Fall 2014 - FCH PPO Provider Newsletter
EXCHANGE NETWORK
The 2nd year of open enrollment for the Health Benefit Exchange
is upon us and First Choice Health Network (FCHN) is excited to
be a part of two insurer offerings on the Washington Exchange
and three offerings on the Oregon Exchange in 2015.
CONTENTS
Exchange Network.................................... 1
Provider Web Experience Update............. 2
Delegated Reporting Tool....................... 2
The Washington Health Benefit Exchange Board announced that 10 insurers
have been approved as qualified health plans for the individual market on the
Washington Health Benefit Exchange. Community Health Plan of Washington
utilized FCHN as their network in 2014 and will continue to do so in 2015. Moda
Health Plan (formerly known as ODS Health Plan) is new to the Washington
Health Benefit Exchange market and will also use FCHN as their network in
Washington in 2015. The three Oregon plans, Oregon’s Health CO-OP, Trillium
and Atrio Health Plans used FCHN in 2014 and will continue to do so in 2015.
FCHA’s 835 / EFT Vendor: PaySpan........ 3
ID cards for both Washington and Oregon exchange members will display the
FCHN logo.
EFT / Virtual Payment Systems.............. 5
Exchange plans offered by CHPW and Moda go by the following product names:
• Community Health Essentials Plus Gold
• Community Health Essentials Plus Silver
• Community Health Essentials Bronze
•
•
•
•
•
Moda Health B Confident
Moda Health B Open (HSA)
Moda Health B Ready
Moda Health B Sensible
Moda Health B Tranquil
Unless you have a direct agreement with the exchange plan, reimbursement
for exchange members (with the exception of Oregon’s Health CO-OP) will be
in accordance with your FCHN contract terms. For Oregon’s Health CO-OP,
FCHN will only provide our network in designated areas. To see a listing of the
designated areas, please search for Oregon’s Health CO-OP as a payor under
the Payor/Employer group search on www.fchn.com or click here to perform
the search. You can view the designated areas by expanding the Client
Information tab.
Health Benefit Exchange offerings are also available for small businesses with
50 or fewer employees in 2015. This portion of the Exchange business is called
the Small Business Health Options Program or “SHOP” for short. Both Kaiser and
Moda were approved to offer SHOP plans in Washington for 2015. Kaiser SHOP
plans will be offered in Clark and Cowlitz counties and Moda SHOP plans will be
offered statewide. Moda’s SHOP plans will utilize FCHN in Washington State.
277CA Electronic Claim
Acknowledgement................................... 3
Client Updates........................................ 4
Provider Appeals.................................... 4
OptumHealth Claims.............................. 4
ICD-10 Implementation Update.............. 5
Announcement from Moda Health......... 6
Just a Reminder..................................... 7
PPO Provider Relations Team................ 8
State of the Network.............................. 9
Fall & Winter Holiday Schedule.............. 9
FCH Charitable Giving Committee.......... 9
Did You Know...?................................... 9
PPO
Provider
News
Corporate
News
Provider Web Experience Update
In the Spring 2014 Provider Newsletter, we
informed providers of our 2014 initiative to
improve the provider tools on the FCH website.
There have been many changes over the past several
months! Listed below are some of the enhancements
made to the PPO and First Choice Health Administrators
(FCHA) provider tools.
PPO Priced Claims Status Tool:
• The ability to search for claims using a calendar
function or manual date entry rather than the
previous dropdown option
Delegated Reporting Tool
During 2015, First Choice Health (FCH) will
be working with certain groups to implement
use of a standardized delegated credentialing
spreadsheet created by the Washington
Credentialing Standardization Group (WCSG).
This is a tool for medical groups delegated to perform
credentialing functions to report provider data to FCH.
• The ability to print multiple claims at once by
adding claims to a print queue
FCHA Claim Status Tool:
• The search results shown now match the RA and
users can recreate the RA and print a copy for
their records
• Claims results will show the user both processed
and in-process claims
• The overall functionality of the Benefits &
Eligibility and Claims Status search
Use of the standardized reporting tool will allow for quicker,
more efficient processing of updates, thus ensuring that
claims are priced accurately and that our directory is current.
It will allow delegated groups to generate one report that
can be used for all organizations.
Next in line for improvement is the Provider Resources
page. This is the page users are directed to when they
select FCH from OneHealthPort. We plan to improve
the navigation of the tools so users can get where they
need to go with fewer clicks and fewer questions.
In the near future, FCH will be reaching out to delegated
groups that participate in WCSG to implement use of the
standardized reporting tool. You can find more information
about the spreadsheet on the Washington Association
Medical Staff Services website (www.wamss.org) under
the ‘Resources’ section.
Look for more improvements
in the coming months!
(800) 231-6935
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PPO
ProviderNews
News
Corporate
277CA
Electronic Claim
Acknowledgement
COMIN
G
SOON!
First Choice Health Network, Inc. is
pleased to inform you that we are
currently working on an X12 277CA
Electronic Claim Acknowledgement.
FCHA’s 835 / EFT Vendor:
PaySpan
Would you like to receive your FCHA claim
payments faster?
Register now with our partner, PaySpan, to receive electronic
claim payments via ACH and be provided with your options
for electronic remittance advice.
Listed below are instructions for how to sign up with PaySpan
and/or register specifically with FCHA.
If you do not have an existing PaySpan account...
• No registration code is required to register for FCHA
• You can visit www.payspanhealth.com to register
• You will be prompted to enter your NPI, TIN, and billing
zip code
If you have an existing PaySpan account...
• The registration code and PIN are required to create a
PaySpan account specifically with FCHA
• To obtain an FCHA-specific registration code, visit
www.payspanhealth.com/RequestRegCode
• If you already have a registration code, visit
www.payspanhealth.com to register
The 277CA is utilized by healthcare payors
to report on the status of claims previously
submitted by providers via 837. FCH providers
typically initiate electronic transactions through
various clearinghouses. As a PPO network, we
can report limited status on claims, based upon
our pricing activities.
FCH performs various validations on claims and
we reject a moderate volume of claims back to
our providers. These are referred to as ‘Provider
Sendbacks.’ Currently, FCH sends the hardcopy
FCH Pricing Worksheet back to you, as a provider,
via US Postal Service. FCH understands that this
adds additional days to your collection time and we
are working on an X12 277 CA to facilitate reducing
the timeframe for claim resolution.
Please note that as we are not the payor in most
situations, we are unable to provide electronic status
on the adjudication performed by our payor partners.
Once we are able to offer this transaction, we will
provide further notice. We will work with the various
clearinghouses to ensure they are able to take in
the claim status details. You should then work with
your clearinghouses, to ensure that the business
rules you set up with them can support the detailed
information. Look forward to a future provider
bulletin when the transaction is available.
If you need assistance, please contact PaySpan Provider
Services at (877) 331-7154, Option 1.
(800) 231-6935
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PPO Provider News
Provider Appeals
In order to ensure your appeals are handled in a timely
and accurate manner, FCH would like to remind you
of our streamlined appeals process.
Client Updates
New Payors
• PacificSource Health Plan: Effective 1/1/2015
Terminated/Terminating Payors
• Masonry Security Plan of Washington: Effective 6/01/2014
• Local Union 598 Plumbing & Pipefitting Industry:
Effective 9/1/2014
• Northwest Metal Crafts Trust Fund: Effective 10/1/2014
• Puget Sound Electrical Workers Health: Effective 11/1/2014
• Government Employees Health Association: Effective 1/1/2015
OptumHealth Claims
UnitedHealthcare® members in Washington
State have access to FCHN’s complementary and
alternative medicine (CAM, e.g., Acupunture and
Massage) provider network as a supplemental
network to the OptumHealthSM network.
Note: If you have an existing contract with ACN
Group, Inc. for the OptumHealth network, your
ACN Group, Inc. contract supersedes your FCH
PPO Network contract.
Look for FCHN’s logo on the back of UnitedHealthcare
members’ identification cards as a way to determine
participation. Not all UnitedHealthcare members are
included, so it is important to look for the logo to help
correctly identify members’ participation.
Claims for this plan are submitted directly to
UnitedHealthcare using either option below:
• Electronically using Payor ID: 87726
• Paper – send claims to:
ACN Group, Inc. DBA OptumHealth
PO Box 30555
Salt lake City, UT 84130-0555
FCH prices claims to the FCH allowed amount according to the
terms of your contract and then forwards them to the payor for
processing. FCH does not process or adjudicate claims and
does not review or make any determination on claims, appeals,
and/or payments regarding appeals.
Here are some common types of appeals that FCH can not handle
or make a determination on:
• Denial of benefits
• Denial due to medical review, cosmetic, experimental and
investigational review
• Denial based on coding, modifier, and/or bundling
• Submission of records as a result of a denied claim
• Denial due to lack of authorization (prior or otherwise)
• Reconsideration of a medical denial
If you are submitting one of these types of appeals, please
send the appeal directly to the payor for reconsideration.
The payor information is located on the patient’s ID card
and/or the EOP/RA you received, along with a processing
summary. Sending your appeal directly to the payor will
ensure the appeal is handled in the most expeditious manner.
If FCH receives an appeal that should go directly to the payor,
we will return the appeal to your office rather than forward it
to the payor. If you need assistance, we will gladly help you
determine the correct payor.
What should I do if my reimbursement rate is incorrect?
If the EOP/RA indicates that you were not reimbursed at the
correct allowed amount or if you are not certain what the
allowable amount should be and the claim was sent to FCH for
pricing (EDI# 91131 or PO Box 2289, Seattle, WA 98101), you
may reference the re-pricing worksheet at www.fchn.com. To
access the pricing worksheet, follow the instructions below:
• Click the ‘Resources for Providers’ link in the top right corner of
our homepage
• Select ‘Priced Claims Status’ to view and print the pricing
worksheet if needed
• You can also access “Priced Claims Status” via the following link:
www.fchn.com/ppo/providers/default.aspx
If the claim was not priced by FCH and if you have any
questions regarding the appeal process or incorrectly priced
claims, please contact Provider Relations.
(800) 231-6935
4
PPO Provider News
ICD-10 Implementation Update
FCH continues to move forward with its commitment to be ICD-10 compliant by the new implementation
date of October 1, 2015. We continue to refine our processes and systems. We are also working with
business partners and vendors to help ensure a smooth transition and minimize any disruption.
We have completed many important milestones
such as:
• Performed an impact assessment and gap analysis
• Remediated internal applications and processes to
support ICD-10
• Developed a custom map using GEMS (CMS General
Equivalency Mappings) as a starting point to remediate
business rules, policies and procedures with ICD-9 to
also support ICD-10
• Updated internal systems to process ICD-10 natively
What can you do to get ready?
The Workgroup for Electronic Data Interchange (WEDI), a
leading authority on health IT, offered the following tips in a
white paper on ICD-10 implementation www.wedi.org:
• Confirm transition plans
• Transition business and technology operations
• Identify ICD-9 touch points in your systems, business
rules and business processes that need to change to
accommodate ICD-10 changes
• Validate vendor readiness and compliance
• Implement change and communications strategies
• Train staff on ICD-10 concepts and changes
• Monitor readiness
• Participate in local and national ICD-10 workgroups
• Internal and External Testing
Compliance
All HIPAA covered entities, including providers and payors,
MUST implement the new code sets with dates of service,
or date of discharge for inpatients, that occur on or after
October 1, 2015.
Claims that do not use ICD-10 diagnosis and procedure codes
appropriately for dates of service on or after October 1, 2015,
will be rejected. This means that claims with a date of service
on or after October 1, 2015, will be rejected if ICD-9 coding is
used. It is important to note, however, that claims for dates of
service before October 1, 2015, must use ICD-9 codes, even
if they are submitted after the compliance date. For inpatient
claims the date of discharge or through date is considered the
date of service for coding compliance.
The National ICD-10 Testing Program
FCH will be testing through the National ICD-10 Testing
Program. End-to-End Testing with selected external partners
is planned to start the fourth quarter of 2014 and continue into
2015. The National ICD-10 Testing Program is a full scale
collaborative testing platform for healthcare. It provides an
open and transparent process for healthcare organizations
of all types and sizes to test with their trading partners for
ICD-10 coding, compliance and reimbursement testing. For
more information visit www.nationaltestingprogram.com.
We are also in the process of acknowledgement testing with
our vendors and clearinghouses.
EFT / Virtual Payment Systems
Please be sure to review the FCH quarterly List of Payors to identify the FCH payors who are
offering EFT (Electronic Funds Transfer).
Contact those payors directly to ensure you are getting reimbursed in the most efficient manner. We would like to remind our
contracted providers that you are not obligated to accept payments from bank card or virtual payment systems and you should
always expect payment based on the terms of your FCH contract including ‘clean claim’ processing standards. Providers should
be able to receive payment by check without a processing fee. As a reminder, FCH is not an insurance company and we do not
pay claims – we are a Preferred Provider Organization (PPO). If you choose to opt out of the bank card option, you will need to
contact the payor(s) directly by calling the number on the EOB and/or the number on the back of the patient’s ID card.
(800) 231-6935
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PPO
Provider
News
Corporate
News
Announcement from Moda Health
Hello. Just over a year ago we changed our name to
Moda Health. This name better reflects who we are and our
passion for helping the communities we serve. And thanks
to great partners, like you, our new name has been a way to
reinforce what it means to be better, together.
Now, we have another exciting change to announce. To align
more with our company name, we’re changing our medical
network names in Oregon, effective October 15, 2014. This
is just a name change and won’t affect your patients’ plans or
benefits in any way.
Q: Will ID cards be reissued?
A: No, because this is just a name change, there is no need
to reissue ID cards. Communication will go out to all of
our contracted providers about this change – so your staff
will know that ID cards with either the old or new network
names are valid. As your patients order new ID cards, the
new network names will be updated (See sample below).
Front
The ODS Plus Network name will become the Connexus
Network, and the Medicare Advantage Network will no longer
include “ODS” in the name. We believe these network names
are simply a better fit for the people who use them. Please
read on to learn more about the new names, as well as get
answers to some frequently asked questions.
Together, we can help your patients achieve their best health.
Back
Explanation for the new names
Answers to your frequently asked questions
Q: Why are you changing the names of your network?
A: We are changing our network names as part of our
rebrand. With the new company name, Moda Health, and
network names still using ODS, members were confused.
These changes will bring our network names in alignment
with our company name.
Q: Are there any other changes to the networks besides
the name?
A: No. The only thing changing is the name. All the great
providers and services that your patients have come to
expect from the network will remain the same.
Q: Will you be updating Find Care, your provider search tool?
A: Yes. Find Care will be updated on October 15, 2014. To
help your patients with this transition, we will list the new
network name and the old network name together.
Still have questions?
We’re here to help. Please contact the Moda Health Medical
Customer Services team toll-free at 877-605-3229.
We offer Benefit Tracker exclusively to our contracted
providers. Visit www.modahealth.com medical today to take
a guided tour and register.
Q: When will this change take effect?
Questions?
A: October 15, 2014
Call (877) 277-7270 or e-mail [email protected]
(800) 231-6935
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PPO Provider News
Just
a
Reminder!
Changes to Provider Demographic Information
Please notify FCH when you make changes to your demographic information such as:
• Tax name changes including “Doing Business As” (DBA) names
• Practitioner name changes or practice location name changes including clinics, hospitals, and facilities
• Changes in practice locations that you are affiliated with
• Physical billing address as required by 5010 (this must be a physical street address”)
• Practice address (the physical address where the practice(s) are located
• Clinic NPI (this is an organizational NPI and should match the CMS website)
• Practitioner NPI (this is the individual rendering practitioner NPI and should match the CMS website)
• Notice of new clinics (additional clinics that the practitioner is associated with and/or new practice locations for an
existing clinic)
• Notice of new practitioners (additional practitioners that are associated with a medical group, clinic or hospital); Please note
that they must be credentialed or joining an entity that has a “delegated credentialing” relationship
• Notice of practitioners no longer with clinic
This information can be submitted to FCH two ways:
• Use the FCHN Provider Update form available online. You can submit the form via e-mail to
[email protected] or via fax to (206) 268-2940 made to Attention: Provider Information
Management. The average time for demographic changes to be entered into the FCH system is ten (10)
business days from date of receipt.
• Use Provider Source to indicate what demographic changes you wish to make. You must indicate that you want FCH to
be notified that you are making the changes; otherwise, we will not know that the changes are there to be picked up.
Getting these changes to FCH in a timely manner will ensure your claims will be priced and forwarded on for processing in the
most efficient manner. In addition, FCH patients will be able to see your most recent demographic information such as where
to call to make an appointment and where your practice is located on our website.
(800) 231-6935
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PPO Provider Relations Team
Kendra Director, Provider Relations
I’ve worked at FCH for 12 years as of April 2015! I began my career at FCH as a Provider Relations
Representative and worked as the Manager of Reimbursement as well. I returned to the Provider Relations
department as a Manager and then as a Director and that is where I am currently. I’ve worked in the health
care industry for over 20 years and have experience with both provider and hospital groups as well as claims
processing experience. Each day I learn something new and look forward to continuing my career here at FCH.
Kim Lead, Provider Relations
With over 38 years in the health care industry, I bring an in-depth knowledge of delivering superior service
and value to our customers/providers. I have been with FCH as the Lead of Provider Relations for 2 ½
years and have a passion for problem solving. FCH is a company that strives for organizational excellence
and continuous quality improvement for our customers/providers. From new ideas to lean thinking, this
company is one that will “turn off the faucet” with issues/problems. Favorite quote: Be the Best of the Best!!
Kathy Provider Services Representative
I have worked for FCH for six years in the Provider Relations department. Prior to coming to FCH I worked
for a payor, which has assisted me in understanding the whole picture from claims pricing to claims
processing. I enjoy working with providers, getting their issues resolved, and teaching the FCH model.
Taking the providers on a tour of our website has been a very positive experience and our providers find the
website answers many of their questions and concerns, which makes them extremely self-sufficient.
Debi Provider Relations Representative
I have been with FCH for six years. My prior work experience was with a union/trust payor and our
own TPA. My claims history background and knowledge has been a great asset to Provider Relations
Representatives and providers. I live in Coeur d’Alene and work in our Spokane office where I assist all
providers, but work very closely with our Idaho provider groups.
Marlyce Provider Relations Representative
I began my journey in healthcare a number of years ago. I remember when DRGs were introduced in
the early 1970s and I have seen how our industry has changed over the years. I have many years in
hospital patient accounting management and I spent 17 years with a contract management system
(I have read over 2,500 contracts from all over the country). I am passionate about our industry and I
love working in Provider Relations as an advocate for you.
Lynn Provider Relations Representative
I have worked in the Spokane office for over seven years, having come from a strong payor and
provider background. I was born in Sandpoint, Idaho and attended the University of Washington before
moving to Spokane. My strengths are working with anesthesia providers, and my area includes North
Idaho and Washington State.
Chaz Provider Services Representative
I started at FCH three years ago as a PPO Customer Representative. For the past year I have been the
newest member of the Provider Relations department, working as a Provider Services Representative. Since
I have joined the department, I have been able to utilize my skills as a customer-focused individual, willing to
go the extra mile to provide excellent service, in order to make sure our providers have a great experience.
(800) 231-6935
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PPO Provider News
State of the Network
Fall & Winter
Holiday Schedule
First Choice Health will be closed
for the following holidays:
• Thanksgiving Day: Thursday, November 27th, 2014
• Day after Thanksgiving: Friday, November 28th, 2014
• Christmas Eve Day: Wednesday, December 24th,
2014 - WE WILL BE OPEN UNTIL 2 PM
• Christmas Day: Thursday, December 25th, 2014
• Day after Christmas: Friday, December 26th, 2014
• New Year’s Day: Thursday, January 1st, 2015
• President’s Day: Monday, February 16th, 2015
In an ongoing effort to maximize value to our network, FCHN is
always working to recruit new providers, target expansion areas, and
fill any gaps that may exist within our network service area. We are
pleased to announce that as of October 2014, our network includes
77,996 practitioners, 318 hospitals, and 2,139 ancillary facilities.
Access to our Customer Service and Provider
Relations voicemail systems will be available
the days we are closed. We will respond to all
messages within 24 hours of re-opening.
If you have any questions regarding the holiday
schedule, please Provider Relations.
FCH Charitable Giving Committee
DID YOU
KNOW...?
FCH CONTINUES TO DISTRIBUTE CHARITABLE GIVING DOLLARS EACH
QUARTER TO ORGANIZATIONS THAT PROVIDE CHARITABLE SUPPORT
THROUGHOUT OUR COMMUNITIES.
For the third quarter of 2014, the following organizations will benefit
from our contributions:
• American Cancer Society
• Clothes for Kids
• Make a Wish - Oregon
• Special Olympics
• You burn more calories eating
celery than it contains (the more
you eat the thinner you become)
• An average person will spend 25
years asleep
• You are about one centimeter taller
in the morning than in the evening
• Human thigh bones are stronger
than concrete
• The average person laughs at
least 10 times a day
CONTACT US
Provider Relations: (800) 231-6935 Ext. 2103 www.fchn.com/ppo/providers/default.aspx
[email protected]
(800) 231-6935
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