSNJ FAMILYCARE ELIGIBILITY6
Provider’s Requirement toConfirm NJ FamilyCare Eligibility Providers must confirm NJ FamilyCare Eligibility eachmonth to ensure that member is currently enrolled Provider must confirm that member is enrolled inHealth Plan and that they have an activeauthorization If Member has changed MCO, provider mustcontact existing Health Plan regarding authorizationupdate7
Medicaid Eligibility Verification System (MEVS)E-Mevs Medicaid Eligibility Verification System (MEVS) is an electronicsystem used to verify recipient Medicaid eligibility. Thiselectronic verification process will provide date specificeligibility which will help reduce claim denials related toeligibility. It can help to eliminate Medicaid fraud. NJ Providers access eMEVS through “Login” on the NJMMISwebsite www.njmmis.com In order to login, individual must have a secure username andpassword Users ids and passwords are requested through ProviderRegistration link on the NJMMIS navigational bar on mainscreen.8
Users access eMEVS byselecting Login
Enter your secureUsername andPassword
Balance BillingA provider shall not seek payment from, and shall notinstitute or cause the initiation of collection proceedings orlitigation against a beneficiary, a beneficiary's familymember, any legal representative of the beneficiary, oranyone else acting on the beneficiary's behalf unless servicedoes not meet criteria referenced in NJAC 10:74-8.7(a).Balance Billing details are also outlined in NJ Family CareNewsletter:Volume 23 No. 15September 2013Limitations Regarding the Billing of NJ Family Care (NJFC) BeneficiariesAll Medicaid/NJ Family Care newsletters posted on http://www.njmmis.com11
Managed Care OrganizationProvider Relations Unit Requirements creating an annual provider manual and preparingupdates as necessary; offering provider education and outreach, and provide a call center for claims troubleshooting forproviders establish process for claims and utilization appeals assign Provider representative or contact to addressProvider contract12
Prior Authorization ParametersPrior authorization decisions for non-emergencyservices shall be made within 14 calendar daysPrior authorization denials and limitations must beprovided in writing in accordance with the HealthClaims Authorization Processing and PaymentAct, P.L. 2005, c.352.Source: Health Claims Authorization Processingand Payment Act, P.L. 2005, c.352.13
Prior Authorization Guidelines forNJ Family Care ServicesNew MemberNo Existing Plan of CareMember Transitions to MCO withexisting Plan of Care for LTCEMCO must prior-authorize serviceMCO must honor continuity of careparameter of contractProvider must be in Network withMCO and/or have a single caseagreement to serve memberMCO and Provider must set up SCAor join network. Approved servicesas per existing plan will bereimbursed until new plan of careestablished14
Managed Care OrganizationClaim Submission Requirements Capture and adjudicate all claims submitted byproviders Support NJs NJ Family Care’s encounter datareporting requirements Comply with "Health Claims Authorization,Processing and Payment Act“ (HCAPPA) for allMedical Services Ensure Coordination of Benefits (exhaust all othersources of payment before NJ Family Care pays)15
Claim Processing Compliance withFederal and State Laws and Regulations 1. The Provider/Subcontractor shall submit claimswithin 180 calendar days from the date of service. 2. The Provider/Subcontractor shall submitcorrected claims within 365 days from the date ofservice. 3. The Provider and Subcontractor shall submitCoordination of Benefits (COB) claims within 60 daysfrom the date of primary insurer’s Explanation ofBenefits (EOB) or 180 days from the dates of service,whichever is later.16
Claim DisputeAdjudicate--the point in the claims/encounterprocessing at which a final decision is reached topay or deny a claim, or accept or deny anencounter.Contested Claim--a claim that is denied becausethe claim is an ineligible claim, the claimsubmission is incomplete, the coding or otherrequired information to be submitted is incorrect,the amount claimed is in dispute, or the claimrequires special treatment.17
Continuity of Care
Continuity of CareDefinition: The plan of care for an enrollee that should assureprogress without unreasonable interruption The Contractor shall ensure continuity of care and fullaccess to primary, behavioral, specialty, MLTSS andancillary care as required under this contract and accessto full administrative programs and support services offeredby the Contractor for all its lines of business and/orotherwise required under this Contract.Source: Article 2.B of the July 2017 NJ FamilyCare ManagedCare Contract19
Utilization Appeals
UM Appeal Process: DefinitionsUM Appeal: An appeal of an adverse UtilizationManagement determination, initiated by the Member(or a provider acting on behalf of a Member with theMember’s written consent)Utilization Management Determination: A decisionmade by a Managed Care Organization (MCO) todeny, reduce, suspend or terminate a service basedon medical necessity21
Utilization Appeals Guidelines forNJ Family Care ServicesIURO(External Appeal)Time FrameMedicaid FairHearingContinuation of BenefitsNJ FamilyCare A andABP MembersYes*YesMember and/or Provideron behalf of member mustrequest within appealtimelinesAppeal Process for NJFCB, C, and D MembersYesNot AvailableMember and /or Provideron Behalf of member mustrequest within appealtimelines(Select services are not eligible for IURO: Adult Family Care, Assisted Living Program, Assisted LivingServices, Caregiver Participant Training, Chore Services, Community Transition Services, HomeBased Supportive Care, Home Delivered Meals, PCA, Respite, Social Day Care, Structured DayProgram )22
Resources for Providers andStakeholders
Mobile Friendly & Browser Independent
Link to Website with Enrollment familycare.org/analytics/home.html
DMAHS Office of Managed Health Care (OMHC)Provider Relations Inquiry ProcessProvider and/or Member contact DMAHS: Provider must submit claim detail to DMAHS:Providers must submit detail indicating that Medicaidguidelines were followed and MCO was contactedprior to outreach to OMHC– check eligibility– request prior authorization,– timely claim submission– Submission of appeal timelyMember: Submits copy of balance billDMAHS will contact the MCOSubmit to mahs.provider-inquiries@dhs.nj.gov26
DMAHS Office of Managed Health Care (OMHC)Provider Relations Inquiry Process OMHC completes inquiry upon receipt of detail indicatingthat MCO contract guidelines were followed OMHC will review and follow-up with MCO on behalf ofthe Provider if initial response does not meet contractguidelines. All inquiries sent to MCO are logged into aSharePoint databaseExample: Claim inquiries are closed upon receipt of claimnumber and amount and /or letter to Provider.27
MCO Provider Relations Reporting MCO Contracted Quarterly Report (Table 3C)includes all inquires submitted to MCO on behalf ofProvider by the Office of Managed Health Care(OMHC) DMAHS prepares a Quarterly Provider Inquires Report(Feb 15th, May 15th, Aug 15th and Nov 15th ) Quarterly Report documents all reported inquiriesand identify inquiries that remain open beyond adesignated quarterly period28
DMAHS Follow-up Based on trends across plans and /or service types– Develop Provider Education– Develop policy guidance– Develop contract changes / updates– Present MCO Notices of Deficiencies orCorrective Action Plans if necessary29
NJ FamilyCare MCO Resources NJ FamilyCare Health Plans Currently Under Contractand Providing Medicaid Managed Care Services inNew clients/medicaid/hmo/index.html Member Relations- Access Member Manual Provider Relations -Provider Quick Reference Guide30
State Resource for Managed Care Providers:Office of Managed Health Care (OMHC)Managed Provider Relations UnitAccess MLTSS s/home/mltss resources.html Behavioral Health hs/news/ebhb.html Form to submit inquiry is located by clicking on highlightDMAHS Provider Relations Inquiry InformationProvider Relations Inquiry Request form – single caseProvider Relations Inquiry Request form – multiple casesEmail detail via secure email to mahs.provider-inquiries@dhs.nj.govSeparate emails should be sent for individual MCOs.Multiple cases must include excel summary of information.31
Questions32
Confirm NJ FamilyCare Eligibility Providers must confirm NJ FamilyCare Eligibility each month to ensure that member is currently enrolled Provider must confirm that member is enrolled in Health Plan and that they have an active authorization If Member has changed MCO, provider must contact existing Health Plan regarding authorization
