September 10, 2018
Area(s) of Interest: Commercial Payors Payor Contracting Payor Issues and Reimbursement Practice Management
As previously reported, Health Net Federal Services (HNFS) has experienced implementation issues since taking over as the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region on January 1. In recent discussions with the California Medical Association (CMA), HNFS said it continues to address the breakdowns in process and resulting consequences that have impacted TRICARE providers in the areas of provider contracting and credentialing, beneficiary reassignment and provider directory inaccuracies. Updates are as follows:
Contracting and Credentialing
Because of staffing and operational issues, physicians may have experienced problems during the contracting and credentialing process including the following:
- Completed provider contracts not entered into the HNFS system
- HNFS unable to locate countersigned provider contracts
- Cases where the contracting or credentialing processes were never completed
HNFS shared with CMA that it has identified the providers impacted by the breakdowns and is nearing completion of the credentialing and contracting cleanup for these impacted providers. Additionally, HNFS will begin scaling back efforts to contract with former United Military and Veteran Services (UMVS) providers except to address network adequacy requirements.
Physicians with questions about their contracting and/or credentialing status with HNFS can check the HNFS credentialing status tool at www.tricare-west.com. Physicians experiencing challenges with the credentialing or contracting process should contact Megan Herrera, Director of HNFS Provider Network Management, at (619) 285-3607 or firstname.lastname@example.org.
Beneficiary Reassignment to New PCMs
During the TRICARE transition, DHA allowed TRICARE Prime beneficiaries to receive care from primary care managers (PCMs) previously in the UMVS network who were not yet in the HNFS network, without incurring out-of-network fees through June 30. The purpose was to allow HNFS additional time to contract with providers, develop its provider network and address operational challenges within the contracting/credentialing process. When the transition ended, approximately 44,000 California enrollees, assigned to 3,800 out-of-network PCMs, were reassigned to HNFS network PCMs. This large number was due in part to the contracting/credentialing problems described above. HNFS reports that to date, 15,000 of those members have been reassigned to their original PCMs with approximately 23,500 members still assigned to new PCMs.
Physicians with concerns or who have been affected by the reassignment of their patients to a HNFS network PCM, should visit the HNFS Tricare West website for more information.
Provider Directory Inaccuracies
HNFS continues efforts to correct the significant number of provider directory inaccuracies through its third party vendor, LexisNexis. While improved accuracy of its provider directory is expected over the next 30-120 days, HNFS reports that the error rate of several directory samplings remains high. Practices are encouraged to check the HNFS online provider directory to confirm participation status and demographic information. If demographic updates are needed, physicians can submit updates via HNFS’ online tool with routine changes to be completed within 14 calendar days and urgent or high priority updates processed within 24 hours.
CMA is working with HNFS to ensure these issues are resolved quickly and adequately. HNFS has advised that updated transition information is available via the HNFS TRICARE Transition FAQ on the HNFS west website. Physicians with questions or concerns can contact Megan Herrera, Director of Provider Network Management at (619) 285-3607 or email@example.com.