PrimeWest Health System

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PrimeWest Health System

• Minnesota Senior Health Options
• MSHO Program
• Effective August 1, 2005

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What is MSHO?

• State-defined program
• Members have combined Medicare and Medicaid
  coverage
• PrimeWest responsible for adjudicating benefits
• Eligibility determined by MN DHS
• Includes pharmacy benefit (effective 1/1/06)

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Billing Medicare Covered Services

• Bill using CMS guidelines
• Check with PrimeWest for exceptions
• All MSHO plans must waive the 3-day qualifying
  hospital stay prior to SNF or home care
• Reimbursement based on CMS rates
• Combined Medicare and Medicaid payment on one
  claim
• Generally no deductibles/coinsurance
• Check your contract for payment rates

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Billing Medicare NON-Covered Services

• Bill using DHS guidelines
• Reimbursement based on DHS rates
• Generally based on MA rates
• Subject to State coinsurance determinations
• Check your contract for payment rates

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Coordination of Benefits (COB)

• When no secondary insurance
• No need to submit multiple claims
• Medicare/Medicaid payment combined into one claim
• Supplemental policies
• PrimeWest will recoup payment from supplement.

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Checking Eligibility

• Check eligibility on all MN Health Care Plan
  enrollees each month.
• Verify eligibility through the Electronic
  Verification System (EVS) at 800-657-3613 or
  through ProviderInsite.org
• A members coverage will never be terminated in
  the middle of a month. PW coverage is not
  retroactive, but if a member is eligible during a
  month, they will be covered throughout the whole
  month. PW does not determine a members
  eligibility. This is determined by the county.

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Benefits for the Members Enrolled in MSHO

• This is Total Coordinated Health care, including
  Medicaid and Elderly Waivered Services.
• Each member is assigned a Care Coordinator and a
  County Case Manager.
• Minimum Yearly assessment of individual.
• 3-day qualifying hospital stay waived to access
  Medicare A benefits for SNF or home care.

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Benefits for the Members Enrolled in MSHO
(Continued)

• No limit on blood transfusions
• Diabetic shoes.
• Automatic enrollment into Medicare Part D program
  through PrimeWest.

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Authorizations

• For all members enrolled in MSHO, PrimeWest pays
  the Medicare and Medicaid benefit in one combined
  payment. If a member chooses to go to a
  non-contracted provider, prior to seeing the
  member, the provider must obtain a service
  authorization.
• This authorization may be obtained by calling
  Medical Administration at [phone].

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Claim Submission

• Members ID number for Part A, B, or D is their
  PrimeWest ID number.
• Claims for Covered Services rendered to MSHO
  members should be submitted to and received by
  PrimeWest no later than one-hundred and eighty
  (180) days from the date of service.
• Claims should be sent to PrimeWest Health System
  at
• 822 South 3rd St., Ste 150
• Minneapolis, MN 55415

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180 day benefit

• 180 day benefit (Nursing Home Residents)
• Any PrimeWest Health System enrollee admitted to
  a nursing home from the community is entitled to
  180 days of care paid for by PrimeWest. After
  the initial 180 days, billing for nursing
  facility care should be submitted to the
  Minnesota Department of Human Services (DHS).If
  a PrimeWest Health System enrollee is currently
  residing in the nursing home at the time they
  enroll in MSHO or MSC, they are NOT entitled to
  the 180 day benefit.

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180 Day Benefit (cont.)

• Medicare SNF days.
• PrimeWest is responsible for services covered
  under the Medicare Advantage Special Needs
  Population (SNP) benefit regardless of whether NF
  liability is indicated on the States Medical
  Assistance file.
• Medicare SNF days for the Enrollee incurred prior
  to the begin date of the 180-day NF benefit do
  not count toward the 180 day benefit. This
  section does not apply to the 90-day NF benefit.

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180 Day Benefit (cont.)Swing Beds

• These include Medicare SNF days and Medicaid room
  and board days provided in swing beds that meet
  all other requirements for use of swing beds,
  including claims processing procedures and
  Minnesota Department of Health approval.

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180 Day Benefit (contd)Swing Beds

• PrimeWest Health System must be notified when a
  member is in a Swing Bed. Use the appropriate
  notification form based on the members
  enrollment.
• MSHO members-MSHO notification form
• PMAP members PMAP form

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Hospice

• When MSHO member chooses to enroll in hospice,
  they remain in MSHO but Medicare assumes direct
  responsibility for all Part A B services for
  that member, including but not limited to the
  hospice services.
• Institutional SNF or NF days that accrue during a
  hospice election period do not cound toward the
  180 day SNF/NF benefit period.
• Institutional room board for these days is paid
  by the State on a fee-for-service basis (DHS
  contract section 4.22.1 C-4)
• Days accrued in the hospice setting do not count
  toward the 180 day SNF/NF benefit.

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Hospice (cont.)

• Essentially a hospice member is still officially
  enrolled in MSHO, but the coverage reverts to a
  status more like Minnesota Senior Care (MSC),
  with PrimeWest responsible only for the
  Medicaid-covered services not covered by Medicare.

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180 Day Benefit (cont.)

• Medicaid NF days
• These may include Medicaid leave days. Leave days
  must be for hospital or therapeutic leave of an
  Enrollee who has not been discharged from a long
  term care facility.
• According to current MA standards, payments for
  hospital leave days are limited to 18 consecutive
  days for each separate and distinct episode of
  Medically Necessary hospitalization, and payments
  for therapeutic leave days are limited to 36
  leave days per calendar year.
• Respite days do not count towards the Medicaid or
  Medicare Benefit Period.

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180 Day Benefit (cont.)

• If a PrimeWest enrollee is in the middle of their
  180 day benefit and they enroll in MSHO, this
  benefit ends. DHS is responsible for this
  members nursing care.

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180 Day Benefit Cont.

• New Admission Example New admit on 12-29-05
  (currently does not have PrimeWest). 1/1/06
  person signs up for PrimeWest/MSHO This
  resident is NOT entitled to the 180 day benefit,
  as he/she was residing in the nursing facility at
  the time of enrollment.

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100 Medicare Days

• MSHO enrollees are entitled up to 100 days of
  Medicare coverage if the Medicare qualifications
  have been met.
• The nursing facility should notify PrimeWest
  Health System of when the resident became a
  Medicare skilled level of care using the MSHO
  notification form.
• Once the 100 days of Medicare coverage are used,
  the person is not entitled to another 100 days,
  unless there has been a 60 day break from the
  Medicare skilled level.

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100 Medicare Days (cont)

• Claims for the Medicare days for an MSHO
  enrollee would be sent to PrimeWest.
• A resident is entitled to the 100 Medicare days
  no matter how long they have been a resident at
  the nursing facility, as long as they meet the
  requirements of a skilled level of care.
• If a resident remains at a Medicare skilled level
  and has used up their 100 days, they are NOT
  entitled to an additional 100 days.

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MSHO Notification Form

• This form is used ONLY for PrimeWest MSHO
  members. Use this form to notify PrimeWest and
  MHP of Medicare days used and notification of the
  180 day benefit. This form must be faxed to both
  PrimeWest and MHP. The only time this form is
  sent to the State is to notify them of the end of
  the 180 day benefit.
• This form can be found on our website
  www.primewest.org (Partners ProvidersgtResources
  gtSNF Notification Form) Instructions for
  completing this form are also on the website.

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PMAP Form

• This form is a notification form for all PMAP
  members that are NOT enrolled in MSHO.
• Use this form to notify PrimeWest and MHP of any
  admission or change in RUG level.
• Use this form to notify the State at the end of
  the 180 day benefit.
• This form must be faxed to MHP and PRIMEWEST.
  This form can be found on the DHS website.

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1503 Form

• Unless you are completing an original 1503 form,
  this form DOES NOT need to be signed by a
  physician. It can be signed by an RN, or
  Director of Nurses.
• The SNF must complete and submit to the county
  financial worker in a timely manner.

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Medicare Reimbursement Program (MREP)

• At this time, this is still in place.
• Continue to file these as you have before MSHO.
• As the entire State goes to MSHO, this may
  eventually be discontinued.

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Billing

• 210 Bill No need for this as PrimeWest Health
  System is paying both portions of the claim.
• The 60 day break in spell of illness will be
  tracked by the MSHO Notification Form.
• Demand Bill The member is entitled to receive
  one if they request it.
• Medicare Denials These are still in place.
  Follow same guidelines as in the past.

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Durable Medical Equipment (DME) Supplies

• When ordering DME supplies for your residents,
  the vendor you order the supplies from may not be
  contracted with PrimeWest.
• To assure that this vendor will be reimbursed for
  these supplies, we encourage you to call Medical
  Administration for a service authorization for
  the item.

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Durable Medical Equipment (cont.)

• Medical Administration at [phone].
• Needs to be done each time an item/supply is
  ordered for this MSHO member.
• If the vendor is interested in contracting with
  PrimeWest Health System
• Robin Zimmerman, Credentialing Specialist
  [phone].

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Bad Debt Reconciliation

• PrimeWest is not part of this process
• We are not a fiscal intermediary
• We are a public program that receives funds from
  the State and CMS to cover only the medical
  services of our members.
• We do not receive extra funds from CMS to
  reimburse this.
• Concerns regarding this need to be addressed
  directly with CMS.

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Other helpful information

• PrimeWest Web site
• www.primewest.org
• Check frequently for timely updates
• Administrative manual
• Prime Pointers
• Pharmacy Link
• Provider Insite
• Credentialing
• This presentation
• Much more!

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Questions?

• Contact numbers
• 1-866-431-0802 (Provider Services)
• 1-866-431-0803 (Medical Admin-Service Auth)
• 1-866-431-0801 (Member Services)
• Provider Relations
• Kathleen Lowden 320-335-5224
• Becky Walsh 320-335-5214
• Marcie Vickerman 320-335-5222
• See hand out for additional contacts.

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• Thank-you!!