Path to Health/Camino A La Salud Provider Billing & Claims Training

Path to Health/Camino A La Salud Provider Billing & Claims Training Presented By Linda Boyd, AMM Director of Administration

2 Important Notice This training is specific to the Path to Health participating clinic organizations only. All Path to Health participating sites underwent a detailed application process, prior to contract eligibility with the program. If your organization is a not listed as part of the 20 Path to Health participating sites, the following training information does not apply. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Path to Health Participating Organizations: Ampla Health Clinicas de Salud del Pueblo, Inc. Coastal Alliance Communicare Health Center Community Medical Center El Dorardo Community Health Center La Clinica de la Raza Madera Community Hospital Family Health Services Marin Community Clinic Mendocino Community Health Clinics Inc. Ole Health Open Door Community Health Centers Oroville Hospital Rural Health Clinics Petaluma Health Center Ritter Center San Benito Health Foundation Santa Rosa Community Health Shasta Community Health Center Tehama County Health Services Agency Winters Healthcare Foundation

3 Meeting Logistics Questions & Answers To ask a question, you will type your question into the “Chat” box in the lower right corner of the screen and click “Send” to the Host. All questions or technical assistance issues, should be asked via the Chat box. Questions will be answered at the end of the presentation as time allows.

4 Q & A Test Using the Chat Box, please type in your name, the name of the Clinic you are representing and your email address. Please make sure to select the host, “Chris Salmon, HOST” , from the drop-down selection each time you send your Chat message. Let’s do a test run. For Example: Type & Submit “Alison, ABC Clinic, [email protected]

5 Presentation Follow Up A recording of this training will be available on August 15th at http://pathtohealth.amm.cc/Providers To access the recording, please enter the password indicated on the website.

6 Key Terms & Abbreviations Abbreviation/ Term Definition CMSP County Medical Services Program Alluma Path to Health Enrollment System Vendor AMM Advanced Medical Management - administrator for medical claims MedImpact Pharmacy Benefit Manager FPL Federal Poverty Level BIC Beneficiary Identification Card – issued by Medi-Cal PPS Prospective Payment System Camino a la Salud Path to Health in Spanish

AGENDA 1. Background & Program Overview 2. Eligibility & Enrollment 3. Member ID Card & Guide 4. Emergency Medi-Cal vs. Path to Health 5. Claims Submission 6. Turn Around Times & Expectations 7. Appeals 8. Provider Support 9. Q & A

PURPOSE 8 The mission of the Path to Health Pilot Project is to: Promote timely delivery and preventative medical services to improve health outcomes Reduce the use of emergency services and inpatient hospitalization TARGET Enable Community Health Centers to redirect resources to other needs POPULATION Up to 25,000 undocumented adults, ages 26 , resident of one of CMSP’s 35 counties Enrolled in restricted scope/emergency only Medi-Cal DURATION The Path to Health Pilot Project: Began enrolling members in February 2019 Ends on January 31, 2022 – unless extended again by the CMSP Governing Board

9 Path to Health Pilot Program Overview Pilot Program Start February 2019 Petaluma Clinic, Santa Rosa Clinic, Ampla Health, Coastal Alliance, Communicare Health Centers, Community Medical Centers, La Clinica de La Raza, Marin Community Clinics, Ole Health, San Benito Health Foundation, & Shasta Community Health Center Go-Live Additional Clinics Added Clinics Go-Live November 2019 August 2020 Ritter Center, Madera Community Hospital Family Health Services, Winters Healthcare Foundation, & Tehama County Health Services Agency Clinics GoLive Clinicas de Salud del Pueblo, Inc., Mendocino Community Health Clinic Inc., Open Door Community Health Centers & Oroville Hospital Rural Health Clinics Pilot Program End January 31, 2022

Path to Health 10 Participating Counties 20 Path to Health Clinic Organizations located in 20 of CMSP’s 35 Counties: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Butte Colusa Del Norte El Dorado Glenn Humboldt Imperial Lake Madera Marin Mendocino Napa Shasta Solano Sonoma Sutter Tehama Yolo Yuba San Benito

11 Path to Health Eligibility

12 Eligibility To enroll in Path to Health Program, a person must: Be a resident of one of CMSP’s 35 counties. Be 26 years old at the time of enrollment. Be enrolled in 1 of 30 restricted scope/ emergency only Medi-Cal Aid Codes: 1U, 3T, 55, 58, 5F, 5T, C1, C2, C3, C4, C5, C6, C7, C8, D2, D3, D4, D5, D6, D7, J3, J4, J6, J8, K3, K5, K7, K9, M2, or M4 (Medi-Cal enrollment will continue through county social services) Apply and be enrolled for Path to Health at a participating clinic location. Enrolled members will receive the Path to Health benefit for up to six months, even if their Medi-Cal aid

13 Eligibility For Undocumented Adults Income Emergency Services Coverage 0 – 138% FPL Medi-Cal 139% – 300% FPL CMSP Primary & Preventative Coverage Effective 2/2019: Path to Health with certain limitations CMSP under Primary Care Benefit with certain limitations

14 Path to Health Member ID Card Following enrollment in the Path to Health Program, the member will receive a Path to Health ID Card (issued & mailed by AMM).

15 Medi-Cal Beneficiary ID Card (BIC) The member should have also received a State of California Beneficiary Identification Card (BIC) to use for restricted-scope Medi-Cal benefits. New Version Old Version *Please note, both versions of the BIC are valid.

16 Path to Health Member Guide Members will receive a Path to Health Member Guide along with their ID Card that contains information regarding covered services and important contacts. For a full copy of the member guide, visit: https://pathtohealth.amm.cc/m

17 Eligibility Verification To complete the Path to Health enrollment process, Community Health Centers will be responsible for registering the patient’s information through the secure registration/enrollment portal maintained by the CMSP Governing Board as well as consent from the patient to participate in the Pilot Program. For eligibility support or questions, please contact the Path to Health Helpdesk at (800) 548-5880. Providers can verify eligibility via the enrollment system website or by contacting AMM Customer Service at (877) 283-PATH (7284). Members are eligible for a period of up to 6 months. Eligibility start and end dates are located on the member’s Path to Health ID Card and can be verified using the Path to Health Enrollment System. REMEMBER: Health Centers must complete and submit the User Access Request form to gain access to the Enrollment Portal. Contact [email protected] for more information.

18 Clinic Assignments Member assignments to clinics are at the clinic system level. So the member may access services at their assigned clinic’s locations if more than one. For example: Ampla Health has 12 sites participating in the pilot. The Path to Health member could be served by all 12 Ampla sites. Changing Clinic Assignment: If a member is enrolled with another clinic organization but would like to be seen within your clinic system, you must disenroll the member from their original clinic organization and re-enroll the member with the Path to Health Program under your parent organization. The new clinic assignment won’t take effect until the following day. For example: A Path to Health enrolled member comes into a Community Medical Center clinic for services but has been assigned to La Clinica de La Raza as their clinic provider. Staff at the Community Medical Center Clinic can go onto the Path to Health enrollment portal, find the member’s eligibility application, disenroll the member from La

19 Checking Medi-Cal Online Be enrolled in 1 of 30 restricted scope/ emergency only Medi-Cal Aid Codes: 1U, 3T, 55, 58, 5F, 5T, C1, C2, C3, C4, C5, C6, C7, C8, D2, D3, D4, NOTE: Medi-Cal Eligibility Message will not reference Path to Health after enrollment

20 Path to Health Covered Benefits

21 Path to Health Covered Benefits Office Visits Minor Medical Procedures Preventative Screenings Routine Lab Test Adult Immunizations Prescription Medication

Emergency Medi-Cal vs. Path to Health Benefits 22 Path to Health Services Non-Emergent Clinic Visits & Minor Medical Procedures Preventative Screenings including HIV, HPV, Hepatitis B/C, & STI Screenings Routine Lab Tests & Adult Immunizations Prescription Medications (Specialty Medications Excluded) Life Threatening Emergencies Emergency Room Visits & Emergent Medications Inpatient Hospital Admissions Related to (Services must be rendered at member’s assigned clinic organization or innetwork pharmacy in order to be payable by Path to Health) Emergenc y Medi-Cal (Excluding pregnancy circumstances. Billing & Reimbursement based on Medi-Cal Guidelines)

23 Path to Health Approved Procedure Codes Click Here for the full list of Path to Health Approved Procedure Codes: https://pathtohealth.amm.cc/Documents/Path%20to%20Health%20Approved%20Procedure%20Code%20List.pdf

24 COVID-19 TESTING As of March 4, 2020, Path to Health will provide coverage for COVID-19 diagnostic testing, not otherwise covered by MediCal, to Path to Health members at no cost. This includes no cost for any provider office visit in order to receive COVID-19 testing. Important items to note: Path to Health has added COVID-19 test codes U0001, U0002, and 87635 to the list of approved billable CPT codes for Path to Health. Diagnosis codes are to be billed in accordance with CMS ICD-10 coding guidelines. For ICD10 Guidelines:

25 Telehealth Services During the State of Emergency Retroactive to dates of service on or after March 4, 2020, Path to Health contracted health centers may provide telehealth services to Path to Health members during the COVID-19 State of Emergency in California if all of the conditions listed on the April 30, 2020 Provider Bulletin are met:

26 Telehealth Coding and Documentation 1. Thoroughly document the visit as if the visit had occurred in person, including but not limited to: Detailed patient history and complete description of the covered benefit provided An assessment/examination of the issues being raised by the patient Medical decision-making by the health care practitioner of low, moderate, or high complexity, as applicable, which should include items such as pertinent diagnosis(es) at the conclusion of the visit, and any recommendations for diagnostic studies, follow-up or treatments, including prescriptions 2. Use the appropriate CPT codes for the particular service(s) rendered. 3. Use the appropriate modifier 95, GT, or GQ. 4. Health centers are not required to use Place of Service 02.

27 Telehealth Corrected Claims Submitting Corrected Telehealth Claims: If health centers have already submitted telehealth claims to Path to Health without using any telehealth modifiers, please resubmit corrected claims that include telehealth modifiers to AMM. Paper UB-04 Claims: Please indicate “Corrected Claim” on the claim preferably in box 80 (remarks) and enter the value of 7 (replacement of prior claims) in the third digit of the Type of Bill [XX7] in Box 4. Add the appropriate telehealth modifier to the professional service CPT or HCPCS code (for example, 99214-95 or 99213GQ). Electronic 837I submissions: Resubmit including the appropriate telehealth modifier and indicate a “Corrected Claim.” For more details to the above, reference the Provider Bulletin dated April 30,

28 Path to Health Pharmacy Benefits Covered medications are available at a 5 copayment per prescription and prescription coverage is limited to a maximum of 500 per claim and a 1500 maximum benefit per Path to Health enrollment period. For questions regarding covered prescription drugs, or If you require assistance with pharmacy billing, please contact: MedImpact Customer Service (800) 788-2949 To access the full prescription drug formulary and list of participating pharmacies, visit https://mypathtohealth.org/resources/

Non-Covered Services 29 Please Note the Following Services are NOT covered under the Path to Health Program, therefore they will NOT be eligible for reimbursement: Any medical service provided at a location other than member’s assigned clinic Acupuncture, including podiatry-related acupuncture services Methadone Maintenance Services Breast and Cervical Cancer treatment services Optometry services and eye appliances Chiropractic care Public transportation Cosmetic procedures Dental services Services by a Psychologist, LCSW, MFT or substance use disorder counselor Family planning services (including contraceptives and family planning counseling and education) Pregnancy-related and infertility services (including abortions) ***Post-Partum Services are only covered 60 days after the pregnancy delivery date; please supply medical records when submitting claims to verify the delivery date.

30 Additional Resources For Contraceptives & Family Planning Services, please contact: Family PACT (916) 650-0414 For Pregnancy-Related Services, please contact: Medi-Cal (800) 541-5555 For Breast and Cervical Cancer Screening Services, please contact: Every Woman Counts (916) 449-5300 For Breast and Cervical Cancer Treatment Services, please contact: Breast & Cervical Cancer Treatment Program (BCCTP) (800) 824-0088

31 Path to Health Claims Submission

32 Reimbursement Rates Clinics will be reimbursed at their corresponding PPS rate for each qualifying visit for a Path to Health member. Services must be rendered by the member’s assigned clinic organization and must be on the pre-approved list of codes in order to be reimbursable. Reminder: The Path to Health Approved Procedure Code List is available online:

33 Path to Health Claims Submission Claims must be submitted on a UB-04 Claim Form. **Please Note: Claims submitted on CMS-1500 Claim Form will be denied as an invalid claim form. Claims must be submitted using member’s Path to Health ID Number (Same as the 9-digit Medi-Cal CIN) Claims can be submitted electronically (preferred) or via mail Timely Filing of Claims First Time Claims Submission – 150 Calendar Days from the Date of Service

34 Paper Claim Submissions Submit Paper Claims to: Path to Health - Advanced Medical Management, Inc. Attn: Claims Department 5000 Airport Plaza Dr., Suite 150 Long Beach, CA 90815-1260

35 Electronic Claim Submissions Submit Electronic Claims to any of the following Clearinghouses: Office Ally – www.officeally.com Support Phone #: (360) 975-7000 Opt. 1 Payer ID: AMM15 Emdeon/Change – https://cda.changehealthcare.com/portal Support Phone #: (888) 363-3361 Payer ID: CMSP1 Claimremedi – https://claimremedi.providersportal.com Support Phone #: (800) 763-8484 Payer ID: CMSP Gateway/Trizetto - http://www.trizetto.com Support Phone #: (800) 556-2231 Payer ID: UMM15

36 Checking Claims Status You can check the status of your submitted claims using the AMM Claims Manager. To Register, visit https://claims.amm.cc/Register.aspx Please allow 24 hours for your account to be approved after registering. Once approved, visit https://claims.amm.cc/Login.aspx to check on the status of your claims.

37 Claims Appeals Appeal forms can be found at: http://pathtohealth.amm.cc/providers Appeals must be faxed or mailed within 60 business days from the claim denial date. Fax 562-766-2007 Mail or CMSP – Advanced Medical Management, Inc. Attn: Claims Department 5000 Airport Plaza Drive, Suite 150 Long Beach, CA 90815-1260

38 Path to Health Important Contacts

39 Key Websites For more information regarding the Path to Health Program, visit: www.caminoalasalud.org www.mypathtohealth.org https://pathtohealth.amm.cc

40 Provider Materials Packet A packet containing Path to Health related materials will be emailed to each of the sites upon joining the Included program in the Packet: A copy of the Member Guide The Provider Operations Manual The Path to Health Pre-Approved Procedure Code List Additional Path to Health materials

41 Important Contact Information AMM Customer Service CMSP /Path to Health Third Party Administrator (877) 283-PATH (7284) https://pathtohealth.amm.cc/Contact MedImpact Customer Service Path to Health Pharmacy Services Administrator (800) 788-2949

42 Q&A To ask a question, you will type your question into the “Chat” box in the lower right corner of the screen and click “Send” to Chris Salmon, Host.

43 Thank you for Attending !