Provider Portal User Guide

Transcription

1 Provider Portal User Guide May

2 TABLE OF CONTENTS SECTION 1 WELCOME TO THE PROVIDER PORTAL SECTION 2 ACCESS THE PROVIDER PORTAL SECTION 3 HOME PAGE SECTION 4 ELIGIBILITY - BENEFITS Section 5 CLAIM STATUS LOOKUP SECTION 6 PAYMENT REMIT SECTION 7 CLAIM APPEALS SECTION 8 AUTHORIZATIONS SECTION 9 MEDICAL CODES SECTION 10 SETUP 2

3 Section 1 Welcome to the Provider Portal Dean Health Plan recognizes the importance for our Providers to simplify everyday tasks, promote efficiency in business and streamline electronic transactions. The Provider Portal allows funciontality to check real-time HIPAA compliant transactions along with Internet-based and self-service funtionalitities. To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. 3

4 Section 2 Access the Provider Portal There are two was to access the Provider Portal. Go directly to Go to Select I Am A Provider Under Provider Portals select Go to Portals Under Provider Portal select Login LOGIN Enter your Username and Password to login Then select the Login button. HIPAA guidelines prohibit users from sharing login information. 4

5 FORGOT PASSWORD If you forgot your password, you can rest your password by entering your Username and selecting Forgot My Password located at the bottom right corner of the login page. I Forgot My Password Form After selecting Forgot My Password, the I Forgot My Password Form will be displayed. After completing the required fields with a red asterik (*) select Submit. Please note: A valid address is required to reset your password. If you cannot answer these questions or have difficulty, contact your assigned Provider Portal Super User (Site Administrator) for assistance. 5

6 Section 3 Dean Health Plan Home Page The Dean Health Plan Home page is designated with a white house icon located on the left side of the navigation bar. This is the first page to populate after the user logs in the Provider Portal. The Dean Health Plan Home page consists of the following features: Message Center The Message Center provides access to secure messaging. Example: An acknowledgement letter confirming receipt of a claim appeal along with a determination letter regarding the claim appeal decision. Flash Messages The Flash Messages feature consists of alerts, important updates about upcoming enhancements or changes and announcements. Example: There will be system maintenance performed on June 16, 2016, starting at 5:15 pm. Dean Health Library The Dean Health Plan Library section consists of helpful documents and links that are also available at deancare.com. Example: Provider Manuals and Brochures and the Medical Management page. Customer Support This section provides online support, tutorials and web-based training, customer support and other information as it pertains to Emdeon now known as Change Healthcare. Please note: If you have any questions regarding the Provider Portal please contact your assigned Provider Network Consultant for assistance. 6

7 Section 4 Eligibility This feature provides human readable real time EDI (Electronic Data Interchange) 270/271 transactions. The information includes detail regarding Dean Health Plan eligibility & benefit plan coverage, co-payments & deductibles. It also provides the member s primary health insurance carriers name, if applicable. To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. After logging into the Provider Portal select the Eligibility feature located on the navigation bar. 7

8 ELIGIBILITY CHECK BENEFITS Maximum eligibility lookup is 12 months There are four steps for checking eligibility-benefits. Step 1 Select Payer *Dean Health Plan is the only selection. Step 2 Select how you wish to search Place your cursor on the drop down arrow and select the search option. There are two search options: Member ID & DOB Member Name & DOB Date of Birth (DOB) is always required. 8

9 Step 3 Enter search criteria *indicates required fields Depending on which search option selected from Step 2- Select how you wish to search will determine the data entry fields populated in Step 3 Enter search criteria. Data entry fields when selecting Member ID & DOB search criteria The Provider Portal Super User will have access to an Edit button that allows the ability to add, remove or modify Requesting Providers. Data entry fields when selecting Member Name & DOB search criteria 9

10 REQUESTING PROVIDER Select the applicable Requesting Provider from the drop down arrow under Provider NPI or use the Select button. Organization Example If an Organization is selected, the First Name entry field will be grayed out. Individual Example If an Individual provider is selected, the First Name entry field will populate. Step 4 Begin Search There are two search options: Send to Payer By selecting this option, your search will be processed and the eligibility and benefit information will be displayed. Refer to next few slides for an example. Reset Page By selecting this option, your search will start all over. 10

11 Eligiblity Transaction Example Primary Payer Other health insurance (Primary) information will be returned. If the other health insurance is listed as the primary payer. At the subscriber level (Loop 2120C). If the other health insurance is effective at the requested Plan Date in the 270 eligibility request (DTP*291). And will only return the Organization Name (NM103). Coverages Once the Eligibility-Benefits transaction appears you can view the entire information by scrolling down. Or to get to a specific type of coverage, place your cursor on the drop down arrow and a list of coverages will be displayed for selection. -Select Coverage- Health Benefit Plan Coverage Durable Medical Equipment Second Surgical Opinion Dental Care Hospital-Emergency Accident Pharmacy Professional (Physician) Visit- Office Psychotherapy Occupational therapy Frames Other Medical 11

12 Health Benefit Plan Coverage Service Type Coverages After checking eligibilty you can go directly to the claim status feasture by selecting the Check Claims box. 12

13 Section 5 Claim Status This feature provides human readable real time EDI (Electronic Data Interchange) 276/277 transactions which allow providers to check the status of a claim to see if it is pending, processed, or in a finalized status. Checking claims status can be done with three simple steps. Select payer Enter search criteria Begin search To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. After logging into the Provider Portal select the Claim Status feature located under the Claims tab on the navigation bar. 13

14 Maximum claim status lookup is 12 months Step 1 - Select Payer (Dean Health Plan is the only selection) Step 2 - Enter Search Criteria Complete the data entry fields in Step 2. The search criteria steps marked with a red asterisk (*) are required fields. 14

15 Although the End Date is not indicated with a red asterisk (*), it is required to retrieve claims with multiple dates of service. Requesting Provider Information Provider ID Type NPI (recommended) and Payer Assigned ID. If you are a Provider Portal Super User, this button will display as Edit. Provider ID (NPI Type 2) The drop down menu will list all Providers that have been added under the Provider Favorites feature which is managed by the Provider Portal Super User assigned to your entity. Individual/Organization Select one Last Name/Organization This data field will prepopulate based on the Provider ID entry. *If an Organization is selected, the First Name entry field will be grayed out. Service Provider Information If the information from the Requesting Provider is the same as the Service Provider, select the Same as Requesting Provider box located at the top left corner of the Service Provider form. This will prompt the back ground for data entry fields to gray out. If the Service Provider is different from the Requesting Provider, complete the data entry fields. Please note: If an Organization is selected the First Name entry field will be grayed out with the inability to data enter information. 15

16 Step 3 - Begin Search There are two search options: Send to Payer By selecting this option, your search will be processed and the claim status information will be displayed. Refer to next few slides for an example. Reset Page By selecting this option, your search will start all over. Claim Status Transaction Example If the claim line(s) denied, no explanation of the denial will be provided. Refer to the Payment Remit feature on the Provider Portal. 16

17 Section 6 Payment Remit The Payment Remits feature provides access to claim payment information online. This feature allows Dean Health Plan to deliver ERAs (Electronic Remittance Advice) or remits to providers online instead of mailing these documents. ERAs are statements from Dean Health Plan documenting payment of claims. To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. After logging into the Provider Portal select the Payment tab located on the navigation bar. There are two categories under the Payment tab. Remits (Payment Remits) Selecting Remits will prompt additional features along with Search Payment. The ability to use additional features falling under the Remit functionality may vary depending on which services a user is set up for with Emdeon. More (Payment Additional Resources) Selecting More will prompt additional resources. Please note: For Dean Health Plan (DHP), the only available feature is the Payment Remits functionality. 17

18 Remits (Payment Remit) Upon selecting the Remit feature the Search Payment screen will appear. The Search Payment screen is used to query Electronic Remit Advice (ERA) payments. Searching for ERAs There are four steps when searching for an ERA. Step 1 - Select the Search Criteria and Search Method Step 2 - Complete the fields in the search criteria selected. Step 3 - Search Results Step 4 - View ERA 18

19 Step 1 - Select the Search Criteria and Search Method There are two types of search criteria: Basic Search and Advanced Search There are two types of search methods: By Batch and By Claim Each of these search methods will display certain search criteria. BASIC SEARCH A basic search criteria can be performed with using data such as Provider Name, Payer Name, Time Period and Payment Date. 19

20 ADVANCED SEARCH The advance search criteria can be used for By Batch or By Claim search methods. By Batch The By Batch search method is the default and used to search for ERAs by batch details. Although both the Tax ID and NPI are indicated as an option only one can be used. By Claim To search for ERAs by claim information select the By Claim button. Step 2 - Complete Data Entry Fields Complete the Search Payment form applicable data entry fields/ Step 3 - Search Select the Search button located at the bottom left corner of the Search Payment form. A message will display indicating Query in Progress. The results will display at the bottom of the screen. 20

21 Search Result Examples Basic Search criteria and Advanced Search critera with By Batch method. Advanced Search criteria with By Claim method Step 4 View ERA Batch Search and Advanced Search with By Batch method: To view an ERA from a particular batch method click on the payment number under the Payment # column. A list of all claims with the transaction will be displayed. By selecting the Additional Info button under the Documents column, a printable Explanation of Payment will be displayed. By Claim Transaction: To view an ERA for a particular claim from a specific transaction click on the patient control number under the Patient Ctrl# column. There is an option to view the entire ERA that includes the individual claim by selecting the payment number under the Payment# column. There is then an option to search by Patient Last Name, Claim Sequence # or PCN (Patient Control Number). 21

22 SHOW PAYMENT The first part of the ERA Show Payment" may vary depending on the type of ERA transaction (by batch/by claim). Claim Display Options Choose Hide or Show the display service line information If the Payment# is selected from the ERA view transaction, an option to sort all claims by will be available. The drop down list consist of Patient Last Name, Claim Sequence # and PCN (Patient Control Number). Electronic Remittance Advice o o o Financial Summary A financial summary is provided when viewing ERAs by batch or claim.this section can be expanded as needed by selecting the (+) symbol.detailed provider information includes grand totals for charges, and adjustments. Record Details Service Line Info This section can be expanded as needed by selecting he (+) symbol to display the Service Line Information of each claim. *See below Show Payment - ERA example. 22

23 Show Payment ERA EXAMPLE Hide or Display Service Line Export to PDF Expand to see Financial Summary Expand to see Service Line Info 23

24 Section 7 Claim Appeals Claims that have been processed with a finalized status (paid-denied) can be appealed directly through the Provider Portal. To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. Please note: Corrected Claims should not be submitted via the online Claim Appeals feature of the Provider Portal. After logging into the Provider Portal select the Claim Appeal feature located under the Claims tab on the navigation bar. 24

25 The Claim Appeal feature has two options: Start a New Claim Appeal This feature allows the submission of a new Claim Appeal View Submitted and Saved Claim Appeals This feature allows the search for claim appeals that may have been started & saved or claim appeals that were submitted. Please note: Up to 500 submitted claim appeals within a six month period will be available to view. SELECT START A NEW CLAIM APPEAL To start a new claim select the Start a New Claim Appeal action. SELECT CLAIM APPEAL TYPE After selecting to Start a New Claim Appeal the Select Claim Appeal Type form will be prompted. Select the dial button by the applicable claim appeal type Click on Select Form 25

26 VALIDATE CLAIM After selecting the applicable Claim Appeal Type, a validation form will be prompted. The validation will determine if the claim appeal is for a Dean Advantage or a Commercial member. Required fields indicated with a red asterisk (*). There are three options located at the bottom of the Validate Claim form. Cancel Request To cancel the claim appeal submission request, select the Cancel Request option located on the bottom right corner of the form. A Cancel Request box will be appear to confirm you would like to cancel the claim appeal request. Save Request To save the information on the Validation form prior to completing, select the Save Request option located on the bottom right corner of the form. Submit *This option is not functional-disregard. 26

27 CLAIM APPEAL FORM *Data entry boxes on the form may differ depending on the claim appeal type. Enter the data for each field indicated on the claim form. Required fields indicated with a red asterisk (*). First Time Review If you select No to the First Time Review question, you will be prompted to complete an additional section-original Claim Appeal Submission Date. CARC (Claim Adjustment Reason Code) Although there is not a red asterisk (*) by the CARC code data field, it is always required. 27

28 Appeal All Claim Lines If you select the Appeal All Claim Lines box, all data entry fields except for CARC will be grayed out. Waiver of Liability The difference between the Dean Advantage and Commercial claim appeal form is the Waiver of Liability. Non-Contracted providers must include a signed waiver of liability form holding the enrollee harmless, regardless of the outcome of the appeal. The claim appeal will not be processed until a signed Waiver of Liability form is received. Attach Supporting Documents Appropriate files types include.jpg,.pdf,.png,.docx,.xlsx and.msg. Chrome browser Drag files Internet Explorer (IE) browser Click or Drag Add Document: *Applicable when using IE browser Once you select to add a file, the Add Document box will appear. Select Browse Attach File Name the Document Select Add 28

29 Once the attachments are added, they will appear in the Attach Supporting Documents section. You can delete an attachment by clicking on the x in the red box. Supporting Documentation: Attach only the documents that are applicable and will support the medical necessity. Required information must be legible and clearly marked. Please do not use highlight markers because they do not show up on scanned images. According to the HIPAA privacy rule the minimum necessary documentation needed for review should only be submitted. The member s entire record should not be submitted unless it can be specifically justified as needed for that purpose. If there is no supporting documentation, the claim appeal will be denied based on the information submitted via online claim appeal submission. Add Claim Appeal You can add multiple claim appeals for the same claim type, such as COB, Timely Filing, Authorization, by selecting the + Add Claim Appeal feature. Selecting the + Add Claim Appeal will prompt the process to start over with completing the validation and claim appeal form. After the completion of the Claim Appeal form, there are three options located at the bottom of the form. Cancel Request Selecting this option will prompt the following message. Are you sure? If you cancel the request, you ll lose the data you ve entered. This will also remove the request if you have previously saved it. Save Request Selecting this option will prompt the following message. Appeal request has been saved. Submit 29

30 Selecting this option will prompt the following message. Acknowledgement Letter An acknowledgement letter will be sent through the Message Center. The letter will confirm receipt of claim appeal and indicate the request is under review and you will be contacted regarding the determination. Determination Letter A determination letter will be sent through the Message Center. This letter will indicate the review of the claim appeal was completed and the decision will be indicated on the electronic remittance advice/835 transaction or Explanation of Payment (EOP). Please note: Upon receiving the claim appeal denial decision, you can re-appeal via online claim appeal submission. *If there is no new or supporting info to be reviewed, a claim appeal should not be re-submitted. MESSAGE CENTER The Message Center is located on the Dean Health Plan Home Page. Acknowledgement & Determination letters regarding claim appeals will be sent though the Message Center. To view messages, select the unread mail message link. The number of unread messages are indicated in bold font. 30

31 Upon selecting the unread message link, the Folders and Messages Lists will appear. Select Message There are two ways to select a message: Double click on the message record Select the message line and select the envelope icon located on the Message Tool Bar. *Unread messages appear in BOLD. View Message Select one of the Save Message Attachments icons. Please do not reply to this . After selecting to save the message you will be prompted to either Open, Save or Cancel the written message/notification. To open the message select Open and the applicable message (letter) will appear. 31

32 VIEW SUBMITTED AND SAVED CLAIM APPEALS This feature allows the search for claim appeals that may have been started & saved or active claim appeals that were submitted. Please note: Up to 500 submitted claim appeals within a six month period will be available to view. Select View Submitted and Saved Claim Appeals action After selecting the View submitted and Saved Claim Appeals action the following screen will be prompted. Saved Appeals Continue Appeal Submitted Appeals Saved Appeals Saved Claim Appeals Saved claim appeals are located at the top section. If you started a claim appeal but didn t submit, you can continue the process by selecting the Continue Appeal button at the end of the saved claim appeal record. Submitted Claim Appeals Submitted claim appeals are located at the bottom section. To view a submitted claim appeal select the View Appeal button located at the end of the submitted claim appeal record. 32

33 View Appeal Select View Appeal to view the details of the claim appeal submitted. Appeal Details After selecting to view appeal the Appeal Details will be displayed 33

34 Section 8 Authorizations A Dean Health Plan authorization should be completed in full by a Primary Care Practitioner (PCP), a Dean Health Plan Specialty Provider or facility/hospital. The authorization must be approved prior to the member obtaining services. Please Note: The Authorization feature of the Provider Portal should not be used for the following types of authorizations as they should be submitted to our applicable external vendor. Rehabilitative and Habilitative Outpatient Physical & Occupational Therapy Behavioral Health Services High-End Radiology Services An authorization should not be submitted for the sole purpose of confirming the service is covered. If a provider is looking to see if a particular procedure is a covered benefit or checking to see if a particular procedure requires an authorization, there are several resources available. deancare.com/providers deancare.com/providers o Provider Manuals o Medical Management o Medical Policy Search o Medical Prior Authorization List o Non-Covered Procedure and Services Contact the Customer Care Center o Refer to the member s ID card for contact information 34

35 SUBMIT AUTHORIZATIONS After logging into the Provider Portal select the Submit Authorizations feature located under the Authorizations tab on the navigation bar. This will allow the submission of new authorizations. Step 1: Select referring provider to do business as Under the Provider NPI or Name data field, select the Referring Provider by: Entering the Provider s NPI Entering the Provider s Name Utilizing the drop down men Step 2: Select a member and classification Fields in BOLD are required. 35

36 Complete all data fields: Auth Class Auth Sub-Class Begin Date of Service/Date of Admission -This field will be visible after selecting the Auth Sub-Class. Auth Type Member: Search Missing Data Fields: If you select CONTINUE without having all five data fields completed a pop up will be displayed The Following information is required in order to continue. The missing data fields will be identified with a red explanation (!) icon. AUTH CLASS Select the appropriate Auth Class from the drop down menu. An Auth Class is a broad category. AUTH SUB-CLASS Select the appropriate Auth Sub-Class from the drop down menu. An Auth Sub-Class is more specific. Please note: The Auth Class is required prior to selecting an Auth Sub-Class. Depending on the Auth Class will determine the Auth Type selections. 36

37 BEGIN DATE OF SERVICE/DATE OF ADMISSION This field will be visible after selecting the Auth Sub-Class. You can enter the date by: Entering month-day-year Selecting the date from the calendar AUTH TYPE Select the appropriate Auth Type from the drop down menu. The Pre-Service Auth Type will automatically populate when the date of service is in the future. The Post-Service Auth Type will automatically populate when the date of service is in the past. MEMBER Select SEARCH by the Member data field and the Portal Member Search screen will appear. Portal Member Search screen There are two search options: Date of Birth (D.O.B.) and Member ID Date of Birth (D.O.B.) and Member First & Last Name After entering the member search criteria there are two options to select, SEARCH to continue or if you wish to cancel select CANCEL. 37

38 SEARCH By selecting SEARCH the member s information will populate into the Portal Member Search data window. If a Member has more than one record, such as active and inactive, both records will be displayed. A record in black color reflects the active eligibility record(s). A record in red reflects the inactive eligibility record(s). The MODIFY SEARCH CRITERIA feature can be used if the incorrect member data was entered. This will allow the user to re-enter the new member information. Example: Search by Member ID & DOB Example: Search by Member Name & DOB Select the applicable record by clicking on the double arrow icon located at the end of the member s record. This will prompt the member s name and plan number to be reflected in the Member data field. The Member information can be modified by selecting the MODIFY feature. By selecting MODIFY it will return to the Portal Member Search screen. After completing the information in Step 2-Select a member and classification, select CONTINUE located at the bottom corner of the screen. Please Note: After the completion of Step 2, the information will be automatically saved. 38

39 MISSING DATA FIELDS If you select CONTINUE without having all five data fields completed a pop up will be displayed The Following information is required in order to continue. The missing data fields will be identified with a red explanation (!) icon. Step 3 - Complete Detail Fields Fields in BOLD are required. The data fields in Step 3 will vary depending on the Auth Class entered. Member s PCP: This will automatically populate, if applicable. Servicing Group or Clinic Name Provider Data Fields: o Possible Provider Entry Selections o Referring (Submitting) Provider-Auto populates from Step 1 o Ordering Provider o Servicing Provider o Servicing Facility Please note: Depending on the Auth Class & Auth Sub Class selections from Step 2 will determine the Provider entry selections. PROVIDER DATA FIELDS The Servicing Provider on an authorization should not reflect a clinic name but rather the name of an individual practitioner or facility/hospital. The address where the member is receiving the services should be reflected. Clinic Setting The Servicing Provider on an authorization should not reflect a clinic name Office Setting If the services are being performed in an office setting, the Servicing Provider on an authorization should reflect an individual practitioner s name. 39

40 Outpatient Facility If the services are being performed in an outpatient facility, the Servicing Provider on an authorization should reflect the facility s name. Facility/Hospital If the services are for inpatient hospitalization, the Servicing Facility on an authorization should reflect the facility s name. Provider Data Entry Selection Examples: Office Setting Outpatient Procedure Outpatient Surgery or ASC Surgery Inpatient Admission PROVIDER SEARCH For Provider and Facility Search, enter the individual Provider or Facility NPI # or partial name then select SEARCH. If the Provider has one location, their information will populate into the data fields. *Only Providers that are in our system will auto-populate. This includes Non-Plan Providers who have an agreement with Dean Health Plan. If a provider has more than one location in our system, all locations will populate into a window for review to determine which location is applicable. 40

41 The Prov# column reflects Dean Health Plan s internal ID number for that particular Provider. The Contract Type column reflects P (Plan-Contracted) and NP (Non-Plan or Non- Contracted) with P contract type being displayed at the top. SELECT PROVIDER To Select Provider, click on the double arrow icon located at the end of the record. The selected Provider will then populate into the applicable data field. VIEW PROVIDER INFORMATION To view Provider Information from a record, select the magnifying glass icon located at the end of a record. To view Provider information when the data has populated into the field, put the curser over the name and select. Provider Info Example SEARCH FEATURE If the individual Provider or Facility ID, NPI # or partial name is either not reflected or not known, select the SEARCH feature and the Provider Search form will appear. Please note: The Search feature should only be used when a Provider and/or location is not listed. 41

42 Complete as much data that is available on the Provider Search form and select SEARCH. Specialty, City and State Example Based on the information entered will bring back the applicable Provider data. To Select Provider, click on the double arrow icon located at the end of the record. If the Provider or location is not listed select the MODIFY SEARCH CRITERIA FEATURE located at the top of the Provider data box. This will prompt an additional section in which the search can be refined. Ad-Hoc Provider Search: If the Provider or location is not listed you can refine your search by completing an additional section. This section is also known as the Ad-hoc box. *Use all CAPITALIZATION for data entry. Fields in BOLD are required. Complete the Ad-Hoc Provider Search There are two options for completing the Ad-Hoc Provider Search. SUBMIT To submit the information, select the SUBMIT function located at the bottom of the form. The provider s information will populate into the Provider data field. CANCEL To cancel, select the CANCEL option located at the bottom of the form. The selected Provider will then populate into the applicable Provider data field. 42

43 DIAGNOSES Enter a diagnosis code or part of the description. Decimals are not accepted. There are two ways to Search: Diagnosis Code Enter code then select the SEARCH function. Key Word or Phrase Enter the key word or phrase then select SEARCH function. A list of possible diagnosis records will appear. Select the applicable diagnosis by clicking on the double arrow icon located at the end of the record. The selected diagnosis code record will then populate into the applicable Diagnosis data field. To remove a Diagnosis, click on the red x located at the end of the data field. When the red x is selected, it will prompt a box to come up confirming the deletion. SERVICES Enter a CPT/HCPCS code or part of the description. Only complete this field if it is displayed in BOLD font. There are two ways to Search: CPT/HCPCS Code Enter code then select the SEARCH function. The code will then populate into the data field. Key Word or Phrase Enter the key word or phrase then select SEARCH function. A list of possible Service Codes will appear. 43

44 Services Key Word or Phrase Search List Select the applicable Service Code by clicking on the double arrow icon located at the end of the record. The selected service code record will then populate into the applicable Services data field. To remove a Service, click on the red x located at the end of the data field. When the red x is selected, it will prompt a box to come up confirming the removal of the service. PRIORITY (STATUS) The Priority is used to communicate how quickly a determination is required based on a member s medical condition or the type of service being requested. 44

45 Priority Status Administratively Urgent Medically Urgent/Expedited Non-Urgent/Standard Concurrent Post Service Description This priority status is used for services that are urgent because of a time sensitive diagnosis and appointment availability. This priority status should ONLY be used if the member has an acute medical condition and is at risk of life or limb. *Requires a signature by the attending Physician This priority status is for routine outpatient requests or elective inpatient admissions. Notification of urgent/emergency admissions to a facility for inpatient/observation. This priority status should not be used for an elective admission. This priority status is used for requests that are received after the services have already been rendered. ADDITIONAL INFORMATION This data is not a required field (not bolded) but would be very helpful in the review for a determination. After completing all required data in Step 3-Complete detail fields, select the CONTINUE feature located at the bottom right corner of the form. Prior to Continuing, the information in Step 3 can be altered. After selecting to CONTINUE, no more altering can be done. 45

46 Step 4 - Attach Supporting Documentation Do you have supporting documentation to accompany this authorization request? What kind of documentation? Paper Documents -By selecting the Paper Documents option, it allows the information to be faxed. Click on PRINT COVER SHEET to print a fax cover sheet to use when sending in supporting documentation. Electronic Files Browse for electronic documents to attach to this authorization request. o Click on the Select button to find the document o Choose the file o Click on UPLOAD DOCUMENT When the document is uploaded a message will be displayed indicating Upload Complete File successfully uploaded. Wait for the file name to appear prior to moving forward. To remove an attachment click on the red x at the end of the attachment record. When the red x is selected, it will prompt a box to come up confirming the deletion. After completing all required data in Step 4 - Attach supporting documentation, select the SUBMIT AUTH REQUEST feature located at the bottom of the form. 46

47 Step 5 - View Confirmation After the Authorization submission is complete, the user will receive a message acknowledging receipt. Thank you for submitting your Pain Management Injection Request. It has been assigned Reference ID P with a status of Submitted. 47

48 VIEW AUTHORIZATIONS The View Authorizations action allows the ability to view authorizations that have been started & saved or submitted. It is the responsibility of the referring/submitting Provider to go onto the Provider Portal Authorizations feature under View Authorizations to check on the status of an authorization. Dean Health Plan will not send determination letters to the referring/submitting Provider who entered the authorization via the Provider Portal. Please note: For services with a non-contracted Provider, the same determination letter in which the member receives will be sent to the non-contracted servicing Provider. Select View Authorizations After logging into the Provider Portal select the View Authorizations feature located under the Authorizations tab on the navigation bar. 48

49 Step 1 - Select referring provider to do business as Under the Provider NPI or Name data field, select the Referring Provider by: Entering the Provider s NPI Entering the Provider s Name Utilizing the drop down men After selecting the referring provider to do business as from Step 1- Select referring provider to do business as, the Search Criteria screen will be displayed. SEARCH CRITERIA Created Date Range is the only required field *The Created Date Range is the only required data entry field. There is a default of two weeks. If the date range is not applicable to the time frame of the applicable authorization, the date range will need to be changed. 49

50 SEARCH CRITERIA EXAMPLES Authorization Class: Outpatient Services Authorization Sub Class: Outpatient Procedure Authorization Status: Approved Created Date Range (required field): default of two weeks Member ID: Member First Name: SALLY Member Last Name: SUNSHINE Created Date Range (required field): default of two weeks After entering the search criteria select the SEARCH feature located at the bottom of the screen. The search results screen will be displayed. 50

51 SEARCH RESULT EXAMPLES SUBMITTED AUTHORIZATIONS To view a submitted authorization, select the underlined Auth # located at the beginning of the record. The Authorization Summary will then be displayed. It is the responsibility of the referring/submitting Provider to go onto the Provider Portal Authorization feature under View Authorizations to check on the status of an authorization. After selecting the applicable authorization, the authorization summary will populate. AUTHORIZATION SUMMARY Export to PDF To view more information on the determination, select Correspondence. INCOMPLETE AUTHORIZATIONS To view an incomplete authorization, click on the double arrow icon located at the end of the record. This will return you to the authorization Step that was not completed. (After the completion of Step 2, the information will be automatically saved. 51

52 Section 9 Medical Codes This feature allows the functionality to search for Procedure, Diagnosis and NDC Codes. To get the best results and performance when using the Provider Portal, we recommend using Google Chrome or Internet Explorer 11. After logging into the Provider Portal select the Medical Code feature located on the navigation bar. There are three Medical Code options to select from: Procedure Codes Diagnosis Codes NDC Codes 52

53 PROCEDURE CODE SEARCH Step 1 - Enter Search Criteria Code Type: CPT/HCPCS-ICD9 Procedure-ICD10 Procedure Code Value or Key Words To search on multiple key words, separate them with spaces. Max Result Rows: 20, 50, & 100 Step 2 - Submit Request Submit or Reset DIAGNOSIS CODE SEARCH Step 1 - Enter Search Criteria Code Type: ICD9 Procedure-ICD10 Procedure Code Value or Key Words To search on multiple key words, separate them with spaces. Max Result Rows: 20, 50, & 100 Step 2 - Submit Request Submit or Reset 53

54 NDC CODE SEARCH Step 1-Enter Search Criteria Code Type-defaults to NDC Step 2-Submit Request Submit or Reset 54

55 Section 10 Set-Up The Set-Up tab has two sub-categories: Manage Users and My Account. Manage Users Provider Portal Super Users (aka Site Administrator), are responsible for managing all users tied to their organization, such as adding new users, editing user information and access levels and activating or deactivating users. Along with the regular maintenance and upkeep, Dean Health Plan requires Provider Portal Super Users to complete an audit of users twice a year. Here are the expectations for the required audit: Deactivate user records for users that are no longer employed by your organization. Identify users who have not accessed Dean Health Plan s Provider Portal within a certain time, such as 90 days, and work with those users to determine if they need to have access to the Provider Portal. Complete an audit of the users and their roles assigned to them to determine if those roles and levels are still appropriate. My Account This is a subcategory of the Setup feature and is available to all users. It allows users to modify or make certain changes to their existing user information. After logging into the Provider Portal select the applicable sub-category under the Setup tab. 55

56 MANAGE USERS After selecting Manage Users, the User management screen will be prompted. USER MANAGEMENT A Provider Portal Super User has the ability to: Add New User Find a User Print User List Filter User List by All Users, Active User, Inactive Users Reset Password Edit user Deactivate User ADD NEW USER Step 1 - Click Add New User Step 2 - Complete the Add User to Location form The required fields are marked with a red asterisk (*). 56

57 User ID The ID should be 6-40 characters. If the user ID already exists in the system, a message will be prompted to choose another login ID. Last Name The name should be alphanumeric characters and can include a space, period, dash, and single quote. First Name The name should be alphanumeric characters and can include a space, period, dash, and single quote. M.I. (Middle initial) - 1 character only Date of Birth Use the following format MMDDYYYY or MM/DD/YYYY Last Four Digits of SSN This does not have to be the user s SSN but rather any type of identifying 5 digit number. Address This should be the address of the new user. Step 3 - When finished, click Save to update the record or Reset to clear all the fields. If selecting to Save, a temporary password is assigned to the new user and will appear in a confirmation message. The user will then be required to enter a new password upon their first login. 57

58 FIND A USER Step 1 - Click Find User and the user list screen will appear. Step 2 - Complete the data entry fields on the Find User form and click the Search. The results will be displayed in the Find User Results screen. PRINTABLE USER LIST To get a list of the all users select Printable User List 58

59 FILTER USER LIST Click on the applicable criteria you would like to filter: All Users, Active Users or Inactive Users. RESET PASSWORD Click on the applicable user name record then select Reset Password from the menu. This will prompt the Reset Password for User: [name of user] form. Enter a New Password Confirm New Password Select Save to save the password This will prompt a message indicating Password successfully changed. To clear both fields from the Reset Password for Users form, select Reset. 59

60 EDIT USER Click on the applicable user name record then select Edit from the menu. The Edit User at Location window will appear. Modify the user data as needed. When finished, click Save to update the record. Select Ok on the Edit User Record screen. DEACTIVATE USER Click on the applicable user name record then select Deactivate User from the menu. After selecting to Deactivate User, the system will be prompted to change the status to Inactive. 60

61 MY ACCOUNT (User Account Information) Provider Portal Super User(s) By default, the fields are populated with data currently contained in the portal database. To make any changes to the user s account all fields indicated with a red asterisk (*) must be entered before saving data. This section will also indicate who the organization s Provider Portal Super User(s)/Site Administrator(s) is. 61