1. health and fitness

PROV19614 APP_4/16/2014
Provider Manual
January 2014
PP196 11/18/2013
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User Guide - Table of Contents
Section 1.0 - Introduction
1.1
1.2
1.3
1.4
1.5
1.6
Provider Welcome
Kentucky Medicaid Program
Overview of Passport Health Plan
Mission and Values
Important Telephone Numbers
Claim Submission
Section 2.0 – Administrative Procedures
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
Eligibility
Passport Health Plan Assignment
Choosing a Primary Care Provider (PCP)
Identification Cards
Member Release for Ethical Reasons
Health Education and Special Programs
Credentialing/Re-Credentialing Process
Provider Terminations/Changes in Provider Information
Provider Grievances and Appeals
Members’ Rights
Member Grievances and Appeals
Title VI Requirements: Translator and Interpreter Services
Section 3.0 – Provider Roles and Responsibilities
3.1
3.2
3.3
3.4
Confidentiality
The Role of the Primary Care Provider (PCP)
The Role of Specialists and Consulting Practitioners
Responsibilities of All Providers
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Section 4.0 – Office Standards
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
Appointment Scheduling Standards
After-Hours Telephone Coverage
Member to Practitioner Ratio Maximum
Provider Office Standards
Medical-Record-Keeping & Continuity &Coordination of
Care
Standards
Hospital Care
Kentucky Health Information Exchange – KHIE
Communication Guidelines
Section 5.0 – Utilization Management
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
Utilization Management
Review Criteria/Standards for Review
Authorization Requirements
Online Authorization
Inpatient Admissions and Observation
Outpatient Services
High-Cost Medications
Prior Authorization for Members with Original Medicare
Retrospective Authorization
Denials
- Appendix A: Radiology Codes
- Appendix B: L codes
- Appendix C: Ostomy Supplies
Section 6.0 – Referrals
6.1
6.2
6.3
Member Self-Referral (Direct Access)
Referral Requirements
Distribution of Referrals
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Section 7.0 – Benefit Summary and Exclusions
7.1
7.2
7.3
Benefit Summary
Services Covered Outside Passport Health Plan
Non-Covered Services
Section 8.0 – Early and Periodic Screening, Diagnosis and
Treatment (EPSDT)
8.1
8.2
8.3
8.4
8.5
8.6
8.7
Overview of EPSDT
EPSDT Eligibility
Covered Services
EPSDT Audits for Screening Elements
EPSDT Tracking/Member Outreach
EPSDT Reporting/Billing (Preventive Health
Screens/Immunizations)
EPSDT Expanded Services
Section 9.0 – Quality Improvement
9.1
9.2
9.3
Quality Improvement Program Description
Quality of Care Concerns
Practitioner Sanctioning Policy
Section 10.0 – Emergency Care / Urgent Care Services
10.1
10.2
10.3
10.4
Emergency Care
Out-of-Service-Area Care
Urgent Care Services
Lock-In Program
Section 11.0 – Special Programs
11.1
11.2
11.3
Case Management
Health and Disease Management Programs
Children Living in Out-Of-Home Placements
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Section 12.0 – Outpatient Pharmacy Services
12.1
12.2
12.3
12.4
Prescribing Outpatient Medications for Passport Health
Plan Members
Covered Outpatient Pharmacy Benefits
Drug Prior-Authorization Procedure
Lock-In Program
Section 13.0 – Obstetrical
13.1
13.2
13.3
13.4
Overview
Member Access to Prenatal Care
Obstetrical Practitioner’s Role
General Procedure for Prior Authorization of Obstetrical
Care and Delivery
Section 14.0 – Family Planning
14.1
14.2
14.3
Services
Network
Claims
Section 15.0 – Provider Billing Manual
15.1
15.2
15.3
15.4
15.5
15.6
15.7
Claim Submission
Provider/Claim Specific Guidelines
Understanding the Remittance Advice
Denial Reasons and Prevention Practices
Timely Filing Requirements
Corrected Claims and Requests for Reconsideration and/or
Refunds
Contact Information for Claims Questions
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Section 16.0 – Behavioral Health
16.1
16.2
16.3
16.4
16.5
16.6
16.7
Administrative Procedures
Access to Care
Behavioral Health Benefits
Care Management and Utilization Management
Authorization Procedures and Requirements
Quality Improvement
Behavioral Health Provider Billing Manual
Section 17.0 – Forms and Documents
17.1
17.2
17.3
17.4
17.5
17.6
Preventive Health, Disease Management & Risk Assessment
Forms
Claim Forms
Provider Contracting and Provider Network Management
Forms
MAP Forms
Utilization Management Forms
Mommy Steps Forms
Section 18.0 – Important Contact Information
18.1
18.2
Passport Health Plan Important Contact Information
Other Important Contact Information
Section 19.0 – Dental Network
19.1
19.2
19.3
19.4
19.5
19.6
19.7
19.8
19.9
Important Contact Information
Administrative Procedures
Credentialing/Re-credentialing
Provider Terminations/Changes in Provider Information
Standards of Care for Dental Offices
Dental Benefits
Care Management and Utilization Management
Authorization Procedures and Requirements
Quality Improvement
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19.10 Dental Provider Billing Manual
19.11 Fraud, Waste and Abuse
19.12 Cultural Competency
Section 20.0 - Acronyms
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Provider Manual
Section 1.0
Introduction
Table of Contents
1.1 Provider Welcome
1.2 Kentucky Medicaid Program
1.3 Overview of Passport Health Plan
1.4 Mission and Values
1.5 Important Telephone Numbers
1.6 Claim Submission
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1.0 Introduction
1.1 Provider Welcome
We are pleased you are part of the Passport Health Plan (Passport throughout this document)
provider network. As a participant in Passport’s network, you have the opportunity to make Passport
beneficial for both you and the members you serve. Passport knows providers are essential in
delivering high-quality, cost-effective medical services to Medicaid recipients in the Commonwealth.
We further recognize that achieving our mission “to improve the health and quality of life of our
members” would not be possible without your participation. Passport is committed to earning your
ongoing support and looks forward to working with you to provide the best service possible to
Passport’s members.
This Provider Manual explains the policies and administrative procedures of Passport. You may use it
as a guide to answer questions about member benefits, claim submissions, and many other issues.
This Provider Manual also outlines day-to-day operational details for you and your staff. It will describe
and clarify the requirements identified in the Provider Agreement you hold with Passport. Updates to
this Provider Manual will be provided on Passport’s website on a periodic basis. As your office receives
communications from Passport, it is important that you and/or your office staff read the Provider
Alerts, Medical Office Notes, Passport eNews, and other special mailings and retain them with this
Provider Manual so you can integrate the changes into your practice. All Passport provider materials,
including the Provider Manual and Provider Directory, are available online at
www.passporthealthplan.com.
Please note, the term “provider” as used throughout this Provider Manual is inclusive of all
practitioners, individual and group affiliated, as well as facilities and ancillary service suppliers, as
appropriate.
1.2 Kentucky Medicaid Program
The Kentucky Department for Medicaid Services (DMS), under the Cabinet for Health and Family
Services (CHFS), is responsible for administering the Kentucky Medicaid Program as explained in
Section 1.3 below. DMS has contracted with Passport, and other managed care organizations
(MCO), to administer Medicaid benefits. The Medicaid Program, identified as Title XIX of the Social
Security Act, was enacted in 1965 and operates according to a state plan approved by the U.S.
Department of Health and Human Services.
Title XIX is a joint federal and state assistance program that provides payment for certain medical
services provided to Kentucky recipients who lack sufficient income or other resources to meet the
cost of their care. The basic objective of the Kentucky Medicaid Program is to aid the medically
indigent of Kentucky in obtaining needed medical care.
In May 2013, Gov. Steve Beshear announced the inclusion of 308,000 more Kentuckians in the
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federal Medicaid health insurance program. “The expansion, together with the creation of the Health
Benefit Exchange, will ensure that every Kentuckian will have access to affordable health insurance.”
This expansion includes eligibility starting on January 1, 2014.
As a provider of medical services, please be aware DMS, Passport, and the provider are bound by
both federal and state statutes and regulations as well as revisions governing the administration of the
state plan. The state cannot be reimbursed by the federal government for monies improperly paid to
providers for non-covered, unallowable medical services. Therefore, Passport may request a return of
any monies improperly paid to providers for non-covered services.
The Kentucky Medicaid Program should not be confused with Medicare. Medicare is a federal
program, identified as Title XVIII, primarily serving persons 65 years of age and older and some
disabled persons under 65 years of age. The Kentucky Medicaid Program and Passport services
eligible recipients of all ages.
1.2.1 Department for Medicaid Services
The Kentucky Department for Medicaid Services (DMS), within the CHFS, bears the responsibility
for developing, maintaining, and administering the policies and procedures, scope of benefits, and
basis for reimbursement for the medical care aspects of the program. As a managed care
organization (MCO) for DMS, Passport makes the actual reimbursement to providers for covered
services provided to Passport members.
It is important to note Passport does not determine eligibility for Medicaid. Determination of the
eligibility status of individuals and families for Medicaid benefits is a responsibility of the local
Department for Community Based Services (DCBS) offices located in each county of the
Commonwealth (see Section 20.2, “Other Important Contact Information” for local offices).
1.2.2 Kentucky Medicaid Member Enrollment and Disenrollment
Kentucky Medicaid members are given the option to participate in an annual open enrollment
period, where they may choose to join one of the MCOs contracted by DMS to serve this region.
New members are also given 90 days after the time of enrollment to change MCOs. DMS is
responsible for this process, and maintains all member eligibility information in their KyHealth Net
online system (see Section 2.4.1 for more information).
Although Passport has policies in place for instances where we may request disenrollment of a
member, DMS is responsible for disenrolling that member from Passport.
1.3 Overview of Passport
Passport is the operating name for University Health Care, Inc. (UHC), a managed care organization
that serves the Medicaid and the Kentucky Children’s Health Insurance Program (KCHIP)
populations in the Commonwealth of Kentucky. UHC is a non-profit health maintenance
organization (HMO) licensed in the Commonwealth of Kentucky.
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Passport is sponsored by the University of Louisville Medical School Practice Association, University
Medical Center, Inc., Jewish Heritage Fund for Excellence, Norton Healthcare, and the
Louisville/Jefferson County Primary Care Association, which includes the Louisville Metro
Department of Health and Welfare and Louisville's two Federally Qualified Health Centers: Family
Health Centers and Park DuValle.
The Partnership Council is a broad coalition of consumers and providers, including physicians,
nurses, hospitals, health departments, and ancillary providers who help govern the operations of
Passport. If you are interested in volunteering to participate on the Partnership Council or one of our
committees, please contact your Provider Relations Specialist.
1.4 Mission and Values
Passport’s vision is:
To be the leading model for collaboration and innovation in health care
Passport’s mission is:
To improve the health and quality of life of our members
The Organizational Values are:
•
•
•
•
Integrity
Community
Collaboration
Stewardship
1.5 Important Telephone Numbers
1.5.1 Case Management (877) 903-0082
The Case Management department is available 8:00 a.m. to 6:00 p.m. EST, (7:00 a.m. to 5:00 p.m.
CST), Monday through Friday. The Case Management department assists members and providers in
managing and coordinating services to meet the members’ medical and social needs.
1.5.2 Compliance Department
Providers are also required to cooperate with the investigation of suspected Fraud and Abuse. If you
suspect Fraud and Abuse by a Passport member or provider, it is your responsibility to report this
immediately by calling one of the telephone numbers listed below:
Passport Compliance Hotline:
(855) 512-8500
Medicaid Fraud Hotline:
(800) 372-2970
Passport Compliance Email Address: [email protected]
1.5.3 Health & Disease Management (877) 903-0082
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The Health & Disease Management department is available 8:00 a.m. to 6:00 p.m. EST (7:00 a.m.
to 5:00 p.m. CST), Monday through Friday. The Health & Disease Management department
offers a number of programs to assist providers and members in the management of their care,
including:
• Chronic Respiratory Disease Management (including asthma and COPD)
• Congestive Heart Failure (CHF) Disease Management
• Diabetes Disease Management
• Early and Periodic, Screening, Diagnosis and Treatment (EPSDT)
• Mommy Steps Perinatal Program
• Obesity (SCORE Program)
1.5.4 Member Services (800) 578-0603
Member Services representatives are available 7:00 a.m. to 7:00 p.m. EST (6:00 a.m. to 6:00 p.m.
CST), Monday through Friday. Member Services representatives assist members by answering
questions regarding changes, benefits, and grievance issues, or by directing members to other
Passport departments as needed, and by sending communication materials to members as needed.
1.5.5 NaviNet Customer Care (888) 482-8057
Passport has partnered with NaviNet to offer you a secure, real-time online connection between your
office and Passport. NaviNet can assist your office processes so that you spend less time on the
phone or processing paperwork. NaviNet registration and usage is offered free of charge. Services
offered include eligibility verification, claim status inquiry, and referral submission and inquiry.
1.5.6 Other Services
Service
Behavioral Health
Provider
Beacon Health Strategies
Telephone
(855) 834-5651
Hours
24 hours/7 days/week
Dental
Avesis Incorporated
(866) 909-1083
7 a.m. to 8 p.m. EST
6 a.m. to 7 p.m. CST
Nurse Advice
McKesson/Care For You
(800) 606-9880
24 hours/7 days/week
Radiology
MedSolutions
(888) 693-3211
(877) 791-4099
8 a.m. to 9 p.m. EST
7 a.m. to 8 p.m. CST
Vision
Block Vision
(800) 243-1401
7 a.m. to 5 p.m. EST
8 a.m. to 6 p.m. CST
1.5.7 Pharmacy Prior Authorization (800) 578-0898
Passport’s Pharmacy Benefits Manager, PerformRx, prior authorization department is available 8:30
a.m. to 6:00 p.m. EST, (7:30 a.m. to 5:00 p.m. CST). The following fax numbers are available to
request drug prior authorizations:
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Standard Fax Requests:
(877) 693-8280
Urgent Fax Requests:
(877) 693-8476
Hospital Discharge:
(877) 693-8476
Urgent requests should be reserved for those situations in which applying the standard procedure
may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function. The use of
urgent fax lines for non-urgent requests is not appropriate. Please refer to Section 12 for prior
authorization procedural requirements.
Note: effective April 1, 2014, Passport’s Pharmacy Benefits Manager will change to Magellan.
Additional provider communication will be given prior to this change.
1.5.8 Provider Claims Service Unit (800) 578-0775 Option 2
The Provider Claims Service Unit (PCSU) receives providers’ calls regarding any issue specific to
claims. The PCSU is available Monday through Friday from 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to
5:00 p.m. CST).
1.5.9 Provider Network Management (502) 585-7943
Provider Relations Specialists are available Monday through Friday, 8:00 a.m. to 5:00 p.m. EST, (7:00
a.m. to 4:00 p.m. CST), to offer orientations and in-service meetings for providers and their staff.
These representatives also provide service calls and process any changes in your provider status, such
as addresses and telephone numbers.
1.5.10 Provider Services (800) 578-0775 Option 3
Provider Services representatives are available Monday through Friday, 8:00 a.m. to 6:00 p.m. EST
(7:00 a.m. to 5:00 p.m. CST), to assist providers with questions about policies, procedures, member
eligibility, and benefits. Representatives are also available if providers need to request forms or
literature, report member noncompliance, or assist members in obtaining ancillary direct access
services or other specialty care.
1.5.11 Utilization Management (800) 578-0636
The Utilization Management department is available 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to 5:00
p.m. CST), Monday through Friday. The Utilization Management department assists providers with
medical necessity determinations and requests for prior authorizations.
Authorization requests for certain services may be submitted online. We highly recommend that
providers utilize this functionality as available. Additional detail is available in Section 6 of this
manual.
Requests for authorization of services may be received during these hours of operation by:
General:
(800) 578-0636
Home Health: (502) 585-7320
DME:
(502) 585-7310
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Radiology:
(877) 791-4099
Requests may be faxed to:
General fax:
Home Health:
DME:
Retro fax:
Therapy fax:
(502) 585-7989
(502) 585-8204
(502) 585-7990
(502) 585-8207
(502) 585-8205
1.6 Claim Submission
New and corrected paper claims are to be submitted to the following address:
Passport Health Plan
P.O. Box 7114
London, KY 40742
Please refer to Section 18 for additional claims filing instructions.
Claims and correspondence for reconsideration or recovery are to be submitted to the following address:
Passport Health Plan
P.O. Box 7114
London, KY 40742
An active valid Kentucky Medicaid identification number, assigned by DMS, is required to receive
any payment for services rendered.
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Provider Manual
Section 2.0
Administrative Procedures
Table of Contents
2.1 Medicaid Eligibility
2.2 Passport Health Plan Assignment
2.3 Choosing a Primary Care Provider (PCP)
2.4 Identification Cards
2.5 Member Release for Ethical Reasons
2.6 Health Education and Special Programs
2.7 Credentialing/Re-Credentialing Process
2.8 Provider Terminations/Changes in Provider Information
2.9 Provider Appeals and Grievances
2.10 Members’ Rights
2.11 Member Appeals and Grievances
2.12 Title VI Requirements: Translator and Interpreter Services
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2.0 Administrative Procedures
2.1 Medicaid Eligibility
Most individuals who meet the Department for Medicaid Services (DMS) eligibility criteria for
Medicaid are assigned to an MCO in the region, and include individuals in the following categories:
A. Temporary Assistance to Needy Families (TANF);
B. Child and family related;
C. Aged, blind, and disabled Medicaid only;
D. Pass through;
E. Poverty level pregnant women and children, including presumptive eligibility;
F. Aged, blind and disabled receiving State supplementation;
G. Aged, blind, and disabled receiving Supplemental Security Income (SSI); or
H. Under the age of twenty-one (21) years and in an inpatient psychiatric facility.
I. Foster Care ages 0 – 18 and Former Foster Care ages 19 – 26
J. ACA Expanded Population ages 19-64
K. Presumptive Eligibility - Pregnant
DMS does not allow certain categories of Medicaid beneficiaries to participate in managed care.
Beneficiaries in the following categories are not eligible for assignment to an MCO:
A. Individuals who shall spend down to meet eligibility income criteria;
B. Individuals currently Medicaid eligible and have been in a nursing facility for more than thirty
(30) days*;
C. Individuals determined eligible for Medicaid due to a nursing facility admission including those
individuals eligible for institutionalized hospice;
D. Individuals served under the Supports for Community Living, Michele P, home and
community-based, or other 1915(c) Medicaid waivers;
E. Qualified Medicare Beneficiaries (QMBs), Specified Low Income Medicare Beneficiaries
(SLMBs) or Qualified Disabled Working Individuals (QDWIs);
F. Timed limited coverage for illegal aliens for emergency medical conditions;
G. Working Disabled Program;
H. Individuals in an intermediate care facility for mentally retarded (ICF-MR); and
I. Individuals who are eligible for the Breast or Cervical Cancer Treatment Program.
* If you have any questions regarding eligibility criteria, contact Provider Services at (800) 578-0775.
2.2 Passport Health Plan Assignment
The Department for Medicaid Services assigns eligible beneficiaries to Passport when the beneficiary
selects Passport on their enrollment application or as part of an automatic assignment process
developed by DMS.
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Once assigned to Passport, a member receives a welcome kit from Passport, which includes a
welcome letter, member identification card, a Health Risk Assessment (HRA), and a Member
Handbook.
2.3 Choosing a Primary Care Provider (PCP)
Making sure our members have a medical home is at the heart of Passport’s approach to managed
care. The PCPs, in their role as the Medical Home, provide our members with primary and
preventive care and arrange other medically necessary services for members. Therefore, Passport
acts quickly to make sure members are linked to a medical home.
Passport has a multifaceted PCP assignment process that meets all DMS requirements. The process
is based on our current Medicaid experience and computer generated assignment of an accessible
PCP.
Our plan and process to assign our members a PCP will occur as follows:
•
•
If known, DMS will send member’s selected PCP via the daily/monthly 834 files. Passport
will validate the transaction and assign the PCP if appropriate (i.e. PCP meets all Passport
criteria for assignment) ensuring the member’s satisfaction and smooth transition to Passport.
If the member requires assignment, our process will be as follows:
o Identify members who require a PCP including SSI adult members (the process
recognizes the need for longer timeframes for adult SSI members)
o Review for historical claims data for PCPs
o Review for prior PCP assignments for member
o Review for PCPs for other family members
Final step, if no assignment can be made, based on the above criteria, PCP assignment will be based
on the member’s address.
At the time of assignment, Passport members will be informed of their assigned PCP in the New
Member Welcome Kit and their confirmation letter. The member will also be notified at this time of
his/her right to change his/her PCP if he/she is not satisfied with our assignment. The member will
also receive an ID card with the practice name and phone number printed on the ID card. If the
member is not required to have a PCP, he/she will receive an ID card with “No PCP required”
printed on the card.
The above processes will be adapted as necessary to effectively assign PCPs to beneficiaries eligible
for coverage (and assigned to Passport) through the Medicaid ACA Expansion population.
2.3.1 Changing PCPs
Members can change PCPs twice in a 12 month period, and PCP changes are effective on the day
the change is requested. To change a PCP, members must call our Member Services department.
Upon receiving an existing member’s request to change a PCP, our Member Services
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Representatives (MSRs) will:
•
•
•
Assist the member in finding a new provider (if requested), using methodologies outlined
above,
Perform the requested change in our system, and
Advise the member of the effective date of the new PCP assignment.
The member will then receive a new ID card with the PCP practice name and phone number
printed on the ID card.
Exceptions to the change of provider rule will apply in cases of provider termination, provider office
closing, provider panel limitations and member re-location. In the case of voluntary provider
termination, we will notify the member no less than thirty (30) days prior to the effective date of
voluntary provider termination. The member will be sent a letter explaining that his/her provider is
leaving Passport’s network and the member will need to contact Member Services to select a new
PCP or to receive assistance selecting a new PCP. If the provider notifies Passport of voluntary
termination with less than thirty (30) days from the effective date of voluntary termination, we will
notify affected members as soon as Passport receives notification.
Fortunately, due to our long history of superior provider satisfaction, most voluntary terminations
are the result of providers retiring or moving out of the service area, not the result of provider
dissatisfaction with Passport’s administration.
In the case of involuntary provider termination, where Passport has decided to remove a provider
from its network, Passport will notify affected members at least fifteen (15) days prior to the
effective date of involuntary termination. Affected members will be sent a letter advising them to
contact Member Services to select a new PCP or to receive assistance finding a new PCP.
In either of these cases, if the member does not contact us to select a new PCP, Passport will use the
auto-assignment process to assign the member to a new PCP.
The goal of Member Services is to always provide satisfactory resolution, but if a request for a
change in PCP is denied and the member is dissatisfied, the member will be advised of their appeal
rights. The member will receive a written notice of the decision made by Passport.
Passport also reviews member activity related to PCP transfers on an ongoing basis and works in
conjunction with Health Management, Quality Improvement, and the Provider Realtions Specialists
to provide education and assist if any areas of improvement are identified.
Each PCP receives a monthly member panel list of those members who have selected or been
assigned to his or her panel. The monthly member panel list is not to be used as a confirmation of
eligibility. To confirm eligibility, call Provider Services at 1-800-578-0775 option 3.
2.4 Identification Cards
Passport issues identification cards for each family member enrolled. Members are advised to keep the ID card
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with them at all times.
ID cards contain the following information:
•
•
•
•
•
Member’s name and date of birth.
PCP group name and telephone number (if applicable).
Passport identification number.
Kentucky Medicaid identification number.
Gender.
In addition to the Passport ID card, each member is issued a Medicaid ID card by the Department
for Medicaid Services (DMS). The Medicaid ID card is NOT the same as the Passport ID card:
The Kentucky Medicaid ID card represents eligibility for the Medicaid Program and is also used to obtain
Medicaid covered services that are not covered through Passport, such as transportation. Members are requested
to keep and present their Kentucky Medicaid ID card along with their Passport ID card.
2.4.1 Member Identification and Eligibility Verification
Passport member eligibility varies by month. Therefore, each participating provider is responsible
for verifying member eligibility with Passport before providing services. Providers may verify
eligibility using any of the following methods:
•
Online – check member eligibility by logging into NaviNet at https://navinet.navimedix.com
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• KyHealth Net System - Use the State’s website to verify eligibility for all five (5) managed
care organizations (MCOs) – including Passport – in one central location. Using your
Medicaid ID (MAID) number, you may log directly onto this system at
https://sso.kymmis.com, or find more information at www.chfs.ky.gov/dms/kyhealth.htm.
• Telephone – you may also check member eligibility by calling our interactive voice response
(IVR) system at (800) 578-0775.
• Utilizing Passport’s real-time member eligibility service. Depending on your clearinghouse or
practice management system, our real-time service supports batch access to eligibility
verification and system-to-system eligibility verification, including point of service (POS)
devices.
• Asking to see the member’s Passport ID card and Kentucky Medicaid ID card. Please note
that Passport cards are not returned to Passport when a member becomes ineligible.
Therefore, the presentation of a Passport ID card is not sole proof that a person is currently
enrolled in Passport.
Providers should request a picture ID to verify that the person presenting is indeed the person
named on the ID card. Services may be refused if the provider suspects the presenting person is not
the card owner and no other ID can be provided. If you suspect a non-eligible person is using a
member’s ID card, please report the occurrence to Passport’s Fraud and Abuse Hotline at (855)5128500 or the Medicaid Fraud Hotline at (800) 372-2970.
2.5 Member Release for Ethical Reasons
A participating provider is not required to perform any treatment or procedure that may be contrary
to the provider’s conscience, religious beliefs, or ethical principles. If such a situation arises, the
provider should contact Provider Services at (800) 578-0775. A Provider Services representative will
work with the provider to review the member’s needs and transfer or refer the member to another
appropriately qualified provider for care.
2.6 Health Education and Special Programs
Passport may refer members to health education classes provided by health agencies and providers or
to Passport-provided programs. Providers who identify members who could benefit from education
for a specific condition, such as pregnancy, asthma, congestive heart failure or diabetes, for example,
may call (877) 903-0082 for class information and schedules. Members also have access to health
topics through an audio health library. Pre-recorded messages on topics provide information on
preventing illness, identifying warning signs and administering self-care. A member may call the 24Hour Nurse Advice Line to access the audio health library (see Section 2.6.3).
2.6.1 Language Assistance for Members
Federal law requires providers to ensure that communications are effective.
Providers who render health services, medical services, or social service programs to Passport
members benefit from a program that receives federal financial assistance and are, therefore, subject
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to the requirements of Title VI of the Civil Rights Act of 1964. This act prohibits recipients of
benefits from a program receiving federal financial assistance, such as Medicaid, from being
prohibited from or refused service on the grounds of race, color, or national origin. The term “on
the grounds of national origin” has been interpreted to include persons with limited-English
proficiency (LEP).
Title VI requires every Medicaid provider, including Passport providers, to offer members equal
access to benefits and services by ensuring that each LEP (limited English proficiency) person can
communicate effectively in his or her language of choice. This law also requires providers to take
necessary steps to provide language assistance at no cost to Medicaid members, including those
enrolled with Passport.
Providers may contact Passport’s Cultural & Linguistics Services Program at (502) 585-7303 for
additional information and/or questions.
2.6.2 Help for Those with Impaired Vision or Hearing
The Member Handbook is available in alternative formats for members with visual impairments.
Additionally, for members with hearing impairments who use a Telecommunications Device for the
Deaf, Passport’s TDD/TTY number for Member Services is (800) 691-5566.
2.6.3 24-Hour Nurse Advice Line and Audio Health Library
PCPs can encourage their patients to talk with a nurse 24 hours a day, 7 days a week by calling the
24-Hour Nurse Advice Line at (800) 606-9880. Passport wants to make certain that you are aware
that through the same number, Passport members may access an audio health library of over 35
categories of health care topics, including:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Allergies and Immune System
Blood and Cancer
Bones, Muscles, and Joints
Brain and Nervous System
Cancer
Heart and Blood Vessels
Children
Mouth and Teeth
Diabetes
Diet and Exercise
Digestive System
Ear, Nose, and Throat
Eyes
General Health
Hormones
Infectious Disease
Injuries
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Medicines
Mental and Behavioral Health
Men’s’ Health
Pain Management
Physical and Sports Medicine
Pregnancy
Preventive Health
Respiratory and Lung Problems.
Sexual and Reproductive Health
Skin
Sleep Disorders
Social and Family
Surgery
Tests and Diagnostic Procedures
Urinary Problems
Women’s Health
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Members with limited English proficiency (LEP) can also access the 24-Hour Nurse Advice Line.
Additionally, for members with hearing impairments who use a Telecommunications Device for the
Deaf, the TDD/TTY number for the Nurse Advice Line is (800) 648-6056.
NOTE: The 24-Hour Nurse Advice Line is not meant to take the place of the PCP and may not be
used for after-hour coverage. However, it is an effective communication mechanism for
dissemination of disease specific educational information as well as an alternative method for
receiving information on self-care techniques in clinically appropriate circumstances.
2.7 Credentialing/Re-Credentialing
2.7.1 Initial Application Process
To join the Passport network an application and credentialing process must be take place. This can
be initiated by calling our Provider Services department at (800) 578-0775. We will send you a
provider application packet and work with you to become credentialed and, if approved, contracted
as a Passport network provider. Providers can also fill out a Provider Enrollment Request form
online at http://www.passporthealthplan.com/providerEnrollment.aspx.
Passport participates with the Council for Affordable Quality Healthcare (CAQH). Providers who
are participating with this common credentialing application database should include their CAQH
provider ID number with documents submitted to Passport.
2.7.1.1 Practitioners
New practitioner applicants are required to complete their residency program and be eligible to
obtain board certification prior to joining Passport. A practitioner is considered hospital based if
they practice exclusively in a facility setting. These practitioners undergo a condensed review as it is
the responsibility of the facility to verify their full credentials.
New practitioners must include the following as applicable:
•
•
A letter adding practitioner to each group.
Completed Provider Application either a CAQH (Council for Affordable Quality Healthcare)
universal credentialing application or the most current version of KAPER1 (Kentucky DMS
application), including:
o Additional copies of pages from the application (as needed);
o Disclosure questions, as applicable, including but not limited to:
 Documentation of any malpractice suits or complaints.
 Documentation of any restrictions placed on practitioner by hospital, medical
review board, licensing board, or other medical body or governing agency.
 Documentation of any conviction of a criminal offense within the last 10 years
(excluding traffic violations); and,
 The attestation page (including the practitioner signature and current date).
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
Original, complete, and signed MAP Forms per the Kentucky DMS provider enrollment web
page, http://chfs.ky.gov/dms/provEnr/Provider+Type+Summaries.htm.
Copy of current State License Registration Certificate.
Copy of current Federal Drug Enforcement Agency Registration.
Copy of CLIA.
Copy of collaborative agreement between an Advance Practice Registered Nurse and
supervising practitioner.
Copy of MAP 612 Statement of Authorization for Payment signed by both the physician
assistant and supervising practitioner.
Curriculum vitae or a summary specifying month and year, explaining any lapse in time
exceeding six months.
Copy of a W-9 with the legal and doing business name of the entity, Tax Identification
Number, and mailing address for all 1099 tax information signed by an authorized agent for
the entity.
Copy of claim history form for each malpractice activity within the past five years.
Copy of current professional liability insurance Certificate of Coverage, including the name
and address of the agent and the minimum amount, in accordance with existing Kentucky
laws at the time of the application submission.
A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services
(CMS) with your unique Medicare provider identification number and practice location).
Copy of social security card (If applicant has as social security card stating “valid for work only
with DHS/INS Authorization,” please refer to additional requirements at
http://www.chfs.ky.gov/dms/provEnr/).
ECFMG (Education Council for Medical Graduates).
FOX verification documentation for National Provider Identifier (NPI) and Taxonomy
Code(s).
2.7.1.2 Organizational Provider
New applicants must submit a completed application, which includes the following as applicable:
•
•
•
•
•
•
•
•
Two signed Participating Provider Agreements.
Completed facility/ancillary service application including the credentials verification release
statement.
Original, complete, and signed MAP Forms per the Kentucky Department for Medicaid
Services provider enrollment web page,
http://chfs.ky.gov/dms/provEnr/Provider+Type+Summaries.htm.
Copy of current State License Registration Certificate.
Hearing aid dealer current license for specializing in hearing instruments.
Copy of CLIA, if applicable.
Copy of a W-9 in the name of the facility/group, including the Tax Identification Number and
mailing address for all tax information.
Copy of current professional liability insurance Certificate of Coverage, including the name
and address of the agent and the minimum amount, in accordance with existing Kentucky
laws at the time of the application submission.
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•
•
•
•
•
•
•
•
•
•
•
A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services
(CMS) with your unique Medicare provider identification number and practice location), as
applicable.
Copy of current facility accreditation or certification.
Model Attestation Letter for Psychiatric Residential Treatment Facilities (PRTF).
DME Accreditation Certificate- exempt organizations need to submit a signed statement
attesting to the exemption and documentation from CMS outlining the exemption.
HME license issued by the KY Board of Pharmacy (per HB 282 and 201 KAR 2:350) (As of
September 30, 2012) - exempt providers need to submit a signed statement attesting to the
exemption.
Medicare certification letter less than three years old with effective date of certification and
physical location of where DME number is to be used. Medicare requires DME providers to
re-enroll every 3 years.
Independent labs must have a laboratory director, who must satisfy requirements set forth in
907 KAR 1:028 Section 1(8) and KRS 333.090 (1), (2), or (3) and supply documentation
thereof.
If not accredited or certified, a copy of the most recent CMS or state review.
A copy of the mechanism that the organizational provider uses to monitor and improve
patient safety.
A copy of the transfer policy.
FOX verification documentation for National Provider Identifier (NPI) and Taxonomy
Code(s).
Failure to submit a complete application may result in a delay in Passport’s ability to start the initial
credentialing process.
Practitioners may contact the Provider Enrollment department at (502) 588-8578 to check the status
of their application.
2.7.2 Credentialing Process
Passport assesses practitioner applicants through Passport’s credentialing process. With the receipt
of all application materials, primary source verification is conducted by Passport's Provider
Enrollment department. Following the verification of credentials, Passport’s Chief Medical
Officer/designated Medical Director and/or Credentialing Committee reviews each application for
participation.
Passport will not initiate the credentialing review until a completed and signed application with
attachments has been received. The normal processing time is between 60 to 90 days from date of
submission of a completed application.
2.7.3 Reimbursement and the Credentialing Process
Providers seeking participation in the Passport network and in the credentialing process will be
reimbursed at the participating provider rate, starting from the date Passport receives a completed
and signed application packet and confirmation that the provider has been issued a Kentucky MAID
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number. If the Credentialing Committee denies participation, any claims paid during the interim will
be recouped, and unpaid claims will be denied.
Providers may begin submitting claims for services provided to Passport members once they have
been notified of the receipt of their completed application and have been assigned a Provider ID
number. Providers are required to submit all claims within 180 days of service, but no payment is
made until Passport receives confirmation that the provider has been issued a Kentucky MAID
number. Please note, claims submitted without a Kentucky Medicaid Identification (MAID) number
will initially deny.
Providers will receive notification from DMS when a MAID number is assigned. Providers are
encouraged to notify Passport of receipt of a MAID number assignment.
After Passport receives notification of a provider MAID number assignment, all claims received
from the provider will be automatically reprocessed, starting from the date Passport received a
completed and signed provider application.
Providers will be considered participating Passport providers once they have met Passport’s
credentialing requirements. Providers will be notified by Passport when they have been successfully
credentialed by Passport. Providers applying for participation are excluded from the Provider Directory
until the credentialing process has been completed in its entirety.
2.7.4 Providing Services Prior to Becoming a Credentialed Passport Provider
If a provider determines a member must be seen prior to the assignment of a Provider ID number
and notification of the receipt of a completed and signed application by Passport, the provider must
obtain an authorization from Passport’s Utilization Management department in order to receive
payment for services. Please note that an authorization for service does not guarantee payment.
2.7.5 Re-credentialing Process
Passport re-credentials its providers, at a minimum, every three years. In addition, Passport conducts
ongoing monitoring of Medicare and Medicaid sanctions as well as licensure sanctions or limitations.
Practitioners who become participating and subsequently have restrictions placed upon their license
will be reviewed by the Credentialing Committee and evaluated on a case-by-case basis, based upon
their ability to continue serving Passport’s members.
Member complaints and adverse member outcomes are also monitored and Passport will implement
actions as necessary to improve trends or address individual incidents. If efforts to improve
practitioner performance are not successful, the practitioner may be referred to the Credentialing
Committee for review prior to his/her normally scheduled review date.
2.7.5.1 Practitioners
Passport will generate a re-credentialing application on all practitioners with current CAQH
applications on file. Practitioners without a CAQH on file will be notified by telephone or letter to
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submit a re-credentialing application (most current version of the KAPER 1 or CAQH) with the
following list of attachments:
• Disclosure questions, as applicable, including but not limited to:
o Documentation of any malpractice suits or complaints.
o Documentation of any restrictions placed on practitioner by hospital, medical review
board, licensing board, or other medical body or governing agency.
o Documentation of any conviction of a criminal offense within the last 10 years
(excluding traffic violations).; and,
• The attestation page (including the practitioner signature and current date).
• Copy of current State License Registration Certificate.
• Copy of current Federal Drug Enforcement Agency Registration - if applicable.
• Copy of current collaborative agreement between an Advance Practice Registered Nurse and
supervising practitioner, as applicable.
• Copy of MAP 612 Statement of Authorization for Payment signed by both the physician
assistant and supervising practitioner, as applicable.
• Copy of current professional liability insurance Certificate of Coverage, including the name and
address of the agent and the minimum amount, in accordance with existing Kentucky laws at
the time of the application submission.
2.7.5.2 Organizational Provider
Passport sends a facility/ancillary service application to the organizational provider for completion.
The re-credentialing application must include the following as applicable:
• Completed facility/ancillary service application including the credentials verification release
statement.
• Copy of current State License Registration Certificate.
• Copy of CLIA, if applicable.
• Copy of a W-9 in the name of the facility/group, including the Tax Identification Number and
mailing address for all tax information.
• Copy of current professional liability insurance Certificate of Coverage, including the name and
address of the agent and the minimum amount, in accordance with existing Kentucky laws at
the time of the application submission.
• Copy of claim history form for each malpractice activity within the past five years.
• A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services
(CMS) with your unique Medicare provider identification number and practice location), as
applicable.
• Copy of current facility accreditation or certification.
• If not accredited or certified a copy of the most recent CMS or state review.
• A copy of the mechanism that the organizational provider uses to monitor and improve patient
safety.
• A copy of the transfer policy.
Failure to return documents in a timely fashion may result in termination. If the termination period
is longer than 30 days, the initial credentialing process would need to be completed in order to rePage 26 of 331
enroll as a participating provider.
Practitioners or providers may contact the Provider Enrollment department at (502) 585-8578 to
check the status of their re-credentialing application.
Should Passport decide to deny or terminate a provider from participation with Passport, the
provider will receive notification of the decision. The notification will include the reasons for the
denial or termination, the provider’s rights to appeal and request a hearing within 30 days of the
date of the denial notice, and a summary of the provider’s hearing rights.
2.8 Provider Terminations/Changes in Provider Information
2.8.1 Provider Terminations
A provider desiring to terminate his/her participation with Passport must submit a written
termination notice, to his/her assigned Provider Relations Specialist, at least ninety (90) days prior to
the desired effective date of the termination.
For terminations by primary care providers, the assigned Provider Relations Specialist will
coordinate member notification and assignment to another PCP based on the PCP’s member panel.
If a solo specialist or an entire specialty group decides to terminate the contract, a list of members
receiving ongoing health care from the specialist and/or group must be sent to Passport within 60
days of the termination date for member notification to occur. The specialist’s Provider Relations
Specialist will work with the specialist to ensure a smooth transition for the member’s continued
care.
2.8.2 Changes in Provider and Demographic Information
Providers are required to provide a 90-day prior written notice to both Passport’s Provider Network
Management department and the Department for Medicaid Services of any changes in information
regarding their practice. Such changes include:
• Address changes, including changes for satellite offices.
• Additions/deletions to a group.
• Changes in billing locations, telephone numbers, tax ID numbers.
Reimbursement may be affected if changes are not reported in accordance with Passport policy.
Please note that providers are required by DMS to annually submit a copy of current license and
annual disclosure of ownership. If these documents are not provided, the provider’s Kentucky
Medicaid (MAID) number may be terminated. Your office will receive notice from the DMS when
these documents are due for submission. Please respond timely to these requests.
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2.8.3 Change in Location
If a provider working in multiple offices discontinues working in one or more locations, written
notification must be provided to Passport within 30 days detailing the locations where he/she will
no longer see patients, as well as the specific offices where he/she will continue to see patients.
2.8.4 Panel Closings
Passport recognizes that PCPs may occasionally need to limit the number of patients in their
practices in order to deliver quality care. Passport will evaluate any requirements for minimal
members per practitioner panel. (For additional information regarding member to practitioner ratios,
see Section 4.3.)
Once a PCP has accepted the number of Passport members agreed upon in the Primary Care
Provider Agreement, a written request must be forwarded to Passport to impose panel restrictions.
Please send your request to your Provider Relations Specialist at 5100 Commerce Crossings Drive,
Louisville, KY 40229.
Passport requests a 90-day advance written notice to change panel status.
2.8.5 Panel Limitations
Panel limitations and/or removal of panel restrictions must be submitted in writing to the Provider
Relations Specialist. Providers are notified by their Provider Relations Specialist of the approval or
denial of the request. Approved panel limitations and/or removal of restrictions become effective
the first of the following month after a request is approved by Passport.
2.8.6 Member Dismissals from PCP Practices
Primary care providers (PCP) have the right to request a member's disenrollment from their practice
and request the member be reassigned to a new PCP for the following circumstances:
• Incompatibility of the PCP/patient relationship;
• Inability to meet the medical needs of the member.
PCPs do not have the right to request a member’s disenrollment from their practice in the following
situations:
•
•
•
•
A change in the member’s health status or need for treatment.
The member’s utilization of medical services.
A member’s diminished mental capacity.
A member’s disruptive behavior that results from the member’s special health care needs
unless the behavior impairs the PCP’s ability to provide services to the member or others.
Disenrollment requests shall not be based on the grounds of race, color, national origin, handicap,
age or gender.
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Disenrollment requests must be submitted to Passport and sent via fax to Provider Enrollment at
(215) 937-5304. Requests must include provider name, provider group ID number, member name,
member ID number, reason for disenrollment request, and effective date. Members are not
disenrolled from the PCP’s practice until all required information is received. Questions regarding
this process may be directed to Provider Services at 1-800-578-0775 or contact your Provider
Network Management Specialist.
Disenrollment requests meeting Passport’s requirements as stated above are reviewed, determined to
be appropriate, and processed within five business days of receipt by Provider Services. The
disenrollment effective date must be at least 30 days from the request date to allow for the member’s
transition to a new PCP unless extenuating circumstances necessitate an immediate effective date.
The initial PCP must continue to serve the member until the new PCP assignment becomes
effective, barring ethical or legal issues. The member has the right to appeal such a transfer via
Passport’s formal appeal process.
If a PCP's request does not meet the above stated requirements, the appropriate Provider Relations
Specialist will contact the PCP directly to discuss.
Please note this process does not apply to "age-out" disenrollment for pediatric practices.
2.8.7 Locum Tenens
According to Passport policy, participating providers may utilize the services of a locum tenens
provider, under temporary circumstances, for a maximum period of sixty (60) consecutive days.
When locum tenens services are needed, participating providers must register the substitute
provider. This process must be completed prior to the provision of any services by a locum tenens
provider.
To register a locum tenens provider, the participating Passport provider must complete a one-page
Registration of Locum Tenens Physician form (available in Section 20 of this Provider Manual). Both the
participating Passport provider and the locum tenens provider must sign the form. To complete the
registration process, the signed form must be returned to Passport by mail or by fax to:
Mail:
Passport Health Plan
Attn: Provider Enrollment
5100 Commerce Crossings Drive
Louisville, Kentucky 40229
Fax:
Attn: Provider Enrollment
(502) 585-8280
Services rendered by a locum tenens provider must be billed utilizing the absent provider’s Passport
Health Plan ID number and the Q6 modifier with the applicable procedure code(s). The Q6
modifier signifies that the service was provided by a locum tenens provider. According to the
Passport Provider Agreement, the absent provider remains liable and all contractual terms remain
effective throughout the employ of a locum tenens provider.
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If services by a locum tenens provider remain necessary beyond the period of sixty (60) consecutive
days, the locum tenens or substitute provider must apply for participation with Passport and
complete the credentialing process and have or apply for a Kentucky Medicaid number. Upon
becoming credentialed with Passport, the provider will be assigned a provider ID number for billing
purposes.
2.9 Provider Appeals and Grievances
2.9.1 What is Appealable?
Passport providers have the right to file an appeal regarding:
•
•
A provider payment issue; or
A contractual issue.
2.9.2 How do Provider’s File an Appeal?
2.9.2.1 Method of Appeal
All provider appeals must be submitted in writing.
Submit Provider Appeals to:
Type of Appeal
Timing of Appeal
Address
Behavioral Health
Must be submitted within sixty
(60) calendar days of the
adverse action.
Beacon Health Strategies
Appeals Coordinator
500 Unicorn Park Drive Suite 401
Woburn, MA 01801
(855) 834-5651
TDD/TTY
(866)834-9441
Claims Payment Issues
Must be submitted within two
(2) years of last process date of
claim.
Passport Health Plan
Claim Appeals
PO Box 7114
London, KY 40742
Contractual Issues
Must be submitted within sixty
(60) calendar days of the
occurrence of the contractual
issue being appealed.
Passport Health Plan
Legal Services / Contractual
Appeals
5100 Commerce Crossings Drive
Louisville, Kentucky 40299
Dental
Must be submitted within
thirty (30) calendar days of
adverse action.
Avesis
Attn: Appeals Department
PO Box 7777
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Type of Appeal
Timing of Appeal
Address
Phoenix, AZ 85011-7777
(866) 909-1083
Medical, Administrative and
Pharmacy Denials
(An Administrative Denial is a
denial issued for untimely
notification of a request for a
clinical service)
Radiology
Must be submitted within sixty
(60) calendar days of the
adverse action.
Passport Health Plan
Appeals Coordinator
5100 Commerce Crossings Drive
Louisville, KY 40229
(502) 585-7307
Fax (502) 585-8461
Must be submitted within sixty
(60) calendar days of the
adverse action.
MedSolutions
Appeals Department
730 Cool Springs Blvd., Suite 800
Franklin, TN 37067
1-877-791-4099
Vision
Must be submitted within
thirty (30) calendar days of
adverse action.
Block Vision
939 Elkridge Landing Road, Suite
200
Linthicum, MD 21090
Attn: Provider Appeals
800-879-6901
2.9.2.2 Conduct of the Review
A board-certified physician, who was not involved in the initial denial, will conduct the clinical
review. The provider can also request that the reviewing physician have clinical expertise in treating
the member’s condition or disease. Providers may submit documents in support of the appeal.
2.9.2.3 Resolution of the Appeal
All provider appeals are resolved within thirty (30) calendar days of receipt of the appeal unless the
time period is extended by fourteen (14) calendar days upon request of the provider or pursuant to
our request. Providers will receive a written notice of the resolution of the appeal.
2.9.3 Provider Grievances
A grievance is defined by federal and state law as an expression of dissatisfaction about any matter
other than an adverse action.
Passport providers have the right to file a grievance of any Passport decision that does not involve
an adverse action.
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2.9.3.1 How do Providers File a Grievance
Timing:
Providers have thirty (30) calendar days from the date of an event causing dissatisfaction to file a
grievance.
Method of Filing a Grievance:
Provider grievances may be submitted orally or in writing.
Submit Provider Grievances to:
Type of Grievance
Dental
Address
Avesis
Attn: Appeals Department
PO Box 7777
Phoenix, AZ 85011-7777
(866) 909-1083
Radiology
MedSolutions
Appeals Department
730 Cool Springs Blvd., Suite 800
Franklin, TN 37067
1-877-791-4099
Vision
Block Vision
939 Elkridge Landing Road, Suite 200
Linthicum, MD 21090
800-879-6901
Pharmacy
PerformRx
Pharmacy Network Administration
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113
800-555-5690
All Other Provider Grievances
Passport Health Plan
5100 Commerce Crossings Drive
Louisville, KY 40229
(800) 578-0775
2.9.3.2 Resolution of the Grievance
All provider grievances are resolved within thirty (30) calendar days of receipt of the grievance
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unless the time period is extended by fourteen (14) calendar days upon request of the provider or
pursuant to our request. For any extension not requested by the Provider, Passport will mail the
Provider written notice of the reason for the extension within two (2) business days of the decision
to extend the timeframe. Providers will receive a written notice of the resolution of the grievance.
2.10 Members’ Rights
Members are informed of their rights and responsibilities through the Member Handbook. Passport
providers are also expected to respect and honor members’ rights.
The rights of our Members include, without limitation, the right to:
A. Respect, dignity, privacy, confidentiality and nondiscrimination;
B. A reasonable opportunity to choose a PCP and to change to another Provider in a reasonable
manner;
C. Consent for or refusal of treatment and active participation in decision choices;
D. Ask questions and receive complete information relating to the Member's medical condition
and treatment options, including specialty care;
E. File a grievance or an appeal and to receive assistance in filing a grievance or appeal;
F. Request a state fair hearing from the Department;
G. Timely access to care that does not have any communication or physical access barriers;
H. Prepare Advance Medical Directives pursuant to KRS 311.621 to KRS 311.643;
I. Access to the Member’s Medical Records in accordance with applicable federal and state laws;
J. Timely referral and access to medically indicated specialty care; and
K. Be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation.
The responsibilities of Passport Members include the responsibility to:
A.
B.
C.
D.
E.
F.
Become informed about Member rights;
Abide by the Contractor's and Department's policies and procedures;
Become informed about service and treatment options;
Actively participate in personal health and care decisions, practice healthy lifestyles;
Report suspected Fraud and Abuse; and
Keep appointments or call to cancel.
2.11 Member Appeals and Grievances
2.11.1 What is Appealable
Members have the right to appeal any Passport decision involving an adverse action. An adverse
action is defined by federal and state law.
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An Adverse Action is:
•
•
•
•
•
•
The denial or limited authorization of a requested service, including the type or level of
service;
The reduction, suspension, or termination of a previously authorized service;
The denial, in whole or in part, of payment for a service;
The failure to provide services in a timely manner;
The failure to act within specified timeframes; or,
The denial of a request to obtain services outside the network for specific reasons.
No Retaliation for Filing an Appeal
At no time will punitive or retaliatory action be taken against a Member for filing an appeal or a
provider for supporting a Member appeal.
2.11.2 How do Members File an Appeal
Timing
Members have thirty (30) calendar days from the date of receiving a notice of adverse action, to file
an appeal.
Method of Appeal
Member appeals can be either oral or in writing. An oral appeal must be followed by a written
appeal, signed by the member and received by us within ten (10) calendar days of the member’s oral
appeal.
Authorized Representatives of Members May File an Appeal:
An authorized representative may file an appeal on behalf of the member. An authorized
representative is a legal guardian of the member for a minor or an incapacitated adult, or a
representative of the member as designated in writing by the member to Passport.
The personal representative of a deceased member may file an appeal on behalf of the member.
A provider may be an authorized representative for a member only with the member’s written
consent. The written consent must include a statement that the member is giving the provider the
right to appeal and must also include a specific statement of the adverse action that is being
appealed. A single written consent shall not qualify as a written consent for more than one:
a. Hospital admission;
b. Physician or other provider visit; or
c. Treatment plan.
Help for Members with filing an Appeal:
Passport members may call Passport Member Services at (800) 578-0603 for help filing an appeal.
Page 34 of 331
LEP persons will be given interpretation/translation assistance when necessary to navigate the
appeals process.
Submit Member Appeals to:
Type of Appeal
Address
To Expedite a Member Appeal
Behavioral Health
Beacon Health Strategies
Appeals Coordinator
500 Unicorn Park Drive
Suite 401
Woburn, MA 01801
(855) 834-5651
TDD/TTY
(866) 834-9441
Denial, in whole or in part, of
payment for a service
Passport Health Plan
Claim Appeals
PO Box 7114
London, KY 40742
Dental
Avesis
Attn: Appeals Department
PO Box 7777
Phoenix, AZ 85011-7777
(866) 909-1083
Medical, Pharmacy, or
Administrative Appeals (An
Administrative Denial is a denial
issued for untimely notification
of a request for a clinical service)
Passport Health Plan
Appeals Coordinator
5100 Commerce Crossings
Drive
Louisville, KY 40229
(502) 585-7307, or 800-578-0603,
option 0, Extension 7307
N/A
(502) 585-7307
Fax (502) 585-8461
Radiology
MedSolutions
Appeals Department
730 Cool Springs Blvd.,
Suite 800
Franklin, TN 37067
1-877-791-4099
Appeals Department
1-877-791-4099
Vision
Block Vision
939 Elkridge Landing Road,
Suite 200
Linthicum, MD 21090
Attn: Member Appeals
800-879-6901
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800-879-6901
Acknowledgement of Receipt of the Appeal:
Within five (5) working days of receiving an appeal, we will send the member a written notice that
the appeal has been received and the expected date of resolution.
Continuance of Services during an Appeal:
A member’s services will continue during the appeal, if the member requested a continuation of
benefits, until one (1) of the following occurs:
1. The member withdraws the appeal;
2. Fourteen (14) days have passed since the date of the resolution letter, if the resolution of the
appeal was against the member and the member has not requested a state hearing or taken any
further action; or,
3. A state hearing decision adverse to the member has been issued.
Expedited Appeals
An expedited review process is available for a member when the standard resolution time frame
could seriously jeopardize the member’s life; health; or ability to attain, maintain, or regain maximum
function.
Expedited appeals are resolved within three (3) working days of receipt of the request. The three (3)
working days timeframe will be extended for up to fourteen days if the Member requests the
extension or we demonstrate to the Department that there is need for additional information and
the extension is in the Member’s interest. If we request the extension, we will give the Member
written notice of the reason for the extension. If we deny a request for a Member request for an
expedited appeal, the appeal will be resolved within thirty (30) calendar days of receipt of the original
request for appeal. We will give the Member prompt oral notice of the decision to deny expedition
of the appeal. We will follow up with a written notice within two (2) calendar days of the denial.
Conduct of the Review
The review will be conducted by an individual who was not involved in the initial decision. Appeals
involving denials for lack of medical necessity, the denial of expedited resolution of the appeal or
clinical issues will be conducted by health care professionals who have the appropriate clinical
expertise concerning the condition or disease under appeal.
Members shall be given a reasonable opportunity to present evidence, and allegations of fact or law,
in person as well as in writing. Members will have the opportunity before and during the appeal to
examine the Member’s file, including any medical records, and any other documents and records
considered during the appeals process.
Resolution of the Appeal
All member appeals are resolved within thirty (30) calendar days of receipt of the appeal, unless the
time period is extended by fourteen (14) calendar days upon request of the member or a request
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made by us. If we request the extension, we will provide the Member with written notice of the
extension and the reason for the extension within two (2) working days of the decision to extend.
Members will receive a written notice of the resolution of the appeal. The notice will include the
right to request a State Fair Hearing.
Member Requests for a State Hearing
If a member is not satisfied with the appeal resolution, the member has the right to request a State
Fair Hearing. Requests for a State Fair Hearing must be made in writing postmarked or filed with
the Kentucky Department for Medicaid Services, within forty-five (45) days of the notice of the
appeal decision. Requests for a State Hearing should be forwarded to:
Kentucky Department for Medicaid Services
Division of Administration and Financial Management
275 East Main St., 6W-C
Frankfort, KY 40601
(800) 635-2570
TDD/TTY (800) 775-0296
Kentucky Ombudsman
Members may also contact the Kentucky Ombudsman at any time at the following address:
Cabinet for Health and Human Services
Office of Ombudsman
275 East Main St., 1E-B
Frankfort, KY 40601
(800) 372-2973
TDD/TTY (800) 627-4702
What is a Grievance?
A grievance is defined by federal and state law as an expression of dissatisfaction about any matter
other than an adverse action.
Passport members have the right to file a grievance concerning any Passport decision that does not
involve an adverse action.
No Retaliation for Filing a Grievance
At no time will punitive or retaliatory action be taken against a Member for filing a grievance or a
provider for supporting a Member grievance.
How do Member’s file a Grievance?
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Timing:
Members have thirty (30) calendar days from the date of an event causing dissatisfaction to file a
grievance.
Method of Filing of Grievance:
Grievances can be submitted either orally or in writing.
Submit Member Grievances to:
Passport Health Plan
5100 Commerce Crossing Drive
Louisville, KY 40229
(800) 578-0603
Help for Members with filing a Grievance:
Members may call Passport Member Services at (800) 578-0603 for help filing a grievance. LEP
persons will be given interpretation/translation assistance when necessary to navigate the grievance
process.
Acknowledgement of Receipt of the Grievance:
Within five (5) working days of receipt of a grievance, we will provide the member with a written
notice that the grievance has been received and the expected date of resolution.
Conduct of the Review
The grievance review will be conducted by an individual who was not involved in the initial decision.
Resolution of the Grievance
All Member grievances are resolved within thirty (30) calendar days of the date the grievance was
received. Members will receive a resolution letter that includes the information considered in
investigating the grievance, findings and conclusions based on the investigation and the disposition
of the grievance.
Resolution may be extended by up to fourteen (14) calendar days if the Member requests the
extension, or if we determine there is a need for additional information and the extension is in the
Member’s interest. For any extension not requested by the Member, Passport will mail the Member
written notice of the reason for the extension within two (2) business days of the decision to extend
the timeframe.
2.12 Title VI Requirements: Translator and Interpreter Services
Title VI of the Civil Rights Act of 1964 is a Federal law that requires any organization receiving direct
or indirect Federal financial assistance to provide services to all beneficiaries without exclusion based
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on race, color, or national origin.
All Passport providers indirectly benefit from Federal financial assistance (via Medicaid). Therefore,
under Title VI and the Culturally and Linguistically Appropriate Services (CLAS) Standards 4 - 7, as
outlined by the Office of Minority Health, U.S. Department of Health and Human Services (DHHS),
all Passport providers are required by law to:
• Provide written and oral language assistance at no cost to any patient, including, but not
limited to, Passport members with limited-English proficiency or other special communication
needs, at all points of contact and during all hours of operation. Language access includes
the provision of competent language interpreters.
Note: The assistance of friends, family, and bilingual staff is not considered competent, quality
interpretation. These persons should not be used for interpretation services except where a
member has been made aware of his/her right to receive free interpretation in their preferred
language and continues to insist on using a friend, family member, or bilingual staff for
assistance in his/her preferred language.
• Provide patients, including Passport members, verbal or written notice (in their preferred
language or format) about their right to receive free language assistance services.
• Post and offer easy-to-read member signage and materials in the languages of the common
cultural groups in your service area. Vital documents, such as patient information forms and
treatment consent forms, must be made available in the preferred language or format of
patients, including Passport members.
Additionally, under the CLAS Standards, Passport providers are strongly encouraged to:
• Provide effective, understandable, and respectful care to all patients, including Passport
members, in a manner compatible with his/her cultural health beliefs and practices of
preferred language/format.
• Implement strategies to recruit, retain, and promote a diverse office staff and organizational
leadership representative of the demographics in your service area.
• Educate and train staff at all levels, across all disciplines, in the delivery of culturally and
linguistically appropriate services.
• Establish written policies to provide interpretive services for patients, including Passport
members.
• Routinely document each patient’s preferred language or format, such as Braille, audio, or large
type, in all medical records.
Potential penalties of non-compliance with Title VI may include:
Loss of federal and state funding, including future funding (i.e. providers may be prohibited
from participating in Medicaid, Medicare, and/or incentive programs such as the Electronic
Health Records incentive).
• Legal action against providers from the DHHS, legal service organizations, and private
individuals.
•
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•
•
"Informed consent" issues which may also lead to medical malpractice charges.
Change in participation status with Passport.
Providers may contact Passport’s Cultural and Linguistics Services Program Coordinator at (502)
585-8251 or e-mail [email protected] for additional information or to schedule an on-site
training.
2.12.1 Title VI Training/Resources
Passport’s Cultural and Linguistics Services (CLSP) Program offers the following training materials
and resources. Contact the CLSP Coordinator at (502) 585-8251-, e-mail
[email protected], or visit our web site,
www.passporthealthplan.com/provider/services/cals, for more details.
•
Onsite Trainings/Resources
Our CLSP staff is a resource for Title VI/CLAS Standards, Cultural Diversity and assists
providers in reaching and maintaining compliance. We offer free on-site trainings for office staff,
an informative Provider Toolkit, and web-based information and resources.
•
Provider Office Materials
In addition to the Provider Toolkit and other educational resources, Passport also offers provider
office signage to assist office staff in complying with Title VI. These materials are available online
or by calling the CLSP coordinator.
•
Translated Member Materials and TDD/TYY Lines
Many member materials, including the Passport Member Handbook , are available in other
languages and alternative formats such as Braille, audio, and large type. Members may call Member
Services for copies.
Additionally, for members with hearing impairments who use a Telecommunications Device for
the Deaf (TDD), Passport’s TDD/TYY number for Member Services is:
Passport - (800) 691-5566
•
Discounts for Telephonic and Video Interpretation
Passport also contracts with a telephonic and video interpretation vendor, InterpreTalk by
Language Services Associates (LSA), to offer our providers a discounted rate. To set up an
account and receive InterpreTalk services, please call (800) 305-9673 and ask for Client Services.
It may take 48 to 72 hours to set up an InterpreTalk account to begin receiving interpretive
services.
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Provider Manual
Section 3.0
Provider Roles and Responsibilities
Table of Contents
3.1 Confidentiality
3.2 The Role of the Primary Care Provider (PCP)
3.3 The Role of Specialists and Consulting Practitioners
3.4 Responsibilities of All Providers
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3.0 Provider Roles and Responsibilities
3.1 Confidentiality
In accordance with federal and state laws, Passport Health Plan has established confidentiality
policies and practices for its own operation and to outline expectations to our provider network. To
obtain a copy of Passport Health Plan’s Notice of Privacy Practices (NPP), please visit
www.passporthealthplan.com/membercenter.
All providers must comply with state and federal laws and regulations and Passport Health Plan’s
policies on the confidential treatment of member information in all settings.
All providers are to treat members’ protected health information (PHI), including medical records,
confidentially and in compliance with all federal and state laws and regulations, including laws
regarding mental health, substance abuse, HIV and AIDS, as well as the Health Insurance Portability
and Accountability Act (HIPAA). It is the provider’s responsibility to obtain the member’s written
consent for the purpose of sharing member health information.
Providers are authorized to share members’ protected health information with Passport Health Plan
for the purposes of treatment, payment, and health care operations recognized as receiving a request
to process claims and administer reimbursement for the same.
Providers rendering services to Passport members are required to obtain special consent
(authorization) from members for any uses or disclosures of protected health information beyond the
uses of payment, treatment, and health care operations. Members have the right to specifically
approve or deny the release of personal health information for uses other than payment, treatment,
and health care operations. Examples of uses and disclosures that require special consent or
authorization include data requested for workers’ compensation claims, release of information that
could result in the member being contacted by another organization for marketing purposes, and data
used in research studies.
In cases where consent is required from members who are unable to give it or who lack the capacity
to give it, Passport Health Plan and its providers/practitioners will accept special consent or
authorization from persons designated by the member. Designated persons, such as parents or
guardians, may authorize the release of personal health information and may obtain access to
information about the member.
Member information transferred from Passport Health Plan to another organization as permitted by
routine or special consent will be protected and secured according to Passport Health Plan’s state and
federal privacy policies and procedures.
Passport Health Plan will use member information for quality studies, health outcomes
measurements, and other aspects of health plan operations and will de-identify the information as
dictated by federal privacy legislation.
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Passport Health Plan members have the right to appeal any Passport decision that involves issues of
information confidentiality and privacy.
Passport Health Plan members are permitted to access, copy, and inspect their medical records upon
request. One copy of a member’s complete medical record must be made available from the provider
upon request at no charge and in accordance with state administrative regulations.
3.2 The Role of the Primary Care Provider (PCP)
A primary care provider (PCP) is a licensed or certified health care practitioner, including a doctor of
medicine, doctor of osteopathy, advanced practice registered nurse (including a nurse practitioner,
nurse midwife and clinical specialist), physician assistant, or clinic (including a FQHC, primary care
center and rural health clinic), that functions within the scope of licensure or certification, has
admitting privileges at a hospital or a formal referral agreement with a provider possessing admitting
privileges, and agrees to provide twenty-four (24) hours per day, seven (7) days a week primary health
care services to individuals.
Additionally, an Obstetrician/Gynecologist can serve as a PCP to a member with obstetrical or
gynecologic health care needs, disability or chronic illness provided the specialist agrees to provide
and arrange for all appropriate primary and preventive care. Passport Health Plan provides
instructional materials that encourage members to seek their PCP’s advice before accessing medical
care from any other source except for direct access services and emergency services. It is imperative
the PCP’s staff fosters this idea and develops a relationship with the member that will be conducive
to continuity of care.
Primary care physician residents may function as PCPs. The PCP serves as the member's initial and
most important point of contact with Passport Health Plan. This role requires a responsibility to both
Passport Health Plan and the Member. Although PCPs are given this responsibility, Passport will
retain the ultimate responsibility for monitoring PCP actions to ensure they comply with Passport
and DMS policies.
Specialty providers may serve as PCPs under certain circumstances, depending on the Member's
needs. The decision to utilize a specialist as the PCP shall be based on agreement among the Member
or family, the specialist, and Passport's medical director. The Member has the right to appeal such a
decision in the formal appeals process.
Passport will monitor the PCP's actions to ensure he/she complies with Passport and DMS policies
including but not limited to the following:
•
•
•
•
Maintaining continuity of the Member's health care;
Exercising primary responsibility for arranging and coordinating the delivery of medicallynecessary health care services to members;
Making referrals for specialty care and other Medically Necessary services, both in and out of
network, if such services are not available within Passport's network;
Maintaining a current medical record for the Member, including documentation of all PCP and
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•
•
•
•
•
•
•
•
•
•
specialty care services, including periodic preventive and well-care services, and providing
appropriate and timely reminders to members when services are due;
Discussing Advance Medical Directives with all members as appropriate. See Section 3.4.4.
Advanced Directives;
Providing primary and preventative care, recommending or arranging for all necessary
preventive health care, and adhering to the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) periodicity schedule and the Vaccines For Children (VFC) immunization
schedule for each Passport Health Plan member younger than 21 years of age. Documenting
all care rendered in a complete and accurate medical record that meets or exceeds the
Department for Medicaid Services’ (DMS) specifications;
Screening and evaluation procedures for the detection and treatment of, or referral for, any
known or suspected behavioral health problems and disorders;
Arranging and referring members when clinically appropriate, to behavioral health providers;
Providing periodic physical examinations as outlined in the Preventive Health Guidelines;
Providing routine injections and immunizations;
Providing or arranging 24-hours a day, seven days a week access to medical care. For
additional information, see Section 4.2 – Office Standards;
Arranging and/or providing necessary inpatient medical care at participating hospitals.
Providing health education and information; and,
Passport members have the right to a second opinion. If the member requests a second
opinion, the PCP should complete a referral to a participating specialist. If there is not a
specialist within the network, the PCP must call Passport’s Utilization Management
department at (502) 578-0636 to request an authorization to a non-participating specialist.
The PCP should perform routine health assessments as appropriate for a member’s age and gender
and maintain a complete individual medical record of all services provided to the member by the
PCP, as well as any specialty or referral services. PCPs are required, with the assistance of Passport
Health Plan, to integrate into the member’s medical records any services provided by school-based
health services or other external service providers.
It is the responsibility of all PCPs to manage the care of their Passport Health Plan panel members
and direct the members to specialty care services when necessary. It is the responsibility of the
specialist practitioner to work closely with the PCP in this process.
Dual eligible members, members who are presumptively eligible - pregnant, disabled children, and
foster care children are not required to have a PCP but may request a PCP. All other members either
make a selection or have Passport select a PCP for their medical home. The name and telephone
number of the PCP or group selected appears on the member’s Passport Health Plan Identification
Card. Please see Section 2.4.1 for more information about member eligibility and identification.
Each PCP receives a monthly member panel list of those members who have selected or been
assigned to him or her. It is advisable to verify eligibility at, or before, the time of service using one
of the online eligibility tools, (NaviNet or KyHealth Net). Even with this verification, there are times
when DMS retroactively terminates eligibility for certain members. In these circumstances, Passport
may decide to recoup any amounts paid for these patients.
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Coordination between Primary Care and Behavioral Health providers is a critical component of
promoting health and wellness for Passport Health Plan members. We encourage primary care
providers to review the behavioral health section of this provider manual for more information about the
covered benefits, authorization requirements and other important behavioral health issues. Members never
need a referral for behavioral health services. If you need assistance establishing behavioral health services for a
Passport member, we encourage you to call our 24-hour Behavioral Health Services Hotline at 855-834-5651.
To support our goal of integrated behavioral and physical health care, we offer a comprehensive
prescription drug intervention program designed to alert our primary care providers of sub-optimal
dosing, polypharmacy or other key issues for members who are prescribed psychotropic medications.
The incorporation of comprehensive Behavioral and Mental Health Services brings about many
changes. Working with the DMS and the Department for Behavioral Health, Developmental and
Intellectual Disabilities (DBHDID), Passport will highlight the expectations for screening for
behavioral health disorders by PCP’s in numerous settings. PCP’s may continue to provide any
clinically appropriate Behavioral Health Services within the scope of their practice. The training
sessions that are offered will review this in greater detail.
New expectations extend to Behavioral Health specialists in that they are expected to communicate
to the PCP the initial evaluation. Additionally, they are expected to provide, at minimum, quarterly
reports of the member’s condition with the consent of the member or their legal guardian.
3.3 The Role of Specialists and Consulting Practitioners
Specialty care practitioners provide care to members referred by their PCP. The specialty care
practitioner must coordinate care through the PCP and must obtain necessary prior authorization for
hospital admissions or specified diagnostic testing procedures. Refer to Section 5.3, “Authorization
Requirements,” for a complete listing of procedures requiring prior authorization from Passport
Health Plan’s Utilization Management department.
Except for Direct Access Services and a few other services (see Section 6.1, “Member Self-Referral
(Direct Access),” all members must obtain a valid referral from the PCP prior to receiving services
from most specialty care providers/practitioners.
Specialty practitioners must review the referral section of the PCP referral form to determine which
services have been referred. The specialist must contact the PCP if he or she intends to provide
services in excess of those initially requested. In these cases, the PCP must generate a second referral
to cover the additional services.
It is important that the specialty care provider communicates regularly with the PCP regarding any
specialty treatment. Specialists are to report the results of their services to the member’s PCP just as
they would for any of their patients. The specialist should copy all test results in a written report to
the PCP. The PCP is to maintain referrals and specialist reports in the member’s central medical
record and take steps to ensure that any required follow-up care or referrals are provided.
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For electronic referral submission guidelines via NaviNet, please refer to Section 6.3.
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3.4 Responsibilities of All Providers
3.4.1 Provider and Member Communications
It is the provider’s responsibility to provide appropriate and adequate medical care to Passport
Health Plan members, and no action of Passport Health Plan or any entity on the Plan’s behalf, in
any way, absolves, relieves, or lessens the provider’s responsibility and duty to provide appropriate
and adequate medical care to all patients under the provider’s care. Passport Health Plan agrees that
regardless of the coverage limitations of the Plan, the provider may freely communicate with
members regarding available treatment options and that nothing in this Provider Manual shall be
construed to limit or prohibit open clinical dialogue between the provider and the member.
3.4.2 Medical Records
Documentation in the medical record shall be timely, legible, current, detailed and organized to
permit effective and confidential patient care and quality review. Complete medical records include,
but are not limited to, medical charts, prescription files, hospital records, provider specialist reports,
consultant and other health care professionals’ findings, appointment records, and other
documentation sufficient to disclose the quantity, quality, appropriateness, and timeliness of services
provided to the member. The member record shall be signed by the provider of service.
Medical record confidentiality policies and procedures shall comply with state and federal guidelines,
HIPAA and Passport Health Plan policy. HIPAA privacy and security audits will be performed to
assure compliance as required by Passport Health Plan’s contract with the DMS.
If a member were to change PCP’s, medical records should be forwarded to the new PCP within ten
(10) days’ of receipt of a signed request.
See Section 4.5 for additional detail regarding Medical Record Keeping
3.4.3 Treatment Consent Forms
Treatment consent forms for specific procedures must be completed and signed by the member. A
copy of the appropriate treatment consent form must be maintained in the member’s record. The
following original treatment consent forms must be sent to the Plan, along with a copy of the claim,
as required by state and federal laws. In accordance with Title VI, all vital documents (i.e. treatment
and consent forms) must be translated into patient’s preferred language. These treatment consent
forms are available from the Department for Medicaid Services (DMS) and in Section 19 of this
Provider Manual:
MAP-250 Consent for Sterilization
MAP-251 Hysterectomy Consent Form
MAP-235 Certification Form for Induced Abortion or Induced Miscarriage
MAP-236 Certification Form for Induced Premature Birth
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For additional information on completion of the above forms, please contact Passport Utilization
Management at 800-578-0636 Additional information on family planning services is located in
Section 17.
3.4.4 Advance Directives
Living will, living will directive, advance directive, and directive are all terms used to describe a
document that provides directions regarding health care to be provided to the person executing the
document. In Kentucky, advance directives are governed by the Kentucky Living Will Directive Act
codified in KRS 311.621 to 311.643, and as otherwise defined in 42CFR 489.100. Matters regarding
application of advanced directives and related legal matters are defined in Kentucky Statutes, some of
which are outlined in greater detail below; however, these should not be considered exhaustive lists.
State and federal laws also provide guidance to these policies. Policies will be updated as soon as
possible after guidance from these organizations is received.
A member who is 18 years of age or older and who is of sound mind may make a written advance
directive that does any or all of the following:
•
•
•
•
Directs the withholding or withdrawal of life-prolonging treatment.
Directs the withholding or withdrawal of artificially provided nutrition or hydration.
Designates one or more adults as a surrogate or successor surrogate to make health care
decisions on his or her behalf.
Directs the giving of all or any part of his or her body upon death for any of the following
reasons: medical or dental education, research, advancement of medical or dental science,
therapy, or transplantation.
A living will form is included in KRS 311.625. The form can be reviewed at
http://www.lrc.ky.gov/krs/311%2D00/625.pdf.
A copy of the living will may also be obtained through the Office of the Attorney General website at
http://ag.ky.gov/civil/consumerprotection/livingwills.htm. Advance directives may be revoked in
writing, by an oral statement, or by tearing up the written living will. The revocation is effective
immediately.
Health Care Surrogates. If a health care surrogate is appointed in the advance directive, the
surrogate is required to consider the recommendations of the attending physician and to honor the
requests made by the grantor in the advance directive.
No Directive. What happens if an adult member does not have decisional capacity and has not
executed an advance directive? Kentucky statutes authorize the following persons, in the order given,
to make such decisions:
• A judicially-appointed guardian of the member.
• Spouse of the member.
• Adult child of the member (or the majority of the children).
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• Parents of the member.
• Nearest living relative.
Conscientious Objections. What happens if the practitioner or health care facility does not want to
comply with a member’s advance directive because of matters of conscience? The
provider/practitioner should notify the member and cooperate with the member in transferring the
member, with all his or her medical records, to another provider/practitioner. The
provider/practitioner must also clarify any differences between institutional conscientious objections
and those that may be raised by individual practitioners. Also, the provider/practitioner must
describe the range of medical conditions or procedures affected by the conscientious objection.
Provider’s Responsibilities. In addition to reviewing the Kentucky Living Will Directives Act,
providers should:
•
Discuss the member’s wishes regarding advance directives for care and treatment at the first
visit, as well as during routine office visits when appropriate;
• Document in the member’s medical record the discussion and whether the member has
executed an advance directive;
• Provide the member with information about advance directives, if asked;
• File the advance directive in the member’s record upon receipt from the member;
• Not discriminate against a member because he or she has or has not executed an advance
directive; and,
• Communicate to the member if the provider has any conscientious objections to the
advance directive as indicated above.
3.4.5 Suspected Child or Adult Abuse or Neglect
Cases of suspected child or adult abuse or neglect might be uncovered during examinations. Child
abuse is the infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment
that results in physical pain or injury, including mental injury. Abuse is an act of commission or
neglect.
If suspected cases are discovered, an oral report should be made immediately, by telephone or
otherwise, to a representative of the local Department for Social Services office at (502) 595-4550.
To facilitate the reporting of suspected child abuse and neglect cases, legislation affecting the
reporting of child abuse (KRS 620.030) is printed on the reverse of the Child Abuse Reporting Form
(DSS-115). These forms may be obtained from the local Department for Social Services office.
Adult abuse is defined by KRS. 209.020 as, “the infliction of physical pain, mental injury, or injury of
an adult.” The statute describes an adult as, “(a) a person 18 years of age who because of mental or
physical dysfunctioning is unable to manage his [her] own resources or carry out the activity of daily
living or protect himself [herself] from neglect or a hazardous or abusive situation without assistance
from others and who may be in need of protective services; or (b) a person without regard to age
who is the victim of abuse and neglect inflicted by a spouse.”
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3.4.6 Fraud and Abuse
The Federal False Claims Act and the Federal Administrative Remedies for False Claims and
Statements Act are specifically incorporated into § 6032 of the Deficit Reduction Act. These Acts
outline the civil penalties and damages against anyone who knowingly submits, causes the
submission, or presents a false claim to any U.S. employee or agency for payment or approval. U. S.
agency in this regard means any reimbursement made under Medicare or Medicaid and includes
Passport Health Plan. The False Claims Acts prohibit anyone from knowingly making or using a
false record or statement to obtain approval of a claim.
Knowingly is defined in the statute as meaning not only actual awareness that the claim is false or
fraudulent, but situations in which the person acts in deliberate ignorance of, or in reckless disregard
of, the truth or falsity of the claim.
The following are some examples of billing and coding issues that can constitute false claims and
high-risk areas under this Act:
•
•
•
•
•
Billing for services not rendered;
Billing for services that are not medically necessary;
Billing for services that are not documented;
Upcoding; and,
Participation in kickbacks.
Penalties (in addition to amount of damages) may range from $5,000 to $10,000 per false claim, plus
three times the amount of money the government is defrauded. In addition to monetary penalties,
the provider may be excluded from participation in the Medicaid and/or Medicare programs.
Passport has developed a Program Integrity plan of internal controls and policies and procedures for
preventing, identifying and investigating enrollee and provider fraud, waste and abuse. Our plan
includes:
•
•
•
•
•
•
•
Enforcement of standards through disciplinary guidelines;
Provisions for internal monitoring and auditing of the member and provider;
Provisions for internal monitoring and auditing of subcontractors. Should issues be
identified, the subcontractor shall be placed on a corrective action plan (CAP). The
Department for Medicaid Services (DMS) will be notified of the CAP.
Processes to collect outstanding debt from providers;
Procedures for appeals;
Compliance with the expectations of 42 CFR 455.20 by employing a method of verifying with the
member whether the services billed by the provider were received by randomly selecting a
minimum sample of 500 Claims on a monthly basis; and,
Programs that run algorithms and edits on Claims data to identify outliers and patterns and trends.
Passport’s Program Integrity Unit (PIU) conducts fraud, waste and abuse investigations for Passport.
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The PIU is comprised of staff from a broad range of Passport departments. All Passport fraud,
waste and abuse activity is reported to the DMS. PIU staff meeting regularly with the state Medicaid
Fraud Control Unit (MFCU) which includes representatives from the DMS, the Office of the
Inspector General (OIG) and the Office of the Attorney General (OAG).
Providers are required to cooperate with the investigation of suspected Fraud and Abuse. If you
suspect fraud, waste or abuse by a Passport member or provider, it is your responsibility to report
this information immediately. Please contact:
Passport Health Plan Compliance Hotline:
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(855) 512-8500
Provider Manual
Section 4.0
Office Standards
Table of Contents
4.1 Appointment Scheduling Standards
4.2 After-Hours Telephone Coverage
4.3 Member to Practitioner Ratio Maximum
4.4 Provider Office Standards
4.5 Medical-Record-Keeping & Continuity & Coordination of Care
Standards
4.6 Hospital Care
4.7 Kentucky Health Information Exchange – KHIE
4.8 Communication Guidelines
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4.0 Office Standards
PCPs are required to provide coverage for Passport Health Plan members 24 hours a day, seven days a
week. When a PCP is unavailable to provide services, the PCP must ensure that he or she has
coverage from another participating provider. Hospital emergency rooms or urgent care centers are
not substitutes for coverage from another participating provider. Participating providers can consult
their Passport Health Plan Provider Directory, or contact Provider Services at (800) 578-0775 with
questions regarding which providers participate in the Passport Health Plan network.
4.1 Appointment Scheduling Standards
Providers must adhere to the following appointment scheduling standards to assure timely access to
medical care as required by the Department for Medicaid Services (DMS). Compliance with these
standards will be audited by periodic on-site review of provider offices and chart sampling.
Appointments with primary care providers (PCP) and specialists must be scheduled within
30 days for routine care and preventive care visits.
• Appointment standards for other situations that might confront a PCP or specialist are
as follows:
 Appointments for urgent care services must be scheduled within 48 hours.
 Non-urgent appointments requiring more immediate attention must be scheduled
within 7 days.
 Appointments for emergency care must be immediately provided.
 Pregnant women in their first trimester are to be provided preventive care visits
within 14 days of request.
 Pregnant women in their second trimester are to be provided preventive care visits
within seven days of request.
 Pregnant women in their third trimester are to be provided preventive care visits
within three days of request.
 Appointments for laboratory and radiology services must be scheduled within 30
days for routine care and 48 hours for urgent care.
•
4.2 After-Hours Telephone Coverage
A PCP’s office telephone must be answered in a way that the member can reach the PCP or another
medical practitioner whom the practitioner has designated. Their telephone must be:
•
•
•
Answered by an answering service that can contact the PCP or another designated medical
practitioner who can return the call within a maximum of 30 minutes; OR
Answered by a recording directing the member to call another number to reach the PCP or
another medical practitioner whom the practitioner has designated to return the call within a
maximum of 30 minutes; OR
Transferred after office hours to another location where someone will answer the telephone
and be able to contact the PCP or another designated medical practitioner who will return the
call within a maximum of 30 minutes.
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Unacceptable after-hours telephone coverage in a PCP’s office includes:
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No answer after office hours.
Telephone answered after hours by a recording that tells members to leave a message.
Telephone answered after hours by a recording that directs members to go to the emergency
room for any services needed.
Not returning calls within 30 minutes
4.3 Member to Practitioner Ratio Maximum
Per DMS regulation 907 KAR 1:705, member to PCP ratios are not to exceed 1500 to 1. If any PCP
is concerned about his or her panel size or prefers a ratio smaller than 1500 to 1, he or she should
notify Provider Network Management in writing at the following address:
Passport Health Plan
5100 Commerce Crossings Drive
Louisville, KY 40229
Attention: Provider Network Management
Passport Health Plan will set the maximum panel size at 1500 members per practitioner. However,
the ratio may be adjusted for practices that employ physician extenders, such as physician assistants.
Passport Health Plan will consider exceptions to the 1500 to 1 ratio upon PCP request. Exceptions
will be allowed based on an analysis of the practice capacity and geographic availability of other PCP
practices contracted with Passport Health Plan.
For additional information regarding requests for panel closings and limitations, please see Section
2.8.
4.4 Provider Office Standards
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Providers must not differentiate or discriminate in the treatment of any member because of
the member’s race, color, national origin, ancestry, religion, health status, sex, marital status,
age, political beliefs, or source of payment.
The office waiting times should not exceed 45 minutes.
Members should be scheduled at the rate of six or less per hour.
Health assessments/general physicals should be scheduled within 30 days.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screens for any new
enrollee younger than 21 years of age should be scheduled within 30 days of enrollment,
unless the child is already under the care of a PCP and the child is current with screens and
immunizations.
EPSDT screens for any new enrollee younger than two years of age should be scheduled
within an appropriate time frame so that the child is not out of compliance with any required
screenings.
• PCPs should have a “no show” follow-up policy. For example, the PCP or specialist might
send two notices of missed appointments to the member, followed up by a telephone call to
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•
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•
•
the member. Any actions for missed appointments should be documented in the member’s
medical record.
Provider Network Management must be notified of all PCP planned and unplanned absences
of more than four days from the practice.
Member medical records must be maintained in an area that is not accessible to persons not
employed by the practice. When releasing a member’s medical record to another practice or
provider, providers are required to first obtain written consent from the member.
Any provider’s office administering care that may have an adverse effect must obtain the
member’s signature on a form that describes the treatment and includes the medical
indication and the possible adverse effects.
Providers must complete specific treatment consent forms, such as hospice, sterilization,
hysterectomy, or abortion as referenced in Section 3.4.3, “Treatment Consent Forms,” as
required by state and federal regulations and laws.
4.5 Medical-Record-Keeping and Continuity and Coordination of Care
Standards
Passport Health Plan has adopted the following medical-record-keeping standards, which cover
confidentiality, organization, documentation, access, and availability of records. These standards are
determined by the National Committee for Quality Assurance (NCQA) and the Department for
Medicaid Services (DMS) and may be revised as needed to conform to new NCQA or DMS
recommendations. Compliance with these standards will be audited by periodic on-site review of
practitioners' offices and chart samplings. Practitioners must achieve an average score of 80% or
higher on the medical records review. Passport Health Plan will monitor practitioners’ scoring less
than 80% through corrective action plans and re-evaluation.
Confidentiality of Records
Medical records are maintained in an area that is only accessible to practitioner office staff. Providers
are also required to:
Have policies addressing privacy and confidentiality of member information.
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Ensure that medical records are NOT accessible to those not employed by the practice.
Post notice of privacy practices (NPP) in a prominent area of the office.
Ensure that HIPAA policies and procedures are easily accessible for all staff members.
Provide disclosures of PHI, patient’s right to request restriction of the use of PHI, and
include a contact person within the practice.
Locate copier and fax machines in an area that restricts unauthorized access or viewing.
Password protect all computer screen savers.
Protect all staff members’ computer access by requiring unique log-ins and time-limited
passwords.
Ensure that office staff shall send all emails containing PHI marked secured or encrypted.
Organization of Records
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•
There is only one medical record per patient.
The medical record is bound or pages fastened to prevent loss of medical information.
Each and every page in the record contains the member’s name or ID number.
The medical record is organized in chronological order with the most recent information
appearing first. The record includes separate sections for progress notes, lab results, x-ray and
other imaging studies, hospital records (ER report and discharge summaries), home health
nursing reports, physical therapy reports, etc.
All charts contain flow sheets for health maintenance.
Documentation
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The record is legible.
Personal data includes date of birth, age, height, gender, home and work addresses, employer,
home and work telephone numbers, marital status, emergency contact information, school
name and telephone numbers (if no phone contact name and number), race, ethnicity,
guardianship/custodial arrangements, and identifies preferred language.
Entries are done in smudge-proof non-erasable ink.
Medication allergies, adverse reactions, and no known allergies are prominently noted in the
record.
There is a completed immunization record in all pediatric records and/or appropriate history
in all adult records.
All charts contain a problem list, a medication list, and a treatment plan. Significant illnesses
and medical conditions are indicated on the problem list, including working diagnoses.
Medical history (for members seen three or more times) is easily identified and includes
medical, surgical, obstetric histories, and serious accidents. For children and adolescents (18
years of age and younger), medical history includes prenatal care, birth, operations, and
childhood illnesses.
Documentation includes weight recorded at each regular visit.
All entries in the medical record are signed or initialed and dated and all providers are
identified by name.
Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or
visits. The specific time of return is noted in weeks, months, or PRN.
Documentation will reflect assessment of and counseling for tobacco, alcohol, substance
abuse, and risk of sexually transmitted diseases.
If a consultation is requested, there is a note from the consultant in the record.
Consultation, lab, and x-ray reports filed in the chart are initialed by the practitioner to
indicate review. Consultation and abnormal lab and imaging study results have a specific
notation in the record of follow-up plans.
Emergency care provided is documented in the medical record, as well as follow-up visits
provided secondary to reports of emergency room care.
Evidence of reportable diseases and conditions are documented and reported appropriately to
local or state health departments.
There is evidence that preventive screenings and services are offered in accordance with
Passport Health Plan’s Clinical Practice Guidelines. Use of risk assessments, disease
maintenance, and preventive health sheets are encouraged (see Section 17, “Forms and
Documents” for samples).
Copies of consent forms, when applicable, are maintained in the record.
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•
The medical record also contains an indication of whether an adult (over 18 years old)
member has executed an advance directive and a copy of the member’s advance directive, as
applicable.
Written denials for service and the reason for the denial are documented in the medical
record.
Hospital discharge summaries are included in the medical record.
Access and Availability of Records
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•
Provider permits Passport Health Plan, on request, access to member medical records to
inspect, review, and copy within five working days of receipt of request.
Members have the right to all information contained in the medical record as required by law.
Medical records must be made available to a member upon request.
When a member changes PCPs, the medical records or copies of medical records shall be
forwarded to the new PCP within ten (10) business days from receipt of request.
When releasing records to an entity other than Passport, providers are first required to obtain
written consent from the member.
Continuity and Coordination of Care
While there are some indicators of continuity and coordination of care included within the
documentation standards, Passport will also assess medical records for evidence of continuity and
coordination of care using the following criteria:
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The record is legible to someone other than the writer. Any record determined illegible by
one reviewer shall be evaluated by a second reviewer.
At each office visit, the history and the physical performed are documented and reflect
appropriate subjective and objective information for presenting complaints, including any
relevant psychological and social conditions affecting the patient’s medical/behavioral health.
The working diagnosis is consistent with the clinical findings.
The plan of action and treatment is consistent with the diagnosis and includes medication
history, medications prescribed; including the strength, amount, and directions for use, as well
as any therapies or other prescribed regimen.
Lab and other studies are ordered as appropriate.
Unresolved problems, referrals, and results from diagnostic tests, including results and/or
status of preventive screening services (EPSDT) from previous office visits are addressed in
subsequent visits.
There is a review for the under-and over-utilization of consultations.
Age or disease-appropriate direct access services or referrals must be documented in the
medical record, for example: immunizations, diabetic retinal eye exams, family planning, and
cancer screening services.
There is no evidence that the patient is placed at inappropriate risk by a diagnostic or
therapeutic problem.
Follow-up plans including consultations, referrals, directions, and time to return.
4.6 Hospital Care
Practitioners must have admitting privileges to a Passport Health Plan network hospital or facility for
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all patient groups for whom they are providing care. With prior written approval from Passport
Health Plan’s Utilization Management department, a practitioner may arrange for another
participating practitioner to provide inpatient coverage.
4.7 Kentucky Health Information Exchange – KHIE
Passport Health Plan is dedicated to improving the health and quality of life of our members and
actively supports the statewide implementation of the Kentucky Health Information Exchange
(KHIE). The KHIE is the secure electronic information infrastructure created by the
Commonwealth for sharing health information among health care organizations and offers health
care providers the functionality to support meaningful use and a high level of patient-centered care.
Passport Health Plan encourages participating PCP’s to connect to the KHIE through various
communication channels such as annual workshops, routine onsite visits, and general provider
relations interaction.
KHIE is a secure, interoperable network which participating providers with certified electronic
health record (EHR) technology can use to locate and share needed patient information with each
other which results in improved coordination of care among physician practices, hospitals, labs, and
across the various health systems. Some of the benefits include:
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Real time access to patient health information including:
 Detailed patient summary
 Rx/medication history
 Laboratory results
 Radiology and other transcribed reports
 Clinical reminders/alerts
Improved patient care quality and safety
Reduced health care costs by reducing duplication of care
Improved efforts to reduce health disparities
Informed medical decisions at the time/place of care.
We encourage you to visit ht t p: //K HI E. KY .G OV /c wk h ie/ Pa ges/ h ome .asp x to obtain
more information on this program and guidance on how you can make the KHIE connection.
4.8 Communication Guidelines
They Kentucky Department for Medicaid Services has developed guidance related to member
materials and other communication for providers participating in Medicaid managed care
organizations in the state. The guidance includes the following:
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•
•
Providers are considered agents of all managed care organizations (MCOs).
MCO’s must have a system of control over the content, form, and method of marketing and
information materials published on its behalf or through its agents.
Any listing of MCO’s in a provider office must include all Medicaid plans with which the
provider does business.
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4.8.1 Approval Process:
• All communication materials referring to Passport Health Plan must be approved in writing
by Passport and by the Kentucky Department for Medicaid Services (DMS).
• Passport is responsible for submitting provider communication & information materials to
the Kentucky Department for Medicaid Services (DMS) for approval.
• DMS has the same approval authority over provider materials as it has over MCO materials.
• Passport must correct any problems or errors on provider materials identified by DMS.
4.8.2 Distribution of Materials:
• Passport may not distribute marketing materials through its provider network.
• Branded health education materials may be distributed to providers by MCOs including
Passport, but distribution must be limited to members of that specific plan.
• Branded materials cannot be left in common areas, such as waiting rooms and lobbies.
• Branded health education materials can not include enrollment or disenrollment information.
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Provider Manual
Section 5.0
Utilization Management
Table of Contents
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
Utilization Management
Review Criteria/Standards for Review
Authorization Requirements
Online Authorization
Inpatient Admissions and Observation
Outpatient Services
High Cost Medication
Prior Authorization for Members with Original Medicare
Retrospective Authorization
Denials
Available forms:
Appendix A: Radiology Codes
Appendix B: L codes
Appendix C: Ostomy Supplies
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5.0 Utilization Management
5.1 Utilization Management
Utilization Management (UM) is the process of influencing the continuum of care by evaluating the
necessity and efficiency of health care services and affecting patient care decisions through assessments
of the appropriateness of care. The UM department helps to assure prompt delivery of medicallyappropriate health care services to Passport Health Plan members and subsequently monitors the
quality of care.
All Passport Health Plan participating providers are required to obtain prior authorization from the
Plan’s UM department for inpatient services and specified outpatient services listed in Section 5.3,
“Authorization Requirements.”
Failure to submit an authorization or failure to submit an authorization in a timely manner may result
in a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be
verified for every request of service.
The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except
holidays. All requests for authorization of services may be received during these hours of operation by
calling or faxing:
Department
Phone Number
Fax Number
General Number
Concurrent Review
Retrospective Review
Home Health
DME
Therapies/Pain
Management/Chiropractic
(800) 578-0636
(502) 585-2023
(502) 585-7972
(502) 585-7320
(502) 585-7310
(502) 585-7989
(502) 585-7989
(502) 585-8207
(502) 585-8204
(502) 585-7990
(502) 585-6055
Cosmetics
Appeals
High Dollar Radiology
Administered by MedSolutions
(502) 585-7069
(502) 585- 7307
1-877-791-4099
(502) 585-8205
Request can be sent via confidential email to:
PassportUMCosmetics
@Passporthealthplan.com
(502) 585-8461
1-888-693-3210 or on-line authorization at
www.Medsolutionsonline.com
After business hours or on holidays, a provider can leave a message and a representative will return the
call the next business day.
Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical
Director, to ask questions about a utilization management issue, or to seek information from the nurse
reviewer about the Utilization Management process and the authorization of care by calling Utilization
Management at (800) 578-0636.
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Because of frequent changes in member eligibility for Medicaid coverage, providers should verify
continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or
Provider Services at (800) 578-0775.
5.2 Review Criteria/Standards for Review
Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the
Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual® Criteria
during the review process. In the event InterQual® Criteria is not available for a specific request, the
reviewer may use internal medical policies which are reviewed and approved by actively practicing
practitioners in the community.
The Partnership Council approves both the use of InterQual Criteria® and Medical Polices. Criteria
are only made available to participating and non-participating providers as allowed under copyright
limitations and trademark considerations.
At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will
provide a copy of up to three (3) InterQual® Criteria guidelines. If the guidelines are not available for
distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to
request the guideline be read over the telephone, or review the guideline at Passport Health Plan.
Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport
Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any
time from the Passport UM Department or the Chief Medical Officer.
Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any
applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines
are shared with providers upon request. These requests may be made by contacting the UM
Department or the Chief Medical Officer. Criteria are distributed to providers who have
Medicare/Medicaid practitioner numbers issued by state and federal entities.
5.3 Authorization Requirements
The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The
general UM department phone number is: (800) 578-0636. The general UM department fax number is
(502) 585-7989.
The following table lists procedures and/or services that require authorization from Passport Health
Plan’s Utilization Management (UM) department.
Services Requiring Authorization
All Inpatient Admissions /
Hospitalizations
Maternity
Code Range: 644.XX through 665.XX --•If stay is less than or equal to 3 days with the above codes, no
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authorization is required
AUTHORIZATION IS REQUIRED FOR:
All Cesarean Sections
All Scheduled inductions
All Non-par providers, regardless of delivery type
Rehabilitation
23 Hour Observation
Pain Management (i.e. Epidural
Blocks – Trigger Point Injections)
Home Hospice
Stem Cell/Progenitor Cell Retrieval
Investigational/Experimental Procedures
Cosmetic Procedures
Ocular Photodynamic Therapy/with Verteporfin (Visudyne)
Neuropsychological Testing
Diabetic Education
Therapy Services
Chiropractic Services
No authorization for the first 12 visits in a calendar year
Services beyond 12 visits require authorization
Benefit limit = total of 26 chiropractic visits within a calendar
period
Specified Outpatient Surgical
Procedures:
PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging
– Authorization administered by MSI
Adenoidectomy - Cardiac
Catheterization - EGD
DME > $500 – rental or purchase
All DME with E1399 Codes
Enteral Products
Select Orthotics / Prosthetics
Ostomy Supplies
Home Health / Skilled Nursing / Private Duty Nursing
Home Infusion – IV Therapy (IVT)
High Cost Medication > $400
Authorization for IVT will be administered
by PBM (Perform RX)
Synagis Injections – Authorizations
administered by PBM (Perform RX)
Nonparticipating Provider Services
Select EPSDT Special Services
Family Planning – Terminations
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Policy for Newborns:
An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If
an infant born via NVD stays <= 3 days, authorization is not required.
An infant born by C-Section does not require authorization until day six (6). If an infant born via CSection stays <= 5 days, authorization is not required.
Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual
cases.
To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion,
please contact the Passport Utilization Management (UM) department.
The assigned authorization number must be submitted on the claim form.
5.4 Online Authorization
Passport Health Plan’s Utilization Management Department utilizes an online authorization system via
NaviNet. The online authorization system is a web-based auto-review system for providers to obtain
authorization for services, including but not limited to:
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Acute Therapies
BiPAP
Cesarean Section
Cardiac Rehabilitation
Hospital Bed
Mediplanner
Home Health Aid
CPAP
EGD
Bili Lites
Pulmonary Rehabilitation
For questions regarding the online authorization, contact NaviNet or your Provider Network Account
Manager.
The online authorization system also allows you, the provider, to search for authorizations by member,
authorization number, date of service and/or physician. View the following information online for each
authorization:
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Member identification number, coverage dates, and PCP
Authorization number
Service requested
Primary diagnosis
Treatment dates
Status of the authorization
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The use of the online authorization system via NaviNet for select services is highly encouraged.
5.5 Inpatient Admissions and Observation Stays
UM reviews all requests for inpatient admissions and observation stays utilizing InterQual® criteria and
internal medical policies. For those requests meeting the established medical necessity criteria, an
inpatient or observation stay will be authorized.
Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical
Director for further review and evaluation.
When requesting a review, at a minimum, documentation must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
To receive authorization for an admission / observation stay, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday,
between the hours of 8 a.m. and 5:30 p.m.
5.5.1 Inpatient Admissions and Observation Requirements
All inpatient admissions and observation stays require an authorization.
If a member is discharged from an inpatient level of care and subsequently re-admitted to the same
hospital within 24 hours, the UM Department continues the member's inpatient stay under the same
case reference number.
Requests for prior authorization of elective inpatient or observation services should be received prior
to the date the requested service will be performed. Passport Health Plan will accept the hospital’s or
the attending physician’s request for prior authorization of elective hospital admissions; however,
neither party should assume that the other has obtained prior authorization.
For an urgent or emergent admission / observation, the facility must notify the plan within one
business day of the admission.
For weekend admissions or observation to a hospital or for services delivered on the weekend or after
normal business hours, authorization must be obtained within one business day of the admission or
service being provided.
If the member’s condition or results of evaluation and testing meet inpatient criteria after the 23-hour
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observation period, the stay will be converted to inpatient beginning with the observation stay
admission date. All claims for this type of stay should be submitted with the entire length of stay as an
inpatient.
Failure to obtain authorization of an admission will result in an administrative denial of the admission.
Denied authorization requests may be appealed (see Section 5.10.2 Administrative Denials).
To receive authorization for an inpatient admission or observation, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday,
between the hours of 8 a.m. and 5:30 p.m. EST.
Failure to obtain authorization of an admission will result in an administrative denial of the admission
(see Section 2.11).
Denied authorization requests may be appealed (see Section 2.11).
Inpatient Only Codes:
In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select
surgical procedures must be performed in the inpatient setting.
A detailed list of codes may be obtained at the following CMS website:
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf
If a provider performs one of the listed procedures in an outpatient setting and the claim is denied,
they may submit supporting medical records documentation for review through the claims appeals
process.
5.5.2 Inpatient Admissions to Non-Participating Facilities
Requests for admission to non-participating facilities should be submitted to the Passport Health Plan
UM department for review.
To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
5.5.3 Elective Participating-Hospital Transfer Policy
Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient
clinical information will be required to complete the authorization process, approve the transfer, and
determine prospective length of stay.
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Either the transferring or receiving facility may initiate the prior authorization; however, the
transferring facility will be able to provide the most accurate required clinical information. If a hospital
transfer request is made by another Passport Health Plan facility, the receiving facility may request that
the transferring facility obtain the authorization before the case will be accepted at the receiving facility.
The receiving facility should contact Passport Health Plan to confirm the authorization.
In cases deemed emergent, notification of the admission is required within one business day after the
transfer.
To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800)
578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m.
and 5:30 p.m.
5.5.4 Inpatient Rehabilitation Admissions
If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the
on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not
an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan’s
Utilization Management via phone (800) 578-0636 or fax (502) 585-7989.
Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient
Pulmonary Rehab.
If the member is to be directly admitted from home or any other sub-acute facility, contact Passport
Health Plan’s Case Management department at (800) 578-0636 ext. 2024.
5.5.5 Inpatient Skilled-Nursing Facility
Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at
skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport
Health Plan is responsible for costs of professional services, such as physician or therapist services that
are not part of the routine facility service. After a member is in a nursing facility for 31 days, the
disenrollment process begins for that member. Passport Health Plan’s responsibility for those nonfacility services continues for any of its members while they are still enrolled with the Plan. After the
Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the
member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any
services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the
DMS-contracted review entity.
5.6 Outpatient Services
For authorization of select outpatient services listed in Section 5.3, “Authorization Requirements,” the
PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by
fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for
payment.
Page 67 of 331
When requesting a review, at a minimum, documentation submitted must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
Requests for prior authorization of elective services should be received prior to the date the requested
service will be performed.
Requests for authorization of urgent and emergent services must be submitted to UM within one
business day of the procedure being performed.
Passport Health Plan will accept the hospital’s or the attending physician’s request for prior
authorization of elective hospital admissions; however, neither party should assume that the other has
obtained prior authorization.
Failure to obtain prior authorization for an elective procedure / service or failure to request
authorization of an urgent or emergent procedure / service within one business day of the procedure/
service being performed or rendered will result in an administrative denial of the service (see Section
5.10.2). Denied requests may be appealed (see Section 2.11).
The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm
authorization, they may verify online via the online authorization system.
5.6.1 Outpatient Procedures / Diagnostics / Services
Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from
the Plan’s Utilization Management Department.
See Table in section 5.3 for outpatient list.
For authorization of select outpatient services listed in Section 5.3, “Authorization Requirements,” the
provider notifies Passport Health Plan via the online authorization system, telephonically or by fax.
The general UM department phone number is: (800) 578-0636. The general UM department fax
number is (502) 585-7989.
For Outpatient Imaging Services requiring authorization, see section 5.6.2.
5.6.2 Outpatient Radiology Services
Providers are required to obtain authorization for select radiological services through the high dollar
Page 68 of 331
radiology program for advanced diagnostic imaging services. This program is administered in
partnership with MedSolutions (MSI).
Authorizations are required for select diagnostic imaging services performed in an outpatient setting.
Advanced diagnostic imaging includes:
•
•
•
•
Computed Tomography (CT); Computed Tomographic Angiogram (CTA)
Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)
Positron Emissions Tomography (PET)
Nuclear Cardiac Imaging (NCM)
Authorizations are performed at MSI using their own internal criteria and medical management system.
MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is
required for advanced diagnostic imaging services performed in any outpatient setting.
Authorization is NOT required if the imaging service is performed in:
•
•
•
Emergency rooms
Inpatient settings
23-hour observations – Service performed in observation do not require an authorization.
However, the observation stay will still require a review by Passport. There are three (3) ways to request
an authorization:
1. Internet: www.medsolutionsonline.com - Available 24/7
2. Phone: (877) 791-4099
Available 8 a.m. - 9 p.m. EST, Monday through Friday
Toll free
3. Fax: 1-888-693-3210
Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer
Service at (877) 791-4099
Only MedSolutions fax forms are accepted
Available 24/7
See Appendix A for a list of codes that require an authorization.
5.6.3 Durable Medical Equipment
The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical
Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the
supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan
follows Medicare guidelines.
DME PURCHASE
DME items with billable charges greater than $500 require an authorization. Requests for authorization
of purchase MUST be received PRIOR to the end of the rental period.
DME RENTAL
Page 69 of 331
Authorization requirements of rentals are determined by the billable price of the item being rented.
Rental charges will be applied to purchase price.
If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the
rental is greater than $500, authorization is required.
All items requiring customization or accessories require prior authorization.
All mini-nebulizers will be a purchase only item and do not require prior authorization.
Authorization requirements for DME purchases are based on total monthly cost or monthly quantity
of items purchased. The following is a list of purchases with authorization requirements by quantity:
Name Brand Diapers
Item
Generic Diapers
Underpads (Chux)
Ostomy Supplies
Bedside Drainage Bags
Syringes
G-Tube
Compression Stockings
Quantity Limitations
 Regardless of quantity, all requests for name
brand diapers require authorization
 180 per month require authorization
 180 per month require authorization
 2 boxes per month require authorization
 4 per month require authorization
 100 per month require authorization
 1 per month requires authorization
 6 pair per year require authorization
* Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM
department.*
Enteral Products
• Enteral products with allowable amounts greater than $500 for a month’s supply require an
authorization.
These services should be billed according to the fee schedule in your Provider Contract (Allowable
Charges).
For authorization of DME, the provider notifies Passport Health Plan via the online authorization
system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number
is: (502) 585-7990.
For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A.
For a list of Ostomy supplies that require an Authorization, see Appendix B.
5.6.4 Home Health Services
When medically appropriate, home health, private duty nursing, or home hospice care, or home
infusion may be a good alternative to hospitalization. Home health care, including both skilled and
unskilled nursing, and hospice care and home infusion may be appropriate at other times as well.
Page 70 of 331
Prior authorization of all home health / private duty nursing / hospice / home infusion services is
required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse
reviewer, the request may be given directly to the on-site review nurse.
Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be
obtained under EPSDT Special Services.
A request for prior authorization must be received prior to the delivery of the service for a non-urgent
request and within one business day of the service being performed for an urgent or emergent service.
For authorization of Home Health Services, including home health care, private duty nursing and home
hospice, the provider notifies Passport Health Plan through the online authorization system,
telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax
number is: (502) 585-8204.
For authorization of home infusion, the provider should submit the infusion therapy authorization
form to PerformRx via fax at 877-693-8280. The authorization form can be found at
http://www.passporthealthplan.com/pharmacy/resources/priorauth/injectable-forms.aspx.
5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services
Providers are required to obtain prior authorization for physical, occupational, aquatic and speech
therapy for acute and chronic conditions and chiropractic services.
• Therapy
Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required.
If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the
request may be given directly to the onsite review nurse. Review is required for the initial therapy
visit and all subsequent visits.
Requests for continuation of a service that is ongoing should be sent to the therapy department
seven days prior to the end of the authorization period. Please fax request together with progress
notes and current plan of care to (502) 585-8204.
For authorization of therapy requests, providers must notify Passport Health Plan through the online
authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The
therapy fax number is (502) 585-8205.
• Chiropractic Services
Authorization requests for chiropractic services are required after the 12th visit. No authorization is
required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic
visits within a 12-month calendar period.
• Outpatient Rehab Services
Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are
required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse
reviewer, the request may be given directly to the onsite review nurse. For authorization of
Page 71 of 331
chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically
at (502) 585-6055 or via fax at (502) 585-8205.
5.7 High-Cost Medications
Providers are required to obtain prior authorization for High-Cost Medications greater than $400
billable amount per dose from the Utilization Management Department.
This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This
does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.
Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section
14 for prior authorizations related to pharmacy.
For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or
fax the request to (502) 585-7989.
5.8 Prior Authorization for Members with Medicare
Prior authorization is not required for services listed on the prior authorization list when the member
has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies
to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit
covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization
requirements apply for both outpatient and inpatient services.
For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior
authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted
during an inpatient hospitalization, notification to Passport Health Plan must be made within one
business day of the notification to the facility of the exhaustion of benefits by Medicare.
5.9 Retrospective Authorization
Retrospective review of inpatient services is performed when the patient was not a member of Passport
Health Plan prior to or at the time of the service. Outpatient services do not require retrospective
review by Utilization Management for members whose eligibility is determined retrospectively.
Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit
medical records for review and utilization management authorization request. If the practitioner does
not provide documentation, the card issue date, segment date, and claims history are used. A decision
and written notification is provided within ten (10) business days of receipt of the medical information
for the retrospective review request. An administrative denial is issued for retrospective requests when
the provider fails to request a utilization management review of the medical record within the timeframe
specified.
The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written
Page 72 of 331
notification is provided.
Requests received beyond 60 days from the card issue date or from the provider’s documentation of the
date when they were aware of the member’s eligibility will be administratively denied.
Send requests for retrospective review to:
Utilization Management Retrospective Review
5100 Commerce Crossings Drive
Louisville, KY 40229
The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart
review, please send records via mail).
5.10 Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols, medical
policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider
Manual.
Members may not be billed by participating providers for deductibles, copays, and coinsurance except
those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members
must be held harmless for denied services.
To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact
Utilization Management at (800) 578-0636.
5.10.1 Medical Necessity Denials
Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render
review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical
Director for clinical review.
A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a
denial is issued, Utilization Management provides the name, telephone number, title, and office hours
of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is
available to discuss any decision rendered with the attending practitioner.
5.10.2 Administrative Denials
An administrative denial is issued for those services for which the provider has not followed the
requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative
denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may
also be issued for failure to notify Utilization Management within one business day of an emergency
service, procedure, or admission.
A provider may appeal an administrative denial by submitting the appeal request in writing to:
Page 73 of 331
Clinical Appeals Department
5100 Commerce Crossings Drive
Louisville, KY 40229
Appendix A: Radiology Codes
The codes on the list below require authorization through MedSolutions
CPT
®
MRI TMJ
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT Angiography (CTA)
CPT®
Code
70336
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
CT Angiography (CTA)
70498
MRI
MRI
MRI
MRA
MRA
MRA
70540
70542
70543
70544
70545
70546
MRA
MRA
MRA
70547
70548
70549
MRI
MRI
MRI
Functional MRI (fMRI)
70551
70552
70553
70554
Functional MRI (fMRI)
70555
CT
CT
CT
71250
71260
71270
CPT®
Description
MRI Temporomandibular Joint (s)
CT Head without contrast
CT Head with contrast
CT Head with & without contrast
CT Orbit, et al without contrast
CT Orbit, et al with contrast
CT Orbit, et al W & W/O
CT Maxillofacial area, (sinus) without contrast
CT Maxillofacial area, (sinus) with contrast
CT Maxillofacial area, (sinus) W & W/O
CT Soft-tissue Neck without contrast
CT Soft-tissue Neck with contrast
CT Soft-tissue Neck with & without contrast W & W/O
CTA HEAD, with contrast, including noncontrast images, if
performed, & image post-processing
CTA NECK, with contrast, including noncontrast images, if
performed, & image post-processing
MRI Orbit, Face and/or Neck without contrast
MRI Orbit, Face and/or Neck with contrast
MRI Orbit, Face and/or Neck W & W/O
MR Angiography (MRA) Head without contrast
MR Angiography (MRA) Head with contrast
MR Angiography (MRA) Head with and without contrast W &
W/O
MR Angiography (MRA) Neck without contrast
MR Angiography (MRA) Neck with contrast
MR Angiography (MRA) Neck with and without contrast W &
W/O
MRI Brain (Head) without contrast
MRI Brain (Head) with contrast
MRI Brain (Head) with and without contrast W & W/O
MRI Brain, functional MRI; including test selection and
administration of repetitive body part movement and/or visual
stimulation, not requiring physician or psychologist administration
MRI, Brain, functional MRI; requiring physician or psychologist
administration of entire neurofunctional testing
CT Chest without contrast
CT Chest with contrast
CT Chest with and without contrast W & W/O
Page 74 of 331
CPT
®
CT Angiography (CTA)
CPT®
Code
71275
MRI
MRI
MRI
MRA
71550
71551
71552
71555
CT
CT
CT
CT
CT
CT
CT
CT
CT
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRI
MRA
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
CT Angiography (CTA)
72191
CT
CT
CT
MRI
MRI
MRI
MRA
CT
CT
CT
CT Angiography (CTA)
72192
72193
72194
72195
72196
72197
72198
73200
73201
73202
73206
MRI
MRI
MRI
MRI
MRI
MRI
73218
73219
73220
73221
73222
73223
CPT®
Description
CTA CHEST, (non-coronary), with contrast, including noncontrast
images, if performed, & image post-processing
MRI Chest without contrast
MRI Chest with contrast
MRI Chest with and without contrast W & W/O
MR Angiography (MRA) Chest (excluding myocardium)- W or
W/O
CT Cervical Spine without contrast
CT Cervical Spine with contrast
CT Cervical Spine with and without contrast W & W/O
CT Thoracic Spine without contrast
CT Thoracic Spine with contrast
CT Thoracic Spine with and without contrast W & W/O
CT Lumbar Spine without contrast
CT Lumbar Spine with contrast
CT Lumbar Spine with and without out contrast W & W/O
MRI Cervical Spine without contrast
MRI Cervical Spine with contrast
MRI Thoracic Spine without contrast
MRI Thoracic Spine with contrast
MRI Lumbar Spine without contrast
MRI Lumbar Spine with contrast
MRI Cervical Spine with and without contrast W & W/O
MRI Thoracic Spine with and without contrast W & W/O
MRI Lumbar Spine with and without contrast W & W/O
MR Angiography (MRA) Spinal Canal and contents -with or w/o
contrast
CTA PELVIS, with contrast, including noncontrast images, if
performed, & image post-processing
CT Pelvis without contrast
CT Pelvis with contrast
CT Pelvis with and without contrast W & W/O
MRI Pelvis without contrast
MRI Pelvis with contrast
MRI Pelvis with and without contrast W & W/O
MR Angiography (MRA) Pelvis -with or without contrast
CT Upper Extremity without contrast
CT Upper Extremity with contrast
CT Upper Extremity with and without contrast W & W/O
CTA Upper Extremity, with contrast, including noncontrast
images, if performed, & image postprocessing
MRI Upper Extremity-other than joint-without contrast
MRI Upper Extremity-other than joint-with contrast
MRI Upper Extremity-other than joint-W & W/O
MRI Any Joint of Upper Extremity--without contrast
MRI Any Joint of Upper Extremity--with contrast
MRI Any Joint of Upper Extremity—W & W/O
Page 75 of 331
MRA
CPT
®
CPT®
Code
73225
CT
CT
CT
CT Angiography (CTA)
73700
73701
73702
73706
MRI
MRI
MRI
MRI
MRI
MRI
MRA
73718
73719
73720
73721
73722
73723
73725
CT
CT
CT
CT Angiography (CTA)
74150
74160
74170
74174
CT Angiography (CTA)
74175
CT
CT
CT
MRI
MRI
MRI
MRA
Diagnostic CT
Colonography (CTC)
Diagnostic CT
Colonography (CTC)
74176
74177
74178
74181
74182
74183
74185
74261
CT Colonography (CTC)
for Screening
Cardiac MRI
Cardiac MRI
74263
Cardiac MRI
75561
Cardiac MRI
75563
Cardiac MRI
75565
74262
75557
75559
CPT®
Description
MR Angiography (MRA) Upper Extremity -with or without
contrast
CT Lower Extremity without contrast
CT Lower Extremity with contrast
CT Lower Extremity with and without contrast W & W/O
CTA Lower Extremity, with contrast, including noncontrast
images, if performed, & image postprocessing
MRI Lower Extremity-other than joint-without contrast
MRI Lower Extremity-other than joint-with contrast
MRI Lower Extremity-other than joint- W & W/O
MRI Any Joint of Lower Extremity--without contrast
MRI Any Joint of Lower Extremity--with contrast
MRI Any Joint of Lower Extremity—W & W/O
MR Angiography (MRA) Lower Extremity-with or without
contrast
CT Abdomen without contrast
CT Abdomen with contrast
CT Abdomen with and without contrast W & W/O
Computed tomographic angiography; abdomen and pelvis; with
contrast material(s), including noncontrast images, if performed, and
image postprocessing
CTA ABDOMEN, with contrast, including noncontrast images, if
performed, & image postprocessing
CT Abdomen & Pelvis, without contrast
CT Abdomen & Pelvis, with contrast
CT Abdomen & Pelvis, with and without contrast
MRI Abdomen without contrast
MRI Abdomen with contrast
MRI Abdomen with and without contrast W & W/O
MR Angiography (MRA) Abdomen-with or without contrast
Computed tomographic (CT) colonography, diagnostic, including
image postprocessing; without contrast material
Computed tomographic (CT) colonography, diagnostic, including
image postprocessing; with contrast material(s) including noncontrast images, if performed
Computed tomographic (CT) colonography, screening, including
image postprocessing
Cardiac MRI for morphology and function without contrast
Cardiac MRI for morphology and function without contrast
material; with stress imaging
Cardiac MRI for morphology and function without contrast,
followed by contrast W & W/O
Cardiac MRI for morphology and function without contrast,
followed by contrast; with stress imaging
Cardiac magnetic resonance imaging for velocity flow mapping
(List separately in addition to code for primary procedure)
Page 76 of 331
CPT
®
Cardiac CT Calcium
Scoring
Cardiac CT
CPT®
Code
75571
CPT®
Description
CT, heart, without contrast with quantitative
75572
CT, heart, with contrast material, for evaluation of cardiac
structure and morphology (including 3D image post processing,
assessment of cardiac function, and evaluation of venous structures,
if performed)
Cardiac CT
75573
CT, heart, with contrast material, for evaluation of cardiac
structure and morphology in the setting of congenital heart disease
(including 3D image post processing, assessment of cardiac LV
function, RV structure and function and evaluation of venous
structures, if performed)
CT Coronary
Angiography (CTCA)
75574
CT, heart, coronary arteries and bypass grafts (when present),
with contrast material, including 3D image post processing
(including evaluation of cardiac structure and morphology,
assessment of cardiac function, and evaluation of venous
structures, if performed)
CT Angiography (CTA)
75635
3D Rendering
3D Rendering
CT
MR Spectroscopy (MRS)
Unlisted CT
Unlisted MR
CT guidance
CT guidance
76376
76377
76380
76390
76497
76498
77011
77012
CT guidance
MR Guidance
MR Guidance
Breast MRI
Breast MRI
CT Bone Density
MRI Bone Marrow
Nuclear Cardiac Imaging
77013
77021
77022
77058
77059
77078
77084
78451
CTA ABDOMINAL AORTA and bilateral iliofemoral lower
extremity runoff, with contrast, including noncontrast images, if
performed, and image post-processing
3D Rendering with interpretation and reporting of CT,
3D Rendering with interpretation and reporting of CT,
CT Limited or Localized follow-up
MR Spectroscopy (MRS)
Unlisted CT procedure (eg, diagnostic, interventional)
Unlisted MR procedure (eg, diagnostic, interventional)
CT guidance stereotactic localization
CT guidance needle placement (eg, biopsy, aspiration, injection,
localization device)
CT Guidance for, and monitoring of, parenchymal tissue
MR guidance for needle placement (eg, for biopsy,
MR guidance for, and monitoring of, parenchymal tissue
MRI BREAST, without and/or with contrast UNILATERAL
MRI BREAST, without and/or with contrast BILATERAL
CT BONE MINERAL DENSITY study, 1 or more sites, axial
MRI Bone Marrow blood supply
Myocardial perfusion imaging, tomographic (SPECT) (including
attenuation correction, qualitative or quantitative wall motion,
ejection fraction by first pass or gated technique, additional
quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)
Nuclear Cardiac Imaging
78452
Myocardial perfusion imaging, tomographic (SPECT) (including
attenuation correction, qualitative or quantitative wall motion, ejection
fraction by first pass or gated technique, additional quantification,
when performed); multiple studies, at rest and/or stress (exercise or
pharmacologic) and/or redistribution and/or rest reinjection
Page 77 of 331
CPT
®
Nuclear Cardiac Imaging
CPT®
Code
78453
CPT®
Description
Myocardial perfusion imaging, planar (including qualitative or
quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); single study,
at rest or stress (exercise or pharmacologic)
Nuclear Cardiac Imaging
78454
Myocardial perfusion imaging, planar (including qualitative or
quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); multiple
studies, at rest and/or stress (exercise or pharmacologic) and/or
redistribution and/or rest reinjection
Cardiac PET
Nuclear Cardiac Imaging
78459
78466
Nuclear Cardiac Imaging
78468
Nuclear Cardiac Imaging
Nuclear Cardiac Imaging
78469
78472
Nuclear Cardiac Imaging
78473
Nuclear Cardiac Imaging
78481
PET Cardiac (myocardial imaging) – metabolic evaluation
Myocardial Imaging, infarct avid, planar; qualitative or
quantitative
Myocardial Imaging, infarct avid, planar; w/ EF by first pass
technique
Myocardial Imaging, infarct avid, planar; tomographic SPECT
Cardiac Blood Pool imaging, gated equilibrium; planar, single
study at rest or stress
Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall
motion plus ejection fraction, at rest and stress
Cardiac Blood Pool imaging, (planar), first pass technique; single
study, at rest or with stress, wall motion study plus ejection
fraction
Nuclear Cardiac Imaging
78483
Cardiac PET
78491
Cardiac PET
78492
Nuclear Cardiac Imaging
Nuclear Cardiac Imaging
78494
78496
Unlisted Nuclear
Cardiology
Non-Cardiac PET
Non-Cardiac PET
Non-Cardiac PET
Non-Cardiac PET
Non-Cardiac PET
Non-Cardiac PET
78499
78608
78609
78811
78812
78813
78814
PET Brain – metabolic evaluation
PET Brain – perfusion evaluation
PET imaging; limited area (eg, chest, head/neck)
PET imaging; skull base to mid-thigh
PET imaging; whole body
PET imaging with concurrently acquired CT for attenuation
correction and anatomical localization; limited area (eg, chest,
head/neck)
Non-Cardiac PET
78815
Non-Cardiac PET
78816
Ceberal Perfusion
0042T
PET imaging with concurrently acquired CT for attenuation
correction and anatomical localization; skull base to mid-thigh
PET imaging with concurrently acquired CT for attenuation
correction and anatomical localization; whole body
Ceberal Perfusion Analysis using CT with contrast
Cardiac Blood Pool imaging, (planar), first pass technique;
multiple studies at rest and with stress, wall motion study plus
ejection fraction
PET Cardiac (myocardial imaging), perfusion single study at rest
or stress
PET Cardiac (myocardial imaging), perfusion multiple studies
rest/stress
Cardiac Blood Pool imaging, gated equilibrium, SPECT
Cardiac Blood Pool imaging, gated equilibrium, RV EF by first
pass
Unlisted Nuclear Cardiology diagnostic nuclear
Page 78 of 331
CPT
®
Analysis
CAD for Breast MRI
Magnetic Source
Imaging
MRCP
MRI Low field
Cardiac CT Calcium
Scoring
CPT®
Code
CPT®
Description
0159T
S8035
CAD, including computer algorithm analysis, BREAST
Magnetic Source Imaging
S8037
S8042
S8092
MRCP (Magnetic ResonancE)
MRI Low field
CT ELECTRON BEAM (Ultrafast CT) for calcium scoring
Page 79 of 331
Appendix B – Orthotics and Prosthetics (L codes)
AUTHORIZATION REQUIRED
HCPCS Description
L0113
Cranial cervical orthosis, torticollis type,
w/wo joint, w/o soft interface, prefab.
Incl. fitting & adj.
L0130
Flex thermoplastic collar molded to
patient
L0170
Cervical collar molded to pt
L0220
Thor rib belt custom fabrica
L0430
Spinal orthosis, Dewall posture
protector
HCPC Description
L5460 Postop app non-wgt bear dsg
L0452
L0456
L0460
L0462
L0464
L0480
L0482
L0484
L0486
L0488
L0491
L0622
L0623
L0624
L0629
L0631
L0632
L0634
L5500
Init bk ptb plaster direct
L5505
L5510
L5520
Init ak ischal plstr direct
Prep BK ptb plaster molded
Perp BK ptb thermopls direct
TLSO flexible, provides trunk support,
upper thoracic region, customized
TLSO, flexible thoracic region, prefab
L5530
Prep BK ptb thermopls molded
L5535
Prep BK ptb open end socket
TLSO, triplanar control prefab
TLSO, triplanar control, prefab
TLSO, triplanar control 4 piece rigid
plastic with interface, prefab
TLSO, triplanar control, one piece rigid
plastic shell
TLSO, triplanor, custom fabricated, one
piece rigid plastic shell, each
TLSO, triplanor control, two piece
L5540
L5560
L5570
Prep BK ptb laminated socket
Prep AK ischial plast molded
Prep AK ischial direct form
L5580
Prep AK ischial thermo mold
L5585
Prep AK ischial open end
L5590
Prep AK ischial laminated
TLSO, triplanor control 2 piece rigid
plastic with interface, custom
TLSO triplanor, one piece, prefab
TLSO 2 rigid plastic shells, pre fab
Sacroiliac orthosis, flexible, custom
Sacroiliac orthosis, rigid or semi-rigid,
pre fab
Sacroiliac orthosis, rigid or semi-rigid,
custom
Lumbar-sacral orthosis, flexible, custom
Lumbar-sacral orthosis, sagittal control,
pre fab
Lumbar-sacral orthosis, sag. Control,
rigid ant./post. Custom
Lumbar-sacral orthosis, sag. Control,
rigid post., custom
L5595
Hip disartic sach thermopls
L5600
L5610
L5611
L5613
Hip disart sach laminat mold
Above knee hydracadence
Ak 4 bar link w/fric swing
Ak 4 bar ling w/hydraul swig
L5614
4-bar link above knee w/swng
L5616
L5639
Ak univ multiplex sys frict
Below knee wood socket
L5643
Hip flex inner socket ext fr
L5645
Ak flexibl inner socket ext
Page 80 of 331
L0635
Lumbar-sacral orthosis, sag-coronal
control, prefab
Lumbar-sacral orthosis, sag-coronal
control, custom
Lumbar-sacral orthosis, sag-coronal
control, rigid ant/post., prefab
Lumbar-sacral orth, sag-coronal control,
rigid ant./post., custom
Lumbar-sacral orthosis, sag.-coronal
control, rigid post. Prefab
Lumbar-sacral orthosis, sag-coronal
control, rigid post., custom
L5647
Below knee suction socket
L5648
Above knee air cushion socket
L5649
Isch containmt/narrow m-l so
L5651
Ak flex inner socket ext fra
L5670
Bk molded supracondylar susp
L5673
L0700
Ctlso a-p-l control molded
L5679
L0710
Ctlso a-p-l control w/ inter
L5681
L0810
L0820
Halo cervical into jckt vest
Halo cervical into body jack
L5682
L5683
L0830
L0999
L1000
L1001
L1200
L1300
L1310
L1499
L1500
L1510
L1520
L1680
L1685
L1686
L1690
Halo cerv into milwaukee typ
Addition to spinal orthosis, NOS
Ctlso milwauke initial model
Cervical TLSO, infant, prefab
Furnsh initial orthosis only
Body jacket mold to patient
Post-operative body jacket
Spinal orthosis NOS
Thkao mobility frame
Thkao standing frame
Thkao swivel walker
Pelvic & hip control thigh c
Post-op hip abduct custom fa
HO post-op hip abduction
Combination bilateral LS/hip/femur
L5700
L5701
L5702
L5704
L5705
L5706
L5707
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
below knee/above knee socket insert,
silicone gel or elastomeric w/locking
mech, custom
below knee/above knee socket insert,
silicone gel or elastomeric no locking
mech, custom
below knee/above knee, custom fab.
Socket inset initial only for cong. Or
atypical
Bk thigh lacer glut/ischia molded
below knee/above knee, custom fab,
socket inset, initial only not cong.or
atypical
Replace socket below knee
Replace socket above knee
Replace socket hip
Custom shape covr below knee
Custom shape cover above knee
Custom shape cvr knee disart
Custom shape cover hip disart
Knee-shin exo mech stance ph
Knee-shin exo frct swg & sta
Knee-shin pneum swg frct exo
Knee-shin exo fluid swing ph
Knee-shin ext jnts fld swg e
Knee-shin fluid swg & stance
Knee-shin pneum/hydra pneum
Addt. to lower limb prosthesis, vacuum
pump, residual limb volume management
and moisture evacuation system
L1700
L1710
L1720
Legg perthes orth toronto typ
Legg perthes orth newington
Legg perthes orthosis trilat
L5782
L5790
L5795
L0636
L0637
L0638
L0639
L0640
Page 81 of 331
Addt. To lower leg prosth. Vacuum
Exoskeletal ak ultra-light m
Exoskel hip ultra-light mate
L1730
L1755
L1832
L1834
L1840
L1843
Legg perthes orth scottish
Legg perthes patten bottom
KO adj jnt pos rigid support
KO w/0 joint rigid molded to
KO derot ant cruciate custom
KO single upright thigh & calfprefabricated, each
KO w/adj jt rot cntrl molded
KO w/ adj flex/ext rotat cus
KO w adj flex/ext rotat mold
KO supracondylar socket mold
AFO molded ankle gauntlet
supramalleolar w/straps w/wo
interface/pads, custom fabricated
AFO, rigid anterior tibial section,pre fab,
incl. Fitting & adj.
L5811
L5814
L5816
L5818
L5822
L5824
Endo knee-shin mnl lck ultra
Endo knee-shin hydral swg ph
Endo knee-shin polyc mch sta
Endo knee-shin frct swg & st
Endo knee-shin pneum swg frc
Endo knee-shin fluid swing p
L5826
L5828
L5830
L5840
L5845
L5848
Miniature knee joint
Endo knee-shin fluid swg/sta
Endo knee-shin pneum/swg pha
Multi-axial knee/shin system
Knee-shin sys stance flexion
Knee-shin system dampening feature
L5856
L1940
AFO, plastic or other material custom
L5857
L1945
AFO molded plas rig ant tib
L5858
L1950
L1951
L5930
L5950
L1960
L1970
AFO spiral molded to pt plas
spiral, IRM type, plastic or other
material prefab, incl. Fitting and adj.
AFO pos solid ank plastic mo; custom
AFO plastic molded w/ankle j
Addt. To lower ext. prosthesis, knee
shin sys.,microprocessor, incl. Sensor,
any type
Addt. To lower ext. prosth., swing
phase only knee shin sys.,micro, incl.
Sensor , any type
Addt. To lower ext. prosth, knee shin
sys.,micro, incl. Sens , stance phase
High activity knee frame
Endo ak ultra-light material
L1980
L1990
L2000
AFO sing solid stirrup calf custom
AFO doub solid stirrup calf; custom
KAFO using fre stirr thi/calf; custom
L5966
L5968
L5973
L2005
KAFO any material, single or dbl. Upright
includes ankle joint custom fabricated
KAFO single upright, free ankle, solid
stirrup
KAFO dbl solid stirrup band/
KAFO dbl solid stirrup w/o j
KAFO full plastic, single upright, w/wo
free motion knee,custom fabricated
KAFO plas doub free knee mol
KAFO plas sing free knee mol
KAFO w/o joint multi-axis an
Hkafo torsion cable hip pelv; custom
L5976
Endo hip ultra-light materia
addt. Endoskeleton above knee,
flexible protective outer surface
Hip flexible cover system
Multiaxial ankle w dorsiflex
Endoskeletal ankle foot system,
microprocessor, incl. power source
Energy storing foot
L5979
Multi-axial ankle/ft prosth
L5980
L5981
L5987
Flex foot system
Flex-walk sys low ext prosth
Shank ft w vert load pylon
L5988
L5990
L5999
L6000
Vertical shock reducing pylo
addt. To lower ext. user adj. ht
Lower extremity prosthesis, NOC
Par hand robin-aids thum rem
L1844
L1845
L1846
L1860
L1904
L1907
L1932
L2010
L2020
L2030
L2034
L2036
L2037
L2038
L2050
L5960
L5964
Page 82 of 331
L2060
L2070
L2080
L2090
L2106
L2108
L2116
L2126
L2128
L2132
L2134
L2136
L2232
L6010
L6020
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
Hand robin-aids little/ring
Part hand robin-aids no fing
Wrst MLd sck flx hng tri pad
Wrst mold sock w/exp interfa
Elb mold sock flex hinge pad
Elbow mold sock suspension t
Elbow mold doub splt soc ste
Elbow stump activated lock h
Elbow mold outsid lock hinge
Elbow molded w/ expand inter
Elbow inter loc elbow forarm
Shlder disart int lock elbow
Shoulder passive restor comp
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6400
L6450
L6500
L6550
L6570
Shoulder passive restor cap
Thoracic intern lock elbow
Thoracic passive restor comp
Thoracic passive restor cap
Postop dsg cast chg wrst/elb
Postop dsg cast chg elb dis/
Postop dsg cast chg shlder/t
Below elbow prosth tiss shap
Elb disart prosth tiss shap
Above elbow prosth tiss shap
Shldr disar prosth tiss shap
Scap thorac prosth tiss shap
L6580
Wrist/elbow bowden cable mol
L6582
L6584
Wrist/elbow bowden cbl dir f
Elbow fair lead cable molded
L3201
L3202
L3203
L3204
Hkafo torsion ball bearing j; custom
Hkafo torsion unilat rot str; custom
Hkafo unilat torsion cable, custom
Hkafo unilat torsion ball br, custom
AFO tib fx cast plaster mold, custom
AFO tib fx cast molded to pt
Afo tibial fracture rigid
Kafo fem fx cast thermoplas
Kafo fem fx cast molded to p
Kafo femoral fx cast soft
Kafo fem fx cast semi-rigid
Kafo femoral fx cast rigid
Addt. To lower extremity orthosis,
rocker bottom, custom fabricated only
Molded inner boot
Lacer molded to patient, custom
Pre-tibial shell molded to p
Prosthetic type socket molded
Th/wght bear quad-lat brim m
Th/wght bear quad-lat brim custom
Th/wght bear m-l brim mo
Th/wght bear m-l brim cu
Thigh/wght bear lacer molded
Plastic mold recipro hip & c
Metal frame recipro hip & ca
Orthotic side bar, Disconnect device,
each
addt. to lower ext-joint, knee or ankle,
custom only, each
Lower extremity orthosis NOS
Foot arch support, removable,
premolded, longitudinal & horizontal,
each
Oxford w supinator/pronator inf each
Oxford w supinator/pronator child each
Oxford w supinator/pronator jun each
Hightop w supp/pronator infant each
L6586
L6588
L6590
L6611
L3206
L3207
L3208
Hightop w supp/pronator child each
Hightop w supp/pronator junior each
Surgical boot, each infant
L6623
L6624
L6638
Elbow fair lead cable dir fo
Shdr fair lead cable molded
Shdr fair lead cable direct
Addt. To upper ext. prosthesis, ext. pwr
switch addt.
Spring-asst. rot wrst w/ latch
Upper ext. addt. Flex. Ext rotation wrist
upper ext addt. To prosth. Electric
locking only for use with manually
powered elbow
L2280
L2330
L2340
L2350
L2510
L2520
L2525
L2526
L2540
L2627
L2628
L2768
L2861
L2999
L3060
Page 83 of 331
L3209
L3211
L3212
L3213
L3214
Surgical boot, each child
Surgical boot, each junior
Benesch boot pair infant
Benesch boot pair child
Benesch boot pair junior
L6686
L6689
L6690
L6693
L6694
L3215
Orthopedic ftwear ladies oxf each
L6695
L3216
Orthopedic ftwear ladies depth each
L6696
L3217
Ladies shoes hightop depth each
L6697
L3219
Orthopedic mens shoes oxford each
L6707
L3221
Orthopedic mens shoes dpth each
L6708
L3222
Mens shoes hightop depth inl each
L6709
L3224
Woman's shoe oxford brace each
L6712
L3225
Man's shoe oxford brace each
L6713
L3230
Custom shoes depth inlay each
L6714
L3250
Custom mold shoe remov prost each
L6721
L3251
Shoe molded to pt silicone s each
L6722
Terminal device, hook or hand, heavy
duty, mechanical, vol. closing, any
material, any size, lined or unlined,
each
L3252
Shoe molded plastazote cust each
L6881
L3253
Shoe molded plastazote cust each
L6882
L3254
L3255
L3257
L3330
Orth foot non-std size/w
Orth foot non-std size/w
Orth foot add charge split
Lift elevation, metal extension, (skate)
each
L6895
L6900
L6905
L6910
Automatic grasp, addt. To upper limb
elect. Prosth. Terminal device
Microprocessor control feature, addt.
To upper limb prosth. Terminal device
Custom glove
Hand restorat thumb/1 finger
Hand restoration multiple fi
Hand restoration no fingers
Page 84 of 331
Suction socket
Frame typ socket shoulder di
Frame typ sock interscap-tho
Locking elbow forearm cntrbal
Add. To upper ext. pros.,for use with
locking mechanism
Add. To upper ext. pros., not for use
with locking mechanism, custom
Add. To upper ext. pros., congenital or
atypical traumatic amputees, initial
only
Add. To upper ext. pros., other than
congenital or traumatic amputees,
initial only
term dev hook, mech vol closing, any
material, any size, lined or unlined
term dev, hand, mech vol opening, any
material, any size
term dev hand, mech vol. closing, any
material, any size
Terminal device, hook,mechanical vol.
closing, any material, any size, lined or
unlined, Pediatric, each
Terminal device, hand, mechanical, vol.
opening, any material, any size,lined or
unlined, Pediatric, each
Terminal device, mechanical, vol.
closing, any material, any size,
Pediatric, each
terminal device, hook or hand, hvy,
dty., mechanical, vol.opening, any
material, any size, lined or unlined,
each
L3649
L3671
L3702
orthopedic shoe modification NOS
Shoulder othosis, cap design w/o joints
elbow orthosis w/o joints, may include
soft interface, straps, custom fabricated
incl. fitting & adj.
L6915
L6920
L6925
Hand restoration replacmnt g
Wrist disarticul switch ctrl
Wrist disart myoelectronic c
L3720
L3730
L3740
L3763
Forearm/arm cuffs free motio
Forearm/arm cuffs ext/flex a
Cuffs adj lock w/ active con
elbow wrist hand orthosis rigid w/o
joints custom fab incl. fitting & adj.
WHFO, incl. 1 or more nontorsion joints.
Custom
WHFO, rigid w/o joints, custom,
Addt. to upper ext. joint, wrist, or
elbow, custom fabricated only, each
Hinge extension/flex wrist/f
Hinge ext/flex wrist finger
Whfo electric custom fitted
wrist/hand orthosis custom
L6930
L6935
L6940
L6945
Below elbow switch control
Below elbow myoelectronic ct
Elbow disarticulation switch
Elbow disart myoelectronic c
L6950
Above elbow switch control
L6955
L6960
Above elbow myoelectronic ct
Shldr disartic switch contro
L6965
L6970
L6975
L7007
L3906
L3907
L3913
Wrist hand orthosis, w/o joints, custom
Whfo wrist gauntlt thmb spica
Hand finger orthosis, w/o joints, may
include soft interface, straps, custom
fabricated, incl fitting & adjustment,
each
L7008
L7009
L7040
Shldr disartic myoelectronic
Interscapular-thor switch ct
Interscap-thor myoelectronic
elect. Hand, myoelectric or switch,
adult
elect. Hand, myoelectric or switch, ped
elect hook, switch or myoelect, adult
Prehensile actuator switch controlled
L3927
L7045
Electric hook, switch or myoelectric
controlled, pediatric
L7170
Electronic elbow hosmer swit
L7180
Electronic elbow utah myoele
L3960
Finger orthosis, PIP/DIP, non-torsion
w/o joint/spring, ext./flex., pre-fab, incl
fitting & adj., each
Finger orthosis, w/o joints, may include
soft interface, custom fabricated, incl.
fitting & adjustment, each
addt. Of joint to upper ext orth. any
material, per joint
Sewho airplan desig abdu pos
L7181
L3962
Sewho erbs palsey design abd
L7185
L3964
L3965
L3966
L3968
L3969
L3971
Seo mobile arm sup att to wc
Arm supp att to wc rancho ty
Mobile arm supports reclinin
Friction dampening arm supp
Monosuspension arm/hand supp
SEHWO, shoulder cap design, custom
fabricated
L7186
L7190
L7191
L7260
L7261
L7266
electronic elbow, sim. Control of elbow
and terminal device
electronic elbow, sim. Variety Village or
equal switch control
Electron elbow child switch
Elbow adolescent myoelectron
Elbow child myoelectronic ct
Electron wrist rotator otto
Electron wrist rotator utah
Servo control steeper or equ
L3806
L3808
L3891
L3900
L3901
L3904
L3905
L3933
L3956
Page 85 of 331
L3999
L7272
Analogue control unb or equa
L7274
L7499
Proportional ctl 12 volt uta
Upper extremity prosthesis NOS
L4010
L4020
L4030
Upper limb orthosis, not otherwise
specified
Repl girdle milwaukee orth
Replacement strap, any orthosis,
includes all components, any lgth., any
type
Replace trilateral socket brim
Replace quadlat socket brim
Replace socket brim cust fit
L7500
L7510
L7520
L4040
L4050
L4205
L4210
Replace molded thigh lacer
Replace molded calf lacer
Repair orthotic device per 15 min labor
repair or replace minor parts
L7600
L7900
L8000
L8001
L5000
Sho insert w arch toe filler
L8002
L5010
L5020
L5050
Mold socket ank hgt w/ toe f
Tibial tubercle hgt w/ toe f
Ank symes mold sckt sach ft
L8020
L8030
L8031
L5060
L5100
L5105
Symes met fr leath socket ar
Molded socket shin sach foot
Plast socket jts/thgh lacer
L8035
L8039
L8040
L5150
Mold sckt ext knee shin sach
L8041
L5160
Mold socket bent knee shin s
L8042
L5200
Knee sing axis fric shin sach
L8043
L5210
No knee/ankle joints w/ ft b
L8044
L5220
No knee joint with artic ali
L8045
L5230
Fem focal defic constant fri
L8046
L5250
Hip canadian sing axi cons fric
L8047
L5270
Tilt table locking hip sing
L8048
L5280
Hemipelvect canadian sing axis
L8049
Prosthetic dvc repair hourly
Repair of prosthetic device, minor parts
Repair prosthetic device, labor
component, per 15 min
Prosthetic donning sleeve, any material
Vacuum erection system
Mastectomy bra - 5 per year
Breast prosthesis , masectomy bra with
integrated breast prothesis form,
unilateral - 5 per year
Breast prosthesis, masectomy bra with
integrated breast prothesis form,
bilateral - 5 per year
Mastectomy form - 2 per year
Breast prosthesis silicone/e - 2 per year
Breast prosthesis, silicone or equal,
with intergral adhesive, each
Custom breast prosthesis
Breast prosthesis, NOS
Nasal prothesis, provided by a nonphysician
Midfacial prothesis, provided by a nonphysician
Orbital prothesis, provided by a nonphysician
Upper facial prosthesis, provided by a
non-physician
Hemi-facial prosthesis, provided by a
non-physician
Prosthetic External Ear provided by a
non-physician
Partial facial prosthesis, provided by a
non-physician
Nasal septal prosthesis, provided by a
non-physician
Unspecified Maxillofacial Prosthesis, by
a non-physician
Repair or modification of maxillofacial
prosthesis, by a non-physician
L4000
L4002
Page 86 of 331
L5301
L8499
Unlisted Misc prosthetic service
L8500
artifical larynx
L8501
Tracheostomy speaking valve
L8505
Artificial larynx replacement
battery/accessory, any type, each
L8619
cochlear implant external speech
processor replacement
L5400
Below Knee molded socket, shin each
foot, endosketal system
Knee disarticulation , molded socket,
external knee joints, shin,sach foot endo
Above Knee, molded socket, open end,
sach foot, endoskelttal system, single
axis knee
Hip disarticulation, Canadian type,
molded socket endoskeletal system, hip
joint, single
Hemipelvectomy, Canadian type,
molded socket, endoskeletal hip joint
single axis knee
Postop dress & 1 cast chg bk
L8627
L5410
Postop dsg bk ea add cast ch
L8628
L5420
Postop dsg & 1 cast chg ak/d
L8629
Cochlear implant, external speech
processor, component, replacement
Cochlear implant, external controller
component, replacement
Transmitting coil and cable, integrated
for use with cochlear implant device,
replacement
L5430
Postop dsg ak ea add cast ch
L8691
L5450
Postop app non-wgt bear dsg
L5311
L5321
L5331
L5341
auditory osseointegrated dev, ext.
sound replacer, repl only
AUTHORIZATION NOT REQUIRED
HCPCS
L0120
L0140
L0150
L0160
Description
Cerv flexible non-adjustable
Cervical semi-rigid adjustab
Cerv semi-rig adj molded chn
Cerv semi-rig wire occ/mand
HCPC
L3670
L3675
L3710
L3760
L0172
Cerv col thermplas foam 2 piece
L3762
L0174
Cerv col foam 2 piece w thor
L3807
L0180
L0190
Cer post col occ/man sup adj
Cerv collar supp adj cerv ba - 1 Per Year
*
Cerv col supp adj bar & thor - 1 per
L3908
L3912
Description
Acromio/clavicular canvas&we
Canvas vest SO
Elbow elastic with metal joi
Elbow orthosis, adj position locking
joints, prefab, inc fitting and adj
Elbow orthosis rigid, w/o joints, prefab,
soft interface, incl. Fitting/adj.
WHFO w/o joints, prefab includes
fitting and adjustments any type
Wrist cock-up non-molded
Flex glove w/elastic finger
L3915
WHFO, rigid with 1 or more joints,
L0200
Page 87 of 331
L0450
L0454
L0466
year *
TLSO flexible, provides trunk support,
uper thoracic region, prefab
TLSO, Flexible, provides trunk support,
sacrococcygeal juntion to T-9, prefab
TLSO Sagittal control, prefab
L3917
L3923
L3925
prefab,
hand orthosis, metacarpal fracture
orthosis, prefab, incl fitting and adj.
Hand finger orthosis, without joint,
prefab, inc fitting and adj
Finger orthosis, PIP/DIP, non-torsion
joint/spring, ext./flex., pre-fab, incl
fitting & adj., each
Hand finger orthosis, incl. 1 or more
nontorsion joints, turnbuckles, elastic
bands/spring, straps, pre-fab, incl.
fitting & adj., each
L0468
TLSO sagittal-coronol control, rigid
posterior frame - 1 per year *
L3929
L0470
TLSO triplanar control - 1 per year *
L3931
Wrist, hand, finger orthosis, incl. 1 or
more nontorsion joints,turnbuckles,
elastic bands/springs, straps, pre-fab,
incl. fitting & adj., each
L0472
TLSO, triplanar control, hyperextension
prefab - 1 per year *
TLSO sagittal coronal control one piece
prefab
TLSO 3 rigid plastic shells, pre fab - 1
per year *
Sacroiliac orthosis, flexible, pre fab
Lumbar orthosis, flexible, pre fab
Lumbar orthosis, sagittal control, pre
fab
Lumbar orthosis, sagittal control with
rigid ant./post. Panels, pre fab
Lumbar-sacral orthosis, flexible, pre fab
Lumbar-sacral orthosis, sag. Control,
pre fab
Lumbar-sacral orthosis, sag. Control,
rigid post., pre fab
Tlso corset front
Lso corset front
Tlso full corset
Lso full corset
Axillary crutch extension
Peroneal straps pair
Stocking supp grips set of 4
Protective body sock each
Ctlso axilla sling
Kyphosis pad
Kyphosis pad floating
Lumbar bolster pad
L3970
Elevat proximal arm support
L3972
Offset/lat rocker arm w/ ela
L3974
Mobile arm support supinator
L3980
L3982
L3984
Upp ext fx orthosis humeral
Upper ext fx orthosis rad/ul
Upper ext fx orthosis wrist
L3995
L4045
L4055
Add. To upper ext. sock, fracture, or
equal, each
Replace non-molded thigh lac
Replace non-molded calf lace
L4060
Replace high roll cuff
L4070
L4080
L4090
L4100
L4110
L4130
L4350
L4360
L4370
L4380
L4386
L4394
Replace prox & dist upright
Repl met band kafo-afo prox
Repl met band kafo-afo calf/
Repl leath cuff kafo prox th
Repl leath cuff kafo-afo cal
Replace pretibial shell
Pneumatic ankle cntrl splint
Pneumatic walking splint
Pneumatic full leg splint
Pneumatic knee splint
Non-pneumatic walking boot
Replacement Foot Drop Splint
L0490
L0492
L0621
L0625
L0626
L0627
L0628
L0630
L0633
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L1010
L1020
L1025
L1030
Page 88 of 331
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L4396
L4398
L5617
L5618
L5620
L5622
L5624
L5626
L5628
Static AFO
Foot drop splint recumbent
AK/BK self-aligning unit ea
Test socket symes
Test socket below knee
Test socket knee disarticula
Test socket above knee
Test socket hip disarticulat
Test socket hemipelvectomy
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5640
L5642
L5644
L5646
L5650
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
Below knee acrylic socket
Syme typ expandabl wall sckt
Ak/knee disartic acrylic soc
Symes type ptb brim design s
Symes type poster opening so
Symes type medial opening so
Below knee total contact
Below knee leather socket
Knee disarticulat leather so
Above knee leather socket
Above knee wood socket
Below knee air cushion socket
Tot contact ak/knee disart s
Suction susp ak/knee disart
Knee disart expand wall sock
Socket insert symes
Socket insert below knee
Socket insert knee articulat
Socket insert above knee
Multi-durometer symes
Multi-durometer below knee
L1847
L1850
L1900
Lumbar or lumbar rib pad
Sternal pad
Thoracic pad
Trapezius sling
Outrigger
Outrigger bil w/ vert extens
Lumbar sling
Ring flange plastic/leather
Ring flange plas/leather molded to
patient
Covers for upright each
Lateral thoracic extension
Anterior thoracic extension
Milwaukee type superstructur
Lumbar derotation pad
Anterior asis pad
Anterior thoracic derotation pad
Abdominal pad
Rib gusset (elastic) each
Lateral trochanteric pad
Abduct hip flex frejka w cvr
Abduct hip flex frejka covr
Abduct hip flex pavlik harne
Abduct control hip semi-flex
Pelv band/spread bar thigh c
HO abduction hip adjustable
HO abduction static plastic
KO elastic with joints
KO elas w/ condyle pads & jo
KO immobilizer canvas longit
KO locking knee joint pre fab incl.
Fitting and adj.
KO adjustable w air chambers
KO swedish type
AFO sprng wir drsflx calf bd
L5666
L5668
L5671
L1902
L1906
L1910
L1920
L1930
AFO ankle gauntlet
AFO multiligamentus ankle su
AFO sing bar clasp attach sh
AFO sing upright w/ adjust s
AFO plastic or other material, includes
L5672
L5676
L5677
L5678
L5680
Below knee cuff suspension
Socket insert w/o lock lower
Addition to lower extremity, below
knee/above knee suspension locking
mechanism
Bk removable medial brim sus
Bk knee joints single axis pair
Bk knee joints polycentric pair
Bk joint covers pair
Bk thigh lacer non-molded
L1120
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1600
L1610
L1620
L1630
L1640
L1650
L1660
L1810
L1820
L1830
L1831
Page 89 of 331
L2035
fitting & adjustment
plastic or other material w/ankle joint,
prefab, incl. Fitting and adj.
KAFO plastic pediatric size
L2040
Hkafo torsion bil rot straps
L5686
L2112
L2114
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2240
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5710
L5711
L5712
L5714
L5785
L2250
L2260
L2265
L2270
L2275
AFO tibial fracture soft, pre-fab
AFO tib fx semi-rigid, pre-fab
Plas shoe insert w ank joint
Drop lock knee
Limited motion knee joint
Adj motion knee jnt lerman t
Quadrilateral brim
Waist belt
Pelvic band & belt thigh fla
Limited ankle motion ea jnt
Dorsiflexion assist each joi
Dorsi & plantar flex ass/res
Split flat caliper stirr & p
Addt. To lower extremity orthosis,
round caliper & plate attachment
Foot plate molded stirrup at
Reinforced solid stirrup
Long tongue stirrup
Varus/valgus strap padded/li
Plastic mod low ext pad/line
L2300
L2310
L2320
L2335
L2360
L2370
Abduction bar jointed adjust
Abduction bar-straight
Non-molded lacer
Anterior swing band
Extended steel shank
Patten bottom
L5920
L5925
L5940
L5962
L5970
L5971
L2375
L2380
L2385
L2387
Torsion ank & half solid sti
Torsion straight knee joint;
Straight knee joint heavy du
Addt. to lower extremity, polycentric
knee joint, for custom fabricated KAFO,
each joint
Offset knee joint each
L5972
L5974
L5975
L5978
Endoskel knee-shin mnl lock
Endo knee-shin frct swg & st
Endo ak/hip knee extens assi
Mech hip extension assist
Addt. Endoskeleton, below knee,
alignable system
Endo ak/hip alignable system
Above knee manual lock
Endo bk ultra-light material
Below knee flex cover system
Foot external keel sach foot
All lower extremity prosthesis, SACH
foot, replacement only
Flexible keel foot
Foot single axis ankle/foot
Combo ankle/foot prosthesis
Ft prosth multiaxial ankl/ft
L5982
Exoskeletal axial rotation
L1971
L2390
L5684
Bk fork strap
L5685
Addt. To lower ext. orthosis, below
knee, susp./sealing sleeve, any mat.
Each
below knee back check extension
control
Bk waist belt webbing
Bk waist belt padded and lin
Ak pelvic control belt light
Ak pelvic control belt pad/l
Ak sleeve susp neoprene/equa
Ak/knee disartic pelvic join
Ak/knee disartic pelvic band
Ak/knee disartic silesian ba
Shoulder harness
Kne-shin exo sng axi mnl loc
Knee-shin exo mnl lock ultra
Knee-shin exo frict swg & st
Knee-shin exo variable frict
Exoskeletal bk ultralt mater
L5810
L5812
L5850
L5855
L5910
Page 90 of 331
L2395
Offset knee joint heavy duty
L5984
L2397
L2405
L2415
L2425
L2430
L2492
L2500
L2530
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L5985
L5986
L6386
L6388
L6600
L6605
L6610
L6615
L6616
L6620
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6640
L6641
L6642
L6645
L6650
L6655
L6660
L2760
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
Suspension sleeve lower ext
Knee joint drop lock ea jnt
Knee joint cam lock each joi
Knee disc/dial lock/adj flex
Knee jnt ratchet lock ea jnt
Knee lift loop drop lock rin
Thi/glut/ischia wgt bearing
Thigh/wght bear lacer non-mo
Thigh/wght bear high roll cu
Hip clevis type 2 posit jnt
Pelvic control pelvic sling
Hip clevis/thrust bearing fr
Hip clevis/thrust bearing lo
Pelvic control hip heavy dut
Hip joint adjustable flexion
Hip adj flex ext abduct cont
Pelvic control band & belt u
Pelvic control band & belt b
Pelv & thor control gluteal
Thoracic control thoracic ba
Thorac cont paraspinal uprig
Thorac cont lat support upri
Plating chrome/nickel pr bar
Addt. Lower ext.,high strength, custom
fab. Only
Extension per extension per
Non-corrosive finish per bar
Drop lock retainer each
Knee control full kneecap
Knee cap medial or lateral p
Knee control condylar pad
Soft interface below knee se
Soft interface above knee se
Tibial length sock fx or equ
Femoral lgth sock fx or equa
L3000
L3001
L3002
foot insert Berkeley shell, each
foot insert Spenco, each
foot insert, Plastazote , each
L6691
L6692
L6698
L6665
L6670
L6672
L6675
L6676
L6680
L6682
L6684
L6687
L6688
Page 91 of 331
Endoskeletal axial rotation, w/wo
adjustability
Lwr ext dynamic prosth pylon
Multi-axial rotation unit
Postop ea cast chg & realign
Postop applicat rigid dsg on
Polycentric hinge pair
Single pivot hinge pair
Flexible metal hinge pair
Disconnect locking wrist uni
Disconnect insert locking wr
Flexion-friction wrist unit
Rotation wrst w/ cable lock
Quick disconn hook adapter o
Lamination collar w/ couplin
Stainless steel any wrist
Latex suspension sleeve each
Lift assist for elbow
Nudge control elbow lock
Shoulder abduction joint pai
Excursion amplifier pulley t
Excursion amplifier lever ty
Shoulder flexion-abduction joint, each
Shoulder universal joint, each
Standard control cable extra
Heavy duty control cable
Teflon or equal cable lining
Hook to hand cable adapter
Harness chest/shlder saddle
Harness figure of 8 sing con
Harness figure of 8 dual con
Test sock wrist disart/bel e
Test sock elbw disart/above
Test socket shldr disart/tho
Frame typ socket bel ow elbow or wrist
Frame typ sock above elbow or elbow
disarticulation
Removable insert each
Silicone gel insert or equal
Add. To upper ext. pros., lock
mechanism, excludes socket insert
L3003
foot insert, Silicone gel , each
L6703
L3010
Longitudinal Arch support each
L6704
L3020
Foot longitud/metatarsal supp
L6706
L3030
Foot arch support remov prem
L6711
L3040
L6805
L3100
Foot arch support remov premolded
longitudinal, each
Hallus-valgus night dynamic splint
L3140
L3150
L3160
L3170
Abduction rotation bar shoe
Abduction rotation bar w/o shoe
Shoe styled postioning device
Foot plastic heel stablizer
L6890
L7360
L7362
L7364
L3260
Ambulatory surgical boot each
L7366
L3265
L3300
Plastazole sandal each
Lift, Elevation Heel, Tapered to Metata
L7367
L7368
L3310
Shoe lift elev heel/sole neo
L7400
L3320
shoe lift elev heel/sole cor
L7401
L3332
Shoe lift inside tapered up to 1/2 inch
L7403
L3334
Shoe, lift elevation, heel, per inch, each
L7404
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
shoe wedge sach
shoe sole wedge
shoe sole wedge outside sole
shoe sole wedge between sole
shoe clubfoot wedge
shoe outflare wedge
shoe metarsal bar wedge
shoe metarsal bar between
full sole/heel wedge btween
shoe heel count plast reinforc
L8010
L8015
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L3440
L3450
heel leather reinforced
shoe heel sach cushion type
L8420
L8430
L6810
Page 92 of 331
term. Device, passive hand mitt, any
material, any size
term. Device, sport/rec/work, any
material, any size
term dev hook, mech vol opening, any
material, any size
Terminal device, hook, mechanical, vol.
opening, any material, any size, lined or
unlined, Pediatric, each
Modifier wrist flexion unit addt to
terminal device
Addt to terminal device, precision
pinch device
Production glove
Six volt battery, each
Battery charger, six volt, each
Twelve volt battery , each - 2 per year
*
Battery charger 12 volt each - 1 per 4
years *
lithium ion battery replacement
Lithium battery charger - 1 per 4 years
*
Addt. To upper ext. prosth. Ultralight
material
Addt. To upper ext. prosthesis above
elbow disart. Ultralight material
Addt. To upper ext. prosth. acrylic
material
addt. To upper ext prosth. Above
elbow disart. Acrylic
Mastectomy sleeve
Ext breast prosthesis garment
Truss single w/ standard pad
Truss double w/ standard pad
Truss addition to std pad wa
Truss add to std pad scrotal
Sheath below knee
Sheath above knee
Sheath upper limb
Prosthetic sheath/sock, incl. gel
cushion layer, below knee or above
knee, each
Prosthetic sock multi ply BK
Prosthetic sock multi ply AK
L3455
L3460
L3465
L3470
L3480
L3485
L3500
L3510
shoe heel new leather standard
shoe heel new rubber standard
shoe heel thomas with wedge
shoe heel thomas extend to B
shoe heel pad &depress for
shoe heel pad removeable for
ortho shoe add leather insol
orthopedic shoe add rub insl
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8507
L3520
ortho shoe add felt w leather insol
L8509
L3530
L3540
ortho shoe add half sole
ortho shoe add full sole
L8510
L8511
L3550
ortho shoe add standard toe tap
L8512
L3560
ortho shoe add horseshoe toe tap
L8513
L3570
ortho shoe add instep extension
L8514
L3580
ortho shoe add instep velcro clos
L8515
L3590
ortho shoe convert firm to soft count
L8615
L3595
ortho shoe add march bar
L8616
L3600
Trans shoe calip plate exist
L8617
L3610
Trans shoe caliper plate new
L8618
L3620
Trans shoe solid stirrup existing
L8621
L3630
Trans shoe solid stirrup new
L8622
L3640
Shoe Dennis Browne splint both
L8623
L3650
Shlder fig 8 abduct restrain
L8624
L3660
Abduct restrainer canvas&web
L8695
Page 93 of 331
Pros sock multi ply upper lm
Shrinker below knee
Shrinker above knee
Shrinker upper limb
Pros sock single ply BK
Pros sock single ply AK
Pros sock single ply upper l
Tracheo-esophageal voice prosthesis,
patient inserted, any type
Tracheo-esophageal voice prosthesis,
inst. by lic. Health care provider, any
type
Voice Amplifier
Insert for Indwelling T/E prosthesis
with or W/O valve replacement each
Gelatin capsules or equ. use with T/E
prosthesis replacement only per 10
Cleaning device used with T/E
prosthesis replacement only each
T/E puncture dilator replacement only
each
gelatin capsule application device for
use with TE voice prosthesis, each
Headset/Headpiece for use with
cochlear implant device, replacement
microphone for use with cochlear
implant device, replacement
transmitting coil for use with cochlear
implant device, replacement
transmitter cable for use with cochlear
implant device, replacement
Zinc air battery for use with cochlear
implant device, each
Alkaline batt. For use with coch. Imp.
Device, any size,each
Lithium ion battery coch. imp. Device
speech proc.other than Ear level, ea
Lithium ion battery for coch. imp.
Device speech proc. Ear level, each
ext recharging sys for battery(ext) for
use with implantable neurostimulator
Appendix C – Ostomy Supplies
Any request that exceeded $500.00 will require prior authorization.
A4421
A4465
A4466
A4483
A4600
A4601
A4649
A4366
AUTHORIZATION REQUIRED
Ostomy supply, miscellaneous
Non elastic binder for extremity
Garment, belt, sleeve or other covering, elastic or similar
stretchable material, any type, each
Moisture exchanger, disposable, for use with invasive mechanical
ventilation, each
sleeve for intmt. Limb compression device, replac. only
Lithium ion battery for non-prosthetic use, repl. Only
Surgical Supply, Miscellaneous
Authorization is required
Authorization is required
Authorization is required
Ostomy vent, any type, each
Authorization required >
1 per calendar month
Authorization required >
1 per calendar month
Authorization required >
1 per calendar month
Authorization required >
10 per calendar month
Authorization required >
20 per calander month
Authorization required >
4 per year
Authorization required > 4
per year
Authorization required >
4 oz per calendar month
Authorization required >
4 per calendar month
Authorization required >
6 per year
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Ostomy belt
A4400
Ostomy irrigation set
A4404
Ostomy ring each
A4362
Solid skin barrier
A4398
Ostomy irrigation bag
A4399
Ostomy irrig cone/cath w brs
A4402
Lubricant price is per oz. 1 oz.=1 unit
A4397
Irrigation supply sleeve
A4361
Ostomy face plate
A4416
Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each
A4417
Ostomy pouch,closed, w/barrier att.,w/built-in convexity, w/filter
1 pc, each
Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each
A4419
A4420
Authorization is required
Authorization is required
Authorization is required
AUTHORIZATION REQUIRED IF QUANTITY LIMIT IS
A4367
A4418
Authorization is required
Ostomy pouch, closed, use on barrier w/non-lock flange,w/filter
2pc, each
Ostomy pouch, closed, use on barrier with lock flange 2 pc, each
Page 94 of 331
A4423
Ostomy pouch closed, 2 pc. Locking flange, each
A4424
Ostomy pouch, drainable,w/barrier 1 pc, each
A4425
Ostomy pouch drainable, non-locking flange 2 pc each
A4426
Ostomy pouch, drainable, with locking flange, 2 pc. Each
A4427
A4428
Ostomy pouch, drainable , use on barrier w/locking flange,
w/filter 2 pc, each
Electrodes, apnea monitor, per pair
A4429
Ostomy pouch, urinary w/convexity, faucet type tap, each
A4430
ostomy pouch urinary, ext. wear, convexity, faucet tap, each
A4431
ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea.
A4432
ostomy pouch, urinary, non-locking flange, faucet type, ea.
A4433
ostomy pouch, urinary, w/locking flange, ea.
A4434
ostomy pouch, urinary, w/locking flange, w/faucet type tap ea.
A4624
Tracheal suction tube
A4625
Trach care kit for new trach
A5082
Continent stoma catheter
A5093
Ostomy accessory convex inse
A4626
Tracheostomy cleaning brush
A5061
Pouch drainable w barrier at
A5062
Drnble ostomy pouch w/o barr
A5063
Drain ostomy pouch w/flange
A5071
Urinary pouch w/barrier
A5072
Urinary pouch w/o barrier
A5073
Urinary pouch on barr w/flng
Page 95 of 331
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
60 per calendar month
Authorization required >
91 per calendar month
Authorization required if
> 1 per calendar month
Authorization required if
> 1 per calendar month
Authorization required if
> 10 per calendar month
Authorization required if
> 2 per calendar month
Authorization required if
> 20 per calendar month
Authorization required if
> 20 per calendar month
Authorization required if
> 20 per calendar month
Authorization required if
> 20 per calendar month
Authorization required if
> 20 per calendar month
Authorization required if >
20 per calendar month
A4623
Tracheostomy inner cannula
A5055
Stoma cap
A5081
Continent stoma plug
A4455
Adhesive remover per ounce
A5051
Pouch clsd w barr attached
A5052
Clsd ostomy pouch w/o barr
A5053
Clsd ostomy pouch faceplate
A5054
Clsd ostomy pouch w/flange
A4392
A4363
A4364
A4365
A4368
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4393
A4394
A4395
A4396
Authorization required if
> 31 per calendar month
Authorization required if
> 31 per calendar month
Authorization required if
> 31 per calendar month
Authorization required if
> 32 ounces
Authorization required if
> 60 per calendar month
Authorization required if
> 60 per calendar month
Authorization required if
> 60 per calendar month
Authorization required if
> 60 per calendar month
AUTHORIZATION NOT REQUIRED
Urinary pouch w st wear barr
Ostomy clamp, any type , each
Adhesive, liquid or equal, any type, per ounce
Ostomy adhesive remover wipe
Ostomy filter
Skin barrier liquid per oz
Skin barrier powder per oz
Ostomy Skin barrier solid 4x4 equiv
Skin barrier with flange
Drainable plastic pch w fcpl
Drainable rubber pch w fcplt
Drainable plstic pch w/o fp
Drainable rubber pch w/o fp
Urinary plastic pouch w fcpl
Urinary plastic pouch w/o fp
Ostomy pouch, urinary, for use on faceplate, plastic, each
Urinary hvy plstc pch w/o fp
Urinary rubber pouch w/o fp
Ostomy faceplt/silicone ring
Ost skn barrier sld ext wear
Ost clsd pouch w att st barr
Drainable pch w ex wear barr
Drainable pch w st wear barr
Drainable pch ex wear convex
Urinary pouch w ex wear barr
Urine pch w ex wear bar conv
Ostomy pouch liq deodorant w/wo lubricant
Ostomy pouch solid deodorant
Ostomy belt with peristomal hernia support
Page 96 of 331
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
A4405
A4406
A4407
A4408
A4409
A4410
A4411
A4412
A4413
A4414
A4415
A4450
A4452
A4456
A4481
A4556
A4557
A4558
A4561
A4562
A4565
A4566
A4595
A4604
A4605
A4606
A4608
A4611
A4612
A4613
A4614
A4618
A4619
A4627
A4628
A4629
A4630
A4635
A4636
A4637
Ostomy skin barrier, non-pectin based, paste, per oz
Ostomy skin barrier, pectin based, per oz
Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4
or <
Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4
or >
Ostomy skin barrier with flange
Ostomy skin barrier, with fl, ex wear, without built in convexity,
>4x4 ea
Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity,
each
Ostomy pouch, drainable, high otpt, use on barrier w/ o filter
each
Ostomy pouch, drainable, high otpt, use on barrier w/ fl with
filter ea
Ostomy skin barrier, with fl, w/o built in convexity 4x4 or <
Ostomy skin barrier, with fl, w/o built in convexity 4x4 or >
Tape, non-water proof, 18 sq inches
Tape, water proof , 18 sq inches
Adhesive remover, wipes, any type, each
Tracheostoma filter
Electrodes, apnea monitor, per pair
Lead wires, apnea monitor per pair
Conductive paste or gel for use with electrical device E.G. tens
Pessary, rubber, any type
Pessary, nonrubber, any type
Slings
Canvas vest SO
TENS suppl 2 lead per month
tubing with integrated heat use with pos. airway pressure device
Tracheal suction catheter, closed system, each
Oximeter probe replacement
Transtracheal oxygen catheter, each
Heavy duty battery, Ventilator, replacement for patient owned
Battery cables
Battery charger
Hand-held PEFR meter
Breathing circuits
Face tent
Spacer, bag or reservoir for inhaler
Oropharyngeal suction cath
Tracheostomy care kit
Repl bat t.e.n.s. own by pt
Underarm crutch pad
Handgrip for cane etc
Repl tip cane/crutch/walker
Page 97 of 331
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
No authorization required
A4640
A5083
Alternating pressure pad
Continent device, stoma absorptive cover for continent device,
each
Page 98 of 331
No authorization required
No authorization required
Provider Manual
Section 6.0
Referrals
Table of Contents
6.1 Member Self-Referral (Direct Access)
6.2 Referral Requirements
6.3 Distribution of Referrals
Page 99 of 331
6.0 Referrals
6.1 Member Self-Referral (Direct Access)
There are a number of services covered by Passport Health Plan for which members can make
appointments with participating Passport Health Plan providers without referrals from their PCP.
These include:
•
•
•
•
•
•
•
•
•
•
•
•
Routine vision care services, including diabetic retinal exams and the fitting of eyeglasses
provided by ophthalmologists, optometrist, and opticians.
Routine dental services and oral surgery services and evaluations by orthodontists and
prosthodontists (orthodontic and prosthodontic services require prior authorization).
Maternity care (authorization is required after the first prenatal visit).
Immunizations for members younger than 21 years of age.
Screening, evaluation, and treatment for sexually transmitted diseases.
Screening, evaluation, and treatment for tuberculosis.
Chiropractic services up to 12 visits.
Testing for HIV, HIV-related conditions, and other communicable diseases.
Pap smears and mammograms.
GYN services, including Pap smears and mammograms.
Voluntary Family Planning in accordance with federal and state laws and judicial opinion
Routine outpatient behavioral health services do not require a PCP referral. Please see section
16.5 (Authorization Procedures and Requirements) for those requiring prior authorization.
NOTE: For family planning services, members may self-refer to any participating Medicaid
provider. For more information, please refer to Section 17, “Family Planning.”
6.1.1 Additional Referral Exceptions
In addition to the direct access services outlined above, members do not need referrals for the
following:
•
•
Services provided by the Commission for Children with Special Health Care Needs or the
WINGS Clinic.
The following list of diagnoses (when billed as the primary diagnosis):
CODE
ESRD
585
586
HIV/AIDS
042
79.51
79.52
79.53
CANCER
140-208
DESCRIPTION
Chronic Kidney Disease (CKD)
Renal failure, unspecified
Human immunodeficiency (HIV) disease
Human T-cell lymphotrophic virus, type I (HTLV-I)
Human T-cell lymphotrophic virus, type II (HTLV-II)
Human immunodeficiency virus, type 2 (HIV-2)
Malignant
Page 100 of 331
230-234.0
235-238
239 – 239.9
•
•
•
Carcinoma in situ
Neoplasm of uncertain behavior
Neoplasm of unspecified behavior
Diabetic retinal exams.
OB/GYN services (Authorization is required after the first prenatal visit).
Perinatologists/geneticists.
The following referral exceptions also apply:
•
•
•
•
One lifetime referral is required for each transplant.
Referrals to specialists are not required for children in foster care or living in out-of-home
placements.
Referrals are not required for participating orthopedists.
Referrals are not required for members with Medicare or Tricare as the primary payer.
6.2 Referral Requirements
Passport’s referral requirements are based on the premise that our members are best served with a
primary home for care and oversight, thus the PCP is responsible for coordinating the member’s
health care. Except as outlined in Sections 7.1 and 7.1.1, if the member needs to see a specialist, the
PCP will complete and issue a referral to the specialist.*
•
•
•
•
•
•
•
•
PCP referrals can only be made to participating specialists, unless the necessary service is not
available from participating Passport Health Plan practitioners.
Prior approval by Utilization Management is not required for referrals to participating
providers, but a referral must be completed.
For referrals to a nonparticipating specialist, the PCP must request prior authorization from
Passport Health Plan’s Utilization Management department. The PCP should verify that the
specialist accepts Kentucky Medicaid.
Requests for retrospective review of inpatient services provided by nonparticipating
providers require review and authorization by Utilization Management.
Cases requiring follow-up visits or treatment by nonparticipating providers that were not
prior authorized must be reviewed by Utilization Management.
Referrals for consultation, diagnostic studies and treatment are valid for a time span
indicated by the referring provider (three, six, nine, or 12 months) with unlimited visits.
The PCP may also designate a visit limit if preferred. If a referral is designated as
consultation, diagnostic studies, and treatment, it is also valid for any outpatient testing or
procedures that are ordered by the specialist unless those services are listed on the Passport
Health Plan prior-authorization list.
Passport Health Plan members have the right to a second opinion. If the member requests a
second opinion, the PCP should complete a referral to a participating specialist. If there is
not a specialist within the network, the PCP can request an authorization to a nonparticipating specialist by calling Passport Health Plan’s Utilization Management department
at (800) 578-0636.
*An exception occurs when a member is new to Passport (in the first 30 days after enrollment) and
has not yet selected or been assigned to a PCP. Under these circumstances, if a member requires
Page 101 of 331
specialist care, a participating specialist provider may contact the UM department to request
authorization of a one-time visit without a referral.
NOTE: Please refer to the Passport Health Plan Real-Time Provider Directory on
www.passporthealthplan.com to verify participating providers.
Occasionally, a referral will be made following a telephone conversation between the member and
the PCP who determines the need for specialty care. When a verbal referral is made, it is the PCP’s
responsibility to follow up with either an electronic or paper referral. Members may not obtain a
referral to a specialist when the PCP can perform the services.
6.2.1 Referral for Urgent Care
A referral is required for all urgent care visits except as indicated below:
•
If it is Saturday, Sunday, a national holiday, or a weekday after 4 p.m., Passport Health Plan
members may go to specified urgent care centers. For the latest listing of participating
centers, please reference Passport’s website (in process).
6.2.2 Original Medicare Primary Member Referrals
Passport Health Plan members who are covered by Medicare or TriCare as their primary insurance
are not required to have referrals for specialist care and may go to any participating or
nonparticipating practitioner, as set forth in this Provider Manual. These members have a Passport
Health Plan identification card with “Medicare Primary” as the PCP. Providers will be paid on a feefor-service basis for all covered services provided to Passport Health Plan members who are also
covered by Medicare or Tricare. Providers are required to bill Medicare or Tricare first and only
submit to Passport Health Plan the coinsurance and deductible amounts or those amounts not
covered by their primary insurance as shown on the EOB.
6.3 Distribution of Referrals
Passport Health Plan currently offers two options for the initiation and submission of referrals.
While paper referral forms remain an option at this time, providers are strongly encouraged to use
the electronic submission process available at www.passporthealthplan.com or by logging onto
NaviNet at https://navinet.navimedix.com.
Distribution of forms is based on the selected method and detailed below:
•
Electronic
Referrals initiated via the web-based program are automatically transmitted to Passport.
PCPs should print three copies of the referral to be distributed as follows:
 Specialist copy (to be sent with member or mailed to a specialist).
 Member’s copy.
 PCP’s copy (to be placed in member’s chart).
•
Paper (See Section 19 for a sample form.)
Page 102 of 331
Completed referral forms should be distributed as follows:
 Copy 1 - Send to Passport Health Plan immediately at:



Passport Health Plan
P.O. Box 7114
London, KY 40742
Copy 2 - Specialist copy (to be sent with member or mailed to specialist).
Copy 3 - Patient’s copy.
Copy 4 - PCP’s copy (to be placed in member’s chart).
Responsibilities of the specialist or consulting practitioner:
• Retain copy of referral form for the member’s file.
• Send a copy of the consult report to the PCP.
Page 103 of 331
Provider Manual
Section 7.0
Benefit Summary and
Exclusions
Table of Contents
7.1 Benefit Summary
7.2 Services Covered Outside Passport Health Plan
7.3 Non-Covered Services
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7.0 Benefit Summary and Exclusions
7.1 Benefit Summary
Basic services covered under Passport Health Plan include, but are not limited to:
• Alternative birthing center services.
• Ambulatory surgical center services.
• Behavioral Health Services, including:
• Community Mental Health Services.
• Impact Plus Services.
• Inpatient behavioral health services.
• Outpatient Mental Health Services.
• Psychiatric Residential Treatment Facilities (Level I and Level II.)
• Chiropractic services.
• Dental services, including oral surgery, orthodontics, and prosthodontics.
• Durable medical equipment (DME), including prosthetic and orthotic devices and
disposal medical supplies.
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening and
special services.
• End stage renal dialysis services.
• Family planning clinic services in accordance with federal and state law and judicial
opinion.
• Hearing services, including hearing aids for members younger than age 21.
• Home health services. Private Duty Nursing (2,000 hours per year)
• Hospice services.
• Independent laboratory services.
• Inpatient hospital services.
• Intensive Case Management.
• Meals and lodging for appropriate escort of members.
• Medical detoxification.
• Medical services, including those provided by physicians, advanced practice
registered nurses, physicians assistants and FQHCs/ primary care centers and rural
health clinics.
• Organ transplant services not considered investigational by the FDA.
• Other laboratory and x-ray services.
• Outpatient hospital services.
• Pharmacy and limited over-the-counter drugs including mental/behavioral health
drugs.
• Podiatry services.
• Preventive health services, including those currently provided in public health
departments, FQHCs/primary care centers, and rural health clinics.
• Specialized Case Management Services for Members with Complex, Chronic
Illnesses (includes adult and child targeted case management).
Page 105 of 331
•
Targeted Case Management.
•
Therapeutic evaluation and treatment, including physical therapy, speech therapy,
occupational therapy.
Transportation to covered services, including emergency and nonemergency
ambulance and other stretcher services.
Urgent and emergency care services.
Vision care, including vision examinations, services of opticians, optometrists and
ophthalmologists, including eyeglasses for members younger than age 21.
Specialized Children's Services Clinics.
•
•
•
•
NOTE: Please remember some services/benefits require a prior authorization. Please
see Section 6.0 for more information.
Meals, lodgings and transportation necessary to maintain a member and one designated
attendant are covered, if necessary, when the member is accessing approved and necessary
medical care at a site, in or outside of Kentucky, which is at a sufficient distance to preclude
daily travel to and from the recipient’s home. This service requires prior approval with
specific maximum rates applicable to standard and high-rate areas.
7.1.1 Allergy Testing and Treatment
Consultation and testing by an allergist is covered for any member with a referral from the
member’s PCP. Allergy injections may be administered by either an allergist or by the
member’s PCP.
7.1.2 Behavioral Health Service
Passport Health Plan has contracted with Beacon Health Strategies, LLC to administer
comprehensive behavioral health benefits for Passport members beginning January 2013.
Section 19 of this provider manual provides comprehensive detail of this service.
7.1.3 Dental Care
Passport Health Plan has contracted with a dental benefits manager to administer and
provide all primary care dental services for all members. A PCP referral is not required for
routine dental services. Members may obtain assistance with locating a dental practitioner by
calling Member Services at (800) 578-0603. Members may also visit the Plan’s web site at
www.passporthealthplan.com.
Specialty dental services do not require a referral, for example, orthodontic evaluation (see
Section 6.1, “Member Self-Referral (Direct Access)”) and are only covered for children
younger than age 21.
For more information, please see Section 1, “Important Telephone Numbers,” for our
Page 106 of 331
dental benefits manager’s contact information.
7.1.4 Durable Medical Equipment (DME)
Passport Health Plan covers medically-necessary durable medical equipment (DME) and
supplies that are covered under the fee-for-service Medicaid program. Members are required
to have a practitioner’s order to receive the covered DME or supplies (see Section 5.6.3).
The Department for Medicaid Services (DMS) requires that an updated Certificate of
Medical Necessity (CMN) be signed by the provider for all supplies and equipment and kept
on file by the supplier for a period of five years. The only exception is oxygen for which
Passport Health Plan follows Medicare guidelines.
7.1.5 Family Planning Services
Family planning services are meant to prevent or delay pregnancy for individuals of
childbearing age. These services include:
•
•
•
•
•
•
•
•
•
•
Health education and counseling.
Limited history and physical exam.
Laboratory tests as medically necessary.
Diagnosis and treatment of STDs.
Screening, testing, and counseling of at-risk individuals for HIV and referral for
treatment.
Follow-up care for complications associated with contraceptive methods issued by a
family planning provider.
Contraceptive prescriptions, devices, supplies.
Tubal ligation with required consent form completed.
Vasectomies with required consent form completed.
Pregnancy testing and counseling.
Passport Health Plan members may obtain family planning services from any state-approved
Medicaid provider. No referral from the PCP is required for routine family planning
services.
Some family planning services require authorization. For more information on benefits
and/or a list of providers, refer to Section 17, “Family Planning” in this Provider Manual.
Please direct members to call our Member Services department at (800) 578-0603.
7.1.6 Home Health Care
When medically appropriate, home health care may be a good alternative to hospitalization.
Home health care, including skilled and unskilled nursing, may be medically appropriate at
other times as well. Passport Health Plan’s Utilization Management department must prior
authorize all home health services (see Section 6.4.2).
Page 107 of 331
7.1.7 Hospice Care
If a member needs hospice care, the hospice provider must contact Passport Health Plan’s
Utilization Management department for prior authorization.
7.1.8 Laboratory Services
All laboratory work should be sent to participating laboratories. For assistance locating a
participating laboratory, providers may go to our online directory at
http://passport.prismisp.com/. Choose “Other Services” > Laboratory Services.
Both PCPs and specialists may order lab services. Participating practitioners who cannot
perform venipuncture in their office should send members to the nearest participating
laboratory.
7.1.9 Prenatal Care
A referral is not necessary to an obstetrical provider, and a member may self-refer to any
participating obstetrical provider. The OB provider should confirm eligibility. Providers are
no longer required to obtain global authorization for antepartum cases. However, you must
submit the initial ACOG or ACOG-like assessment which includes the member’s medical
and obstetric history within two business days of a member’s initial prenatal visit. You can
email the completed form to [email protected] or fax it to
(502) 585-7970.
7.1.10 Prescriptions
Prescription benefits are administered for Passport Health Plan members through a
pharmacy benefits manager (PBM). Members must have prescriptions filled at participating
pharmacies. For assistance locating a participating pharmacy, members should call Member
Services (800) 578-0603 or search the on-line pharmacy directory.
For additional information on the outpatient pharmacy benefits, please refer to Section 14 of
this Provider Manual or visit www.passporthealthplan.com.
7.1.11 Presumptive Eligibility
Presumptive Eligibility (PE) was implemented on November 1, 2001 by the Kentucky
Department for Medicaid Services (DMS). PE enables qualified pregnant women to receive
prenatal care (for up to 90 days) while their eligibility for full Medicaid benefits is
determined.
For additional information regarding PE (including the complete list of covered services),
please see Section 16.13.
Page 108 of 331
7.1.12 Radiology
PCPs and specialists may order routine radiology services for members.
Specialty Radiology: Prior Authorization is required for select CT/CTA, MRI/MRA, PET,
and NCM/MPI through MedSolutions. Refer to Section 5.3 – Prior Authorization
Requirements.
7.1.13 Skilled-Nursing Facility
Should a member need authorization for admission to a skilled-nursing facility, the PCP
should contact the Department for Medicaid Services (DMS). They will coordinate necessary
arrangements between the PCP and the skilled-nursing facility in order to provide continuity
of the member’s care.
Passport Health Plan covers the costs of health care services that are not part of nursing
facility costs for up to 31 days or until the member is disenrolled from Passport Health Plan
by DMS. After the member has been in a skilled nursing facility for 31 days, the
disenrollment process begins. After disenrollment, the member is re-enrolled with the feefor-service Medicaid program except when a member is under the care of Hospice and in a
skilled-nursing facility. In this case, Passport Health Plan will continue to cover services
under the hospice benefit even after 31 days.
7.1.14 Transportation
Emergency transportation and stretcher services are covered by Passport Health Plan.
Members may be eligible for non-emergency transportation services to and from medical
appointments. This is a covered benefit by DMS.
Members should call the appropriate transportation broker at least three days ahead of time
when scheduling transportation.
The telephone numbers for transportation brokers for each county can be found in Section
20.2, “Other Important Contact Information.” Members may also access this information by
calling Passport Health Plan Member Services at (800) 578-0603.
7.1.15 Vision Care
Passport Health Plan has contracted with a vision benefits manager to administer and
provide routine vision care benefits to members. A PCP referral is not required for vision
services.
An annual routine eye refraction exam is covered for adult and child members. Eyeglasses
are a benefit for children under age 21. Some exceptions apply to KCHIP members.
Members may obtain a list of vision practitioners by calling Member Services at
Page 109 of 331
(800) 578-0603 or by checking the provider directory on the Plan’s website at
www.passporthealthplan.com.
Members requiring vision care because of a medical condition must be referred by their PCP
to a participating Passport Health Plan ophthalmologist. For more information, call Provider
Services at (800) 578-0775 or refer to Section 1, “Important Telephone Numbers,” for our
vision benefits manager’s contact information.
7.2 Services Covered Outside Passport Health Plan
Members may continue to receive certain health services not covered by Passport Health
Plan but covered by DMS. Members may obtain these services from any Medicaid provider
by using their Medicaid ID. Members choosing to obtain these services are encouraged to
notify their PCP to update their medical records. The following services are covered outside
Passport Health Plan:
•
•
•
•
•
Nursing facility services.
Early-intervention services for children.
School-based services for any child member younger than the age of 21 with an
individualized education plan.
Waiver services.
Nonemergency transportation.
Additional information about these services can be obtained from DMS.
7.3 Non-Covered Services
Services that are not covered by Passport Health Plan or the Kentucky Medicaid Program
include:
•
•
•
•
•
•
•
•
•
•
•
•
Non-medically-necessary services.
Cosmetic services.
Custodial, convalescent, or domiciliary care.
Experimental procedures not approved by Kentucky’s Medicaid Program.
Hysterectomy procedures, if performed for hygienic reasons or sterilization only.
Infertility treatment (medical or surgical).
Paternity testing.
Personal items or services, such as a television or telephone, while the patient is in the
hospital.
Postmortem services.
Reversal of sterilization services.
Sex-change procedures.
Sterilization of a mentally incompetent or institutionalized individual.
Page 110 of 331
The following are services currently not covered by the Kentucky Medicaid Program:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Any laboratory service performed by a provider without current certification in
accordance with the Clinical Laboratory Improvement Amendment (CLIA). This
requirement applies to all facilities and individual providers of any laboratory service;
Cosmetic procedures or services performed solely to improve appearance;
Hysterectomy procedures, if performed for hygienic reasons or for sterilization only;
Medical or surgical treatment of infertility (e.g., the reversal of sterilization, invitro
fertilization, etc.);
Induced abortion and miscarriage performed out-of-compliance with federal and
Kentucky laws and judicial opinions;
Paternity testing;
Personal service or comfort items;
Post mortem services;
Services including, but not limited to, drugs that are investigational, mainly for
research purposes or experimental in nature;
Sex transformation services;
Sterilization of a mentally incompetent or institutionalized member;
Services provided in countries other than the United States, unless approved by the
Secretary of the Kentucky Cabinet for Health and Family Services;
Services or supplies in excess of limitations or maximums set forth in federal or state
laws, judicial opinions and Kentucky Medicaid program regulations referenced herein;
and,
Services for which the Member has no obligation to pay and for which no other
person has a legal obligation to pay are excluded from coverage.
NOTE: Under EPSDT, some exceptions may be made if a service is medically-necessary.
Page 111 of 331
Provider Manual
Section 8.0
Early and Periodic Screening,
Diagnosis and Treatment (EPSDT)
Table of Contents
8.1 Overview of EPSDT
8.2 EPSDT Eligibility
8.3 Covered Services
8.4 EPSDT Audits for Screening Elements
8.5 EPSDT Tracking/Member Outreach
8.6 EPSDT Reporting/Billing (Preventive Health
Screens/Immunizations)
8.7 EPSDT Expanded Services
Page 112 of 331
8.0 Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT)
8.1 Overview of EPSDT
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a federally mandated Medicaid
program developed to ensure that the Medicaid population younger than the age of 21 is monitored
for preventable and treatable conditions which, if undetected, could result in serious medical
conditions and/or costly medical care. Passport must track the progress of all members younger
than the age of 21 and perform outreach as needed to encourage members to obtain EPSDT health
screens according to the Bright Futures/American Academy of Pediatrics (AAP) Guidelines for
screening intervals. Once a condition is detected, treatment may be considered under EPSDT
Special/Expanded Services if it is not a current covered benefit under Medicaid, if medical necessity is
proven. EPSDT preventive health screens that result in any treatment recommendations must be
monitored to ensure follow-up has occurred.
8.2 EPSDT Eligibility
8.2.1 Member Eligibility
Passport members from birth to age 21 are entitled to receive EPSDT services.
8.2.2 Practitioner Eligibility
All Passport PCPs who see children younger than the age of 21 are required to conduct EPSDT
screenings and complete all EPSDT billing requirements.
8.3 Covered Services
The following services are covered under the EPSDT preventive care program:
• Comprehensive screening exams according to the Bright Futures/American Academy of
Pediatrics (AAP) periodicity schedule see
http://www.passporthealthplan.com/pdf/provider/resources/epsdt/aap-periodicityschedule.pdf :
• All Passport eligible members under the age of 21 are entitled to EPSDT services
8.4 EPSDT Audits for Screening Elements
As part of Passport’s Quality Improvement Program, the EPSDT/Quality Improvement (QI)
department will conduct an annual audit of submitted EPSDT claims by providers to review for
completion of the age appropriate elements based on the approved Periodicity schedule. A
benchmark has been established that each provider score at least 80% on the completion of all
Page 113 of 331
elements of an age appropriate screen. If a provider scores less than 80%, the EPSDT/QI staff will
provide a detailed report of missing elements and education regarding the age appropriate standards.
The provider will be reviewed again in six months after the education has been completed. If a
provider does not meet the 80% score at that time, the provider must submit a corrective action plan
that is to be reviewed and approved by the Chief Medical Officer (CMO) and Child and
Adolescent/Quality Medical Management Committees (C&A/QMMC). Additional sanctions are to
be determined and approved by the CMO and C&A/QMMC.
8.5 EPSDT Tracking/Member Outreach
Tracking begins at enrollment for both newborns and other members and continues periodically
thereafter:
•
•
•
The EPSDT program and the importance of preventive care are outlined in the Member
Handbook. EPSDT articles are included in all member newsletters, on Passport’s web site,
and in Passport’s telephone on-hold messages.
Reports are generated to check for members who are due/overdue for preventive screens. If
no documentation from the PCP has been processed, follow-up calls are made or notices are
mailed to members.
Reports are generated for members who cannot be reached through written notification or
by telephone. These members are referred for home visit outreach.
8.6 EPSDT Protocols
To complete an EPSDT preventive health screen:
Verify member’s eligibility via KyHealth Net, referencing the PCP monthly panel list, utilizing
the EPSDT Eligibility Confirmation Form, or contacting the EPSDT team at (877)
903-0082, ext. 8210.
• For more information about KyHealth Net, or to create an account, visit
www.chfs.ky.gov/dms/kyhealth.htm.
• Once eligibility is verified, inform the parent/guardian that the visit will be an EPSDT
screening.
• Have the parent or legal guardian sign a consent form authorizing the practitioner to perform
screening tests or other assessment procedures pertaining to EPSDT preventive health
screens.
•
To receive reimbursement, all EPSDT services must be submitted as part of the standard
electronic (837) or paper (CMS-1500) claims submission process.
To submit EPSDT services via claims:
•
Continue to bill using the codes for comprehensive history and physical exam as used
today. These codes must correspond with the member's age.
CPT Code Modifier
Code Description
Billing Format
99381EP
New Patient
837/CMS-1500
99385
Page 114 of 331
9939199395
•
•
•
•
•
EP
Established Patient
837/CMS-1500
Add an "EP" modifier to the physical exam code only when all components of the
appropriate EPSDT screening interval have been completed and documented in the
member's medical record. Do not add the EP modifier to other services being billed (i.e.
immunizations).
Acknowledge the following health evaluation services have been completed by
submitting the appropriate CPT Category II codes, according to the member's age, as
outlined below. CPT II codes must include a nominal charge (i.e. $.01 or $1.00 not blank or
zero) in order to adjudicate correctly.
Two years of age and above: 3008F to confirm the BMI has been performed and
documented in the member's medical record.
Nine years of age and above: 2014F to confirm the member's mental status has been assessed
and documented in the member's medical record.
Note in the appropriate box on the Referral Form that a referral has been made for
additional services, related to an EPSDT screening.
Mail Paper Claims to:
Passport Health Plan
P.O. Box 7114
London, KY 40742
8.8 EPSDT Reporting/Billing (Preventive Health Screens/
Immunizations)
Practitioners who perform complete EPSDT health screens according to the recommendations in the
Preventive Health Guidelines will be reimbursed a fee-for-service rate. EPSDT health screens must be
billed on the standard electronic (837) or paper (CMS-1500) claim form.
Practitioners will be reimbursed an additional administration fee for recommended childhood and
adolescent immunizations.
Page 115 of 331
Provider Manual
Section 9.0
Quality Improvement
Table of Contents
9.1 Quality Improvement Program Description
9.2 Quality of Care Concerns
9.3 Practitioner Sanctioning Policy
Page 116 of 331
9.0 Quality Improvement
9.1 Quality Improvement Program Description
The purpose of the Quality Improvement (QI) Program is to provide the infrastructure for the
continuous monitoring, evaluation and improvement in care, safety, and service.
Providers may obtain a copy of Passport Health Plan’s complete “Quality Improvement Program
Description,” “Quality Improvement Program Evaluation,” or “Quality Program Committee
Structure” and/or a copy of a summary of its annual evaluation by visiting the Passport website at
www.passporthealthplan.com/member/eng/qi-program/index.aspx or by contacting their Provider
Relations Specialist.
9.2 Quality of Care Concerns
Quality of Care Concerns may be reported by both internal and external customers such as members,
providers, and advocates. All reported concerns are investigated and monitored for trends.
In the event a quality of care concern is reported, Passport requires full cooperation with the
investigation of the concern. This includes the timely submission of requested medical records and
the implementation of corrective action plans. Providers have the right to respond to reported
concerns.
For more information regarding quality of care concerns, please contact the Quality Improvement
department at (800) 578-0636, ext. 8571.
9.3 Practitioner Sanctioning Policy
In the event Passport Health Plan identifies health care services rendered to a Passport Health Plan
member by a participating practitioner that are outside the recognized treatment patterns of the
organized medical community and quality management and/or credentialing standards, the
practitioner may be subject to sanctions. The National Practitioner Data Bank (NPDB) may be
notified of all negative outcomes if formal sanctioning proceedings are implemented and if the
outcome is to last 30 days or more.
In addition to the above, Passport Health Plan will exclude and/or penalize a provider under any of
the following conditions:
•
•
•
The Plan has received recommendations to take such actions as a result of an investigation
conducted by the Office of the Inspector General or other appropriate state and/or federal
agency.
The provider fails to cooperate with an investigation of alleged fraud and abuse.
The provider has been listed on the Medicare/Medicaid Sanctions Report.
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Possible sanctions for deviation from accepted quality management and/or credentialing standards
and program integrity violations include:
•
•
•
•
Limiting a PCP’s panel, not necessarily limited to freezing new member assignment.
Termination of participating provider status.
Withholds from future claims payments of amounts that are improperly paid or reasonable
estimates of such amounts.
Suspension of claims activity.
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Provider Manual
Section 10.0
Emergency Care/Urgent Care
Services
Table of Contents
10.1 Emergency Care
10.2 Out-of-Service-Area Care
10.3 Urgent Care Services
10.4 Lock-In Program
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10.0 Emergency Care/Urgent Care Services
10.1 Emergency Care
10.1.1 Definition
Services for medical emergencies are covered when provided in a hospital, physician’s office or
other ambulatory setting. As defined in 42 USC 139dd(e) and 42 CFR 438.114, Emergency Medical
Condition means: (A) a medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect that the absence of immediate medical attention to result in (i)
placing the health of the individual (or with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious
dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having
contractions (i) that there is an inadequate time to effect a safe transfer to another hospital before
delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn
child.
10.1.2 PCP Responsibilities
If the member calls the primary care practitioner’s (PCP) office prior to going to the ER and if the
situation can be handled in the PCP’s office, it is the PCP’s responsibility to comply with Passport’s
access standards. A referral or authorization is not required for a member to be seen in the
emergency room (ER). It is also the responsibility of the PCP, per his or her contract with Passport,
to have after-hours call service 7 days a week, 24 hours a day. Use of Passport’s 24-Hour Nurse
Advice Line is not an acceptable alternative to after-hours call service.
Giving members easily understood instructions during regular office visits may help avoid afteroffice-hours calls or ER visits. Reviewing home treatment for common conditions, such as fever,
vomiting, diarrhea, and earaches may give members or their caregivers more confidence in handling
these conditions when they arise. Providing written instructions to be used as a reference may also
be helpful.
10.2 Out-of-Service-Area Care
10.2.1 Definition
Emergency care as described in Section 10.1.1 is also a covered benefit for Passport members when
they are out of the service area. A referral or prior authorization is not required for out-of-servicearea emergency care in the ER. For an out-of-network provider to receive reimbursement a
Kentucky Medicaid ID number and Passport Provider ID number is needed.
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10.3 Urgent Care Services
10.3.1 Definition
Urgent care may be a covered service in an urgent care center, PCP office, or other ambulatory
setting. Urgent care means care for a condition not likely to cause death or lasting harm but for
which treatment should not wait for a normally scheduled appointment. Members are advised via
Passports educational materials to contact their PCP before seeking medical treatment elsewhere.
10.3.2 PCP Responsibilities
If the member calls prior to going to a licensed, credentialed urgent care center and the situation can
be handled in the PCP’s office, it is the PCP’s responsibility to see the member within Passport’s
access guidelines.
For the current listing of urgent care centers, please visit the Provider Directories section of our web
site, www.passporthealthplan.com/provider/resources/directories.
To request a hard copy of this listing, please contact your Provider Relations Specialist or Provider
Services at (800) 578-0775.
10.4 Lock-In program
The Passport Health Plan Lock-In Program is designed to ensure medical and pharmacy benefits are
received at an appropriate frequency and are medically necessary. The Lock-In Program is a
requirement of the Kentucky Department for Medicaid Services (DMS).
Inappropriate use or abuse of Medicaid benefits may include:
•
•
•
Excessive emergency room or practitioner office visits;
Multiple prescriptions from different prescribers and/or pharmacies; and/or,
Reports of fraud, abuse, or misuse from law enforcement agencies, practitioners, Office of the
Inspector General, pharmacies, and Passport staff.
Under the Lock-In Program, a member’s medical and pharmacy claims history and diagnoses are
reviewed for possible overutilization. Members who meet the criteria will either be locked-in to a
designated hospital for non-emergency services; and/or one prescriber, who may not necessarily be
the member’s PCP, and one pharmacy for controlled substances.
•
•
•
Members who receive services from a non-designated or non-referred provider (i.e. via
PCP) and are informed of the financial responsibility before the service is provided will be
responsible for payment.
Members who receive services provided in the emergency department of a hospital for a
condition that is not determined to be an emergency will also be responsible for payment.
Lock-in members must be provided the Acknowledgement of Responsibility for Payment
form located at : http://www.chfs.ky.gov/dms/provider.htm
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All designated providers (i.e. PCPs, controlled substance prescribers, hospitals and pharmacies) will
receive written notice of the member’s Lock-In status. All members have the right to appeal within
the first 30-days of the Lock-In effective date.
Initially, a member will be locked-in for a minimum of 24 months. At least annually, members will be
reviewed to determine whether to maintain their lock-in status for another 12-month period.
The Lock-In Program is not intended to penalize or punish the member. The program is intended to:
•
•
•
•
Connect members with case managers who can identify reasons for over use of medical
services and provide education on their health care needs;
Reduce inappropriate use of health care services;
Facilitate effective utilization of health care services; and,
Enhance quality of care by developing a stable patient-physician and patient-pharmacist
relationship.
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Provider Manual
Section 11.0
Special Programs
Table of Contents
11.1 Case Management
11.2 Health and Disease Management Programs
11.3 Children Living in Out-Of-Home Placements
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11.0 Special Programs
11.1 Case Management
11.1.1 Definition
Case Management is a collaborative process of assessment, planning, facilitation, care coordination,
evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive
health needs through communication and available resources to promote quality cost-effective
outcomes.
11.1.2 Target Populations
Members who may benefit from case management are those with ongoing complex medical needs.
The following may warrant case management; however, these are certainly not all-inclusive:
•
•
•
•
•
•
Children in/or receiving foster care or adoption assistance;
Blind/Disabled children under the age of 19 and related populations eligible for SSI;
Adults over the age of 65;
Homeless;
Individual with chronic physical health illnesses; and,
Individuals with chronic behavioral health illnesses.
11.1.2.1 How are Referrals Generated?
Referrals to Case Management are received through many sources:
•
•
•
•
•
•
•
Member Services line;
Passport member and provider inquiries;
Completed Health Risk Assessments (HRAs);
Recently discharged members from hospitals or who have required Emergency Room care;
Outreach calls by RROT case managers to members who have called the 24-hour Nurse
Line and require further assistance from our Case Management staff;
Internal department referrals; and,
Providers seeking case management referrals for their patients.
11.1.3 How to Request Case Management Services
Practitioners, as well as members and other interested parties, may request case management
services. Practitioners may contact the Rapid Response department at (877) 903-0082 from 8:00
a.m. to 6:00 p.m. EST to make a case management referral or by completing the Care Coordination
Referral Form available online at
http://www.passporthealthplan.com/provider/resources/tutorials/index.aspx. If you would like
to speak with the case manager once he or she is assigned, notify the Rapid Response coordinator
when you make a case management request. Participation in Case Management is voluntary and the
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member has the right to decline any or all parts of the program.
11.1.4 Rapid Response Outreach Team
The Rapid Response Outreach (RROT) team was developed at Passport to address members’
health questions, to identify members in need of care coordination services, and to address the
urgent needs of our members. Our goal is to reduce both unnecessary emergency room visits and
in-patient stays, as well as assist in removing barriers to needed healthcare services.
The team consists of Registered Nurses, and Case Management Technicians (under the direction of
the clinical staff), with Social Workers, Pharmacists, Pharmacy Technicians and Durable Medical
Equipment support staff.
11.1.4.1 What we do
The members of the Passport Rapid Response Outreach Team are trained to assist in the rapid
triage of members' needs. The team assists members in investigating and overcoming the barriers
to achieving their health care goals. The RROT can assist with:
•
•
•
•
•
•
•
•
•
•
Questions concerning how to obtain supplies or services from Durable Medical providers;
Transportation scheduling;
Assisting with pharmacy and barriers to receiving medications;
Collaborating with specialists;
Coordination of physician appointments;
Scheduling preventive health screens;
Facilitating medication access;
Informing members of the available community resources, assist them in completing the
application process and follow through of services;
Outreaching to members for HEDIS® measures; and,
Resources for resolution of legal questions such as the creation of advanced directives, living
trusts, or other types of legal assistance.
11.1.4.2 Contact the Rapid Response Outreach Team
The Rapid Response Outreach Team can be reached at 877-903-0082 from 8:00 a.m. until 6:00
p.m. EST, Monday through Friday. After hours, there is a 24-hour Nurse Call Line available to all
members at 800-606-9880.
11.2 Health and Disease Management Programs
11.2.1 Introduction
Passport is committed to working with providers to help keep members healthy by supporting
preventative care. One way to do this is through Health and Disease Management programs that
ideally prevent or decrease exacerbation of an illness by a comprehensive, integrated approach to
care. Passport’s Health and Disease Management programs include the Diabetes Disease
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Management Program, the Chronic Respiratory Disease Management Program, the Congestive
Heart Failure (CHF) Program, the Mommy Steps Perinatal Program, and the Obesity Program.
Practitioners are informed about the programs through various methods, including Passport’s
Provider Manual, web site, provider communications, New Provider Orientation Kit, office sitevisits by the Provider Relations Specialists, and face-to-face education visits by the disease specific
provider.
11.2.2 Purpose of Programs
Each program emphasizes education for targeted members and providers to improve the overall
health, wellness, and quality of the member’s life. The goal of the programs is to provide tools to
educate the member on promoting improved health through better prevention, detection,
treatment, and education. These programs aim to facilitate member understanding and
responsibility of the disease process as well as coordination of care between the member and/or
caregiver and the provider. Programs focus on increasing both member and provider adherence
with well-established and professionally recognized guidelines.
11.2.3 Evaluation of Programs
The objectives, activities, and outcomes of each Health and Disease Management Program are
continually evaluated and measured against national standards. Updates and revisions are made as
needed, with the programs being reviewed at least annually. Reviews consist of:
•
•
•
•
•
Measuring participation rates;
Determining whether the programs have demonstrated improvement in outcomes and
quality of care provided to members;
Evaluating the overall effectiveness of the programs;
Exploring he barriers and limitations of the programs; and,
Revising areas as needed to improve effectiveness of the programs.
11.2.4 Type of Disease Management Program
Passport offers the following Disease Management Programs:
•
•
•
•
•
Diabetes Disease Management Program
Chronic Respiratory Disease Management Program
Congestive Heart Failure (CHF) Disease Management Program
Obesity Disease Management Program
Mommy Steps Program (for Pregnant Members)
Please reference Passport’s website at www.passporthealthplan.com for additional program
information.
11.3 Children Living in Out-Of-Home Placements
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This term refers to children living in one of the following:
• Foster care.
• Guardianship.
• Department of Juvenile Justice.
• Psychiatric residential treatment facilities.
• Group home.
• Adoption assistance.
Due to the nature of children requiring an out-of-home placement, the Department for Medicaid
Services (DMS) sometimes moves children outside of the Passport service area where Passport may
not have participating providers.
Children living in out-of-home placements do not choose a PCP. Participating or nonparticipating
practitioners with a valid Kentucky Medicaid Identification (MAID) number may provide medical
treatment for these children. Children living in out-of-home placements can be treated by specialists
without a referral. They require prior authorization for the following services only: inpatient hospital
admissions, private duty nursing, skilled services provided at a special needs daycare, and home health
services. To pre-certify these services, contact Utilization Management at (800) 578-0636. In
addition, non-participating OB providers are required to obtain authorization for OB services.
Children living in out-of-home placements will have “No PCP Required” located on their Passport
card where the name of the PCP usually appears. These children may relocate often and may present
for treatment without a card or with a card that is not current. Providers may contact Provider
Services at (800) 578-0775 to verify eligibility and out-of-home placement status. Eligibility may also
be checked via NaviNet at www.navinet.navimedix.com. Foster Parents/Guardians can direct
questions to Member Services at (800) 578-0603.
11.3.1 Foster Care/Adoption/Guardianship Liaison
The Foster Care/Adoption/Guardianship Liaison works in collaboration with the Department for
Community Based Services to identify DCBS clients for Care Coordination Services. The Foster
Care/Adoption/Guardianship Liaison is responsible for identifying and correcting problems with
special populations including Foster Care, Guardianship, Department of Juvenile Justice, Kinship,
Adoptive Assistance, Residents of Psychiatric Treatment Facilities, and Group Homes. The Foster
Care/Adoption/Guardianship Liaison serves as a primary contact for foster and adoptive parents,
guardians and DCBS supervisor for issues and concerns. Foster Parents/Guardians can direct
questions to Member Services at (800) 578-0603.
11.3.2 Homeless Services
Passport provides ongoing face-to-face member/benefits education sessions throughout the year.
These sessions are conducted at the various transitional and homeless shelters throughout the
state. Special attention is given to those victims of domestic violence residing in emergency
shelters.
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Provider Manual
Section 12.0
Outpatient Pharmacy Services
Table of Contents
12.1 Prescribing Outpatient Medications for Passport Health Plan
Members
12.2 Covered Outpatient Pharmacy Benefits
12.3 Drug Prior-Authorization Procedure
12.4 Lock-In Program
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12.0 Outpatient Pharmacy Services
12.1 Prescribing Outpatient Medications for Passport Health Plan
Members
Any health care provider licensed to prescribe medications in the Commonwealth of Kentucky may
write a prescription for a Passport Health Plan member provided it is within the scope of the
provider’s medical licensure and the prescriber has a valid, current Kentucky Medicaid license
number. The provider’s National Provider Identifier (NPI) and Medicaid number must appear on
the prescription presented to the member for the prescription to be filled. Pharmacies must include
the prescriber’s NPI when submitting all prescriptions for coverage.
12.2 Covered Outpatient Pharmacy Benefits
Passport Health Plan must have available to its members all medications appearing on the
Department for Medicaid Services (DMS) Drug List; however, Passport may impose additional
requirements for medical necessity through the use of prior authorizations. In addition, Passport
covers certain diabetic supplies. Passport may also impose quantity limits or day supply limits, and
other appropriate edits to promote both safety and evidence-based therapy. The Pharmacy and
Therapeutics Committee, comprised of practitioners, pharmacists, and consumer representatives,
meets regularly to update the preferred drug list. Working with Passport Health Plan’s pharmacy
benefits manager (PBM), the Pharmacy and Therapeutics Committee annually reviews each category
of drugs to identify preferred drugs based upon clinical and pharmacoeconomic data to promote
cost-effective, evidence-based practices.
Providers are encouraged to use Passport’s Preferred Drug List. Providers may view the preferred
drug list via Passport’s online searchable formulary. Updates to the Preferred Drug List are also
distributed via Passport’s Pharmacy News Bulletin which is also available through your Provider
Network Account Manager or Passport’s website
www.passporthealthplan.com/pharmacy/communication/news/index.aspx
12.2.1 Categories of Covered Drugs
Three categories of drugs (available on Passport Health Plan’s web site,
http://www.passporthealthplan.com/pharmacy/formulary/index.aspx) are covered for Passport
Health Plan members:
•
Preferred medications: Drugs that have been evaluated by Passport Health Plan’s Pharmacy
and Therapeutics Committee and found to provide pharmacoeconomic value, therapeutic
benefits, and a history of safe use. Some preferred drugs may have age edits and require step
therapy.
•
Prior authorized drugs (PA): These drugs may require the use of a non-prior authorized
drug (step therapy) and/or meet additional medical necessity criteria for approval. Medical
necessity criteria may include peer-reviewed criteria, relevant and statistically-appropriate
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studies, and FDA approvals for drug use.
•
Selected categories of over-the-counter (OTC) drugs: Covered OTC drugs should be
used in the course of current or ongoing therapy. A valid prescription for these medications
is required for dispensing.
Drugs in all three of the above categories may have limits for quantity dispensed, days’ supply, and
requirements for use to ensure medical necessity.
12.2.2 Categories of Covered Diabetic Supplies
The following diabetic supplies are only covered through the pharmacy with a valid prescription:
•
•
•
•
•
•
•
•
•
Blood glucose meter
Blood glucose test strips
Calibrator solutions
Insulin syringes
Blood ketone test or reagent strips
Urine test or reagent strips
Lancets
Lancing devices
Pen needles
Quantity limits may apply.
12.3 Drug Prior-Authorization Procedure
12.3.1 Prescription Medications and Prior Authorization
12.3.1.1 When is a Prior Authorization (PA) Required?
PA is necessary for some medications to establish medical necessity and to ensure eligibility for
coverage per State and/or Federal regulations. This may be due to specific Food and Drug
Administration (FDA) indications, the potential for misuse or overuse, safety limitations, or costbenefit justifications.
PA is required for medications that are:
•
•
•
•
•
•
•
Outside the recommended age, dose or gender limits;
Non-preferred (potential for “step therapy1” before approval);
Non-formulary;
Duplication in therapy (i.e. another drug currently used within the same class);
New to the market and not yet reviewed by Passport’s Pharmacy & Therapeutics (P&T)
Committee;
Prescribed for off-label use or outside of certain diseases or specialties; or,
An incorrect ICD-9 code when required.
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12.3.1.2 How to Submit and Receive Notification on a PA
STEP 1: Determine if the drug requires PA.*
• For the PA status of specific covered medications, please refer to our online searchable
formulary by visiting www.passporthealthplan.com/pharmacy.
STEP 2: Complete the PA form in its entirety.
• The Passport Prior Authorization Form is available on
www.passporthealthplan.com/pharmacy.
• A physician, nurse practitioner, or pharmacist may complete this form.
STEP 3: Submit the completed form for review to (877) 693-8280 or complete the online
submission form at www.passporthealthplan.com/pharmacy and click on “Online Prior
Authorization.” If the request is for a hospital discharge, check that box on the form.
STEP 4: Receive the response.
You may expect a response within 24 hours after submission.
Your office must have the area code programmed into your fax machine with a Called Subscriber
Identification (CSID) number in order to receive fax confirmation of PA receipt.
Step therapy is defined as a trial of the safest and most cost effective therapy prior to progressing to other, more costly
or recently-approved therapies (i.e. “step protocol”).
1
*Timeframes are developed in accordance with requirements established by the Kentucky Department for Medicaid
Services (DMS) and are subject to change. Incomplete or unclear information on the form may delay processing of a
PA.
12.3.1.3 What Happens During the PA Review Process:
1st review: A pharmacy technician compares all information on the request to Passport’s clinical
authorization criteria. Passport utilizes medical criteria developed in collaboration with
our Pharmacy Benefits Manager (PBM) and the P&T Committee. Criteria are derived
from one or more of the following:
•
•
•
•
•
Published American Federal Food and Drug approval indications for Therapy;
Federal and/or State regulatory requirements;
Drug compendia such as the American Hospital Formulary Service-Drug Information
(AHFS-DI), the Gold Standard Clinical Pharmacology, the DrugDex or “Facts and
Comparisons;”
Evidence-based guidelines provided by non-biased resources from government agencies, such
as the Agency for Healthcare Review and Quality(AHRQ), the American Society of Clinical
Oncologists (ASCO), or the American Academy of Pediatrics (AAP); and/or,
Current medical literature and peer-reviewed, non-biased publications based on appropriate
scientifically designed study protocol with validated outcome endpoints.
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2nd review: If the request does not meet Passport’s clinical authorization criteria, it is forwarded to
a registered pharmacist. Additional information may be requested via fax or telephone
from the prescribing provider.
3rd review: If the pharmacist cannot approve the request, the request is forwarded electronically to
a Passport Medical Director for a decision.
12.3.1.4 How Providers Are Notified of PA Decisions
A fax will be sent to the requesting provider’s submitted fax number with one of the following PA
decisions.
Approved
The PA request has been approved for pharmacy reimbursement. Based on the
medication and if requested by the prescriber, approvals may be granted for up to
twelve (12) months.
Partial
Denial
Reimbursement has been approved for a therapeutic alternative or for a different
dose than requested.
Deferral
The final PA action was not decided due to the need for additional information.
Providers must fax the requested information back to the PBM in order to obtain a
final PA decision.
Denial
The PA request was denied. All PA denials are issued by a licensed physician. These
decisions may be appealed.
Denial rationale is included on every PA denial fax, and whenever possible, with a
recommendation for an alternate preferred medication. However, denials for medications not
indicated for clinical use may not include medication alternatives.
12.3.1.5 Emergency Supply
Pharmacies may dispense a 72-hour emergency supply of medication if they are unable to contact
the prescriber for prior authorization. This does not apply to drugs excluded from coverage by state
and federal regulations.
12.3.1.6 Prescription Cost Sharing
Beginning January 1, 2014, some Passport Health Plan members will have a copay for
prescriptions. Copay requirements are as follows:
2014 Cost Sharing Requirements
$0 Generic Drugs
$2 Preferred Drugs
$4 Non-preferred Drugs
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Total cost sharing cannot exceed an aggregate of 5% of a family’s income per calendar quarter.
The pharmacy will be made aware of any copayment responsibility and will collect it from the
member when the claim is adjudicated.
A pharmacist may refuse to dispense a prescription to a member who does not pay the cost sharing
amount at the time of picking up the prescription; however, the pharmacist must dispense a 72hour supply of the prescribed drug if the member has an emergency condition which requires an
emergency supply of the drug.
The following members do not have a copayment requirement unless they receive a non-preferred
medication.
•
•
•
•
•
•
•
Members 18 years of age and under;
Pregnant members;
Institutionalized members;
Members receiving family planning services and supplies;
American Indians receiving services directly by an American Indian health care provider or
through referral under contract health services;
Members in hospice care; and,
Members receiving preventive services.
12.3.2 Denial and Appeal Process
An authorization request for outpatient pharmacy services may be denied for lack of medical
necessity, or it may be denied for failure to follow administrative procedures outlined in the Provider
Contract or this Provider Manual. Denial letters are generated by Passport to the member and the
prescriber. The PBM faxes a denial notification to the prescriber and the pharmacy if fax numbers
are available.
Your office must have the area code programmed into your fax machine with a CSID (Called
Subscriber Identification) in order to receive fax confirmation of PA receipt with the seven (7) digit
transaction number identifier. This 7-digit identifier is required if you call regarding a PA status.
Appeals for pharmacy services are handled by Passport Health Plan following the same procedure as
pre-service appeals (see Section 2.11 for additional information).
12.4 Lock-In Program
The Passport Health Plan Lock-In Program is designed to ensure medical and pharmacy benefits
are received at an appropriate frequency and are medically necessary. The Lock-In Program is a
requirement of the Kentucky Department for Medicaid Services (DMS).
Inappropriate use or abuse of Medicaid benefits may include:
• Excessive emergency room or practitioner office visits;
• Multiple prescriptions from different prescribers and/or pharmacies; and/or
• Reports of fraud, abuse, or misuse from law enforcement agencies, practitioners, Office of the
Inspector General, pharmacies, and Passport staff.
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Under the Lock-In Program, a member’s medical and pharmacy claim history and diagnoses are
reviewed for possible overutilization. Members who meet the criteria will either be locked-in to a
designated hospital for non-emergency services; and/or one prescriber, who may not necessarily
be the member’s PCP, and one pharmacy for controlled substances.
• Members who receive services from a non-designated or non-referred provider (i.e. via
PCP) and are informed of the financial responsibility before the service is provided will be
responsible for payment.
• Members who receive services provided in the emergency department of a hospital for a
condition that is not determined to be an emergency will also be responsible for payment.
• Lock-in members must be provided the Acknowledgement of Responsibility for Payment
form located at : http://www.chfs.ky.gov/dms/provider.htm.
All designated providers (i.e. PCPs, controlled substance prescribers, hospitals and pharmacies)
will receive written notice of the member’s Lock-In status. All members have the right to appeal
within the first 30-days of the Lock-In effective date.
Initially, a member will be locked-in for a minimum of 24 months. At least annually, members will
be reviewed to determine whether to maintain their lock-in status for another 12-month period.
The Lock-In Program is not intended to penalize or punish the member. The program is
intended to:
• Connect members with case managers who can identify reasons for over use of medical
services and provide education on their health care needs;
•
•
•
Reduce inappropriate use of health care services;
Facilitate effective utilization of health care services; and
Enhance quality of care by developing a stable patient-physician and patient-pharmacist
relationship.
12.4.1 How to Refer a Member
To refer a member, to determine if a member is part of the Lock-In program, or for general
questions regarding the program, please contact the Pharmacy Coordinator for pharmacy or
controlled substance prescriber inquires or the ER Coordinator at 502-588-8564 for hospital
inquiries.
12.4.2 How to Report Fraud and Abuse
If you suspect fraud and/or abuse by a Passport Health Plan member or provider, it is your
responsibility to report this immediately by calling one of the telephone numbers listed below:
Corporate Compliance Hotline:
(855) 512-8500
KyHealth Choices Medicaid Fraud Hotline: (800) 372-2970
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Provider Manual
Section 13.0
Obstetrical
Table of Contents
13.1 Overview
13.2 Member Access to Prenatal Care
13.3 Obstetrical Practitioner’s Role
13.4 General Procedure for Prior Authorization of Obstetrical Care
And Delivery
13.5 Perinatal Labs
13.6 Change of Obstetrical Practitioners
13.7 Evaluation and/or Treatment by Perinatologists, Geneticists or
Endocrinologists
13.8 Maternity Observation Stay
13.9 Prenatal Appointment Scheduling Standards
13.10 Subsequent Perinatal Care & Delivery
13.11 No-Show-Visit Protocol (Prenatal and Postpartum
Appointments)
13.12 Claims Submission
13.13 Presumptive Eligibility
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13.0 Obstetrical
13.1 Overview
Passport Health Plan recognizes that access to effective prenatal and obstetrical care helps form a
strong foundation for individual’s health for years to come. As a result Passport’s Mommy Steps
Program works with obstetrical clinicians, local health departments, home health agencies, and
others to identify the psychosocial, nutritional and educational needs of pregnant members. Once
these needs are identified, Passport aids in coordinating the perinatal care services for these
members. The care management plans that are created may include counseling, home care, health
education, and referrals to appropriate community services.
Our aim is to coordinate care to increase the likelihood that every pregnancy will progress to full
term resulting in improved birth outcomes. By collaborating with our network clinicians and
facilities we can decrease the rate of prematurity, infant mortality, low birth weight and very low
birth weight babies.
13.2 Mommy Steps
Passport has dedicated associates available to assist members and obstetrical providers with
questions. They can be reached at (877) 903-0082 or via fax at (502) 585-7970 Monday through
Friday, 8:00 a.m. to 6:00 p.m. EST (excluding business approved holidays).
We will provide newly pregnant members with a welcome packet to our program that includes:
education about prenatal care (including coverage for classes conducted by certified prenatal
educators), community resources (eg. WIC, HANDS, and Healthy Start), smoking cessation
resources, treatment options for substance use and behavioral health conditions, domestic violence
support, dental and vision services, legal assistance contacts, and transportation service contact
information. High-risk pregnancy members receive additional contacts and services from one of
our Care Managers.
Participation in the Mommy Steps Program, as with all Care Management Programs, is voluntary,
and the member has the right to decline any or all parts of the program.
13.3 Member Access and/or Authorization Requirements
All components of obstetrical care are directly accessible by members including testing and prenatal
care. Appointment standards must be provided for prenatal care as follows:
•
•
•
•
1st Trimester-within 14 business days of request.
2nd Trimester-within 7 business days of request.
3rd Trimester-within 3 business days of request.
High-risk pregnancies-within 1 business day of the identification of a high-risk condition or
immediately if an emergency exists.
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In addition referrals to perinatologists, geneticists, and endocrinologists are not required for high
risk conditions and evaluation during pregnancy.
Maternity observation stays do not require authorizations. These are defined as a hospital stay of 23
hours or less for the observation of members with medical conditions related to pregnancy. One
23-hour maternity observation stay per member within a 23-hour time frame is allowed.
13.4 Responsibility of Providers
Follow the Passport Health Plan Clinical Practice Guideline for Perinatal Care which was adopted
from the American College of Obstetrics and Gynecology (ACOG).
Submit the initial ACOG or ACOG-like assessment which includes the member’s medical and
obstetric history within two business days of the initial prenatal visit. It is the responsibility of the
provider to confirm that an ACOG (or ACOG-like) form has been received by Mommy Steps if
they assume the care of a member from another provider.
Contact the Mommy Steps Program if the pregnancy becomes high risk.
Direct members to their PCP for the evaluation and treatment of conditions not related to
pregnancy.
Coordinate care with the member’s PCP or other treatment clinicians as appropriate.
Notify the Mommy Step’s Program via fax within two business days of all missed prenatal
appointments. Following this process is required for reimbursement as outlined in the fee schedule
for No-Show-Visits.
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Provider Manual
Section 14.0
Family Planning
Table of Contents
14.1 Services
14.2 Network
14.3 Claims
Page 138 of 331
14.0 Family Planning
14.1 Services
Family Planning Services includes complete medical history, physical examination, laboratory and
clinical test supplies, educational material, counseling and prescribed birth control methods to best
suit the patient's needs.
Family planning services include but are not limited to:
•
•
•
•
•
Routine OB/GYN exams leading to dispensing of contraceptives.
Birth control/contraceptives, such as pills, sponges, condoms, jellies.
Intrauterine devices (IUDs) – implantation and removal.
Injectable long-acting contraceptives.
Implantable contraceptive devices.
Sterilization*
•
•
•
Tubal ligations.
Postpartum tubal ligations.
Vasectomies.
Termination of Pregnancy**
•
•
First trimester – up to 12 weeks.
Second trimester – 12 to 22.5 weeks.
* Requirements for Sterilization:
1. MAP 250 form must be completed (Male and Female sterilization)
2. MAP 250 form must be completed 30 days PRIOR to the scheduled procedure
3. Member must be at least 21 years of age or older
4. Consent expires 180 days from the member’s signature
5. Form must be attached to all claims
If the form is not attached or the form is incomplete, the claim may be denied
6. Prior authorization IS NOT required for sterilization
** Requirements for Termination of pregnancy (Induced Abortion or Induced Miscarriage):
1. MAP 235 form must be completed
2. Termination is covered ONLY:
A. In cases of Rape or Incest
B. If the life of the mother would be endangered if the fetus were carried to term. If the
requirements for termination of pregnancy are not met, alternative funding can be located at
http://www.fundabortionnow.org/funds/AFund-Inc
3. Prior authorization IS required for termination of pregnancy. Medical Record must be
submitted for review MAP 235 must be submitted for review.
4. Requests for authorization of services may be received Monday through Friday from 8:00 a.m.
Page 139 of 331
to 5:30 p.m. EST, except holidays, by calling (800) 578-0636 or faxing to (502) 585-7989.
Requests submitted without complete medical records and a MAP 235 form will not be able to be processed
The member and the provider must complete and comply with all terms and conditions of the
Kentucky Department for Medicaid Services (DMS) consent forms. Consent for Sterilization (MAP
250) and Certification Form for Induced Abortion or Induced Miscarriage (MAP 235) forms may be
accessed on the DMS web site, http://chfs.ky/gov. Sample forms are located in Section 19 of this
Provider Manual. The provider must ensure that non-English speaking, visually impaired and/or
hearing-impaired members understand what they are signing.
14.2 Network
Passport members may obtain family planning services from any participating provider. No referral
from the member’s primary care practitioner (PCP) is required for family planning services.
14.3 Claims
All family planning claims are to be submitted to the following address:
Passport Health Plan
P.O. Box 7114
London, KY 40742
For Sterilization Services: (Tubal ligations, Postpartum tubal ligations, Vasectomies) a completed
MAP 250 form must be attached to all claims. Failure to submit the completed form with the claim
may result in the claim being denied.
Claims for presumptively eligible (PE) members should be submitted according to the guidelines in
Section 18.
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Provider Manual
Section 15.0
Provider Billing Manual
Table of Contents
15.1 Claim Submission
15.2 Provider/Claim Specific Guidelines
15.3 Understanding the Remittance Advice
15.4 Denial Reasons and Prevention Practices
15.5 Timely Filing Requirements
15.6 Corrected Claims and Requests for Reconsideration and/or
Refunds
15.7 Contact Information for Claims Questions
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15.0 Provider Billing Manual
15.1 Claim Submission
15.1.1 Procedures for Claim Submission
Passport Health Plan (Passport) is required by state and federal regulations to capture specific data
regarding services rendered to its members. The provider must adhere to all billing requirements in
order to ensure timely processing of claims.
When required data elements are missing or invalid, claims will be rejected by Passport for
correction and resubmission.
The provider who performed the service to the Passport member must submit the claim for a billable
service.
Claims filed with Passport are subject to the following procedures:
•
•
•
•
•
•
•
Verification that all required fields are completed on the CMS-1500 or UB-04 forms.
Verification that all diagnosis and procedure codes are valid for the date of service.
Verification of the referral for specialist or non-primary care physician (PCP) claims.
Verification of member eligibility for services under Passport during the time period in which
services were provided.
Verification that the services were provided by a participating provider or that the “out- ofnetwork” provider has received authorization to provide services to the eligible member
(excluding “self-referral” types of care).
Verification of whether there is Medicare coverage or any other third party resources and, if
so, verification that Passport is the “payer of last resort” on all claims submitted to Passport.
Verification that an authorization has been given for services that require prior authorization by
Passport.
As part of the agreement between Passport and the provider, the provider agrees to cooperate with
Passport in its efforts to comply with all applicable Federal and State laws, including specifically the
provisions of Section 6032 of the Deficit Reduction Act of 2005, PL-019-171, False Claims Act,
Federal Remedies for False Claims and Statements Act, and KRS 205.8451, et. Seq. (relating to
fraud).
15.1.2 Rejected and Denied Claims
Rejected claims are defined as claims with invalid or missing data elements (such as the provider tax
identification number) that are returned to the provider or EDI source without registration in the
claims processing system. Since rejected claims are not registered in the claims processing system,
the provider must re-submit corrected claims within 180 calendar days from the date of service. This
requirement applies to claims submitted on paper or electronically.
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Rejected claims are different than denied claims, which are registered in the claims processing system
but do not meet requirements for payment Passport guidelines. For more information on denied
claims, see Section 15.3 and 15.4 in this Provider Manual.
15.1.3 Claim Mailing Instructions
Passport encourages all providers to submit claims electronically. For those interested in electronic
claim filing, contact your EDI software vendor or the Emdeon Provider Support Line at (800)
845-6592 to arrange transmission.
Additional questions may be directed to the EDI Technical Support Hotline at (877) 234-4275 or
via e-mail to [email protected].
If you choose to utilize paper claims, please submit to Passport at the following address:
Passport Health Plan
P. O. Box 7114
London, KY 40742
15.1.4 Claim Filing Deadlines
Original invoices must be submitted to Passport within 180 calendar days from the date services were
rendered or compensable items were provided.
Previously denied claims (with corrections and requests for adjustments) must be submitted within
two years of the process date.
15.1.5 Exceptions
Submission of claims for members retroactively enrolled in Passport by the Department for Medicaid
Services is based on the date of notification of enrollment. Claims with Explanation of Benefits
(EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer’s
EOB.
15.1.6 Claims Status Review
Providers may view claims status using any of the following methods:
•
•
•
Online – check eligibility/claims status by logging into NaviNet at
https://navinet.navimedix.com
Telephone – you may also check eligibility and/or claims status by calling our interactive
voice response (IVR) system at (800) 578-0775.
Real-Time – depending on your clearinghouse or practice management system, real-time claims
status information is available to participating providers. Contact your clearinghouse to access:
 Emdeon Products for claims status transactions.
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 All other clearinghouses: Ask your clearinghouse to access transactions through
Emdeon.
15.1.7 Notification of Denial via Remittance Advice
When a claim is denied because of missing or invalid mandatory information, the claim should be
corrected, marked as a second submission or corrected claim, and resubmitted within two years of
the process date to the general claim address:
Passport Health Plan
P.O. Box 7114
London, KY 40742
15.1.8 Claims Adjustment/Reconsideration Requests
If you believe there was an error made during claims processing or if there is a discrepancy in the
payment amount, please call the Provider Claims Service Unit (PCSU) at (800) 578-0775, option 2.
Our representatives can help you resolve the issue, process a claim via the phone, and advise whether
a corrected claim or a written appeal needs to be submitted.
15.1.9 Claim Submission for New Providers
New providers with Passport awaiting receipt of their Medicaid Identification (MAID) number are
subject to the timely filing guidelines and may begin to submit claims once their Passport ID number
has been assigned. These claims will initially deny for no MAID number. After Passport receives a
provider’s MAID number, all claims submitted and initially denied will be reprocessed without
resubmission.
15.1.10 Claim Forms and Field Requirements
The following charts describe the required fields that must be completed for the standard CMS-1500
or UB-04 claim forms. If the field is required without exception, an “R” (Required) is noted in the
“Required or Conditional” box. If completing the field is dependent upon certain circumstances, the
requirement is listed as “C” (Conditional) and the relevant conditions are explained in the
“Instructions and Comments” box.
The CMS-1500 claim form must be completed for all professional medical services, and the UB-04
claim form must be completed for all facility claims. All claims must be submitted within the
required filing deadline of 180 days from the date of service.
Although the following examples of claim filing requirements refer to paper claim forms, claim data
requirements apply to all claim submissions, regardless of the method of submission (electronic or
paper).
15.1.10.1 Claim Data Sets Billed by Providers
To facilitate timely and accurate claim processing, you must assure billing on the correct form for
your provider type. The table below outlines the requirements as defined by Kentucky Medicaid:
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CMS-1500
Hospital - Acute Care Inpatient
Hospital – Outpatient
Hospital - Long Term Care
Inpatient Rehabilitation Facility
Inpatient Psychiatric Facility
Home Health Care
Skilled Nursing Facility
Ambulance (Land and Air)
Ambulatory Surgical Center
Dialysis Facility (Chronic, Outpatient)
Durable Medical Equipment
Drugs (Part B)
Laboratory
Physician and Practitioner Services
Federally Qualified Health Centers
Rural Health Clinics
UB-04 (CMS-1450)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
15.1.10.2 CMS-1500 Claim Form and Required Fields
Use of the CMS-1500 form (08/05) was required as of April 1, 2007. The form includes several fields
that accommodate the use of your National Provider Identifier (NPI).
Although the form requires use of the NPI, we recommend you continue to report your current
plan-assigned Provider Identification Numbers in the appropriate shaded areas of the form (17A, 24J,
32B, and 33B). Current Provider Identification Numbers must be preceded by a two-character
qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you
do not currently bill electronically, please use G2 as your qualifier ID.
Providers are also required to populate filed 19 with the ZZ qualifier ID and the Billing & Rendering
Provider’s Primary Taxonomy Code (Box 33b for Billing and Box 19 for Rendering).
Required Fields for the CMS-1500 Claim Form
NOTE: *Required (R) fields must be completed on all claims. Conditional (C) fields must be
completed if the information applies to the situation or the service provided.
CMS 1500 Claim
Field
1
Field Description
INSURANCE
PROGRAM
IDENTIFICATION
Instructions and Comments
Check only the type of health coverage
applicable to the claim. This field
indicates the payer with whom the
claim is being filed. Select “D”, other.
Page 145 of 331
Required or
Conditional*
R
Passport’s member identification
number as it appears on the member’s
Passport ID card.
EDI details ASC X12 4010A. Subscriber R
number less than 11 digits.
2010BA, NM108=MI NM109 less than
11 digits. Subscriber is required.
1A
INSURED I.D. NUMBER
2
PATIENT’S NAME (Last Name,
First Name, Middle Initial)
3
Enter the member’s name as it appears
on the member’s Passport ID card.
R
PATIENT’S BIRTH DATE / SEX
MMDDCCYY
R
4
INSURED’S NAME (Last Name,
First Name, Middle Initial)
Enter the member’s name as it
appears on the member’s Passport ID
card, or enter the mother’s name when
the member is a newborn.
R
5
PATIENT’S ADDRESS (Number,
Street, City, State, Zip Code, and
Telephone, Including Area Code)
R
6
PATIENT RELATIONSHIP
TO INSURED
Enter the member’s complete address
and telephone number (Do not
punctuate the address or phone
number).
Always indicate self.
R
7
INSURED’S ADDRESS (Number,
Street, City, State, Zip Code)
Telephone (include area code)
Enter the member’s complete address
and telephone number (Do not
punctuate the address or phone
number).
R
8
PATIENT STATUS
Enter the member’s marital status.
Indicate if the member is employed or is R
a student.
9
OTHER INSURED’S NAME (Last
Name, First Name, Middle Initial)
Refers to someone other than the
member. REQUIRED if member is
C
covered by another insurance plan.
Enter the complete name of the insured.
9A
OTHER INSURED’S POLICY
OR GROUP NUMBER
REQUIRED if field 9 is completed.
Page 146 of 331
/
M or F
C
CMS 1500 Claim
Field
Field Description
Instructions and Comments
9B
OTHER INSURED’S BIRTH DATE /
SEX
9C
EMPLOYER’S NAME OR SCHOOL
NAME
9D
INSURANCE PLAN NAME OR
PROGRAM NAME
REQUIRED if field 9 is completed. MM
C
DD YY /
Sex must be indicated by “M” or “F.”
This field is related to the insured in
field 9.
C
REQUIRED if # 9 is completed.
C
10A,B,C IS PATIENT’S CONDITION RELATED Indicate Yes or No for each category.
TO:
10D
Required or
Conditional*
RESERVED FOR LOCAL USE
R
Not required
11
INSURED’S POLICY GROUP OR
FECA NUMBER
Required when other insurance is
available.
Complete if more than one other
medical insurance is available, or if
“yes” to field 10 A, B, C.
11A
INSURED’S BIRTH DATE / SEX
Complete information if other insurance is
listed in field 11.
C
11B
EMPLOYER’S NAME OR SCHOOL
NAME
Required if employment is indicated in
field # 10.
C
C
11C
INSURANCE PLAN NAME OR
PROGRAM NAME
Enter name of Health Plan.
REQUIRED if field 11 is completed.
C
11D
IS THERE ANOTHER HEALTH
BENEFIT PLAN?
Y or N by check box.
If yes, complete 9 A-D.
R
12
PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE
Not required
13
INSURED’S OR AUTHORIZED
PERSON’S SIGNATURE
Not required
14
DATE OF CURRENT: ILLNESS (First
symptom) OR INJURY (ACCIDENT)
OR PREGNANCY (LMP)
MMDDYY
C
15
IF PATIENT HAS SAME OR SIMILAR
MMDDYY
ILLNESS. GIVE FIRST DATE
C
Page 147 of 331
CMS 1500 Claim
Field
Field Description
Instructions and Comments
16
DATES PATIENT UNABLE TO
WORK IN CURRENT
17
NAME OF REFERRING PHYSICIAN
OR OTHER SOURCE
Required or
Conditional*
C
REQUIRED if a provider other than
the member’s primary care physician
rendered invoiced services.
C
Enter Passport provider number for the
referring physician.
The qualifier indicating what the number
represents is reported in the qualifier
field to the immediate right of field 17A.
If the other ID number is the Health
C
Plan ID number, enter G2.
If the other ID number is another
unique identifier, refer to the NUCC
guidelines for the appropriate qualifier.
REQUIRED if field 17 is completed.
17A
I.D. NUMBER OF
REFERRING PHYSICIAN
17B
Enter the NPI number of the referring
NATIONAL PROVIDER IDENTIFIER provider, ordering provider or other
source.
(NPI)
REQUIRED if field 17 is completed.
C
18
HOSPITALIZATION DATES
REQUIRED when place of service is
RELATED TO CURRENT SERVICES inpatient. MMDDYY
C
19
BILLING PROVIDER’S TAXONOMY
CODE
Populate field with the ZZ qualifier
ID and the Billing Provider’s Primary
Taxonomy Code.
R
20
OUTSIDE LAB CHARGES
For billing diagnostic tests subject to
purchase price limitations.
C
All diagnosis codes must be valid
ICD-9 codes for the date of service.
“E” codes are NOT acceptable as a
primary diagnosis. List in priority
order.
R
For resubmissions or adjustments,
enter the claim ID number of the
original claim.
NOTE: Resubmissions may NOT
currently be submitted via EDI.
Original claim ID is required if claim is
a corrected or resubmitted claim.
C
21
22
DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY (RELATE
ITEMS 1, 2, 3, OR 4 TO ITEM 24E BY
LINE).
MEDICAID RESUBMISSION CODE
ORIGINAL REF. NO.
Page 148 of 331
CMS 1500 Claim
Instructions and Comments
Required or
Conditional*
Field
Field Description
23
Enter the referral or authorization
number.
Refer to Section 18.6 in this Provider
PRIOR AUTHORIZATION NUMBER
Manual to determine if services
rendered require an authorization or
referral.
C
R
24A
DATE (S) OF SERVICE
“From” date: MMDDYY.
If the service was performed on one
day, there is no need to complete the
“to” date.
24B
PLACE OF SERVICE
Enter the CMS standard place of
service code.
R
EMG
This field was originally titled “Type of
Service” and is no longer used.
This is now an emergency indicator
field.
Enter Y for “Yes” or leave blank for
“No” in the bottom (unshaded area of
the field).
C
PROCEDURES, SERVICES OR
SUPPLIES CPT/HCPCS MODIFIER
Procedure codes (5 digits) and
modifiers (2 digits) must be valid for
date of service.
NOTE: Modifiers affecting
reimbursement must be placed in the
1st position.
R
24E
DIAGNOSIS CODE
Diagnosis Pointer - Indicate the
associated diagnosis by referencing
the pointers listed in field 21 (1, 2, 3,
or 4). All diagnosis codes must be
valid ICD-9 codes for the date of
service.
R
24F
CHARGES
Enter charges for each line item.
Value entered must be greater than
zero ($0.01)
R
24G
DAYS OR UNITS
Enter quantity for each line item.
Value entered must be greater than
zero (EDI allows two characters).
R
24H
EPSDT FAMILY PLAN
24C
24D
Not required
Page 149 of 331
CMS 1500 Claim
Field Description
Instructions and Comments
Required or
Conditional*
ID QUALIFIER
If the rendering provider does not have
an NPI number, the qualifier indicating
what the number represents is reported
in the qualifier in field 24I.
If the other ID number is the Health
Plan ID number, enter G2.
If the other ID number is another
unique identifier, refer to the NUCC
guidelines for the appropriate
qualifier. The shaded area allows you to
identify the two-character qualifier ID
of the Rendering Provider (G2). The
un-shaded area is pre-filled with NPI.
R
24J
RENDERING PROVIDER ID
The shaded area allows you to submit
Passport assigned provider ID number
of the Rendering Provider which
coincides with the two- character
qualifier ID reported in 24I. The unshaded area accommodates the
Rendering Provider’s NPI.
R
25
FEDERAL TAX I.D. NUMBER SSN/
EIN
Physician or supplier’s Federal Tax ID
number.
R
26
PATIENT’S ACCOUNT NO.
The provider’s billing account number.
R
ACCEPT ASSIGNMENT
Always indicate Yes.
Refer to the back of the CMS 1500
form for the section pertaining to
Medicaid payments.
R
TOTAL CHARGE
Enter the total of all charges listed on
the claim.
Value entered must be greater than
zero dollars ($0.00).
R
29
AMOUNT PAID
REQUIRED when another carrier is the
primary payer.
Enter the payment received from the
C
primary payer prior to invoicing
Passport.
Medicaid programs are always the payers
of last resort.
30
BALANCE DUE
REQUIRED when field 29 is
completed.
Field
24I
27
28
Page 150 of 331
C
CMS 1500 Claim
Field
Field Description
Instructions and Comments
Required or
Conditional*
31
SIGNATURE OF PHYSICIAN OR
SUPPLIER INCLUDING DEGREES
OR CREDENTIALS / DATE
Signature on file, signature stamp,
computer generated or actual
signature is acceptable.
R
32
32A
32B
REQUIRED unless field 33 is the
NAME AND ADDRESS OF FACILITY
same information.
WHERE SERVICES WERE
Enter the physical location (P.O. Box
RENDERED (if other than home or
Numbers are not acceptable here).
office).
Required unless rendering provider is
SERVICE FACILITY NPI NUMBER
atypical and is not required.
SERVICE FACILITY TWO
CHARACTER QUALIFIED ID AND
CURRENT PROVIDERS ID
R
R
R
33
BILLING PROVIDER INFO &
TELEPHONE NUMBER
REQUIRED - Identifies the provider
that is requesting to be paid for the
services rendered and should always be
completed.
Enter physical location. P.O. boxes
are not acceptable.
33A
BILLING PROVIDER NPI NUMBER
REQUIRED
R
BILLING PROVIDER TWO
CHARACTER QUALIFIER ID AND
PLAN ASSIGNED PROVIDER ID
NUMBER
REQUIRED when the Rendering
Provider does not have an NPI
number.
Enter the two-digit qualifier identifying
the non-NPI number followed by the
provider ID number. Do not enter a
space, hyphen, or other separator
between the qualifier and the number.
EDI instructions 2310B loop,
REF01=G2, REF02=Plan’s Provider
Network Number. Less than 13
alphanumeric digits.
NOTE: Do not send the provider on
the 2400 loop.
Enter the health plan ID # (strongly
recommended).
R
33B
Provider Group Taxonomy Code
R
Populate filed with the ZZ qualifier ID
and the Group Provider’s Primary
Taxonomy Code.
15.1.10.3 UB-04 Claim Form and Required Fields
Although the UB-04 claim form accommodates the NPI, you are encouraged to report your current
Passport Provider Identification Numbers in the appropriate areas of the form.
Page 151 of 331
Required Fields UB-04 Claim Form
NOTE: *Required (R) fields must be completed on all claims. Conditional (C) fields must be
completed if the information applies to the situation or the service provided.
Required fields for the UB-04 Claim Form
Field
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Outpatient,
Bill Types
13X, 23X,
33X
Required or Required or
Conditional* Conditional*
1
Billing Provider Name,
Address and
Telephone Number
Line A: Enter the complete provider
name.
Line B: Enter the complete address
or post office number.
Line C: City, State, and Zip
Code Line D: Enter the area
code, telephone number.
Left justified.
2
Pay-to Name and
Address
Enter the facility Medical Assistance
I.D. (MAID)
number. Left
Justified.
R
R
3A
PATIENT
CONTROL NO.
Provider’s patient account/control
number
R
R
3B
MEDICAL/HEALTH
RECORD NUMBER
The number assigned to the
member’s medical/health record
by the provider.
R
R
R
R
4
TYPE OF BILL
Enter the appropriate three-digit or
four-digit code. 1st position is a
leading zero. (Note: Do not include
the leading zero on electronic
claims.)
2nd position indicates type of facility.
3rd position indicates type of care.
4th position indicates billing
sequence.
Page 152 of 331
R
R
Field
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
5
FED. TAX NO.
Enter the number assigned by the
federal government for tax reporting
purposes.
R
R
6
STATEMENT
COVERS PERIOD
FROM/ THROUGH
Enter dates for the full ranges of
services being invoiced.
MMDDYY
R
R
7
UNLABELED
Not used – leave blank.
8A
PATIENT
IDENTIFIER
C
C
PATIENT NAME
Last name, first name, and middle
initial.
Enter the member’s name as it
appears on the member’s
Passport ID card.
Use a comma or space to separate the
last and first names.
R
Titles (Mr., Mrs., etc.) should not
be reported in this field.
No space should be left after the prefix o
a name (e.g. McKendrick). Both names
should be capitalized and separated by a
hyphen (no space).
A space should separate a last name and
suffix.
R
9A-E
PATIENT ADDRESS
Enter the member’s complete
mailing address.
9A. Street Address
9B. City
9C. State
9D. ZIP Code
9E. Country code (report if other
than USA)
R
R
10
BIRTH DATE
Member’s Date of Birth MMDDYYYY R
R
SEX
Enter the member’s sex as recorded
at the time of admission, outpatient
service or start of care. Only M and
F are acceptable.
R
8B
11
Patient ID is conditional if the
number is different from field 60.
Page 153 of 331
R
Field
12A
12B
13
14
15
16
17
18-28
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
ADMISSION 12-15
The start date for this episode of
care. For inpatient services, this is
ADMISSION DATE
the date of admission.
Right Justified.
The code referring to the hour
during which the member was
ADMISSION HOUR
admitted for inpatient or outpatient
care.
Left justified.
A code indicating the priority of this
ADMISSION TYPE
admission/visit.
ADMISSION SRC
A code indicating the source of
(Source of Referral for
the referral for the admission or
Admission or Visit)
visit.
A code indicating the discharge
D HR (Discharge Hour) hour of the member from inpatient
care.
A code indicating the disposition or
discharge status of the member at
Patient Discharge Status the end service for the period
covered on this bill, as reported in
field 6.
A code(s) used to identify
conditions or events relating to this
bill that may affect processing. Enter
one of the following codes
in the second column as a
Reason Code:
CONDITION CODES • 35 if Medicare benefits are
(the following is unique
exhausted.
to Medicare eligible
• 50 if one of the following applies
Nursing Facilities;
to why Medicare does not cover
condition codes should
the services:
be billed when Medicare  No 3-day prior hospital stay;
Part A does not
 Not within 30-days of
cover Nursing
hospital discharge;
Facility Services)
 100 benefit days are exhausted ;
 No 60 day break in daily
skilled care;
 Medical necessity requirements
are not met; and/or,
 Daily skilled requirements are
Page 154 of 331
R
R
R
R
R
Not required
R
C
R
R
R
R
C
C
Field
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Outpatient,
Bill Types
13X, 23X,
33X
Required or Required or
Conditional* Conditional*
29
ACCIDENT STATE
The accident state field contains the two
digit state abbreviation where the
accident occurred.
REQUIRED when applicable.
30
UNLABELED FIELD
Enter DRG on the lower
line. REQUIRED when
applicable.
C
C
31A, B34A, B
OCCURRENCE CODES
AND DATES
Enter the appropriate occurrence code
and date. REQUIRED when
applicable.
C
C
35A, B36A, B
OCCURRENCE
SPAN CODES AND
DATES
A code and the related dates that
identify an event that relates to the
payment of the claims.
REQUIRED when applicable.
C
C
37A, B
UNLABELED FIELD
38
RESPONSIBLE
PARTY
The name and address of the
party responsible for the bill.
C
C
39A, B,
C, D41A, B,
C, D
42
VALUE CODES AND
AMOUNTS
REV.CD.
C
C
A code structure to relate
amounts or values to identify data elements
necessary to process this claim as qualified
by the payer organization
Value Codes and amounts.
If more than one value code applies, list in
alphanumeric order.
C
REQUIRED when applicable. NOTE: If
a value code is populated, then the value
amount must also be populated and vice
versa.
Codes that identify specific
accommodation, ancillary service
or unique billing calculations or
arrangements.
Page 155 of 331
R
C
R
Field
43
44
Field Description
DESCRIPTION
HCPCS/RATE
S/ HIPPS
CODE
45
SERV. DATE
46
SERV. UNITS
47
TOTAL CHARGES
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
The standard abbreviated description
of related revenue code categories is
included on this bill. See the NUBC
R
instructions for field
42 for a description of each
revenue/code category.
1. The Healthcare Common
Procedure Coding System
(HCPS) is applicable to ancillary
services and outpatient bills.
2. The accommodation rate for
inpatient bills.
3. Health Insurance Prospective
Payment System (HIPPS) rate
codes represent specific sets of
patient characteristics (or casemix groups) on which payment
determinations are made under
several prospective payment
systems.
Enter the applicable rate, HCPS or
HIPPS code, and modifier based on
the bill type of Inpatient or
Outpatient.
Report line item dates of service
for each revenue code or
HCPCS/CPT code.
Report units of service.
A quantitative measure of service
rendered by revenue category to or for
the patient to include items such as
number of accommodations days,
miles, pints of blood, renal dialysis
treatments, etc.
Total charges for the primary payer
pertaining to the related revenue code
for the current billing period as
entered in the statement covers
period.
Total charges include both covered
and non-covered charges. Report
grand total of submitted charges.
Value entered must be greater than
zero dollars ($0.00).
Page 156 of 331
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
R
R
R
R
R
R
R
R
R
Field
Field Description
48
NONCOVERED
CHARGES
49
UNLABELED FIELD
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
To reflect the non-coverage charges
for the destination payer as it pertains
C
to the related revenue
code. REQUIRED when Medicare is
primary.
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
C
Not required Not required
PAYER
Enter the name for each payer being
invoiced. When the member has
other coverage, list the payers as
indicated below.
Line A refers to the primary payer;
B, secondary; and C, tertiary.
R
R
HEALTH PLAN ID
The number used by the health
plan to identify itself.
Passport’s Payer ID is
61129.
R
R
52
REL. INFO
Release of Information
Certification Indicator. This field is
required on paper and electronic
invoices.
Line A refers to the primary payer; B
refers to secondary; and C refers to
R
tertiary.
It is expected that the provider/
practitioner have all necessary
release information on file. It is
expected that all released
invoices contain “Y.”
R
53
ASG. BEN.
Valid entries are “Y” (yes) and “N”
(no).
R
R
54
PRIOR PAYMENTS
The A, B, C indicators refer to the
information in Field 50.
R
R
EST. AMOUNT DUE
Enter the estimated amount due
(the difference between “total
charges” and any deductions such as
other coverage).
C
C
50
51
55
Page 157 of 331
Field
56
57A, B
C
58
59
60
61
Field Description
Instructions and Comments
The unique identification number
assigned to the provider submitting
the bill; NPI is the national provider
NATIONAL
identifier.
REQUIRED if the health
PROVIDER
care
provider
is a Covered Entity as
IDENTIFIER-BILLING
defined
in
HIPAA
Regulation.
PROVIDER
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
R
R
OTHER
(BILLING)
PROVIDER
IDENTIFIER
A unique identification number assigned by the health plan to the
provider submitting the bill.
REQUIRED on or after May 23,
2007 if NPI is not mandated in field
56.
The UB-04 does not use a qualifier
to specify the type of Other
(Billing) Provider Identifier. Use
this field to report other provider
identifiers as assigned by
the health plan listed in field 50 A,
B, C.
R
R
INSURED’S NAME
Information refers to the payers
listed in field 50. In most cases, this
will be the member’s name. When
other coverage is available, the
insured is indicated here.
R
R
P. REL
Enter the member’s relationship to
insured. For Medicaid programs the
member is the insured.
(Code 01: Patient is Insured)
R
R
INSURED’S UNIQUE
ID
Enter the member’s Passport ID,
exactly as it appears on the
member’s ID card, on line B or C.
When other insurance is present,
enter the Passport ID on line A.
R
R
C
C
GROUP NAME
Use this field only when a patient
has other insurance and group
coverage applies. Do not use
this field for individual coverage.
Line A refers to the primary
payer; B, secondary; and C,
tertiary.
Page 158 of 331
Field
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Outpatient,
Bill Types
13X, 23X,
33X
Required or Required or
Conditional* Conditional*
62
63
INSURANCE
GROUP NO.
TREATMENT
AUTHORIZATI
ON CODES
Use this field only when a member
has other insurance and group
coverage applies.
Do not use this field for individual
coverage.
Line A refers to the primary payer;
B refers to secondary; and C refers
to tertiary.
Enter the Passport referral or
authorization number.
Line A refers to the primary payer;
B refers to secondary; and C refers
to tertiary.
C
C
R
R
DCN
Document Control
Number. New field.
The control number assigned to the
original bill by the health plan or
the health plan’s fiscal agent as part
of their internal control. Previously,
field 64 contained the Employment
Status Code (ESC). The ESC field
has been eliminated. NOTE:
Resubmitted claims must contain
the original claim ID.
C
C
65
EMPLOYER NAME
The name of the employer that
provides health care coverage for
the insured individual identified in
field 58. REQUIRED when the
employer of
C
the insured is known to potentially be
involved in paying this claim.
Line A refers to the primary payer;
B refers to secondary; and C refers
to tertiary.
C
66
DIAGNOSIS AND
PROCEDURE
CODE QUALIFIER
(ICD VERSION
INDICATOR)
The qualifier that denotes the
version of International
Classification of Diseases (ICD)
reported.
Not required.
C
64
Page 159 of 331
C
Field
67
Field Description
PRIN. DIAG. CD.
AND PRESENT ON
ADMISSION (POA)
INDICATOR
67 A-Q
OTHER DIAG.
CODES 67A-Q
68
UNLABELED FIELD
69
70
ADM. DIAG. CD.
PATIENT’S
REASON FOR
VISIT
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
The ICD-9-CM codes describing the
principal diagnosis (i.e., the
condition established after study to be
chiefly responsible for occasioning the
admission of the member for care).
Present on Admission (POA) is
defined as present at the time the
order for inpatient admission occurs – R
conditions that develop during an
outpatient encounter, including
emergency department, are considered
as POA.
The POA Indicator is applied to the
principal diagnosis as well as all
secondary diagnoses reported.
The ICD-9-CM diagnoses codes
corresponding to all conditions that
coexist at the time of admission, that
develop subsequently, or that affect
C
the treatment received
and/or the length of stay.
Exclude diagnoses that relate to an
earlier episode which have no bearing
on the current hospital stay.
The ICD diagnosis code describing
the member’s diagnosis at the time
of admission.
R
REQUIRED for inpatient admissions.
Each diagnosis code must be valid for
the date of service.
The ICD-9-CM diagnosis codes
describing the member’s reason for
visit at the time of outpatient
registration.
C
REQUIRED for all unscheduled
outpatient visits.
Up to three ICD-9-CM codes may be
entered in fields A,B, & C.
Page 160 of 331
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
R
C
C
C
Field
71
72 A-C
73
74
74 A-E
Field Description
PROSPECTIVE
PAYMENT
SYSTEM (PPS)
CODE
EXTERNAL CAUSE
OF INJURY (ELC)
CODE
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
The PPS code assigned to the claim
to identify the DRG based on the
grouper software called for under
contract with the primary payer.
C
REQUIRED when the
Health Plan/ Provider contract
requires this information.
Up to 4 digits.
The ICD diagnosis codes
pertaining to external cause of
injuries, poisoning, or adverse
effect.
C
External Cause of Injury “E”
diagnosis codes should not be billed as
primary and/or admitting diagnosis.
REQUIRED if applicable.
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
C
C
UNLABELED FIELD
PRINCIPAL
PROCEDURE
CODE AND DATE
OTHER
PROCEDURE
CODES AND DATES
The ICD code that identifies the
inpatient principal procedure
performed at the claim level during the C
period covered by this bill and the
corresponding date. Inpatient Facility
– ICD-9 is REQUIRED when a
surgical procedure is performed.
Outpatient Facility or
Ambulatory Surgical Center – CPT,
HCPCS or ICD-9 is REQUIRED
when a surgical procedure is
R
performed.
The ICD codes identifying all
significant procedures other than the
principal procedure and the dates
(identified by code) on which the
procedures were performed. Inpatient
Facility – ICD-9 is REQUIRED when
C
a surgical procedure is performed.
Outpatient Facility or Ambulatory
Surgical Center – CPT, HCPCS or
ICD-9 is REQUIRED when a surgical
procedure is performed.
Page 161 of 331
C
R
C
Field
75
76
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Required or
Conditional*
Outpatient,
Bill Types
13X, 23X,
33X
Required or
Conditional*
UNLABELED FIELD
ATTENDING
PROVIDER
NAME AND
IDENTIFIERS
NPI/QUALIFIER
/ OTHER ID
Enter the NPI of the physician who
has primary responsibility for the
member’s medical care or treatment
in the upper line, and their name in
the lower line, last name first.
If the attending physician has another R
unique ID, enter the appropriate
descriptive two-digit qualifier followed
by the other ID. Enter the last name
and first name of the Attending
Physician.
R
Enter the NPI of the physician who
performed surgery on the member
in the upper line; enter the
physician’s name in the lower line.
(NOTE: The last name should be
entered first.)
If the operating physician has another C
unique ID, enter the appropriate
descriptive two-digit qualifier followed
by the other ID. Enter the last name
and first name of the Attending
Physician. REQUIRED when a
surgical procedure code is listed.
C
78-79
Enter the NPI of any physician, other
than the attending physician, who
has responsibility for the member’s
OTHER PROVIDER
medical
care or treatment in the
(INDIVIDUAL) NAME
upper line, and their name in the
C
AND IDENTIFIERS
lower
line,
last
name
first.
NPI/QUALIFIER/
If the other physician has another
OTHER ID
unique ID, enter the appropriate
descriptive two-digit qualifier
followed by the other ID.
C
80
REMARKS
77
OPERATING
PHYSICIAN NAME
AND
IDENTIFIERS
NPI/QUALIFIERS
NPI/QUALIFIER/
OTHER ID
Area to capture additional
information necessary to adjudicate
the claim.
Page 162 of 331
C
C
Field
Field Description
Instructions and Comments
Inpatient,
Bill
Types
11X, 12X,
21X, 22X,
32X
Outpatient,
Bill Types
13X, 23X,
33X
Required or Required or
Conditional* Conditional*
81CC,
A-D
CODE-CODE FIELD
To report additional codes related to
Form Locator (overflow) or to report
externally maintained codes approved C
by the NUBC for inclusion in the
institutional data set.
C
Required fields for the UB-04 Claim Form
15.1.2 Electronic Data Interchange (EDI) for Medical and Hospital Claims
15.1.2.1 Procedures for Electronic Submission
Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claims submission
for providers. EDI, performed in accordance with nationally recognized standards, supports the
health care industry’s efforts to reduce administrative costs.
The benefits of billing electronically include:
•
•
•
•
•
Reduction of overhead and administrative costs. EDI eliminates the need for paper
claims submission. It has also been proven to reduce claim rework (adjustments).
Receipt of reports as proof-of-claim receipt. This makes it easier to track the status of
claims.
Faster transaction time for claims submitted electronically. An EDI claim averages
about 24 to 48 hours from the time it is sent to the time it is received. This enables providers
to easily track their claims.
Validation of data elements on the claim form. By the time a claim is successfully
received electronically, information needed for processing is present. This reduces the chance
of
data entry errors that occur when completing paper claim forms.
Faster claim completion. Claims that do not need additional investigation are generally
processed more quickly. Reports have shown that a large percentage of EDI claims are
processed within 10 to 15 days of their receipt.
15.1.2.2 Requirements for Electronic Claim Filing
The following sections describe the procedures for electronic submission for hospital and medical
claims, including descriptions of claims and report process flows, information on unique electronic
billing requirements, and various electronic submission exclusions.
Page 163 of 331
15.1.2.2.1 Hardware/Software Requirements
Providers may use different products to bill electronically. Providers may submit claims
electronically as long as their software has the capability to send EDI claims to Emdeon (through
direct submission or another clearinghouse/vendor).
Emdeon has the capability to accept electronic data from numerous providers in several
standardized EDI formats. Emdeon forwards the accepted information to carriers in an agreed
upon format.
15.1.3 Contracting with Emdeon and Other Electronic Vendors
Providers without Emdeon EDI capabilities who are interested in electronic claims submission may
contact the Emdeon Sales Department at (877) 469-3263, option 6. Providers may also choose to
contract with another EDI clearinghouse or vendor who already has EDI capabilities.
15.1.4 Certification Requirements
After the registration process is completed and providers have received all certification material,
providers must:
•
•
Read over the instructions carefully, with special attention to the information on exclusions,
limitations, and especially, the rejection notification reports.
Contact their system vendor and/or Emdeon to initiate electronic submissions to Passport.
(Be prepared to inform the vendor of Passport’s electronic payer identification number
61129.)
15.1.5 Specific Data Record Requirements
Claims transmitted electronically must contain all the same data elements identified within Section 18
of this Provider Manual. EDI clearinghouses or vendors may require additional data record
requirements.
15.1.6 Electronic Claim Flow Description
To send claims electronically to Passport, all EDI claims must first be forwarded to Emdeon via a
direct submission or through another EDI clearinghouse or vendor.
Upon receipt of the transmitted claims, Emdeon validates the submitted information against
Emdeon’s proprietary specifications and Passport specific requirements. Claims not meeting the
requirements are immediately rejected and returned to the sender via an Emdeon error report. The
name of this report may vary based on the provider’s contract with its intermediate EDI vendor or
Emdeon.
Emdeon forwards accepted claims to the Passport and immediately returns an acceptance report to
the sender. Passport immediately validates claims for Emdeon for provider identification number
requirements. Claims not meeting this requirement are rejected and returned to Emdeon. Emdeon
then forwards this rejection notice to the original sender (i.e. its trading partner, EDI vendor or
Page 164 of 331
provider.)
Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or
rejected claims received from Emdeon or other contracted vendors must be reviewed and validated
against transmittal records daily.
Passport also validates claims containing valid provider identification numbers against member
eligibility records before being accepted. If a patient cannot be identified as a member of Passport, a
denial letter will be forwarded directly to the provider. This letter is sent to the payment address
documented in Passport’s provider file. Claims passing eligibility requirements are then passed to the
claim processing queues. Claims are not considered as received under timely filing guidelines if
rejected for missing or invalid member data.
Since Emdeon returns acceptance reports directly to the sender, submitted claims not accepted by
Emdeon are not transmitted to Passport.
If you would like assistance in resolving submission issues reflected on either the Acceptance or
R059 Plan Acceptance (Claim Status) reports, contact the Emdeon Helpdesk at (800) 845-6592 or
the EDI Technical Support Hotline at (877) 234-4275, or by e-mail to [email protected].
15.1.7 Invalid Electronic Claim Record Rejections/Denials
All claim records sent to Passport must first pass Emdeon proprietary edits and specific edits prior
to acceptance. Claim records that do not pass these edits are invalid and will be rejected without
being recognized as received at Passport. In these cases, the claim must be corrected and resubmitted
within the required filing deadline of 180 calendar days from the date of service. It is important for
each provider to review the rejection notices (the functional acknowledgements to each transaction
set) received from Emdeon in order to identify and resubmit these claims correctly. Rejected
electronic claims may be resubmitted electronically once the error has been corrected.
15.1.8 Plan Specific Electronic Edit Requirements
15.1.8.1 Exclusions
Certain claims are excluded from electronic billing. At this time, these claims must be submitted on paper.
Excluded Claim Categories
CMS-1500 Claim records for corrected billing.
Claim records for medical, administrative or claim appeals.
Excluded Provider Categories
Providers contracted with vendors that are not transmitting through Emdeon.
Important: Requests for reconsideration/adjustments may be submitted by telephone to the
Provider Claims Service Unit (PCSU) at (800) 578-0775, option 2.
Page 165 of 331
Common Rejections
Invalid Electronic Claims Records – Common Rejections from Emdeon
Claim with missing or invalid batch level records
Claim records with missing or invalid required fields
Claim records with invalid (unlisted, discontinued, etc.) codes (CPT, HCPCS, ICD-9, etc.)
Claims without provider numbers
Claims without member numbers
Important: Also, unique cases are not HIPAA Compliant.
Invalid Electronic Claims Records – Common Rejections from Passport (EDI Edits Within the
Claims System)
Claim for providers who are not approved for EDI submission including test claim
Claims received with invalid provider numbers
Important: Provider identification number validation is not performed at Emdeon. Emdeon will
reject claims for provider information only if the provider number fields are empty.
15.1.8.2 Electronic Billing Inquiries
Please direct inquiries as follows:
Action
Contact
If you have specific EDI technical questions …
Contact EDI Technical Support at:
(877) 234-4275
If you have general EDI questions or questions on
where to enter required data …
Contact EDI Technical Support at:
(877) 234-4275
If you have questions about your claims
transmissions or status reports …
Contact your System Vendor - call the Emdeon
Corporation Help Desk at: (800) 845-6592 or
access Emdeon’s web site, www.emdeon.com.
If you have questions about your claim status
(receipt or completion dates) …
Contact Provider Claims Service Unit at:
(800) 578-0775, option 2
If you have questions about claims that are
reported on the Remittance Advice …
Contact Provider Claims Service Unit at:
(800) 578-0775, option 2
If you need to know a provider ID number …
Contact Provider Services at: (800) 5780775, option 3
If you would like to update provider, payee,
UPIN, tax ID number, or payment address
information …
For questions about changing or verifying provider
Information.
Notify your Provider Relations Specialist in writing
at:
Passport Health Plan
Provider Network Management
5100 Commerce Crossings Drive
Louisville, KY 40229
Fax: (502) 585-6060
Telephone: (502) 585-7943
Page 166 of 331
15.1.9 Submitting Member Encounters
As a fiscal agent for the Department for Medicaid Services (DMS), Passport is required to submit
encounter data to the Commonwealth of Kentucky. Provider assistance is an essential component
of this requirement.
The Commonwealth requires complete, accurate, and timely encounter data in order to effectively
assess the availability and costs of services rendered to Medicaid members. The data we provide
affects the Commonwealth’s funding of the Medicaid Program, including Passport.
Data regarding encounters is also used to fulfill the Centers for Medicare & Medicaid Services (CMS)
required reporting in support of the Federal funding of State Medicaid plans.
According to Passport policy, providers must report all member encounters by claims submission
either electronically or by mail to Passport.
15.2 Provider/Claim Specific Guidelines
15.2.1 Primary Care Practitioner
15.2.1.1 Allergy Serum
Coverage for Allergy Injections/Serum is limited to members under 21 years of age; however,
allergy testing is covered for all members.
A referral is required from the PCP to the specialist. Services rendered by a non-participating
provider require an authorization. Either an allergist or a PCP may bill the service and serum.
PCPs will be paid based on Passport’s fee schedule.
15.2.1.2 Immunization Administration
Immunizations are “Direct Access” services. This means members may go anywhere (i.e. their PCP,
their local Department of Health, or another PCP) to receive immunizations.
15.2.1.3 Vaccines Codes and Administration Codes
The immunization and vaccines codes must be billed for the payment of the administration of these
services. The payment for the administration is actually generated on claim lines billed with the
immunization and vaccine codes.
15.2.1.4 Family Planning Claims
Family planning claims must be submitted to:
Passport Health Plan
P. O. Box 7114
London, KY 40742
Page 167 of 331
All other services (medical) must be billed as normal to Passport. Please note, combined
ancillary charges (e.g. supplies, room use, lab/x-ray) do not need to be separated and may be
included in the medical claim billed to Passport.
All claims for sterilization procedures must be submitted with the appropriate Sterilization MAP
250 treatment consent form available on the Kentucky Department for Medicaid Services (DMS)
web site, http://www.chfs.ky/gov.
Termination requests require an authorization and MAP 235 treatment form available on the
Kentucky Department for Medicaid Services (DMS) web site, http://www.chfs.ky/gov.
Members and providers must complete and comply with all terms and conditions of the DMS consent
forms thirty days prior to a procedure being provided. Providers must also ensure that individuals
with limited English proficiency and visually impaired and/or hearing-impaired members understand
what they are signing.
15.2.2 EPSDT
Passport provides all preventive health benefits covered under the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) program for members from birth to age twenty-one (21).
To submit claims for EPSDT services you must:
1. Continue to bill using the same codes for comprehensive history and physical exam you
use today. These codes must correspond with the member’s age.
• 99381-99385 – New Patient Series
• 99391-99395 – Established Patient Series
2. Add an “EP” modifier to the physical exam code only when all components of the
appropriate EPSDT screening interval have been completed and documented in the member’s
medical record. Do not add the EP modifier to other service being billed (i.e. immunizations).
As a reminder, do not bill lab or testing components individually if they were conducted as
part of an EPSDT screening interval.
3. Acknowledge the following health evaluation services have been completed* by
submitting the appropriate CPT Category II codes, according to the member’s age, as outlined
below. CPT II codes must include a nominal charge (i.e. $.01 or $1.00, not blank or zero) in
order to adjudicate correctly.
Member Age:
CPT II
Code:
Two (2) Years and Above
3008F
Nine (9) Years and Above
2014F
Description
To confirm the BMI has been performed and
documented in the member’s medical record
To confirm the member’s mental status has been
assessed and documented in the member’s medical
record
*Please note this requirement does not apply to EPSDT services rendered prior to October 1, 2010.
For more information about EPSDT, please see section 9 of this Provider Manual.
Page 168 of 331
15.2.3 Specialists
15.2.3.1 Payment Requirements - Office Related (Place of Service 11)
Services performed in a participating provider’s office require a valid referral unless the service is
noted as an exception to referral requirements in Section 7 of this Provider Manual. Services
performed in a non-participating provider’s office require an authorization.
15.2.3.2 Range of Dates on CMS-1500
Date ranges for E/M codes are unacceptable. All days must be submitted separately. For example, if
the member receives services ranging from 8/1/12 to 8/5/12, and is being billed with 99232 for
$400.00, bill as follows:
Date
Procedure
Quantity
Requested Amount
8/1/12
8/2/12
8/3/12
8/4/12
8/5/12
99232
99232
99232
99232
99232
1
1
1
1
1
$80.00
$80.00
$80.00
$80.00
$80.00
15.2.3.3 Surgeries
If a physician bills an evaluation and management service on the same date of service as a surgical
procedure, the surgical procedure is payable and the evaluation and management service is not
payable. If more than one surgical procedure is performed, multiple procedures reduction logic will
apply.
Many surgeries include a global surgery follow-up period (0, 10 or 90 days). All care provided during
the global follow-up period in which a surgery occurred is compensated through the surgical payment.
Visits by the same physician on the same day as the minor surgery or endoscopy are included in the
payment for the procedure, unless a separately identifiable service with an unrelated diagnosis is also
performed. The appropriate modified should be used to facilitate billing of evaluation and management
services on the day of a procedure for which separate payment may be made upon review against Passport’s
clinical editing criteria.
The global surgical fee includes payment for hospital observation services unless the criteria for the
Appropriate CPT modifiers are met.
15.2.3.4 Obstetrical Services
Referrals are not required for any obstetrical services.
Members may self-refer to any Passport contracted obstetrical practitioner to obtain prenatal care
and delivery services; therefore, a referral from the primary care provider is not required.
Page 169 of 331
Submitting the ACOG Form assists Passport in accurately determining a member’s risk factors.
Upon receipt of the completed ACOG or ACOG-like form, Passport will enroll the member in the
Mommy Steps Program. All pregnant members identified will receive educational mailings and,
when appropriate, be assigned to a care manager. Participation in the Mommy Steps Program is
voluntary, and the member has the right to decline any or all parts of the program.
The Mommy Steps Program hours of operation are Monday through Friday, 8:00 a.m. to 6:00 p.m.
EST (except for business-approved holidays).
If a member with the required ACOG form on file misses a perinatal appointment, the obstetrical
practitioner should fax the No-Show Visit Form to the Mommy Steps Program at (502) 585-7970.
All No-Show Visit Forms must be received by Passport within two business days of the missed
appointment. If the obstetrical practitioner complies with this standard, Passport will reimburse the
practitioner as outlined in the fee schedule. No-Show Visit Forms will be provided to OB
practitioners and are not to be invoiced on the same date of service as a perinatal care visit.
If a member is seen for a prenatal visit and received diagnostic testing in the participating obstetrical
practitioner’s office during that visit, the practitioner may bill for both the prenatal visit and the
diagnostic test.
No referral or authorization is required for OB ultrasounds done at a participating facility.
For a circumcision to be paid, it MUST be billed under the baby’s date of birth. If the claim is billed
under the mother’s birth date, the claim will deny. Always include the first and last name of the
mother and baby on the claim form. If the baby has not been named, insert “Boy” as the baby’s first
name; include the baby’s last name if it is different than the mother’s. Verify that the appropriate last
name is recorded for the mother and baby.
15.2.3.5 Delivery and Postpartum Care
For billing of multiple deliveries and/or ultrasounds, payment is made when the designated CPT
codes are billed. CPT codes for unique, individual services provided must be billed for all perinatal
care, i.e. each prenatal visit, delivery code, and postpartum visit must be billed separately.
15.2.4 Departments of Health (DOHs)
Services conducted by participating Departments of Health are payable without authorizations or referrals.
15.2.5 Chiropractors
Chiropractic services are covered for 26 visits in a calendar year regardless of changes in providers
or diagnoses. The first twelve visits do not require an authorization. Services beyond twelve visits
require an authorization.
15.2.6 Home Health
Home health care is encouraged as an alternative to hospitalization (when medically appropriate),
and is utilized for the following types of services:
Page 170 of 331
•
•
•
•
•
•
•
•
•
Skilled nursing
Private Duty Nursing
Occupational therapy
Infusion therapy
Social workers
Physical therapy
Speech therapy
Home health aides
MediPlanner
The Utilization Management Department will coordinate medically necessary home care needs with
the PCP, hospital, home care departments, and other providers of home care services.
The home health contract is revenue code based. Claims must be billed with valid revenue and HCPC
codes.
15.2.6.1 Nurse Supervision
When home health aides are used, registered nurse (RN) supervision is required at least once every
two (2) weeks. This supervised visit is not covered by Passport, as it is considered part of the cost
for the home health aides.
15.2.6.2 Services and Visits in Nursing Facilities
Ancillary services (other than room and board charges) billed with POS 31 or 32 are payable for
both participating and non-participating providers without an authorization or referral (benefits are
not payable for facility charges). Members may be seen by any PCP (regardless of whether the PCP
is the member’s PCP) and the provider will be reimbursed fee for service.
15.2.6.3 Y1 Indicator (Home Health Services Not Covered by Medicare)
Services not covered by Medicare may be submitted to Passport for payment without submitting to
Medicare first. Providers must submit these types of claims with a “Y1”indicator in Field 24 of the
UB-04 claim form. An EOB is not required if the “Y1” indicator is on the bill. Passport
authorization requirements apply for these services.
15.2.7 Hospice
All hospice services must be authorized. Payment for hospice care is made at one of four
predetermined rates for each day that a member is under the care of hospice. The rates paid for any
particular day vary depending on the level of care provided to the member. The four levels of care
by which each day is classified are described below.
15.2.7.1 Routine Home Care
Hospice is paid the routine home care rate for each day the member is under the care of the hospice
without receiving one of the other categories of hospice care. This rate is paid without regard to the
Page 171 of 331
volume or intensity of routine home care services provided on any given day, and is also paid when
the member is receiving outpatient hospital care for a condition unrelated to the terminal condition.
15.2.7.2 Continuous Home Care
Hospice is paid the continuous home care rate when continuous home care is provided. The rate
is paid only during a period of crisis and only as necessary to maintain the terminally ill member at
home. The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate.
For every hour or part of an hour of continuous care furnished, the hourly rate is paid for up to 24
hours a day.
Hospice provides a minimum of eight hours of care during a 24-hour day, which begins and ends at
midnight. This care need not be continuous (i.e. four hours could be provided in the morning and
another four hours could be provided in the evening).
The care must be predominantly nursing care provided by either a registered nurse (RN) or licensed
practical nurse (LPN). In other words, at least half of the hours of care are provided by the RN or
LPN. Homemaker or home health aide services may be provided to supplement the nursing care.
15.2.7.3 Inpatient Respite Care
Hospice is paid at the inpatient respite care rate for each day the member stays in an approved
inpatient facility and receives respite care. Payment for respite care may be made for a maximum of
five continuous days at a time (including the date of admission but not counting the date of
discharge). Payment for the sixth and any subsequent days is to be made at the routine home care rate.
More than one respite period (of no more than five days each) is allowable in a single billing period. If
the member dies under inpatient respite care, the day of death is paid at the inpatient respite care rate.
15.2.7.4 General Inpatient Care
Payment at the inpatient rate is made when general inpatient care is provided.
15.2.8 DME
Referrals are never required for Durable Medical Equipment (DME). The DME authorization
requirements are based off of total monthly-billed charges or monthly quantity of items purchased.
For a complete list of benefits requiring authorization by quantity, please refer to Section 5 of this
Provider Manual.
If the DME item is not mentioned in this Provider Manual, the authorization requirement is
determined by cost as outlined below.
•
If the provider’s billed charges are greater than $500 for a monthly supply of the same item, an
authorization is required.
An authorization is required for all nonparticipating providers unless the service is a
Medicare covered service and Medicare is primary or the member is in out-of-home
placement.
Page 172 of 331
15.2.8.1 DME Rentals
A modifier “RR” should be used for all rented equipment. All mini-nebulizers must be purchased,
with the exception of claims involving coordination of benefits. If Passport is secondary to another
carrier who has reimbursed the mini-nebulizer as a rental, the benefits are coordinated as a rental.
15.2.8.2 Enteral Therapy
Enteral therapy does not require an authorization unless the billed amount is greater than $500 for a
month’s supply. Claims should be submitted with an NDC number so they may be reimbursed
from the average wholesale price (AWP) of the drug.
15.2.9 Home Infusion
All nursing visits MUST be authorized in addition to the infusion therapy services. Infusion therapy
requires an authorization if the billed amount is $400.00 or greater. Catheter maintenance charges are
always reimbursed based on the authorization.
As of October 1, 2013, medications for Home Infusion will be authorized by the Pharmacy Benefit
Manager - this includes Synagis injections. To obtain an authorization for a Home Infusion
Medication, please complete the following steps:
•
•
•
Submit Home Infusion therapy authorization form to PerofrmRx via fax at 877-693-8280 for
authorization of infusion therapy dosages, associated nursing vistis, and supplies.
Bill all infusion therapy drug claims directly to PerformRx using the online adjudication
system.
Bill all associated nursing visits and supplies directly to Passport Health Plan at P. O. Box
7114, London, KY 40742 or electronically with payer ID# 61129 to receive reimbursement.
15.2.9.1 Medically Billed Drugs
All claims, paper and electronic, submitted to Passport with drug codes must include valid National
Drug Code (NDC) numbers and NDC units.
15.2.10 Inpatient/Outpatient Hospital Care
Facility claims for inpatient services should be submitted on the hospital’s standard billing form (UB04). The prior authorization number issued at the time of admission notification should appear on the
claim form. Inpatient claims must be submitted after the services were rendered or compensable items
were provided within the timeframe indicated in the Passport Hospital Agreement.
Claims for outpatient services should be submitted on the hospital’s standard billing form (UB-04).
The Passport prior authorization number for services (if necessary) should be included on the claim
form.
15.2.10.1 Initial Observation Care
All related evaluation and management services provided by the physician on the same day are
Page 173 of 331
included in the admission for hospital observation. Only one physician may report initial
observation services. Do not use these observation codes for post-recovery in regard to a
procedure considered to be a global surgical service.
If a member who is admitted on an observation status is also admitted on an inpatient status
before the end of the date on which the member was admitted to observation, only the inpatient
service will be paid. Providers may not bill initial observation care codes for services provided on
the dates they admit patients on an inpatient status.
15.2.10.2 Observation Care Discharge Service
Observation discharge code 99217 is to be used only when discharge from observation status
occurs on a date other than the initial date of observation status.
15.2.10.3 Hospital Inpatient Services
The codes for hospital inpatient services report admissions to a hospital setting, follow-up care
provided in a hospital setting, observation or inpatient care for the same day admission and
discharge, and hospital discharge day management.
The initial hospital care codes should be used by the admitting physician to report the first hospital
inpatient encounter. All evaluation and management services provided by the admitting physician in
conjunction with the admission, regardless of the site of the encounter, are included in the initial
hospital care service. Services provided in the ER, observation room, physician’s office, or nursing
facility specifically related to the admission cannot be reported separately.
Codes 99238 and 99239 are for hospital discharge day management, but exclude discharge of the
member from observation status. When a physician other than the attending physician provides
concurrent care on a discharge day, these services must be billed using the subsequent hospital
inpatient or outpatient codes.
15.2.10.4 Consultations
Claims for inpatient consultations and subsequent procedures/treatments are covered without regard to
the authorization for the inpatient stay. Consulting physicians must bill both the consultation CPT code
and the procedure and/or treatment code to be paid for services rendered during the inpatient stay.
15.2.10.5 Critical Care Services
Critical care codes include evaluation and management of the critically ill or injured member,
requiring direct delivery of medical care. Note that 99292 is an add-on code and must be used in
conjunction with 99291. Critical care of less than 30 minutes should be reported using an
appropriate evaluation and management code. Critical care of less than 15 minutes beyond the first
hour or less than 15 minutes beyond the final 30 minutes should not be reported.
15.2.10.6 Identifying Newborn Inpatient Services
Services for newborns are processed under the newborn’s Passport member ID number.
Page 174 of 331
15.2.11 Free-Standing Facilities
Free-standing radiology facilities who bill with a place of service of 11 (office) do not require a
referral for radiology services.
15.2.12 Ambulance Services
Ambulance services and emergent air transportation do not require authorization for payment. Nonemergent air transportation will require an authorization.
Providers must report an origin and destination modifier for each ambulance trip in accordance with
guidelines in the HCPCS manual. Origin and destination modifiers used for ambulance services are
created by combining two alpha characters. Each alpha character, with the exception of X,
represents an origin code or a destination code. The pair of alpha codes creates one modifier. The
first position alpha equals origin: the second position alpha code equals destination.
15.3 Understanding the Remittance Advice
15.3.1 Electronic Remittance Advice (ERA/835)
Remittance Advices explain the payment of a claim and/or any adjustments made. For each claim,
there is a remittance advice (RA) that lists each line item payment, reduction, and/or denial. Payment
for multiple claims may be reported on one transmission of the RA.
Standard adjustment reason codes are used on remittance advices. These codes report the reasons
for any claim financial adjustments, and may be used at the claim or line level. Multiple reason codes
may be listed as appropriate.
Remark codes are used on an RA to further explain an adjustment or relay informational messages.
Please see the end of this section for a sample Passport remittance advice.
15.3.1.1 Receiving the Electronic Remittance Advice (ERA/835)
If you are interested in receiving ERAs, please register through Emdeon Business Services. Once
registered, you will receive an ERA/835 transaction.
For additional information or questions, please contact the EDI Technical Support Hotline
(877) 234-4275, option 4 or by email at [email protected]
15.3.1.2 Adjustment/Denial Codes
Description
Benefit/Service Rule
Denial Valid
Correct NDC required
for consideration.
Required for J code
Infusion Therapy
drugs. Verify if an NDC
was billed on the HCFA.
Submit corrected claim.
Page 175 of 331
Denial Invalid
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Invalid/Deleted code,
modifier or description.
The claim was either billed
without a procedure code or
billed with an invalid
procedure code. Compare
the codes billed on the CMS
1500 to the codes processed
on the remittance advice.
Submit corrected claim.
Itemized Bill/Date of
Service/Charges/
Invoice required.
Usually required for DME
misc. codes (E1399) and
Renal Dialysis Claims. We
need the itemized
bill in order to know how
much to reimburse.
Submit copy of the
itemized invoice to
correspondence.
Received after filing
time limit.
The timely filing deadline is
180 days. If COB related, the
deadline is 60 days from the
notification date on the
primary carrier EOB for CMS
submissions and 180 days for
UB-04 submissions. Verify
that all supporting
documentation was included
in initial claims submission.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Submit proof of
timely filing
documentation to
Passport
correspondence.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Submit corrected claim.
Contact Provider
Claims
Service Unit at
(800)5780775, option 2.
Diagnosis invalid/
missing/deleted.
Requires 4th/5th digit.
The claim was either billed
without a DX code or billed
with an invalid DX code.
Verify the diagnosis code in
box 21 on the CMS 1500.
Not enrolled on date
of service.
Verify if you have copy of the
The member will have
Medicaid care for the month
to follow up with
of the date of
his/her caseworker.
service.
Resubmit with EOB
from primary carrier
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
The member is showing with
primary carrier coverage.
Submit primary carrier
Verify if EOB was included
EOB to Passport
with initial claim submission. correspondence.
Page 176 of 331
Mail copy of
Medicaid card to
Passport
correspondence
Resubmit claim
with primary
carrier
information.
Description
Benefit/Service Rule
Carrier of Service Block Vision
Assistant Surgeon
Payment
Denial Valid
Submit claim to Block
Vision
This is a processing
explanation code, not a denial. Final
Denial Invalid
Block Vision
Claims &
Eligibility at (866)
819-4298 from
9 a.m. to 8 p.m.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This code is usually used on
claims for a newborn.
Combined payment mother & baby.
The newborn claim is written
off by the provider, and they
Final
receive payment for the
mother’s delivery claim
instead.
Not enrolled on date
of service.
Verify if you have a copy of
the Medicaid ID card for the
month of the
date of service.
The member will have
to follow up with
his/her caseworker.
Duplicate claim
previously paid
at correct rate.
Passport has
previously processed a claim
submitted for the same date
of service and from the
same provider.
Final
Used to signify a payment
reduction due to multiple
surgical or therapy
procedures billed on the
same date of service.
Final
Over max procedure/
benefit limit.
This denial code could be
used for a variety of claim
processing scenarios.
Final
Payment reflects
coordination of
benefits, if $0, max
liability met.
COB, secondary
payment.
If Passport payment is
$0, then the primary
carrier paid over the
Passport allowable
amount.
Final
This is a processing
explanation code, not a
denial.
Page 177 of 331
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Mail copy of
Medicaid card to
Passport
correspondence.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at 1-800578-0775, option 2.
Description
Same procedure paid to
a different provider.
Service not covered.
Benefit/Service Rule
Denial Valid
Passport has previously paid a
claim submitted with the
same procedure code for the Final
same date
of service to a different
provider.
This denial code could be
used for a variety of claim
processing scenarios.
Services were not
provided.
This rejection code
is usually used when the
provider has called in to
request a payment
recoupment.
Submit charges to MA
fee for service program.
Administrative
approval.
Final
Pre-cert/Auth not
obtained, denied
or invalid.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Final
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This claim is considered
mental health related.
Final
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This is a processing
explanation code, not a
denial code.
Final
It is usually used when the
Medical Review or Appeals
department has overturned
a previous processing.
No PCP referral.
Denial Invalid
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
No referral on file.
Verify if copy of referral was
included with initial claim
submission.
Contact Provider
Submit copy of referral to
Claims
Passport correspondence.
Service Unit at (800)
578-0775, option 2.
No authorization on file.
Provider may contact
the Utilization
Management
Department at (800)
578-0636 for retro
authorization options.
Page 178 of 331
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Description
Duplicate of previously
submitted EPSDT
screening.
Provider wasn’t
the member’s PCP.
Charges considered
included in inpatient
admission.
Inappropriate coding
for contract agreement.
Benefit/Service Rule
Denial Valid
This means that a member
has already received an
EPSDT screening or checkup
for the particular interval or
timeframe. Verify this
member’s periodicity schedule
Final
with the
EPSDT calculator, then
review his/her EPSDT
screening history.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This member is showing a
different PCP for the date of Final
service.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This denial code could be
used for a variety of claim
processing scenarios.
Final
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
This denial code could be
used for a variety of claim
processing scenarios.
Final
Carrier of service
- MCNA.
Final
Carrier of service
- AmeriHealth, Inc.
Final
Payment included
in other billed
services.
Denial Invalid
This denial code could be
used for a variety of claim
processing scenarios.
Final
This rejection means that
EOB/Attachments were there is a complication
incomplete/ illegible.
with the primary carrier
EOB.
Review the primary
carrier EOB for any
inconsistencies.
Need newborn
member number.
Resubmit corrected
claim.
Resubmit claim with the
ID for the newborn.
Page 179 of 331
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 3.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578 0775
i 3
Description
Benefit/Service Rule
Denial Valid
Denial Invalid
Resubmit to primary
carrier for appeals
process.
Passport can only
coordinate secondary
payment with a final
processing documented on
a primary carrier EOB.
Provider must
resubmit claim to
primary carrier
appeals process.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Provider must
resubmit corrected
claim with physician
ID/name.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Provider must resubmit a
corrected claim with
POS.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Attending physician
ID/name missing/
invalid.
Missing place of
service.
Member’s age not valid
for procedure code.
This occurs most frequently
when a hospital bills a UB04 without an attending
physician’s name or ID.
Review claim to
verify if physician
name/ID was included
with initial submission.
This claim wasn’t billed
with a place of service.
This denial code could be
used for a variety of claim
processing scenarios.
Review member’s age.
Final
Member’s sex not valid
for procedure code.
Review the State system to
verify the gender loaded
for this member.
Not covered for
presumptive
eligibility member.
The particular type of
service that is being billed
is not a service that is
covered for a presumptive
eligibility member.
Missing charges/units
This procedure code billed on
this claim didn’t include any
unites. Review claim form to Submit corrected claim.
verify units billed.
Final
Member will have to
contact his/her
caseworker for options
regarding eligibility
reinstatement.
Page 180 of 331
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Description
Inappropriate claim
form for professional
services.
Benefit/Service Rule
This occurs when an
individual practitioner
bills his/her professional
services on a UB-04.
This mistake most
commonly occurs with ER
professional fees.
Denial Valid
Submit a corrected claim
on a CMS-1500 to ACS.
Denial Invalid
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Provider may contact
the Utilization
Management
Department at 1-800578-0636 for retro
authorization options.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Dates and/or services
outside auth.
The information approved
on the authorization does
not match what was billed
on the claim.
Authorization expired.
The date of service billed
is outside the last
approved date on the
authorization.
Provider may contact
the Utilization
Management
Department at 1-800578-0636 for retro
authorization options.
Group ID not payable.
Passport will not accept
provider group IDs. The
provider must bill with the
individual provider ID.
Provider must submit a
corrected claim
with the individual
provider ID.
Subset/Incidental
Procedure disallow.
The rejected procedure code
is considered inclusive or
incidental
to another paid
procedure code.
Redundant procedure.
This rejection is very
similar to the subset
reject.
Final
Final
Page 181 of 331
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Fax in medical
records to
Provider Claims
for medical
claim review.
Fax in medical
records to
Provider Claims
for medical
claim review.
Description
Benefit/Service Rule
Denial Valid
Denial Invalid
Manual Denial.
This is a generic denial code
used by adjusters to
manually deny a claim.
There should be
additional denial code
information listed
explaining the manual
denial.
Follow the applicable
denial response guideline
located on this grid.
Follow the
applicable denial
response
guideline located
on this grid.
MAID Missing or
Invalid.
Passport does not have the
billing provider’s Kentucky
Medicaid ID (MAID). The
MAID is expired.
Contact your Provider
Relations Specialist or
Provider Services at (800)
578-0775
Contact Provider
Claims
Service Unit at (800)
578-0775, option 2.
Page 182 of 331
PASSPORT
HEALTH * PLAN
Passport Health Plan
5100 Commerce Crossi ngs
For further inquiries on this remittance advise contact:
Louisville, ,KY 40229
Passport Health Plan
5100 Commerce Crossings
R eturn Service R equested
Louisville, KY 40229
Or call l·8CJ0.578·0775
Dave P Smith, MD
1 23 Main Street
Anywhere.KY 40229
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Tax iO:
1234567
123456789
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Check No.:
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Page 183 of 331
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15.4 Denial Reasons and Prevention Practices
15.4.1 Billed Charges Missing or Incomplete
A billed charge amount must be included for each service/procedure/supply on the claim form.
15.4.2 Diagnosis Code Missing 4th or 5th Digit
Precise coding sequences must be used in order to accurately complete processing. Review the ICD9-CM manual for the 4th and 5th digit extensions. The 4th symbol indicates a 4th digit must be
included. The 5th symbol indicates a 4th and 5th digit must be included.
15.4.3 Diagnosis, Procedure or Modifier Codes Invalid or Missing
Coding from the most current coding manuals (ICD-9-CM, CPT or HCPCS) is required to
accurately complete processing. All applicable diagnosis, procedure, and modifier fields must be
completed.
15.4.4 DRG Codes Missing or Invalid
Hospitals contracted for payment based on DRG codes must include this information on the claim form.
15.4.5 Corrected Claims
Corrected or resubmitted claims must be sent to Passport on paper, with either “corrected” or
“resubmitted” noted on the claim as appropriate. Claims that originally denied for missing/invalid
information or for inappropriate coding must be submitted as a corrected claim. In addition to
writing “Corrected Claim,” the corrected information should be circled to easily identify the
corrected information.
Claims that have been denied for additional information must be submitted as a resubmitted claim.
“Resubmitted Claim” must be written on the form and the new information must be attached. It is
important to remember that these claims are scanned as part of the resubmission process. Red ink
and/or highlighted text is not legible.
NOTE: Please use BLUE or BLACK ink only.
15.4.6 EOBs (Explanation of Benefits)
A copy of the EOB from all third party insurers must be submitted with the original claim form if
billing via paper. Include pages with run dates, coding explanation and messages.
15.4.7 EPSDT Information Missing or Incomplete
All tests and services listed on the Passport EPSDT Program Periodicity and Screening Schedule
must be performed within the indicated time periods.
Page 184 of 331
15.4.8 Illegible Claim Information
Information on the claim form must be legible to avoid delays or inaccuracies in processing. Review
billing processes to ensure forms are typed or printed in black ink, no fields are highlighted (this
causes information to darken when scanned or filmed), and spacing and alignment are appropriate.
Handwritten information often causes delays or inaccuracies due to reduced clarity.
15.4.9 Incomplete Forms
All required information must be included on the claim form to ensure prompt and accurate processing.
15.4.10 Newborn Claim Information Missing or Invalid
Always include the first and last name of the mother and baby on the claim form. If the baby has not
been named, insert “Girl” or “Boy” as the baby’s first name; include the baby’s last name if it is
different than the mother’s. Verify the appropriate last name is recorded for the mother and baby.
Please include the baby’s date of birth.
15.4.11 Payer or Other Insurer Information Missing or Incomplete
Include the name, address and policy number for all insurers covering the Passport member.
15.4.12 Place of Service Code Missing or Invalid
A valid and appropriate two-digit numeric code must be included on the claim form.
15.4.13 Provider Name Missing
The name of the provider of service must be present on the claim form and must match the service
provider name and Tax Identification Number (TIN) on file with Passport.
15.4.14 Provider Identification Number Missing or Invalid
Passport’s assigned individual and group identification numbers must be included on the claim form
for the provider of service.
15.4.15 Revenue Codes Missing or Invalid
Facility claims must include a valid revenue code. Refer to UB-04 reference material for a complete
list of revenue codes.
15.4.16 Signature Missing
The signature of the provider of service must be present on the claim form and must match the
service provider name and TIN on file with the Passport. See Section 18.1.12.2 CMS-1500 Claim
Form and Required Fields for additional information on acceptable signature formats.
Page 185 of 331
15.4.17 Spanning Dates of Service Do Not Match the Listed Days/Units
Span dating is only allowed for identical services provided on consecutive dates of service. Always
enter the corresponding number of consecutive days in the days/unit field.
15.4.18 Tax Identification Number (TIN) Missing or Invalid
The Tax ID number must be present and must match the service provider name and payment entity
(vendor) on file with the Passport.
15.4.19 Third Party Liability (TPL) Information Missing or Incomplete
Any information indicating a work related illness/injury, no fault, or other liability condition must be
included on the claim form. Additionally, if billing via paper, a copy of the primary insurer’s explanation of
benefits (EOB) or applicable documentation must be forwarded along with the claim form.
15.4.20 Type of Service Code Missing or Invalid
A valid alpha or numeric code must be included on the claim form.
15.4.21 Billing Bilateral Procedures
Modifier ‘50’ is used to report bilateral procedures performed in the same session. The use of
modifier ‘50’ is applicable only to services and/or procedures performed on identical anatomical
sites, aspects, or organs. The intent of this modifier is to be appended to the appropriate unilateral
code as a one-line entry on the claim form indicating that the procedure was performed bilaterally.
When a procedure code is appended with modifier ‘50’, the units box on the claim form should
indicate that “1” unit of service was provided, since one procedure was performed bilaterally. Placing
the procedure on two lines will bill for two charges, and will result in a denial for one of the billed
lines. When a procedure code is billed with a ‘50’ modifier and a ‘1’ in the unit field, the code will
reimburse at 150% of the allowable amount.
Some CPT codes were developed for unilateral and bilateral procedures, so it may not always be
appropriate to append modifier ‘50’ if there is a CPT code to report the bilateral procedure.
15.4.22 Billing with Modifiers ‘25’ and ‘59’
Use modifier ‘25’ when the E/M service is separate from that required for the procedure and a
clearly documented, distinct and significantly identifiable service was rendered, or the procedure
performed was above and beyond the usual preoperative and postoperative care. The modifier ‘25’
must be placed on the E/M code to assure appropriate review of your claim.
Modifier ‘59’ is used to indicate a procedure or service was distinct or independent from other services
performed on the same day. When another already established modifier is appropriate it should be used
rather than modifier ‘59’. Only if a more descriptive modifier is not available, and the use of modifier
‘59’ best explains the circumstances, should modifier ‘59’ be used.
Page 186 of 331
15.5 Timely Filing Requirements
Original invoices must be submitted to Passport within 180 calendar days from the date services were
rendered or compensable items were provided.
Resubmission of previously processed claims with corrections and/or requests for adjustments must
be submitted within two years of the last process date.
Claims originally rejected for missing or invalid data elements must be corrected and resubmitted
within 180 calendar days from the date of service. Rejected claims are not registered as received in the
claims processing system.
15.5.1 Timely Filing Exceptions
•
•
•
•
•
•
Submission of claims for members retroactively enrolled in Passport by the Department for
Medicaid Services must be submitted within 180 days from the date of notification to Passport
of enrollment by DMS.
Claims with Explanation of Benefits (EOBs) from Medicare Part A must be submitted within
180 days of the date of the Medicare EOB.
Claims with Explanation of Benefits (EOBs) from primary insurers other than Medicare Part
A must be submitted within 60 days of the date of the primary insurer’s EOB.
Out of home placement services are exempt from timely filing guidelines.
Mommy Steps services are exempt from timely filing guidelines.
Medicare crossover claims are exempt from timely filing guidelines.
15.6 Corrected Claims and Requests for Reconsideration and/or
Refunds
If you would like to discuss claims payments, you may call the Provider Claims Services Unit (PCSU)
at (800) 578-0775, option 2.
Providers have the right to appeal the outcome of a claim. The appeal must be submitted in writing
and received within two (2) years of the last process date and include supporting documentation.
The Plan will respond to the appeal within thirty (30) days from the receipt date with a determination
or status of the review.
The provider will receive written notification of the outcome of the appeal whether it is upheld or
overturned. All upheld determinations will be sent to the provider in a letter with the reason the plan
upheld the appeal. Any appeals overturned by the plan will be reprocessed and the provider will
receive an explanation of benefits (EOB) as notification.
Corrected/resubmitted claims should be resubmitted on paper. The word “corrected” or
“resubmitted” must be noted on the claim as appropriate:
•
Claims originally denied for missing/invalid information for inappropriate coding should be
submitted as corrected claims. In addition to writing “corrected” on the claim, the corrected
information should be circled so that it can be identified.
Page 187 of 331
•
•
Claims originally denied for additional information should be sent as a resubmitted claim. In
addition to writing “resubmitted” on the claim, the additional/new information should be
attached.
Corrected and resubmitted claims are scanned during reprocessing. Please remember to use
blue or black ink only and refrain from using red ink and/or highlighting that could affect the
legibility of the scanned claim.
Corrected/Resubmitted claims should be sent to:
Passport Health Plan
P.O. Box 7114
London, KY 40742
Following these instructions will reduce the probability of erroneous or duplicate claims and timely
filing denials on second submissions.
When the need for a refund is identified, the provider should call the PCSU at (800) 578-0775, option
2, to report the over-payment. Claim details will need to be provided such as reason for refund, claim
number, member number, dates of service, etc. The claim will be adjusted, the money will be
recovered and the transaction will be reported on the Remittance Advice. There is no need to
submit a refund check.
If Passport recognizes the need for a refund, a letter outlining details will be sent 30 days prior to the
recovery occurring. These adjustments will also be reported on the Remittance Advice.
15.7 Contact Information for Claims Questions
Passport encourages all providers to submit claims electronically. For those interested in electronic
claim filing, contact your EDI software vendor or Emdeon (formerly WebMD) to arrange
transmission. For additional questions, call the EDI Technical Support Hotline at (877) 234-4275 or
send an email to [email protected].
15.7.1 Claim Mailing Instructions
Submit claims-related correspondence, corrected claims, requests for reconsiderations, and refunds
to Passport at the following address:
Passport Health Plan
P.O. Box 7114
London, KY 40742
15.7.2 Claims Status Review
Providers may view claims status using any of the following methods:
•
•
Online – check eligibility/claims status by logging into NaviNet at
https://navinet.navimedix.com
Telephone – you may also check eligibility and/or claims status by calling our interactive voice
response (IVR) system at (800) 578-0775.
Page 188 of 331
•
Real-Time – depending on your clearinghouse or practice management system, real-time claims
status information is available to participating providers. Contact your clearinghouse to access:
 Emdeon Products for claims status transactions.
 All other clearinghouses: ask your clearinghouse to access transactions through Emdeon.
Page 189 of 331
Provider Manual
Section 16.0
Behavioral Health
Table of Contents
16.1 Administrative Procedures
16.2 Access to Care
16.3 Behavioral Health Benefits
16.4 Care Management and Utilization Management
16.5 Authorization Procedures and Requirements
16.6 Quality Improvement
16.7 Behavioral Health Provider Billing Manual
Page 190 of 331
16.0 Behavioral Health
Passport Health Plan (Passport) has contracted with Beacon Health Strategies, LLC to coordinate the
delivery of behavioral health services for its members.
Passport’s behavioral health program provides members with access to a full continuum of recovery
and resiliency-focused behavioral health and substance disorders services through a network of
contracted providers. The primary goal of the program is to provide medically necessary care in the
most clinically appropriate and cost-effective therapeutic settings. By ensuring that all Passport
members receive timely access to clinically appropriate behavioral health and substance disorder
services, Passport believes that quality clinical services can achieve improved outcomes for our
members.
16.1 Administrative Procedures
Passport has contracted with Beacon Health Strategies, LLC to manage the delivery of behavioral
health and substance disorder services for its members. Beacon’s website,
www.beaconhealthstrategies.com, contains answers to frequently asked questions, Beacon's clinical
practice guidelines, clinical articles, links to numerous clinical resources, and important news for
providers.
eServices, Beacon’s secure web portal, supports all provider transactions, such as verifying member’s
eligibility, claims status, and authorization submission and inquiry while saving providers’ time,
postage expense, billing fees, and reducing paper waste. eServices provides important Provider
communications and is completely free to Passport contracted providers. Providers may register and
access these services through www.beaconhealthstrategies.com twenty four hours a day, seven days a
week.
Interactive voice recognition (IVR ) is available to providers as an alternative to eServices. It provides
accurate, up-to-date information by telephone, and is available for selected transactions at (888) 2102018. In order to maintain compliance with HIPAA and all other federal and state
confidentiality/privacy requirements, providers must have their practice or organizational tax
identification number (TIN), national provider identifier (NPI), as well as the member’s full name,
Plan ID and date of birth when verifying eligibility.
Electronic data interchange (EDI) is available for claim submission and eligibility verification directly
by the provider to Beacon or via an intermediary. For information about testing and setup for EDI,
download Beacon’s 837 & 835 companion guides at the following web site locations:
http://www.beaconhealthstrategies.com/private/pdfs/Beacon_835CompanionGuide_v1.pdf
http://www.beaconhealthstrategies.com/private/pdfs/Beacon_837CompanionGuide.pdf
For technical and business related questions, email [email protected]. To submit EDI
claims through an intermediary, contact the intermediary for assistance. If using Emdeon, use
Beacon’s Emdeon Payer ID (43324) and Beacon’s Passport Health Plan ID (028).
Page 191 of 331
Electronic Transactions Availability:
Available 24/7 On
eServices at
www.beaconhealt
hstrategies.com
IVR
888.210.2018
• Verify member eligibility, benefits and
copayment
• Check number of visits available
Yes
Yes
Yes
Yes
•
•
•
•
•
Yes
Yes
Yes
Yes
Yes
Transaction / Capability
•
•
•
•
•
•
Submit authorization requests
View authorization status
Update practice information
Submit claims
Upload EDI claims to Beacon and view
EDI upload history
View claims status and print EOBs
Print claims reports and graphs
Download electronic remittance advice
EDI acknowledgment & submission
reports
Pend authorization requests for internal
approval
Access Beacon’s level-of-care criteria &
provider manual
Yes
Yes
Yes
Yes
EDI at
www.beaconhealth
strategies.com
Yes (HIPAA
270/271)
Yes (HIPAA
270/271)
Yes
Yes (HIPAA 837)
Yes (HIPAA 837)
Yes
Yes (HIPAA 835)
Yes (HIPAA 835)
Yes (HIPAA 835)
Yes
Yes
16.2 Access to Care
Passport members may access behavioral health services 24 hours a day, seven days a week by
contacting Passport’s Behavioral Health Hotline, administered by Beacon Health Strategies, at (855)
834-5651. Members do not need a referral to access behavioral health services and authorization is
never required for emergency services. Passport and Beacon adhere to State and National Committee
for Quality Assurance (NCQA) guidelines for access standards for member appointments. Contracted
providers may only provide such behavioral health and physical health services within the scope of
their license and must adhere to the following:
Appointment Standards and After Hours Accessibility:
Type of Care
Emergency Care with Crisis Stabilization
Urgent Care
Post Discharge from Acute Hospitalization
Other routine referrals/appointments
Appointment Availability
Within twenty four (24) hours
Within forty eight (48) hours
Within 7 days of discharge
Within ten (10) days
Page 192 of 331
In addition, Passport providers must adhere to the following guidelines to ensure members have
adequate access to services:
Service Availability
On-Call
Crisis Intervention
Hours of Operation:
• 24-hour on-call services for all members in treatment; and,
Ensure that all members in treatment are aware of how to contact the
treating or covering provider after hours and during provider vacations.
• Services must be available 24 hours per day, 7 days per week;
Outpatient facilities, physicians and practitioners are expected to
provide these services during operating hours; and
After hours, providers should have a live telephone answering service
or an answering machine that specifically directs a member in crisis to
a covering physician, agency-affiliated staff, crisis team, or hospital
emergency room.
• Outpatient providers should have services available Monday through
Outpatient Services
Friday from 9:00 a.m. to 5:00 p.m. EST at a minimum; and,
Evening and/or weekend hours should also be available at least two (2)
days per week.
All members receiving inpatient psychiatric services should be scheduled for outpatient follow-up
and/or continuing treatment prior to discharge. Outpatient treatment must occur within seven (7)
days from the date of discharge (note: subject to latest statewide changes). Providers are required to
contact members who have missed appointments within twenty-four (24) hours to reschedule
appointments.
16.2.1 Out of Network Providers
Out of network behavioral health benefits are limited to those services that are not available in the
existing Passport network, emergency services and transition services for members who are currently
in treatment with an out of network provider who is either not a part of the network or who is in the
process of joining the network.
Out of network providers must complete a Behavioral Health single case agreement with Passport.
Out of network providers may provide one evaluation visit for Passport members without an
authorization upon completion and return of the signed single case agreement. After the first visit,
services provided must be authorized. Authorization requests for outpatient services can be obtained
through Beacon’s electronic outpatient request for (eORF) which can be requested by calling Beacon
at (855)834-5651 or on Beacon’s website www.beaconhealthstrategies.com. If this process is not
followed, Beacon may administratively deny the services and the out of network provider must hold
the member harmless.
Notifications of authorization will be provided by Beacon within seven (7) days of the request.
Beacon will verify member eligibility at the time of authorization. However, the member’s eligibility
Page 193 of 331
is subject to change. Out of network providers are encouraged to verify eligibility.
16.3 Behavioral Health Benefits
Passport covers behavioral health and substance disorder services to members located within the
Commonwealth. Under Passport, the following levels of care are covered, provided that services are
medically necessary, delivered by contracted network providers, and that the authorization procedures
outlined in this manual are followed. DSM-IV (or DSM-V upon DMS implementation) multi-axial
classification should be used when assessing members for services and documented in the member’s
medical record. Covered Services include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Inpatient mental health
Crisis stabilization – adult and child
Emergency room visits
Medical detoxification
Psychiatric Residential Treatment Facilities (PRTF)
Extended Care Units (ECU)
Residential substance abuse rehabilitation (EPSDT special service through age 21 only)
Outpatient mental health services, such as therapy, groups, peer support, parent
training, etc.
Electroconvulsive Therapy (ECT)
Psychological and neuropsychological testing
Community Mental Health Center Services, such as therapeutic rehabilitation,
tiered case management services, etc.
IMPACT Plus services
Behavioral health and substance disorder EPSDT special services
Mobile Crisis
Substance Disorder Inpatient (detox, rehabilitation, SUDS) and Outpatient
(individual/group/PHP, Day Treatment, Wellness Recovery) services for adults
Partial Hospitalization (BH and SA)
Assertive Community Outreach Team (ACT)
Medication Assisted Treatment (MAT)
Access to behavioral health and substance disorder treatment is an essential component of a
comprehensive health care delivery system. Plan members may access behavioral health and
substance disorder services by self-referring to a network provider, by calling Beacon, or by referral
through acute or emergency room encounters. Members may also access behavioral health and
substance disorder services by referral from their primary care provider (PCP); however, a PCP
referral is not required for behavioral health or substance disorder services. Network providers are
expected to coordinate care with a member’s primary care and other treating providers whenever
possible.
16.4 Care Management and Utilization Management
Page 194 of 331
16.4.1 Care Management
Beacon’s Intensive Clinical Management Program (ICM), a component of Beacon’s Care
Management Program (CM), through collaboration with members and their treatment providers,
PCPs, Passport’s medical care managers, and state agencies (DHM and DCF) is designed to ensure
the coordination of care, including individualized assessment, care management planning, discharge
planning and mobilization of resources to facilitate an effective outcome for members whose clinical
profile or usage of service indicates that they are at high risk for readmission into 24-hour psychiatric
or substance disorder treatment settings. The primary goal of the program is stabilization and
maintenance of members in their communities through the provision of community-based support
services. These community-based providers can provide short-term service designed to respond with
maximum flexibility to the needs of the individual member. The intensity and amount of support
provided is customized to meet the individual needs of members and will vary according to the
member’s needs over time.
When clinical staff or providers identify members who demonstrate medical co-morbidity (i.e.,
pregnant women), a high utilization of services, and an overall clinical profile which indicates that
they are at high-risk for admission or readmission into a 24-hour behavioral health or substance
disorder treatment setting, they may be referred to Beacon’s CM Program. The ICM program utilizes
specialty community support providers that offer outreach programs uniquely designed for adults
with severe and persistent mental illness, dually diagnosed adults, members with behavioral health or
substance disorders, and children with serious emotional disturbance.
Criteria for ICM include but are not limited to the following:
•
•
•
•
•
•
•
•
Member has a prior history of acute psychiatric or substance use admissions authorized by
Beacon with a readmission within a 60 day period;
First inpatient hospitalization following lethal suicide attempt, or treatment for first psychotic
episode;
Member has combination of severe, persistent psychiatric clinical symptoms, and lack of
family or social support, along with an inadequate outpatient treatment relationship which
places the member at risk of requiring acute behavioral health services;
Presence of a co-morbid medical condition that when combined with psychiatric and/or
substance use issues could result in exacerbation of fragile medical status;
Member that is actively using substances, or requires acute behavioral health treatment
services;
A child living with significant family dysfunction and continued instability following
discharge from inpatient or intensive outpatient family services that requires support to link
family, providers and state agencies, which places the member at risk of requiring acute
behavioral health services;
Multiple family members that are receiving acute behavioral health and/or substance
disorder treatment services at the same time; and,
Other, complex, extenuating circumstances where the ICM team determines the benefit of
Page 195 of 331
inclusion beyond standard criteria.
Members who do not meet criteria for ICM may be eligible for Care Coordination. Members
identified for Care Coordination have some clinical indicators of potential risk due to barriers to
services, concern related to adherence to treatment recommendations, new onset psychosocial
stressors, and/or new onset of co-morbid medical issues that require brief targeted care management
interventions.
Care Coordination is a short term intervention for members with potential risk due to barriers in
services, poor transitional care, and/or co-morbid medical issues that require brief targeted care
management interventions.
ICM and Care Coordination are voluntary programs and member consent is required for
participation. For further information on how to refer a member to care management services, please
contact the Beacon Health Strategies at (855) 834-5651.
16.4.2 Utilization Management
Utilization management (UM) is a set of formal techniques designed to monitor the use of, or
evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services,
procedures or settings. Such techniques may include, but are not limited to, ambulatory review,
prospective review, second opinion, certification, concurrent review, care management, discharge
planning and retrospective review.
Beacon’s UM program is administered by licensed, experienced clinicians who are specifically trained
in utilization management techniques and in Beacon’s standards and protocols. All Beacon
employees with responsibility for making UM decisions have been made aware that:
• All UM decisions are based upon Beacon’s Level of Care /medical necessity Criteria (LOCC);
• Financial incentives based on an individual UM clinician’s number of adverse determinations or
denials of payment are prohibited; and,
• Financial incentives for UM decision makers do not encourage decisions that result in
underutilization.
16.4.2.1Medical Necessity
All requests for authorization are reviewed by Beacon clinicians based on the information provided
according to the definition of medical necessity that is outlined in the Kentucky Administrative
Regulations. 907 KAR 3:130 defines medical necessity in the following way:
"Medical necessity means a covered benefit is: Reasonable and required to identify, diagnose, treat, correct, cure,
palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy; Clinically
appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical
practice; Provided for medical reasons rather than primarily for the convenience of the individual, the individual's
caregiver, or the health care provider, or for cosmetic reasons; Provided in the most appropriate location, with regard to
Page 196 of 331
generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and
effectively provided; Needed, if used in reference to an emergency medical service, to evaluate or stabilize an emergency
medical condition that is found to exist using the prudent layperson standard; Provided in accordance with early and
periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C. 1396d(r) and 42
CFR Part 441 Subpart B for individuals under twenty-one (21) years of age; and Provided in accordance with 42
CFR 440.230."
16.4.2.2 Level-of-Care Criteria (LOCC)
Beacon’s LOCC are the basis for all medical necessity determinations, are accessible through
eServices, and includes Beacon’s specific LOCC for Kentucky for each level-of-care. Providers can
also contact Beacon at (855) 834-5651 to request a printed copy of Beacon’s LOCC.
Beacon’s LOCC were developed from the comparison of national, scientific and evidence-based
criteria sets, including but not limited to those publicly disseminated by the American Medical
Association (AMA), the American Psychiatric Association (APA), the Substance & Mental Health
Services Administration (SAMHSA), and the American Society of Addiction Medicine (ASAM).
They are reviewed and updated annually or more often as needed to incorporate new treatment
applications and technologies that are adopted as generally accepted professional medical practice.
Beacon’s LOCC are applied to determine appropriate care for all members. In general, members are
certified only if they meet the specific medical necessity criteria for a particular level-of-care.
However, the individual’s specific needs and the characteristics of the local service delivery system
may also be taken into consideration.
Behavioral Health Providers must refer members with known or suspected and untreated physical
health problems or disorders to their PCP for examination and treatment with the Members or the
Members’ legal guardian’s consent. Behavioral Health providers may only provide physical health
care services if they are licensed to do so.
16.4.2.3 Utilization Management Terms and Definitions
The definitions below describe utilization review including the types of the authorization requests
and UM determinations used to guide Beacon’s UM reviews and decision making. All
determinations are based upon review of the information provided and available to Beacon at the
time.
Adverse
Determination:
A decision to deny, terminate, or modify (an approval of fewer days, units or another
level-of-care other than was requested, which the practitioner does not agree with) an
admission, continued inpatient stay, or the availability of any other behavioral health care
service, for:
a) failure to meet the requirements for coverage based on medical necessity,
b) appropriateness of health care setting and level-of-care effectiveness, or
c) Health plan benefits.
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Adverse Action:
The following actions or inactions by Beacon or the provider organization:
1. Beacon’s denial, in whole or in part, of payment for a service; failure to provide covered
services in a timely manner in accordance with the waiting time standards;
2. Beacon’s denial or limited authorization of a requested service, including the
determination that a requested service is not a covered service;
3. Beacon’s reduction, suspension, or termination of a previous authorization for a
service;
4. Beacon’s denial, in whole or in part, of payment for a service, where coverage of the
requested service is at issue, provided that procedural denials for requested services do not
constitute adverse actions, including but not limited to denials based on the
following:
a. Failure to follow prior authorization procedures
b. Failure to follow referral rules
c. Failure to file a timely claim
5. Beacon’s failure to act within the timeframes for making authorization decisions;
6. Beacon’s failure to act within the timeframes for making appeal decisions.
Non-Urgent
Any review for an extension of a previously approved, ongoing course of treatment
Concurrent
over a period of time or number of days or treatments. A non-urgent concurrent decision
Review & Decision may authorize or modify requested treatment over a period of time or a number of days
or treatments, or deny requested treatment, in a non-acute treatment setting.
Non-Urgent PreService Review &
Decision
Any case or service that must be approved before the member obtains care or services.
A non-urgent pre-service decision may authorize or modify requested treatment over a
period of time or number of days or treatments, or deny requested treatment, in non-acute
treatment setting.
Post-Service
Review & Decision
(Retrospective
Decision)
Any review for care or services that have already been received. A post-service decision
would authorize, modify, or deny payment for a completed course of treatment where a
pre-service decision was not rendered, based on the information that would have been
available at the time of a pre-service review.
Urgent Care
Request &
Decision
Any request for care or treatment for which application of the normal time period for a
non-urgent care decision:
• Could seriously jeopardize the life or health of the member or the member’s ability
to regain maximum function, based on a prudent layperson’s judgment; or,
• In the opinion of a practitioner with knowledge of the member’s medical condition,
would subject the member to severe pain that could not be adequately managed without
the
r r trfor tm
nt th t isextension
r q st dof a previously approved, ongoing course of
Any review
a requested
Urgent Concurrent
Review Decision
Urgent Pre-Service
Decision
treatment over a period of time or number of days or treatments in an acute treatment
setting, when a member’s condition meets the definition of urgent care above.
Formerly known as a pre-certification decision. Any case or service that must be approved
before a member obtains care or services in an inpatient setting for a member whose
condition meets the definition of urgent care above. An urgent pre-service decision may
authorize or modify requested treatment over a period of time or number of days or
treatments, or deny requested treatment in an acute treatment setting.
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16.5 Authorization Procedures and Requirements
Authorization Procedures and Requirements
This section describes the processes for obtaining authorization for inpatient, diversionary and
outpatient levels of care, and for Beacon’s medical necessity determinations and notifications. In all
cases, the treating provider, whether admitting facility or outpatient practitioner, is responsible for
following the procedures and requirements presented in order to ensure payment for properly
submitted claims.
Administrative denials may be rendered when applicable authorization procedures, including
timeframes, are not followed. Members cannot be billed for services that are administratively denied
due to a provider not following the requirements listed in this manual.
16.5.1 Member Eligibility Verification
The first step in seeking authorization is to determine the member’s eligibility. Since member
eligibility changes occur frequently, providers are advised to verify a plan member’s eligibility upon
admission to, or initiation of treatment, as well as on each subsequent day or date of service to
facilitate reimbursement for services.
Member eligibility can change and possession of a health plan member identification card does not
guarantee that the member is eligible for benefits. Providers are strongly encouraged to check
Beacon’s eServices, or by calling their IVR line at (888) 210-2018.
16.5.2 Emergency Services
Definition
Emergency services are those physician and outpatient hospital services, procedures, and treatments,
including psychiatric stabilization and medical detoxification from drugs or alcohol, needed to
evaluate or stabilize an emergency medical condition. The definition of an emergency is listed in your
Behavioral Health Services agreement with Passport.
Emergency care will not be denied, however subsequent days do require pre-service authorization.
The facility must notify Beacon as soon as possible and no later than 24 hours after an emergency
admission and/or learning that the member is covered by the health plan. If a provider fails to notify
Beacon of an admission, Beacon may administratively deny any days that are not prior-authorized.
16.5.2.1 Passport Health Plan Behavioral Health Crisis Line
Our toll-free crisis line, (855) 834-5651, is available to members in the event of an emergency and is
staffed by trained personnel twenty-four (24) hours a day, seven (7) days a week, three hundred
sixty-five (365) days a year. Behavioral Health Services professionals are available to assess, triage
and address behavioral health emergencies through this crisis line. Passport can arrange for
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emergency and crisis Behavioral Health Services through mobile crisis teams in the member’s
community. Face to face emergency services are available twenty-four (24) hours a day, seven (7)
days a week through Passport’s behavioral health network.
16.5.2.2 Emergency Screening and Evaluation
Passport members must be screened for an emergency medical condition by a qualified behavioral
health professional from the hospital emergency room, mobile crisis team, or by an emergency
service program (ESP). This process allows members access to emergency services as quickly as
possible and at the closest facility or by the closest crisis team.
After the evaluation is completed, the facility or program clinician should call Beacon to complete a
clinical review, if admission to a level-of-care that requires pre-certification is needed. The
facility/program clinician is responsible for locating a bed, but may request Beacon’s assistance.
Beacon may contact an out-of-network facility in cases where there is not a timely or appropriate
placement available within the network. In cases where there is no in-network or out-of-network
psychiatric facility available, Beacon will authorize boarding the member on a medical unit until an
appropriate placement becomes available.
16.5.2.3 Beacon Clinician Availability
All Beacon clinicians are experienced licensed clinicians who receive ongoing training in crisis
intervention, triage and referral procedures. Beacon clinicians are available 24 hours a day, 7 days a
week, to take emergency calls from members, their guardians, and providers. If Beacon does not
respond to the call within 60 minutes, authorization for medically necessary treatment can be
assumed and the reference number will be communicated to the requesting facility/provider by the
Beacon UR clinician within four hours.
Disagreement between Beacon and Attending Physician
For acute services, in the event that Beacon’s physician advisor (PA) and the emergency service
physician do not agree on the service that the member requires, the emergency service physician’s
judgment shall prevail and treatment shall be considered appropriate for an emergency medical
condition, if such treatment is consistent with generally accepted principles of professional medical
practice and is a covered benefit under the member’s program of medical assistance or medical
benefits. All Beacon clinicians are experienced, licensed clinicians who receive ongoing training in
crisis intervention, triage and referral procedures.
16.5.2.4 Authorization Requirements
16.5.2.4.1 Outpatient Treatment (Initial Encounters):
Passport members are allowed thirty (30) initial therapy sessions without prior authorization. These
sessions, called initial encounters or IEs, must be provided by contracted in-network providers and
are subject to meeting medical necessity criteria.
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To ensure payment for services, providers are strongly encouraged to ask new patients if they have
been treated by other therapists. Via eServices, providers can look up the number of IEs that have
been billed to Beacon; however, the member may have used additional visits that have not been
billed. If the member has used some IEs elsewhere, the new provider is encouraged to contact
Beacon before beginning treatment.
The following services count against the member’s 30 IEs:
1. Outpatient behavioral health, including individual and family therapy
2. Outpatient substance use services
3. Combined psychopharmacology and therapy visits (CPT Codes 90805 and 90807).
The following services require no authorization and do not count against the member’s
IEs.
1. Medication management sessions (90862, 96372); and E&M codes
2. Group therapy sessions (CPT code 90853); and,
3. Collateral therapy (90887)
The following table outlines the authorization requirements for each service. Services that indicate
“eRegister” will be authorized via Beacon’s eServices portal. Providers will be asked a series of
clinical questions to support medical necessity for the service requested. If sufficient information is
provided to support the request, the service will be authorized. If additional information is needed,
the provider will be prompted to contact Beacon via phone to continue the request for
authorization. While it is preferred that providers make requests via eServices, Beacon will work
with providers who do have technical or staffing barriers to requesting authorizations in this way.
Outpatient Services:
Benefit/Service
Medication Management
Injection Administration
Diagnostic Interview
Assessment
Individual Therapy
Family Therapy
Group Therapy
Collateral Services (under 21)
Parent/Peer Support
Authorization Requirements
No authorization required for medication management injection,
group counseling, collateral therapy or evaluations.
Psychological & Neuropsychological
Testing
ECT
Faxed Prior Authorization Required to (781) 994-7633.
For all other services, provider may see member for 30 visits
without prior authorization. Submission of Electronic Outpatient
Request Form (eORF) required before the 31st visit. This form
can be faxed to (781) 994-7633.
Community Based Services:
Benefit/Service
Notification
Requirement
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Initial Authorization Parameters (All
determinations based on medical
necessity)
Therapeutic
Rehabilitation Services
(Adult and Child)
eRegister within 2
weeks of initial date of
service
Authorization as requested, up to 6 hours
daily for initial 30 days. Submit eServices request
prior to 30th day for continued stay review.
Intensive Outpatient
Telephonic Prior
Authorization
Initial authorization up to 6 hours days/per
week; weekly telephonic continued stay review.
Partial Hospitalization
Telephonic Prior
Authorization
Initial authorization up to 5 hours daily/per week;
weekly telephonic continued stay review
Assertive Community
Treatment (ACT)
Telephonic Prior
Authorization
Initial authorization up to max monthly; monthly
telephonic continued stay review
Day Treatment
Telephonic Prior
Authorization
Initial authorization up to max weekly; weekly
telephonic continued stay review
Medication Assisted
Treatment
Telephonic Prior
Authorization
Initial authorization up to weekly allowable
amount; weekly telephonic continued stay review
Tiered Case Management- Register within 2
weeks of initial date of
Adult
service
Emergency
No authorization
Services/Mobile Crisis
Required
Initial authorization for 3 months; submit
continued stay request through eServices prior to
90th day of service.
No authorization required
Authorization decisions are posted on eServices within the decision timeframes outlined below.
Providers receive an email message alerting them that a determination has been made. Beacon also
faxes authorization letters to providers upon request; however providers are strongly encouraged to
use eServices instead of receiving paper notices. Providers can opt out of receiving paper notices
on Beacon’s eServices portal. All notices clearly specify the number of units (sessions) approved,
the timeframe within which the authorization can be used, and explanations of any modifications
or denials. All denials can be appealed according to the policies outlined in this Manual.
All forms can be found on the Beacon web site under Provider Tools http://www.beaconhealthstrategies.com/private/provider/provider_tools.aspx.
16.5.2.4.2 Inpatient Services
All inpatient services (including inpatient ECT and inpatient EPSDT special services such as
chemical dependency, residential substance abuse services, and extended care units) require
telephonic prior authorization within 24 hours of admission. Providers should call Beacon at (855)
834-5651 for all inpatient admissions, including detoxification that is provided on a psychiatric
floor or in freestanding psychiatric facilities. All other requests for authorization for detoxification
should be directed to Passport’s UM Department at (800) 578-0636, option 2. Admissions to Crisis
Stabilization Units (for children only) do not require authorization until after the first 48 hours and
are authorized for up to a maximum of 10 days. Beacon typically authorizes inpatient stays in 2-3
day increments, depending on medical necessity. Continued stay reviews require updated clinical
information that demonstrates active treatment. Additional information about what is required
during pre-service and concurrent stay reviews is listed below.
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UM Review Requirements – Inpatient and Diversionary
Pre-Service Review
The facility clinician making
the request needs the following
information for a pre-service
review:
• Member’s health plan identification
number;
• Member’s name, gender, date of
birth, and city or town of residence;
Admitting facility name and date of
admission;
• DSMIV diagnosis: All five axes are
appropriate; Axis I and Axis V are
required. (A provisional diagnosis is
acceptable);
• Description of precipitating event
and current symptoms requiring
inpatient psychiatric care;
• Medication history;
• Substance use history;
• Prior hospitalizations and
psychiatric treatment;
• Member’s and family’s general
medical and social history; and,
• Recommended treatment plan
relating to admitting symptoms and
the member’s anticipated response to
treatment.
Continued Stay (Concurrent)
Review
To conduct a continued stay
review, call a Beacon UR
clinician with the following
required information:
• Member’s current diagnosis
and treatment plan, including
physician’s orders, special
procedures, and medications;
• Description of the member’s
response to treatment since the
last concurrent review;
• Member’s current mental
status, discharge plan, and
discharge criteria, including
actions taken to implement the
discharge plan;
• Report of any medical care
beyond routine is required for
coordination of benefits with
health plan (Routine medical care
is included in the per diem
rate).
Post-Service Review
Post-service reviews may be
conducted for inpatient, diversionary
or outpatient services rendered when
necessary. To initiate a post-service
review, call Beacon. If the treatment
rendered meets criteria for a postservice review, the UR clinician will
request clinical information from
the provider including documentation
of presenting symptoms and treatment
plan via the member’s medical record.
Beacon requires only those section(s)
of the medical record needed to
evaluate medical necessity and
appropriateness of the admission,
extension of stay, and the frequency or
duration of service. A Beacon physician
or psychologist advisor completes a
clinical review of all available
information, in order to render a
decision.
Authorization determinations are based on the clinical information available at the time the care
was provided to the member.
Notice of inpatient authorization is mailed to the admitting facility. Members must be notified of
all pre-service and concurrent denial decisions. Members are notified by courier of all acute preservice and concurrent denial decisions. For members in inpatient settings, the denial letter is
delivered by courier to the member on the day the adverse determination is made, prior to
discharge. The service is continued without liability to the member until the member has been
notified of the adverse determination. The denial notification letter sent to the member or
member’s guardian, practitioner, and/or provider includes the specific reason for the denial
decision, the member’s presenting condition, diagnosis and treatment interventions, the reason(s)
why such information does not meet the medical necessity criteria, reference to the applicable
benefit provision, guideline, protocol or criterion on which the denial decision was based, and
specific alternative treatment option(s) offered by Beacon, if any. Based on state and/or federal
statutes, an explanation of the member’s appeal rights and the appeals process is enclosed with all
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denial letters. Providers can request additional copies of adverse determination letters by
contacting Beacon.
16.5.2.4.3 IMPACT Plus
Impact Plus services are available to Passport members according to the eligibility criteria outlined
in 907 KAR 3:030. Beacon is responsible for screening members for eligibility and for making
medical necessity determinations for IMPACT Plus Services. Providers requesting services for
IMPACT Plus for Passport members must submit IMPACT Plus member eligibility applications
directly to Beacon via fax at (781) 994-7633 through or eServices. Incomplete applications will not
be accepted.
Eligibility materials can be found on eServices or on the following Kentucky DBHDID link:
http://dbhdid.ky.gov/dbh/impactplusforms.asp. Eligibility packets must be signed by a behavioral
health professional or a behavioral health professional under supervision. Documentation of
clinical need must be sufficient to support the intensity of service provided under IMPACT Plus.
Providers must follow the guidelines outlined in the Kentucky Department for Behavioral Health,
Developmental and Intellectual Disabilities (DBHDID) Impact Plus User’s Manual for the
provision and documentation of Impact Plus Services.
Beacon will adhere to the maximum service limits outlined in the DBHDID IMPACT Plus User’s
Manual. Covered services and authorization requirements are outlined in the table below.
Benefits/Services
Targeted Case
Management
Cap Limit
4 units per month
Minimum
Behavioral Health
Evaluation
Therapeutic Child
Support Services
(professional and
paraprofessional)
Max 5 hours per
Evaluation
Max 16 units per day
Parent to Parent
Services
After School Program
Summer Program
Individual Therapy
(including w/ MD)
Max 16 units per day
Partial Hospitalization
Intensive Outpatient
Day Treatment
Max 16 units per day
Max 24 units per day
Max of 16 units of
90884 and 90887
combined per day; Max of
48 units
combined per week
Notification Requirements
Members must be determined eligible for
IMPACT Plus prior to receiving services with the
exception of crisis stabilization.
Collaborative Service Plans and requests for
authorization are required within 14 days of
eligibility determination. Services will be
authorized based on medical necessity. Initial
continued stay review required again in 30 days via
Fax or eServices.
Telephonic review may be required if additional
clinical information is needed. Continued stay
review (frequency) to be determined based on
clinical documentation presented during the first
continued stay review.
Max 5 hours per day
Max 3 units per day; 9
units per week
Max 7 units per day
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Therapeutic Foster
Care
Therapeutic Group
Residential
Crisis Stabilization
N/A
N/A
Max of 10 consecutive
units
Telephonic or eServices prior authorization
required.
Telephonic or eServices prior authorization
required
No authorization required for first 48 hours, then
telephonic continued stay review.
16.5.2.4.4 Return of Inadequate or Incomplete Treatment Requests
All requests for authorization must be original and specific to the dates of service requested and
tailored to the member’s individual needs. Beacon reserves the right to reject or return
authorization requests that are incomplete, lacking in specificity, or incorrectly filled out. Beacon
will provide an explanation of action(s) which must be taken by the provider to resubmit the
request.
16.5.2.4.5 Notice of Inpatient/Diversionary Approval or Denial
Verbal notification of approval is provided at the time of pre-service or continuing stay review.
Notice of admission or continued stay approval is mailed to the member or member’s guardian and
the requesting facility within the timeframes specified later in this chapter.
If the clinical information available does not support the requested level-of-care, the UR clinician
discusses alternative levels of care that match the member’s presenting clinical symptomatology
with the requestor. If an alternative setting is agreed to by the requestor, the revised request is
approved. If agreement cannot be reached between the Beacon UR clinician and the requestor, the
UR clinician consults with a Beacon psychiatrist or psychologist advisor (for outpatient services
only). All denial decisions are made by a Beacon physician or psychologist (for outpatient services
only) advisor. The UR clinician and/or Beacon physician advisor offers the treating provider the
opportunity to seek reconsideration if the request for authorization is denied.
All member notifications include instructions on how to access interpreter services, how to
proceed if the notice requires translation or a copy in an alternate format, and toll-free telephone
numbers for TDD/TTY capability in established prevalent languages, (Babel Card).
16.5.2.4.6 Termination of Outpatient Care
Beacon requires that all outpatient providers set specific termination goals and discharge criteria for
members. Providers are encouraged to use the LOCC (accessible through eServices) to determine
if the service meets medical necessity for continuing outpatient care.
16.5.2.4.7 Decision and Notification Timeframes
Beacon is required by the state, federal government, NCQA and the Utilization Review
Accreditation Commission (URAC) to render utilization review decisions in a timely manner to
accommodate the clinical urgency of a situation. Beacon has adopted the strictest time frame for all
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UM decisions in order to comply with the various requirements.
The timeframes below present Beacon’s internal timeframes for rendering a UM determination,
and notifying members of such determination. All timeframes begin at the time of Beacon’s receipt
of the request. Please note, the maximum timeframes may vary from those on the table below on a
case-by-case basis in accordance with state, federal government, NCQA or URAC requirements
that have been established for each line of business.
Decision and Notification Timeframes:
Type of
Decision
Decision
Timeframe
Verbal
Notification
Written
Notification
Within
24 hours
Within 24
hours
Within 24 hours
Urgent
Within 72 hours
Within 24
hours
Within 24 hours
Standard
Within 2
Calendar Days
Within 2
Calendar Days
Within 2
Calendar Days
Urgent/
Within 24 hours
Within 24
hours
Within 24 hours
Non-Urgent/
Standard
Within 2
Calendar Days
Within 2
Calendar Days
Within 2
Calendar Days
NonUrgent/
Standard
Within 10
Calendar Days
Within 10
Calendar Days
Within 10
Calendar Days
Pre-Service Review
Initial Auth for Inpatient
Behavioral Health
Urgent
Initial Auth for Other
Urgent Behavioral
Health Services
Initial Auth for NonUrgent Behavioral
Health Services
Concurrent Review
Continued Auth for
Inpatient and Other
Urgent Behavioral Health
Services
Continued Auth for
Non Urgent Behavioral
Health Services
Post Service
Authorization for
Behavioral Health
Services Already
Rendered
Expedited
When the specified timeframes for standard and expedited prior authorization requests expire
before Beacon makes a decision, an adverse action notice will go out to the member on the date
the timeframe expires.
16.6 Quality Improvement
Passport and Beacon strongly encourage and support providers in the use of outcome measurement
tools for all members. Outcome data is used to identify potentially high-risk members who may need
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intensive behavioral health, medical, and/or social care management interventions.
Providers are also required to communicate (with member consent) with Primary Care Providers
(PCPs) on a regular basis. Providers are required to send initial and quarterly (or more frequently if
clinically indicated) summary reports of a members' behavioral health status to the PCP (with the
member's or the member's legal guardian's consent). The purpose of this reporting is to ensure
coordination between the PCP and behavioral health provider and improve the quality of member
care.
Passport and Beacon receive aggregate data by provider including demographic information and
clinical and functional status without member-specific clinical information.
Communication between Behavioral Health Providers and Other Service Providers:
Communication between Outpatient Behavioral
Health Providers and PCPs, Other Service Providers
Outpatient behavioral health providers are expected to
communicate with the member’s PCP and other OP
behavioral health providers if applicable, as follows:
• Notice of commencement of outpatient
treatment within 4 visits or 2 weeks,
whichever occurs first;
• Updates at least quarterly during the course
of treatment;
• Notice of initiation and any subsequent
modification of psychotropic medications;
and,
• Notice of treatment termination within
2 weeks.
• Refer for known or suspected and
untreated physical health problems or
disorders for examination and treatment.
Behavioral health providers may use Beacon’s
Authorization for Behavioral Health Provider and PCP to
Share Information and the Behavioral Health-PCP
Communication Form available for initial communication
and subsequent updates, in Appendix B, or their own
form that includes the following information:
• Presenting problem/reason for admission;
• Date of admission;
• Admitting diagnosis;
• Preliminary treatment plan;
• Currently prescribed medications;
• Proposed discharge plan; and
• Behavioral health provider contact name and
telephone number.
Request for PCP response by fax or mail within 3
business days of the request to include the following
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Communication between Inpatient/
Diversionary Providers and PCPs, Other
Outpatient Service Providers
With the member’s informed consent, acute
care facilities should contact the PCP by
phone and/or by fax, within 24 hours of a
member’s admission to treatment. Inpatient
and diversionary providers must also alert the
PCP 24 hours prior to a pending discharge,
and must fax or mail the following member
information to the PCP within 3 days postdischarge:
• Date of Discharge;
• Diagnosis;
• Medications;
• Discharge plan; and
• Aftercare services for each type, including:
- Name of provider;
- Date of first appointment;
- Recommended frequency of
appointments;
- Treatment plan.
Inpatient and diversionary providers should
make every effort to provide the same
notifications and information to the member’s
outpatient therapist, if there is one.
Acute care providers’ communication
requirements are addressed during continued
stay and discharge reviews and documented in
Beacon’s member
record.
health information:
• Status of immunizations;
• Date of last visit;
• Dates and reasons for any and all
hospitalizations;
• Ongoing medical illness;
• Current medications;
• Adverse medication reactions, including
sensitivity and allergies;
• History of psychopharmacological trials;
and,
• Any other medically relevant information
Outpatient providers’ compliance with
communication standards is monitored
through requests for authorization
submitted by the provider, and through
chart reviews.
16.6.1 Transitioning Members from one Behavioral Health Provider to Another
If a member transfers from one behavioral health provider to another, the transferring provider must
communicate the reason(s) for the transfer along with the information above (as specified for
communication from behavioral health provider to PCP), to the receiving provider.
Routine outpatient behavioral health treatment by an out-of-network provider is not an authorized
service covered by Beacon. Members may be eligible for transitional care within 30 days after joining
the health plan, or to ensure that services are culturally and linguistically sensitive, individualized to
meet the specific needs of the member, timely per Beacon’s timeliness standards, and/or
geographically accessible.
16.6.2 Follow Up After Mental Health Hospitalization
Members discharged from inpatient levels of care are assigned an aftercare coordinator/case
manager by Beacon prior to or on the date of discharge. The Beacon case managers and other
behavioral health service providers participate in discharge planning meetings to ensure compliance
with federal Olmstead and other applicable laws. Members being discharged from inpatient levels of
care are scheduled for follow up appointments within 7 days of discharge from an acute care setting.
Providers are responsible for seeing members within that timeframe and for outreaching members
who miss their appointments to reschedule. Beacon’s case managers and aftercare coordinators work
with providers to assist in this process by sending reminders to members; working to remove barriers
that may prevent a member from keeping his or her discharge appointment and coordinating with
treating providers. Network providers are expected to aid in this process as much as possible to
ensure that members have the supports they need to maintain placement in the community and to
prevent unnecessary readmissions.
16.6.3 Accessing Medications
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Behavioral health service providers will assist member in accessing free or discounted medication
through the Kentucky Prescription Assistance Program (KPAP) or other similar assistance programs.
16.6.4 Reportable Incidents and Events
Beacon requires that all providers report adverse incidents, other reportable incidents and sentinel
events involving the Passport members to Beacon as follows:
Adverse Incidents
Incident /
Event
Description:
Sentinel Events
An adverse incident is an occurrence
that represents actual or potential
serious harm to the wellbeing of a
health plan member who is
currently receiving or has been
recently discharged from
behavioral health services.
A sentinel event is any
situation occurring within or
outside of a facility that either
results in death of the member
or immediately jeopardizes the
safety of a health plan member
receiving services in any level-ofcare.
• All medico-legal or non-medico•All medico-legal deaths;
legal deaths;
•Any medico-legal death is
• Any Absence without
any death required to be
Authorization (AWA) involving a
reported to the Medical
member who does not meet the
Examiner or in which the
criteria above;
Medical Examiner takes
• Any injury while in a 24-hour
jurisdiction;
program that could or did result in
•Any absence without
transportation to an acute care
authorization (AWA)
hospital for medical treatment or
involving a patient
hospitalization;
involuntarily admitted or
• Any sexual assault or alleged sexual
committed and/or who is at
assault;
high risk of harm to self or
• Any physical assault or alleged
others;
physical assault by a staff person or
•Any serious injury resulting
another patient against a member;
in hospitalization for medical
• Any medication error or suicide
treatment;
attempt that requires medical
•A serious injury is any injury
attention beyond general first aid
that requires the individual to be
procedures;
transported to an acute care
• Any unscheduled event that results in
hospital for medical treatment
the temporary evacuation of a
and is subsequently medically
program or facility (e.g. fire resulting
admitted;
in response by fire department;
Page 209 of 331
Other Reportable
Incidents
An “other reportable
incident” is any incident
that occurs within a
provider site at any level-ofcare, which does not
immediately place a health
plan member at risk but
warrants serious concern.
•Any non-medico-legal
death;
•Any absence without
authorization from a
facility involving a member
who does not meet the
criteria for a sentinel event
as described above;
•Any physical assault or
alleged physical assault by
or against a member that
does not meet the criteria
of a sentinel event;
•Any serious injury while in
a 24hour program
requiring medical
treatment, but not
hospitalization;
•A serious injury, defined as
any injury that requires the
individual to be
transported to an acute
care hospital for medical
treatment and is not
•Any medication error or
suicide attempt that requires
medical attention beyond
general first aid procedures;
•Any sexual assault or alleged
sexual assault;
• Any physical assault or alleged
physical assault by a staff
person against a member; and
•Any unscheduled event that
results in the evacuation of a
program or facility whereby
regular operations will not be in
effect by the end of the business
day and may result in the need
for finding alternative placement
options for member.
subsequently medically
admitted; and
• Any unscheduled event
that results in the
temporary evacuation of a
program or facility such
as a small fire that requires
fire department response.
Data regarding critical
incidents is gathered in
the aggregate and trended
on a quarterly basis for the
purpose of identifying
opportunities for quality
improvement.
Reporting
Method:
• Beacon’s Clinical Department is available 24 hours a day;
• Providers must call, regardless of the hour, to report such incidents;
• Providers should direct all such reports to their Beacon clinical manager or UR clinician by
phone;
• In addition, providers are required to fax a copy of the Adverse Incident Report Form (for
adverse and other reportable incidents and sentinel events) to Beacon’s Ombudsperson at
(888)204-5581; and,
• Incident and event reports should not be emailed unless the provider is using a secure messaging
system.
Prepare to
Provide the
Following:
Providers should be prepared to present:
• All relevant information related to the nature of the incident;
• The parties involved (names and telephone numbers); and,
• The member’s current condition.
16.7 Behavioral Health Provider Billing Manual
16.7.1 Billing Transactions
This chapter presents all information needed to submit claims to Beacon. Beacon strongly
encourages providers to rely on electronic submission, either through EDI or eServices in order to
achieve the highest success rate of first-submission claims payment.
16.7.2 General Claim Policies
Beacon requires that providers adhere to the following policies with regard to claims:
16.7.3 Definition of “Clean Claim”
A clean claim, as discussed in this provider manual, the provider services agreement, and in other
Beacon informational materials, is defined as one that has no defect and is complete including
Page 210 of 331
required, substantiating documentation of particular circumstance(s) warranting special treatment
without which timely payments on the claim would not be possible.
16.7.4 Electronic Billing Requirements
The required edits, minimum submission standards, signature certification form, authorizing
agreement and certification form, and data specifications as outlined in this manual must be fulfilled
and maintained by all providers and billing agencies submitting electronic medical claims to Beacon.
16.7.5 Provider Responsibility
The individual provider is ultimately responsible for accuracy and valid reporting of all claims
submitted for payment. A provider utilizing the services of a billing agency must ensure through legal
contract (a copy of which must be made available to Beacon upon request) the responsibility of a
billing service to report claim information as directed by the provider in compliance with all policies
stated by Beacon.
16.7.6 Limited Use of Information
All information supplied by Beacon or collected internally within the computing and accounting
systems of a provider or billing agency (e.g., member files or statistical data) can be used only by the
provider in the accurate accounting of claims containing or referencing that information. Any
redistributed or dissemination of that information by the provider for any purpose other than the
accurate accounting of behavioral health claims is considered an illegal use of confidential
information.
16.7.7 Prohibition of Billing Members
Providers are not permitted to bill health plan members under any circumstances for covered
services rendered, excluding co-payments when appropriate.
16.7.8 Beacon’s Right to Reject Claims
At any time, Beacon can return, reject or disallow any claim, group of claims, or submission received
pending correction or explanation.
16.7.9 Recoupments and Adjustments by Beacon
Beacon reserves the right to recoup money from providers due to errors in billing and/or payment,
in accordance with Kentucky law and regulations. In that event, Beacon applies all recoupments and
adjustments to future claims processed, and reports such recoupments and adjustments on the EOB
with Beacon’s record identification number (REC.ID) and the provider’s patient account number.
16.7.10 Claim Turnaround Time
All clean claims will be adjudicated within thirty (30) days from the date on which Beacon Health
Page 211 of 331
Strategies receives the claim.
16.7.11 Claims for Inpatient Services
• The date range on an inpatient claim for an entire admission (i.e., not an interim bill) must
include the admission date through the discharge date. The discharge date is not a covered day
of service but must be included as the “to” date. Refer to authorization notification for correct
date ranges.
•
•
•
Beacon accepts claims for interim billing that include the last day to be paid as well as the
correct bill type and discharge status code. On bill type X13, where X represents the “type of
facility” variable, the last date of service included on the claim will be paid and is not
considered the discharge day.
Providers must obtain authorization from Beacon for all ancillary medical services provided
while a plan member is hospitalized for a behavioral health condition. Such authorized
medical services are billed directly to the health plan.
Beacon’s contracted reimbursement for inpatient procedures reflect all-inclusive per diem
rates.
16.7.12 Coding
When submitting claims through eServices, users will be prompted to include appropriate codes in
order to complete the submission, and drop-down menus appear for most required codes. See EDI
Transactions – 837 Companion Guide on the Beacon web site www.beaconhealthsolutions.com for
placement of codes on the 837 file. Please note the following requirements with regard to coding:
•
•
•
•
•
•
Providers are required to submit HIPAA-compliant coding on all claim submissions; this
includes HIPAA-compliance revenue, CPT, HCPCS, and ICD-9 codes.
Providers should refer to their exhibit A for a complete listing of contracted, reimbursable
procedure codes.
Beacon accepts only ICD-9 diagnosis codes listed as approved by CMS and HIPAA. In
order to be considered for payment by Beacon, all claims must have a Primary ICD-9
diagnosis in the range of 290-298.9, 300.00-316.
All diagnosis codes submitted on a claim form must be a complete diagnosis code with
appropriate check digits.
Claims for inpatient and institutional services must include the appropriate discharge status
code. Table 6-1 lists HIPAA-compliant discharge status codes.
DSM-IV (or most recent) classification should be used for behavioral health billing.
Table 6-1 Discharge Status Codes
Code
01
02
03
04
05
06
Description
Discharged to Home / Self Care
Discharged/Transferred to Another Acute Hospital
Discharged/Transferred to Skilled Nursing Facility
Discharged/Transferred to Intermediate Care Facility
Discharged/Transferred to Another Facility
Discharged/Transferred to Home / Home Health Agency
Page 212 of 331
07
08
09
20
30
Left Against Medical Advice or Discontinued Care
Discharged/Transferred Home / IV Therapy
Admitted as Inpatient to this Hospital
Expired
Still a Patient
* All UB04 claims must include the 3-digit bill type codes according to the Table below:
Table 6-2 Bill Type Codes
Type of Facility 1st Digit
Bill Classification 2nd Digit
Frequency – 3rd Digit
1.Admission through
Discharge Claim
1.Hospital
1.Inpatient
1.Skilled Nursing
Facility
2.Inpatient Professional
Component
2.Home Health Care
3.Outpatient
3.Interim Continuing
Claims
4.Diagnostic Services
4.Interim – Last Claim
5.Intermediate Care –
Level I
5. Late Charge Only
6.Intermediate Care –
Level II
6 – 8. Not Valid
3.Christian Science
Hospital
5.Christian Science
Extended Care
Facility
6.Intermediate Care
Facility
2.Interim – First Claim
6.7.13 Modifiers
Modifiers can reflect the discipline and licensure status of the treating practitioner or are used to
make up specific code sets that are applied to identify services for correct payment. Table lists
HIPAA-compliant modifiers accepted by Beacon.
Table 6-3 Modifiers
Professional Provider Type
Psychiatrist
Licensed Psychologist
Licensed Clinical Social Worker
Psychiatric Resident, Physician
Certified Prevention Professional, Community Support Staff Member, Peer Counselor
Professional Equivalent
Licensed Marriage and Family Therapist, Licensed Psychological Practitioner, Certified
Professional Counselor, Certified Professional Art Therapist,
Advance Registered Nurse Practitioner
Physician Assistant
Psychiatric Nurse, Registered Nurse AD or Diploma Degree, Registered Nurse with
BS Degree
Certified Social Worker, Licensed Professional Counselor Associate, Licensed
Psychological Associate, Marriage and Family Therapy Associate
Page 213 of 331
Modifier
AF
AH
AJ
AM
HM
HN
HO
SA
U1
U2
U4
Mental Health Associate
Certified Alcohol and Drug Counselor
U5
U6
6.7.14 Time Limits for Filing Claims
Beacon Health Strategies must receive claims for covered services within the designated filing limit:
• Within 180 days of the dates of service on outpatient claims, or
• Within 180 days of the date of discharge on inpatient claims
Providers are encouraged to submit claims as soon as possible for prompt adjudication. Claims
submitted after the 180-day filing limit will deny unless submitted as a waiver or reconsideration
request, as described in this chapter.
6.7.15 Coordination of Benefits (COB)
Passport follows a Coordination of Benefits policy when members have other medical insurance
including Medicare. Because Passport administers a Medicaid program, it is considered the “payer of
last resort” on all claims. All insurance including any automobile (personal protection) coverage or
other medical coverage, including Medicare, pays the member’s claims before Passport. These types
of coverage are considered “primary” coverage.
In accordance with The National Association of Insurance Commissioners (NAIC) regulations,
Beacon Health Strategies coordinates benefits for behavioral health and substance use claims when it
is determined that a person is covered by more than one health plan, including Medicare:
•
•
When it is determined that Passport / Beacon Health Strategies is the secondary payer, claims
must be submitted with a copy of the primary insurance’s explanation of benefits report and
received by Beacon within 60 days of the date on the EOB.
Beacon Health Strategies reserves the right of recovery for all claims in which a primary
payment was made prior to receiving COB information that deems Beacon the secondary
payer. Beacon applies all recoupments and adjustments to future claims processed, and reports
such recoupments and adjustments on the EOB.
6.7.16 Claim Inquiries and Resources
Additional information is available through the following resources:
Email Contact
• [email protected]
• [email protected]
Telephone
• Interactive Voice Recognition (IVR): (888)210-2018
You will need your practice or organization’s tax ID, the member’s identification number
and date of birth, and the date of service.
Page 214 of 331
•
•
Claims Hotline: (888)249-0478
Hours of operation are 8:30 a.m. to 5:30 p.m. EST Monday through Thursday and 9:00 a.m.
to 5:00 p.m. EST on Friday.
Beacon’s Main Telephone Numbers
Provider Relations
(855)834-5651
EDI
(855)834-5651
TTY
(866)727-9441
6.7.17 Electronic Media Options
Providers are expected to complete claim transactions electronically through one of the following,
where applicable:
Electronic Data Interchange (EDI) supports electronic submission of claim batches in
HIPAA- compliant 837P format for professional services and 837I format for institutional
services. Providers may submit claims using EDI/837 format directly to Beacon or through
a billing intermediary. If using Emdeon as the billing intermediary, two identification
numbers must be included in the 837 file for adjudication:
o Beacon’s payor ID is 43324; and
o Beacon’s health plan-specific ID is 028.
• eServices enables providers to submit inpatient and outpatient claims without completing a
CMS 1500 or UB04 claim form. Because much of the required information is available in
Beacon’s database, most claim submissions take less than one minute and contain few, if any
errors.
• IVR provides telephone access to member eligibility, claim status and authorization status.
•
6.7.18 Claim Transaction Overview
Table 6-4 below, identifies all claim transactions, indicates which transactions are available on each of
the electronic media, and provides other information necessary for electronic completion. Watch for
updates as additional transactions become available on EDI, eServices and IVR.
Table 6-4: Claim Transaction Overview
Member
Eligibility
Verification
Submit
Standard Claim
Applicable When:
IVR
EDI
Transaction
eServices
Access
on:
• Completing any claim
transaction; and
• Submitting clinical
authorization requests
Y
Y Y
Y
Submitting a claim for
Y N authorized, covered services,
within the timely filing limit
Page 215 of 331
Timeframe for
Receipt by
Beacon
Other Information
n/a
n/a
Within 180 days
after the date of
service
n/a
Resubmission
of Denied
Claim
Y
180-Day
Waiver*
(Request for
waiver of timely
filing limit)
Previous claim was denied for
Y N any reason except timely filing
Within 180 days
after the date on
the EOB.
A claim being submitted for
the first time will be received by
Beacon after the original 180day filing limit, and must include
evidence that one of the
following conditions is met:
N
• Provider is eligible for
reimbursement retroactively;
or
• Member was enrolled in
Plan retroactively; or
• Services were authorized
retroactively.
• Third party coverage is
available and was billed first.
(A copy of the other
N N
insurance’s explanation of
benefits or payment is
required);
Page 216 of 331
Within 180 days
from the
qualifying event.
• Claims denied for
late filing may be
resubmitted as
reconsiderations.
• Rec ID is required to
indicate that claim is
a resubmission.
• Waiver requests will
be considered only
for these 3
circumstances. A
waiver request
that presents a
reason not listed
here will result in
a claim denial on a
future EOB.
• A claim submitted
beyond the filing
limit that does not
meet the above
criteria may be
submitted as
reconsideration
request.
• Beacon’s waiver
determination is
reflected on a
future EOB with a
message of
Waiver Approved
or Waiver Denied:
if waiver of the
filing limit is
approved, the
claim appears
adjudicated; if the
request is denied,
the denial reason
appears.
Request for
Reconsideration
of Timely
Filing Limit*
N
Request to
Void Payment
N
Y N Claim falls out of all timeframes
and requirements for
resubmission, waiver and
adjustment.
• Claim was paid to provider in
error; and,
N N • Provider needs to return the
entire paid amount to Beacon.
Request for
Adjustment
Within 180 days
from the date of
payment or
nonpayment.
n/a
• The amount paid to
provider on a claim, was
incorrect;
• Adjustment may be
requested to correct:
o Underpayment
(positive request); or,
o Overpayment (negative
request)
Y
• Positive
request must
be received by
Beacon within
180 days from
the date of
original
payment;
Y N
• No filing limit
applies to
negative
requests.
Obtain Claim
Status
View/Print
Remittance
Advice (RA)
N
Available 24/7 for all claim
Y Y transactions submitted by
provider.
n/a
N
Available 24/7 for all claim
Y N transactions received by
Beacon.
n/a
Page 217 of 331
Future EOB shows
“Reconsideration”
“Approved” or
“Reconsideration
Denied” with denial
Do NOT send a refund
check to Beacon.
• Do NOT send a
refund check to
Beacon
• A RecID is required
to indicate that the
claim is an
adjustment.
• Adjustments are
reflected on a
future EOB as
recoupment of the
previous
(incorrect) amount
and, if
money is owed to
provider, repayment of the
claim at the
correct amount.
• If an adjustment
appears on an
EOB and is not
correct, another
adjustment request
may be submitted
based on the
previous incorrect
adjustment.
• Claims that have
been denied cannot
be adjusted, but
may be resubmitted.
Claim status is
posted within 48 hours
after receipt by Beacon.
Printable RA is
posted within 48
hours after receipt
by Beacon.
*Please note that waivers and reconsiderations apply only to the claims filing limit; claims
are still processed using standard adjudication logic and all other billing and authorization
requirements must be met. Accordingly, an approved waiver or reconsideration of the filing
limit does not guarantee payment, since the claim could deny for another reason.
6.7.19 Paper Claim Transactions
Providers are strongly discouraged from using paper claim transactions where electronic methods are
available, and should be aware that processing and payment of paper claims is slower than that of
electronically submitted claims. Electronic claim transactions take less time and have a higher rate of
approval since most errors are eliminated.
For paper submissions, providers are required to submit clean claims on the National Standard
Format CMS1500 or UB04 claim form. No other forms are accepted.
Mail paper claims to:
Beacon Health Strategies
Passport Health Plan Claims Department
500 Unicorn Park Drive, Suite 401
Woburn, MA 01801-3393
Beacon does not accept claims transmitted by fax.
Beacon discourages paper transactions.
B EFOR E SUB M IT T IN G PAPER CL AIM S, PL EASE R EVIEW ELECT R ON IC OPT ION S
EARLIER IN TH IS CH APTER.
Paper submissions have more fields to enter, a higher error rate / lower approval rate, and slower payment.
16.7.20 Professional Services: Instructions for Completing the CMS 1500 Form
Table 6-5 below lists each numbered block on the CMS 1500 form with a description of the
requested information, and indicates which fields are required in order for a claim to process and
pay.
Page 218 of 331
Table 6-5: CMS 1500 Form
Table
Block #
1
1a
2
3
4
5
6
7
8
9
9a
9b
9c
9d
10a-c
11
11a
11b
11c
11d
12
13
14
15
16
17
17 B
18
19
20
21
22
23
24a
24b
Required?
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
Yes
No
Yes
Yes
Yes
24d
Yes
24e
24f
24g
Yes
Yes
Yes
Description
Check Applicable Program
Member’s Health Plan ID Number
Member’s Name
Member’s Birth date and Sex
Insured’s Name
Member’s Address
Member’s Relationship to Insured
Insured’s Address
Member’s Status
Other Insured’s Name (If Applicable)
Other Insured’s Policy or Group Number
Other Insured’s Date of Birth and Sex
Employer’s Name or School Name
Insurance Plan Name or Program Name
Member’s Condition Related to Employment
Member’s Policy, Group or FICA Number (If Applicable)
Member’s Date of Birth (MM, DD, YY) and Sex (check box)
Employer’s Name or School Name (If Applicable)
Insurance Plan Name or Program Name (If Applicable)
Is there another health benefit plan?
Member’s or Authorized Person’s Signature and Date On File
Member’s or Authorized Person’s Signature
Date of Current Illness
Date of Same or Similar Illness
Date Client Unable to Work in Current Occupation
Name of Referring Physician or Other Source (If Applicable)
NPI of referring Physician
Hospitalization Dates Related to Current Services (If Applicable)
Former Control Number (Record ID If Applicable)
Outside Lab?
Diagnosis or Nature of Illness or Injury
Medicaid Resubmission Code
Prior Authorization Number (If Applicable)
Date of Service
Place of Service code (HIPAA Compliant)
Procedure Code (HIPAA-compliant between 290 and 319) and
Modifier when applicable (See Table 6-3 for acceptable modifiers)
Diagnosis Code- 1,2,3 or 4
Charges
Days or Units
Page 219 of 331
24h
24i
24 j
25
26
27
28
29
30
31
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
32
Yes
32a
33
33 a
33 b
No
Yes
Yes
No
EPSDT
ID Qualifier
Rendering Provider Name and Rendering Provider NPI
Federal Tax ID Number
Provider’s Member Account Number
Accept Assignment (check box)
Total Charges
Amount Paid by Other Insurance (If Applicable)
Balance Due
Signature of Physician/Practitioner NPI
Name and Address of Facility where services were rendered (Site
ID). If missing, a claim specialist will choose the site shown as
‘primary’ in Beacon’s database
NPI of Servicing Facility
Provider Name
Billing Provider NPI
Pay to Provider Beacon ID Number
Institutional Services: Instructions for Completing the UB04 Form
Beacon discourages paper transactions.
BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS
EARLIER IN THIS CHAPTER
Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment.
Table 6-6 below lists each numbered block on the UB-04 claim form, with a description of the
requested information and whether that information is required in order for a claim to process and
pay.
Table 6-6 UB-04 Claim Form
Block #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Required?
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
Provider Name, Address, Telephone #
Untitled
Provider’s Member Account Number
Type of Bill (See Table 6-2 for 3-digit codes)
Federal Tax ID Number
Statement Covers Period (Include date of Discharge)
Covered Days (Do not include date of Discharge)
Member Name
Member Address
Member Birth Date
Member Sex
Admission Date
Admission Hour
Admission Type
Page 220 of 331
15
16
17
18 -28
29
30
31-34
35-36
37
38
39-41
42
43
44
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
45
46
47
48
49
50
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6
7
7
7
7
7
7
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
Yes
No
No
No
No
No
No
Admission Source
Discharge Hour
Discharge Status (See Table 6-1: Discharge Status Codes)
Condition Codes
ACDT States
Unassigned
Occurrence Code And Date
Occurrence Span
REC.ID For Resubmission
Untitled
Value CD/AMT
Revenue Code (If Applicable)
Revenue Description
Procedure Code (CPT) (Modifier may be placed here beside the HCPCS code.
See Table 6-3 for acceptable modifiers)
Service Date
Units Of Service
Total Charges
Non-Covered Charges
Modifier (If Applicable - See Table 6-3 for acceptable modifiers)
Payer Name
Beacon Provider Id Number
Release Of Information Authorization Indicator
Assignment Of Benefits Authorization Indicator
Prior Payments (If Applicable)
Estimated. Amount Due
Facility NPI
Other ID
Insured’s Name
Member’s Relationship To Insured
Member’s Identification Number
Group Name
Insurance Group Number
Prior Authorization Number (If Applicable)
Document Control Number
Employer Name
Employer Location
Principal Diagnosis Code
A-Q Other Diagnosis
Admit Diagnosis
Patient Reason Diagnosis
PPS Code
ECI
Unassigned
Principle Procedure
Unassigned
Page 221 of 331
7
7
78 -79
8
8
Yes
No
No
No
No
Attending Physician NPI First And Last Name (Required)
Operating Physician NPI
Other NPI
Remarks
Code-Code
6.7.21 Paper Resubmission
Beacon discourages paper transactions.
BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS
EARLIER IN THIS CHAPTER
Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment.
•
•
See Table 6-4 for an explanation of claim resubmission, when resubmission is appropriate, and
procedural guidelines.
If the resubmitted claim is received by Beacon more than 180 days from the date of service.
The REC.ID from the denied claim line is required and may be provided in either of the
following ways:
 Enter the REC.ID in box 64 on the UB04 claim form or in box 19 on the CMS 1500 form.
 Submit the corrected claim with a copy of the EOB for the corresponding date of
service; or
•
The REC.ID corresponds with a single claim line on the Beacon EOB. Therefore, if a claim has
multiple lines there will be multiple REC.ID numbers on the Beacon EOB.
•
The entire claim that includes the denied claim line(s) may be resubmitted regardless of the
number of claim lines; Beacon does not require one line per claim form for resubmission.
When resubmitting a multiple-line claim, it is best to attach a copy of the corresponding EOB.
Resubmitted claims cannot contain original (new) claim lines along with resubmitted claim
lines.
Resubmissions must be received by Beacon within 180 days after the date on the EOB. A
claim package postmarked on the 180th day is not valid.
If the resubmitted claim is received by Beacon within 180 days from the date of service, the
corrected claim may be resubmitted as an original. A corrected and legible photocopy is also
acceptable
•
•
•
6.7.21.1 Paper Submission of 180-Day Waiver
•
•
•
•
•
•
•
See Table 6-4 for an explanation of waivers, when a waiver request is applicable, and
procedural guidelines;
Watch for notice of waiver requests becoming available on eServices.
Download the 180-Day Waiver Form;
Complete a 180-Day Waiver Form for each claim that includes the denied claim(s),per the
instructions below;
Attach any supporting documentation;
Prepare the claim as an original submission with all required elements;
Send the form, all supporting documentation, claim and brief cover letter to:
Page 222 of 331
Beacon Health Strategies
Claim Department / Waivers
500 Unicorn Park Drive, Suite 401
Woburn, MA 01801-3393
6.7.21.2 Completion of the Waiver Request Form
To ensure proper resolution of your request, complete the 180-Day Waiver Request Form as
accurately and legibly as possible.
1. Provider Name:
Enter the name of the provider who provided the service(s).
2. Provider ID Number:
Enter the provider ID Number of the provider who provided the service(s).
3. Member Name:
Enter the member’s name.
4. Health Plan Member ID Number:
Enter the Plan member ID Number.
5. Contact Person
Enter the name of the person whom Beacon should contact if there are any questions regarding
this request.
6. Telephone Number
Enter the telephone number of the contact person.
7. Reason for Waiver
Place an “X” on all the line(s) that describe why the waiver is requested.
8. Provider Signature
A 180-day waiver request cannot be processed without a typed, signed, stamped, or computergenerated signature. Beacon will not accept “Signature on file.”
9. Date
Indicate the date that the form was signed.
6.7.22 Paper Request for Adjustment or Void
Beacon discourages paper transactions.
BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS
EARLIER IN THIS CHAPTER
Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment.
• See Table 6-4 for an explanation of adjustments and voids, when these requests are
applicable, and procedural guidelines;
• Do not send a refund check to Beacon. A provider who has been incorrectly paid by Beacon
must request an adjustment or void;
• Prepare a new claim as you would like your final payment to be, with all required elements;
place the REC.ID in box 19 of the CMS 1500 claim form, or box 64 of the UB04 form or;
• Download and complete the Adjustment/Void Request Form per the instructions below;
• Attach a copy of the original claim;
• Attach a copy of the EOB on which the claim was paid in error or paid an incorrect
Page 223 of 331
amount; Send the form, documentation and claim to:
Beacon Health Strategies
Claim Departments – Adjustment Requests
500 Unicorn Park Drive, Suite 401
Woburn, MA 01801-3393
6.7.22.1 To Complete the Adjustment/Void Request Form
To ensure proper resolution of your request, complete the Adjustment/Void Request form as
accurately and legibly as possible and include the attachments specified above.
1. Provider Name
Enter the name of the provider to whom the payment was made.
2. Provider ID Number
Enter the Beacon provider ID Number of the provider that was paid for the service. If the claim
was paid under an incorrect provider number, the claim must be voided and a new claim must be
submitted with the correct provider ID Number.
3. Member Name
Enter the member’s name as it appears on the EOB. If the payment was made for the wrong
member, the claim must be voided and a new claim must be submitted.
4. Member Identification Number
Enter the Plan member ID Number as it appears on the EOB. If a payment was made for the
wrong member, the claim must be voided and a new claim must be submitted.
5. Beacon Record ID number
Enter the record ID number as listed on the EOB.
6. Beacon Paid Date
Enter the date the check was cut as listed on the EOB.
7. Check Appropriate Line
Place an “X” on the line that best describes the type of adjustment/void being requested.
8. Check All that Apply
Place an “X” on the line(s) which best describe the reason(s) for requesting the adjustment/void.
If
“Other” is marked, describe the reason for the request.
9. Provider Signature
An adjustment/void request cannot be processed without a typed, signed, stamped, or
computer- generated signature. Beacon will not accept “Signature on file”.
10. Date
List the date that the form is signed.
6.7.23 Provider Education and Outreach
Summary
In an effort to help providers that may be experiencing claims payment issues, Beacon runs quarterly
reports identifying those providers than may benefit from outreach and education. Providers with
low approval rates are contacted and offered support and documentation material to assist in
reconciliation of any billing issues that are having an adverse financial impact and ensure proper
Page 224 of 331
billing practices within Beacon’s documented guidelines.
Passport’s goal in this outreach program is to assist providers in as many ways as possible to receive
payment in full, based upon contracted rates, for all services delivered to members.
6.7.23.1 How the Program Works
•
•
•
A quarterly approval report is generated that lists the percentage of claims paid in relation to
the volume of claims submitted.
All providers below 75% approval rate have an additional report generated listing their most
common denials and the percentage of claims they reflect.
An outreach letter is sent to the provider’s Billing Director as well as a report indicating the
top denial reasons. A contact name is given for any questions or to request further assistance
or training.
6.7.24 Grievances
Providers with grievances or concerns should contact Beacon at the number provided below and ask
to speak with the clinical manager for Passport. All provider complaints are resolved within thirty
(30) days of receipt. The Provider or Passport may request a fourteen (14) day extension for
resolution of the grievance or appeal.
If a Passport member complains or expresses concern regarding Beacon’s procedures or services,
Plan procedures, covered benefits or services, or any aspect of the member’s care received from
providers, he or she should be directed to call Beacon’s Ombudsperson at (855)834-5651 or TTY at
(866)727-9441.
6.7.24.1 Appeals and Grievances
Please see Section (2.9) for information concerning provider appeals and grievances.
6.7.24.2 Peer Review
A peer review conversation may be requested at any time by the treating provider, and may occur
prior to or after an adverse determination, upon request for a reconsideration. Beacon UR clinicians
and PAs are available daily to discuss denial cases by phone at (855)834-5651.
Page 225 of 331
Provider Manual
Section 17.0
Forms and Documents
Table of Contents
17.1 Preventive Health, Disease Management & Risk Assessment
Forms
17.2 Claim Forms
17.3 Provider Contracting and Provider Network Management Forms
17.4 MAP Forms
17.5 Utilization Management Forms
17.6 Mommy Steps Forms
Page 226 of 331
17.0 Forms and Documents
17.1 Preventive Health, Disease Management & Risk Assessment
Forms
17.1.1
Diabetes Care Tool
17.2 Claim Forms
17.2.1
17.2.2
17.2.3
17.2.4
17.2.5
Claim Issue Form
Recoupment Form
UB-04 Form and Instructions
CMS-1500 Claim Form and NPI Instructions
Third Party Liability Lead Form
17.3 Provider Contracting and Provider Network Management Forms
17.3.1
17.3.2
17.3.3
17.3.4
Provider Information Change Form
Adding a Practitioner to a Current Participating Provider Group
Nonparticipating Provider Registration Form
Registration of Locum Tenens Physician
17.4 MAP Forms
17.4.1
17.4.2
17.4.3
17.4.4
MAP-250 Consent for Sterilization
MAP-251 Hysterectomy Consent Form
MAP-235 Certification Form for Induced Abortion or Induced
Miscarriage
MAP-236 Certification Form for Induced Premature Birth
17.5 Utilization Management Forms
17.5.1
17.5.2
17.5.3
17.5.4
17.5.5
17.5.6
17.5.7
17.5.8
17.5.9
17.5.10
17.5.11
17.5.12
Referral Form
Home Health Authorization Form
DME Authorization Form
Home Infusion Authorization Form
Pain Management Medical Necessity Review Check List
Cosmetic Prior Authorization Form
Initial Therapy Authorization Form
Continued Therapy Authorization Form
Chiropractic Service Prior Authorization Request Form
Behavioral Health Liaison Form
Care Coordination Referral Form
Private Duty Nursing Form
17.6 Mommy Steps Forms
17.6.1
No-Show Visit for OB Appointment Form
Page 227 of 331
DIABETES CARE TOOL
Patient Name:
DOB:
Height:
Smoker: Yes No (circle one)
Type of Diabetes: 1 2 (circle one)
Pneumococcal Vaccine Date(s):
KENTUCKY DIABETES NETWORK, INC.
_
A statewide partnership striving to
improve the treatment and outcomes
for Kentuckians with diabetes.
Year of Diabetes Diagnosis:
This tool is based on the 2009 American Diabetes Association’s “Standards of Medical Care for Patients with Diabetes Mellitus” and indicates
minimum services to be provided in the continuing (initial visits have additional components) care of adults with diabetes. It is not intended to
replace or preclude clinical judgment or more intensive management where medically indicated. Use it as a reminder for exams or important tests, to
simplify record keeping and as a way to continually improve care to all patients with diabetes.
Enter result, checkmark, or date as you deem appropriate.
DATE OF VISIT
EVERY VISIT
Weight
B/P (Goal <130/80)
A1C Hemoglobin A1c every 3–6 mo. (Goal <7%)
Foot Exam: V = Visual
Review Self-Management Goals and BG Log
Foot Exam:
• Monofilament (sensation), foot structure,
biomechanics, vascular, and skin integrity
ANNUAL
Fasting Lipid Profile:
• Total Cholesterol (Goal < 200)
•
LDL (Goal < 100)
•
HDL (Goal Men > 40, Women > 50)
•
Triglycerides (Goal < 150)
Microalbumin: Unless urine dipstick (+) for protein
Serum Creatinine: For estimation of glomerular
filtration rate (GFR)
Dilated Eye Exam/ Referral Date
Flu Vaccine
SELFMANAGEMENT
Oral Visualization Exam
Self-Management Education/ Referral Date
Exercise /Physical Activity
Medical Nutrition Therapy Referral
Tobacco Cessation
(1-800-QUIT NOW or 1-800-784-8669)
Preconception Counseling (women of childbearing age)
OTHER
Aspirin Therapy
St=start, Cont=continue, D/C=discontinue,
CI/MA=contraindicated/medical allergy, Dec=declined
Circle: ACE-I or ARB
St, Cont, D/C, CI/MA, Dec
Statin or Lipid Lowering Agent: St,
Cont, D/C, CI/MA, Dec
Assess Mental/Behavioral Health
This tool may be obtained from www.kentuckydiabetes.net and reprinted in its entirety without permission. Revisions in content may not be
endorsed by the Kentucky Diabetes Network, Inc.
04/2009
Passport Health Plan
Attn: Provider Claims Unit P.O.
Box 7114
London, KY 40742
Phone: 800-578-0775
Fax: 502-585-8339
CLAIM ISSUE FORM
Date:
Provider ID:
Provider Name:
Phone Number:
Email Address:
Contact Name:
Submitted By:
Please provide the following information regarding the issue:
Member ID:
Claim Number:
Remittance Number:
Remittance Date:
Please explain the issue you have with the claim:
□Underpayment
□Overpayment
□COB/TPL
□Claim processed incorrectly
□Authorization issues
□Referral issues
□Claim paid to the wrong provider
□ Duplicate payment
□ Other (explanation required)
FOR PHP US E ON LY
Rep. Name:
Response Date
Comments
RECOUPMENT FORM
Provider Name
Provider ID
Contact Name
Phone #
Passport Health Plan
Attn: Recoupments
P.O. Box 7114
London, KY 40742
Phone: 800-578-0775
Fax: 502-585-8339
Provider Email Address
Member’s ID
Member Name
Claim(s) #
Remit #
Date of Service
Total Amount Billed
Check Number (from Passport Health Plan)
Recoupment Amount
Reason for recoupment:
CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual and entity to whom it is addressed and may
contain information that is confidential and exempt from disclosure under applicable law. If you are not the intended addressee nor
authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone
the message or any information contained in the message. If you have received this fax in error, please immediately advise the sender
at the phone number at the top of the page and shred the fax. Thank you very much.
New UB-04 Form
& Instructions
The Office of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC) previously approved the
UB-04 claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier
(NPI) and incorporated other important changes. This form replaced the UB-92 claim form and was phased in over a
transition period beginning March 1, 2007.The UB-04 form has been used exclusively for institutional billing beginning May
23, 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed.
The UB-04 Claim Form and NPI
The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the
NPI, you must continue to report your current provider identification numbers in the appropriate areas of the form.
UB-04 Data Field Requirements
FIELD LOCATION
UB-04
DESCRIPTION
1
Provider Name and Address
Required
Required
2
Pay-To Name and Address
Situational
Situational
3a
Patient Control Number
Required
Required
3b
Medical Record Number
Required
Required
4
Type of Bill
Required
Required
5
Federal Tax Number
Required
Required
6
Statement Covers Period
Required
Required
7
Future Use
N/A
N/A
8a
Patient ID
Situational
Situational
8b
Patient Name
Required
Required
INPATIENT
OUTPATIENT
9
Patient Address
Required
Required
10
Patient Birthdate
Required
Required
11
Patient Sex
Required
Required
12
Admission Date
Required
Required
13
Admission Hour
Required
Required
14
Type of Admission/Visit
Required
N/A
15
Source of Admission
Required
Required
16
Discharge Hour
Required
Required
17
Patient Discharge Status
Required
Required
18-28
Condition Codes
Required if Applicable
Required if Applicable
29
Accident State
Situational
Situational
30
Future Use
N/A
N/A
31-34
Occurrence Code and Dates
Required if Applicable
Required if Applicable
35-36
Occurrence Span Codes and Dates
Required if Applicable
Required if Applicable
37
Future Use
N/A
N/A
38
Subscriber Name and Address
Required
Required
39-41
Value Codes and Amounts
Required if Applicable
Required if Applicable
42
Revenue Code
Required
Required
43
Revenue Code Description
Required
Required
44
HCPCS/Rates
Required if Applicable
Required if Applicable
*For additional information on the completion of fields, please refer to the NUBC Official UB-04 Data Specifications Manual.
© 2012 PASSPORT HEALTH PLAN (PA-111378)
FIELD LOCATION
UB-04
DESCRIPTION
INPATIENT
OUTPATIENT
45
Service Date
N/A
Required
46
Units of Service
Required
Required
47
Total Charges (By Rev. Code)
Required
Required
48
Non-Covered Charges
Required if Applicable
Required if Applicable
49
Future Use
N/A
N/A
50
Payer Identification (Name)
Required
Required
51
NPI
Required
Required
52
Release of Info Certification
Required
Required
53
Assignment of Benefit Certification
Required
Required
54
Prior Payments
Required if Applicable
Required if Applicable
55
Estimated Amount Due
Required
Required
56
NPI
Required
Required
57
Health Plan IDs
Required
Required
58
Insured’s Name
Required
Required
59
Patient’s Relation to the Insured
Required
Required
60
Insured’s Unique ID
Required
Required
61
Insured Group Name
Situational
Situational
62
Insured Group Number
Situational
Situational
63
Treatment Authorization Codes
Required if Applicable
Required if Applicable
64
Document Control Number
Situational
Situational
65
Employer Name
Situational
Situational
66
Diagnosis/Procedure Code Qualifier
Required
Required
67
Principal Diagnosis Code/Other Diagnosis Codes
Required
Required
68
Future Use
N/A
N/A
69
Admitting Diagnosis Code
Required
Required if Applicable
70
Patient’s Reason for Visit Code
Situational
Situational
71
PPS Code
Situational
Situational
72
External Cause of Injury Code
Situational
Situational
73
Future Use
N/A
N/A
74
Principal Procedure Code/Date
Required if Applicable
Required if Applicable
75
Future Use
N/A
N/A
76
Attending Name/ ID-Qualifier
Required
Required
77
Operating ID
Situational
Situational
78-79
Other ID
Situational
Situational
80
Remarks
Situational
Situational
81
Code-Code Field/Qualifiers
*0-A0
N/A
N/A
*A1-A4
Situational
Situational
*A5-B0
N/A
N/A
*B1-B2
Situational
Situational
*B3
Required
Required
We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan
strongly recommends the continued use of plan identification numbers in addition to NPI.
© 2012 PASSPORT HEALTH PLAN (PA-111378)
837 I Data Field Requirements
====================== 837 I ====================== BILLING TAXONOMY LOOP ======================
LOOP ID
Loop Name
Segment Name
PRV01 Qualifier
PRV02 Qualifier
PRV03 Value
2000A
Billing/Pay-To Provider Specialty Information
PRV
BI
PT
ZZ
= Taxonomy
NM101 Qualifier
NM108 Qualifier
NM109 Value
85
24
34
= TAX ID
= SSN
XX
= NPI
====================== 837 I ====================== BILLING PROVIDER LOOP ======================
LOOP ID
2010AA
Loop Name
Billing Provider
Segment Name
NM1
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
REF02 Value
2010AA
Billing Provider Secondary Identification
REF
SY
EI
= SSN
= TAX ID
1D
= MAID
====================== 837 I ====================== PAY TO PROVIDER LOOP ======================
LOOP ID
2010AB
LOOP ID
Loop Name
Pay-To-Provider
Loop Name
Segment Name
NM1
Segment Name
NM109 Value
NM101 Qualifier
NM108 Qualifier
87
24
34
= TAX ID
= SSN
XX
= NPI
REF02 Value
REF01 Qualifier
SY
2010AB
Pay-To-Provider Secondary Identification
REF
EI
1D
====================== 837 I ====================== ATTENDING PROVIDER LOOP ======================
LOOP ID
2310A
Loop Name
Attending Physician
Segment Name
NM1
NM109 Value
NM101 Qualifier
NM108 Qualifier
82
24
34
= TAX ID
= SSN
XX
= NPI
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
REF02 Value
2310A
Attending Physician Secondary Identification
REF
N5
= Facets ID
====================== 837 I ====================== SERVICE FACILITY LOOP ======================
LOOP ID
2310E
Loop Name
Service Facility Location
Segment Name
NM1
NM109 Value
NM101 Qualifier
NM108 Qualifier
82
24
34
= TAX ID
= SSN
XX
= NPI
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
REF02 Value
2310E
Service Facility Location Secondary Identification
REF
N5
= Facets ID
Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the
NPI, the application process, or reporting your NPIs to us, please contact your Provider Relations representative.
Sample INPATIENT UB-04 Form
4
3a PAT.
CNTL #
b. MED.
REC. #
2
__
1
6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
b
STATEMENT COVERS PERIOD
FROM
THR OUGH
11 SEX
31
OCCURRENCE
CODE
DATE
12
DATE
c
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
32
OCCURRENCE
CODE
DATE
33
OCCURRENCE
DATE
CODE
18
7
a
b
10 BIRTHDATE
TYPE
OF BILL
19
20
34
OCCURRENCE
CODE
DATE
CONDITION CODES
22
23
24
21
35
CODE
25
26
OCCURRENCE SPAN
FROM
THROUGH
27
36
CODE
d
28
e
29 ACDT 30
STATE
OCCURRENCE SPAN
FROM
THROUGH
37
a
a
b
b
38
39
CODE
VALUE CODES
AMOUNT
40
CODE
VALUE CODES
AMOUNT
41
CODE
VALUE CODES
AMOUNT
a
b
c
d
42 REV. CD.
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE
23
OF
CREATION DATE
50 PAYER NAME
52 REL.
INFO
51 HEALTH PLAN ID
53 ASG.
BEN.
TOTALS
54 PRIOR PAYMENTS
23
55 EST. AMOUNT DUE
56 NPI
A
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED’S NAME
59 P. REL 60 INSURED’S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
A
B
B
C
C
66
DX
67
I
A
J
REASON DX
69 ADMIT
70 PATIENT
DX
74
PRINCIPAL PROCEDURE
a.
CODE
DATE
B
K
a
b
OTHER PROCEDURE
CODE
DATE
C
L
D
M
c
E
N
CODE
71 PPS
ECI
72
b.
OTHER PROCEDURE
CODE
DATE
e.
OTHER PROCEDURE
75
F
O
a
76 ATTENDING
G
P
b
NPI
LAST
c.
PR
CODE
DATE
OTHER
OCEDURE
d.
OTHER PR
CODE
DATE
OCEDURE
CODE
DATE
77 OPERATING
QUAL
FIRST
NPI
QUAL
81CC
a
80 REMARKS
UB-04 CMS-1450
QUAL
FIRST
NPI
LAST
78 OTHER
H
Q
c
APPROVED OMB NO.
b
LAST
c
79 OTHER
d
LAST
FIRST
NPI
.
Green = Required/Preferred
Black = situational/Required if applicable/Reserved
© 2012 PASSPORT HEALTH PLAN (PA-111378)
QUAL
FIRST
68
73
Sample OUTPATIENT UB-04 Form
4
3a PAT.
CNTL #
b. MED.
REC. #
2
__
1
6
5 FED. TAX NO.
8 PATIENT NAME
9 PATIENT ADDRESS
a
b
STATEMENT COVERS PERIOD
FROM
THR OUGH
11 SEX
31
OCCURRENCE
CODE
DATE
12
DATE
32
OCCURRENCE
CODE
DATE
c
ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT
33
OCCURRENCE
DATE
CODE
18
7
a
b
10 BIRTHDATE
TYPE
OF BILL
19
20
34
OCCURRENCE
CODE
DATE
CONDITION CODES
22
23
24
21
35
CODE
25
26
OCCURRENCE SPAN
THROUGH
FROM
27
36
CODE
d
28
e
29 ACDT 30
STATE
OCCURRENCE SPAN
THROUGH
FROM
37
a
a
b
b
38
39
CODE
VALUE CODES
AMOUNT
40
CODE
VALUE CODES
AMOUNT
41
CODE
VALUE CODES
AMOUNT
a
b
c
d
42 REV. CD.
44 HCPCS / RATE / HIPPS CODE
43 DESCRIPTION
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
PAGE
23
OF
CREATION DATE
50 PAYER NAME
51 HEALTH PLAN ID
52 REL.
53 ASG.
INFO
BEN.
TOTALS
54 PRIOR PAYMENTS
23
55 EST. AMOUNT DUE
56 NPI
A
57
A
B
OTHER
B
C
PRV ID
C
58 INSURED’S NAME
59 P. REL 60 INSURED’S UNIQUE ID
61 GROUP NAME
62 INSURANCE GROUP NO.
A
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 DOCUMENT CONTROL NUMBER
65 EMPLOYER NAME
A
A
B
B
C
C
67
I
66
DX
X
69 ADMIT
D
A
J
B
K
a
REASON DX
70 PATIENT
b
C
L
c
D
M
E
N
CODE
71 PPS
74
PRINCIPAL PROCEDURE
CODE
DATE
a.
OTHER PROCEDURE
CODE
DATE
b.
OTHER PROCEDURE
CODE
DATE
c.
OTHER PROCEDURE
CODE
DATE
d.
OTHER PROCEDURE
CODE
DATE
e.
OTHER PROCEDURE
CODE
DATE
ECI
72
75
F
O
a
76 ATTENDING
G
P
b
NPI
LAST
77 OPERATING
81CC
a
UB-04 CMS-1450
APPROVED OMB NO.
78 OTHER
b
LAST
c
79 OTHER
d
LAST
NUBC
™
National Uniform
Billing Committee
68
73
QUAL
FIRST
NPI
LAST
80 REMARKS
H
Q
c
QUAL
FIRST
NPI
QUAL
FIRST
NPI
QUAL
FIRST
THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
LIC9213257
Green = Required/Preferred
Black = situational/Required if applicable/Reserved
© 2012 PASSPORT HEALTH PLAN (PA-111378)
Revised 1500 Claim Form
and NPI instructions
The National Uniform Claim Committee (NUCC) released a revised 1500 Claim Form, which is commonly referred to as
the CMS-1500. The revised CMS-1500 (08/05) replaced the former CMS-1500 (12/90). Use of the revised form was
required as of April 1, 2007. A sample form is attached for your review.
The 1500 Claim Form and NPI
Revisions to the 1500 Claim Form include several fields that accommodate the use of your National Provider Identifier
(NPI).
Though the revised form accommodates NPI, you must continue to report current plan assigned provider identification
numbers in the appropriate shaded areas of the form (17a, 24J, 32b, and 33b). Current provider identification numbers must
be preceded by a two-character qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If
you do not currently bill electronically, please use the following ID: N5
Important Revisions to the 1500 Claim Form
The revised 1500 Claim Form expands the length of some existing fields, incorporates several new fields, and accommodates
use of your NPI. Some important fields that have been revised or added are listed below [new fields are highlighted]:
Please Note: In addition to the revised fields, we will now require you to populate Field 19 with the ZZ qualifier ID and the
Billing Provider’s Primary Taxonomy Code (Example: ZZ207LP2900X).
Field 19
Field must be populated with the ZZ qualifier ID and the Billing Provider’s Primary Taxonomy Code (Example: ZZ207LP2900X)
Field 21, parts 1-4
Diagnosis code fields have been updated to allow four characters of information following the pre-filled decimal point.
Field 24
The shaded area extending from fields 24A through 24G will accommodate supplemental information, such as the narrative description of unspecified codes.
Field 24C
“EMG” (previously “Type of Service”). EMG was previously Field 24I.
Field 24D
“Procedures, Services, or Supplies” has been extended by three characters; you may now record up to four modifiers on the same line.
Field 24E
Now titled “Diagnosis Pointer” (previously “Diagnosis Code”); size decreased by three characters.
Field 24H
“EPSDT Family Plan” decreased in size by one character.
Field 24I
“ID. Qual” (previously “EMG”). The shaded area of this field (part 1) allows you to identify the two-character qualifier ID of the Rendering Provider (Example:
N5). The unshaded area (part 2) is pre-filled with “NPI.” Field is required.
Field 24J
“Rendering Provider ID #” (previously “COB”). The shaded area of this field (part 1) allows you to submit the current provider identification number of the
Rendering Provider that coincides with the two-character qualifier ID reported in the shaded area of 24I (part 1). The unshaded area (part 2) accommodates the
Rendering Provider NPI. Both areas of this field are required.
Field 33a
Billing Provider NPI (previously “PIN#”).
Field 33b
Billing Provider two-character qualifier ID and current provider identification number (Example: N51234567001) (previously “GRP#) Field is required.
For additional information about the 1500 Claim Form, please visit the NUCC’s website at www.nucc.org.The NUCC offers a
helpful Instruction Manual titled 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version, which
features walkthroughs of each field of the 1500 Claim Form. You can currently access the guide in PDF form at the following
location: http://www.nucc.org/images/stories/PDF/claim_form_manual_v1-3_7-06.pdf
© 2012 PASSPORT HEALTH PLAN (PA-111379)
We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan
strongly recommends the continued use of plan identification numbers in addition to NPI.
837 P Data Field Requirements
====================== 837 P ====================== BILLING TAXONOMY LOOP ======================
LOOP ID
2000A
Loop Name
Billing/Pay-To Provider Specialty Information
Segment Name
PRV01 Qualifier
PRV02 Qualifier
PRV03 Value
PRV
BI
PT
ZZ
= Taxonomy
NM109 Value
= TAX ID
====================== 837 P ====================== BILLING PROVIDER LOOP ======================
LOOP ID
Loop Name
Segment Name
NM101 Qualifier
NM108 Qualifier
24
2010AA
Billing Provider
NM1
85
34
XX
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
2010AA
Billing Provider Secondary Identification
REF
SY
EI
= SSN
= TAX ID
1D
= MAID
= SSN
= NPI
REF02 Value
====================== 837 P ====================== PAY TO PROVIDER LOOP ======================
LOOP ID
Loop Name
Segment Name
NM101 Qualifier
NM108 Qualifier
24
NM109 Value
= TAX ID
2010AB
Pay-To-Provider
NM1
87
34
XX
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
2010AB
Pay-To-Provider Secondary Identification
REF
SY
EI
= SSN
= TAX ID
1D
= MAID
= SSN
= NPI
REF02 Value
====================== 837 P ====================== RENDERING PROVIDER LOOP ======================
LOOP ID
Loop Name
Segment Name
NM101 Qualifier
NM108 Qualifier
24
2310B
Rendering Provider
NM1
82
34
XX
LOOP ID
Loop Name
Segment Name
REF01 Qualifier
USED IN LOB
2310B
Rendering Provider Secondary Identification
REF
N5
NM109 Value
= TAX ID
= SSN
= NPI
REF02 Value
= Facets ID
====================== 837 P ====================== RENDERING PROVIDER TAXONOMY LOOP ======================
LOOP ID
2310B
Loop Name
Rendering Provider Specialty Information
Segment Name
PRV
PRV01 Qualifier
PE
PRV02 Qualifier
ZZ
PRV03 Value
= Taxonomy
NM109 Value
====================== 837 P ====================== SERVICE FACILITY LOOP ======================
LOOP ID
Loop Name
Segment Name
NM101 Qualifier
NM108 Qualifier
2310D
Service Facility Location
NM1
82
24
34
= TAX ID
= SSN
XX
= NPI
LOOP ID
Loop Name
Segment Name
2310D
Service Facility Location Secondary Identification
REF
REF01 Qualifier
77
REF02 Value
= Service Location
FA
LI
= Facility
= Independent Lab
TL
= Testing Laboratory
Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the
NPI, the application process, or repor ting your NPIs to us, please contact your Provider Relations representative.
REVISED
ABC1234567800
Doe, John B.
03 20
Doe, John B.
71
1234 Main Street
1234 Main Street
Anytown
Anytown
NJ
08999
856 555-2222
15974
72431
21
NJ
08999
856 555-2222
Doe, Mary
10
Member I.D. Number
(No Suffix for CompSelect®/
Comprehensive Major
Medical [CMM])
03 20
71
Watch Repair, Inc.
70
self-employed
AmeriHealth PPO
HMO, Inc.
Referring Provider’s
Current Provider ID
Referring Provider’s
two-character qualifier ID
10 28
06
G2 0123456789
999999999
Josephine Smith, M.D.
ZZ207LP2900X
ZZ qualifier ID and Billing Provider’s
Primary Taxonomy Code
11
01
06
11 04
06
Referring Provider’s NPI
401
251
8
123456789
11 02 06
11
02 06 21
11 03 06
11 03
06 21
6
99205
6
20600
25
Referral/Preauthorization Number
1
$50 00
1
2
$250 00
1
N5 1234567000
8888888888
Two-character qualifier ID
of the Rendering Provider
Modifier (if applicable)
Provider’s
Federal
Tax ID #
(Billing Entity)
Service
Facility
NPI
22-1234567
Richard B. Smith, M.D.
11/5/06
Service Facility
two-character
qualifier and
Current Provider
ID number
ABC Hospital
123 Street
Anytown, NJ 08999
0000001234
G21234567002
Green items are required.
Blue items are required when applicable to the patient’s condition/situation.
Black items are optional.
100
Billing
Provider
NPI
00
0 00
100 00
856 555-5555
ABC Medical Group
8 North American Street
Anytown, NJ 08999
2222222222
Billing Provider
two-character
qualifier ID and
current provider
identification number
N51234567001
Indicates new field and/or requirement.
Indicates field required for processing.
Third Party Liability Lead Form
Provider Name:
Provider Phone Number:
Provider ID Number:
Member Name:
Member Phone Number:
Member ID Number:
Address:
Date of Birth:
From Date of Service:
To Date of Service:
Date of Admission:
Date of Discharge:
Insurance Carrier Name:
Address:
Policy Number:
Start Date:
End Date:
Date Claim was Filed with Insurance Carrier:
Please check the one that applies:
*
No Response in Over 120 Days
*
Policy Termination Date:
*
Other: (Please explain in the space provided below)
Contact Name:
Contact Telephone Number:
Signature:
Date:
Mail with claim to:
Passport Health Plan • P.O. Box 7114 • London, KY 40742
Provider Information Change Form
You have requested a change to your Passport Health Plan provider information. To verify the change, please
complete the information below and send to:
FAX: (502) 585-6060
-OR-
MAIL: Passport Health Plan
ATTN: Provider Relations
5100 Commerce Crossings Drive, Louisville, KY 40229
Plan ID #:
NPI:
Medicaid Individual #:
Group Medicaid ID #:
PRACTICE NAME
OLD:
NEW:
TAX ID NUMBER
TELEPHONE NUMBER
OLD:
OLD:
NEW:
NEW:
FAX NUMBER
E-MAIL ADDRESS
OLD:
OLD:
NEW:
NEW:
REMIT ADDRESS
SITE ADDRESS
OLD:
OLD:
NEW:
NEW:
1099 / TAX ADDRESS (IF DIFFERENT FROM REMIT)
q USE REMIT ADDRESS
OLD:
NEW:
Effective Date of Change:
Signature of Person Providing Information
Telephone #
Date
© 2013 Passport Health Plan (PMN-13111)
MAIL TO:
PASSPORT HEALTH PLAN
Attn: Provider Enrollment
5100 Commerce Crossings Drive
Louisville, KY 40229
(502) 588-8578
Fax: (502) 585-7987
[email protected]
Adding a Practitioner to a Participating Group
(use one form per group attachment)
FACILITY BASED PRACTITIONER?
YES
NO
(Does this practitioner provide services strictly in an inpatient or ER/facility setting?)
Please add
Name
,
Title
to the group indicated below, effective
Individual NPI #:
Individual KY Medicaid #:
Date
Taxonomy Code:
nd
(The KY Medicaid # must be active. See Requirements on 2 page.)
MAP Forms Directly Sent to Kentucky Medicaid:
MAP 811
Medicaid MAP 347
Medicare #:
Social Security #:
Practitioner’s Specialty:
Date of Birth:
CAQH #:
(Include any Subspecialty)
Provider Group Name:
Add Practitioner to:
• Primary location only:
• All locations:
• Other:
Grp NPI #:
Passport group #:
YES
NO
YES
NO
Attach a list of specific locations
Grp KY MAID #:
Grp Taxonomy Code:
Tax ID #:
If the group is new, please complete and submit a “New Group Set-Up Form” and indicate pending for the Passport group number.
Page 1 of 2
PANEL LIMITATIONS (If Applicable)
Please confirm the Panel Limitations that should be placed on this practitioner. Please remember that any
limitations should be consistent with what has already been established for your group:
PANEL LIMITATIONS:
Min
GROUP PANEL STATUS:
Max
Open
Male Only
Female Only
Both
Closed
CURRENT AFFILIATIONS (If Applicable)
Please indicate from which provider group(s) the practitioner should be terminated upon joining your
group.
Group Name:
Group Tax ID #:
Group Name:
Group Tax ID #:
REQUIREMENTS
To expedite your request, please include:
•
A signed W-9 form with the appropriate tax information.
•
A completed KY Medicaid MAP 811 form, if applicable.
•
A completed KY Medicaid MAP 347 form which will connect the practitioner to your Group KY
Medicaid ID #, if applicable.
•
A completed MCO KY MAP 347 form which will connect the practitioner to Passport Health Plan.
•
KY Medicaid MAP forms are available at http://chfs.ky.gov/dms/provEnr/Provider+Types.htm
•
Plan notices will be sent electronically via POIS (Passport Online Information Service) and posted on
the Plan’s website.
Name of person submitting this request
Telephone Number
Date
Email Address:
Any questions regarding this form, please call the Provider Enrollment department at (502) 588-8578 or you may email us
at [email protected].
Page 2 of 2
REGISTRATION FOR NON-PARTICIPATING PROVIDERS
A. CONTACT INFORMATION
Contact Name:
Phone:
Date:
Fax:
Email address:
B. PRACTICE INFORMATION
Last Name
Specialty:
First Name:
NPI Number:
MI:
Title/Degree:
Taxonomy Code:
Specialty:
NPI Number:
Taxonomy Code:
Physical Address:
City:
Phone:
*Kentucky Medicaid Number:
State:
Fax:
Group/Facility Name:
Zip:
County:
SSN:
*Required for payment of services rendered*
State License Number:
State:
Medicare Number:
C. BILLING INFORMATION:
Tax Identification Number:
Tax Name:
Billing Contact:
Billing Address:
City:
Phone:
State:
Zip:
County:
Please fax completed form along with a W-9 to: Provider Maintenance (484) 496-7685
or email to [email protected]
Upon receipt of completed form, a provider ID number will be assigned and returned to you via fax. Passport Health Plan claims will not be processed without an
active Kentucky Medicaid Number. Questions? Please contact Provider Services at (800) 578-0775.
To apply for a Kentucky Medicaid Number, please visit: http://chfs.ky.gov/dms/provenr/application+information.htm
IMPORTANT INFORMATION, PLEASE READ
It is important that you review the Plan’s Member Rights and Responsibilities. To review this document as well as any other provider communications and/or the
Provider Manual, please visit www.passporthealthplan.com. If you are unable to access this information online, please contact Provider Services at (800) 578-0775 to
obtain a printed copy.
OFFICE USE ONLY – PROVIDER ID NUMBER ASSIGNMENT
Date Reviewed:
Assigned PM Rep:
Plan ID #:
Effective Date:
© 2012 PASSPoRT HEALTH PLAN (PNM-12145)
LAST REvISIoN: 04/13/2012
REGISTRATION OF LOCUM TENENS PHYSICIAN
The maximum time may not exceed sixty (60) continuous days.
I certify and attest, by my signature below, under penalty of perjury, that the information contained herein is true and faithful.
This physician is the TEMPORARY REPLACEMENT who applies and will
actually perform the services on a short term basis.
This physician will be ABSENT during the billing and will not perform the
services.
Applicant (Locum Tenens Provider) Full Name
Regular Physician Full Name
Permanent Address 1 (May not use a PO Box)
Office Address 1 (May not use a PO Box)
Address 2
Address 2
City, State, Zip
City, State, Zip
Specific Duration – Not to exceed 60 consecutive days:
Social Security Number
NPI #
Exp. date
DEA #
Exp. date
Kentucky Medical License Number
to
MM/DD/YY
NPI #
MM/DD/YY
Exp. date
DEA #
Exp. date
Is a CONTRACT AGENCY involved in this placement?
Passport Health Plan Provider ID Number
CHECK OFF REQUIRED ATTACHMENTS:
_ NO
_ YES – If yes, please supply name and address of agency: Address
_ Copy of valid physician license, DEA certificate, and a copy of any
applicable board certification for the locum tenens physician
_ PROOF of malpractice insurance coverage for the locum tenens physician for
period of physician substitution
1
The Q-6 Modifier must be used for billing services performed by a locum tenens
physician.
Address 2
City, State, Zip
To my knowledge, I attest that I am not subject to any of the following:
•
A pending criminal or civil investigation regarding the provision of health care
services;
•
Formal disciplinary sanctions from any board or professional association
pursuant to KRS311.565; and/or
•
A federal or state sanction or penalty that would prevent me from participation in Medicare or Medicaid.
The holder of the valid provider number is required to bill the services of any locum
tenens physician by utilizing the Health Care Procedure Coding System with the
procedure modified code Q-6 in item 24d of form HCFA-1500 for every procedure
performed by the locum tenens physician. Failure to bill cor- rectly may be
considered a violation of the terms of the Provider Agreement.
Signature (regular physician)
Date
RETURN THIS FORM TO:
FAX: (502) 585-6060
MAIL: Passport Health Plan
Attn: Provider Network Management
5100 Commerce Crossings Drive
Louisville, KY 40229
© 2012 PASSPORT HEALTH PLAN (PNM-12156)
Form Approved: OMB No. 0937-0166
Expiration date: 11/30/2009
CONSENT FOR STERILIZATION
NOTICE:
YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING
OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
STATEMENT OF PERSON OBTAINING CONSENT
CONSENT TO STERILIZATION
I have asked for and received information about sterilization from
. When I first asked
doctor or clinic
for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care
or treatment. I will not lose any help or benefits from programs receiving
Federal Funds, such as A.F.D.C. or Medicaid that I am now getting or for
which I may become eligible.
I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED
PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO
NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER
CHILDREN.
I was told about those temporary methods of birth control that are
available and could be provided to me which will allow me to bear or father
a child in the future. I have rejected these alternatives and chosen to be
sterilized.
I understand that I will be sterilized by an operation known as a
. The discomforts, risks
and benefits associated with the operation have been explained to me. All
my questions have been answered to my satisfaction.
I understand that the operation will not be done until at least thirty days
after I sign this form. I understand that I can change my mind at any time
and that my decision at any time not to be sterilized will not result in the
withholding of any benefits or medical services provided by federally
funded programs.
I am at least 21 years of age and was born on:
Before
signed the
name of individual
consent form, I explained to him/her the nature of sterilization operation
, the fact that it is
intended to be a final and irreversible procedure and the discomforts, risks
and benefits associated with it.
I counseled the individual to be sterilized that alternative methods of
birth control are available which are temporary. I explained that sterilization is different because it is permanent.
I informed the individual to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services or
any benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be sterilized is
at least 21 years old and appears mentally competent. He/She knowingly
and voluntarily requested to be sterilized and appears to understand the
nature and consequences of the procedure.
Signature of person obtaining consent
Facility
Address
PHYSICIAN’S STATEMENT
Shortly before I performed a sterilization operation upon
on
Month Day Year
I,
, hereby consent of my own
name of individual
, the fact that it is
doctor
by a method called
. My
consent expires 180 days from the date of my signature below.
I also consent to the release of this form and other medical records
about the operation to:
Representatives of the Department of Health and Human Services,
or Employees of programs or projects funded by the Department
but only for determining if Federal laws were observed.
I have received a copy of this form.
Date:
Signature
Month Day Year
You are requested to supply the following information, but it is not required: (Ethnicity and Race Designation) (please check)
Race (mark one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
INTERPRETER’S STATEMENT
If an interpreter is provided to assist the individual to be sterilized:
I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also
read
him/her
the
consent
form
in
language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
Interpreter’s Signature
HHS-687 (11/2006)
.
date of sterilization
I explained to him/her the nature of the sterilization operation
free will to be sterilized by
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Date
Date
specify type of operation
intended to be a final and irreversible procedure and the discomforts, risks
and benefits associated with it.
I counseled the individual to be sterilized that alternative methods of
birth control are available which are temporary. I explained that sterilization is different because it is permanent.
I informed the individual to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services or
benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be sterilized is
at least 21 years old and appears mentally competent. He/She knowingly
and voluntarily requested to be sterilized and appeared to understand the
nature and consequences of the procedure.
(Instructions for use of alternative final paragraphs: Use the first
paragraph below except in the case of premature delivery or emergency
abdominal surgery where the sterilization is performed less than 30 days
after the date of the individual’s signature on the consent form. In those
cases, the second paragraph below must be used. Cross out the paragraph which is not used.)
(1) At least thirty days have passed between the date of the individual’s
signature on this consent form and the date the sterilization was performed.
(2) This sterilization was performed less than 30 days but more than
72 hours after the date of the individual’s signature on this consent form
because of the following circumstances (check applicable box and fill in
information requested):
Premature delivery
Individual’s expected date of delivery:
Emergency abdominal surgery (describe circumstances) :
Physician’s Signature
Date
PSC Graphics (301) 443-1090
EF
PAPERWORK REDUCTION ACT STATEMENT
A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of
information will vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer,
ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201.
Respondents should be informed that the collection of information requested on this form is authorized by
42 CFR part 50, subpart B, relating to the sterilization of persons in federally assisted public health programs.
The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and consequences, and to assure the voluntary and informed consent of all
persons undergoing sterilization procedures in federally assisted public health programs. Although not required,
respondents are requested to supply information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization
procedures funded through federally assisted public health programs.
All information as to personal facts and circumstances obtained through this form will be held confidential,
and not disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations.
HHS-687 (11/2006)
MAP-251
Commonwealth of Kentucky
CABINET FOR HEALTH AND FAMILY SERVICES
Department for Medicaid Services
(Rev. 10/2010)
HYSTERECTOMY CONSENT FORM
Medicaid Recipient Name
Medicaid ID #
Physician’s Name
Date of Hysterectomy
>>>>COMPLETE ONLY ONE OF THE REMAINING SECTIONS & COMPLETE ALL BLANKS IN SECTION<<<<
SECTION A:
COMPLETE THIS SECTION FOR RECIPIENT WHO ACKNOWLEDGES RECIEPT
PRIOR TO HYSTERECTOMY
I HAVE BEEN INFORMED ORALLY AND IN WRITING THAT A HYSTERECTOMY WILL RENDER ME PERMANENTLY
INCAPABLE OF REPRODUCING.
PATIENT’S SIGNATURE
DATE
WITNESS’ SIGNATURE
DATE
SECTION B:
COMPLETE THIS SECTION WHEN ANY OF THE EXCEPTIONS LISTED BELOW IS
APPLICABLE. CHECK ONLY ONE SELECTION.
I certify that before I performed the hysterectomy procedure on the recipient listed below:
1 [ ] I informed her that this operation would make her permanently incapable of reproducing. (This certification for
retroactively eligible recipient only – a copy of the Medicaid card which covers the date of the hysterectomy, or
a copy of the retroactive approval notice, must accompany this form before the reimbursement can be made.)
2 [ ] She was already sterile due to
CAUSE OF STERLITY
3 [ ] She had a hysterectomy performed because of a life-threatening situation due to
DESCRIBE EMERGENCY SITUATION
And the information concerning sterility could not be given prior to the hysterectomy. Life-threatening should indicate that
the patient is unable to respond to the information pertaining to the acknowledgement agreement.
PHYSICIAN’S SIGNATURE
SECTION C:
DATE
COMPLETE THIS SECTION FOR MENTALLY-INCOMPETENT RECIPIENT ONLY
I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy’s being performed, that if a hysterectomy
is performed on the above recipient, it will render her permanently incapable of reproducing.
WITNESS’ SIGNATURE
DATE
PATIENT REPRESENTATIVE SIGNATURE
PHYSICIAN’S STATEMENT
I affirm that the hysterectomy I performed on the above recipient was medically necessary due to
DATE
REASON FOR HYSTERECTOMY
And was not done for sterilization purposes, and that to the best of my knowledge the individual on whom the hysterectomy was
performed is mentally incompetent. Before I performed the hysterectomy on her I counseled her representative, orally and in writing
that the hysterectomy would render that individual permanently incapable of reproducing; and the individual’s representative has
signed a written acknowledgement of receipt of the foregoing information.
PHYSICIAN’S SIGNATURE
DATE
CERTIFICATION FORM FOR INDUCED ABORTION
OR INDUCED MISCARRIAGE
I,
, certify that on the basis of
(Physician’s Name)
my professional judgment, the life of
(Patient’s Name)
of
(MAID #)
(Patient’s Address)
(Please check appropriate box)
Suffered from a
physical disorder,
physical injury, and/or
physical illness
that placed her in danger of death if the fetus were carried to term. I further certify that the
following procedure(s) were medically necessary to induce an abortion or miscarriage.
(Please indicate date and the procedure that was performed)
Physician’s Signature
Name of Physician
License Number
Date
MAP-235 (2/00)
MAP-236 (8/78)
CERTIFICATION FORM FOR INDUCED PREMATURE BIRTH
I,
, certify that on the basis of
(Physician’s Name)
my professional judgment, it was necessary to perform the following procedure on
to induce premature birth intended to produce a live viable child.
This Procedure was necessary for the health of
(MAID #)
(Date)
(Procedure)
(Name of Mother)
of
(Address)
and/or her unborn child.
Physician’s Signature
Name of Physician
License Number
Date
Referral Form
Member’s Name
Member’s Passport Health Plan ID Number
PCP Group Name
Member’s Date of Birth
PCP Group ID Number
Passport Health Plan Members and Providers Please Note:
•
•
•
•
•
•
This referral form may only be used for referral from a PCP to a participating specialist and/or participating Urgent Care
Center. Referrals to non-participating providers require prior authorization.
Passport Health Plan will pay for only those services specifically noted and requested by the PCP and covered under the
Benefit plan.
Services rendered without a referral will not be covered by Passport Health Plan.
Specialists cannot refer to other specialists. Additional specialty services must be coordinated by the PCP.
Referral by the PCP does not guarantee payment.
Please refer to the Provider Manual for information on services that do not require a referral.
This member is being referred to: (the following
information is required.)
(Please use group or facility name/ID unless provider is a sole practitioner.)
Provider Name
Specialty Type
Street Address
City
Diagnosis and ICD-9 Code (Please provide all available diagnoses)
Is this referral related to an EPSDT screen?
_ Yes
Passport Health Plan Provider ID Number
Zip Code
_ No
PCP must check ONE of the following:
_ Referral for CONSULTATION, DIAGNOSTIC STUDIES and TREATMENT.
Good for unlimited visits within: q 3 months, q 6 months, q 9 months, q 12 months
_ Referral for CONSULTATION, DIAGNOSTIC STUDIES and TREATMENT.
Number of visits approved: q 1 visit, q 2 visits, q 3 visits, q 4 visits, q 5 visits, q 6 visits
_ Referral for CONSULTATION and DIAGNOSTIC STUDIES.
Number of visits approved: q 1 visit, q 2 visits, q 3 visits, q 4 visits, q 5 visits, q 6 visits
_ Referral for CONSULTATION only (second opinion). PCP must forward all lab/x-rays, etc.
_ Unlimited referrals for cancer diagnosis and transplants.
_ Referral for urgent care services at an Urgent Care Center administered on
.
(Must be issued within five [5] business days of the service.)
Authorizing Signature
Date
X
If you have any questions, please call Provider Services at (800) 578-0775.
Send a copy of this completed form to:
Passport Health Plan
PO Box 7114
London, KY 40742
PLEASE PROVIDE A COPY OF THIS REFERRAL TO THE SPECIALIST AND MEMBER.
© 2012 PASSPORT HEALTH PLAN (RR-12155)
19.6.2
Date:
Auth #:
Fax to: 502-585-8204 PHP R.N. Initials:
Attn: PHP Home Health
HOME HEALTH AUTHORIZATION FORM
MEMBER INFORMATION
AUTHORIZATION NUMBER ____________________________________
MEMBER’S NAME ___________________________________________
PASSPORT ID ____________________________
MEMBER’S DOB ____________________________
PROVIDER INFORMATION
ORDERING MD _____________________________________
PROVDER ID ___________________________ PROVIDER CONTACT ________________________________
REQUESTING PROVIDER _____________________________________________________________________
PROVIDER PHONE____________________________ PROVIDER FAX _________________________________
CLINICAL INFORMATION
INITIAL REQUEST? YES NO
IF NO: NUMBER OF VISITS TO DATE _______ DATE OF LAST VISIT__________
DIAGNOSIS _______________________________________________________________________________
DIAGNOSIS ICD 9 CODE _____________________________________________________________________
DISCIPLINE AND NUMBER OF VISITS FOR EACH: _________________________________________________
Discipline
# visits
RN
HH
PT
DATES OF SERVICE: FROM _____________________
OT
ST
TO _________________________
CLINICAL SUMMARY: (INCLUDE WOUND MEASUREMENTS AND LABS IF APPLICABLE)
WHY ARE VISITS REQUIRED?
SW
RD
20.5.3
Date:
Attn:
Auth #:
PASSPORTPASSPORT DME
Fax to: 502-585-7990
DME AUTHORIZATION FORM
MEMBER INFORMATION
AUTHORIZATION NUMBER
MEMBER’S NAME
PASSPORT ID
MEMBER’S DOB
PROVIDER INFORMATION
NAME
PROVIDER ID
ADDRESS
PHONE
FAX
PASSPORT DME PROVIDER
CONTACT NAME
MD INFORMATION
DME PROVIDER INFORMATION
N/A FOR MD
N/A FOR MD
N/A FOR MD
DME INFORMATION
Rental
Purchase
Yes No
Yes No
Date Range for rental:
Date for purchase:
Diagnosis Code(s):
Diagnosis Description:
LINE
#
DESCRIPTION
HCPCS
QUANTITY
BILLABLE CHARGES
1
2
3
4
5
6
7
8
9
10
Please attach documentation on the patient’s abilities and limitations as they relate to the need for the equipment.
Call 1-800-578-0636 ext. 7310 with any questions or for further information.
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
20.5.4
Date:
Auth #:
Fax to: 502-585-8204
PASSPORT R.N.
Initials:
Attn:
PASSPORT Home
Health
HOME INFUSION AUTHORIZATION FORM
MEMBER INFORMATION
AUTHORIZATION NUMBER
MEMBER’S NAME
PASSPORT ID
MEMBER’S DOB
IF MEDICARE PRIMARY, PROVIDE REASON AS TO UABLE TO BILL MEDICARE:
PROVIDER INFORMATION
ORDERING MD
PROVDER ID
PROVIDER CONTACT
REQUESTING PROVIDER
PROVIDER PHONE
PROVIDER FAX
CLINICAL INFORMATION
INITIAL REQUEST?
YES
NO
IF NO: NUMBER OF VISITS TO DATE
DATE OF LAST VISIT
DIAGNOSIS
DIAGNOSIS
ICD
9
CODE
INFUSION THERAPY REQUESTED WITH DATES OF SERVICE
CLINICAL SUMMARY:
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
20.5.5
Pain Management Medical Necessity Review Check List
Patient Name
Passport ID
1. Procedure requested
Number and frequency
2. Diagnosis
3. Number of previous injections (if known)
4. Relative history & physical (including ht & wt of member) – signs and symptoms
Date symptoms began:
5. Radiologic studies (date and results)
6. Functional/physical disability – Including extent of any change on a 1-10 scale where
applicable
Symptoms: (0 = no pain, 10 = extreme pain)
Impairment (0 = no impairment, 3 = severe
impairment)
Personal Care
Driving
Pain
Working
Sleep
Headache
Difficulty Lifting
Recreation
Other
7. Medication(s) – address duration
Name of medication(s) & dose/how long
8. Previous interventions (PT, Chiro, (address response)
Type/site of injection/when
Response
Relief
Yes No
Yes No
Yes No
Yes No
9. Treatment plan with all relevant CPT codes
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
Provider Name:
Date of service:
(Please print)
Place of Service (Passport provider ID if known):
Provider Phone & Fax
Your Name:
Passport Fax #: 502-585-7989
Your Authorization #:
Attach additional sheets if needed
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
20.5.6
Date:
Fax to: 502-585-7989
Attn:
PASSPORT Home
Health
Auth #:
PASSPORT R.N.
REQUEST CAN BE SENT VIA SECURE EMAIL TO: [email protected]
CHECK MARK FOR DATE OF SERVICE CHANGE - COMPLETE ASTERISKS ** ONLY
COSMETIC PRIOR AUTHORIZATION FORM
Please complete this form and attach to all cosmetic requests
MEMBER INFORMATION
MEMBER’S NAME **
PASSPORT ID **
MEMBER’S DOB
PROVIDER INFORMATION
ORDERING MD
CONTACT PHONE # **
PROVIDER / MD CONTACT **
PROVIDER MD FAX **
INPATIENT
OUTPATIENT
23 HOUR OBSERVATION
FACILITY
CLINICAL INFORMATION
DATE OF SERVICE **
DIAGNOSIS
CPT CODE WITH DESCRIPTION
PREVIOUS ASSOCIATED SURGERIES
CLINICAL SUMMARY:
If photos are required, request must be mailed to
Passport Health Plan – Attention Cosmetics
5100 Commerce Crossing
Louisville, Ky. 40229
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
20.5.7
INITIAL THERAPY AUTHORIZATION FORM
PATIENT NAME
DOB
PASSPORT ID#
ORDERING MD
DIAGNOSIS
PT
START DATE
TIMES/WEEK
# OF WEEKS
OT
START DATE
TIMES/WEEK
#OF WEEKS
ST
START DATE
TIMES/WEEK
#OF WEEKS
INJURY/ACCIDENT/DATES:
TPL Information:
Note any therapy provided by 1st Steps or the school system, type and frequency.
Note any previous therapy received, type, frequency, dates and provider.
Requesting Provider
Provider ID#
Contact Person
Phone #
PROPRIETARY AND CONFIDENTIAL
Fax #
PASSPORT HEALTH PLAN
1
SERVICES APPROVED: PASSPORT TO COMPLETE
Total Visits
Times/Week
#/Weeks
Authorization #
Date of Service Approved
Date Authorized
By _
PROPRIETARY AND CONFIDENTIAL
to
PASSPORT HEALTH PLAN
2
INITIAL THERAPY EVALUATION FORM
NAME
DATE OF EVAL
HISTORY AND PHYSICAL
SUMMARY OF CURRENT STATUS
RECOMMENDATIONS / TREATMENT PLAN
SHORT TERM GOALS
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
3
LONG TERM GOALS
THERAPIST SIGNATURE / DATE
PROPRIETARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
4
20.5.8
CONTINUED THERAPY AUTHORIZATION FORM
PATIENT NAME
DOB
PASSPORT ID#
ORDERING MD
DIAGNOSIS
PT
START DATE
TIMES/WEEK
# OF WEEKS
OT
START DATE
TIMES/WEEK
#OF WEEKS
ST
START DATE
TIMES/WEEK
#OF WEEKS
INJURY/ACCIDENT/ TPL: INCLUDE DATES
Note any therapy provided by 1st Steps or the school system, type and frequency.
Note any previous therapy received, type, frequency, dates and provider.
Requesting Provider
Provider ID#
Contact Person
Phone #
PROPRIETARY AND CONFIDENTIAL
Fax #
PASSPORT HEALTH PLAN
SERVICES APPROVED: PASSPORT TO COMPLETE
Total Visits
Times/Week
Authorization #
Date Authorized
PROPRIETARY AND CONFIDENTIAL
#/Weeks
Date of Service Approved
to
By
PASSPORT HEALTH PLAN
Continued Therapy Evaluation Form
NAME ____________________________________________________________
DATE OF EVALUATION _______________________________________________
UPDATE HISTORY & PHYSICAL & THERAPEUTIC EVENTS: e.g. BOTOX INJECTIONS,
SURGERIES, UPDATED EQUIPMENT, OR ORTHOTICS.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________
PROGRESS TOWARDS PREVIOUS GOALS (BE SPECIFIC)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________
CURRENT GOALS
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________
TREATMENT PLAN
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________
THERAPIST SIGNATURE/DATE
__________________________________________________________________
PROPRITARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
CHIROPRACTIC SERVICE PRIOR AUTHORIZATION REQUEST FORM
FAX (502) 585-8205
The chiropractic provider must be a participating Passport Health Plan Provider. The
provider must contact Passport Health Plan during regular business hours, MondayFriday 8:00 a.m.-5:30 p.m., to communicate the requested continued chiropractic
services. No prior authorization is required for the initial 12 chiropractic visits in one
rolling calendar year.
PATIENT NAME
DATE
PASSPORT ID#
DOB
ORDERING MD
PHONE
FAX
DIAGNOSIS
INITIAL 12 VISITS: DATES OF SERVICE AND PROGRESS MADE TOWARDS GOALS
WHEN DID PAIN BEGIN?
DESCRIBE PAIN (constant, intermittent, dull, ache, stabbing, sharp, intense, radiation of pain.)
INITIAL (date)
CURRENT (date)
RADIOLOGICAL FINDINGS, IF DONE
INITIAL (date)
CURRENT (date)
PROPRITARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
RANGE OF MOTION
INITIAL (date)
CURRENT (date)
STRENGTH / OTHER PERTINENT PHYSICAL FINDINGS
INITIAL (date)
CURRENT (date)
SUBLUXATION: PRESENCE AND LOCATION
INITIAL (date)
CURRENT (date)
# of visits requested, frequency, dates of service
Types of Services receiving: Chiropractic
manipulative treatment Diagnostic
services
Application of hot and cold packs to one or more areas
Application of electrical stimulation to one or more areas
Application of ultrasound to one or more areas
Application of mechanical traction to one or more areas
Other
GOALS
INITIAL
PROGRESS TOWARDS GOALS
PROPRITARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
GOALS
COMMENTS
PROPRITARY AND CONFIDENTIAL
PASSPORT HEALTH PLAN
MAIL TO:
PASSPORT HEALTH PLAN
5100 Commerce Crossings Drive
Louisville, KY 40229
PH: (877) 903-0082
FX: (502) 585-7970
NO-SHOW VISIT FOR OB APPOINTMENT
NOTE: For payment, fax to Mommy Steps staff at (502) 585-7970 within 48 hours of scheduled visit
PROVIDER INFORMATION
Provider Name:
Provider ID #:
Provider Fax #:
MEMBER INFORMATION
Member ID #:
EDC:
Member Name:
Member’s Current Address:
Apt./Bldg#:
City:
State:
Member’s Current Phone #:
Zip:
Alternative #:
NO-SHOW INFORMATION
Date of No-Show:
Procedure = 99499
Time of Appointment:
Charge = $25.00
COMMENTS
DATE FOLLOW-UP COMMENTS FAXED BACK TO OB PROVIDER OFFICE:
a.m./p.m.
Provider Manual
Section 18.0
Important Contact Information
Table of Contents
18.1 Passport Health Plan Important Contact Information
18.2 Other Important Contact Information
Page 268 of 331
18.0 Important Contact Information
18.1 Passport Health Plan Important Contact Information
Main Switchboard
Telephone:
(502) 585-7900
Web site
www.passporthealthplan.com
Appeals
Submit medical-necessity and administrative appeals to:
Passport Health Plan
Attn: Appeals Coordination
5100 Commerce Crossings Drive
Louisville, KY 40229
Behavioral Health
Beacon Health Strategies, LLC
Toll-Free:
Web site:
(855) 834-5651
www.beaconhealthstrategies.com
Case Management
Telephone:
Fax:
(877) 903-0082
(502)585-7997
Claims Filing Address
New and corrected claims, claims for reconsideration/recoupment, and medical record requests:
Passport Health Plan
P.O. Box 7114
London, KY 40742
Dental Provider Contractor
Avesis
Toll-free:
Website: www.avesis.com
(866) 909-1083
Drug Prior Authorization (PA)
PA Standard Fax:
PA Urgent Fax:
Hospital Discharge:
(877) 693-8280
(877) 693-8476
(877) 693-8476
EDI Technical Support
Hotline:
E-mail:
(877) 234-4275, option 4
[email protected]
Page 269 of 331
EPSDT
Eligibility:
Fax:
(502) 585-8210
(502) 585-8457
Interactive Voice Response (IVR)
Toll-free:
(800) 578-0775, option 1
Medical Authorization
General Utilization Management (UM) Fax:
Durable Medical Equipment (DME) Fax:
Home Health/Home Infusion Fax:
Retro Auth Fax:
Therapy Auth (PT, OT, Speech) Fax:
Radiology – MedSolutions - Toll-Free:
(502) 585-7989
(502) 585-7990
(502) 585-8204
(502) 585-8207
(502) 585-8205
(877) 791-4099
Member Services
Toll-free:
(800) 578-0603
Mommy Steps Program
Telephone:
Fax:
(877) 903-0082
(502) 585-7970
Pharmacy Benefits Manager Help Desk
PerformRx - Toll-free:
(800) 578-0898
Hours:
Pharmacy Director
Telephone:
24 Hours/7 days a week
(502) 585-8445
Pharmacy/Provider Mailbox for General Inquiries
Telephone:
(502) 585-8249
Provider Claims Service Unit (PCSU)
Toll-free:
(800) 578-0775
Provider Enrollment
Telephone:
(502) 588-8578
Provider Lock-In Pharmacy Coordinator
Telephone:
(502) 585-7947
Provider Network Management Department
Telephone:
Fax:
(502) 585-7943
(502) 585-6060
Provider Services
Toll-free:
(800) 578-0775
Page 270 of 331
Rapid Response
Telephone:
Fax for the Diabetes, Yes, You Can! (Quit Smoking),
CAD, CHF, Chronic Respiratory Program, and
Obesity Programs
(877) 903-0082
(502)585-7997
Behavioral Health Liaison
Telephone:
(877) 903-0082
Utilization Management
Toll-free:
Fax:
(800) 578-0636, option 2
(502) 585-7989
Vison Provider Contractor
Block Vision
Provider Relations
Webiste: www.blockvision.com
(800) 243-1401
9:00 a.m. – 6:00 p.m.
Yes, You Can! Quit Smoking Program
Toll-free:
Fax:
(877) 903-0082
(502) 585-8458
24-Hour Nurse Advice Line
McKesson
Toll-free:
(800) 606-9880
Page 271 of 331
18.2 Other Important Contact Information
Department for Medicaid Services MCO Hotline
Toll-free:
(855) 446-1245
Emdeon Business Solutions Client Services
Toll-free:
Web site:
(800) 845-6592
www.emdeon.com/epayment
Kentucky Medical Ombudsman
Toll-free:
TDD/TTY:
Address:
(800) 372-2973
(800) 627-4702
Kentucky Department for Medicaid
Services
Office of the Ombudsman
275 East Main Street
Frankfort, KY 40621
State Hearing Request
Toll-free:
Address:
(800) 635-2570
Kentucky Department for Medicaid
Services
275 East Main Street
Frankfort, KY 40621
Page 272 of 331
Provider Manual
Section 19.0
Dental Network
Table of Contents
19.1 Important Contact Information
19.2 Administrative Procedures
19.3 Credentialing/Re-credentialing
19.4 Provider Terminations/Changes in Provider Information
19.5 Standards of Care for Dental Offices
19.6 Dental Benefits
19.7 Care Management and Utilization Management
19.8 Authorization Procedures and Requirements
19.9 Quality Improvement
19.10 Dental Provider Billing Manual
19.11 Fraud, Waste and Abuse
19.12 Cultural Competency
Page 273 of 331
19.0 Dental
Passport Health Plan (Passport) is pleased to partner with Avesis Incorporated (Avesis) for the
administration of our Dental Program.
Passport and Avesis recognize the importance of promoting and providing good oral hygiene for
Medicaid members in Kentucky. We understand the linkage between good oral health and overall
health. By helping to ensure all Passport members receive appropriate and timely dental services, we
can continually improve the oral health of members.
The provisions set out in this Section of Passport’s Provider Manual supplement the provisions in
previous sections as applicable, and include additional information specific to dental providers.
Updates to this Dental Section of the Provider Manual will be provided on a periodic basis and
available on the below-stated websites. As your office receives communications from Avesis and
Passport, it is important that you and/or your office staff read these Dental Network Alerts and
other special mailings and retain them with this Provider Manual so you can integrate the changes
into your practice. All provider materials, including this Provider Manual and the Provider Directory,
are available online at www.passporthealthplan.com and www.avesis.com.
Please take the time to familiarize yourself with this Provider Manual, including this Section. If you
have any questions, require clarification regarding the Provider Manual, or need assistance or
information that is not included within this Provider Manual, please contact
Provider Services: (866) 909-1083
Monday - Friday 7:00 a.m. to 8:00 p.m. (EST)
All offices will be notified thirty (30) days prior to the effective date of any changes or revisions to
this Provider Manual affecting their practice, unless the change is required by law or regulation.
Information in this Provider Manual will be updated on the Avesis and Passport websites at
www.avesis.com. and www.passporthealthplan.com. It is the provider’s responsibility to stay abreast
of changes to this Provider Manual.
The Avesis website also contains important information including but not limited to Dental Alerts,
eligibility verification, claims submission and claims status. Providers may also visit the Passport
website for information on Passport and the Dental Program.
19.1 Important Contact Information
19.1.1 Dental Provider Services Call Center (866) 909-1083
The Dental Provider Services Call Center is available Monday through Friday, 7:00 a.m. to 8:00 p.m.
EST to assist providers with questions about policies, procedures, member eligibility, and benefits.
Representatives are also available if providers need to request forms or literature, or to report
member noncompliance.
A Dental Provider Field Representative can offer orientations and in-service meetings for providers
Page 274 of 331
and their staff. This representative can also provide service calls and process any changes in
provider status, such as addresses and telephone numbers.
19.1.2 Provider Services and Utilization Management
Provider Services
(866) 909-1083
Monday – Friday, 7:00 a.m. - 8:00 p.m. EST
Utilization Management
(866) 653-5544 (secure fax)
Monday – Friday, 7:00 a.m. - 8:00 p.m. EST
19.1.3 Avesis Chief Dental Officer and State Dental Director
Avesis Chief Dental Officer
Fred L. Sharpe, DDS
[email protected]
(800) 522-0258 x 11288
Avesis State Dental Director
Dr. Jerry Caudill
[email protected]
(502) 662-2101
19.1.4 Claims Submission and EFT
Initial Claims Submission:
Avesis Third Party Administrators, Inc.
Attn: Dental Claims
P.O. Box 7777
Phoenix, Arizona 85011-7777
For Claims Correction:
Avesis Third Party Administrators, Inc.
Attn: Corrected Dental Claims
P.O. Box 7777
Phoenix, Arizona 85011-7777
Avesis EFT Contact:
Avesis Third Party Administrators, Inc.
Attn: Finance
P.O. Box 782
Owings Mills, Maryland 21117
19.1.5 Pre-Treatment Estimate and Post Review
Avesis Pre-Treatment Estimate:
Avesis Third Party Administrators, Inc.
Attn: Pre-Treatment Estimate
P.O. Box 7777
Phoenix, Arizona 85011-7777
Avesis Post Review:
Avesis Third Party Administrators, Inc.
Attn: Post Review
P.O. Box 7777
Phoenix, Arizona 85011-7777
19.2 Administrative Procedures
19.2.1 Member Identification and Eligibility Verification
Member eligibility information is detailed in Section 2.0. of the Provider Manual. As noted, Passport
member eligibility varies by month. Therefore, each participating provider is responsible for
verifying member eligibility before providing services. Dental providers may verify eligibility using
Page 275 of 331
any of the methods below. Please be mindful, verification of coverage only is provided, utilization of
benefit information is not available when checking eligibility.
IVR (Interactive Voice Response System)
1.
2.
3.
4.
Call the IVR at: (866) 234-4806.
Enter your Provider PIN number.
Enter the member’s KY Medicaid Identification number.
You will receive a real time response.
Website/Internet
1.
2.
3.
4.
5.
Go to www.avesis.com.
Enter your User Name and Password.
Click “Check Eligibility.”
Enter the member’s KY Medicaid Identification number.
You will receive a real time response.
FAX
1. Complete the Avesis Eligibility Verification Fax Form (included as Attachment D of
this Dental Section).
2. Fax toll free to: (866) 332-1632.
3. You will receive a reply to the fax within one (1) business day.
Provider Services
1. Call Dental Provider Services toll free at (866) 909-1083.
2. Provide your Provider PIN number.
3. Provide the member‘s KY Medicaid Identification number.
Remember: Eligibility verification is not a guarantee of payment. Benefits are determined
at the time the claim is received for processing. These options will only provide eligibility
information for Passport. Eligibility for other health plans is not provided.
Please note that Passport Health Plan cards are not returned to Passport when a member
becomes ineligible. Therefore, the presentation of a Passport ID card is not sole proof that a
person is currently enrolled in Passport.
As a way to help prevent Medicaid “card sharing,” remember to always ask to see the member’s
Passport ID card or the member’s Kentucky Medicaid ID card and request a picture ID to verify
that the person presenting is indeed the person named on the ID card.
Services may be refused if the provider suspects the presenting person is not the card owner and no
other ID can be provided. If you suspect a non-eligible person is using a member’s ID card, please
report the occurrence to the Passport Fraud and Abuse Hotline at (855)-512-8500 or the Medicaid
Fraud Hotline at (800) 372-2970.
Page 276 of 331
It is not necessary to refuse treatment to a member who does not present with his/her Passport
identification card. Eligibility can be verified 24 hours a day 7 days a week as detailed above.
Members may also produce their KY Medicaid ID Card.
19.2.2 Dental Claim Submission
Paper claims and correspondence for reconsideration or recovery are to be submitted to the
following address:
Avesis Third Party Administrators, Inc.
Attention: Dental Claims
P.O. Box 7777
Phoenix, AZ 85011-7777
To submit claims electronically, register on the Avesis website at www.avesis.com.
An active valid Kentucky Medicaid Provider Identification (MAID) number, assigned by the
Kentucky Department for Medicaid Services (DMS), is required to receive any payment for services
rendered.
19.2.3 Statement of Providers’ Rights and Responsibilities
Providers shall have the right and responsibility to:
•
•
•
•
•
•
•
•
•
•
Communicate openly and freely including, but not limited to, support of Provider Services and
Customer Services representatives and information on participating providers for the purpose
of referrals;
Obtain written parental or guardian consent for treatment to be rendered to members who
have not yet reached the age of maturity in accordance with State Dental Board rules or ADA
guidelines;
Obtain information regarding claim status and pre-treatment estimates for services to be
rendered and re-submit claims with additional information by following the guidelines set
forth herein;
Receive prompt payments for clean claims;
Make a complaint or file an appeal on behalf of a member with the member’s consent and
inform the member of the status of the appeal;
Question policies and/or procedures implemented on behalf of Passport;
Request Pre-Treatment Estimate for services identified herein as requiring pre-treatment
estimates;
Refer members to participating specialists for treatment that is outside the provider’s normal
scope of practice;
Inform Avesis in writing immediately upon notification of any revocation, suspension and/or
limitation of your license to practice, certification(s), and/or DEA number by any licensing or
certification authority;
Consistent with credentialing and re-credentialing policies, inform Avesis in writing prior to
changes in licensure status, tax identification numbers, telephone numbers, addresses, loss or
Page 277 of 331
•
•
•
•
modification of insurance or any other change that would affect status. Failure to notify prior
to these changes may result in delays in claims processing and payment;
Consistent with the terms of the Provider Agreement, notice of termination of participation
must be submitted at least ninety (90) days prior to the termination effective date;
Maintain an environmentally safe office with equipment in proper working order to comply
with city, county, state and federal regulations concerning safety and public hygiene;
Respond promptly to requests for dental records as needed to review appeals and/or quality
of care issues; and,
Abide by the rules and regulations set forth under applicable provisions of State or Federal
law.
All provides are prohibited from:
•
•
•
•
•
•
•
Discriminating against members on the basis of race, color, national origin, disability, age,
religion, mental or physical disability, or limited English proficiency. Provider agrees to
comply with the Americans with Disabilities Act, and the Rehabilitation Act of 1973 and all
other applicable laws related to the same. See Title VI Civil Rights Act of 1964,
www.usdoj.gov/crt/cor/coord/titlevi.htm;
Discriminating against qualified individuals with disabilities for employment purposes;
Discriminating against employees based on race, color, religion, sex, or national origin;
Offering or paying or accepting remuneration to or from other providers for the referral of
members for services provided under the Dental Program;
Referring members directly or indirectly to or solicit from other providers for financial
consideration;
Referring members to an independent laboratory, pharmacy, radiology or other ancillary
service in which the provider or professional corporation has an ownership interest; and,
Billing, charging, or seeking compensation, remuneration, or reimbursement from any
member other than for supplemental charges, copayments (example: in 2014, there are no
copayments or fees for covered services).
Please refer to Section 3.4 of the Provider Manual for additional information regarding provider
responsibilities.
19.2.4 Member Appeals and Grievances
Please refer to Section 2.10 of the Provider Manual.
19.2.5 Provider Appeals and Grievances
Please refer to Section 2.12 of the Provider Manual.
19.3. Credentialing/Re-Credentialing
19.3.1 Initial Application Process
To begin the application process and join Passport, first call Dental Provider Services at (866) 9091083. A provider application packet will be mailed and Avesis will work with the provider to
Page 278 of 331
become credentialed and, if approved, contracted as a Passport dental provider.
Avesis participates with the Council for Affordable Quality Healthcare (CAQH). Providers who are
participating with this common credentialing application database should contact Dental Provider
Services at (866) 909-1083 and include their CAQH Provider ID number with the documents
submitted.
New dental practitioner (hereafter referred to as practitioner) applicants are required to complete all
residency and/or training programs prior to joining the network. Practitioners still completing a
residency program are required to bill under the attending practitioner.
Applicants must submit a completed application, which includes the following as applicable:
•
•
•
•
•
•
•
•
•
•
•
Two Participating Provider Agreements signed by the provider indicating their intent to join
the network if approved after being credentialed.
Completed Provider Application, either a CAQH (Council for Affordable Quality Healthcare
universal credentialing application) or the most current version of KAPER1 (Kentucky
Department for Medicaid Services application), including:
o Additional copies of pages from the application (as needed);
o Disclosure questions, as applicable, including but not limited to:
 Documentation of any malpractice suits or complaints.
 Documentation of any restrictions placed on practitioner by hospital, medical
review board, licensing board, or other medical body or governing agency.
 Documentation of any conviction of a criminal offense within the last 10 years
(excluding traffic violations).; and,
o The attestation page (including the practitioner signature and current date).
Original, complete, and signed MAP Forms, if a Kentucky Medicaid Provider Identification
(MAID) number is needed per the Kentucky Department for Medicaid Services (DMS)
provider enrollment web page. If the provider has a current Kentucky MAID number, the
provider must include a completed MAP-347 form.
Copy of current State License Registration Certificate.
Copy of current Federal Drug Enforcement Agency Registration - if applicable.
Curriculum vitae or a summary specifying month and year for work history, explaining any
lapse in time exceeding six months.
Copy of a completed, dated and signed W-9 in the name of the provider or facility/group,
including the Tax Identification Number and mailing address for all tax information.
Copy of claim history form for each malpractice activity within the past five years.
Copy of current professional liability insurance Certificate of Coverage, including the name
and address of the agent and the minimum amount, in accordance with existing Kentucky
laws at the time of the application submission.
A letter adding practitioner to each existing group contract, including group ID number(s), if
applicable.
Copy of social security card (if applicant has as social security card stating “valid for work only
with DHS/INS Authorization,” please refer to additional requirements at
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•
http://www.chfs.ky.gov/dms/provenr/),if submitted MAP forms for Kentucky MAID
numbers
ECFMG (Education Council for Medical Graduates), if applicable.
Failure to submit a complete application may result in a delay of the credentialing process.
Practitioners may contact Dental Provider Services at (866) 909-1083 to check the status of their
applications.
19.3.2 Credentialing Process
Practitioner applicants are assessed through Passport Health Plan’s credentialing process. With the
receipt of all of the application materials, primary source verification is conducted. Following the
verification of credentials, the Chief Dental Officer/designated Dental Director or Credentialing
Committee reviews each application for participation. A credentialing review will not be initiated
until a completed and signed application with attachments has been received. The normal processing
time is between thirty (30) and sixty (60) days from date of submission of a completed application.
19.3.3 Reimbursement and the Credentialing Process
Providers will be considered participating Passport providers once they have met Passport
credentialing requirements and have an executed agreement and a Kentucky MAID number.
Providers will be notified when they have been credentialed. Providers applying for participation are
excluded from the Provider Directory until the credentialing process has been completed in its entirety.
Providers will be reimbursed at the participating provider rate, retroactive to the first of the month
in which the application is received provided the provider has an active Kentucky Medicaid MAID
number and has submitted the MAP 347 form to be linked to Passport Health Plan. Providers may
begin submitting claims for services provided to Passport members once they have been notified of
the receipt of their completed application and have been assigned a Kentucky MAID number.
Providers are required to submit all claims within 180 days of service, but no payment is made until
Passport Health Plan receives confirmation that the provider has been issued a Kentucky MAID
number. Please note, claims submitted without a Kentucky MAID number will be denied. Providers
will receive notification from DMS when a MAID number is assigned.
Providers must notify Avesis of receipt of a MAID number assignment.
19.3.4 Providing Services Prior to Becoming a Credentialed Passport Provider
If a provider determines a Passport member must be seen prior to the assignment of a KY MAID
number, the provider should see the member and submit for reimbursement under the plan after
receiving his/her KY MAID number. As stated previously, the provider will not be eligible for
payment until he/she has an executed contract and a KY MAID number. If payment is denied
because the provider is not participating or he/she does not have a Kentucky MAID number, the
member cannot be held liable.
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19.3.5 Re-credentialing and Ongoing Monitoring Process
Passport re-credentials its providers, at a minimum, every 36 months. In addition, Passport conducts
ongoing monitoring of Medicare and Medicaid sanctions and sanctions or limitations on licensure.
Practitioners who become participating and subsequently have restrictions placed upon their license
will be reviewed by the Credentialing Committee and evaluated on a case-by-case basis, based upon
their ability to continue serving Passport members.
Member complaints and adverse member outcomes are also monitored and Passport will implement
actions as necessary to improve trends or address individual incidents. If efforts to improve
practitioner performance are not successful, the practitioner may be referred to the Credentialing
Committee for review prior to his/her normally scheduled review date.
A re-credentialing application will be generated on all practitioners with current CAQH applications
on file. Practitioners without a CAQH on file will be notified by letter to submit a re-credentialing
application (most current version of the KAPER 1 or CAQH) with the following list of attachments:
•
Disclosure questions, as applicable, including but not limited to:
o Documentation of any malpractice suits or complaints.
o Documentation of any restrictions placed on practitioner by licensing board, or
governing agency.
o The attestation page (including the practitioner signature and current date).
o Copy of current State License Registration Certificate.
o Copy of current Federal Drug Enforcement Agency Registration - if applicable.
o Copy of current professional liability insurance Certificate of Coverage, including the
name and address of the agent and the minimum amount, in accordance with existing
Kentucky laws at the time of the application submission.
Failure to return documents in a timely fashion may result in a period of non-participation. The
initial credentialing process will need to be completed in order to re-enroll as a participating
provider. Practitioners may contact the Dental Provider Services at (866) 909-1083 to check the
status of their re-credentialing application. Should Passport decide to deny or terminate a provider,
the provider will receive notification of the decision. The notification will include the reasons for the
denial or termination, the provider’s rights to appeal and request a hearing within thirty (30) days of
the date of the denial notice, and a summary of the provider’s hearing rights.
19.4 Changes in Provider Information
19.4.1 Changes in Provider and Demographic Information
Providers are required to provide a written notice to both the Provider Network Management
department and the Department for Medicaid Services (DMS) of any changes in information
regarding their practice. Such changes include:
•
•
Address changes, including changes for satellite offices.
Additions to a group.
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•
Changes in billing locations, telephone numbers, tax ID numbers.
Reimbursement may be affected if changes are not reported in accordance with Passport Health
Plan policy. Please note that providers are required by DMS to annually submit a copy of current
license and annual disclosure of ownership. If these documents are not provided, the provider’s
Kentucky Medicaid (MAID) number may be terminated. Your office will receive notice from the
DMS when these documents are due for submission. Please respond timely to these requests.
Untimely response to this requirement may result in claims denials and/or untimely claims
payment.
19.5 Standards of Care for Dental Offices
The Passport Dental Program has established standards that our provider offices are expected to
fulfill. The following are summaries of these standards:
19.5.1 Appointment Scheduling Standards
Dental care is a direct access benefit for Passport members. Dental services do not require a referral
from the member’s PCP. Passport adheres to state and National Committee for Quality Assurance
(NCQA) guidelines for access standards for member appointments. Contracted providers may only
provide such dental services within the scope of their license and must adhere to the following
appointment standards and after-hours requirements:
Type of Care
Emergency Care
Urgent Care
Routine Care
Hygiene Appointments (cleaning & comprehensive
exam)
Routine Symptomatic (member requests a follow-up
for a tooth extraction)
Appointment Availability
Within 24 hours
Within 48 hours
Within 21 days
Within 6 weeks
Within 2 weeks
19.5.2 Preventive Treatment
Patients should be encouraged to return for a recall visit as frequently as indicated by their individual
oral status and within Passport time parameters. It is important that each dental office has a recall
procedure in place. The following should be accomplished at each recall visit:
•
•
•
•
•
Update medical history
Review of oral hygiene practices and necessary instruction provided
Complete prophylaxis and periodontal maintenance procedures
Topical application of fluoride, if indicated
Sealant application, if indicated.
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19.5.3 Reminder, Follow-up and Outreach Call Policy and Procedures
Each Passport provider office is required to maintain and document the following member recall
policy and procedures for all eligible members:
•
•
•
•
For members of record (under age 18), providers must attempt to make contact at least two
(2) times per year. Members of record are those members who have been routinely treated at
the provider’s office.
For adult members of record (over age 18), providers must attempt to make contact at least
one (1) time per year. Again, members of record are those members who have been routinely
treated at the provider’s office.
Have a functional recall system in place for notifying members of the need to schedule dental
appointments. The recall system must include the following requirements for all enrolled
members:
o The system must include either written or verbal notification.
o The system must have procedures for scheduling and notifying members of
routine check-ups, follow up appointments and cleaning appointments.
o The system must have procedures for the follow up and rescheduling of missed
appointments.
Passport encourages its providers to make efforts to decrease the number of “no shows.” It is
suggested the provider contact the member prior to the appointment either by phone or in
writing to remind him/her of the time and place of the appointment. Follow-up phone calls or
written information should be provided - encouraging the member to reschedule the
appointment in the event the appointment is missed.
CMS comprehensive and preventive child health program for individuals under the age of twentyone (21) is called Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT). Based
upon the requirements of the EPSDT program, each Passport provider office is required to maintain
and document the following member recall policy and procedures for all eligible members:
•
For members of record (under age 21), providers must attempt to make contact at least two
(2) times per year.
The recall policy must be written and implemented upon the commencement of the Passport Dental
Program. The office procedures may be determined by each dental office, but must include a written
process of notification for members including:
•
•
•
Recall month for routine preventive care
Date of a missed appointment(s)
Date for follow up appointments
Note: Follow up appointments must be scheduled within thirty (30) calendar days following the
initial appointment and incrementally thereafter. This system may be audited during any office visit.
A log must be kept notating when a “Reminder Notice” was sent to the member or a telephone
attempt was made to the member prior to the appointment.
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Documentation of contact attempts and results must be submitted on a quarterly basis, if requested.
19.5.3.1 Follow-up Procedure
The dentist or specialist shall conduct an affirmative outreach whenever a member misses an
appointment. This outreach should be documented in the medical/dental record. Such an effort
shall be deemed to be reasonable if it includes the prescribed number of attempts to contact the
member. Such attempts may include but are not limited to written attempts and telephone calls. At
least one attempt must be a follow-up telephone call, whenever possible.
19.5.4 Dental Professional Standard of Care
Each dentist and dental specialist within the Passport network is expected to practice within the
standard of care for dentists within Passport. All providers are required to practice within the scope
of dental practice as established by the State board of dentistry. Providers are expected to be aware
of any applicable state and federal laws that impact their position as an employer, a business owner
and a healthcare professional.
19.5.5 Parameters of Care
Providers should be aware of the ADA parameters of care that can be found on the Internet at:
http://www.ada.org/Members/prac/tools/parameters/index.asp. While only guidelines, Passport
will look to these parameters as indicative of the appropriate care for the situations described. For
the actual treatment that occurs, providers are expected to use all relevant training, knowledge and
expertise to provide the best care for the member.
19.5.6 Office Standards
Each dentist office must:
•
•
•
•
•
•
•
•
Have a sign containing the names of all dentists practicing at the office. The office sign must
be visible when the office is open.
Have a mechanism for notifying members if a dental hygienist or other non- dentist dental
professional may provide care.
Be accessible to all patients, including but not limited to its entrance, parking and bathroom
facilities.
Have offices that are clean, presentable and have a professional appearance.
Have clean and properly equipped patient toilet and hand-washing facilities.
Have a waiting room that will accommodate at least (4) four patients.
Have treatment rooms that are clean, properly equipped and contain functional, adequately
supplied hand-washing facilities.
Have at least one (1) staff person (in addition to the dentist) on duty during normal office
hours.
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•
•
•
•
•
•
•
Provide a copy of current licenses and certificates for all dentists, dental hygienists and other
non-dentist dental professionals practicing in the office, Including state professional licenses
and certificates, Federal Drug Enforcement and State Controlled Drug Substance licenses and
certification (where applicable).
Keep a file and make available any state required practices and protocols or supervising
agreements for dental hygienists and other non-dentist dental professionals practicing in the
office.
Have appropriate, safe x-ray equipment. Radiation protection devices, including, without
limitation, lead aprons shall be available and used according to professionally recognized
guidelines (e.g. Food and Drug Administration).
Maintain the standards and techniques of safety and sterility in the dental office required by
applicable federal, state and local laws and regulations including, but not limited to, those
mandated by OSHA and as advocated by the American Dental Association (ADA) and state
and local societies.
Comply with all applicable federal, state and local laws and regulations regarding the handling
of sharps and environmental waste, including the disposal of waste and solutions.
Make appointments in an appointment book (or an electronic equivalent as acceptable to
Passport). Appointments should be made in a manner that will prevent undue patient
waiting time and in compliance with the access criteria listed in this manual.
Upon request, provide patients with a copy of their rights and responsibilities as listed in this
Provider Manual.
19.5.6 Standards for Member Records
Each member shall have an individual record and an individual file kept at the dental office. In
accordance with 201 KAR 8:540, the dentist must keep accurate, readily accessible, and complete
records which include:
•
•
•
•
•
•
•
•
•
•
•
•
•
The patient’s name;
The patient’s date of birth;
The patient’s medical history and documentation of the physical exam of the oral and perioral
tissues;
The date of treatment;
The tooth number, surfaces, or areas to be treated;
The material used in treatment;
Local or general anesthetic used, the type, and the amount;
Sleep or sedation dentistry medications used, the type, and the amount;
Diagnostic, therapeutic, and laboratory results, if any;
The findings and recommendations of the dentist and a description of each evaluation or
consultation, if any;
Treatment objectives;
All medications, including date, type, dosage, and quantity prescribed or dispensed; and,
Any post treatment instructions.
19.5.6.1 Review
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A Passport representative may visit your office to review the patient records of Passport members.
The member’s record must:
1. Contain a signed consent to permit Passport access to patient records upon request.
2. Be retained by you for all covered services rendered for the greater of ten (10) years for adults
and thirteen (13) years for minors or longer as required by state and federal law.
19.5.6.2 Access
Providers are required to comply with Passport’s rules for reasonable access to patient records
during the Agreement term and upon termination allowing:
1. The following parties may have access to the members’ records:
Passport representatives or their delegates, the member’s subsequent physician(s), or any
authorized third party including employees or agents of the Kentucky Department for
Medicaid Services, CMS, and the Department of Insurance.
2. For a maintenance period of ten (10) years from the last Date of Service for adult patients and
at least thirteen (13) years from date of last service for minors.
19.5.6.3 Copies
Passport has the right to request copies of the member’s complete record.
When medical records are required due to a claims appeal initiated by the provider or by the
member, the provider may not charge a fee for the medical records.
Please refer to Section 4.5 of the Provider Manual for complete details and requirements regarding
medical record keeping and continuity and coordination of care standards.
19.5.7 Standards for Infection Control
The dental office shall follow all appropriate state and federal guidelines including any from OSHA
and the CDC that impact clinical dental practice. The office shall perform appropriate sterilization
procedures on all instruments and dental hand pieces. Furthermore, appropriate disinfection
procedures for all surfaces in the treatment areas shall be performed following each patient visit.
Masks and gloves shall be worn for all member treatment. Protective eyewear shall be available for
all dental staff. Members shall be protected from all chemical and biological hazards at all times.
Office Standards:
•
•
•
•
•
All personnel should wash with bacterial soap before all oral procedures.
New gloves should be worn for each patient.
All instruments should be thoroughly scrubbed and debrided before sterilization.
Light chair switches, hand pieces, cabinet working surfaces and water/air syringes and their
tips, should be disinfected, using approved techniques, after each use.
ADA approved sterilization solutions should be utilized.
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•
•
All equipment should be monitored using process indicators with each load and spore testing
on a weekly basis.
Handling of all environmental waste, including the disposal of waste and solutions, must be in
compliance with all applicable federal, state and local laws and regulations.
19.5.8 Medical Emergencies
All office staff shall be prepared to deal with any medical emergency through the implementation of
the following guidelines:
•
•
•
•
The dentist and at least one other staff member must have current CPR training.
The dental office must have a formal medical emergency plan and staff members must
understand their individual responsibilities. The emergency plan must include documented
emergency procedures, including procedures addressing treatment, evacuation and
transportation plans to provide for the safety of members. All emergency numbers must be
posted.
Patients with medical risk shall be identified in advance.
All dental offices must have a portable source of oxygen with a positive demand valve, blood
pressure cuff and stethoscope.
19.5.9 Standards for Radiation Protection
All staff required to use radiograph technology must be trained on the proper use of this technology prior to
its use. The dental office shall have only radiograph machines that have been checked by the appropriate State
authorities and were confirmed to be within the standards set down by statute or regulation. Members shall
be given proper shielding for all radiographs and the processing shall be done according to manufacturer’s
specifications. For digital radiographs, the computer system shall have the appropriate storage and back-up
protection as described in the ADA parameters of care. Radiation badges to monitor the levels of radiation in
the dental office shall also be worn by all personnel on a voluntary basis.
19.5.10 Standard for Member Contacts
Each provider office shall maintain accurate contact information for each member and shall have appropriate
contact numbers for parent(s) or legal guardian if the member is under the age of majority. Members shall be
offered appointments within the period of time dictated by the State administration. Emergency coverage
shall be in keeping with the requirements established in the Provider Agreement, by the State administration
and as described within this Provider Manual. No charges shall be permitted for late or broken appointments
as required by the Passport Dental program.
19.5.11 Standard for Member Appointments
Each new member must have thorough medical and dental health histories completed before any treatment
begins. Each new member must have a complete clinical examination and oral cancer screening. Each
member must have appropriate radiographs for diagnosis and treatment based upon their age and dentition.
Each member must have a written treatment plan in the member record that clearly explains all necessary
treatment(s).
19.5.12 Standard for Treatment Planning
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All treatment plans must be recorded and presented to the member and parent or legal guardian, if the
member is a minor. The member must be given the opportunity to accept or reject the treatment
recommendations and the member’s response must be recorded in the member’s record.
19.5.13 Standard for Services not covered under the Passport Dental Program
The provider’s office should be aware of those dental services that are not covered under the Passport Dental
Program. If the member is willing to have a provider provide any non-covered services and is willing and able
to pay directly for those services, the provider must complete the enclosed Non-Covered Services Disclosure Form
(Attachment B) or use a similar disclosure form that contains all of the elements on the Non-Covered Services
Disclosure Form included herein. A copy of the completed form shall be maintained in the member’s record.
The member must be advised in advance that the service(s) is not covered and how much it will cost.
19.5.14 Standards for Submitting Claims
Claims must be submitted for all dental services within 180 days of the member’s appointment and
with all of the necessary materials included for review. Failure to submit claims within 180 days will
result in claims processing denials for untimely filing.
19.6 Dental Benefits
19.6.1 Dental Services
Dental services are outlined in 907 KAR 1:026. Coverage shall be limited to services identified in 907
KAR 1:626, Section 3, in the following CDT categories:
•
•
•
•
•
•
•
•
•
•
Diagnostic;
Preventive;
Restorative;
Endodontics;
Periodontics;
Removable prosthodontics;
Maxillofacial prosthetics;
Oral and maxillofacial surgery;
Orthodontics; and
Adjunctive general services.
Please see Attachment F - Covered Benefits Schedule for additional information on benefits.
Information is also available on the Avesis website at www.avesis.com.
In 2014, there are no copayments or fees for covered services.
19.6.2 Non - Covered Items or Services
Passport will not pay providers for non-covered services. Providers will hold harmless Passport,
Avesis and DMS for payment of non-covered dental services.
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Non-covered services include investigational items and experimental drugs or procedures not
recognized by the United States Food and Drug Administration, the United States Public Health
Service, CMS, and the Avesis Chief Dental Officer and State Dental Director as universally accepted
treatment, including but not limited to, positron emission tomography, dual photon absorptiometry,
etc.
The member may purchase additional services as non-covered procedure(s) or treatment(s) for an
additional charge. Passport requires that the provider and the member complete the Non-Covered
Services Disclosure Form (see Attachment B) or a similar form that contains all of the elements of
the Passport Non-Covered Services Disclosure Form prior to rendering these services. If the member elects
to receive the non-covered procedure(s) or treatment(s), the member would pay the provider’s usual
and customary rate as payment in full for the agreed upon procedure(s) or treatment(s). The member
is financially responsible for such services. If the member will be subject to collection action upon
failure to make the required payment, the terms of the action must be kept in the member’s
treatment record. Failure to comply with this procedure will subject the provider to sanctions up to
and including termination.
Members may not be billed for any service, with the exception of services in which a Passport NonCovered Services Disclosure Form has been signed, prior to the service being rendered.
19.6.3 Periodicity Schedule
RECOMMENDATIONS FOR PREVENTIVE PEDIATRIC ORAL HEALTH CARE
Periodicity and Anticipatory Guidance Recommendations
Dental Health Guidelines – Ages 0-18 Years Recommendations for Preventive Pediatric Dental Care
(AAPD Reference Manual 2002-2003)
Age
6-12
months
12-24
months
2-6 years
6-12 years
>12
years
Clinical oral examination1
X
X
X
X
X
Assess oral growth and
development2
X
X
X
X
X
Caries-risk assessment3
X
X
X
X
X
Radiographic assessment4
X
X
X
X
X
Prophylaxis & topical fluoride3,4
X
X
X
X
X
Page 289 of 331
Age
6-12
months
12-24
months
2-6 years
6-12 years
>12
years
Fluoride supplementation5
X
X
X
X
X
Anticipatory guidance/
counseling6
X
X
X
X
X
Oral hygiene counseling7
Parent
Parent
Patient/Parent
Patient/Parent
Patient
Dietary counseling8
X
X
X
X
X
Injury prevention counseling9
X
X
X
X
X
Counseling for nonnutritive
habits10
X
X
X
X
X
Counseling for speech/ language
development
X
X
X
Substance abuse counseling
X
X
Counseling for intraoral/ perioral
piercing
X
X
Assessment and treatment of
developing malocclusion
X
X
X
Assessment for pit and fissure
sealants11
X
X
X
Assessment and/or removal of
third molars
X
Transition to adult dental care
X
1.
First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child's risk status/susceptibility to
disease. Includes assessment of pathology and injuries.
2.
By clinical examination.
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3.
Must be repeated regularly and frequently to maximize effectiveness.
4.
Timing, selection, and frequency determined by child's history, clinical findings, and susceptibility to oral disease.
5.
Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years.
6.
Appropriate discussion and counseling should be an integral part of each visit for care.
7.
Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
8.
At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and
childhood obesity.
9.
Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing, including the importance of mouth guards.
10.
At first, discuss the need for additional sucking: digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For
11.
For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption..
school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.
19.7 Care Management and Utilization Management
19.7.1 CDT Codes for Dental Programs
Detailed descriptions for CDT Codes including benefit limitations and attachments required for
claims processing may be found on the Covered Benefits Schedule (Attachment F).
Medically necessary dental services must be appropriate and consistent with the standard of care for
local dental practices. Providers understand that the omission of appropriate services could adversely
affect the member’s condition. The nature of the diagnosis and the severity of the symptoms must
not be provided solely for the convenience of the dental professional or facility or other entity.
However, there must be no other effective and more conservative or substantially less costly
treatment available.
Furthermore, for certain procedures requiring prior-authorization as set forth herein, the procedure
should be dentally or medically necessary to prevent or minimize the recurrence and progression of
periodontal disease in recipients who have been previously treated for periodontitis; prevent or
reduce the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of
the natural teeth; and increase the probability of locating and treating, in a timely manner, other
diseases or conditions found within the oral cavity.
19.7.2 Services Performed by the General/Pediatric Dentist
The Passport Dental Program is intended to be a general/pediatric dentistry program. Passport
considers the general/pediatric dentist to be the provider responsible for rendering all primary dental
care to members. That dentist is responsible for the initial examination and basic radiographs
necessary for any professional review.
General/pediatric dentists should render the following services whenever possible:
•
•
•
Preliminary diagnostic and all preventive care.
Simple forceps extractions (D7140).
All anterior (D3310) and bicuspid (D3320) root canal therapies.
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•
•
•
Initial root planning, scaling (requires Prior Authorization) and follow-up evaluation for all
periodontal cases.
Endodontic treatment may require a request for Prior Authorization along with radiographs
and is not considered for cases with rampant cavities or multiple missing teeth.
Routine restorative dentistry.
The above procedures should not be referred to a specialist unless they present with unusual
complications or fall outside the scope of the general/pediatric dentist practice.
Also, it is the responsibility of the general/pediatric dentist to provide a copy of diagnostic quality
radiographs to any successor dental provider, whenever possible. Appropriate radiographs are clear,
labeled to identify the area of the mouth and show the parts of the tooth or teeth to be treated.
Digital radiographs must have a date stamp or some date identification.
If radiographs cannot be obtained from the general/pediatric dentist, the successor dental provider
shall contact Avesis. Avesis will notify the general/pediatric dentist, in writing, within thirty (30)
calendar days or less, that the successor dental provider did not receive diagnostic quality
radiographs. If necessary, Avesis will charge back the general/pediatric dentist for radiographs that
the successor dental provider must retake for appropriate care if:
•
•
The general/pediatric dentist has taken radiographs that were not of diagnostic quality as
determined by clinical staff; and/or,
Radiographs were not submitted to the successor dental provider within ten (10) business days
following a request for said radiographs.
For those providers requesting radiographs less than ten (10) days prior to a member being treated
by the successor dental provider, Avesis will not charge back the general/pediatric dentist.
If the specialist deems that radiographs do not need to be repeated, the specialist must include a
narrative to clearly explain the dental conditions found upon examination.
19.7.3 Clinical Criteria
Requests for approvals for treatment are evaluated using criteria as defined in the American Dental
Association's most current CDT volume. Determinations are reached using generally accepted
dental standards for authorization, such as radiographs, periodontal charting, treatment plans, or
descriptive narratives. In some instances, the State legislature or other state or federal agency will
define the requirements for dental procedures and medical necessity.
These criteria and policies are designed as guidelines for dental service authorization and payment
decisions and are not intended to be all-inclusive or absolute. Additional narrative information is
appreciated when there may be a special situation. Passport recognizes that "local community
standards of care" may vary from region to region and will continue our goal of incorporating
generally accepted criteria that will be consistent with both the concept of local community
standards and the current ADA concept of national community standards.
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The following are general criteria. Services described may not be covered. There may be program
specific criteria regarding authorization for specific services. Therefore, it is essential providers
review the Covered Benefits Schedule (Attachment F) prior to providing any treatment.
19.7.3.1 Criteria for Dental Extractions
•
•
•
•
The prophylactic removal of asymptomatic teeth (i.e. third molars) or other teeth exhibiting
no overt clinical pathology (for orthodontics) may be covered, based on the clinical history
provided.
Symptoms should be present for approval of all third molar extractions. Those symptoms may
include cysts, resorption of adjacent teeth, angulation causing inability for tooth to erupt and
other clinical symptoms. Normal eruption pain is not considered a pathological symptom that
would require an extraction, unless accompanied by another symptom.
The removal of primary teeth whose exfoliation is imminent does not meet criteria, unless the
tooth presented with any unusual complication(s).
Alveoloplasty (Code 07310) in conjunction with three or more extractions in the same
quadrant will be covered subject to consultant post-review.
19.7.3.2 Criteria for Cast Crowns
•
•
•
•
In general, criteria for crowns will be met only for permanent teeth or primary teeth where no
permanent successor is present or needing multi-surface restorations where other restorative
materials have a poor prognosis.
Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and
that destruction should involve four or more surfaces and two or more cusps.
Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma,
and that destruction should involve three or more surfaces and at least one cusp.
Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma,
and that destruction must involve four or more surfaces and at least 50% of the incisal edge.
A request for a crown following endodontic therapy must meet the following criteria:
•
•
•
•
•
•
•
Request should include a dated post-endodontic radiograph.
The endodontic treatment of the tooth should show a fill sufficiently close to the radiological
apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the
canal that limits the ability to fill the canal to the apex.
The endodontic fill must be properly condensed or obturated.
Endodontic filling material should not extend excessively beyond the apex.
The crown must be opposed by a tooth or denture in the opposite arch or be an abutment for
a partial denture.
The tooth should demonstrate no probings greater than 5mm.
The patient must be free from active and advanced periodontal disease.
Authorizations for crowns will not meet criteria if:
•
•
A lesser means of restoration is possible.
Tooth has subosseous and/or furcation caries.
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19.7.3.3 Criteria for Endodontics
•
•
Tooth must be damaged as a result of trauma or carious exposure.
Fill must be properly condensed/obturated. Filling material does not extend excessively
beyond the apex.
Authorizations for endodontic therapy will not meet criteria if:
•
•
•
•
•
•
•
•
The endodontic treatment is for aesthetic reasons.
Gross periapical or periodontal pathosis is demonstrated radiographically.
Caries is demonstrated radiographically to be present belong the crestal bone or into the
furcation, deeming the tooth non-restorable.
The generally poor oral condition does not justify root canal therapy.
Endodontic therapy is being requested for third molars, unless they are an abutment for a
partial denture.
The tooth has advanced periodontal disease and/or pocket depths greater than 5mm.
Endodontic therapy is in anticipation of placement of an overdenture.
An endodontic filling material not accepted by the Federal Food and Drug Administration is
used.
19.7.3.4 Criteria for Removable Prosthodontics (Full and Partial Dentures)
•
•
•
•
Prosthetic services must be intended to restore oral form and function due to premature loss
of permanent teeth that would result in significant occlusal dysfunction.
Requests for partial dentures will only be considered for recipients with good oral health and
hygiene, good periodontal health (AAP Type I or II), and a favorable prognosis where
continuous deterioration is not expected.
Abutments should be adequately restored and not have advanced periodontal disease.
Pre-existing removable prosthesis (includes partial and full dentures), must be at least 5 years
old and unserviceable to qualify for replacement.
Authorizations for a removable prosthesis will not meet criteria if:
•
•
•
•
•
•
There is a pre-existing prosthesis which is not at least 5 years old and unserviceable.
Good oral health and hygiene, good periodontal health, and a favorable prognosis are not
present.
There are untreated caries on or active periodontal disease around the abutment teeth.
Less than 50% bone support is visible radiographically in abutment teeth.
The recipient cannot accommodate and properly maintain the prosthesis (i.e. gag reflex,
potential for swallowing the prosthesis, severely handicapped).
The recipient has a history or an inability to wear a prosthesis due to psychological or
physiological reasons.
19.7.3.5 Criteria for General Anesthesia and Intravenous (IV) Sedation
The use of general anesthesia or IV sedation is considered acceptable for procedures covered by
Passport, if appropriate criteria are met, including but not limited to any of the following:
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•
Extensive or complex oral surgical procedures such as:
o
o
o
o
Impacted wisdom teeth.
Surgical root recovery from maxillary antrum.
Surgical exposure of impacted or unerupted cuspids.
Radical excision of lesions in excess of 1.25 cm.
and/or one of the following medical conditions:
o Medical condition(s) which require monitoring (e.g. cardiac problems, severe
hypertension).
o Underlying hazardous medical condition (cerebral palsy, epilepsy, mental retardation,
including Down syndrome) which would render patient noncompliant.
o Documented failed sedation or a condition where severe periapical infection would
render local anesthesia ineffective.
o Patients 5 years old and younger with extensive procedures to be accomplished.
19.7.3.6 Criteria for Periodontal Treatment
19.7.3.6.1 Gingivectomy or Gingivoplasty
Criteria for approval of gingivectomy or gingivoplasty includes evidence of one or more of the
following:
•
•
Comprehensive periodontal evaluation (i.e. description of periodontal tissues, pocket depth
chart, tooth mobility, mucogingival relationships).
Documentation of severe gingival hyperplasia restricting the ability to perform effective
daily oral hygiene procedures (i.e. photos).
19.7.3.6.2 Periodontal Scaling and Root Planing
Criteria for approval of periodontal scaling and root planing include evidence of one or more of
the following:
•
•
•
•
Radiographically demonstrated evidence of bone loss.
3-5mm pocket depths on at least 3 or more teeth in each quadrant with perio charting no
more than a year old.
Medication related gingival hyperplasia.
Persistent inflammation characterized by generalized bleeding points on at least ½ of the
remaining dentition per quadrant.
19.7.6.3 Orthodontic Coverage Criteria
Members age 20 and under may qualify for orthodontic care under the program. KCHIP III
members are not eligible for orthodontic benefits. Members must have a severe, dysfunctional,
handicapping malocclusion.
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Since a case must be dysfunctional to be accepted for treatment, members whose molars and
bicuspids are in good occlusion seldom qualify. Crowding alone is not usually dysfunctional in spite
of the aesthetic considerations.
Minor tooth guidance, if a covered benefit, will be authorized on a selective basis to help prevent
the future necessity for full-banded treatment. All appliance adjustments are incidental and included
in the allowance for the tooth guidance appliance. With the exception of situations involving
gingival stripping or other nonreversible damage, appliances for minor tooth guidance (codes
D8010 through D8030) will be approved when they are the only treatment necessary. If treatment is
not definitive, the movement will only be covered as part of a comprehensive orthodontic
treatment plan.
All orthodontic services require prior authorization. The member should present with a fully
erupted set of permanent teeth. At least 1/2 to 3/4 of the clinical crown should be exposed, unless
the tooth is impacted or congenitally missing.
Diagnostic study models (trimmed) with wax bites or OrthoCad electronic equivalent, and
treatment plan must be submitted with the request for prior authorization of services. Treatment
should not begin prior to receiving notification indicating coverage or non-coverage for the
proposed treatment plan. Dentists who begin treatment before receiving an approved or denied
prior authorization are financially obligated to complete treatment at no charge to the member or
face possible termination of their Provider Agreement. Providers cannot bill prior to services being
performed.
If the case is denied, the prior authorization will be returned to the provider indicating Passport will
not cover the orthodontic treatment. However, an authorization will be issued for the payment of
the pre-orthodontic visit (code D8660), which includes treatment plan, radiographs, and/or photos,
records and diagnostic models, for full treatment cases only (Code D8080), at the provider's
contracted rate. This payment will be automatically generated for any case denied for full treatment.
19.7.3.6.1 Cleft Palate Services
Orthodontic care under the program will be evaluated based on medical necessity. All orthodontic
services require prior authorization by a Dental Consultant.
19.7.3.6.2 General Billing Information for Orthodontics
The start and billing date of orthodontic services is defined as the date when the bands, brackets,
or appliances are placed in the member's mouth. The member must be eligible on the first date of
service. Should the member lose eligibility during treatment, the full treatment will be
covered/paid.
To guarantee proper and prompt payment of orthodontic cases, please follow the steps below:
Electronically file, fax or mail a copy of the completed ADA form with the date of service
(banding date) filled in. Our fax number is (866) 653-5544.
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19.7.3.6.3 Orthodontic Payment Information
•
•
•
•
•
Initial payments for orthodontics (code D8080) includes pre-orthodontic visit, radiographs,
treatment plan, records, diagnostic models, initial banding, debanding, 1 set of retainers,
and 12 months of retainer adjustments (If retainer fees are not separate).
Once Avesis receives the banding date, the initial payment for code D8080 will be set to
pay out. Providers must submit a claim for a periodic treatment visits (code D8670) after
six months of treatment to receive the final payment for orthodontics. At the end of
treatment, providers may bill for code D8680 for retention.
The maximum case payment for orthodontic treatment will be one (1) initial payment
(code D8080) and one (1) periodic orthodontic treatment visits (code D8670) six months
after banding. Members may not be billed for broken, repaired, or replacement of brackets
or wires.
Payment of records for cases that are denied will be made automatically. There is no need
to submit for the records payment (code D8660).
Payment of records/exams (code D8660) will NOT be paid prior to the case being
reviewed by the consultant. Please do not submit separate claims for these procedures.
Please notify Avesis immediately should the member discontinue treatment for any
reason.
19.7.3.6.4 Continuation of Orthodontic Treatment:
The following information is required for possible payment of continuation of care cases:
•
•
•
The original banding date.
A detailed paid-to-date history showing dollar amounts for initial banding and periodic
orthodontic treatment fees.
A copy of the member's prior approval including the total approved case fee, banding fee,
and periodic orthodontic treatment fees.
If the member started treatment under commercial insurance or fee for service, the ORIGINAL
diagnostic models (or OrthoCad) must be provided, or radiographs (optional), banding date, and a
detailed payment history.
It is the provider’s and member's responsibility to get the required information. Cases cannot be
set-up for possible payment without complete information.
Payments for orthodontics (code D8080) include pre-orthodontic visit, radiographs, treatment
plan, records, diagnostic models, initial banding, 1 set of retainers, and 12 months of retainer
adjustments.
The maximum case payment for orthodontic treatment will be 1 initial payment (code D8080),
initial and final records (code D8660), o n e ( 1) payment for the 6 periodic orthodontic treatment
visits (code D8670), and retention (code D8680). Members may not be billed for broken,
repaired, or replacement of brackets or wires.
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See Attachment D for Orthodontic Criteria Index Form.
See Attachment E for Orthodontic Continuation of Care Form.
19.7.3.7 Post Treatment Review Routine Services
While some dental services will be reviewed after the treatment is completed, payment will not be
delayed for this review. Providers are responsible for submitting all necessary attachments. If these
attachments are not received, payment and/or claims will be denied and additional information
requested.
If the Avesis State Dental Director or a member of the Dental Advisory Board determines the
treatment was inappropriate or excessive based upon the status of the tooth on the radiograph,
future claim payments may be reduced to recoup monies already paid for the service. If there are
extenuating circumstances that are relevant, it is imperative that the dental provider include a
written explanation with the claim.
Dental service codes requiring post treatment review are provided below.
CDT Code
D3310
D3320
D3330
D3410
D3421
Description
Root canal - Anterior (excluding final restoration)
Root canal - Bicuspid (excluding final restoration)
Root canal - Molar (excluding final restoration)
Apicoectomy/periradicular surgery – anterior
D3425
D3426
D4341
D4355
Apicoectomy/periradicular surgery - molar (first root)
Apicoectomy/periradicular surgery (each additional root)
Periodontal scaling and root planing, per quadrant
Full mouth debridement to enable comprehensive evaluation and diagnosis
Apicoectomy/periradicular surgery - bicuspid (first root)
All of these services will require copies of pre-treatment radiographs of the tooth or teeth to be
included at the same time that the claim form is submitted. The claim form and pre-treatment
radiographs may be submitted either electronically or on the current ADA claim form. Please note
that no additional radiographs will be requested other than those necessary for proper diagnosis and
treatment.
19.8 Authorization Procedures and Requirements
Prior Authorization is a request made in advance for dental services to be performed by the Passport
network general/pediatric dentist.
19.8.1 Prior Approval for Non-Emergency Situations
Non-emergency treatment for services requiring prior approval started prior to the granting of prior
authorization will be performed at the financial risk of the dental office. If authorization is denied,
the dental office or treating provider may not bill the member, Passport, or Avesis. Receipt of
authorization or denial of the request for prior approval will be provided within two (2) business
days.
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Services that require Prior Approval for non-emergency care include
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED
YES / NO
All
Yes for members age
5 and under only
D0330
Panoramic film
All
One per patient per dentist or
dental group every 24 months.
Part of D8660 for orthodontic
patients. Authorization
required for ages 0 - 5.
D0340
Cephalometric
Film
All
Part of D8660
D4210
Gingivectomy or
gingivoplasty-four
or more
contiguous teeth
or bounded teeth
spaces per
quadrant
D4211
Gingivectomy or
gingivoplasty- one
to three
contiguous teeth
or bounded
spaces per
quadrant
All
One per 12 months. A
minimum of four (4) teeth in
the affected quadrant.
Limited to patients with
gingival overgrowth due to
congenital, heredity or drug
induced causes.
Yes for members age
5 and under only
All
Yes--prepayment
review
All
Yes--prepayment
review
All
One per 12 months. One (1)
to three (3) teeth in the
affected quadrant. Limited to
patients with gingival
overgrowth due to congenital,
heredity or drug induced
causes.
D4341
Periodontal
scaling and root
planing, per
quadrant
All
One per 12 months. A
minimum of three (3) teeth in
the affected quadrant. Cannot
bill in conjunction with D1110
or D1201. One per 3 months
for patients diagnosed with
AIDS.
All
Yes-post review
since 10/1/12 and
prior authorization
effective ?
D4355
Full mouth
debridement to
enable
comprehensive
evaluation and
diagnosis
All
Covered for pregnant women
only. One per pregnancy.
All
Post review to
confirm pregnancy
D5820
Interim partial
denture
(maxillary)
All
One per 12 months per
patient.
0-20
Yes
D5821
Interim partial
denture
(mandibular)
All
One per 12 months per
patient.
0-20
Yes
D5913
Nasal prosthesis
All
Covered for Prosthodontists
only.
All
Yes
Page 299 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED
YES / NO
D5914
Auricular
prosthesis
All
Covered for Prosthodontists
only.
All
Yes
D5919
Facial prosthesis
All
Covered for Prosthodontists
only.
All
Yes
All
Covered for Prosthodontists
only.
All
Yes
All
Covered for Prosthodontists
only.
All
Yes
All
Covered for Prosthodontists
only.
All
Yes
All
Covered for Prosthodontists
only.
0-13
Yes
D5931
D5932
D5934
D5952
Obturator
prosthesis,
surgical
Obturator
prosthesis,
definitive
Mandibular
resection
prosthesis
Speech aid pediatric (13 and
under)
D5953
Speech aid - adult
(14 -20)
All
Covered for Prosthodontists
only.
14-20
Yes
D5954
Palatal
augmentation
prosthesis
All
Covered for Prosthodontists
only.
All
Yes
D5955
Palatal lift
prosthesis
All
Covered for Prosthodontists
only.
All
Yes
D5988
Oral surgical
splint
All
Covered for Prosthodontists
only.
All
Yes
All
Covered for Prosthodontists
only.
All
Yes
1-32
No Limitations
0-20
Yes-prepayment
review
D5999
D7280
Unlisted
maxillofacial
prosthetic
procedure
Surgical access of
an unerupted
tooth
D7880
Occlusal orthotic
device, by report
All
Once per lifetime.
0-20
Yes-prior
authorization
D8080
Comprehensive
orthodontic
treatment of the
adolescent
dentition
All
No Limitations
0-20
Yes
D8210
Removable
Appliance
Therapy
All
0-20
Yes
D8220
Fixed Appliance
Therapy
All
0-20
Yes
This appliance is not to be
used to control harmful
habits. Limit of two (D8210,
or D8220) per 12 months.
This appliance is not to be
used to control harmful
habits. Limit of two (D8210,
or D8220) per 12 months.
Page 300 of 331
ADA
CODE
D8660
D8670
D8680
D8999
DESCRIPTOR
Pre-orthodontic
treatment visit
Periodic
orthodontic
treatment visit(as
part of the
contract)
Orthodontic
Retention(removal
of appliances,
construction and
placement of
retainer(s))
Unspecified
orthodontic
procedure, by
report
TEETH
COVERED
BENEFIT LIMITATIONS
AGE
LIMITATIONS
All
Used to pay for records. Final
records will be paid only if
member is age 20 and under
and still eligible for benefits
on date of service. Member
cannot be billed for final
records.
AUTHORIZATION
REQUIRED
YES / NO
0-20
Yes
All
Quarterly Payment
No limitations
Yes
All
Final Payment
No limitations
Yes
All
Six month payment.
0-20
Yes
All EPSDT Special Services (aka Expanded Services) require prior authorization.
This list is also available at www.avesis.com.
Form to use: ADA Claim Form for Pre-Treatment Estimates. Providers may submit a pre-treatment
estimate in one of two ways:
1. Electronic submission, please go to www.avesis.com; or
2. Mail on an ADA claim form to:
Avesis Third Party Administrators, Inc.
P. O. Box 7777
Phoenix, Arizona 85011-7777
Attn: Dental Pre-Treatment Estimate
ADA dental claim forms are not accepted via fax. Because all prior authorization requests for prior
approval for non-emergency situations must be submitted electronically on our website or on an
ADA dental claim form, the provider must either submit them on the website or mail in an ADA
dental claim form with the appropriate box checked indicating the provider is submitting a request
for a pre-treatment estimate.
Prior authorization of dental services must be performed as a part of a complete dental treatment
program and must be accompanied by a detailed treatment plan. The treatment plan must include all
of the following:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
pertinent dental history;
pertinent medical history, if applicable;
the strategic importance of the tooth;
the condition of the remaining teeth;
the existence of all pathological conditions;
preparatory services performed and completion date(s);
documentation of all missing teeth in the mouth;
the general oral hygiene condition of the member;
all proposed dental work;
identification of existing crowns, periodontal services, etc.
identification of the existence of full and/or partial denture(s), with the date of initial insertion,
if known;
the periodontal condition of the teeth, including pocket depth, mobility, osseous level, vitality
and prognosis;
identification of abutment teeth by number;
periodontal services, include a comprehensive periodontal evaluation.
For those situations where dental services are limited to services provided in an inpatient hospital,
hospital short procedure unit or ambulatory surgical center, please include a statement identifying
where the service will be provided. Please see Sections 19.8.4 and19.8.5 for information regarding
referrals to hospitals and other facilities for dental treatment.
19.8.2 Emergency Care
A dental emergency is a situation where the member has or believes there is a current, acute dental
crisis that could be detrimental to his/her health if not treated promptly.
In the event a dental emergency occurs after business hours and the provider cannot treat the
member within twenty-four (24) hours, please refer the member to Avesis at 1-866-909-1037 for
further assistance. Passport requires providers ensure sufficient access to help keep the member
from having services rendered in a hospital emergency room.
19.8.2.1 Emergency Access and Authorizations
All Passport provider offices are responsible for the effective response to, and treatment of, dental
emergencies. In relation to dental emergencies, there are two types of members:
1) Members of record (i.e., members who are routinely treated by the provider); or
2) Members who have not been previously seen by the office.
and two situations:
1) during regular office hours; or
2) after hours.
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To confirm whether the situation is a true emergency, the dentist should speak with the member to
determine the member’s problem and take the necessary actions. If it is determined by the provider
and the member that it is a true dental emergency (that is: a situation that cannot be treated simply
by medication and, that left untreated, could affect the member’s health or the stability of his/her
dentition), then the provider may either: A) render services in the dental office to treat the
emergency, or B) assist the patient in obtaining proper dental care from another dental provider or a
hospital emergency room, if the condition warrants emergency room treatment.
19.8.2.2 Members of Record
If the member telephones with an emergency before 12 noon, the provider must respond to the
member the same business day, if possible. If the member telephones after 12 noon, the member
must be responded to the same day if possible, but no later than the following business day. If the
provider is not treating patients the following business day, then weekend requirements will apply.
For a weekend, holiday, or other "off hour" dental emergency, the provider must make available an
answering service or telephone number available for the member of record to contact. The
responding dentist should assess the emergency request from the patient and make arrangements to
provide appropriate follow-up care. If the situation is determined to be a true dental emergency (a
situation that cannot be treated simply by medication and, that left untreated, could affect the
member’s health or the stability of his/her dentition), the responding dentist must either:
•
•
arrange for the member to come into the office to treat the emergency, or
assist the member in obtaining proper dental care from another network
dental provider.
Passport is committed to providing effective emergency care for patients without the use of hospital
emergency rooms, unless absolutely necessary. Members of record shall be required to see their
dentist of choice prior to any hospital admission. The dentist must request prior approval from
Passport (see Sections 19.8.4 and 5.1).
19.8.2.3 Members Not Previously Treated By Provider
In the case of a Dental Emergency or Urgent dental condition, the provider must make every effort
to see the member immediately or see the member on the next business day or sooner, if possible.
For weekend Dental Emergencies, the provider must have an answering service or cell phone
number available for contact. Passport will permit treatment of all dental services necessary to
address the Dental Emergency for the member without prior authorization. However, elective
dental services, not necessary for the relief of pain and/or prevention of immediate damage to
dentition, fall under the standard Pre-Treatment/Prior Authorization estimate procedures.
19.8.2.4 Waiver of Pre-Treatment Estimate/Prior Approval for Emergencies
Passport recognizes that in the case of emergency care, the provider may not be able to obtain a
Pre-Treatment Estimate / Prior Authorization. In this situation, required documentation must be
submitted after treatment along with the provider’s ADA claim form including radiographs,
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narrative, and CDT codes within thirty (30) business days of the date of service. Claims sent
without documentation will be denied and the member is not liable for payment. The minimum
materials must include:
•
•
•
•
•
Narrative explaining the emergency and treatment rendered;
Claim form complete with all applicable ADA-CDT codes or
medical CPT codes;
Radiograph(s) of tooth / teeth and any area of treatment, if appropriate;
Hospital records, if admitted to hospital; and,
Anesthesia records, if general anesthesia was administered.
The clinical reviewer and/or the State Dental Director or Dental Advisory Board Member will
review the claim along with the accompanying documentation submitted. If the claim is found to
not be a qualified emergency, the payment may be reduced or denied.
In the event the emergency occurs after business hours and the provider cannot treat the member
within twenty-four (24) hours, the provider must contact Avesis at 1-866-909-1037 to allow for the
arranging of timely emergency care. Although Passport requires dental providers ensure sufficient
access so that the provider attempts to limit having services rendered in a hospital emergency room,
the provider should refer members to a hospital emergency room when he/she cannot provide or
arrange immediate care.
Emergency services shall not include the following:
•
•
•
•
Prophylaxis, fluoride and routine examinations.
Routine restorations, including stainless steel and composite crowns.
Dentures, partial dentures and denture relines and repair.
Extraction of any asymptomatic teeth, including 3rd molars.
19.8.3 Specialty Referral Process
A member requiring a referral to a dental specialist can be referred directly to any specialist
contracted with Passport without authorization. The dental specialist is responsible for obtaining
prior authorization for services. If the provider is unfamiliar with the Passport contracted specialty
network or needs assistance locating a certain specialty, please contact the Provider Services
department. In addition, members may self-refer to any network provider without authorization.
Members have direct access to dental specialists. A referral is not necessary.
19.8.4 Hospital Referral
Hospital referrals will be handled by Passport. If hospitalization of a member for dental services is
necessary, the hospital must be authorized using the regular process for Passport. Please refer to
Section 5.1 of the Provider Manual.
19.8.5 Participating Ambulatory Surgical Centers (ASC) and Hospitals for PreTreatment Estimate/Prior Approval
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With Pre-Treatment Estimate/Prior Approval, providers may render services at Passport approved
Ambulatory Surgical Centers (ASC), IV Sedation Clinics or hospitals when services are unable to be
performed in the dental clinic setting. Please see the following link for a list of Passport ASCs, IV
Sedation Clinics and hospitals:
http://www.passporthealthplan.com/apps/provider-directory/index.asp
19.8.6 Second Opinion
The dentist should discuss all aspects of the patient’s treatment plan prior to beginning treatment.
Make sure all of the member’s concerns and questions have been answered. If the patient indicates
he/she would like a second opinion, inform the member he/she may do so and that Passport will
cover the cost of a second opinion if h e / s h e sees a dentist within the Passport network of
participating dentists. The dentist must provide copies of the chart, radiographs and any other
information to the dentist performing the second opinion upon request.
19.9 Quality Improvement
Passport strongly encourages and supports providers in the use of outcome measurement tools for all
members. Outcome data is used to identify and understand why there are areas of under-utilization.
Annual analysis of HEDIS results along with quarterly statistical provider reviews facilitates our
efforts and is complemented by on-site surveys and quarterly wait time reviews as described below.
19.9.1 Quarterly Statistical Provider Review
At the end of each quarter, Avesis compiles and reviews total services rendered by all dental
providers in the Passport Dental Program. The objective of the utilization review process is intended
to provide feedback regarding the demand for dental services and appropriateness of care. Each
code will be analyzed against the number of total Passport dental members being treated. The result
will be an average frequency of services per 100 recipients treated in the Passport Dental Program.
Providers’ per member cost will be calculated for the quarter. An average per member cost income
will be the result. The following items formulate the basis of the utilization review:
•
Average Service Comparison – a summary of the statistical results by ADA code for each
provider compared with the state average. An analysis will be performed only if the provider
has treated a sufficient number of Passport dental members in that quarter. Providers that
qualify must fall within a reasonable range of the state average. Those providers falling outside
of the range will be reviewed for over or under-treatment patterns.
•
Relative Service Comparison – Certain dental services are typically performed with or after
other services. A series of related dental services will be reviewed for appropriate care.
Examples of such services are:
o A root canal on a tooth, D3310 or D3320, followed by the placement of a stainless
steel crown, D2930
o A fluoride treatment for a child being performed at the same appointment as their
prophylaxis. These related services would be compared to the averages and to other
similarly utilized providers to detect any over or under utilization.
Page 305 of 331
•
Total Quarterly Per Member Cost –A calculation of the per member cost for all Passport
providers using the services rendered during each quarter. The results shall be compared to all
other providers and to previous quarters. Providers may request a summary of their per
member cost compared to the state average.
•
Accurate Claim Submission – This will be assessed via the following:
o During the quarterly statistical review, Passport will look for any services that
would be impossible due to a tooth being previously extracted or a service done on
a tooth that would not require that service (i.e. placing an amalgam on a tooth that
already had a stainless steel crown).
o Compliance with processes.
The goal in the utilization review process is to ensure provider satisfaction along with quality care for
members.
19.9.2 On-Site Office Survey
The office site survey has two components: prospective and ongoing for participating offices. Each
review highlights essential areas of the office management and dental care delivery. During the site
survey (which may or may not be scheduled), the following areas will be evaluated:
•
•
•
•
•
•
•
General Information – the name of the practice, address, name of principal owner and
associates, license numbers, staffing information, office hours, list of foreign languages
spoken in the office, availability of appointments and method of providing twenty-four
(24) hour coverage (e.g. answering machine, answering services, etc.) the name of the
covering dentist when the office is closed, such as on vacation.
Practice History – the office provides information regarding malpractice suits, settlements
and disciplinary actions, if applicable.
Office Profile - indicates services they routinely perform.
Facility Information – includes location, accessibility (including handicap accessibility)
description of interior office such as the reception area, operatory and lab, type of infection
control, equipment and radiographic equipment.
Risk Management – includes review of personal protective equipment (such as gloves,
masks, handling of waste disposal, sterilization and disinfection methods), training
programs for staff, radiographic procedures and safety, occupational hazard control
(regarding amalgam, nitrous oxide and hazardous chemicals), medical emergency
preparedness training and equipment.
Recall System – includes review of procedures for assuring patients are scheduled for recall
examinations and follow-up treatment.
Verification that all participating dental providers in a group practice are credentialed.
19.9.3 Quarterly Wait Time Review
In lieu of requiring providers to submit a report of average wait times on a quarterly basis, random
and anonymous surveys are performed of provider practices to inquire whether scheduling wait
Page 306 of 331
times as well as office wait times are excessive. Providers found to have excessive wait times will be
required to implement a corrective action plan.
1.
If a member complains to Passport, DMS, CMS or other state or federal agency that wait
times in a provider’s office were excessive, it is required for us to contact the provider to
advise there was a complaint filed against their office. Once the provider is notified, Passport
will work with the provider to formulate a written corrective action plan and follow up to
ensure the action has been implemented.
2. If a member complains to Passport, DMS, CMS, or other state or federal agency that it was
difficult to make an appointment for routine care, Passport is required to contact the
provider’s office to advise the provider there was a complaint filed against their office. Once
the provider is notified, a written corrective action plan will be formulated and follow up to
ensure the action has been implemented.
It is important to note that providers who do not implement a corrective action plan upon request
may be subject to termination from the network.
19.9.4 Dental Committees
Passport welcomes involvement from the dentists who participate in the Passport Dental Program.
There are currently three active committees that are staffed with dentists who participate in the
Passport Dental Program. These committees provide opportunities for feedback from our local
dental communities.
The Credentialing Committee helps to ensure the acceptability of new dentists before their entry
into the Passport network as well as upon re-credentialing. The committee credentials new network
providers and reviews the credentials upon re-credentialing every thirty-six (36) months. In addition,
this committee reviews disciplinary information received during the continuous credentialing process
on a monthly basis and conducts review of any appeals from dentists who have been sanctioned.
Meetings are held every other week.
The Quality Assurance Committee is a multi-disciplinary committee whose critical focus is the
review of the statistical summary data to determine the primary areas to focus on for improvement.
Committee members review planned efforts toward continuous quality improvement, establish
standards for quality review of the Dental Program and provide input toward Passport planning for
future planned improvements. Meetings are held on a quarterly basis.
The Complaint Resolution /Peer Review Committee includes the Chief Dental Officer, Advisory
Board and up to (3) dentists from the Passport provider network. Its critical focus includes
reviewing the complaints received from members and dental network providers to determine the
validity of the complaints and the appropriate response to the party bringing the complaint. The
committee addresses decisions concerning the appropriate settlement of clinical disputes between
providers and patients. Meetings are held quarterly.
The State Dental Director is an employee or contractor with Avesis who serves as the provider’s
local contact as a dental professional. The State Dental Director represents Avesis at meetings of the
Page 307 of 331
local Dental Association and its component societies and at meetings with Passport. The State
Dental Director is available for discussion and consultation concerning issues of importance to
Passport’s dental network providers. Providers may contact Provider Services at (866) 909-1083 to
speak with the State Dental Director.
All of Passport Dental Program committees include the Chief Dental Officer as either an active
member or as an attendee.
19.10 Dental Provider Billing Manual
All claims submitted will be processed and paid according to the Passport Covered Benefits Schedule.
Passport follows the American Dental Association (ADA) Current Dental Terminology (CDT)
guidelines. Each claim must include the appropriate line item with the provider’s usual charge,
current CDT Code, and tooth number, when applicable.
Claims must be received within one hundred eighty (180) days from the date of service to meet timely
filing requirements. Claims received after the one hundred eighty (180) days will be denied.
Claims may be submitted in one of the following three formats:
•
•
•
Through EDI (arrangements must be made with the Avesis IT Department prior to submission);
On our website at: www.avesis.com; or
On paper, submit ADA claim form to:
Avesis Third Party Administrators, Inc.
Attn: Dental Claims
P.O. Box 7777
Phoenix, Arizona 85011-7777
19.10.1 Electronic Claims Submission via Clearinghouses
Providers may submit claims using Emdeon or EHG clearinghouses that can convert paper claims
into a HIPAA Compliant Electronic Data Interchange (EDI) format. The Avesis payer identification
number is 86098. If you have any questions regarding Emdeon, please contact Emdeon directly at
(877) 469-3263. If you have any questions regarding EHG, please contact EHG directly at (800)
576-6412.
19.10.1.1 Electronic Attachments
Providers may submit images, charting, and notes directly to Avesis at no charge on our website at
www.avesis.com. Avesis also accepts electronic attachments via FastAttach™, a National Electronic
Attachment, LLC (NEA) company, for Prior Authorizations requests requiring these documents.
This program allows transmissions via secure internet lines. For more information, contact
FastAttach™ at: www.fast.nea.com or NEA at: (800) 782-5150.
Page 308 of 331
19.10.2 Claim Follow -Up
The provider has a right to correct information submitted by another party or to correct his/her
own information submitted incorrectly. Changes must be made in writing and directed to the
attention of the Claims Manager within the appropriate time frame.
When calling or writing to follow up on a claim(s), please have the following information available:
1.
2.
3.
4.
5.
6.
8.
Patient’s Name
Date of Service
Patient’s Date of Birth
Member’s Name
Member’s KY Medicaid ID Number
CDT Codes
Claim Number, if the claim has been paid
Providers are encouraged to follow-up on any and all claims not paid within thirty (30) days of the
date that the claim was filed. Do not wait more than thirty (30) days after claim submission before
notifying of a claim that has not been adjudicated. We are required to strictly adhere to the timely
filing guideline of one hundred eighty (180) days. There will be no exceptions. Claims received after
the filing deadline will be denied.
Note: Members cannot be balanced billed for any charges or penalties incurred as a result of late or
incorrect submissions.
19.10.3 To Resubmit Claims
Resubmitted claims must be submitted within ninety (90) days of the initial submission and include
the original claim number. If submitting them on an ADA claim form, please write CORRECTED
at the top of the form to ensure proper handling of the claim in the Processing Department.
19.10.4 Summary of Claim
A summarization of the claim payment will be included with the provider’s claim check. A
summarization of previously submitted claims for underpayments and/or overpayments may also be
included. Summarizations of claim payments are available after submission of a claim on Avesis'
website. In addition, providers may view remittance advices within one business day of payment on
the website at www.avesis.com.
19.10.5 Payment
Passport complies with all applicable prompt payment laws regarding the processing and payment of
clean claims. Check runs are routinely done on a weekly basis. A “CLEAN” claim contains the
following correct and true information:
1. Member’s Name
2. Member’s Date of Birth
3. Member’s KY Medicaid Identification Number
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4.
5.
6.
7.
Acceptable CDT Code
Approval Number, if applicable
Provider information including NPI number and State Medicaid number, if applicable
Provider’s signature
Missing or incorrect information will cause delays in payment or the claim may be returned to the
provider unpaid.
If payment is not received in a timely manner, it may be due to:
1. Claim not received
2. Eligibility verification
3. Claim was returned to the provider for missing information
Do not wait more than thirty (30) calendar days after claim submission before notifying of a claim
that has not been adjudicated.
Note: Members cannot be balance billed for any charges or penalties incurred as a result of
late or incorrect submissions
Claims being investigated for fraud or abuse or pending medical necessity review are not
Clean Claims.
19.10.6 EPSDT Claims
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a federally mandated program
developed to ensure that the Medicaid population younger than the age of 21 is monitored for
preventable and treatable conditions.
EPSDT Special Services (aka Expanded Services) are available to some Passport members younger
than 21 years of age depending on the category of aid. These are services required to treat
conditions detected during an encounter with a health professional and are eligible for payment
under the federal Medicaid program but not currently recognized under the state plan. KCHIP III
members are not eligible for EPSDT Expanded Services. (Note this pertains to KCHIP III members
only - not KCHIP I and II). Please refer to Section 8.0 for detailed information on EPSDT.
All EPSDT Special Services require pre-authorization. Indicate “EPSDT” on the pre-authorization
form and submit with X-rays and/or charting. Requests for pre-authorization must be made on an
ADA form with supporting documentation explaining the rationale for treatment. Requests for
EPSDT Special Services pre-authorization may be submitted electronically via the website or mailed
to our office at:
Avesis
PO Box 7777
Phoenix, AZ 85011-7777
Page 310 of 331
19.10.7 Coordination of Benefits
Primary vs. Secondary Insurance
Passport is the payer of last resort for members. All claims must be filed with commercial insurance
companies or third party administrators prior to filing claims with Passport for reimbursement for
services rendered to Passport members. If it is later determined that the member had other
insurance coverage, you will be notified and will be required to either reimburse Passport for the
amounts paid to the provider or the money will be recouped from future payments.
If Passport is not the primary payer, you must bill the primary payer first. If the claim is initially filed
with Avesis, the claim will be denied. If the primary payer pays less than the agreed upon fee, you
may bill for the balance. You must enclose the Remittance Advice from the primary payer. The
claim must be received within 180 days after receiving the Remittance Advice. Remaining charges
will be reimbursed up to the maximum Passport allowed amount. However, Passport agrees to pay
all clean claims for EPSDT services to children. Cost avoidance of these claims is prohibited.
19.10.8 Payment
Passport complies with the federal and Commonwealth of Kentucky prompt pay law requiring that
all eligible clean claims be processed within 30 business days. Passport will pay eligible clean dental
claims on a weekly basis. Providers submit a clean claim form or file electronically after services and
materials have been provided. Should the provider’s clean claim not be processed within thirty (30)
business days, Passport will pay interest in accordance with state and federal requirements.
Providers are eligible to receive payments via Electronic Funds Transfer thereby enabling dental
practices to maintain a positive cash flow. Providers may access their remittance advice electronically
within twenty-four (24) hours of the payments being deposited (Please see Attachment C for
Electronic Funds Transfer Agreement). The remittance advice will still be mailed to the address of
record in the provider file once weekly as well.
All claims should be submitted on an ADA claim form. The claim form must include the
following information:
•
•
•
•
•
•
•
•
•
Member name
Member KY Medicaid Identification number
Member and/or Guardian Signature (or Signature on File)
Member date of birth
Description of services rendered
Dentist Individual NPI, group NPI if applicable, taxonomy code, group taxonomy code if
applicable and Medicaid number (included with electronic or online submissions)
Dentist name, state license number and signature (included with electronic or online
submissions)
Dentist address, office ID# and phone number (included with electronic or online
submissions)
Proper CDT coding with tooth numbers, surfaces, quadrants and arch when applicable
Page 311 of 331
•
Full mouth x-ray series, bitewings and/or periapical x-rays when needed
Explanations of Benefits (EOBs) will be available online for all offices.
•
•
•
•
For offices receiving Electronic Funds Transfer (EFT) payments, the EOB will only be
available online.
For offices receiving a paper check, the EOB will be included in the envelope.
Offices that receive EFT payments have the option to request a paper.
EOB be sent at the time of payment.
19.11 Fraud, Waste and Abuse
Passport is committed to preventing, detecting and reporting possible fraud, waste and abuse.
Providers are required to cooperate with the investigation of suspected fraud, waste and abuse. If
you suspect fraud, waste or abuse by a Passport member or provider, it is your responsibility to
report this information immediately. Please contact:
Passport Health Plan Compliance Hotline:
(855) 512-8500
Please refer to Section 3.4.6 of the Provider Manual for detailed information on Fraud and Abuse.
19.12 Cultural Competency
Please refer to Section 2.11 of the Provider Manual for important information regarding Title VI
Requirements including but not limited to translator and interpreter services as well as training and
resources available to providers.
Page 312 of 331
Attachment A
Avesis Eligibility Verification Fax Form
Provider Name: __________________________________________
Provider PIN#:
_________________________________________
Provider Tax ID #: ________________________________________
Fax Number:
Member
ID #:
________________________________________
Member Name
Member
DOB
Date of
Service
Active
Coverage:
Yes
No
Member eligible for:
D0120
D1110
D0220
D0230
Restorations
Instructions: Complete the appropriate fields indicated above (one line per Member) and fax to Avesis’ secure
fax line at: (866) 332-1632. You will receive a reply by fax within one (1) business day.
Page 313 of 331
Attachment B
Non - Covered Services Disclosure Form
To be completed by Dentist Rendering Care
I am recommending that _____________________________________ receive
Member Name and Identification Number
services that are not covered by the Passport Health Plan Covered Benefits Schedule. I am willing to accept my
Usual and Customary Fee as payment in full. The following procedure codes are recommended:
CODE
DESCRIPTION
FEES
The total amount due for service(s) to be rendered is $___________
Provider’s Signature
Date
To be completed by Member
I ________________________________________________, have been told
Print Your Name
that I require services or have requested services that are not covered by the
Covered Benefits Schedule.
Read the question and check either YES or NO
Passport Health Plan
YES
NO
My doctor has assured me that there are no other covered benefits.
I am willing to receive services not covered by the dental program.
I am aware that I am financially responsible for paying for these services.
I am aware that Passport Health Plan is not paying for these services.
As agreed to with the dentist, I agree to pay $_________. If I fail to make the agreed upon payment(s) I
may be subject to collection action.
Member’s Signature if over eighteen (18) or Parent / Guardian
Date
Page 314 of 331
Attachment C
Electronic Funds Transfer Agreement
ACCOUNT REGISTRATION INFORMATION
Name
Tax ID Number
Address
City, State, Zip Code
BANK INFORMATION
Bank Name
Checking
Savings
Other ____________
Address
City, State, Zip Code
Routing #
Account #
I, ____________________________________, as the authorized party, allow Avesis to deposit funds into my
Bank Account using Electronic Funds Transfer. A voided check is included with this agreement to facilitate this
process. This transfer is for my convenience. All claims filed are in accordance with the terms of the executed
Passport Agreement and the Passport Provider Manual. All funds shall be deposited into my bank account at
the banking institution shown above. The bank shall provide to Avesis your most current address upon request.
I understand that:
1. The origination of electronic credits to my account must comply with the provisions of
United States law.
2. Avesis and the Bank will share with each other limited account and contract information as
necessary to affect these credits.
3. By signing this document, I agree to accept the terms of the Electronic Funds Transfer.
4. This form must processed by Avesis before funds will be transferred into my Bank
Account.
Page 315 of 331
Printed Name of Account Holder
Signature of Account Holder
Date
Printed Name of Joint Account Holder
Signature of Joint Account Holder
Date
Telephone Number:
Please mail to:
Avesis Third Party Administrators, Inc.
Attention: Finance
PO Box 782 Owings Mills, Maryland 21117
Page 316 of 331
Attachment D
First Review ____
Second Review ____
Models
____
Orthocad
____
Ceph Films ____
X-Rays ____
Photos ____
Narrative ____
ORTHODONTIC CRITERIA INDEX FORM - COMPREHENSIVE D8080
Patient Name: ____________________________________
DOB: ___________________
ABBREVIATIONS
CRITERIA
YES
DO
Deep impinging overbite that shows palatal impingement of the majority of lower
incisors
AO
True anterior open bite. (Not including one or two teeth slightly out of occlusion or
where the incisors are not fully erupted).
AP
Demonstrates a large anterior-posterior discrepancy. (Class II and Class III
malocclusions that are virtually a full tooth Class II or Class III)
AX
Anterior crossbite. (Involves more than two teeth in crossbite or in cases where
gingival stripping from the crossbite is demonstrated).
PX
Posterior transverse discrepancies. (Involves several posterior teeth in crossbite, one
of which must be a molar AND must also contribute to a handicapping malocclusion
i.e.: “functional shift, facial asymmetry, complete buccal or lingual crossbite (scissor
bite) or speech concern.
PO
Significant posterior open bites. (Not involving partially erupted teeth or one or two
teeth slightly out of occlusion).
IMP
Impacted teeth (one or more) that will not erupt into the arches without orthodontic
or surgical intervention. (Does not include 3rd molars or cases where teeth are going
to erupt ectopically).
OJ
Has extreme overjet in excess of eight (8) to nine (9) millimeters AND one (1) of the
skeletal conditions specified above (DO, AO, AP, PX, or PO). Overjet alone is not
sufficient for approval.
TR
Has trauma or injury resulting in severe misalignment of the teeth or alveolar
structures, and does not include simple loss of teeth with no other affects.
CDD
Dentition exhibits a profound impact from a congenital or developmental disorder.
FAS
Significant facial asymmetry requiring a combination of orthodontics and
orthognathic surgery for correction.
ANO
Has developmental anodontia in which several congenitally missing teeth result in a
handicapping malocclusion or arch deformation.
Approved
Page 317 of 331
NO
Attachment E
ORTHODONTIC CONTINUATION OF CARE FORM
Member ID Number:
____________________________________________________
Member Name (Last/First):
Date of Birth:
_______________________________________________
_________________________________________________________
Name of Previous Vendor that issued original approval:
_____________________________________________________________________
Banding Date:
________________________________________________________
Case Rate Approved By Previous Vendor:
___________________________________
Amount Paid for Dates of Service That Occurred Prior to Avesis:
Amount Owed for Dates of Service That Occurred Prior to Avesis:
Balance Expected for Future Dates of Service:
Number of Adjustments Remaining:
Additional information required:
•
•
•
_________________
________________
_______________________________
________________________________________
___________________________________________
Completed ADA claim form listing services to be rendered.
If the Member is transferring from an existing Medical Assistance program: A copy of the original
orthodontic approval.
If the Member is private payer transferring from a commercial insurance program, please enclose the
original diagnostic models (or OrthoCad equivalent). Radiographs are optional.
Mail to:
Avesis
2300 Lake Park Drive, Suite 400
Smyrna, Georgia 30080
Attn: Utilization Management
Page 318 of 331
Attachment F
Covered Benefits Schedule
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D0140
Limited Oral EvaluationProblem Focused
All
All
No
Requires a prepayment
review
D0120
Periodic Oral Evaluation
- established patient
All
All
No
None
D0150
Comprehensive Oral
Evaluation
All
All
No
None
D0210
Intraoral - complete
series (including
bitewings)
Intraoral - periapical first
view
All
All
No
None
All
No
None
D0230
Intraoral - periapical each
additional film
All
All
No
None
D0270
Bitewing - single film
All
All
No
None
D0272
Bitewing - two film
All
All
No
None
D0274
Bitewing - four films
All
All
No
None
D0330
Panoramic film
All
Not reimbursable on the
same day as D0120 and
D0150. Trauma related
injuries only. May only be
billed in conjunction with
D0220, D0230, D0270,
D0272, D0274, D0330,
D2330, D2331, D2332,
D2335, D7140, D7130,
D7250, D7530, D7910 and
D9240.
Only one exam (D0120 or
D0150) every 6 months per
patient per dentist or dental
group.
One comprehensive exam
(D0150) per patient per
dentist or dental group every
12 months. Only one exam
(D0120 or D0150) every 6
months per patient per
dentist or dental group.
Cannot be billed on the same
day as D0120, D0140,
D1510, D1515, D1520,
D1525.
One per patient per dentist or
dental group every 12
months.
Total of 14 (D0220 and
D0230) per patient per
dentist or dental group every
12 months. Not to be billed
in the same 12 months as a
D0210.
Total of 14 (D0220 and
D0230) per patient per
dentist or dental group every
12 months. Not to be billed
in the same 12 months as a
D0210.
Total of 4 bitewing x-rays per
patient per dentist or dental
group every 12 months. Not
to be billed in the same 12
months as a D0210.
Total of 4 bitewing x-rays per
patient per dentist or dental
group every 12 months. Not
to be billed in the same 12
months as a D0210.
Total of 4 bitewing x-rays per
patient per dentist or dental
group every 12 months. Not
to be billed in the same 12
months as a D0210.
One per patient per dentist or
dental group every 24
months. Part of D8660 for
orthodontic patients.
Authorization required for
ages 0 - 5.
All
Yes for members age 5
and under only
None
D0220
All
Page 319 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D0340
Cephalometric Film
All
Part of D8660
Yes for members age 5
and under only
None
D1110
Prophylaxis - Adult
All
One per 12 months.
D1120
Prophylaxis - Child (Age
0 to 13)
All
Two per 12 months.
21 and older
No
None
0-20
No
None
D1208
Topical application of
fluoride - Child
(prophylaxis not
included)
All
Two per 12 months.
Fluoride must be applied
separately from prophylaxis
paste.
0-20
No
None
D1351
Sealant - per tooth
All
0-20
No
None
0-20
No
None
0-20
No
None
0-20
No
None
0-20
No
None
All
One per 48 months.
Maximum of 3 times.
Occlusal surfaces only. Teeth
must be caries free. Sealant
will not be covered when
placed over restorations.
Repair, replacement or
reapplication of the sealant
within the four year period is
the responsibility
Limit of 2 (D1510, D1515,
D1520 or D1525) per 12
months.
Limit of 2 (D1510, D1515,
D1520 or D1525) per 12
months.
Limit of 2 (D1510, D1515,
D1520 or D1525) per 12
months.
Limit of 2 (D1510, D1515,
D1520 or D1525) per 12
months.
No Limitations
D1510
Space maintainer-fixedunilateral
All
D1515
Space maintainer-fixedbilateral
All
D1520
Space maintainerremovable-unilateral
All
D1525
Space maintainerremovable-bilateral
All
D2140
Amalgam-one surface,
permanent/primary
All
No
None
D2150
Amalgam-two surfaces,
permanent/primary
All
No Limitations
All
No
None
D2160
Amalgam-three surfaces,
permanent/primary
All
No Limitations
All
No
None
D2161
Amalgam-four surfaces
or more,
permanent/primary
All
No Limitations
All
No
None
D2330
Resin-based composite one surface, anterior
Anterior
Teeth only
No Limitations
All
No
None
D2331
Resin-based composite two surfaces, anterior
Anterior
Teeth only
No Limitations
All
No
None
D2332
Resin-based composite three surfaces, anterior
Anterior
Teeth only
No Limitations
All
No
None
D2335
Resin-based composite four or more surfaces,
anterior
Anterior
Teeth only
No Limitations
All
No
None
D2391
Resin-based composite, 1
surface-posterior
primary/permanent
Posterior
Teeth only
No Limitations
All
No
None
D2392
Resin-based composite, 2
surfaces-posterior
primary/permanent
Posterior
Teeth only
No Limitations
All
No
None
Page 320 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D2393
Resin-based composite, 3
surfaces-posterior
primary/permanent
Posterior
Teeth only
No Limitations
All
No
None
D2394
Resin-based composite,
4+ surfaces-posterior
primary/permanent
Posterior
Teeth only
No Limitations
0-11
No
None
D2930
Prefabricated stainless
steel - primary tooth
No Limitations
0-20
No
None
D2931
Prefabricated stainless
steel - permanent tooth
No Limitations
0-20
No
None
D2932
Prefabricated Resin
crown
No Limitations
0-20
No
None
D2934
Prefabricated esthetic
coated stainless steel
crown - primary tooth
(Stainless steel primary
crown with exterior
esthetic coating)
Primary
Teeth only
(A-T)
Permanent
Teeth only
(1-32)
Only
Anterior
teeth 6-11,
22-27, c-h,
m-r
Anterior
Primary
Teeth only(ch,m-r)
2 per anterior tooth, per
member, per lifetime.
Anterior primary teeth only
(C, D, E, F, G, H, M, N, O,
P, Q, R).
0-11
No
None
D2951
Pin retention - per tooth,
in addition to restoration
Only for
Permanent
Molars(13,14-16,1719,30-32)
0-20
No
None
D3110
Pulp cap - direct
(excluding final
restoration)
Therapeutic pulpotomy
(excluding final
restoration) removal of
pulp coronal to the
dentinocemental junction
and application of
medicament.
All
Limited to permanent molars;
used in conjunction with
D2160, D2161, D2931, or
D2932. Lifetime maximum
of two per molar. Limit of
one per tooth per date of
service.
No Limitations
0-20
No
None
1-32, A-T
Shall not be billed in
conjunction with D3310,
D3320, or D3330 on the
same day.
0-20
No
None
D3310
Root canal - Anterior
(excluding final
restoration)
Only for
teeth 6-11
and 22-27
Once per lifetime.
0-20
Post review
Pre and Post treatment
radiographs showing
endodontic fill
D3320
Root canal - Bicuspid
(excluding final
restoration)
Only for
teeth 4, 5, 12,
13, 20, 21, 28,
29
Once per lifetime.
0-20
Post review
Pre and Post treatment
radiographs showing
endodontic fill
D3330
Root canal - Molar
(excluding final
restoration)
Only for
teeth 1-3, 1419, 30-32
Once per lifetime.
0-20
Post review
Pre and Post treatment
radiographs showing
endodontic fill
D3410
Apicoectomy/periradicul
ar surgery - anterior
Only for
teeth 6-11,
22-27
Once per lifetime.
All
Post review
1) Pre and PostTreatment radiographs
showing endodontic fill
of tooth (teeth) involved.
2) Complete treatment
plan.
D3220
Page 321 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D3421
Apicoectomy/periradicul
ar surgery - bicuspid
(first root)
Only for
teeth 4, 5, 12,
13, 20, 21, 28,
29
Once per lifetime.
All
Post review
1) Pre and PostTreatment radiographs
showing endodontic fill
of tooth (teeth) involved.
2) Complete treatment
plan.
D3425
Apicoectomy/periradicul
ar surgery - molar (first
root)
Only for
teeth 1-3, 1419, 30-32
Once per lifetime.
All
Post review
1) Pre and PostTreatment radiographs
showing endodontic fill
of tooth (teeth) involved.
2) Complete treatment
plan.
D3426
Apicoectomy/periradicul
ar surgery (each
additional root)
Only for
teeth 1-5, 1221, 28-32
Once per lifetime.
All
Post review
1) Pre and PostTreatment radiographs
showing endodontic fill
of tooth (teeth) involved.
2) Complete treatment
plan.
D4210
Gingivectomy or
gingivoplasty-four or
more contiguous teeth or
bounded teeth spaces per
quadrant
All
One per 12 months. A
minimum of four (4) teeth in
the affected quadrant.
Limited to patients with
gingival overgrowth due to
congenital, heredity or drug
induced causes.
All
Yes--prepayment
review
1) Comprehensive
periodontal evaluation
documentation.
2) Narrative
documenting necessity.
3) Pre-treatment
radiographs
4)Periodontal charting
D4211
Gingivectomy or
gingivoplasty- one to
three contiguous teeth or
bounded spaces per
quadrant
All
One per 12 months. One
(1) to three (3) teeth in the
affected quadrant. Limited to
patients with gingival
overgrowth due to
congenital, heredity or drug
induced causes.
All
Yes--prepayment
review
1) Comprehensive
periodontal evaluation
documentation.
2) Narrative
documenting necessity.
3) Pre-treatment
radiographs
4)Periodontal charting
D4341
Periodontal scaling and
root planing, per
quadrant
All
One per 12 months. A
minimum of three (3) teeth in
the affected quadrant.
Cannot bill in conjunction
with D1110 or D1201. One
per 3 months for patients
diagnosed with AIDS.
All
Yes-post review since
10/1/12 and prior
authorization effective?
1) Periodontal charting.
2) Narrative
documenting necessity.
3) Pre-Treatment
radiographs.
4) List number of
quadrants required on
Pre-Treatment/ Prior
Approval estimate.
D4355
Full mouth debridement
to enable comprehensive
evaluation and diagnosis
All
Covered for pregnant women
only. One per pregnancy.
All
Post review to confirm
pregnancy
None
D5520
Replace missing or
broken teeth - complete
denture (each tooth)
All
One per 12 months per
denture per patient.
0-20
No
None
D5610
Repair resin denture base
All
Three per 12 months per
patient.
0-20
No
None
D5620
Repair cast framework
All
Three per 12 months per
patient.
0-20
No
None
Page 322 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D5640
Replace broken teeth per tooth
All
One per 12 months per
patient per dentist.
0-20
No
None
D5750
Reline complete
maxillary denture
(laboratory)
All
0-20
No
None
D5751
Reline complete
mandibular denture
(laboratory)
All
0-20
No
None
D5820
Interim partial denture
(maxillary)
Interim partial denture
(mandibular)
All
One per 12 months per
denture per patient. Not
covered within 6 months of
placement.
One per 12 months per
denture per patient. Not
covered within 6 months of
placement.
One per 12 months per
patient.
One per 12 months per
patient.
0-20
Yes
Narrative
0-20
Yes
Narrative
D5913
Nasal prosthesis
All
All
Yes
Narrative
D5914
Auricular prosthesis
All
All
Yes
Narrative
D5919
Facial prosthesis
All
All
Yes
Narrative
D5931
Obturator prosthesis,
surgical
All
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
All
Yes
Narrative
D5932
Obturator prosthesis,
definitive
All
Covered for Prosthodontists
only.
All
Yes
Narrative
D5934
Mandibular resection
prosthesis
All
Covered for Prosthodontists
only.
All
Yes
Narrative
D5952
Speech aid - pediatric (13
and under)
All
Covered for Prosthodontists
only.
0-13
Yes
Narrative
D5953
Speech aid - adult (14 20)
Palatal augmentation
prosthesis
All
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
14-20
Yes
Narrative
All
Yes
Narrative
D5955
Palatal lift prosthesis
All
All
Yes
Narrative
D5988
Oral surgical splint
All
All
Yes
Narrative
D5999
Unlisted maxillofacial
prosthetic procedure
All
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
Covered for Prosthodontists
only.
All
Yes
Narrative
D7111
Coronal Remnants Deciduous tooth
A-T
No Limitations
All
No
None
D7140
Extraction, erupted tooth
or exposed root
No Limitations
All
No
None
D7210
Surgical removal of
erupted tooth requiring
elevation of
mucoperiosteal flap and
removal of bone and/or
section of tooth
1 - 32, 51 82, A-T, ASTS
1-32, 5 -82,
A-T, AS-TS
Includes cutting of gingiva
and bone, removal of tooth
structure and closure.
All
No
None
D7220
Removal of impacted
tooth - soft tissue
1-32, 51-82
No Limitations
All
No
None
D7230
Removal of impacted
tooth - partially bony
1-32, 51-82
No Limitations
All
No
None
D7240
Removal of tooth completely bony
Removal of impacted
tooth - completely bony,
with unusual surgical
complications
1-32, 51-82
No Limitations
All
No
None
1-32, 51-82
Unusual complications such
as nerve dissection, separate
closure of the maxillary sinus,
or aberrant tooth position.
All
No
None
Surgical removal of
residual tooth roots cutting procedure
1-32, 51-82,
A-T, AS-TS
Will not be paid to the
dentists or group that
removed the tooth.
All
No
None
D5821
D5954
D7241
D7250
All
All
Page 323 of 331
ADA
CODE
D7260
D7280
D7310
D7320
DESCRIPTOR
Oroantral fistula closure
Surgical access of an
unerupted tooth
Alveoloplasty in
conjunction with
extractions - per
quadrant
Alveoloplasty not in
conjunction with
extractions per quadrant
D7410
Radical excision - lesion
diameter up to 1.25 cm
D7472
Removal of torus
palatinus
Removal of torus
mandibularis
D7473
TEETH
COVERED
All
1-32
BENEFIT
LIMITATIONS
No Limitations
No Limitations
AGE
LIMITATIONS
All
0-20
AUTHORIZATION
REQUIRED?
No
Yes-prepayment review
Per quadrant
- 10 (UR), 20
(UL), 30
(LL), 40 (LR)
Per quadrant
- 10 (UR), 20
(UL), 30
(LL), 40 (LR)
Per quadrant
- 10 (UR), 20
(UL), 30
(LL), 40 (LR)
Upper Arch
(01, UA)
Lower Arch
(02, LA)
Once per lifetime. Minimum
of three extractions in the
affected quadrant. Usually in
preparation for a prosthesis.
Once per lifetime. No
extractions performed in an
edentulous area.
All
No
ATTACHMENTS
REQUIRED
None
Approved orthodontic
plan
None
All
No
None
No Limitations
All
No
None
Once per lifetime.
All
No
None
Once per lifetime.
All
No
None
D7510
Incision and drainage of
abscess (intraoral)
All
No Limitations
All
No
None
D7520
Incision and drainage of
abscess (extraoral)
All
No Limitations
All
No
None
D7530
Removal of foreign body
All
All
No
None
D7880
Occlusal orthotic device,
by report
Suture of recent small
wounds up to 5 cm
All
Shall not pertain to removal
of stitches (sutures) or teeth.
Once per lifetime.
0-20
Yes-prior authorization
Narrative
All
No
None
D7960
Frenulectomy
All
Shall not be billed in
conjunction with any other
surgical procedure. It shall
not pertain to repair of
surgically induced wounds.
Once per lifetime. Limited
to one per date of service.
All
No
None
D8080
Comprehensive
orthodontic treatment of
the adolescent dentition
All
No Limitations
0-20
Yes
1)Cephalometric image
with tracing
2)Panoramic or full
mouth image
3)Intraoral and extraoral
facial frontal and profile
pictures
4)Occluded and trimmed
models or digital images
of models
5)Initial payment is made
when treatment is started
D8210
Removable Appliance
Therapy
All
0-20
Yes
Arch or quadrant must
be indicated on the claim
D8220
Fixed Appliance Therapy
All
0-20
Yes
Arch or quadrant must
be indicated on the claim
D8660
Pre-orthodontic
treatment visit
All
This appliance is not to be
used to control harmful
habits. Limit of two (D8210,
or D8220) per 12 months.
This appliance is not to be
used to control harmful
habits. Limit of two (D8210,
or D8220) per 12 months.
Used to pay for records.
Final records will be paid
only if member is age 20 and
under and still eligible for
benefits on date of service.
Member cannot be billed for
final records.
0-20
Yes
1)Cephalometric image
with tracing
2)Panoramic or full
mouth image
3)Intraoral and extraoral
facial frontal and profile
pictures
4)Occluded and trimmed
models or digital images
of models
5)Initial payment is made
when treatment is started
D7910
All
Page 324 of 331
ADA
CODE
DESCRIPTOR
TEETH
COVERED
BENEFIT
LIMITATIONS
AGE
LIMITATIONS
AUTHORIZATION
REQUIRED?
ATTACHMENTS
REQUIRED
D8670
Periodic orthodontic
treatment visit(as part of
the contract)
All
Quarterly Payment
No limitations
Yes
Approved orthodontic
treatment
D8680
Orthodontic
Retention(removal of
appliances, construction
and placement of
retainer(s))
All
Final Payment
No limitations
Yes
Beginning and final
records
D8999
Unspecified orthodontic
procedure, by report
All
Six month payment.
0-20
Yes
1) Complete narrative
describing Member's
condition, compliance
with and need for
treatment, estimated
treatment period
2) Study models
3) Radiographs
D9110
Palliative (emergency
treatment of dental pain minor procedure)
(Not payable in
conjunction with other
dental services except
radiographs.)
All
Not allowed with any other
services other than
radiographs. One per patient
per dentist or dental group
per date of service.
All
No
None
D9241
Intravenous
sedation/analgesia - first
30 minutes
All
"This procedure code shall
not be used for billing local
anesthesia or nitrous oxide."
(Kentucky State Dental
Manual page 4.11).
0-20
No
1) Narrative detailing
medical necessity and
dental treatment done or
to be done.
2) The person
responsible for the
administration must have
a current valid permit
from the Kentucky State
Board of Dentistry to do
so.
D9420
Hospital call
(Requires 24 hour
notification after services
rendered.)
All
No other procedures may be
billed in conjunction with
D9420. Not applicable for
nursing home visits (D0150
or D9110). One per patient
per dentist or dental group
per date of service. Cannot
bill conjunctively.
All
Yes
Narrative
Page 325 of 331
Provider Manual
Section 20.0
Acronyms
Table of Contents
Acronym - Definitions
Page 326 of 331
20.0 Acronyms
Acronym
Definition
AAP
American Academy of Pediatrics
ABMS
American Board of Medical Specialties
ACOG
American College of Obstetricians & Gynecologists
ADA
American Dental Association
ADA
American Diabetes Association
AFDC
Aid to Families with Dependent Children
AHFS
American Hospital Formulary System
AIS
Alternative Intermediate Services
AMA
American Medical Association
APRN
Advanced Practice Registered Nurse
CAQH
Council for Affordable Quality Healthcare
CHFS
Cabinet for Health and Family Services
CLAS
Culturally and Linguistically Appropriate Standards
CLIA
Clinical Laboratory Improvement Amendments
COA
Category of Aid
COE
Category of Eligibility
CMS
Center for Medicare and Medicaid Services
DCBS
Department for Community Based Services
DD
Developmental Disabilities
DEA
Drug Enforcement Agency
Page 327 of 331
Acronym
Definition
DME
Durable Medical Equipment
DMS
Department for Medicaid Services
DOS
Date of Service
DRA
Deficit Reduction Act
DRE
Dilated Retinal Exam
DRG
Diagnosis Related Group
EDI
Electronic Data Interchange
EFT
Electronic Funds Transfer
EOB
Explanation of Benefits
EPSDT
Early Periodic, Screening, Diagnosis and Treatment
ER
Emergency Room
ERA
Electronic Remittance Advice
FDA
U.S. Food and Drug Administration
FFS
Fee-for-Service
FFSEs
Fee-for-Service Equivalents
FQHC
Federally Qualified Health Centers
GHAA
Group Health Association of America
HANDS
Health Access Nurturing Developing Services
HEDIS®
Healthcare Effectiveness Data and Information Set
HHS
Health and Human Services Department
HIPAA
Health Information Portability and Accountability Act
IBNRs
Incurred But Not Reported Claims
ID
Identification Card
Page 328 of 331
Acronym
Definition
ICF
Intermediate Care Facility
IVR
Interactive Voice Response System
KCHIP
Kentucky Children’s Health Insurance Program
KHC
Kentucky Health Choices (a.k.a. Ky Health Choices)
KTAP
Child and Family Related Medical Cases
LEP
Limited-English Proficiency
LOS
Length of Stay
LPCC
Licensed Primary Care Center
MAID
Kentucky Medicaid Identification Number
NCCI
National Correct Coding Initiative
NCQA
National Committee for Quality Assurance
NDC
National Drug Code
NHLBI
National Heart, Lung and Blood Institute
NIH
National Institute of Health
NPDB
National Practitioner Data Bank
NPI
National Provider Identifier
OTC
Over-the-Counter
PA
Prior Authorization
PBM
Pharmacy Benefits Manager
PCC
Primary Care Center
PCP
Primary Care Provider/Practitioner
PCS
Patient Clinical Summary
PCSU
Provider Claims Service Unit
Page 329 of 331
Acronym
Definition
PE
Presumptive Eligibility
PHI
Protected Health Information
PASSPORT
Passport Health Plan
PIC
Program Integrity Coordinator
PMPM
Per Member Per Month
POIS
Passport Online Information Service
PRP
Provider Recognition Program
PRTF
Psychiatric Residential Treatment Facility
QAPI
Quality Assessment Program Improvement
QDWIs
Qualified Disabled Working Individuals
QI
Quality Improvement
QMBs
Qualified Medicare Beneficiaries
RBRVS
Resource Based Relative Value Scale
RHC
Rural Health Center
RN
Registered Nurse
SCMBs
Specified Low Income Medicare Beneficiaries
SOBRA
Sixth Omnibus Budget Reconciliation Act
SNF
Skilled Nursing Facility
SSI
Supplemental Security Income
TANF
Temporary Assistance to Needy Families
TIN
Tax Identification Number
TPA
Third Party Administrator
TPL
Third Party Liability
Page 330 of 331
Acronym
Definition
UHC
University Health Care, Inc.
UM
Utilization Management
UPL
Upper Payment Limit
USP
United States Pharmacopeia
USPDI
United States Pharmacopeia Dispensing Information
VFC
Vaccines for Children
WIC
Women, Infants, and Children
Page 331 of 331