| |
| |
| Q1 2025 PROVIDER NEWSLETTER | |
| |
FROM STEPHEN SCHNEIDER, ASSISTANT VICE PRESIDENT, NETWORK DEVELOPMENT & PROVIDER RELATIONS | |
| |
At Partners Health Plan (PHP), we believe partnership is key to achieving optimal outcomes for the individuals we mutually support. As your Provider Relations team, we serve as your primary point of contact for all provider-related needs, ensuring you have the resources to navigate managed care effectively. | | | |
We are also responsible for capturing the necessary data to make sure that each of our members is receiving high-quality care and support tailored to their unique needs.
We offer 24/7 assistance for our network of providers. Whether you have administrative queries, need assistance with a claim or have questions about credentialing, we’re here to help! - You can find important resources, forms and guidelines for providers in the PHP network on our website.
- The 2025 PHP Provider Manual offers comprehensive guidance on working with PHP, covering key policies, procedures and contact details for internal and external support (more details below).
Our Provider Relations team also plays an active role in PHP’s education and advocacy efforts. We regularly host webinars where providers can learn, share insights and get up-to-date information on best practices for serving the intellectual and/or developmental disabilities (IDD) population.
The more we connect and exchange knowledge, the better we can work together to support our members. On behalf of our entire Provider Relations team, we look forward to partnering with you in the coming year to enhance care, strengthen collaboration and promote the health and wellness of the individuals we serve. If you have questions, you can contact us by calling 1-855-747-5483 or emailing providerrelations@phpcares.org. | |
| |
| |
| |
The Provider Manual is a key resource and offers easy access to information on partnering with PHP. If you have a question, problem or concern that the Provider Manual does not fully address, please call our Provider Services staff at 1-855-747-5483 or email us at providerrelations@phpcares.org. | | | |
PHP will update the Provider Manual at least annually and distribute bulletins as needed to alert you about any changes. Please check our website for the most up-to-date version of the Provider Manual at www.phpcares.org.
The PHP Provider Manual is available in hard copy form at no charge by contacting our Provider Relations Department. | |
| |
| |
| |
| |
| |
New York’s Consumer Directed Personal Assistance Program (CDPAP) is making some changes that impact PHP members enrolled in the CDPAP. Starting March 28, one organization, Public Partnerships LLC (PPL), will now manage the program as Fiscal Intermediary.
If any of your patients are currently part of CDPAP, they and their personal assistant(s) must register with PPL by March 28. They can register by phone or online. This change will not immediately impact their care plan, service hours, or the right to choose a personal assistant(s). However, fewer home care organizations will be working with PPL, so you should refer to the updated list of agencies on the PPL website.
Please be aware of the risk of misinformation and possible scams related to this change. There are no fees to make the required changes. Individuals impacted should not have to pay anything or adjust or remove Medicaid status codes. Encourage patients to seek out information from trusted sources such as PPL, their care managers or the New York State Department of Health.
As a provider, you can help ease this transition for patients by informing them of this change and directing them to PPL for registration and further details.
To contact PPL, patients can email NYCDPAP@pplfirst.com or call their support center at 1-833-247-5346 (TTY: 1-833-204-9042). | |
| |
New address for Utilization Management/Authorizations and Appeals | |
PHP Care Complete FIDA-IDD Plan
Utilization Management
4700 McCorkle Avenue SE, Suite 104
Charleston, WV 25304-1922 | |
| |
| |
Some of your members may be eligible to access Enable Dental, a mobile dental services provider. Enable offers dental exams, cleanings, x-rays, extractions, dentures, night guards, fillings, hygiene instruction, crowns and more. Because Enable uses portable technology, they can treat members in home and community environments. Have eligible members contact their care management team if they would like to schedule an appointment.
Enable Dental Testimonial for Use “Enable Dental is easily accessible for homebound individuals. They respond quickly to concerns and are genuinely open to feedback. Enable Dental ensures vulnerable populations have access to much-needed dental care.” -Danielle G., Family Member. | |
| |
| |
As of January 1, 2025, BeneCare is PHP’s new dental provider. Given that BeneCare has worked with us in the past, we anticipate a smooth transition for both providers and the individuals we support.
You should have received direct communications from BeneCare and PHP’s previous member dental program provider, DentaQuest, about the necessary next steps. If you have questions or need additional support contracting with BeneCare, don’t hesitate to contact your Provider Relations account manager. | |
| |
HEDIS & PREVENTATIVE SERVICES
| |
| |
HEDIS: What is HEDIS, and how can you help? | |
The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of measures used to evaluate the quality of care — or how well health plan members are being cared for each year. These measures cover everything from preventive care to managing chronic conditions, medication adherence and ensuring members have access to the right services.
Every year, PHP is required to submit HEDIS data to show how well we’re doing in these areas and to meet national quality standards. As we approach HEDIS season, we want to make you aware that PHP is contracted with the HEDIS vendor, Cotiviti, who may be contacting your practice to request medical records. This process will begin in February and continue through the end of April. These record requests and fulfillments are a critical component in helping us to demonstrate the quality of care provided for our IDD population.
The requested records will primarily focus on important health measures, including blood pressure screenings, A1c values, eye exams, functional assessments, pain assessments and medication reviews. We understand that fulfilling these requests takes time, and we truly appreciate your collaboration in this process. Your participation is essential in ensuring that we can continue to improve care and outcomes for the individuals we serve. If you have any questions or need assistance during this time, please don’t hesitate to reach out.
Thank you for your ongoing dedication and partnership. | |
| |
| |
PHP will soon be reaching out to providers with important materials designed to support comprehensive patient care and ensure accurate documentation for Centers for Medicare and Medicaid Services (CMS) reporting.
Each year, CMS develops a “complexity score” for every patient based on the conditions documented in the previous year’s encounters. This score informs the resources allocated for each patient’s care in the year ahead. As a nonprofit health plan serving the IDD community, PHP is committed to making sure each member’s needs are fully recognized and addressed.
In the upcoming outreach, you will receive: - Patient-specific documentation listing conditions documented over the last two years. If the condition remains stable, it should be acknowledged and recorded during at least one evaluation and management (E&M) visit during the year. Making this a part of your regular healthcare maintenance visits will help reduce the number of medical record requests from PHP.
- A preventive services checklist designed to support comprehensive annual care planning for your patients.
PHP maintains an “open-door” policy for all members of our provider network. If you have any questions about the CMS reporting materials, need help identifying your patient’s care manager or would like additional support, we encourage you to reach out to our Provider Services line at 1-855-747-5483. | |
| |
| |
| |
| |
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual standardized survey conducted by CMS from March to May to assess consumers’ experience with their providers and health plan. A random sample of Partners Health Plan (PHP) members are selected for the CAHPS survey by CMS and your patients may be included. Patient satisfaction not only helps to increase retention but can also help increase adherence to physician recommendations and improve patient outcomes.
The next CAHPS Survey is scheduled to be fielded from March – May 2025. Providers can help improve response rates by reminding PHP members to check for and complete the survey.
Thank you for the support you provide for PHP members. Together, we strive to create a positive experience that will benefit your practice and increase patient satisfaction.
| |
| |
Frequently Asked Questions | |
PHP’s Provider Relations Department has developed a Frequently Asked Questions resource for OPWDD Waiver Service providers. This FAQ can be found on the Provider Resources section of the PHP website under DD Provider Resources. | |
| |
Re-credentialing In-Network OPWDD Providers | |
PHP’s Network Development and Provider Relations (NDPR) department is continuing efforts to ensure timely re-credentialing for all in-network OPWDD Waiver Service Providers.
Moving forward, OPWDD providers will be re-credentialed every three years after joining the network. This is being done to ensure PHP has the most up-to-date service information on file for our members. PHP also wants to ensure we have your organization’s most updated demographic information and that we are maintaining updated operating certificates from OPWDD.
If you receive an email from a PHP NDPR Account Manager regarding re-credentialing, we ask that you return any requested documents in a timely manner. If you have any questions, please open a ticket with NDPR. | |
| |
MediSked Portal for DD Providers | |
Please utilize the MediSked Provider Portal to review and approve Life Plans for the individuals you support. To obtain access to the portal, please email portalaccess@phpcares.org.
For more information, please visit the Provider Portal page on our website or contact the applicable Care Manager. | |
| |
| |
FROM BRITTANY MISKE, VICE PRESIDENT OF HEALTHCARE MANAGEMENT AND CLINICAL SUPPORT
| |
| |
PHP recently held a virtual session on Winter Cardiovascular Wellness. Cardiovascular (CV) conditions are common among individuals with IDD. Watch the recorded webinar to learn more about the effects of cold weather on CV disease and individuals with IDD, as well as complications and prevention strategies.
| |
| |
PHP will hold a virtual session on Trauma-Informed Care designed to arm you with timely information and ways to better support the mental health of our members on May 14 at 1 PM ET. Stay tuned for more information on the topic and registration.
| |
| |
| |
| |
The Provider Spotlight series is an opportunity for providers to showcase their services to PHP care managers. We are seeking developmental disabilities (DD), healthcare or behavioral health providers, community organizations and more to present to our team.
This series will allow PHP care managers to learn the latest and greatest information that your organization has to offer and make referrals to your services. If you are interested in presenting, please open a ticket, and a member of our team will be in touch.
We would like to express our gratitude to some of our recent spotlight presenters! A BIG thanks to the following providers:
| |
| |
PHP IN THE NEWS AND ON THE ROAD
| |
| |
New York Disability Advocates (NYDA) Rally
PHP members, families and advocates of the Capitol and Upper Hudson Valley regions came together on February 25 at the State Capitol Building to make their voices heard. We engaged legislators to advocate for greater investment in the IDD service delivery system — ultimately supporting people with IDD, their families and our workforce. | | | |
| |
Jawonio Rally in the Valley
Lower and Upper Hudson Valley region PHP members, families and care managers will assemble at the NY Boulders Stadium on March 7 to support our advocacy efforts. The goal is to make sure our message is heard loud and clear: funding is essential to keep our current supports in place and meet the needs of our growing membership.
| | | |
| |
| |
| |
Claim Submissions Made Easy | |
We encourage providers to take advantage of the ease of establishing and submitting claims electronically. We would also like to remind everyone to regularly confirm with their billing service (Clearinghouse) that all electronic submissions have been successfully transmitted and received. If a claim is not successfully transmitted, there will be delays in PHP’s ability to adjudicate the claims on a timely basis. Please check all error logs and resubmit the claim accordingly. Timely filing rules still apply for resubmissions. To ensure prompt adjudication, please review our Billing and Claims resources for submission options and other information and reminders. Please remember to send all claims to PHP using one of the following options:
Mail Electronic Submission Options: PHP’s Submitter ID is 14966 HealthSmart Clearinghouse – CareVu If already set up with CareVu, no action needed. If you’d like to establish a connection directly with CareVu, please complete the EDI Enrollment Packet. For more information, you can contact CareVu at: 888-744-6638
Optum: 866-678-8646 Other Clearinghouses: Where you previously selected Change Healthcare, now you should select Optum
Web-based Claims Submission: Providers can easily create and upload a professional or institutional single claim as a PDF file via the provider portal (https://php.healthsmart.com). Web-based claims are considered paper claims and will follow all existing claim submission protocols. Please note that only valid claim forms (CMS 1500 or UB 04) may be uploaded using this method.
Please note that our Third-Party Administrator, HealthSmart, no longer has an exclusive Clearinghouse/EDI Gateway relationship with Availity. | |
| |
Provider Portal for Inpatient Authorizations | |
For NEW Inpatient Admissions, you can now submit a prior authorization request directly through our Utilization Management Provider Portal. Note this is not applicable to previous or existing authorizations. To utilize this portal, please register by clicking the button below:
| |
| |
| |
Eligibility and Claims Status for All Providers | |
Do you want to avoid placing a phone call to our Provider Services call center? You’re in luck! You can check a member’s eligibility and claim status using our online portal.
Please note that Multi-Factor Authentication (MFA) has been enabled for portal access. Users will now need to authenticate using the phone number that was entered by the user during registration. If you need to update the phone number for your account, please contact the portal helpdesk at 1-800-638-0968. For more information, please view the MFA user guide. | |
| |
Credentialing & Re-Credentialing | |
Please remember to keep all information updated with PHP! Be sure to send us any changes to your organization’s demographic information, as well as any updates to individual providers, to ensure we always have the most up-to-date information loaded in our system!
Please include the NYS Medicaid ID, NYS Medicaid License Number and Medicare ID for all providers. | |
| |
How to receive assistance from PHP's Network Development and Provider Relations team | |
To contact the Provider Relations department to request assistance or information, please open a ticket using the Provider Ticket Submission Form. Once a ticket is submitted, a Provider Relations team member will reach out to you as soon as possible. | |
| |
| |
Hear news as it happens. Connect with us on social media. | | | |
| |
| |
