Doing Business with NHP

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Doing Business with NHP

• MAPAM Insurers Day
• May 21, 2009
• Ramona Bourguignon
• Director, Provider Relations

2
Presentation Objectives

• About NHP
• Current Initiatives
• Working Together
• Questions and Answers

3
About NHP

• 23 years of service excellence!
• State-wide HMO service public and private sectors
  
• Nationally recognized for robust care management
  programs
• Total Membership 194,014
• Commercial (including Commonwealth Choice)
  29,166
• Commonwealth Care 33,730
• MassHealth131,118
• NCQA Excellent accreditation recipient
• Ranked 2 nationally by U.S. News World
  Reports 2008 Best Medicaid Health Plans

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Current Initiatives

• A New Image!
• SFY10 Clinical Performance Improvement Initiative
  (CPII)
• Network Expansion Efforts
• Nurse Practitioner Credentialing
• Provider Enrollment Infrastructure
• Enhanced Provider On-boarding
• Member ID Card Changes

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Current Initiatives (Clinical Performance
Improvement Initiative (CPII)

• Contractual GIC requirement
• Part of GICs Select Save enrollee program
• Co-pay structure rewards members for seeing high
  performing physicians (quality and cost effective
  care delivery)
• Three distinct tier levels with unique co-pays
• Tier I (Excellent) - lowest co-pay
• Tier II (Good) middle co-pay
• Tier III (Standard) highest co-pay

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Clinical Performance Improvement Initiative
(continued)

• Performance analysis using multi-plan commercial
  claims data
• Millions of claim lines submitted by six GIC
  participating health plans
• Scope 2005-2007 paid and denied claims
• Quality assessment Resolution Health, Inc (RHI)
• Efficiency assessment Mercer/Vips

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NHP State Fiscal Year 2010 CPII

• Effective July 1, 2009 to June 30, 2010
• Applies to GIC members only
• Primary care physicians tiered at the group
  level
• Specialty care physicians tiered individually
• Cardiology, Endocrinology, ENT/Otolaryngology,
  Obstetrics/Gynecology, Gastroenterology,
  Rheumatology, Orthopedic Surgery, Pulmonology
• No additional information used to inform tier
  decisions
• Co-pay structure
• Primary Care 10/20/25 Specialty Care
  20/30/40 NT 30
• Providers with insufficient data (ID) for tiering
• Primary Care 20 Specialty Care 30
• Non tiered specialty providers 30
• Bold denotes new tiered specialties

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Current InitiativesNetwork Expansion Efforts

• Over 600 recently contracted provider entities
• New contracted facilities
• Anna Jacque Hospital
• Falmouth Hospital
• Harrington Memorial
• Health Alliance (Leominster Fitchburg)
• Hubbard Regional Hospital
• Marlborough Hospital
• Nashoba Medical Center
• Winchester Hospital
• Wing Memorial Hospital
• Provider re-contracting and data validation
• 7/1/09 CVS Limited License Clinic agreement for
  GIC product

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Current InitiativesNurse Practitioner
Credentialing

• Proudly enrolling Nurse Practitioners since 2005
• Pilot basis initially Primary care sites only
• Certified Nurse Midwife (CNM) enrollment
• Specialty capacity
• Primary care Nurse Practitioner enrollment
• With or without panel
• No differential reimbursement
• Policies modified to support recent mandate

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Current InitiativesProvider Enrollment

• Revised provider enrollment infrastructure
• Centralized all non-credentialing transactions
• Dedicated Provider Enrollment Unit
• Enhanced data change submission tool
• Direct data entry for routine transactions
• Improved turnaround results
• Currently assessing reporting capabilities
• Exploring provider confirmation/acknowledgment
  options

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Current InitiativesProvider Onboarding

• Revised provider contracting process
• Early Provider Relations representative
  assignment
• Enhanced provider welcome kit
• New provider service metrics
• Provider welcome call
• First provider visit
• Provider orientation
• Follow up satisfaction survey

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Current InitiativesMember ID Card Changes

• Single NHP ID card stock (with LLC co-pays for
  GIC members)
• Transitioning from SSN ID number format
• System generated alpha-numeric ID (NHP0123456)
• MassHealth ID to be included, when applicable
• ID card conversion July through December 2009
• Missing MedMetrics logo no pharmacy coverage
• Missing Doral logo no dental coverage

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Customer Care CenterMonday-Friday 800 to 600
pmThursdays 800 am to 800 pm

• Bilingual staff and resources
• Eligibility and enrollment verifications
• Claims status inquiries
• Adjustment requests
• Policy clarification and benefit inquiries
• Patient information changes
• Member education and outreach
• The Welcome Call
• Health Needs Assessment and Screening
• Re-determination assistance

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Eligibility Verification

• Commercial Commonwealth Choice Members
• NHP ID card
• Enrollment form copy or temporary ID card
• NHP Customer Care Center 800-462-5449
• MassHealth Members
• MassHealth Customer Service 800-554-0042
• Point of Service device
• NHP Customer Care Center 800-462-5449
• Commonwealth Care Members
• Commonwealth Care Customer Service 877-623-7773
• NHP Customer Care Center 800-462-5449
• Other Resources
• NHPNet (all members)
• NEHEN (all members)
• NEHEN Net (all members)

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Claim Submissions

• 90 days filing limit (or as contractually
  required)
• Weekly check runs and Explanation of Payment
  (EOP)
• 90 days adjustment request and appeals filing
  limit
• Significant EDI submission rate
• NHP Payer ID number 04293
• Dedicated P. O. Box for all paper submissions
• Provider Appeals
• Two appeal levels
• 90 days filing limit
• 30 days turnaround

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Appeal submissions

• Medical Appeals
• Neighborhood Health Plan
• Appeals Department
• 253 Summer Street,
• Boston, MA 02210
• Behavioral Health Appeals
• Beacon Health Strategies
• Appeals Department
• 500 Unicorn Park Drive, Suite 401
• Woburn, MA 01801

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Behavioral Health

• Behavioral Health Manager Beacon Health Strategy
• State-wide provider network
• www.beaconhealthstrategies.com
• Eligibility
• Claims and authorization status
• Provider information
• Resource materials
• Contact Information
• E-mail provider.relations_at_beaconhs.com
• Fax[phone]
• Phone [phone]

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E-Services

• NHPNet Provider Portal Transactions
• Eligibility verification
• Institutional claim submissions
• Professional claim submissions
• Claim status inquiry
• Electronic Remit
• Pre-certification status
• PCP changes
• Membership rosters
• Redetermination reports
• Disease Management reports
• Fall 2009
• NEHEN Net supported (www.nehennet.org)
• Primary Care sites only

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Other Resources

• Neighborhood Health Plan website www.nhp.org
• General provider updates
• NHP Provider Manual
• Reference tools (Administrative Clinical)
• Member benefits, programs products information
• Provider Directory
• Community Resources (SMART Neighbor)
• Provider newsletters (Administrative Clinical)
• Pharmacy coverage with drug look up functionality
• Prior Authorization Grid
• Doral Dentals Provider Manual
• Beacon Healths Provider Manual

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Provider Relations Representative

• Primary liaison between NHP and network
  providers
• Provide education
• Facilitate problem resolution
• Disseminate information
• Monitor contract compliance
• Provider Relations Department
• Phone [phone]
• Fax [phone]
• E-mail prweb_at_nhp.org

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Questions?

• Thank you!
• Contact Information
• Ramona Bourguignon
• Phone [phone]
• Fax [phone]
• E-mail ramona_bourguignon_at_nhp.org