CONIFER VALUE BASED CARE Cap Connect User Guide

Transcription

1 CONIFER VALUE BASED CARE Cap Connect User Guide

2 Table of Contents New User Registration... 1 The Home Tab... 2 Member Data... 2 New Members... 2 New /Recent Hospitalizations... 2 Members with CCS... 2 Members Requiring Service... 3 Member Eligibility Roster... 3 Termed Members... 3 Initial Health Assessment Members... 3 HCC Patient Conditions... 4 Members Not Seen... 4 Case Management Members... 4 Medical Director Reviews... 4 Referrals Pending Medical Review are listed here... 4 Today s New Documents... 5 All... 5 Authorizations... 5 Check Remittance (PCP Capitation Reports)... 5 EOB... 5 Executive Reports... 5 Member Reports... 5 Miscellaneous... 5 Pay 4 Performance... 5 Messages... 5 Quality Performance Measures... 5 Members Requiring Services link:... 6 Drug Payment Requirements... 6 Performance Metric Indicators... 6 The Claims Resources Tab... 7 To Search For a Claim... 7 How to read Claim/Encounter Details... 8 Attach a Document to a Claim... 9 Referrals Tab How to check Referral Status Referrals Tab How to Request a Referral Referrals Tab... 15

3 My Referrals Referrals Tab How to search for a Provider Eligibility Tab How to verify eligibility My Documents Tab View and Print Documents: Contact Us How to contact Conifer Health Solutions... 17

4 New User Registration 1. Go to 2. Client Login 3. Cick on CapConnect under Client Login 4. Provider Login Screen appears. Click on Register Here The Request Web Account Window will appear and the user will be required to provide the following: first name * last name * address phone address medical license number tax id# * IPA / Group affiliated Access level requested Additional accounts Once the account has been created, an will be sent to the address the user entered in the Request Web Account process. The will contain information about the User Name and temporary password. Users will be asked to reset the password at initial account validation. September 2015 page 1

5 The Home Tab Member Data Ability to view and print the following data: New Members New/Recent Hospitalizations Members with CCS(only applies to CA) Members requiring service Member eligibility roster Termed Members Initial Health Assessment Member HCC Patient Conditions Members Not Seen Case Management Members New Members New /Recent Hospitalizations Members with CCS September 2015 page 2

6 Members Requiring Service (Asthma, URI, Breast Cancer, Cervical Cancer, Chlamydia, Colorectal Cancer, Child Immunization, Cholesterol Management, Comp Diabetes, Approriate Testing for Adults with Acute Bronchitis, Inapproriate Testing for Adults with Acute Bronchitis, Imaging Studies for Low Back Pain, Immunizations for Adolescents, Annual Monitoring for Patient on Persistent Medication) Member Eligibility Roster Termed Members Initial Health Assessment Members September 2015 page 3

7 HCC Patient Conditions Members Not Seen Case Management Members Medical Director Reviews Referrals Pending Medical Review are listed here September 2015 page 4

8 Today s New Documents All Authorizations Check Remittance(PCP Capitation Reports) EOB Executive Reports Member Reports Miscellaneous Pay 4 Performance Messages Cap Connect Enhancements Messages from Conifer Quality Performance Measures Actionable reports from My Documents folder (P4P) reports September 2015 page 5

9 Members Requiring Services link: Use this report to make patient reminders/authorization requests for needed services. Drug Payment Requirements Performance Metric Indicators September 2015 page 6

10 The Claims Resources Tab To Search For a Claim 1. From the Home tab, click on Claims, Claims Payment Inquiries 2. Search byone field option only:(note: If a user enters multiple search fields on this screen, a no records found message will be displayed.) Claim # or Member Last Name or Member First Name or Health Plan ID# AND 3. Select Status: o None Selected (default) o In Process o Paid (This status means claim has been processed. It does not necessarily mean that a payment was made.) 4. Narrow search, by selecting More Claim Search Options This option will allow user to search with multiple fields and provides more search options such as: : Member Date of Birth; and/or Date(s) of Service; and/or Provider Name; and /or Health Plan 5. Once all search fields have been entered, click on Search bar 6. Once you click search ; the results appear in a table format. Double click on a claim number to see and print claim/encounter detail September 2015 page 7

11 How to read Claim/Encounter Details This is a sample what appears when user clicks on a claim # from the claim search results Please refer to this claim # when corresponding with Customer Service regarding payment. Services Key: Contract Eligible charges considered under the provider contract or the default rate based on regulatory requirements. Co-Pay The amount specified by the Health Plan based on the members benefit that a member must pay for the service provided. Billed The charge for each service Withold: The amount withheld from payment, if applicable Adjust Benefits payable for services provided after subtracting either prior payments for the same service. If a capitated service, the contract amount that is adjusted as it is part of capitation. Net The amount payable to provider Total Column totals September 2015 page 8

12 Attach a Document to a Claim From the Claim/Encounter detail page, user can click here to attach a document to a claim: This feature is available from the Claims Section only if the claim is not in a Paid status. September 2015 page 9

13 Referrals Tab How to check Referral Status 1. From the Referrals Drop Down Menu, select Referral Status 2. Enter Search criteria o Referral Number and/or o Member last Name and/or o Member first nameand/or o Health Plan ID# o Status default is none selected. Search can be refined by selecting from 1. Approved 2. Modified 3. Denied 4. Deferred 5. Contested 6. Requested Click here for more search options Requested Date Authorization Date Expiration Date Referring Provider 3. The preferred search method is using the member ID# unless the user has the referral# available. A more detailed search can be done by using the More Referral Search Options field. When all search criteria has been entered, click on the search button 4. The search results appear in a table format similar to this: Referral #: Click on the referral number to get Referral Details Status: Approved, Denied, or System Hold Member Name: Click on the member name to see HEDIS measures details Referring Provider: Click on provider name to see provider details September 2015 page 10

14 When you click on a Referral #, this is a sample of the referral detail page that will appear. There is a printer friendly option at the top of the page. Referral Details Exceptional Care Serendib Healthways Status Information Referral #: xxxxxxxxx Request Date: Status: APPROVED Auth/Action Date: Units: 0 Expiration Date: Place of Service: OFFICE Memo: xxxxxxxxxx Member Information Member Name: xxxxxxxxx Sex: x DOB: xxxxx Age: xx Member ID: xxxxxxxx Health Plan: ANTHEM BLUE CROSS MEDI-CAL Diagnosis: OVARIAN CYST NEC/NOS Decision Timeframes for Authorizations are as follows: Urgent (72 hours), Routine (5 business days for Commercial Members and 14 calendar days for Senior Members), and Retro Requests (30 days). Referring Physician Provider Name: xxxxxxx Provider ID: xxxx Specialty: PEDIATRICS Phone: xxxxx Fax: xxxxxx Requested Physician Provider Name: xxxxxx Provider ID: 5xxxxx Specialty: RADIOLOGY Phone: xxxxxx Fax: (xxxxxxx [[ Clinical Notes ]] xxxxxxxxxx Web Auth Request Notes Services Requested ce Type Description Modify Qty Status P US EXAM PELVIC COMPLETE UAPP - approved 1.0 APPROVED ** THIS AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT ** BILLING DIRECTIONS he following items must be provided 2. For Other insurance: 3. Submit Bill to: mized bill; a. Obtain an assignment of benefits from pt; of this referral/authorization; b. Send initial billing to other insuror, the cal summary or report of balance will be paid by Medical Group/IPA n; according to contracted rates; r insurance, see #2 c. Send Copy of EOB statement (which comes with reimbursement from other insuror) with bill. September 2015 page 11

15 When you click on a member name, this is a sample of the HEDIS measures page that will appear. There is a printer friendly option at the bottom of the page. HEDIS Measures - Services Needed (Last Updated ) IPA Name: Sample Health Member Name: Sample Patient Date of Birth: xxxxxxxxx Member ID: xxxxxxxxxx Service Description Status 2015 Adolescent Well-Care Visits 2015 IHA - Age 2 and Older 2014 IHA - Age 2 and Older Continue to Member Detail Service Needed Services Completed When you click on a Referring Provider name, this is a sample of the Provider detail page that will appear. September 2015 page 12

16 Referrals Tab How to Request a Referral 1. From the Referrals Drop Down Menu, select Referral Request 2. Populate the data entry fields: Request Type, Routine is the default setting, or user can select one: 1. Routine 2. Urgent 3. Hospital Face Sheet Request Option, Physician Requested is the default setting, or user can select one: 1. Physician requested 2. Patient requested Member- 1. Click on I can t find the Member when member is not found, but eligibility has been verified with the health plan. User will be prompted to manually type the member information for verification by Conifer. Requested Provider 1. If you know the provider Name or ID enter it here 2. If you want to search by specialty, select from drop down box 3. Click on I can t find the provider if requested provider is not found. The user will be prompted to manually type the provider information. The UM Department and Client Delivery will work together to review why this feature is used. General rule is that a non network physician authorization request will not be accepted if the specialty is available in-network. September 2015 page 13

17 PCP/Requesting Provider: User will only have an option of selecting their own office based on the user credentials. 1. Select provider from drop down menu Place of Service 1. Select from drop down menu Facility ID (optional) To Enter Diagnosis Codes 1. Select from Top 50 frequently used diagnosis codes and click on Add. 2. And/Or Enter diagnosis code(s) 3. And/Or Search for diagnosis code 4. Click on Validate Codes Now To enter Procedure Codes 1. Select from top 50 frequently used procedure codes and click on Add. 2. And/Or enter procedure in text box 3. Qty default will be 1. User can revise this number 4. If applicable, enter a modifier code. If a modifier code is entered, a description of the modifier will be displayed in the show codes column. 5. Diag Ref= Enter the corresponding diagnosis code for the procedure code from the top of the form. 6. Click on Validate Codes Now Additional Information: Free form text box Submit Referral: A web Id # will be displayed to identify that the request was successful. September 2015 page 14

18 Referrals Tab My Referrals Click here to see User s activity for the past 30 days. Referrals Tab How to search for a Provider 1. Click on Referrals Tab; Provider Search 2. Search by: Name Specialty Health Plan Hospital City Zip 3. Search result will be displayed in a table format. If an account has preferred providers for a given specialty, only the preferred providers will be made available for selection by the user. Click here to select the provider for a Referral September 2015 page 15

19 Eligibility Tab How to verify eligibility Click on Eligibility Tab Search by:name and/or; Member ID and/or; Health Plan and/or; Date of Birth and/or; Gender Search will result in a table display SS Click on copy to Auth Request to select this member for the referral. Click on Quick View to see member data and Services Needed for this member. September 2015 page 16

20 My Documents Tab View and Print Documents: Authorizations Check Remittance EOB Executive Reports Member Reports Miscellaneous Pay 4 Performance Contact Us How to contact Conifer Health Solutions Referrals Cal Optima Member Services Claims Customer Service Credentialing Eligibility Member Services Network Management Director of Client Delivery Client Delivery Liaison Client Delivery Coordinator September 2015 page 17