MAPAM 2021 Boston Medical Center HealthNet Plan 1

MAPAM 2021 Boston Medical Center HealthNet Plan 1

Topics BMCHP Overview ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are rewarded for value – My HealthNet improving total cost of care and outcomes – not volume Updates and Reminders The primary focus is on improving patient outcomes by: COVID-19 COVID-19 Promoting healthy behaviors Telehealth Telehealth Newborn Newborn Notification Notification Expanding population health management programs, and Provider Provider Demographics Demographics data exchange between payers and providers Improving Provider Provider Contacts Contacts EFT EFT Senior Senior Care Care Options Options –– Model Model of of Care Care Special Special Kids Kids Special Special Care Care Questions 2

BMCHP Overview 3

Who We Are ACOs are provider-led organizations that coordinate care, have an BMCHP is a non-profit managed care organization committed to providing the enhanced role for primary care, and are rewarded for value – highest quality healthcare coverage to underserved populations. improving total cost of care and outcomes – not volume We operate in MA and NH The primary focus is on improving patient outcomes by: – MassHealth (including ACO) healthy behaviors – MAPromoting Qualified Health Plan which includes ConnectorCare – MAExpanding Senior Carepopulation Options* health management programs, and Improving exchange payers and providers *Available data in these counties:between Barnstable, Bristol, Hampden, Plymouth & Suffolk – NH Medicaid (under the trade name Well Sense Health Plan) 4

BMCHP MassHealth Plans include: BMCHP MassHealth MCO – Primary Care within the BMCHP MCO Network BMCHP Community Alliance ACO – Primary Care within the BMCHP Community Alliance ACO Network. BMCHP Mercy Alliance ACO – Primary Care within the BMCHP Mercy Alliance ACO Network. BMCHP Signature Alliance ACO – Primary Care within the BMCHP Signature Alliance ACO Network. BMCHP Southcoast Alliance ACO – Primary Care within the BMCHP Southcoast Alliance ACO. BMCHP’s full network of MassHealth contracted facilities, specialists and ancillary services is available for all above Plans 5

Additional BMCHP Plans include: ConnectorCare – BMCHP’s full network of ConnectorCare contracted facilities, primary care, specialists and ancillary services is available. Qualified Health Plans - BMCHP’s full network of Qualified Health Plan contracted facilities, primary care, specialists and ancillary services is available. Senior Care Options - BMCHP’s full network of Senior Care Options contracted facilities, primary care, specialists and ancillary services is available. 6

Find a participating Doctor, Hospital, or Pharmacy by visiting the BMCHP Provider Directory: https://www.bmchp.org/utility-nav/find-a-provider 7

Member ID Numbers – MH ACO’s ACO Member ID’s have number sequencing according to the ACO they are assigned: 8 ACO Prefix ID Numbering Scheme (note: the 00 is the suffix for all Subscribers and will be on the ID Card) COMMUNITY ALLIANCE 2 2#########00 MERCY ALLIANCE 3 3#########00 SIGNATURE ALLIANCE 4 4#########00 SOUTHCOAST ALLIANCE 5 5#########00

Member ID Numbers – MCO, QHP & SCO Member ID sequencing for MCO, QHP & SCO Masshealth MCO Prefix ID Numbering Scheme (note: the 00 is the suffix for all Subscribers and will be on the ID Card) 2 B#########00 3 Qualified Health Plan Senior Care Options 9 4 C#########00 1#########00

Member Eligibility MH (including ACO): By accessing the Masshealth website: @ gateway.hhs.state.ma.us/authn/login.do BMC HealthNet Plan: Secure Provider Portal: www.BMCHP.org via My HealthNet or 1-888-5660008 (most accurate method of verification for ConnectorCare/QHP members) ConnectorCare/QHP: BMC HealthNet Plan: Secure Provider Portal: www.BMCHP.org via HealthTrio or 1-888-566-0008 (most accurate method of verification for ConnectorCare/QHP members) Senior Care Options: BMC HealthNet Plan: Secure Provider Portal: www.BMCHP.org via HealthTrio or 888-566-0008 *****Important Note***** SCO Members - Eligibility for SCO members changes on the first of the month, however we still recommend that you verify eligibility prior to the date of service. Member panel reports are not an accurate method for verifying eligibility. These reports are only intended to inform you of the member’s assigned to your panel. ConnectorCare/QHP - For ConnectorCare/QHP Members you are not able to verify eligibility via EVS, you must verify eligibility with the QHP Plans directly Please check member eligibility on the date of service before delivering services and daily for inpatient admissions 10

My HealthNet 11

We've launched our improved Provider Portal MyHealthNet! Based on provider feedback, we've enhanced features to help make your job easier. Check out our new homepage to access top time-saving features Improved Claims Process: Providers can submit Corrected Claims, Appeals, COB, EOB, and TPL review requests online and get reimbursed faster. Streamlined Authorization Process: Our submission process is now more intuitive and allows providers to upload supporting documentation to their online PA requests. Providers may check the status of their PA request as well! New Member PCP Update Feature: Providers can now request member PCP updates online while the member is in the office Training guides are available on our Training and Support page @ BMCHP.org https://www.bmchp.org/I-Am-A/Provider/Training-and-Support If you have any questions or would like to schedule additional training, please contact your dedicated Provider Relations Consultant. 12

IMPORTANT REMINDER Providers will be required to utilize our provider portal for claim status inquiries o Due to the success of our self-service portal, MyHealthNet, and efforts to make our call center staff available to assist you efficiently with more complex inquiries, we are mandating that the request for the status of claims be verified via our portal. This mandate goes into effect on April 1, 2021. o Please share this important information with your billing agencies and third party billers to ensure access to our secure portal is established in a timely manner. We also provide you with access via our secure portal to check on the status of your auth requests-this saves you time and is more efficient. 13

APPEALS PROCESS - REMINDER Effective February 17, 2020 - We no longer offer two levels of appeals We have a process in place to allow providers to submit provider administrative claims appeals. Under new leadership, we are streamlining the process to provide the most efficient and thorough processing of these appeals. After conducting research we have identified that the 2nd level appeal is not often utilized and as a result the plan will no longer accept second level provider administrative claim appeals. To ensure all appeals are processed timely and accurately, providers are required to submit all required documentation when submitting an appeal. Utilize our Provider Portal to submit a Request for Claim Review Form, along with, supporting documentation. 14

Updates and Reminders 15

BMC HealthNet – COVID-19 We are honored to be partnered with you during this time and are working internally to ensure that you have the support you need from us as a health plan. To better serve our patients and provider partners during COVID-19 crisis, we are regularly updating our COVID-19 FAQ to help support you while caring for your patients, our members. Please reference our COVID resource page for more information and details as specific benefits may vary by product. https://www.bmchp.org/I-Am-A/Provider/COVID-19-Resources 16

BMC HealthNet – Telehealth BMC HealthNet Plan will cover telephonic visits in addition to telehealth visits for our members until further notice. The Health Plan currently covers Telehealth for both Medical and Behavioral Health Providers as long the provider is In-Network. Telehealth appointments cost the same as in-person doctor’s appointments. We also cover tele-psychiatry visits for our members. Not all providers offer a telehealth option. Member will need to call the provider’s office to see confirm if this is an available option. 17

Newborn Notifications Newborns Hospitals treating our MassHealth members must complete a MassHealth Notification of Birth (NOB-1) form and submit it directly to the MassHealth Enrollment Center Notification of Birth Unit in a timely manner, no later than 30 calendar days after the delivery. Please indicate birth weight and gestational age on this form. The Plan covers routine nursery charges and well newborn care. If eligible, the newborn must be enrolled in BMCHP within 30 days of date of birth for us to cover any other medically necessary services rendered to the newborn 18

BMC HealthNet - Demographic Changes It is critical to notify us of Provider Demographic Changes Plan is required to keep provider information up to date and ensure plan online directory is kept current with the most accurate information. Providers are expected to notify the plan of any provider changes or updates as they occur and regularly, by working with their Provider Consultant to verify their Provider Demographic Rosters. Demographic changes that you should notify us about include: Payment Changes- this affects payments and will delay or interrupt payment if incorrect Tax Identification Number or Entity Affiliation change (W-9 required) Group Name or Affiliation change National Provider Identifier Mailing Address change Telephone and/or Fax number update Termination or Expiration Provider updates in Panel Status Provider/Termination Change Form can be emailed to [email protected]. Please include a W9 for remittance changes. Providers who appear in our directory will receive updates on our progress in rolling out DirectAssure. 19

BMC HealthNet - Provider Contacts To ensure you receive important updates and notices please be sure to keep your contact information up to date with us. Please reach out to your Provider Relations Consultant to inform us of staff changes in your office to ensure you and they are receiving our important email notifications. You can also reach us at [email protected] to request a General Contact Form so we can update your contacts as requested. 20

BMC HealthNet – EFT Reminder Make sure that your provider office takes advantage of Electronic Funds Transfer (EFT), a convenient and efficient option for claims payments. EFT permits an electronic direct deposit of your BMC HealthNet Plan claim reimbursements into the bank that you designate. Advantages of EFT include: Prompt payment – no waiting for checks to clear Improved cash flow No lost checks or postal delays Administrative savings Reduced paperwork Secure payment environment For more information about how to enroll in EFT, please call your dedicated Provider Relations Consultant or call the provider line at 888-566-0008. 21

BMC HealthNet – SCO Model of Care As with all Senior Care Options plan, BMC HealthNet Plan’s Model of Care requires that network providers receive annual training and attest on an annual basis. For the convenience of our providers, we have prepared a short, web-based training module – Senior Care Options Model of Care Training which is available to you through our online portal. https://www.bmchp.org/I-Am-A/Provider/Training-and-Support At the end of the training you will be asked to click through to attest that you have completed the training. To complete the attestation you must have your NPI number. If you are a larger group practice, we suggest that you reach out to your Provider Relations Consultant who can assist with coordinating the training and attestation process. 22

Special Kids Special Care (SKSC) MassHealth and the Department of Children and Families (DCF) co-sponsor the Special Kids Special Care (SKSC) medical program for children in foster care with special health care needs BMC HealthNet Plan was selected to provide to the SKSC MH Population Plan types include MassHealth Standard, Standard Disabled, and MassHealth CommonHealth SKSC members have access to the same medical benefits as BMCHP’s MCO and ACO members and in addition can be seen by Private Duty Nurses. The SKSC program includes dedicated Pediatric Nurse Practitioners (PNP) and Pediatric Nurse Managers who develop a plan of care and arrange the delivery of care for each qualified program participant. Collaboration of care may take place between the PCP, specialists and other health care providers in addition to DCF, the foster family guardians and birth parents. Care and services can be rendered in the member’s home, doctor’s office, hospital, outpatient facility, day care center or school. Per MassHealth guidelines, PCPs may contract with BMCHP to provide primary care services to these members regardless of the PCP participation with other MassHealth managed care plans or participation in any ACO. 23

Who are the Plan’s Clinical Vendors? Beacon Health Strategies Available 24/7 for members and providers. Behavioral Health Manages inpatient and outpatient behavioral health and substance use services, and will be contracting on behalf of the ACO for BH Community Partner services. Prior authorization may be required for certain services. Visit: Beacon’s website for more resources or to find a provider Call Beacon Health Strategies at: For QHP Members: 1-888-217-3501 For ACO and MCO Members: 1-877-957-5600 For SCO Members: 1-855-833-8125 Northwood Durable Medical Equipment, Prosthetics, and Orthotics Manages durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) network. Prior authorization is required for all DMEPOS dispensed and billed by a DMEPOS supplier. Visit: Northwood, Inc. Call: 866-802-6471 24

Who are the Plan’s Clinical Vendors? Express Scripts Pharmacy Benefits eviCore Manages outpatient non-emergency high end radiology (MRI, CT, PET, Nuclear Cardiology) Prior authorization may be required for certain services. Visit: eviCore (formerly MedSolutions) Call: 866-802-6471 AxisPoint Health Available 24/7 for members Nurse Advice Line An audio health library of recorded information, by topic, can be accessed through the advice line High End Radiology 25 Submit a coverage review request online through one of these ePA portals: Surescripts, CoverMyMeds, or ExpressPAth. If you do not have access to an ePA system, you may contact Express Scripts to submit your request at 877-417-1822 (for MassHealth members) or 877-417-0528 (for Qualified Health Plan members), or you can submit the General Medication Request Form Call: 866-763-4695 (ConnectorCare/QHP) Call: 800-973-6273 (MH)

Claims and Filing Limits To expedite payment, we strongly encourage you to submit claims electronically and only submit paper claims when necessary Filing Limits: MassHealth (including ACO) 150 days ConnectorCare/QHP 90 days Senior Care Options 150 days *Coordination of Benefits and other party liability rules apply Electronic Claims: BMC HealthNet Plan has partnered with TriZetto Provider Solutions (TPS) to manage our electronic data interchange (EDI) transactions exclusively. Effective September 2, 2020, all clearinghouse service organizations and billing agencies that submit EDI transactions must send through TPS. Paper Claims Mailing Address: Boston Medical Center HealthNet Plan P.O. Box 55282 Boston, MA 02205-5282 Professional Claims can also be submitted via our Online Portal @ BMCHP.org via MyHealthNet 26

Requirement for BMCHP network provider to enroll with MassHealth Changes in federal Medicaid law (set forth at 42 CFR § 438.602) require all managed care entity (MCE) network providers, including BMCHP network providers, to enroll with MassHealth. This means all BMCHP network providers must have two provider contracts in place: (1) a network provider contract with [MCE/Vendor]; and (2) a provider contract with MassHealth. MassHealth has developed the MassHealth Nonbilling Managed Care Entity (MCE) Network-only Provider Contract for MCE network providers who do not already have a provider contract with MassHealth. This specific MassHealth provider contract does not require BMCHP network providers to render services to MassHealth fee-for-service members. Visit https://www.mass.gov/forms/submit-the-masshealth-nonbilling-managedcare-entity-network-only-providercontract to complete a MassHealth Nonbilling MCE Network-only Provider Contract under this requirement within 30 days of receiving confirmation of your BMCHP enrollment. 27

Questions? Thank you! Provider Relations [email protected] 28