Provider FAQ

Frequently Asked Questions from Providers


About Empower

About Empower

Q: What is Empower Healthcare Solutions (Empower)?

A: Empower is one of four PASSE organizations in the state. We empower individuals to lead fuller, healthier lives at home and in their communities. PASSE (Provider-Led Arkansas Shared Savings Entity) is a new Medicaid program to address the needs of individuals who have intensive behavioral health, intellectual disability, or developmental disability service needs.

Q: What will be different for providers on March 1, 2019?

A: Starting March 1, 2019, Empower will be responsible for the total management of the member’s care, including being responsible for the total cost of care for the member. All providers will submit claims directly to Empower for payment.

Q: Why is the PASSE program good for my patients?

A: The goal of the PASSE model is to improve the health of Arkansans who need intensive levels of specialized care due to behavioral health issues or developmental/intellectual disabilities. The PASSE model includes Care Coordination which coordinates care for all community-based services for these individuals to improve total health outcomes for these members.

Joining the Empower Network

Joining the Empower Network

Q: How can I join Empower as a provider?

A: To contract with Empower, please email empower.network@empowerhcs.com. If you have questions please contact Empower Provider Relations at 866-261-1286.

Q: Can I join more than one PASSE network?

A: Yes, a provider may join any or all PASSEs as a network provider. A provider will likely want to be a provider in all PASSEs to ensure there is a continuum of coverage for the members that it serves.

Q: What happens after I join Empower?

A: When you join Empower as a provider, you will submit required Prior Authorizations and claims to Empower for payment of services.

Q: What are my rights and responsibilities as an Empower Provider?

A: Provider Rights and Responsibilities are listed in the Empower Provider Handbook, which will be available soon.

Q: How can I get a copy of the Empower Provider Manual?

A: The provider manual will be available electronically prior to March 1, 2019, on the Empower website, www.getempowerhealth.com.

Q: Who can answer questions about my contract as an Empower Provider?

A: You can contact the Empower network team at empower.network@empowerhcs.com for help with questions about your Provider contract.

About Empower Benefits and Services

About Empower Benefits and Services

Q: What types of services will be covered for Empower Members?

A: Empower members will be eligible for all services covered under the Medicaid state plan, as well as under Section 1915(i) and CES waiver services, including therapy services and services through the Early Periodic Screening Diagnosis and Treatment (EPSDT) program for children. In short, members will have access to services covered under the Medicaid program today, as long as those services are deemed medically necessary and documented in the member’s Person Centered Service Plan (PCSP).

Q: How do Empower Members get a Primary Care Provider?

A: Members select their PCP when they sign up for Medicaid. Members who are also eligible for Medicare are able to keep their Medicare PCP. For any members who do not select a PCP or whose non-Medicare PCP is not in the Empower network, Empower will automatically assign a PCP based on:

  • the member’s claims history (who they have seen in the past);
  • a member’s geographical location;
  • appropriate distribution by provider (so that members are not overly concentrated with the same PCP).

Members ages 18 and older will be assigned to a general or family practitioner, internal medicine, or other specialty provider approved by the state. Members under 18 years old will be assigned to a pediatrician or family practitioner. At any time, a member can call Empower Member Services and request that their PCP be changed, and Empower will honor that request.

Q: How do I know if an individual is a member of Empower?

A: All Empower members will have a member ID card. Members should always present their ID at the time of service, but an ID card, in and of itself, is not a guarantee of eligibility. Providers must verify a member’s eligibility on every date of service.

The ID card will contain the following information:

  • Member’s name, Date of Birth, and Gender
  • PASSE ID number
  • Pharmacy ID number
  • Empower contact information
  • Claims filing address

Empower member eligibility varies by month. Therefore, each participating provider is responsible for verifying eligibility with Empower before providing services to a member. Beginning March 1, 2019, providers may verify eligibility using the following methods:

  • Online – Visit our website at www.getempowerhealth.com
  • Telephone –Providers will be able to contact the Provider Services team beginning in February 2019 for support at 1-855-429-1028.

The Empower Healthcare Solutions Provider Handbook will provide you with much more information about how to verify eligibility for your Empower patients.

Submitting Claims and Getting Paid for Rendered Services

Submitting Claims and Getting Paid for Rendered Services

Q: How do I submit a Prior Authorization (PA), and what services require a PA?

A: Some services require prior authorization from Empower for reimbursement to be issued to the provider. All inpatient stays require notification within 24 hours of admission to Empower. You will be able to verify whether a prior authorization is necessary or obtain a prior authorization by calling Member Services or by requesting authorization through the provider portal beginning March 1, 2019.

A list of services requiring prior authorization will be available upon request and will be posted to the website as an addendum to the Provider Handbook.

Q: What is the process for submitting Pharmacy PAs, and what pharmacy services require a PA?

A: Empower is committed to providing appropriate, high-quality, cost-effective drug therapy to all of our members. Empower works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered.

The plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by an Empower physician. The pharmacy program does not cover all medications. Some drugs have a generic equivalent or a brand-name drug from a different manufacturer that is covered. Some medications require prior authorization or have limitations on age, dosage, maximum quantities, or any combination of these.

Prior Authorization is necessary for some medications to establish medical necessity, and to ensure eligibility for coverage per State regulations, Federal regulations, or both. This may be due to specific Food and Drug Administration (FDA) indications, the potential for misuse or overuse, safety limitations, or cost- benefit justifications.

PA is required for certain medications that are:

  • Outside the recommended age, dose, or gender limits;
  • Not listed on the Preferred Drug List (PDL);
  • Listed on the PDL but still require Prior Authorization;
  • Brand name drugs when a generic exists;
  • A Duplication in therapy (i.e. another drug currently used within the same class);
  • New to the market and not yet reviewed by the P&T Committee;
  • Prescribed for off-label use or outside of certain diseases or specialties; or
  • Self-injectable and infusion medications (including chemotherapy) with some exceptions.

Beginning on March 1, 2019, providers may request an exception to Empower’s PDL either verbally or in writing. For written requests, providers should complete a Prior Authorization Request Form that includes pertinent enrollee medical history and information. A Prior Authorization Request Form may be accessed on Empower’s website at www.getempowerhealth.com.

If authorization cannot be approved or denied, and the drug is medically necessary, up to a 72-hour emergency supply of the drug can be supplied to the member.

Q: How and when can I access information electronically about Empower Members?

A: Empower’s web portal service allows providers to instantly access many tools and resources. Contracted providers and their office staff can register for our secure provider website in just four easy steps.

Starting on March 1, 2019, just go to www.getempowerhealth.com, select the “Log On” link, and follow instructions.

Once registered, the secure portal will allow you to:

  • Request and track authorizations
  • View claims payment history
  • Verify member eligibility
  • Contact us securely and confidentially
  • Access the provider directory

The Empower Provider Relations team will be offering training and support on how to use our secure site in the near future.

Q: How can I verify eligibility of a member?

A: Providers will be able to verify eligibility through Empower’s secure portal or through our IVR call system beginning March 1, 2019.

Q: How do I submit a claim and when can I submit a claim?

A: To make sure that Empower can process your claims in a timely manner, it is important that providers ensure Empower has accurate billing information on file. Providers also must have a current, active Arkansas Medicaid Provider ID.

Please confirm with Empower’s Network department (empower.network@empowerhcs.com) that the following information is current in our files:

  • Provider name (as noted on current W-9 form)
  • National Provider Identifier (NPI)
  • Tax Identification Number (TIN)
  • Taxonomy code
  • Physical location address (as noted on current W-9 form)
  • Billing name and address

Network providers are encouraged to participate in Empower’s electronic claims/encounter filing program. Empower can receive ANSI X12N 837, or most current version, professional, institution, or encounter transactions. It can also generate an ANSI X12N 835, or most current version electronic remittance advice known as an Explanation of Payment (EOP).

Electronic billing has many benefits to providers. For example, electronic billing reduces your overhead and administrative costs. EDI eliminates the need for paper claims submission. It has also been proven to reduce claim rework (adjustments). Electronic claims have a faster transaction time, as well. An EDI claim averages about twenty-four (24) to forty-eight (48) hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Providers that bill electronically have the same timely filing requirements as providers filing paper claims.

Providers that bill electronically also must monitor their error reports and EOPs, to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters.

Providers may use different products to bill electronically. Providers may submit claims electronically as long as the software has the capability to send EDI claims to Change Healthcare (formerly Emdeon) through either direct submission or through another clearinghouse/vendor.

Empower’s Payor ID is: 12956, and our clearinghouse is Change Healthcare (formerly Emdeon). Beginning March 1, 2019, you will be able to visit Empower’s website for our electronic Companion Guide.

Providers without Change Healthcare EDI capabilities who are interested in electronic claims submission may contact the Change Healthcare Sales Department at (877) 469-3263, option 6. Providers may also choose to contract with another EDI clearinghouse or vendor who already has EDI capabilities.

After the registration process is completed and providers have received all certification material, providers must:

  • Read over the instructions carefully, with special attention to the information on exclusions, limitations, and especially, the rejection notification reports.
  • Contact their system vendor and/or Change Healthcare to initiate electronic submissions to Empower (provide Payor ID listed above).

Providers without electronic billing capability may also submit paper claims using the appropriate National Standard Claim Forms. Claims for professional services and durable medical equipment should be submitted on a CMS-1500 (formerly HCFA 1500) form and claims for hospital based inpatient and outpatient services as well as swing bed services on a UB-04 (CMS 1450) form. All paper claims should be mailed to:

Empower Healthcare Solutions LLC PO Box 211446 Eagan, MN 55121

Since Empower coverage takes effect on March 1, 2019, providers will be able to submit claims for services rendered to eligible members beginning on that day.

Q: What are the timely claims filing standards for Empower?

A: In accordance with state and Federal requirements, providers must file claims within 365 days of the date of service.

Q: Can I submit a paper claim?

A: Yes. Providers who do not have electronic claims submission capability may submit paper claims using the appropriate National Standard Claim Forms. Please see instructions for submittal above.

Q: How can I ensure that my claims are not denied?

A: Empower will process clean claims in a timely manner in accordance with the state’s Prompt Pay policies. A clean claim means a claim received for adjudication in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider of the services to be processed and paid.

Providers are encouraged to submit clean claims. Clean claims should meet the following requirements:

  • The member is eligible on the date of service.
  • The service provided is a covered benefit and included on the member’s service plan on the date of service.
  • Prior-authorization processes were followed.
  • The claim conforms to billing guidelines as outlined by Empower.
  • The plan does not require additional information to determine medical necessity
  • Billed services are not for provider-preventable conditions caused by billing provider.
  • Provider is not under investigation for Fraud or Abuse

Q: How can I file a request for appeal, correct a claim, or request a refund?

A: Rejected claims are defined as claims with invalid or missing data elements (such as the provider tax identification number) that are returned to the provider or EDI source without registration in the claims processing system. Since rejected claims are not registered in the claims processing system, the provider must re-submit corrected claims within 365 days from the date of service. This requirement applies to claims submitted on paper or electronically. Denied claims are different than rejected claims and are registered in the claims processing system, but they do not meet requirements for payment under Empower guidelines.

When a claim is denied because of missing or invalid mandatory information, the claim should be corrected, marked as a second submission or a corrected claim, and resubmitted within ninety (90) days of notification of payment/denial either electronically or to the general claim address:

Empower Healthcare Solutions LLC PO Box 211446 Eagan, MN 55121

If you believe there was an error made during claims processing or if there is a discrepancy in the payment amount, you will be able to call the Provider Services line. Our team of representatives can help you resolve the issue or advise whether a corrected claim or a written appeal needs to be submitted. Please submit Claims Issue Forms to the P.O. Box above.

Providers have the right to appeal the outcome of a claim. The appeal must be submitted in writing and received within 90 days of the last process date and include supporting documentation. The Plan will respond to the appeal within thirty (30) days from the receipt date with a determination or status of the review.

The provider will receive written notification of the outcome of the appeal whether it is upheld or overturned. All upheld determinations will be sent to the provider in a letter with the reason the plan upheld the appeal. Any appeals overturned by the plan will be reprocessed, and the provider will receive an explanation of payment (EOP) as notification.

Resubmitted claims should be resubmitted on paper. Corrected claims can be sent electronically. All corrected claims should have the corrected claim indicator (a 7) on the claim and the original claim number that you are correcting.

Q: I would like to set up EFT/ERA to be paid electronically. How and when can I do this?

A: Just as the state of Arkansas offers electronic funds transfer (EFT) for Medicaid providers today, Empower will offer electronic payment to its provider network. Empower is working with InstaMed to deliver claim payments via electronic remittance advice (ERA) and EFT. ERA/EFT is a convenient, paperless and secure way to receive claim payments. Funds are deposited directly into your designated bank account and include the TRN Reassociation Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard transactions.

Additional benefits of ERA/EFT include:

  • Accelerates access to funds with direct deposit into your existing bank account
  • Reduces administrative costs by eliminating paper checks and remittances
  • Avoids disruption to your current workflow – there is an option to have ERAs routed to your existing clearinghouse

To expedite payment, you can sign up for Instamed Payer Payments today. Just visit http://www.instamed.com/eraeft or complete the documents attached in the appendix of this FAQ. Even if you are already enrolled with Instamed, make sure Instamed has added Empower to your profile (Payor ID # 12956).

Q: Can I bill the member for covered services if the usual and customary fees are greater than the fee schedule?

A: Empower will only reimburse providers for services that are medically necessary and covered through the PASSE program. Payments made to providers by Empower for Medicaid covered services for Empower members are considered payment in full. Providers are not allowed to bill (also called “balance bill”) members for any covered services provided, even if the provider’s usual and customary charge for the covered services is greater than what is allocated in the Empower fee schedule. Providers also may not make arrangements to provide costlier services or items than those covered by Empower on the condition that the member supplement payments made by Empower.

Q: I have additional questions about billing. Who can answer my questions and when can they answer them?

A: Empower’s Provider Services team will be available to help you via phone Monday through Friday (except holidays), from 8:00 AM to 5:00 PM CT, beginning in February 2019. The Empower Provider Handbook also will have more information.

Q: How should I handle members with Medicare and PASSE coverage?

A: Like all Medicaid programs, the PASSE program is considered the payer of last resort. Providers should make a reasonable effort to determine the legal liability of third parties including Medicare to pay for services furnished to Empower members. If a member is a dual-eligible member (has Medicare and PASSE coverage), then providers must bill Medicare for the services. Medicare will process the claim then forward any portion(s) of the claim that is a covered service to Empower.

Care Coordination and Quality

Care Coordination and Quality

Q: What is Care Coordination?

A: Care Coordination is when health care providers and Empower staff work together to organize provider visits and other services to make sure members get the best care. Members, family/support systems, and providers work together to create a Person Centered Service Plan (PCSP) to meet the members care needs.

Q: Will all members have a Care Coordinator?

A: Every member of Empower receives this service through the Care Coordination program.

Q: How can providers contact Care Coordinators?

A: Any provider, including PCPs, specialists, HCBS providers, discharge planners and UM professionals, can contact Empower to speak to a Care Coordinator 24 hours a day/7 days a week Toll Free: 866-261-1286 TTY: 888-479-6532

Q: What is a Person Centered Service Plan (PCSP)?

A: The PCSP is a care plan developed by the Care Coordinators in collaboration with the member, guardian, or both along with anyone else the member wants to include in the development of the PCSP. The PCSP will incorporate functional status and barriers to care such as lack of caregiver supports, impaired cognitive abilities, and transportation needs. The services available to the member based on needs identified will be included in the member’s PCSP.

Q: Will I be required to report any quality measures for Empower?

A: Empower is committed to ensuring that continuous quality/performance improvement occurs. There is consistent and ongoing monitoring for applicability so Empower can achieve efficiency and effectiveness with improved outcomes for our members. HEDIS Measures will be used.

Cultural Competency & Member Rights

Cultural Competency & Member Rights

Q: Will Empower offer Cultural Competency training?

A: Empower will introduce Cultural Competency and other training topics during Provider Orientation to ensure required topics are covered. Provider offices should have their own cultural sensitivity and competency training, and Empower will perform an annual evaluation of Cultural Competency practices.

Q: What are the rights of Empower Members?

A: Member Rights and Responsibilities are listed in the Member Handbook which will be made available on the website.

Training

Training

Q: What training will be provided to me as a PASSE provider and when?

A: Empower is working in cooperation with all of the PASSEs to plan statewide town hall provider trainings in January 2019. These trainings will cover topics such as:

  • how to check eligibility
  • how to submit a claim
  • how claims are paid
  • what needs prior authorization
  • timeline for claims submission
  • PASSE websites
  • the provider portals
  • provide contacts for support
  • more

Additional provider trainings will be regularly scheduled.