Credentialing and the Sanford Provider Hub - Sanford Health Plan
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Provider Fast Facts March 2021 | An eNewsletter from Sanford Health Plan Credentialing and the Sanford Provider Hub In 2021, Sanford Health is moving credentialing to a secure, cloud-based software solution. This new Sanford Provider Hub will provide: • A user-friendly, automated experience • Streamlined processes • A reduction in paperwork We’re excited to bring the Sanford Provider Hub to you in April 2021! Watch for further details via email and U.S. mail soon. 1
Policies Update Below, you’ll find the latest policy updates—additions, deletions, edits—for your reference. Please call us at (800) 601-5086 Option 2, Option 4 for Provider Relations if you have any questions. New Benefit Reimbursement Policies: • Dental Services • Oral and Maxillofacial Surgery • Reconstructive Surgery Upcoming Policies: • O utpatient Services Prior to Inpatient Admission effective 4/1/21 • Increased Procedural Services (Modifier 22) effective 4/1/21 • Benefit Reimbursement Policy effective 4/1/21 • Consultation Services Benefit Reimbursement effective 4/1/21 Optum CES Edits Sanford Health Plan continues to implement additional claims edits. Check periodically for details of future edits to be released. A document detailing the claim edits is available to you here on the PROVIDER RESOURCES PAGE. The resource will be updated as Sanford Health Plan implements new edits. 2
Helping Your Patients Get Screened for Colorectal Cancer Many times your patients rely on your professional recommendation and the discussions you have with them on their options will help them schedule their screening for colorectal cancer. By letting your patients know what to expect — including what their responsibility is for each type of screening, you can help make their preparation process much more manageable and less intimidating. Most insurance plans classify colorectal cancer screening as a preventive health care service and, therefore, cover the cost of the screening. With that being said, your patients should know that preventive services like screening tests may sometimes result in a follow-up diagnostic procedure, especially if a polyp is found and biopsied. Once a preventive services like colorectal cancer screening becomes diagnostic, this may change a patient’s coverage. The patient may then be required to pay an out-of-pocket expense (co-pay, deductible, coinsurance). A deductible may need to be paid if the colonoscopy is prescribed to diagnose an unknown health problem the patient is experiencing, such symptoms as bleeding or irregularity. In this circumstance, the procedure would be considered diagnostic. Discussing these key points with your patients during their exams is one way to help ease their nerves and help increase your screening rates. If your patients have questions regarding their benefits, they can call the Customer Service number found on their Sanford Health Plan ID card or log into mySanfordHealthPlan member portal. For more information regarding screening guidelines, please log onto the Sanford Health Plan website and review the Clinical Practice Guidelines. At Home Testing Update At-home testing kits such as Fit or Cologuard that produce an adverse result indicates a colonoscopy is needed. Currently, with an adverse result the colonoscopy would not be treated as a screening, but instead as diagnostic and would be subject to copay, deductible or coinsurance. Effective 4/1/21, Sanford Health Plan will allow colonoscopies to be covered at 100% when done after an at-home screening with an adverse result. Preventative Screening Diagnostic Testing A test (eg, colonoscopy, FIT, stool DNA test, or FOBT) A colonoscopy to diagnose a health condition in response performed on a patient who does not have symptoms to symptoms, such as: but who is in a group at risk for colorectal cancer, such • Bleeding or irregularity as those: • Positive results of a preventive screening • Between the ages of 50 and 75 with a family history of The patient may have to pay a co-pay, coinsurance, colorectal cancer or deductible. • With few exceptions, health care plans cover screenings with no out-of-pocket cost to the patient. Example A: For a patient’s 50th birthday, he chooses to Example A: The FOBT has a positive result; his doctor have a simple FOBT. recommends a colonoscopy to determine the cause of the bleeding. The colonoscopy may be considered diagnostic since it will be used to determine why the patient has blood in his stool. Example B: A patient’s mother had colorectal cancer, so Example B: During the preventive screening she opts for a colonoscopy. colonoscopy, polyps are found, removed, and sent to a lab for testing. The testing itself may be considered diagnostic since the lab results will need to be reviewed to determine if the polyp is cancerous. 3
Changes Coming for Prior Authorizations Participating providers will be responsible for not approving the request. Additionally, the obtaining authorizations starting in 2021. If a member may also appeal if they feel they are provider is non-participating, the member will be being held responsible when not appropriate, responsible for obtaining the prior authorization. and documentation must be submitted to prove In the event that an authorization is not obtained, whether the member consented to proceed with the and a retrospective authorization is requested procedure. For further questions regarding these and deemed not medically necessary after review, changes, please see our FAQ document HERE or the provider will be responsible for the charges, call Provider Relations at (800) 601-5086. resulting in provider write off. Some exceptions will be made on a case by case scenario. For Q: W ill the entire claim deny to Provider example, if a provider submits a prior authorization Responsibility if no Authorization is in place? that results in a denied request and the member A: No, the denial will continue to be at the line chooses to still have the procedure done, it will be item level considered member responsibility. In this event, Q: W hat is the time period given to submit a the provider should bill with a GA or GY modifier retroactive authorization? so that the responsibility is on the member. If the A: As of 1/1/21 the time period for retroactive modifier is not used, the provider may submit a authorizations to be accepted has been shortened reconsideration for review. The provider must from 180 days to 60 days. submit documentation that proves to member agreed to proceed with the care despite insurance Electronic Prior Authorization To better serve our members and providers, we will require electronic prior authorization submission effective Oct. 1, 2020. Providers currently not using the electronic submission option will need to submit referrals electronically. Sanford Employees and internal users: Please see the training resource HERE , or sign up for additional classes in the Sanford Success Center. EXTERNAL PROVIDERS: Please submit authorization requests via Provider Portal HERE. For questions, please contact Provider Relations at (800) 601-5086. Covid Vaccine Administration Allowed Amount Sanford Health Plan has established the following allowed amounts for administration of the Covid vaccine. Please note this is for administration only. We will continue monitoring vaccine developments and will add administration allowed amounts for vaccines produced by other manufacturers when they become available. Code Description Allowed Amount 0001A Pfizer 1st dose $28.81 0002A Pfizer 2nd dose $48.29 0011A Moderna 1st dose $28.81 0012A Moderna 2nd dose $48.29 0021A AstraZeneca 1st dose $28.81 0022A AstraZeneca 2nd dose $48.29 0031A Janseen* (1 shot dose) $48.29 *Janseen is a division of Johnson & Johnson 4
Utilization Management: Phone Prompts Innovating to Improve Access Have Recently to Medically Necessary Care Changed PA REQUIREMENTS FOR ADVANCED IMAGERY To provide you with you Sanford honors its commitment to you, our providers, and most certainly our patients / members by continuing to look for ways to optimize efficiencies the best experience we across our enterprise operations. As a part of these ongoing efforts, we have updated our phone are working to modernize our Utilization Management (UM) capabilities by systems and with this enhancing Prior Authorization (PA) processes to alleviate administrative and change there may be provider burden while improving the overall patient experience and access to high quality care. some differences. You will still use the numbers Last month we provided detail on one of Sanford Health Plan initiatives which will expand the authorization process to include advanced imaging at the end of this through our partnership with eviCore Healthcare. Based on evidence-based publication to reach the clinical guidelines, this effort will enable the organization to confidently appropriate departments. provide the highest quality, appropriate care to our patients. Beginning Prior to arriving at the Dec. 14th, 2020, select Sanford Health members will require prior authorization from eviCore for dates of service Jan. 1, 2021 and thereafter. appropriate department, Services performed without authorization may not be reimbursed. you will be prompted Standardization and automation of PA processes will offer additional to enter if you are a support and efficiency across key UM functions and will enable member, provider or improved outcomes and an enhanced patient experience by providing have sales inquiry. Once the right care, with the right provider, and in the right setting. Stay within the provider tuned for more information and updates on our progress regarding these exciting enhancements, and to learn more about Sanford’s efforts menu your call will be to deliver greater value to you and the communities we serve. routed to the team that To learn more about this new requirement please check out the will most efficiently be dedicated website for Providers HERE. On the dedicated website able to answer your you will be able to: questions. We thank you 1. Register for training (in General Resources Tab, Registration Instructions) for your patience as we 2. Register for sign in (in General Resources Tab, Registration Instructions) embark on some amazing 3. Review CPT code list for services that require authorization technology to create (in Solution Resources Tab, Radiology icon) the best experience 4. Access Evidence Based Clinical Guidelines for you as a provider For questions on how to get started please call: eviCore’s call and our members. center is open from 7 a.m. to 7 p.m. CST (844) 635-7225. COVID-19: Updated Coverage Announcement Stay up-to-date on all COVID-19 information and find resources specifically for providers by visiting this webpage. Have additional COVID-19 questions? Submit your questions HERE. 5
Contact Us: CONTACT FOR: Member eligibility & benefits, member claim status, provider directory, complaints, appeals, report member discrepancy information memberservices@sanfordhealth.org Customer Service Monday-Friday, 8 a.m. to 5 p.m. CST | 800) 752-5863 NDPERS Customer Service Monday-Friday, 8 a.m. to 5:30 p.m. CST | (800) 499-3416 ND Medicaid Expansion Monday-Friday, 8 a.m. to 5 p.m. CST | (855) 305-5060 CONTACT FOR: Preauthorization/precertification of prescriptions or formulary questions pharmacyservices@sanfordhealth.org Pharmacy (855) 305-5062 NDPERS Pharmacy (877) 658-9194 ND Medicaid Expansion (800) 755-2604 | TTY: 711 CONTACT FOR: Preauthorization/precertification for medical services um@sanfordhealth.org Utilization Management (800) 805-7938 NDPERS Utilization Management (888) 315-0885 ND Medicaid Expansion (855) 276-7214 CONTACT FOR: Assistance with fee schedule inquiries, check adjustments & reconciling a negative balance, request explanation of payment (EOP), claim reconsideration requests, W-9 form, change/ updating information, provider education providerrelations@sanfordhealth.org Provider Relations (800) 601-5086 CONTACT FOR: Requests to join the network and contract-related questions and fee schedule negotiation sanfordhealthplanprovidercontracting@sanfordhealth.org Provider Contracting (855) 263-3544 Hearing or speech impaired TTY | TDD (877) 652-1844 Translation Assistance for Non-English Speaking Members (800) 892-0675 6
You can also read