ADDENDUM
TO
2014 PROVIDER MANUAL
Coventry Health Care of Louisiana, Inc.
3838 North Causeway Blvd.
Suite 3350
Metairie, LA 70002
(504) 834-0840
(800) 245-8327
www.la.chcadvantra.com
Table of Contents
Advantra specific information has been added to the following Chapters.
Chapter 1
Introduction
2
Chapter 2
Administrative Procedures
8
Chapter 3
Benefit Plan Options
11
Chapter 4
Provider Participation Information
20
Chapter 5
Authorizations
36
Chapter 6
Reimbursement & Claims
38
Chapter 7
Utilization and Quality Management
41
1
Chapter
Introduction
Coventry Health Care of Louisiana is committed to
working with your office staff toward the success of both
your provider practice and the plan.
W
elcome! The goal of Coventry Health Care of Louisiana Inc.
(CHC) is to develop and sustain strong, mutually beneficial
relationships with our providers and their office staff. We
encourage your active participation in the Health Plan and appreciate your
comments. By working together, we create a unique team of people to deliver
the most appropriate health care in the most cost efficient manner. We share
a common goal of preserving the quality of care for patients who seek the
benefits and preventative care of a managed care plan within traditional
physician/patient relationships.
P R O V I D E R
R E L A T I O N S
D E P A R T M E N T
5 0 4 - 8 3 4 - 0 8 4 0
E X T
5 0 3 - 2 1 7 6
is to answer important questions about
administering health care services specifically to Coventry Health Care of
Louisiana’s Advantra Members. This addendum is to supplement the 2014
Coventry Health Care of Louisiana, Inc. Provider Manual. The two
documents represent the entire Provider Manual for a participating CHC
Advantra Provider. The manual is referenced as part of the Provider
Agreement between you and Coventry Health Care. The manual describes
administrative policies and procedures, as well as other pertinent information.
If there is a conflict between this addendum and the 2014 Provider Manual,
this addendum will rule.
The purpose of this manual
From time to time, it will be necessary to update this manual. When this
happens, you will receive replacement pages, along with an explanation of the
changes. For significant changes, you will also receive periodic fax blast
updates, which will provide you with valuable information. Please add those
updates to the back of this manual for future reference. Any updates, fax
3
blasts and other reference material can be found on our website at
www.la.chcadvantra.com.
M E D I C A R E
A D V A N T A G E
S E R V I C E
Coventry Health Care of Louisiana’s Medicare Advantage product has two
major service areas in the Metro New Orleans and Baton Rouge Markets.
The Markets are comprised of 4 parishes.
A R E A
These Metro New Orleans parishes are:

Orleans

Jefferson
The Metro Baton Rouge parishes are::

East Baton Rouge

Ascension
Who to Contact for More Information
4
Coventry Health Care
W E B
A C C E S S
www.coventryhealthcare.com
Coventry Health Care of Louisiana www.la.chcadvantra.com
Advantra
Coventry Health Care of Louisiana
www.chcla.com
Coventry Health Care Provider Portal
www.directprovider.com
Coventry Health Care of Louisiana
Advantra Contact Information
Department
Contact Information
When to contact
Customer Service
(888) 360-6626
Advantra Members
Benefits/Eligibility inquiries
711 TTY/TDD
Health Services
Claims inquiries
Authorization inquiries
(800) 245-8327
Prior authorization requests
(800) 459-5612 fax
Concurrent Review
Discharge planning
Pharmacy
Precertification
(877) 215-4100
Provider
Relations
(800) 245-8327
Pharmacy authorization
(866) 669-5575 fax
(504) 834-0840
(800) 834-1308 fax
Provider participation
questions including
reimbursement and
contracts.
Office orientation needs
Sales/ Marketing
(855) 879-8822
Information about
Medicare product offerings.
5
A D V A N T R A
C L A I M S
Always confirm the mailing address for claims on the back of the Member
identification card.
Coventry Health Care of Louisiana Inc.
P.O. Box 7819
London, KY 40742-7819
Electronic Payor Number: 25133
A P P E A L S
Mail appeals to :
For Part C:
Coventry Health Care of Louisiana, Inc.
Attn: Medicare Medical Appeals & Grievance Department
P.O. Box 7776
London, KY 40742
For Part D
Coventry Health Care of Louisiana, Inc.
Attn: Medicare Part D Appeals & Grievance Department
PO Box 7773
London, KY 40742
For updates on appeal status, contact Customer Service at (866) 613-4977.
A L L
O T H E R
C O R R E S P O N D E N C E
Mail all correspondence other than claims to:
Coventry Health Care of Louisiana, Inc.
3838 North Causeway Blvd.
Suite 3350
Metairie, LA 70002
6
2
Chapter
Administrative
Procedures
This section details administrative procedures specific to
Coventry Health Care of Louisiana, Inc. Advantra.
Participating Providers
P
articipating providers include those physicians, hospitals, skilled
nursing facilities, urgent care centers or other duly licensed
institutions or health professionals that have a contract with Coventry
Health Care of Louisiana. In order for a Member to be eligible for
the highest level of covered services, participating providers must be utilized
unless non-participating providers are specifically authorized by CHC before
services are rendered.
Please be aware that our Directory is subject to change. You should verify the
participation status of a provider with Customer Service or via the web
before referring a patient. They can be reached at (888) 360-6626 or
www.la.chcadvantra.com
7
An identification card
does not guarantee
that the patient is
eligible for services.
Therefore, verifying
the Member’s eligibility
is essential.
Member Identification
All Coventry Health Care of Louisiana Members receive a CHC
identification card shortly after enrollment. Members must present their card
to their Provider at the time services are rendered. If the Member is a recent
enrollee who has not yet received a card, he/she must present a copy of the
enrollment form. The ID card will list the Member’s name, Member number,
Primary Care Physician (PCP), group name and number, the benefit plan
type, as well as copayments or coinsurance for office visits, prescriptions,
outpatient and inpatient services. Benefits vary among our different product
lines. Therefore, it is important to reference the Member ID card for the
correct copayment or coinsurance amount. The ID card will also contain
important Customer Service phone numbers for CHC, our Pharmacy
Vendor, and our Mental Health Vendor.
To verify a Member’s eligibility:
Check the Member’s ID card, enrollment form, or other identification card.
Eligibility can then be confirmed by calling Customer Service or by logging
onto www.directprovider.com. .
How to Read a Coventry Health Care of
Louisiana Identification Card
When you receive an identification card, it will contain the following key
items:
Logo(s)- Look for the Coventry Health Care of Louisiana Advantra
Logo
to identify that the Member will be accessing the CHC Advantra
contracts.
Member Name and Identification Number
Group Name- The group name refers to the type of benefit plan that
the Member has.
PCP Name- The Member’s PCP’s name will be displayed in this field.
8
Member Responsibility Section (Copay)- This section will show the
Member’s responsibility at the time of service.
Point of Service Benefit. – This will give the Member’s benefit when
accessing care from noncontracted providers. For plans without out of
network benefits such as HMO, this line will be omitted.
ID Card Template
9
3
Chapter
Benefit Plan Options
Coventry Health Care of Louisiana offers a Medicare
Advantage benefit plan for Medicare eligible Members to
choose from. This section will assist you in determining
the benefits of our Advantra Members.
What is Medicare?
M
edicare is a Federal Health Insurance Program established in 1965
as an amendment to the Social Security Act. It provides hospital
(Part A) and supplemental medical (Part B) coverage for people
65 years of age and older, certain disabled people, and those of
any age with End Stage Renal Disease (ESRD).
The Medicare Program is administered by The Center for Medicare &
Medicaid Services (CMS), formerly Health Care Financial Administration
(HCFA), of the U.S. Department of Health and Human Services
(DHHS).
C O V E N T R Y
M E D I C A R E
A D V A N T A G E
P L A N S
Coventry Health Care of Louisiana, Inc. (CHC) has entered into a
contract with the CMS that authorizes CHC to provide comprehensive
health services to persons who are entitled to Medicare benefits and who
choose to enroll in the Medicare Advantage (MA) Health Management
Organization (HMO), called Advantra.
Advantra Plans are not Medigap policies or Medicare Supplement Plans.
Advantra is a MAPD Plan that includes Medicare Part A and B benefits and
Part D pharmacy benefits as well as enhanced benefits not covered by
traditional Fee for Service Medicare. Enhanced benefits may include
preventive care, and under some benefit plan options, vision, hearing, dental
and wellness programs.
10
W H A T
I S
A D V A N T R A ?
Advantra Members must obtain all of their medical care through
Advantra contracted providers to receive the highest level of benefits.
The exception to this requirement includes emergency services within the
service area and emergency or urgently needed services outside the
service area.
Advantra Members must choose a Primary Care Physician (PCP).
Members should have their medical care provided or arranged by their
Primary Care Physician to ensure that services are covered.
H O W
T H E
D O E S
P R O G R A M
W O R K ?
The Advantra HMO offers a new approach, with greater flexibility,
freedom and savings. Members on an HMO plan, do not have coverage
when accessing care from a nonparticipating provider except for
emergency services or when authorized by CHC.
Advantra Members pay zero or low monthly premiums to Coventry
for their coverage, must be eligible for Medicare Part A and are
required to continue paying their Medicare Part B premium.
U N I Q U E
S E R V I C E S
Advantra offers a more comprehensive benefit package for its Members
compared to original Medicare. Examples of these service enhancements
are described below. Please note that Advantra products have coverage
limitations that are different from the Coventry commercial HMO &
POS products. In most cases, the coverage limitations follow Medicare
Fee-for-Service coverage guidelines.
Please note: Members are subject to the copayment indicated on their
identification card for certain services.
Outpatient
Services
Preventive Care
Routine Physicals are covered once per year. Benefits
may vary per plan.
Diagnostic X-Ray
These services need to be coordinated by the Primary
Care Physician
Mammograms are covered annually. As required by
CMS, Members may self-refer to a contracted facility for
the annual screening mammogram. Coventry does
remind each Member that they should also have a breast
11
exam by their Primary Care Physician or a contracted
gynecologist in conjunction with obtaining a
mammogram.
Durable Medical Equipment (DME) and Prosthetic
Appliances
Coventry follows Medicare guidelines for coverage of
DME, Prosthetics and Orthotic devices. Prosthetic
devices must be on Medicare’s list of approved prosthetic
devices. A copayment or coinsurance may apply.
Diabetic Supplies
Diabetes and self-monitoring training and supplies
includes coverage for glucose monitors (Lifescan
Models), test strips, lancets and self-management
training. A copayment or coinsurance may apply.
Gynecological Visit
Members are entitled to one office visit per year for a
routine annual exam including a pap smear without a
referral from the PCP when using an Advantra
contracted gynecologist. A copayment may apply.
Immunizations and Vaccinations
Members have direct access (through self-referral) for
influenza and pneumococcal vaccines and their
administration and are covered in full.
Mammography Screening
Members have direct access (through self-referral) to
screening mammography
12
Oral Surgery
Members have coverage for initial treatment received
within 24 hours of an accidental injury. Benefits also
include non-dental treatment relating to medically
diagnosed congenital defects, birth abnormalities, or
treatment for tumors and cysts (including pathological
examination) of jaw, cheeks, lips, tongue, roof and floor
of mouth.
Outpatient Rehabilitation Services

Medically
necessary
Physical
Therapy,
Occupational Therapy, and Speech and Language
Therapy services are covered. A copayment will
apply for Medicare covered visits.

Cardiac and Pulmonary Rehabilitation services
will require a prior authorization.
o Cardiac Medicare covered rehabilitation
o Intensive Cardiac Rehabilitation
o Pulmonary rehabilitation services
Podiatry
Members have access to Medicare covered podiatric
services. A copayment may apply.
Chiropractic Care
Advantra follows Medicare guidelines for Chiropractic
services.
Inpatient
Services
Inpatient Hospital Services
Inpatient hospital services include substance abuse and
rehabilitation services. A copayment will apply.
13
Skilled Nursing
Medically necessary coverage is limited to 100 days per
Medicare Benefit Period. The three (3) day hospital stay
will be waived. No prior hospitalization is required.
Inpatient Behavioral Health
Mental Health: Members have a lifetime limit of 190 days
for care in a psychiatric hospital. Benefit limitations
follow Medicare guidelines.
The telephone number for MHNet is 800-752-7242.
For specific question regarding Medicare covered services and
requirements, please contact Customer Service at (888) 360-6626.
S U P P L E M E N T A L
B E N E F I T S
Coventry contracts with several ancillary providers for supplemental benefits
such as mental health, pharmacy, and chiropractic.. The following services are
not routinely covered by Original Medicare, but are covered under Coventry.
Mental Health/Substance Abuse Services
MHNet provides access to inpatient and outpatient mental health and
substance abuse services for Members. Members have a lifetime limit of 190
days of care in a psychiatric hospital. Benefit limitations follow Medicare
guidelines. Members can obtain a referral to a MHNet participating
practitioner and/or facility by calling MHNet at (800) 752-7242.
Pharmacy Services
Individual Members have a pharmacy benefit that is subject to
limitations. Members also have coverage for Medicare Part B drugs.
Please refer to the Member Summary of Benefits and Evidence of
Coverage for more specific information. Please contact the Customer
Service Department at (888) 360-6626 for more information on
prescription drug coverage for Advantra Members. Self-injectable
medications are not covered unless it is a Medicare approved Part B drug.
Express Scripts provides the administration of the drug benefit for Advantra
Members. All prescriptions must be filled at a participating pharmacy.
14
Questions regarding general pharmacy benefits should be directed to
Customer Service at (888) 360-6626.. Questions regarding pharmacy benefits
and pharmacy and drug coverage should be directed to Express Scripts
Customer Service at (800) 922-1557. All drug prior authorization requests
should be directed to (877) 215-4100 or faxed to (866) 669-5575.
CHC has developed a drug formulary to maintain that high quality costeffective pharmaceuticals are dispensed to Members. The formulary consists
of a list of medications that are approved for use by the Coventry Health
Care Pharmacy and Therapeutics Committee (P&T Committee). This
committee is composed of physicians from various medical specialties and
pharmacist. Periodic changes to the formulary occur based upon the
decisions of the P&T Committee, and are published annually.
Generic drugs provide cost-effective drug therapy. Most prescription benefit
plans provide a lower copay for the Member when they receive generic
medications along with coverage through the Gap. Providers are encouraged
to prescribe generic products. If you prescribe medicines that are not
included on the formulary, your patients may incur the cost of the
medication. In some cases, dosage limitations and prior authorization
requirements apply for certain drugs.
Drugs requiring prior authorization can be found on our website at
www.la.chcadvantra.com
You can access the plan’s Web site http://LAformulary.coventrymedicare.com for the most current Drug List.
Vision Services
Members are entitled to vision coverage in accordance with Medicare
guidelines.
Members, regardless of the benefit plan selected are also entitled to
benefits for eyeglasses or contact lenses after cataract surgery. This
benefit follows the Medicare guideline for coverage.
Chiropractic Coverage
Advantra does provide chiropractic coverage in accordance with Medicare
guidelines.
15
S P E C I A L
S T A T U S
M E D I C A R E
M E M B E R S
The Centers for Medicare & Medicaid Service (CMS) reimburses
contractors at different rates for each Member based on age, sex, county
of residence, and also on the classification into one of five special Status
Categories.
The Special Status Categories include:

Institutional Status

End Stage Renal Disease

Medicare/Medicaid Dual Eligible

Hospice

Working Aged
It is important that you understand the different Special Status Categories
and take the actions defined below when you identify a Member who
meets the Special Status definition.
Institutional Status is defined as an individual enrolled in a Medicare
Advantage who has been a resident in a skilled nursing facility, nursing
facility, ICF/MR, psychiatric hospital, rehabilitation hospital, long-term
care hospital, swing-bed hospital for at least 30 consecutive days.
If you are making rounds on a Member in one of these facilities and the
Member has been there for more than 30 days, please make sure your
Utilization Management contact is aware of this Member. These types of
Members must be submitted to CMS each month for CMS to provide
the Plan with a higher reimbursement rate.
End Stage Renal Disease (ESRD) is defined by CMS as the state of
renal impairment that appears to be irreversible and permanent, and
requires a regular course of dialysis or kidney transplantation to maintain
life.
If 36 months or more has elapsed since a kidney transplant, the person is
no longer considered to have ESRD status.
It is very important that you inform your Utilization Management contact
of any enrolled Members who now meet the ESRD definition. ESRD
status is reported to CMS through the ESRD Network Organization
located in 18 geographic areas in the United States. The provider, usually
a contracted nephrologist or renal dialysis facility submits the completed
CMS 2728-U4, “Medical Evidence Report Form,” to the applicable
ESRD Network Organization.
16
The ESRD Network Organization reviews the form and transmits the
data to CMS electronically. CMS will notify the Plan of Members who
are ESRD. (NOTE: Coventry may be secondary payor for individuals
who have both Medicare coverage and Employer Group Health Plan
coverage.)
Medicare/Medicaid Dual Eligible is an individual who is covered
under both the Medicare and Medicaid programs.
A qualified Medicare beneficiary (QMB), has the state Medicaid program
pay for annual Medicare Part A deductible, Medicare Part A coinsurance,
monthly Medicare Part B premium, annual Part B deductible and
Medicare Part B coinsurance.
Hospice is a Member who has selected Medicare certified Hospice
coverage. Prospective Members are entitled to enroll in Advantra if they
are receiving Hospice coverage.
An Advantra Member becomes Medicare certified for Hospice when
he/she completes a Hospice Election Form. This form is usually
provided by a Medicare certified Home Health or Hospice provider. The
provider then submits the form along with the provider bills to the fiscal
intermediary. The fiscal intermediary pays the Hospice claims, not
Coventry Advantra.
Working Aged is defined as the CMS Medicare Advantage risk payment
category for an individual who is defined as eligible for Medicare and (1)
is either working for an employer with more than 20 employees or (2)
has a spouse with coverage under an Employer Group Health Plan which
covers the Advantra Member.
If you identify a Member with Employer Group Health Plan
coverage in addition to their Advantra coverage, please inform
Advantra Customer Service. If a Member is Working Aged, you
should bill the other carrier as primary and Coventry Advantra as
the secondary payor.
17
4
Chapter
Provider Participation
Information
In addition to the responsibilities outlined in the
Coventry Health Care of Louisiana, Inc. Provider
Manual, your participation in the Medicare Advantra
product requires some additional requirements and
responsibilities. This section outlines those
Responsibilities.
Responsibilities
M E D I C A L
R E C O R D S
A N D
R E C O R D
R E T E N T I O N
Providers should safeguard the privacy of the Member’s medical record.
Original medical records should be released only in accordance with
Federal or State laws, court orders or subpoenas.
All records should be kept confidential and maintained for 10 years and
in certain instances described in the Medicare Advantage regulation,
periods in excess of 10 years or more. All Member information should
be available to be transferred upon request by the Member, or authorized
representative, to any organization with which the Member may
subsequently enroll, or to a provider to ensure continuity of care.
Ensure timely access by Member to pertinent records and information
upon request.
The provider must abide by all Federal and state laws regarding
confidentiality, documentation on whether or not a Member has
18
executed an Advance Directive and disclosure for mental health records
and medical records.
As a requirement of Medicare, all providers must maintain for a period of
10 years books and in certain instances described in the Medicare
Advantage regulation, periods in excess of 10 years for more records,
documents and other evidence of accounting procedures and practices,
physical facilities and equipment and records related to Medicare
enrollees and any additional relevant information CMS may require.
C M S
R E Q U I R E M E N T S
Please be advised that marketing material communications that
promote, communicate or explain the Medicare health plan to
Advantra Members require approval by the Center for Medicare &
Medicaid Services (CMS).
Health education materials are
generally not under the purview of CMS marketing review.
The Plan has various CMS-approved materials that we can make available
to you for you to announce your participation with the Advantra
program. Please contact the Advantra Marketing Department if you are
interested in pursuing any communication to Members of your practice
regarding the Advantra products.
Laws and Regulations
All Plan providers must comply with applicable Medicare laws and
regulations, including Title VI of the Civil Rights Act of 1964, the Age
Discrimination Act of 1975, the Americans with Disabilities Act, the
Rehabilitation Act of 1973, and other laws applicable to recipients of
Federal funds.
Coventry's policy, as well as the Federal law, is that no form of
discrimination prohibited by law will be permitted on the basis of sex,
race, color, disability, age, religion or ethnic origin, and that all Members
will have access to their medical services at all contracted provider
facilities.
Disclosure of Information
At the request of the MA Organization or CMS, the provider shall
disclose all information necessary to (1) administer and evaluate the
program, to include quality performance indicators and information
regarding Members’ satisfaction and health outcomes; and (2) establish
and facilitate a process for current and prospective beneficiaries to
exercise their right to choose Medicare services
19
Continuation of Benefits
Provider shall continue to provide covered services to Advantra
Members who are hospitalized on the date the CMS contract terminates
or expires, of if Coventry Health Care of Louisiana becomes insolvent,
through the date of each Advantra Member’s discharge or for the
remainder of the period for which the Member’s Medicare premium has
been paid.
External Review
Provider agrees to cooperate with all independent quality review and
improvement organization activities required by CMS and/or Coventry
Health Care of Louisiana pertaining to the provision of services for
Advantra Members.
Plan Provider Termination Notices
The MA Organization must make a good faith effort to notify Members
of the termination of a provider’s contract 30 days before the termination
is effective. Providers must follow the termination provision as defined
in their Physician Agreement to ensure timely notification.
The MA Organization will notify physicians in writing of the reason(s)
for any denial, suspension or termination of the physician’s participation
in the provider network.
When contracted providers choose to opt out of Medicare or sanctions
are taken against that provider, the MA Organization will take immediate
steps to terminate that provider’s contract with the Organization.
Compliance with Medical Management
Providers must agree to comply with the Plan’s Medical policies, QI and
Medical Management Programs, and adhere to appeals/grievance
procedures.
Hold Harmless
Provider shall only bill, charge, collect a deposit from, or seek
compensation for services rendered under the Agreement. For purposes
of this section, services rendered under the Agreement include those
health care services delivered to Medicare Advantage Members by any
and all health care professionals employed by or independently
contracted with the Provider. This section shall not prohibit collection
20
of copayments, coinsurance, or deductibles in accordance with the
Medicare Advantage Member’s Member Contract.
Hold Harmless for Dual Enrollees
As required by CMS, effective January 1, 2010 Provider shall look solely
to Plan or the appropriate State source for payment of Covered Services
furnished to Medicare Members who are eligible for both Medicare and
Medicaid. Provider shall not seek to collect payment from the dual
eligible member for any portion of the Medicare Part A and Part B
Copayment/Coinsurance and Deductible when the applicable State
program is responsible for paying such amounts. Provider shall not seek
to collect any Copayment/Coinsurance and Deductible that exceeds the
amount of Copayment/Coinsurance and Deductible that would be
permitted to be paid by the individual under Title XIX (Medicaid) if the
individual were not enrolled in the plan. Provider shall be responsible for
determining the appropriate amount, if any, of Copayment/Coinsurance
and Deductible that may be collected from the Medicare Member. With
respect to any amount that the Provider is prohibited from collecting
from the member, Provider shall either (i) accept payment from the Plan
as payment in full or (ii) bill the appropriate State source for any
remaining amount. CHC will assist Provider in locating information
about Medicare and Medicaid benefits and rules for members eligible for
Medicare and Medicaid.
MEDICARE PROVIDER TRAINING & EDUCATION
Coventry Health Care, Inc. (“Coventry”) is pleased to have the
opportunity to work with you as a provider or provider organization in
delivering high value services to our members. Our association,
particularly in relation to our Medicare product lines, relies on a
contracted relationship that establishes your entity as a first tier1 or related
entity2. As a first tier or related entity, there are several requirements
imposed upon you, some by federal law, some by federal regulations as
promulgated by the Centers for Medicare & Medicaid Services (“CMS”),
and other requirements in light of your contracted relationship with
Coventry. As a result, you, your entity, any downstream entities3 and/or
related entities under your direction, and in several cases your individual
employees who are assigned to work on Coventry’s Medicare business,
must complete a number of requirements.
The requirements are summarized below and are applicable to your
organization, as well as any of your downstream and/or related entity
arrangements.
21
1. General Compliance and Fraud, Waste and Abuse
(“FWA”) Training
You and/or your organization must complete general compliance
training. In addition, you must complete the FWA portion of the
training unless you are deemed to have met the FWA certification
requirements through enrollment into Parts A or B of the
Medicare program or through accreditation as a supplier of
DMEPOS.
You must provide general compliance training to all of your
employees, downstream, and related entity arrangements who are
assigned to work on Coventry Medicare business initially upon
hire and annually thereafter. You must also provide FWA
training, initially upon hire and annually thereafter, to all your
employees, downstream, and related entity arrangements who are
assigned to work on Coventry Medicare business unless these
individuals are deemed to have met FWA certification
requirements as described above. In addition, your organization
must provide either Coventry’s Code of Conduct (“COC”) or
your own equivalent COC to all of your employees, downstream,
and related entities who are assigned to work on Coventry
Medicare business initially upon hire or contract commencement
and annually thereafter
2. Reporting Mechanisms
You and/or your organization must report compliance concerns
and suspected or actual misconduct to Coventry.
3. Exclusion/Debarment
You and/or your organization must ensure that none of its
employees or downstream and/or related entities that service
Coventry Medicare business are on any of the following excluded
persons, sanction and debarment lists: HHS Office of Inspector
General (OIG); General Services Administration (GSA).
4. Downstream and Related Entity Oversight
You and/or your organization must ensure that compliance is
maintained by you and/or your organization as well as any of
your contracted downstream and/or related entities that service
Coventry Medicare business.
5. Offshore Operations
22
You and/or your organization must ensure that you do not
engage in offshore operations for Coventry-related Medicare
business without the express consent of an authorized Coventry
representative. Offshore operations are usually contractually
prohibited by Coventry. Any Coventry-approved offshore
arrangements are subject to reporting requirements to alert CMS
of these activities and therefore must be reported to Coventry
before utilization.
You must access the training and compliance materials mentioned above,
along with additional information concerning these requirements,
available for you on the Coventry Medicare FDR Training and Education
Portal under Provider and Provider Group FDRs. This portal can be
accessed
through
the
following
URL
link
www.CoventryMedicareFDRs.com.
Further, if you and/or your organization utilizes downstream and/or
related entities to perform Coventry Medicare work or serve Coventry
Medicare members, that entity is also responsible for satisfaction of all of
the above requirements. Due to the unique nature of the relationship
between you and your downstream and/or related entities, Coventry
expects that you ensure that they receive these requirements.
You and/or your organization are responsible to ensure that evidence of
the effectuation for all of the requirements is developed and maintained.
This evidence may be in the form of attestations, training logs, or other
means determined by you to best represent fulfillment of your
obligations. Please be reminded that Coventry and CMS require records
to be retained for a period of ten (10) years, and that your records must
be available to Coventry and/or CMS upon request.


A first tier entity is defined as any party that enters into a written
arrangement acceptable to CMS with a Sponsor (i.e., Coventry)
to provide administrative or health care services for a Medicare
eligible individual under Part C or Part D.
A related entity is defined as any entity that is related to the
Sponsor by common ownership or control and a) performs some
of the Sponsor’s management functions under contract or
delegation; b) furnishes services to Medicare enrollees under an
oral or written agreement, or c) leases real property or sells
materials to the Sponsor at a cost of more than $2500 during a
contract period. 42 CFR 423.501
23

M E M B E R
R I G H T S
Advantra Members have the right to:
Timely, Quality Care
A N D
R E S P O N S I B I L I T I E S
A downstream entity is defined as any party that enters into a
written arrangement, acceptable to CMS, below the level of the
arrangement between the Sponsor and the first tier entity. These
written arrangements continue down to the level of provider of
both health and administrative services.

Choice of a qualified Contracting Primary Care Physician and
Contracting Hospital.

Candid discussion of appropriate of Medically Necessary
treatment options for their condition, regardless of cost or
benefit coverage.

Timely access to Primary Care Physician and Referrals to
Specialists when Medically Necessary.

Timely access to all Covered Services, both clinical and nonclinical.

To go to a women’s health specialist without a referral.

Access to Emergency Services without prior authorization when
they, as a prudent layperson, acting reasonably would have
believed that an Emergency Medical Condition existed and
payment will not be withheld in cases where they seek
Emergency Services.

Actively participate in decisions regarding their own health and
treatment options.

Receive urgently needed services when traveling outside the
Plan’s service area or in Plan’s service area when unusual or
extenuating circumstances prevent them from obtaining care
from their Primary Care Physician.
Treatment with Dignity and Respect

Be treated with dignity, respect and fairness at all times, and to
have their right to privacy of their medical records and personal
health information recognized.
24

Exercise these rights regardless of their race, physical or mental
ability, ethnicity, gender, sexual orientation, creed, age, religion or
their national origin, cultural or educational background,
economic or health status, English proficiency, reading skills, or
source of payment for their care. Expect these rights to be
upheld by both Coventry and its contracted providers.

Confidential treatment of all communications and records
pertaining to their care. They have the right to access their
medical records. Coventry must provide timely access to your
records and any information that pertains to them. Written
permission from them or their authorized representative shall be
obtained before medical records can be made available to any
person not directly concerned with your care or responsible for
making payment for the cost of such care.

Know how their health information has been given out and used
for non-routine purposes.

Be involved in decisions to withhold resuscitative services, or
forgo or withdraw life-sustaining treatment.

Extend their rights to any person who may have legal
responsibility to make decisions on their behalf regarding their
medical care.

Refuse treatment or leave a medical facility, even against the
advice of physicians (providing they accept the responsibility and
consequences of the decision).

Complete an Advance Directive, Living Will or other directive to
their Contracting Medical Providers.
Advantra Information

To be informed of Medicare Advantage policies and procedures
regarding services, benefits, providers, and our Member Rights &
Responsibilities and be notified of any significant changes.

Information about Medicare Advantage and Covered Services
written in a manner that truthfully and accurately provides
information in a format that is easy to read and understand.

Know the names and qualifications of physicians and health care
professionals involved in their medical treatment.

Receive information about an illness, the course of treatment and
prospects for recovery in terms that they can understand.
25

Information regarding how medical treatment decisions are made
by the Contracting Medical Group or Coventry, including
payment structure.

Information about their medications – what they are, how to take
them and possible side effects.

To receive a notice that tells about their privacy rights and
explains how we protect the privacy of their health information.

To ask Plan providers to make corrections or additions to their
medical records.

Receive as much information about any proposed treatment or
procedure as they may need in order to give an informed consent
or to refuse a course of treatment. Except in cases of Emergency
Services, this information shall include a description of the
procedure or treatment description, the medically significant risks
involved, any alternate course of treatment or non-treatment and
the risks involved in each, and the name of the person who will
carry out the procedure or treatment.

Reasonable continuity of care and to know in advance the time
and location of an appointment, as well as the physician
providing care.

Be advised if a physician proposes to engage in experimentation
affecting their care or treatment. They have the right to refuse to
participate in such research projects or experimental treatment.

Be informed of continuing health care requirements following
discharge from inpatient or outpatient facilities.

Examine and receive an explanation of any bills for Non-Covered
Services, regardless of payment source.

General coverage and Plan comparison information.

Utilization control procedures.

Summary of statistical data on grievances and appeals that
Members have filed against the Medicare Advantage Program.

The financial condition of Coventry.

Summary of provider compensation agreements.

To make recommendations regarding the organization's Member
Rights & Responsibilities Policies.
26
Timely Problem Resolution

Make complaints and appeals without discrimination and expect
problems to be fairly examined and appropriately addressed.

Responsiveness to reasonable requests made for services.

Receive a detailed explanation from Coventry if you believe that a
Plan provider has denied care that you believe you are entitled to
receive.
As a Member of Advantra, they have the responsibility to:
A D V A N C E
D I R E C T I V E

Provide their physicians or other care Providers the information
needed in order to care for them.

Do their part to improve their own health condition by following
treatment plans, instructions and care that they have agreed on
with their physician(s).

Understand their health problems and participate in developing
mutually agreed upon treatment goals to the degree possible.

Behave in a manner that supports the care provided to other
patients and the general functioning of the facility.

Accept the financial responsibility for any Copayment or
Coinsurance associated with covered services received while
under the care of a physician or while a patient at a facility.

Accept the financial responsibility for any premiums associated
with Membership in Medicare Advantage Plans.

Review information regarding Covered Services, policies and
procedures as stated in their Evidence of Coverage Information.

Ask questions of their Physician or Coventry. If they have a
suggestion, concern, or a payment issue, we recommend they call
Advantra Customer Service. (number of located on back of ID
Card)
An Advance Directive is a written formal document, written by the
Member in advance of an incapacitating illness or injury.
27
When an Advantra Member visits your office, we ask that you discuss
Advance Directives and document in the medical records whether or not
the Member has executed an Advance Directive.
COVENTRY HEALTH CARE MEDICAL CARE ADVANCE
DIRECTIVE POLICY
Coventry believes in the right of the patient to make the appropriate
decisions concerning his/her care. We also understand that in some
medical situations that power may not be within the patient’s realm of
physical or mental capacities. As a Health Maintenance Organization, we
believe in and support a patient’s right to make advance arrangements for
the direction of his/her medical care in these instances. The state of
Louisiana recognizes and enforces the provisions of the Patient SelfDetermination Act of 1990. In response to this legislation the state of
Louisiana recognizes two forms of medical care Advance Directive.

“Living Will”

Health Care Agent Designation (Durable Power of Attorney)
To download and print the Living Will Declaration Form, and for
additional information regarding End of Life Registry Programs, go to
the Louisiana Secretary of State website at:
http://www.sos.la.gov/OurOffice/EndOfLifeRegistries/Pages/default.a
spx
Coventry requires our network and contracted providers to notify and
educate the Member/patient about his/her rights and how to exercise
them. The following is the policy followed by Coventry.
1. The Member’s primary care physician will be responsible for
asking whether the Member has executed an Advance Directive.
This discussion must be documented in the Member’s medical
record. If the Attending Physician is not the Member’s primary
care physician, the Attending Physician shall also document the
Member’s Advance Directive information in the Member’s
medical record.
28
2. Members shall be advised of their responsibility to inform outside
providers/facilities that they have executed an Advance Directive
3. The existence of a medical care Advance Directive will not
cause or create a change in the provision of care provided or
result in any discrimination against the individual because of
this choice. This provision shall, not, however, be construed to
require care in conflict with the medical care Advance
Directives.
4. New Advantra Members will be provided written information
regarding Louisiana law on Advance Directive rights which
includes the right to make decisions concerning their medical care
the right to accept or refuse medical or surgical treatment, their
right to formulate Advance Directives. Members may receive
information regarding Advance Directives through member
newsletters or member handbooks.
5. Coventry will protect each Member’s right to accept or refuse
medical or surgical treatment and to formulate Advance
Directives.
6. The member has the right to file a complaint with Coventry or
the state survey and certification agency if they find noncompliance with the Advance Directive requirements.
7. Coventry will strongly urge each provider to inform each adult
Member about the medical care Advance Directive in the
following situations:

for hospital provider, at the time of the patient’s
admission:

for a SNF, at the time of admission;

at the time of admission to a nursing facility as a resident

at the time of arranging for home health care, before the
patient comes under

the care of the home health provider; or

at the time of the initial advice on hospice care.
29
8. The Health Plan recognizes that an Advance Directive can be
revoked at any time by the Member, regardless of physical or
mental status. In order to be effective, the Member’s revocation
must be communicated to the Attending Physician by the Member
or by a person acting at the direction of the Member. The
Attending Physician must record in the Member’s medical record
the time, date, and place of the revocation, as well as the time,
date, and place when the Attending Physician received
notification of the revocation (if different). If the Attending
Physician is not the Member’s primary care physician, the
Attending Physician shall also notify the Member’s primary care
physician of this revocation.
If the member filed a Declaration with the Secretary of State’s
office, they must file a written notice of revocation in that office.
The revocation will not be honored until the Secretary of State
indicates on the Declaration the date and time that the office
received notice of the revocation.
Coventry further believes in the rights of any provider to object to the
implementation of medical care Advance Directive. Those providers are
required to inform the patient of their objection, how that will impact the
request for medical care Advance Directive and provisions for referral or
reassignment to a primary care physician that has compatible beliefs with
the patient.
All Advantra Members receive an Advance Directive document as part
of their Membership materials.
Extra copies can be obtained through Advantra Customer Service
Department at (888) 360-6626.
For additional information pertaining to the Louisiana Physician Order
for Scope of Treatment (LaPOST) go to:
http://www.lhcqf.org/lapost-home.
30
5
Chapter
Authorizations
Coventry Health Care requires prior authorization and
precertification for certain services. This section will
outline those requirements which are specific to Advantra.
A
uthorizations are required for inpatient and some outpatient
hospital admissions, certain medical, surgical, or diagnostic
procedures, and care by nonparticipating providers. The
Authorization list is updated periodically by Coventry Health Care.
Please make sure an authorization for applicable services is issued prior to
Members receiving the services unless it is an emergency. If you are unsure
about a particular procedure or for more information, contact Customer
Service or log onto www.chcla.com to access the current Prior Authorization
List, or log onto www.directprovider.com for a code specific look up tool.
Advantra authorization request can be accepted through several methods
including:

Via phone call to our Health Services Department at (800) 2458327

Via faxed authorization form to Health Service Department
(800) 459-5612

Via submission through directprovider.com
Prior Authorization List
Prior authorization is the approval of services by Coventry Health Care as
medically necessary before the services are actually rendered. Prior
authorization is required for the payment of claims for certain services. If the
service is approved, an approval letter is sent to the Advantra HMO Member
31
and the provider performing the service. Denial notices are sent if the
services are not authorized.
Providers may be held responsible for the cost of services when prior
authorization is required but not obtained. The Member may not be billed for
the applicable services. Retroauthorizations are not covered.
The Prior Authorization list for Coventry is located on the Coventry Health
Care of Louisiana website, www.chcla.com, Provider Portal under Document
Library. All Medicare members will follow the Prior Authorization list with a
few exceptions to include:


Cardiac and Pulmonary rehabilitation
Hemodialysis
Those services will be identified by bolded print, so please refer to the Prior
Authorization listing.
D U R A B L E
M E D I C A L
E Q U I P M E N T
A M D
P R O S T H E T I C
A P P L I A N C E S
CHC providers are required to obtain prior authorization for Members for
the rental of durable medical equipment or purchase of items greater than
$500. Advantra follows Medicare guidelines for the coverage of DME, and
prosthetic appliances. Prosthetics must be on Medicare’s list of approved
prosthetic appliances. Equipment must be obtained from a participating
provider. Please consult Customer Service to verify the Member’s benefits at
(888) 360-6626..
32
6
Chapter
Reimbursement &
Claims
Providers are reimbursed through a fee for service
arrangement. This section outlines the procedures for
claims submission which are specific to Advantra.
P
hysician reimbursement under CHC is a fee for service arrangement. Fee
for service reimbursement compensates the provider only for services
rendered based on the CPT codes submitted. Physician allowances are set
by CPT codes. When submitting claims, please include all applicable
modifiers to ensure the claims proper payment. Claims submitted to
Coventry should include your usual fee for services rendered by CPT code.
Proper coding remains the responsibility of the billing provider. Fee charged
for services provided to CHC Members should be the same as those
charged to non-Coventry Members for the same services.
Claims Filing Procedures
Coventry Health Care has adopted the standard billing guidelines so that
completion of the CMS Form is consistent with Medicare Guidelines.
Providers should submit charges on an HCFA 1500 Health Insurance
Claim form (or UB92 if applicable) directly to the Claims Address listed
on the Member’s Identification Card.

You must include your NPI number on each Claim Form
submitted.

All hospitals (inpatient & outpatient) services and physician
services information are required to be submitted to CMS.
33

The mailing address for Advantra claims is:
Advantra
P.O. Box 7819
London, KY. 40742 - 7819

For Electronic submission, please use Payor ID #25133
IMPORTANT PROVIDER ENCOUNTER INFORMATION
REGARDING MEDICARE ADVANTAGE RISK ADJUSTMENT
PAYMENT METHODOLOGY
The Balanced Budget Act of 1997 specifically required implementation of
a Risk Adjustment Method Payment methodology. Starting 2004,
Medicare Advantage Organizations will receive a portion of their
payment from CMS based on the “health status” of the Medicare
beneficiary. The payment model recognizes diagnoses from inpatient
hospital data and ambulatory settings.
Based on the Balance Budget Act of 1997, Medicare Advantage
Organizations must collect and submit all inpatient hospital, outpatient
hospital and physician encounter data to the Center of Medicare &
Medicaid Services (CMS) on all enrolled Medicare Advantage HMO &
HMO/POS Members.
Effective July 1, 2002, all encounters submitted to CMS must contain all
relevant diagnoses noted during hospital inpatient stays and hospital
outpatient and physician visits.
All hospitals and physicians must use current valid International
Classification of Diseases - 9th Edition - Clinical Modification (ECD-9CM) Codes; report all diagnoses related to service performed and
justified by medical record documentation and following coding
guidelines using the most specific code.
All providers who participate in the Medicare-Choice Program are
required to submit complete and accurate claims data and maintain clear,
concise and complete medical record documentation practices.
The following procedures have been identified to assist providers in
complying with the regulatory requirements of submitting encounter
information.

Provider should provide ongoing training to staff regarding
appropriate use of ICD-9-CM code set for reporting diagnoses.
34

Submit all diagnosis that impact the patient evaluation, care and
treatment:
o Main reason for a visit or admission
o Co-existing acute condition
o Chronic conditions
o Permanent past conditions

Providers should periodically review their claim/encounter data
submission to ensure that they are accurate, complete and
truthful and are supported by the medical record or other
relevant documentation.

Provider should fully communicate diagnosis details to coding
staff, so that the visit or admission is coded to the highest level of
specificity known.
Importance of Medical Record Documentation

Accurate risk adjusted payment relies on complete medical record
documentation and diagnostic coding.

CMS annually conducts risk adjustment data validation by
Medical Record Review.

The medical record chronologically documents the care of the
patient and is an important element contributing to high quality
care.
Resources - ICD-9-CM Coding
www.hcfa.gov/medlearn/cbticd9.htm for a computer-based course on
ICD-9-CM
www.cms.hhs.gov (Conduct a site search for ICD-9-CM)
www.mcoservice.com
35
7
Chapter
Utilization and Quality
Management
Utilization management tracks health care costs while assuring the quality of
and access to health care, while quality management assures that all health
care services provided to Members meet the highest standards of quality. This
section details the processes of utilization and quality management at
Coventry Health Care of Louisiana which is specific to Advantra.
U
tilization management occurs by reviewing how health care resources are
utilized by Members and identifies and evaluates appropriateness, timeliness,
medical necessity, utilization patterns and clinical outcomes.
Utilization management at Coventry Health Care consists of the following
functions:

Preauthorization of hospital admissions and outpatient services
to determine medical necessity.

Concurrent review of inpatient care to ensure appropriate
treatment and length of hospital stay.

Retrospective review of health care service and costs

Use of alternative resources and settings

Case management
36
A D V A N T R A
P E R S O N A L
H E A L T H
P R O F I L E S
C A S E
M A N A G E M E N T

Disease management programs

Oversight of delegated utilization management functions
All new Members are sent an Advantra Personal Health Questionnaire
within the first 90 days of enrollment. The questionnaire is completed by
the Member and sent back to Coventry Health Care of Louisiana.
Coventry requests that the Member discuss their Personal Health
Questionnaire with their PCP. The information from the Personal
Health Questionnaire will assist the PCP or Specialist in providing
direction regarding the Member's health needs and potential treatment
options. This will allow the Member to participate in the development of
their own treatment plan. Coventry will also assist in the coordination of
care for complex or serious disease cases with the PCP or Specialist and
will inform Members of any follow-up care and provide training in selfcare through the Case Management or Disease Management Program.
Case management provides high quality, cost effective service to Members
who have encountered, or have the potential to utilize, significant medical
services. Case management includes but is not limited to:

Treating patients in the least restrictive setting or environment

Providing services at the most appropriate site

Providing support for Primary Care Physicians with complex
cases

Managing patient’s real and perceived needs

Serving as a patient/family advocate
Members may be referred to complex case management if they meet one
or more of the following key indicators and one or more admissions or
ER visits for the following conditions. If you have a Member who you
would like to refer into the Case Management Program, please contact
our Health Services department at (800) 245-8327
37

New stroke

Diabetic ketoacidosis

Hypoglycemia

Uncontrolled Diabetes

Cellulitis with diabetes

Foot ulcer with diabetes

Retinopathy or blindness

Sepsis

Hospital admission with primary
diagnosis of malignancy, HIV or
complications (dehydration, pain
control, etc)

Receiving home care
Respiratory: (Asthma,
Chronic Obstructive
Pulmonary Disorder,
Cystic Fibrosis, etc)

Asthma

Cystic Fibrosis

Chronic Obstructive Pulmonary
Disease
Trauma/Medical
Surgical/Miscellaneous:

Burns greater than 25% of the
body

Myasthenia gravis

Spinal cord injury/fracture

Traumatic brain injury

Multiple fractures

Complex wounds
Transplants:

Any transplant evaluation
Non-Diagnosis Related
Indicators:

Discharge planning: Home Care
with Two (2) or more services
required for longer than one
month (i.e., physical, speech,
respiratory therapy, nursing,
Cardiovascular:
Endocrinology:
(Diabetes mellitus, renal,
etc.)
Oncology/Immunodeficiency Disorders:
38
infusion, durable medical
equipment, etc.)

Emergency Department visits:
Three (3) or more visits within a 45
day period

Hospital admissions: Greater than
one hospital admission within six
(6) months for the same diagnosis.

Pharmacy: Poly-pharmacy with
ten (10) or more prescriptions in
thirty days

A variety of providers consulting
on a seemingly straightforward
case

A Member taking large quantities
of pain medications or
antidepressant medications

Repeated falls

Nursing home admission

Dialysis
PCPs will be informed for any interventions and any follow-up needs.
39