PersonalCare Plan User Guide



PersownalCare Plan Partner System

Quick reference guide

WHAT IS A PERSONALCARE PLAN?

It’s a different kind of plan—one that’s based on “accountable care.” Providers in a PersonalCare Partner System are accountable for the patient experience—the quality and cost of care—for customers who choose them.

• Premera offers PersonalCare Plans in King, Snohomish, and Pierce counties.

• PersonalCare Plans have 6 care systems, called Partner Systems.

• Partner Systems function similarly to an accountable care organization, which means that Partner Systems coordinate their patients’ care within their network of providers.

• Patients can visit providers in the Heritage Signature/Heritage Prime networks with a referral from their Partner System.

• Providers not in the Heritage Signature/ Heritage Prime networks are out of network.

PARTNER SYSTEM = CENTRAL POINT OF CARE

• Partner Systems are trusted local providers.

• Each system of hospitals, clinics, and providers commits to working together with Premera to provide care that saves time.

• Your patients should receive all of their care within their Partner System and talk with their primary care provider about their care options.

Things to remember

• Your patients’ Partner System is their central point of care.

• They choose their primary care provider within their Partner System. When they need care, your patients should always start by contacting their primary care provider.

• Their primary care provider coordinates with specialists and hospitals in their Partner System to make sure everyone stays focused on their needs.

• The Partner System name is included on the member’s ID card, but their primary care provider isn’t.

What you do as a Partner System

• Collaborate with Premera to ensure that new patients understand that their primary care provider coordinates their care.

• Coordinate patient care within the Partner System and referral network.

• Educate patients before and after seeing a provider outside of the Partner System so they understand how the plan and Partner System works.

Network

• If a primary care provider recommends care that isn’t available within the Partner System, the primary care provider may complete a referral for the customer to see another provider in the Heritage Signature/Heritage Prime network.

• If your patient receives care outside of their Partner System without a referral from their Partner System, they may have to pay the full cost of the care out of pocket—the only exception is medical emergencies.

WHO’S IN NETWORK?

• 6 Partner Systems support PersonalCare Plans:

o The Everett Clinic Integrated Care Network

o EvergreenHealth Partners

o MultiCare Connected Care

o Northwest Physicians Network

o UW Medicine Accountable Care Network

o Virginia Mason Medical Center

• Each Partner System is part of the Heritage Signature/Heritage Prime network. Premera considers any provider who isn’t in the Heritage Signature/Heritage Prime network out of network.

GETTING STARTED

1. We’ll send you a list of your PersonalCare Plan members on a monthly basis.

2. Each Partner System should contact (email, call, etc.) new members to welcome them to the Partner System and let them know their primary care provider will coordinate their care, including specialty care if needed.

3. Premera will also welcome new members and provide important information about using their PersonalCare Plan.

4. Partner Systems can help their patients schedule a free annual preventive checkup with their primary care provider and explain how important this visit is, so their provider can help coordinate their care for any immediate or future healthcare needs (if a provider addresses medical conditions during the preventive visit there may be a member cost share).

Providers should always:

• Verify eligibility and benefits before seeing a Premera member.

• Check the member’s ID card to see if a there is a Partner System name on it. If it’s listed, this means the member is on a Partner System referral-based plan.

• See the member only if they’re Heritage Signature/Heritage Prime network providers and have a referral from the member’s Partner System, or they’re providing a service that doesn’t require a referral.

CARE TEAMS

• Partner System providers work hard to give patients information they need to make informed choices about their healthcare.

• A patient’s primary care provider within their Partner System coordinates care with specialists to streamline their experience and make sure the patient only receive the tests and care they really need based on their condition.

• Partner Systems use data Premera provides to identify patients that could benefit from care management outreach.

ELIGIBILITY AND ENROLLMENT

• Always verify eligibility and benefits before seeing Premera patients.

• Check the patient’s ID card to see if a there is a PersonalCare Partner System on it.

ID card

Member ID cards include the name of their Premera PersonalCare Plan Partner System (see yellow highlight below). For more information about the ID card, see our ID card guide in our Learning Center.

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Patient selects primary care provider

Patients choose a primary care provider who is their main point of contact and coordinates their care. Designating a primary care provider is important because customers pay a lower cost share on their visits. We ask that you encourage Premera members to take action and designate their primary care provider as soon as possible.

|Providers who can be primary care providers |

|Family practice physician |Nurse practitioner |

|General practice provider |Obstetrician |

|Geriatric practice provider |Pediatrician |

|Gynecologist |Physician Assistant |

|Internist | |

How patients select a primary care provider on

Patients will receive the following messages when they log into to choose their primary care provider:

• Have an account? Log in at to choose or change your primary care provider (the change will take effect the next day).

• Don’t have an account? It’s easy to create one; you just need the identification number from their ID card.

BILLING

Submit claims to Premera like you normally would for your other Premera business.

• Electronic claims

To speed claims turnaround, we urge you to submit electronically. If you’re an electronic submitter, refer to your electronic billing manual for specific formatting for electronic claims.

• Paper claims

If you’re unable to submit claims electronically, you can submit paper claims on CMS-1500 or UB-04 forms. To speed claims processing, we use document imaging and optical character recognition (OCR) equipment to read your claims. Below are tips to ensure that OCR reads your paper claims accurately:

o Use only red CMS-1500 forms (no photocopied forms).

o Type forms in black ink (handwritten forms cannot be read by OCR equipment).

o Don’t fold, staple, or tape your claim.

o Line up information correctly within the respective fields (data that overlaps another field/box cannot be read accurately).

o Don’t write or stamp extra information on the form.

o Avoid white correction fluid.

o Avoid highlighting information.

REFERRAL PROCESS

1. Check the patient’s ID card to see if there’s a PersonalCare Partner System listed.

2. Partner Systems coordinate their patients’ care within their network of providers. Referrals within the Partner Systems’ network of providers don’t require submission to Premera. In addition to the Partner System and their network of providers, patients also have access to a free 24-Hour NurseLine and video-based doctor visits with Teladoc® virtual care services.

3. Referrals outside the Partner System are rare. Partner Systems can refer their patients to providers in the Heritage Signature/Heritage Prime networks. Partner Systems should verify if the service requires a referral first. If a patient needs a referral, you can submit a referral using our online referral tool. You can access the tool via a web link that’s available from your internal Premera point person and/or liaison. The online tool replaced the paper and online email referral forms starting in January 2018. Premera will reject claims for referrals submitted using the old forms. For more information about the referral tool, see our FAQ and training video on the Partner Systems webpage.

Note: If a patient receives care outside of their Partner System network of providers without a referral from their Partner System, they may have to pay the total cost of the service out of pocket—the only exception is medical emergencies.

4. Providers not in the Heritage Signature/Heritage Prime networks are out of network.

Services that don’t require referrals

Click here for a detailed list of services that don’t require a referral for PersonalCare Plan patients. Note that durable medical equipment (DME) no longer requires a referral starting April 1, 2018.

|No referral required, but care must be received within the |

|Heritage Signature/Heritage Prime Network: |

|Naturopath |Contraceptive management and sterilization |

|Acupuncture |Home medical equipment |

|Chiropractor |Pediatric vision |

|Outpatient physical, occupational, speech, and massage therapy |Prescription drugs |

|Mental health |Telehealth virtual care services |

|Behavioral health |Emergency room (in-network coverage anywhere they travel, with provider option|

|Substance abuse |to balance bill) |

|DME | |

Referrals outside of a patient’s Partner System are rare!

Urgent care

• Urgent care services are included in the Partner Systems’ network of providers and don’t require a Partner System referral; urgent care services outside the Partner System require a referral by the Partner System. In addition to the Partner System and their network of providers, patients also have access to a free 24-Hour NurseLine and video-based doctor visits with Teladoc® virtual care services.

• Premera covers non-emergency services outside the Partner Systems, but within the Heritage Signature/Heritage Prime network only when referred by the patients’ Partner System.

• Urgent care services received outside of the Heritage Signature/Heritage Prime network are out of network and not covered.

INCENTIVES

Premera and your Partner System have entered into a risk contract. If the Partner System successfully manages PersonalCare Plan patients’ total cost of care and improves quality, the Partner System has an opportunity to earn incentives.

QUESTIONS

If you have any questions about Premera’s PersonalCare Partner System network, contact your Premera point person/liaison.

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