IVA-PM-0001-13 2.13
Every Time. Every Touch.
Provider Manual 1.855.323.5588
●
www.intotalhealth.org
Copyright July 2013 INTotal Health All rights reserved. This publication, or any part thereof, may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without the prior written permission of INTotal Health. How to apply for participation: If you are interested in participating in our network, please go to www.intotalhealth.org or call a Provider Relations Representative at 1-‐800-‐231-‐8076.
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TABLE OF CONTENTS 1
INTRODUCTION ............................................................................................................................................................. 1
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OVERVIEW ...................................................................................................................................................................... 2
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QUICK REFERENCE INFORMATION ....................................................................................................................... 3
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PRIMARY CARE PROVIDERS ..................................................................................................................................... 7 Primary Care Provider Role .................................................................................................................................................. 7 Provider Specialties .............................................................................................................................................................. 7 Primary Care Provider Onsite Availability ........................................................................................................................... 8 Provider Disenrollment Process ........................................................................................................................................... 8 Member Enrollment ............................................................................................................................................................. 9 Newborn Enrollment.......................................................................................................................................................... 10 Members Eligibility Listing ................................................................................................................................................. 10 Member Identification Cards ............................................................................................................................................. 11 Americans with Disabilities Act Requirements .................................................................................................................. 13 Medically Necessary Services ............................................................................................................................................ 13
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HEALTH CARE BENEFITS AND COPAYMENTS .................................................................................................. 14 Covered Services ................................................................................................................................................................ 14 Starring: Baby and Me Program ........................................................................................................................................ 20 Well-‐Child Visits/Early and Periodic Screening, Diagnosis, and Treatment ...................................................................... 21 Well-‐Child Visits Reminder Program.................................................................................................................................. 21 Blood Lead Screening......................................................................................................................................................... 22 Family Planning Services.................................................................................................................................................... 22 Outpatient Laboratory and Radiology Services ................................................................................................................. 22 Vision Services.................................................................................................................................................................... 23 Pharmacy Services ............................................................................................................................................................. 23 Specialty Drug Program ..................................................................................................................................................... 26 Pharmacy Lock-‐In Program ............................................................................................................................................... 28 Behavioral Health Services ................................................................................................................................................ 29 Cost-‐sharing Information................................................................................................................................................... 30 FAMIS Copayments ............................................................................................................................................................ 30 Self-‐Referral Services ......................................................................................................................................................... 31 Member Rights and Responsibilities ................................................................................................................................. 31 Member Grievance Resolution .......................................................................................................................................... 32 Dissatisfaction with Grievance Decisions .......................................................................................................................... 34 Tracking and Reporting ..................................................................................................................................................... 35 First Line of Defense Against Fraud and Abuse ................................................................................................................. 35 Disclosure of Ownership and Exclusion from Federal Health Care Programs ................................................................... 36 HIPAA ................................................................................................................................................................................. 37
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MEMBER MANAGEMENT SUPPORT ...................................................................................................................... 39 Welcome Call ..................................................................................................................................................................... 39 Appointment Scheduling ................................................................................................................................................... 39 Nurse HelpLine ................................................................................................................................................................... 39 Interpreter Services ............................................................................................................................................................ 39 Health Promotion .............................................................................................................................................................. 39 Case Management............................................................................................................................................................. 40 Disease Management ........................................................................................................................................................ 40 Communicable Disease Services ........................................................................................................................................ 42 Health Education Advisory Committee .............................................................................................................................. 42 Women, Infants and Children Program ............................................................................................................................. 42
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PROVIDER RESPONSIBILITIES ............................................................................................................................... 43
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Medical Home .................................................................................................................................................................... 43 Responsibilities of the Primary Care Provider ................................................................................................................... 43 Primary Care Provider Access and Availability .................................................................................................................. 44 Member Missed Appointments ......................................................................................................................................... 45 Noncompliant Members .................................................................................................................................................... 45 Primary Care Provider Transfers ........................................................................................................................................ 46 Covering Physicians ........................................................................................................................................................... 46 Specialist as a Primary Care Provider ................................................................................................................................ 46 Reporting Changes in Address and/or Practice Status ...................................................................................................... 46 Specialty Referrals ............................................................................................................................................................. 47 Second Opinions ................................................................................................................................................................ 47 Specialty Care Providers .................................................................................................................................................... 48 Role and Responsibility of the Specialty Care Provider ..................................................................................................... 48 Specialty Care Providers Access and Availability ............................................................................................................... 50 Cultural Competency ......................................................................................................................................................... 50 Member Records................................................................................................................................................................ 52 Patient Visit Data ............................................................................................................................................................... 54 Clinical Practice Guidelines ................................................................................................................................................ 54 Advance Directives............................................................................................................................................................. 55 8
MEDICAL MANAGEMENT......................................................................................................................................... 56 Medical Review Criteria ..................................................................................................................................................... 56 Precertification and Notification Process .......................................................................................................................... 56 Medical Appeal Process and Procedures ........................................................................................................................... 57 First-‐Level Appeal .............................................................................................................................................................. 57 Second-‐Level Appeal .......................................................................................................................................................... 58 FAMIS External Review ...................................................................................................................................................... 60 State Fair Hearing .............................................................................................................................................................. 60
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HOSPITAL AND ELECTIVE ADMISSION MANAGEMENT ................................................................................ 62 Inpatient Reviews .............................................................................................................................................................. 72 Discharge Planning ............................................................................................................................................................ 74 Confidentiality of Information ........................................................................................................................................... 74 Emergency Services ........................................................................................................................................................... 74 Urgent Care ....................................................................................................................................................................... 75
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QUALITY MANAGEMENT ......................................................................................................................................... 76 Quality Management Program ......................................................................................................................................... 76 Quality Management Committee ...................................................................................................................................... 76 Medical Advisory Committee ............................................................................................................................................. 77 Credentialing ..................................................................................................................................................................... 77
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PROVIDER COMPLAINT AND GRIEVANCE PROCEDURES ............................................................................ 82
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CLAIM SUBMISSION AND ADJUDICATION PROCEDURES ............................................................................. 83 Electronic Submission ........................................................................................................................................................ 83 Paper Claims Submission ................................................................................................................................................... 83 Encounter Data .................................................................................................................................................................. 85 Claims Adjudication ........................................................................................................................................................... 85 Clean Claims Payment ....................................................................................................................................................... 86 Claims Status ..................................................................................................................................................................... 87 Provider Reimbursement ................................................................................................................................................... 87 Procedure for Processing Overpayments .......................................................................................................................... 87 Provider Payment Disputes................................................................................................................................................ 88 Coordination of Benefits .................................................................................................................................................... 89 Billing Members ................................................................................................................................................................. 90
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Our Website and Provider Services Line ............................................................................................................................ 91 13
APPENDIX A – FORMS ................................................................................................................................................ 92 Referral and Claim Submission Forms ............................................................................................................................... 93 WIC Referral Form ............................................................................................................................................................. 94 Specialist as PCP Request Form ......................................................................................................................................... 97 CMS-‐1500 (08-‐05) Claim Form .......................................................................................................................................... 98 CMS-‐1450 Claim Form ....................................................................................................................................................... 98 HIV Antibody Blood Forms ................................................................................................................................................. 99 Counsel for the HIV Antibody Blood Test ......................................................................................................................... 100 Consent for the HIV Antibody Blood Test ........................................................................................................................ 101 Results of the HIV Antibody Blood Test ........................................................................................................................... 102 Practitioner Evaluation and Audit Tools .......................................................................................................................... 103 Practitioner Clinical Medical Record Audit ...................................................................................................................... 104 Advance Directives........................................................................................................................................................... 106 Living Will ........................................................................................................................................................................ 107 Durable Power of Attorney .............................................................................................................................................. 108
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APPENDIX B – CLINICAL PRACTICE GUIDELINES ......................................................................................... 109
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INTRODUCTION
Welcome to the INTotal Health network provider family. We are pleased you have joined the network, which represents some of the finest health care providers in the Commonwealth. We participate in the Medicaid and Family Access to Medical Insurance Security (FAMIS) programs. Medicaid is Virginia’s managed care health insurance program. FAMIS is Virginia’s children’s health insurance program. The Virginia Department of Medical Assistance Services (DMAS) is the administrator of these programs. We are a licensed Health Maintenance Organization (HMO). We bring the best expertise available nationally to operate local, community-‐based health care plans with experienced local staff to complement our operations. We are committed to assisting you in providing quality health care. We believe hospitals, physicians and other providers play a pivotal role in managed care. We can only succeed by working collaboratively with you and other caregivers. Earning your loyalty and respect is essential to maintaining a stable, high-‐quality provider network. All network providers are contracted with us through a Participating Provider Agreement. If you are interested in participating in any of our quality improvement committees or learning more about specific policies, please contact us. Most committee meetings are prescheduled at times and locations intended to be convenient for you. Please call the Provider Relations Department at 1-‐800-‐231-‐8076 with any suggestions, comments or questions you may have. Together, we can arrange for and provide an integrated system of coordinated, efficient and quality care for our members.
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OVERVIEW
Who is INTotal Health? INTotal Health is a wholly owned subsidiary of Inova Health System. Mission Our mission is to operate a community-‐focused managed care company with an emphasis on the public sector health care market. We will coordinate members’ physical and behavioral health care, offering a continuum of education, access, care and outcome programs, resulting in lower cost, improved quality and better health status for these Americans. Strategy Our strategy is to: • Improve access to preventive primary care services by ensuring the selection of a Primary Care Provider (PCP) who will serve as provider, care manager and coordinator for all basic medical services • Improve the health status and outcomes of members • Educate members about their benefits, responsibilities and the appropriate use of health care services • Encourage stable, long-‐term relationships between providers and members • Discourage medically inappropriate use of specialists and emergency rooms • Commit to community-‐based enterprises and community outreach • Facilitate the integration of physical and behavioral health care • Foster quality improvement mechanisms that actively involve providers in re-‐engineering health care delivery • Encourage a customer service orientation with regular measurement of member and provider satisfaction Summary Escalating health care costs are driven in part by a pattern of fragmented, episodic care and, quite often, unmanaged health problems of members. We strive to educate members to encourage the appropriate use of the managed care system and to be involved in all aspects of their health care.
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QUICK REFERENCE INFORMATION
Please call Provider Services for precertification/notification, health plan network information, member eligibility, claims information, inquiries and recommendations you may have about improving our processes and managed care program. Important Phone Numbers Provider Services: 1-‐855-‐323-‐5588 Provider Services Fax: 703-‐286-‐3994 Automated Provider Inquiry Line: 1-‐855-‐323-‐5588 Behavioral Health Services: 1-‐855-‐323-‐5588 Behavioral Health Fax: 1-‐888-‐393-‐8978 Disease Management: 1-‐855-‐323-‐5588 Nurse HelpLine: 1-‐855-‐323-‐5588 Member Services: 1-‐855-‐323-‐5588 Pharmacy Services: 1-‐877-‐433-‐7643 TTY/TTD -‐ AT&T Relay Service: 1-‐800-‐855-‐2880 for English, 1-‐800-‐855-‐2884 for Spanish Vision Services – Block Vision: 1-‐800-‐428-‐8789 Dental Services – Smiles for Children (administered by DentaQuest Dental): 1-‐888-‐912-‐3456 Transportation Services – LogistiCare: Members may call 1-‐800-‐894-‐8139 to make a reservation. To check on the status of a ride, members may call LogistiCare at 1-‐800-‐894-‐8396. Electronic Data Interchange (EDI) Hotline: Emdeon – 1-‐877-‐469-‐3263 Capario – 1-‐800-‐586-‐6938 Gateway EDI -‐ 1-‐800-‐969-‐3666 Availity -‐ 1-‐800-‐282-‐4548 www.intotalhealth.org Our website contains a full complement of online provider resources, including tools you can use to check eligibility in real time, claims status and precertification/notification status. In addition, the site provides general information such as forms, our Preferred Drug List (PDL), drugs requiring a prior authorization, provider
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manuals, referral directories, provider newsletters, claims status, Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) information, updates, clinical guidelines and other information to help you work best with us. The website may be accessed at www.intotalhealth.org.
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Ongoing Provider Communications To ensure providers are up to date with information required to work effectively with us and our members, we provide frequent communications to providers in the form of broadcast faxes, provider manual updates, quarterly newsletters and information posted to the website. Below you will find additional information that will assist you in your day-‐to-‐day interaction with us. Additional Information Member Eligibility
Notification/Precertification
Check the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderLogin or contact Provider Services at 1-‐855-‐323-‐5588. • May be telephoned, submitted online or faxed to us: Telephone: 1-‐855-‐323-‐5588 Medical Fax: 1-‐888-‐393-‐8978 Behavioral Health Fax: 1-‐888-‐393-‐8978 • Data required for complete notification/precertification: o Member ID number o Legible name of referring provider o Legible name of individual referred to provider o Number of visits and/or services o Dates of service o Diagnosis o Current Procedural Terminology (CPT) codes • In addition, clinical information is required for precertification.
Authorization Request Forms are located at www.intotalhealth.org. Claims Information
•
Submit paper claims to:
•
Electronic claims Payer ID: o Emdeon is 10262 o Capario is IHP02 o Availity is: – IHP001 -‐ Professional Claims – IHP002 -‐ Institutional Claims o Gateway EDI is IHP01
Claims INTotal Health P.O. Box 5446 Richmond, VA 23220-‐0446
• • •
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Timely filing of medical claims is within 180 days of the date of service or per the terms of the provider agreement. For other claims (vision, pharmacy and transportation), refer to the Health Care Benefits and Copayments section. We provide an online resource designed to significantly reduce the time your office spends on eligibility verification, claims status and
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Additional Information
authorization status. Visit www.intotalhealth.org. If you are unable to access the Internet, you may receive claims, eligibility and precertification status over the telephone at any time by calling Provider Services at 1-‐855-‐323-‐5588. Medical appeals must be filed within 90 calendar days of the date of the notice of action. • A provider has 90 calendar days from receipt of Explanation of Payment (EOP) to request a claim dispute resolution review. We will send a determination letter within 30 calendar days of receiving all necessary information. If the provider is dissatisfied with the resolution, the provider may submit an appeal of the resolution within 30 calendar days of receipt of the notification. • File a payment dispute (appeal) at: Payment Dispute Unit INTotal Health 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 • File a medical administrative review for medical necessity at: INTotal Health Appeals Unit 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 • Provider grievances should be submitted to: INTotal Health Grievances 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 • Our case managers are available during normal business hours from 8:30 a.m. to 5:30 p.m. Eastern time. • For urgent issues, assistance is available after normal business hours, on weekends and on holidays, through Provider Services at 1-‐855-‐323-‐ 5588. For further assistance, contact your INTotal Health Provider Relations Representative at 1-‐800-‐231-‐8076. •
Medical Appeal Information Payment Dispute
Grievances
Case Managers
Provider Relations Representatives
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PRIMARY CARE PROVIDERS
Primary Care Provider Role Virginia operates mandatory Medicaid, Children’s Health Insurance Program (CHIP), and Fee-‐for-‐Service (FFS) programs. INTotal Health, formerly Amerigroup Virginia LLC, began participation in the Northern Virginia region September 1, 2005, and has since expanded into other regions of the state. The Primary Care Provider (PCP) is a network provider who has the responsibility for the complete care of his or her patient, who is an INTotal Health member. The PCP serves as the entry point into the health care system for the member. The PCP is responsible for the complete care of his or her patient, including but not limited to providing primary care, coordinating and monitoring referrals to specialist care and maintaining the continuity of care. The PCP responsibilities shall include at a minimum: • Managing the medical and health care needs of members to assure all medically necessary services are made available in a timely manner • Monitoring and following up on care provided by other medical service providers for diagnosis and treatment, to include services available under Fee-‐For-‐Service (FFS) Medicaid • Providing the coordination necessary for the referral of patients to specialists and for the referral of patients to services that may be available through FFS Medicaid • Providing education and coordination for recommended preventive health care services and appropriate guidance for healthy behaviors • Maintaining a medical record of all services rendered by the PCP and other referral providers A PCP must be a physician or network provider or subcontractor who provides or arranges for the delivery of medical services, including case management, to ensure all services which are found to be medically necessary are made available in a timely manner. The PCP may practice in a solo or group setting or may practice in a clinic (e.g., a Federally Qualified Health Center [FQHC], Rural Health Center [RHC]) or outpatient clinic). We encourage members to select a PCP who provides preventive and primary medical care, as well as authorization and coordination of all medically necessary specialty services. Members are encouraged to make an appointment with their PCP within 90 calendar days of their effective date of enrollment. FQHCs and RHCs may function as a PCP. Providers must arrange for coverage of services to assigned members: • 24 hours a day, 7 days a week, in person or by an on-‐call physician • Providers must also answer emergency telephone calls from members within 30 minutes • Each PCP must provide a minimum of 20 office hours per week of personal availability as a PCP
Provider Specialties Physicians with the following specialties can apply for enrollment with us as a PCP: • Family practitioner • General practitioner • General pediatrician • General internist • Nurse practitioners certified as specialists in family practice or pediatrics
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Specialists who perform primary care functions, (e.g., surgeons, clinics, including but not limited to FQHC, RHC, Health Departments and other similar community clinics) Other providers approved by DMAS
The provider must be enrolled in the Medicaid program at the service location where he or she wishes to practice as a PCP before contracting with us. Independent Advanced Practice Nurses (APN) interested in participating with us cannot enroll as a PCP but can participate using a Memorandum of Collaboration (MOC) with a participating PCP.
Primary Care Provider Onsite Availability We are dedicated to ensuring access to care for our members, and this depends upon the accessibility of network providers. Our network providers are required to abide by the following standards: • PCPs must offer 24-‐hour-‐a-‐day, 7-‐day-‐a-‐week telephone access for members. • A 24-‐hour telephone service may be used. The service may be answered by a designee such as an on-‐call physician or nurse practitioner with physician backup, an answering service or a pager system; however, this must be a confidential line for member information and/or questions. An answering machine is not acceptable. If an answering service or pager system is used, the call must be returned within 30 minutes. • The PCP or another physician/nurse practitioner must be available to provide medically necessary services. • Covering physicians are required to follow the referral and precertification guidelines. • It is not acceptable to automatically direct the member to the emergency room when the PCP is not available. • We encourage our network PCPs to offer after-‐hours office care in the evenings and on weekends.
Provider Disenrollment Process Providers may cease participating with us for either mandatory or voluntary reasons. Mandatory disenrollment occurs when a provider becomes unavailable due to immediate, unforeseen reasons. Examples of this include death and loss of license. Members are auto-‐assigned to another PCP to ensure continued access to our covered services, as appropriate. We will notify members of any termination of PCPs or other providers from whom they receive ongoing care. We will provide notice to affected members when a provider disenrolls for voluntary reasons such as retirement. Providers must provide written notice to us within the time frames specified in the Participating Provider Agreement with us. Members who are linked to a PCP that has disenrolled for voluntary reasons will be notified to self-‐select a new PCP.
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Member Enrollment All eligible recipients, except those meeting identified exemptions, must enroll in a Managed Care Organization (MCO). During the initial 90 days following the member’s effective date of enrollment, the member may disenroll from one MCO to move to another without cause. The 90-‐day time frame applies to the member’s initial period of enrollment and to any subsequent enrollment periods when he or she enrolls in a new MCO. Following the initial enrollment period into an MCO, members are restricted to that MCO until the next open enrollment period (Medicaid recipients) or for the remainder of their 12-‐month enrollment period (FAMIS recipients) unless the member requests a new MCO or delivery system for cause and receives approval from DMAS. For Medicaid, the enrollment periods are determined by DMAS based on the member’s region and not the member’s initial enrollment date. For updates or changes, please visit www.virginiamanagedcare.com and go to Changing Health Plans or Doctors. Members are excluded from Medicaid participation if they meet one of the following criteria: • Members who are inpatients in state mental hospitals. • Members who are approved by DMAS as inpatients in long-‐stay hospitals* (Article IID1.b. in the Medallion II Managed Care Contract), nursing facilities, or intermediate care facilities for the intellectually disabled (MCO members who become enrolled in the Technology Assisted Waiver continue to be disenrolled from the MCO). • Members who are placed on spend-‐down. • Member who are participating in Plan First. • Members who are participating in the tech waiver or in federal waiver programs for home-‐based and community-‐based Medicaid coverage prior to managed care enrollment. • Members under age 21 who are approved for DMAS residential facility Level C programs as defined in 12VAC30-‐130-‐860. • Newly eligible members who are in their third trimester of pregnancy and who request exclusion within a department-‐specified timeframe of the effective date of their MCO enrollment. Exclusion may be granted only if the member’s obstetrical provider (e.g., physician, hospital, and midwife) does not participate with the enrollee’s assigned MCO. Exclusion requests made during the third trimester may be made by the member, MCO, or provider. DMAS shall determine if the request meets the criteria for exclusion. Following the end of the pregnancy, these members shall be required to enroll to the extent they remain eligible for Medicaid. • Members, other than students, who permanently live outside their service area of residence for greater than 60 consecutive days, except those individuals placed there for medically necessary services funded by the MCO. • Members who receive hospice services in accordance with DMAS criteria. • Members with other comprehensive group or member health insurance coverage, including Medicare, insurance provided to military dependents, and any other insurance purchased through the Health Insurance Premium Payment Program (HIPP). • Members requesting exclusion who are inpatients in hospitals, other than #1 and #2 above of this subsection, at the scheduled time of MCO enrollment or who are scheduled for inpatient hospital stay or surgery within 30 calendar days of the MCO enrollment effective date. The exclusion shall remain effective until the first day of the month following discharge. This exclusion reason shall not apply to members admitted to the hospital while already enrolled in a department-‐contracted MCO.
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•
•
• • • •
Members who request exclusion during preassignment to an MCO or within a time set by DMAS from the effective date of their MCO enrollment who have been diagnosed with a terminal condition and who have a life expectancy of six months or less. The member’s physician must certify the life expectancy. Certain members between birth and age three certified by the Department of Behavioral Health and Developmental Services as eligible for services pursuant to Part C of the Members with Disabilities Education Act (20 USC §1471 et seq.) who are granted an exception by DMAS to the mandatory Medallion II enrollment. Members who have an eligibility period that is less than three months. Members who are enrolled in the Commonwealth’s Title XXI SCHIP program. Members who have an eligibility period that is only retroactive. Children enrolled in the Virginia Birth-‐Related Neurological Injury Compensation Program established pursuant to Chapter 50 (§ 38.2-‐5000 et seq.) of Title 38.2 of the Code of Virginia.
DMAS reserves the right to exclude from participation in the Medallion II managed care program any individual who has been consistently non-‐compliant with the policies and procedures of managed care or who is threatening to providers, MCOs, or DMAS. There must be sufficient documentation from various providers and the MCO shall promptly notify DMAS upon learning that a member meets one or more of these exclusion criteria.
Newborn Enrollment Any newborn whose parent or guardian is enrolled in Medicaid, FAMIS MOMS or FAMIS with us at the time of birth will be an INTotal Health member for the birth month plus two months regardless of whether the newborn has a Medicaid or FAMIS ID. The parent or guardian has the right to change plans within the three-‐month period, though. In the case where the MCO terminates its contract with DMAS, the MCO is still responsible for the coverage of the newborn until the newborn receives a Medicaid or FAMIS number and is disenrolled by DMAS or for the birth month plus two months time frame, whichever is earlier. With respect to each hospital admission for delivery, the hospital agrees to notify us by the end of the following business day after the admission. The notification must include identification of the covered person as well as birth information as required for reporting to the Commonwealth. While the newborn’s continued enrollment is not contingent on the parent’s or guardian’s enrollment, the newborn must have a Medicaid or FAMIS ID number before the end of the third month in order to continue coverage. In order for newborns of FAMIS MOMS to receive continued coverage, the parent or guardian must notify the FAMIS Central Processing Unit (CPU) at 1-‐866-‐87FAMIS.
Members Eligibility Listing The PCP will receive a listing of his or her panel of assigned members twice each month. If a member calls to change his or her PCP, the change will generally be effective either the date of the request or the following business day. The PCP should verify that each INTotal Health member receiving treatment in his or her office is on the membership listing. If a PCP does not receive the lists in a timely manner, he or she should contact a Provider Relations Representative. For questions regarding a member’s eligibility, providers may access our website at www.intotalhealth.org or call Provider Services at 1-‐855-‐323-‐5588.
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Member Identification Cards Each member enrolled with the health plan will have an INTotal Health ID card. The ID card will include: • The member’s name (first and last name and middle initial) • The Medicaid/FAMIS member’s identification number • The member’s date of birth • The member’s enrollment effective date • The member’s copayment responsibility • INTotal Health address and telephone number • Toll-‐free phone numbers for information and/or authorizations • Toll-‐free Nurse HelpLine 24 hours a day, 7 days a week • Descriptions of procedures to be followed for emergency or special services • PCP’s name and telephone number INTotal Health member identification card samples are provided below. This card is applicable to Medicaid program. Effective Date: EFF_DATE Date of Birth: Member_DOB_Date Medicaid Number: MED_ID Member Name:
Vision:
Primary Care Provider (PCP):
Dental:
Member_Name Prov_Name
PCP Telephone #: Prov_Phone_NO
Member Services/ Nurse HelpLine and Behavioral Health:
1.800.428.8789
1.855.323.5588
Smiles For Children 1.888.912.3456
Transportation:
Copays:
Inpatient Hospital: $0 Outpatient Hospital or Doctor: $0 Pharmacy: $0 (up to 34-day supply) $0 (35 to 90-day supply) Emergency Room Visits: $0 Vision: $0 (routine exam)
Logisticare 1.800.894.8139 (appts) 1.800.894.8396 (status)
INTotal Health MEDICAID
This card is applicable to the FAMIS MOMS program.
Effective Date: EFF_DATE Date of Birth: Member_DOB_Date Medicaid Number: MED_ID Member Name:
Vision:
Primary Care Provider (PCP):
Dental:
Member_Name Prov_Name
PCP Telephone #: Prov_Phone_NO
1.800.428.8789 Smiles For Children 1.888.912.3456
Copays:
Inpatient Hospital: $0 Outpatient Hospital or Doctor: $0 Pharmacy: $0 (up to 34-day supply) $0 (35 to 90-day supply) Emergency Room Visits: $0 Vision: $0 (routine exam)
INTotal Health FAMIS MOMS
Member Services/ Nurse HelpLine and Behavioral Health: 1.855.323.5588
Transportation:
Logisticare 1.800.894.8139 (appts) 1.800.894.8396 (status)
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This card is applicable to FAMIS members whose federal poverty levels are greater than 150 percent. Effective Date: EFF_DATE Date of Birth: Member_DOB_Date Medicaid Number: MED_ID Member Name:
Vision:
Primary Care Provider (PCP):
Dental:
Member_Name Prov_Name
PCP Telephone #: Prov_Phone_NO
Member Services/ Nurse HelpLine and Behavioral Health:
1.800.428.8789
1.855.323.5588
Smiles For Children 1.888.912.3456
Transportation:
Copays:
Inpatient Hospital: $25 Outpatient Hospital or Doctor: $5 Pharmacy: $5 (up to 34-day supply) $10 (35 to 90-day supply) Emergency Room Visits: $5 Vision: $5 (routine exam)
Logisticare 1.800.894.8139 (appts) 1.800.894.8396 (status)
INTotal Health FAMIS Program
This card is applicable for FAMIS members whose federal poverty levels are at or below 150 percent.
Effective Date: EFF_DATE Date of Birth: Member_DOB_Date Medicaid Number: MED_ID Member Name:
Vision:
Primary Care Provider (PCP):
Dental:
Member_Name Prov_Name
PCP Telephone #: Prov_Phone_NO
Member Services/ Nurse HelpLine and Behavioral Health:
1.800.428.8789
1.855.323.5588
Smiles For Children 1.888.912.3456
Transportation:
Copays:
Inpatient Hospital: $15 Outpatient Hospital or Doctor: $2 Pharmacy: $2 (up to 34-day supply) $4 (35 to 90-day supply) Emergency Room Visits: $2 Vision: $5 (routine exam)
Logisticare 1.800.894.8139 (appts) 1.800.894.8396 (status)
INTotal Health FAMIS Program
This card is applicable for American Indians, Alaskan Natives and FAMIS members who have met their maximum copayment. Effective Date: EFF_DATE Date of Birth: Member_DOB_Date Medicaid Number: MED_ID Member Name:
Vision:
Primary Care Provider (PCP):
Dental:
Member_Name Prov_Name
PCP Telephone #: Prov_Phone_NO
1.800.428.8789 Smiles For Children 1.888.912.3456
Copays:
Inpatient Hospital: $0 Outpatient Hospital or Doctor: $0 Pharmacy: $0 (up to 34-day supply) $0 (35 to 90-day supply) Emergency Room Visits: $0 Vision: $0 (routine exam)
INTotal Health MEDICAID
Member Services/ Nurse HelpLine and Behavioral Health: 1.855.323.5588
Transportation:
Logisticare 1.800.894.8139 (appts) 1.800.894.8396 (status)
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Americans with Disabilities Act Requirements Our policies and procedures are designed to promote compliance with the Americans with Disabilities Act of 1990. Providers are required to take actions to remove an existing barrier and/or to accommodate the needs of members who are qualified individuals with a disability. This action plan includes: • Street-‐level access • Elevator or accessible ramp into facilities • Access to lavatory that accommodates a wheelchair • Access to examination room that accommodates a wheelchair • Handicap parking clearly marked, unless there is street-‐side parking
Medically Necessary Services Medically necessary behavioral health services: • Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder or to improve, maintain or prevent deterioration of functioning resulting from such a disorder • Are acceptable clinical guidelines and standards of practice in behavioral health care • Are available in the most appropriate and least restrictive setting in which services can be safely provided • Are at the appropriate level or supply of service that can safely be provided • If omitted, would adversely affect the member’s mental and/or physical health or the quality of care rendered Medically necessary health services mean health services other than behavioral health services that are: • Reasonable and necessary to prevent illness or medical conditions or provide early screening, interventions and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a member or endanger life • Available at appropriate facilities and at the appropriate levels of care for the treatment of the member’s health condition(s) • Consistent with health care practice guidelines and standards endorsed by professionally recognized health care organizations or governmental agencies • Consistent with the diagnosis of the conditions • No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness and efficiency Note: We do not cover the use of any experimental procedures or experimental medications except under certain circumstances.
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HEALTH CARE BENEFITS AND COPAYMENTS
Covered Services The following list shows the health care services and benefits we cover for MedicaidFAMIS MOMS and FAMIS members. Please note that covered services for FAMIS MOMS are the same as the covered services for Medicaid members. FAMIS MOMS do not have cost sharing for the services they receive while enrolled. See Cost Sharing Information under FAMIS Copayments later in this section. COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Abortions Chiropractic Services
Clinic Services
Colorectal Cancer Screening Court-‐ordered Services Dental Care
Durable Medical Equipment (DME)
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Covered by FFS if services meet federal CHIP requirements. Coverage of medically necessary spinal manipulation and outpatient chiropractic services to treat an illness or injury. Benefits are limited to $500 per calendar year. Covered services include preventive, diagnostic, therapeutic, rehabilitative or palliative care. Renal dialysis clinic visits are also a covered benefit. Not a covered benefit.
Covered by Medicaid FFS if services meet federal Medicaid requirements. Not a covered benefit unless recommended at an Early Periodic Screening, Diagnosis and Treatment (EPSDT) visit.
Not a covered benefit unless it is medically necessary and a FAMIS covered benefit. Dental services are provided through DentaQuest Dental, a dental benefit administrator contracted with the Department of Medical Assistance Services (DMAS). The toll-‐free number for DentaQuest Dental is 1-‐888-‐912-‐3456. We cover medically necessary services, resulting from a dental accident for medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures.
Covered services include court-‐ordered Medicaid services.
Medically necessary DME is a covered benefit.
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Covered services include preventive, diagnostic, therapeutic, rehabilitative or palliative care. Renal dialysis clinic visits are also a covered benefit. Covered benefit.
Dental services are provided through DentaQuest Dental, a dental benefit administrator contracted with DMAS. The toll-‐free number for DentaQuest Dental is 1-‐888-‐912-‐3456. We cover medically necessary services resulting from a dental accident and medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures. We also cover transportation services for dental care for Medicaid members, as well as hospitalization or anesthesia as part of medically necessary services. Coverage of medically necessary medical supplies and equipment are covered benefits. The following supplies are noncovered supplies: • Space conditioning equipment • Medical supplies for any hospital or nursing facility resident
COVERED SERVICES FAMIS
MEDICAID & FAMIS MOMS
• Comfort and convenience items • Home or vehicle modifications • Job or education-‐related equipment (e.g., computers); speech devices are covered when medically necessary Early Intervention Early intervention services provided to children who have been determined eligible Services for Part C of the Individuals with Disabilities Education Act are covered by DMAS FFS. Services must be rendered by providers certified by the Department of Behavioral Health and Developmental Services. The MCO must cover medically necessary rehabilitative/developmental therapies within EPSDT guidelines, including for Early Intervention enrolled children where appropriate. Early and Periodic See Well-‐baby and Well-‐child Care for EPSDT program covers screening and Screening, covered benefits. diagnostic services to determine physical or Diagnosis, and mental defects in recipients from birth Treatment (EPSDT) through age 20, as well as health care and other measures to correct or ameliorate any defects and chronic conditions discovered. We cover all medically necessary EPSDT services except for School-‐Based Private Duty Nursing Services (SBPDN). SBPDN services are covered through the special education director in the school district. We will contact the parent and/or guardian and provide a name and telephone number of the special education director. We also complete the SBPDN Referral Form and forwards it to the DMAS specialized services unit, along with any clinical documentation related to the Private Duty Nursing (PDN) services required. We also send a copy of the completed SBPDN form to the child’s parent, school special education director and the PDN provider. Immunizations are a covered benefit.
Emergency and Poststabilization Services
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Emergency and medically necessary poststabilization services do not require a referral or precertification. An emergency medical condition is a medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably 15
EPSDT screening services shall reflect the age of the child and should be provided according to the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics. Emergency and medically necessary poststabilization services do not require a referral or precertification. An emergency medical condition is a medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention
COVERED SERVICES FAMIS
Family Planning Services and Supplies
Hearing Aids
HIV Testing and Treatment PRM-‐July 2013
MEDICAID & FAMIS MOMS
expect the absence of immediate medical attention could result in the following: • Physical or mental health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy • Serious impairment to bodily functions • Serious dysfunction of any bodily organ or part • Serious harm to self or others due to an alcohol or drug abuse emergency • Injury to self or bodily harm to others • A pregnant woman having contractions; (i) that there is adequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child Coverage of family planning services and supplies are a benefit for all members of childbearing age. Family planning services and supplies include: • Education and counseling necessary to make informed choices and understand contraceptive methods • Initial and annual complete physical examinations, including pelvic and breast exams • Lab and pharmacy • Follow-‐up, brief and comprehensive visits • Contraceptive supplies and follow-‐up care • Diagnosis and treatment of sexually transmitted diseases Not covered: Infertility services and treatment, elective abortions, and services performed at the time of abortion. Hearing aids are a covered benefit twice every five years. Not a covered benefit.
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could result in the following: • Physical or mental health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy • Serious impairment to bodily functions • Serious dysfunction of any bodily organ or part • Serious harm to self or others due to an alcohol or drug abuse emergency • Injury to self or bodily harm to others • A pregnant woman having contractions; (i) that there is adequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child
Coverage of family planning services and supplies are a benefit for all members of childbearing age. Family planning services and supplies include: • Education and counseling necessary to make informed choices and understand contraceptive methods • Initial and annual complete physical examinations, including pelvic and breast exams • Lab and pharmacy • Follow-‐up, brief and comprehensive visits • Contraceptive supplies and follow-‐up care • Diagnosis and treatment of sexually transmitted diseases Sterilization consent form is required for claims submission. Not covered: Infertility services and treatment, elective abortions, and services performed at the time of abortion. Hearing aids and related supplies are covered for EPSDT members, age 0–20 years only. Coverage of HIV testing and treatment. Counseling for pregnant women is a
COVERED SERVICES FAMIS
MEDICAID & FAMIS MOMS
Counseling Home Health Services
covered benefit. Coverage of medically necessary home health services include: • Nursing services, rehabilitation therapies and home health aide services • Home health aide services are limited to 32 visits per year • Skilled home health visits are limited based on medical necessity
Coverage of medically necessary home health services include: • Skilled nursing • Personal care services • Home health aide services • Physical therapy • Occupational therapy • Speech therapy • Hearing therapy • Inhalation therapy
Hospice
Inpatient Hospital Services Inpatient Mental Health/Substance Abuse Services
Limit: 90 total visits per year Coverage of medically necessary Hospice services are covered by DMAS FFS. hospice care for members with a life expectancy of six months or less Inpatient hospital services in general acute care and rehabilitation hospitals are covered. • Inpatient (IP) freestanding • Inpatient freestanding psychiatric psychiatric facility – not covered* facility – covered only for members under age 21 and over age 64 • Inpatient state psychiatric facility – not covered • Inpatient state psychiatric facility – not covered • Inpatient acute care facility – covered up to 30 days for all ages; • Inpatient acute care facility – covered includes partial hospitalization for all ages treatment • Partial hospitalization – not covered • Partial hospitalization – covered up to 30 days; combined with inpatient acute care treatment * May be covered based upon review criteria for enrollees up to age 19 Transportation and pharmacy services necessary for the treatment of substance abuse (including carved out services) are the responsibility of INTotal Health.
Laboratory and X-‐ray Services
Organ Transplants
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Community Mental Health Rehabilitation Services (CMHRS) are covered by the Department of Medical Assistance Services. For specific service coverage, please contact DMAS or see the DMAS CMHRS manual online. Coverage of all laboratory and X-‐ray Coverage of all laboratory and X-‐ray services ordered, prescribed and services ordered, prescribed and directed or directed or performed within the performed within the scope of the license scope of the license of a practitioner. of a practitioner. No copayments shall be charged for laboratory and X-‐ray services that are performed as part of an encounter with a physician. Coverage of medically necessary Coverage of kidney, cornea, heart, lung, transplant services that is not liver and pancreas transplants for all experimental or investigational. members. High-‐dose chemotherapy and/or Coverage of services to identify a bone marrow transplants are limited to 17
COVERED SERVICES FAMIS
MEDICAID & FAMIS MOMS
donor is limited to $25,000 per member.
Outpatient Hospital Services
Outpatient Mental • Health/Substance Abuse Services
Physical Therapy, Occupational Therapy, Speech-‐ Language Pathology and Audiology Services
Physician Services
Pregnancy-‐related Services
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members with myeloma, lymphoma, breast cancer or leukemia. All medically necessary transplants that are not experimental are covered for members under age 21. Coverage of outpatient hospital services that are preventive, diagnostic, therapeutic, rehabilitative or palliative are covered benefits.
Coverage of outpatient hospital services that are preventive, diagnostic, therapeutic, rehabilitative or palliative are covered benefits. Covered Services: • Outpatient individual, family and group mental health and substance abuse treatment (excluding opioid treatment) • Outpatient electroconvulsive therapy • Outpatient detoxification Transportation and pharmacy services necessary for the treatment of substance abuse (including carved out services) are the responsibility of INTotal Health. Community Mental Health Rehabilitation Services (CMHRS) are covered by the Department of Medical Assistance Services. For specific service coverage, please contact DMAS or see the DMAS CMHRS manual online. Coverage of medically necessary Coverage of medically necessary services services provided at the inpatient or provided at an inpatient or outpatient outpatient hospital or by a home hospital or home health service. Medically health service. All children of school necessary intensive outpatient age should be evaluated for school-‐ rehabilitation services in facilities certified based speech therapy prior to as Comprehensive Outpatient precertification at a nonschool-‐based Rehabilitation Facilities (CORF) and location. outpatient rehabilitation services provided in agencies are also covered. Coverage of all symptomatic visits to Coverage of all symptomatic visits to physicians or physician extenders physicians or physician extenders and within the scope of their licenses. routine physicals for children up to age 21 Physician services, including services under EPSDT. Annual routine physical while admitted in the hospital, examinations are covered for adults age 21 outpatient hospital department, in a and older. clinic setting or in a physician’s office are covered benefits. Services for pregnant women, Coverage of medically necessary pregnancy-‐ including prenatal care. Covered related and postpartum services, services to services include: treat any other medical condition that may complicate pregnancy, prenatal services • Pregnancy planning and perinatal health promotion and education for and case management services for high-‐risk pregnant women. Covered services include: reproductive-‐age women • Pregnancy planning and perinatal health • Perinatal risk assessment of promotion and education for nonpregnant women; pregnant, reproductive-‐age women postpartum women; and newborns and children up to 5 months of age • Perinatal risk assessment of nonpregnant women; pregnant, postpartum women; • Childbirth education classes for all and newborns and children up to 5 pregnant women and their chosen months of age partner • Childbirth education classes for all 18
COVERED SERVICES FAMIS
Prescription Drugs
Private Duty Nursing
Prosthetic and Orthotic Services
School-‐based Services Skilled Nursing Facility Services PRM-‐July 2013
MEDICAID & FAMIS MOMS
• Emergency care • Lactation consultation and breast pumps • Medically necessary tobacco cessation services, including counseling and pharmacotherapy • Transfer and care of pregnant women, newborns and infants at tertiary care facilities if necessary • Network OB/GYNs, anesthesiologists and neonatologists appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems • Inpatient care and professional services relating to labor and delivery for pregnant/delivering members and neonatal care for newborn members at the time of delivery up to 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated caesarean delivery • No copays apply Prescription drugs include those prescribed by a provider during a physician visit or other visits covered by a mental health provider. Please reference Pharmacy Services for formulary information. A covered benefit when medically necessary and provided only by a nurse or licensed practical nurse. Chief Medical Officer’s approval required. Medically necessary prosthetic services and devices that include artificial arms, legs and their attachments. Medically necessary orthotic services and devices are also covered.
Select services are covered. Call 1-‐855-‐ 323-‐5588 for more information. Medically necessary nursing facility services up to 180 days per stay. 19
• • •
•
•
•
pregnant women and their chosen partner Emergency care Lactation consultation and breast pumps Medically necessary tobacco cessation services, including counseling and pharmacotherapy Transfer and care of pregnant women, newborns and infants at tertiary care facilities if necessary Network OB/GYNs, anesthesiologists and neonatologists appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems Inpatient care and professional services relating to labor and delivery for pregnant/delivering members and neonatal care for newborn members at the time of delivery up to 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated caesarean delivery
Prescription drugs include those prescribed by a provider during a physician visit or other visits covered by a mental health provider. Please reference Pharmacy Services for formulary information. A covered benefit for children only under age 21. Chief Medical Officer’s approval required.
Medically necessary prosthetic services and devices that include artificial arms, legs, internal body parts, breast (including reconstructive breast surgery) and eyes. Medically necessary orthotics, regardless of member’s age when recommended as part of an approved intensive rehabilitation program. Medically necessary orthotic services and devices are covered for children under age 21. Select services are covered. Call 1-‐855-‐323-‐ 5588 for more information. Skilled nursing facility services are covered by DMAS FFS.
COVERED SERVICES FAMIS
MEDICAID & FAMIS MOMS
Tobacco Cessation
Medically necessary services, including counseling and pharmacotherapy, are covered. Emergency and nonemergency transportation to and from all Medicaid covered services, including visits to and from the doctor’s office, hospitals and other providers, including community mental health and outpatient rehabilitation services are a covered benefit. Members can contact LogistiCare for assistance in scheduling transportation. Coverage of routine eye exams, frames and lenses every 24 months. Contact lenses are covered for members up to age 21 when medically necessary.
Transportation
Vision Services
Well-‐baby and Well-‐child Care
Women’s Health Care Services
Medically necessary services, including counseling and pharmacotherapy, are covered. As a value-‐added benefit, FAMIS members can receive up to 10 round trips to medically necessary appointments through LogistiCare. Professional ambulance services when medically necessary are covered when used locally or from a covered facility or provider office. Coverage of routine eye exams, frames and lenses every 24 months. Contact lenses are covered for members up to age 21 when medically necessary. Diabetics: An annual eye screening for diabetic retinal disease is covered. Coverage of routine well-‐baby and well-‐child care services includes routine office visits with health assessments and physical exams, routine lab work and age-‐appropriate immunizations. For female members over age 13, coverage of an annual exam and routine health services (including a Pap smear and mammogram) does not require precertification from a PCP.
As a value-‐added benefit, medically necessary eyeglasses are covered for members age 21 and older. See EPSDT.
For female members age 13 and older, coverage of an annual exam and routine health care services (including Pap smear) performed by a PCP or in-‐network GYN does not require precertification. Mammograms for women age 35 or older are also covered without precertification. Precertification is required for breast prostheses and reconstructive breast surgery.
Note: We do not cover the use of any experimental procedures or experimental medications except under certain circumstances.
Starring: Baby and Me Program We offer Starring: Baby and Me to all expectant mothers. The program objective is to provide coordinated, comprehensive prenatal management with the intent of identifying members prior to an adverse health event and providing them with care management, education and incentive gift rewards to promote healthy outcomes.
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Prenatal Program A package will be sent upon enrollment into the Starring: Baby and Me program that includes a pregnancy book. Upon completing prenatal checks, members are eligible for a $10 gift card (e.g., Walmart, Target, etc.). Postpartum Program Upon completing the postpartum check, the member will be mailed a diaper bag, a Starring: Baby and Me book and a safety kit, including child thermometer. Notification to INTotal Health Provider Services at 1-‐855-‐323-‐5588 is required at the first prenatal visit. Starring: Baby and Me provides care management to: • Improve the level of knowledge of the member about her pregnancy stage • Create systems that support the delivery of quality of care • Measure and maintain or improve member outcomes related to the care delivered • Facilitate care with providers to promote collaboration, coordination and continuity of care Health education is provided and encouraged through prenatal and postpartum health promotion packets that also include information on foster program participation and gift incentives. Information about available health-‐related community services is provided to members as appropriate. All identified pregnant members will automatically receive information on Starring: Baby and Me.
Well-‐Child Visits/Early and Periodic Screening, Diagnosis, and Treatment We encourage our members to contact their physician within the first 90 days of enrollment to schedule a well-‐child visit and within 24 hours for newborns. Our Medicaid members are eligible to receive these services from birth through age 20. The well-‐child program in Virginia provides the following: • Comprehensive health and development history, including physical and mental development • Comprehensive unclothed physical examination • Age-‐appropriate immunizations • Appropriate laboratory tests • Lead toxicity screening • Health education • Vision services • Dental services • Hearing services • Other necessary health care Well-‐child services should be performed for newborns in the hospital and then in compliance with the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care. Children between ages 3 and 21 should be seen by a PCP annually. We educate our members about these guidelines and monitor encounter data for compliance.
Well-‐Child Visits Reminder Program Each quarter, we send lists to our PCPs of our members who, based on our claims data, may not have received well-‐child services according to schedule. Additionally, we mail information to these members, encouraging them to contact their PCPs’ offices to set up appointments for needed services.
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By enrolling with the Virginia Vaccines For Children (VVFC) program, you can get vaccines free of charge. Call 1-‐800-‐568-‐1929 or 804-‐864-‐8055, or email
[email protected] to receive an enrollment packet. You cannot bill for these vaccines, but we will reimburse you for the administration fee. Please note: • Specific services needed for each member are listed in the report. Reports are based only on services received during the time the member is enrolled with us. • Services must be rendered on or after the due date in accordance with federal EPSDT and state Department of Health guidelines. In accordance with these guidelines, services received prior to the specified schedule date do not fulfill EPSDT requirements. Refer to the INTotal Health Health Care Benefits and Copayments table within this manual for covered services and to the Virginia Periodicity Schedule and the Advisory Committee on Immunization Practices (ACIP) immunization tables. • FAMIS enrollees do not qualify for the free Vaccines for Children program. • The PCP list is generated based on our claims data received prior to the date printed on the list. In some instances, the appropriate services may have been provided after the report run date. • To ensure accuracy in tracking preventive services, please submit a completed claim form for those dates of service to our Claims Department at: Claims INTotal Health P.O. Box 5446 Richmond, VA 23220-‐0446
Blood Lead Screening Providers will furnish a screening program for the presence of lead toxicity in children that consists of a screening and blood test. During every well-‐child visit for children between the ages of 6 months and 6 years old, the PCP will screen each child for lead poisoning. A blood test will be performed at 12 months and 24 months of age to determine lead exposure and toxicity. In addition, children over the age of 24 months up to 72 months should receive a blood screening lead test if there is not a past record of a test. Results of lead testing, both positive and negative results, must be reported to the Virginia Department of Health, Office of Epidemiology. Please see blood lead risk forms located in Appendix A – Forms.
Family Planning Services Members of childbearing age have direct access to both network and non-‐network providers for all family planning services and supplies that delay or prevent pregnancy but do not include services to treat infertility or to promote fertility. Services include exams, assessments, drugs, supplies and traditional contraceptive devices.
Outpatient Laboratory and Radiology Services All outpatient laboratory tests should be performed at a network facility outpatient lab or at one of our preferred network lab vendors (Laboratory Corporation of America [LabCorp] or Quest Diagnostics) unless the provider has a Clinical Laboratory Improvement Amendment (CLIA) certification and either a clinical laboratory license, a certification of waiver or a certificate of registration and an identification number. Laboratories with certificates of waiver will provide only the types of tests permitted under the terms of the waiver. Laboratories with certificates of registration may perform the full range of services for which they are certified. Visit the Centers for Medicare & Medicaid Services (CMS) website at www.cms.hhs.gov for a complete list. Only after-‐hours STAT laboratory services can be directed to a participating hospital. For a current listing of STAT lab locations, please refer to the Provider Directory online at www.intotalhealth.org. PRM-‐July 2013
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We have a radiology management program for outpatient scans with MedSolutions. MedSolutions is a radiology services organization that specializes in managing diagnostic services. For all elective outpatient Magnetic Resonance Angiogram (MRA), Magnetic Resonance Imaging (MRI), Computerized Tomography (CT), Positron Emission Tomography (PET) scan and nuclear cardiology, providers will obtain precertification from MedSolutions. Contact MedSolutions at 1-‐888-‐693-‐3211 or go online at www.medsolutions.com.
Vision Services Our members may self-‐refer for accessing their eye care benefits by calling Block Vision at 1-‐800-‐428-‐8789. We cover one eye examination, frames and lenses every 24 months. Contact lenses are covered for members up to age 21 when medically necessary. Medicaid members age 21 and older are also eligible to receive medically necessary eyeglasses as a value-‐added benefit we offer. For FAMIS members, we will reimburse for frames and lenses up to the amounts listed below. Members pay for costs above these amounts: $25 • Eyeglass frames $35 • Single vision lenses $50 • Bifocal lenses $88.50 • Trifocal lenses $100.00 • Contact lenses As medically necessary See Health Care Benefits and Copayments sections for the covered benefit for vision services and FAMIS copayments. Please note that diabetic retinal eye exams are a covered benefit, regardless of age or benefit package.
Pharmacy Services Our pharmacy benefit provides coverage for medically necessary medications from licensed prescribers for the purpose of saving lives in emergency situations or during short-‐term illness, sustaining life in chronic or long-‐ term illness, or limiting the need for hospitalization. Members have access to most national pharmacy chains and many independent retail pharmacies. We’ve contracted with Caremark as our Pharmacy Benefits Manager. Caremark’s pharmacy network is the designated pharmacy network. All members must use a network pharmacy when filling prescriptions in order for benefits to be covered. For specialty drugs, please continue to use Caremark Specialty Pharmacy at 1-‐877-‐433-‐ 7643. Prescriptions for specialty products can only be filled through Caremark Specialty Pharmacy as described below. Monthly Limits All prescriptions are limited to a maximum 31-‐day supply per fill.
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Covered Drugs Our Pharmacy program uses a Preferred Drug List (PDL). This is a list of the preferred drugs within the most commonly prescribed therapeutic categories. The PDL is comprised of drug products reviewed and approved by our Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is comprised of network physicians, pharmacists and other health care professionals who evaluate safety, efficacy, adverse effects, outcomes and total pharmacoeconomic value for each drug product reviewed. The PDL also includes several Over-‐The-‐Counter (OTC) products that are recommended as first-‐line treatment where medically appropriate. To prescribe medications that do not appear on the PDL, please contact Pharmacy Services at 1-‐877-‐433-‐7643. Please refer to our PDL on our website at www.intotalhealth.org. Updates to the PDL or changes in pharmaceutical procedures will be available via the website and followed by written notification. Copies of the PDL or other pharmaceutical management procedures are available upon request. The following are examples of covered items: • Legend drugs • Insulin • Disposable insulin needles and syringes • Disposable blood, urine glucose and acetone testing agents • Lancets and lancet devices • Compounded medication of which at least one ingredient is a legend drug and listed on the INTotal Health PDL • Any other drug which under the applicable state law may only be dispensed upon the written prescription of a physician or other lawful prescriber and is listed on the PDL • PDL-‐listed legend contraceptives (for Medicaid members, injectable contraceptives may be dispensed in up to a 90-‐day supply) Prior Authorization Drugs We strongly encourage you to write prescriptions for preferred products as listed on the PDL. If for medical reasons a member cannot use a preferred product, you’re required to contact Pharmacy Services to obtain prior authorization. Prior authorization may be requested by calling Caremark Pharmacy Services at 1-‐877-‐433-‐7643 or faxed to 1-‐855-‐762-‐5205 (24 hours a day, 7 days a week). Please be prepared to provide relevant clinical information regarding the member’s need for a nonpreferred product or a medication requiring prior authorization. Decisions are based on medical necessity and are determined according to certain established medical criteria. Examples of medications that require authorization are listed below. (Note: This list is not all-‐inclusive and is subject to change. The complete PDL, including the current updates and information on additional requirements and limitations such as prior authorization, quantity limits, age limits or step therapy, are available online at www.intotalhealth.org: • Drugs not listed on the PDL • Brand-‐name products for which there are therapeutically equivalent generic products available • Self-‐administered injectable products • Drugs that exceed certain limits (for information on these limits, please contact the Pharmacy Services) • Adapaline (Differin) • Adefovir dipivoxil (Hepsera) • Agalsidase beta (Fabrazyme) • Becaplermin gel 0.1% (Regranex) • Botulinim Toxin (Botox) • Celecoxib (Celebrex) • Cyclosporine emulsion (Restasis) • Dornase alfa (Pulmozyme) • Doxercalciferol (Hectoral) PRM-‐July 2013
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• Droperidol (Inapsine) • Epoetin alfa (Procrit) • Filgrastim (Neupogen) • Imiquimod (Aldara) • Interferon alfa-‐2a (Roferon-‐A) • Interferon alfa-‐2b (Intron-‐A) • Interferon alfacon-‐1 (Infergen) • Laronidase (Aldurazyme) • Leuprolide acetate (Lupron, Lupron Depot) • Levalbuterol hcl soln (Xopenex) • Midazolam inj/syrup (Versed) • Omalizumab (Xolair) • Orlistat (Alli) • Pegfilgrastim (Neulasta) • Peginterferon alfa-‐2a (Pegasys) • Peginterferon alfa-‐2b (PEG-‐Intron) • Pimecrolimus (Elidel) • Pramlintide (Symlin) • Ribavirin + interferon alfa-‐2b (Rebetron) • Sargramostim (Leukine) • Sevelamer (Renagel) • Sibutramine (Meridia) • Somatropin (Nutropin, Nutropin AQ, Nutropin Depot, Saizen) • Teriparatide (Forteo) • Thalidomide (Thalomid) • Tizanidine (Zanaflex) Over-‐the-‐counter Drugs Medicaid and FAMIS MOMS members may obtain specified OTC or nonlegend drugs. In order to access this benefit, a prescription is required. The following are examples of OTC medication classes covered. Please refer to our PDL for a complete list of covered items. • Analgesics and antipyretics • Antacids • Antibacterials, topical • Antidiarrheals • Antiemetics • Antifungals, topical • Antifungals, vaginal • Antihistamines • Contraceptives • Cough and cold preparations • Decongestants • Laxatives • Pediculocides • Respiratory agents (including spacing devices) • Topical anti-‐inflammatories
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Excluded Drugs The following drugs are examples of medications that are excluded from the pharmacy benefit: • Weight control products (except Meridia and Alli which require prior authorization) • Anti-‐wrinkle agents (e.g., Renova) • Drugs used for cosmetic reasons or hair growth • Experimental or investigational drugs • Drugs used for experimental or investigational indication • Immunizing agents • Infertility medications • Implantable drugs and devices (Norplant, Mirena IUD) are covered under the family planning benefit • Erectile dysfunction drugs to treat impotence • Nonlegend (OTC) drugs, other than those listed above or specifically listed under Covered Nonlegend Drugs Specialty Drug Program We contract with Caremark Specialty Pharmacy Services as its exclusive supplier of high-‐cost, specialty and injectable drugs that treat a number of chronic or rare conditions, including: • Anemia • Immunologic disorders • Crohn’s disease • Multiple sclerosis • Cystic fibrosis • Neutropenia • Gaucher disease • Primary pulmonary hypertension • Growth hormone deficiency • Rheumatoid arthritis • Hemophilia • Respiratory Syncytial Virus (RSV) disease • Hepatitis C To obtain one of the listed specialty drugs, please fax your request to CaremarkConnect at 1-‐800-‐323-‐2445 or call CaremarkConnect at 1-‐800-‐237-‐2767. *This is not a complete list but represents the most commonly prescribed injectables. ALLERGIC ASTHMA HEMOPHILIA, IMMUNE DEFICIENCIES PULMONARY ARTERIAL Xolair VON WILLEBRAND Baygam HYPERTENSION DISEASE, AND Carimune NF Remodulin CROHN’S DISEASE RELATED BLEEDING Cytogam Revatio Remicade DISORDERS Flebogamma Tracleer Advate Gamimune N ENZYME REPLACEMENT Alphanate Gammagard S/D PULMONARY DISEASE FOR LYSOSOMAL Alphanine SD Gammar-‐P I.V. Aralast STORAGE Amicar GammaSTAN Pulmozyme DISORDERS Autoplex T Gamunex TOBI Aldurazyme Bebulin VH Iveegam EN Elaprase Benefix Octagam PSORIASIS Fabrazyme Feiba VH Immuno Panglobulin Amevive Naglazyme Genarc Polygam SD Enbrel Myozyme Helixate FS Vivaglobin Raptiva Hemofil-‐M WinRho SDF GAUCHER DISEASE Humate-‐P RESPIRATORY Cerezyme Koate-‐DVI MULTIPLE SCLEROSIS SYNCYTIAL VIRUS Ceredase Kogenate FS Avonex Synagis Monarc-‐M Betaseron Monoclate-‐P Copaxone PRM-‐July 2013
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GROWTH HORMONE DISORDERS Genotropin Humatrope Norditropin ** Norditropin Nordiflex ** Nutropin Nutropin AQ Saizen Serostim Tev-‐Tropin Zorbtive HEMATOPOIETICS* Aranesp Epogen Leukine Neulasta Neumega Neupogen Procrit
HEMOPHILIA, VON WILLEBRAND DISEASE, AND RELATED BLEEDING DISORDERS (CONT’D) Mononine Novoseven Profilnine SD Proplex T Recombinate Refacto Stimate HEPATITIS C Copegus Infergen Intron-‐A Pegasys ** Peg-‐Intron Rebetol Rebetron Ribavirin Roferon-‐A HORMONAL THERAPIES Eligard Lupron Depot Lupron Depot -‐ Ped Trelstar Depot Trelstar LA Vantas Viadur Zoladex
MULTIPLE SCLEROSIS (CONT’D) Novantrone Rebif Tysabri ONCOLOGY Gleevec Herceptin Nexavar Novantrone Revlimid Rituxan Sprycel Sutent Tarceva Temodar Thalomid Vidaza Xeloda Zolinza OSTEOARTHRITIS Euflexxa Hyalgan Orthovisc Supartz Synvisc
RHEUMATOID ARTHRITIS Enbrel ** Humira ** Kineret Orencia Remicade Rituxan OTHER Actimmune NF Alferon N Apligraf Botox Fuzeon Forteo Increlex Lucentis Macugen Myobloc Octreotide Acetate Proleukin Rhogam available at retail Sandostatin Sandostatin LAR Somavert Thyrogen Visudyne Vivitrol
Call our Pharmacy Department at 1-‐877-‐433-‐7643 for precertification of the following drugs provided by the physician office and/or infusion center:
CATEGORY
EXAMPLES
Erythropoiesis Stimulating Agents (ESA)
Epogen Procrit Aranesp Neupogen Neulasta Leukine Carimune Cytogam Flebogamma Gamastan Gammagard Gammar-‐P
Colony Stimulating Factors (CSF)
IVIG
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Growth Hormones
Biological Response Modifiers
Hyaluronic Acid Derivatives
Biological Oncology Agents
Gamunex Immune globulin Iveegam Octagam Panglobulin Polygam Venoglobulin-‐S Vivaglobin Nordititropin Humatrope Somatropin Protropin Genotropin Nutropin Saizen Tev-‐Tropin Zorbtive Omnitrope Remicade Enbrel Humira Kineret Amevive Raptiva Synvisc Hyalgan Supartz Orthovisc Erbitux Avastin Rituxan Camptosar Eloxatin Gemzar Ixempra Tasigna Taxol Taxotere
Pharmacy Lock-‐In Program Our Pharmacy Lock-‐In Program limits a member to use one pharmacy for prescription needs when utilization shows a potential lack of care coordination. The purpose of the program is to control duplicate and inappropriate drug therapies in cases of multiple prescribers and/or pharmacies being used. Each month our clinical pharmacists review a six-‐month profile of members who have met certain criteria and whose activities indicate they would benefit from pharmacy restriction or referral to the program by a health care representative. Members identified through the pharmacist review exhibit activity that indicates the need for restriction due to lack of coordination of care or inappropriate behavior. These members will be referred to the health plan for further review. Our health plan review of the member’s profile will also include the medical PRM-‐July 2013
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background as it pertains to prescription history and will note a restriction of the member’s pharmacy use if necessary. The member’s selected pharmacy will be notified in writing of the member’s decision. The member’s assigned PCP will be notified in writing of the member’s designated pharmacy. The Pharmacy Benefits Manager (PBM) will be notified of the decision to implement the lock-‐in program for the member and of the designated pharmacy. The pharmacy chosen by the member will be the only pharmacy allowed to fill prescriptions for the member. If there is an urgent or interim need due to member access to the designated pharmacy or access by the designated pharmacy to a particular medication, a pharmacy other than the designated pharmacy will be allowed to dispense a 72-‐hour emergency supply of medication. During administration of the program, we will work with the member and providers to furnish care management and education reinforcement of appropriate medication and pharmacy use. Prescriptions from all participating providers will be honored. This includes drugs prescribed by mental health or substance abuse providers. This program does not limit the number of providers a member may have. Placement in the lock-‐in program may be appealed by contacting the appeals department. The member will have 30 days to appeal this action of discipline. Appeals must be submitted in writing to our Appeals Unit. The provider and member will be notified of the appeal decision by telephone or facsimile. In addition, in the case of a denial, the provider and member will be sent a written notice of the denial within two business days following a verbal denial. The member may also utilize the state fair hearing process. Providers requesting information on this program may call Provider Services at 1-‐855-‐323-‐5588.
Behavioral Health Services Members may self-‐refer or you may direct members to our network of behavioral health care providers for assessment services. Inpatient services and outpatient follow-‐up care must be precertified. We are responsible for arranging for the provision of mental health, alcohol and other drug abuse assessment services for FAMIS and Medicaid members as follows: • Inpatient mental health services in an acute care facility • Inpatient substance abuse services in a substance abuse treatment facility • Inpatient psychiatric services in a freestanding psychiatric hospital for Medicaid members only, up to age 21 or age 65 and older • Psychological testing • Traditional outpatient mental health services and outpatient substance abuse services (excluding opioid treatment)
NOTE: If a member has been prescribed drugs for opioid treatment and obtains these drugs through an independent pharmacy, the drugs are the responsibility of INTotal Health. If the opioid treatment is administered by the substance abuse provider and obtains the drugs for the member, these drugs will be covered by DMAS. Transportation (for Medicaid members) and pharmacy services necessary for the treatment of substance abuse (including carved out services) are our responsibility. Community Mental Health Rehabilitation Services (CMHRS) are covered by the Department of Medical Assistance Services. For specific service coverage, please contact DMAS or see the DMAS CMHRS manual online.
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Cost-‐sharing Information FAMIS Copayments The following table lists the FAMIS copayment schedule according to family income. Copayments for medical services or prescription drugs are paid to the health care provider at the time of service. No copayments are paid for preventive care such as well-‐child or well-‐baby visits, immunizations, or dental checkups. FAMIS MOMS receive Medicaid benefits and are not subject to copays. The member’s health plan ID card lists the copayments that apply to the family. The member should present the ID card at the time of the office visit or at the pharmacy to have a prescription filled.
Services
American Indians and Alaskan Natives
VA FAMIS At or below 150 percent of Federal Poverty Levels
VA FAMIS 150 – 200 percent of Federal Poverty Levels
Ambulance
$0
$2
$5
Chiropractic
$0
$2
$5
Clinic Early intervention Early intervention services provided to children who have been determined eligible for Part C of the Individuals with Disabilities Education Act are covered by DMAS FFS. The MCO must cover medically necessary rehabilitative/developmental therapies where appropriate.
$0
$2
$5
$0
Emergency room use (emergency)
$0
$2 per visit
$5 per visit
Family planning
$0
$2 per visit
$5 per visit
Hearing aids
$0
$2
$5
Home health
$0
$2 per visit
$5 per visit
Inpatient hospital
$0
$15 per admission
$25 per admission
Laboratory and X-‐ray
$0
$2 per visit
$5 per visit
Medical equipment (including prosthetics and orthotics)
$0
$2 per item
$5 per item
Emergency room use (nonemergency)
$0
$10 per visit
$25 per visit
Outpatient hospital or doctor
$0
$2 per visit
$5 per visit
Physical and occupational therapy, speech $0 pathology and audiology
$2 per visit
$5 per visit
Pregnancy-‐related care
$0 per visit
$0 per visit
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Services Prescription drugs (excluding family planning, pregnancy-‐related medications and medications provided to children) • Up to a 34-‐day supply • 35 to 90-‐day supply
American Indians and Alaskan Natives $0
VA FAMIS At or below 150 percent of Federal Poverty Levels
VA FAMIS 150 – 200 percent of Federal Poverty Levels
$2 per prescription $4 per prescription
$5 per prescription $10 per prescription
Private duty nursing
$0
$2 per visit
$5 per visit
Second opinions
$0
$2 per visit
$5 per visit
Skilled nursing facility care
$0
$15 per admission
$25 per admission
Therapy • Inpatient • Outpatient *Vision • Routine exam
$0 $0 $0
$15 per admission $2 per visit $2
$25 per admission $5 per visit $5
Yearly copayment limit per family
$0
$180
$350
*See Vision Services for more details on covered services. Once a family member meets the yearly copayment limit per family, no member of that family will pay a copayment when receiving additional services. Once the cost-‐share limit is met, a new member ID card will be issued reflecting no copayments.
Self-‐Referral Services Members may access family planning services and emergency care without a referral from their PCP. The services may be rendered by an in-‐ or out-‐of-‐network provider qualified to provide the service. The following services do not need a referral from a PCP: • Emergency care (regardless of network status with INTotal Health) • Family planning (regardless of network status with INTotal Health) • Behavioral health assessments (nonparticipating providers must seek prior approval from INTotal Health) • OB care (nonparticipating providers must seek prior approval from INTotal Health) • Well-‐woman/GYN care (nonparticipating providers must seek prior approval from INTotal Health) • EPSDT/Well-‐child (nonparticipating providers must seek prior approval from INTotal Health)
Member Rights and Responsibilities Members have rights and responsibilities when participating with a Managed Care Organization (MCO). Member Services representatives serve as advocates for our members. The following lists include the rights and responsibilities of our members. Members have the right to: • Receive information in accordance with federal guidelines • Receive information about INTotal Health and our policies, services, practitioners and providers, and members’ rights and duties • Be treated with respect and with due consideration for their dignity and privacy PRM-‐July 2013
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Receive information from their providers on available treatment options and alternatives presented in a manner appropriate to your condition and ability to understand, regardless of cost or benefit coverage • Participate in decisions regarding their health care, including the right to refuse treatment • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion • Request and receive a copy of their medical records and request that they be amended or corrected as specified by 45 CFR 164.524 and 164. 526 • Freely exercise rights; the exercise of these rights does not adversely affect the way they are treated by INTotal Health and our providers • Voice grievances or appeals about INTotal Health or the care given by our providers • Make recommendations regarding the health plan’s members rights and responsibilities policy • Receive health care services in accordance with contractual requirements • Be free from any liability for payment of any services received if INTotal Health becomes insolvent • Request a copy of the INTotal Health Member Handbook or the INTotal Health Provider Directory from INTotal Health at any time Members have the responsibility to: • Supply information that the health plan and its practitioners and providers need in order to provide care • Follow plans and instructions for care that they have agreed to with their providers • Understand their health problems and participate in developing mutually agreed-‐upon treatment goals to the degree possible
•
Member Grievance Resolution We will provide members access to a grievance resolution process. All members or a person acting on behalf of the member has a right to voice dissatisfaction of any aspect of ours or a provider’s operations. You cannot file a grievance on behalf of a member unless the member has granted you permission to act as his or her personal representative. You must adhere to the regulated time frames that are the same for the member. Member grievances do not relate to Medical Management actions or interpretation of medically necessary benefits. Members may file a grievance for causes other than adverse action we may have taken to deny, reduce, terminate, delay or suspend a covered service, as well as any other acts or omissions which impair the quality, timeliness or availability of such benefits. Definitions: Action: The denial or limited authorization of a requested service, including the type and level of service; the reduction, suspension or termination of a previously authorized service; the denial, in whole or in part, of payment for a covered service for a member; the failure to provide services in a timely manner; the failure of the MCO to act within certain time frames. For a resident of a rural area with only one MCO, the denial of a Medicaid member’s request to exercise his or her right to obtain services outside the network. Appeal: A request for a review of an action as action is defined in this section. Complainant: Any member (family member or caregiver of a member) or provider (treating physician, dentist, or other person or agency designated to act on behalf of the member, including the state’s Medicaid managed care division or the state’s ombudsman program) who files a grievance. PRM-‐July 2013
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Grievance: Any dissatisfaction expressed by a complainant, orally or in writing, regarding any aspect of service provision or administration other than a request for reconsideration of an authorization decision. Requests for medical reconsideration are addressed in the Member Adverse Action Policy. (See Section 8 – Medical Appeal Process and Procedures.) First-‐Level Review: Grievances result in a first-‐level review. Second-‐Level Review: Second-‐level reviews follow the member’s or provider’s right to disagree with the decision of a first-‐level review. Inquiry: A member issue that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the member. Level I Grievance: We will respond to member grievances in a timely manner and attempt to resolve all member grievances to the member’s satisfaction. Member grievances will be resolved consistent with Plan policies, covered benefits and member rights and responsibilities. We will respond to member grievances in a timely manner and attempt to resolve all member grievances to the member’s satisfaction. Member grievances will be resolved consistent with plan policies, covered benefits and member rights and responsibilities. We will accept and review grievances filed by a member or his or her designee. Grievances may be oral (contact Member Services at 1-‐855-‐323-‐5588) or written. We fully investigate each grievance, including any clinical aspects of the grievance and document the substance of the grievance. The total time for acknowledgement, investigation and resolution of the grievance will be within 30 calendar days for the Medicaid members and within 14 calendar days for FAMIS members from the date we received the initial grievance from the member or a person acting on behalf of the member. If an issue would seriously jeopardize the life or health of a member, or the member’s ability to reach and maintain maximum function, an expedited process may be requested. Expedited reviews will be completed within 48 hours for FAMIS members and within three calendar days for Medicaid members. If delays are outside of the health plan’s control (e.g., the result of a third party’s failure to provide documentation in a timely manner or waiting response from the complainant for additional information), we may extend the time for resolution an additional 14 calendar days. We will notify the member in writing of the cause for the extension before the 30th day for Medicaid members and by the 14th day for FAMIS members and issue a written decision regarding the grievance within an additional 14 calendar days. The member will be notified in writing of our resolution and the process for appealing the resolution. A grievance appeal form and a description of the grievance procedures and time frames will be attached to the resolution letter. The member or person acting on behalf of a member (including the provider if acting as the member’s personal representative) may file a grievance orally, by fax, by mail or in person. Any supporting documentation must accompany the grievance. Requests should be sent to: INTotal Health Member Advocate PRM-‐July 2013
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2600 Park Tower Drive, Suite 600 Vienna, VA 22180 Within three business days of receiving a grievance, we will send an acknowledgement letter to the member. A grievance form and a description of the grievance procedures and time frames will be included with the letter. We will not take any action against a provider on the basis that the provider represents a member in a grievance filed.
Dissatisfaction with Grievance Decisions Level II Grievance Review If a member expresses dissatisfaction with an adverse grievance decision, he or she may either send a letter by mail or fax to us within 10 days of receipt of the written grievance resolution. Oral requests for review of the decision are followed up with a written request from the member or the member’s representative. We provide the member with an opportunity to express dissatisfaction with an adverse grievance decision which is described below. If additional supporting documentation has been submitted since the original grievance resolution, the additional information is reviewed by the quality management staff. The quality management staff will attempt to gather as much information as possible, including any aspects of clinical care involved to assist the health plan in making an informed decision. If no additional supporting documentation has been submitted, the health plan will appoint a panel of qualified individuals who have neither been involved in the matter giving rise to the grievance nor involved in the resolution of the original grievance to review the grievance appeal for resolution. This does not apply to grievances that have previously been appealed clinically in the case of an appeal from the proposal, refusal or delivery of a health care procedure, treatment or service. The health plan shall appoint one or more individuals to the panel to resolve the appeal. The member or person acting on behalf of the member may also attend. A meeting is scheduled at a reasonable time and location for the member. The member is notified at least seven days in advance of the meeting date and given the time and location. We will issue a Level II Grievance Resolution Letter to the complainant within 30 calendar days for Medicaid members and 14 calendar days for FAMIS members from receipt of the request for a level II review. If an issue would seriously jeopardize the life or health of a member or the member’s ability to reach and maintain maximum function, an expedited process may be requested. Expedited reviews will be completed within three business days for Medicaid members and within 48 hours for FAMIS members. If delays are outside of the health plan’s control (i.e., the result of a third party’s failure to provide documentation in a timely manner or awaiting response from the complainant for additional information), we may extend the time for resolution an additional 14 calendar days. We will notify the member in writing of the cause for the extension and issue a written decision regarding the grievance within the extended time frame. The member will be notified in writing of our resolution containing the following information: • The decision we reached • The reason and policies or procedures that are the basis for our decision • The right to further remedies allowed by law • The address and telephone number through which a member may contact a quality management representative to obtain more information about the decision or the right to an appeal PRM-‐July 2013
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Tracking and Reporting Grievances will be tracked and trended by our Quality Management department. Grievance records will include, but information is not limited to: • Date grievance filed • Date and outcome of all actions and findings • Date and decision of any appeal proceeding • Date and proceedings of any litigation • All letters and documentation submitted regarding the grievance The Quality Management department will maintain grievance records and keep them readily available for state inspection.
First Line of Defense Against Fraud and Abuse General Obligation to Prevent, Detect and Deter Fraud Waste and Abuse As a recipient of funds from state and federally sponsored health care programs, we each have a duty to help prevent, detect and deter fraud, waste and abuse. Our commitment to detecting, mitigating and preventing fraud, waste and abuse is outlined in our Corporate Compliance Program. As part of the requirements of the federal Deficit Reduction Act, each of our providers is required to adopt our policies on detecting, preventing, and mitigating fraud, waste and abuse in all the federally and state funded health care programs in which we participate. Our policy on Fraud, Waste and Abuse Prevention and Detection is part of our Compliance Program. Electronic copies of this policy and our Code of Business Conduct and Ethics are available at www.INOVA.org. We maintain several ways to report suspected fraud, waste and abuse. As an INTotal Health provider and a participant in government-‐sponsored health care, you and your staff are obligated to report suspected fraud, waste and abuse. These reports can be made anonymously by calling the external hotline at 1-‐888-‐800-‐4030. Members may report suspected fraud by calling Member Services at 1-‐855-‐323-‐5588. You may also reach out directly to our Plan Compliance Officer via email at
[email protected]. In order to meet the requirements under the Deficit Reduction Act, you must adopt our fraud, waste and abuse policies and distribute them to any staff members or contractors who work with us. If you have questions or would like to have more details concerning our fraud, waste and abuse detection, prevention and mitigation program, please contact our chief compliance officer. Importance of Detecting, Deterring and Preventing Fraud, Waste and Abuse Health care fraud costs taxpayers increasingly more money every year. There are state and federal laws designed to crack down on these crimes and impose strict penalties. Fraud, waste and abuse in the health care industry may be perpetuated by every party involved in the health care process. There are several stages to inhibiting fraudulent acts, including detection, prevention, investigation and reporting. In this section of the provider manual, we educate providers on how to help prevent member and provider fraud by identifying the different types so you can be the first line of defense. Many types of fraud, waste and abuse have been identified, including the following: Provider Fraud, Waste and Abuse PRM-‐July 2013
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Billing for services not rendered Billing for services that were not medically necessary Double billing Unbundling Upcoding You can help prevent fraud, waste and abuse by ensuring the services rendered are medically necessary, accurately documented in the medical records and billed according to American Medical Association (AMA) guidelines. Member Fraud, Waste and Abuse • Benefit sharing • Collusion • Drug trafficking • Forgery • Illicit drug seeking • Impersonation fraud • Misinformation and/or misrepresentation • Subrogation and/or third-‐party liability fraud • Transportation fraud To help prevent fraud, waste and abuse, providers can educate members about the types of fraud and the penalties levied. Also, spending time with patients and reviewing their records for prescription administration will help minimize drug fraud and abuse. One of the most important steps to help prevent member fraud is as simple as reviewing the INTotal Health member identification card. It is the first line of defense against fraud. We may not accept responsibility for the costs incurred by providers rendering services to a patient who is not a member even if that patient presents an INTotal Health member identification card. It’s important to verify the cardholder is the person named on the card. You can verify eligibility quickly and easily right from our website. Additionally, encourage members to protect ID cards as they would a credit card or cash, carry the INTotal Health member ID card at all times and reporting any lost or stolen cards to us as soon as possible. We believe awareness and action are vital to keeping the state and federal programs safe and effective. Understanding the various opportunities for fraud, waste or abuse and working with members to protect their INTotal Health identification card can help prevent fraud, waste and abuse. We encourage our members and providers to report any suspected instance of fraud, waste or abuse by calling Member Services at 1-‐855-‐323-‐ 5588 or by contacting our Plan Compliance Officer. An anonymous report can also be made by calling the external hotline at 1-‐888-‐800-‐4030. No individual who reports violations or suspected fraud, waste or abuse will be retaliated against; and we will make every effort to maintain anonymity and confidentiality. • • • • •
Disclosure of Ownership and Exclusion from Federal Health Care Programs As an INTotal Health provider, you must fully comply with federal requirements for disclosure of ownership and control, business transactions, and information for persons convicted of crimes against federal related health care programs, including Medicare, Medicaid, and/or CHIP programs, as described in 42 CFR § 455 Subpart B. Please familiarize yourself with federal requirements regarding providers and entities excluded from participation in Federal health care programs (including Medicare, Medicaid and CHIP programs). Screen new employees and contractors to verify they have not been excluded from participation from these programs, and verify monthly that existing employees or contractors have not been excluded. The Federal Health and Human PRM-‐July 2013
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Services – Office of Inspector General (HHS-‐OIG) online exclusions database is available at exclusions.oig.hhs.gov. If you discover any exclusion information, please immediately report to us. For questions related to Disclosure of Ownership or Exclusions from Federal Health Care Programs, please contact our Plan Compliance Officer via email at
[email protected]. If you prefer to remain anonymous, you may call the external hotline at 1-‐888-‐800-‐4030.
HIPAA The Health Insurance Portability and Accountability Act (HIPAA, also known as the Kennedy-‐Kassenbaum bill) was signed into law in August 1996. The legislation improves the portability and continuity of health benefits, ensures greater accountability in the area of health care fraud and simplifies the administration of health insurance. In 2009, HIPAA was enhanced by the American Recovery and Reinvestment act’s section on Health Information Technology for Economic and Clinical Health act (HITECH). Provisions of HITECH improve member privacy and security by: • Requiring patient notification of breaches of unsecure Protected Health Information (PHI) while creating a safe harbor for encrypted electronic PHI and shredded paper PHI • Applying certain provisions of the privacy and security rules to business associates • Modifying the marketing and fundraising rules Guidance regarding the breach notification rule can be found at www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/index.html. Proposed changes to HIPAA are located at www.hhs.gov/news/press/2011pres/05/20110531c.html. We strive to ensure that both we and contracted participating providers conduct business in a manner that safeguards patient and member information in accordance with the privacy regulations enacted pursuant to HIPAA. Effective April 14, 2003, contracted providers shall have the following procedures implemented to demonstrate compliance with the HIPAA privacy regulations. We recognize our responsibility under the HIPAA privacy regulations to only request the minimum necessary member information from providers to accomplish the intended purpose. Conversely, network providers should only request the minimum necessary member information required to accomplish the intended purpose when contacting us. However, please note that the privacy regulations allow the transfer or sharing of member information, which we may request to conduct business and make decisions about care, such as a member’s medical record, to make an authorization determination or resolve a payment appeal. Such requests are considered part of the HIPAA definition of treatment, payment or health care operations. Fax machines used to transmit and receive medically sensitive information should be maintained in an environment with restricted access to individuals who need member information to perform their jobs. When faxing information to us, verify that the receiving fax number is correct, notify the appropriate staff at INTotal Health and verify that the fax was appropriately received. Internet email (unless encrypted) should not be used to transfer files containing member information to us (e.g., Excel spreadsheets with claim information). Such information should be mailed or faxed.
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Please use professional judgment when mailing medically sensitive information such as medical records. The information should be in a sealed envelope marked confidential and addressed to a specific individual, post office box or department at INTotal Health. Our voice mail system is secure and password protected. When leaving messages for our associates, only leave the minimum amount of member information required to accomplish the intended purpose. When contacting us, please be prepared to verify your name, address and Tax Identification Number (TIN) or National Provider Identifier (NPI) numbers.
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6
MEMBER MANAGEMENT SUPPORT
Welcome Call As part of our member management strategy, we offer a welcome call to new members. During the welcome call, new members who have been identified through their health risk assessment as possibly needing additional services are educated regarding the health plan and available services. Additionally, Member Services representatives offer to assist the member with any current needs, such as scheduling an initial checkup.
Appointment Scheduling We, through our participating providers, ensure our members have access to primary care services for routine, urgent and emergency services and to specialty care services for chronic and complex care. Please respond to our member’s needs and requests in a timely manner. PCPs should make every effort to schedule our members for appointments using the guidelines outlined in Section 7 – PCP Access and Availability.
Nurse HelpLine Our Nurse HelpLine is a service designed to support the provider by offering information and education about medical conditions, health care and prevention to members after normal physician practice hours. The Nurse HelpLine provides triage services and helps direct members to appropriate levels of care. Our Nurse HelpLine telephone number is 1-‐855-‐323-‐5588 and is listed on the member’s ID card. This ensures members have an additional avenue of access to health care information when needed. Features of the Nurse HelpLine include: • Availability 24 hours a day, 7 days a week • Information based upon nationally recognized and accepted guidelines • Free translation services for 150 different languages and for members with difficulty hearing • Education for members about appropriate alternatives for handling nonemergent medical conditions • The member’s assessment report faxed by a nurse to the provider’s office within 24 hours of receipt of the call
Interpreter Services Interpreter services are available if needed. Over-‐the-‐telephone interpreter services are available 24 hours a day 7 days a week. For in-‐office interpreter services, call Provider Services at 1-‐855-‐323-‐5588 to arrange for the service.
Health Promotion We strive to improve healthy behaviors, reduce illness and improve the quality of life for our members through comprehensive programs. Educational materials are developed or purchased and disseminated to our members, and health education classes are coordinated with our contracted community organizations and network providers. We manage projects that offer our members education and information regarding their health. Ongoing projects include: • A bi-‐annual member newsletter
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• • • • •
Creation and distribution of Star Points, our health education brochures used to inform members of health promotion issues and topics Health Tips on Hold (educational telephone messages while the member is on hold) A monthly calendar of health education programs offered to members Development of health education curricula and procurement of other health education tools (e.g., breast self-‐exam cards) Relationship development with community-‐based organizations to enhance opportunities for members
Case Management Case management is designed to proactively respond to a member’s needs when conditions or diagnoses require care and treatment for long periods of time and/or high degree of service intensity or complexity. When a member is identified (usually through precertification, admission/discharge review, claims/encounter data, pharmacy data and/or provider or member request), the INTotal Health case manager helps to identify medically appropriate alternative methods or settings in which care may be delivered. You, on behalf of a member, may request participation in the program. The nurse will work with you, the member and/or the hospital to identify the necessary: • Intensity level of case management services needed • Appropriate alternate settings where care may be delivered • Health care services required • Equipment and/or supplies required • Community-‐based services available • Communication required between member and PCP One of our case managers will assist the member, utilization review team and PCP and/or hospital in developing the discharge plan of care, ensuring that the member’s medical needs are met and linking the member with community resources and INTotal Health programs for outpatient case and/or disease management. If you have identified a member who could benefit from our case management services, please call 1-‐855-‐323-‐ 5588, Monday through Friday, 8:30 a.m. to 5:30 p.m. Eastern time, and ask to speak to a case manager.
Disease Management Our Disease Management programs are based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing members with chronic diseases. The program includes a holistic, member-‐centric care management approach that allows care managers to focus on multiple needs of members. Disease Management (DM) Programs: • Behavioral health • Bipolar disorder • Cardiac − Coronary artery disease − Congestive heart failure • Diabetes • HIV/AIDS • Pulmonary PRM-‐July 2013
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Asthma Chronic obstructive pulmonary disease Schizophrenia Hypertension Obesity − −
• • •
Additional DM programs may be available for members in your area. Please call the number provided to learn if these programs apply to your members. Program features: • Proactive population identification processes • Evidence-‐based national practice guidelines • Collaborative practice models to include physician and support-‐service providers in treatment planning for members • Continuous patient self-‐management education, including primary prevention, behavior modification programs and compliance/surveillance, as well as home visits and case/care management for high-‐risk members • Ongoing process and outcomes measurement, evaluation and management • Ongoing communication with providers regarding patient status You can call Provider Services at 1-‐855-‐323-‐5588 to receive a printed copy of the guidelines. Who is eligible? All our members with the above diagnoses are eligible for DM services. Members are identified through continuous case finding efforts to include, but not limited to, early case finding welcome calls, claims mining and referrals. As a valued provider, you can also refer patients who can benefit from additional education and care management support. Members identified for participation in any of the programs are assessed and risk stratified based on the severity of their disease. Once enrolled in a program, he or she is provided with continuous education on self-‐ management concepts which include primary prevention, behavior modification and compliance/surveillance, as well as case/care management for high-‐risk members. Program evaluation, outcome measurement and process improvement are built into all the programs. Providers are given updates regarding patient status and progress. Disease Management Provider Rights and Responsibilities As a participating provider with members enrolled in the disease management program, you have additional rights and responsibilities. You have the right to: • Obtain information about INTotal Health, including programs and services, our staff and their qualifications, and any contractual relationships • Decline to participate in or work with the INTotal Health programs and services for our members, if contractually possible • Be informed of how the organization coordinates our disease management-‐related interventions with treatment plans for individual patients • Know how to contact the person responsible for managing and communicating with your patients • Be supported by INTotal Health to make decisions interactively with patients regarding their health care • Receive courteous and respectful treatment from the INTotal Health staff • Communicate grievances to INTotal Health regarding disease management as outlined in the INTotal Health provider grievance procedure PRM-‐July 2013
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Hours of Operation Our care managers are licensed nurses/social workers and are available from 8:30 a.m. to 5:30 p.m. Eastern time, Monday through Friday. Confidential voice mail is available 24 hours a day. The Nurse HelpLine is available 24 hours a day and 7 days a week for our members. Contact Information Please call 1-‐855-‐323-‐5588 to reach one of our care managers and obtain information about our DM program.
Communicable Disease Services We make communicable disease services available to our members. Communicable disease services help control and prevent diseases such as Tuberculosis (TB), Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) infection. Providers should encourage members to receive TB, STD and HIV/AIDS services through INTotal Health to ensure continuity and coordination of a member’s total care. Please report all cases of TB, STD and HIV/AIDS infection to the state public health agency within 24 hours of notification by provider or from date of service. You also must report all diseases reportable by health care workers regardless of whether the case is also reportable by laboratories.
Health Education Advisory Committee The health education advisory committee provides advice to us from members to INTotal Health regarding health education and outreach programmatic development. The committee strives to ensure materials and programs meet cultural competency requirements and are both understandable to the member and address the member’s health education needs. The health education advisory committee’s responsibilities are to: • Identify health education needs of the membership based on review of demographic and epidemiologic data • Identify cultural values and beliefs that must be considered in developing a culturally competent health education program • Assist in the review, development, implementation and evaluation of the member health education tools for the outreach program • Review the health education plan and make recommendations on health education strategies
Women, Infants and Children Program
Medicaid recipients eligible for Women, Infants and Children (WIC) benefits include the following classifications: • Pregnant women • Women who are breastfeeding infants up to one year postpartum • Women who are non-‐breastfeeding up to six months postpartum • Infants under age 1 • Children under age 5 Members may apply for WIC services at their local WIC agency. Please call Provider Services at 1-‐855-‐323-‐5588 for the agency nearest to the member. PRM-‐July 2013
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7
PROVIDER RESPONSIBILITIES
Medical Home The PCP is the foundation of the medical home, responsible for providing, managing and coordinating all aspects of the member’s medical care and all care that is within the scope of his or her practice. The PCP is responsible for coordinating member care with specialists and conferring and collaborating with the specialists using a collaborative concept known as a medical home. We promote the medical home concept to all our members. The PCP is the member’s and family’s initial contact point when accessing health care. The PCP’s relationship with the member and family, together with the health care providers within the medical home and the extended network of consultants and specialists with whom the medical home works, have an ongoing and collaborative contractual relationship. The providers in the medical home are knowledgeable about the member’s and family’s special, health-‐related social and educational needs and are connected to necessary resources in the community that will assist the family in meeting those needs. When a member is referred for a consultation or specialty and/or hospital services or health and health-‐related services by the PCP through the medical home, the medical home provider maintains the primary relationship with the member and family. He or she keeps abreast of the current status of the member and family through a planned feedback mechanism with the PCP who receives them into the medical home for continuing primary medical care and preventive health services.
Responsibilities of the Primary Care Provider The PCP is a network physician responsible for the complete care of his or her members, whether providing it himself or herself or by referral to the appropriate provider of care within the network. FQHCs and RHCs may be included as PCPs. Below are highlights of the PCP’s responsibilities. The PCP shall: • Manage the medical and health care needs of members, including monitoring and following up on care provided by other providers including FFS • Provide education and coordination for recommended preventive health care services and appropriate guidance for healthy behaviors • Provide coordination necessary for referrals to specialists and FFS providers (both in-‐ and out-‐of-‐network); maintain a medical record of all services rendered by the PCP and other providers • Provide 24-‐hour-‐a-‐day, 7-‐day-‐a-‐week coverage with regular hours of operation clearly defined and communicated to members • Provide services ethically, legally and in a culturally competent manner and meet the unique needs of members with special health care needs • Participate in any system established by INTotal Health to facilitate the sharing of records, subject to applicable confidentiality and HIPAA requirements • Make provisions to communicate in the language or fashion primarily used by his or her membership • Participate and cooperate with us in any reasonable internal and external quality assurance, utilization review, continuing education and other similar programs we’ve established • Participate in and cooperate with our grievance procedures; we will notify the PCP of any member grievance • Not balance-‐bill members; however, the PCP is entitled to collect applicable copayments for certain services • Continue care in progress during and after termination of his or her contract for up to 60 days until a continuity of care plan is in place to transition the member to another provider or through postpartum care for pregnant members in accordance with applicable state laws and regulations • Comply with all applicable federal and state laws regarding the confidentiality of patient records PRM-‐July 2013
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Develop and have an exposure control plan in compliance with Occupational Safety and Health Administration standards regarding blood-‐borne pathogens Establish an appropriate mechanism to fulfill obligations under the Americans with Disabilities Act Support, cooperate and comply with our quality improvement program initiatives and any related policies and procedures; to provide quality care in a cost-‐effective and reasonable manner Inform us if a member objects to provision of any counseling, treatments or referral services for religious reasons Treat all members with respect and dignity; provide members with appropriate privacy and treat member disclosures and records confidentially, giving the members the opportunity to approve or refuse their release Provide members complete information concerning their diagnosis, evaluation, treatment and prognosis and give members the opportunity to participate in decisions involving their health care except when contraindicated for medical reasons Advise members about their health status, medical care or treatment options, regardless of whether benefits for such care are provided under the program or have limitations; advise members on treatments which may be self-‐administered Contact members when clinically indicated, as quickly as possible for follow-‐up regarding significant problems and/or abnormal laboratory or radiological findings Have a policy and procedure to ensure proper identification, handling, transport, treatment and disposal of hazardous and contaminated materials and wastes to minimize sources and transmission of infection Agree to maintain communication with the appropriate agencies such as local police, social services agencies and poison control centers to provide high-‐quality patient care Agree that any notation in a patient’s clinical record indicating diagnostic or therapeutic intervention as part of the clinical research shall be clearly contrasted with entries regarding the provision of nonresearch-‐ related care
Note: We do not cover the use of any experimental procedures or experimental medications except under certain circumstances.
Primary Care Provider Access and Availability All providers are expected to meet the federal and state accessibility standards and those defined in the Americans with Disabilities Act of 1990. Health care services provided through INTotal Health must be accessible to all members. We’re dedicated to arranging access to care for our members. We have the ability to provide quality access depending upon the accessibility of network providers. You’re required to adhere to the following access standards: Routine primary care visits Within 30 days Maternity Care: Routine specialty care visits Within 30 days First trimester Within 14 days Routine physical exams for adults Within 30 days Second trimester Within 7 days Routine physical exams for children Within 30 days Third trimester Within 3 business days Emergency care Immediately High-‐risk Within 3 business days Urgent care Within 24 hours pregnancies PRM-‐July 2013
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You may not use discriminatory practices such as preference to other insured or private-‐pay patients, separate waiting rooms or appointment days. We routinely monitor our providers’ adherence to the access care standards. To ensure continuous 24-‐hour coverage, PCPs must maintain one of the following arrangements for their members to contact the PCP after normal business hours: • The office telephone is answered after hours by an answering service, which can contact the PCP or another designated network medical practitioner. All calls answered by an answering service must be returned within 30 minutes. • The office telephone is answered after normal business hours by a recording in the language of each of the major population groups served by the PCP, directing the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone; another recording is not acceptable. • The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or a designated INTotal Health network medical practitioner who can return the call within 30 minutes. The following telephone answering procedures are not acceptable: • Office telephone is only answered during office hours • Office telephone is answered after hours by a recording that tells members to leave a message • Office telephone is answered after hours by a recording which directs members to go to an emergency room for any services needed • Returning after-‐hours calls outside of 30 minutes
Member Missed Appointments
Our members may sometimes cancel or not appear for necessary appointments and fail to reschedule those appointments. This can be detrimental to their health. We require you to attempt to contact members who have not shown up for or canceled an appointment without rescheduling the appointment. The contact can either be in writing or by telephone and should be designed to educate the member about the importance of keeping appointments and to encourage the member to reschedule the appointment. Our members who frequently cancel or fail to show up for an appointment without rescheduling the appointment may need additional education in appropriate methods of accessing care. In these cases, please call Provider Services at 1-‐855-‐323-‐5588 to address the situation. Our staff will contact the member and provide more extensive education and/or case management as appropriate. Our goal is for members to recognize the importance of maintaining preventive health visits and to adhere to a plan of care recommended by their PCP. Note: Members cannot be billed for missed appointments.
Noncompliant Members We recognize you might need help in managing nonadherent members. If you have an issue with a member regarding behavior, treatment cooperation and/or completion of treatment, and/or making or appearing for appointments, please call Provider Services at 1-‐855-‐323-‐5588. A member advocate will contact the member either by telephone or in person to provide the education and counseling to address the situation and will report to you the outcome of any counseling efforts.
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Primary Care Provider Transfers To maintain continuity of care, we encourage members to remain with their PCP. However, members may request to change their PCP for any reason by contacting Member Services at 1-‐855-‐323-‐5588. The member’s name will be provided to the PCP on the membership roster. Members can call to request a PCP change any day of the month. PCP change requests will be processed generally on the same day or by the next business day. Members will receive a new ID card within 10 days.
Covering Physicians During your absence or unavailability, you need to arrange for coverage for your members. You can either: (1) make arrangements with one or more network providers to provide care for your members or (2) make arrangements with another similar licensed and qualified provider who has appropriate medical staff privileges at the same network hospital or medical group, as applicable, to provide care to your members. In addition, the covering provider will agree to the terms and conditions of the network provider agreement including, without limitation, any applicable limitations on compensation, billing and participation. To arrange for covering services, both providers must submit their requests in writing to their respective Provider Relations representatives at the address listed under Reporting Changes in Address and/or Practice Status.
Specialist as a Primary Care Provider When a member requires the regular care of the specialist, we may approve a specialist to serve as a member’s PCP. The criteria for a specialist to serve as a member’s PCP include the member having a chronic, life-‐ threatening illness or condition of such complexity whereby: • The need for multiple hospitalizations exists • The majority of care needs to be given by a specialist • The administrative requirements arranging for care exceed the capacity of the nonspecialist PCP. This would include members with complex neurological disabilities, chronic pulmonary disorders, HIV/AIDS, complex hematology and/or oncology conditions, cystic fibrosis, etc. The specialist must meet the requirements for PCP participation (including contractual obligations and credentialing); provide access to care 24 hours a day, 7 days a week; and coordinate the member’s health care, including preventive care. When such a need is identified, the member or specialist must contact our Case Management department and complete a Specialist as PCP Request Form. One of our case managers will review the request and submit it to our Chief Medical Officer. We will notify the member and the provider of our determination in writing within 30 days of receiving the request. If we deny the request, we will provide written notification to the member and provider outlining the reasons for the denial of the request within one day of the decision. Specialists serving as PCPs will continue to be paid FFS while serving as the member’s PCP. The PCP designation cannot be retroactive. For further information, see the Specialist as PCP Request Form located in the Appendix A – Forms section of the manual.
Reporting Changes in Address and/or Practice Status Please report any status changes using the methods below: • Fax to: 703-‐286-‐3994 • Mail to: Provider Relations Department INTotal Health 2600 Park Tower Drive, Suite 600 PRM-‐July 2013
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Vienna, VA 22180
Specialty Referrals In order to reduce the administrative burden on the provider’s office staff, we have established procedures that are designed to permit a member with a condition that requires ongoing care from a specialist physician or other health care provider to request an extended authorization. You can request an extended authorization by contacting the member’s PCP. You must supply the necessary clinical information that will be reviewed by the PCP to complete the authorization review. An extended authorization will be approved on a case-‐by-‐case basis. In the event of termination of a contract with the treating provider, the continuity of care provisions in the provider’s contract with us will apply. The provider may renew the authorization by submitting a new request to the PCP. Additionally, we require the specialist physician or other health care provider to provide regular updates to the member’s PCP (unless acting also as the designated PCP for the member). If the need arises for a secondary referral, the specialist physician or other health care provider must contact us for a coverage determination. If the specialist or other health care provider needs to furnish ongoing care for a specific condition not available in our network, the referring physician shall request authorization from us for services outside the network. Access will be approved to a qualified non-‐network health care provider within a reasonable distance and travel time at no additional cost if medical necessity is met. If a provider’s application for an extended authorization is denied, the member (or the provider on behalf of the member) may appeal the decision through our medical appeal process.
Second Opinions A member, parent and/or legally appointed representative or the member’s PCP may request a second opinion in any situation where there is a question concerning a diagnosis or the options for surgery or other treatment of a health condition. The second opinion shall be provided at no cost to the member. The second opinion must be obtained from a network provider (see Provider Referral Directory) or a non-‐network provider if there is not a network provider with the expertise required for the condition. Once approved, the PCP will notify the member of the date and time of the appointment and forward copies of all relevant records to the consulting provider. The PCP will notify the member of the outcome of the second opinion. We may also request a second opinion at our own discretion. This may occur under the following circumstances: • If there is a concern about care expressed by the member or the provider • If potential risks or outcomes of recommended or requested care are discovered by the health plan during its regular course of business • Before initiating a denial of coverage of service • If denied coverage is appealed • If an experimental or investigational service is requested When we request a second opinion, we’ll make the necessary arrangements for the appointment, payment and reporting. We’ll inform the member and the PCP of the results of the second opinion and the consulting provider’s conclusion and recommendations regarding further action.
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Specialty Care Providers To participate in the Medicaid managed care model, you must have applied for enrollment in the Virginia Medicaid program and be a licensed provider by the state before signing a contract with us. We contract with a network of provider specialty types to meet the medical specialty needs of members and provide all medically necessary covered services. The specialty care provider is a network physician who has the responsibility for providing the specialized care for members, usually upon appropriate referral from a PCP within the network (See Role and Responsibility of the Specialty Care Provider). In addition to sharing many of the same responsibilities to members as the PCP (See Responsibilities of the PCP), the specialty care provider provides services that include: • Allergy and immunology services • Burn services • Community behavioral health (e.g., mental health and substance abuse) services • Cardiology services • Clinical nurse specialists, psychologists, clinical social workers – behavioral health • Critical care medical services • Dermatology services • Endocrinology services • Gastroenterology services • General surgery • Hematology and/or oncology services • Neonatal services • Nephrology services • Neurology services • Neurosurgery services • Obstetrics and gynecology • Ophthalmology services • Orthopedic surgery services • Otolaryngology services • Perinatal services • Pediatric services • Psychiatry (adult) assessment services • Psychiatry (child and adolescent) assessment services • Trauma services • Urology services
Role and Responsibility of the Specialty Care Provider Specialist providers may treat members who have been referred to them by network PCPs or members who self-‐ refer and will provide covered services only to the extent and duration indicated on the referral. Obligations of the specialists include, but are not limited to, the following: • Complying with all applicable statutory and regulatory requirements of the Medicaid program • Accepting all members referred to them • Submitting required claims information, including source of referral and referral number to us • Arranging for coverage with network providers while off duty or on vacation • Verifying member eligibility and precertification of services (if required) at each visit
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Providing consultation summaries or appropriate periodic progress notes to the member’s PCP on a timely basis following a referral or routinely scheduled consultative visit Notifying the member’s PCP when scheduling a hospital admission or scheduling any procedure requiring the PCP’s approval Coordinating care as appropriate with other providers involved in providing care for members, especially in cases where there are medical and behavioral health comorbidities or co-‐occurring mental health and substance abuse disorders
The specialist shall: • Manage the medical and health care needs of members, including monitoring and following up on care provided by other providers, including those engaged on a FFS basis; provide coordination necessary for referrals to other specialists and FFS providers (both in and out of network); and maintain a medical record of all services rendered by the specialist and other providers • Provide 24-‐hour-‐a-‐day, 7-‐day–a-‐week coverage and maintain regular hours of operation that are clearly defined and communicated to members • Provide services ethically and legally in a culturally competent manner and meet the unique needs of members with special health care requirements • Participate in the systems we’ve established that facilitate the sharing of records, subject to applicable confidentiality and HIPAA requirements • Participate and cooperate with us in any reasonable internal or external quality assurance, utilization review, continuing education or other similar programs we’ve established • Make reasonable efforts to communicate, coordinate and collaborate with other specialty care providers, including behavioral health providers involved in delivering care and services to members • Participate in and cooperate with our grievance processes and procedures; we’ll notify the specialist of any member grievance brought against the specialist • Not balance-‐bill members • Continue care in progress during and after termination of his or her contract for up to 60 days until a continuity of care plan is in place to transition the member to another provider or through postpartum care for pregnant members in accordance with applicable state laws and regulations • Comply with all applicable federal and state laws regarding the confidentiality of patient records • Develop and have an exposure control plan regarding blood-‐borne pathogens in compliance with Occupational Safety and Health Administration (OSHA) standards • Make best efforts to fulfill the obligations under the Americans with Disabilities Act applicable to his or her practice location • Support, cooperate and comply with our quality improvement program initiatives and any related policies and procedures designed to provide quality care in a cost-‐effective and reasonable manner • Inform us if a member objects for religious reasons to the provision of any counseling, treatment or referral services • Treat all members with respect and dignity; provide members with appropriate privacy; and treat member disclosures and records confidentially, giving the members the opportunity to approve or refuse their release as allowed under applicable laws and regulations • Provide to members complete information concerning their diagnosis, evaluation, treatment and prognosis and give members the opportunity to participate in decisions involving their health care, except when contraindicated for medical reasons • Advise members about their health status, medical care or treatment options, regardless of whether benefits for such care are provided under the program or have limitations; and advise members on treatments that may be self-‐administered
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When clinically indicated, contact members as quickly as possible for follow-‐up regarding significant problems and/or abnormal laboratory or radiological findings Have a policy and procedure to ensure proper identification, handling, transport, treatment and disposal of hazardous and contaminated materials and wastes to minimize sources and transmission of infection Agree to maintain communication with the appropriate agencies such as local police, social services agencies and poison control centers to provide quality patient care Agree that any notation in a patient’s clinical record indicating diagnostic or therapeutic intervention that is part of a clinical research study is clearly distinguished from entries pertaining to nonresearch related care
Note: We do not cover the use of any experimental procedures or experimental medications except under certain preauthorized circumstances.
Specialty Care Providers Access and Availability We will maintain a specialty network to ensure access and availability to specialists for all members. You’re considered a specialist if you have a provider agreement with us to provide specialty services to our members. Specialist must adhere to the following access guidelines: Service Access Requirement Urgent, nonemergency visits Within 24 hours Routine primary care visits Within 30 days Routine primary care visits for FAMIS Within two weeks members Maternity care – first trimester Within 14 days Maternity care – second trimester Within seven days Maternity care – third trimester Within three business days High-‐risk pregnancies Within three business days
Cultural Competency Cultural competency is the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter. Cultural competency assists providers and members to: • Acknowledge the importance of culture and language • Embrace cultural strengths with people and communities • Assess cross-‐cultural relations • Understand cultural and linguistic differences • Strive to expand cultural knowledge The quality of the patient-‐provider interaction has a profound impact on the ability of a patient to communicate symptoms to his or her provider and to adhere to recommended treatment. Some of the reasons that justify a provider’s need for cultural competency include but are not limited to: • The Perceptions that illness and disease and their causes vary by culture • The diversity of belief systems related to health, healing and wellness • Culture influences help-‐seeking behaviors and attitudes toward health care providers • Individual preferences affect traditional and nontraditional approaches to health care • Patients must overcome their personal biases within health care systems PRM-‐July 2013
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Health care providers from culturally and linguistically diverse groups are underrepresented in the current service delivery system
Cultural barriers between the provider and member can impact the patient-‐provider relationship in many ways, including but not limited to: • The member’s level of comfort with the practitioner and the member’s fear of what might be found upon examination • The differences in understanding on the part of diverse consumers in the United States health care system • A fear of rejection of personal health beliefs • The member’s expectation of the health care provider and of the treatment To be culturally competent, we expect providers serving members within this geographic location to demonstrate the following: Cultural Awareness Needed Including The Ability To: • Recognize the cultural factors (norms, values, communication patterns and world views), which shape personal and professional behavior • Modify one’s own behavioral style to respond to the needs of others, while at the same time maintaining one’s objectivity and identity Knowledge Needed: • Culture plays a crucial role in the formation of health or illness beliefs. • Culture is generally behind a person’s rejection or acceptance of medical advice. • Different cultures have different attitudes about seeking help. • Feelings about disclosure are culturally unique. • There are differences in the acceptability and effectiveness of treatment modalities in various cultural and ethnic groups. • Verbal and nonverbal language, speech patterns and communication styles vary by culture and ethnic groups. • Resources, such as formally trained interpreters, should be offered to and used by members on behalf of various cultural and ethnic differences. Skills Needed Including The Ability To: • Understand the basic similarities and differences between and among the cultures of the persons served • Recognize the values and strengths of different cultures • Interpret diverse cultural and nonverbal behavior • Develop perceptions and understanding of other’s needs, values and preferred means of having those needs met • Identify and integrate the critical cultural elements of a situation to make culturally consistent inferences and to demonstrate consistency in actions • Recognize the importance of time and the use of group process to develop and enhance cross-‐cultural knowledge and understanding • Withhold judgment, action or speech in the absence of information about a person’s culture • Listen with respect • Formulate culturally competent treatment plans • Use culturally appropriate community resources • Know when and how to use interpreters and to understand the limitations of using interpreters PRM-‐July 2013
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Treat each person uniquely Recognize racial and ethnic differences and know when to respond to culturally based cues Seek out information Use agency resources Respond flexibly to a range of possible solutions Accept ethnic differences among people and understand how these differences affect the treatment process Work with clients of various ethnic minority groups
Member Records Using nationally recognized standards of care, we work with providers to develop clinical policies and guidelines of care for our membership. The Medical Advisory Committee (MAC) oversees and directs INTotal Health in formalizing, adopting and monitoring guidelines. We require medical records to be maintained in a manner that is current, detailed and organized and permits effective and confidential patient care, and quality review. You’re required to maintain medical records that conform to good professional medical practice and appropriate health management. A permanent medical record will be maintained at the primary care site for every member and be available to the PCP and other providers. Medical records must be kept in accordance with INTotal Health and state standards as follows: Medical Record Standards The records reflect all aspects of patient care, including ancillary services. Documentation of each visit must include: 1. Date of service 2. Grievance or purpose of visit 3. Diagnosis or medical impression 4. Objective finding 5. Assessment of patient’s findings 6. Plan of treatment, diagnostic tests, therapies and other prescribed regimens 7. Medications prescribed 8. Health education provided 9. Signature and title or initials of the provider rendering the service; if more than one person documents in the medical record, there must be a record on file as to what signature is represented by which initials. These standards will, at a minimum, meet the following medical record requirements: 1. Patient identification information. Each page or electronic file in the record must contain the patient’s name or patient ID number. 2. Personal and biographical data. The record must include age, sex, address, employer, home and work telephone numbers and marital status. 3. Date and corroboration. All entries must be dated and author identified. 4. Legibility. Each record must be legible to someone other than the writer. A second reviewer should evaluate any record judged illegible by one physician reviewer. 5. Allergies. Medication allergies and adverse reactions must be prominently noted on the record. Absence of allergies (No Known Allergies [NKA]) must be noted in an easily recognizable location. 6. Past medical history (for patients seen three or more times). Past medical history must be easily identified, including serious accidents, operations and illnesses. For children, the history must include prenatal care following birth. 7. Physical examination. A record of physical examinations appropriate to the presenting grievance or condition. PRM-‐July 2013
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8. Immunizations. For pediatric records age 13 and under, a completed immunization record or a notation of prior immunization must be recorded including vaccines and their dates of administration when possible. 9. Diagnostic information. Documentation of the clinical findings and evaluation for each visit. 10. Medication information includes medication information and instructions to patient. 11. Identification of current problems. Significant illnesses, medical and behavioral health conditions and health maintenance concerns must be identified in the medical record. A current problem list must be included in each patient’s record. 12. Instructions. Record must include evidence that the patient was provided with basic teaching, instructions regarding physical and/or behavioral health condition. 13. Smoking/alcohol/substance abuse. A notation concerning cigarettes and alcohol use and substance abuse must be stated if present for patients age 12 and older. Abbreviations and symbols may be appropriate. 14. Preventive services and risk screening. The record must include consultation and provision of appropriate preventive health services and appropriate risk screening activities. 15. Consultations, referrals and specialist reports. Notes from any referrals and consultations must be in the record. Consultation, lab and X-‐ray reports filed in the chart must have the ordering physician’s initials or other documentation signifying review. Consultation and any abnormal lab and imaging study results must have an explicit notation in the record of follow-‐up plans. 16. Emergencies. All emergency care provided (directly by the contracted provider or through an emergency room) and the hospital discharge summaries for all hospital admissions while the patient is part of the PCP’s panel must be noted. 17. Hospital discharge summaries. Discharge summaries must be included as part of the medical record for all hospital admissions that occur while the patient is enrolled and for prior admissions, as appropriate. Prior admissions pertaining to admissions that may have occurred prior to the patient being enrolled may be pertinent to the patient’s current medical condition. 18. Advance directive. For medical records of adult patients, the medical record must document whether or not the individual has executed an advance directive. An advance directive is a written instruction such as a living will or durable power of attorney that directs health care decision making for individuals who are incapacitated. 19. Security. Provider must maintain a written policy to ensure that medical records are safeguarded against loss, destruction or unauthorized use. Physical safeguards require records to be stored in a secure manner that allows access for easy retrieval by authorized personnel only. Staff receives periodic training in member information confidentiality. 20. Release of information. Written procedures are required for the release of information and obtaining consent for treatment. 21. Documentation. Documentation is required setting forth the results of medical, preventive and behavioral health screening and of all treatment provided and results of such treatment. 22. Multidisciplinary teams. Documentation is required of the team members involved in the multidisciplinary team of a patient needing specialty care. 23. Integration of clinical care. Documentation of the integration of clinical care in both the physical and behavioral health records is required. Such documentation must include: • Screening for behavioral health conditions (including those which may be affecting physical health care and vice versa) and referral to behavioral health providers when problems are indicated • Screening and referral by behavioral health providers to PCPs when appropriate • Receipt of behavioral health referrals from physical medicine providers and the disposition and/or outcome of those referrals • At least quarterly (or more often if clinically indicated), a summary of the status and progress from the behavioral health provider to the PCP • A written release of information that will permit specific information sharing between providers
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Documentation that behavioral health professionals are included in primary and specialty care service teams described in this contract when a patient with disabilities or chronic or complex physical or developmental conditions has a co-‐occurring behavioral disorder
Patient Visit Data Documentation of individual encounters must provide adequate evidence of at a minimum: 1. A history and physical exam that includes appropriate subjective and objective information obtained for the presenting grievances 2. For patients receiving behavioral health treatment, documentation that includes at-‐risk factors (danger to self and/or others, ability to care for self, affect, perceptual disorders, cognitive functioning and significant social health) 3. An admission or initial assessment that must include current support systems or lack of support systems 4. For patients receiving behavioral health treatment, a documented assessment that is done with each visit relating to client status and symptoms to the treatment process and that may indicate initial symptoms of the behavioral health condition as decreased, increased or unchanged during the treatment period 5. A plan of treatment that includes activities, therapies and goals to be carried out 6. Diagnostic tests 7. Documented therapies and other prescribed regimens for patients who receive behavioral health treatment and that include evidence of family involvement as applicable and include evidence that the family was included in therapy sessions, when appropriate 8. Regarding follow-‐up care encounter forms or notes with a notation indicating follow-‐up care, a call or a visit that must note in weeks, months or as needed (PRN) the specific time to return with unresolved problems from any previous visits being addressed in subsequent visits 9. Referrals and results including all other aspects of patient care such as ancillary services We’ll systematically review medical records to ensure compliance with the standards. We’ll institute actions for improvement when standards are not met. Compliance with the medical records performance standards is a medical records score of 80 percent including six critical elements that must be met. Clinical Medical Record Audit and Office Site Visit Forms are located in Appendix A – Forms. We maintain an appropriate record-‐keeping system for services to members. This system will collect all pertinent information relating to the medical management of each member and make that information readily available to appropriate health professionals and appropriate state agencies. All records will be retained in accordance with the record retention requirements of 45 CFR 74.164, e.g., records must be retained for seven years from the date of service.
Clinical Practice Guidelines Using nationally recognized standards of care, we work with providers to develop clinical policies and guidelines for the care of its membership. The MAC oversees and directs us in formulating, adopting and monitoring guidelines. We select at least four evidence-‐based clinical practice guidelines that are relevant to the member population. We’ll measure performance against at least two important aspects of each of the four clinical practice guidelines annually. The guidelines must be reviewed and revised at least every two years or whenever the guidelines change. Clinical Practice Guideline Forms are located on our website at www.intotalhealth.org. Login to the secure site by entering your log in name and password. On the Online Inquiries page, scroll down to Resources, click on PRM-‐July 2013
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the Clinical Practice Guidelines link. A copy of the guidelines can be printed from the website, or you can contact Provider Services at 1-‐855-‐323-‐5588 to receive a printed copy. Advance Directives We respect each member’s right to control decisions relating to his or her own medical care, including the decision to have provided, withheld or withdrawn the medical or surgical means or procedures calculated to prolong his or her life. This right is subject to certain interests of society, such as the protection of human life and the preservation of ethical standards in the medical profession. We adhere to the Patient Self-‐Determination Act and maintain written policies and procedures regarding advance directives. Advance directives are documents signed by a competent person giving direction to health care providers about treatment choices in certain circumstances. There are two types of advance directives—a durable power of attorney for health care and a living will. A durable power of attorney for health care (durable power) allows the member to name a patient advocate to act on behalf of the member. A living will allows the member to state his or her wishes in writing but does not name a patient advocate. Member services and outreach associates encourage members to request an advance directive form and education from their PCP at their first appointment. Members over age 18 and emancipated minors are able to make an advance directive. A member’s response to executing an advance directive should be documented in the medical record. We will not discriminate or retaliate based on whether a member has or has not executed an advance directive. While each member has the right without condition to formulate an advance directive within certain limited circumstances, a facility or an individual physician may conscientiously object to an advance directive. No INTotal Health associate may serve as witness to an advance directive or as a member’s designated agent or representative. We note the presence of advance directives in the medical records when conducting medical chart audits. A Living Will and Durable Power of Attorney are located in Appendix A – Forms.
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MEDICAL MANAGEMENT
Medical Review Criteria We use review criteria that are objective, based on medical evidence and nationally recognized standards of care as guidelines in medical decision-‐making. In addition to the existing clinical decision support tools, we’ve added the Aetna Clinical Policy Bulletins for outpatient medical necessity determinations. INTotal Health works with network providers to develop clinical guidelines of care for our membership. The Medical Advisory Committee assists INTotal Health in formalizing and monitoring guidelines. If we use noncommercial criteria, the following standards apply to the development of the criteria: • Criteria are developed with involvement from appropriate providers with current knowledge relevant to the content of treatment guidelines under development. • Criteria are objective, based on medical evidence, review of market practice, national standards and best practices. • Criteria are evaluated at least annually by appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria of treatment guidelines under review and updated, as necessary. The criteria must reflect the names and qualifications of those involved in the development, the process used in the development, and when and how often the criteria will be evaluated and updated. Clinical Criteria We use InterQual and the Aetna Clinical Policy Bulletins for clinical decision support for medical management coverage decisions. The criteria provide a system for screening proposed medical care based on member-‐ specific, best medical care practices and rule-‐based systems to match appropriate services to member needs based upon clinical appropriateness. Criteria include: • Acute care • Rehabilitation • Subacute care • Home care • Surgery and procedures • Imaging studies and X-‐rays Our utilization reviewers use these criteria as part of the precertification of scheduled admission, concurrent review and discharge planning process to determine clinical appropriateness and medical necessity for coverage of continued hospitalization.
Precertification and Notification Process We may require members to seek a referral from their PCP prior to accessing nonemergency specialty physical health services. Precertification is defined as the prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered and a member’s severity of illness, medical history and previous treatment to determine the medical necessity and appropriateness of a given coverage request. Prospective means the coverage request occurred prior to the service being provided. Notification is defined as telephonic, facsimile or electronic communication received from a provider informing us of the intent to render covered medical services to a member. There is no review against medical necessity criteria; however, we do verify member eligibility and provider status (network and non-‐network). Notification should be provided prior to rendering services. For services that are emergent or urgent, notification should be within 24 hours or the next business day. PRM-‐July 2013
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We’re staffed with clinical professionals who coordinate services provided to members and are available 24 hours a day, 7 days a week to accept precertification requests or accept calls regarding utilization management issues.
Medical Necessity Decisions Medical necessity decisions are objective, based on medical evidence and are applied according to the individual needs of the member and an assessment of the local delivery system. We make utilization management criteria available to practitioners upon request. If a medical necessity decision results in a denial, practitioners are welcome to discuss the denial decision with the Chief Medical Officer. All denial decisions are made by appropriately licensed and qualified physicians. Practitioners can obtain utilization management criteria or speak to a Chief Medical Officer by calling the INTotal Health Provider Relations Department at 1-‐800-‐231-‐8076.
Medical Appeal Process and Procedures We have established and maintain a system for the resolution of appeals filed by a member or a provider acting on behalf of a member with respect to the denial or limitation of coverage of health care services. This process is referred to as an action to: • Deny or limit an authorization or a requested service • Reduce, suspend or terminate coverage of a previously authorized service • Deny payment for a service • Failure to provide services in a timely manner • Failure of INTotal Health to act within the appropriate time frames for the resolution of an appeal • For a resident of a rural area with only one MCO, the denial of a Medicaid member’s request to exercise his or her right to obtain services outside of the network Note: Clinical appeals do not relate to nonmedical issues. These are called grievances or complaintsand are addressed in the INTotal Health member grievances policy and procedures. If you need assistance with the Appeal process, please call Provider Services at 1-‐855-‐323-‐5588. First-‐Level Appeal A member, a member’s representative, the member’s PCP or the member’s health care provider may appeal an INTotal Health action within 30 calendar days from receipt of the action decision. The action decision letter describes the appeal rights to the member, including the right to member representation, to submit written comments, documents or other information relevant to the appeal and the expedited appeal process and time frame. The medical appeal process includes as parties to the medical appeal the member and the person acting on behalf of the member, or the legal representative of a member or deceased member’s estate. A clinical peer will be designated to review each medical appeal. Each appeal, due to the nature of the medical or clinical matters, will be reviewed by an appropriate health care professional that is in the same or similar specialty as the health care provider who typically manages the medical condition, procedures or treatment under review. The clinical peer will not have had any involvement or be a subordinate of anyone involved in the initial action that is the subject of the medical appeal. Upon submission of a medical appeal, we’ll notify the party filing the medical appeal in writing that we’ve received the medical appeal and all information that is required to evaluate the medical appeal within 10 calendar days. The member or person acting on behalf of the member will also be notified of the right to present evidence and allegations of fact or law in person, as well as in writing. The medical appeal process also affords the member or person acting on behalf of the member the opportunity PRM-‐July 2013
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before and during the medical appeal review process to examine the member’s case file, including medical records and any other documentation considered during the medical appeal review process. If the medical appeal is initiated via the telephone, we’ll send the member the one-‐page form titled Appeal Form. The member must complete the form and return it to us within 10 calendar days in order for us to continue reviewing their request for a medical appeal. The total time of acknowledgement, investigation and resolution of this level will be made no more than 30 calendar days from receipt of appeal for Medicaid members and up to 30 calendar days from receipt of appeal and after all information has been received for FAMIS members. We’ll notify the party filing the appeal, the member, the member’s PCP and any other health care provider who recommended the health care service involved in the medical appeal review of its decision orally followed by the written notice of determination. The written determination letter will provide the following information: • The decision reached along with a clear and detailed reason for the determination • The medical or clinical criteria for the determination, which is based on sound clinical evidence and is reviewed on a periodic basis • Notification that the member can obtain a copy upon request of the actual benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based • Notification that the member is entitled to receive upon request reasonable access to and copies of all documents relevant to the member’s appeal • A list of titles and qualifications including specialties of individuals participating in the appeal review • In the case of an upheld action, the procedures for requesting a second-‐level appeal or State Fair Hearing (Medicaid members) within 30 calendar days of date of the letter and how to do so • The right to continue to receive benefits pending the outcome of the state fair hearing • The way to request the continuation of benefits • Information explaining that the member may be liable for the cost of any continued benefits if the adverse determination is upheld in a state fair hearing Second-‐Level Appeal If an appeal filed under first-‐level appeal or first-‐level expedited appeal results in an upheld action for a reason including, but not limited to, the ones listed below, any involved party (e.g. the member, the member’s representative, the member’s PCP or the member’s health care provider) may request a second-‐level appeal from INTotal Health: • The service, procedure or treatment not viewed as medically necessary • Denial of coverage of referral to specialist physicians • Denial of coverage of hospitalization requests or length of stay requests A second-‐level appeal review consists of either a specialty review or a committee review, depending on the type of case being appealed. We may appoint a panel of qualified individuals to resolve a second-‐level appeal. Individual(s) appointed to review second-‐level appeals have not been previously involved and are not the subordinate of anyone involved in the matter regarding the original action or the first-‐level appeal. The panel will include one or more individuals who: • Have knowledge in the medical condition, procedure or treatment at issue • Are in the same licensed profession as the provider who proposed, refused or delivered the care • Do not have a direct business relationship with the member or the member’s health care provider
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The member or the member’s representative will be notified at least 5 business days in advance of the panel in order to have the opportunity to either appear in person or to communicate with the panel through other appropriate means. A second-‐level appeal resolution letter is sent to the party filing the appeal, the member, the member’s PCP and any other health care provider who recommended the health care service involved in the appeal no later than 15 calendar days for Medicaid and 14 calendar days for FAMIS members after receipt of the formal request. The written determination will provide the following information: • The decision reached along with a clear and detailed reason for the determination • A reference to the medical or clinical criteria for the determination, which is based on sound clinical evidence and is reviewed on a periodic basis • Notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, upon request • Notification that the member is entitled to receive reasonable access to and copies of all documents relevant to the member’s appeal, upon request • A list of titles and qualifications, including specialties of individuals participating in the appeal review • In the case of an upheld action, the procedures for requesting a fair hearing (Medicaid members) or an external review (FAMIS members) Expedited Medical Appeal A member can request an expedited medical appeal in cases where time expended in a standard resolution could jeopardize the member’s life or health or ability to attain, maintain or regain maximum function. An expedited medical appeal concerns one of our decisions or actions that relate to: • Health care services including, but not limited to, procedures or treatments for a member with an ongoing course of treatments ordered by a health care provider, the denial of which in the provider’s opinion could significantly increase the risk to a member’s health or life • A treatment referral, services, procedure or other health care service, the denial of which could significantly increase the risk to a member’s health or life The member, a member’s representative, the member’s PCP or the member’s health care provider can request a medical appeal orally or in writing. We’ll notify the party filing the medical appeal and the member, member’s PCP and any health care provider who recommended the health care services involved in the expedited appeal of the decision orally within three calendar days of receipt of the appeal for Medicaid members and within 48 hours for FAMIS members. Following the oral notice, a written notice of the determination will occur within two calendar days. The written determination letter will provide the following information: • A clear and detailed reason for the determination • A reference to the medical or clinical criteria for the determination, which is based on sound clinical evidence and is reviewed on a periodic basis • Notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, upon request • Notification that the member is entitled to receive reasonable access to and copies of all documents relevant to the member’s appeal, upon request • A list of titles and qualifications, including specialties of individuals participating in the appeal review • In the case of an upheld action, additional appeal rights • The right to continue to receive benefits pending the outcome of the appeal • The way to request the continuation of benefits PRM-‐July 2013
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•
Information explaining that the member may be liable for the cost of any continued benefits if the adverse determination is upheld
FAMIS External Review FAMIS members have the option to request an external review after the INTotal Health internal appeal process has been exhausted. We’ll notify the member or responsible party in writing that a final adverse decision has been rendered and that the member or responsible party may submit a request to DMAS within 30 calendar days of receipt of our final decision and the accompanying notice regarding the member’s right to request an external review. If not initiated within 30 days, the member waives his or her right to an external review. Send requests to: Department of Medical Assistance Services FAMIS External Review Request Health Care Services Division 600 East Broad Street, Suite 1300 Richmond, VA 23219
FAX: 804-‐786-‐5799 The decision by the independent reviewer is final and binding on us. If the external independent reviewer determines the coverage of health care service to be medically appropriate, we’ll pay for the health care service. State Fair Hearing Medicaid members have the right to request a fair hearing from the DMAS to review an adverse decision we made. The member or the member’s provider on behalf of the member may request a fair hearing at the same time that he or she appeals to us or after he or she has exhausted his or her appeal rights with us or instead of appealing to us. The member has a right to representation at a State Fair Hearing. To request a fair hearing, the member or the member’s representative can. submit a written request within 30 calendar days of the member’s receipt of notice of any action to deny, delay, terminate or reduce a service authorization to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 Phone: 804-‐371-‐8488 Fax: 804-‐371-‐8491 A member may have longer than 30 days to request a fair hearing in the following situations: • The member was seriously ill and was prevented from contacting us • The member did not receive notice of our decision • The member sent the request for appeal to another government agency in good faith within the time limit • Unusual or unavoidable circumstances prevented the filing If a member or his or her designee requests a fair hearing, we’ll promptly provide an appeal summary describing the basis of denial to DMAS. The fair hearing decision is final and binding on us. If the decision under the fair hearing deems coverage of the health care service to be medically appropriate, we’ll pay for the health care service. PRM-‐July 2013
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Continuation of Benefits Our members may request a continuation of their benefits during the medical appeal process by contacting Member Services at 1-‐855-‐323-‐5588. To ensure continuation of currently authorized services, the member or person acting on behalf of the member must file a medical appeal on or before the latter of 10 calendar days following our mailing the notice of action or the intended effective date of the action. We will continue the member’s coverage of benefits if the following conditions are met: • The member or the provider files the appeal in a timely manner (as defined above) • The appeal involves the termination, suspension or reduction of a previously authorized course of treatment • The services were ordered by an authorized provider • The original period covered by the initial authorization has not expired • The member requests extension of benefits If at the member’s request we continue or reinstate the member’s benefits while the appeal is pending, the benefits will be continued until one of the following occurs: • The member withdraws the medical appeal or request for the State Fair hearing • Ten calendar days pass after we mail the medical appeal determination letter unless the member has, within the 10 calendar days, requested a state fair hearing with continuation of benefits until a state fair hearing decision is reached • The time period or service limit of a previously authorized service has been met The member may be responsible for the continued benefits if the final determination of the medical appeal is not in the member’s favor. If the final determination of the medical appeal is in the member’s favor, we will authorize coverage of and arrange for disputed services promptly and as expeditiously as the member’s health condition requires. If the final determination is in the member’s favor and the member received the disputed services, we will pay for those services.
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9
HOSPITAL AND ELECTIVE ADMISSION MANAGEMENT
We require precertification of all inpatient elective admissions. The referring primary care or specialist physician is responsible for precertification. The referring physician identifies the need to schedule a hospital admission and must submit the request to our Clinical Services Department. Requests for precertification with all supporting documentation should be submitted immediately upon identifying the inpatient request or at least 72 hours prior to the scheduled admission. This will allow us to verify benefits and process the precertification request. For services that require precertification, we make case-‐by-‐ case determinations that consider the individuals’ health care needs and medical histories, in conjunction with nationally recognized standards of care. The hospital can confirm that an authorization is on file by calling Provider Services at 1-‐855-‐323-‐5588. If coverage of an admission has not been approved, the facility should call Provider Services at 1-‐855-‐323-‐5588-‐. We’ll contact the referring physician directly to resolve the issue. For services that require precertification, we use nationally recognized standards of care. We’re available 24 hours a day, 7 days a week to accept precertification requests. When a request is received from the physician via telephone or fax for medical services, the care specialist will verify eligibility and benefits. This information will be forwarded to the precertification nurse. The precertification nurse will review the coverage request and the supporting medical documentation to determine the medical appropriateness of diagnostic and therapeutic procedures. When appropriate, the precertification nurse will assist the physician in identifying alternatives for health care delivery as supported by the Chief Medical Officer. When the clinical information received is in accordance with the definition of medical necessity and in conjunction with nationally recognized standards of care, an INTotal Health reference number will be issued to the referring physician. All utilization guidelines must be supported by an individualized determination of medical necessity based on the member’s needs and medical history. If medical necessity criteria for the admission are not met on the initial review, the Chief Medical Officer will send an adverse determination letter with an explanation for the denial. If the precertification documentation is incomplete or inadequate, the precertification nurse will not approve coverage of the request but will notify the referring provider to submit the additional necessary documentation. If the Chief Medical Officer denies coverage of the request, the appropriate denial letter (including the member’s appeal rights) will be mailed to the requesting provider, member’s PCP and member.
Emergent Admission Notification Requirements We prefer immediate notification by network hospitals of emergent admissions. Network hospitals must notify us of emergent admissions within one business day. Our Clinical Services staff will verify eligibility and determine benefit coverage. We’re available 24 hours a day, 7 days a week to accept emergent admission notification at Provider Services at 1-‐855-‐323-‐5588. PRM-‐July 2013
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Coverage of emergent admissions is authorized based on review by a concurrent review nurse. When the clinical information received meets nationally recognized standards of care, an INTotal Health reference number will be issued to the hospital.
Nonemergent Outpatient and Ancillary Services – Precertification and Notification Requirements We require precertification for coverage of selected nonemergent outpatient and ancillary services (see chart below). To ensure timeliness of the authorization, the expectation of the facility and/or provider is that the following must be provided: • Member name and ID • Name, telephone number and fax number of physician performing the elective service • Name of the facility and telephone number where the service is to be performed • Date of service • Member diagnosis • Name of elective procedure to be performed with Current Procedural Terminology (CPT-‐4) code • Medical information to support requested services (medical information includes current signs, symptoms, past and current treatment plans, response to treatment plans and medications) The table below contains precertification and notification requirement guidelines: Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Behavioral Health/Substance Abuse
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REQUIREMENT Precertification Inpatient mental health services, including partial day treatment services, are covered for up to 30 days per calendar year. Inpatient hospital services may include room, meals, general nursing services, prescribed drugs and emergency room services leading directly to admission. The MCO is not required to cover any services rendered in freestanding psychiatric hospitals to enrollees up to 19 years of age.
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Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE
REQUIREMENT
Medicaid/ FAMIS Moms
Inpatient (IP) – freestanding psychiatric facility
•
IP – state psychiatric facility
•
IP – acute care facility
Partial hospitalization
FAMIS
Covered • only for members under age 21 and over age 64 Not • covered
Not covered
•
All ages covered
• •
•
Not covered
•
All ages covered Covered up to 30 days, including partial day treatment Covered up to 30 days, combined with IP acute care facility All ages covered
Not covered
Outpatient (OP) – • All ages • covered individual, family, and group mental health and substance abuse treatment (excluding opioid treatment) OP – electroconvulsive therapy OP – detoxification NOTE: If a member has been prescribed drugs for opioid treatment and the member obtains such drugs through an independent pharmacy, the drugs are the responsibility of INTotal Health if the opioid treatment is administered by the substance abuse provider and that provider obtains the drugs for the member, such drugs will be covered by the Department of Medical Assistance Services (DMAS). • Transportation and pharmacy services necessary for the treatment of substance abuse (including carved-‐out PRM-‐July 2013
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Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE
REQUIREMENT services) are the responsibility of INTotal Health. Community Mental Health Rehabilitation Services (CMHRS) are covered by DMAS. For specific service coverage, please contact DMAS or see the DMAS CMHRS manual online. • Precertification is required for coverage of all services. Precertification is required for coverage of inpatient chemotherapy services. No precertification is required for coverage of chemotherapy procedures when performed in outpatient settings by a participating facility, provider office, outpatient hospital or ambulatory surgery center. For information on coverage of and precertification requirements for chemotherapy drugs, please see the Pharmacy section. FAMIS • MedicaidNot covered unless recommended at an • Covered up to $500 per EPSDT visit calendar year • We cover medically necessary services resulting from a dental accident or for medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures. We also cover hospitalization and anesthesia related to these services. • Precertification is required for coverage of trauma to the teeth and oral maxillofacial medical and surgical conditions including TMJ. • Dental services are provided through DentaQuest, a dental benefits administrator contracted with the Department of Medical Assistance Services. The toll-‐free number for DentaQuest is 1-‐888-‐912-‐3456. • No precertification is required for E&M, testing or most procedures. • Services considered cosmetic in nature or related to previous cosmetic procedures are not covered. • See the Diagnostic Testing section below. • Visit our website to look up specific service codes for precertification/notification requirements. • No precertification is required for routine diagnostic testing. • Precertification is required for video EEGs. • MedSolutions provides diagnostic radiology management services and will precertify the following: CAT and PET scans, MRA, MRI, and nuclear cardiology. • Contact MedSolutions at 1-‐888-‐693-‐3211 or www.medsolutionsonline.com. •
Cardiac Rehabilitation Chemotherapy
Precertification Inpatient – Precertification Outpatient – No precertification
Chiropractic Services
Precertification
Dental Services
Dermatology Services
Diagnostic Testing
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Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Dialysis
Durable Medical Equipment
REQUIREMENT • • • • Precertification • and certificate of medical necessity •
Early and Periodic Screening, Self-‐referral Diagnosis, and Treatment Visit Early Childhood Intervention Educational Consultation Emergency Room
ENT Services (Otolaryngology)
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No precertification is required for dialysis procedures. Nonstandard laboratory tests require precertification. Drugs require precertification. For more information, see the Pharmacy section For code-‐specific precertification requirements for DME, prosthetics and orthotics, please visit our website or fax your request to 1-‐888-‐393-‐8978. All DME billed with an RR modifier (rental) requires precertification. • The following items require a Certificate of Medical Necessity (CMN) along with precertification: − Continuous positive airway pressure devices − Enteral and parenteral nutrition devices − External infusion pumps − Hospital beds − Lymphedema pumps − Oxygen − Osteogenesis stimulators − Power operated vehicles − Seat lift mechanisms − Support surfaces − Transcutaneous electrical nerve stimulator units − Wheelchairs, motorized and manual • All customized wheelchair precertification require an INTotal Health Chief Medical Officer’s review. • Miscellaneous items must include a manufacturer invoice with precertification request and claim submission. • INTotal Health and provider must agree on HCPCS and/or other codes for billing covered services. • See the Medical Supplies section for more information. Use EPSDT schedule and document visits.
Services are covered under the DMAS Fee-‐For-‐Service (FFS) Program. No notification or precertification is required. Self-‐referral • No notification is required. • If emergency care results in an admission, notification is required within 24 hours or the next business day. • See the Observation section for more information. No • Precertification is required for tonsillectomy and/or precertification adenoidectomy, nasal, nasal/sinus surgery, and cochlear is required for implant surgery and services. E&M, testing or • See the Diagnostic Testing section for more information. procedures 66
Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Family Planning/STD Care
REQUIREMENT Self-‐referral •
•
Gastroenterology Services
• •
Gynecology Hearing Aids
Hearing Screening
Home Health Care (see also Rehabilitation Therapy)
Hospice Services
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Covered services include pelvic and breast examinations, drugs, biological, genetic counseling, and devices and supplies related to family planning (e.g., IUD). Infertility services and treatment, elective abortions, and services performed at the time of abortion are not covered. No precertification is required for E&M, testing or most procedures. Precertification is required for upper endoscopy and bariatric surgery, including insertion, removal, and/or replacement of adjustable gastric restrictive devices and subcutaneous port components See the Diagnostic Testing section for more information. No precertification is required.
• Self-‐referral • Precertification Precertification and Chief Medical Officer’s approval is required for digital hearing aids. • MedicaidEPSDT members FAMIS 0–20 years of age only • All ages covered No notification or precertification is required for coverage of diagnostic and screening tests, hearing aid evaluations, or counseling. Precertification Medicaid FAMIS • Home health aide services • Covered services include are limited to 32 visits per skilled nursing, personal year. care, home health aide, physical, occupational, • Skilled home health visits, speech, hearing and nursing services and inhalation therapy rehabilitative therapy are services. covered based on medical necessity. • Limit: 90 total visits per year Drugs and DME require separate precertification. Precertification Medicaid • Hospice services are covered through the FFS Medicaid Program. For assistance, contact 1-‐800-‐552-‐8627.
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FAMIS • Precertification is required for coverage of inpatient hospice services. • Notification is required for outpatient hospice services. • If services are provided in the member’s home and/or DME is provided, see the DME and Home Health Services sections
Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE
REQUIREMENT
Hospital Admission
Precertification • • •
• Laboratory Services (Outpatient)
•
•
Medical Supplies
• •
Neurology
• •
• Observation
Obstetrical Care
No • precertification or notification • is required for in-‐network observation • • • •
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for more information. Elective admissions require precertification for coverage. Emergency admissions require notification within 24 hours or the next business day. Preadmission testing must be performed by an INTotal Health preferred lab vendor or network facility outpatient department. See the Provider Directory for a complete listing of participating vendors. Same-‐day admission is required for surgery. Preadmission services are not permitted. All laboratory services furnished by non-‐network providers require precertification, except for hospital laboratory services provided for an emergency medical condition. For offices with limited or no office laboratory facilities, lab tests should be referred to one of the INTotal Health preferred lab vendors. See the Provider Directory for a complete listing of participating lab vendors. No precertification is required for coverage of disposable medical supplies. Disposable medical supplies are disposed of after one use by a single individual. No precertification is required for network providers for E&M, testing or procedures. Precertification is required for the following: − Neurosurgery − Spinal fusion − Artificial intervertebral disc surgery See the Diagnostic Testing section of this QRC for more information. No precertification or notification is required for in-‐network observation. If observation results in an admission, notification is required within 24 hours or on the next business day. If admission occurs, all charges for observation services roll up into the admission. Notification is required at the FIRST prenatal visit. Notification of delivery is required within 24 hours with newborn information. No precertification is required for coverage of obstetrical (OB) visits, diagnostic tests and laboratory services. Coverage includes labor, delivery, circumcision up to 12 weeks, ultrasounds, biophysical profile, nonstress test and amniocentesis. See the Diagnostic Testing section for more information. 68
Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Ophthalmology
REQUIREMENT • •
Oral Maxillofacial
• • • •
Otolaryngology (ENT) Services
•
Out-‐of-‐Area/ Out-‐of-‐Plan Care Outpatient/ Ambulatory Surgery
Precertification •
• •
Pain Management
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•
OB case management programs are available. No precertification is required for E&M, testing or most procedures. Precertification is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. See the Diagnostic Testing section for more information. See the Plastic/Cosmetic/Reconstructive Surgery section for information. See the ENT Services (Otolaryngology) section for information. Precertification is required except for coverage of emergency care (including self-‐referral) and OB delivery. Precertification requirement is based on the service performed. Please visit our website for procedure specific precertification requirements. Precertification is required for coverage of all services and procedures related to pain management.
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Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Pharmacy
REQUIREMENT •
•
•
Physiatry, Physical Medicine and Rehabilitation Plastic/Cosmetic/Reconstructi ve Surgery (including Oral Maxillofacial Services)
• • •
•
•
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The Pharmacy benefit covers medically necessary prescription and Over-‐The-‐Counter (OTC) medications prescribed by a licensed provider. Exceptions and restrictions exist as the benefit is provided under a closed formulary/Preferred Drug List (PDL). Please refer to the PDL for the preferred products within therapeutic categories as well as requirements around generics, prior authorization, step therapy, quantity edits and the prior authorization process. Most self-‐injectable medications and self-‐administered oral specialty medications and many office administered specialty medications are available through Caremark Specialty pharmacy and require Prior Authorization (PA). To initiate a PA request, please call 1-‐877-‐433-‐7643. Please contact Caremark at 1-‐800-‐237-‐2767 to schedule delivery once you receive a PA approval notice. For a complete list of drugs available through Caremark Specialty, please visit the Pharmacy section of our website. The following injectable drugs and their counterparts in the same therapeutic class require precertification through INTotal Health when administered from a provider’s supply: Epogen, Procrit, Aranesp, Neupogen, Neulasta, Neumega, Leukine, IVIG, Enbrel, Remicade, Kineret, Humira, Amevive, Synvisc, Erbitux, Avastin, Rituxan, Camptosar, Eloxatin, Gemzar, Ixempra, Tasigna, Taxol, Taxotere and growth hormone, Xolair, Lupron, Zoladex, Botox, Cinryze, Mozobil, Nplate, Octreotide, Berinert and hemophilia factor products. See the Pain Management section for information. No precertification is required for coverage of E&M codes. Precertification is required for services related to trauma to the teeth, oral maxillofacial, medical and surgical conditions including TMJ. Services considered cosmetic in nature or services related to previous cosmetic procedures (e.g., scar revision, keloid removal resulting from pierced ears) are not covered. Reduction mammoplasty requires an INTotal Health Chief Medical Officer’s review.
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Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Podiatry
Private Duty Nursing Radiation Therapy
Radiology Rehabilitation Therapy: OT, RT, PT and ST (Short Term)
Skilled Nursing Facility
Sleep Study Sports Physicals
Sterilization
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REQUIREMENT •
No precertification is required for coverage of E&M, testing and procedures. • Precertification requirement is based on the service performed. • See the DME section for more information. • Please visit our website for procedure-‐specific precertification requirements. • Precertification is required. • A Chief Medical Officer’s review is required. • No precertification is required for coverage of radiation therapy procedures when performed in the following participating provider settings: office, outpatient hospital and ambulatory surgery center. • See the Diagnostic Testing section. • Early Intervention Services are covered under the DMAS FFS Program. • Notification is not required for initial evaluation. • Precertification is required for coverage of subsequent visits. You may fax your requests to 1-‐888-‐393-‐8978. • All children of school age should be evaluated for school-‐based speech therapy prior to precertification at a nonschool based location. FAMIS • Medicaid Skilled nursing facility services are • Precertification is required covered through the FFS for coverage. Medicaid Program. For • Medically necessary assistance call services provided in a 804-‐225-‐4222. skilled nursing facility are covered for up to 180 days per confinement. Precertification • Precertification is required. • Sport physicals are a value-‐added benefit for FAMIS and Medicaid members. • Coverage is limited to one sport physical exam per year for members between ages 10 and 18. • Maximum allowable reimbursement of $30 with no applicable member copayments. • Sterilization services are a covered benefit for members age 21 and older and require a 30-‐day waiting period. • No precertification or notification is required for coverage of sterilization procedures including tubal ligation and vasectomy. • Reversal of sterilization is not covered. • Sterilization consent form is required for claims submission. 71
Precertification/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICE Transportation Services
REQUIREMENT Medicaid • Unlimited nonemergent transport to medically necessary appointments is provided through LogistiCare.
Urgent Care Center
Vision Care (Routine) Well-‐woman Exam
Self-‐referral Self-‐referral
Revenue Codes
FAMIS • As a value-‐added benefit, FAMIS members receive 10 round trips per year to medically necessary appointments through LogistiCare. • Providers and members may contact LogistiCare for assistance in scheduling transportation with three days prior notice. • Members may call 1-‐800-‐894-‐8139 to make a reservation. • To check the status of a ride, members may call LogistiCare at 1-‐800-‐894-‐8396. • No precertification or notification is required except for coverage of air transport (airplane or helicopter). • No notification or precertification is required for participating facility. • Members may call Block Vision at 1-‐800-‐428-‐8789. • Well-‐woman exams are covered once per calendar year when performed by a PCP or in-‐network GYN. Exam includes routine lab work, STD screening, Pap smear and mammogram (age 35 or older). To the extent the following services are covered benefits, precertification or notification is required for all services billed with the following revenue codes: • All inpatient and behavioral health accommodations • 0023 – Home health prospective payment system • 0240 through 0249 – All-‐inclusive ancillary psychiatric • 0632 – Pharmacy multiple source • 3101 through 3109 – Adult day care and foster care
If the notification documentation provided is incomplete or inadequate, we will not approve coverage of the request but will notify the hospital to submit the additional necessary documentation. If the Chief Medical Officer denies coverage of the request, the appropriate denial letter will be mailed to the hospital, member’s PCP and member.
Inpatient Reviews Inpatient Admission Reviews All inpatient hospital admissions, including urgent and emergent admissions, will be reviewed within 1 business day. Our utilization review clinician determines the member’s medical status through communication with the hospital’s Utilization Review department. Appropriateness of the stay is documented, and concurrent review is initiated. Cases may be referred to the Chief Medical Officer, who renders a decision regarding the coverage of PRM-‐July 2013
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hospitalization. Diagnoses meeting specific criteria are referred to the Chief Medical Officer for possible coordination by the care management program. Affirmative Statement about Incentives We require associates who make Utilization Management (UM) decisions to adhere to the following principles: • UM decision-‐making is based only on appropriateness of care and service and existence of coverage. • We do not reward practitioners or other individuals for issuing denials of coverage or service. • Financial incentives for our UM decision makers do not encourage decisions that result in underutilization. Medical Review Criteria Admission approval and continuing Length-‐of-‐Stay (LOS) approvals are determined utilizing the nationally recognized InterQual Criteria for Acute Inpatient Care. Upon request, providers can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which a denial decision is based by calling 1-‐ 885-‐323-‐5588. Inpatient Concurrent Review Each network hospital will have an assigned UM clinician. Each UM clinician will conduct a concurrent review of the hospital medical record at the hospital or by telephone to determine the authorization of coverage for a continued stay. When an INTotal Health UM clinician reviews the medical record at the hospital, he or she also attempts to meet with the member and family to discuss any discharge planning needs and verify that the member or family is aware of the member’s PCP’s name, address and telephone number. The UM clinician will conduct continued stay reviews and evaluate discharge plans, unless the patient’s condition is such that it is unlikely to change within the upcoming 24 hours and discharge planning needs cannot be determined. When the clinical information received meets medical necessity criteria, approved days and bed-‐level coverage will be communicated to the hospital for the continued stay. If the discharge is approved, the INTotal Health UM clinician will help coordinate discharge planning needs with the hospital utilization review staff and attending physician. The attending physician is expected to coordinate with the member’s PCP regarding follow-‐up care after discharge. The PCP is responsible for contacting the member to schedule all necessary follow-‐up care. In the case of a behavioral health discharge, the attending physician is responsible for ensuring that the member has secured an appointment for a follow-‐up visit with a behavioral health provider to occur within seven calendar days of discharge. We will authorize covered length of stay one day at a time based on the clinical information that supports the continued stay. Exceptions to the one-‐day length of stay authorization are made for confinements when the severity of the illness and subsequent course of treatment are likely to be several days or are predetermined by state law. Examples of confinement and/or treatment include the following: Intensive Care Unit (ICU), Cardiac Care Unit (CCU), behavioral health rehabilitation and C-‐section or vaginal deliveries. Exceptions are made by the Chief Medical Officer. If after several attempts to speak with the attending physician, the Chief Medical Officer denies coverage for an inpatient stay request the appropriate denial letter will be mailed to the hospital, member’s PCP and the member.
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Discharge Planning Discharge planning is designed to assist the provider in the coordination of the member discharge when acute care (hospitalization) is no longer necessary. When long-‐term care is necessary, we work with the provider to plan the member’s discharge to an appropriate setting for extended services. These services can often be delivered in a nonhospital facility, such as: • Hospice facility • Convalescent facility • Home health care program (e.g., home IV antibiotics) When you identify medically necessary and appropriate services for the member, we’ll help you and the discharge planner in providing a timely and effective transfer to the next appropriate level of care. Discharge plan authorizations follow nationally recognized standards of care. Authorizations include and are not limited to transportation, home health, DME, pharmacy, follow-‐up visits to practitioners or outpatient procedures.
Confidentiality of Information Utilization management, case management, disease management, discharge planning, quality management and claims payment activities are designed to ensure that patient-‐specific information, particularly protected health information obtained during review, is kept confidential in accordance with applicable laws, including HIPAA. Information is used for the purposes defined above. Information is shared only with entities who have the authority to receive such information and only with those individuals who need access to such information in order to conduct utilization management and related processes.
Emergency Services We provide a 24-‐hour-‐a-‐day, 7-‐day-‐a-‐week Nurse HelpLine service with clinical staff to provide triage advice and referral and, if necessary, to make arrangements for treatment of the member. The staff has access to qualified behavioral health professionals to assess behavioral health emergencies. We do not discourage members from using the 911 emergency system or deny access to emergency services. Emergency services are provided to members without requiring precertification. Any hospital or provider calling for an authorization for emergency services will be granted one immediately upon request. Emergency services coverage includes services that are needed to evaluate or stabilize an emergency medical condition. Criteria used to define an emergency medical condition are consistent with the prudent layperson standard and comply with federal and state requirements. Emergency medical condition is defined as a physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in the following: (1) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; and (3) serious dysfunction of any bodily organ or part.
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Emergency response is coordinated with community services, including the police, fire and Emergency Medical Services (EMS) departments, juvenile probation, the judicial system, child protective services, chemical dependency, emergency services and local mental health authorities, if applicable. When a member seeks emergency services at a hospital, the determination as to whether the need for those services exists will be made for purposes of treatment by a physician licensed to practice medicine or to the extent permitted by applicable law, by other appropriately licensed personnel under the supervision of, or in collaboration with a physician licensed to practice medicine. The physician or other appropriate personnel will indicate in the member’s chart the results of the emergency medical screening examination. We’ll compensate the provider for the screening, evaluations and examination that are reasonable and calculated to assist the health care provider to determine whether or not the patient’s condition is an emergency medical condition. If there is concern surrounding the transfer of a patient (i.e., whether the patient is stable enough for discharge or transfer or whether the medical benefits of an unstable transfer outweigh the risks), the judgment of the attending physician actually caring for the member at the treating facility prevails and is binding on INTotal Health. If the emergency department is unable to stabilize and release the member, we’ll help in coordination of the inpatient admission regardless of whether the hospital is network or non-‐network. All transfers from non-‐ network to network facilities are to be conducted only after the member is medically stable and the facility is capable of rendering the required level of care. If the member is admitted, an INTotal Health concurrent review nurse will implement the concurrent review process to ensure coordination of care.
Urgent Care We require our members to contact their PCP in situations when urgent, unscheduled care is necessary. Precertification is not required for a member to access a participating urgent care center. Utilization review timeline standards • Nonurgent preservice: For precertification of nonurgent care, a decision will be made within 14 calendar days. • Urgent preservice: For precertification of urgent preservice care, a decision will be made within 72 hours of receipt of the request for the service. • Urgent concurrent: For urgent concurrent care, a decision will be made within 24 hours of the receipt of the request for service or notification of an inpatient admission. • Postservice: For postservice care, a decision will be made within 30 calendar days. • Extensions: Based upon insufficient information to make a decision, extensions to the standard time frames may be appropriate and can be used within certain restrictions. Appropriate notification will be made if an extension is applicable.
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10 QUALITY MANAGEMENT Quality Management Program Overview We maintain a comprehensive Quality Management (QM) program to objectively monitor and systematically evaluate the care and service provided to members. The scope and content of the program reflects the demographic and epidemiological needs of the population served. Members and providers have opportunities to make recommendations for areas of improvement. The QM program goals and outcomes are available, upon request, to providers and members. Studies are planned across the continuum of care and service, with ongoing proactive evaluation and refinement of the program. The initial program development was based on a review of the needs of the population served. Systematic re-‐evaluation of the needs of the health plan’s specific population occurs on an annual basis. This includes not only age and sex distribution, but also a review of utilization data – inpatient, emergent, urgent care and office visits by type, cost and volume. This information is used to define areas that are high-‐volume or that are problem-‐prone. Healthcare Effectiveness Data and Information Set (HEDIS) performance is evaluated annually and compared against national benchmarks. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is evaluated for member satisfaction and experience annually. Performance is analyzed for barriers and best practices and interventions are developed to improve performance. There is a comprehensive committee structure in place with oversight from the INTotal Health governing body. Not only are the traditional MAC and Credentialing Committee in place with participation from network physicians and practitioners; but a Health Education Advisory Committee consisting of members and community representatives are also integral components of the QM committee structure. Quality of Care All physicians, advanced registered nurse practitioners and physician assistants are evaluated for compliance with pre-‐established standards as described in our credentialing program. Review standards are based on medical community standards, external regulatory and accrediting agencies’ requirements, and contractual compliance. Reviews are conducted by QM coordinators and associate professionals who strive to develop relationships with providers and hospitals that will positively impact the quality of care and services provided to our members. Results are submitted to our QM department and incorporated into a profile. Our quality program includes review of quality of care issues identified for all care settings. QM staff use member grievances, reported adverse events and other information to evaluate the quality of service and care provided to our members.
In accordance with DMAS guidance, we adhere to the Provider Preventable Condition guidelines found in the Federal Register, available online at www.gpo.gov/fdsys/pkg/FR-‐2011-‐06-‐06/pdf/2011-‐13819.pdf.
Quality Management Committee The purpose of the Quality Management Committee (QMC) is to maintain quality as a cornerstone of our culture and to be an instrument of change through demonstrable improvement in care and service. The QMC’s responsibilities are to: • Establish strategic direction and monitor and support implementation of the QM program PRM-‐July 2013
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• • • • • • • • • • •
Establish processes and structure that ensure NCQA compliance Review planning, implementation, measurement and outcomes of clinical, service quality improvement studies Coordinate communication of QM activities throughout the health plans Review HEDIS data and action plans for improvement Review and approve the annual QM program description Review and approve the annual work plans for each service delivery area Provide oversight and review of delegated services Provide oversight and review of subordinate committees Receive and review reports of utilization review decisions and take action when appropriate Analyze member and provider satisfaction survey responses Monitor the health plan’s operational indicators through the plan’s senior staff
Medical Advisory Committee The MAC has multiple purposes. It assesses levels and quality of care provided to members and recommends, evaluates and monitors standards of care. The MAC identifies opportunities to improve services and clinical performance by establishing, reviewing and updating clinical practice guidelines based on review of demographics and epidemiologic information to target high-‐volume, high-‐risk and problem-‐prone conditions. It oversees the peer review process that provides a systematic approach for the monitoring of quality and the appropriateness of care. The MAC conducts a systematic process for network maintenance through the credentialing and recredentialing process. The MAC advises the health plan administration in any aspect of the health plan policies or operations affecting network providers or members. The MAC approves and provides oversight of the peer review process, the QM and utilization review programs. It oversees and makes recommendations regarding health promotion activities. The MAC responsibilities are to: • Use an ongoing peer review system to monitor practice patterns to identify appropriateness of care and to improve risk prevention activities • Approve clinical protocols and guidelines which help ensure the delivery of quality care and appropriate resource utilization • Review clinical study design and results • Develop action plans and recommendations regarding clinical quality improvement studies • Consider and act in response to provider sanctions • Provide oversight of Credentialing Committee decisions to credential and recredential providers for participation in the health plan • Approve credentialing and recredentialing policies and procedures • Oversee member access to care • Review and provide feedback regarding new technologies • Approve recommendations from subordinate committees
Credentialing Our credentialing policies and procedures incorporate the current NCQA standards and guidelines for the accreditation of MCOs, as well as DMAS requirements for the credentialing and recredentialing of licensed independent providers and organizational providers with whom it contracts.
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Each provider agrees to submit for verification all requested information necessary to credential or recredential physicians providing services in accordance with the standards we’ve established. Each provider will cooperate with us as necessary to conduct credentialing and recredentialing pursuant to our policies, procedures and rules. Credentialing Requirements Each provider, applicable ancillary, facility and hospital will remain in full compliance with our credentialing criteria as set forth in our credentialing policies and procedures and all applicable laws and regulations. The provider, applicable ancillary, facility and hospital will complete our application form upon our request. Providers will comply with other such credentialing criteria as may be established by INTotal Health. Credentialing Procedures We’re committed to operating an effective, high-‐quality credentialing program. We credential the following provider types: medical doctors, doctors of osteopathy, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of chiropractic, physician assistants, optometrists, dentists, nurse practitioners, certified nurse midwives, licensed professional counselors and social workers, psychologists, physical and occupational therapists, speech and language therapists and other applicable or appropriate midlevel providers as well as hospitals and allied services (ancillary) providers. During recredentialing, you must show evidence of satisfying these policy requirements and must have satisfactory results relative to our measures of quality of health care and service. We will establish a credentialing committee and a MAC for the formal determination of recommendations regarding credentialing decisions. The Credentialing Committee will make decisions regarding participation of initial applicants and their continued participation at the time of recredentialing. The oversight rests with the MAC. Our credentialing policy is revised periodically based on input from several sources including, but not limited to, the Credentialing Committee, the health plan Chief Medical Officer, state and federal requirements. The policy will be reviewed and approved as needed, but at a minimum annually. Your application contains your actual signature that serves as an attestation of the credentials summarized on and included with the application. Your signature also serves as a release of information to verify credentials externally. We’re responsible for externally verifying specific items attested to on the application. Any discrepancies between information included with the application and information we obtain during the external verification process will be investigated and documented and may be grounds for refusal of acceptance into the network or termination of an existing provider relationship. The signed agreement documents compliance with our managed care policies and procedures. You have the right to inquire about the status of your application. You may do so by the following methods: (1) telephone, (2) facsimile, (3) contact through his or her Provider Relations representative or (4) in writing. As an applicant for participation with us, you have the right to review information obtained from primary verification sources during the credentialing process. Upon notification from us, you have the right to explain information obtained that may vary substantially from that provided and to provide corrections to any erroneous information submitted by another party. You must submit a written explanation or appear before the credentialing committee if deemed necessary. Currently, the following verifications are completed as applicable prior to final submission of a practitioner file to the health plan Chief Medical Officer or Credentialing Committee. To the extent allowed under applicable law or state agency requirements per NCQA standards and guidelines, the Chief Medical Officer has authority to approve clean files without input from the credentialing committee. All files not designated as a clean file will be presented to the Credentialing Committee for review and decision regarding participation. PRM-‐July 2013
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In addition to the submission of an application and the execution of a participating provider agreement, the following must be reviewed and approved by the Credentialing Committee or the Chief Medical Officer. 1. Board Certification. Verification by referencing the American Medical Association (AMA) Provider Profile, American Osteopathic Association (AOA), the American Board of Medical Specialties (ABMS), American Board of Podiatric Surgery (ABPS), and/or American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM). 2. Verification of Education and Training. Verification by referencing board certification or the appropriate state-‐licensing agency. 3. Verification of Work History. The practitioner must submit a curriculum vitae documenting work history for the past five years. Any gaps in work history greater than six months must be explained in written format and brought to the attention of the Chief Medical Officer and Credentialing Committee as applicable. 4. Hospital Affiliations and Privileges. To the extent allowed under applicable law or state agency requirements, verification of clinical privileges in good standing at an INTotal Health network hospital may be accomplished by the use of an attestation signed by the provider. If an attestation is not acceptable, hospital admitting privileges in good standing are verified for the practitioner. This information is obtained in the form of a written letter from the hospital, roster format (multiple practitioners), Internet access or by telephone contact. The date and name of the person spoken to at the hospital are documented. 5. State Licensure or Certification. Verification of state license information to ensure that the practitioner maintains a current legal license or certification to practice in the State. This information can be verified by referencing data provided to INTotal Health by the state via roster, telephone or the Internet. 6. DEA Number. Verification of the Drug Enforcement Administration (DEA) number to ensure that the practitioner is currently eligible to prescribe controlled substances. This information is verified by obtaining a copy of the DEA certificate or by referencing the National Technical Information Service (NTIS) data. If the practitioner is not required to possess a DEA Certificate but does hold a state-‐controlled substance certificate, the Controlled Dangerous Substance (CDS) certificate is verified to ensure the practitioner is currently eligible to prescribe controlled substances. This information is verified by obtaining a copy of the CDS certificate or by referencing CDS online or Internet data if applicable. 7. Professional Liability Coverage. To the extent allowed under applicable law or state agency requirements, verification of malpractice coverage may be accomplished by the use of an attestation signed by the provider indicating the name of the carrier, policy number, coverage limits and the effective and expiration dates of such malpractice coverage. If an attestation is not acceptable, the practitioner’s malpractice insurance information is verified by obtaining a copy of the professional liability insurance face sheet from the practitioner or from the malpractice insurance carrier. Practitioners are required to maintain professional liability insurance in specified amounts. 8. Professional Liability Claims History. Verification of an applicant’s history of professional liability claims, if any, reviewed by the Health Plan Credentialing Committee to determine whether acceptable risk exposure exists. The review is based on information provided and attested to by the applicant and information available from the National Practitioner’s Data Bank (NPDB). The Credentialing Committee’s policy is designed to give careful consideration to the medical facts of the specific cases, total number and frequency of claims in the past five years and the amounts of settlements and/or judgments. 9. CMS Sanctions. Verification that the practitioner’s record is clear of any sanctions by Medicare/Medicaid. This information is verified by accessing the NPDB. 10. Disclosures – Attestation and Release of Information. The INTotal Health provider application will require responses to the following: • Reasons for the inability to perform the essential functions of the position with or without accommodation • Any history or current problems with chemical dependency, alcohol or substance abuse
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History of license revocations, suspension, voluntary relinquishment, probationary status or other licensure conditions or limitations • History of conviction of any criminal offense other than minor traffic violations • History of loss or limitation of privileges or disciplinary activity, including denial, suspension, limitation, termination or nonrenewal of professional privileges • History of grievances or adverse action reports filed with a local, state or national professional society or licensing board • History of refusal or cancellation of professional liability insurance • History of suspension or revocation of a DEA or CDS certificate • History of any Medicare/Medicaid sanctions • Attestation by the applicant of the correctness and completeness of the application • Any issue identified must be explained in writing. These explanations are presented with the provider’s application to the credentialing committee. 11. The NPDB is queried against applicants and INTotal Health contracted providers. The NPDB will provide a report for every practitioner queried. These reports are shared with the Chief Medical Officer and the Credentialing Committee for review and action as appropriate. The Federation of State Medical Boards for Doctors of Medicine (MDs), Doctors of Osteopathy (DOs) and Physician Assistants (PAs) is queried to verify any restrictions and/or sanctions made against the practitioner’s license. The appropriate state-‐licensing agency is queried for all other providers. All sanctions are investigated and documented, including the health plan’s decision to accept or deny the applicant’s participation in the network. 12. Recredentialing. At the time of recredentialing (every three years) information for PCPs from quality improvement activities and member grievances is presented for Credentialing Committee review. You will be notified by telephone or in writing if any information obtained in support of the assessment or reassessment process varies substantially from the information you’ve submitted. You have the right to review the information submitted in support of the credentialing and recredentialing process and to correct any errors in the documentation. This will be accomplished by submission of a written explanation or by appearance before the Credentialing Committee, if so requested. The decision to approve or deny initial participation will be communicated in writing within 60 days of the Credentialing Committee’s decision. To the extent allowed under applicable law or state agency requirements, per NCQA standards and guidelines, the Chief Medical Officer may render a decision regarding the approval of clean files without the benefit of input from the Credentialing Committee. In the event your continued participation is denied, you will be notified by certified mail. If continued participation is denied, you will be allowed 30 days to appeal the decision. Credentialing Organizational Providers Your application contains your actual signature that serves as an attestation that the health care facility agrees to the assessment requirements. Providers requiring assessments are as follows: hospitals, home health agencies, skilled nursing facilities, nursing homes, ambulatory surgical centers and behavioral health facilities providing mental health or substance abuse services in an inpatient, residential or ambulatory setting. Your signature also serves as a release of information to verify credentials externally. Currently, the following steps are completed in addition to the application and network provider agreement before approval for participation of a hospital or organizational provider. • State licensure is verified by obtaining a current copy of the state license from the organization or by contacting the state-‐licensing agency. Primary source verification is not required. Any restrictions to a
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•
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license are investigated and documented, including the decision to accept or deny the organization’s participation in the network. We contract with facilities that meet the requirements of an unbiased and recognized authority. Hospitals (e.g., acute, transitional or rehabilitation) should be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Healthcare Facilities Accreditation Program (HFAP) or the American Osteopathic Association (AOA). The Commission on Accreditation of Rehabilitation Facilities (CARF) may accredit rehabilitation facilities. Home health agencies should be accredited by JCAHO or the Community Health Accreditation Program (CHAP). Nursing homes should be accredited by JCAHO. JCAHO or the Accreditation Association for Ambulatory Health Care (AAAHC) should accredit ambulatory surgical centers. If facilities, ancillaries or hospitals are not accredited, we will accept a copy of a recent state or CMS review in lieu of performing an onsite review. If accreditation or a copy of a recent review is unavailable, an onsite review will be performed. A copy of the malpractice insurance face sheet is required. Organizations are required to maintain malpractice insurance in the amounts specified in the provider contract and according to our policy. We will track a facility’s or ancillary’s reassessment date and reassess every 36 months as applicable. Requirement for recredentialing of organizational providers are the same for reassessment as they are for the initial assessment.
Your organization will be notified either by telephone or in writing if any information obtained in support of the assessment or reassessment process varies substantially from the information your organization has submitted. Your organization has the right to review the information submitted in support of the assessment process and to correct any errors in the documentation. This will be accomplished by submission of a written explanation or by appearance before the Credentialing Committee if so requested. The decision to terminate your organization’s participation will be communicated in writing via certified mail. Delegated Credentialing We will ensure the quality of its credentialing program through direct verification and through delegation of credentialing functions to qualified provider organizations. If your provider group is believed to have a strong credentialing program, we may evaluate a delegation of credentialing and recredentialing. To do this, your provider group must have a minimum of 150 participating providers. The Credentialing Department will review the written credentialing policies of your group for adequacy. Steps, if any, are identified where your group’s credentialing policies do not meet our standards. We will perform or arrange for your group to perform our credentialing steps not addressed by your group. We will perform a pre-‐delegation audit of your group’s credentialing practices. A passing score is considered to be an overall average of 90 percent compliance. Your group is expected to submit an acceptable corrective action plan within 30 days of receipt of the audit results. If there are serious deficiencies, we will deny the delegation or will restrict the level of delegation. We, at our discretion, may waive the need for the predelegation on-‐sight audit if the delegated entity’s credentialing program is NCQA certified to include all credentialing and recredentialing elements. We are responsible for oversight of any delegated credentialing arrangement and schedules appropriate reviews. The reviews are held at least annually. Peer Review The peer review process provides a systematic approach for monitoring the quality and appropriateness of care. Peer review responsibilities are: • To participate in the implementation of the established peer review system PRM-‐July 2013
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• To review and make recommendations regarding individual provider peer review cases • To work in accordance with the executive Chief Medical Officer If an investigation of a member grievance results in concern regarding a physician’s compliance with community standards of care or service, all elements of peer review will be followed. Dissatisfaction severity codes and levels of severity are applied to quality issues. The Chief Medical Officer assigns a level of severity to the grievance. Peer review includes investigation of physician actions by or at the discretion of the Chief Medical Officer. The Chief Medical Officer takes action based on the quality issue and the level of severity, invites the cooperation of the physician, and then consults and informs the MAC and the peer review committee. The Chief Medical Officer informs the physician of the committee’s decision, recommendations, follow-‐up actions and/or disciplinary actions to be taken. Outcomes are reported to the appropriate internal and external entities which include the quality management committee. The peer review process is a major component of the MAC’s monthly agenda. The peer review policy is available upon request.
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PROVIDER COMPLAINT AND GRIEVANCE PROCEDURES
We have a grievance and appeal process for the handling of disputes pertaining to administrative issues and nonpayment-‐related matters. For payment disputes, see Section 12 – Provider Payment Disputes. A provider grievance will be resolved fairly and consistently with our policies and covered benefits. Your time frame to file a grievance to us not related to a member or payment dispute is equal to a member’s time frame for filing and resolution of grievances. You’re not penalized for filing grievances. Any supporting documentation should accompany the grievance. File grievances in writing to: INTotal Health Attn: Grievances2600 Park Tower Drive, Suite 600 Vienna, VA 22180 We will send an acknowledgement letter to the provider within 10 calendar days of receipt. At no time will we cease coverage of care pending a grievance investigation.
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12
CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
Electronic Submission We encourage the submission of claims electronically through Electronic Data Interchange (EDI). Submit claims within 180 days from the date of discharge for inpatient services or from the date of service for outpatient services or according to the terms outlined in your contract. Electronic claims submission is available through: • Emdeon (formerly WebMD) – Claim Payer ID 10262 • Capario (formerly MedAvant) – Claim Payer ID IHP02 • Gateway EDI – Claim Payer ID IHP01 • Availity (formerly THIN) – Claim Payer ID IHP001 for Professional Claims – Claim Payer ID IHP002 for Institutional Claims The advantages of electronic claims submission are as follows: • Facilitates timely claims adjudication • Acknowledges receipt and rejection notification of claims electronically • Improves claims tracking • Improves claims status reporting • Reduces adjudication turnaround • Eliminates paper • Improves cost-‐effectiveness • Allows for automatic adjudication of claims The guide for EDI claims submission is located at www.intotalhealth.org. The EDI claim submission guide includes additional information related to the EDI claim process. To initiate the electronic claims submission process or obtain additional information, please contact our the Clearinghouse for further information:
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Emdeon Gateway Capario Availity
1-‐877-‐469-‐3263 1-‐800-‐969-‐3666 1-‐800-‐586-‐6938 1-‐800-‐282-‐4548
Paper Claims Submission You also have the option of submitting paper claims. We use Optical Character Recognition (OCR) technology as part of our front-‐end claims processing procedures. The benefits include the following: • Faster turnaround times and adjudication • Claims status availability within five days of receipt • Immediate image retrieval by our staff for claims information, allowing more timely and accurate response to your inquiries To use OCR technology, claims must be submitted on original red claim forms (not black and white or photocopied forms) laser printed or typed (not handwritten) in a large, dark font. Submit a properly completed PRM-‐July 2013
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CMS-‐1450 (UB-‐04) or CMS-‐1500 (08-‐05) within 180 days from the date of discharge for inpatient services or from the date of service for outpatient services, except in cases of Coordination of Benefits (COB)/subrogation or in cases where a member has retroactive eligibility. For cases of COB/subrogation, the time frames for filing a claim will begin on the date that the third party documents resolution of the claim. In accordance with the implementation timelines set by CMS and the National Uniform Claim Committee (NUCC), we require the use of the new CMS-‐1500 (08-‐05) for the purposes of accommodating the National Provider Identifier (NPI). In accordance with the implementation timelines set by CMS and the National Uniform Billing Committee (NUBC), we require the use of the new CMS-‐1450 (UB-‐04) for the purposes of accommodating the NPI. CMS-‐1500 (08-‐05) and CMS-‐1450 (UB-‐04) must include the following information (HIPAA compliant where applicable): • Patient’s ID number • Patient’s name • Patient’s date of birth • International Classification of Diseases (ICD-‐9) diagnosis code/revenue codes • Date of service • Place of service • Procedures, services or supplies rendered, CPT-‐4 codes/HCPC codes/Diagnosis Related Group (DRGs) with appropriate modifiers, if necessary • Itemized charges • Days or units • Modifiers as applicable • Provider tax ID number and state Medicaid ID number • Provider name according to contract • INTotal Health provider number • NPI of billing provider when applicable • COB/other insurance information • Authorization/precertification number or copy of authorization/precertification • Name of referring physician • NPI and Taxonomy code • NPI of referring physician when applicable • Any other state required data We cannot accept claims with alterations to billing information. Claims that have been altered will be returned to you with an explanation of the reason for the return. We will not accept entirely handwritten claims. Submit paper claims within 180 days of the date of service to the following address: INTotal Health Attn: Claims P.O. Box 5446 Richmond, VA 23220-‐0446
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Encounter Data We have established and maintain a system to collect member encounter data. Due to reporting needs and requirements, network providers who are reimbursed by capitation must send us encounter data for each member encounter. Encounter data can be submitted through EDI submission methods or on a CMS-‐1500 (08-‐05) claim form unless we approve other arrangements. Data will be submitted in a timely manner, but no later than 180 days from the date of service. The encounter data will include the following: • Member ID number • Member name (first and last name) • Member date of birth • Provider name according to contract • INTotal Health provider number • COB information • Date of encounter • Diagnosis code • Types of services provided (using current procedure codes and modifiers if applicable) • Provider tax ID number and state Medicaid ID number • NPI and Taxonomy code Encounter data should be submitted to the following address: INTotal Health Attn: Claims P.O. Box 5446 Richmond, VA 23220-‐0446 Through claims and encounter data submissions, HEDIS information is collected. This includes but is not limited to the following: • Preventive services (e.g., childhood immunization, mammography, Pap smears) • Prenatal care (e.g., low birth weight, general first trimester care) • Acute and chronic illness (e.g., ambulatory follow-‐up and hospitalization for major disorders) Compliance is monitored by our utilization and quality improvement staff, coordinated with the Chief Medical Officer and reported to the QM committee on a quarterly basis. PCPs are monitored for compliance with reporting of utilization. Lack of compliance will result in training and follow-‐up audits and could result in termination.
Claims Adjudication We’re dedicated to providing timely adjudication of your claims for services rendered to members. All network and non-‐network provider claims submitted for adjudication are processed according to generally accepted claims coding and payment guidelines. The guidelines comply with industry standards as defined by the CPT-‐4 and ICD-‐9 manuals. Institutional claims should be submitted using EDI submission methods or a CMS-‐1450 (UB-‐04) and provider services using the CMS-‐1500.
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You must use HIPAA-‐compliant billing codes when billing INTotal Health. This applies to both electronic and paper claims. When billing codes are updated, you’re required to use appropriate replacement codes for submitted claims. We will not reimburse any claims submitted using noncompliant billing codes. We reserve the rights to use code-‐editing software to determine which services are considered part of, incidental to or inclusive of the primary procedure. We use a code auditing system to ensure consistent physician and facility reimbursement. The system automatically evaluates provider claims in accordance with CPT guidelines, accepted industry coding standards and corporate policies. This aligns with our fraud, waste and abuse program in that it ensures correct coding and billing practices are followed. The system is updated periodically to conform to changes in coding standards and to include new procedures and diagnosis codes. We use Version 43 of ClaimCheck. For claims payment to be considered, adhere to the following time limits: • Submit claims within 180* days from the date the service is rendered or for inpatient claims filed by a hospital within 180 days from the date of discharge • In the case of other insurance, submit the claim within 180* days of receiving a response from the third-‐ party payer • Claims for members whose eligibility has not been added to the state’s eligibility system must be received within 180* days from the date the eligibility is added and we are notified of the eligibility/enrollment • Claims submitted after the 180*day filing deadline will be denied * Or per the terms outlined in your contract After filing a claim with us, review the weekly Explanation of Payment (EOP). If the claim does not appear on an EOP within 30 business days as adjudicated or you have no other written indication that the claim has been received, check the status of your claim using our website at www.intotalhealth.org or telephonically on the Provider Inquiry Line at 1-‐855-‐323-‐5588. If the claim is not on file with us, resubmit your claim within 180 days from the date of service. If filing electronically, check the confirmation reports for acceptance of the claim that you receive from your EDI or practice management vendor.
Clean Claims Payment A clean claim is a request for payment for a service you’ve rendered that: • You’ve submitted in a timely manner • Is accurate • Is submitted on a HIPAA-‐compliant standard claim form including a CMS-‐1500 (08-‐05) or CMS-‐1450 (UB-‐04) or successor forms thereto or the electronic equivalent of such claim form • Requires no further information, adjustment or alteration by you or by a third party in order for us to process and pay it Clean claims are adjudicated within 30 calendar days of receipt of a clean claim. If we do not adjudicate the clean claim within the time frames specified above, we will pay all applicable interest as required by law. We produce and mail EOPs on a biweekly basis, which delineate for you the status of each claim that has been adjudicated during the previous week. Upon receipt of information we’ve requested from you, we must complete processing of the clean claim within 30 calendar days. Paper claims that are determined to be unclean will be returned to the billing provider along with a letter stating the reason for the rejection. Electronic claims (EDI) determined to be unclean will be returned to the INTotal Health contracted clearinghouse that submitted the claim. PRM-‐July 2013
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Claims Status Use the INTotal Health online resources located at www.intotalhealth.org or call the automated Provider Services at 1-‐855-‐323-‐5588 to check claims status.
Provider Reimbursement Electronic Remittance Advice and Electronic Funds Transfer We offer Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) with online viewing capability. You can elect to receive INTotal Health payments electronically through direct-‐deposit to your bank account. In addition, you can select from a variety of remittance information options, including: • ERA presented online and printed in your office • HIPAA-‐compliant data file for download directly to your practice management or patient accounting system • Paper remittance printed and mailed by us Some of the benefits providers may experience include: • Faster receipt of reimbursement from us • The ability to generate custom reports on both payment and claim information based on the criteria specified • Online capability to search claims and remittance details across multiple remittances • Elimination of the need for manual entry of remittance information and user errors • Ability to perform faster secondary billing To register for ERA/EFT, please visit our website at www.intotalhealth.org. Primary Care Provider Reimbursement We reimburse PCPs according to their contractual arrangement. Specialist Reimbursement Reimbursement to network specialty care providers and network providers not serving as PCPs is based on their contractual arrangement with us. Specialty care providers will obtain PCP and our approval prior to rendering or arranging any treatment that is beyond the specific treatment authorized by the PCP’s referral or beyond the scope of self-‐referral permitted under this program. Specialty care provider services will be covered only when there is documentation of appropriate notification or precertification and receipt of the required claims and encounter information to us.
Procedure for Processing Overpayments Refund notifications may be identified by two entities, our Cost Containment Unit (CCU) or the provider. The CCU researches and notifies the provider of an overpayment requesting a refund check. The provider may also identify an overpayment and proactively submit a refund check to reconcile the overpayment amount.
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Once we’ve identified an overpayment, the CCU will notify the provider of the overpayment. The provider will submit a Refund Notification Form (RNF) along with the refund check. If a provider identified the overpayment and returns the INTotal Health check, please include a completed RNF specifying the reason for the return. This form can be found on the provider website at www.intotalhealth.org.The submission of the RNF will allow the CCU to process and reconcile the overpayment in a timely manner. Once the CCU has reviewed the overpayment, you will receive a confirmation letter explaining the details of the reconciliation. For questions regarding the refund notification procedure, please call Provider Services at 1-‐855-‐323-‐5588 and select the appropriate prompt.
Provider Payment Disputes You may access a timely payment dispute resolution process. A payment dispute is any dispute between the health care provider and INTotal Health for reasons including, but not limited to: • Denials for timely filing • Contractual issues • Lost or incomplete claim forms or electronic submissions • Requests for additional explanation as to services or treatment rendered by a provider • Inappropriate or unapproved referrals initiated by providers • Provider appeals without member’s consent • Emergency room payment dispute • Retrospective review No action is required by the member. Payment disputes do not include medical appeals. You will not be penalized for filing a payment dispute. The Payment Dispute Unit will receive, distribute and coordinate all payment disputes. To submit a payment dispute, please complete the Provider Payment Dispute and Correspondence Submission form located in Appendix A – Forms or online at www.intotalhealth.org and submit to: INTotal Health Attn: Payment Dispute Unit 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 As a network provider, you must file a payment dispute so it is received by us within 90 business days of the paid date of the EOP. Submit a written request with an explanation of what is in dispute and why including supporting documentation such as an EOP, or a copy of the claim, medical records or contract page. Any payment dispute received with supporting clinical documentation will be retrospectively reviewed by a licensed/registered nurse. Established clinical criteria will be applied to the payment dispute. After retrospective review, the payment dispute may be approved or forwarded to the health plan Chief Medical Officer for further review and resolution. A Level I determination will be sent to you within 30 calendar days from receipt of the payment dispute. If the decision is to adjust the claim to allow full reimbursement, we’ll mail you an EOP. If the decision is to partially adjust the claim or uphold the previous decision, we’ll mail you a first-‐level payment dispute response letter. The response letter will include the following information: • Provider name • Member name, ID number and date of birth PRM-‐July 2013
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• • • • • • •
Date of service Claim number Dispute number Date of initial filing of concern Written description of the concern Decision Further dispute options
If you’re dissatisfied with the Level I payment dispute resolution, you may file a Level II dispute. This must be a written dispute submitted and received by us within 30 calendar days of the date of the Level I determination letter. Medicaid providers also have the right to appeal adverse decisions to DMAS once the provider has exhausted our internal dispute process. If you disagree with our final determination, you may appeal this decision to DMAS in writing within 30 days of the date of our final determination letter. To request an appeal, submit your written request to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 Upon receipt of notification of a dispute by the DMAS, we will prepare and submit dispute summaries to DMAS Appeals Division, the DMAS Contract Monitor and the provider involved in the dispute. We will attend all dispute hearings or conferences, whether informal or formal or whether in person or by telephone, or as deemed necessary by the DMAS Appeals Division.
Coordination of Benefits State-‐specific guidelines will be followed when COB procedures are necessary. We agree to use covered medical and hospital services whenever available or other public or private sources of reimbursement for services rendered to members in our plan. We and our providers agree that the Medicaid program will be the payer of last resort when third-‐party resources are available to cover the costs of medical services provided to Medicaid members. When we are aware of these resources prior to paying for a medical service, we will avoid payment by either rejecting your claim and redirecting you to bill the appropriate insurance carrier or, if we do not become aware of the resource until sometime after payment for the service was rendered, by pursuing post-‐payment recovery of the expenditure. You must not seek recovery in excess of the Medicaid payable amount. You’re obligated to report these cases to us. We will avoid payment of claims where third-‐party resources are identified prior to payment. Otherwise, we will follow a pay and pursue policy on prospective and potential subrogation cases. Paid claims are reviewed and researched post payment to determine likely cases with multiple letters and phone calls being are made to document the appropriate details. The filing of liens and settlement negotiations are handled internally and externally via a subrogation vendor.
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We will require members to cooperate in the identification of any and all other potential sources of payment for services. Any questions or inquiries regarding paid, denied or pended claims should be directed to Provider Services at 1-‐855-‐323-‐5588.
Billing Members Overview Before rendering services, always inform members that the cost of services not covered by INTotal Health will be charged to the member. If you choose to provide services not covered by INTotal Health: • Understand that we only reimburse for services that are medically necessary, including hospital admissions and other services • Obtain the member’s signature on the client acknowledgment statement specifying that the member will be held responsible for payment of services • Understand that you may not bill for or take recourse against a member for denied or reduced claims for services that are within the amount, duration and scope of benefits of the Medicaid program Our members must not be balance billed for the amount above that which we pay for covered services. In addition, you may not bill a member if any of the following occurs: • Failure to submit a claim in a timely manner, including claims not received by us • Failure to submit a claim to us for initial processing within the 180-‐day filing deadline • Failure to submit a corrected claim within the 180-‐day filing resubmission period • Failure to appeal a claim within the 90-‐day administrative appeal period • Failure to appeal a utilization review determination within 30 days of notification of a coverage denial • Submission of an unsigned or otherwise incomplete claim • Errors made in claims preparation, claims submission or the appeal process
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Client Acknowledgment Statement You may bill an INTotal Health member for a service that has been denied as not medically necessary or not a covered benefit only if both of the following conditions are met: • The member requests the specific service or item • You obtain and keep a written acknowledgement statement signed by you and the member stating:
“I understand that, in the opinion of (provider’s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under INTotal Health as being reasonable and medically necessary for my care or that are not a covered benefit. I understand that INTotal Health has established the medical necessity standards for the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be medically necessary standards for my care or not a covered benefit.” Signature: _________________________________________________ Date: ___________________________________________________
Our Website and Provider Services Line Our website provides a host of online resources at www.intotalhealth.org, featuring our online provider inquiry tool for real-‐time claim status, eligibility verification and precertification status. You can also submit a claim or a precertification, print referral forms or directories, or obtain a member roster. Detailed instructions for the use of the online provider inquiry tool can be found on our website. Our toll-‐free Provider Services Line 1-‐855-‐323-‐5588 offers real-‐time member status, claim status and precertification status. This option also offers the ability to be transferred to the appropriate department for other needs, such as seeking advice in case/care management.
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APPENDIX A – FORMS
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Referral and Claim Submission Forms
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WIC Referral Form SAMPLE WIC REFERRAL FORM PL103-‐448, §204(e) requires states using managed care arrangements to serve their Medicaid beneficiaries to coordinate their WIC and Medicaid Programs. This coordination should include the referral of potentially eligible women, infants and children and the provision of medical information to the WIC Program. To help facilitate the information exchange process, please complete this form and send it to the address listed below. Thank you for your cooperation. Name of Person Being Referred: _____________________________________________________________________________ Address: __________________________________________________________________________ Telephone Number: _________________________________________________________________ The following classifications describe the populations served by the WIC program. Please check the category that most appropriately describes the person being referred: ____ Pregnant woman ____ Woman who is breastfeeding her infants up to 1 year postpartum ____ Woman who is non-‐breastfeeding up to 6 months postpartum ____ Infant (age 0-‐1) ____ Child under age 5 States may consider using this space to either include specific medical information or to indicate that such information can be provided if requested by the WIC Program. Provider's Name: ____________________________________________________________________ Provider's Phone: ____________________________________________________________________ I, the undersigned, give permission for my provider to give the WIC Program any required medical information. ______________________________________________________________________________ (Signature of the patient being referred or, in the case of children and infants, signature and printed name of the parent/guardian) Send completed form to: Local WIC Program Center: ____________________________________________________________ Address: ___________________________________________________________________________ Telephone Number: __________________________________________________________________
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Phone 1-‐855-‐323-‐5588
AUTHORIZATION REQUEST
Fax 1-‐888-‐393-‐8978
** To avoid delay, please print clearly ** TODAY’S DATE PROVIDER RETURN FAX # MEMBER INFORMATION (Please verify eligibility prior to rendering service) Name (Last name, First name) Date of birth Address City, State ZIP code Medicaid # Other insurance/workers’ comp REFERRING PROVIDER INFORMATION Name Medicaid provider # Office contact name NPI TIN Phone Other phone Fax RENDERING PRACTITIONER (complete if applicable) Practitioner (Last name, First name, Provider specialty) NPI TIN Phone Fax Address City, State RENDERING FACILITY (complete if applicable) Facility name NPI TIN Phone Fax Address City, State REQUESTED SERVICES Date(s) of Service ICD-‐9 code/diagnosis/reason for referral CPT/HCPCS/RV Code(s) Number of visits/units requested PMH/previous studies/treatments Service location: □ Inpatient □ Outpatient □ Extended stay □ Home □ Office □ Other (please specify) Service Type: □ Durable Medical Equipment □ Home Health □ Hospice □ Other(please specify) MATERNITY CARE For initial notification of pregnancy, please use the Maternity Notification form. For all other services related to pregnancy, please use this form (e.g., ultrasound, fetal non-‐stress test). ** Note: Participating providers requesting authorization for advanced imaging services such as PET scans, MRI’s and CAT scans must submit these requests through Medsolutions at phone 888-‐693-‐3211 or fax 888-‐ 693-‐3210.
**PLEASE ATTACH CLINICAL INFORMATION TO SUPPORT MEDICAL NECESSITY. ** This referral is valid
only for services authorized by this form. Only completed referrals will be processed. If the consultant/provider recommends another service or surgery, additional authorization is required. Certification does not guarantee that benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions and exclusions. PF-‐MULT-‐0013-‐12
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Fax 1-‐888-‐393-‐8978 Maternity Notification Form Disclaimer: This is not an authorization for hospital admission. Only completed referrals will be processed. Certification does not guarantee that benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions and exclusions. Member Information Member’s name
Medicaid ID #
Date of Birth
Address
City, State, Zip
Home Phone
Cell
Emergency Contact
EDC__________ Gravida __________ Para __________ (Term_________ Preterm_________) AB___________ WT _________ HT __________ Current medications ________________________________________________ Planned delivery site ____________________________________________________________________________ Provider Information Date of initial office visit
Name of office/clinic
Provider’s Name NPI _________________ TIN ___________________ Address City, State, Zip Phone
Fax
CPT Codes Please check all that apply:
* Current preterm labor * Hypertension * Multiple gestation * Diabetes * Gestational Diabetes
* History of PTL * History of PIH/pre-‐eclampsia * History of IUGR * History of GDM * Psychosocial risk (specify)
Current or history of substance use __________________ Specify Substance _____________________________ Uterine/cervical abnormalities _________________________ Other (specify) ___________________________ From completed by: ______________________________________ Date _____________________________
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Specialist as PCP Request Form
Date:
____________________________________________________
Member’s Name:
____________________________________________________
Medicaid ID:
____________________________________________________
PCP’s Name (if applicable):
____________________________________________________
Specialist/Specialty:
____________________________________________________
Member’s Diagnosis:
____________________________________________________
Describe the medical justification for selecting a specialist as PCP for this member. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ __________________________________________________ The signatures below indicate agreement by the specialist, INTotal Health and the member that the specialist will function as this member’s PCP, including providing to the member access 24 hours a day, 7 days a week. Specialist’s Signature: ________________________________
Date: ___________________
Chief Medical Officer’s Signature: __________________________
Date: ___________________
Member’s Signature: _________________________________
Date: ___________________
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CMS-‐1500 (08-‐05) Claim Form This form is available from the Centers for Medicare and Medicaid Services at www.cms.hhs.gov.
CMS-‐1450 Claim Form This form is also available from the Centers for Medicare and Medicaid Services at www.cms.hhs.gov. The rest of this page is intentionally left blank.
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HIV Antibody Blood Forms
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Counsel for the HIV Antibody Blood Test
use patient imprint
Name: _______________________________________________________________________ In accordance with Chapter 174, P.L. 1995: I acknowledge that ____________________________________________ has counseled (Name of physician or other provider) and provided me with: A. Information concerning how HIV is transmitted B. The benefits of voluntary testing C. The benefits of knowing if I have HIV or not D. The treatments which are available to me and my unborn child should I test positive E. The fact that I have a right to refuse the test and I will not be denied treatment I have consented to be tested for infection with HIV. I have decided not to be tested for infection with HIV. This record will be retained as a permanent part of the patient’s medical record. ______________________________________ ____________________________ Signature of Patient Date ______________________________________ Signature of Witness
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Consent for the HIV Antibody Blood Test I have been told that my blood will be tested for antibodies to the virus named HIV (Human Immunodeficiency Virus). This is the virus that causes AIDS (Acquired Immunodeficiency Syndrome), but it is not a test for AIDS. I understand that the test is done on blood. I have been advised that the test is not 100 percent accurate. The test may show that a person has antibodies to the virus when they really don’t – this is a false positive test. The test may also fail to show that a person has antibodies to the virus when they really do – this is a false negative test. I have also been advised that this is not a test for AIDS and that a positive test does not mean that I have AIDS. Other tests and examinations are needed to diagnose AIDS. I have been advised that, if I have any questions about the HIV antibody test, its benefits or its risks, I may ask those questions before I decide to agree to the blood test. I understand that the results of this blood test will only be given to those health care workers directly responsible for my care and treatment. I also understand that my results can only be given to other agencies or persons if I sign a release form. By signing below, I agree that I have read this form or someone has read this form to me. I have had all my questions answered and have been given all the information I want about the blood test and the use of the results of my blood test. I agree to give a tube of blood for the HIV antibody tests. There is almost no risk in giving blood. I may have some pain or a bruise around the place that the blood was taken. ___________________________________ __________________________________ Date Patient’s/Guardian’s Signature ___________________________________ ___________________________________ Witness Signature Patient’s/Guardian’s Printed Name ____________________________________ Physician Signature INTotal Health recognizes the need for strict confidentiality guidelines.
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Results of the HIV Antibody Blood Test
A. EXPLANATION This authorization for use or disclosure of the results of a blood test to detect antibodies to HIV, the probable causative agent of Acquired Immunodeficiency Syndrome (AIDS), is being requested of you to comply with the terms of Confidentiality of Medical Information Act, Civil Code Section 56 et seq. and Health and Safety Code Section 199.21(g). B. AUTHORIZATION I hereby authorize _____________________________________________________ to furnish (Name of physician, hospital or health care provider) to ________________________________________________________ the results of the blood (Name or title of person who is to receive results) test for antibodies to HIV. C. USES The requester may use the information for any purpose, subject only to the following limitation: ____________________________________________________________________. D. DURATION This authorization shall become effective immediately and shall remain in effect indefinitely or until ________________________, 20____, whichever is shorter. E. RESTRICTIONS I understand that the requester may not further use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. F. ADDITIONAL COPY I further understand that I have a right to receive a copy of this authorization upon my request. Copy requested and received: Yes No _______________ Initial Date: ______________, 20________ ________________________________________ Signature _________________________________________ Printed Name Note: this form must be in at least 8-‐point type.
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Practitioner Evaluation and Audit Tools The rest of this page is intentionally left blank. Forms are located on subsequent pages.
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Practitioner Clinical Medical Record Audit Physician Name: ________________________________ Office Manager: ________________________________ Office Address: ______________________________________________________________________ Specialty: _____________________ Date: ___________ Reviewer Name: ______________________ Patient Name: ____________________________ Chart/Member #: __________________________
Point Value
Y
N
Point Score
1
Is chart accessible?
3
2
Do all pages contain patient ID (name/ID #)?
4
3
Is there personal/biographical data?
3
4
Is the provider identified on each entry?
4
5
Are all entries dated?
3
6
Is the record legible?
4
7
Are significant illnesses and medical conditions indicated on the problem list or, if patient has not know allergies or history of adverse reaction, is this appropriately noted in the record? *
4
8
Are allergies and adverse reactions to medications prominently displayed or, if patient has no known allergies or history of adverse reaction, is this appropriately noted in the record? *
4
9
Is there an appropriate past medical history in the record (for patients seen three or more times) which includes serious accidents, operations or illnesses, emergency care and discharge summaries? Age 18 and under should include prenatal care, birth, operations and childhood illnesses. *
4
10 Is there documentation of smoking habits and history of alcohol or substance abuse (age 12 and over)?
3
11 Is there a pertinent history and physical exam?
4
12 Are labs and other studies ordered as appropriate and reflect PCP review?
4
13 Are working diagnoses consistent with findings? *
4
14 Do plans of action/treatments appear consistent with diagnosis? *
4
15 Is there a date for a return visit or other follow-‐up plan for each encounter?
4
16 Are problems from previous visits addressed?
3
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Point Value
Y
N
Point Score
17 Is there evidence of appropriate use of consultants?
3
18 Is there evidence of continuity and coordination of care between primary and specialty physicians?
4
19 Do consultant summaries, lab and imaging study results reflect PCP review?
3
20 Does the care appear to be medically appropriate? (There is no evidence that patient was placed at inappropriate risk by diagnostic or therapeutic procedure.) *
4
21 Is there a completed immunization record (ages 13 and under)?
4
22 Are preventive services appropriately used?
3
23 Are advance directives present on the chart (21 and older)?
3
24 Does pediatric documentation include: (4 points total)
1.5
1
1.5
25 Is there a list of current medications?
4
26 Are copies of any emergency treatment and/or hospital admission present in the chart?
1
27 If a mental health problem is noted, was a referral made, or did the PCP perform treatment?
3
28 If a substance abuse problem is noted, was a referral made, or was treatment or education noted?
3
29 If smoking is noted, was patient advised to quit (age 12 and older)?
1
30 Is there evidence of blood lead risk assessment (verbal assessment or blood lead test, age 6 months to 6 years old)?
1
100
-‐ Growth chart (1.5 pts.)
-‐ Head circumference chart (1 pt.)
-‐ Developmental milestones (1.5 pts.)
TOTAL
* These critical elements must be met, in addition to receiving an average score of 80 percent to achieve an acceptable rating on the Clinical Medical Record Review.
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Advance Directives The rest of this page is intentionally left blank.
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Living Will You can make a living will by filling out this form. You can choose another form or use the one your doctor gives you, too. If you make a living will, give it to your PCP. I, (Print your Name Here) ________________________________________________, am of sound mind. I want to have what I say here followed. I am writing this for when something happens to me and I cannot make decisions about my medical care. These instructions are to be used if I am not able to make decisions. I want my family and doctors to honor what I say here. These instructions will tell what I want to have done if 1) I am in a terminal condition (going to die), or 2) I am permanently unconscious and have brain damage that is not going to get better. If I am pregnant and my doctor knows it, then my instructions here will not be followed during the time I am still pregnant and the baby is living. TREATMENT I DO NOT WANT. I do not want (put your initials by the services you do not want): _____ Any form of medical services _____ Cardiac resuscitation (start my heart pumping after it has stopped) _____ Mechanical respiration (machine breathing for me if my lungs have stopped) _____ Tube feeding (a tube in my nose or stomach that will feed me) _____ Antibiotics (drugs that kill germs) _____ Hydration (water and other fluids) _____ Other (say what it is here) ___________________________________________________________________ TREATMENT I DO WANT. I want (put your initial by the services you do want): _____ Pain relief _____ All treatment to keep me alive as long as possible _____ Other (say what it is here) __________________________________________________________________ What I say here will happen unless I decide to change it or decide not to have a living will at all. I can change my living will any time I wish. I just have to let my doctor know I want to change it or not have it at all. Signature: ___________________________________________________________ Date: ___________________ Address: ____________________________________________________________
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Durable Power of Attorney
You can name a durable power of attorney by filling out this form. You can use another form or use the one your doctor gives you, too. If you name a durable power of attorney, give it to your PCP.
I, (Name) __________________________________________, want ___________________________________________, _____________________________, (Name of person I want to carry out my wishes) and (person’s address)
to make treatment decisions for me if I cannot. This person can make decisions when I am in a coma, not mentally able to or so sick I just cannot tell anyone.
If the person I named is not able to do this for me, then I name another person to do it for me. This person is _________________________________, _____________________________. (Name of second person I want to carry out my wishes) and (second person’s address)
TREATMENT I DO NOT WANT. I do not want (put your initials by the services you do not want):
_____ Any form of medical services _____ Cardiac resuscitation (start my heart pumping after it has stopped) _____ Mechanical respiration (machine breathing for me if my lungs have stopped) _____ Tube feeding (a tube in my nose or stomach that will feed me) _____ Antibiotics (drugs that kill germs) _____ Hydration (water and other fluids) _____ Other (say what it is here) ___________________________________________________________________
TREATMENT I DO WANT. I want (put your initial by the services you do want):
_____ Pain relief _____ All treatment to keep me alive as long as possible _____ Other (say what it is here) ___________________________________________________________________
What I say here will happen unless I decide to change it or decide not to have a durable power of attorney at all. I can change my durable power of attorney any time I wish. I just have to let my doctor know I want to change it or not have it at all.
Signature____________________________________________________ Date: ___________________ Address: _____________________________________________________________________________
Statement of Witness
I am not related to this person by blood or marriage. I know that I would not get any part of the person’s estate when he or she dies. I am not a patient in the health care facility where this person is a patient. I am not a person who has a claim against any part of this person’s estate when he or she dies. Furthermore, if I am an employee of a health facility in which this person is a patient, I am not involved in providing direct patient care to him or her. I am not directly involved in the financial affairs of the health facility.
Witness: _________________________________________________ Date: ___________________ Address: _______________________________________________________________________
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Appendix B – Clinical Practice Guidelines
As part of its quality improvement process, we’ve adopted nonpreventive and preventive clinical practice guidelines for acute and chronic medical and behavioral health conditions that are scientific and evidenced-‐based. This is determined by scientific evidence, review of government research sources, review of clinical or technical literature, involvement of board-‐certified practitioners from appropriate specialties or professional standards. Recognized sources of the evidenced-‐based guidelines include national organizations such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), professional medical specialty organizations such as the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecologists (ACOG), American Academy of Family Practice (AAFP) and voluntary health organizations such as the American Diabetes Association (ADA) and American Cancer Society (ACS). The American Psychiatric Association (APA), American Academy of Child and Adolescent Psychiatry (AACAP), Texas Implementation of Medication Algorithm (TIMA) and Texas Medicaid Algorithm Project (TMAP) are currently more specific sources recognized for behavioral health guidelines. Other sources that may be referenced in developing or updating behavioral health guidelines include organizations such as the Substance and Mental Health Services Administration (SMHSHA) and National Institute of Mental Health (NIMH). The guidelines are based on valid and reliable clinical evidence, a consensus of health care professionals in a particular field, and the needs of our members. The guidelines are adopted and approved in consultation with network health care professionals. They are reviewed and updated periodically as appropriate but at a minimum of every two years. We will disseminate the preventive and nonpreventive clinical practice guidelines for acute and chronic medical and behavioral health conditions to all affected providers every two years and more frequently if an update has occurred. Preventive health guidelines will be distributed upon request to members and potential members. Our decisions regarding disease management, case management, utilization management, member education, coverage of services and other areas included in the guidelines will be consistent with our guidelines. Data is gathered and monitored using HEDIS, ad hoc medical records review and other sources to measure performance against the guidelines and improve the clinical care process. Visit our website at www.intotalhealth.org and log in to the secure site by entering your Login Name and Password.. A copy of the guidelines can be printed from the website, or you can contact Provider Services at 1-‐855-‐323-‐5588 to receive a copy.
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www.intotalhealth.org
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1.855.323.5588
