EHS Medical Group - Fresno Frequently Asked Questions (F.A.Q.)


	Why did I get a letter from Anthem Blue Cross? Do I have to choose an IPA to continue seeing my Blue Cross Medi-Cal patients? Can I continue receiving payment on a fee-for-service basis? Is Blue Cross leaving Fresno County? Will I continue to be paid for my CHDP and vaccines? Why hasn't anyone approached me yet? Where can I learn more about EHS's contract? What laboratories do you have contracted? Will EHS have a local office? What about local staff? Will EHS accept claims electronically? I signed the contract. When will my members transition to EHS-Fresno? What if I signed a contract with EHS-Fresno but a patient shows up from another IPA? I used to send everything to Blue Cross. What services are the IPA's financial responsibility and what services remain Blue Cross' responsibility? How can I sign up for SynerMedConnect? Where can I get training? I am a primary care physician. What needs an authorization and what can I do without an authorization? I submitted my claim several weeks ago. When will I get paid? The codes that Blue Cross told me to bill with are no longer valid. How will I get paid for these services? What are some helpful hints for adding authorizations? back to EHS Fresno Frequently Asked Questions (F.A.Q.) Why did I get a letter from Anthem Blue Cross? Anthem Blue Cross is changing its business model in Fresno County, moving from a direct contracting model to a delegated IPA model. We cannot comment on WHY Anthem Blue Cross is making this decision. You would have to take this up with Anthem directly. Suffice it to say that EHS was invited to participate as a delegated IPA as a result of its size, scope, experience and history of doing business with Anthem Blue Cross in other areas of the state. Do I have to choose an IPA to continue seeing my Blue Cross Medi-Cal patients? Yes. Anthem Blue Cross sent letters to all contracted participating providers in Fresno County notifying them of the change in business model. If you are a PCP, you must choose one of the IPAs offered and sign a contract with them. If you do not contract with one of the IPAs offered, you could be at risk of losing your Blue Cross Medi-Cal members. If you are a specialist or ancillary service provider, you may choose to contract with any or all of the IPAs offered. Can I continue receiving payment on a fee-for-service basis? Yes. EHS is not entering the market to make changes to a reimbursement system you are already familiar with. Instead, we are offering FFS rates competitive to those you already receive from Anthem Blue Cross. We also offer other compensation models, including capitation, for those primary care physicians who have an interest in this method of payment. However, please understand that we will not force any particular kind of payment methodology on you. Is Blue Cross leaving Fresno County? No. Blue Cross is not leaving; only its business model is changing. In fact, Anthem's Community Resource Center (CRC) will continue to be open to facilitate physician office and member issues. Will I continue to be paid for my CHDP and vaccines? If you elect to be paid on a fee-for-service basis, then you will continue to be paid for CHDP services. If you elect to be paid on a capitated basis, then CHDP services will be considered part of the negotiation. Vaccines for Medi-Cal members are covered by the federal Vaccines for Children (VFC) program. EHS will pay an administrative fee for rendering the service. Why hasn't anyone approached me yet? EHS staff are making the rounds to all provider offices who received the Anthem Blue Cross letter. We are not ignoring anyone. We're just prioritizing our resources. For more information on the EHS contract, see next question below. Where can I learn more about EHS's contract? EHS has posted both its primary care and specialty contract boilerplates online. Go to the EHS Fresno page, fill out your information so we know who you are, and then click on the download button. Most of your questions will be answered once you read the document. What laboratories do you have contracted? EHS has executed contracts with Maharlika and Quest laboratories. Will EHS have a local office? Yes. EHS has secured space in downtown Fresno at 1221 Van Ness Ave, Suite 310, Fresno, CA 93721. What about local staff? The head of our Fresno operation is James "JR" Richardson. He can be reached at (559) 266-1000. His email is jrichardson@isynermed.com. Will EHS accept claims electronically? Yes. By signing up with our secure internet web portal at www.synermedconnect.com, you can review eligibility, make referral authorization requests, and even submit claims electronically. In fact, EHS can accept claims in several different formats. If you use a clearinghouse for your billing, we can accept those as long as they are routed as pass-through claims to Office Ally (payor ID = SYMED). We can also accept claims directly from your billing system, bypassing a clearinghouse altogether. You can even input your claims directly into our system. Detailed instructions for all methods are available once you log in as a registered user on our web portal at www.synermedconnect.com. I signed the contract. When will my members transition to EHS-Fresno? There are two factors that determine when a primary care physician's members will transition to the IPA. First is the signing of the contract, and second is receiving a copy of a "transfer letter" requesting that Anthem Blue Cross assign your members to EHS-Fresno. Upon receipt of both of these items, as well as your credentialing information, the process of moving your members begins. This process takes a minimum of 45 days, as Anthem Blue Cross is required to notify both the State and the Members of the change. As a result, some PCPs became effective with us in February, others in March, still others in April, etc. Furthermore, until you actually start seeing members with new Anthem Blue Cross ID cards showing EHS-Fresno as the IPA, you should continue to verify eligibility on both the State's and Anthem's eligibility systems. What if I signed a contract with EHS-Fresno but a patient shows up from another IPA? Primary care physicians may only sign a contract with a one IPA. Specialty physicians and other providers may sign contracts with multiple IPAs. If you are an EHS-Fresno PCP and a patient shows up with an ID card from a competing IPA, you may not get paid if you see that patient. You must tell the patient that s/he must go to the assigned PCP on their ID card if they wish to receive care. If the patient still wants to see you, they must first call Anthem Blue Cross and request to transfer from one IPA to the other AND they need to choose you as their PCP. Please note that the transfer will not occur until the first day of the month FOLLOWING the date of the request, so if the request comes in on the 10th of the month, the change will not become effective until the 1st of the following month. It also means that if you choose to see that member BEFORE they become effective with you, you may not get paid for that visit. If a specialist office has a contract with EHS-Fresno AND another IPA, check your contract with that particular IPA for specific instructions on how to handle referrals from that specific IPA. I used to send everything to Blue Cross. What services are the IPA's financial responsibility and what services remain Blue Cross' responsibility? For the most part, professional services rendered in a physician office are the IPA's financial responsibility. Most ancillary services (lab and x-ray) are also the IPA's financial responsibility. Hospital and other inpatient services remain Anthem Blue Cross’s responsibility. We meet regularly with Anthem Blue Cross staff if a particular service falls into a gray zone. How can I sign up for SynerMedConnect? Where can I get training? Just go to www.synermedconnect.com. PDF instructions are available by download. Anyone with EHS members or who sees EHS patients can obtain a login. As for training, please contact Diana Curry at (909) 291-1984 to register for a class or schedule an in-service for your office. I am a primary care physician. What needs an authorization and what can I do without an authorization? Primary care physician contracts specifically list those services that may be performed by a PCP without an authorization. Anything not in the contract, whether performed by a PCP in the office or by any other specialty physician or ancillary service outside of the office, will require an authorization. If there is a specific service a PCP wishes to perform in the office without an authorization that is not in the contract, the PCP should write a letter to our EHS Utilization Management Committee for consideration. Our UM medical directors will review the request for medical appropriateness and make a determination. I submitted my claim several weeks ago. When will I get paid? Regardless of the method by which EHS receives your claim, once we receive a clean claim (with everything completed correctly), by law we have 30 calendar days to process your claim. That does not mean it takes 30 days; just that the law allows for it. Check runs are generated weekly. Providers and physician offices may check the status of their claim on our secure SynerMedConnect web portal. The codes that Blue Cross told me to bill with are no longer valid. How will I get paid for these services? In the past, Anthem Blue Cross required physicians and provider offices to bill with proprietary codes for certain services. EHS does not recognize these codes. Instead, we require that all physicians and provider offices bill using current Medi-Cal codes, including codes identified for immunization and other preventive medicine services What are some helpful hints for adding authorizations? How to add an authorization for a Provider not found in the web portal: 1. In Provider Search, enter UNKNOWN PROVIDER. 2. Select and Add the UNKNOWN PROVIDER. 3. Enter in the NOTES section the information of the provider you would like the member to see, including the complete name of the provider, the specialty of the provider, and their address, phone number and fax number. 4. Our UM Department will try to locate the provider in our system, and, if appropriate and no other coverage is available, we will start the process to contract the provider requested. How to add an authorization for a Member not found in the web portal: 1. In MEMBER search, enter PENDING. 2. Select and Add the PENDING VERIFICATION member with ID#99999999D. 3. In the NOTES section, enter the member’s information: • Members Full Name • ID# & SSN (if available) • Date of Birth • Address, City, State/Zip • Phone Number Utilize the Auth Inquiry to save a phone call and send your authorization questions directly to the UM department: 1. If you have a question related to an auth, view the auth via the web portal. 2. Click on the "REQUEST INFO/MODIFICATION" tab located in the section above the patient's name. 3. Enter your question(s) in the MESSAGE area and hit SEND. 4. The message will be routed to our UM Department. When submitting "new information" by faxing with the prepared fax cover sheet, submit an auth inquiry through the SynerMedConnect web portal indicating that new information has been provided so our case management staff can review your auth promptly. back to EHS Fresno