What payment mechanisms are used for specialty providers? Can I get a list of the FFS payments by Evaluation and Management (E&M) code for office visits? Are enhanced payments available for care coordination? How do we apply for those enhanced payments? What is the plan’s policy for timely payment? What is your plan’s rate of denied claims for primary care visits? Access to Providers/Specialty Care: Can LHD specialists serve as primary care providers for their patients? Does the insurer recognize certain LHD immunization services as a specialty or subspecialty? What is the plan’s credentialing requirements for primary care providers, nurse practitioners, physician assistants or other clinicians in the LHD? What access standards must the provider address? For example, does the insurer have requirements regarding hours and days of operation, coverage during evening and weekend business hours, after-hour and on-call coverage when a designated provider is unavailable, maximum waiting time for an appointment, required intervals for providing specific immunization services, and maximum waiting-room times? Coverage and Benefits: Who determines medical necessity? Where are the criteria posted? What is the process for reconsideration of a determination that a service is not a medical necessity? Is authorization required? How does the payer define preventive medical services (PMS) related to immunization administration? Which immunization administration (IA) codes will be covered? The immunization administration codes specify that the counseling must be performed by a physician or qualified health care professional (OQHCP).” How does the insurer “other define OQHCP? Are all preventive immunizations covered under the medical portion of a program/health plan, or are some covered under a separate drug plan? Will a deductible, copayment or coinsurance be applied to the immunization? What utilization management and review procedures does the insurer employ? Quality and Reporting: Does your plan have immunization-related quality measures? If so, request a copy of measures. What are your reporting requirements for providers? For Medicaid plans: Can you send me the most recent report summarizing the plan’s clinical quality measure performance for services provided in this state? For private plans: Can you send me the most recent report summarizing the plan’s Healthcare Effectiveness Data and Information Set (HEDIS) performance for services provided in this state?
What payment mechanisms are used for specialty providers? Can I get a list of the FFS payments by Evaluation and Management (E&M) code for office visits? Are enhanced payments available for care coordination? How do we apply for those enhanced payments? What is the plan’s policy for timely payment? What is your plan’s rate of denied claims for primary care visits? Access to Providers/Specialty Care: Can LHD specialists serve as primary care providers for their patients? Does the insurer recognize certain LHD immunization services as a specialty or subspecialty? What is the plan’s credentialing requirements for primary care providers, nurse practitioners, physician assistants or other clinicians in the LHD? What access standards must the provider address? For example, does the insurer have requirements regarding hours and days of operation, coverage during evening and weekend business hours, after-hour and on-call coverage when a designated provider is unavailable, maximum waiting time for an appointment, required intervals for providing specific immunization services, and maximum waiting-room times? Coverage and Benefits: Who determines medical necessity? Where are the criteria posted? What is the process for reconsideration of a determination that a service is not a medical necessity? Is authorization required? How does the payer define preventive medical services (PMS) related to immunization administration? Which immunization administration (IA) codes will be covered? The immunization administration codes specify that the counseling must be performed by a physician or “other qualified health care professional (OQHCP).” How does the insurer define OQHCP? Are all preventive immunizations covered under the medical portion of a program/health plan, or are some covered under a separate drug plan? Will a deductible, copayment or coinsurance be applied to the immunization? What utilization management and review procedures does the insurer employ? Quality and Reporting: Does your plan have immunization-related quality measures? If so, request a copy of measures. What are your reporting requirements for providers? For Medicaid plans: Can you send me the most recent report summarizing the plan’s clinical quality measure performance for services provided in this state? For private plans: Can you send me the most recent report summarizing the plan’s Healthcare Effectiveness Data and Information Set (HEDIS) performance for services provided in this state?
SMookencherry%20IMM%20Credentialing-Contracting%20for%20Public%20Health%20Depts%2008-17-16.docx