To:
From:
Date:
RE:
CoventryCares of Kentucky Providers
CoventryCares of Kentucky Provider Relations
February 26, 2013
Important Reminders & Updates
Effective March 1, 2013, CoventryCares of Kentucky will resume instituting the Lock-In Program, in compliance with
907 KAR 1:677.
Based on a member’s claims history, a member may be placed in the Lock-In Program based on his/her use of multiple
providers, hospitals, pharmacies, and prescriptions, or for the use of the emergency department for non-emergency
medical conditions. A member may be locked into a primary care provider (PCP) and a pharmacy, and/or a hospital for
an initial period of two (2) years. The long-term goal of the Program is to help members learn to use medical care
appropriately while ensuring quality of care.
Letters informing members of their lock-in status and their designated providers were mailed on January 2, 2013. The
providers of these members also received a letter to notify them of the members that have been assigned to them.
Members have been assigned to designated lock-in providers based on claims history. Best efforts have been made to
assign members to their existing PCPs and most often used pharmacies and hospitals. New members will be identified
each month for assignment to this program.
Designated PCPs - The designated PCP is responsible for authorizing referrals for the member’s services from other
providers. The designated PCP is the only authorized prescriber for the member unless the PCP has authorized a referral
for non-designated provider services.
Pharmacy - Members may only get prescriptions filled at their designated pharmacy. If a member tries to get a
prescription filled at a non-designated pharmacy, the pharmacist will receive a point-of-sale denial. Prescriptions
written by providers other than the member’s designated PCP will also be denied at point-of-sale unless the non-lock-in
provider received the referral from the members lock-in PCP.
Hospital - As required by Kentucky Medicaid regulations, CoventryCares does not cover non-emergent services provided
to lock-in members, if provided by any hospital other than their designated hospital. CoventryCares will pay for a
screening to determine if the member has an emergency medical condition. CoventryCares will reimburse a hospital
under the DRG methodology, $25 for a screening of a lock-in member, to determine if an emergency medical condition
exists. Hospitals should bill revenue code 451 for the emergency medical condition screening.
Designated lock-in providers serve for at least twenty-four (24) months except in cases where: (a) the designated
provider requests in writing to be released from serving as a member’s lock-in provider, and CoventryCares identifies a
new provider; (b) the member relocates outside of the designated provider’s geographic area; (c) the member requests
in writing, a change to their designated lock-in provider and satisfies the requirements for a change; (d) the designated
provider no longer participates in our network; or (e) either CoventryCares or the Department for Medicaid services
determines it is in the member’s best interest to change their designated lock-in provider.
If you have questions regarding the Lock-In Program, please call 1-888-470-0550, option 8, 8:00 a.m. to 5:00 p.m.,
Monday through Friday, Eastern Time, or you may contact your Provider Relations representative.
Lock-In
Frequently Asked Questions
Below are answers to some commonly asked questions regarding the Lock-In Program, these will better assist
you and your patients in understanding the program. This document will be updated as additional questions
are identified.
Questions That Your Patients May Have
Q.
What is the Lock-In Program?
A.
The Lock-In Program is designed to provide support to members who need assistance in
managing health care needs through the establishment of a medical home. People who
use one doctor, one pharmacy and one hospital get coordinated care. Providers know
more about the person’s health and can better diagnose and treat health conditions.
Fewer providers help make sure that a person gets the right medicine in the right
amounts.
Q.
A.
Why am I locked-in?
You are locked in because a review of your claims showed that you used a high number of
health care services and/or a high number of different providers over the past year.
Kentucky has a law that says that people who see too many different providers, go to the
emergency room too many times without an emergency medical condition, or get too
many prescriptions filled, can be restricted to one prescriber, one pharmacy and/or one
hospital. Lock-In status is based on a member’s claims history. You are identified for the
Lock-In Program if you meet the following criteria;
1. Member has received services from at least five (5) different providers, received at least
ten (10) different prescription drugs; and received prescriptions from at least three (3) or
more pharmacies;
OR
2. Member had at least four (4) hospital emergency room visits for a condition that was not
an emergency medical condition; OR
Member received services from at least three (3) different hospital emergency rooms for a
condition that was not an emergency medical condition
Q.
A.
Are my other family members locked-in?
Only people who received a letter are locked-in. Lock-in is decided for each member, not
as a family. Other family members could be placed in lock-in if they meet the above
criteria.
Q.
What if I am locked-in to a PCP, pharmacy and/or hospital that I do not use? Or my LockIn provider is too far away for me?
A.
Most Lock-In members are assigned to the PCP CoventryCares of Kentucky currently has
on record for the member. If a member did not have a PCP or CoventryCares of Kentucky
medical staff determined a member needed a different PCP, the member is usually
assigned to the doctor seen for most chronic and routine medical needs (for example:
blood pressure and/or diabetes treatment). Most members are assigned to the
CoventryCares of Kentucky network pharmacy and/or hospital they went to most often. If
an assigned provider was not selected from a member’s claims history, the provider was
selected based on the Commonwealth’s network access standards. This means that a
provider close to your home was chosen for you.
Every member who is locked-in to a provider has the right to request a different provider.
Please send your request in writing to:
CoventryCares of Kentucky
Attention: Lock-In Coordinator
9900 Corporate Campus Drive, Suite 1000
Louisville KY 40223
You may also call 1-855-300-5528 (711 TTY/TDD) from 7 a.m. to 7 p.m. Eastern Time,
Monday through Friday. CoventryCares of Kentucky Lock-In Team will process change
requests within five (5) business days. Expedited requests will be addressed within one (1)
business day. CoventryCares of Kentucky makes the determination as to whether a
request is expedited. Provider changes are subject to CoventryCares of Kentucky’s
discretion.
Q.
A.
What is the waiting period to be removed from Lock-In?
The Commonwealth of Kentucky requires members to be locked-in for two years. After
two years, CoventryCares of Kentucky will review the member’s Lock-In status to
determine if the member should continue in the program or no longer be required to be in
the Lock-In Program.
Q.
A.
What can I do to be removed from Lock-In?
If you believe you should not be locked-in because of your medical condition, you may file
an appeal within 30 days of the date on your Lock-In letter. Please send your appeal in
writing to:
CoventryCares of Kentucky
Attention: Lock-In Appeals
9900 Corporate Campus Drive, Suite 1000
Louisville, KY 40223
You should include documents that support the medical condition that you feel makes you
not eligible for the Lock-In Program. You may also call 1-888-470-0550, Option # 8, 8:00
a.m. to 5:00 p.m., Eastern Time, Monday through Friday.
If you do not appeal or your appeal is unsuccessful, you must limit the use of multiple
pharmacies, providers, and non-emergent hospital visits for a minimum of two (2) years.
The Commonwealth of Kentucky requires lock-in members to be in the program for at
least two (2) years.
Q.
A.
Will I be notified if I am removed from the Lock-In Program?
Yes. The Lock-In Committee will review a member’s claims and information from the
member’s Lock-In providers to determine if the member should continue in the Lock-In
Program. The review will occur annually after the initial two (2) year Lock-In period
expires. The member and designated providers will be notified of the decision in writing.
Q.
A.
What do I need to do if I go out of town?
If you plan to go out of town, you will need to call your assigned PCP to coordinate your
care while you are gone.
Q.
A.
What if I have an emergency?
If you have an emergency medical condition, you may go to any hospital emergency
department.
Q.
A.
How do I know if I have an emergency?
An emergency is a sudden injury or serious illness that if not treated right away, could
cause death or permanent harm. If you are pregnant, it could mean harm to you or your
baby’s health. Some examples of an emergency are:
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Trouble breathing
Poisoning
Broken bones
Chest pains
Unconsciousness (black out)
Severe or unusual bleeding
Convulsions or seizures
Sudden Severe pain
Severe burns
Any vaginal bleeding in pregnancy
You may call your PCP or our 24 Hour Nurse Line at 1-855-620-3924 to help you decide if
you should go to the emergency room or schedule a sick visit with your PCP.
Q.
A.
Q.
A.
What if I go to another provider, hospital (non-emergent) or pharmacy? Will my services
be paid?
No. If you go to a provider other than your assigned PCP without a referral from your PCP,
CoventryCares of Kentucky will not pay for your services. The provider may make you pay
for those services.
What if my Lock-In PCP is not available to refer my care?
Your PCP provides coverage 24/7 or will have another physician provide coverage to give
you any care you need.
Q.
A.
What if I go to an emergency department and I do not have an emergency?
The hospital may perform an exam to determine if you need emergent care. If your care
can wait, the hospital may refer you to your PCP.
Hospital Questions
Q.
How will a hospital know how many visits a member has exhausted at other hospitals
that the member is not locked into? Is there a “cap” on the number of visits?
A.
There is no “cap” on the number of visits a member may have. A member may go to any
hospital at any time for an emergency medical condition. When a member goes to a
hospital for a non-emergency condition, the member may only go to their designated
hospital. The hospital is responsible for screening the member to determine if the
member has a medical emergency.
Q.
A.
How do I bill for a screening for a Lock-In member?
Non-critical access hospitals must bill for the screening with Revenue Code 451. The
hospital will be reimbursed a $25 screening fee. Critical access hospitals should follow
standard CoventryCares of Kentucky billing rules.
Q.
A.
A member locked-in to a different hospital comes to our hospital. What do we do?
You are responsible for providing a screening to determine if a medical emergency exists
under the prudent layperson rule. If an emergency exists, provide appropriate treatment
to the member. Members who seek emergency department services for non-emergent
care should be re-directed to their PCP and/or the 24 Hour Nurse Line at 1-855-620-3924.
Hospitals that provide non-emergency services to a Lock-In member will not be
reimbursed for the services rendered to a member other than the $25 screening fee.
Q.
What is the definition of non-emergency and will it be based on admitting diagnosis or final
diagnosis?
A.
CoventryCares of Kentucky uses the prudent layperson rule related to emergencies. An
emergency is determined during the required screening.
A prudent layperson is defined in state and federal law as one who possesses an
average knowledge of health and medicine.
The laws call for coverage of emergency services by managed care organizations without
pre-authorization when symptoms are severe enough to lead a prudent layperson to
believe that his or her health, or the health of an unborn child, is in immediate jeopardy
(American Medical Association).
Q.
A.
Will we be paid if they are emergent?
Q.
How will Critical Access Hospitals be reimbursed since they are cost based? Will they still be
settled out with a cost report as long as the claim was not denied?
A.
Critical Access Hospitals that are part of the CoventryCares of Kentucky network will be
reimbursed pursuant to their contract terms. Non-participating Critical Access Hospitals
will be reimbursed at 90% of the Kentucky Medicaid fee schedule.
Q.
How much education is being provided to CoventryCares of Kentucky members? How much
education is being provided to physicians that tell the patient to just go to the ER?
A.
Lock-In members are receiving letters informing them of their enrollment in the program
and their responsibilities. CoventryCares of Kentucky Member Services and Case
Management are trained on assisting Lock-In members and providers of Lock-In members
on the details of the program. Fax Blasts have been sent to all providers educating them
on the program on <<Insert Date>>.
Emergency services are covered for any CoventryCares of Kentucky member.
Lock-In Primary Care Provider Questions
Q.
What duties will I need to perform as a Lock-In PCP?
A.
Please refer to the letter you received giving you notice that a member has been locked
into your care. It will give you more detail. Generally, you serve as the gatekeeper for
members that are assigned to you and all of the member’s care and prescriptions are
coordinated through you. Should a member need to see another provider or specialist,
you will need to provide a referral for the member. You can obtain the referral number by
calling the Prior Authorization line at 1-888-725-4969, (711 TDD/TTY) 7:00 a.m. to 7:00
p.m., Monday through Friday, Eastern Time, or you may fax your request, using the LockIn Referral Form, to 1-855-454-5579. This form can be found at
www.coventrycaresky.com, click provider tab and go to Document Library.
Q.
A.
If I am part of a primary care group practice, can one of my partners treat my Lock-In
patients while I am away on vacation? Am I required to notify the plan of this absence
and my coverage plans? If so, who do I notify and what should be included in the
notification?
When a designated PCP who is an individual practitioner is out of the office or unavailable
to see the Lock-In member, the PCP has 14 days from the date of service to submit a
referral form to:
CoventryCares of Kentucky
Attention: Lock-In Coordinator
9900 Corporate Campus Drive, Suite 1000
Louisville KY 40223
Forms may also be submitted via fax at 1-855-454-5579. The Prior Authorization
Department will enter the referral into the claims system to allow the covering provider’s
claim to pay. Please remember that the covering provider must be in the CoventryCares
of Kentucky network. A list of participating providers is available at
www.CoventryCaresKy.com.
If a group practice, all providers at the PCP’s practice site may treat the Lock-In member
without a referral.
Q.
A.
Q.
A.
Q.
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Q.
A.
If a Lock-In patient/member is at a pharmacy trying to fill a prescription other than the
one they are assigned to within the Lock-In Program or one written by another
physician, will the pharmacy call me for further information or approval, or will the
pharmacy claim simply reject at the point of service?
The pharmacy claim system will reject the claim at the point of service. The pharmacist has
the discretion to contact the Lock-In provider and/or the prescriber to obtain information
on the prescription for the member. The pharmacist, in his/her discretion, may contact
ESI/Medco to obtain a five (5) day emergency fill override code. The pharmacy will have
the denial information. We are asking pharmacists to relay the denial reason to the
member.
Has the letter been sent to all CoventryCares of Kentucky providers or just to those who
will be assigned Lock-In Members?
A provider fax blast was sent to all CoventryCares of Kentucky providers and posted on our
website. Assignment letters were mailed to all members to be enrolled in the Lock-In
Program and their designated providers.
How and when will a provider know who and how many Lock-In Members have been
assigned to them?
Each designated PCP, pharmacy and hospital will receive a letter notifying them of each
member that has been assigned to them.
Is there a cap/limit on the number of Lock-In members that can be assigned to a
provider?
There is not a limit on the number of Lock-In members that can be assigned to a PCP.
However, no one PCP has been assigned more than 40 members during the initial roll-out
of the program. On average, a designated PCP has 4 Lock-In members assigned to them.
Q.
A.
What is the effective date of the Lock-In Program?
Members will be enrolled in the Lock-In Program as of the date on the notification letter
you received unless the member appeals. Each notice letter will notify the recipient of the
effective Lock-In date for the assigned member.
Q.
Will the designated PCP have to get an authorization from CoventryCares of Kentucky or
will the physician referral alone be honored?
A.
The designated PCP can issue a referral to another provider to treat a Lock-In member.
The referral will be for a consult or a consult and treat. The designated PCP must obtain a
referral number from CoventryCares of Kentucky’s Lock-In Coordinator. If questions,
please call 1-888-725-4969, Monday through Friday 7:00 a.m. to 7:00 p.m., Eastern Time.
If a consult and treatment referral is given, the treating provider must specify if the
treatment period is for one, three, six, nine or twelve months.
Q.
If there is a prior authorization from CoventryCares of Kentucky, will there be dates of
service and number of visits, or limited number of visits?
Yes. The authorization request will be reviewed for the specified dates of service and
number of visits requested. Once a decision has been rendered, you will be notified by
the Prior Authorization Department. The designated PCP may obtain a referral number for
another provider to: a) consult or b) consult and treat the Lock-In member.
A.
Q.
A.
Q.
A.
Will a provider be able to determine Lock-In status from CoventryCares of Kentucky’s
website or will this information be on the Medicaid website?
Information is available by calling CoventryCares of Kentucky Member Services at 1-855300-5528, Monday through Friday, 7:00 a.m. to 7:00 p.m., Eastern Time. Lock-In
information will be available on KyHealthNet once the Commonwealth completes its
processing. The lock-in status of a member will also be available on directprovider.com.
A Lock-In member assigned to me has a medical condition (i.e. cancer, transplant) and I
don’t believe Lock-In is appropriate for this member. What do I do?
CoventryCares of Kentucky did use best efforts to review all reported medical diagnoses
present on the member’s claims. We excluded members with these complex and
complicated medical conditions from the Lock-In Program. If you have a member who you
believe is inappropriate for Lock-In based on his/her medical condition, please send your
recommendation with clinical support to:
CoventryCares of Kentucky
Attention: Lock-In Coordinator
9900 Corporate Campus Drive, Suite 1000
Louisville KY 40223
Non Lock-In Provider Questions
Q.
I am a specialist; if a patient is referred to me, can I get a prior authorization for services
to a Lock-In member?
A.
All care provided by any provider other than the member’s designated PCP requires a
referral. The designated PCP may give a consult or a consult and treat referral. Consult
and treat referrals may be for a period of one, three, six, nine or twelve months. The
specialist must note and track the end date of the referral and request a new referral. If a
specialist who already has a referral from the PCP wishes to refer the member to another
specialist for additional services, he/she will need to consult with the PCP. The PCP will
issue a referral for the requested services, if deemed necessary. If a service requires a
prior authorization, the specialist uses the regular process to request a new referral.
Q.
A.
Q.
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Q.
A.
I am currently treating a member that is now Locked-In. I have been prescribing the
member medication for a chronic condition. How do I get authorization to treat and
prescribe medication for my patient?
PCPs are the gatekeeper for all patient care. If the PCP determines that a long-term
relationship with a specialist is appropriate, they can obtain a referral for you to be able to
treat and prescribe medication for the member. The PCP will provide a referral to you and
obtain the referral number from CoventryCares of Kentucky.
I am a Lock-In member’s behavioral health care provider. Am I allowed to prescribe
medication to the member?
You need to coordinate care with the member’s designated PCP to obtain a long-term
referral. The PCP must issue a referral to enable your prescriptions to be filled for your
member.
A Lock-In member is being treated at my pain management facility. What do I need to
do?
Generally, pain management providers are not CoventryCares of Kentucky PCPs. The
member’s designated PCP may issue a referral to allow you to consult or consult and treat
the member. The PCP will obtain a referral number from CoventryCares of Kentucky.
Pharmacy Questions
Q.
What if I need a prescription filled and my Lock-In pharmacy is closed?
A.
Wait until the next day and go to your Lock-In pharmacy. If it is an emergency, go to any
open pharmacy and they will be able to call for authorization of a five (5) day supply if the
medication is refillable and deemed emergent by the pharmacist on call.
Q.
A.
Q.
A.
If a member shows up at a pharmacy and they do not know that they are locked into a
different pharmacy, what will happen?
The pharmacist will get a rejection code when trying to process the prescription. He/She
will call Medco for the information and then will be transferred to CSO to obtain the
information and determine what pharmacy the member needs to go to or the member
can call Member Services at 1-855-300-5528, (711 TDD/TTY), 7:00 a.m. to 7:00 p.m.
Monday through Friday, Eastern Time, for the same information.
What if I would like to change pharmacies?
Call Member Services at 1-855-300-5528, (711 TDD/TTY), 7:00 a.m. to 7:00 p.m. Monday
through Friday, Eastern Time, or mail in your request to:
CoventryCares of Kentucky
Attention: Lock-In Coordinator
9900 Corporate Campus Drive, Suite 1000
Louisville KY, 40223.
Lock-In Non-Designated Provider Referral
Form
Phone: 1-888-725-4969
Fax: 1-855-454-5579
Lock-in/Referring Provider:
Name:
Date of Referral:
NPI #:
Provider TIN #:
Medicaid ID #:
Contact Name:
Fax Number:
Phone Number:
Provider Being Referred To:
Name:
Practice Name:
NPI #:
Provider TIN #:
Medicaid ID #:
Contact Name:
Fax Number:
Phone Number:
Member Information:
CoventryCares
Member ID #:
Member Name:
Diagnosis:
(Including CPT Code)
Reason for Referral:
Type of Referral: □ Consult
□ Consult and Treat
If Consult and Treat, length of treatment:
□ 1 month □ 3 months □ 6 months □ 9 months □ 12 months
Plan Use Only
Referral #:
From Date:
To Date:
Length of treatment approved:
□ 1 month
□ 3 months
□ 6 months
□ 9 months
□ 12 months
Plan Prior
Authorization:
_________________________________________
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Signature of Referring PCP
Date