WELCOME TO LOUISIANA HEALTHCARE CONNECTIONS

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WELCOME TO LOUISIANA HEALTHCARE CONNECTIONS Your
Plan for Success
Title of Presentation
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LPCA OUR LOCAL PARTNER
Provider-Based A joint venture partnership
between Louisiana Partnership for Choice Access
and Centene, Louisiana Healthcare Connections
brings the dedication and experience of 19
non-profit Federally Qualified Health Centers
(FQHCs) across Louisiana who specialize in
healthcare for low-income and uninsured
populations
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CENTENE OUR CORPORATE PARTNER

• History Scope
• Established in 1984 in Milwaukee, WI
• Headquartered in St. Louis, MO
• Fortune 500 company
• Employs approximately 4,000 individuals
• Serves over 2 million members across the country
• Currently operates health plans in 15 states
• Contracts with 85,000 physicians and 1,000
  hospitals
• Corporate Philosophy
• Quality healthcare is best delivered locally.

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LOUISIANA HEALTHCARE CONNECTIONS

• Local Approach
• Our local presences means 200 jobs total for
  the markets we serve.
• Our locally-based health plan infrastructure
  ensures each member is supported by someone who
  understands the local culture as well as the
  available community resources.
• Our local perspective engages members and
  advocates in directing the way services are
  provided and how we communicate to them on a
  daily basis.

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LOUISIANA HEALTHCARE CONNECTIONS
Mission Louisiana Healthcare Connections will
provide the best benefits and programs possible
in order to improve the overall healthcare
outcomes of the Louisiana families it serves.
Vision Louisiana Healthcare Connections
delivers quality healthcare through local and
community resources that reflect and celebrate
Louisianas unique and vibrant way of life.
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LOUISIANA HEALTHCARE CONNECTIONS
Core Values Compassionate      Louisiana
Healthcare Connections treats everyone with
kindness, dignity and respect. Sensitive   
Louisiana Healthcare Connections supports
diverse community and cultural values. Reliable   
   Louisiana Healthcare Connections provides
coordinated care services across all channels
with responsive, diligent efficiency.
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LOUISIANA HEALTHCARE CONNECTIONS
Enhanced Member Benefits Provider Visits No
limits on how many times members can see their
PCP. CentAccount Cash rewards in a special
account for healthy habits such as regular visits
and yearly exams. Connections Plus Cell phones
for qualified members to use when staying in
touch with their case manage or receiving
appointment reminders.
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LOUISIANA HEALTHCARE CONNECTIONS
Enhanced Member Benefits Start Smart for Your
Baby Special benefits and support programs for
keeping pregnant moms and their baby
healthy. NurseWise Free access to
around-the-clock phone lines with nurses who can
answer health questions. MemberConnections
Personal helpers for help with information about
needs such as access to services, choosing a
doctor or getting food, clothing and housing.
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BAYOU HEALTH OVERVIEW

• Formerly known as Louisianas Medicaid and LaCHIP
  (Louisiana Childrens Health Insurance Program),
  BAYOU HEALTH replaces the former fee-for-service
  system with a coordinated care model.
• Goals
• Better quality of care
• Improved outcomes through
• --Prevention
• --Better coordination of care
• --Active management of chronic illnesses
• --Comprehensive patient-centered medical home
• Increased access to care

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BAYOU HEALTH OVERVIEW

• Key Health Indicators
• Reduction in avoidable hospitalizations
• Reduction in hospital readmissions
• Reduction in preterm births and neonatal costs
• Reduction in emergency room costs
• Reduction in duplicative services
• Improved outcomes through early detection and
  treatment

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BAYOU HEALTH OVERVIEW

• Mandatory Eligibility Groups
• Section 1931 (children, individual and families)
• TANF (Temporary Assistance for Needy Families)
• CHAMP (Child Health And Maternity Program) and
  LaCHIP
• Deemed Eligible Child Program
• Youth Aging Out of Foster Care
• Regular Medically Needy Program
• Pregnant Women (LaMoms, LaCHIP Phase IV)
• Breast and Cervical Cancer Program
• ABD (Aged, Blind, Disabled) SSI, Extended
  Medicaid Programs, Disabled Widows/Widowers,
  Blood Product Litigation Program, Medicaid
  Purchase Plan Program, Disability Medicaid
  Program

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BAYOU HEALTH OVERVIEW

• Voluntary Eligibility Groups
• Children under 19 who are
• Eligible for SSI under Title XVI
• Eligible under Section 1902(e)(3) of the Act
• In foster care or out of home placement
• Receiving foster care or adoption assistance
• Receiving services through a family-centered,
  community based coordinated care system that
  receives grant funds under Section 501(a)(1)(D)
  of Title V
• Enrolled in the Family Opportunity Act Medicaid
  Buy-in Program
• Native Americans who are members of federally
  recognized tribes

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BAYOU HEALTH OVERVIEW

• Member categories not eligible for enrollment
• Individuals receiving hospice
• Individuals residing in a Nursing facility (NF)
  or Intermediate Care Facility for People with
  Developmental Disabilities (ICF/DD)
• Dual Eligibles (receiving both Medicaid and
  Medicare)
• Individuals receiving services through the
  Tuberculosis Infected Individual Program
• Individuals receiving services through 1915(c)
  Home and Community Based Waiver (ADHC, NOW, EDA,
  CC, ROW, Supports Waiver, other HCBS)
• Individuals under 21 otherwise eligible listed on
  the Office of Citizens with Development
  Disabilities (OCDDs) Request for Services
  Registry (Chisholm Class Members)

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BAYOU HEALTH OVERVIEW

• Member categories not eligible for enrollment
• Individuals enrolled in the Program for
  All-Inclusive Care for the Elderly (PACE)
• Individuals with Limited Eligibility (Spend-down,
  ER services only, families who lose LIFC or TANF)
• LaChip Affordable Plan Program (La Chip Phase V)
• Individuals enrolled in Section 1115 Family
  Planning Waiver (Take Charge)
• Individuals enrolled in the Louisiana Health
  Insurance Premium Payment (LaHIPP) Program
  (Section 1906)

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BAYOU HEALTH OVERVIEW

• Excluded Services (Carve Outs)
• Pharmacy
• Dental
• Specialized Behavioral Health
• All Hospice
• Targeted Case Management
• Personal Care Services (Children and Adults)
• All Nursing Facility Services
• Individual Education Plan (IEP) Services Billed
  Through School Districts

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BAYOU HEALTH TIMELINE
GSA A (Regions, 1 and 9) December 15,
2011 Choice Letters Mailed January 26,
2012 Enrollment Deadline February 1, 2012 Go
Live GSA B (Regions 2, 3 and 4) February 15,
2012 Choice Letters Mailed March 28,
2012 Enrollment Deadline April 1, 2012 Go
Live GSA C (Regions 5, 6, 7 and 8) April 16,
2012 Choice Letters Mailed May 29,
2012 Enrollment Deadline June 1, 2012 Go
Live
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HEALTH PLAN OVERVIEW
Member Identification Card front back
IMPORTANT TELEPHONE NUMBERS Members Member
Services 1-866-595-8133 TDD/TTY
1-877-285-4514 24/7 NurseWise 1-XXX-XXX-XXXX Visio
n 1-XXX-XXX-XXXX File a Grievance 1-XXX-XXX-XXXX R
eport Fraud 1-800-488-2917 Providers Provider
Services 1-XXX-XXX-XXXX Eligibility/PriorAuth
1-866-595-8133 Medical Claims Louisiana
Healthcare Connections Attn CLAIMS
PO Box 4040
Farmington, MO 63640-3826
Provider/claims via the web
www.LouisianaHealthConnect.com
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HEALTH PLAN BENEFITS

• CentAccount
• The CentAccount program promotes the use of
  preventative services by rewarding members for
  practicing healthy behavior.
• Features
• Members receive a prepaid MasterCard debit card
• Credit is added to the account balance when the
  member receives a certain screening or
  preventative care
• Members may use to purchase healthcare goods and
  services

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HEALTH PLAN BENEFITS

• MemberConnections
• MemberConnections is an outreach program
  designed to provide education to our members on
  how to access healthcare and develop healthy
  lifestyles in a setting where they feel most
  comfortable.
• Features
• Community Connections
• Connects members to community resources.
• Home Connections
• Connects members who are home bound to other
  resources.
• Connections Plus
• Provides free pre-programmed cell phones to
  members who are in disease management programs.

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HEALTH PLAN BENEFITS

• Start Smart for Your Baby
• Special prenatal support and care for keeping
  pregnant moms and their baby healthy. Designed to
  decrease infant mortality rates, increase number
  of pregnant women receiving early prenatal care,
  increase abstinence from alcohol and other
  harmful drugs as well as increase number of
  mothers who breastfeed.
• Features
• Incorporates Clinical and Outreach efforts to
  assist pregnant women with issues that affect
  their pregnancy such as smoking.
• Works in conjunction with established healthcare
  delivery systems, provider community care
  coordinators and community resources.

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MEDICAL MANAGEMENT

• Services
• Utilization Management (Prior Authorizations)
• Case Management (OB/GYN Management)
• Disease Management (Asthma, Diabetes Management)
• Quality Review (Clinical Outcomes Review)
• Hours of Operation
• Monday - Friday 800 A.M. to 500 P.M. CST
  (excluding holidays)
• After normal business hours or holidays,
  NurseWise representatives answer questions about
  authorization requirements.
• Prior Authorizations may be called in, faxed or
  submitted electronically via our secure web site.
• ER services do not require Prior Authorization.

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MEDICAL MANAGEMENT

• Prior Authorization Services
• Some DME
• Genetic Testing
• Hi-Tech Radiology
• Home Health
• Elective Inpatient Services
• Out of Network except for Emergency Services
• Pain Management
• Sleep Studies
• Therapies
• Transplants
• Non Emergent Medical Transportation
• Services managed by a vendor
• Visit our website to view the covered services
  Prior Authorization list

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MEDICAL MANAGEMENT

• National Imaging Associates (NIA)
• Provides Hi Tech Radiology Management services
• Accredited by NCQA and URAC certified
• A subsidiary of Magellan Health Services
• Application of clinical algorithms and guidelines
  to identify the most appropriate test early in an
  episode of care for our members
• Clinical peer to peer consultation with 86
  board-certified physicians representing radiology
  and a host of other specialties
• Prior Authorization is required for Non-Emergent
  Outpatient CT/CTA/CCTA, MRI/MRA

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MEDICAL MANAGEMENT

• National Imaging Associates (NIA)
• All other procedures will be authorized and paid
  for by Louisiana Healthcare Connections
• The ordering physician is responsible for
  obtaining prior authorization but the rendering
  provider must ensure that prior authorization has
  been obtained to ensure proper reimbursement
• NIA does not accept faxes for initial
  authorization requests
• Providers can use NIAs website at www.radmd.com
  and click on the RadMD Sign In for 24/7 online
  access
• RadMD provides instant access to much of the high
  tech imaging prior authorization information

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MEDICAL MANAGEMENT

• CENPATICOSpecialty Therapy and Rehabilitative
  Services (STRS)
• A wholly owned subsidiary of Centene Corporation
• Prior authorization is required for outpatient
  and home health occupational, physical or speech
  therapy services
• Prior Authorization Requests should be submitted
  to Cenpatico STRS using the Outpatient Treatment
  Request (OTR) form located at http//www.cenpatico
  .com/providers/forms/louisiana/
• Prior Authorization Requests may be faxed to
  Cenpatico at 1-855-254-1798 or submitted
  electronically via our secure website
• Medical Necessity Criteria can be found at
  http//www.cenpatico.com/providers/forms/

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OPERATIONS

• Claims
• Initial Claims must be submitted within 365
  calendar days from DOS
• Corrected Claims must be submitted within 90
  calendar days from EOP
• Clean Claims will be adjudicated (finalized as
  paid or denied) at the following levels
• --90 within 15 business days of the receipt
• --99 within 30 calendar days of the receipt
• Louisiana Healthcare Connections accepts paper
  claims but prefers electronic transactions
• Louisiana Healthcare Connections Payer ID is
  68069 with the following clearinghouses
• --Emdeon
• --Availity
• --Gateway

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ONLINE RESOURCES

• www.louisianahealthconnect.com
• Provider Handbook
• Provider Billing Manual
• Prior Authorization List
• Operational Forms
• Plan News
• Clinical Guidelines
• Provider Newsletter

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ONLINE RESOURCES

• Secure Portal Functionality
• Verify eligibility and benefits
• View eligibility list
• View and submit authorizations
• Submit and check status of claims
• Review payment history
• Secure Contact Us
• Secure Portal Benefits
• No waiting
• No on-hold music
• No time restrictions
• Registration is free and easy

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ONLINE RESOURCES

• Electronic Transactions
• Member Providers are encouraged to participate in
  our Electronic Claims/Encounter Filing Program.
• Features
• Receive an ANSI X12N 837 professional,
  institutional or encounter transaction (claims)
• Generate an ANSI X12N 835 electronic remittance
  advice (aka EOP-- Explanation of Payment)
• Create electronic transaction speed payments
• Reduce manual intervention and errors

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PROVIDER BENEFITS

• Payformance/PaySpan
• Free service
• Providers are not charged any fees to use the
  service
• Eliminates re-keying of remittance data
• Electronic remittance advices can be imported
  directly into Practice Management Software or
  Patient Accounting Systems, eliminating the need
  for manual keying off of paper remittance advices
• Establishes control over bank accounts
• Providers keep control over the destination of
  claim payment funds. Supports multiple practices
  and accounts
• Matches payments to advices quickly
• Providers can match electronic payments with
  electronic remittance advices quickly and easily

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PROVIDER BENEFITS

• Payformance/PaySpan
• Pursues secondary billings faster
• Accelerates the revenue life cycle
• Improves cash flow
• Electronic payments can mean faster payments and
  improved cash flow
• Connects with multiple payers
• Providers can quickly connect with any Payer that
  use PaySpan Health to settle claims

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QUALITY IMPROVEMENT

• Program Overview
• The culture, systems and processes of Louisiana
  Healthcare Connections are all designed around
  our mission to improve the health of our members.
  
• Our Board of Directors (BOD) has the ultimate
  authority and oversight of the quality of care
  and service provided to our members.
• The Quality Improvement Committee (QIC) is
  comprised of Louisiana Healthcare Connections
  senior management and includes physician
  representation directly accountable to the BOD.
• The purpose of the QIC is to provide oversight
  and direction in assessing the appropriateness of
  services provided and to continuously enhance and
  improve the quality of care and services provided
  to members.

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QUALITY IMPROVEMENT

• Oversight of Quality Improvement Committee (QIC)
• Credentialing Committee
• Utilization Management Committee
• Pharmacy and Therapy Committee
• Performance Improvement Team
• Member and Provider Advisory Committee
• Peer Review Committee (Ad Hoc Committee)
• Community Advisory Committee

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PATIENT CENTERED MEDICAL HOME

• Louisiana Healthcare Connections is committed to
  the Patient Centered Medical Home model and
  supports its providers becoming Medical Homes and
  gaining formal recognition as a Patient Centered
  Medical Home. We will
• Conduct readiness surveys of contracted providers
• Provide education on the process of becoming a
  certified Medical Home
• Make resource tools and Best Practices
  available
• Provide Health Information Technology through our
  secure Provider Portal including
• --Online Care Gap Notification
• --Member Panel Roster
• --Trucare Service Plan
• --Health Records
• --Provider Overview Report
• For more information, contact your Provider
  Relations Representative

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FRAUD ABUSE PREVENTION

• Our Fraud Abuse Prevention Program is overseen
  by our Director of Regulatory Affairs
  Compliance who maintains
• Overall responsibility and authority for carrying
  out the provisions of the compliance program
• Commitment to identify, investigate, sanction and
  prosecute suspected fraud and abuse
• Provider network expected to cooperate fully with
  FA investigations and proceedings
• Anonymous and confidential Hotline at
  1-866-685-8664
• All reports of potential waste, abuse or fraud
  are taken seriously and thoroughly investigated.

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PROVIDER RELATIONS

• Top Ten Reasons to contact your
• Provider Relations Representative
• Report any changes to your practice (locations,
  NPI, TIN numbers)
• Initiate credentialing of a new practitioner
• Schedule an in-service training for new staff
• Conduct ongoing education for existing staff
• Obtain clarification of policies and procedures
• Obtain clarification of a provider contract
• Request fee schedule information
• Obtain membership roster questions
• Obtain responses to claims questions
• Learn how to use electronic solutions on web
  authorizations, claims submissions and member
  eligibility

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PROVIDER MARKETING

• Guidelines
• The Department of Health Hospitals (DHH) is
  allowing Primary Care Providers to assist their
  current patients with enrollment into BAYOU
  HEALTH if such assistance is expressly requested
  by the patient. This assistance is limited to
• Providing a paper Enrollment Form and assisting
  the patient with completion and transmission of
  the Form to the Enrollment Center
• Using the telephone to call the Enrollment
  Center,
• Placing the call to the Enrollment Center to
  enroll the patient in the BAYOU HEALTH Plan
  selected by the patient, with the patient
  present
• Using a computer or laptop to electronically
  enroll the patient in the BAYOU HEALTH Plan
  selected by the patient with the patient present.
  

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PROVIDER MARKETING

• Restrictions
• Providers shall not steer patients to a Health
  Plan
• Providers shall not provide choice counseling to
  patients and must direct and/or assist the
  patient to contact the Enrollment Center
• Providers shall not cold-call or provide
  unsolicited assistance
• Providers shall not assist patients except when
  assistance is requested
• Providers shall not  require or encourage
  patient  to request assistance 
• Providers shall not pre-fill Enrollment Forms
  with specific BAYOU HEALTH Plan identified
• Providers must include information on Enrollment
  Form identifying the individual who assisted with
  the enrollment process
• If access to computers or telephones is provided,
  Providers must ensure such access affords
  sufficient privacy for an unbiased choice and
  protected disclosure of personal information to
  others

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PROVIDER MARKETING
QA