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Community HealthChoices: Recap Third Thursday Webinar (May 17th, 2018)

June 01, 2018
Reimbursement By Jennifer Matoushek, Senior Consultant

On May 17, 2018, during the Department of Human Services’ (DHS) Third Thursday Webinar, DHS announced they have met all goals to date. These goals included: assuring no participant service interruptions, assuring no interruption in provider payment, and a launching a successful first phase.


DHS continues to prep for the next phase of Community HealthChoices (CHC) and will focus on the preparation of a comprehensive participant communication launch for the Southeast (SE) implementation effective January 1, 2019.

DHS'S SE implementation will focus on:

  • Implementing a robust readiness review
  • Preparation of provider communication and training
  • The pre-transition and plan selection for southeast participants
  • Incorporating the southwest implementation and launch lessons learned

DHS acknowledges that the population is greater in the SE when compared to the Southwest region (SW) and plans to modify implementation as needed. As of today, approximately 80,000 participants have transitioned to the CHC program.

The SW is still experiencing the following issues during the CHC implementation:
  • Transportation services are difficult to navigate and schedule
  • Participants are worried about losing access to their existing service coordinator
  • Approval from home modifications and continued Durable Medical Equipment (DME) access are more difficult than before
  • Billing coding challenges
  • Non-Medical transportation: Managed Care Organization (MCO) handling it differently

The SW is still experiencing the following issues:

  • Difficulty with navigating and scheduling transportation services
  • Participants concerns about losing access to their existing service coordinator
  • Approval for home modifications and access to continued Durable Medical Equipment (DME)
  • Billing coding challenges
  • Inconsistencies with the handling of non-medical transportation by Managed Care Organizations (MCOs)

So, what has DHS learned so far from CHC?

  • Earlier stakeholder engagement opportunities are a must
  • Enhanced communication materials and training regarding Medicare vs. CHC is necessary
  • The need for additional education and communication on continuity-of-care
  • MCO Provider Training and outreach needs to occur earlier and more often
  • Earlier Omnibus Budget Reconciliation Act (OBRA) reassessments are vital
  • An earlier date clean-up in Home and Community Services Information System (HCSIS) and Systems for Award Management (SAM)
  • The need for earlier pre-transition notices

Unfortunately, some nursing facilities are still experiencing claim denials. As a result, the DHS has investigated the top 10 reasons behind this.

The top 10 reasons for Skilled Nursing Facilities (SNF) claim denials:

  1. Definite duplicate claim
  2. Inappropriate coding for contract/agreement
  3. Service prior to subscriber effective date
  4. Member not eligible at time of service
  5. Members birth date submitted is not valid
  6. Code not payable for provider/specialty
  7. Diagnosis inv/missing/deleted
  8. Denied claim disallow
  9. Resubmit on UB04
  10. Duplicate claim previously paid at correct rate/cap

SE facilities should review these claim denials to ensure they will be prepared for the next CHC implementation. It is also very important for nursing facilities to study the Enrollment Verification System (EVS) to confirm residents are still participating in the prior month’s MCO’s plan.

A major issue that SW nursing facilities are currently dealing with is transportation reimbursement. The CHC-MCOs are taking steps to address transportation issues, such as increasing communication and training to key stakeholders. 

 DHS plans to focus on improving the following areas for the SE region:

  • OBRA Assessments
  • Participant Communications Planning
  • Provider Outreach and Education
  • Populations Identification

Nursing facilities in Phase 2 are encouraged to reach out to the MCOs instead of waiting to hear from them. 

To read our last recap of CHC's Third Thursday webinar, click here.


Still haven’t prepared for CHC? Contact us to see how we can help your facility.

Call Jennifer Matoushek at 717-213-3130 or email to see how we can help.