For Providers

Important information for providers:

IMPORTANT PRE-AUTHORIZATION CHANGES

September 25, 2009

Dear Provider:

Total Care requires pre-authorization for certain services. We have recently reviewed the pre-authorization program and based on our experience and the needs of the current membership we are adding Outpatient Mental Health services to the program.
The expanded program will include

• New referrals to your practice after October 15, 2009
• Existing patients in your practice after October 15, 2009

New Referrals
All requests in excess of 4 visits will require preauthorization. See below for procedure to follow to request these services. As is currently the process, an Initial evaluation for Mental Health Services and Follow Up after Mental Health Hospitalization (up to 30 days) will not require an authorization.

Existing Patients
We are reviewing each member individually and will contact you for treatment plans as we review the members’ case. Continue to see your patients until we contact you for the specific treatment plan. Please see attached listing of treatment plans we are requesting.

Procedure
To expedite the pre-authorization requirements, we ask providers to use the attached Pre-Authorization form an treatment plan. Completed forms along with detailed treatment plan must be faxed to (315) 425-5502 OR 315-234-5928. The treatment plan must reflect current treatment goals and rationale for frequency of visits. The Pre-Authorization Form can also be found on our website, www.totalcareny.com. We will review each case and notify you of our authorization decision.
These changes are effective with dates of service on or after October 15, 2009.

As part of continuous quality improvement we will evaluate the pre-authorization program and the changes made and make adjustments as necessary. As always please direct any questions or suggestions for improvement to Provider Relations or the Utilization Review Department at 1-877-872-4716.

Thank you for providing high quality health care services to the Total Care members.

Sincerely,

Diane Green-E1, MD, MBA
Medical Director
 

August 24, 2009

Dear Total Care Provider:

TOTAL CARE is committed to assuring access to high quality, comprehensive, cost-effective health care services to all of our members.  This commitment extends to ensuring, in partnership with the physicians and other providers in our network, that health care resources are utilized most effectively and efficiently.

Total Care requires pre-authorization for certain services. We have recently reviewed the pre-authorization program and based on our experience and the needs of the current membership we are adding services to the program. Again based on the experience of the last several years we are also removing some services from requiring pre-authorization. We will continue to use the nationally accepted InterQual criteria for the pre-authorization program.

To expedite the pre-authorization requirements, we ask providers to use the attached Pre-Authorization form. This should eliminate the need for the physician/provider offices to make phone calls, in many instances. Completed forms must be faxed to (315) 425-5502. We are adding an additional fax line and will notify you of the number prior to September 15, 2009. The Pre-Authorization Form can also be found on our website, www.totalcareny.com.

The attachments provide details regarding the added services requiring pre-authorization and identifies those services that will no longer need pre-authorization. These changes are effective with dates of service on or after September 15, 2009.

In summary the following services are added to the pre-authorization program:

DME Preauthorization

Rad Codes

• Identified radiological services (MRI, MRA, CT, PET scans and nuclear medicine)
• Durable Medical Equipment (including Orthotics and Prosthetics)
• Physical Therapy, Speech Therapy and Occupational Therapy (in excess of 8 visits)
• Genetic Testing for Breast and Ovarian Cancer
• Mental Health (new referrals for treatment in excess of 4 visits after evaluation). A separate communication will be sent to Mental Health Providers who are seeing members already in treatment.

The attachments provide details on specific services included in the areas outlined.

DME Preauthorization

Outpatient Surgery - No Prior Authorization Required

Rad Codes

We have previously required pre-authorization for all ambulatory surgery. We are now removing specific ambulatory surgery services from this requirement. Again see the attachments for specifics.

Total Care values your participation in our network of high quality health services providers. The changes to our pre-authorization program will ensure that we can continue to provide the highest quality care and use the available health care resources as efficiently as possible.

As part of continuous quality improvement we will evaluate the pre-authorization program and the changes made and make adjustments as necessary.  As always please direct any questions or suggestions for improvement to Provider Relations or the Utilization Review Department at 1-877-872-4716.

Thank you for providing high quality health care services to the Total Care members.

Sincerely,

Diane Green-El, MD, MBA

Medical Director

ADJUSTMENT REQUESTS TO TOTAL CARE

Requests to TOTAL CARE for claim adjustments must be submitted on paper.  This includes claims that were originally submitted electronically. It has come to our attention that some of our electronic UB04 submitters are using Type of Bill Codes with the Frequency Indicators listed below.   Adjustments submitted electronically are being denied as duplicate claims.   These codes are valid but may only be used on paper adjustments.                                             

•   5         Late Charge(s) Only
•   7         Replacement of Prior Claim
•   8         Void/Cancel of Prior Claim

For your convenience, click on this link for a copy of our Request for Claim Adjustment Form.  This form may also be emailed to you, please email your request to claimsstatus@totalcareny.com.   Because of volume and privacy concerns, we ask that you mail your completed form back to us rather than emailing. This form should always be used when requesting adjustments from TOTAL CARE.   Using this Form will expedite your adjustment request.  It is also used when requesting adjustments on the CMS 1500 Claim Form.  

If you have any questions regarding this matter, please feel free to contact our Member/Provider Service Department toll free at (800) 223-7242.   Your support and cooperation are always appreciated.  Thank You.



INPATEINT/OUTPATIENT DATA ELEMENT FOR UB04 BILLING REMINDER

July 9, 2008

Dear Inpatient/Outpatient UB04 Submitter:

Your submissions of accurate and complete UB04 claim forms to TOTAL CARE, be it by electronic or paper means,  enables the most efficient way to quickly adjudicate claims and provide you with speedy and accurate payments for your services.   We are certain that you are currently making use of national billing standards which our reimbursements are derived.  Based on these national billing standards, the attached list is being provided for your reference of claim data items that TOTAL CARE has deemed as critical in adjudicating your claims for payment. 

Effective August 1, 2008, TOTAL CARE will begin a system generated review of inpatient/outpatient UB04 electronic and paper claims based on the attached list (Click here for the attached list).  Incomplete claims that are missing the required data elements or contain inaccurate/invalid data will be returned to the submitter for completion. 

If you have any questions, please contact our Provider Relations Department at (877) 872-4716.

NOTICE

In accordance with Insurance Law Sections 3224-b and 4803(a) and Public Health Law Section 4406-d(1), as amended by Chapter 551 of the Laws of 2006, the claims processing software product utilized by SCHC Total Care, Inc. is AMISYS, Version 34. This software incorporates CPT 2007 in editing procedure codes and for claim pricing determinations.  If you have any questions or need additional information, please contact our Provider Relations Department at (315) 234-5901 or toll free at (877)872-4716.