2016-2017
Provider Operations Manual
www.healthnetaccess.com
Provider Services 888-788-4408
1
Disclaimer: The forms contained in this manual are for reference and not intended for copying or reproduction for use. For the latest version of a form please refer to www.healthnetaccess.com >Providers>Forms.
Table of Contents Chapter 1: Introduction to Health Net Access.............................................................................................. 2 Chapter 2: Contact Information..................................................................................................................... 4 - Contacts................................................................................................................................................... 4 Chapter 3: Provider Relations......................................................................................................................... 10 Chapter 4: Provider Oversight........................................................................................................................ 11 - Contracting............................................................................................................................................. 28 - Credentialing.......................................................................................................................................... 36 Chapter 5: Benefits............................................................................................................................................44 Chapter 6: Early and Periodic Screening, Diagnostic and Treatment (EPSDT)................................... 124 Chapter 7: Utilization Management............................................................................................................ 156 Chapter 8: Pharmacy (Prescription Drug Program)................................................................................. 167 Chapter 9: Quality Improvement................................................................................................................. 173 - Medical Records................................................................................................................................... 204 Chapter 10: Member Rights and Responsibilities...................................................................................... 209 Chapter 11: Eligibility and Enrollment........................................................................................................ - Enrollment........................................................................................................................................... - Eligibility.............................................................................................................................................. - ID Card................................................................................................................................................. - Copayments..........................................................................................................................................
217 217 218 219 221
Chapter 12: Referrals and Authorization (Prior Authorization)............................................................. 222 - Prior Authorization............................................................................................................................. 222 - Referrals................................................................................................................................................ 234 Chapter 13: Coordination of Benefits......................................................................................................... 238 - Third Party Liability............................................................................................................................ 239 Chapter 14: Claims, Provider Reimbursement and Encounters............................................................. - Claims and Provider Reimbursement.............................................................................................. - Claims Coding Policies...................................................................................................................... - Encounters...........................................................................................................................................
241 241 255 255
Chapter 15: Dispute Resolution and Appeals............................................................................................ 256 Chapter 16: Compliance and Regulations.................................................................................................. 266 Chapter 17: Glossary of Terms..................................................................................................................... 271
1
Chapter 1 Introduction to
Health Net Access AHCCCS
Mississippi, Missouri, New Hampshire, Ohio,
The Arizona Health Care Cost Containment
South Carolina, Texas, Washington, and
System (AHCCCS) is Arizona’s Medicaid
Wisconsin. Health Net Access serves our Arizona
agency that offers health care programs to
members consistent with our core philosophy
eligible Arizona residents. Individuals must
that quality healthcare is best delivered locally.
meet certain income and other requirements
We are an organization committed to building
to qualify for services.
interactive partnerships with providers.
Who We Are – Health Net Access
Since October 2013, Health Net Access has
Health Net Access, Inc. (Health Net Access)
population and is dedicated to promoting healthy
is one of the managed care organization
outcomes and improve the quality of life for
(MCO) contracted with AHCCCS to provide
our members. Health Net Access is responsible
services to the Acute Medicaid population.
for the delivery of acute care, long term care,
Health Net Access is locally managed and
behavioral health and case management services
administered and headquartered in Tempe,
to members via arrangements with selected
Arizona. Health Net Access serves members
providers to furnish comprehensive services
in Maricopa county.
including formal programs for quality and
been providing care for Arizona’s Acute care
medical management and the coordination of Health Net Access is a Centene company.
care. We at Health Net Access strive to provide
Centene and its wholly-owned health plans
members with an improved health status and
have a long and successful track record
continually work to improve member and
offering Medicaid managed care services. For
provider satisfaction.
more than 20 years, Centene has provided
A partial list of Health Net Access’ covered
comprehensive managed care services to the
services includes:
Medicaid population and currently operates
• Nurse hotline 24 hours a day
multiple health plans in Arizona, Arkansas,
• Behavioral health programs
California, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts,
Please refer to the section titled “Covered Services” in this manual for more details.
2
Introduction to Health Net Access
Health Net Access Guiding Principles
• Performing its administrative responsibilities in a
• Provide high quality, accessible, cost-effective
superior fashion
healthcare for our members
Health Net Access programs, policies and procedures are
• Integrity and the highest ethical standards
designed to minimize the administrative responsibilities
• Mutual respect and trust in our working
in the management of care, enabling you to focus on the
relationships
healthcare needs of your patients, our members.
• Communication that is open, consistent and two-way • Diversity of people, cultures and ideas
Health Net Access Summary
• Teamwork and meeting our commitments to one
Health Net Access philosophy, for our Acute Medicaid members, is to provide access to high quality, culturally
another
sensitive healthcare services by combining the talents of Health Net Access allows open practitioner/member
PCPs and specialty providers with a highly successful,
communication regarding appropriate treatment
experienced managed care administrator. Health Net
alternatives, including medication treatment options,
Access believes that successful managed care is the
regardless of benefit coverage limitations.
delivery of appropriate, medically necessary services - not
Health Net Access does not penalize practitioners for
the elimination of such services.
discussing medically necessary or appropriate care with It is the policy of Health Net Access to conduct its
the member.
business affairs in accordance with the standards and All of our programs, policies and procedures are designed
rules of ethical business conduct and to abide by all
with these goals in mind. We hope that you will assist
applicable federal and state laws. At Health Net Access,
Health Net Access in reaching these goals.
we take the privacy and confidentiality of our members’ health information seriously. We have processes, policies
Health Net Access Approach
and procedures to comply with the Health Insurance
Recognizing that a strong health plan is predicated on
Portability and Accountability Act of 1996 (HIPAA) and
building mutually satisfactory associations with providers,
state privacy law requirements. If you have any questions
Health Net Access is committed to:
about Health Net Access privacy practices, please contact
• Working as partners with participating providers
our Vice President of Compliance & Regulatory Affairs
• Demonstrating that healthcare is a local issue
(Privacy Official) at 1.866.475.3129.
Disclaimer Health Net Access participating providers are required to comply with applicable federal and state laws and regulations and Health Net Access policies and procedures. The contents of Health Net Access operations manuals are supplemental to the Provider Participation Agreement (PPA) and its addendums. When the contents of Health Net Access operations manuals conflict with the PPA, the PPA takes precedence.
3
Chapter 2
Contact Information 1. AHCCCS Children’s Rehabilitative
Detailed instructions for filling out claim forms is
Services
available on the following AHCCCS websites:
Enrollment Unit
http://azahcccs.gov > Fee For Service Provider
(602) 417-4545
Manual > Chapter 5 > CMS 1500 Claim Form http://azahcccs.gov > Fee For Service Provider
2. Animas Diabetes Care, LLC
Manual > Chapter 6 > UB-04 Claim Form
Provider of insulin pumps and supplies. 5. Arizona Smokers’ Helpline (ASHLine)
(877) 937-7867
(800) 556-6222 3. Arizona Department of Health Services Bureau of Women’s and Children’s Health
6. Arizona State Immunization Information
Hotlines
System (ASIIS)
• Pregnancy and Breastfeeding:
(877) 491-5741
(800) 833-4642
www.asiis.state.az.us/
• Children’s Information Center:
150 N. 18th Avenue, #120
(800) 232-1676
Phoenix, AZ 85007
• Women Infants and Children (WIC): 7. Bridgeway Prior Authorization Department
(866) 229-6561
Bridgeway Prior Authorization Department 4. Arizona Health Care Cost Containment
Verify member eligibility on the AHCCCS website at azweb.statemedicaid.us. AHCCCS (State) IVR - Maricopa County: (602) 417-7200 Outside Maricopa County, within Arizona: 1-800-331-5090
4
1-866-295-9729
Contact Information 8. Clearinghouse Electronic Claims Submission Information
Health Net Payer Identification (ID) Number CA, OR & WA AZ CT, NJ, & NY
Clearinghouse
Telephone Number
Website
Capario (formerly MedAvant)
AZ, CA, OR & WA(888) 894-7888
www.capario.com
95567
38309
06108
www.transact.emdeon.com
95567
38309
06108
CT, NJ, & NY (800) 792-5256
Emdeon (WebMD) (877) 469-3263
As a result of Health Net’s agreement with MD On-Line, all Health Net claims can be submitted electronically via Health Net’s website a www.healthnetaccess.com. MD On-Line
(888) 499-5465
www.mdon-line.com
95567
38309
06108
The payer ID must be included with every claim. 9. Crisis Preparation and Recovery, Inc. -SMI
13. Health Net Access Behavioral Health Coordinator
Evaluation Department
(602) 794-1493
(480) 804-9542 14. Health Net Access Behavioral Heath Case 10. Crisis Response Network
Management Department
(602) 222-9444
1-855-299-3196
(800) 631-1314
Fax: 1-855-825-6146
TTY: (602) 274-3360
CMAccess/GRP/HNCA/
[email protected]
11. eviCore healthcare
15. Health Net Access Case Management Department
For radiology services, contact:
1-800-977-7281
(888) 693-3211
Fax: 1-855-825-6146
Fax: (888) 693-3210 16. CHealth Net Access Claim Submission
www.evicore.com
Health Net Access, Inc.
Provider Assistance Desk:
PO Box 14095
(800) 575-4517, option 2
Lexington, KY 40512
For radiation therapy services, contact: (888) 693-3211
17. Health Net Access EPSDT Tracking Form Submission
www.carecorenational.com
Copies of EPSDT tracking forms should be submitted to: Health Net Arizona Medicaid
12. Hanger Prosthetics and Orthotics
PO Box 419071
(800) 245-0937
Rancho Cordova, CA 95741
5
Contact Information
18. Health Net Access Member Appeals and Grievances
26. Health Net Decision Power Referral Fax
Department
(800) 451-4730 or (678) 355-4018 for pregnancy
PO Box 9007
notification only.
Tempe, AZ 85281-9707
To discuss a referral for a Health Net member, call
Fax: (855) 844-0687
Decision Power at (800) 893-5597 and select the physician/provider option.
19. Health Net Access Prior Authorization Department
1-888- 926-1736
27. Health Net EDI Claims Department
Fax: 1-855-764-8513
(866) EDI-HNET or (866) 334-4638 California, Oregon and Washington providers
20. Health Net Access Provider Disputes
(800) 977-3568
1230 West Washington Street, Suite 401 Tempe, AZ 85281
28. Health Net Encounter Department
fax: 1-855-405-6889
[email protected] Send completed EPSDT forms to:
21. Health Net Access Provider Network Management
PO Box 419071
1-888-788-4408
Rancho Cordova, CA 95741
22. Health Net Access Provider Relations Team
29. Health Net Fraud Hotline
1230 W. Washington St., Suite #401
Health Net, Inc. Special Investigations Unit
Tempe, AZ 85281
PO Box 2048
1-888-788-4408
Rancho Cordova, CA 95741-2048 (800) 977-3565
23. Health Net Access Provider Services Center
1-888-788-4408
30. Health Net Health Education Department Health
TTY/TDD: 1-888-788-4872
(800) 804-6074 (800) 804-6074
24. Health Net Access Provider State Fair Hearing
Fax: (800) 628-2704
1230 West Washington Street, Suite 401 Tempe, AZ 85281
31. Health Net Hospital Notification Unit
fax: 1-855-405-6889
(888) 926-1736 Fax: (855) 764-8513
25. Health Net Credentialing Department
5255 East Williams Circle, #4000 Tucson, AZ 85711
6
Contact Information
32. Health Net MCH/EPSDT Manager
37. Health Net Provider Network Management
(602) 794-1880
Tempe: Health Net of Arizona, Inc.
33. Health Net Newborn Data Collection
Attn: Provider Network Management
HMO and PPO - (800) 977-7518
1230 W. Washington Street, Suite 401
Health Net Access - (888) 926-1736
Tempe, AZ 85281 Fax: (602) 794-1803
34. Health Net Overpayment Recovery Department
Tucson:
Health Net of Arizona Claims Refunds
Health Net of Arizona, Inc.
File 749801
Attn: Provider Network Management
Los Angeles, CA 90074-9801
5255 E Williams Circle, Suite 4000
Claims pending further information from the provider
Tucson, AZ 85711
should be sent to:
Fax: (520) 258-5172
Health Net of Arizona Inc. Pended Claims
38. Health Net Access Quality Management Department
PO Box 279377
[email protected]
Sacramento, CA 95827-9377 39. Health Net Request for Reconsideration 35. Health Net Pharmaceutical Services
Participating providers who feel their claim has been paid
1-800-410-6565
or denied incorrectly can submit a written request for
5255 East Williams Circle, Ste 4000
reconsideration to:
Tucson, AZ 85711
Health Net of Arizona, Inc.
Fax: 1-800-977-4170
P.O. Box 279378 Sacramento, CA 95827-9378
36. Health Net Provider Appeals
Attn: Request for Reconsideration
Submit provider appeals to the following address:
Fax: (800) 977-6762
Health Net of Arizona, Inc. Attention: Provider Appeals
40. Health Net Utilization Management Department
P.O. Box 279378
1230 W. Washington Street, #401
Sacramento, CA 95827-9378
Tempe, AZ 85281
Fax: (800) 977-6762
(602) 794-1690
7
Contact Information
41. Health Net of Arizona Customer Service Manager
Health Net of Arizona Customer Service Manager P.O. Box 276090 Sacramento, CA 95827-6090 Fax: (800) 204-3778 (Attn: Customer Service Manager) 42. MHN
HMO, Health Net Access, Medicare Advantage HMO, Medicare Advantage PPO (800) 977-0281 43. MiniMed Distribution Corp, Inc.
(800) 795-0618 Fax: (800) 611-1716 44. Preferred Home Care
(800) 636-2123 45. Regional Behavioral Health Authority
(800) 564-5465 Secure fax: (844) 424-3975 46. United Healthcare Community Plan Children’s Rehabilitative Services Provider Ombudsman
(602) 255-8242 47. Vaccines for Children (VFC)
(602) 364-3642
8
Decision Power Referral to Health Net Fax Form
9
Chapter 3
Provider Relations Provider Relations Team
• In-service training upon contract execution
The Provider Relations team is a liaison between
In-service training topics include, but are not
Health Net Access and our providers. They train,
limited to:
maintain and strengthen the provider network in
• Member eligibility
accordance with regulations.
• Member rights and responsibilities
Provider Relations conducts onsite provider training, problem identification and resolution, site visits, accessibility audits and assist in the development of provider communication materials.
• Provider responsibilities • Medical management • Quality management • Billing and claims submission online via www.healthnetaccess.com
A Provider Relations representative is assigned
• Claims submission requirements
to each provider’s office. You may reach your
• Claims dispute process
representative directly by calling 888-788-4408.
• Interpreter services • Fraud, waste and abuse reporting
Contact Provider Relations for assistance with:
• Maintenance of the provider manual, orientation and reference materials, including the plan’s network newsletter
• Cultural competency, including servicing people with disabilities and Americans with Disabilities Act (ADA) regulations • Authorization processes
• Initiation of demographic information changes and oversight of completion of change requests
• Case management services available for members • Behavioral health services and how to access
• Provider education
them
• EFT/ERA enrollment
• Provider rights and responsibilities
• Physician and office staff orientation
• Member rights and responsibilities, including
• Ongoing targeted provider education, updates and training (in coordination with the plan’s claims educators, quality management, medical management, and appeals and grievances associates)
performance standards • Provider complaint and appeal procedures Health Net Access Provider Relations 1230 W. Washington St., Suite #401
• Provider conferences/forums • Effectively responding to external provider-
Tempe, AZ 85281 1-888-788-4408
related issues
10
Chapter 4
Provider Oversight to access after-hours care. The appropriate time
Advertising All advertising bearing any Health Net name, mark or logo must by approved by the
frame should be modified, as applicable, according to each line of business.
Arizona Department of Insurance (ADOI) or Arizona Health Care Cost Containment System (AHCCCS) before use. The Centers for Medicaid and Medicare Services (CMS) and accreditation entities have additional restrictions and requirements. Providers must
Health Net makes the script available in the following threshold languages: • Chinese/Cantonese • English • Spanish
submit any advertising bearing a Health Net name, mark or logo to Health Net prior to use in order to secure regulatory approval.
Contact the Health Net Quality Improvement Department or Quality Managment Department for more information on the script templates.
After-Hours Template Directing members to the appropriate level of care using simple and comprehensive instructions can improve the coordination and continuity of the member’s care, health outcomes and satisfaction. Health Net has designed an after-hours script template that providers who have a centralized triage service or other answering service can use as a guide for staff answering the telephone. For physicians or providers who use an automated answering system/answering machine, this template can be used as a script to advise members on how to access care. The script includes basic information that members need
11
Provider Oversight
Appointment Accessibility Standards The following appointment access guidelines ensure timely health services are available to Health Net Access members.
Appointment accessibility standards are subject to change as regulatory requirements are updated.
Type of Care
Accessibility Standard
Primary Care Emergency
Same day or within 24 hours of member’s call
Urgent care
Within 2 days of request
Routine
Within 21 days of request
Emergency
Within 24 hours of referral
Urgent care
Within 3 days of referral
Routine
Within 45 days of referral
1st trimester
Within 14 days of request
2nd trimester
Within 7 days of request
3rd trimester
Within 3 days of request
High-risk pregnancies
Within 3 days of identification
Emergency
Within 24 hours of request Urgent care
Urgent care
Within 3 days of request
Routine
Within 45 days of request
Specialty Referral
Maternity
Dental
The wait time in the office must be less than 45 minutes, except when the provider is unavailable due to an emergency.
12
Provider Oversight The following are behavioral health appointment access guidelines:
Appointment Type
Description
Standard
Immediate
Within 2 hours - may include telephonic or Behavioral health services provided within face-to-face interventions a time frame indicated by behavioral health condition, but no later than 2 hours from identification of need or as quickly as possible when a response within 2 hours is geographically impractical
Urgent
Behavioral health services provided within a time frame indicated by behavioral health condition but no later than 24 hours from identification of need
Routine - initial assessment
Appointment for initial assessment with a BHP Within 7 days of referral within 7 days of referral or request for behavioral health services
Routine - first behavioral health service
Includes any medically necessary covered behavioral health service including medication management and/or additional services
Appointments for psychotropic medication
Within 24 hours
Within 7 days of assessment
The member’s need for medication is assessed immediately and, if clinically indicated, the member is scheduled for an appointment within a time frame that ensures: 1. The member does not run out of any needed psychotropic medications; or 2. The member is evaluated for the need to start medications to ensure that the member does not experience a decline in his or her behavioral health condition.
Referrals or requests for psychotropic medications
Screening, consultation, assessment, medication management, medications, and/or lab testing services, as appropriate
Non-emergency transportation
In-office wait times
Assess the urgency of the need immediately. If clinically indicated, provide an appointment with a BHP within a time frame indicated by clinical need, but no later than 30 days from the referral/initial request for services. Member must not arrive sooner than one hour before his or her scheduled appointment; and Member must not have to wait for more than one hour after the conclusion of his or her appointment for transportation home or to another pre-arranged destination.
The member must not wait more than 45 minutes in the office to see his or her provider; except when the provider is unavailable due to an emergency.
13
Within 45 minutes
Provider Oversight
After-Hours Access Guidelines
stating, “If this is an emergency, hang up and call 911 or go
As required by applicable statutes, under Code of
to the nearest emergency room.” If a member calls after
Federal Regulations (CFR) 42 Section 422.112(a)(7)
hours or on a weekend for a possible medical emergency,
and 42 Section 438.206(c)(1)(iii)) and according to the
the practitioner is liable for authorization of, or referral to,
signed Provider Participation Agreement (PPA), Health
emergency care given by the answering service. After office
Net participating providers must ensure that, when
hours (outside of normal business hours or when the offices
medically necessary, services are available 24 hours a
are closed) physicians are required to return calls and pages
day, seven days a week; and PCPs are required to have
within four hours. If the member indicates a need to speak
appropriate back-up for absences. Medical groups and
with the physician or calls for an urgent matter, PCPs or
PCPs who do not have services available 24 hours a day
on-call physicians should return telephone calls and pages
may use an answering service or answering machine to
within four hours and be available 24 hours a day, seven days
provide members with clear and simple instruction on
a week.
after-hours access to medical care. Answering service staff handling member calls cannot After office hours (outside of normal business hours or
provide telephone medical advice if they are not a licensed,
when the offices are closed), PCPs or on-call physicians
certified or registered health care professional. Staff members
are required to return calls and pages within four hours.
may ask questions on behalf of a licensed professional in
If an on-call physician cannot be reached, the after-
order to help ascertain the condition of the member so
hours answering service or machine must direct the
that the member can be referred to licensed staff; however,
member to a medical facility where emergency or urgent
they are not permitted, under any circumstance, to use
care treatment can be provided. According to Arizona
the answers to questions in an attempt to assess, evaluate,
Administrative Code (AAC) Section R-20-6-1914(4), in-
advise, or make any decision regarding the condition of the
area urgent care services from a participating provider
member, or to determine when a member needs to be seen
must be available seven days per week.
by a licensed medical professional. Unlicensed staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed provider.
The PCP or the on-call physician designee must provide urgent and emergency care. The member must be transferred to an urgent care center or hospital
Additionally, non-licensed, non-certified or non-registered
emergency room as medically necessary.
health care staff cannot use a title or designation when speaking to a member that may cause a reasonable person
Answering Services
to believe that the staff member is a licensed, certified or
The provider is responsible for the answering service
registered health care professional. Answering services
he or she uses. There must be a message immediately
frequently have high staff turnover, so providers should
14
Provider Oversight
monitor the answering service to be sure that it follows
meets Health Net of Arizona’s threshold of 300 Health Net
emergency procedures.
members before closing the panel.
Health Net encourages answering services to follow
If a patient of the PCP, while a member of another health
these steps when receiving a call:
care plan, joins Health Net, the PCP must continue to accept
• Inform the member that if they are experiencing a
the member as a patient even if his or her practice is closed
medical emergency, they should hang up and call
to new Health Net members.
911 or proceed to the nearest emergency medical
A PCP may close his or her practice to all new patients from
facility.
all insurance or health plans at any time.
• Question the member according to the PCP’s or medical group’s established instructions (who, extent of the problem and offer interpreter services
Covering and Collaborating Physicians
assistance as needed.
Health Net providers who use other physicians to cover their
what, when, and where) to assess the nature and
practice while on vacation or leave must use their best efforts
• Contact the on-call physician with the facts as
to find a Health Net participating physician within the same
stated by the member.
specialty. If a Health Net participating physician is unable to
• After office hours, the on-call physician must return
cover the practice, the following must occur:
telephone calls and pages within four hours. If an
• The non-participating physician must agree in writing
on-call physician cannot be reached, direct the member to a medical facility where he or she can
to abide by the terms of Health Net’s contract and all
receive emergency or urgent care treatment. This
Health Net policies and procedures • Health Net must give prior approval for the use of a
is considered authorization, which is binding and
non-participating physician
cannot be retracted. • In the event of a hospitalization, the medical group/IPA or hospital must contact the Health Net
Providers may request approval to use a non-participating,
Hospital Notification Unit within 24 hours or the
covering physician by contacting Health Net’s Provider
next business day of the admission
Network Management Department. When choosing a provider to collaborate on a case,
• Document all calls.
providers must use participating providers. Payment for
Conditions of PCP Practice Closure
surgical assistants as well as second opinions may be the responsibility of the requesting provider if the provider utilized is not participating with Health Net. Payment by
Participating primary care physicians (PCPs) may
Health Net for these services is dependant on medical
close their practices to new Health Net members
appropriateness, contract status, member eligibility, and the
while remaining open to members of other insured
member’s benefit plan.
or managed health care plans, provided that the PCP
15
Provider Oversight
Deficit Reduction and Federal False Claims Act
• Authorizing to make or deliver a document, certifying receipt of property used by the government and
The Provider Participation Agreement (PPA) requires
intending to defraud the government and making or
all providers to adhere to Deficit Reduction Act (DRA)
delivering a receipt without completely knowing that
requirements. The DRA requires that any entity that
the information on the receipt is true. • Knowingly buying, or receiving as a pledge of an
receives or makes payments under a state plan approved under Title XIX or under any waiver of such plan,
obligation or debt, public property from an officer
totaling at least $5 million annually, must establish
or employee of the government, or a member of the
written policies for its employees, management,
Armed Forces, who lawfully may not sell or pledge the
contractors, and agents regarding the federal False
property. • Knowingly making, using or causing to be made or
Claims Act (FCA).
used, a false record or statement to conceal, avoid or The FCA applies to claims presented for payment by
decrease an obligation to pay or transmit money or
federal health care programs. The FCA allows private
property to the government.
persons to bring a civil action against those who knowingly submit false claims upon the government.
The definition of “knowing” and “knowingly” as it relates
The following are activities for which one may be liable
to the FCA includes actual knowledge of the information,
under the FCA:
acting in deliberate ignorance of the truth or falsity of the information, and/or acting in reckless disregard of the truth
• Knowingly presenting to an officer or employee of the United States government a false or fraudulent
or falsity of the information. Proof of specific intent to
claim for payment or approval.
defraud is not required for reporting potential violations of the law.
• Knowingly making, using or causing a false record or statement to get a false or fraudulent claim paid
Penalties under the Federal False Claims Act
or approved by the government.
Any individual or corporation who violates the FCA is
• Conspiring to defraud the government by getting
subject to civil monetary penalties ranging from $5,500 to
false or fraudulent claims allowed or paid.
$11,000 for each false claim submitted in violation of the
• Having possession, custody or control of property or money used, or to be used by the government,
FCA. In addition to the civil penalty, individuals are liable to
and intending to defraud the government by
the government for three times the amount of damages the
willfully concealing property, delivering or causing
government sustains.
to be delivered less property than the amount for
Required Training and Education
which the individual receives.
Providers must train their staff on the FCA, including, but
16
Provider Oversight
not limited, to the following topics:
of Business Conduct and Ethics, or accessing personal
• FCA provisions
information or protected health information (PHI)
• Administrative remedies for false claims and
without authorization.
statements • State laws related to civil or criminal penalties for
FWA Authority and Responsibility
false claims and statements
The Health Net Special Investigations Unit has overall
• Whistleblower protections under state laws
responsibility and authority for carrying out the provisions of the compliance program. Health Net Access is committed to
All training must be conducted in a manner that can be
identifying and reporting cases of suspected fraud and abuse.
verified by Health Net Access.
Health Net Access is required to report cases of suspected fraud or abuse to the Arizona Health Care Cost Containment
Fraud, Waste and Abuse
System (AHCCCS) Office of Inspector General (OIG). Other
Health care fraud contributes to the rising cost of health
agencies may have involvement in cases of criminal activity
insurance, reduces the amount of funds available to pay
or abuse. The AHCCCS OIG is responsible for determining
providers, and increases premiums to employers and
whether suspected fraud or abuse cases warrant referral to
members. Health Net Access investigates allegations
the State Attorney General’s office. The AHCCCS Office of
of fraud, waste, and abuse (FWA) and reports of
Inspector General has the authority to levy civil monetary
noncompliance at every level. Below are examples
penalties, issue recoupment letters and utilize other types of
of health care fraud and unethical or noncompliant
sanctions if fraud, waste or abuse is substantiated.
activities: • Consumer health care fraud: Filing claims for
Reporting FWA
services or medications not received, forging or
State law requires that Health Net Access report instances of
altering bills or receipts, or using someone else’s
suspected insurance fraud. Such instances may include, but
coverage or insurance card.
are not limited to:
• Provider health care fraud: Billing for services not
• Material misstatements of facts or omissions on
actually performed, falsifying a patient’s diagnosis to
insurance applications.
justify tests, surgeries or other procedures that are
• False claims.
not medically necessary, or upcoding - billing for a
• False, forged or altered prescriptions.
more costly service than the one actually performed.
• Misuse of Health Net Access identification (ID) cards.
• Unethical or noncompliant activities: Falsifying or tampering with company documents or records,
Health Net Access has adopted processes to receive, record
accepting gifts or favors that may influence a
and respond to compliance questions, reports of potential
business decision, violating Health Net Access’ Code
or actual noncompliance, and fraud, waste and abuse from
17
Provider Oversight
contractors, agents, directors, enrollees, first-tier,
code (AAC R9- 22-1101 Civil Monetary Penalties and
downstream and related entities (FDRs), and providers.
Assessments).
Health Net Access maintains confidentiality to the extent possible, allowing callers to remain anonymous if
Health Net Policies and Procedures
desired and ensuring nonretaliation against those who
All participating providers agree to abide by Health Net’s
report suspected misconduct.
policies and procedures. Failure to comply with Health Net’s policies and procedures may result in claim delays, denials or
Anyone who suspects member or provider fraud
sanctions, up to and including termination of the Provider
or abuse may report it to the Health Net Special
Participation Agreement (PPA).
Investigations Unit. Providers must report suspected
Questions regarding Health Net’s policies and procedures
fraud involving a Health Net Access member to the
and complete policies and procedures are available through
Health Net Fraud Hotline. Health Net Access also asks
Health Net’s Provider Network Management Department.
providers to assist Health Net Access and, if necessary, the Arizona Department of Insurance (ADOI) or
Missed Appointments/No Show
Arizona Health Care Cost Containment System
Providers are expected to follow up with members who
(AHCCCS) in investigating instances of suspected
miss or cancel appointments and to notify Health Net
fraud.
when a member has missed or cancelled three or more visits. Providers may utilize the Health Net Access Missed
FWA State References
Appointment/No Show Log.
To prevent and detect fraud, waste and abuse, many
Providers are encouraged to use the recall system in order to
states have enacted laws similar to the FCA but with
reduce the number of missed or cancelled appointments.
state-specific requirements, including administrative
Monitoring Medicaid Provider Exclusions
remedies and relater rights. Those laws generally prohibit the same types of false or fraudulent claims for payments for health care related goods or services as are
Arizona’s Health Care Cost Containment System (AHCCCS)
addressed by the federal FCA. Additional information
requires contractors and their subcontractors to monitor
on the Deficit Reduction Act and FCA is available on
federal exclusions lists. The parties or entities on these lists
the following websites:
are excluded from various activities, including rendering
• www.azleg.state.az.us/ArizonaRevisedStatutes.
services to Medicaid enrollees (unless in the case of an
asp (ARS 13-1802 Theft; 13-2002 Forgery; 13-
emergency, as stated in 42 CFR §1001.1901), and employing
2310 Fraudulent schemes and practices/willful
or contracting with excluded parties to provide services to
concealment; 36-2918 Duty to report fraud).
Medicaid enrollees. Health Net requires that its medical
• www.azsos.gov/rules/arizona-administrative-
groups, hospitals, ancillary providers, and physicians
18
Provider Oversight
frequently monitor federal exclusion lists.
check the LEIE and EEDP federal exclusion lists prior to hiring or contracting with any new employee, temporary
Monitoring for Excluded Parties
employee, volunteer, consultant, governing body member,
The names of parties that have been excluded from
or subcontractor for Medicaid-related activities. Medicaid
Medicaid participation are published in the Office
managed care entities and their subcontractors must
of the Inspector General U.S. Department of Health
frequently monitor these lists at least monthly to ensure
and Human Services (OIG-HHS) List of Excluded
parties or entities that were previously screened have not
Individuals and Entities (LEIE), and on the General
become excluded later.
Services Administration’s (GSA) Exclusions Extract Data Package (EEDP) (or Excluded Parties List System (EPLS),
LEIE
which was replaced by the EEDP), as referenced through
The OIG-HHS imposes exclusions under the authority of
the System for Award Management (SAM) website at
sections 1128 and 1156 of the Social Security Act. A list of
www.sam.gov. In addition, Medicaid providers who are
all exclusions and their statutory authority are available
excluded by AHCCCS are listed on the AHCCCS website
on the Exclusion Authority website at https://oig.hhs.
at www.azahcccs.gov/ > OIG > Excluded Providers.
gov/exclusions/authorities.asp. The current LEIE is available on the OIG-HHS website
Medicaid managed care programs and their
at https://oig.hhs.gov/exclusions/exclusions_list.asp.
subcontractors must abide by the regulations documented
Frequently asked questions (FAQs) and additional
in the Social Security Act 1862(e)(1)(B), 42 CFR
information on the LEIE is available at https://oig.hhs.
§422.503(b)(4)(vi)(F), 422.752(a)(8), and 1001.1901. These
gov/faqs/exclusions-faq.asp.
federal exclusion requirements are further interpreted and communicated as guidance in the AHCCCS contract
EEDP
with Health Net. Additional regulations that require
The GSA’s EEDP is a government-wide compilation of
sponsors to include CMS requirements in their contracts,
various federal agency exclusions, and replaces the EPLS.
as well as monitor their subcontractors, are available in 42
Exclusions contained in the EEDP are governed by each
CFR §422.504(i)(4)(B)(v).
agency’s regulatory or legal authority. The EEDP also includes parties and entities from other federal exclusion
Health Net and Provider Responsibilities
databases. All parties or entities listed on the EEDP are
Health Net is required to monitor federal exclusion lists
subject to exclusion from Medicaid participation. The
to ensure that Health Net is not hiring, contracting or
current EEDP is available on the SAM website at www.
paying excluded parties or entities for services rendered
sam.gov, with additional information located under Help
to enrollees in Health Net’s Medicaid plans. Medicaid
> User Guides > Quick User Guides > Helpful Hints for
managed care entities and their subcontractors must
Public Users.
19
Provider Oversight
AHCCCS - OIG
behavioral health services when provided without a PCP
AHCCCS - OIG provides a list of excluded
referral).
Medicaid providers on the AHCCCS website at
• Initiating referrals for medically necessary specialty care.
www.azahcccs.gov/ > OIG > Excluded Providers.
• Maintaining continuity of care for each assigned member.
Health Net, its medical groups, hospitals, and
• Maintaining the member’s medical record, including
ancillary providers cannot pay participating and non-participating parties or entities included on
documentation of all services provided to the member
these lists for any services using federal funds,
by the PCP, as well as any specialty or referral services
except for emergency services provided by excluded
including behavioral health.
providers under certain circumstances. Contracting
• Utilizing the Arizona Health Care Cost Containment
providers must have a documented process in place
Systems (AHCCCS)-approved Early and Periodic
to ensure compliance with these guidelines, and
Screening, Diagnosis and Treatment (EPSDT) tracking
notify enrollees who obtain services from excluded
form. • Providing clinical information regarding members’
parties and make claims payments as allowed under these exceptions. This documentation is subject to
health and medications to the treating provider
audit upon request from Health Net or CMS.
(including behavioral health providers) within 10 business days of a request for information from the provider.
Office Hours and Equipment
• If serving children, enrolling as a Vaccines for Children
Participating providers must maintain offices,
(VFC) provider.
equipment and personnel required to provide all contracting services within the scope of their licensure. Offices must be open during normal business hours and
Provider Responsibilities
available by telephone 24 hours a day, seven days a week
Participating providers are responsible for: • Providing health care services to Health Net Access
for emergencies. After-hours availability may be through
members within the scope of the provider’s practice and
a coverage arrangement.
qualifications. • Providing care that is consistent with generally accepted
PCP Responsibilities
standards of practice prevailing in the provider’s
Primary care providers (PCPs) are responsible for the
community and the health care profession.
following:
• Accepting Health Net Access members as patients on the
• Supervising, coordinating and providing care
same basis that the provider accepts other patients (non-
to each assigned member (except for children’s
discrimination).
dental, emergency, OB/GYN, family planning, and
• When consistent with provision of appropriate quality of
20
Provider Oversight
care, referring Health Net Access members only to
records that may include payment or medical records
participating providers in compliance with Health
to determine the proper application of benefits, as well
Net Access’ written policies and procedures.
as the propriety of payments (including any claims
• Obtaining current insurance information from the
payment recovery actions performed on behalf of Health
member.
Net Access.
• Cooperating with Health Net Access in connection
• In the event of provider termination, cooperating with
with health plan performance of utilization
Health Net Access and other participating providers to
management and quality improvement activities,
provide or arrange for continuity of care to members
including prior authorization of necessary services
undergoing an active course of treatment, subject to the
and referrals.
requirements and limitations of Arizona statute.
• Informing the member that referral services may
• Operating and providing contracting services in
not be covered by Health Net when referring to
compliance with all applicable local, state and
non-participating providers.
federal laws, rules, regulations, and institutional and
• Providing Health Net Access with medical
professional standards of care, including federal laws
record information if requested for a member for
and regulations designed to prevent or ameliorate fraud,
processing his or her application for coverage;
waste and abuse, including, but not limited to, applicable
prior authorizing services or processing claims for
provisions of federal criminal law, the False Claims
benefits; or for purposes of health care provider
Act (31 U.S.C. 3729 et. seq.), the anti-kickback statute
credentialing, quality assurance, utilization review,
(section 1128B(b)) of the Social Security Act), and Health
case management, peer review, and audit. Health
Insurance Portability and Accountability Act (HIPAA)
Net Access has a valid signed authorization from
administrative simplification rules at 45 CFR parts 160,
our members authorizing any physician, health
162, and 164.
care provider, hospital, insurance or reinsurance company, the Medical Information Bureau, Inc.
The following responsibilities are minimum requirements to
(MIB), or other insurance information exchange
comply with contract terms and all applicable laws. Providers
to release information to Health Net Access if
are contractually obligated to adhere to and comply with
requested. Participating providers may obtain a
all terms of Health Net Access, provider contract and
copy of this authorization by contacting Health
requirements in this manual. Health Net Access may or may
Net Access. Health Net Access does not reimburse
not specifically communicate such terms in forms other than
for the cost of retrieval, copying and furnishing of
the contract and this manual. This section outlines general
medical records.
provider responsibilities; however, additional responsibilities
• Cooperating with any authorized Health Net
are included throughout the manual.
Access employee who may need to access member
Participating providers must ensure the following described below in detail:
21
Provider Oversight
• Adhere to the Arizona Health Care Cost Containment Systems (AHCCCS) appointment
Other provider rights and responsibilities are included in the
standards; refer to Appointment Standards section
Provider Participation Agreement (PPA).
for more information.
Regulatory Agency Information
• Provide service coverage on a 24/7 basis (including on-call).
Health Net is required to comply with all state and
• Respect AHCCCS member rights.
federal regulations set forth by the Centers for Medicare
• Provide services in a culturally sensitive manager.
and Medicaid Services (CMS), Arizona Health Care
• Adhere to Americans with Disability Act (ADA)
Cost Containment System (AHCCCS) and the Arizona
requirements.
Department of Insurance (ADOI).
• Provide services in a non-discriminatory manner. • Report suspected fraud, waste and abuse. • PCPs must utilize the AHCCCS-approved and Periodic Screening, Diagnosis and Treatment (EPSDT) tracking form. • PCPs must provide clinical information regarding a member’s health and medication to a treating physician (including behavioral health) within 10 business days of the request. • If treating children, enroll as a Vaccines for Children (VFC) provider. • Provider complaint and appeal procedures. Participating providers must complete initial, annual and ongoing Health Net Access trainings that include, but are not limited to, the following topics: • Member appeals and grievances. • Appointment standards and wait times. • Language line services. • Proper emergency department usage. • Fraud, waste and abuse/ false claims act training. • Contacting the health plan. • How to file claims and claim disputes.
22
Provider Oversight
After-Hours Sample Script - Chinese
23
Provider Oversight
After-Hours Sample Script - English
24
Provider Oversight
After-Hours Sample Script - Spanish
25
Provider Oversight
CONTACTS
Fax: (520) 258-5172
Health Net Quality Improvement Department
Health Net Fraud Hotline
Contact Health Net’s Quality Improvement (QI) Department
To report suspected fraud, waste or abuse involving
for questions regarding the QI program, medical records or
a Health Net member, contact Health Net at:
site reviews.
Health Net, Inc. Special Investigations Unit
[email protected]
PO Box 2048 Rancho Cordova, CA 95741-2048
Health Net Quality Management Department
(800) 977-3565
Contact Health Net’s Quality Management (QM) Department for questions regarding the QM program, or
Health Net Interpreter Support Services
medical records documentation standards and audits.
Information regarding telephonic interpreter
[email protected]
services is available by contacting the Provider Services Center. (800) 289-2818 Monday - Friday, 7:00 a.m. to 6:00 p.m
Health Net Provider Network Management Health Net Provider Network Management staff serve as key contacts for participating medical groups, hospitals and ancillary providers to address contractual and operations matters. Tempe: Health Net of Arizona, Inc. Attn: Provider Network Management 1230 W. Washington Street, Suite 401 Tempe, AZ 85281 Fax: (602) 794-1803 Tucson: Health Net of Arizona, Inc. Attn: Provider Network Management 5255 E Williams Circle, Suite 4000 Tucson, AZ 85711
26
Provider Oversight FORMS Health Net Access Missed Appointment/No Show* Log Fax completed log to Health Net Provider Network Management at (602) 794-1803.
Practice Name: Contact Name: Member Name
Practice Tax identification #: Contact Telephone Number: Member AHCCCS ID#
Member Telephone #
Date of Missed Appointment
Previous Missed Appointments? (yes/no)
Date Health Net Completed Follow-up
*Health Net defines a missed appointment/no show as an appointment not kept by the member and the provider was not notified at least 24 hours in advance of the scheduled appointment time.
27
Contracting
Modifications
When changing a tax ID number, include a new W-9 and the effective date. Participating providers may be held
A request to add new providers to an existing Provider
responsible for Internal Revenue Service (IRS) fines imposed
Participation Agreement (PPA) requires completion of
by Health Net associated with incorrect tax IDs if the
the AzAHP Practitioner Data Form for physicians or
provider fails to notify Health Net in writing prior to the
AzAHP Organizational Data Form for other provider
change. Health Net is unable to change tax IDs retroactively.
types. New physicians are not permitted to treat Health Net members until all credentialing requirements have
Changes must be submitted in writing to the Health Net
been met and the physician has been formally added to
Provider Network Management Department 60 days prior to
the PPA.
the change or as soon as reasonably possible. Note: Providers must include their National Provider Health Net must approve any new or modified subcontracts
Identifier (NPI) on the Provider Participation Request
prior to the effective date. Submit a copy of the proposed
form they submit to Health Net. Providers participating
agreement to the Health Net Provider Network Management
in Health Net Access must include the Arizona
Department.
Health Care Cost Containment System (AHCCCS) identification number and NPI. Any subsequent
Provider Online Demographic Data Verification
changes to either the AHCCCS identification (ID) number or NPI require completion and submission of a
Physicians, hospitals, ancillary providers, and medical
Demographic Update form, as described below.
groups or IPAs are required to provide advance notification to Health Net or their medical groups or IPAs with
Any changes to demographic information for
changes to their demographic information. On a monthly
physicians, clinicians or other entities listed as
basis, providers should validate that their demographic
participating providers on an existing PPA require
information is reflected correctly on the provider website
completion of the Demographic Update form.
under ProviderSearch.
Demographic changes include: • Name changes.
Demographic Information
• Tax ID numbers or changes or additions of
Providers’ demographic data information should include the
AHCCCS ID numbers.
following:
• Primary address and billing address changes.
• name
• Addition or deletion of locations.
• address
• Provider termination notifications.
• telephone number
• Specialty or sub-specialty changes.
• fax number • office hours
28
Contracting
• languages other than English spoken by the
Requesting Participation in the Health Net Network
physician • handicap accessibility status for parking (P), exterior
Providers who are interested in participating in the Health
building (EB), interior building (IB), restroom
Net network must submit a completed AzAHP Practitioner
(R), exam room (ER), and exam table/scale (T) - if
Data Form for physicians or AzAHP Organizational Data
accessibility is not yes to all, then indicate no
Form for other provider types. Mail or fax the completed form to the Health Net Provider Network Management
Notification and Maintenance Requirements
Department. A provider network representative will contact
According to the terms of the Provider Participation
your office via telephone or mail.
Agreement (PPA), participating providers are required to provide a minimum of 30 days advance notice of any changes to their demographic information. If the
Terminations
change pertains to the status of accepting new patients,
Participating providers terminating a physician, clinician
the provider must notify Health Net or the applicable
or other entity from an existing Provider Participation
medical group or IPA within five business days.
Agreement (PPA) must submit the following information: • Physician’s full name
Providers directly contracting with Health Net must
• Specialty type (or entity type if facility or ancillary)
notify Health Net of changes by completing the online
• License number
form, which is available on the provider website under
• Practice location
Manage My Account > Account Management Tools >
• Effective date of the change
Update Provider Information.
• Covering physician • Contact name, address and telephone number
Providers contracting through a medical group or IPA must notify the medical group or IPA directly of
This information must be submitted in writing to the Health Net
changes, and the medical group or IPA notifies Health
Provider Network Management Department at least 60 days prior
Net. Medical groups or IPAs must have policies in
to the termination. Upon termination, Health Net may invoke
place that establish and implement processes to collect,
a 12-month waiting period before the provider may re-apply for
maintain and submit their provider demographic
a contract; however, the termination clause varies based on the
changes to Health Net on a real-time basis. Real-time is
PPA..
within 30 days, as defined by the Centers for Medicare & Medicaid Services (CMS).
Health Net must be notified of participating providers who terminate a subcontract. This information must be submitted in writing to the Health Net Provider Network Management Department at least 60 days prior to the termination.
29
Contracting AzAHP Organizational Data Form
30
Contracting
31
Contracting
Demographic Update Form
32
Contracting Practitioner Data Form
33
Contracting
34
Contracting
35
Credentialing
Application Process
Approval, Denial or Termination of Credentialing Status
Practitioners or organizational providers subject to credentialing and recredentialing, and contracting directly
Each month, or more frequently as dictated by business needs,
with Health Net, must provide a completed application to
the Health Net Credentialing Committee or medical director
the specified vendor. By submitting a completed application,
committee chair reviews rosters of delegated and nondelegated
the practitioner or provider:
practitioners and organizational providers meeting all Health
• Affirms the comprehensiveness and truthfulness of
Net standards for participation and approves admittance
representations made in the application, including
or continued participation in the Health Net network. The
lack of present and illegal drug use
Credentialing Committee also reviews and accepts rosters of
• Indicates a willingness to provide additional
practitioners and providers that do not meet credentialing or
information required for the credentialing process
recredentialing criteria for administrative reasons, such as expired
• Authorizes Health Net to obtain information
license, inadequate malpractice insurance coverage or incomplete
regarding the applicant’s qualifications, competence
work history. Practitioners and providers who fail to respond
or other information relevant to the credentialing
to requests for a completed recredentialing application are
review
administratively terminated from the Health Net network.
• Releases Health Net and its independent contractors, agents and employees from any liability
Practitioners and providers who have been administratively
connected with the credentialing review
denied or terminated from network participation are eligible to reapply as soon as the administrative matter is resolved.
Health Net does not discriminate in terms of participation, reimbursement or indemnification against any health care
Network applicants are notified in writing of the Credentialing
practitioner or provider acting within the scope of licensure
Committee’s participation decision within 180 days of Health
and certification under federal or state law. Assurance
Net’s receipt of a completed application. Temporary or provisional
of nondiscrimination is met by using standardized
credentialing is completed no more than 14 calendar days from
credentialing criteria.
receipt of a completed application packet.
All Health Net Credentialing Committee members sign
The Credentialing Committee follows a peer-review process for
confidentiality/conflict of interest statements attesting to
practitioners and providers with a history of adverse actions,
adherence to Health Net’s non-discriminatory credentialing
member complaints, negative quality improvement (QI) activities,
practices. Cases reviewed by the Credentialing Committee
impaired health, substance abuse, health care fraud and abuse,
are blinded and tracking and trending practices monitor
criminal history, or similar conditions to determine whether a
reasons for network denial or termination.
practitioner should be admitted or retained in the Health Net network. If a network denial or termination decision is based
36
Credentialing
on health status, quality of care or disciplinary action, the
on quality issues, to terminate or restrict the practice of individual
practitioner or provider is afforded appeal rights.
practitioners, providers and sites, regardless of the credentialing delegation status of the group.
All committee decisions regarding approval, denial,
Each delegated practitioner or provider losing delegated
limitation, suspension, or termination of credentialing status
credentialing status must complete Health Net’s initial
are communicated in writing in a manner that is consistent
credentialing process within six months.
with health plan, state and federal regulatory requirements,
Health Net Standards of Participation
and accrediting entity standards. Such notice, when applicable, includes information regarding the reasons for denial or termination.
All practitioners participating in Health Net’s network must comply with the following Health Net standards for participation
Credentialing Responsibility, Oversight and Delegation
in order to receive or maintain credentialing.
Health Net may delegate to individual practitioners or
Applicants seeking credentialing and practitioners due for
medical groups the responsibility for activities associated
recredentialing must complete all items on an approved
with credentialing and recredentialing. Credentialing
credentialing application and supply supporting documentation,
procedures used by these entities may vary from Health Net
if required. The verification time limit for a Health Net-approved
procedures, but must be consistent with health plan, state
application is 180 days. All practitioner applications are completed
and federal regulatory requirements and accrediting entity
and accessed via the Council for Affordable Quality Healthcare
standards.
(CAQH) website by selecting the Universal Credentialing DataSource link. Supporting documentation includes:
Prior to entering into a delegation agreement, and
• Current, unencumbered state medical license
throughout the duration of any delegation agreement, the
• Valid, unencumbered Drug Enforcement Agency (DEA)
oversight of delegated activities must meet or exceed Health
certificate, as applicable. A practitioner who maintains professional
Net standards. Health Net oversees delegated responsibilities
practices in more than one state must obtain a DEA certificate for
on an ongoing basis through an annual audit and semi-
each state
annual, or more frequent, review of delegated group-specific
• Continuous work history for the previous five years with a
data.
written explanation of any gaps of more than six months (initial credentialing only)
Health Net can revoke the delegation of any or all
• Evidence of adequate education and training for the services the
credentialing activities if the delegated medical group
practitioner is contracting or contracted to provide
or entity is deemed noncompliant with established
• Board certification status (physicians only)
credentialing standards. Health Net retains the right, based
• Evidence of active admitting privileges in good standing, with
37
Credentialing
no reduction, limitation or restriction on privileges, with at
• Evidence of adequate education and training for the
least one Health Net participating hospital or surgery center.
services the practitioner is contracting to provide
A documented coverage arrangement with a Health Net
• Malpractice insurance coverage through his or her own
credentialed/contracting practitioner of a like specialty or
practice or through the hiring Health Net-participating
participating hospitalist group meets this requirement
provider
• Malpractice insurance coverage that meets Health Net
• Absent of any sanctions that would not allow them to
standards
see a Medicare member
• Answers to all confidential questions and explanations
Additionally, the practitioner must be absent from:
provided in writing for any question answered adversely
• The Medicare Opt Out report if treating Medicare
Additionally, the practitioner must be absent from:
members
• The Medicare/Medicaid Cumulative Sanction Report
• The Office of the Inspector General’s (OIG) sanctions list
• The Health and Human Services Office of Inspector General
of individuals and entities (LEIE) if treating Medicaid
(HHS-OIG) List of Excluded Individuals/Entities (LEIE)
and Medicare members
• General Services Administration (GSA) Excluded Parties
• The System for Award Management’s Exclusions Extract
List System (EPLS)
Data Package (EEDP) if treating Medicare members
Only licensed, qualified applicants meeting these standards
• The Federal Employee Health Benefits Program
and participation requirements are accepted or retained in
Debarment Report if treating federal members
the Health Net network. Health Net’s participating providers are responsible for ongoing
Hiring Non-Participating Provider
monitoring of sanctions and validating licensing. All Health Net participating providers are required to comply with applicable federal, state and local laws and regulations as well as Health Net
In an effort to comply with applicable federal and state
policies and procedures as outlined in the Provider Participation
laws and regulations, all participating providers in Health
Agreement (PPA).
Net’s network must comply with the following Health Net standards when hiring a non-participating provider to provide services to Health Net members. Health Net’s
Investigations
participating providers must be able to demonstrate
Health Net investigates adverse activities indicated in a
that each non-participating provider has supporting
practitioner’s or provider’s initial credentialing or recredentialing
documentation that includes:
application materials or as identified between credentialing cycles.
• Current, unencumbered state medical license
Health Net may also be made aware of such activities through
• Valid, unencumbered Drug Enforcement Agency
primary source verification utilized during the credentialing
(DEA) certificate, as applicable or Chemical
process or by state and federal regulatory agencies. Health Net
Dependency Services (CDS) certificate, as applicable
may require a practitioner or provider to supply additional
38
Credentialing
information regarding any such adverse activities. Examples
recredentialing by Health Net or its delegated entities include, but
of such activities include, but are not limited to:
are not limited to:
• State or local disciplinary action by a regulatory
• Hospitals
agency or licensing board
• Home health, hospice and home infusion providers
• Current or past chemical dependency or substance
• SNFs
abuse
• FSSCs/ASCs, including abortion clinics
• Health care fraud or abuse
• Dialysis/end-stage renal disease (ESRD) care providers
• Member complaints
• Laboratories
• Substantiated quality of care concerns
• Office-based surgery suites
• Impaired health
• Comprehensive outpatient rehabilitation facilities
• Criminal history
• Physical therapy and speech pathology providers
• Office of Inspector General (OIG) Medicare/
• Portable X-ray suppliers
Medicaid sanctions
• Radiology/imaging centers
• Federal Employees Health Benefits Program
• Behavioral health facilities (inpatient, residential and
(FEHBP) debarment
ambulatory)
• Substantiated media events
• Sleep study centers
• Trended data
• Urgent care centers • Federally qualified health centers and rural health clinics
At Health Net’s request, a practitioner or provider must assist
• Outpatient self-management training providers
Health Net in investigating any professional liability claims,
• Other providers, as deemed necessary
lawsuits, arbitrations, settlements, or judgments that have occurred within prescribed time frames.
Providers contracting directly with Health Net must submit a completed, signed Health Net-approved organizational provider
Organizational Providers
credentialing application and supporting documentation
An organizational provider (OP) is an institutional
to Health Net’s contracting vendor for processing. The
provider of health care services that is licensed by the state
documentation, at a minimum, includes: • Evidence that the provider has met all state and federal
or otherwise authorized to operate as a health care facility.
licensing and regulatory requirements
Examples of OPs include, but are not limited to, hospitals,
• Copy of a current accreditation certificate appropriate
home health agencies, skilled nursing facilities (SNFs), and freestanding or and ambulatory surgical centers (FSSCs/
for the facility. If not accredited, then a copy of the most
ASCs).
recent Centers for Medicare and Medicaid Services (CMS) certification or state licensure review/audit may be substituted. Health Net obtains a copy of each
Organizational providers that require credentialing and
provider’s site survey report and ensures each provider
39
Credentialing
has received a favorable rating. This may include a
the practitioner within 72 hours of the date and time
completed corrective action plan (CAP) and CAP
when such information is available for review at Health
acceptance letter. A favorable site review consists
Net’s Credentialing Department. Upon written request,
of compliance with quality of care standards
the Credentialing Department provides details of the
established by CMS or the applicable state health
practitioner’s current status in the initial credentialing or
department
recredentialing process.
• Professional and general liability insurance coverage that meets Health Net requirements
Practitioners are notified in writing, via letter or fax, when
• Overview of the facility’s quality assurance and
information obtained by primary sources varies substantially
quality improvement program upon request
from information provided on the practitioner’s application. Examples include reports of a practitioner’s malpractice
Organizational providers are recredentialed at least every
claim history, actions taken against a practitioner’s license or
36 months to ensure each entity has maintained prescribed
certificate, suspension or termination of hospital privileges,
eligibility requirements. Arizona network urgent care centers
or board-certification expiration when one or more of these
are recredentialed within 24 months.
examples have not been self-reported by the practitioner on his or her application. Practitioners are notified of the
Practitioner Rights
discrepancy at the time of primary source verification.
Right of Review and Request for Current Network Status
Sources are not revealed if information obtained is not
A practitioner has the right to review information
intended for verification of credentialing elements or is
obtained by Health Net for the purpose of evaluating
protected from disclosure by law.
that practitioner’s credentialing or recredentialing application. This includes non-privileged information
A practitioner who believes erroneous information has been
obtained from any outside source (for example,
supplied to Health Net by primary sources may correct
malpractice insurance carriers, state licensing boards or
such information by submitting written notification to
the National Practitioner Data Bank (NPDB)/Healthcare
the Credentialing Department. Practitioners must submit
Integrity Protection Data Bank (HIPDB)), but does
a written notice via letter or fax, along with a detailed
not extend to review of information, references or
explanation to the Credentialing Department manager or
recommendations protected by law from disclosure.
supervisor. Notification to Health Net must occur within 48 hours of Health Net’s notification to the practitioner of a
A practitioner may request to review such information
discrepancy or within 24 hours of a practitioner’s review of
at any time by sending a written request via letter or fax
his or her credentials file. Upon receipt of notification from
to Health Net’s credentialing manager or supervisor.
the practitioner, Health Net re-verifies the primary source
The manager or supervisor of credentialing notifies
information in dispute. If the primary source information has changed, a correction is made immediately to the
40
Credentialing
practitioner’s credentials file. The practitioner is notified
• Audiologist (AU)
in writing, via letter or fax, that the correction has been
• Dentist and dental hygienist
made. If, upon re-review, primary source information
• Doctor of chiropractic medicine (DC)
remains inconsistent with the practitioner’s notification,
• Doctor of dental surgery (DDS)
the Credentialing Department notifies the practitioner
• Doctor of medical dentistry (DMD)
via letter or fax.
• Doctor of medicine (MD) • Doctor of naturopathic medication (ND)
The practitioner may then provide proof of
• Doctor of osteopathy (DO)
correction by the primary source body to Health Net’s
• Doctor of podiatric medicine (DPM)
Credentialing Department via letter or fax within 10
• Licensed clinical social worker (LCSW); marriage and
business days. The Credentialing Department re-verifies
family therapist (MFT); marriage, family and child
the primary source information if such documentation
counselor (MFCC); mental health counselor (MHC)
is provided. If after 10 business days the primary source
• Optometrist (OD)
information remains in dispute, the practitioner is
• Oral and maxillofacial surgeon
subject to administrative denial or termination.
• Physician assistant (PA) • Physical therapist and occupational therapist (PT/OT)
Primary Source Verification for Credentialing and Recredentialing
• Psychologist (PhD, PsyD, et al.) • Registered nurse anesthetist (RNA), nurse practitioner (NP) and certified nurse midwife (CNM) • Speech therapist/speech pathologist (ST/SP)
The Health Net Credentialing Department obtains and reviews information on a credentialing or
Organizational Providers
recredentialing application and verifies the information
• Behavioral health facilities (inpatient, residential and
in accordance with the Health Net primary source
ambulatory)
verification practices. Health Net requires medical
• Comprehensive outpatient rehabilitation facilities
groups/IPAs to which credentialing has been delegated
• Dialysis and ESRD providers
to obtain primary source information (outlined
• Federally qualified health centers/rural health clinics
below)* in accordance with Health Net standards of
• Freestanding and ambulatory surgery centers
participation, state and federal regulatory requirements
• Home health/hospice and home infusion providers
and accrediting entity standards.
• Hospitals • Laboratories
Primary Source Verification Tables*
• Office-based surgery suites
• Acupuncturist (AC)
• Outpatient self-management training providers • Physical therapy/speech pathology providers
41
Credentialing
• Portable X-ray suppliers
obtain a DEA certificate for each state
• Radiology and imaging centers
• Evidence of active admitting privileges in good standing,
• Sleep study centers
with no reduction, limitation or restriction on privileges,
• Skilled nursing facilities (SNFs)
with at least one Health Net participating hospital or
• Urgent care centers
surgery center. A documented coverage arrangement with a Health Net credentialed or contracting
Practitioner and provider types that fall within the scope
practitioner of a like specialty or a participating
of Health Net’s credentialing program are subject to
hospitalist group meets this requirement
change at any time.
• Malpractice insurance coverage that meets Health Net standards
Recredentialing of Practitioners
• Assessment of internal data, including occurrences of
Health Net’s credentialing program establishes criteria
member complaints, quality of care trends, and other
for evaluating continuing Health Net participating
performance indicators
practitioners. This evaluation, which includes applicable primary source verifications, is conducted in
Site Evaluations
accordance with health plan, state and federal regulatory
Health Net or its designee conducts initial site visits for
requirements and accrediting entity standards.
primary care physician (PCP) and obstetrician/gynecologist
Practitioners are subject to recredentialing within 36
(OB/GYN) applicants that include:
months. Only licensed, qualified practitioners meeting
• Vaccine and medication storage regulations
and maintaining Health Net standards for participation
• Emergency and resuscitation equipment policy
requirements are retained in the Health Net network.
• Americans with Disabilities Act (ADA) requirements
Practitioners due for recredentialing must complete
Facility site reviews (FSRs) are also conducted to investigate
all items on a Council for Affordable Quality
member complaints relating to any practice location,
Healthcare (CAHQ) application and supply required
regardless of practitioner specialty. This occurs when three
documentation. Documentation includes, but is not
or more complaints are received about a practice site within
limited to:
six months. A review of member complaint reports or related
• Current state medical license
information is conducted at least every 60 days.
• Attestation to the ability to provide care to Health Net members without restriction
Events that initiate an investigation to conduct a site visit
• Valid, unencumbered Drug Enforcement Agency
include, but are not limited to:
(DEA) certificate. A practitioner who maintains
• Physical accessibility
professional practices in more than one state must
• Physical appearance • Adequacy of waiting and examining room space
42
Credentialing
When there are member complaints, a Health Net medical site coordinator or designee conduct office site evaluations using an approved Health Net site evaluation tool, which consists of the following elements: • Physical accessibility • Physical appearance • Adequacy of waiting and examining room space • Equipment • Medical recordkeeping • Other issues, including safety If any office site visit results in an overall score below 100 percent, Health Net creates a corrective action plan (CAP) to outline deficient criteria and the actions that need to be taken by the office. Participating practitioners who refuse an office site evaluation, do not meet the CAP within a specified time frame or refuse to participate in the CAP are referred to the Health Net Credentialing Committee for administrative termination. Sites that have complied with a CAP are retained in the Health Net network.
Terminated Contracts and Reassignment of Members Health Net notifies members as required under state and federal law if a practitioner’s contract participation status is terminated. Health Net oversees reassignment of these members to another participating practitioner where appropriate.
43
Chapter 5
Benefits Audiology Coverage Health Net Access covers medically necessary audiology services, within certain limitations, to evaluate hearing loss and rehabilitate persons with hearing loss through means other than medical/surgical procedures.
Hearing aids can be dispensed only by a dispensing audiologist or an individual with a valid hearing aid dispensing license. Hearing aids, provided as a part of audiology services, are covered only for members under age 21 receiving Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services or those enrolled
Covered services include: • Exams or evaluations for hearing aids • Exams or evaluations for cochlear
in KidsCare. Health Net Access does not cover hearing aids for members ages 21 and older.
implants Arizona Health Care Cost Containment Services
• Evaluations for prescription of speech-generating and non-speechgenerating augmentative and alternative
(AHCCCS) eliminated coverage of boneanchored hearing aid (BAHA), also known as osseointegrated implants, and cochlear implants
communicating devices • Therapeutic service(s) for the use of speech-generating and nonspeech-generating devices, including programming and modification, and devices such as hearing aids, cochlear implants, speech-generating and nonspeech-generating Audiology services must be provided by an audiologist who is licensed by the Arizona Department of Health Services (ADHS) and who meets federal requirements specified under 42 CFR 440.110.
44
for members ages 21 and older. Supplies, equipment maintenance and repair of component parts remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided when requesting prior authorization.
Benefits
Behavioral Health Overview
provider in the Health Net Access behavioral health provider network.
The Arizona Department of Health Services/Division
• attention deficit hyperactivity disorder (ADHD)
of Behavioral Health Services (ADHS/DBHS) monitors
• anxiety
and oversees the state behavioral health system. ADHS/
• depression
DBHS contracts with the Regional Behavioral Health
• postpartum depression
Authority (RBHA), and the Tribal/Regional Behavioral Health Authority (T/RBHA) for members who are
The Health Net Access behavioral health coordinator is
American Indians, to provide covered behavioral health
available to assist in bridging the gap between Health
services to adults and children.
Net Access and RHBA for non-dual-eligible members, regarding coordination of all services identified as medically
Effective October 1, 2015, dual-eligible members who
necessary, including, but not limited to, referral of members
are enrolled in both Medicare and Medicaid, and have?
requiring specialty behavioral health services and dispute
general mental health/substance abuse (GMH/SA)
resolution. PCPs may submit a referral for a SMI eligibility
behavioral health needs are the responsibility of acute
determination directly by contacting the Crisis Preparation
care plans, such as Health Net Access. Members may
and Recovery, Inc.’s SMI Evaluation Department.
be aligned (both Medicare and Medicaid with the same plan) or unaligned (separate plans for Medicare and
Comprehensive GMH/SA services are available to Health
Medicaid). If the member is unaligned, the Medicaid
Net Access dual-eligible members. A direct referral for a
acute care plan is the primary payer of behavioral health
behavioral health evaluation can be made by any health care
services. This does not include services for children
professional in coordination with the member’s assigned
under age 18 or individuals determined to have a serious
PCP and case manager. Health Net Access members may
mental illness (SMI). These members continue to receive
also self-refer for all behavioral health services to RBHA.
services through the RBHA. When deemed medically
The level and type of behavioral health services are provided
necessary, comprehensive behavioral health services are
based on the member’s strengths and needs and with respect
covered for Health Net Access members.
to the member’s culture. Health Net Access covers the full continuum of GMH/ Behavioral health services include, but are not limited to:
SA services for dual-eligible members. Primary
• behavior health case management (personal care, family
care providers (PCPs) continue to be responsible
support/home care training, peer support)
for providing general mental health services for the
• behavioral health nursing services
conditions listed below. When the member’s diagnosis
• emergency behavioral health care
or behavioral health needs are beyond the scope of the
• emergency and non-emergency transportation
PCP’s practice, the member should be referred to a
• evaluation and assessment
45
Benefits
• individual, group and family therapy/ counseling
• licensed independent substance abuse counselors
• inpatient hospital services
• residential treatment facilities
• non-hospital inpatient psychiatric facilities services
• behavioral health residential facilities.
(level I residential treatment centers and sub-acute
• partial hospital programs
facilities)
• intensive outpatient programs
• lab and radiology services for psychotropic
• substance abuse programs
medication regulation and diagnosis
• inpatient hospital facilities
• opioid agonist treatment
• community service agency
• partial care (supervised, therapeutic and medical
Alternative Living Arrangements
day programs) • psychosocial rehabilitation (living skills training,
Health Net Access members may be eligible for the following
health promotion, supportive employment services)
alternative living arrangements:
• psychotropic medication
• Behavioral health inpatient facility - this setting provides
• psychotropic medication adjustment and
behavioral health treatment with 24-hour supervision.
monitoring
Services may include onsite medical services and
• respite care (with limitations)
intensive behavioral health treatment programs. These
• rural substance abuse transitional agency services
are often located in a locked hospital setting.
• home care training to home care client
• Traumatic brain injury treatment facility - this setting
• behavioral health/substance abuse screenings
provides treatment and services for people with
• wellness and recovery services
traumatic brain injuries. • Residential treatment center - this setting provides
Behavioral Health Provider Types
treatment for chemical dependency treatment, co-
Many provider types can typically provide behavioral
occurring disorders or acute psychiatric treatment, in a
health services for Health Net Access members. These
non-locked residential facility.
may include, but are not limited to, the following
Emergency Services
licensed agencies and individuals: • outpatient behavioral health clinics
Health Net Access benefits include behavioral health
• psychiatrists
emergency services for members. If a member is experiencing
• psychologists
a behavioral health crisis, providers should contact the Crisis
• certified psychiatric nurse practitioners
Response Network. During a member’s behavioral health
• licensed clinical social workers
emergency, a behavioral health hotline clinician may dispatch
• licensed professional counselors
a behavioral health mobile crisis team to the site of the
• licensed marriage and family therapists
member to de-escalate the situation and evaluate the member for behavioral health services. All medically necessary services
46
Benefits
are covered by Health Net Access.
Information necessary for the member’s treatment can be shared with the other party. This process begins once
Behavioral Health Screening
a member is identified as meeting medical necessity for
Members should be screened by their PCPs for
seeing a behavioral health provider by the behavioral health
behavioral health needs during routine or preventive
coordinator. Information can be shared with other parties
visits, as required at each Early and Periodic Screening,
with written permission from the member or the member’s
Diagnostic and Treatment (EPSDT) visit for members
guardian.
under age 21.
PCP Coordination of Care Behavioral Health Appointment Standards
The PCP and behavioral health provider must established
Health Net Access routinely monitors providers for
communication once the PCP is informed his or her member
compliance with appointment standards. The minimum
is seeing a behavioral health provider. PCPs must maintain
standard requirements are:
strong communication with the behavioral health provider.
• emergency - within 24 hours of referral
PCPs are expected to exchange any relevant information,
• routine - within 30 days of referral
such as medical history, current medications, diagnosis, and
• post-hospitalization - within 7 days of discharge
treatment within 10 business days of receiving the request from the behavioral health provider.
Behavioral Health Coordination and Provider Responsibilities
A medical provider must coordinate care with the behavioral health provider within a timely manner when he or she identifies a change in the member’s health status. The update
It is critical that strong communication be maintained
should include, but is not limited to, diagnosis of chronic
between behavioral health providers and the following:
conditions, support for the petitioning process, and all
• Primary care providers (PCPs) and other medical
medication prescribed.
providers. • Member’s guardian, power of attorney and/or Public
The PCP must review all documentation from the
Fiduciary Department (if proper documentation is
behavioral health provider who is treating the member and
provided).
documenting it in the member’s medical record. All efforts
• Veterans office (when applicable).
to coordinate care on behalf of the member should also be
• The court system, such as probation, parole, mental
documented in the member’s medical record.
health court, Adult Protective Services, and Child Protective Services, as applicable.
Medication
• Other specialty providers involved in the member’s care.
The PCP assesses member for psychotropic medication and reviews the recipient’s profile in the Arizona State
47
Benefits
Board of Pharmacy Controlled Substance Prescription
participation in counseling or psychiatric sessions, and
Monitoring Program (CSPMP) database when initiating
providing transportation or social support to the member.
a controlled substance (such as amphetamines, opiates,
Written permission is required to share member’s personal
benzodiazepines, etc.) that will be used on a short-term
health information.
or regular basis.
Court-Ordered Treatment and Petition Process
Prior Authorization Requirements and Process
Certain situations require members to be petitioned through
Health Net Access requires prior authorization for
the mental health court.
certain outpatient behavioral health services and continued hospital stays to ensure medical necessity.
Emergent Petition
Health Net Access makes authorization decisions within
An emergent petition is a request for involuntary
14 days of receipt for a standard request, and within
commitment for psychiatric treatment due to the member
3 business days of receipt for an expedited request.
being an immediate danger to himself/herself or others.
Unauthorized services are not reimbursed.
An emergent petition can be completed by any clinical professional who has witnessed petitionable behavior and
Authorization is not a guarantee of payment. To
statements. A crisis team can be used to pursue an emergent
request authorization, providers must contact the
petition as well as hospital staff.
Prior Authorization Department at 1-888-926-1736 prior to delivery of services. Explain the necessity for
Non-Emergent Petition
prior authorization, including the type of services to
Non-emergent petitions apply to persistently and acutely
be delivered, frequency of services, and duration of
disabled or gravely disabled (PAD/GD) members and are
services.
defined as follows: • Gravely disabled (GD): Unable to take care of own basic
Family Involvement
needs.
Family involvement in a member’s treatment is an
• Persistently or acutely disabled (PAD): Likely to suffer
important aspect to recovery. Studies have shown
severe mental or physical harm because of impaired
members who have family involved in their treatment
judgment cause by a mental health condition.
tend to recover quicker, are less dependent on outside agencies, and rely less on emergency resources. Family is
Non-emergent petitions are filed by calling the Crisis
defined as any person related to the member biologically
Response Network and require at least two witnesses of the
or appointed (step-parent, guardian and/or power of
member’s petitionable behavior and statements.
attorney). Treatment includes treatment planning,
48
Benefits
Members Determined to Need Court-Ordered Treatment
member into a RBHA or T/RBHA based on the member’s residential ZIP code. Health Net Access PCPs may provide behavioral health services within the scope of their practice
For members who are already under court-ordered
(such as to treat ADHD, anxiety, depression, and postpartum
treatment through the Mental Health Court, Health
depression) and coordinate referrals for members requiring
Net Access is responsible for tracking the status of the
specialty and inpatient behavioral health services. Health
member’s treatment and reports to the Mental Health
Net Access provides coordination of care as needed by
Court as necessary. As such, treating providers must
collaborating with the member/guardian, support system,
notify Health Net Access of any treatments or other
PCP, and clinical team, to initiate appropriate referrals.
appropriate status updates.
Health Net Access’ behavioral health coordinator is available to facilitate referrals and to assist the PCP in maintaining
For non-dual-eligible members (Medicaid only), children
continuity of care for the member. Health Net Access PCPs
under age 18, and members with serious mental illness
coordinate all services identified as medically necessary,
(SMI), these services continue to be provided by the
including referral of members requiring specialty behavioral
Regional Behavioral Health Authority (RBHA) or
health services to RBHA, T/RBHA or to the appropriate
Tribal Regional Behavioral Health Authority (T/RBHA)
provider.
and are excluded from Health Net Access coverage responsibilities. Behavioral health services are described
Court-Order Definitions
in Title XIX and Title XXI of the ADHS/DBHS Division.
Mental disorder: deemed by ARS Title 36 as follows: A
All behavioral health services are carved-out and
substantial disorder of the person’s emotional processes,
excluded from coverage under Health Net Access’
thought, cognition or memory.
Arizona Health Care Cost Containment System (AHCCCS) acute care contract. Other than behavioral
Danger to others (DTO) [ARS §36-501-4]: Judgment of a
health services rendered by the Health Net Access
person having a mental disorder is so impaired that he/she is
contracting primary care provider (PCP), this exclusion
unable to understand his need for treatment and as a result
includes outpatient and inpatient behavioral health
of his/her mental disorder, his/her continued behavior can
services. Health Net Access is not responsible for
reasonably be expected, on the basis of a competent medical
reimbursement of inpatient facility and professional
opinion, to result in serious physical harm.
behavioral health services to hospitalized members with primary behavioral health diagnoses. Reimbursement is
Danger to self (DTS) [ARS §36-501-5]: Behavior which, as a
unrelated to the bed or floor where the member is placed.
result of a mental disorder, constitutes a danger of inflicting serious physical harm upon oneself, including attempted
AHCCCS assigns each Health Net Access-enrolled
suicide or the serious treat thereof, or if the threat is expected that it will be carried out in light of context and previous acts
49
Benefits
and which as a result of a mental disorder will, without
be reasonably expected, on the basis of competent medical
hospitalization, result in serious physical harm or
opinion, to result in serious physical harm.
serious illness to the person except that behavior which
Emergency Services
establishes only the condition of Gravely Disabled.
Health Net Access is responsible for all emergency medical Gravely disabled (GD) [ARS §36-501-15]: Condition
services, including triage, physician assessment, diagnostic
evidenced by behavior in which a person, as a result of
tests, ambulance transportation, and other medically
a mental disorder, is likely to come to serious physical
necessary transportation provided to Health Net Access
harm or serious illness because he/she is unable to
members.
provide for his/her basic physical needs. For dual-eligible members, Health Net Access is Persistently or acutely disabled (PAD) [ARS §36-501-
responsible for medically necessary professional psychiatric
29]: Severe mental disorder, which:
consultations in emergency department or inpatient settings
1. If not treated has a substantial probability of causing
and reimburses ambulance transportation or other medically
the person to suffer severe and abnormal mental,
necessary transportation provided to members requiring
emotional or physical harm that significantly
behavioral services after medical stabilization.
impairs judgment, reason, behavior or capacity to recognize reality;
For Medicaid-only members, the Regional Behavioral Health
2. Substantially impairs the person’s capacity to the
Authority (RBHA) or Tribal Regional Behavioral Health
extent they are incapable of understanding and
Authority (T/RBHA) is responsible for medically necessary
expressing an understanding of the consequences
professional psychiatric consultations in emergency
of accepting treatment as well as the alternatives
department or inpatient settings and reimburses ambulance
to the particular treatment after the advantages,
transportation or other medically necessary transportation
disadvantages, and alternatives are explained; and,
provided to a member requiring behavioral services after
3. Has a reasonable prospect of being treatable by
medical stabilization.
outpatient, inpatient, or combined treatment.
Health Net Responsibilities
Exclusions to what constitutes a serious mental illness:
Health Net Access is responsible for:
the person is primarily disabled due to drug abuse,
• monitoring appropriate referral by primary care
alcoholism, or mental retardation; declining mental
physicians (PCPs) for members in need of specialty and
abilities that accompany impending death; or character
behavioral health services
and personality disorders characterized by life-long
• providing psychotherapeutic medications as prescribed
and deeply ingrained anti-social behaviors that can
by the PCP
50
Benefits
• monitoring pharmacy utilization to ensure
the PCP has seen the assigned member. The following
appropriate prescribing and dispensing
information may be kept in an appropriate labeled file and
• facilitating and monitoring the coordination of care
must be associated with the member’s medical record as
between the PCP and behavioral health providers
soon as one is established:
• providing transportation for the member’s
• referral forms
first behavioral health intake appointment and
• use of Arizona Health Care Cost Containment System
subsequent appointments
(AHCCCS) behavioral health toolkit or other clinically
• providing Arizona Health Care Cost Containment
approved tools or evidence-based guidelines
System (AHCCCS) approved toolkits to PCPs for
• release of information regarding substance abuse or HIV
treatment of the diagnoses listed below. Toolkits
• treatment information received from Health Net Access,
are available on the provider website at www.
RBHA or T/RBHA behavioral health provider, such as
healthnetaccess.com Behavioral Health for PCPs,
medication, diagnosis, laboratory results, hospital, or
or by contacting the Health Net Access behavioral
emergency visits
health coordinator. o adult ADHD
Medical records are randomly selected and audited annually
o adult anxiety
for compliance. For audit questions, PCPs should contact the
o adult depression
Health Net Access behavioral health coordinator.
o postpartum depression o child ADHD
PCP Treatment and Referrals
o child anxiety
Primary care physicians (PCPs) are responsible for
o child depression
identifying and treating, or making specialty medical
• providing medically necessary covered behavioral
referrals for, members’ general medical conditions and
health services for dual-eligible Medicare and
behavioral health that cause or exacerbate psychological
Medicaid enrollees with General Mental Health/
symptoms.
Substance Abuse (GMH/SA) and not determined to have a serious mental illness (SMI)
Treatment PCPs may provide medication management services for
Medical Record Documentation
select behavioral health disorders, such as anxiety, mild
Primary care physicians (PCPs) must establish a medical
depression, postpartum depression, and attention deficit
record when behavioral health information is received
hyperactivity disorder (ADHD). Medication management
from Health Net Access, the Regional Behavioral Health
services may include medication monitoring, prescriptions,
Authority (RBHA) or Tribal/Regional Behavioral Health
laboratory services, and other diagnostic tests necessary
Authority (T/RBHA) provider, regardless of whether
to diagnose and treat behavioral disorders PCPs may use
51
Benefits
the Arizona Health Care Cost Containment System
• psychiatric hospitalization
(AHCCCS) approved toolkits or other clinically
• identification of behavioral health diagnosis outside the
approved tools or evidence-based guidelines for best
scope of the PCP or substance abuse issues
practices addressing the treatment of these disorders. The AHCCCS toolkits include assessment tools,
PCPs may refer members for the following services by
scoring instructions and recommended medication
contacting the Health Net Access Behavioral Health Unit
lists, and are available on the provider website at www.
(for dual-eligible members) or the RBHA or T/RBHA (for
healthnetaccess.com or by contacting the Health Net
Medicaid-only members):
Access behavioral health coordinator.
• behavioral health services • consultation with a Health Net Access or T/RBHA
Referrals
behavioral health provider
PCPs are also responsible for coordinating referrals for
• one-time, face-to-face psychiatric evaluation with the
members requiring specialty or inpatient behavioral
Health Net Access or RBHA or T/RBHA behavioral
health services through Health Net Access (for dual-
health provider for treatment, ongoing behavioral health
eligible), the Regional Behavioral Health Authority
care or medication management. To request this service,
(RBHA), or the Tribal/Regional Behavioral Health
PCPs must complete and submit the behavioral health
Authority (T/RBHA). Tribal members and veterans
referral form and check one-time, face-to-face request
retain choice in where they access all or part of their services from, including Indian Health Services/638
Additionally, PCPs are encouraged to call or refer members
facilities or the Veterans Administration. Behavioral
to the Maricopa Crisis Line, 24 hours, seven days a week, if
health services for individuals determined to have a
the member experiences a behavioral health crisis, including
serious mental illness (SMI) are provided by the RBHA
danger to self or others.
or T/RBHA and are excluded from Health Net Access coverage responsibilities.
If the member’s behavioral health needs require behavioral health services outside the PCP’s scope, the PCP is required
PCPs are required to comply with Health Net Access,
to refer the member to Health Net Access (for dual-eligible
AHCCCS and RBHA or T/RBHA guidelines for
members) or the RBHA or T/RBHA for assessment and
referring their assigned members for behavioral health
referral to a behavioral health care provider.
services. Referrals are based on, but not limited to: • member request (members may also self-refer to a
For dual-eligible members, PCPs should contact Health Net
behavioral health provider)
Access using the behavioral health telephone number on the
• sentinel event, such as a member-defined crisis
member’s Health Net Access identification card for a referral
episode
to Health Net Access contracted behavioral health provider. For non-dual-eligible members, PCPs may use the ADHS/
52
Benefits
DBHS Referral For Behavioral Health form located at
health provider contracting with Health Net Access (for
www.healthnetaccess.com to make a referral. The PCP
dual-eligible members) or the Regional Behavioral Health
must ensure the member is transitioned to the RBHAor
Authority (RBHA) or Tribal/Regional Behavioral Health
T/RBHA by:
Authority (T/RBHA) if symptoms become severe or if the
• completing the member transfer notification
member needs additional behavioral health services. PCPs
• providing information on the member’s medication
must ensure members are not simultaneously receiving
prescription and management
behavioral health medication from both the behavioral
• ensuring medications are bridged until the member
health provider and PCP. When the member is identified
is transitioned
to be simultaneously receiving medications from the PCP and behavioral health provider, the PCP must immediately
If a PCP determines the member needs an SMI
contact the behavioral health provider to coordinate care and
eligibility determination, they should contact the Mercy
agree on who will continue to medically manage the person’s
Maricopa Member Services Line.
behavioral health condition.
Problem Resolution
PCPs must use step therapy as needed for ADHD, anxiety
The Health Net Access behavioral health coordinator
disorder, mild depression, and postpartum depression. Step
initiates Health Net’s problem resolution policy
therapy is required for medication not on the Arizona Health
and procedure when problems arise concerning the
Care Cost Containment System (AHCCCS) or Division
provision of behavioral health treatment services,
of Behavioral Health Services (DBHS) preferred drug list.
excluding member and provider grievance and appeals.
This includes the requirement that if the PCP receives documentation from Health Net Access, RBHA or T/RBHA behavioral health providers regarding completion of step
Psychotropic Prescription and Management
therapy, the PCP continues prescribing the same brand and dosage of current medication unless a change in medical
Primary care physicians (PCPs) may treat and prescribe
condition is clearly evident.
medication for the following behavioral health diagnoses:
Psychotropic medications are listed in the Health Net
• attention deficit hyperactivity disorder (ADHD)
Access Drug List, available on the provider website at www.
• anxiety disorder
healthnetaccess.com. For additional information regarding
• mild depression
pharmacy benefits, contact Health Net Pharmaceutical
• postpartum depression
Services.
PCPs must transfer the member to a behavioral
53
Benefits
Breast Reconstructive Surgery after Mastectomy
replacements are not covered when the purpose of the original implant was cosmetic, such as augmentation • External prostheses, including a surgical brassiere, for
Health Net covers breast reconstruction surgery
members who choose not to have breast reconstruction,
for eligible Health Net Access members following a
or who choose to delay breast reconstruction until a later
medically necessary mastectomy regardless of the
time
member’s eligibility status at time of the mastectomy. Health Net does not cover services provided solely for
Prior authorization is required for breast reconstruction
cosmetic purposes.
surgery. Coverage for prosthetic devices and reconstructive surgery is subject to copayment that is applicable to the
A member may elect to have breast reconstruction
mastectomy and all other terms and conditions applicable to
surgery immediately following a mastectomy or
other benefits.
may choose to delay breast reconstruction, but the member must be enrolled in Health Net Access at
Covered and Non-Covered Medical Services
the time of breast reconstruction surgery. The type of breast reconstruction performed is determined by the physician in consultation with the member.
Covered Services For covered medical benefits, detailed service descriptions,
Breast reconstructive surgery coverage includes:
and exclusions and limitations, including behavioral health
• Reconstruction of the affected and the unaffected contralateral breast. Reconstructive breast surgery
services, refer to the AHCCCS Medical Policy Manual
of the unaffected contralateral breast following
(AMPM) as follows:
mastectomy is considered medically necessary
• www.azahcccs.gov/ > Medical Policy Manual > Chapter 300
only when required to achieve relative symmetry
• www.azahcccs.gov/ > Medical Policy Manual > Chapter 1200
with the reconstructed affected breast. The surgeon
• www.azahcccs.gov/ > Covered BHS Guide
must determine medical necessity and request prior authorization for reconstructive breast surgery of
Non-Covered Services
the unaffected contralateral breast prior to the time
The following services are not covered for Health Net Access
of reconstruction or during the immediate post-
members: • Services from a provider who is not contracting with
operative period
Health Net Access (unless prior authorized).
• Medically necessary implant removal and implant
• Cosmetic services or items unless medically necessary
replacement when the original implant was the
and prior authorized.
result of a medically necessary mastectomy. Implant
• Personal care items, such as combs, razors, soap, etc.
54
Benefits
• Any service that requires prior authorization that
Additional Non-Covered Services for Adults
was not prior authorized.
The following services are also not covered for Health Net
• Services or items given free of charge or for which
Access adult members (ages 21 and older):
charges are not usually applicable.
• Hearing aids, including bone-anchored hearing aids.
• Services of special duty nurses unless medically
• Cochlear implants.
necessary and prior authorized.
• Microprocessor controlled lower limbs and
• Routine circumcisions.
microprocessor controlled joints for lower limbs.
• Services that are determined to be experimental by
• Percussive vests.
the Health Net Access medical director/designee.
• Services performed by a podiatrist (excluding dually
• Pregnancy terminations and pregnancy termination
eligible Health Net Medicare members*))
counseling unless medically necessary, pregnancy
• Routine eye examinations for prescriptive lenses or
is the result of rape or incest, or if physical illness
glasses.
related to the pregnancy endangers the health of the
• Routine dental services and emergency dental services
mother.
unless related to the treatment of a medical condition,
• Health services for incarcerated members.
such as acute pain, infection or fracture of the jaw.
• Experimental organ transplants unless approved by
• Chiropractic services (excluding dually eligible Health
AHCCCS.
Net Medicare members*)
• Sex change operations.
• Outpatient speech and occupational therapy (excluding
• Reversal of voluntary sterilization.
dually eligible Health Net Medicare members*)
• Medications and supplies without a prescription. • Treatment to straighten teeth unless medically
*Dually eligible Health Net Medicare members are those that
necessary and approved.
are enrolled with Health Net for their Medicare benefit and
• Prescriptions not on the Health Net Access list of
Health Net Access for their Medicaid benefit. These members
covered medications unless prior authorized.
are eligible for their Medicare benefits under the Health Net
• Diapers solely for personal hygiene.
Medicare program. Health Net Access is the secondary payer.
• Physical exams for the purpose of qualifying for employment or sports activities.
Conscious Sedation Coverage
• Children’s Rehabilitative Services (CRS) for
Health Net Access covers conscious sedation for members
members enrolled in CRS or who have been
receiving Early and Periodic Screening, Diagnostic and
accepted for the CRS program, but have declined to
Treatment (EPSDT) services. Conscious sedation provides
enroll.
a state of consciousness that allows the member to tolerate an unpleasant procedure while continuously maintaining adequate cardiovascular and respiratory function, as well
55
Benefits
as the ability to respond purposely to verbal command
health, function and esthetics of those structures and
and/or tactile stimulation.
tissues. • Dietary counseling.
Additional applications of conscious sedation for
• Referrals to dental specialists when care cannot directly
members receiving EPSDT services are considered on
be provided within the dental home.
a case-by-case basis and require medical review and prior authorization by Health Net Access for enrolled
Members must be assigned to a dental home by age one and
members.
seen by a dentist for routine preventive care according to the AHCCCS Dental Periodicity Schedule. Members must also
Dental Home
be referred for additional oral health care concerns requiring
The American Academy of Pediatric Dentistry (AAPD)
additional evaluation and/or treatment.
defines the dental home as the ongoing relationship between the dentist and the member, inclusive of all
Although the AHCCCS Dental Periodicity Schedule
aspects of oral health care delivered in a comprehensive,
identifies when routine referrals begin, PCPs may refer
continuously accessible, coordinated, and family-
EPSDT members for a dental assessment at an earlier age if
centered way. The dental home must include:
their oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment
• Comprehensive oral health care, including acute care and preventive services in accordance with the
by a dental professional. In addition to PCP referrals, EPSDT
Arizona Health Care Cost Containment System
members are allowed self-referral to dentists who are in the
(AHCCCS) Dental Periodicity Schedule.
Health Net Access provider network.
• Comprehensive assessment for oral diseases and
Dental Services for Members Ages 21 and Older
conditions. • Individualized preventive dental health program based upon a caries-risk assessment and a
Health Net Access covers medical and surgical services
periodontal disease risk assessment.
provided by a dentist only to the extent such services:
• Anticipatory guidance about growth and
• May be performed under state law by either a physician
development issues (such as teething, digit or
or a dentist and,
pacifier habits).
• The services would be considered physician services if
• Plan for acute dental trauma.
provided by a physician.
• Information about proper care of the child’s teeth and gingivae. This would include the prevention,
Health Net Access also covers limited dental services as a
diagnosis and treatment of disease of the supporting
prerequisite to covered transplantation and when they are in
and surrounding tissues and the maintenance of
preparation for radiation treatment for certain cancers.
56
Benefits
Covered Services
Exclusions and Limitations
Services provided by dentists are covered for members
Except for limited dental services covered for pre-transplant
ages 21 and older, and must be related to the treatment
candidates and for members with cancer of the jaw, neck or
of a medical condition, such as acute pain (excluding
head described above, covered services furnished by dentists
temporomandibular joint (TMJ) pain), infection
to members ages 21 and older do not include services that
or fracture of the jaw. Covered services include a
physicians are not generally competent to perform, such
limited problem-focused examination of the oral
as dental cleanings, routine dental examinations, dental
cavity, required radiographs, complex oral surgical
restorations including crowns and fillings, extractions,
procedures, such as treatment of maxillofacial fractures,
pulpotomies, root canals, and the construction or delivery
administration of an appropriate anesthesia and
of complete or partial dentures. Diagnosis and treatment of
the prescription of pain medication and antibiotics.
TMJ is not covered except for reduction of trauma.
Diagnosis and treatment of TMJ is not covered except
Dental Services for Members Younger than Age 21
for reduction of trauma.
Exception for Transplant and Cancer Cases
Health Net Access dental providers must adhere to the Arizona Health Care Cost Containment System (AHCCCS)
For members who require medically necessary dental
appointment standards listed in the table below:
services as a prerequisite to covered organ or tissue transplantation, covered dental services are limited to
Category Emergency Urgent care Routine
the elimination of oral infections and the treatment of oral disease, which include dental cleanings, treatment of periodontal disease, medically necessary extractions
AHCCCS Dental Appointment Standards Within 24 hours of request Within 3 days of request Within 45 days of request
and the provision of simple restorations. For purposes of this policy a simple restoration means silver amalgam
EPSDT Covered Services
and/or composite resin fillings, stainless steel crowns
Early and Periodic Screening, Diagnostic and Treatment
or preformed crowns. Health Net Access covers these
(EPSDT) covers the following dental services:
services only after a transplant evaluation determines
• Emergency dental services, including:
that the member is an appropriate candidate for organ
o Treatment for pain, infection, swelling and/or injury.
or tissue transplantation.
o Extraction of symptomatic (including pain), infected and nonrestorable primary and permanent teeth,
Prophylactic extraction of teeth in preparation for
as well as retained primary teeth (extractions are
radiation treatment of cancer of the jaw, neck or head is
limited to teeth which are symptomatic).
also covered.
o General anesthesia, conscious sedation or anxiolysis
57
Benefits
when local anesthesia is contraindicated or
legal guardian.
when management of the patient requires
• Application of topical fluorides. The use of a prophylaxis
it. (Refer to Conscious Sedation Coverage
paste containing fluoride or fluoride mouth rinses do not
section.).
meet the AHCCCS standard for fluoride treatment.
• Preventive dental services provided as specified in
• Dental sealants for first and second molars are covered
the Arizona Health Care Cost Containment System
every three years up to age 15, with a two-time maximum
(AHCCCS) Dental Periodicity Schedule, including,
benefit. Additional applications must be deemed
but not limited to:
medically necessary and require prior authorization
o Diagnostic services, including comprehensive
through Health Net Access.
and periodic examinations. Health Net Access
• Space maintainers when posterior primary teeth are
allows two oral examinations and two oral
lost and when deemed medically necessary through the
prophylaxis and fluoride treatments per
Health Net Access PA process.
member per year (one every six months) for
• All therapeutic dental services are covered when they are
members ages 12 months through age 20 years.
considered medically necessary and cost effective, but
o Radiology services screening for diagnosis
may be subject to prior authorization through Health
of dental abnormalities and/or pathology,
Net Access. These services include, but are not limited to:
including panoramic or full-mouth X-rays,
o Periodontal procedures, scaling/root planing,
supplemental bitewing X-rays, and occlusal
curettage, gingivectomy, and osseous surgery.
or periapical films, as medically necessary
o Crowns:
and following the recommendations by the
• When appropriate, stainless steel crowns may be used for
American Academy of Pediatric Dentistry
both primary and permanent posterior teeth; composite,
(AAPD).
prefabricated stainless steel crowns with a resin window
o Panorex films are covered as recommended
or crowns with esthetic coatings should be used for
by AAPD, up to three times maximum per
anterior primary teeth, or
provider for children between ages 3 to 20.
• Precious or cast semi-precious crowns may be used
Additional panorex films needed above this
on functional permanent endodontically treated teeth,
limit must be deemed medically necessary
except third molars, for members who are ages 18
through the Health Net Access prior
through 20.
authorization process. Preventive services,
o Endodontic services, including pulp therapy for
including:
permanent and primary teeth, except third molars
• Oral prophylaxis performed by a dentist or dental
(unless a third molar is functioning in place of a
hygienist which includes self-care oral hygiene
missing molar).
instructions to member, if able, or to the parent/
o Restoration of carious permanent and primary teeth with accepted dental materials other than cast
58
Benefits
or porcelain restorations, unless the member
Services or items furnished solely for cosmetic purposes are
is age 18 through 20 and has had endodontic
excluded.
treatment.
KidsCare Members Under Age 19
o Restorations of anterior teeth for children under age 5, when medically necessary. Children
KidsCare services must be provided according to community
ages 5 and older with primary anterior tooth
standards and standards set forth for members enrolled for
decay should be considered for extraction
EPSDT services. Service descriptions and limitations for
if presenting with pain or severely broken
EPSDT also apply for the KidsCare program.
down tooth structure, or be considered for observation until the point of exfoliation as
Informed Consent
determined by the dental provider.
Informed consent is a process by which the dental provider
o Removable dental prosthetics, including
advises the member or member’s parent or legal guardian of
complete dentures and removable partial
the diagnosis, proposed treatment and alternate treatment
dentures.
methods with associated risks and benefits of each, as well as
o Orthodontic services and orthognathic surgery
the associated risks and benefits of not receiving treatment.
are covered only when these services are necessary to treat a handicapping malocclusion.
Informed consents for oral health treatment include:
Services must be medically necessary and
• A written consent for examination and/or any
determined to be the primary treatment
preventive treatment measure, which does not include
of choice or an essential part of an overall
an irreversible procedure, as mentioned below. This
treatment plan developed by both the PCP
consent is completed at the time of initial examination
and the dentist in consultation with each
and is updated at each subsequent six month follow-up
other. Orthodontic services are not covered for
appointment.
cosmetic purposes. Examples of conditions that
• A separate written consent for any irreversible, invasive
may require orthodontic treatment include the
procedure, including, but not limited to dental fillings,
following:
pulpotomy, etc. In addition, a written treatment plan
• Congenital craniofacial or dentofacial
must be reviewed and signed by both parties, as
malformations requiring reconstructive surgical
described below, with the member’s parent or legal
correction in addition to orthodontic services,
guardian receiving a copy of the complete treatment
• Trauma requiring surgical treatment in addition to
plan.
orthodontic services, or • Skeletal discrepancy involving maxillary and/or
Providers must complete the appropriate informed consents
mandibular structures.
and treatment plans for Health Net Access members as listed
59
Benefits
above, in order to provide quality and consistent care, in a manner that protects and is easily understood by the member and/or the member’s parent or legal guardian. Consents and treatment plans must be in writing and signed and dated by both the provider and the member or the member’s parent or legal guardian, if the member is age 18 and under, or older and considered an incapacitated adult. Completed consents and treatment plans must be maintained in the member’s chart and are subject to audit.
Dental Periodicity Schedule
60
Benefits
Overview
to a medical emergency. Services furnished to Health Net Access members outside the United States are not covered.
Health Net covers hemodialysis and peritoneal dialysis services provided by participating Medicare-certified hospitals or Medicare-certified end-stage renal disease
Coverage
(ESRD) providers. Hemoperfusion is covered when
Durable medical equipment (DME) is paid for in accordance
medically necessary. Services may be provided on an
with the Provider Participation Agreement (PPA). Fee-for-
outpatient basis or on an inpatient basis if the hospital
service (FFS) providers may be directed to any participating
admission is not solely to provide chronic dialysis
Health Net Access DME provider, including Preferred
services. Hospital admissions solely to provide chronic
Homecare.
dialysis are not covered. Prosthetic and orthotic services are not available through Medically necessary outpatient dialysis treatments are
Health Net Access’ preferred DME provider (Preferred
covered, including:
Homecare). They may be obtained through prosthetic and orthotic providers, such as Hanger Prosthetics and Orthotics.
• Supplies • Diagnostic testing (including routine medically
Exclusions and Limitations
necessary laboratory tests)
Health Net Access does not cover the following items:
• Medications
• Personal care items, unless needed to treat a medical Inpatient dialysis treatments are covered when the
condition (except incontinence briefs and pads for
hospitalization is for:
members over age 3 and under age 21). • First aid supplies (except under a prescription).
• Acute medical condition requiring dialysis
• Hearing aids for members ages 21 and older.
treatments (hospitalization related to dialysis)
• Prescriptive lenses for members ages 21 and older (except
• Medical condition requiring inpatient
if medically necessary following cataract removal).
hospitalization experienced by a member routinely
• Penile implants or vacuum devices for members who are
maintained on an outpatient chronic dialysis
ages 21 and older.
program • Placement, replacement or repair of the chronic
Orthotics
dialysis route
Orthotics are rigid or semi-rigid devices affixed to the body
Limitations
externally and required to support or correct a defect of form
Out-of-state services are covered as provided for under
or function of a permanently inoperative or malfunctioning
Subpart B of 42 CFR 431. This includes services that,
body part, or to restrict motion in a diseased or injured part
as determined on the basis of medical advice, are more
of the body.
readily available in other states, and services needed due
61
Benefits
Custom Orthotics
Service Providers
A prior authorization is required for custom orthotics.
Durable medical equipment (DME) is paid for in accordance
Coverage for Members Under Age 21
with the Provider Participation Agreement (PPA). Fee-for-
Orthotic devices are a covered benefit for Health Net
service (FFS) providers may be directed to any participating
Access members under age 21 when they are medically
Health Net DME provider, including Preferred Homecare.
necessary and the orthotics cost less than other treatments that are as helpful for the condition.
For insulin pumps and supplies, contact Animas Diabetes Care, LLC or MiniMed, Inc.
Coverage for Members Ages 21 and Older Orthotic devices are a covered benefit for Health Net
Members may obtain orthotics and prosthetics from
Access members ages 21 and older when all of the
any Health Net participating provider, such as Hanger
following apply:
Prosthetics and Orthotics.
• The use of the orthotic is medically necessary as the preferred treatment option consistent with Medicare
Emergency Services
guidelines.
Health Net Access provides coverage for emergency
• The orthotic is less expensive than all other
services to all members. An emergency medical condition is
treatment options or surgical procedures to treat the
defined as the treatment for a medical condition, including
same diagnosed condition.
emergency labor and delivery, which manifests itself by
• The member’s primary care physician (PCP) or
acute symptoms of sufficient severity, including severe pain,
other physician orders the orthotic.
such that a prudent layperson with an average knowledge of health and medicine, could reasonably expect in the absence
The following prosthetics are not covered for members ages 21 and older.
of immediate medical attention to result in: • Serious jeopardy to the health of the individual or, in the
• bone-anchored hearing aids (BAHA), also known as
case of a pregnant woman, the health of the woman or
osseointegrated implants
her unborn child.
• cochlear implants
• Serious impairment to bodily functions.
• insulin pumps
• Serious dysfunction of any bodily organ or part.
• percussive vests Orthotic services are not available through Health
Emergency medical services are services provided for the
Net’s preferred DME provider (Preferred Homecare).
treatment of an emergency medical condition and are:
They may be obtained through prosthetic and orthotic
• Furnished by a provider qualified to furnish emergency
providers, such as Hanger Prosthetics and Orthotics.
services. • Needed to evaluate or treat an emergency medical condition.
62
Benefits
Emergency services are covered both in-network and
may also be enrolled in an emergency room diversion
out-of-network and do not require prior authorization. In
case management program to assist in coordinating care,
accordance with the Arizona Health Care Cost Containment
educating members on appropriate use of the ER, and
Systems (AHCCCS) and 42 CFR 438.114, emergency room
identifying appropriate actions to take when care is needed.
screening and stabilization services do not require prior
Case managers work with members’ PCPs to address
authorization to be covered by Health Net.
concerns.
If a member receives emergency care at an out-of-
Providers, including emergency departments, may refer
network hospital and needs inpatient care after the
members to the emergency room diversion program by
emergency condition is stabilized, he or she must receive
calling the Case Management Department or by faxing a
inpatient care at the out-of-network hospital authorized
Case Management Referral form. Providers may contact the
by Health Net Access. The cost is the cost-sharing
Provider Services Center for general questions.
amount the member would pay at a network hospital. Health Net Access expects members to schedule For members who are hospitalized at an out-of-network
appointments during office hours whenever possible instead
hospital, Health Net Access and its delegates may offer
of using urgent care facilities or emergency rooms. Providers
to move the member, when the attending emergency
must follow appointment standards to meet members’ urgent
physician or the treating physician determines the
and emergent care needs.
member is sufficiently stabilized for transfer or discharge, to an in-network hospital when ongoing
Coverage Explanation
inpatient care is indicated. Health Net Access recognizes
Health Net Access covers eye and optometric services
the attending emergency physician or the treating
provided by qualified eye/optometry professionals within
physician makes the determination as to when the
certain limits based on member age and eligibility:
patient is stable for transfer.
• Emergency eye care, which meets the definition of an emergency medical condition
In accordance with Senate bill (SB) 1034, Health Net
• For members age 21 and older, treatment of medical
Access is required to educate its members about the
conditions of the eye, excluding eye examinations for
appropriate use of emergency services when a member
prescriptive lenses and the provision of prescriptive
inappropriately seeks care at a hospital emergency
lenses
department four or more times in a six-month
• Vision examinations and the provision of prescriptive
period. Health Net Access sends an emergency room
lenses for members under the Early and Periodic
educational letter to all identified members and their
Screening, Diagnosis and Treatment (EPSDT), KidsCare
assigned primary care providers (PCPs). Members
program and for adults when medically necessary
63
Benefits
following cataract removal
Provider Responsibility
• Cataract removal for all eligible members under
Health Net Access members may obtain family planning
certain conditions. Details of coverage criteria
services and supplies from any qualified family planning
are available on the Arizona Health Care Cost
provider without referral or prior authorization. Family
Containment System (AHCCCS) website at www.
planning services are covered for members who voluntarily
azahcccs.gov/ > Medical Policy Manual > Chapter 300
choose to delay or prevent pregnancy.
Coverage Specifications for Children (Under age 21)
All providers are responsible for: • Making appropriate referrals to health professionals who
• Medically necessary emergency eye care, vision
provide family planning services.
examinations, prescriptive lenses and treatments for
• Keeping complete medical records regarding referrals.
conditions of the eye are covered
• Verifying and documenting a member’s willingness to
• Primary care physicians (PCPs) are required to
receive family planning services.
provide initial vision screening in their office as part
• Providing medically necessary management of members
of the EPSDT program
with family planning complications.
• Members under age 21 with vision screening
• Notifying members of available contraceptive services
of 20/60 or greater should be referred to the
and making these services available to all members of
contracting vision provider for further examination
reproductive age using the following guidelines:
and possible provision of glasses
o Information for members who are ages 17 and
• Replacement of lost or broken eyeglasses is covered
younger must be given to the member’s parent or
• Contact lenses are not covered
guardian. o Information for members between ages 18 to 55
Coverage Specifications for Adults (Age 21 and older)
must be provided directly to the member or legal guardian.
• Emergency care for eye conditions that meet the
o Whenever possible, contraceptive services should
definition of an emergency medical condition is
be offered in a broad-spectrum counseling context,
covered
which includes discussion of mental health and
• Cataract removal and/or medically necessary
sexually transmitted diseases, including AIDS.
vision examinations, including prescriptive lenses if
o Members of any age whose sexual behavior exposes
needed following cataract removal, is covered
them to possible conception or sexually transmitted
• Routine eye exams and glasses are not covered
infections (STIs) should have access to the most effective methods of contraception. o Every effort should be made to include male or female partners in such services.
64
Benefits
Member Education
in preventing sexually transmitted diseases (including
In order for members to make informed decisions,
AIDS). Documentation must be recorded in the member’s
counseling should provide accurate, up-to-date
medical record that each member of reproductive age was
information regarding available family planning
notified verbally or in writing of the availability of family
methods and prevention of sexually transmitted
planning.
diseases. Such discussions must be: • Provided in a manner free from coercion or behavioral/
Health Net Access providers are responsible for:
mental pressure.
• Providing counseling and education to members of both genders that is age appropriate and
• Available and easily accessible to members.
includes information on prevention of unplanned
• Provided in a manner that assures continuity and confidentiality.
pregnancies.
• Provided by, or under the direction of, a qualified
• Counseling for unwanted pregnancies. Counseling
provider.
should include the member’s short- and long-term
• Documented in the medical record.
goals. • Spacing of births to promote better outcomes for
Sterilization
future pregnancies. • Preconception counseling to assist members
Sterilization services, including hysteroscopic tubal
in deciding on the advisability and timing of
sterilizations, are covered for both male and female members
pregnancy, to assess risks and to reinforce habits
who meet the requirements specified in the Health Net
that promote a healthy pregnancy.
Access policy for sterilization services.
• Discussion of sexually transmitted diseases, to include methods of prevention, abstinence, and
The following requirements must be met for sterilization
changes in sexual behavior and lifestyle that
services to be covered:
promote the development of good health habits.
• The member is at least age 21 at the time he or she signs
• Contraceptives should be recommended and
the consent form.
prescribed for sexually active members.
• Mental competency is determined. • Voluntary consent was obtained without coercion.
Providers are required to discuss the availability of
• 30 days, but not more than 180 days, have passed
family planning services annually. If a member’s sexual
between the date of informed consent and the date of
activity presents a risk or potential risk, the provider
sterilization, except in the case of a premature delivery or
should initiate an in-depth discussion on the variety of
emergency abdominal surgery.
contraceptives available and their use and effectiveness
• Members may consent to be sterilized at the time of
65
Benefits
a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since they
Sterilization consents may not be obtained when a member is:
gave informed consent for the sterilization. In the
• In labor or childbirth.
case of premature delivery, the informed consent
• Seeking to obtain, or is obtaining, pregnancy
must have been given at least 30 days before the
termination.
expected date of delivery.
• Under the influence of alcohol or other substances that affect that member’s state of awareness.
Members requesting sterilization must sign an appropriate consent form with a witness present.
Foot and Ankle Services
Suitable arrangements must be made to ensure that
Health Net Access covers medically necessary foot and ankle
the information in the consent form is effectively
care services, including the following, when ordered by a
communicated to members with limited-English
member’s primary care physician (PCP), attending physician
proficiency or reading skills, and those with diverse
or practitioner within certain limits for eligible Health Net
cultural and ethnic backgrounds, as well as members
Access members.
with visual and/or auditory limitations. Prior to signing
• Under age 21 - Bunionectomies, casting for the purpose
the consent form, a member must be offered factual
of constructing or accommodating orthotics, medically
information, including:
necessary orthopedic shoes that are an integral part of
• Consent form requirements.
a brace, and medically necessary routine foot care for
• Answers to questions asked regarding the specific
patients with a severe systemic disease that prohibits care
procedure to be performed.
by a non-professional person
• Notification that withdrawal of consent can occur
• Age 21 or older - Wound care, treatment of pressure
at any time prior to surgery without affecting
ulcers, fracture care, reconstructive surgeries, and
future care and/or loss of federally funded program
limited bunionectomy services. Medically necessary
benefits.
routine foot care services are only available for members
• A description of available alternative methods.
with a severe systemic disease that prohibits care by a
• A full description of the discomforts and risks that
nonprofessional. Services are not covered when provided
may accompany or follow the performing of the
by a podiatrist or podiatric surgeon. Members can be
procedure including an explanation of the type and
referred to other contracting providers who can perform
possible effects of any anesthetic to be used.
medically necessary foot and ankle procedures, including
• A full description of the advantages or disadvantages
reconstructive surgeries. A prescription written by
that may be expected as a result of the sterilization.
a podiatrist would not automatically disqualify the
• Notification that sterilization cannot be performed
prescribed medication (device or service) from payment.
for at least 30 days post-consent.
However, the prescribed medication, device or service
66
Benefits
may be subject to prior authorization to determine
to:
whether it is covered
• Anticoagulation therapy in progress • Arteriosclerosis obliterans (arteriosclerosis of the
Bunionectomies are covered only when the bunion is
extremities, occlusive peripheral arteriosclerosis)
present with:
• Buerger’s disease (thromboangiitis obliterans)
• Overlying skin ulceration
• Chronic thrombophlebitis
• Neuroma secondary to bunion (neuroma to be
• Diabetes mellitus
removed at same surgery and documented by
• Peripheral neuropathies involving the feet
pathology report)
• Chemotherapy in progress • Pernicious anemia
Bunionectomies are not covered if the sole indications
• Hereditary disorder, such as hereditary sensory radicular
are pain and difficulty finding appropriate shoes.
neuropathy or Fabry’s disease • Hansen’s disease or neurosyphilis
Routine Foot Care
• Malabsorption syndrome
Routine foot care is defined as services performed in
• Multiple sclerosis
the absence of localized illness, injury or symptoms
• Traumatic injury
involving the foot. Routine foot care is considered
• Uremia (chronic renal disease)
medically necessary in very limited circumstances. These services include:
Treatment of a fungal (mycotic) infection is considered
• Cutting or removal of corns or calluses
medically necessary foot care and is covered when the
• Nail trimming (including mycotic nails)
member has all of the following:
• Other hygienic and preventive maintenance care in
• A systemic condition
the realm of self-care (such as cleaning and soaking
• Clinical evidence of mycosis of the toenail
the feet, and the use of skin creams to maintain skin
• Compelling medical evidence documenting the member
tone of both ambulatory and bedfast patients)
either: o Has a marked limitation of ambulation due to the
Routine foot care is considered medically necessary
mycosis, which requires active treatment of the foot
when the member has a systemic disease of sufficient
o In the case of a nonambulatory member, has a
severity that performance of foot care procedures by
condition that is likely to result in significant medical
a nonprofessional would be hazardous. Conditions
complications in the absence of such treatment.
that might necessitate medically necessary foot care
Limitations
include metabolic, neurological and peripheral vascular
Coverage is limited as follows:
systemic diseases. Examples include, but are not limited
• Coverage for medically necessary routine foot care must not exceed two visits per quarter or eight visits
67
Benefits
per contract year (this does not apply to Early
• Hypertension screening (annually)
and Periodic Screening, Diagnosis and Treatment
• Cholesterol screening (once; additional tests based on
(EPSDT) members)
history)
• Coverage of mycotic nail treatments does not
• Routine mammography annually after age 40 and at any
exceed one bilateral mycotic nail treatment (up to
age if considered medically necessary
10 nails) per 60 days (this does not apply to EPSDT
• Cervical cytology, including Pap smears (annually for
members)
sexually active women; after three successive normal
• Neither general diagnoses, such as arteriosclerotic
exams, the test may be less frequent)
heart disease, circulatory problems, vascular disease,
• Colon cancer screening (digital rectal exam and stool
venous insufficiency, or incapacitating injuries or
blood test, annually after age 50, as well as baseline
illnesses, such as rheumatoid arthritis, CVA (stroke)
colonoscopy after age 50)
or fractured hip, are diagnoses under which routine
• Sexually transmitted disease screenings (at least once
foot care is covered.
during pregnancy; other based on history) • Tuberculosis screening (once, with additional testing
Overview
based on history; for members residing in a facility,
Health Net Access covers health risk assessment and
as necessary, per health care institution licensing
screening tests provided by a physician, primary
requirement)
care physician (PCP) or other licensed practitioner
• HIV screening
within the scope of his or her practice under state law
• Immunizations
for all members. These services include appropriate
• Prostate screening (annually after age 50; screening is
clinical health risk assessments and screening tests,
recommended annually for males ages 40 and older who
immunizations, and health education, as appropriate for
are at high risk due to immediate family history) • Physical examinations, periodic health examinations or
age, history and current health status.
assessments, diagnostic workups or health protection packages designed to:
Health risk assessment and screening tests are also covered for members under the Early and Periodic
o Provide early detection of disease
Screening, Diagnosis and Treatment Program (EPSDT)
o Detect the presence of injury or disease
and KidsCare Program.
o Establish a treatment plan o Evaluate the results or progress of the treatment plan or disease
Covered Services
o Establish the presence and characteristics of a
Preventive health risk assessment and screening test
physical disability which may be the result of disease
services for non-hospitalized adults include, but are not
or injury
limited to:
Screening services provided more frequently than these
68
Benefits
professionally recommended guidelines are not covered
• Home health aid services
unless medically necessary.
• Medically necessary supplies • Therapy services
Services Not Covered Physical examinations not related to covered health care
Home health services require prior authorization. Refer to
services or performed to satisfy the demands of outside
the Prior Authorization Requirements for Health Net Access
public or private agencies, such as the following, are not
for additional information.
covered services:
Face-to-Face Encounters for Continued Hospice Eligibility
• Qualification for insurance • Pre-employment physical examination • Qualifications for sports or physical exercise
Hospice physicians or hospice nurse practitioners (NPs)
activities
must have a face-to-face encounter with every hospice
• Pilots examinations (Federal Aviation
patient to determine continued hospice eligibility. To satisfy
Administration)
this requirement, the following criteria must be met:
• Disability certification for the purpose of
1. The face-to-face encounter must occur no more than
establishing any kind of periodic payments
30 calendar days prior to the start of the third benefit
• Evaluation for establishing third party liability
period and no more than 30 calendar days prior to every
• Preventive examinations in the absence of any know
subsequent benefit period thereafter.
disease or symptom for members ages 21 and older
2. The hospice physician or NP who conducts the faceto-face encounter must attest in writing to it. The
Overview
attestation must be on a separate and distinct section of,
Home health services are provided on a part-time
or addendum to, the recertification form, be clearly titled
or intermittent basis to prevent hospitalization or
and include the rendering physician’s or NP’s signature
institutionalization. Home health services must be
and date of face-to-face encounter. When an NP
obtained through a participating provider. Providers are
conducts the face-to-face encounter, the attestation must
required to utilize the preferred provider network for
state the clinical findings were provided to the certifying
the member’s benefit plan. Providers who are unsure
physician for use in determining whether the patient
of the preferred provider network should contact the
continues to have a life expectancy of six months or less,
Health Net Access Provider Services Center.
if the illness runs its normal course.
Home health services include medically necessary
In cases where a hospice newly admits a patient in the third
services provided in the member’s place of residence,
or later benefit period, exceptional circumstances may
including:
prevent a face-to-face encounter prior to the start of the
• Home health nursing visits
benefit period (as described in criteria 1). For example, if
69
Benefits
the patient is an emergency admission on a weekend,
• Inpatient respite care, which is short-term care provided
it may be impossible for a hospice physician or NP
to the member only when necessary to relieve the family
to see the patient until the following Monday, or the
or other persons caring for the member. Not to exceed
hospice may be unaware that the member is in the
more than 5 consecutive days at a time and not provided
third benefit period. In such documented cases, a face-
when the member is a nursing facility resident or
to-face encounter within two days after admission is
receiving services in an inpatient setting
considered timely. If the patient dies within two days of
• Routine home care
admission without a face-to-face encounter, a face-to-
• Medical social service consultations by a qualified social
face encounter can be deemed as completed.
worker • Therapy, including physical, occupational, respiratory,
The hospice must retain the certification statements and
speech, music, and recreational
have them available for Health Net’s audit purposes.
• 24-hour on-call availability to provide services such as reassurance, information and referral for members,
Hospice Care
family and caretakers • Volunteer services provided by individuals who are
Hospice services are covered when Health Net Access members have met hospice care requirements and the
specially trained in hospice and who are supervised by a
services are authorized by Health Net or a participating
designated hospice employee • Medical and surgical supplies and durable medical
provider. The member’s treating physician must certify
equipment, including medications
the member as terminally ill and expected to live six months or less. The hospice and its employees must
Hospital and Skilled Nursing Facility Inpatient Services
be Medicare-certified and licensed by the Arizona Department of Health Services (ADHS).
Health Net Access covers medically necessary inpatient The following services are covered under hospice when
hospital and skilled nursing facility (SNF) services provided
provided in an approved setting:
by participating hospitals and SNFs for Health Net Access
• Bereavement services
members.
• Continuous home care • Dietitian services
Hospital services include accommodation, appropriate
• Home health aid services
staffing, supplies, equipment, and services for the following:
• Homemaker services
• Routine acute medical care.
• Nursing services provided by or under the
• Intensive and coronary care.
supervision of a registered nurse
• Neonatal intensive care.
• Pastoral services
• Maternity care, including labor, delivery and recovery
70
Benefits
rooms, birth centers, and nursery and related
tube feedings, personal care services, routine testing of
services.
vital signs and blood glucose monitoring, assistance with
• Surgical care, including recovery rooms and
eating and/or maintenance of catheters.
anesthesiology services.
• Basic patient care equipment and supplies.
• Obstetrics and newborn nurseries.
• Dietary services, including special diets and adaptive
• Behavioral health emergencies.
tools for eating.
• Nursing services.
• Physician visits made for meeting state requirements.
• Dietary services.
• Non-customized durable equipment and supplies.
• Ancillary services, including:
• Rehabilitation therapies ordered as a maintenance
o chemotherapy
regimen.
o dialysis
• Over-the-counter medications and laxatives.
o laboratory
• Social activity, recreational and spiritual services.
o radiology
• Any other services, supplies or equipment that are state
o medications
or county regulatory requirements or are included in the
o medical supplies
SNF’s room and board rate.
o respiratory therapy o rehabilitation services (PT, OT, speech therapy)
An admission to a SNF must be prior authorized by the
o blood and blood derivatives
Health Net Medical Management Department before a
o dental surgery for members in the Early and
member is admitted.
Periodic Screening, Diagnosis and Treatment
When Member Disenrolls While Hospitalized
(EPSDT) program
Health Net Access notifies the hospital when a member Health Net Access covers semiprivate inpatient hospital
disenrolls from Health Net Access while hospitalized. The
accommodations, except when the member’s medical
hospital must contact the member’s new health plan for
condition requires isolation.
authorization of continued services and discharge planning. Health Net Access concurrent review nurses work closely
Health Net Access covers up to 90 days of care in a
with the hospital to ensure that care is coordinated during
SNF per contract year (generally October 1 through
the member’s transition.
September 30) for members who are not eligible for Arizona Long-Term Care System (ALTCS) services.
Upon completion of the member’s initial consultation with
Services that are not covered separately when provided
a genetics physician and metabolic nutritionist, and the
in a SNF include:
determination of metabolic formula and/or low-protein
• Nursing services, such as administering medication,
foods necessary to meet the member’s nutritional needs, the provider forwards the request for metabolic nutrition to the
71
Benefits
medical foods liaison at AHCCCS/Office of Medical
Special Considerations for Hysterectomy
Policy and Programs (OMP) for review and processing. All approvals and payments for medical foods are the
Health Net Access covers medically necessary hysterectomy
responsibility of AHCCCS administration.
services in accordance with federal regulations (42 CFR 441.250). Federal regulation 42 CFR 441.251 defines
Overview
hysterectomy as a medical procedure or operation for the
Health Net contracts with several hospitalist service
purpose of removing the uterus. Sterilization is defined
providers. Primary care physicians (PCPs) and
by this regulation as any medical procedure, treatment
specialists may admit their patients who are Health Net
or operation for the purpose of rendering an individual
members, otherwise participating hospitalists must be
permanently incapable of reproducing.
used whenever hospitalist services are required. For assistance locating a participating hospitalist, contact
Health Net Access does not cover hysterectomies when they
the admitting facility directly or the Health Net Provider
are performed solely to render the individual permanently
Network Management Department during normal
incapable of reproducing.
business hours. Hysterectomy services coverage is limited to cases in
Continuity of Care
which medical necessity has been established and, prior to
Hospitalists are required to provide the following
hysterectomy, there was a trial of medical or surgical therapy
member discharge information to the member’s primary
that was not effective in treating the member’s condition.
care physician (PCP) within 72 hours of the member’s discharge from the hospital:
Hysterectomy may be indicated for the following reasons,
• Admission and discharge dates
which include, but are not limited to:
• Presenting problem
• Dysfunctional uterine bleeding or benign fibroids
• Discharge diagnoses
associated with dysfunctional bleeding. A hysterectomy
• Discharge medications
may be considered for members for whom medical and
• Follow-up instructions
surgical therapy has failed, and childbearing is no longer a consideration
Refer to the Health Net Discharge Summary Form or
• Endometriosis. A hysterectomy is indicated for members
incorporate the information noted above into the form
with severe disease when future child-bearing is not a
currently used.
consideration, and when disease is refractory to medical or surgical therapy • Uterine prolapse. A hysterectomy may be indicated in women with uterine prolapse for whom childbearing
72
Benefits
is no longer a consideration and for whom
documentation must be kept in the member’s medical
nonoperative and/or surgical correction, such as
record. A copy must also be kept in the member’s
suspension or repair, will not provide the member
medical record maintained by the member’s Health Net
adequate relief
Access primary care provider.
Conditions Not Subject to Prior Therapy Trial
Participating providers must ensure members sign a
Hysterectomy services may be considered medically
consent form and may use the Arizona Health Care
necessary without prior trial of therapy in the following
Cost Containment System (AHCCCS) Hysterectomy
cases:
Consent form or other similar forms, as long as prior
• Invasive carcinoma of the cervix
acknowledgement information is provided.
• Ovarian carcinoma • Endometrial carcinoma
Exceptions from Prior Acknowledgement
• Carcinoma of the fallopian tube
Prior acknowledgment is not required in either of the
• Malignant gestational trophoblastic disease
following situations:
• Life-threatening uterine hemorrhage, uncontrolled
• The member was already sterile before the hysterectomy.
by conservative therapy
The physician must certify in writing that the member
• Potentially life-threatening hemorrhage as in
was already sterile at the time of the hysterectomy and
cervical pregnancy, interstitial pregnancy or
specify the cause of sterility
placenta abruption
• The member requires a hysterectomy due to a lifethreatening emergency situation in which the physician
Prior Acknowledgement and Documentation
determines that prior acknowledgement is not
Prior to performing a hysterectomy, providers are
possible. The physician must certify in writing that the
required to:
hysterectomy was performed under a life-threatening
• Inform the member and her representative, if
emergency situation in which the physician determined
applicable, both orally and in writing that the
that prior acknowledgement was not possible
hysterectomy will render the member incapable of
Coverage Explanation
reproducing. • Obtain from the member or representative, if
Medically necessary immunizations, as determined by
applicable, a signed, dated written acknowledgment
Health Net, are covered under all Health Net plans and
stating that the information above has been
include adult immunizations recommended by the Centers
received and that the individual has been
for Disease Control and Prevention (CDC) Advisory
informed and understands the consequences of
Committee on Immunization Practices (ACIP), and
having a hysterectomy (result in sterility). This
childhood and adolescent immunizations recommended by
73
Benefits
the ACIP, the American Academy of Pediatrics (AAP)
Treatment (EPSDT) program covers all child and adolescent
or the American Academy of Family Physicians (AAFP).
immunizations, as specified in the Centers for Disease
Most immunizations do not require a copayment.
Control and Prevention (CDC) recommended childhood immunization schedules. All appropriate immunizations
Flu Shots
must be provided to establish and maintain up-to-date
Flu shots are available to all members. Copayments may
immunization status for each member based on his or her
only be collected for flu shots when given in conjunction
age. Refer to the CDC website at www.cdc.gov/vaccines/
with an office visit.
schedules/index.html for current immunization schedules.
Immunization Administration
For adult immunization coverage, refer to Chapter 300 Medical Policy for AHCCCS Covered Services, Policy 310-M,
Primary care providers (PCPs) are responsible
or to the CDC website at www.cdc.gov/vaccines/schedules/
for immunizing members and maintaining all
index.html for adult immunization recommendations.
immunization information in the member’s medical record. Local health departments (LHDs) may also
Vaccines for Children Program
immunize Health Net Access members.
The federal Vaccines for Children (VFC) program is available to physicians who provide immunizations to
PCPs must be available to administer immunizations
Medicaid- eligible members. Providers are required to
during routine office hours. It is the PCP’s responsibility
enroll in the program in order to participate. This federally
to update the immunization record card or other form
funded program furnishes free vaccines in bulk to enrolled
of immunization record, and enter all immunizations
providers. All Medicaid-eligible children under age 19 may
into the Arizona State Immunization Information
receive VFC vaccines.
System (ASIIS) registry.
Health Net Access does not reimburse participating
At each visit, the PCP should inquire whether the
providers for vaccines covered by the VFC program. Health
patient has received immunizations from another
Net Access reimburses for the administration of these
provider. The PCP should also educate members
immunizations only, not to exceed the maximum allowable
regarding their responsibility to inform the PCP if they
set by the Centers for Medicare and Medicaid Services
receive immunizations elsewhere (such as from an
(CMS). Refer to the VFC Program Billing Procedures
LHD or nonparticipating provider). This information
discussion for more information on reimbursement.
is necessary for documentation and for the member’s
Participating providers must register with Arizona
safety.
Department of Health Services (ADHS) as a vaccine provider. Providers must enroll in the VFC program and re-
EPSDT Program
enroll annually.
The Early and Periodic Screening, Diagnostic and
74
Benefits
AHCCCS Recommended Childhood and Adolescent Immunization Schedules
75
Benefits
76
Benefits
77
Benefits
78
Benefits
Immunization - Recommended Childhood and Adolescent Schedule
79
Benefits Immunization - Recommended Childhood and Adolescent Schedule
80
Benefits Immunization - Recommended Childhood and Adolescent Schedule
81
Benefits Immunization - Recommended Childhood and Adolescent Schedule
82
Benefits Immunization - Recommended Childhood and Adolescent Schedule
83
Benefits Immunization - Recommended Childhood and Adolescent Schedule
84
Benefits
Injectable Medications
1. Complete a Health Net Prior Authorization/Formulary Exception Request Fax Form.
Participating providers must obtain any injectable
2. Fax the form to Health Net Pharmaceutical Services.
medications they administer. Members cannot obtain these medications through there outpatient prescription
Most requests receive a response via fax within two business
medication benefits.
days. Refer to the member’s Evidence of Coverage (EOC) and Summary of Benefits for complete injectable medication
Self-Injectable Medications
benefit coverage information. Particpating providers
Most self-injectable medications, other than preferred
can also go to www.healthnetaccess.com Pharmacy
insulins, require prior authorization. Refer to the Injectable
Information for medication information.
Drugs Requiring Prior Authorization/Precertification list for more information. This is not intended to be an all-
Prior Authorization
inclusive list and is subject to change as new injectables become available. For more information on medication
Health Net covers medically necessary injectable
prior authorization, refer to the Health Net website at www.
medications administered by a Health Net participating
healthnetaccess.com Pharmacy Information.
providers in an office setting. Most injectable medications administered in the office do not require
Members must obtain self-injectable medications at
prior authorization; however, prior authorization is
retail pharmacies through the members’ outpatient
required for the medications listed on the in-office
pharmacy benefits and cannot obtain self-injectables
Injectable Drugs Requiring Prior Authorization/
from a participating provider’s office. Some self-injectable
Precertification list. This is not intended to be an all-
medications must be obtained from Health Net’s preferred
inclusive list and is subject to change as new brand-
specialty pharmacies (as indicated in the prior authorization
name equivalents become available. All self-injectable
approval).
medications other than preferred insulin vials require prior authorization. Prior authorization is also required
On rare occasions, self-injectable medications may require
for growth hormones prescribed for home use.
administration by a health care professional and prior
Prior Authorization Procedures
authorization is required.
To obtain prior authorization from Health Net
Healthy Pregnancy Program
Pharmaceutical Services (HNPS) for in-office-
The Decision Power®Healthy Pregnancy program educates
administered injectable medications, self-injectable
women and provides screening to identify high-risk
medications and non-preferred medications:
pregnancies. This program has been effective in prolonging
85
Benefits
pregnancies, improving birth weights and minimizing
identification of pregnancy, medically necessary prenatal
hospitalizations, by featuring the following:
services for the care of pregnancy, the treatment of
• Initial assessment and risk screening, conducted at
pregnancy-related conditions, labor and delivery services,
time of enrollment
and postpartum care. In addition, related services such
• Online educational resources
as outreach, education, and family planning services are
• The book, Your Journey Through Pregnancy, which
provided whenever appropriate, based on the member’s
includes information from early pregnancy through
current eligibility and enrollment.
the baby’s first weeks, and a resource bookmark • Access to BabyLine® - a telephone line answered by
All maternity care services must be delivered by qualified
highly experienced nurses, 24 hours a day, seven
physicians and non-physician practitioners and must be
days a week, for questions related to pregnancy
provided in compliance with the most current American
• Second assessment at approximately 28 weeks
Congress of Obstetricians and Gynecologists (ACOG)
• Referrals to case management for those at-risk
standards for obstetric and gynecologic services. Services
participants identified during assessments
may be provided by physicians, physician assistants, nurse
• Final assessment completed post-delivery
practitioners, certified nurse midwives, or licensed midwives.
• Assessment report for participants and their
Prenatal care, labor and delivery, and postpartum care
physicians
services may be provided by licensed midwives within their scope of practice.
Pregnant members identified as high risk and enrolled in the high-risk obstetric case management program
Pregnant members have the option to select a primary care
have access to the expertise and experience of high-
physician (PCP) who provides obstetrical care. Members
risk obstetric nurse case managers who are available
who receive maternity services from a certified nurse
to program participants 24 hours a day, seven days a
midwife or a licensed midwife are also assigned to a PCP for
week. The case manager creates a care plan unique for
other health care and medical services.
each participant, by helping to set goals and develop strategies to assist the participant. Case managers also
To ensure continuity of care, members who transition to
coordinate home-care and neonatal intensive care
or enrolled with another health plan during their third
unit (NICU) care as needed. Refer eligible Health Net
trimester may continue to receive maternity care from their
expectant mothers to this program via fax.
current AHCCCS-registered provider.
Overview
High-Risk Maternity Care
Maternity care services include, but are not limited
In partnership with obstetric providers, Health Net Access’
to, medically necessary preconception counseling,
Medical Management Department identifies pregnant
86
Benefits
women who are at risk for adverse pregnancy outcomes.
• multiple gestation • teenage mothers
Health Net Access offers a multidisciplinary program
• hyperemesis
to assist providers in managing the care of pregnant
• poor weight gain
members who are at risk because of medical conditions,
• advanced maternal age
social circumstances or non-compliant behaviors.
• substance abuse
Health Net Access also considers factors, such as
• mental illness
noncompliance with prenatal care appointments and
• domestic violence
medical treatment plans, in determining risk status.
• non-compliance with obstetric appointments
Members identified as at risk are reviewed and evaluated
• members taking prescription opioids
for ongoing follow-up during their pregnancy by an obstetric case manager.
Reporting High-Risk and Non-Compliant Behaviors
A Health Net Access obstetric case manager provides
Obstetric providers must refer all at risk members to Health
comprehensive care management services to high-
Net Access by contacting the Provider Services Center or
risk pregnant members, for the purpose of improving
faxing the member’s information to the Health Net Access
maternal and fetal birth outcomes. The obstetric case
Case Management Department.
manager takes a collaborative approach with all involved in the member’s prenatal care, including obstetric
The following situations must be reported to Health Net
providers, primary care providers (PCPs) and specialists,
Access:
to engage high-risk pregnant members telephonically
• Members who are diabetic and display consistent
throughout their pregnancies and postpartum periods.
complacency regarding dietary control and/or use of
Members who have high-risk perinatal conditions
insulin.
should be referred to perinatal case management by
• Members who fail to follow prescribed bed rest.
faxing the member’s information to the Health Net
• Members who fail to take tocolytics as prescribed or do
Access Case Management Department. These conditions
not follow home uterine monitoring schedules.
include:
• Members who admit to or demonstrate continued
• history of preterm labor before 37 weeks of gestation
alcohol and/or other substance abuse.
• bleeding and blood clotting disorders
• Members who show a lack of resources (such as food,
• chronic medical conditions
shelter and clothing) that could influence their well-
• polyhydramnios or oligohydramnios
being or that of their child.
• placenta previa, abruption or accrete
• Members who frequently visit the emergency
• cervical changes
department/urgent care setting with complaints of acute pain and request prescriptions for controlled analgesics
87
Benefits
and/or mood altering medications.
All providers must adhere to the standards of care
• Members who fail to appear for two or more
established by ACOG, including, but not limited to the
prenatal visits without rescheduling, or fail to keep
following:
rescheduled appointments.
• Use of a standardized prenatal medical record and risk
o Providers should make two attempts to bring
assessment tool, such as the ACOG form.
the member in for care prior to contacting
• Documenting all aspects of maternity care.
the Health Net Access Case Management
• Completion of history, including medical and personal
Department.
health (including infections and exposures), menstrual cycles, past pregnancies and outcomes, family and
Maternity Care Provider Requirements
genetic history. • Clinical expected date of confinement. • Performance of physical exam, including determination
Prior authorization is required at the time of the
and documentation of pelvic adequacy.
member’s first prenatal visit. The authorization applies
• Performance of laboratory tests at recommended time
to obstetrical care for the duration of the member’s
intervals.
pregnancy. Providers must submit the Health Net Access
• Comprehensive risk assessment incorporating
Request for Prior Authorization form at the time of the
psychosocial, nutritional routine prenatal visits
first prenatal visit.
with blood pressure, weight, fundal height (tape measurement), fetal heart tones, urine dipstick for
Providers must adhere to the American Congress of
protein and glucose, ongoing risk assessment with any
Obstetricians and Gynecologists (ACOG) standards of
change in pregnancy risk recorded, and an appropriate
care, including the use of a standardized medical risk
management plan.
assessment tool and ongoing risk assessment.
• Antenatal and postpartum depression screening.
Providers are required to identify risk factors
All maternity care providers must ensure they do the
by completing a comprehensive tool that covers
following:
psychosocial, nutritional, medical, and educational
• Request prior authorization from Health Net Access
factors, such as the ACOG or Mutual Insurance
promptly when members have tested positive for
Company of Arizona (MICA) assessment tool, when
pregnancy.
submitting the prior authorization request.
• Refer high-risk members to a qualified physician and are receiving appropriate care.
Licensed midwives must provide services within their
• Educate members about health behaviors during
scope of practice.
pregnancy, including the importance of proper nutrition; smoking cessation; avoidance of alcohol and other
88
Benefits
harmful substances, including illegal drugs and
other infant care information.
opioids; screening for sexually transmitted diseases;
• Offering HIV/AIDS testing and confidential post testing
the physiology of pregnancy; risk assessment and
counseling to all members.
screening for lead exposure, which, in pregnancy,
• Ensuring delivery meets Health Net Access criteria.
can adversely affect both mother and fetus health;
• Reminding delivery hospital of requirement to notify
process of labor and delivery; breastfeeding; other
Health Net Access on the date of delivery.
infant care information, including selecting a
• Referring member to Health Net Access case
pediatric provider for the baby; and postpartum
management, and other known support services and
follow-up.
community resources, as needed.
• Appropriately maintain member medical records
• Encouraging members to participate in childbirth classes
and document all aspects of maternity care
at no cost to them.
provided.
o The member may call the facility where she will
• Inform members of voluntary HIV testing and
deliver and register for childbirth classes.
that counseling is available if the test is positive or indeterminate.
Providers may consult with the Health Net Access medical
• Refer members for support services to the Special
director, or other qualified designee, for members with other
Supplemental Nutrition Program for Women,
conditions that are deemed appropriate for perinatology
Infants and Children (WIC), as well as other
referral.
community-based resources, to support healthy pregnancy outcomes. .
In non-emergent situations, all obstetrical care providers
• Notify members that in the event they lose
must refer members to Health Net Access providers in
eligibility for services, they may contact the Arizona
accordance with the following guidelines:
Department of Health Services Bureau of Women’s
• Referrals outside the participating provider network
and Children’s Health Hotlines for referrals to low-
must be prior authorized.
or no-cost services.
• Failure to obtain prior authorization for non-emergent
• Provide postpartum services to members within 60
obstetric or out-of-network newborn services will result
days of delivery.
in claim denials. • Members may not be billed for covered services if the
Additional obstetrical provider requirements include:
provider neglects to obtain the appropriate approvals.
• Educating members on healthy behaviors during pregnancy, including: proper nutrition, effects of
Obstetrical Care Appointment Standards
alcohol and drugs, the physiology of pregnancy, the
Health Net Access has specific standards for the timing
process of labor and delivery, breast feeding and
of initial and return prenatal appointments. All obstetric providers must make it possible for members to obtain initial
89
Benefits
prenatal care appointments within the following time
members continue to receive primary care services from
frames:
their assigned PCPs during their pregnancy.
• Category appointment availability: o First trimester - within 14 days of the request for
Health Net Access is involved in many community efforts
an appointment
to increase awareness of the need for prenatal care. Health
o Second trimester - within 7 days of the request
Net Access encourages PCPs to actively participate in these
for an appointment
outreach and education activities, including WIC. Providers
o Third trimester - within 3 days of the request for
should encourage members to enroll in this program.
an appointment
Various other services are available in the community to
o Return visits - return visits should be scheduled
help pregnant women and their families. Contact the Health
routinely after the initial visit
Net Access Provider Services Center for information about
• Members must be able to obtain return prenatal visits:
helping patients use these services.
o First 28 weeks - every four weeks o From 28 to 36 weeks - every two to three weeks
Pregnancy Termination
o From 37 weeks until delivery - weekly
Pregnancy termination is covered if one of the following
• High-risk pregnancy care appointments - Members
conditions is met:
must be able to obtain an initial appointment
• The pregnant member suffers from a physical disorder,
within three days of identification of high-risk by
physical injury or physical illness, including a life-
Health Net Access or maternity care provider, or
endangering physical condition caused by or arising
immediately if an emergency exists.
from the pregnancy itself that would, as certified by a physician, place the member in danger of death unless
Outreach, Education and Community Resources
the pregnancy is terminated. • The pregnancy is a result of rape or incest.
Health Net Access is committed to maternity care
• The pregnancy termination is medically necessary
outreach. The goal of maternity care outreach is to
according to the medical judgment of a licensed
identify pregnant members and begin prenatal care as
physician who attests that continuation of the pregnancy
soon as possible.
could reasonably be expected to pose a serious physical or mental health problem for the pregnant member.
PCPs should ask about pregnancy status when members call for appointments and report positive pregnancy
Conditions, Limitations and Exclusions
tests to Health Net Access. PCPs should provide general
The attending physician must acknowledge that a pregnancy
education and information about prenatal care, when
termination has been determined medically necessary
appropriate, during member office visits. Pregnant
by submitting the Certificate of Necessity for Pregnancy
90
Benefits
Termination and clinical information that supports the
Prior Authorization
medical necessity for the procedure.
Except in cases of medical emergencies, the provider The form must be submitted with the request for
must obtain prior authorization for all covered pregnancy
prior authorization to the Health Net Access Prior
terminations. When pregnancy termination is considered
Authorization Department and must certify that, in the
due to rape or incest, or because the mother’s health is in
physician’s professional judgment, one or more of the
jeopardy secondary to medical complications, fax a prior
above criteria have been met.
authorization request to 1-866-295-9729 along with the lab, radiology, consultation, and other test results that support
Additional Required Documentation
the medical necessity for the procedure, including:
• The provider must obtain a written informed
• A copy of the member’s medical record.
consent and keep it in the member’s chart for all
• A completed and signed copy of the Certificate of
pregnancy terminations. If the pregnant member
Necessity for Pregnancy Termination.
is younger than age 18, or is age 18 or older and
• Written explanation of the reason that the procedure is
considered an incapacitated adult, a dated signature
medically necessary. For example, the pregnancy is:
of the pregnant member’s parent or legal guardian
o Creating a serious physical or mental health problem
indicating approval of the pregnancy termination
for the pregnant member.
procedure is required.
o Seriously impairing a bodily function of the
• When the pregnancy is the result of rape or incest,
pregnant member.
documentation must be obtained that the incident
o Causing dysfunction of a bodily organ or part of the
was reported to the proper authorities, including
pregnant member.
the name of the agency to which it was reported, the
o Exacerbating a health problem of the pregnant
report number if available, and the date the report
member.
was filed.
o Preventing the pregnant member from obtaining
• When mifepristone is administered, the following
treatment for a health problem.
documentation is also required:
• If the pregnancy termination is requested as a result of
o Duration of pregnancy in days.
incest or rape, providers must also include identification
o The date intrauterine device (IUD) was removed
of the proper authority to which the incident was
if the member had one.
reported, including the name of the agency, the report
o The date mifepristone was given.
number and the date the report was filed.
o The date misoprostol was given. o Documentation that pregnancy termination
All terminations requested for minors must include a
occurred.
signature of a parent or legal guardian or a certified copy of a
91
Benefits
court order.
hospitalizations that do not exceed 48 hours of inpatient hospital care for a normal vaginal delivery
In cases of medical emergencies, the provider must
or 96 hours for a cesarean delivery
submit all documentation of medical necessity to the
o A newborn may be granted an extended stay in
Health Net Access Prior Authorization Department
the hospital of birth when the mother’s stay in the
within two business days of the date on which the
hospital is medically necessary beyond a 48-/96-
pregnancy termination procedure was performed.
hour stay. If the mother’s stay in the hospital exceeds the 25-day inpatient limit, the newborn may be
The Health Net Access medical director or qualified
granted an extended stay and is not subject to the
designee reviews all requests for medically necessary
25-day inpatient limit
pregnancy terminations.
• Home uterine monitoring - Medically necessary home uterine monitoring technology for members with
Related Services with Special Policies
premature labor contractions before 35 weeks gestation, as an alternative to hospitalization, is a covered benefit • Labor and delivery services provided in freestanding
Covered related services with special policy and
birthing centers
procedural guidelines include, but are not limited to:
o Services rendered in a freestanding birthing center
• Routine circumcision of newborn male infants,
must be provided by a physician (the member’s
which is not a covered service unless it is
primary care physician (PCP) or obstetrician with
determined to be medically necessary (ARS 36-
hospital admitting privileges) or by a registered
2907(b))
nurse midwife who is accredited/certified by the
• Inpatient hospital stays
American College of Nurse Midwives and has
o For members under age 21, Health Net Access
hospital admitting privileges for labor and delivery
covers up to 48 hours of inpatient hospital care
services
for a normal vaginal delivery and up to 96 hours
o Only members for whom an uncomplicated
of inpatient hospital care for a cesarean delivery
prenatal course and a low-risk labor and delivery
o For members age 21 and older, Health Net
can be anticipated may be scheduled to deliver at a
Access covers up to 48 hours of inpatient
freestanding birthing center
hospital care for a normal vaginal delivery and
• Labor and delivery services provided in a home setting
up to 96 hours of inpatient hospital care for a
o Only members for whom an uncomplicated prenatal
cesarean delivery to the extent that the stay does
course and a low-risk labor and delivery can be
not exceed the 25-day inpatient hospital stay
anticipated to deliver in the member’s home
limit
o Physicians and practitioners who render home labor
o Prior authorization is not required for
and delivery services must have admitting privileges
92
Benefits
at an acute care hospital in close proximity to
• HMG CoA lyase deficiency
the site where the services are provided in the
• cobalamin A, B, C deficiencies
event of complications during labor and/or delivery
Medical foods are metabolic formula or modified low-
• Licensed midwife services
protein foods produced or manufactured specifically for
o Licensed midwife services may only be provided
persons with a qualifying metabolic disorder and are not
to members for whom an uncomplicated
generally used by persons in the absence of a qualifying
prenatal course and a low-risk labor and
metabolic disorder. Soy formula is covered for members
delivery can be anticipated. The age of the
receiving Early and Periodic Screening, Diagnosis and
member must be included as a consideration in
Treatment (EPSDT) services and KidsCare members
the risk status evaluation
diagnosed with galactosemia and only until they are able to
o Labor and delivery services provided by a
eat solid lactose-free foods.
licensed midwife cannot be provided in a hospital or other licensed health care institution
Upon completion of the member’s initial consultation with a genetics physician and metabolic nutritionist, and the
Medical Food
determination that metabolic formula and/or low-protein
Health Net Access covers medical foods when
foods are necessary to meet the member’s nutritional needs,
medically necessary for Health Net Access members
providers forward the request for metabolic nutrition to the
diagnosed with one of the following inherited metabolic
Health Net Access Prior Authorization unit for review and
conditions:
processing. All approvals and payments for medical foods are the responsibility of Health Net Access.
• phenylketonuria • homocystinuria • maple syrup urine disease • galactosemia (requires soy formula) • beta keto-thiolase deficiency • citrullinemia • glutaric acidemia type I • 3 methylcrotonyl CoA carboxylase deficiency • isovaleric acidemia • methylmalonic acidemia • propionic acidemia • arginosuccinic acidemia • tyrosinemia type I
93
Benefits
Neonate Transfers between Acute Care Facilities Acutely ill neonates may be transferred from one acute care center to another, given certain conditions. The chart that follows provides the levels of care, conditions appropriate for transfer, and criteria for transfer. Level of Care From
Transfer Criteria
To
1.
The nursing and medical staff of the sending hospital cannot provide: • The level of care needed to manage the infant beyond stabilization to transport
Primary
Secondary
• The required diagnostic evaluation and consultation services needed 2. Transportation orders specify the type of transport, the training level of the
Secondary
transport crew and the level of life support Same as above Same as above Same as above 1. The sending and receiving neonatalogists
Tertiary Tertiary Primary
(and surgeons, if involved) have spoken and agreed that the transfer is safe. Tertiary
Tertiary (rare)
2. The infant is expected to remain stable, considering the period of time required for the distance to be traveled. 3. Transport orders specify the type of transport and training level of the transport crew.
Secondary Primary
Same as above Same as above
94
Benefits
Transfers Following Emergency Hospitalization
System (AHCCCS) on the transfer of a particular member, AHCCCS applies the criteria listed in the AHCCCS Medical Policy Manual (AMPM), Chapter 500, Policy 530 and
Transfers initiated by Health Net Access between
Arizona Revised Statute 36-2909(B).
inpatient hospital facilities may be made when the following conditions are met:
Overview
• The attending emergency physician, or the provider
Health Net Access covers services provided by non-
treating the member, determines that the member
physician surgical first assistants who are licensed in
is sufficiently stabilized for transfer and will remain
Arizona as a physician’s assistant or registered nurse,
stable for the period of time required for the
and who are registered as an Arizona Health Care Cost
distance to be traveled
Containment System (AHCCCS) provider, and contracting
• The receiving physician agrees to the member
and credentialed with Health Net to render non-physician
transfer
surgical first services.
• Transportation orders are prepared specifying the type of transport, training level of the transport
Nutritional Assessment and Nutritional Therapy
crew and level of life-support • A transfer summary accompanies the member
Nutritional assessments are part of the Early and Periodic Transfer to a lesser level of care facility may be made
Screening, Diagnosis and Treatment (EPSDT) program for
when one or more of the following criteria are met:
Health Net Access members under age 21, whose health
• Member’s condition does not require full acute
status may improve with nutrition intervention. Nutritional
hospital capabilities for diagnostic and/or treatment
therapy is covered for EPSDT-eligible Health Net Access
procedures
members for the below enteral, parenteral or oral basis when
• Member’s condition has stabilized or reached a
determined medically necessary to provide either complete
plateau and will not benefit further from intensive
daily dietary requirements, or to supplement a member’s
intervention in an acute care hospital
daily nutritional and caloric intake. • Enteral nutritional therapy - Provides liquid
The attending emergency physician or the provider
nourishment directly to the digestive tract of a member
treating the member and Health Net’s medical director
who cannot ingest an appropriate amount of calories
or designee are responsible for determining whether
to maintain an acceptable nutritional status. Enteral
a particular case meets criteria established in policy.
nutrition is commonly provided by jejunostomy tube
In the event the treating provider requests a decision
(J-tube), gastrostomy tube (G-tube) or nasogastric (N/G)
by the Arizona Health Care Cost Containment
tube • Parenteral nutritional therapy - Provides nourishment
95
Benefits
through the venous system to members with severe
Containment System (AHCCCS) covers nutritional therapy
pathology of the alimentary tract, which does not
on an enteral, parenteral and oral basis when determined
allow absorption of sufficient nutrients to maintain
medically necessary to provide either complete daily dietary
weight and strength
requirements, or to supplement a member’s daily nutritional
• Commercial oral supplemental nutritional feedings
and caloric intake.
- Provides nourishment and increases caloric intake as a supplement to the member’s intake of other age-
Nutritional assessments and nutritional therapy are covered
appropriate foods, or as the sole source of nutrition
benefits for members ages 21 and older when all of the
for the member. Nourishment is taken orally and is
following apply:
generally provided through commercial nutritional
• The member is currently underweight with a BMI of less
supplements available without prescription
than 18.5 presenting serious health consequences for the member, or the member has demonstrated a medically
Health Net Access covers the following for members
significant decline in weight within the past three
with a medical condition described in the section above:
months (prior to the assessment).
• Special Supplemental Program for Women, Infants
• The member is able to consume no more than 25 percent
and Children (WIC)-eligible infant formulas,
of his or her nutritional requirements from typical food
including specialty infant formulas
sources.
• Medical foods
• The member has been evaluated and treated for medical
• Parenteral feedings
conditions that may cause problems with weight gain
• Enteral feedings
(such as feeding problems, behavioral conditions or psychosocial problems, or endocrine or gastrointestinal
Refer to the Medical Foods section for Health Net
problems).
Access members with a congenital metabolic disorder,
• The member has had a trial of higher caloric foods,
such as phenylketonuria, homocystinuria, maple syrup
blenderized foods or commonly available products
urine disease, or galasctosemia.
that may be used as dietary supplements for a period no less than 30 days in duration. After this trial,
Nutritional Assessment and Nutritional Therapy - Members Ages 21 and Older
there is clinical documentation and other supporting evidence indicating that higher caloric foods would be detrimental to the member’s overall health.
Nutritional assessments and nutritional therapy is
Referrals for Nutritional Assessment
provided for members whose health status may improve
Nutritional assessments are conducted to assist members
with nutrition intervention. Arizona Health Care Cost
whose health status may improve with nutritional intervention. Health Net Access covers the assessment of
96
Benefits
nutritional status, as determined necessary and as a
assessment or may refer the member to a registered dietician.
part of health risk assessment and screening services provided by the member’s primary care provider (PCP).
To initiate a referral for a nutritional assessment, complete
Nutritional assessment services provided by a registered
the Health Net Access referral form and fax to the Health
dietitian are covered when ordered by the member’s PCP.
Net Prior Authorization Department. If the nutritional assessment is ordered by the member’s PCP, prior
To initiate a referral for a nutritional assessment,
authorization is not required.
complete the Health Net Access Referral form and fax it to the Health Net Access Prior Authorization
Prior Authorization
Department.
Prior authorization is always required for nutritional therapy. Providers must submit all clinically relevant information for
Prior Authorization
medical necessity review and prior authorization requests.
Providers must submit all clinically relevant information
To obtain prior authorization for enteral or parenteral
for medical necessity review and prior authorization
nutritional therapy, providers must complete and submit a
requests. To obtain prior authorization for commercial
Request for Prior Authorization form to the Health Net Prior
oral nutritional supplements (medical foods), providers
Authorization Department.
must complete and submit the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form and Request for Prior Authorization form in its
Commercial Oral Supplemental Nutritional Feedings
entirety to the Health Net Access Prior Authorization
Prior authorization is required for commercial oral
Department.
supplemental nutritional feedings, including specialty infant formulas, unless the member is also currently receiving
Nutritional Assessment and Referral
nutrition through enteral or parenteral feedings. Prior authorization is not required for the first 30 days if the
The assessment of a Health Net Access member’s
member requires commercial oral nutritional supplements
nutritional status is covered as part of the Early and
on a temporary basis due to an emergent condition. An
Periodic Screening, Diagnosis and Treatment (EPSDT)
example of a nutritional supplement is an amino acid-based
program specified in the Arizona Health Care Cost
formula used by a member for eosinophilic gastrointestinal
Containment System (AHCCCS) EPSDT Periodicity
disorder.
Schedule, and on an inter-periodic basis as determined necessary by the member’s primary care physician
The primary care physician (PCP) or attending physician
(PCP). This includes members who are under or
must determine medical necessity on an individual basis for
overweight. A PCP may perform the nutritional
commercial oral nutritional supplements, using the specified
97
Benefits
criteria below.
decline in weight within the past three months (prior to the assessment)
Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
• Able to consume/eat no more than 25 percent of his or her nutritional requirements from age-appropriate food
For prior authorization on commercial oral
sources
supplemental nutritional feedings, the member’s PCP
• Has absorption problems as evidenced by emesis,
or attending physician must complete and submit
diarrhea, dehydration, and weight loss; and intolerance
the Arizona Health Care Cost Containment System
to milk or formula products has been ruled out
(AHCCCS)-approved Certificate of Medical Necessity
• Requires nutritional supplements on a temporary
for Commercial Oral Nutritional Supplements form to
basis due to an emergent condition; such as post-
the Health Net Prior Authorization Department.
hospitalization (prior authorization is not required for the first 30 days)
The PCP or attending physician must have
• At high risk for regression due to chronic disease or
documentation that nutritional counseling was
condition and there are no alternatives for adequate
provided as part of the Early and Periodic Screening,
nutrition
Diagnosis and Treatment (EPSDT) program and specify alternatives that were tried in an effort to boost caloric
Overview
intake and change food consistencies before considering
Observation services are reasonable and necessary services
commercially available nutritional supplements for oral
provided on a hospital’s premises, on an outpatient basis,
feedings, or to supplement feedings.
for evaluation to determine whether the member should be admitted for inpatient care, discharged or transferred
The PCP or attending physician must indicate on the
to another facility. Observation services include use of a
Certificate of Medical Necessity for Commercial Oral
bed, periodic monitoring by a hospital’s nursing staff or, if
Nutritional Supplements form which criteria were
appropriate, other staff necessary to evaluate, stabilize or
met when assessing medical necessity of providing
treat medical conditions of significant instability or disability
commercial oral nutritional supplements. The member
on an outpatient basis.
must meet at least two of the following criteria: • At or below the 10th percentile on the appropriate
Observation services do not apply when a member with a
growth chart for his or her age and gender for three
known diagnosis enters a hospital for a scheduled procedure
months or more
or treatment that is expected to keep the member in the
• Reached a plateau in growth and/or nutritional
hospital for less than 24 hours. This is considered an
status for more than six months (prepubescent)
outpatient procedure, regardless of the hour in which the
• Already demonstrated a medically significant
member presented to the hospital, whether a bed was utilized
98
Benefits
or whether services were rendered after midnight.
• Medical records documentation
Extended stays after outpatient surgery must be billed as
o Written orders for observation services
recovery room extensions.
o Written follow-up orders at least every 24 hours o Changes from observation to inpatient or inpatient
Observation services must be ordered in writing by
to observation
a physician or other individual authorized to admit
o Changes from inpatient to observation must occur
patients to the hospital or to order outpatient diagnostic
within 12 hours after admission as an inpatient and
tests or treatments. There is no maximum time limit
have supporting medical documentation
for observation services as long as medical necessity
o Physician’s daily written progress notes
exists. Factors taken into consideration when ordering
Overview
observation services include: • Severity of the patient’s signs and symptoms
Health Net Access covers physician services for all members
• Degree of medical uncertainty where the patient
within certain limits based on member age and eligibility.
may experience an adverse occurrence
Physician services include medical assessment, treatment
• Need for diagnostic studies that appropriately are
and surgical services performed in the office, clinic, hospital,
outpatient services (their performance does not
home, nursing facility, or other location by a licensed doctor
ordinarily require the member to remain in the
of medicine or osteopathy.
hospital for 24 hours or more) to assist in assessing whether the patient should be admitted
Covered Services
• The availability of diagnostic procedures at the time
• Services as appropriate to the member’s medical need
and location where the patient presents
and physician’s scope of practice
• It is reasonable, cost-effective and medically
• Complete physical examinations for new members to
necessary to evaluate a medical condition or to
determine disease risk, provide early detection and
determine the need for inpatient admission
establish a prevention or treatment plan
• Length of stay observation services are medically
• Annual periodic examinations to monitor health status
necessary for the patient’s condition
Limitations The medical record must document the basis for the
The following physician services are not covered:
observation services and at a minimum must include:
• Services not directly related to medical care, such as
• Physician notes
physician visits to a nursing facility for the purpose of
o Condition necessitating observation
30-60 day certification
o Justification of need to continue observation
• Moderate sedation (conscious sedation) performed by
o Discharge plan
the physician performing the underlying procedure for
99
Benefits
which sedation is desired for members age 21 and
and treatment limitations do not apply to over-
over
the-counter medications or prescriptions intended
• Monitored anesthesia care, including all levels of
to treat allergy symptoms. Such medications are
sedation, provided by qualified anesthesia personnel
covered for affected members in accordance with
(physician anesthesiologist or certified nurse
the pharmacy benefit and prior authorization
anesthetist)
requirements
• Allergic immunotherapy - Except for members
• Medical marijuana - Health Net Access does not
under age 21 under EPSDT when medically
cover office visits or any other services that are
necessary and as described below, allergy testing
primarily for the purpose of determining whether a
and immunotherapy, including testing for
member would benefit from medical marijuana
common allergens and desensitization treatments administered via subcutaneous injections (such as
Occupational Therapy
allergy shots), sublingular immunotherapy (such as
Occupational therapy services are medically prescribed
slits) or via other routes of administration for adults
treatments to improve or restore functions that have been
ages 21 and older
impaired by illness or injury, or that have been permanently lost or reduced by illness or injury. Occupational therapy is
Exceptions
intended to improve the member’s ability to perform tasks
o Allergy testing is covered in instances when a
required for independent functioning. Prior authorization
member has either sustained an anaphylactic
for occupational therapy is required.
reaction to an unknown allergen or has
Health Net Access covers medically necessary inpatient
exhibited such a severe allergic reaction (such
occupational therapy services for all members. Outpatient
as severe facial swelling, breathing difficulties,
occupational therapy services are covered only for members
epiglottal swelling, or extensive (not localized)
under age 21 receiving Early and Periodic Screening,
urticaria) that it is reasonable to assume further
Diagnostic and Treatment (EPSDT) services, KidsCare
exposure to the unknown allergen may result in
members and Arizona Long-Term Care System (ALTCS)
a life-threatening situation. In such instances,
members.
allergy testing is covered to identify the unknown allergen
Inpatient occupational therapy consists of evaluation and
o Self-administered epinephrine or similar
therapy. Therapy services may include:
treatment modalities is covered for members
• Cognitive training
with a history of previous severe allergic
• Exercise modalities
reactions, whether the specific cause of that
• Hand dexterity
reaction has been identified. These testing
• Hydrotherapy
100
Benefits
• Joint protection
the direct supervision of a qualified speech pathologist. Prior
• Manual exercise
authorization is required.
• Measuring, fabrication or training in use of prosthesis, arthrosis, assistive device, or splint
Health Net Access covers medically necessary speech therapy
• Perceptual motor testing and training
services provided to all members who are receiving inpatient
• Reality orientation
care at a hospital (or a nursing facility) when services are
• Restoration of activities of daily living
ordered by the member’s primary care physician (PCP).
• Sensory re-education
Speech therapy provided on an outpatient basis is covered
• Work simplification and/or energy conservation
only for members under age 21 receiving Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services,
Physical Therapy
KidsCare and ALTCS members.
Physical therapy is a covered service when provided by, or under the supervision of, a registered physical
Inpatient speech therapy consists of evaluation and therapy.
therapist to restore, maintain or improve muscle tone,
Therapy services may include: • Articulation training
joint mobility or physical function.
• Auditory training Health Net Access covers medically necessary physical
• Cognitive training
therapy services for all members. Physical therapy is
• Esophageal speech training
covered on an inpatient and outpatient basis. Outpatient
• Fluency training
physical therapy visits are limited to both 15 visits to
• Language treatment
restore a level of function and 15 visits to maintain
• Lip reading
or help achieve a level of function per contract year
• Non-oral language training
(October 1 - September 30) for adult members ages
• Oral-motor development
21 and older who are not Medicare-eligible. For those
• Swallowing training
members who are also Medicare recipients, refer to the Arizona Health Care Cost Containment System
Overview
(AHCCCS) Medical Policy Manual, Chapter 300,
Respiratory therapy is a covered treatment ordered by
Exhibit 300-3C regarding the outpatient physical
the attending physician to restore, maintain or improve
therapy limit.
respiratory functioning.
Speech Therapy
Services include administration of pharmacological,
Speech therapy is the medically prescribed provision of
diagnostic and therapeutic agents related to respiratory and
diagnostic and treatment services provided by or under
inhalation care procedures, observing and monitoring signs
101
Benefits
and symptoms, general behavioral and general physical
cannot be rendered safely in a less restrictive setting,
response to respiratory care, diagnostic testing and
such as at home by a home health services provider.
treatment, and implementing appropriate reporting and
• The 90 days of coverage is per member, per contract
referral protocols.
year and does not restart if the member transfers to a different nursing facility. Health Net Access members
Health Net Access covers medically necessary
residing in a SNF at the beginning of a new contract year
respiratory services for all members on both an
begin a new 90-day coverage period. Unused days do not
outpatient and inpatient basis. Services must be
carry over.
provided by a qualified respiratory practitioner under
• The 90 days of coverage begins on the day of admission
ARS §32-3501, respiratory therapist or respiratory
regardless of whether the member is covered by a third-
therapy technician, licensed by the Arizona Board of
party insurance carrier, including Medicare.
Respiratory Care Examiners.
• If the member has applied for Arizona Long Term Care System (ALTCS) and a decision is pending, Health Net
Overview
Access must notify the ALTCS eligibility administrator
Health Net Access covers medically necessary services
when the member has been residing in the nursing
provided in contracting skilled nursing facilities (SNFs)
facility for 60 days. This allows time to follow-up on the
for members who need defined nursing care 24 hours
status of the ALTCS application. • If the member becomes ALTCS-eligible and is enrolled
a day, but who do not require acute hospital care under
with the ALTCS program before the end of the
the daily direction of a physician.
maximum 90 days of coverage, Health Net Access is Prior authorization is required for SNF services
only responsible for the SNF coverage during the time
prior to admission, except in those cases for which
the member is enrolled with Health Net Access. The
retro-eligibility precludes the ability to obtain prior
SNF must coordinate with the member or his or her
authorization. In these cases, the case is subject to
representative on alternate methods of payment for
medical review.
continuation of services beyond the 90-day coverage with Health Net Access until the member is enrolled in
Medically necessary SNF services are covered for a
the ALTCS program or until the beginning of the new
period not to exceed 90 days per contract year (October
contract year.
1 to September 30). The following criteria apply: • A participating physician has ordered SNF services.
Care Coordination
• The medical condition of the member is such that
Participating providers should identify and refer potentially
if SNF services are not provided, it would result
eligible Health Net Access member to ALTCS. If a Health
in hospitalization, or the treatment is such that it
Net Access member is referred to and approved for ALTCS enrollment, Health Net Access coordinates the transition
102
Benefits
with the assigned ALTCS contractor to assure continuity
• Any other services, supplies or equipment that are state
and quality of care is maintained during and after the
or county regulatory requirements or are included in the
transition.
SNF’s room and board charge.
Limitations
Coverage Explanation
Services that are not covered separately when provided
Health Net Access provides benefits for standard
in a SNF include:
polysomnography inpatient and outpatient sleep studies in
• Nursing services, including:
the following settings:
o medication administration
• A licensed and certified hospital facility
o tube feedings
• A nonhospital facility that meets one of the following
o personal care services
sets of criteria:
o routing testing of vital signs and blood glucose
o Is licensed by the Arizona Department of Health
monitoring
Services (ADHS) and the facility is accredited by the
o assistance with eating
American Academy of Sleep Medicine
o catheter maintenance
o Has a medical director who is certified by the
• Basic patient care equipment and sickroom supplies,
American Board of Sleep Medicine and has a
such as bedpans, urinals, diapers, bathing and
managing sleep technician who is registered
grooming supplies, walkers, and wound dressings or
by the Board of Registered Polysomnographic
bandages.
Technologists
• Dietary services, including, but not limited to,
o For sleep electroencephalogram (EEG) only, the
preparation and administration of special diets and
facility must have a physician who is a board-
adaptive tools for eating.
certified neurologist. No ADHS license is required
• Administrative physician visits made solely for the purpose of meeting state certification requirements.
Criteria for Coverage
• Non-customized durable medical equipment (DME)
Standard polysomnography is covered in the following
and supplies, such as manual wheelchairs, geriatric
indications:
chairs and bedside commodes.
• Suspected sleep-related breathing disorders, such
• Rehabilitation therapies ordered as a maintenance
as obstructive sleep apnea (OSA), when one of the
regimen.
following two criteria are met:
• Administration, medical director services, plant
o Witnessed apnea during sleep greater than 10
operations, and capital.
seconds in duration
• Over-the-counter medications and laxatives.
o Suspected sleep-related breathing disorders, such
• Social activity, recreational and spiritual services.
as obstructive sleep apnea (OSA) when one of the
103
Benefits
following two criteria are met:
o Other health conditions in which sleep studies have
• Excessive daytime sleepiness - Must
been shown to be medically necessary for their
rule out as a cause for these symptoms:
proper diagnosis or treatment
poor sleep hygiene, medication, drugs, alcohol, hypothyroidism, other medical
The preferred method is a split night study in which the
diagnoses, psychiatric or psychological
sleep study is performed during the first half of the night
disorders, social or work schedule
and positive air pressure system, such as continuous positive
changes
airway pressure (CPAP) or biphasic intermittent positive
• Persistent or frequent snoring
airway pressure (BiPAP), titration is performed during the
• Obesity (body mass index (BMI)
second half of the night.
greater than 30 kg/M2 or hypertension) • Choking or gasping episodes associated
In cases where testing and titration cannot be completed in
with awakenings
one session, Health Net may authorize a second night subject
o Suspected narcolepsy, demonstrated by
to medical necessity criteria.
symptoms, such as sleep paralysis, hypnagogic
Limitations
hallucinations and cataplexy o Suspected period movement disorder, including
• Polysomnography is not covered for the following
excessive daytime sleepiness together with
symptoms or conditions existing alone in the absence of
witnessed periodic limb movements of sleep
other features suggestive of OSA:
o Suspected parasomnias that are unusual or
o Snoring
atypical based on patient’s age, frequency or
o Obesity
duration of behavior
o Hypertension
o Suspected restless leg syndrome, when
o Morning headaches
uncertainty exists in the diagnosis
o Decrease in intellectual functions
o To assist with the diagnosis of paroxysmal
o Memory loss
arousals or other sleep disruptions that are
o Frequent nighttime awakenings
thought to be seizure-related when the initial
o Other sleep disturbances, such as insomnia (acute or
clinical evaluation and results of a standard EEG
chronic), night terrors, sleep walking, epilepsy where
are inclusive
nocturnal seizures are not suspected
o Under limited circumstances, titration of
o Common uncomplicated non-injurious parasomnias
positive airway pressure in adults with a
• Follow-up sleep studies are not covered unless the
documented diagnosis of OSA for whom
member’s condition has changed significantly and those
positive airway pressure has been approved
changes are likely to modify the need for CPAP or other treatments
104
Benefits
• Sleep studies performed in the home or in a mobile unit are not covered • Pulse oximetry alone as a sleep study is not covered • Repeat polysomnography in follow-up patients with OSA treated with CPAP when symptoms attributable to sleep study have resolved is not covered
Coverage Information Overview Health Net Access covers medically necessary consultative and/or treatment telemedicine services for all eligible members within the limitations described in this policy when provided by an appropriate Arizona Health Care Cost Containment System (AHCCCS) registered provider.
Definitions Term Consulting provider Store and forward
Telehealth
Distant site Originating site Telepresenter
Definition Any AHCCCS provider who is not located at the originating site who provides an expert opinion to assist in the diagnosis or treatment of a member The transmission of a patient’s medical information from the originating site to the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present The use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance • Telemedicine - The practice of health care delivery, diagnosis, consultation and treatment, and the transfer of medical data between the originating and distant sites through realtime interactive audio, video or data communications that occur in the physical presence of the member • Telecommunications technology (which includes store and forward) - Transfer of medical data from one site to another through the use of a camera, electronic data collection system, such as an electrocardiogram (ECG) or other similar device, that records (stores) an image which is then sent (forwarded) via telecommunication to another site for consultation. Services delivered using telecommunications technology, but not requiring the member to be present during their implementation, are not considered telemedicine The location of the telemedicine consulting provider, which is considered the place of service The location where the member is receiving the telemedicine service A designated individual who is familiar with the member’s case and has been asked to present the member’s case at the time of telehealth service delivery if the member’s originating site provider is not present. The telepresenter must be familiar, but not necessarily medically expert, with the member’s medical condition in order to present the case accurately
105
Benefits
Use of Telemedicine For the services listed below, Health Net Access provides
Use of Telecommunications
benefits for medically necessary services provided via
Services delivered using telecommunications are generally
telemedicine. Services must be real-time visits otherwise
not covered by Health Net Access as telemedicine services.
reimbursed by Health Net Access. Both the member and
The exceptions to this are described below: • A provider in the role of telepresenter may be providing
the originating provider or knowledgeable telepresenter must be present. Prior authorization is not required
a separately billable service under the scope of practice,
when covered services are provided as described in this
such as performing an ECG or an X-ray. In this case, the
section.
separately billable service is covered, but the specific act of telepresenting is not covered • A consulting provider at the distant site may offer a
The following medical services are covered: • Cardiology
service that does not require real-time interaction with
• Dermatology
the member. Reimbursement for this type of service is
• Endocrinology
limited to dermatology, radiology, ophthalmology, and
• Hematology/oncology
pathology, and is subject to review by Health Net Access
• Infectious diseases
medical management. The consulting physician should
• Neurology
bill covered services using modifier GQ • In the special circumstance of the onset of acute stroke
• Obstetrics/gynecology
symptoms within three hours of presentation,
• Oncology/radiation
Health Net Access recognizes the critical need for
• Ophthalmology • Orthopedics
a neurology consultation in rural areas to aid in
• Pain clinic
the determination of suitability for thrombolytic
• Pathology
administration. Therefore, when the member presents
• Pediatrics and pediatric subspecialties
within three hours of onset of stroke symptoms, Health
• Radiology
Net Access reimburses the consulting neurologist if
• Rheumatology
the consult is placed for assistance in determining
• Surgery follow-up and consultations
appropriateness of thrombolytic therapy even when
• Behavioral health
the patient’s condition is such that real-time video
• Diagnostic consultation and evaluation
interaction cannot be achieved due to an effort to expedite care
o Psychotropic medication adjustment and monitoring
Conditions, Limitations and Exclusions
o Individual and family counseling
• Both the referring and consulting providers must be
o Case management
registered with AHCCCS
106
Benefits
• A consulting service delivered via telemedicine by
specifically address transplant services and related topics
other than an Arizona registered provider licensed
as follows: Specific non-experimental transplants which
to practice in the state or jurisdiction from which
are approved for reimbursement are covered services
the consultation is provided or, if employed by an
(Arizona Revised Statute (ARS) §36-2907)
Indian Health Services (IHS), tribal or urban Indian
• Services which are experimental, or which are provided
health program, be appropriately licensed based on
primarily for the purpose of research are excluded from
IHS and 638 tribal facility requirements
coverage (Arizona Administrative Code (AAC) R9-22-
• At the time of service delivery via real-time
202)
telemedicine, the member’s health care provider
• Medically necessary is defined as those covered services
may designate a trained telepresenter to present
“provided by a physician or other licensed practitioner
the case to the consulting provider if the member’s
of the healing arts within the scope of practice under
primary care physician (PCP) or attending
state law to prevent disease, disability or other adverse
physician, or other medical professional who is
conditions, or their progression, or prolong life” (AAC
familiar with the member’s medical condition, is not
R9-22-101)
present. The telepresenter must be familiar with the
• Experimental services as defined in AAC R9-22-203
member’s medical condition in order to present the
• Standard of care is defined as “a medical procedure or
case accurately. Medical questions may be submitted
process that is accepted as treatment for a specific illness,
to the referring provider when necessary, but no
injury or medical condition through custom, peer review
payment is made for such questions
or consensus by the professional medical community”
• Health Net Access provides benefits for
(AAC R9-22-101)
nonemergency transportation to and from the telemedicine originating site to receive a medically
Transplant coverage is limited for members ages 21 and
necessary covered consultation or treatment service
older; however, Health Net Access covers all medically necessary, non-experimental transplants for members under
Covered Services
age 21 under the Early and Periodic Screening, Diagnostic
The following describes covered services for transplants
and Treatment (EPSDT) program. Transplants are excluded
under the Health Net Access product:
for members who are eligible for only emergency services under the Federal Emergency Services Program.
• Health Net Access covers medically necessary
• Covered transplants must meet nationally recognized
transplants based on Arizona Health Care Cost Containment System (AHCCCS) direction. In
criteria for nonexperimental, noninvestigational and not
order to be covered, a transplant must be medically
primarily for purposes of research. Details of transplant
necessary, cost effective, and federally and state
coverage and criteria are available in the AHCCCS
reimbursable. Arizona state laws and regulations
Medical Policy Manual located on the AHCCCS website at www.azahcccs.gov/ > Medical Policy Manual >
107
Benefits
Chapter 300, Policy 310-DD.
o Intestine alone o Intestine with pancreas
Covered Transplants for Members Ages 21 and Older
o Intestine with liver o Intestine, liver, pancreas en bloc
The following organ and tissue transplant services
• Any other transplants not specifically listed under
are covered for members ages 21 and older if prior
Covered Transplants for Members Ages 21 and Older
authorized and coordinated with Health Net Access: • Heart, including transplants for the treatment of
Where there is a transplant of multiple organs, only the
non-ischemic cardiomyopathy
covered transplants are reimbursed.
• Lung • Liver, including transplants for patients with
The following transplant and transplant-related services
Hepatitis C
are not covered when the transplant procedure itself is not
• Kidney (cadaveric and liver donor)
covered:
• Simultaneous pancreas/kidney (SPK)
• Artificial or mechanical hearts or xenografts
• Pancreas after a kidney transplant (PAK)
• Workups to evaluate the patient as a possible transplant
• Autologous and allogeneic related and unrelated
candidate
hematopoietic cell transplants
• Hospitalization for the above procedures
• Cornea
• Organ procurement
• Bone
Transplant Services and Settings Health Net Access may consult with the AHCCCS
Transplant services are covered only when performed in
consultant for guidance in those cases requiring medical
specific settings, as follows:
determinations. If Health Net Access does not use the
• Solid organ transplantation services must be provided
AHCCCS consultant, Health Net obtains its own expert
in a Centers for Medicare and Medicaid Services
opinion.
(CMS) certified transplant center that is contracted with AHCCCS and that is also a United Network for
Non-Covered Transplants for Members Ages 21 and Older
Organ Sharing (UNOS) approved transplant center, unless otherwise approved by Health Net Access, and/
• Pancreas only, if not performed simultaneously with
or the AHCCCS chief medical officer (CMO), AHCCCS
or following a kidney transplant
medical director or designee
• Partial pancreas (including autologous and
• Hematopoietic stem cell transplant services must be
allogeneic islet cell transplants)
provided in a facility that has achieved Foundation
• Visceral transplantation
for the Accreditation of Cellular Therapy (FACT) accreditation and is contracted with AHCCCS, unless
108
Benefits
otherwise approved by Health Net Access and/or the
parent or guardian will adhere to the rigorous therapy,
AHCCCS chief medical officer (CMO), AHCCCS
daily monitoring and re-evaluation schedule after
medical director or designee
transplant • The member has been adequately screened for potential
Assessment for Transplant Consideration
comorbid conditions that may impact the success of the transplant. When the member’s medical condition is
The first step in the assessment for transplant
such that the evaluation must proceed immediately, the
consideration is the initial evaluation by the member’s
screenings may be provided by the PCP concurrent with
primary care physician (PCP) and/or the specialist
the transplant evaluation
treating the condition necessitating the transplant. In
• The member’s condition has failed to improve with all
determining whether the member is appropriate for
other conventional medical and surgical therapies. The
referral for transplant consideration, the PCP and/
likelihood of survival with transplantation, considering
or specialist must determine that all of the following
the member’s diagnosis, age and comorbidities, is
conditions are satisfied:
greater than the expected survival rate with conventional
• The member will be able to attain an increased
therapies. This information must be documented and
quality of life and chance for long-term survival as a
submitted to Health Net at the time of request for
result of the transplant
evaluation
• There are no significant impairments or conditions that would negatively impact the transplant surgery,
Exception for Transplant and Cancer Cases
supportive medical services, or inpatient and
For members who require medically necessary dental
outpatient post-transplantation management of the
services as a prerequisite to AHCCCS covered organ or
member
tissue transplantation, covered dental services are limited
• There are strong clinical indications that the
to the elimination of oral infections and the treatment of
member can survive the transplantation procedure
oral disease, which include dental cleanings, treatment of
and related medical therapy (such as, chemotherapy
periodontal disease, medically necessary extractions, and the
and immunosuppressive therapy)
provision of simple restorations. A simple restoration means
• There is sufficient social support to ensure
silver amalgam and/or composite resin fillings, stainless steel
the member’s compliance with treatment
crowns or preformed crowns. Benefits are provided for these
recommendations, such as, but not limited to,
services only after a transplant evaluation determines that
immunosuppressive therapy, other medication
the member is an appropriate candidate for organ or tissue
regimens and pre- and post-transplantation
transplantation.
physician visits. For a pediatric/adolescent member, there is adequate evidence that the member and
109
Benefits
AHCCCS Covered Solid Organ and Hematopoietic Stem Cell Transplants
• Bone grafts and corneal transplants are AHCCCS covered services, based on medical necessity and prior authorized by Health Net Access
• Only solid organ and hematopoietic stem cell transplants that are AHCCCS covered services when
Emergency Transportation Services
medically necessary, cost effective, nonexperimental, and not primarily for purposes of research, are covered under the Health Net Access product. Live
Health Net Access covers emergency ground and air
donor kidney transplants are covered for pediatric
ambulance transportation services within certain limitations.
and adult members. Live donor transplants may be
Covered transportation services include:
considered on a case-by-case basis for solid organs,
• Emergency ground and air ambulance services
other than kidney, when medically appropriate and
required to manage an emergency medical condition
cost effective. Detailed criteria regarding specific
at an emergency scene and in transport to the nearest
transplants are found under the heading Solid
appropriate facility
Organ Transplants and Related Devices:Specific
• Maternal transport program (MTP), newborn intensive
Indications and Contraindications/Limitations
care program (NICP), basic life support (BLS),
located in the Medical Policy Manual on the
advanced life support (ALS), and air ambulance services
AHCCCS website at www.azahcccs.gov/ > Medical
depending upon the member’s medical needs
Policy Manual > Chapter 300, Policy 310-DD.
Coverage Limitations and Exclusions
Other Transplants and Devices
The following limitations and exclusions apply to emergency
Following is additional information on coverage for
transportation services:
other transplants and devices under the Health Net
• Coverage of ambulance transportation is limited to those
Access product.
emergencies in which specially equipped transportation
• Circulatory Assist Device (CAD) is an AHCCCS
is required to safely manage the member’s medical
covered service when used as a bridge to
condition
transplantation and other specific criteria are met,
• Emergency transportation is covered only to the nearest
when medically necessary and prior authorized by
appropriate facility medically equipped to provide
Health Net Access. Refer to Solid Organ Transplants
definitive medical care
and Related Devices: Specific Indications and
• Emergency transportation to an out-of-state facility is
Contraindications/Limitations located in the
covered only if it is to the nearest appropriate facility
Medical Policy Manual on the AHCCCS website
• Mileage reimbursement is limited to loaded mileage.
at www.azahcccs.gov/ > Medical Policy Manual >
Loaded mileage is the distance traveled, measured in
Chapter 300, Policy 310-DD
miles while a member is on board the ambulance and
110
Benefits
being transported to receive emergency services
required medical service.
• A provider who responds to an emergency call and provides medically necessary treatment at the scene,
Round-trip air or ground ambulance transportation services
but does not transport the member is eligible for
may be covered when a hospitalized member is transported
reimbursement limited to the approved base rate
to another facility for necessary specialized diagnostic and/or
and medical supplies used
therapeutic services, if all of the following requirements are
• A provider who responds to an emergency call, but
met:
does not treat or transport a member as a result of
• The member’s condition is such that the use of any other
the call is not eligible for reimbursement
method of transportation is not appropriate
• When two or more members are transported in the
• Services are not available in the hospital in which the
same ambulance, each shall be charged an equal
member is an inpatient
percentage of the base rate and mileage charges
• The hospital furnishing the services is the nearest one
• Air ambulance services are covered under the
with such facilities
following conditions:
• The member returns to the point of origin
o The point of pick-up is inaccessible by ground ambulance
Medically necessary nonemergency transportation to and
o Great distances or other obstacles are involved
from participating Health Net Access providers is a covered
in getting the member to the nearest hospital
service for members who are not able to arrange or pay
with appropriate facilities
for transportation. Transportation is limited to the cost of
o The member’s medical condition requires air
transporting the member to the nearest Health Net Access
ambulance services and ground ambulance
provider capable of meeting the member’s medical needs.
services will not suffice
Transportation is only provided to transport the member to
• Details regarding emergency transportation services
and from the required Access-covered medical service.
are available in the Arizona Health Care Cost
• Details regarding nonemergency medical transportation
Containment System (AHCCCS) Medical Policy
services are available in the Arizona Health Care Cost
Manual on the AHCCCS website at www.azahcccs.
Containment System (AHCCCS) Medical Policy Manual
gov/ > Medical Policy Manual > Chapter 300,
on the AHCCCS website at www.azahcccs.gov/ >
Policy 310-BB.
Medical Policy Manual > Chapter 300, Policy 310-BB.
Nonemergency Medical Transportation Services
Laboratory Services
Health Net Access covers medically necessary non-
laboratory provider. Services provided by a non-participating
emergency ground and air transportation to and from a
provider or facility must be authorized by Health Net
Laboratory services must be provided by a participating
111
Benefits
prior to the services being provided or the member is
cancer or other diseases
responsible for payment. Medically necessary diagnostic
• Genetic testing is also not covered for members
testing and screening are covered services.
diagnosed with cancer to determine whether their particular cancer is due to a hereditary genetic mutation
Participating providers may offer laboratory work in
known to increase the risks of developing that cancer
their offices; however, some services are considered bundled charges and are not paid in addition to an office
Radiology Services
visit fee.
Health Net Access provides benefits for medically necessary radiology and medical imaging services for all eligible
Genetic Testing Provisions
members when ordered by a primary care physician (PCP)
All genetic testing requires prior authorization. Prior
or other practitioner for diagnosis, prevention, treatment, or
authorization requests must include documentation
assessment of medical conditions.
regarding how the genetic testing is consistent with the genetic testing coverage limitations.
Radiology services must be provided by a participating
• Genetic testing is only covered when the results of
radiology provider. Members may be responsible for
such testing are necessary to differentiate between
copayments that correspond to the type of facility where
treatment option specific diagnoses or syndromes
services are rendered.
when such diagnoses would not definitively alter the medical treatments of the member
Complete the entire radiology order form when requesting
• Genetic testing is not covered to determine the
radiology services, including all insurance information.
likelihood of associated medical conditions occurring in the future
Participating providers with applicable radiology equipment
• Routine, non-genetic testing for other medical
can provide diagnostic radiology services in their office.
conditions (such as renal disease and hepatic disease) that may be associated with an underlying genetic condition is covered when medically necessary • Genetic testing is not covered as a substitute for ongoing monitoring or testing of potential complications or sequelae of a suspected genetic anomaly • Genetic testing is not covered to determine whether a member carries a hereditary predisposition to
112
Benefits Linked Documents Certificate of Necessity for Pregnancy Termination
113
Benefits
FORMS Case Management Referral Form - Access
114
Benefits
Certificate of Medical Necessity for Commercial Nutritional Supplements - Age 21 and Older
115
Benefits Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
116
Benefits Discharge Summary Form
117
Benefits Application of Physical Therapy 15 Visit Outpatient Limit
118
Benefits Health Net Access Request for Prior Authorization
119
Benefits Hysterectomy Consent Form
120
Benefits Prior Authorization/Formulary Exception Request Fax Form
121
Benefits
Referral Form
Referral Form has a page within Benefits Word doc but there was no image or form to export. i left space here for it. Look on page 75 in Word doc for this.
122
Benefits Sterilization Consent Form
123
Chapter 6
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program Description The Early and Periodic Screening, Diagnostic and Treatment program (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under age 21. EPSDT services include screening services, vision services,
• primary prevention • early intervention • diagnosis • medically necessary treatment • follow-up care of physical and behavioral health conditions • all services required to treat or improve a defect, problem or condition identified in an EPSDT screening
dental services, hearing services, and all other medically necessary, mandatory and optional services listed in Federal Law 42 USC 1396d (a) to correct or ameliorate defects and physical and behavioral/mental illnesses and conditions identified in an EPSDT screening,
A well child visit is synonymous with an EPSDT visit. EPSDT services include all screenings and services listed in the AHCCCS EPSDT Periodicity Schedule and AHCCCS Dental Periodicity Schedule.
whether or not the services are covered under the AHCCCS state plan. Limitations and exclusions, other than the requirement for medical necessity and cost-effectiveness, do not apply to EPSDT services. All primary care providers (PCPs) who provide services to members under age 21 are required to provide comprehensive health care, screening and preventive services, including, but not limited
EPSDT includes, but is not limited to, coverage of inpatient and outpatient hospital services, laboratory and X-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive, and rehabilitative services.
to:
124
EPSDT
EPSDT services do not include services that are
the PCP) that (a) the services are approved, and (b)
experimental, solely for cosmetic purposes or not
identifies the provider that has been authorized, the
cost-effective when compared to other interventions or
frequency, duration, and the service begin and end dates.
treatments.
• Health Net Access follows the Code of Federal Regulation 42 438.210 for completion of prior
Arizona Early Intervention Program Procedures
authorization requests. o Health Net Access provides a decision as expeditiously as the member’s health condition
AHCCCS and AzEIP jointly developed procedures
requires, but not later than 14 calendar days
for the coordination of services under Early Periodic
following the receipt of a standard authorization
Screening, Diagnostic and Treatment (EPSDT) and
request, with a possible extension of up to 14
AzEIP to ensure the coordination and provision of
calendar days if the member or provider requests
EPSDT and AzEIP services.
an extension or if Health Net Access justifies a need for additional information and the delay is in the
PCP-Initiated Services
member’s best interest.
When concerns about a child’s development are initially
o In the event that a provider indicates or Health
identified by the child’s primary care physician (PCP),
Net determines that using the standard time
the PCP requests an evaluation and, if medically
frame could seriously jeopardize the member’s life
necessary, approval of services from Health Net Access.
or health or ability to attain, maintain or regain maximum function, Health Net Access makes an
Evaluation/Services: Health Net Access may pend
expedited authorization decision and provide notice
approval for services until the evaluation has been
as expeditiously as the member’s health condition
completed by the provider and may deny services if the
requires no later than three business days following
PCP determines there is no medical need for services
the receipt of the authorization request (date of
based on the results of the evaluation.
receipt of request), with a possible extension of up to
• Requests for services from PCPs, licensed
14 calendar days if the member or provider requests
providers or the AzEIP service coordinator based
an extension or if Health Net Access justifies a need
on the Individual Family Service Plan (IFSP)
for additional information and the delay is in the
must be reviewed for medical necessity prior to
member’s best interest.
authorization and reimbursement.
• Referral to AzEIP: After completing the evaluation,
• If services are approved, Health Net Access
the provider who conducted the evaluation submits
authorizes the services with a Health Net Access
an evaluation report to the PCP (requesting provider
participating provider, whenever possible, and
if other than the PCP) and Health Net Access Prior
notifies the PCP (requesting provider if other than
125
EPSDT
Authorization Department for authorization of
• If an EPSDT-eligible child is referred to AzEIP, AzEIP
medically necessary services.
screens and, if needed, conduct evaluation to determine
o If the evaluation indicates that the child scored
the child’s eligibility for AzEIP. AzEIP obtains parental
two standard deviations below the mean,
consent to request and release records to and from
which generally translates to AzEIP’s eligibility
Health Net Access and the child’s PCP.
criteria of 50 percent developmental delay,
• The PCP reviews all AzEIP documentation and
the child continues to receive all medically
determines which services are medically necessary based
necessary EPSDT covered services through
on review of the documentation.
Health Net Access. The Health Net Access
• The PCP takes no longer than 10 business days from the
EPSDT coordinator refers the child to AzEIP
date the EPSDT coordinator faxes the documentation
for non-medically necessary services that are
to the PCP to determine which services are medically
not covered by Medicaid, but are covered under
necessary and returns the signed AzEIP AHCCCS
IDEA Part C.
Member Service Request form (Exhibit 430-4) to the
o If the evaluation report indicates that the child
EPSDT coordinator.
does not have a 50 percent developmental delay,
• The PCP will determine the requested services are
the EPSDT coordinator continues to coordinate
medically necessary:
medically necessary care and services for the
o Within two business days, the EPSDT coordinator
child.
sends the completed AzEIP AHCCCS Member Service Request form (Exhibit 430-4) to the AzEIP
Health Net Access and AzEIP continue to coordinate
service coordinator and PCP advising them that: (a)
services for Medicaid children who are eligible for and
the services are approved, and (b) identifying the
enrolled in both AzEIP and Medicaid. The EPSDT
provider that has been authorized, the frequency,
coordinator assists the parent or caregiver in scheduling
duration, and the service begin and end dates.
the EPSDT covered services, as necessary or as
o Health Net Access authorizes services with a Health
requested. The EPSDT services are provided by Health
Net Access participating provider whenever possible.
Net Access’s participating provider (or AzEIP service
o AzEIP providers may only be reimbursed (a) if they
provider reimbursed by Health Net Access) until the
are AHCCCS registered and (b) for the categories of
services are determined by the PCP and provider to no
services for which they are registered and that were
longer be medically necessary.
provided. Billing must be completed in accordance with AHCCCS guidelines.
AzEIP-Initiated Service Requests
• When services are determined by the PCP and service
When concerns about a Medicaid enrolled child’s
provider to be no longer medically necessary, the
development are initially identified by AzEIP:
AzEIP service coordinator implements the process for amending the IFSP, which may include (a) non-
126
EPSDT
medically necessary services covered by AzEIP,
appointment when the condition was identified
and (b) changes made to IFSP outcomes and IFSP
• Refer potentially eligible children to Children’s
services, including payer, setting, etc.
Rehabilitative Services (CRS)
• The AzEIP service coordinator, family and other
• Provide the appropriate authorization to have the
IFSP team members review the IFSP at least every
services provided by a nonparticipating provider when
six months or sooner if requested by any team
the member requires services that are unavailable in
member. If services are changed (deleted or added)
Health Net’s provider network
during an annual IFSP or IFSP review, the AzEIP
• Request care coordination from Health Net’s Health
service coordinator notifies the EPSDT coordinator
Care Services Department if indicated for the member’s
and PCP within two business days of the IFSP
condition
review. If a service is added, the AzEIP service
• Process for coordination of care and services by
coordinator’s notification to the EPSDT coordinator
appropriate state agencies for Early and Periodic
initiates the process for determining medical
Screening, Diagnosis, and Treatment (EPSDT) eligible
necessity and authorizing the service as outlined
members (such as Children’s Rehabilitative Services
above.
(CRS), Arizona Early Intervention Program (AzEIP), Special Supplemental Nutrition Program for Women,
Care Coordination
Infants, and Children (WIC), Vaccines for Children
Primary care physicians (PCPs) in their care
(VFC), Arizona State Immunization Information System
coordination roles serve as referral agents for specialty
(ASIIS), Head Start)
and referral treatments and services provided to Health Net Access members assigned to them, and attempt
Documentation Requirements
to ensure coordinated quality care that is efficient and
All Early and Periodic Screening, Diagnosis, and Treatment
cost effective. PCP responsibilities include, but are not
(EPSDT) participating providers who deliver care to
limited to:
members under age 21 must complete the appropriate EPSDT Tracking form. The EPSDT Tracking form is used
• Supervision of physician extenders, ongoing care and the coordination of all services their members
for Medicaid members and to monitor compliance with
receive
EPSDT and Dental periodicity schedules. Electronic medical records must include all the elements of the most current
• Verify any suspected serious medical condition, such as heart murmur, scoliosis and developmental
age appropriate EPSDT Tracking form. The provider who
problems. If needed services fall outside the
performed the screening must sign the tracking form and
PCP’s scope of practice, appropriate referrals
provide a valid National Provider Identifier (NPI) number (if
must be made with the initiation of treatment to
an electronic medical record is used an electronic signature
occur within 60 days from the health assessment
must be used).
127
EPSDT
A copy of the EPSDT Tracking form must be filed in
Reminders are mailed to Health Net Access members who
the member’s medical record. In addition, EPSDT
have not received EPSDT screening, advising them to
exams, services and findings must be documented in the
contact their primary care physician (PCP) to schedule an
medical record progress notes.
appointment for the screening.
A second copy must be sent to the Health Net
Follow-Up for Missed Appointments
Encounter Department.
No-show appointments must be followed up with a telephone call or a letter from the provider’s office to
EPSDT Screening Schedule
the member’s parent or guardian to schedule another
Participating providers are required to provide Early and
appointment (this includes the member’s failure to follow-
Periodic Screening, Diagnostic and Treatment (EPSDT)
up on a referral to a specialist). Place a copy of the letter and
screenings to Medicaid members under age 21. EPSDT
documentation of any follow-up attempts in the member’s
screening services should reflect the age of the child
medical record. After two no-shows, PCPs should contact
and should be provided periodically according to the
Health Net’s maternal child health (MCH)/EPSDT manager.
following schedule:
The MCH/EPSDT manager: • Coordinates with members and providers to reduce no-
• Neonatal exam (2-4 days)
show appointment rates for EPSDT services
• Under 6 weeks (1 month)
• Provides targeted outreach to those members who do
• 2 months
not show for appointments
• 4 months
• Encourages providers to schedule the next periodic
• 6 months • 9 months
screen at the current office visit, especially for children
• 12 months
ages 24 months and younger
• 15 months • 18 months
Other Covered EPSDT Services
• 24 months
Eye Examinations and Prescriptive Lenses
• 3 years
EPSDT includes eye exams and prescriptive lenses to correct
• 4 years
or ameliorate defects, physical illness and conditions. PCPs
• 5 years
are required to perform basic eye exams and refer members
• 6 years
to the contracting vision provider for further assessment.
• 7-8 years • 9-12 years
Tuberculin Skin Testing
• 13-17 years
Providers should perform tuberculin skin testing as
• 18-21 years
appropriate to age and risk. Children at increased risk of
128
EPSDT
tuberculosis (TB) include those who have contact with
Chiropractic Services
individuals: • Confined due to TB or suspected of TB.
Chiropractic services are covered when ordered by a
• In jail during the last five years.
member’s PCP and approved by Health Net Access.
• Living in a household with an HIV-infected individual or the child is infected with HIV
Personal Care Services
traveling/emigrating from, or having significant
Personal care services are covered, as appropriate, for EPSDT
contact with individuals indigenous to, endemic
members.
countries.
Incontinence Briefs Conscious Sedation
Health Net Access covers incontinence briefs, including
AHCCCS covers conscious sedation for members
pull-ups and incontinence pads, for EPSDT membersto
receiving EPSDT services. Coverage is limited to the
prevent skin breakdown and to enable participation in social,
following procedures except as specified below:
community, therapeutic, and educational activities when the
• bone marrow biopsy with needle or trocar
following conditions are met:
• bone marrow aspiration
• Member is over age 3 and under age 21.
• intravenous chemotherapy administration - push
• Member is incontinent due to a documented disability
technique
that causes incontinence of bowel or bladder.
• chemotherapy administration into central nervous
• PCP or attending physician has issued a prescription
system by spinal puncture
ordering the incontinence briefs.
• diagnostic lumbar spinal puncture Prior authorization is required for incontinence products
• therapeutic spinal puncture for drainage of
and must be renewed every 12 months. Supplies must be
cerebrospinal fluid
obtained from Health Net Access’s DME preferred provider. Additional applications of conscious sedation for
Up to 240 briefs per month are covered unless the member’s
members receiving EPSDT services are considered on
PCP or attending physician provides documentation to
a case-by-case basis and require medical review and
support medical necessity for a larger supply.
prior authorization by Health Net Access for enrolled
Medically Necessary Therapies
members.
Physical therapy, occupational therapy and speech therapy
Religious Non-Medical Health Care Institution Services
necessary to correct or ameliorate defects and physical and
Services received in religious non-medical health care
under both inpatient and outpatient bases as medically
institutions are covered for members eligible for EPSDT.
necessary.
mental illnesses discovered by screening services are covered
129
EPSDT
• Notify PCPs when a NICU-discharged member is
Organ and Tissue Transplantation Services
assigned to their panel
Organ and tissue transplantation services are covered,
• Monitor providers for compliance with training and use
as appropriate, for EPSDT members (see Transplant
of the PEDS tool
Services for additional information).
• Implement specific interventions to improve provider compliance of PEDS training and use
Parent’s Evaluation of Developmental Screening Tool
• Ensures that the newborn screening tests are conducted,
Primary care physicians (PCPs) must use the Parent’s
including initial and second screening, in accordance
Evaluation of Developmental Screening (PEDS) tool
with 9 AAC 13, Article 2
for developmental screening at each visit for neonatal intensive care unit (NICU) discharged members from
Problem Resolution
birth to age eight. The PEDS tool can be obtained by
Health Net’s maternal child health (MCH)/EPSDT manager
contacting the maternal child health MCH/EPSDT
resolve disputes that arise regarding responsibility for
manager.
necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services. The Health Net Health Services
The PEDS tool is designed for use in conjunction with
staff continues to coordinate and authorize all immediate
the well-child (EPSDT) visit for further assessment of
health care needs in collaboration with the primary care
developmental milestones, including social, emotional
physician (PCP) until the matter is resolved.
and cognitive development for NICU graduates. Providers must be trained prior to using the tool. All
Procedural Requirement for EPSDT Providers
PCPs must complete PEDS tool training in order to
PCPs are required to comply with EPSDT regulatory
bill Health Net Access. PEDS tool trained providers
requirements, including the following: • Document immunizations within 30 days of
are reimbursed for using the tool on members who are graduates from the NICU.
immunization to the Arizona State Immunization
The Health Net maternal child health MCH/EPSDT
Information System (ASIIS). o Enroll every year in the Vaccines for Children (VFC)
manager:
program.
• Works with providers to ensure utilization of the
• Provide all screening services according to the AHCCCS
Arizona Health Care Cost Containment System (AHCCCS)-approved standard developmental
Periodicity Schedule and community standards of
screening tools and complete training in the use of
practice. • Ensure all infants receive both the first and second
the tools
newborn screening tests.
• Assist families with NICU-discharged children in
o Specimens for the second test may be drawn at the
the selection of PEDS-trained providers
130
EPSDT
PCP’s office and mailed directly to the Arizona
providers as necessary.
State Laboratory, or the member may be referred to the contracting laboratory for the draw.
An EPSDT well-child visit must include the following basic
• Providers must use the standardized EPSDT
elements:
Tracking Forms provided by AHCCCS (or an
• Comprehensive health and developmental history,
electronic equivalent that includes all components
including growth and development screening (includes
from the hard-copy form) at every EPSDT visit.
physical, nutritional and behavioral health assessments).
EPSDT Tracking Forms are available on the
• Developmental screening (using an AHCCCS-approved
AHCCCS website at www.azahcccs.gov > Medical
developmental screening tool) for members ages 9, 18
Policy Manual > Appendix B.
and 24 months.
• Send copies of EPSDT tracking forms to Health
• Comprehensive unclothed physical examination.
Net Access on a monthly basis, at a minimum. Fax
• Appropriate immunizations according to age and health
forms to the EPSDT fax line.
history.
• Use all clinical encounters to assess the need for
• Laboratory tests appropriate to age and risk for blood
EPSDT screening and services.
lead, tuberculosis skin testing, anemia testing and sickle
• Document in the medical record the member’s
cell trait.
decision not to participate in the EPSDT program, if
• Health education, counseling, chronic disease self-
appropriate.
management, counseling about child development,
• Make referrals for diagnosis and treatment when
healthy lifestyles and accident and disease prevention.
necessary and initiate follow-up services within 60
• Appropriate dental screening and referral.
days.
• Fluoride varnish application every six months (by
• Schedule the next appointment at the time of the
providers who have completed training) for members’
current office visit for children ages 24 months and
age 6-24 months with at least one tooth eruption.
younger.
• Appropriate vision and hearing/speech testing.
• Report all EPSDT encounters on required claim
• Nutritional assessment.
forms, using the Preventive Medicine Codes.
• Obesity screening using the body mass index (BMI)
• Refer members to Children’s Rehabilitative Services
percentile for children.
(CRS) when they have conditions covered by the
• Behavioral health screening and services.
CRS program.
• Tuberculin skin testing.
• Referring members to Women, Infants and Children
• Preventive guidance.
(WIC), the Arizona Early Intervention Program
Health Education
(AzEIP) and Head Start as appropriate.
PCPs are responsible for ensuring health counseling and
• Initiate and coordinate referrals to behavioral health
131
EPSDT
education are provided at each EPSDT visit. PCPs
The following developmental screening tools are available for
should discuss preventive guidance, so parents or
members at their 9-, 18- and 24-month EPSDT visit:
guardians know what to expect with respect to the
• Ages and Stages Questionnaires™ Third Edition (ASQ) is
child’s development. PCPs should also cover accident
a tool used to identify developmental delays in the first
and disease prevention, and the benefits of a healthy
five years of a child’s life. The sooner a delay or disability
lifestyle.
is identified, the sooner a child can be connected with services and support that make a real difference. The tool
Screenings
is available online at www.agesandstages.com. • Ages and Stages Questionnaires®: Social-Emotional
Periodic Screenings
(ASQ: SE) is a tool used to identify developmental delays
The AHCCCS EPSDT Periodicity Schedule specifies
for social-emotional screening. The tool is available at
the screening services to be provided at each stage of
www.agesandstages.com. • The Modified Checklist for Autism in Toddlers
a child’s development. The schedule follows American
(M-CHAT) used only as a screening tool by a PCP, for
Academy of Pediatrics recommendations.
members ages 16 to 30 months, to screen for autism Children may receive additional interperiodic screening
when medically indicated. The tool is available online at
at the discretion of the provider. Health Net Access does
www.m-chat.org. • The Parents’ Evaluation of Developmental Status (PEDS)
not limit the number of well-child visits that members
used for developmental screening of EPSDT-aged
under age 21 receive.
members. The tool is available online at www.pedstest. com or www.forepath.org.
Annual well-child visits are comprehensive and should include all of the services required for sports or other activities. Physicals completed solely for the purpose of
Payment for use of screening tools is covered when the
sports activities are not covered by AHCCCS; therefore,
following criteria are met: • The member’s EPSDT visit is at 9, 18, or 24 months.
no additional payment would be made.
• Prior to providing the service, the provider must
Developmental Screening Tools
complete the required training for the developmental
Primary care providers (PCPs) must be trained in
screening tool being utilized and submit a copy of the
the use and scoring of developmental screening
training certificate to the Council for Affordable Quality
tools. Training resources may be found at Arizona
Healthcare (CAQH).
Department of Health Services website at www.azdhs.
• The code is appropriately billed (96110-EP).
gov/clinicians/training-opportunities/developmental/
Providers must retain copies of the completed tools in the member’s medical record and submit it to Health Net
index.php.
Access with the completed EPSDT Tracking Form.
132
EPSDT
EPSDT Oral Health Care Screening and Referrals
Health Net Access assigns members under age 21 to a dental
The PCP must screen children younger than age three at
for routine preventive care and according to the AHCCCS
each EPSDT visit to identify those who require a dental
EPSDT Periodicity Schedule. The physician may refer
referral for evaluation and treatment.
EPSDT recipients for a dental assessment at an earlier age, if
home and encourages referrals to the dentist begin at age one
their oral health screening reveals potential carious lesions or PCPs and attending physicians must refer EPSDT
other conditions requiring assessment and/or treatment by a
recipients to dentists for appropriate services based on
dental professional.
the needs identified through the screening process and for routine dental care at least annually based on the
PCP Application of Fluoride Varnish
AHCCCS EPSDT Periodicity Schedule. The American
Physicians who have completed the AHCCCS required
Association of Pediatric Dentistry recommends that
training may be reimbursed for fluoride varnish applications
dental visits begin by age one, but the referral isn’t
completed at the EPSDT visit for recipients who are at least
mandatory until age three. Evidence of the referral must
age six months, with at least one tooth eruption. Additional
be documented on the ESPDT Tracking Form and in the
applications occurring every six months during an EPSDT
recipient’s medical record. Documented dental findings
visit, up until the recipient’s second birthday, are also
and treatment must be included in the member’s
reimbursed.
medical record in the PCP’s office. Depending on the results of the oral health screening, referral to a dentist
AHCCCS recommended training for fluoride varnish
should be made according to the following time frames:
application is located at the Smiles for Life website under Training Module 6 that covers caries risk assessment,
• Urgent (within 24 hours) - pain, infection, swelling and/or soft tissue ulceration of approximately two
fluoride varnish and counseling. Upon completion of the
weeks duration or longer.
required training, providers should upload a copy of their certificate to the Council for Affordable Quality Healthcare
• Early (within three weeks) - decay without pain, spontaneous bleeding of the gums and/or suspicious
(CAQH) site. This certificate is used in the credentialing
white or red tissue areas.
process to verify completion of training necessary for reimbursement. An oral health screening must be part of
• Routine (next regular checkup) - none of the above
an EPSDT screening conducted by a PCP; however, it does
problems identified.
not substitute for examination through direct referral to a The member’s parent or guardian may also self-refer and
dentist. PCPs must refer EPSDT members for appropriate
schedule dental appointments for the member with any
services based on needs identified through the screening
contracting general dentist. Members may go directly
process and for routine dental care based on the AHCCCS
to the dentist without seeing the PCP first and no
EPSDT Periodicity Schedule. Evidence of this referral must
authorization is required.
be documented on the EPSDT Tracking Form and in the
133
EPSDT
member’s medical record.
Cochlear and osseointegrated implantation require prior authorization.
Blood Lead Screening All children are considered at risk of and must be
Behavioral Health Screening
screened for lead poisoning. Children at ages 12 and 24
Screenings for mental health and substance abuse problems
months must receive a blood lead test. Children between
must be conducted at each EPSDT visit. Treatment services
ages 36 and 72 months must receive a blood lead test if
are a covered benefit for members under age 21.
they have not been previously screened. PCPs are expected to: • Initiate and coordinate necessary referrals with the
A verbal risk assessment must be completed at each EPSDT visit for children 6 through 72 months to
Regional Behavioral Health Authority (RBHA) for
determine risk category and the need for any follow-up
behavioral health services. • Monitor whether a member has received services.
services.
• Keep any information received from a behavioral health Providers must report blood lead levels equal to or
provider regarding the member in the member’s medical
greater than 10 micrograms of lead per deciliter of whole
record.
blood to the ADHS.
• Initial and date copies of referrals or information sent to a behavioral health provider before placing in the
Hearing and Speech Screening
member’s medical record.
Hearing evaluation consists of appropriate hearing
o If the member has not yet been seen by the PCP, this
screens given according to the EPSDT schedule.
information may be kept in an appropriately labeled
Evaluation consists of history, risk factors, parental
file in lieu of actually establishing a medical record,
questions, and impedance testing. Pure-tone testing
but must be associated with the member’s medical
should be performed when medically necessary.
record as soon as one is established.
Speech screening must be performed to assess the member’s language development at each EPSDT visit.
PCPs may treat attention deficit hyperactivity disorder (ADHD), depression and anxiety. All other behavioral health
Cochlear and Osseointegrated Implantation
conditions must be referred to the RBHA. PCPs that elect
When determined medically necessary, Health Net
anxiety disorders must complete an annual assessment of the
Access covers cochlear implantation and osseointegrated
member’s behavioral health condition and treatment plan.
to prescribe medications to treat ADHD, depression or
implants for EPSDT members. Cochlear implantation is limited to one functioning implant per member.
134
EPSDT
Health Net Access requests PCPs to implement
• The diagnosis must be documented in the medical
postpartum depression screenings to identify and refer
record and should include the test results used in
mothers who would benefit from additional treatment
establishing the diagnosis.
due to concerns related to postpartum depression
• Nutritional therapy requires prior authorization and
during EPSDT visits for infants up to age one.
approval by the Health Net Access medical director or other qualified health professional designee.
Nutritional Assessment & Nutritional Therapy
• After prior authorization has been issued, the Health Net Access Prior Authorization Department sends the
Nutritional therapy for EPSDT members on an enteral,
request to the medical foods vendor.
parenteral or oral basis is covered when determined medically necessary to provide either complete daily
Body Mass Index
dietary requirements, or to supplement a member’s daily
Primary care providers (PCPs) should calculate each
nutritional and caloric intake.
child’s body mass index (BMI) starting at age three until the member is age 21. BMI is used to assess underweight, overweight and those at risk for overweight. BMI for
The following requirements apply:
children is gender and age specific. PCPs are required
• Medical foods must be essential to sustain the member’s growth within nationally recognized
to calculate the child’s BMI and percentile. Additional
height/weight or body mass index (BMI) levels,
information is available at the Centers for Disease Control
maintain health and support metabolic balance.
and Prevention (CDC) website regarding BMI.
• PCPs must complete the Certificate of Medical Necessity for EPSDT members form and fax to
The following established percentile cutoff points are used to
Health Net Access Prior Authorization Department.
identify underweight and overweight in children:
• PCPs must reassess needs at each visit.
BMI Table
• PCPs must refer members in need of nutritional
BMI (kg/m2) ≥ 95th percentile 85th to < 95th percentile 5th to < 85th percentile < 5th percentile
therapy for consult with both a metabolic nutritionist and genetic specialist. o Health Net Access utilizes the metabolic nutritionist at Phoenix Children’s Hospital. o The metabolic nutritionist works with the member and guardian to develop a treatment plan to meet the member’s needs and requests prior authorization from Health Net Access, as applicable.
135
Classification Obese Overweight Healthy Weight Underweight
EPSDT
programs help build relationships with families that support
State Programs
family well-being and many other important areas.
Arizona Early Intervention Program
Early Head Start Programs serve infants, toddlers and
The Arizona Early Intervention Program (AzEIP) is
pregnant women and their families who have incomes below
an early intervention program that offers a statewide
the federal poverty level.
system of support and services for children who have disabilities or developmental delays, from birth through
PCPs and other community advocates may directly refer
age three and their families. This program was jointly
members to the Head Start program. Parents and guardians
developed and implemented by AHCCCS and AzEIP
may self-refer.
to ensure the coordination and provision of EPSDT and early intervention services, such as physical therapy,
Visit the Head Start website for additional information
occupational therapy, speech/language therapy, and
ateclkc.ohs.acf.hhs.gov/hslc. Providers may also contact
care coordination under Section 1905 [42 U.S.C 1396d].
Maternal Child Health Case Management for referral
Concerns about a child’s development may be initially
assistance.
identified by the child’s primary care provider (PCP) or by AzEIP.
Women Infant and Children The Arizona Supplemental Nutrition Program for Women,
Health Net Access coordinates with AzEIP to ensure
Infants, and Children (WIC) provides nutrition education
that members receive medically necessary EPSDT
and breastfeeding support services, supplemental nutritious
services in a timely manner to promote optimum child
foods and referrals to health and social services. WIC serves
health and development. For additional information,
pregnant, breastfeeding and postpartum women; infants;
contact the Health Net Access EPSDT coordinator.
and children under age five who are determined to be at nutritional risk. The WIC program is funded by the United
Head Start Program
States Department of Agriculture.
Head Start and Early Head Start programs are federal programs provided at no cost to families.
For more information about WIC, visit the ADHS website at
Head Start promotes school readiness of children from
azdhs.gov/prevention/azwic/index.php.
birth to age five from low-income families by enhancing their cognitive, social and emotional development.
Children’s Rehabilitative Services
Head Start programs provide a learning environment
The Arizona Children’s Rehabilitative Services (CRS)
that supports children’s growth in many areas, such
program provides medical treatment, rehabilitation and
as language, literacy, and social and emotional
related support services to AHCCCS members who meet the
development. Head Start emphasizes the role of parents
eligibility criteria to be enrolled in CRS.
as their child’s first and most important teacher. These
136
EPSDT
Providers may fax CRS referrals for eligible Health
administered to children under age 19. Immunizations
Net Access members and supporting medical records
must be reported at least monthly to ADHS. Reported
to the Health Net Access CRS coordinator . For more
immunizations are held in a central database, the Arizona
information and assistance with referrals, contact Health
State Immunization Information System (ASIIS), and can be
Net Access Behavioral Health Case Management.
accessed online to obtain complete, accurate records.
Providers may access the CRS Application forms and
Health Net Access requests that all primary care providers
instructions at AHCCCS website at: www.azahcccs.gov
(PCPs) and pediatricians caring for newborns review each
> Providers > CRS Referrals.
member’s immunization records fully upon the initial visit, and subsequent follow-up visits, regardless of where the
For general questions regarding the CRS Program
child was delivered. Newborns must receive all required
contact the AHCCCS CRS Enrollment Unit or contact
vaccines and those who have not received the birth dose of
the United Healthcare Community Plan CRS Provider
the hepatitis B vaccine in the hospital must be caught up by
Ombudsman.
their PCP.
Vaccine for Children Program EPSDT covers all child and adolescent immunizations. Immunizations must be provided according to the Arizona Health Care Cost Containment System (AHCCCS) Recommended Childhood Immunization Schedules, which follow the CDC guidelines and must be up-to-date. Providers are required to coordinate with the Arizona Department of Health Services (ADHS) Vaccines for Children (VFC) program to obtain vaccines for Health Net Access members who are ages 18 and under. Current immunization schedules are available on the CDC website at www.cdc.gov/vaccines/schedules/ index.html. Additional information can be attained by calling VFC or by accessing the ADHS website at www. azdhs.gov/preparedness/epidemiology-disease-control/ immunization/index.php#vaccines-children-home. Arizona law requires the reporting of all immunizations
137
EPSDT
EPSDT Program - AHCCCS EPSDT Periodicity Schedule EPSDT Tracking Form - 12 Months Old
138
EPSDT EPSDT Tracking Form - 13-17 Years Old
139
EPSDT EPSDT Tracking Form - 15 Months Old
140
EPSDT EPSDT Tracking Form - 18 Months Old
141
EPSDT EPSDT Tracking Form - 18-21 Years Old
142
EPSDT EPSDT Tracking Form - 24 Months Old
143
EPSDT EPSDT Tracking Form - 9-12 Years Old
144
EPSDT EPSDT Tracking Form - Five Years Old
145
EPSDT EPSDT Tracking Form - Four Months Old
146
EPSDT EPSDT Tracking Form - Four Years Old
147
EPSDT EPSDT Tracking Form - Nine Months Old
148
EPSDT EPSDT Tracking Form - One Month Old
149
EPSDT EPSDT Tracking Form - Seven through Eight Years Old
150
EPSDT EPSDT Tracking Form - Six Months Old
151
EPSDT EPSDT Tracking Form - Three Years Old
152
EPSDT EPSDT Tracking Form - Two Months Old
153
EPSDT EPSDT Tracking Form - three through five Days Old
154
EPSDT Certificate of Medical Necessity for Commercial Oral Nutritional
155
Chapter 7
Utilization Management Avoidable Admissions An avoidable admission is broadly defined as a hospital admission that may not have occurred had the patient received timely coordinated and appropriate ambulatory care. An avoidable admission is categorized as an admission to an inpatient level of care that could have been appropriately managed at an alternative level of care. Health Net uses national criteria in
operate according to Case Management Society of America standards. Health Net case managers, or delegated medical group assure that potential medically catastrophic cases are managed in cooperation with the member’s primary care physician (PCP) to achieve optimum care and coverage benefits for the member. Case manager provide assistance by working with members, caregivers, physicians, and the Health Net Claims Department.
determining whether an admission could have been avoided. Examples of avoidable admissions include hospitalizations for immunizable conditions, asthma, gastroenteritis, dehydration, ear nose and throat (ENT) conditions, and kidney or
The following referral criteria are used for case management: • Lack of an established or ineffective treatment plan - for example, a member with multiple providers and multiple services who continues to use the emergency room
bladder infections.
or continues to have multiple admissions for An impacted inpatient day is defined as an additional inpatient day resulting from a delay in treatment, discharge or other service delay. An avoidable admission may result in denial of payment to the
the same conditions • Over-, under- or inappropriate utilization of services - for example, a member who inappropriately over-utilizes emergency room services, or who does not have an established PCP or specialty care provider,
practitioner or facility.
when appropriate • Permanent or temporary alteration of
Case Management Health Net case management functions
156
functional status - for example, a member with a hip replacement who is discharged
Utilization Management
with no home support or is unable to get to medical
a senior member who needs transportation, home help
appointments and/or physical therapy
or other noncovered items
• Medical/psychosocial/functional complications
• Transition of care - for example, a new member who
- for example, an elderly member with multiple
needs assistance in coordinating services or interpreting
medical conditions (comorbidity) and depression
benefits beyond the assistance available through Health
who is unable to manage activities of daily living,
Net Member Services
medications and diet
• Exhaustion of benefits - for example, a member with
• Barriers to receiving appropriate care within the
medical necessity for a specialized hospital bed, but the
system - for example, a newly diagnosed cancer
member’s durable medical equipment (DME) benefit is
patient who has been educated by coaches, but
exhausted
who would also benefit from coordination of care
• Member asks to speak with a Health Net nurse or case
services through Health Net’s case management
management - for example, a member who requests
• Nonadherence to treatment or medication
evaluation for case management services or assistance in
regimens or missed appointments - for example,
coordinating services or obtaining medications
a member with transportation needs who is
• Pregnant women at risk - for example, a woman who
unable to get to physician appointment, or who
is pregnant with triplets, has hyperemesis, is at risk for
has transportation or financial barriers to filling
premature delivery, or is over age 45
medication prescriptions
• Non-urgent behavioral health referrals - for example,
• Compromised patient safety - for example, an
suspected reports of substance abuse, neglect, physical
elderly member, post hip replacement, who lives on
abuse, and/or depression
the second floor requires home evaluation for safety concerns
Physicians should complete a Health Net Case Management
• High cost injury or illness - for example, a member
Referral Form for commercial/Medicare members or Health
in a severe motor vehicle accident with multiple
Net Access members to facilitate a member considered
injuries would require coordination of and
for case management, or contact the Case Management
authorization for multiple services for an extended
Department (commercial/Medicare or Health Net Access)
period of time
for referrals and additional information.
• Lack of family or social support - for example, a post-operative member with wound care, but
Concurrent Review
without family support to assist with dressing needs
Concurrent review is the process of reviewing an inpatient
• Lack of financial resources to meet health needs -
stay at admission and throughout the stay to determine
for example, a member requiring extensive wound
the medical necessity for an inpatient level of care utilizing
vacuum services but who has exhausted benefits, or
appropriate resources, level of care and service according
157
Utilization Management
to professionally recognized standards of care, such
providers, encounters, and procedures so that the member
as McKesson’s InterQual® Severity of Illness, Intensity
receives timely, medically necessary health services without
of Service criteria. Concurrent review validates the
interruption.
medical necessity for admission and continued stay and evaluates quality of care. Concurrent review is
The system comprises several procedural components that
initiated upon notification to the Health Net Hospital
are required to the extent of the severity of the member’s
Notification Unit that a member has been admitted
health condition. Primary care physicians (PCPs) must
(in the case of an urgent or emergency admission).
adhere to the following basic procedures to maintain
Concurrent review includes, but is not limited to:
continuity of care: • Documentation of member encounters, missed
• Quality of care • Plan of treatment
appointments, extensions of appointment waiting time
• Severity of illness
(noted that a longer waiting time for appointment will
• Intensity of service
not have a detrimental impact on the health of the
• Treatment plan
member), and referrals in members’ medical record
• Length of stay
• Referring members who need specialty health services
• Level of care
• Forwarding summaries of pertinent medical findings to specialists
• Discharge plan
• Documentation of services provided by a specialist in Based on the concurrent review process, the hospital
the member’s primary care medical record
stay is approved or denied. If the stay is approved, the
• Monitoring members who have ongoing medical
hospital receives an authorization tracking number. The
conditions
authorization tracking number must be indicated on the
• Notifying Health Net of member referrals to specialists,
billed hospital claim to Health Net.
care management or public health programs
All potentially nonapproved services identified by the
Additional procedures are required of PCPs when members’
Health Net concurrent review nurse are reviewed with
health conditions require urgent, emergency or inpatient
a Health Net medical director or a specialty advisor.
health services, including:
Physicians and members have the right to appeal denied
• Documentation in members’ medical record of
services.
emergency and urgent medical care and follow-up • Coordinated hospital discharge planning
Continuity of Care
• Post-discharge care
Continuity of care refers to the system of directing and Health Net suggests that each provider develop protocols to
monitoring a member’s care among multiple health care
158
Utilization Management
maintain continuity of care. A log system for tracking
Preventive care may be medically necessary, but coverage
prior authorizations, referrals to specialists, follow-up
for medically necessary preventive care is governed by the
of missed appointments, and acknowledgment and
terms of the Provider Participation Agreement (PPA) and the
verification of such things as lab and X-ray findings
member’s Evidence of Coverage (EOC).
is recommended. The system can be manual or computerized.
When considering whether a service or treatment is experimental or investigational, if such service or treatment
Definition of Medical Necessity
is medically necessary, as defined above, the service or
Medically necessary services or medical necessity
treatment is paid for unless specifically excluded from Health
is defined as health care services that a physician,
Net coverage.
exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating,
Hospital Discharge Planning
diagnosing or treating an illness, injury, disease, or its
The Health Net Concurrent Review Department collaborates
symptoms, and that are:
with inpatient facilities in appropriate and timely discharge planning for Health Net members, including post-hospital
• In accordance with generally accepted standards of
care. The admitting physician is responsible for all aspects
medical practice
of the member’s medical care, including making the
• Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective
determination regarding the appropriateness of discharge
for the patient’s illness, injury or disease
and post-hospitalization services.
• Not primarily for the convenience of the patient, physician or other health care provider, and not
Each hospital must have a written discharge planning policy
more costly than an alternative service or sequence
and process that includes, but not limited to: • Counseling for the member or family members to
of services at least as likely to produce equivalent
prepare them for post-hospital care, if needed
therapeutic or diagnostic results as to the diagnosis
• A transfer summary accompanying the member upon
or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted
transfer to a skilled nursing facility (SNF), intermediate-
standards of medical practice” means standards that
care facility, or a part-skilled nursing or intermediate
are based on credible scientific evidence published
care service unit of the hospital • Information regarding durable medical equipment
in peer-reviewed medical literature generally
(DME)
recognized by the relevant medical community,
• Reconciliation of discharge medications with
physician specialty society recommendations, the
medications the member was taking prior to admission
views of physicians practicing in relevant clinical
• Providing member with each medication dispensed
areas, and any other relevant factors
159
Utilization Management
upon discharge
Health Net evaluates medical technologies based upon
• Making a post-discharge follow-up call to ensure
principles of evidence-based medicine. Results of
members’ needs are met
multicenter, randomized, prospective clinical trials published in peer-reviewed medical literature that show the treatment
The concurrent review nurse is available to assist with
to be at least as effective or more effective as other established
authorization for post-discharge services.
modalities of therapy and/or to be associated with fewer adverse effects are considered the most scientifically rigorous
Medical Policy Development and Evaluation of Medical Technologies
evidence. Factors that are taken into account during the evaluation process include, but are not limited to: • Whether the procedure, device, medication, technique, or biological has final approval from the appropriate
As part of Health Net’s quality assurance and utilization
governmental regulatory bodies
management programs, Health Net’s National Medical
• Whether peer-reviewed scientific evidence is sufficient to
Policy Unit reviews published scientific literature
permit conclusions about the effect of the technology on
pertaining to the efficacy and safety of existing
health outcomes
and emerging technologies or new uses of existing
• Whether the technology is capable of demonstrating
technologies. The Medical Policy Unit prepares
improvement in overall health outcomes
proposed draft utilization review guidelines (national
• Whether the technology is at least as beneficial as any
medical policies) designed to assist Health Net medical
established alternatives
directors in making utilization review determinations
• Whether the improvement demonstrated is attainable
relevant to the effectiveness and appropriateness of
outside of investigational settings
medical technology, including a service, procedure,
• Whether specific clinical situations can be identified
device, medication, technique, or biological. This
under which the technology will be used
determination is based upon the principles of evidence-
• Decisions are based on safety, efficacy and effectiveness
based medicine and a review of currently available clinical information from peer-reviewed published
In addition to available evidence, policy decisions are also
medical literature, the regulatory status of the
based on established nationally accepted governmental
technology, public health and health research agencies,
and professional society recommendations, as well as
guidelines and positions of leading national health
other recognized sources. Examples include Hayes, Inc.
professional organizations, views of expert physicians
Technology Assessments, InterQual® criteria and the Food
practicing in relevant clinical areas, and other factors.
and Drug Administration (FDA). If relevant, information
Health Net may revise these policies as new clinical
from manufacturers about procedures and training issues
information becomes available.
may be considered.
160
Utilization Management
Health Net’s national medical policies are provided
beneficiaries residing in the plan’s service area. Health Net
to Health Net’s National Medical Advisory Council
complies with CMS’ National Coverage Determinations
(MAC), which reviews proposed policies and revises,
(NCD), general coverage guidelines included in original
rejects or approves them. MAC’s membership consists of
Medicare manuals and instructions, and written Local
a clinically and geographically diverse group of Health
Coverage Determinations (LCD), coverage decisions of
Net medical directors and medical management team
local Medicare contractors, with jurisdiction for claims in
representatives. Final approved national medical policies
the geographic area in which services are covered under the
are made available to participating providers through
MA plan. In some instances, however, a Medical Advisory
the Health Net website.
Contractor (MAC) outside of Health Net’s service area may have exclusive jurisdiction over a Medicare-covered item or
Health Net’s national medical polices are developed to
service and processes all claims for a particular Medicare-
assist in administering plan benefits; however, they do
covered item or service for all Medicare beneficiaries around
not constitute a description of plan benefits nor can
the country. This generally occurs when there is only one
they be construed as medical advice. They represent
supplier of a particular item, medical device or diagnostic
a determination of whether or not certain services or
test, such as certain pathology and lab tests furnished by
supplies are considered cosmetic, medically necessary
independent laboratories. In these situations, MA plans must
or appropriate, or experimental and investigational. The
follow the coverage requirements or LCD of the MAC that
policies do not constitute authorization or guarantee
enrolled the supplier and processes all of the Medicare claims
coverage for a particular procedure, device, medication,
for that item, test or service.
service, or supply. In the event a conflict of information is present between a medical policy, legal and regulatory
Notification of Admissions
mandates and requirements, and any Health Net
To notify Health Net of an urgent or emergent inpatient
plan document under which a member is entitled to
and outpatient observation admissions and skilled
covered services, the plan document and regulatory
nursing facility (SNF) admissions, providers must contact
requirements take precedence. Plan documents include,
Health Net’s Hospital Notification Unit within 24 hours
but are not limited to, subscriber contracts, summary
of admission, the next business day or as outlined in the
plan documents and other coverage documents
Provider Participation Agreement (PPA). Elective inpatient
prepared by Health Net.
admissions require authorization from the Health Net Prior Authorization Department.
For Medicare Advantage members, Health Net provides coverage of, by furnishing, arranging for, or making
For behavioral health admissions for Health Net Access
payment for, all services that are covered by Part
General Mental Health/Substance Abuse (GMH/SA)
A and Part B of Medicare and that are available to
members, fax or call in admission notifications to the Health Net Hospital Notification Unit.
161
Utilization Management
Notify Health Net of a newborn within 24 hours or
Notification Process
no later than three days of delivery, by contacting the
When Health Net is notified of hospital admissions, the
Health Net Hospital Notification Unit.
hospital notification unit staff verifies eligibility, hospitalist,
When reporting inpatient admissions, the following
behavioral health provider, or primary care physician
information is required:
(PCP) assignment and whether the service requires prior
• facility name
authorization. Health Net enters the notification into the
• name of caller reporting admission
system to generate a case tracking number and issues the
• telephone number of caller reporting admission
number to the caller. If Health Net’s systems are unavailable,
• member’s full name
a temporary tracking number is assigned. The facility is
• member’s Health Net identification (ID) number
responsible for obtaining the permanent tracking number by
• member’s date of birth
contacting Health Net prior to claim submission.
• admission date • admission time
All elective detox, urgent and emergency inpatient, and
• room number (for emergency room (ER)
skilled nursing facility (SNF) admissions must be reported to
notifications, there may not be a room number
the Health Net Hospital Notification Unit within 24 hours or
assigned)
the next business day, unless otherwise stated in the facility
• admit type (elective, direct, urgent, or emergent)
contract.
• admitting diagnosis or chief complaint • type of admission (medical, surgical, observation,
Services may be reviewed after they are provided to
detox, telemetry, or intensive care)
determine medical appropriateness. Payment is not made for
• admitting or attending physician (ER physicians
services that are inappropriate, not a covered benefit or not
cannot be identified as they are not going to follow
medically necessary.
the member during the facility stay. When notifying Health Net of a newborn admission, identify the
Retrospective Review
admitting pediatrician.)
Retrospective review is review of the quality and medical
• other insurance if Health Net is not primary carrier
necessity of services after care has been rendered.
• status of admission (inpatient, skilled nursing or
Retrospective professional review involves an evaluation of
sub-acute rehabilitation)
services that fall outside Health Net’s established guidelines for coverage. These claims are reviewed by Health Net’s
Services denied for late or non-notification are
professional review specialists (registered nurse reviewers)
considered non-reimbursable and cannot be billed to
and a Health Net medical director or a specialty advisor
the member.
where the initial reviewer recommends that a claim be denied for lack of medical necessity.
162
Utilization Management
findings must be called to the PCP within 24 hours or by the
Separation of Medical Decisions and Financial Concerns
next business day.
Medical decisions regarding the nature and level of care
The PCP is required to review the specialist’s findings to
to be provided to a member, including the decision of
determine whether follow-up care is medically necessary.
who renders the service (for example, primary care
The PCP is responsible for directing all member care through
physician (PCP) instead of specialist or in-network
the referral process.
provider instead of out-of-network provider), must be made by qualified medical providers, unhindered
Services Received in an Alternate Care Setting
by fiscal or administrative concerns. Utilization
Alternative care settings must send the member’s PCP the
management (UM) decisions are, therefore, made by
following:
medical staff and are based solely on medical necessity.
• Report with findings, recommended treatment and
Providers may openly discuss treatment alternatives
results of treatment for services performed outside the
(regardless of coverage limitations) with members
PCP’s office
without being penalized for discussing medically
• Emergency department reports, hospital discharge
necessary care with the member. Health Net requires
summaries and other information
that each medical group and hospital’s UM program
• Home health care agencies treatment plans after an
include provisions to ensure that financial and
authorized evaluation visit and every 30 days afterward
administrative concerns do not affect UM decisions,
for review of home health care and authorization
and that each member of the medical group’s UM staff
• Reports regarding diagnostic or imaging services with
sign an acknowledgment of this. Failure to comply may
abnormal findings or evaluations and subsequent action
result in withdrawal of delegated UM and ultimately, termination of the Provider Participation Agreement (PPA) with Health Net.
Utilization/Care Management Program
Specialist Reports
Health Net Access’ Utilization/Care Management program is designed to manage the use of resources to maximize the
Specialists are required to submit a written report to the
effectiveness of care provided to members. The program
referring physician. This written report must include the
involves pre-service, concurrent and post-service evaluation
specialist’s findings, recommended treatment, results of
of utilization of health services and assessment of utilization
any studies, tests, procedures, and recommendations for
practices. The program requires cooperative participation
continued care. The primary care physician (PCP) must
of Health Net Access, participating medical and behavioral
receive the report within two weeks of the member’s
health practitioners, delegates, hospitals, and other providers
visit with the specialist. Emergency care reports or
to ensure a timely, effective and medically sound program.
163
Utilization Management
It is structured to ensure that medical decisions are
appropriate clinical information and criteria sets make
made by qualified health professionals, using written
appropriate utilization management decisions.
criteria based on sound clinical evidence, without
• Establish standards for the timeliness of utilization
undue influence of Health Net Access management or
management decision-making and operate within the
concerns for the plan’s fiscal performance. The model is
standards established by the Centers for Medicare and
patient-centric and when members actively work with
Medicaid Services (CMS), Department of Insurance
a case manager, it empowers members with knowledge
(DOI) and the National Committee for Quality
that allows them to become more active participants in
Assurance (NCQA), as applicable.
health care decisions.
• Ensure that the reasons for each denial are clearly documented and communicated to members and
The Utilization/Care Management program is
practitioners, as stated within policy and procedure
designed to promote fair, safe and consistent utilization
guidelines.
management decision-making. The program is under
• Establish processes to monitor and oversee utilization of
the clinical supervision of Health Net Access’ chief
high-risk and high-cost procedures and services.
medical officer, who has substantial involvement in
• Develop and update written guidelines and criteria based
developing and implementing the program. It is updated
on sound clinical evidence and ensure that policies and
as necessary and evaluated and approved annually by
procedures for applying these criteria are appropriate.
the Health Net Access Medical Management/Utilization
Ensure that current technology and scientific evidence is
Management Committee (MM/UM).
used in the utilization review decision. • Develop and implement processes and tools for
Pre-service, concurrent review and post-service review
transition of care, case management, continuity of care,
components are conducted, as applicable, in accordance
discharge planning, and other utilization management
with the type of service and the member’s clinical
functions to improve efficiency, continuity of care and
condition. Health Net Access clinical associates, or
standardization of application.
delegates, conduct utilization management reviews in
• Monitor utilization of select services against benchmarks
collaboration with Health Net Access medical directors.
and provide feedback to improve providers’ knowledge
Non-emergency services provided outside the network
of current medical evidence to enable providers to
receive concurrent or post-service review.
measure their own effectiveness to benchmarks.
The objectives of the Utilization/Care Management
• Establish processes to collect and periodically monitor
program are to:
data, implement interventions and measure results
• Ensure that members have equitable access to care
of the interventions for effective strategies to achieve
across the network.
appropriate utilization.
• Ensure that qualified health professionals using
• Identify and intervene when quality of care issues
164
Utilization Management
are identified individually or through delegates’
available 24 hours a day, seven days a week for admission
utilization management review of over- or under-
notifications.
utilization. • Review over- or under-utilization thresholds and metrics. • Comply with all applicable federal and state laws, regulations and accreditation requirements. • Maintain and improve the health status of members with chronic conditions through development of nationally consistent clinical programs for identification and management of members.
Contacts Health Net Access Case Management Department Information on and referrals to case management programs. 1-800-977-7281 Fax: 1-855-825-6146
Health Net Case Management Department Information on and referrals to case management programs. 1-800-898-4638 Commercial/Medicare Fax: 1-800-745-6955
Health Net Hospital Notification Unit Contact the Health Net Hospital Notification Unit for inpatient admission notification. (888) 926-1736 Fax: (855) 764-8513 After business hours, a voicemail and fax system is
165
Utilization Management Case Management Referral Form - Access
166
Chapter 8
Pharmacy (Prescription Drug Program) obtained from or administered by a health care
Overview Health Net offers a prescription medication
professional.
program with comprehensive medication coverage. The Health Net Access Drug List was developed by the Pharmacy and Therapeutics (P&T) Committee, with involvement and recommendations from physicians, pharmacists and other health care
Self-injectable medications are available through Health Net outpatient prescription medication benefits. Most self-injectable medications, except preferred insulins in vials, require prior authorization.
professionals. Development and maintenance of The Health Net Access Drug List is a detailed and ongoing process. The Health Net Access Drug List is continually reviewed and revised in response to recommendations from participating providers, and as new scientific and clinical data and pharmaceuticals become available. Therapeutic needs and cost-effectiveness are also considered when adding or removing medications from The
Select medications, including both brand-names and generics, may require prior authorization. Prior authorization is required for medications not listed on the Health Net Access Drug List. To request medication prior authorization, complete the Prior Authorization/Formulary Exception Request Fax Form. Quantity limits may apply to medications obtained at a participating pharmacy. Members may refer to their plan documents or the Health Net Access Drug List
Health Net Access Drug List.
for specific limitations. The Health Net Access Drug List only applies to outpatient prescription medications. It does not apply to inpatient medications (received in a hospital, skilled nursing facility or nursing home) or to medications
167
Diabetic Supplies Diabetic supplies are limited to a one-month supply (to the nearest package size) with a prescription.
Pharmacy
Exclusions The following items, by way of example, are not
Prescribing providers must clinically justify the use of a
reimbursable:
brand-name medication over the use of its generic equivalent through the prior authorization process.
• Drug efficacy study implementation (DESI) medications (those considered less than effective by
Health Net Access Drug List
the Food and Drug Administration (FDA)). • Non-FDA approved agents.
The Health Net Access Drug List identifies the medications,
• Any medication limited by federal law to
selected by the Pharmacy and Therapeutics (P&T)
investigational use only.
Committee, that are clinically appropriate to meet the
• Medications used for cosmetic purposes.
therapeutic needs of members in a cost effective manner.
• Medications for erectile dysfunction.
The Health Net Access Drug List is developed, reviewed and
• Medications used to increase fertility.
updated monthly, as necessary by the P&T Committee. Medications are added or removed based on objective,
For more information regarding pharmacy benefits,
clinical and scientific data. Considerations include efficacy,
contact the Health Net Access Provider Services Center.
side-effect profile, and cost and benefit comparisons to alternative agents, if available. At a minimum, the Health Net
Generic Substitutions
Access Drug List includes all medications on the AHCCCS
Health Net Access and its participating providers must
Drug List. Additional medications may also be included.
utilize a mandatory generic medication substitution policy that requires the use of a generic equivalent
Key considerations for the Health Net Access Drug List are as
medication whenever one is available. The exceptions to
follows: • Preferred medications on the AHCCCS Drug List for
this requirement are as follows:
specific therapeutic classes
• A brand-name medication may be covered when
• To view or to print a hard-copy of the AHCCCS Drug
a generic equivalent is available when Health Net Access’ negotiated rate for the brand-name
List, go to www.azahcccs.gov > Resources > Guides
medication is equal to or less than the cost of the
Manuals Policies > pharmacy updates. • Therapeutic advantages outweigh cost considerations in
generic medication. • AHCCCS may require Health Net Access to provide
all decisions to change medications on the Health Net
coverage of a brand-name medication when the cost
Access Drug List. Market-share shifts, price increases,
of the generic medication has an overall negative
generic availability, and varied dosage regimens may
financial impact to the state of Arizona. The overall
affect the actual cost of therapy. • Products are not added to the Health Net Access Drug
financial impact to the state includes consideration
List if there are less expensive, similar products on the
of the federal and supplemental rebates.
168
Pharmacy
formulary.
The Health Net Access Drug List is available electronically
• When a medication is added to the Health Net
on the Health Net provider website at www.healthnetaccess.
Access Drug List, other medications may be
com. Providers can request a printed version of the Health
removed.
Net Access Drug List by calling the Health Net Access
• Participating physicians may request additions or
Provider Services Center.
deletions for consideration by the P&T Committee. Requests should include the following:
For more information regarding pharmacy benefits, contact
o Basic product information, indications for
the Health Net Access Provider Services Center.
use and its therapeutic advantage over
Notification of Formulary Updates
medications currently on the list.
Health Net Access provides 60-day advance notice to affected
o Which medication(s), if any, the recommended medication would replace in
members and their prescribing providers of medication
the current Health Net Access Drug List.
removal from the Health Net Access Drug List to allow time to prescribe an alternative medication.
o Any published supporting literature from peer-reviewed medical journals
Health Net Access is not required to send a hard copy of Health Net Access may invite the requesting
the Health Net Access Drug List each time it is updated,
physician to the P&T Committee to support the
unless requested. Health Net Access notifies members and
addition to the Health Net Access Drug List and
providers of updates and changes and may refer providers to
answer related questions. Health Net Access
view the updated Health Net Access Drug List on the Health
does not permit pharmaceutical representatives
Net Access website. Providers and members may request a
to participate in or attend P&T Committee
printed version of the Health Net Access Drug List by calling
meetings. All requests for additions to the
Member Services.
Health Net Access Drug List should be sent to
Prior Authorization Requirements
the Health Net Access Pharmacy Department.
Prior authorization may be required as follows: Prescription medications may be prescribed by any
• If the medication is not included on the Health Net
authorized provider, such as a primary care provider
Access Drug List.
(PCP), attending physician, dentist, etc. Prescriptions
• If the prescription requires compounding.
should be written to allow generic substitution
• For injectable medications dispensed by a pharmacy,
whenever possible and signatures on prescriptions must
with the exception of insulins on the Health Net Access
be legible in order for the prescription to be dispensed.
Drug List. o Note: If the member has a primary health plan
169
Pharmacy
that reimburses for injectable medications,
indications and limits.
Health Net Access will only coordinate benefits
• Published practice guidelines and treatment protocols.
as the secondary payer if the Health Net Access
• Comparative data evaluating the efficacy, type and
pharmacy prior authorization process was
frequency of side effects and potential medication
followed.
interactions among alternative products as well as the
• For injectable medications requiring prior
risks, benefits and potential member outcomes.
authorization dispensed by the physician and billed
• Drug facts and comparisons.
through the member’s health plan, call Health Net
• American Hospital Formulary Service Drug
Access Pharmacy Department at 1-800-410-6565
Information.
to initiate prior authorization for the requested
• United States Pharmacopeia drug information.
specialty medication.
• DRUGDEX Information System.
• For medication quantities that exceed
• UpToDate®, an evidence-based clinical decision support
recommended doses.
resource
• For specialty medications that require certain
• Peer-reviewed medical literature, including
established clinical guidelines be met before
randomized clinical trials, outcomes, research data, and
consideration for prior authorization.
pharmacoeconomic studies.
• For certain medications that may require additional documentation.
A non-FDA indication may not be the sole basis of denial, as off-label prescribing may be clinically appropriate as
Allow up to 14 calendar days for the prior authorization
outlined above. Prescribing providers must submit a prior
review process.
authorization request to Health Net Access for review and coverage determination.
In instances where a prescription is written for medications not on the Health Net Access Drug List, the
Smoking Cessation Therapy
pharmacy may contact the prescriber to either request
Health Net Access covers nicotine replacement therapy
an alternative or to advise the prescriber that prior
(NRT) (such as nicotine transdermal patches), Zyban® or
authorization is required for non-covered medications.
Chantix™, for members ages 18 or older, subject to formulary
Prior authorization requests submitted for review must
limitations. The maximum a member may receive of a
be evaluated for clinical appropriateness based on
tobacco cessation product is a 12-week supply in a six-month
the strength of the scientific evidence and standards
time period, which begins on the date the pharmacy fills
of practice that include, but are not limited, to the
the first tobacco cessation product. A prescription from
following:
the primary care physician (PCP) is required for coverage
• Food and Drug Administration (FDA)-approved
of tobacco cessation products, including over-the-counter
170
Pharmacy
(OTC) products. Health Net Access encourages members to enroll in the Health Net Access’s Arizona Smokers’ Helpline (ASHLine) program, which offers a variety of options to members to help them quit smoking and stay tobaccofree.
Contacts Arizona Smokers’ Helpline (ASHLine) Information on and referrals to case management programs. (800) 556-6222
Health Net Access Provider Services Center The Health Net Access Provider Services Center is available 24 hours a day, seven days a week to assist providers with: • Eligibility. • Claims. • Benefit verification. • Third-party recovery. • Coordination of benefits. • Refunds. • Appeals and grievances (member). • Contact information. • Ongoing provider education and updates (in coordination with the Health Net Access Provider Network Department). • Facilitation of communication between providers and Health Net Access internal departments. 1-888-788-4408 TTY/TDD: 1-888-788-4872
171
Pharmacy Prior Authorization/Formulary Exception Request Fax Form
172
Chapter 9
Quality Improvement Quality Management Program The Health Net Access quality management (QM) program is designed to monitor and evaluate the adequacy, safety and appropriateness of health care and
care and service, the measurement of compliance to the standards, and implementation of actions to improve performance. The scope of these activities takes into account the enrolled populations’ demographics and health risk characteristics, as well as current national, state and regional public health goals. The QM program impacts the
administrative services provided to Health Net Access members on a continuous basis, and to support the identification and pursuit of opportunities aimed at improving health outcomes, as well as member and provider satisfaction. The QM program maintains full compliance with the QM requirements of regulatory agencies, such as the Arizona Healthcare Cost Containment System (AHCCCS) and the Centers for Medicare and Medicaid Services (CMS).
following: • Health Net Access members in all demographic groups and in all Health Net Access contracting and licensed service areas. • Network providers, including practitioners, facilities, hospitals, ancillary providers, and any other contracting or subcontracting provider types. • Aspects of care, including level of care, health promotion, maternal and child health, continuity of care and transitions, appropriateness, timeliness, safety, and
The QM program is conducted using a comprehensive, systematic and continuous multidisciplinary approach, integrating efforts and input from affiliated providers, members, Health Services Advisory Group (HSAG), Arizona Quality Improvement Organization, public health agencies, and community entities. The program includes standards for clinical
173
clinical effectiveness of care, and Health Net Access covered services. • Communication ensuring the provision of
Quality Improvement
culturally and linguistically appropriate care.
organizations, including, but not limited to, the American
• Integration of behavioral health aspects of care to
Diabetes Association (ADA), the Centers for Disease Control
monitor and evaluate the care and service provided
and Prevention (CDC), National Institutes of Health (NIH),
to improve behavioral health care, in coordination
American College of Cardiology (ACC), American Academy
with other medical conditions and services.
of Pediatrics (AAP), and the Centers for Medicare and
• Provider performance related to professional
Medicaid Services (CMS), as well as analysis of peer-reviewed
licensing and credentialing, accessibility and
literature. Many of the metrics in the guidelines are measured
availability of care, and quality and safety of care/
and reported to regulatory agencies, such as CMS or the
service, including practitioner and office associate
Arizona Healthcare Cost Containment System (AHCCCS).
behavior, medical record keeping practices,
Guidelines are posted on www.healthnetaccess.com and are
environmental safety and health, and health
accessible through Medical Policies link, which provides more
promotion.
condensed guidelines for the management of such conditions
• All covered Health Net Access health care services.
as asthma, chronic obstructive pulmonary disease (COPD),
• Internal administrative processes related to
coronary artery disease (CAD), diabetes, and heart failure
service and quality of care, provider qualifications
(HF).
and selection, confidential handling of medical records and information, preventive services,
To receive a hard copy of the clinical practice guidelines,
health education, information services, and quality
contact the Health Net Access Provider Network Management
management.
Department.
The program is reviewed, evaluated and updated at least
Compliance Monitoring
annually or more often as necessary. On request, the
The Health Net Access Quality Management (QM) program
Health Net Access Quality Management Department
includes the development and implementation of standards
makes available to providers and members information
for clinical care and service, the measurement of compliance
about the QM program, including a description of
to the standards and implementation of actions to improve
the QM program and a report on Health Net Access’
performance. The scope of these activities takes into account
progress in meeting its goals and minimum performance
the enrolled populations’ demographics and health risk
standards.
characteristics, as well as current national, state and regional public health goals. The Health Net Access QM program
Overview
develops an annual work plan addressing all Arizona Health
Health Net Access has clinical practice guidelines
Care Cost Containment System (AHCCCS) requirements
available to assist in the care of members. Guidelines
and supports the Health Net Access QM goals and objectives,
are developed utilizing recommendations from national
including compliance with all AHCCCS requirements.
174
Quality Improvement
Health Net Access established the Quality Management/ Performance Improvement (QM-PI) Committee structure to foster quality management discussions and activities from multidisciplinary areas to ensure compliance with regulatory requirements. The Health Net QM-PI Committee structure promotes plan integration and provider network accountability for the identification, evaluation and measurement of key clinical and service activities.
175
Quality Improvement Cultural and Linguistic Community Referral Resources
176
Quality Improvement
177
Quality Improvement
178
Quality Improvement
179
Quality Improvement
180
Quality Improvement
181
Quality Improvement
182
Quality Improvement
Cultural and Linguistic Services
Arizona Smokers’ Helpline (ASHLine) Tobacco Cessation Program
Cultural and linguistic services are available in written and verbal form for all identified threshold languages. Health Net Access provides 24-hour access to interpreter
Health Net Access’s Arizona Smokers’ Helpline (ASHLine)
services. Cultural and linguistic services representatives
program offers a variety of options to members to help
develop, establish and monitor programs for members
them quit smoking and stay tobacco-free. Health Net
that meet the contractual requirements established by
Access members may access free telephone counseling from
the Arizona Health Care Cost Containment System
ASHLine in English and Spanish. ASHLine’s telephone
(AHCCCS).
support includes: • Treatment sessions scheduled at the participant’s
For more information on cultural and linguistic services
convenience
provided by Health Net Access, contact the Health Net
• Access to tobacco treatment specialists for the duration
Cultural and Linguistic Services Department.
of treatment
For more information on how to work with an
• Recommendations on type, dose and duration of
interpreter, providers should refer to the Industry
medication, if appropriate
Collaboration Effort (ICE) toolkit, Provider Tools to
• Educational materials
Care for Diverse Populations.
In addition to free telephone-based coaching services,
To obtain a comprehensive list of community referrals,
members may also use an online tobacco cessation program
refer to the Cultural and Linguistics Community
through WebQuit. Members can work through activities,
Referrals contact sheet.
set goals and monitor their progress 24 hours a day, 7 days a week. WebQuit is available at www.ashline.org.
Overview Health Net is committed to producing better outcomes
Decision Power Disclaimer
for members through the promotion of evidence-based
Health Net members have access to Decision Power® through
disease management programs. Health Net coordinates
their current enrollment with any of the following Health Net
disease management programs for select disease states.
companies: Health Net of Arizona, Inc., Health Net Access,
This includes member education, regular contact with
Inc. and Health Net Life Insurance Company. Decision
a case manager and coordination with the member’s
Power is not part of Health Net’s commercial medical benefit
physician to ensure the member receives the appropriate
plans nor affiliated with Health Net’s provider network and it
information and level of service. These programs are
may be revised or withdrawn without notice. Decision Power
available to all Health Net members at no cost.
is part of Health Net’s Medicare Advantage benefit plans. It is not affiliated with Health Net’s provider network. Decision
183
Quality Improvement
Power services, including clinicians, are additional
Disease Management Program
resources that Health Net makes available to enrollees of
The Health Net Access disease management program
the above listed Health Net companies. Health Net and
provides support to members with chronic conditions,
Decision Power are registered service marks of Health
including heart failure (HF), chronic obstructive pulmonary
Net, Inc. All rights reserved.
disease (COPD), coronary heart disease (CAD), diabetes, and asthma. Decision Power disease management helps
Decision Power Program
increase the efficiency and effectiveness of care, leads to
The Decision Power® program provides a fully
more timely actions by the member, and helps develop more
integrated, health management solution to improve
personalized and actionable solutions that ultimately lead
the health and quality of life for Health Net Access
to improved health outcomes. Health Net Access provides
members. Through personalized interventions and
participants and their providers the programs, tools,
contemporary behavior change methodologies, an
connectivity, and information to make better health care
experienced clinical staff can assist members at-risk
decisions to: • Slow the progression of the disease and the development
and diagnosed with chronic health conditions to
of complications through proven program interventions.
better manage their conditions through education,
• Change behaviors and improve lifestyle choices by using
empowerment and support. Decision Power includes
demonstrated behavior change methodologies.
disease management, case management and complex
• Improve compliance with guidelines and physician care
case management programs.
plans. The Decision Power program provides support 24 hours
• Manage medications and enhance symptom control.
a day, seven days a week, through Nurse24 services.
• Educate members regarding recommended preventive
Health Net Access members can refer to the back of
screenings and tests in accordance with national clinical
their member identification (ID) cards for this telephone
guidelines. • Reduce emergency room visits, hospitalization and
number. Decision Power clinicians are specially trained
medication errors, and prevent future occurrences.
professionals, who are always available to support Health Net Access members through telephone interaction. The goal of the Decision Power program is
Case Management
to support members’ self-care skills, increase their self-
The Health Net Access complex case management program
confidence and help them work effectively with their
targets members with the most complex cases, often with
physicians to manage their health conditions. Providers
life-limiting diagnoses, and assists members who have
may also refer Health Net members to the Decision
critical barriers to their care. A trained nurse case manager
Power program by fax, or they can call Decision Power
provides intensive, face-to-face contact with Health Net
to discuss referrals.
Access members, their families and caregivers. These
184
Quality Improvement
members often have multiple comorbid conditions and
for accuracy of translation, cultural content and reading
need assistance in planning, managing and executing
level.
their care. Providers are required to have educational materials This ambulatory case management program is available
available in approved threshold languages. Health Net Access
to high-risk members with less complex needs. The
evaluates member materials with the assistance of experts,
initial assessment is conducted over the telephone with
focus groups, and individual and group interviews when
a minimum follow-up contact every other week until
appropriate.
the members’ needs are met and the case can be closed. Use the Health Net Case Management Referral Form for
Health health education materials may be ordered by mailing
Health Net Access members to refer members for case
or faxing a completed copy of the Provider Order Form
management.
for Health Education Materials to the Health Net Health Education Department .
Neonatal Intensive Care Management
Health Net Quality ManagementPerformance Improvement Committee
Neonatal intensive care management is available for Health Net Access members who are admitted to neonatal intensive care units (NICUs) or specialty care nurseries. A trained neonatal nurse case manager
The Health Net Access Quality Management-Performance
monitors the progress of the infant from initial
Improvement (QM-PI) Committee structure includes
admission into NICU through the transition to home.
various sub-committees and workgroups. The Health
This trained clinician ensures that parents and family
Net Access QM-PI Committee has been delegated the
members are prepared to take their newborn home, and
responsibility for oversight of the Health Net Access
assists with arranging necessary home-based services for
Quality Management (QM) program from the board of
the family.
directors and is responsible for monitoring the quality and safety of care and services rendered to Health Net Access
Health Education Materials
members. The Health Net Access QM-PI Committee ensures
Printed information for Health Net Access members,
the QM program, work plan and annual evaluation are
including health education brochures and fact sheets,
implemented effectively and result in improvements in care
is provided at a sixth-grade (or lower) reading level in
and service. The Health Net Access QM-PI also assesses and
an easy-to-read format. Diverse cultural backgrounds
recommends, as needed, resources to implement quality
are taken into consideration when these materials are
improvement activities
created and translated. The Health Net Cultural and
The following committees report to the Health Net Access
Linguistic Services Department reviews these materials
QM-PI Committee:
185
Quality Improvement
• Health Net AccessMedical Management/Utilization
Credentialing/Peer Review Committee
Management (MM/UM) Committee
The Health Net Access Credentialing/Peer Review
• Health Net Access Credentialing/Peer Review
Committee verifies and reviews practitioners and
Committee
organizational providers who contract to render professional
• Pharmacy and Therapeutics Committee
services to Health Net Access members for training,
• Delegation Oversight Committee
licensure, competency, and qualifications that meet
• Health Net Access Network QM Subcommittee
established standards for credentialing and recredentialing. The Credentialing Committee ensures credentialing and
Health Net Access Medical Management/ Utilization Management Committee
recredentialing criteria for participation in the Health
The MM/UM Committee is responsible for the review
Net Access QM-PI Committee delegates authority and
of the medical management and utilization management
responsibility for credentialing and recredentialing and peer
data and management activities and utilizes the data
reviews to this committee. This committee is also responsible
to make recommendation for action. The committee
for peer review activities and decisions regarding quality
monitors the effectiveness of any action taken and
management follow-up on service and clinical matters,
reports significant findings to the Health Net Access
including quality of care cases. The committee provides a
QM-PI Committee. The MM/UM Committee monitors
forum for instituting corrective action as necessary, and
the activities and patterns in:
assesses the effectiveness of these interventions through
• Pharmacy management
systematic follow-up for both inpatient and outpatient care
• Prior authorization and referral management
and services.
Net Access network are met and maintained. The Health
• Development and/or adoption of practice guidelines • Concurrent review
This committee reports to the Health Net Access QM-PI
• Continuity and coordination of care
Committee and provides a summary of activities to the
• Over- and under-utilization patterns
Health Net Access board of directors.
• New medical technologies and use of existing technologies
Pharmacy and Therapeutics Committee
• Disease management and chronic care programs
The Pharmacy and Therapeutics (P&T) Committee ensures
• Early and Periodic Screening, Diagnosis, and
appropriate and cost-effective delivery of pharmaceutical
Treatment (EPSDT)
agents to Health Net Access membership. Committee
• Maternal child health
responsibilities include the review and approval of policies that outline pharmaceutical restrictions, preferences,
The MM/UM Committee is chaired by the Health Net
management procedures, explanation of limits or quotas,
Access medical director.
delineation of Preferred Drug List (PDL) exceptions,
186
Quality Improvement
substitution and interchange, step-therapy protocols,
appointments.
and adoption of prescription safety procedures.
• Sign-language services for medical appointments. • A statement in all notices Health Net Access sends to
The P&T Committee includes a Health Net medical
members that indicates how to access language services
director, practitioners and clinical pharmacists and
in any applicable non-English language.
reports to the Health Net Access QM-PI Committee. Delegation Oversight Committee
Applicable languages are identified by the Department of Health and Human Services (HHS) annually. Currently,
The Delegation Oversight Committee (DOC) is
HHS has identified the following languages in the United
responsible for overseeing the formal process by
States as requiring language assistance services: Spanish,
which another entity is given the authority to perform
Chinese, Navajo, and Tagalog. In Maricopa County, the
functions on behalf of Health Net Access. The DOC
identified threshold language is Spanish.
ensures there is a contractual agreement between Health Net Access and the delegate, which outlines
All Health Net Access hearing impaired members can
responsibilities, activities, reporting, evaluation
contact the Health Net Access Provider Services Center
process, and remedies for deficiencies. The DOC’s
through the Health Net Access dedicated TDD/TTY line for
responsibilities include:
services.
• Monitoring and evaluating a delegate’s performance
Requirements
through due diligence prior to granting delegation. • Monitoring and evaluating a delegate’s performance
Health Net Access participating providers are required to
through routine reporting and an annual evaluation
support language assistance services by complying with the
of the delegate’s processes in compliance with all
following:
regulatory and accreditation standards.
• Interpreter services - Use qualified interpreters for
• Taking action when monitoring reveals deficiencies
limited-English proficient (LEP) members. Telephonic
in the delegate’s processes.
interpreter services are provided by Health Net Access at no cost to providers or members.
Language Assistance Services
• Medical record documentation - Document the
As required under federal regulations, Health Net
member’s language preference (including English) and
provides no-cost language assistance services to
the refusal or use of interpreter services in the member’s
members. Health Net Access provides the following in
medical record. Health Net Access strongly discourages
order to comply with mandated cultural and linguistic
the use of family, friends or minors as interpreters.
appropriateness standards:
If, after being informed of the availability of no-cost telephonic interpreter services, the member prefers to
• Telephone interpreter services for medical
use family, friends or minors as interpreters, the provider
187
Quality Improvement
must document this in the member’s medical
confidentiality of members’ medical records is maintained.
record.
Health Net Access requires its providers to maintain current, organized and detailed clinical records in order to permit
Interpreter Services
effective and confidential patient care. These records must be
Information regarding telephonic interpreter services
consistent with standard medical and professional practice.
is available by contacting the Health Net Access
All protected health information (PHI) must be handled in
Customer Contact Center. When calling, the following
accordance with established policies and procedures, and
information is required:
federal and state regulations, in order to safeguard patient
• Member name
confidentiality. Health Net Access requires that providers
• Member Health Net Access ID number
safeguard the confidentiality of those records and member
• Appointment date and time, if necessary
information in accordance with applicable laws.
Cultural Competency Training
Health Net Access QM policies also establish basic standards
Health Net Access recommends that all providers
for the administration of clinical records and medical
participate in a cultural competency training course
record documentation requirements for providers in order
as part of their continuing education. The HHS’ Office
to ensure quality care and service are provided to enrolled
of Minority Health (OMH) offers a computer-based
Health Net Access members. Primary care providers (PCPs),
training (CBT) on cultural competency for health care
obstetricians/gynecologists (OB/GYNs), pediatricians,
providers. This program was developed to furnish
high-volume specialists, dentists, and medical groups are
providers with competencies enabling them to better
required to maintain a legible clinical record for each Health
treat the increasingly diverse population. For more
Net Access member who has been seen for medical and
information, refer to the OMH Think Cultural Health
dental appointments or procedures, or has received medical/
website.
behavioral health/dental records from other providers who have seen the member. Organizational providers are also
Providers who would like information on topics, such
required to maintain a comprehensive medical record for
as cross-cultural communication, health literacy or
each enrolled Health Net Access member as appropriate. The
accessing interpreter services, may contact Health Net’s
record must be up-to-date, well organized and comprehensive
Cultural and Linguistic Services Department .
with sufficient detail to promote effective patient care and quality review. The Health Net Access QM Department has
Medical Record Documentation
implemented a process for monitoring contracting providers’
In accordance with Health Net Access Quality
medical record documentation to ensure compliance with
Management (QM) policies, providers are responsible
established AHCCCS and Health Net Access standards. PCPs,
to ensure that complete and accurate content and
OB/GYNs, pediatricians, high-volume specialists, dentists, and medical groups are included in the monitoring process.
188
Quality Improvement
Performance Improvement Projects
• Appeals, grievances and other complaints (such as quality of care).
The Health Net Access’ Quality Management (QM)
For each PIP, Health Net Access assesses performance using
program participates in Arizona Health Care
indicators that are objective, clearly and unambiguously
Cost Containment System (AHCCCS)-mandated
defined, and based on current clinical knowledge or
Performance Improvement Projects (PIPs) on topics
health services research. Interventions are implemented
that take into account comprehensive aspects of
to improve performance, based on an evaluation of
members’ needs, care and services. In addition, the
barriers to care or use of services, and an evidence-based
QM Department may select and design, with AHCCCS
approach to improving performance, as well as any unique
approval, additional PIPs that are specific to members’
factors of Health Net Access membership, provider
needs and identified through internal monitoring of
network or geographic area served. Health Net Access
data for trends. Selected PIP topics take into account
reports interventions, analysis of interventions, internal
comprehensive aspects of member needs, care and
measurements, changes or refinements to interventions, as
services for a broad spectrum of members, or focused
well as any actual or projected results annually to AHCCCS
subset of the AHCCCS population. PIPs include
as required.
measuring the impact of the interventions or activities toward improving the quality of care and service
Quality Improvement Referrals
delivery. Clinical focus topics for PIPs may include:
Health Net Access members, associates, participating
• Primary, secondary and/or tertiary prevention of
providers, and community citizens may make written
acute conditions.
or verbal referrals to the Health Net Access Quality
• Primary, secondary and/or tertiary prevention of
Management (QM) Department when a suspected or
chronic conditions.
identified problem exists in the delivery of health care to a
• Care of acute conditions.
member by a Health Net Access provider.
• Care of chronic conditions. • High-risk services.
Potential quality of care issues include preventable and
• Continuity and coordination of care.
avoidable conditions, delays in obtaining treatment, surgical complications, morbidity or mortality, and poor medical
Non-clinical focus topics may include:
record documentation.
• Availability, accessibility and adequacy of the service delivery system.
The QM Department documents and tracks all QM referrals.
• Cultural competency of services.
The QM Referrals Report documents the type of concern,
• Interpersonal aspects of care (such as quality of
severity, provider involved, and outcomes. Health Net
provider/member encounters).
189
Quality Improvement
Access medical directors make the final determinations
monitors and evaluates the adequacy and appropriateness
on whether referrals are presented to the Peer Review
of health care and administrative services on a continuous
Committee for further discussion or action (Health
and systematic basis. The QM program also supports the
Net Access complies with federal law 42 U.S.C. 1112 and
identification and pursuit of opportunities, based on input
Arizona Statute A.R.S. 36-2404, which provides for
from affiliated providers and members, to improve health
confidentiality of peer review and regulatory agency
outcomes, the continuum of care, and both member and
information).
provider satisfaction.
Reports specific to a provider are included as part of the recredentialing process.
Quality of Care Issues In compliance with regulatory requirements, Health Net Access monitors and evaluates potential quality issues (PQIs) involving Health Net Access members. Use the Potential Quality Issue (PQI) Referral form to fax reports of potential or suspected deviation from standards of care that cannot be justified without additional review or investigation. The Health Net Access Quality Management (QM) program monitors and reports performance and processes related to the quality of care and services provided. QM program policies have established standards for both the quality and safety of clinical care and service delivery for enrolled members. All Heath Net Access contracting providers are required to report to the appropriate regulatory agency, such as Adult Protective Services (APS) or Arizona Department of Child Safety (DCS), and to the Health Net Access QM Department any suspected incidences of member abuse, neglect, exploitation, or unexpected death as soon as they become aware of the incident. The QM program
190
Quality Improvement ICE Provider Tools to Care for Diverse Population
Source Word doc has a pdf thumbnail image of a doc 15-238_ICEbooklet.pdf It is 60 pages long. Should it be included?
191
Quality Improvement LINKED DOCUMENTS Cultural and Linguistic Community Referral Resources
192
Quality Improvement
193
Quality Improvement
194
Quality Improvement
195
Quality Improvement
196
Quality Improvement
197
Quality Improvement
198
Quality Improvement Case Management Referral Form - Access
199
Quality Improvement Potential Quality Issue Referral Form
200
Quality Improvement
201
Quality Improvement
202
Quality Improvement Provider Order Form for Health Education Materials
203
Medical Records
Overview A physician or other clinician must establish a record at the time of the member’s first visit or contact and maintain adequate records throughout the course of the member’s medical care. Health Net and its participating providers must maintain books, records, documents, and other evidence of accounting procedures and practices for 10 years. If the member is a child, records must be kept for at least three years after the child’s 18th birthday, or for at least six years after the date the child
records for appeals and grievances. This statement is valid to obtain medical records on behalf of the member. Behavioral health records contain information that must not be released as part of the regular medical record and subject to more stringent legal requirements regarding confidentiality. Therefore, when receiving correspondence from a behavioral health clinician, it is recommended that the medical physician keep all behavioral health correspondence in a separate, removable section of the record.
received medical or health care services, whichever
Advance Directives
occurs last.
Health Net complies with all state and federal laws regarding advance directives. Participating practitioners and providers
All participating providers must comply with applicable
are required to provide information regarding advance
state and federal laws, regulations and requirements
directives to members ages 18 and older to educate them
regarding confidentiality of member medical records.
about their rights to create an advance directive. Advance
All participating providers are required to implement
directive education provided to the member, whether a
and maintain procedures that guard against disclosure
member has executed an advance directive, and the location
of confidential information to unauthorized persons.
of the advance directive must be documented in a prominent part of the member’s medical record. Health Net monitors
Health Net has the right to review medical records
medical records to ensure compliance with requirements
for the purposes of research for appeals or grievances
regarding advance directives.
and for quality and safety of care and services, unless otherwise prohibited by law or a member’s express
Annual Medical Record Review
written refusal to permit such access to records. When
Health Net has established standards to ensure that medical
requested, unless otherwise indicated in the provider’s
records are current, detailed and organized, and permit
contract, the provider must produce copies of medical
effective, continuous and confidential member care and
records to Health Net at no charge. When a member
services.
signs his or her Health Net enrollment form, the signature gives Health Net authorization to obtain
Primary care physicians (PCPs), OB/GYNs and high-volume
certain medical records on the member’s behalf. A
specialists are monitored at a minimum of every three years
medical records release form is sent to the physician
in accordance with the credentialing cycle. Organizational
stating, “Member’s Signature on File,” when requesting
and service providers are monitored annually.
204
Medical Records
Providers are required to maintain records in an accurate and timely manner in accordance with industry standards and regulatory requirements, and document all care in a manner that meets these standards. In addition, the records should reflect all aspects of member care including past, current and future health status or treatment in order to develop a comprehensive picture of member needs and utilization patterns over time.
HIV-Related and Substance Abuse Information A release of confidential HIV related information must be signed by the member or a legally-authorized person consenting for the member if the member lacks capacity to consent. A release must be dated and specify to whom disclosure is authorized, the purpose for disclosure and the time period for which the release is effective. A general authorization for the release of medical or other information
The medical record documentation audit tool is a review tool approved by the Quality Management (QM) Committee and used to ensure consistent review. Each element in the review is given a point value. Upon completion of the review, the score is tabulated. The
is not a release of confidential HIV related information unless the authorization specifically indicates its purpose as a general authorization and an authorization for the release of confidential HIV related information and complies with the state requirements.
threshold is 85 percent. Scores below 85 percent require corrective action and a subsequent re-audit. Those scoring below the threshold are notified in writing of the results and the need for a corrective action plan. Any results of a re-audit that remain below the threshold of 85 percent are presented for further review and discussion at the QM Peer Review Committee.
Health Net requires that all participating providers respect each member’s right to confidentiality and treat member information in a respectful, professional and confidential manner consistent with all applicable federal and state requirements. Discussion of member information must be limited to what is necessary to perform the duties of the job. Reports from specialty behavioral health services and
The medical record policy, audit tool and guidelines are available by contacting the Health Net Access Quality Management Department.
consultations are placed in the member’s medical record. Behavioral health services are considered confidential and sensitive. Health Net recommends that any written follow-up consultation the PCP receives from the specialist or therapist
Changes to PCP
is placed in a confidential section of the member’s medical record.
When a member changes his or her primary care physician (PCP), the current PCP must forward a copy of the member’s medical record to the new PCP within 10 business days from the request for transfer.
According to A.R.S. § 36-568.02, a competent adult or emancipated minor may restrict the release of the adult’s or the minor’s medical or behavioral health records, or both, and information that is otherwise allowable under state and federal law.
205
Medical Records
Medical Record Elements
Medical Record Requests
Each participating provider must have in place policies and
Under Arizona law, members are entitled to a copy of their medical
procedures to ensure member medical records are legible,
records annually at no cost from any health care professional who
complete and current. The following are elements that must be
has treated them. If a member’s appeal or request requires Health
noted in all member medical records:
Net to review medical records, the provider must release the
• Member’s name or identification (ID) number on each page • Demographic data
records to Health Net. Certain restrictions may apply if the records contain information regarding the member’s behavioral health status or genetic testing results.
• Initial history • Past medical history
Providers must ensure availability and accessibility of members’
• Immunization records
medical records to the member in a timely manner in accordance
• Dental history
with industry standards.
• Current problem list • Current medication list, including dosage, frequency
Release of medical information guidelines must address:
and diagnosis
• Requests for personal health information (PHI) via
• Current & complete EPSDT forms
telephone
• Documentation of clinical findings and evaluation
• Demands made by subpoena duces tecum
for each visit
• Timely transfer of medical records to ensure continuity
• Laboratory, X-ray and imaging consultant reports
of care when a Health Net member chooses a new
initialed and filed
primary care physician (PCP)
• Advance directives
• Availability and accessibility of member medical records
• Release of information documentation, when
to Health Net and to state and federal authorities or
applicable
their delegates involved in assessing quality of care or
• Continuity of care documentation
investigating enrollee grievances or other complaints
• Signed informed consents, when applicable
• Availability and accessibility of member medical records to the member in a timely manner in accordance with
In lieu of establishing a medical record, behavioral health
industry standards 422.118(d)
information, when received from the behavioral health
• Requirements for medical record information between
provider about an assigned member, even if the medical
providers of care requesting information from another
provider has not yet seen the assigned member, may be kept
treating provider as necessary to provide care
in an appropriately labeled file, but must be associated with the member’s medical record as soon as one is established.
Requests by the State or Health Plan Arizona Health Care Cost Containment System (AHCCCS) is not
206
Medical Records
required to obtain written approval from a member before
• Medical record organization standards - Policy and
requesting the member’s medical record from the PCP or any
procedure must include information about individual
other organization or agency. Health Net may obtain a copy of
medical records; securely fastened medical records;
a member’s medical record without written approval from the
medical records with member identification on
member if the request is directly related to the administration
each individual page; and a consistent area in the
of the AHCCCS program. The medical record must be sent
medical record designated for the member’s history,
within 20 business days of receipt of request or sooner if
allergies, problem list, medication list, preventive care,
necessary.
immunizations, progress notes, therapeutic, diagnostic operative, and specialty physician reports, discharge
Written Protocols
summaries, and home health information
Participating providers are required to have systems and
• Filing system for records (electronic or hardcopy)
procedures in place that provide consistent, confidential and
• Formal system for the availability and retrieval of
comprehensive record-keeping practices. Written procedures
medical records - allow for the ease of accessibility to
must be available upon Health Net’s request for:
medical records for scheduled member encounters within the facility or in an approved health record
• Confidentiality of patient information - Policy
storage facility off the facility premises
and procedure must address the protection of
• Filing of partial medical records - must outline the
confidential protected health information (PHI) of the patient in accordance with the Health
process for filing partial medical records offsite,
Information Portability and Accountability Act
including a process that alerts authorized staff regarding
(HIPAA), 45 CFR 164.530(i)(1) and applicable state
the offsite filing of the partial record • Retention of medical records in accordance with federal
law. The policy must include a written or electronic functioning mechanism designed to safeguard
laws and regulations (for providers who accept Medicaid
records and information against loss, destruction,
patients) • Preventive care guidelines for pediatric (including the
tampering, unauthorized access or use, and additional safeguards to maintain confidentiality
use of AHCCCS-approved EPSDT forms) and adult
during verbal discussions about patient information.
members
Information about written, electronic and
• Referrals to specialists
verbal privacy, periodic staff training regarding
• Accessibility of consultations, diagnostic tests,
confidentiality of PHI, and securely stored records
therapeutic service and operative reports, and discharge
that are inaccessible to unauthorized individuals
summaries to health care providers in a timely manner • Inactive medical records - Policy and procedure must
must also be included
include guidelines that describe how and when a medical
• Release of medical records and information,
record becomes inactive. Member medical records
including faxes
may be converted to microfilm or computer disks for
207
Medical Records
long-term storage. Every health care provider who creates, maintains, preserves, stores, abandons, or destroys medical records must do so in a manner that preserves the confidentiality of member information and is in compliance with federal and state regulations
CONTACTS Health Net Access Quality Management Department Contact the Health Net Access Quality Management (QM) Department for questions regarding the QM program, or medical records documentation standards and audits.
[email protected]
208
Chapter 10
Member Rights and Responsibilities do so
Overview
• Receive information on available treatment
Members have the right to: • Be treated with respect, and recognition of their dignity and right to privacy • Not be discriminated against based on race, color, creed, ancestry, national origin, religion, gender, age, intellectual or physical disability, sexual preference, genetic information, marital status, or
options and alternatives, presented in a manner appropriate to the members’ conditions and ability to understand the information • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation • Be provided with information about
source of payment • Have services provided in a culturally competent manner, with consideration for members with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, or
formulating advance directives with his or her health care providers • Receive information in a language and format that they understand • Know about providers who speak languages other than English
visual or auditory limitations • Select a primary care physician (PCP) from Health Net’s participating PCPs, including the right to refuse care from
• Be provided with information regarding grievance, appeals and request for hearing • Complain about the managed care organization
specific providers • Participate in decision-making regarding their health care, including the right to refuse treatment and have a representative facilitate care or treatment decisions when the member is unable to
209
• Have access to review medical records in accordance with applicable federal and state laws • Request and receive annually, at no cost, a copy of their medical records
Member Rights and Responsibilities
• Receive a response from Health Net Access within
not required to pay for care that is in direct conflict with an
30 days to the members’ request for a copy of
advance directive.
medical records (response may be the copy of the medical record or written denial, which includes the
Information about advance directives is provided by Health
basis for the denial and information on how to seek
Net in the member’s Evidence of Coverage (EOC) or Member
review of the denial in accordance with 45 CFR Part
Handbook, which is updated annually. The EOC or Member
164)
Handbook includes the following information:
• Amend or correct their medical records
• Advance directives are written instructions prepared or
• Freely exercise their rights without adversely
completed by members that advise the member’s family,
affecting their treatment by Health Net Access or
friends and physicians what the member wants done
associated providers
in case of serious injury or illness causing them to be unable to speak for themself
Members have the responsibility to:
• Participating providers must honor any member’s
• Provide, to the extent possible, information needed
advance health care directive in accordance with federal
by professional staff to care for the member
and state laws. Health Net does not condition the
• Follow instructions and guidelines given by those
provision of coverage or discriminate against a member
providing health care
based on whether or not he or she has executed an
• Know the name of his or her assigned PCP
advance directive
• Schedule appointments during office hours whenever possible instead of using urgent care
If the member has completed a living will or health care power
facilities or emergency rooms
of attorney, he or she is responsible for delivering it directly to
• Arrive for appointments on time
his or her primary care physician (PCP), to be placed in the
• Notify the provider in advance when it is not
member’s medical record.
possible to keep an appointment
Americans with Disabilities Act of 1990
• Bring immunization records to every appointment for children ages 18 or younger
Health Net and its participating providers do not discriminate against members who have physical disabilities. The
Advance Directives
Americans with Disabilities Act of 1990 (ADA) requires
Advance directive information (English or Spanish)
that places of public accommodation, including hospitals
must be documented in a prominent place in the
and medical offices, provide auxiliary aids and services
member’s chart, including the date of discussion of an
(for example, an interpreter for deaf members) to disabled
advance directive. Members have the right to make and
members. Health Net’s policy describes nondiscrimination
control their own health care decisions. Health Net is
toward members with physical disabilities and the
210
Member Rights and Responsibilities
participating provider’s responsibility to provide needed
for treatment any member in need of the health care services
auxiliary aids and services.
that are offered by the provider.
Member Confidentiality
Health Net and its participating providers must not
Participating providers must respect each member’s right
discriminate against any provider that serves high-risk
to confidentiality. Providers are expected to treat member
populations or specializes in conditions that require costly
information in a respectful, professional and confidential
treatment.
manner that is consistent with all applicable federal and state requirements. Confidentiality is the principle that
All organizations that provide Medicaid, including Health Net
member information and medical records are protected
and its participating providers, must obey federal laws against
against unlawful disclosure and that those with access to
discrimination, including Title VI of the Civil Rights Act of
member information and medical records do not share
1964, the Rehabilitation Act of 1973, the Age Discrimination
such information inappropriately.
Act of 1975, the Americans with Disabilities Act (ADA), and all other laws that apply to organizations that receive federal funding, and any other laws and rules that apply for any other
Notice of Non-Discrimination
reason.
When Health Net makes decisions about employment of staff or provides health care services, it does not
Primary Care Physician Assignment
discriminate based on a person’s race, disability, religion, sex, sexual orientation, ethnicity, creed, age, national
Selection Criteria
origin, or any factor that is related to health status,
Member assignment is based on the member’s choice
including, but not limited to the following:
and auto-assignment; therefore, Health Net Access does
• Medical condition, including behavioral, as well as
not guarantee that a provider will receive a set number
physical illness
of members. Members reserve the right to select another
• Claims experience
primary care provider (PCP) after initial assignment and
• Receipt of health care
anytime thereafter. Health Net Access auto-assigns PCPs to
• Medical history
new members enrolled in the Health Net Access plan using
• Genetic information
the following process:
• Evidence of insurability, including conditions
• PCPs are located within 10 miles of the member’s
arising out of acts of domestic violence
residence, which is broadened in five-mile increments, if
• Disability
necessary, until a PCP is located. • PCPs must not have reached Health Net Access’s
Additionally, the participating provider must have
maximum capacity.
practice policies that demonstrate that he or she accepts
• Members under ages 12 are assigned to a pediatrician.
211
Member Rights and Responsibilities
• Members under ages 18 are not assigned to an
Health Net Access mails a member identification (ID) card to
internal medicine PCP.
the member after the PCP is assigned.
• New members under age 18 who share the same case number as an existing Health Net Access
Welcome Kit
member under age 18 are assigned to the same PCP
Health Net Access mails a welcome letter and Member
regardless of the maximum capacity designated by
Handbook to new members or their families, as applicable.
Health Net Access.
Additionally, Health Net Access sends a PCP notice letter to
• Members who are currently in Health Net’s
new members detailing the PCP’s contact information and
Medicare Advantage Special Needs Plan are
how to request a PCP change. These letters are mailed within
assigned to the same PCP, when possible, if the
12 business days following Health Net Access’ receipt of the
PCP is registered with Arizona Health Care Cost
enrollment file from AHCCCS.
Containment System (AHCCCS).
Second Opinion
• Members previously enrolled with Health Net Access are assigned to the same PCP if the member
Health Net Access members have the right to seek a second
was dis-enrolled for less than 90 calendar days.
opinion for diagnosis and treatment at no cost from a qualified health care provider in or out of Health Net’s
Member Capacity
participating provider network. Prior authorization is required
PCPs must follow the below guidelines regarding
to access a non-participating provider.
member capacity: • The PCP must contact his or her Health Net Access Services representative if he or she declared a specific member capacity for his or her practice and want to make a change to that capacity. • The PCP must not refuse to treat members as long as the PCP has not reached requested member capacity. • Providers must notify Health Net Access at least 45 days in advance of their inability to accept additional Medicaid members. Health Net Access prohibits all providers from intentionally segregating members from fair treatment and covered services provided to other non-Medicaid members.
212
Member Rights and Responsibilities
The Advance Directive - Spanish
213
Member Rights and Responsibilities
214
Member Rights and Responsibilities The Advance Directive
215
Member Rights and Responsibilities
216
Chapter 11
Eligibility and Enrollment Enrollment Overview Arizona Health Care Cost Containment
month is the month in which a member was first enrolled in one of the state health program plans.
System (AHCCCS) pre-enrolls most acute care members in the health plan of their
Coverage Out of State
choice when they apply for eligibility
A member who is temporarily out of state, but
through the Arizona Department of
still an Arizona resident, is entitled to receive
Economic Security (DES) and the Social
Arizona Health Care Cost Containment System
Security Administration (SSA).
(AHCCCS) benefits under any of the following conditions:
Members who select a health plan while waiting for eligibility determination are enrolled on the same day as the eligibility determination date. Members who do not select a health plan are auto-assigned a health plan and have 30 days to enroll in a
• Medical services are required due to a medical emergency • Documentation of the emergency must be submitted with the claim • The member requires a particular treatment that can only be obtained in another state • The member has a chronic illness
different health plan if desired.
necessitating treatment during a temporary Providers are reimbursed for covered
absence from the state, or the member’s
services during the prior period coverage
condition must be stabilized before returning
(PPC) time frame. The PPC is the period
to the state
between the member’s starting date of AHCCCS eligibility and the date of
Services furnished to AHCCCS members outside
enrollment with Health Net.
the United States are not covered.
Health Net Access members who maintain
Eligibility Overview
eligibility may change plans once a year
Eligibility for Arizona Health Care Cost
during their enrollment anniversary
Containment System (AHCCCS) is determined
month. The enrollment anniversary
217
Eligibility
by different agencies depending on the program to
Maricopa County.
which the member is applying. These agencies/entities
• Health Net Access telephone verification through the
include AHCCCS, Department of Economic Security
Provider Services Center (to be use as the last resort). To
(DES) and the Social Security Administration (SSA).
protect member confidentiality, providers are asked for
For most members, eligibility is effective from the first
at least three pieces of identifying information, such as
day of the month of application or the first day of the
member identification number, date of birth and address,
month in which the member meets the qualification for
before any eligibility information can be released. When
AHCCCS coverage or the date of birth, whichever is
calling, use the prompt for the providers.
later.
Newborn Eligibility Eligibility Verification
All babies born to Arizona Health Care Cost Containment
Providers are responsible for verifying eligibility each
System (AHCCCS)-eligible mothers are also AHCCCS-
time a member schedules an appointment and when all
eligible and may remain eligible for up to one year if the
medical services are provided. The member’s assigned
newborn continues to reside in Arizona.
primary care provider (PCP) must also be verified prior
Newborns born to mothers receiving Federal Emergency
to rendering primary care services. Health Net Access
Services (FES) are also eligible for up to age one. The mother
does not reimburse providers for services rendered to
is covered under FESP; the newborn is enrolled in an
members who lost eligibility or were not assigned to the
AHCCCS health plan.
PCP’s panel unless the provider is a physician covering Newborns born to mothers enrolled in KidsCare are
for a PCP.
approved for KidsCare beginning with the newborn’s date of Providers may verify member eligibility with one of the
birth unless the child is eligible for Medicaid.
following: Newborns receive separate AHCCCS identification (ID)
• Health Net Access provider website at www. healthnet.com/ahcccsprovider. Providers must be
numbers and services for them must be billed separately
registered and have a password.
using the newborn’s ID. Services for a newborn that are included on the mother’s claim are denied.
• MediFax: An electronic system available through AHCCCS that stores key member information. Use to verify member eligibility for pharmacy, dental,
Contacts
transportation and specialty care.
Arizona Health Care Cost Containment System (AHCCCS) Resources
• AHCCCS interactive voice response (IVR). There are two contacts, one for providers within Maricopa
Verify member eligibility on the AHCCCS website at azweb.
County and another for providers outside of
statemedicaid.us.
218
ID Cards
AHCCCS (State) IVR - Maricopa County:
ID Cards Overview
(602) 417-7200
A new identification (ID) card is automatically sent when:
Outside Maricopa County, within Arizona:
• A member enrolls
1-800-331-5090
• A member changes his or her name
Detailed instructions for filling out claim forms is
• A dependent is added or deleted from the policy
available on the following AHCCCS websites:
• Other changes are made to provider or health plan
http://azahcccs.gov
information
- Fee For Service Provider Manual Chapter 5 - Fee For Service Provider Manual Chapter 6
Refer to the Health Net Access member ID card to view a picture and general description of a Health Net Access
Health Net Access Provider Services Center
member ID card.
The Health Net Access Provider Services Center is available 24 hours a day, seven days a week to assist providers with: • Eligibility. • Claims. • Benefit verification. • Third-party recovery. • Coordination of benefits. • Refunds. • Appeals and grievances (member). • Contact information. • Ongoing provider education and updates (in coordination with the Health Net Access Provider Network Department). • Facilitation of communication between providers and Health Net Access internal departments. 1-888-788-4408 TTY/TDD: 1-888-788-4872
219
ID Cards Health Net Access Member ID Card Sample
220
Copayments
Copayments Copayment Requirements Members eligible for Health Net Access through the Transitional Medical Assistance (TMA) and Childless Adults/Title XIX Waiver Group (TWG) programs may be subject to mandatory copayments when receiving covered services. Providers may deny services to members who do not pay applicable copayments. However, certain services (such as emergency services) and specific populations (such as members under the age of 19) are exempt from mandatory copayments. Copayments are never charged for the following: • Hospitalizations • Emergency services • Family planning services and supplies • Pregnancy-related health care and health care for any other medical condition that may complicate the pregnancy, including tobacco cessation treatment for pregnant women
Copayment Levels Members are assigned a copayment level, which indicates whether they are exempt from copayments or subject to copayments. Providers can locate a member’s copayment level on the first page of the member’s eligibility screen on the Arizona Health Care Cost Containment System (AHCCCS) website at https:// azweb.statemedicaid.us/home.asp.
221
Chapter 12
Referrals and Authorization (Prior Authorization) Prior Authorization Overview Prior authorization is the process by which Health Net determines in advance whether a service is covered, based on the initial request and information received from the provider. To ensure a complete review, Health Net may request additional documentation to substantiate whether the requested service meets Health Net Access criteria. Prior authorization does not guarantee payment. Reimbursement is based on the accuracy of the information received with the prior authorization request, on whether or not the service is substantiated through concurrent and medical review, and/or on whether the claim meets claim submission requirements. All other coverage requirements must also be met in order for a claim to be eligible for payment. Prior authorization does not replace the participating provider’s judgment with respect to the member’s medical condition or treatment requirements. Obtaining prior authorization is the provider’s responsibility; the member must not be billed if the
222
provider fails to obtain prior authorization before performing services. When Health Net is the member’s secondary coverage, no prior authorization is required; however, Health Net determines whether a requested service meets the criteria for medical necessity when the primary carrier denies a service for lack of medical necessity. Health Net covers the requested service after medical necessity is determined.
Emergency Services Health Net provides coverage for emergency services to all members. An emergency medical condition is defined as the treatment for a medical condition, including emergency labor and delivery, which manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine, could reasonably expect in the absence of immediate medical attention to result in: • Serious jeopardy to the health of the individual or, in the case of a pregnant
Prior Authorization
woman, the health of the woman or her unborn
request turnaround times are as follows:
child
• Standard request is less than 72 hours
• Serious impairment to bodily functions
• Expedited request is less than 24 hours
• Serious dysfunction of any bodily organ or part If approved, the approval notice is faxed to the physician or Emergency services are covered both in-network and
pharmacy.
out-of-network and do not require prior authorization. In accordance with the Arizona Health Care Cost
Prior Authorization Process
Containment Systems (AHCCCS) and 42 CFR 438.114,
Health Net uses established clinical criteria guidelines for
emergency room screening and stabilization services
making medical determinations based on medical necessity.
do not require prior authorization to be covered by
Health Net’s utilization management and prior authorization
Health Net. Refer to the Emergency Services section for
criteria are based on sound clinical evidence. Prior to Health
additional information.
Net making a determination based on medical necessity, a member must meet all eligibility and coverage of benefit
Non-Delegated Medical Group/ IPA Denials
requirements.
Medical groups and independent practice associations
Health Net adopted medical necessity criteria for medical
(IPAs) that are not delegated for denial determinations
necessity review, including all regulatory criteria for medical
must notify Health Net of all potential authorization
necessity that have been established for the program, which
denials. The prior authorization request and pertinent
may include the following evidence-based guidelines:
documentation must be faxed to the Health Net Prior
• InterQual®
Authorization Department (HMO and Medicare
• Medicare national and local coverage guidelines
Advantage HMO or Health Net Access) within one
• National Institutes of Health (NIH) consensus statements
business day.
• National Guidelines Clearinghouse (NGC) • American Medical Association (AMA)
Prescription Medication Prior Authorization Requests
• American Psychological Association (APA) • Agency for Healthcare Research and Quality (AHRQ)
Some in-office injectables and medications listed on
• American Association of Health Plans (www.guidelines.
the Health Net Access Drug List may require prior
gov) as approved by the Medical Practice Committee and
authorization. Physician or pharmacy must obtain prior
the Quality Council
authorization by telephone or fax through Health Net
• Arizona Health Care Cost Containment Systems
Pharmaceutical Services (HNPS). Prior authorization
(AHCCCS) Medical Policy Manual content
223
Prior Authorization
Health Net’s national medical and behavioral health
a medical management reviewer or physician reviewer by
policies are reviewed at least annually with input from
contacting the Health Net Prior Authorization Department.
network practitioners and updated as necessary, and are available on the Health Net provider website at www.
Participating providers and their staff are prohibited from
healthnetaccess.com.
giving Health Net members verbal denials. All requests, regardless of coverage, must be processed.
Medical directors are always available to discuss prior authorization requests and denials with the requesting
Requesting Prior Authorization
physician. They can be reached by contacting the Prior
Completion of the Health Net Access Request for Prior
Authorization Department. The denial letter includes
Authorization form is the primary method used by Health
criteria used in a decision that results in a denial
Net to manage the referral process for providers directly
determination (Notice of Action) and an explanation of
contracting with Health Net. It enables Health Net to
the appeal process. A copy of the criteria utilized in the
monitor the care provided to members and provides
decision can be obtained upon request and all criteria
instructions to the specialist regarding authorized services.
are available for review at the Health Net office. Prior Authorization requests for dual-eligible General
Prior Authorization Responses
Mental Health and Substance Abuse (GMHSA) members
Upon receipt of all necessary information, Health
should be submitted to the Health Net Prior Authorization
Net processes all routine requests within 14 calendar
Department. Prior authorization requests for Health Net
days. Expedited requests are turned around within
Access only members (non- dual-eligible) behavioral
three business days of the receipt of the request. If
health and substance abuse services must be referred to
Health Net needs additional information, the request
the Regional Behavioral Health Authority (RBHA). If
determinations may be extended up to 14 calendar days,
coordination assistance with RBHA is needed, contact the
when justified.
Health Net Access Member Services Department.
In the event the request fails to meet established
When faxing a prior authorization request, attach
medically necessary criteria, a letter is automatically
pertinent medical records, treatment plans, test results, and
sent to the member and the requesting physician,
evidence of conservative treatment to support the medical
and the primary care physician (PCP), if applicable,
appropriateness of the request.
for all denied service requests. The letter includes an explanation of how a copy of the criteria utilized in
Guidelines for Referrals
the decision can be obtained and an explanation of the
Primary care physicians (PCPs) and specialists should
appeal process. The physician may discuss the case with
follow the guidelines below when completing the Health Net
224
Prior Authorization
Access Request for Prior Authorization form to request
for services must be directed to the Health Net Prior
prior authorization of services. Providers are required
Authorization Department.
to complete all fields within the form to expedite
Prior Authorization Requirements
processing of prior authorization requests.
Based on medical necessity, the services, procedures and
• If the number of units or visits is not indicated in the Professional field, only one visit is authorized
equipment listed in the Prior Authorization Requirements -
by Health Net. That visit must take place within 60
Health Net Access require prior authorization.
days of the order date. If more than one consultation
Behavioral Health Services Not Requiring Prior Authorization
is required, another request must be submitted to Health Net for review.
Authorization is not required for some services, including
• Select the product line (Health Net Access). This field assists the Health Net Prior Authorization
outpatient visits, as long as the member meets medical
Department in determining the sets of prior
necessity criteria based on population-based care shaping
authorization guidelines as it varies by product line.
with the treatment providers. Services that do not require prior authorization include:
• Designate the type of request (urgent or elective).
• office or home visits for evaluations and/or counseling
• Designate service requested to determine prior
• crisis intervention services and behavioral health
authorization requirements.
professional services in an emergency room
• The “From” provider information refers to who is requesting the prior authorization for services.
• emergency transportation services via air or ground
The “To” provider information refers to where the
• telehealth and telemedicine services for services that do not require authorization
services will be rendered. A PCP or specialist can be
• multisystemic therapy for juveniles (MST)
the “From” provider information.
• methadone maintenance treatment
• ICD-10 and CPT codes as well as descriptions are
• developmental testing
required fields.
• behavioral health day programs - supervised, therapeutic
• Requesting providers (PCPs or specialists) must sign
community treatment and day programs
the Request for Prior Authorization form.
• behavioral health rehabilitation services - personal care
• Providers need to attach all pertinent medical information in order for the request to be reviewed
services, home care training, unskilled respite care,
for medical necessity.
supported housing • behavioral health support services - skills training;
Providers can submit the Health Net Access Request
developmental, cognitive and psychosocial
for Prior Authorization form to request standard or
rehabilitation; health promotion; psychoeducational
urgent authorization. Requests for prior authorization
services; and ongoing support to maintain employment • home passes
225
Prior Authorization
Health Net Access Prior Authorization Requirements
226
Prior Authorization
Health Net Access Prior Authorization Requirements
227
Prior Authorization
Health Net Access Prior Authorization Requirements
228
Prior Authorization
Health Net Access Prior Authorization Requirements
229
Prior Authorization
Health Net Access Prior Authorization Requirements
230
Prior Authorization
Contacts
Business hours are 8:00 a.m. to 5:00 p.m., Monday through
Health Net Access Prior Authorization Department
(800) 977-7518 or (800) 978-3424
Friday. Fax: (800) 840-1097 for general prior authorization requests
Contact the Health Net Access Prior Authorization
Fax: (800) 916-8996 for durable medical equipment (DME)
Department for prior authorization requests and
and home health requests
assistance with hospital discharge planning. Business hours are 8:00 a.m. to 5:00 p.m., Monday through
After business hours, a voicemail and fax system is available
Friday.
24 hours a day, seven days a week for prior authorization requests and admission notifications.
1-888- 926-1736
When discharge planning is required for Health Net
Fax: 1-855-764-8513 for general prior authorization
members discharging on a weekend or holiday, leave a
requests
message for the on-call nurse. The on-call voicemail box is monitored from 9:00 a.m. to 4:30 p.m. Saturday, Sunday
After business hours, a voicemail and fax system is
and holidays, and the on-call nurse returns calls to assist
available 24 hours a day, seven days a week for prior
providers with urgent weekend discharge planning needs
authorization requests.
during this time. When discharge planning is required for Health Net Access members discharging on a weekend or holiday, leave a message for the on-call nurse. The on-call voicemail box is monitored from 9:00 a.m. to 4:30 p.m., Saturday, Sunday and holidays, and the on-call nurse returns calls to assist providers with urgent weekend discharge planning needs during this time.
Health Net Prior Authorization Department Contact the Health Net Prior Authorization Department for prior authorization requests, inpatient admission notification and assistance with hospital discharge planning.
231
Prior Authorization Health Net Access Request for Prior Authorization INPATIENT
Fax to: 855-764-8513
Prior Authorization Fax Form Standard Request - Determination within 14 calendar days of receiving all necessary information.
Date of Birth
MEMBER INFORMATION Member ID
*
*1125*
Expedited Request -I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. URGENT REQUESTS MUST BE SIGNED BY THE X REQUESTING PHYSICIAN TO RECEIVE PRIORITY. * INDICATES REQUIRED FIELD
*
(MMDDYYYY)
Last Name, First
REQUESTING PROVIDER INFORMATION Requesting NPI
Requesting TIN
*
Requesting Provider Contact Name
*
Requesting Provider Name
Phone
Fax
SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI
*
Servicing TIN
Servicing Provider Contact Name
*
Servicing Provider/Facility Name
Phone
Fax
AUTHORIZATION REQUEST Primary Procedure Code
(CPT/HCPCS)
Start Date OR Admission Date
(Modifier)
*
Diagnosis Code
*
(ICD-10)
(MMDDYYYY)
Additional Procedure Code
Discharge Date (if applicable) otherwise Length of Stay will be based on Medical Necessity Additional Diagnosis Code
(CPT/HCPCS)
(MMDDYYYY)
(Modifier)
INPATIENT SERVICE TYPE *
(ICD-10)
(Enter the Service type number in the boxes)
141 Premature/False Labor 300 Neonate
970 Medical
121
209 Transplant Surgery
Long Term Acute Care
411
Delivery 779 C-Section
Surgical
720 Vaginal Delivery Inpatient Rehab Comprehensive Inpatient Rehab 220 Facility 479 Inpatient Hospital
492 Sub Acute 402 Skilled Nursing Facility
ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered benefit and medically necessary with prior authorization as per Ambetter policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of Rev. 05 12 2016 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately XZ-PAF-1125 and destroy this document.
232
Prior Authorization Health Net Access Request for Prior Authorization Complete and Fax to: 855-764-8513 OUTPATIENT PRIOR AUTHORIZATION FAX FORM Request for additional units. Existing Authorization
Units
Standard Request - Determination within 14 calendar days of receiving all necessary information
*1126*
Expedited Request -I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. URGENT REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY.
X
*INDICATES REQUIRED FIELD
Date of Birth
MEMBER INFORMATION Member ID/Medicaid ID
*
(MMDDYYYY)
*
Last Name, First
REQUESTING PROVIDER INFORMATION Requesting NPI
*
Requesting TIN
*
Requesting Provider Contact Name
Requesting Provider Name
Phone
Fax
SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI
*
Servicing TIN
*
Servicing Provider Contact Name
Servicing Provider/Facility Name
Phone
Fax
AUTHORIZATION REQUEST
*
*
Primary Procedure Code
*
Additional Procedure Code
Start Date OR Admission Date
(CPT/HCPCS)
(Modifier)
(CPT/HCPCS)
(MMDDYYYY)
(ICD-10)
Total Units/Visits/Days
(Modifier)
Additional Procedure Code
Additional Procedure Code
End Date OR Discharge Date
(CPT/HCPCS)
(CPT/HCPCS)
(MMDDYYYY)
(Modifier)
OUTPATIENT SERVICE TYPE *
(Modifier)
(Enter the Service type number in the boxes)
412 Auditory Services 422 Biopharmacy 417 120 299 922 709 799
Diagnosis Code
249 Home Health 927 Outpatient Hospice DME 290 Hyperbaric Oxygen Therapy Rental 410 Observation Purchase $ 792 Vendor (Purchase Price) Nutritional Supplements and/or services Drug Testing Experimental & Investigational Services 407 Enteral Feedings 441 Parenteral Feedings Genetic Testing 360 Modified Solid Food Supplements Genetic Counseling
650 472 499 109 724 997 365 370 375
Radiation Therapy Stereotactic Radiosurgery Transplants - Office Visit Transplants - Other Visit Transportation Office Visit/Consult (non par) Office Visit/Vaccines & Administration Office Visit/Dermatology Procedure Office Visit/ Dental
ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.
233
Rev. 05 19 2016
XZ-PAF-1126
Referrals
into consideration input from the member regarding
Referrals
proposed treatment plans
Behavioral Health Referral Primary care physicians (PCPs) may provide outpatient
If Health Net’s network of specialists cannot perform the
behavioral health services for select behavioral health
services required, prior authorization is required to refer
diagnoses, including attention deficit hyperactivity
outside Health Net’s network.
disorder (ADHD), depression and anxiety within the
Providers may complete the Health Net Referral Form or use
scope of their practice. PCPs must coordinate referrals
their own forms or script to facilitate the referral process.
for members requiring specialty or inpatient behavioral health services through Health Net Access for members
Role of the Primary Care Provider
eligible for both Medicare and Medicaid. For Medicaid-
The primary care provider (PCP) is responsible for providing
only members, PCPs must coordinate referrals for
or ensuring the provision of comprehensive first contact
behavioral health services with the Regional Behavioral
and continuing covered primary care services for Health
Health Authority (RBHA)/Tribal RBHA (TRBHA)
Net Access members and supervising preventive, acute
system. Tribal members and veterans retain choice in
and chronic health care for those members. These services
where they access all or part of their care, including
include, at a minimum, the treatment of routine illness,
through Indian Health Services/638 facilitates or the
maternity services if applicable, immunizations, Early and
Veterans Administration. Refer to the Behavioral Health
Periodic Screening, Diagnosis and Treatment (EPSDT)
section for additional information.
services for eligible members under age 21, adult health screening services, and medically necessary treatments for
Referrals to Specialists
conditions identified in an EPSDT or adult health screening.
Most specialty services can be provided by Health Net
This responsibility includes initiating, supervising and
participating specialists. When making a referral, the
coordinating referrals for specialty care inpatient and skilled
following guidelines apply:
facilities, home health care and similar services. Generally,
• If a member requires specialty services, available specialists in the medical group/IPA’s specialty
PCPs are expected to understand and coordinate the total
network must be utilized as the primary resource
course of their patients’ care and ensure continuity in their
• If a member requires services that cannot be
care. The PCP must also take into consideration input from
provided by the medical group/IPA’s specialty
the member regarding proposed treatment plans. In this way,
network, Health Net’s entire network may
the PCP serves a critical role in helping the member obtain
be available to the member; however, prior
the highest coverage levels available.
authorization is required
PCPs in their care coordination role serve as referral agents
• The primary care physician (PCP) must also take
for specialty treatments and services provided to Health
234
Referrals
Net Access members assigned to them, and attempt to
responsibility to forward all pertinent information to the
ensure coordinated quality care that is efficient and cost
specialist for the referral. In order to promote continuity
effective. Coordination responsibilities include, but are
of care, the PCP must also have on record all treatment,
not limited to:
examination and results performed by other physicians or
• Referring members to providers or hospitals within
clinicians, including service dates. Summaries are acceptable
the Health Net Access network, as appropriate, and
in lieu of complete chart notes.
if necessary, referring members to out-of-network specialty providers.
Role of the Specialist
• Coordinating with Health Net Access for prior
Primary care providers (PCPs) must provide a written
authorization procedures for members.
referral for a member to receive services from a specialist,
• Conducting follow-up for referral services that
Coverage is not available for services rendered to a member
are rendered to their assigned members by other
by a specialist unless the member has a written referral from
providers, specialty providers and/or hospitals,
the member’s PCP (except for services for which a member
including maintenance of records of services
may self-refer. The referral allows for a specialist to provide
provided in the members’ medical records.
an initial consultation, in-office treatment and follow-up
• Coordinating medical care of Health Net Access
care. The PCP is responsible for coordinating the specialist
members assigned to them, including, at a
referral and must forward all pertinent information to the
minimum:
specialist for the referral.
o Oversight of medication regimens to prevent negative interactive effects.
If the member needs to be referred to another physician
o Follow-up for all emergency services.
for the same medical condition, the specialist may refer the
o Coordination of inpatient care.
member to another in-network specialist or may contact the
o Coordination of services provided on a
member’s PCP for assistance.
referral basis. o Assurance that care rendered by specialty
The PCP must maintain a record of treatment, examination
providers is appropriate and consistent with
and results performed by other physicians or clinicians,
each member’s health care needs.
including service dates in the member’s medical record. Treatment plans, follow-up needs, any complications, and
The PCP must maintain medical records, including
prescribed medications must be included. Summaries are
records on preventive care, past medical treatment, past
acceptable in lieu of complete chart notes.
and current health status, and treatment plans for the future in the member’s medical record. When initiating
Self-Referral Benefits
a referral to a specialist, it is the referring physician’s
Members may self-refer to a specialist or may request the
235
Referrals
assistance of the primary care provider (PCP) for the following services (subject to benefit limitations) • Behavioral health care. • OB/GYN for annual Pap smear and pelvic examination. • Dental services (children under age 21). • Emergency services. Members must receive these self-referral services from a Health Net Access participating provider who is registered with the Arizona Health Care Cost Containment System (AHCCCS). The member must work with his or her PCP to receive referral and authorization to an out-of-network provider when there is no Health Net Access participating provider available that can provide these services. The PCP should inquire about all services a member has received in order to facilitate a complete medical record for the member.
Standing Referrals Health Net is required to have and follow a procedure by which a member may receive a standing referral to a specialist. Standing referrals are referrals by a primary care physician (PCP) to a specialist for more than one visit without the PCP having to provide a specific referral for each visit. A treatment plan may limit the number of visits to the specialist, limit the period of time for which the visits are authorized, and require that the specialist provide the PCP regular reports on the health care provided to the member.
236
Referrals Referral Form
237
Chapter 13
Coordination of Benefits for cost shares or copayments. Therefore, it is
Overview Coordination of benefits (COB) is required before submitting claims for members who are covered by one or more health insurers other than Health Net Access. Health Net
advisable to wait until payment is received from both carriers before collecting from the member. Copayments are waived when a member has other insurance as primary coverage.
Access is always the payor of last resort, including Medicare and TRICARE.
Providing COB Information In order for Health Net to document member
Participating providers are required
records and process claims appropriately, include
to administer COB. The participating
the following information on all coordination of
provider should ask the member for
benefits (COB) claims:
possible coverage through another health
• Name of the other carrier
plan and enter the other health insurance
• Subscriber identification (ID) number with the other carrier
information on the claim.
COB Payment Calculations Overview
If a Health Net member has other group health
As the secondary carrier, Health Net
• First, file the claim with the other carrier
coordinates benefits and pays balances,
• After the primary carrier has paid, attach a
up to the member’s liability, for covered
copy of the Explanation of Payment (EOP)
services. However, the dollar value of the
or Explanation of Benefits (EOB) to a copy
balance payment cannot exceed the dollar
of the claim and submit both to Health Net
value of the amount that would have been
within the timely filing limit of six months
paid had Health Net Access been the
from the date of service. COB claims can also
primary carrier.
be submitted electronically with the details
coverage, follow these steps:
from the other payer ERA appropriately In most cases, members who have coverage through two carriers are not responsible
238
submitted in the 837 transaction COB loops
Third Party Liability
• If the primary carrier has not made payment or
complete care without charge from the participating provider
issued a denial, submit the claim to Health Net prior
and may not feel that it is necessary. The participating
to the timely filing limit of six months from the date
provider must check for this liability where treatment is
of service. Health Net must receive a clean claim
being provided. The participating provider must develop
within 12 months of the date of service
procedures to identify these cases. After TPL has been established, the participating provider
If denied on the basis of timeliness, the claims are
must provide Health Net with the information using the
treated as non-reimbursable and the member cannot be
Authorization to Treat a Health Net Member form or other
billed.
correspondence. The participating provider must continue to provide benefits in accordance with the Evidence of
Third Party Liability Overview
Coverage.
If a Health Net Access member is injured through the act or omission of another person, the participating
Workers’ Compensation
provider must provide benefits in accordance with the
If the provider identifies that the member’s injuries are
Evidence of Coverage (EOC). If the member is entitled
due to a workers’ compensation injury, the provider must
to recovery, Health Net is entitled to recover and retain
bill the employer’s industrial insurance carrier first when
the value of the services provided from any amounts
responsibility has been established. Health Net pays for
received by the member from sources, including, but not
claims denied by the employer’s industrial insurance carrier
limited to, the following:
if all of the following occurs:
• Uninsured/underinsured motorist insurance
1. A copy of the denial is sent with the claim to Health Net.
• Workers’ compensation
2. All Health Net authorization requirements have been met.
• Estate recovery
3. The service provided is a covered benefit under the member’s benefit plan.
• First- and third-party liability insurance • Tort feasors, including casualty • Restitution recovery
Pending Cases
• Special treatment trust recovery
In cases pending settlement or possible legal action, providers should bill Health Net as usual, giving all details regarding the injury or illness. Health Net pays usual
Provider and Member Responsibilities
benefits and may then file a lien for reimbursement from the
Provider Responsibilities
responsible party when permitted under law.
The participating provider must question the member
Member Responsibilities
for possible third-party liability (TPL) and workers’
An injured member entitled to recovery is required to:
compensation in injury cases. Often, the member does
• Inform Health Net and participating providers of the
not mention that this liability exists, having received
239
Third Party Liability
name and address of the third party, if known, the name and address of the member’s attorney, if using a attorney, and describe how the injuries were caused • Complete any paperwork that Health Net or the participating providers may reasonably require to assist in enforcing the lien • Promptly respond to inquiries from the lien holders about the status of the case and any settlement discussions • Notify the lien holders immediately upon the member or the member’s attorney receiving any money from the third parties or their insurance companies • Hold any money that the member or the member’s attorney receives from the third parties or their insurance companies in trust, and reimburse Health Net and the participating providers for the amount of the lien as soon as the member is paid by the third party
240
Chapter 14
Claims, Provider Reimbursement and Encounters receives non-covered services. The provider
Billing the Member Guidelines for billing Health Net Access
must notify the member in advance of the charges, have the member sign a statement
members are listed as follows: • Health Net Access members must not be billed or reported to a collection agency for any covered service provided. • Providers may not charge members for services that are denied or reduced due to the provider’s failure to comply with
that clearly states the services to be performed, the non-eligible status and the amount of the charge and agreeing to pay for the services. The document must be retained in the member’s medical record.
billing requirements, such as timely filing,
Claim Status
lack of authorization or lack of clean
To receive automated claim status information,
claim status.
contact the Health Net Access Provider Services
• Providers must not collect copayments,
Center interactive voice response (IVR) system.
coinsurance or deductibles from
Providers can also check claims status online at
members with other insurance whether
www.healthnetaccess.com.
it’s Medicare or a commercial carrier. Providers must bill Health Net for these amounts and Health Net coordinates benefits.
Claim Submission Timelines In accordance with Arizona Revised Statutes
• AHCCCS mandatory copayments should
(ARS) §36-2904 (G), claims for services provided
be collected at the time of service, but
to an Arizona Health Care Cost Containment
may be billed to the member if payment
System (AHCCCS) member must be received in
does not occur.
a timely manner as follows:
• Providers may bill a Health Net Access member when the member knowingly
241
• The initial claim must be received no later
Claims and Provider Reimbursement
than six months from the date of service or the
which would decrease the original payment due to
date of eligibility posting; whichever is later. For
collections from Medicare or other third party payers.
inpatient claims, date of service is the patient’s date
Claims Reimbursement
of discharge. • Claims initially received after the six-month time
Claims reimbursement is based on contractual agreements
frame, are denied.
that utilize the Arizona Health Care Cost Containment
• If a claim is originally received within the six-month
System (AHCCCS) pricing methodologies. These are
time frame, the provider has up to 12 months from
inclusive of, but are not limited to:
the date of service or date of eligibility posting
• All patient refined diagnosis related group (APR-DRG)
(whichever is later) to resubmit the claim in order to
• Tiered per diem payment structure.
achieve clean claim status or to adjust a previously
• Outpatient Hospital Fee Schedule (OPFS) for outpatient
processed claim.
facilities.
• If the claim does not achieve clean claim status or is
• AHCCCS fee schedules and negotiated rates.
not adjusted correctly within 12 months, Health Net
• Arizona Department of Health Services (ADHS) rates.
Access is not liable for payment. • This time limit does not apply to adjustments,
Claims Submission Requirements
which would decrease the original payment due
Health Net participating providers are required to submit
to collections from Medicare or other third party
claims for all services that are provided to Health Net Access
payers.
members.
Retro-Eligibility Claims
Submit claims to the Health Net Access Claims Submission
A retro-eligibility claim is a claim where no eligibility
address using the most current CMS-1500 or CMS-1450
was entered in the AHCCCS system for the date(s)
(UB-04) form. Claim forms must be printed in Flint OCR
of service, but at a later date eligibility was posted
Red, J6983, or exact match ink. Health Net Access no longer
retroactively to cover the date(s) of service. Timely filing
accepts handwritten red and black forms or copied claim
time frames are as follows:
forms.
• The initial claim must be received no later than six months from the AHCCCS date of eligibility
Although a copy of the CMS-1500 and CMS-1450 form
posting.
can be downloaded, copies of the form cannot be used
• Retro-eligibility claims must obtain clean claim
for submission of claims, since a copy may not accurately
status no later than 12 months from the AHCCCS
replicate the scale and OCR color of the form. Paper claims
date of eligibility posting.
received by the plan are scanned using OCR technology.
• This time limit does not apply to adjustments,
242
Claims and Provider Reimbursement
This scanning technology allows for the data contents
mark, X or Y if the service was an emergency service
contained on the form to be read while the actual form
• procedures, services and supplies - enter the CPT or
fields, headings and lines remain invisible to the scanner.
HCPCS procedure code that identifies the service
Photocopies cannot be scanned and, therefore, are no
provided
longer accepted by Health Net Access.
• diagnosis code pointer
CMS-1500 and CMS-1450 completion and coding
• billed amount for each service line
instructions, as well as the print specifications are
• service units
available in Chapter 26 of the Medicare Claims
• rendering provider NPI (box 24J)
Processing Manual (Pub.100-04).
• billing provider tax ID number • patient account number, if applicable
The following information must be included on the claim:
• total charges for the claim • amount previously paid, if applicable - enter the total payment amount the provider received for this claim
CMS-1500 Claim Form
from all sources other than Health Net Access
• Arizona Health Care Cost Containment System
• signature and date - the provider or his or her
(AHCCCS) identification (ID) number (paper
representative must sign and date the claim
claims only)
• service facility location information, NPI and AHCCCS
• member’s name, gender and date of birth
ID number, if applicable
• diagnosis code number (ICD-10) - enter at least one
• billing provider’s name, address, telephone number, and
ICD-10 diagnosis code to describe the member’s
NPI
condition. Up to 12 ICD-10 codes may be entered. The codes must be entered in the A, B, C format
UB-04 Claim Form
order indicated on the claim form. Behavioral health
• name, address and telephone number of the provider
providers must not use DSM-4 or DSM-5 diagnosis
rendering service
codes
• patient control number, if applicable
• Medicaid resubmission code (box 22 on the CMS-
• bill type
1500), if applicable - enter the appropriate code (7
• facility’s federal tax ID number
to indicate a replaced or corrected claim or 8 to
• statement covers period - enter the beginning and
indicate a void of a previous claim), along with the
ending dates of the billing period
applicable claim identification number
• patient name, address, date of birth and gender
• date(s) of service - enter the beginning and ending
• admission/start of care date
service dates
• admission hour, if applicable
• place of service
• type of admission
• emergency indicator, if applicable - enter a check
243
Claims and Provider Reimbursement
• point of origin for admission or visit
without obtaining additional information from the provider
• discharge hour
of service or from a third party, but does not include claims
• patient discharge status
under investigation for fraud or abuse or claims under
• condition codes, if applicable
review for medical necessity.
• occurrence codes, if applicable • responsible party name and address, if applicable
A claim is considered “clean” when the following conditions
• value codes and amounts, if applicable
are met: • All required information has been received by Health
• revenue code(s)
Net.
• revenue code description/NDC code, if applicable
• The claim meets all Arizona Health Care Cost
• HCPCS/rates - enter the inpatient accommodation
Containment System (AHCCCS) submission
rate and the appropriate CPT or HCPCS code
requirements.
• service date and service units
• The only acceptable claim forms are those printed in
• total charges for each revenue code
Flint OCR Red, J6983 or exact match ink.
• non-covered charges, if applicable
• Any errors in the data provided have been corrected.
• payer - enter the name and identification number, if
• All medical documentation required for medical review
available, of each payer who may have full or partial
has been provided.
responsibility for the charges incurred
Reasons for claim denial include, but are not limited to, the
• billing provider’s NPI
following:
• diagnosis and procedure code qualifier • principle diagnosis code, admitting diagnosis code
• Duplicate submission.
• other diagnosis codes, if applicable
• Member is not eligible for date of service.
• principle procedure code and dates, if applicable
• Incomplete data.
• attending provider name and identifiers, if
• Non-covered services. • Provider of service is not registered with AHCCCS on
applicable
the date of service.
• operating physician and identifiers, if applicable
• Information from the primary carrier is required.
• other procedure codes, if applicable Detailed instructions on how to fill out the claim forms can be found on the AHCCCS website.
Corrected Claims Submission Providers must correct and resubmit claims to Health
Clean Claim Submission Guidelines
Net within the 12-month clean claim time frame. When resubmitting a denied claim, the provider must submit a
As defined by Arizona Revised Statutes (ARS) §36-2904
new claim containing all previously submitted lines. The
(G)(1) a “clean claim” is a claim that may be processed
resubmission indicator (7 for replacement or 8 to void a
244
Claims and Provider Reimbursement
prior claim) must be indicated in Box 22 along with the
Clearinghouse
Health Net Payer Identification (ID) Number
advice (RA) must be included on the claim in order
Capario
38309
for Health Net to identify the claim resubmitted. If the
Change Health Care
38309
claim reference number is missing, the claim may be
As a result of Health Net’s partnership with Ability Network, all payer claims can be submitted electronically via Health Net Access’ website at www.healthnetaccess.com.
original claim reference number from the remittance
entered as a new claim and denied for being submitted beyond the initial submission time frame.
Ability Network
38309
Corrected claims must be appropriately marked as such
Reports
and submitted to the appropriate claims mailing address.
For successful electronic data interchange (EDI) claim
Electronic Claim Submission
submission, participating providers must utilize the
Health Net contracts with Capario, Change Health Care
electronic reporting made available by their vendor or
(formerly Emdeon (WebMD)) and Ability Network
clearinghouse. There may be several levels of electronic
(formerly MD On-Line) to provide claims clearinghouse
reporting:
services for Health Net electronic claim submission.
• Acceptance/rejection reports from EDI vendor
The benefits of electronic claim submission includes:
• Acceptance/rejection reports from EDI clearinghouse • Acceptance/rejection reports from Health Net
• Reduction and elimination of costs associated with printing and mailing paper claims
Providers are encouraged to contact their vendor/
• Improvement of data integrity through the use of
clearinghouse to see how these reports can be accessed/
clearinghouse edits
viewed. All electronic claims that have been rejected must
• Faster receipt of claims by Health Net, resulting in
be corrected and resubmitted. Rejected claims may be
reduced processing time and quicker payment
resubmitted electronically.
• Confirmation of receipt of claims by the clearinghouse
Providers may also check the status of paper and electronic
• Availability of reports when electronic claims are rejected and ability to track electronic claims,
claims online at provider.healthnetaccess.com.
resulting in greater accountability
For questions regarding electronic claims submission, contact the Health Net EDI Claims Department.
245
Claims and Provider Reimbursement
Filing a Claim Health Net Access encourages the electronic filing of
treated as non-reimbursable and cannot be billed to the member.
claims whenever possible. When submitting claims, it is important to accurately provide all required information
Acceptable proof of timely filing includes: • EOB from another insurance carrier dated within Health
as described in Claim Submission Requirements.
Net’s timely filing limits.
Claims submitted with missing data may result in a
• Denial letter from another insurance carrier, printed on
delay in processing or a denial of the claim. Health Net
its letterhead and dated within Health Net’s timely filing
requires that all facility claims be submitted on a UB-04
limits.
claim form. Professional fees must be submitted on an
• Electronic data interchange (EDI) rejection report from
original (red) CMS-1500 claim form. Copies of claim
clearinghouse which indicates claim was forwarded and
forms are not accepted. Participating providers receive a
accepted by Health Net (showing date received versus
Remittance Advice (RA) each time a claim is processed.
date of service) that reflects the claim was submitted
When Health Net Access is the primary payer, claims
within Health Net’s timely filing limits. Claims that were
must be submitted no later than six months from
rejected must be corrected and resubmitted in a timely
the date of service or the date of eligibility posting
manner.
(whichever is later). For inpatient hospital claims, the date of service is considered to be the date of discharge. Initial claims submitted more than six months after the
Unacceptable proof of timely filing includes: • Screen-print of claim invoice.
date of service are denied.
• Billing ledger. • Copy of original claim.
When Health Net Access is the secondary payer,
• Denial letter from another insurance carrier without a
claims must be submitted within six months from
date and not on letterhead.
the date of service even if payment from Medicare or
• Record of billing stored in an Excel spreadsheet.
other insurance has not been received. A copy of the primary carrier’s Explanation of Benefits (EOB) must be submission, Health Net Access allows submission of the
Health Net Access Interest Calculation
secondary claim for up to one year from the primary
The following information applies to interest rate
EOB date. The submission must include the primary
calculations and turnaround times for Medicaid claims.
attached to the claim form. Following the initial claim
carrier’s EOB.
Non-Hospital Claims If payment is denied based on a provider’s failure to
Interest is due on payment for clean claims not reimbursed
comply with timely filing requirements, the claim is
within the required turn-around time. The interest period
246
Claims and Provider Reimbursement
begins on the day after payment is due and ends on
until the claim is paid. The calculation is determined based
the date of payment. Interest is prorated on a daily
on the difference between the claim receipt date and the date
basis at a rate of 10percent per annum unless otherwise
of payment.
indicated contractually. It is calculated based on the difference between the date of claim receipt and the date
Clean claims for a skilled nursing facility that is not paid
of payment. Interest is not paid on claims for which no
within 30 calendar days after the claim is received accrues
payment is due or claims that are fully denied.
interest at the rate of one percent per month from the date the claim is submitted. The interest is prorated on a daily
Claims Payment Standards
basis and must be paid at the time the clean claim is paid.
Health Net Access insures that 95 percent of all clean claims are adjudicated within 30 calendar days of receipt
Obstetrical Services
of the clean claim, and 99 percent are adjudicated within
The global obstetrical (OB) package includes all antepartum
60 calendar days of receipt of the clean claim.
visits, delivery, postpartum visits, and all services associated with admission to and discharge from a hospital.
Hospital Claims Turnaround Times
• Only services not included in the global OB care CPT
Hospital claims for participating and non-participating
• While there is not a separate reimbursement for the
code (59400 or 59510) may be billed separately.
providers must be paid or denied within 60 calendar
evaluation and management services that are provided
days.
during the prenatal and postpartum care periods, AHCCCS requires that the codes and individual dates of
Interest
services be included in the global OB service billing.
For outpatient and inpatient acute care hospital clean
• Claims for ineligible services are denied when billed in
claims, Health Net applies quick pay discounts and
addition to the global OB code.
slow payment penalties for participating and nonparticipating providers in accordance with Arizona
Services not included in the global OB package and may be
Health Care Cost Containment System (AHCCCS)
billed separately include:
guidelines. A quick pay discount is applied to hospital
• amniocentesis
claims with AHCCCS provider type 02 and C4 at a rate
• ultrasound
of one percent when a claim is paid within 30 calendar
• special screening tests for genetic conditions
days of the clean claim receipt date. A slow payment
• visits for unrelated conditions
penalty is applied for claims paid at 61 days or over, and continues to accrue at the rate of one percent per month
Refer to the Maternity Care and Delivery section of the CPT
(based on a 30 calendar-day month) or partial month
247
Claims and Provider Reimbursement
code book for details regarding the appropriate coding
of Health Net Access, the provider must follow the
to use for obstetrical services.
overpayment refund instructions provided by the vendor
Overpayment Recovery Procedures
If a provider believes he or she has received a Health Net Access check in error and the provider has not cashed the check, he or she should return the check to the Health Net
Health Net Access makes every attempt to identify a
Overpayment Recovery Department with the applicable RA
claim overpayment and indicate the correct processing
and a cover letter indicating why the check is being returned.
of the claim on the provider’s remittance advice (RA). An automatic system offset, where applicable, might occur in accordance with the reprocessing of the claim
Prior Period Coverage
for the overpayment, or on subsequent check runs.
Prior period coverage refers to the time frame from the effective date of eligibility to the day the member is enrolled
In the event that a provider independently identifies an
with Health Net Access. Health Net Access is responsible
overpayment from Health Net Access (such as a credit
for payment of all claims for medically necessary covered
balance), the provider must take the following steps:
services, including behavioral health services provided on or after October 1, 2015 to dual-eligible members with General
• Send a check made payable to the appropriate entity (Health Net of Arizona, Inc. or Health Net Life
Mental Health/Substance Abuse (GMH/SA) needs, during
Insurance Company)
prior period coverage.
• Include a copy of the RA that accompanied the overpayment to expedite Health Net Access’
Professional Claim Editing
adjustment of the provider’s account. If the RA is
Health Net Access claim processing includes programs
not available, the following information must be
that support editing related to National Correct Coding
provided: Health Net Access member name, date
Initiatives (NCCI), bundling/unbundling, multiple
of service, payment amount, Health Net Access
procedure/surgical reductions and global E&M bundling
member identification (ID) number, vendor name,
standards. The source logic is obtained through various
provider tax ID number, provider number, vendor
resources such as the Centers for Medicare & Medicaid
number, and reason for the overpayment refund. If
Services (CMS), the American Medical Association (AMA)
the RA is not available, it takes longer for Health Net
and other specialty academies. Health Net Access has
Access to process the overpayment refund
the ability to apply advanced contextual processing for application of Health Net Access edit logic.
• Send the overpayment refund and applicable details to the Health Net Overpayment Recovery Department. If a provider is contacted by a thirdparty overpayment recovery vendor acting on behalf
248
Claims and Provider Reimbursement
Remittance Advice Health Net Access’ remittance advice (RA) contains important information about claims submissions and cash receipts for overpayments. The RA should be
To register for ERA or EFT, contact the Health Net EDI Department.
reviewed upon receipt and reconciled against billing
Specific Billing Requirements
records. The RA includes Health Net member names
The following are billing requirements for specific services
and dollar amounts paid for all claims processed during
and procedures.
the course of a week. Processing claims and adjustments results in one of the following remittance situations: • Positive remittance - A remittance that totals to a positive amount and results in a payment to the provider. The total at the bottom of the RA agrees with the check or electronic payment the provider receives.
Anesthesia - Anesthesia services (except epidurals) require the continuous physical presence of the anesthesiologist or certified nurse anesthetist (CRNA). Anesthesiologists and CRNAs must enter the approved American Society of Anesthesiologists (ASA) code in field 24D and the total number of minutes in field 24G of the CMS 1500 claim form.
• Negative remittance - A remittance produced when the adjusted dollars exceed the total amount
Assistant Surgeon - Include the name of the surgeon in
of payment on the remittance. The total at the
box 17 of the CMS-1500 form. Use the appropriate modifiers
bottom of the RA is negative, and does not result in
to reflect the assistant surgeon provider type (80/AS) as well
a check or electronic payment to the provider.
as any services subject to multiple surgery guidelines.
Health Net Access makes every attempt to identify a
Billing by Report - Include the operative report or
claim overpayment and indicate the correct processing
chart notes for “by report” procedures, including high level
of the claim on the provider’s RA. An automatic system
examinations or consultations.
offset, where applicable, might occur in accordance with the reprocessing of the claim for the overpayment, or on
Multiple Surgeons - Include the appropriate modifiers
immediate subsequent check runs.
to ensure proper payment of claims. Use modifier 80/AS for assistant surgeon, modifier 62 for co-surgeons and modifier
Providers are encouraged to register to receive Health
66 for surgical team.
Net Access’ electronic RA (ERA) and electronic funds transfer (EFT). Providers must submit a registration
Newborn Billing - Health Net’s Newborn Data
form to Health Net Access along with a registration
Collection Unit must be notified of all newborn admissions.
form to one of the approved clearinghouses.
Identification of the admitting pediatrician must be provided
249
Claims and Provider Reimbursement
when calling in the notification. Notification must be
number of vaccines provided.
given no later than three days after the birth in order
o Usual and customary charge
to ensure proper enrollment of the newborn with the Arizona Health Care Cost Containment System
Providers must submit administration and vaccine codes on
(AHCCCS) and Health Net Access.
one claim form. Multiple claims should not be submitted. Providers submitting multiple CMS-1500 for successor forms
Newborns whose mothers are Health Net Access
must staple the completed forms together and number the
members are eligible for Health Net Access from the
pages appropriately.
time of delivery. Newborns receive separate Health Net Access identification (ID) numbers, and services for a
Use of modifier SL sufficiently identifies the claim as a
newborn must be billed separately using the newborn’s
state-supplied vaccine for which the billed vaccine charge is
ID number.
not reimbursed. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration
Vaccines for Children Program Billing Procedures Arizona Health Care Cost Containment System (AHCCCS) providers who have registered for the Vaccines for Children (VFC) program must submit claims to Health Net Access for the VFC program supplied immunizations in order to receive reimbursement for the administration. The vaccines must be on the VFC listing and must be billed as follows: For each immunization administered, the claim must include: • Vaccine CPT code with the modifier SL (indicating a state-supplied vaccine) o No charge • Applicable administration CPT code with the modifier SL (indicating a state supplied vaccine)
fee and the vaccination is included in performance measurements. These billing procedures are designed to standardize billing practices and eliminate erroneous payments for state-supplied vaccines, which necessitate collection of overpayments from providers. Health Net Access may seek reimbursement of amounts that were paid inappropriately. Failure to bill VFC claims in accordance with the billing procedures noted above results in denials for both the vaccine and the associated administration.
Claims Coding Policies Basic Coding Guidelines Current ICD-10-CM codes, CPT codes, HCPCS codes, and modifiers reflective of the date of service are required on all Health Net Access claims.
and unit value equal to the code description and
250
Claims and Provider Reimbursement
These codes should be used in basic accordance with the
the time of claim submission; however, in the event the claim
publishers’ stated guidelines. Three major publications,
is audited, documentation may be required.
the American Medical Association’s (AMA) CPT-
Supporting Sources
4 code book, the Centers for Medicare & Medicaid Services (CMS) HCPCS code book and the ICD-
• AMA CPT code book
10-CM, represent the basic standard of service code
• CMS national policy
documentation and reference required by Health Net.
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Valid ICD-10-CM diagnosis codes are required on all claims. The first diagnosis on the claim form is reserved
Global Surgery
for the primary diagnosis. Up to four diagnoses may be
The global surgical package includes all necessary services
reported.
normally provided by the surgeon before, during and after the surgical procedure. The global surgical package applies to
Code each diagnosis to the highest level of specificity
minor procedures that have a zero or 10-day post-operative
(fourth or seventh digit when available).
period and major procedures that have a 90-day postoperative period as defined by the Centers for Medicare &
Valid AMA CPT-4 and Level II HCPCS procedure codes
Medicaid Services (CMS) Physician Fee Schedule. It also
are required on all claims. A three-month grace period
applies to obstetrical procedures that have a 42-day post-
for submitting deleted codes is allowed. After three
operative period.
months, deleted codes are denied. The global surgical package policy applies to all places of Procedure codes should be chosen based on the
service.
publishers’ definitions and be appropriate for the age and gender of the patient.
Services Included in the Global Package The following services are included in the global surgical
Procedure code modifiers are to be used only when the
package and, therefore, are not eligible for separate payment:
service meets the definition of the modifier and are to be
• Preoperative evaluation and management (E&M)
linked only to procedure codes intended for their use.
services that are performed one day prior to major
If a deleted code and its current replacement code are
surgery or on the same day as a minor or major
submitted on the same date of service, the last code
procedure.
submitted is denied as a duplicate.
o Exception: New patient visits (CPT codes 9920199205) on the same day as a minor surgery are
Health Net Access does not require documentation at
not included in the global package.
251
Claims and Provider Reimbursement
• Intraoperative services that are a usual and
-24 should be added to the E&M code.
necessary part of the surgical procedure.
• Critical care when billed for serious injuries or burns.
• Anesthesia provided by the surgeon.
• Services of other physicians not in the same provider
• Supplies.
group of the physician that performed the surgery,
• All additional medical or surgical services required
except where a formal transfer of care occurs.
of the surgeon during the post-operative period
• Diagnostic tests and procedures, including diagnostic
because of complications, which do not require
radiological procedures.
additional trips to the operating room.
• Clearly distinct surgical procedures during the post-
• Post-operative E&M services that are related to the
operative period that are not re-operations or treatment
surgery.
for complications. Modifiers -58 (staged procedure)
• Post-operative pain management by the surgeon.
or -79 (unrelated procedure or service performed by a
• Dressing changes, local incision care, removal of
physician during the post-operative period) should be
operative packs, removal of cutaneous sutures,
added to the surgical procedure code.
staples, lines, wires, tubes, drains, and splints,
• Treatment of post-operative complications that require
insertion, irrigation and removal of urinary
a trip to the operating room. Modifier -78 should be
catheters, routine peripheral intravenous lines,
added to the surgical procedure code.
nasogastric and rectal tubes, and change and
• Immunosuppressive therapy for organ transplants.
removal of tracheostomy tubes.
Modifier -24 should be added to the E&M code.
Services Not Included in the Global Surgery Package
Note: An E&M service that was significant and separately
The following services are not included in the global
the same day that falls within a global period of a previous
surgical package and are eligible for separate payment:
service but is not related to the previous service requires
identifiable from the minor surgical procedure performed on
• E&M service that was significant and separately
both a modifier -25 and a modifier -24.
identifiable from the minor surgical procedure performed on the same day. Modifier -25 should be
Health Net Access does not require documentation at
added to the E&M code.
the time of claim submission unless the service is listed
• E&M service performed the day prior to or on the
as by report; however, in the event the claim is audited,
same day of surgery that resulted in the decision for
documentation may be required.
a major surgical procedure. Modifier -57 should be
Supporting Sources
added to the E&M code.
CMS national policy
• E&M services that occur during the post-operative period that are unrelated to the surgery. Modifier
252
Claims and Provider Reimbursement
All procedures should be billed together on one claim to
Multiple Procedure Reduction
avoid subsequent retractions and adjustments that may
When multiple procedures are performed by the same
occur when procedures are billed separately.
provider at the same session, they are typically subject to the multiple procedure reduction. The primary
Health Net Access does not require documentation at
procedure code is reported as listed and is reimbursed
the time of claim submission other than for by report
at the full allowed amount. The additional procedure
procedures; however, if the claim is audited, documentation
code(s) is reported with a modifier -51 and is reimbursed
may be required.
at a reduced amount. Add-on codes and American Medical Association (AMA) CPT modifier -51 exempt
Supporting Sources
codes should not be reported with modifier -51 as they
• CMS national policy
are excluded from multiple procedure reduction.
• AMA CPT code book • AHCCCS reference files
Health Net Access applies the multiple procedure reduction to the list of codes on the Centers for Medicare & Medicaid Services (CMS) National
Professional Claim Editing
Physician Fee Schedule that are subject to multiple
Health Net Access utilizes several sources to validate
surgery guidelines with the exception of the AMA
professional claim editing and associated policies. Health
CPT modifier -51 exempt codes on the list. These codes
Net Access has the ability to apply advanced contextual
are not subject to multiple procedure reduction. Final
processing for application of Health Net edit logic.
adjudication is based on information presented in the Arizona Health Care Cost Containment System
Provider Preventable Conditions
(AHCCCS) reference files. If there is a conflict, the
Section 2702 of the Patient Protection and Affordable Care
AHCCCS reference files will be the guideline utilized,
Act reduces or prohibits payments to health care providers
but a request for review can be initiated with supporting
for Medicaid services rendered as a result of certain
documentation.
preventable health care acquired illnesses or injuries. Health Net Access processes medical claims utilizing the list of
Health Net Access reimburses multiple procedures using
provider preventable conditions (PPCs) and surgical errors
a 100 percent, 50 percent, 50 percent methodology. The
and reduces or prohibits payments for PPCs.
procedure with the highest reimbursement value is paid at 100 percent of the allowed amount. Subsequent
The Centers for Medicare & Medicaid Services (CMS) issued
procedures are paid at 50 percent of the allowed amount.
a final rule implementing section 2702, which reduces or prohibits payments related to PPCs. This rule was built on
253
Claims and Provider Reimbursement
Medicare’s strategies that already reduce or prohibit
surgery procedures.
hospital payments for preventable conditions, and
o Deep vein thrombosis or pulmonary embolism
also improved alignment between Medicare and
following total hip or knee procedures, except in
Medicaid payment policies. Although the new rule
pediatric or obstetrical patients.
gives states the flexibility to expand the list of other
• Other Provider-Preventable Condition (OPPC) - Applies
provider preventable conditions (OPPCs), Arizona
to Medicaid inpatient or outpatient health care settings
currently employs only the Medicare National Coverage
and includes any of the three Medicare NCDs:
Determinations (NCDs) list as described in the Other
o Surgery on the wrong patient.
Provider-Preventable Conditions definition below.
o Wrong surgery on a patient. o Surgery on the wrong site.
Definitions Reporting Requirements
PPCs are defined as either of the following:
Health Net Access requires providers to both report to
• Health Care-Acquired Condition (HCAC) - Applies only to Medicaid inpatient hospital settings and are
the proper Arizona authorities and to Health Net Access
included in the following Medicare list of hospital-
incidents of abuse, neglect, as well as any injury (such as
acquired conditions (HACs):
falls and fractures), exploitation, HCAC, and/or unexpected death as soon as the providers are aware of the incident.
o Retained foreign object following surgical
In turn, Health Net Access reports all incidents of abuse,
procedures. o Air embolism.
neglect, injury, exploitation, HCAC, and unexpected deaths
o Blood incompatibility.
to the Arizona Health Care Cost Containment System
o Stage III and IV pressure ulcers.
(AHCCCS) Clinical Quality Management Unit.
o Injuries resulting from falls and trauma.
Reporting to Health Net Access
o Catheter-associated urinary tract infections.
• Potential Quality Issue (PQI) Referral Form - Providers
o Vascular catheter-associated infections. o Manifestations for poor glycemic control.
must complete a Health Net Access PQI referral form
o Mediastinitis following coronary artery bypass
to report all incidents of abuse, neglect, as well as any injury (such as falls and fractures), exploitation, HCAC,
graft (CABG) procedures.
and/or unexpected death as soon as the provider is
o Surgical site infections following orthopedic surgery procedures involving spinal column
aware of the incident. Submit the completed form
fusion or re-fusion, arthrodesis of the shoulder
directly via secure fax to Health Net Access at 1-877-808-
or elbow, or other procedures on the shoulder
7024 within one business day of the event or occurrence • Claim forms (UB-04 and CMS-1500) - Under the federal
or elbow.
rule implementing Section 2702, providers must report
o Surgical site infections following bariatric
254
Claims Codes and Encounters
the occurrence of any PPC in a Health Net Access
Provider Reimbursement section of the provider operations
member, regardless of whether the provider has
manual for claims submission details.
submitted a claim for payment for the services that resulted in the PPC. Providers should
Health Net is required to send encounter data electronically
report these occurrences through the use of the
to AHCCCS. Accordingly, providers’ reporting of complete
appropriate codes on the UB-04 claim form for
and accurate claims data to Health Net is critical.
facility services or the CMS-1500 claim form for professional services
Codes HCACs use ICD-10 diagnosis codes as well as CMS HAC codes. Unlike HCACs, OPPCs are not confined to conditions occurring in the inpatient hospital setting, but may occur in either the inpatient or outpatient setting. In this case, outpatient is not limited to hospital outpatient departments, but may include other outpatient settings, such as a clinic, ambulatory surgical center (ASC), federally qualified health center (FQHC), or physician’s office. Health Net Access utilizes the following modifiers to define conditions considered to by OPPCs: • PA - Surgery wrong body part • PB - Surgery wrong patient • PC - Wrong surgery on patient
Encounters An encounter is a claims record of medical services provided to a member enrolled in the Health Net Access plan. Providers are required to submit claims to Health Net for all services rendered to Access members on the most current CMS-1500, UB-04 or other appropriate claim form. Providers may access Claims Submission Requirements in the Claims and
255
Chapter 15
Dispute Resolution and Appeals satisfied with the quality of care or service he
Overview Health Net Access members have grievance and appeal rights mandated by Arizona law.
or she has received. There is no time limit for a member to file a grievance.
The Arizona Health Care Cost Containment System (AHCCCS) regulates the appeal process. Health Net Access members may file appeals or grievances with Health Net Access regarding concerns they may have with the quality of care or service or in response to a denial. Health Net Access is required to
A member’s authorized representative or provider acting on behalf of the member can initiate an appeal or grievance by calling the Health Net Access Provider Services Center or by mailing or faxing the information to the Health Net Access Member Appeals and Grievances Department.
respond to appeals and grievances within a very short time frame; therefore, when Health Net Access requests medical records,
Participating providers may be asked to provide information needed for Health Net Access to reach a timely resolution of a grievance or
providers must respond promptly.
appeal initiated by a member. Providers are An appeal is a request for review of an action that in most cases resulted in Health Net Access sending a Notice of Action letter to the member. This could be a denial for a prior authorization request or for a claim
strongly encouraged to have a process in place for responding to member grievances and appeals and must treat each seriously, since practice patterns and trends are tracked as part of the recredentialing process.
payment or reimbursement request that has been denied. Appeals may be filed up to 60 calendar days from the date Health Net Access sent the Notice of Action letter to the
According to state law, Health Net Access must respond to member appeals within certain time limits depending upon the urgency of the appeal. The appeal process often requires Health Net
member.
Access to review member records that must A grievance is filed when the member is not
256
be obtained from providers. It is important
Dispute Resolution and Appeals
that participating providers promptly submit records
overturn it and approve the requested medical services or
requested by Health Net Access.
pay the claim.
Appeal Process
If an expedited or standard appeal is denied or the resolution
Expedited Appeals
is not completed when the timeframe expires, the member may file a request for a state fair hearing.
Members can request expedited resolution to an appeal. The expedited resolution to an appeal is requested when
Extensions
a standard timeframe could seriously jeopardize the
Health Net Access’ time frame for appeal resolution is three
member’s life or health or ability to attain, maintain
business days for an expedited appeal and 30 calendar days
or regain maximum function. The timeframe for an
for a standard appeal. Expedited and standard appeals may
expedited appeal is no longer than three business days
have a 14 calendar day extension beyond the usual resolution
after Health Net Access receives the appeal.
timeframe. The member may request the extension, or Health Net Access can request the extension if there is a need
A member or provider can initiate the expedited
for additional information and the delay is in the member’s
medical review by mailing, faxing or telephoning the
interest. If Health Net Access requests the extension, Health
request to the Health Net Access Member Appeals
Net Access sends the member a written notice of the reason
and Grievances Department. Once Health Net Access
for the extension.
receives the necessary information, Health Net Access provides an acknowledgement within one business day.
Continuation of Services Members may request continued services when they file
Standard Appeals
appeals. Members must make this request within 10 business
A standard appeal may be requested if Health Net
days from the date of the Notice of Action or the intended
Access has denied a request for prior authorization
date of the action, whichever is later. Services are continued
or a claim for payment for services already received.
if they were previously authorized and the original period
A request for an appeal can be submitted by calling
covered by the authorization has not expired. The benefits
the Health Net Access Member Services Center or by
must then be continued until one of the following occurs:
mailing or faxing the request to the Health Net Access
• The member withdraws the appeal
Member Grievances and Appeals Department. Health
• A period of 10 business days passes after the Grievance
Net Access sends the member an acknowledgement
and Appeal Case Coordinator mails the notice of
within five business days of receiving the appeal. Health
resolution (unless within that 10 business day time-
Net Access responds with a decision within 30 days
frame the member requested continuation of the benefit
of receipt, and may uphold the original decision or
pending the hearing process)
257
Dispute Resolution and Appeals
• The member receives an adverse hearing decision
Provider Dispute Resolutions Process
If the appeal decision is unfavorable to the member, he or she may be responsible for paying for these
General Information
services provided during the appeal.
Providers should exhaust all authorized processing or resubmisson procedures before filing a claim dispute with
State Fair Hearing
Health Net Access.
If a member disagrees with the resolution of an expedited or standard appeal, he or she may file a
It is recommended that providers follow the guidelines below
request for a state fair hearing in writing within 30 days
before filing a claim dispute:
of receipt of the Health Net Access denial. The process
• If the provider has not received a Health Net Access
for requesting a hearing is provided in the decision
remittance advice (RA) identifying the status of the
letter. The hearing is conducted by an administrative law
claim, he or she should call the Provider Services
judge at the Office of Administrative Hearings.
Center to inquire whether the claim has been received, processed and what the status is.
Grievance Process
• Providers should allow ample time following claim
A member may file a grievance at any time by telephone,
submission before inquiring about a claim. However,
mail or in person when he or she has a concern about
providers should inquire well before six months from
the quality of care or service received. Health Net Access
the date of service because of the time frame for initial
provides reasonable assistance in completing forms and
claim submission and for filing a claim dispute.
taking other procedural steps.This includes, but is not
• If a claim is pending in Health Net Access’ claim system,
limited to, providing interpreter services and toll-free
a claim dispute is not investigated until the claim is paid
numbers that have adequate TTY/TDD and interpreter
or denied. A delay in processing a claim may be a cause
capability in the filing process of a grievance. Grievances
for Health Net Access to entertain a claim dispute on a
may be resolved within 10 business days of receipt,
pended claim provided all claim dispute deadlines are
barring extraordinary circumstances, and will not
met.
exceed 90 calendar days for resolution.
• If the provider has exhausted all authorized processing procedures, the provider has a right to request a provider
Grievances must be filed with Health Net Access.
state fair hearing through the Arizona Health Care Cost
Members are not permitted to file a grievance directly
Containment System (AHCCCS).
with the state. The findings and decisions made by Health Net Access regarding a grievance are final; there
Definition of a Provider Dispute
is no state fair hearing process available to members for
A provider dispute is a written notice from the provider to
grievances.
258
Dispute Resolution and Appeals
Health Net Access that:
or a request for reimbursement of an overpayment of a
• Challenges, appeals or requests reconsideration of a
claim, the dispute must include a clear identification of the
claim (including a bundled group of similar claims)
disputed item, the date of service, and a clear explanation as
that has been denied or adjusted.
to why the provider believes the payment amount, request
• Challenges a request for reimbursement for an
for additional information, request for reimbursement of an
overpayment of a claim.
overpayment, or other action is incorrect.
• Seeks resolution of a billing determination.
A provider dispute that is submitted on behalf of a member for services not billed or rendered and for which there is an
Provider Dispute Time Frame
authorization denial will be processed through the member
Health Net Access accepts disputes if they are submitted
appeals process, granted the member has authorized the
no later than 12 months from the date of service, 12
provider to appeal on the member’s behalf. When a provider
months after the date of eligibility posting or within 60
submits a dispute on behalf of a member, the provider is
days after the payment, denial or recoupment of a timely
assisting the member with his or her member appeal and
claim submission, whichever is later and as described
it should be submitted through the member appeals and
above.
grievances process.
If the provider’s contractual agreement provides for a
If the provider dispute involves a member, the dispute must
dispute-filing deadline that is greater or less than 365
include the member’s name, ID number, a clear explanation
calendar days, this time frame continues to apply unless
of the disputed item, the date of service, billed and paid
and until the contract is amended.
amounts, and the provider’s position. Health Net Access does not request that providers resubmit claim information or
Submission of Provider Disputes
supporting documentation that was previously submitted to
Providers should submit provider disputes on a Provider
Health Net Access as part of the claims adjudication process
Dispute Resolution Request form and send to Health
unless Health Net returned the information to the provider.
Net Access Provider Disputes. If the dispute is for
Health Net Access does not discriminate or retaliate against
multiple and substantially similar claims, a Provider
a provider due to a provider’s use of the provider dispute
Dispute Resolution Request spreadsheet should be
process.
submitted along with the form.
Acknowledgement of Provider Disputes The provider’s dispute must include the provider’s
Health Net Access acknowledges receipt of each provider
name, identification (ID) number, contact information
dispute, regardless of whether the dispute is complete, within
with telephone number, and the number assigned to
five business days of receipt.
the original claim. If the dispute is regarding a claim
259
Dispute Resolution and Appeals
Resolution Time Frame
why the request for hearing was filed and resolves the
Health Net Access resolves each provider dispute within
matter when appropriate. If Health Net Access decides to
30 business days following receipt of the dispute, and
reverse its decision, in full or in part, through the appeal
provides a written determination.
process, Health Net Access reprocesses and pays the claim in a manner consistent with the decision along with any
Past-Due Payments
applicable interest within 15 business days of the date of the
If the provider dispute involves a claim and it is
decision.
determined to be in favor of the provider, Health Net Access pays any outstanding money due, including any
Contacts
required interest or penalties, within 15 business days of the date of the decision. When applicable, accrual of the
Health Net Access Member Appeals and Grievances Department
interest and penalties commences on the day following
Health Net Access Member Appeals and Grievances
the date when the claim should have been processed.
Department
Dispute Resolution Costs A provider dispute is processed without charge to the
PO Box 9007 Tempe, AZ 85281-9707 Fax: (855) 844-0687
provider; however, Health Net Access has no obligation to reimburse any costs that the provider has incurred during the dispute process.
Provider State Fair Hearing If a provider disagrees with the resolution of a dispute, he or she may file a request to Health Net Access for a state fair hearing through the AHCCCS Office of Administrative Legal Services (OALS). The request must
Health Net Access Provider Disputes Submit provider dispute requests to the following address: Health Net Access Provider Disputes 1230 West Washington Street, Suite 401 Tempe, AZ 85281 fax: 1-855-405-6889
be received in writing within 30 days of the dispute
Health Net Access Provider Services Center
decision and Health Net Access submits all supporting
The Health Net Access Provider Services Center is available
documentation received to the OALS no later than five
24 hours a day, seven days a week to assist providers with:
business days from the date Health Net Access receives
• Eligibility.
the provider’s written request.
• Claims. • Benefit verification.
When a provider files a written request for a hearing,
• Third-party recovery.
Health Net Access reviews the matter to determine
• Coordination of benefits.
260
Dispute Resolution and Appeals
• Refunds. • Appeals and grievances (member). • Contact information. • Ongoing provider education and updates (in coordination with the Health Net Access Provider Network Department). • Facilitation of communication between providers and Health Net Access internal departments. 1-888-788-4408 TTY/TDD: 1-888-788-4872
Health Net Access Provider State Fair Hearing Submit provider state fair hearing requests to the following address: Health Net Access State Fair Hearing 1230 West Washington Street, Suite 401 Tempe, AZ 85281 fax: 1-855-405-6889
261
Dispute Resolution and Appeals Health Net Access Provider Claim Dispute Form
262
Dispute Resolution and Appeals Health Net Access Provider Claim Dispute Form
263
Dispute Resolution and Appeals Health Net Access Provider State Fair Hearing Request
264
Dispute Resolution and Appeals Health Net Access Provider State Fair Hearing Request
265
Chapter 16
Compliance and Regulations Form Instructions)
Federal Lobbying Restrictions
• File quarterly updates, such as a disclosure form at the end of any calendar quarter in
United States Code Title 31, Section 1352, prohibits the use of federal funds for lobbying purposes in connection with any federal
which disclosure is required or in which an event occurs that materially affects the previously filed disclosure form
contract, grant, loan, cooperative agreement, or extension, or continuation of any of them. Participating providers are required to develop and comply with filing procedures as follows: • File a declaration with Health Net certifying that no inappropriate use of federal funds has occurred or will occur (use Certification for Contracts, Grants, Loans, and Cooperative Agreements Form). This extends to any subcontract a participating provider may have that exceeds $100,000 in value. In these cases,
While the statute and related regulations do not specify that the $100,000 limit mentioned in the first bullet is to be calculated annually, Health Net believes it reasonable to apply the $100,000 threshold to the term of the Provider Participation Agreement (PPA). If the PPA term is for one year, renewable automatically if not terminated, the threshold would renew at the beginning of each new one-year term. If it is a multiyear term, the calculation of the threshold would be based on the payments received throughout the multiyear term.
the participating provider is required to collect and retain these declarations • File a specific disclosure form if nonfederal funds have been used for lobbying purposes in connection with any Health Net line of business (use Disclosure of Lobbying Activities Form and Disclosure
266
Participating providers who complete the Certification for Contracts, Grants, Loans, and Cooperative Agreements Form should send it directly to their assigned Health Net provider network representative.
Compliance and Regulations
Health Net participating providers are required to comply with applicable state laws and regulations and Health Net policies and procedures. The contents of Health Net’s operations manuals are supplemental to the PPA and its addendums. When the contents of Health Net’s operations manuals conflict with the PPA, the PPA takes precedence.
Provider Right to Advocate on Members’ Behalf Health Net Access must ensure that its providers, acting within the lawful scope of their practices, are not prohibited or otherwise restricted from advising or advocating on behalf of members for the following: • The member’s health status, medical care or treatment options, including any alternative treatment that may be self-administered • Any information the member needs in order to decide among all relevant treatment options • The risks, benefits and consequences of treatment or non-treatment • The member’s right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions
267
Compliance and Regulations FORMS Certification for Contracts, Grants, Loans, and Cooperative Agreements Form
268
Compliance and Regulations Disclosure of Lobbying Activities Form and Disclosure Form Instructions
269
Compliance and Regulations
270
Chapter 17
Glossary of Terms central database maintained by the Arizona
Overview This glossary is provided for reference purposes and is not intended to supersede definitions or explanations contained in controlling or governing documents, such as the Provider Participation Agreement (PPA) or the member’s Evidence of Coverage (EOC).
Department of Health Services to record all immunizations administered to children under age 19. APPEAL - A means to provide physicians,
practitioners, facilities, and members with an avenue for reconsideration of Health Net’s action,
ARIZONA DEPARTMENT OF INSURANCE
(ADOI) - State of Arizona regulatory body responsible for oversight of insurance companies, including HMOs and PPOs.
including, but not limited to, non-payment of services or authorization denial. APPEALS AND GRIEVANCES DEPARTMENT -
Health Net department designated to resolve ARIZONA EARLY INTERVENTION PROGRAM (AzEIP) - Provides services to
children from birth through age three, who are at risk of or have a developmental delay, and
member appeals and complaints. CAPITATION PAYMENT - Predetermined
periodic payment, which can be based upon the rate code, age and gender of assigned members
their families.
that is made to a participating physician or other ARIZONA HEALTH CARE COST
provider by Health Net for providing covered
CONTAINMENT SYSTEM (AHCCCS) - State
services.
of Arizona regulatory body responsible for Medicaid.
CARVE-OUT - Any service identified by an
ICD-10-CM diagnosis code, CPT procedure code, ARIZONA STATE IMMUNIZATION
patient age, or CPT modifier that is eligible for fee
INFORMATION SYSTEM (ASIIS) - The
schedule reimbursement.
271
Glossary of Terms
CLAIMS FILING DEADLINE - All claims where Health
COPAYMENT - Fixed amount of out-of-pocket expenses
Net is the primary payer must be submitted within 120
that a member is required to pay a participating provider
calendar days of the service date. Claims submitted more
when receiving covered services. Copayments are due
than 120 days after the date of service are denied. In no
to the provider at the time covered services are received.
event does Health Net consider the filing of a claim or
Copayments may be in addition to coinsurance or deductible
appeal of a denial of a claim more than one year from the
amounts the member must pay under his or her plan,
date of service.
dependent upon the plan selected by the member’s employer.
CLAIMS RECOVERY UNIT - A multiunit recovery area
COVERED SERVICES - Medically necessary health and
for Health Net that encompasses coordination of benefits
medical services, as defined in the member’s plan document.
(COB), medical-pay benefits, subrogation, refunds, and
Some services may be noted as covered only with prior
cash-receipt tracking.
authorization.
CENTERS FOR MEDICARE AND MEDICAID
CUSTOMER SERVICE - Health Net staff designated to
SERVICES (CMS) - A federal agency within the
coordinate communication with members and act as member
Department of Health and Human Services, responsible
advocates. Customer service representatives also assist
for oversight of the federal requirements of the health
physicians, clinicians and other providers with claims and
care industry for Medicare recipients and Medicare
eligibility questions.
benefits. It is the governing body over Medicare DEDUCTIBLE - Amount of money that must be paid each
Advantage (MA) plans.
year by the member before Health Net’s obligation to provide COINSURANCE - Portion of a covered charge that the
covered benefits arises.
member must pay for covered services and supplies. Coinsurance amounts are shown in the Schedule of
DENIAL - An unfavorable determination made regarding any
Benefits. For example, coinsurance may be shown as
claim, service or appeal.
20 percent. This means the member pays 20 percent of covered charges and Health Net pays 80 percent of
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND
covered charges.
TREATMENT (EPSDT) PROGRAM - A comprehensive
child health program to prevent, treat, correct, and improve COMPLAINT - Any verbal or written expression of
physical and mental health problems for Medicaid members
dissatisfaction by a physician or member.
under age 21.
CONCURRENT REVIEW NURSE - Nurse assigned to
EMERGENCY MEDICAL CONDITION - Health care services
coordinate inpatient discharge needs or services.
provided to a member for a medical condition that manifests
272
Glossary of Terms
itself by symptoms of sufficient severity (including
INTERNATIONAL CLASSIFICATION OF DISEASES - 9TH
severe pain) that a prudent layperson, with an average
REVISION - CLINICAL MODIFICATION (ICD-10-CM) -
knowledge of health and medicine, could reasonably
Coding schemata used by physicians to classify a disease into
expect the absence of immediate medical attention to
a code value.
result in any of the following: INDEMNITY INSURANCE - “Traditional” insurance that
• Serious jeopardy to the patient’s health, or, in the case of a pregnant woman, the health of the woman
provides insurance for health care costs incurred by the
or her unborn child
member in exchange for a monthly premium. Insurance
• Serious impairment to bodily functions
coverage is generally based on a percentage of the member’s
• Serious dysfunction of any bodily organ or part
actual medical expenses, subject to maximum allowable amounts as determined by the insurance carrier. The member
EMERGENCY SERVICES - Covered inpatient and
is financially responsible for charges not covered by the
outpatient services:
insurance carrier. The member does not have a primary care physician (PCP) and may see any physician.
• Furnished by a provider qualified to furnish emergency services; and
INITIAL DETERMINATION - Written notice that must be
• Needed to evaluate or stabilize an emergency
provided to a physician denying a request for payment that
medical condition
advises the physician of his or her right to an appeal. ENCOUNTER - Record of medical services provided to a IN-NETWORK - For PPO and Point of Service (POS) plus
member where services were prepaid.
plans, it refers to care delivered by participating physicians or ENROLLMENT - Process by which a person who has
preferred providers. Also refer to Out-of-Network.
been determined eligible becomes a member of Health LENGTH OF STAY - Number of days a patient is an inpatient,
Net.
per admission, either totally or in a particular unit or level of GRIEVANCE - Any member’s complaint or dispute
care.
other than one involving an organization determination. Examples include office waiting times, and physician and
MEDICAL SERVICES - Covered services pertaining to medical
staff demeanor and behavior.
care performed at the direction of a physician on behalf of members or eligible persons by physicians, dentists, nurses,
HEALTH MAINTENANCE ORGANIZATION (HMO) -
or other health-related professionals and technical personnel.
An entity that provides, offers or arranges for coverage of
Services determined to be necessary for prevention, diagnoses
designated health services by plan members, usually for a
or treatment of a patient or patient condition.
fixed amount.
MEDICALLY NECESSARY - CMS defines medical necessity
273
Glossary of Terms
and medically necessary services as services or supplies
for medically necessary preventive care is governed by the
that: are proper and needed for the diagnosis and
terms of the Provider Participation Agreement (PPA) and the
treatment of illness or injury, or to improve functioning
member’s Evidence of Coverage (EOC).
of a malformed body member, or for prevention of an illness, or for the palliation and management of terminal
When considering whether a service or treatment is
illness; meet the standards of good medical practice in
experimental or investigational, if such service or treatment
the local area; and are not mainly for the convenience of
is medically necessary, as defined above, said service or
the patient or health care provider.
treatment is paid for unless specifically excluded from Health Net coverage. “New technology” is defined as a service,
For HMO and PPO plans, medically necessary services
procedure, device, test, or other item that, as of the effective
or medical necessity is defined as health care services
date of this agreement (i) is not performed by provider, or (ii)
that a physician, exercising prudent clinical judgment,
is not covered by Health Net under a benefit program, or (iii)
would provide to a patient for the purpose of preventing,
for which there is no CPT or other relevant code defined.
evaluating, diagnosing, or treating an illness, injury, MEDICAID - A health care coverage program that is jointly
disease, or its symptoms, and that are: • In accordance with generally accepted standards
financed by the state and the federal government for children,
of medical practice. For these purposes, “generally
pregnant women, parents, seniors, and individuals with
accepted standards of medical practice” means
disabilities.
standards that are based on credible scientific evidence published in peer-reviewed medical literature generally
MEDICARE - A federal health insurance program for people
recognized by the relevant medical community,
age 65 or older, some people under age 65 with certain
physician specialty society recommendations, the
disabilities and people with end-stage renal disease (ESRD)
views of physicians practicing in relevant clinical areas,
(generally those with permanent kidney failure who need
and any other relevant factors
dialysis or a kidney transplant).
• Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for
MEDICARE ADVANTAGE ORGANIZATION (MAO) - Public
the patient’s illness, injury or disease
or private entity organized and licensed under state law as a
• Not primarily for the convenience of the patient,
risk-bearing entity that is certified by CMS as meeting MA
physician or other health care provider, and not
contract requirements. Health Net of Arizona is an MAO.
more costly than an alternative service or sequence of services at least as likely to produce equivalent
MEDICARE ADVANTAGE (MA) PLAN - Health benefits
therapeutic or diagnostic results as to the diagnosis or
coverage and pricing structure that the MAO offers to
treatment of that patient’s illness, injury or disease
beneficiaries. SeniorCare and SeniorCare Gold are MA plans. MEMBER - Individual who has been determined eligible by
Preventive care may be medically necessary, but coverage
274
Glossary of Terms
Health Net and enrolled with Health Net or one of its
used to calculate the capitation budget pools.
affiliates to receive services. PHYSICIAN - A person who: NOTICE OF ACTION LETTER - A written denial letter
• Is recognized and licensed under the laws of the state
to a member regarding a prior authorization request and
where treatment is received as qualified to treat the type
action by Health Net Access.
of injury or illness for which a claim is made. • Is practicing within the scope of his or her license.
NOTICE OF EXTENSION LETTER - A written notice
• Is a duly licensed doctor of medicine (M.D.), doctor of
to a member extending the time frame by up to 14
osteopathy (D.O.) or other health professional for whom
days for making an urgent/expedited or standard
reimbursement is mandated under applicable Arizona or
prior authorization decision if criteria for a service
federal law, when licensed in the state where services are
authorization extension are met.
received.
OUT-OF-AREA CARE - Care received by a Health Net
PHYSICIAN SERVICES - Services provided within the scope
member when outside of the member’s service area.
of practice of medicine or osteopathy or under the personal supervision of an individual licensed under Arizona law to
OUT-OF-NETWORK - For PPO and POS plus plans,
practice medicine or osteopathy.
it refers to care delivered by non-participating/nonPOINT OF SERVICE (POS) - Health care system in which the
preferred physicians. Also refer to In-Network.
patient may choose varied benefit levels based on the desire to PARTICIPATING PHYSICIAN - Physician who has
control costs (in-network) or to obtain care not coordinated
entered into an agreement, or on whose behalf an
by the primary care physician (PCP) (out-of-network).
agreement has been entered into, with Health Net to PREFERRED PROVIDER ORGANIZATION (PPO) - Health
provide medical services to enrolled members.
care system in which the patient may choose varied benefit PARTICIPATING PROVIDER - Any person or entity that
levels based on the desire to control costs (in-network) or
has entered into a contract with Health Net to provide
to obtain care outside of the Health Net participating or
covered services to enrolled members. Participating
preferred network (out-of-network).
providers include, but are not limited to, hospitals, urgent care facilities, physicians, pharmacies, and other health
PRIMARY CARE PHYSICIAN (PCP) - Participating physician
professionals within the
who provides, arranges and coordinates a member’s health
Health Net service area.
care, usually associated only under an HMO plan. PCPs are physicians in the areas of family practice, general medicine,
PER MEMBER PER MONTH (PMPM) - Dollar amount
internal medicine, and pediatrics. Upon enrollment, a
275
Glossary of Terms
member selects a physician from the list of participating
REFERRAL - Request made through the PCP for
physicians. Obstetricians may also act as a member’s PCP
authorization of specialty services or equipment on behalf of a
during pregnancy and postpartum periods. Members do
member.
not need to contact Health Net to change their PCP to an RETROSPECTIVE REVIEW - Formal process of reviewing
obstetrician during pregnancy and postpartum periods.
Health Net/payer-requested medical documentation or PRIOR AUTHORIZATION/PRE-CERTIFICATION -
invoices to support medical appropriateness of services,
Prior assessment that proposed health care services
medications, costs, or durable medical equipment (DME)
are medically appropriate and a covered benefit for a
submitted for reimbursement, regardless if such service
particular member using standard guidelines.
rendered or any procedure involving a member requires authorization.
PRIORITY ASSIGNMENT - PCPs who are in good
standing with Health Net and have excellent availability
SERVICE AREA - Geographic area approved by CMS within
are eligible for this program. Priority assignment reflects
which a Medicare Advantage (MA)-eligible individual may
eligible PCPs as “priority” for membership assignment.
enroll in a particular MA plan offered by Health Net. For HMO and PPO plans, it is the geographic area serviced
PROVIDER INQUIRY DEPARTMENT - Health Net staff
by Health Net, as authorized by the state of Arizona and
designated to assist physicians with questions regarding
designated by Health Net for the provision of covered services.
complaints, appeals and grievances.
These areas may change from time-to-time, as designated by Health Net.
PROVIDER NETWORK MANAGEMENT (PNM) -
Health Net staff designated to coordinate communication
SERVICE DENIALS - Medical service authorization requests
and education between Health Net and physicians or
that are not approved.
clinicians, and other health care facility and ancillary providers. PNM representatives also assist physicians
URGENT CARE - CMS defines urgently care services as
with network changes and questions regarding policies
covered services that:
and covered services.
• Are not emergency services as defined by CMS • Are provided when an enrollee is temporarily absent
QUALITY IMPROVEMENT (QI) STAFF - Provides
from the Medicare Advantage (MA) plan’s service (or,
technical support to the QI committees, and conducts QI
if applicable, continuation) area, or the plan network is
studies and activities.
otherwise not available, and, • Are medically necessary and immediately required, meaning that: o The urgently needed services are a result of an
276
Glossary of Terms
unforeseen illness, injury or condition, and
Schedule of Benefits (SB)
o Given the circumstances, it was not reasonable
The Schedule of Benefits (SB) is a brief list of benefits,
to obtain the services through the MA plan’s
with applicable copayment, coinsurance and deductible
participating provider network
information for the member’s health plan. It does not list the exclusions and limitations or other important legal and
For HMO and PPO plans, services provided for the relief
contractual terms applicable to the plan; these are described
of acute pain, initial treatment of acute infection, or a
in the EOC or COI.SBs are available to members on the
medical condition that requires medical attention, but a
member portal at www.healthnetaccess.com, or in hard copy
brief time lapse before care is obtained does not endanger
on request.
life or permanent health. Urgent conditions include, but are not limited to, minor sprains, fractures, pain, heat
Definition - Participating Provider
exhaustion, and breathing difficulties, other than those of
As defined in the Health Net’s National provider contract
sudden onset and persistent severity.
templates:
Participating Provider. A facility, physician, physician
Definition - EOC/SB/COI
organization, other health care provider, supplier, or other organization, which has met applicable credentialing and/or
Evidence of Coverage (EOC)
recredentialing requirements, if any, and has, or is governed
The Evidence of Coverage (EOC) is a document
by, an effective written agreement directly with Health
containing statements of the services and benefits to
Net, or indirectly through another entity, such as, another
which a Health Net HMO member is contractually
participating provider, to provide covered services.
entitled. The EOC for each HMO and POS plan contains comprehensive terms and conditions of Health Net portal at www.healthnetaccess.com, or in hard copy on
Definition - Primary Care Physician
request. Providers may obtain a copy of a member’s EOC
As defined in the Health Net’s National provider contract
by requesting it from the Health Net Provider Services
templates:
Center. EOCs apply to Health Net HMO and POS plans
Primary Care Physician (PCP). A doctor of medicine (MD),
only. Language used in these documents is reflective
doctor of osteopathy (DO) or other health care professional
of current laws and regulations and meets disclosure
who: (1) is duly licensed and qualified under the laws of
requirements applicable to health plan documents. The
the relevant jurisdiction to render contracted services; (2)
text included in the EOC is wholly subject to regulatory
is a participating provider and (3) meets the credentialing
review and approval prior to use.
standards of Health Net for designation as a PCP and who
coverage. EOCs are available to members on the member
provides for continuity of care and 24-hour-a-day, 7-day-aweek availability to beneficiaries.
277
