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Eastpointe
August 20, 2014
10:00am until 1:00pm
University of Mount Olive
• Welcome and Overview
Karen Salacki
• CFAC Updates
Nancy Moore
• Eastpointe Provider Network Council
Barry Dixon
• AHEC Presentation
La-Lisa Hewett-Robinson
(Southeastern Regional AHEC)
Debbie Canton Rogers (Eastern AHEC)
Olivia Herndon (Southeastern AHEC)
•
External Operations
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Karen Salacki
Current Applications Accepted
Fiscal Year 2014/2015 Contracts- IPRS and Medicaid
State and Local Updates
Mystery Shopper
Disaster Preparedness
Kate Abell
DMH/DD/SAS
Provider Monitoring
Program Integrity
Susan Bryan
Utilization Management Updates
Mike Baldwin
Eastpointe Claims and Funding
Jessica Bulluck
Network Operations
Linda Hawley Isbell
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Contract Terminations
Closing a Site or Service
Transition Team
Calcium Calendars & Member Appointment Follow-Up Form
Agency Grid Sheets
Provider Choice Database
Provider Residential Bed Vacancy Reporting
Resolving Attending
Provider Denials
Melanie Weatherford
Eastpointe Training Dept.
Dildra Jessup
Eastpointe’s List Serve
Karen Salacki
Provider Meeting Schedule 2014 Karen Salacki
If you have a questions following this meeting
please contact Network Operations at (888)9772160 or [email protected] .
If you have topics that you would like us to
discuss at upcoming meetings please also send
those to [email protected] .
Nancy Moore
La-Lisa Hewett-Robinson (Southeastern
Regional AHEC)
Debbie Canton Rogers (Eastern AHEC)
Olivia Herndon (Southeastern AHEC)
Barry Dixon, Chair
Eastpointe Provider Network Council
For Council Information: Go to
www.eastpointe.net, then For Provider
Community, the Eastpointe Provider Network
Council Information
Contact Information:
[email protected]
Eastpointe is accepting MCO applications from
Hospitals.
An Agency can add Psychiatrists.
We will also accept applications from
Psychiatrists in private practice. They will need
to submit an LIP application to
[email protected] .
We are not accepting applications for contracts
for LIP’s in private practice.
Agencies can add LIP’s to provide Outpatient
Services. They will not be linked to your your
agency until they are Credentialed. They cannot
provide services to our Members until they are
credentialed.
You will need to submit the LIP Application and
Release form.
You will also need to submit a Grid Sheet. If the
LIP is an Associate you must list the physician
that they will be bill Incident To. The physician
must be already credentialed with Eastpointe.
You can add an LIP to replace an LIP on a team
that has left your agency. Please submit on your
letterhead to indicate which LIP is leaving that
the new LIP will be replacing. Please remember
that it is a requirement to notify us that an LIP
has left your agency and when you hire
someone to replace them.
Additional teams are not being credentialed at
this time.
Fiscal Year 2014/2015
ContractsIPRS
and
Medicaid
Thank you to all providers who submitted the
entire contract packet in a timely manner.
All 2014/2015 IPRS and Medicaid contracts
were due to Eastpointe on 5/15/14.
There are still a number of providers who have
not returned their Medicaid contracts.
Providers who did not return their contracts or
returned them without the required documents
will be unable to obtain authorizations or bill at
this time.
Please be advised that the cover letter that
went out with contracts stated that you needed
to address any changes that you felt needed to
be made to your contract in a letter.
Please note that just because you hand wrote
changes on your contract that it does not mean
that this items will automatically be added to
your contract.
You must have a Certificate of Insurance (COI)
with the required amount of insurance per your
contract to be able to have a fully executed
contract. There will be no exceptions.
Please be reminded that our network is closed
and we are not adding new services to
contracts.
If you have questions about this please contact
[email protected] .
We conducted a Mystery Shopper project in
April 2014. All providers were sent a letter to
notify them of any out of compliance
information.
We will be conducting another Mystery Shopper
project in the future.
Please review all of your information to make
sure that all of it is complete and up to date on
the Provider Choice Database.
Please review the information from
Communication Bulletin #14.
Please remember that it is not appropriate to
leave the phone number for a local hospital as
your crisis number. You will be found out of
compliance if you do this.
All instructions on your voicemail should be
clear. Please remember that Members or their
family members may use your Crisis number
when the Member is in crisis.
If a provider has one or more out of compliance
issues during this review they will be issued a
Plan of Correction.
Kate Abell
DMH/DD/SAS
Susan Bryan
Director, Provider Monitoring and Program Integrity
[email protected]
08/15/2014
Unlicensed Alternative Family Living (U-AFL): When a provider agency
identifies a potential U-AFL Home in which they would like to subcontract
to provide Innovations Residential Supports, the provider agency will
follow the following procedures. Consumers are NOT to be placed in the
U-AFL until approval of the subcontract has been granted by the Chief of
External Operations. Eastpointe consumers residing in U-AFL homes not
approved via the below detailed procedure MAY result in a sanction
Submit a written request for subcontract approval to
Karen Salacki, Chief of External Operations. This
request must include a copy of your Certificate of
Insurance showing the physical site address of the AFL
and contains required coverage as outlined in the
Request for LME Approval Letter to Subcontract. The
Request For LME Approval Letter to Subcontract can be
found on Eastpointe’s website www.eastpointe.net
Go to For Provider Community and Provider Forms.
After review by the Chief of External Operations
she will refer the information to a Provider
Relations Specialist to review the Certificate of
Insurance. Once the Certificate of Insurance has
been confirmed accurate a Health and Safety
Onsite Review will be scheduled by Provider
Monitoring Staff. The Provider Monitoring
Specialist will schedule a time within the next
thirty (30) days to complete the Health and
Safety Review Check sheet.
The Provider Monitoring Specialist will submit the
completed check sheet to the Chief of
External Operations for review.
The Chief of External Operations will notify the
Provider Relations Specialist as to whether the
subcontract has been approved or not approved.
The Provider Relations Specialist will send a letter to
the provider agency to notify them if the subcontract
request has been approved or not approved.
The procedure is listed on the Eastpointe
website: go to => www.eastpointe.net
http://www.eastpointe.net/providers/providerf
orms/contracts/Procedure%20for%20Subcontra
ct%20Approval%20for%20an%20Unlicensed%2
0Alternative%20Family%20Living.pdf
Announcements with updates and changes to
the Routine Monitoring Tools are sent out via
Constant Contact to the Eastpointe Network.
Once a provider has received the outcomes of
the Routine Monitoring from Eastpointe, the
provider is requested by NC DHHS to complete
a survey. In order to access this survey, go to:
http://www.ncdhhs.gov/mhddsas/providers/pr
ovidermonitoring/index.htm
The PPR is an integral part of monitoring's,
special investigations and just cause audits,
including when following up on incidents and
complaints. PPR’s are required for licensed
facilities.
Susan Bryan
Director, Provider Monitoring and Program Integrity
[email protected]
08/15/2014
Need to report suspicious activity related to
fraud, waste and abuse:
www.eastpointe.net =>For Provider Community
=>Program Integrity =>Complete the Forms Desk
Form. The referral may be anonymous; however,
Eastpointe will not be able to follow up with the
referral if the referral is anonymous.
Eastpointe has posted at www.eastpointe.net
both a webinar and training documents for the
provider community. Below is a snapshot on
how to access the Program Integrity
information. Additional information will be
posted on the Eastpointe website for providers
for continued education.
Fraud, waste and abuse affect both Eastpointe
members and providers. Program Integrity
referrals can be made by calling our Corporate
Compliance toll free line at 855-243-3147 or
completing the web submission form.
Monitoring questions can be sent to
[email protected]
Program Integrity questions can be sent to
[email protected]
• Process created in response to Bulletin
#72
• It is a Step-Down Plan
• Designed to ensure a smooth
transition for the member in the event
of an adverse decision
• On 8/1/14, we updated the TAR to
accommodate for DSM-V.
.• As DSM –V no longer requires reporting of an
axis, those fields will no longer be required on
the TAR.
• Instead, you will have the ability to put up to
four diagnoses on the TAR when you fill it out.
• For all existing TARs, you will have the ability to
go back and review what you had entered in the
past.
• The 2014-2015 fiscal year benefit plan
is currently being reviewed and will be
.
posted to Eastpointe’s website once
completed.
• Please continue to utilize the fiscal
year 2013-2014 benefit plan until
further notice.
Best Clinical Practice Guidelines
Links can be found on Eastpointe website under
provider community/ Medicaid Utilization Review/
top three links on left hand side
• Network Operations Call Center:
1-888-977-2160
Network Operations Call Center staff will forward
question to the appropriate UM staff to assist if
additional information needed
• Lynnette Gordon, UM Director
[email protected] 910-298-7036
• Requesting a peer to peer
1-888-977-2160
• Requesting a copy of the clinical rationale
1-800-513-4002 option 3
Updates; Effective 8/1/2014
TIMEFRAME FOR CLAIM SUBMISSION
CHANGES
State or Local Funded Services
• Denied claims must be re-submitted within 20 days of the receipt date of the denial.
Medicaid Funded Services
• Denied claims must be re-submitted within 90 days of the receipt date of the denial.
• If 90 days from the “date of service” has expired, the resubmission must be done
using a claims inquiry form with the reason marked as “claims inquiry”. This is to
avoid a system denial for timely filing if the resubmission is within the additional
90 days allowed to resubmit a correctable denied claims.
•
Coordination of Benefit Claims
Providers shall submit a claim within 30 days of the date of determination of coverage
or payment response from a third party if it is past the 90 day timely filing guideline
for submitting claims.
•
Updates; Effective 8/1/2014
REPLACEMENT CLAIMS (MCO Standardization)
• Billing days for a replacement claim is 180 days from the original billing date for
Medicaid and State Funded Services.
• Claims submitted past 180 days from the original billing date will be denied for
exceeding billing days.
• For State Funded Services, if the 180 day correction window crosses into a
subsequent fiscal year, the allowed days will be the number of days left in the
current fiscal year.
Example: If a claim is originally billed on March 31, the billing days for a
replacement claim will be 91 days. (April 1 through June 30; the last day of the
fiscal year.
•
MCO STANDARDIZATION
• REPLACEMENT CLAIM GUIDELINES
Found on Claims & Billing web page. www.eastpointe.net
• UNIFORM RATE TEMPLATE
• PLACE OF SERVICE CODES
• DENIAL AND ADJUSTMENT CODES
•
Updates to Claims & Billing Web Page
•
Reminder
FY14 IPRS/NCTRACKS FINAL CUT-OFF
The deadline to submit claims for dates of service 7/1/2013 –
6/30/2014 for State Funded (IPRS/NCTracks) services will be the last
scheduled check write cutoff in August.
All state funded claims for FY 2013-2014 must be received by
Eastpointe on or before 5PM on Tuesday, August 26, 2014 for claims
to be considered for payment.
Claims & Billing Web Page
WWW.EASTPOINTE.NET
•
For Provider Community
•
•
Medicaid 1915 b/c Waiver Information
Claims and Billing
Your contract states that all Providers will
comply with the North Carolina Continuity of
Care statute (GS 122C-63).
This statute requires a 60 day notice to
Eastpointe of intent to close a facility or
discharge a Member with IDD services and 30
day notice for a Member with an Mental
Illness/Substance Abuse services from the
stated termination date.
Process to Terminate
Submit that in writing on your agency letterhead
Requires the signature of your CEO or other
authorized individual
Must state the effective date of the termination
Complete and submit the Transition Forms on our
website www.eastpointe.net
Please note that if you are serving Members at
the time that you decide to terminate a service,
a site or terminate your contract it is you or
your agencies responsibility to offer choice of
other Providers to the Members that you are
serving. You will need to offer provide choice
through the list of Providers on the Provider
Choice Database.
Your contract states that all Providers will
comply with the North Carolina Continuity of
Care statute (GS 122C-63).
This statute requires a 60 day notice to
Eastpointe of intent to close a facility or
discharge a Member with IDD services and 30
day notice for a Member with an Mental
Illness/Substance Abuse services.
It is our priority to ensure continuity of care for
our Members. We expect this to be your
priority as well.
Any notice other than listed above is
unacceptable
We are going to be tracking this and if you do
not meet this timeline you will be out of
compliance with your contract which may affect
the status of your contract.
When we are notified that you have made a
decision to close a site or service or if a decision
has been made to terminate a service or your
contract you will receive a letter from our
Transition Team.
The letter from our Transition Team reminds
you of your responsibility to complete the Initial
and Final Caseload Transition Forms as well as
the Medical Records Storage Form. All three of
these forms are required.
The Transition Team also sends a letter to all
Members that you have been serving to notify
them of the termination.
If you have any questions about this process
please contact
[email protected] or call (888)
977-2160.
Please make sure that you have appointments
available on their Calcium Calendars to be able
to ensure that Members can receive services
within the timeframe needed for Emergent,
Urgent or Routine.
Who needs to have a Calcium Calendar and
submit a Member Appointment Follow-up Form
(formerly known as Appointment Follow-Up
Submission Form)?
Agencies who are a Mental Health/Substance
Abuse Provider who provides enhanced services
and basic benefit services.
All Intellectual and Developmental Disability
Providers that provide assessments.
Licensed Independent Practitioners who have an
LIP contract with Eastpointe.
This form must be completed and submitted to
Eastpointe by the end of the business day of the
appointment scheduled for Urgent and within
24 hours of the scheduled appointment date for
routine.
There are providers who are not complying with
this requirement.
Providers who are not complying will be
contacted through certified mail to attend a
mandatory training.
Providers who fail to attend the mandatory
training will be required to submit a Plan of
Correction (POC) to address the systemic issues
identified.
If you have questions about your Calcium
Calendar or the Member Appointment FollowUp Form please contact
[email protected] or call (888)
977-2160.
To locate the form please go to For Provider
Community, then Web Submission Forms and
then Member Appointment Follow-Up Form.
Please note that when an agency submits an LIP
application to add an LIP to provide Outpatient
Therapy or to replace an LIP on a team they
must also submit a Grid Sheet.
The Grid Sheet is used to connect the LIP to
your agency once they are credentialed.
It is also required that an agency submit a Grid
Sheet when an LIP leaves your agency.
No LIP should be providing services unless they
have been credentialed through Eastpointe.
You can locate the Grid Sheets by going to our
website then
For Provider Community
Provider Forms
Agency Grid Sheet
The Provider Choice Database is a critical
information system for our Members, their
family members, providers, our community and
for Eastpointe.
The Database gives Members options of
providers for services.
It gives providers the ability to list their
information to be used for choice by Members.
It gives our community information about the
behavioral health services in our community.
Please review each site location as well as your
corporate location that is listed on our website.
If there is no information listed than this means
that you or your agency have not submitted an
Eastpointe Provider Change Form.
If there is incomplete information than this
means that you have not submitted an
Eastpointe Provider Change Form with all
required information.
What information is required?
Demographic Information
Contact Person
After Hours Crisis #
CABHA Status
Counties Served- (one or more counties need to be
listed)
Culture(s) Served- (one or more cultures needs to
be listed)
Language(s)- (one or more languages need to be
listed)
Operating Hours Served
Payer Sources Accepted-(one or more payer source
must be listed)
Presenting Disability Type- (one or more disability
type must be listed)
Services provided- (Only services that you are
contracted for should be submitted on the
Eastpointe Provider Change Form)
The following item needs to be listed if
applicable:
Specialty Service(s)
Effective 8/1/14 it became MANDATORY that all
Eastpointe Network Providers who have
residential beds submit a Provider Residential
Bed Vacancy Form when:
They have bed availability/vacancy
When that bed availability/vacancy has been filled.
Providers who have the following Residential
bed types are required to submit this
information:
Residential Treatment Level II Family (Therapeutic
Foster Care)
Residential Treatment Level II Group Home
Residential Treatment Level III
Residential Treatment Level IV
Psychiatric Residential Treatment Facility (PRTF)
All licensed group homes including 5600A, 5600B,
5600C, 5600-ICF, 5600D, 5600E and 5600F
5600F (Licensed AFL’s)
Unlicensed AFL’s
ICF/IDD 15 beds or more
To locate the Provider Residential Bed Vacancy
Form please go to our website,
www.eastpointe.net then For Provider
Community then Residential Vacancies.
You will also find a tab with an Instruction Sheet
for using this form.
We have added a tab for a Provider Residential
Vacancy Report . You can run this report to see
immediate availability of residential beds.
There is a power point on Resolving Attending
Provider denials that was recently recorded. The
purpose of this training is to help
clearinghouses and providers to resolve denials
associated with NPI errors.
NPI errors occur when a claim is submitted on
an 837 and contains an NPI number that is not
recognized by our billing system.
This could occur due to NPI numbers not being
set up correctly in the system or if an NPI
number was not submitted by the provider.
Network Operations will begin to send out
certified letters to providers that have
submitted an 837 and NPI attending provider
errors have occurred.
There are 3 different types of letters being
mailed to providers that provide necessary
steps to correct NPI Attending Errors.
A letter will be sent to Contracted In-Network
providers to correct NPI Attending Errors.
If there is an NPI attending provider error the
agency grid sheet needs to be updated.
Send completed form to
[email protected]
Please remember that LIPs will be linked to your
agency after they have been credentialed into
the network. The effective date will be the date
that all required forms are received by the MCO.
A letter will be sent to Physician
Groups/Hospitals for ER Claims to correct NPI
Attending Provider Errors.
Physician Groups/Hospitals are required to send
in an Emergency Department set up form. This
is required prior to billing for Medicaid.
If a physician group/hospital has not completed
the attached form specifically for Emergency
Departments it can be found on the Eastpointe
website under Provider Forms.
If additional physicians are hired after the form
has been submitted, the hospital registration
worksheet needs to be completed to show any
updates. This also can be located on the website
under provider forms.
Please send completed forms to
[email protected]
A letter will be sent to Contracted Hospitals in
the Network to correct NPI Attending Provider
Errors.
If you have physicians or other licensed
clinicians that are employed by the hospital
providing behavioral health services, a hospital
registration worksheet should be completed so
these physicians can be linked with the hospital.
The form can be located on the Eastpointe
website under Provider forms.
Send completed forms to
[email protected]
Once the appropriate forms are received within
(10) business days from the date of receipt or
attempted delivery of the letter, Eastpointe staff
will update the billing system with the NPI’s.
Any errors that were previously billed for
“Attending Provider ID is missing, Invalid, or
Unresolved” may be resubmitted and will be
processed against Eastpointe’s normal billing
guidelines.
If the requested information is not received
within the timeframe, the claim will be denied.
Agency Grid Sheet can be located at the
following link:
http://www.eastpointe.net/providers/providerf
orms/providerforms_main.aspx
Emergency Department set up form can be
located at the following link:
http://www.eastpointe.net/providers/providerf
orms/providerforms_main.aspx
The hospital registration worksheet can be
located at the following link:
http://www.eastpointe.net/providers/providerf
orms/providerforms_main.aspx
Partnership with providers
Evidenced Based Practice Trainings
Reputable and knowledgeable trainers
Affiliation with Local Area Health Education
Centers for CEUs.
Positive outcomes in service delivery process
Members benefit when staff are trained
All Training announcements are listed on the
Calendar of Events on our website.
Go to www.eastpointe.net then to For Provider
Community and then click on Calendar of
Events.
Training announcements are sent out monthly
via Constant Contact.
Eastpointe recognizes and embraces the
importance of serving individuals in a culturally
and linguistically appropriate manner.
Eastpointe is committed to ensuring that its
personnel and its provider partners, as well as
its infrastructure, policies, procedures, and
programs are structured in such a way as to
meet the diverse needs of all members.
Eastpointe believes that addressing cultural and
linguistic issues not only improves access to
services and the services themselves, but it
enhances the cost-effectiveness of care
provided.
Establishment of Eastpointe Cultural
Competency Committee.
Eastpointe has established a Cultural Competence
Advisory Committee consisting of:
1. Eastpointe staff members.
2. Consumer Family Advisory Committee
representatives.
3. Underserved populations,
professional/community organizations
4. Network provider representatives.
Development of Eastpointe Cultural
Competency Program Description.
Development and implementation of SelfAssessment Tool.
Development of Cultural Competency Training.
Recruitment Needs.
Developing respect for differences.
Cultivating successful approaches to diversity.
Increasing awareness of one’s self and of
unstated institutional cultural norms and
practices.
Gaining a working knowledge of the history,
culture, beliefs, values and needs of diverse
consumers and communities.
Requires that agencies examine and potentially
transform components of services, including but
not limited to:
1. Assessment
2. Treatment
3. Habilitation
4. Evaluation
The journey towards cultural competence must be
in partnership and collaboration with members,
families and community members as guides and
cultural brokers, not just as passive recipients of
services.
Review the Eastpointe Cultural Competency Program Description.
Take an active interest in increasing your cultural competence by attending
cultural competence trainings. View these training as both desirable and
clinically necessary.
Actively reflect on personal biases and beliefs as compared to the cultural
majority in the United States.
Utilize appropriate translation services and well-validated instruments to
enhance cultural communication skills .
Become familiar with the basic vocabulary of cultural competence and
regularly assess your level of cultural competence on an informal basis.
Make sincere attempts to avoid stereotyping individuals and acting upon
cultural generalizations without verifying whether this generalization fits a
particular individual.
Cultural Competency for Adults and Children
September 19, 2014 - Eastpointe MCO Rocky Mount, NC
Presenter: Tonya D. Armstrong, Ph.D., M.T.S., is the founder and CEO of The
Armstrong Center for Hope (www.armstrongcfh.com), an interdisciplinary
group practice cultivating psychological and spiritual wellness for all ages. Dr.
Armstrong has published consistently in the areas of spirituality, AfricanAmerican mental health, end-of-life care, and grief, and focuses clinically on
culturally-competent interventions that optimize mental health and holistic
care for children, adolescents, and their families.
Credits: 0.6 CEUs and/or 6.0 Contact Hours credit
Cost: Free
Additional Information: www.eastpointe.net
To Register: Fill out registration form electronically & email it to:
[email protected] Or fax form to: 910-323-0674
Constant Contact
Directions for signing up for the new list serve:
1. Go to Eastpointe’s website at
http://www.eastpointe.net
2. Click on For Provider Community
3. Go to Provider Listserv, then click on
Eastpointe Provider Listserv Sign-Up
Form
4. Enter your email address (make sure you type
it correctly), enter your first
and last name, and agency
5. Click on the Sign Up button
6. After you sign up, a Thank you page will
open. You have been added to the
mailing list and can exit
You will receive an email that your request has
been submitted
Please remember to register on our website
under Provider Community and then Calendar
of Events to make sure you reserve a seat.
Our next meeting is scheduled for September
17, 2014 from 10:00am until 1:00pm and it will
be a webinar.
Website: www.eastpointe.net
Network Operations Phone: 888-977-2160
Email: [email protected]
Fax: 252-407-2450
Member Call Center 800-913-6109
Fax: (910) 345-8971