Pharmacy Claims Optum Rx (through 2020) Medi-Cal Rx (effective 2021) BIN 610011 BIN 022659 PCN GCHP PCN 6334225 Group GCHP Group N/A Updated Email Addresses: Provider RelationsProviderRelations@goldchp.org Provider ContractingProviderContracting@goldchp.org Provider demographic updates < email tbd >
Updated Provider Manual . ... Effective January 1, 2021, new members and members requesting a new member ID ... pharmacy benefits as of January 1, 2021.
Enterprise Transformation Initiatives 2020 Provider Resource Guide This multi-part guide will inform providers about the changes prompted by Gold Coast Health Plan's Enterprise Transformation initiatives. 2 Enterprise Transformation Initiatives Introduction Gold Coast Health Plan (GCHP) is transitioning two health care information systems enabling health plan operations: · Claims administration system · Provider credentialing and contracting management system These transitions will be effective December 14, 2020. We developed this guide to inform you of changes that will be visible to you as a provider who is contracted with GCHP and to help you navigate these changes. In each section, we have recommended action steps that you will want to consider when preparing for these changes. We will notify you of any additional updates and will provide new content for this Resource Guide as appropriate. In addition to this Resource Guide, the latest information regarding GCHP's systems' transitions can be found on our website. We understand that there are many changes and hope this Resource Guide enables you to take necessary action to embrace them. We appreciate the value you provide and your commitment as we work together. If you have questions about any of the information provided in this guide, please contact us at ProviderRelations@goldchp.org. Thank you! Gold Coast Health Plan Provider Relations Team Gold Coast Health Plan Provider Resource Guide 2020 3 Table of Contents Changes to GCHP Contact Information..................................................................................................................................................... 4 Changes to GCHP Provider Identification Numbers............................................................................................................................. 5 Changes to GCHP Member Identification Numbers and Cards...................................................................................................... 6 Changes to Provider Contracting................................................................................................................................................................... 9 Changes to Provider Directory.....................................................................................................................................................................10 Changes to Enrollment and Eligibility Verification.................................................................................................................................11 Changes to Provider Portal.............................................................................................................................................................................12 Changes to Claims Submission......................................................................................................................................................................14 Changes to Claims Processing........................................................................................................................................................................15 Changes to Provider Customer Service / Relations.............................................................................................................................17 Changes to Encounter Data Submission...................................................................................................................................................18 Changes to Delegation Oversight Documents.......................................................................................................................................19 Changes to Utilization Management: Authorization Letters, Processing and Reporting......................................................20 Changes to Authorization Request Forms...............................................................................................................................................21 Changes to Pharmacy Services......................................................................................................................................................................22 Updated Provider Manual.................................................................................................................................................................................24 Managed Care Accountability Set (MCAS) / Healthcare Effectiveness Data and Information Set (HEDIS)................25 www.goldcoasthealthplan.org 4 Enterprise Transformation Initiatives Changes to GCHP Contact Information Effective December 14, 2020 Updated Web URLs: GCHP Website GCHP 2020 Claims System Change Website Provider Portal Forms www.goldcoasthealthplan.org https://www.goldcoasthealthplan.org/for-providers/providerupdates/2020-claims-system-change/ < url tbd > < url tbd > Updated Claims Mailing Addresses: Medical Claims Gold Coast HealthPlan ATTN: Claims P.O. Box 9152 Oxnard, CA 93031 Pharmacy Claims Optum Rx (through 2020) BIN 610011 PCN GCHP Group GCHP Medi-Cal Rx (effective 2021) BIN 022659 PCN 6334225 Group N/A Updated Email Addresses: Provider Relations Provider Contracting Provider demographic updates Encounter data operations team Electronic Funds Transfer (EFT) or ERA enrollment questions Appeals and Grievances ProviderRelations@goldchp.org ProviderContracting@goldchp.org < email tbd > EncounterData@goldchp.org < email tbd > < email tbd > Updated Phone Numbers: Dedicated Provider Line Advice Nurse Line (888) 301-1228 (805) 437-5001 or (877) 431-1700 (toll free) Those who use a TTY should call 711. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 5 Changes to GCHP Provider Identification Numbers Effective December 14, 2020 We will issue new Provider Identification Numbers to all providers. Providers will be sent an email informing them of their new Provider ID and providing them with instructions to create a new user account enabling access to GCHP's new Provider Portal. See the "Changes to Provider Portal" section for more information. Effective December 14, 2020, all providers will have one valid Provider ID. Provider IDs are used to access the new GCHP Provider Portal. On or after December 7, 2020, providers may contact GCHP Customer Service to obtain their new Provider ID. Provider ID Distribution: Change A new provider ID will be issued to all providers. Action Required Use the new Provider ID to access the new GCHP Provider Portal. Return to the Table of Contents | www.goldcoasthealthplan.org 6 Enterprise Transformation Initiatives Changes to GCHP Member Identification Numbers and Cards Effective January 1, 2021 GCHP Member Identification Numbers will not be changing. However, the GCHP Member Identification Cards will be changing. Effective January 1, 2021, new members and members requesting a new member ID card will receive the newly formatted member ID card. In late December 2020, all GCHP members will be sent newly formatted member ID cards. · Changes to Member ID Cards: » Removal of PBM / Pharmacy information Prompted by the state Department of Health Care Services (DHCS) Medi-Cal Rx initiative, OptumRx's information has been removed from the member ID card since GCHP will no longer be responsible for pharmacy benefits as of January 1, 2021. See https://medi-calrx.dhcs.ca.gov/home/ for more information regarding Medi-Cal Rx. » Updated phone numbers The phone number for the 24/7 Advice Nurse Line has been added to the card. TTY numbers for Member Services and GCHP's partners, such as Beacon Health Options and Vision Service Plan (VSP), have been added to the card. · Changes to cover letter accompanying Member ID cards: » The cover letter accompanying the Member ID Cards will change slightly when all members are provided newly formatted member ID cards. Please note that the design of the final ID cards may vary slightly from the mockups on the following pages. Gold Coast Health Plan | Return to the Table of Contents Current GCHP Member ID Card Front and Back Provider Resource Guide 2020 7 Member Name: Member ID#: Effective Date: PCP Name: PCP Phone: Rx Bin: 610011 Rx PCN: GCHP This card does not prove eligibility nor guarantee coverage. Emergency services provided to plan members will be reimbursed by Gold Coast Health Plan (GCHP) without prior authorization. Please notify the PCP on the front of this card within 24 hours of emergency treatment. Please call the health plan at 888-301-1228 for information about authorizations. GCHP is a Medi-Cal Health Plan. MEMBERS PROVIDERS Member Services: 1-888-301-1228 Claims Address: Pharmacy: OptumRx 1-855-297-2870 Gold Coast Health Plan Vision: VSP 1-800-877-7195 P.O. Box 9152 Behavioral Health: Beacon 1-855-765-9702 Oxnard, CA 93031 Prior Authorization Fax Number: 888-310-3660 www.GoldCoastHealthPlan.org Return to the Table of Contents | www.goldcoasthealthplan.org Member Services: 1-888-301-1228 Claims Address: Pharmacy: OptumRx 1-855-297-2870 Gold Coast Health Plan Vision: VSP 1-800-877-7195 P.O. Box 9152 Behavioral Health: Beacon 1-855-765-9702 Oxnard, CA 93031 8 Enterprise Transformation Initiatives Prior Authorization Fax Number: 888-310-3660 www.GoldCoastHealthPlan.org New GCHP Member ID Card Front and Back Required Actions: Action Inform all staff about the new Member ID Card. How Use the information cited above to train staff. When As soon as possible. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 9 Changes to Provider Contracting Effective December 14, 2020 There are some changes to the contracting of providers administered by GCHP. · What changed: » DHCS / Medi-Cal converted Local Codes may no longer be billed. Provider contracts containing the affected Local Codes have been updated to contain the acceptable codes. Valid DHCS / Medi-Cal Local Codes can be accessed at: https://files.medi-cal.ca.gov/pubsdoco/hipaacorrelations_home.aspx » Pharmacies no longer need to contract with GCHP's Pharmacy Benefit Manager, OptumRx. Any pharmacy wishing to fill prescriptions for GCHP members must enroll with DHCS. See < url tbd > for more information. » GCHP is using a new information system, eVIPS, for provider credentialing (Effective Quarter 1, 2021). Providers may view and update their demographics via a new system called eApply, which may be accessed via https://gchpeapply.evips.com/Prod. Providers may view the status of their credentialing application via a new system called eStatus, which may be accessed via https://gchpestatus.evips.com/Prod. · What did not change: » The way you communicate with GCHP will remain the same, which is through ProviderRelations@goldchp.org or the dedicated Provider Line: (888) 301-1228. Required Actions: Action Inform all impacted staff of the changes outlined above. Discontinue billing for DHCS converted Local Codes. How Use this document and updated provider contract(s) to train staff. Review updated contract(s) for affected Local Codes. When As soon as possible. As soon as possible. Return to the Table of Contents | www.goldcoasthealthplan.org 10 Enterprise Transformation Initiatives Changes to Provider Directory Effective December 14, 2020 GCHP's online Provider Directory will not be changing. · What changed: » GCHP's online provider search capability is being updated to provide enhanced search capabilities. · What did not change: » GCHP's online Provider Directory will continue to be updated monthly. Required Actions: Action Inform staff of the changes outlined above. How Use this document to train staff. When As soon as possible. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 11 Changes to Enrollment and Eligibility Verification Effective December 14, 2020 GCHP is introducing a new Provider Portal through which member enrollment and eligibility may be verified. Providers will need to establish new user accounts in order to access the new Provider Portal. Instructions are provided below. · What changed: » GCHP is introducing a new Provider Portal through which providers can perform many functions including member enrollment and eligibility verification. See the "Changes to Provider Portal" section for more information. · What did not change: » Providers may continue verifying member enrollment and eligibility via the dedicated Provider Line: (888) 301-1228. Required Actions: Action Inform all impacted staff of the changes outlined above. Participate in upcoming online training sessions to be scheduled and conducted by GCHP. Register to create a new user account to gain access to the new Provider Portal. How Use this document to train staff. Keep an eye out for future notices of online training sessions. See < url tbd > When As soon as possible. Per dates cited in future notices. Beginning in early December 2020. Return to the Table of Contents | www.goldcoasthealthplan.org 12 Enterprise Transformation Initiatives Changes to Provider Portal Effective December 14, 2020 GCHP is introducing a new Provider Portal through which providers can perform many functions, including member enrollment and eligibility verification, claims status verification, and the submission of prior authorizations and referrals. Effective December 14, 2020, access to the existing GCHP Provider Portal will no longer be permitted. Providers will need to establish new user accounts in order to access the new Provider Portal. Instructions are provided below. · What changed: » GCHP is introducing a new Provider Portal. Detailed information regarding the new Provider Portal, including instructions on how to access it and create a new user account will be available on GCHP's website see < url tbd >. Providers must establish a new user account(s) in order to access the new Provider Portal as follows: All providers will be issued a new, single Provider ID to be used to access the new Provider Portal. See the "Changes to GCHP Provider Identification Numbers" section for more information. In early December 2020, providers will be sent emails with their new Provider ID and an Access Code, along with instructions to create a new user account for the new Provider Portal. After establishing a new user account, providers may log into the new Provider Portal via < url tbd > » The new Provider Portal online user experience will be different than the experience providers have been accustomed to. However, similar capabilities are available within the new Provider Portal e.g., Member enrollment and eligibility verification Claims status verification Note: Historical claims with dates of service from July 1, 2018 onward may be viewed within the new Provider Portal. Submission of prior authorizations and referrals and related status verification Note: The ability to enter five or more procedure codes when submitting an authorization and the ability to add associated attachments to an authorization in PDF format persist. » Provider communications can be viewed in the Provider Portal. · What did not change: » Current services and functions available in the Provider Portal (e.g., eligibility verification, claims status). » Provider Login Assignment Form is available for new providers to request access see < url tbd >. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 13 Required Actions: Action Inform all impacted staff of the changes outlined above. Participate in forthcoming online training sessions to be scheduled and conducted by GCHP. Register to create a new user account to gain access to the new Provider Portal. How Use this document to train staff. Keep an eye out for future notices of online training sessions. See < url tbd > When As soon as possible. Per dates cited in future notices. Beginning in early December 2020. Return to the Table of Contents | www.goldcoasthealthplan.org 14 Enterprise Transformation Initiatives Changes to Claims Submission Effective December 14, 2020 There are some changes regarding the submission of claims to GCHP as summarized below. · What changed: » The 25-1 Long-Term Care (LTC) claim form will no longer be accepted effective December 14, 2020. All LTC services must be billed on the UB-04 claim form or via a HIPAA 5010 837i. » Converted DHCS / Medi-Cal Local Codes will no longer be accepted after December 14, 2020 regardless of the date of service. Provider contracts containing the affected Local Codes have been updated to contain the acceptable codes. · What did not change: » The clearinghouses through which electronic claims may be submitted to GCHP. » Claims mailing address: Gold Coast Health Plan ATTN: Claims P.O. Box 9152 Oxnard, CA 93031 Note: GCHP has informed the clearinghouses used by our contracted providers of necessary changes and related implications. Required Actions: Action Inform all impacted staff of the changes outlined above. Discontinue billing for affected Local Codes. How Use this document and updated provider contract(s) to train staff. Review updated contract(s) for affected Local Codes. When As soon as possible. As soon as possible. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 15 Changes to Claims Processing Effective December 14, 2020 There are some changes regarding the processing (adjudication) of claims. · What changed: » Share of Cost Member Share of Cost validation will be applied during claims adjudication. If the Share of Cost has not been met per the Medi-Cal eligibility validation, the claim will be denied. » Explanation of Benefits Timely Filing Requirements Payment reduction penalties will be applied if a claim is submitted 7-12 months from the date of service or discharge date on an inpatient claim (UB-04). Months 7-9 will reimburse 75% of allowable covered charges. Months 10-12 will reimburse 50% of allowable covered charges. Claims submitted more than one year from the date of service or discharge date on an inpatient claim (on the 366th day) will not be paid. » DHCS / Medi-Cal Local Codes Converted DHCS / Medi-Cal Local Codes will no longer be accepted after December 14, 2020 regardless of the date of service. Provider contracts containing the affected Local Codes have been updated to contain the acceptable codes. » Denial Reason Codes Denial verbiage has been updated to provide a more detailed description of the denial reason(s). Explanation of Benefit codes have changed » Provider Identification Number Medicare Crossover Claims will no longer appear on a separate explanation of benefits / check / EFT. » Claim Number The claim number will change format from a 12-digit number to a shorter number. » Claim Rejection Letter The claim rejection letter has been updated to further describe the reason for the rejection » National Correct Coding Initiative (NCCI) Edits Update Our claim editing system has been updated to reflect the most current Medi-Cal specific NCCI edits. These edits include, but are not limited to, the following: Procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedure Terminology (CPT) codes that should not be reported together for a variety of reasons; and Medically Unlikely Edits (MUE), which are units of service edits that define for each HCPCS / CPT code identified the allowable number of units of service; units of service in excess of this value are not feasible for the procedure under normal conditions (e.g., claims for excision of more than one gall bladder or more than one appendix). · What did not change: » Share of Cost billing requirements for CMS1500 and UB04 claims and EDI equivalent Note: GCHP has informed the clearinghouses used by our contracted providers of necessary changes and related implications. Return to the Table of Contents | www.goldcoasthealthplan.org 16 Enterprise Transformation Initiatives Required Actions: Action Inform all impacted staff of the changes outlined above. Discontinue billing for affected Local Codes. Ensure that claims are submitted within six months after the date of service or discharge. How Use this document and updated provider contract(s) to train staff. Review updated contract(s) for affected Local Codes. Use this document and updated provider contract(s) to train staff. When As soon as possible. As soon as possible. As soon as possible. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 17 Changes to Provider Customer Service / Relations Effective December 14, 2020 There are no changes regarding Provider Customer Service administered by GCHP. · What changed: » N/A · What did not change: » You may contact us at ProviderRelations@goldchp.org or via the dedicated Provider Line: (888) 301-1228. Required Actions: Action No action required. How N/A When N/A Return to the Table of Contents | www.goldcoasthealthplan.org 18 Enterprise Transformation Initiatives Changes to Encounter Data Submission Effective December 14, 2020 There are several changes to encounter data and encounter data submission prompted by the systems transition. · What changed: » Encounter data may only be submitted through the following clearinghouses: Office Ally: Encounter Payer ID - EC1CA Conduent EDI Gateway » Converted Local Codes will no longer be accepted after December 14, 2020 This applies to any encounters submitted after December 14, 2020 regardless of date of service or date of discharge. · What did not change: » Contact information for our Encounter Data Team: EncounterData@goldchp.org. » Encounter data submission timeliness requirements. Required Actions: Action Inform all impacted staff of the changes outlined above. Discontinue submitting DHCS / Medi-Cal converted Local Codes. How Use this document and updated provider contract(s) to train staff. Review updated contract(s) for affected Local Codes. When As soon as possible. As soon as possible. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 19 Changes to Delegation Oversight Documents Effective December 14, 2020 There are changes to delegation oversight compliance documents that must be submitted to GCHP. · What changed: » TBD · What did not change: » Contact information and primary points of contact. GCHP will continue to have a dedicated delegation oversight team. » Delegation oversight requirements remain unchanged based on your contract. Audit requests and other forms will be posted on our website at: < url tbd > Required Actions: Action How Review these forms with staff responsible for submitting compliance forms. Use these forms as a resource and distribute accordingly. When As soon as possible. Return to the Table of Contents | www.goldcoasthealthplan.org 20 Enterprise Transformation Initiatives Changes to Utilization Management: Authorization Letters, Processing and Reporting Effective December 14, 2020 There are no changes to the Utilization Management process. · What changed: » GCHP is introducing a new Provider Portal through which providers can perform many functions, including the submission of outpatient prior authorizations. See the "Changes to Provider Portal" section for more information. · What did not change: » Only outpatient authorizations may be submitted via the Provider Portal. All requests for inpatient services must be submitted via fax. » Requests for any type of authorization may still be submitted via fax using our prior authorization form available here. Required Actions: Action No action required. Participate in forthcoming online training sessions to be scheduled and conducted by GCHP. Register to create a new user account to gain access to the new Provider Portal. How N/A Keep an eye out for future notices of online training sessions. See < url tbd > When N/A Per dates cited in future notices. Beginning in early December 2020. Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 21 Changes to Authorization Request Forms Effective December 14, 2020 There are no changes to GCHP's authorization request forms. The authorization request forms remain accessible on our website here. Required Actions: Action No action required. How N/A When N/A Return to the Table of Contents | www.goldcoasthealthplan.org 22 Enterprise Transformation Initiatives Changes to Pharmacy Services Effective January 1, 2021 There are changes to the administration of pharmacy benefits prompted by DHCS' Medi-Cal Rx initiative. DHCS and GCHP will begin informing stakeholders of this change as follows: Date August 2020 September 2020 October 2020 November 2020 December 2020 Early 2021 Audience Providers and Pharmacies Providers and Pharmacies Pharmacies and Members Pharmacies and Members Pharmacies and Members Members Topic Training announcements and instructions 120-day pharmacy transition 90-day notice letter 60-day notice letter 30-day notice letter New Member ID Cards Visit https://medi-calrx.dhcs.ca.gov/home/ for more information regarding DHCS' Medi-Cal Rx initiative, including details regarding the transition policy, prior authorizations, and appeals. · What changed: » Effective January 1, 2021, responsibilities regarding the administration of Pharmacy benefits will change as follows: Responsibility Maintain Medi-Cal Pharmacy Policy Make Final Determination on PAs Denials and SFH Negotiation of Rebates Pharmacy Reimbursement Methodology Pharmacy Network Care Coordination Oversee pharmacy adherence and disease / medication management programs Pharmacy Services billed on medical / institutional claims Participate in the DUR Board Pharmacy claim administration, processing and payment Coordination of Benefits with OHI Utilization Management (including all PAs with 24 hours) Prospective and Retrospective DUR Drug Rebate Administration State X X X X X GCHP X X X X Medi-Cal Rx X X X X X Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 23 Line of business / network and claims processing information Retail Pharmacy Network Mail Service Pharmacy Specialty Pharmacy Medi-Cal Rx BIN 022659 PCN 6334225 Group N/A Medi-Cal Rx Network Medi-Cal Rx Network Medi-Cal Rx Network · New phone number for prescription eligibility and prior authorization issues: (800) 977-2273. · New pharmacy portal for eligibility verification and/or prior authorization submission and status: www.Medi-CalRx.dhcs.ca.gov. · Pharmaceuticals billed on medical claims are not affected by this change; this change only affects pharmacy claims. Required Actions: Action Review this information with staff responsible for pharmacy services. How Use this information as a resource and distribute accordingly. When As soon as possible. Return to the Table of Contents | www.goldcoasthealthplan.org 24 Enterprise Transformation Initiatives Updated Provider Manual Effective Quarter 1, 2021 We continually update GCHP's Provider Manual when warranted. The purpose of the Provider Manual is to provide guidance for the provision of covered health care services to GCHP Members. GCHP's Provider Manual contains policies, procedures, information on quality and utilization management, encounter reporting, health education, member and provider grievances, and other administrative guidelines to comply with state and federal regulations, which have been updated. · What changed: » The GCHP Provider Manual will be updated with the information cited herein in Quarter 1, 2021. GCHP's Provider Manual can be accessed and downloaded on our website here and within the new Provider Portal. Required Actions: Action Download updated provider manual(s) and review for any changes that may impact you. How Access the link above to download updated provider manuals. When In Quarter 1, 2021 Gold Coast Health Plan | Return to the Table of Contents Provider Resource Guide 2020 25 Managed Care Accountability Set (MCAS) / Healthcare Effectiveness Data and Information Set (HEDIS) There are no changes to the processes for measuring and reporting performance measures, called the Managed Care Accountability Set (MCAS). MCAS measures are derived from select Centers for Medicare and Medicaid Services (CMS) Adult and Child Health Care Quality Measures for Medicaid, as well as the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. MCAS Resources Providers can find MCAS resources on the GCHP website. Materials include MCAS Frequently Asked Questions, MCAS Measures Quick Reference Guide, and tip-sheets for MCAS measure specifications. Providers can download these materials here. Required Actions: Action Continue with MCAS / HEDIS reporting processes. How See above. When N/A Return to the Table of Contents | www.goldcoasthealthplan.org 26 Enterprise Transformation Initiatives Notes: Gold Coast Health Plan | Return to the Table of Contents Notes: Provider Resource Guide 2020 27 Return to the Table of Contents | www.goldcoasthealthplan.org 711 East Daily Drive, Suite 106 Camarillo, CA 93010-6082 www.goldcoasthealthplan.orgAdobe PDF Library 15.0 Adobe InDesign 16.0 (Macintosh)