Provider Bulletin | May 2010

Welcome to the May edition of the Provider Bulletin. In this edition, you will find useful information to ensure you’re compliant with HIPAA privacy and security rules, tips to help your claims get processed as quickly as possible and upcoming training available for providers.

If you have any comments or questions, send them to provider.bulletin@communitycareinc.org.

Complying With HIPAA Privacy And Security Rules

We’re all familiar with HIPAA privacy and security rules since we work in the field of health care. However, what may be news to you is the recent expansion of this Act signed into law with the American Recovery and Reinvestment Act of 2009. As a provider of services to Community Care members, these new rules apply to you.

The name of this new Act is HITECH which stands for Health Information Technology for Economic Clinical Health Act. There are two main elements of this Act currently in effect: enforcement and breach notifications. It has been widely known that enforcement of HIPAA rules in the past have been lax. Under HITECH, mandatory penalties will be imposed for “willful neglect.” Defining “willful neglect” will likely be done on a case-by-case basis, but having a patient privacy and security process in place can help you identify possible areas where measures need to be improved.

A breach is the use or disclosure in violation of HIPAA that compromises the security or privacy of the protected health information and poses a significant risk of financial, reputational, or other harm to the affected individual. This new Act requires providers to notify patients of any unsecured breach and depending on the number of patients affected, HHS and the media may also need to be notified.

Who does this impact?
You, as a provider of services to Community Care members.

What does this mean for you?
The HITECH Act creates more rights for individuals and additional obligations for you. The Act also increases the penalties that may be imposed for non-compliance and violations of the privacy and security provisions.

Complying with these new requirements.
In response to this new Act, you should have policies and procedures that address your protected health information (PHI), security processes for use and disposal of electronic PHI, and the hardware and software on which it is stored. You should also have written processes in place to notify Community Care if you discover a breach and provide training to your staff so that they are aware of your new obligations under HIPAA and the HITECH Act.

How can you develop or update your policies and procedures?
If you haven’t developed policies and procedures to ensure the security and privacy of protected health information or need to reevaluate the effectiveness of your current policies, information from the U.S. Department of Health and Human Services is available here.

It is important that you stay informed of how the new rules will affect your organization. The information covered here is not legal advice, just a brief overview of the HITECH Act. Click here for more information about the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic Clinical Health Act (HITECH Act).

Advances In Member Services Enhance Member Care

To continue enhancing member care, Community Care has made improvements to member services in the PACE and Partnership programs. Members have been informed of these changes and teams will keep them up-to-date. Changes include:

Team and care planning improvements:
• Nurses and social workers will be paired up. This may cause some members to have a change in their team members, but will not affect their care plan or services. In the long run, we believe that teams will be able to respond even better to members’ needs.
• Members will be asked more questions during the care planning process, which will help us in supporting their goals.

Scheduling improvements:
• We are using a new computerized system, which will help improve scheduling appointments for services provided at our Community Care clinics and day centers. It will also help Community Care staff track member availability for appointments and visits.
• We will offer appointments earlier and later in the day, and will work with members to schedule a day and time that works best for them.

Other improvements:
• Members will be able to contact the pharmacy directly for refills.

Why Is My Claim Denied Or Delayed? (part 2)

Two common reasons that claims are denied, delayed or paid incorrectly are:

1. Claim submitted with Procedure Codes or incorrect rates not listed on your current Contract or Letter of Agreement.
Community Care shall pay Provider for services that are approved for payment by the Community Care Management Team in accordance with the Letter of Agreement.

*If you have questions regarding proper claim submission or your current contract and/or Letter of Agreement, please contact our Provider Hotline at 1-866-937-2783.

2. Claims submitted in the improper format.
Section 3.1(B): Provider shall submit invoices on a form or in a format approved by Community Care. Currently you have options on claim submission. They are as follows:
• E-Form Claim Submission - Non Medical Services Only (Preferred method of submission)
• Electronic Data Exchange - HCFA 1500 and UB04
• Community Care approved Paper Claim Form (Only for providers without internet access)

Do you want to receive your claim reimbursement faster?
Try E-forms! E-form claim submission will speed up the time it takes from submission to reimbursement an average of 3-5 days. If you are interested, email us. If you have questions regarding member eligibility or claims contact the Provider Hotline at 1-866-937-2783.

Provider Claims Education Training Schedule

Community Care conducts claims education training to providers on a monthly basis. You are welcome to attend any of the sessions listed below. Current and new non-medical providers are welcome.

Waukesha County Site
When: May 20, 2010 and June 17, 2010
Time: 1:00 to 3:00 p.m.
Where: Community Care, 1801 Dolphin Drive, Waukesha, WI 53186

Additional training sessions will be provided in other counties on future dates. If you have any questions, or would like to sign up for a session, email us.