1. health and fitness

Provider
Manual
America’s 1st Choice Provider Manual – South Carolina
1. ABOUT AMERICA’S 1ST CHOICE ...............1 Introduction .......................................................1 Mission Statement ............................................1 Core Values ......................................................1 America’s 1st Choice Service ............................2 Service Areas ...................................................2 Medicare ...........................................................2 2. PHYSICIAN RESPONSIBILITIES ................4 Introduction .......................................................4 Primary Care Physician
(PCP) Responsibilities ......................................4 Specialist Responsibilities ................................5 Responsibilities of All Plan Providers ...............5 Provider Licensure, Credentials and
Demographic Information Changes ..................6 Physician Availability & Accessibility ................6 Appointment Scheduling ...................................7 After-Hours Services .........................................7 PCP-Initiated Member Transfer ........................8 Closing Physician Panel ...................................8 Provider Information Changes ..........................8 Participation & Credentialing ............................9 Provider Termination ........................................9 Continuity of Care – Terminated Provider ........9 Utilization Management & Quality
Management Programs (UM/QM) ...................10 Preferred Drug List .........................................10 Confidential Member Information & Release
of Medical Records .........................................10 Adult Health Screening Services ....................11 Required Service Components .......................11 Cultural Competency ......................................13 Member Rights & Responsibilities ..................13 Advance Medical Directives ............................13 Fraud and Abuse Reporting............................14 Marketing Prohibitions ....................................21 3. CREDENTIALING ......................................22 Introduction .....................................................22 Credentialed Providers ...................................23 Initial Credentialing Process ...........................24 Re-Credentialing .............................................25 Professional Liability Insurance ......................26 Updated Documents .......................................26 4. MEMBER ELIGIBILITY & SERVICES .......27 Member Services ............................................27 Staff Selection and Training ............................27 Service Standards ..........................................27 Member Identification Card .............................28 Methods of Eligibility Verification ....................28 5. UTILIZATION MANAGEMENT
DEPARTMENT .............................................. 30 Introduction .................................................... 30 Department Philosophy .................................. 30 UM Staff Availability ....................................... 30 Contact Information ........................................ 30 General Information ....................................... 31 Status of a Pre-Service Request .................... 31 Emergency and Urgent Care Services........... 32 Pharmacy and Provider Access During a
Federal Disaster or Other Public Health
Emergency Declaration .................................. 33 Concurrent Review & Discharge Planning ..... 34 Second Opinions ............................................ 34 Covered Services ........................................... 34 Podiatry Services ........................................... 35 Chiropractic Services ..................................... 35 Vision Services............................................... 36 Behavioral Health Services ............................ 36 Well Woman – Routine & Preventive
Services ......................................................... 36 Initial Health Assessment Tool (HAT) ............ 36 Disease Specific Health Assessment Tool
(DS HAT) ........................................................ 36 Clinical Practice Guidelines............................ 36 Disease Management Programs.................... 37 Preventive Health Guidelines ......................... 38 Financial Incentives........................................ 38 6. MEDICATION MANAGEMENT ................. 39 Introduction .................................................... 39 Preferred Drug List ......................................... 39 Generic Substitution ....................................... 39 Drugs Not on the Preferred Drug List............. 39 Prior Authorization (PA) ................................. 40 Step Therapy (ST).......................................... 40 Quantity Limits ............................................... 40 Co-payments .................................................. 40 Injectables ...................................................... 41 Pharmacy Use ............................................... 41 Drug Utilization Review Program ................... 41 7. QUALITY MANAGEMENT PROGRAMS .. 42 Overview ........................................................ 42 Goals & Objectives......................................... 42 Provider Notification of Changes.................... 43 Medical Health Information ............................ 44 Medical Record Standards ............................. 44 Medical Record Review ................................. 47 Medical Record Privacy & Confidentiality
Standards ....................................................... 48 America’s 1st Choice Provider Manual – South Carolina
8. CLAIMS ......................................................51 General Payment Guidelines ..........................51 Member Responsibility ...................................51 Prohibition on Billing Members .......................52 Maximum Out-of-Pocket Expenses
(MOOP) ...........................................................52 Timely Submission of Claims ..........................52 Physician and Provider Reimbursement .........52 Completion of Paper Claims ...........................53 Electronic Claims Submission ........................53 Electronic Transactions and Code Sets ..........54 Encounter Data ...............................................54 Coordination of Benefits (COB) ......................55 Correct Coding................................................55 Claims Appeals ...............................................55 Fee Schedule Updates ...................................56
9. GRIEVANCE & APPEALS ........................ 57 Introduction .................................................... 57 Definitions ...................................................... 57 Grievance & Appeals System ........................ 57 Grievance & Appeals ..................................... 58 Member Grievance & Appeals ....................... 58 Participating Provider Claims Appeals ........... 58 Non-participating Provider Appeals................ 59 Expedited Claims Appeals ............................. 59 Medicare Grievance Process ......................... 59 Provider Complaint Process........................... 60 10. SAMPLE FORMS & DOCUMENTS......... 61
America’s 1st Choice Provider Manual – South Carolina
1. ABOUT AMERICA’S 1ST CHOICE
Introduction
America’s 1st Choice Health Plans, Inc. is an independently owned health plan offering benefit
plans in South Carolina, with corporate headquarters in Columbia, South Carolina. The company
was founded with the primary goal of designing and offering outstanding health care products to
the communities we serve. This manual addresses provision of service to our Preferred Provider
Organization (PPO) enrollees in South Carolina. For information on the terms and conditions of
participation for our Private Fee-for-Service (PFFS) benefit plans in South Carolina, please refer
to our Terms and Conditions document, available on our website at www.americas1stchoice.com.
You may request a written copy by calling our Provider Relations Department at: 1-866-321-3947.
Mission Statement
To be a leader within the government-sponsored health care industry in partnership with
Providers and the government to provide innovative, cost-effective and quality health care
services to our Members.
Core Values
Integrity and Accountability – All Associates must earn the trust of others by following through
on commitments, demonstrating efficiency and accepting accountability for all courses of action
undertaken.
Teamwork – All Associates are expected to willingly participate with others in a forthright and
supportive manner, to collaborate in the work and activities of the team and to use their best
personal efforts to maximize the team’s effectiveness.
Open Communication – We believe that the open discussion of ideas, suggestions and concerns
is important to our mutual success. All Associates are encouraged to bring forth their
recommendations, questions, problems or any other issues which are believed to be important and
which can contribute to the resolution of problems and help build a better, stronger organization.
What makes America’s 1st Choice Different?

America’s 1st Choice is committed to promptly and accurately pay “clean” claims, meeting
all regulatory guidelines.

America’s 1st Choice focuses on providing a seamless, streamlined health care delivery
system.

America’s 1st Choice is committed to operating state-of-the-art information technology for
claims processing, Member services, enrollment management, Physician profiling and data
analysis.

America’s 1st Choice has well-trained and experienced Physician and Provider
representatives available to answer all Provider inquiries.
UpdatedDecember2012
Page 1
America’s 1st Choice Provider Manual – South Carolina
America’s 1st Choice Service
America’s 1st Choice is committed to providing extraordinary service. We will accomplish our goal
of superior service to Members, Physicians and Providers through:

Outstanding telephone customer service,

Cutting-edge Web access,

Dedicated Provider Relations “field” staff,

State-of-the-art claims processing software,

Recruiting only the most highly qualified staff, and

Dedication to training.
Service Areas
In 2013, we offer Medicare Advantage Network Private-Fee-for-Service (PFFS) and Preferred
Provider Organization (PPO) plans in the following counties: Beaufort, Berkeley, Charleston,
Cherokee, Chester, Chesterfield, Colleton, Greenville, Jasper, Lancaster, Lexington, Orangeburg,
Richland, Spartanburg and York.
Medicare
Providing Medicare health care services is our expertise. We take pride in offering competitive
benefits and excellent care.
What is Medicare? Medicare is a health insurance program for people:

Age 65 or older,

Under age 65 with certain disabilities, and

Of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or
a kidney transplant).
Medicare has:
Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse
already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance)
helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing
facilities (not custodial or long-term care). It also helps cover hospice care and some home health
care. Beneficiaries must meet certain conditions to get these benefits.
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B
(Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other
medical services that Part A does not cover, such as some of the services of physical and
occupational therapists, and some home health care. Part B helps pay for these covered services
and supplies when they are medically necessary.
Prescription Drug Coverage – In January of 2006, prescription drug coverage became available to
everyone with Medicare. Everyone with Medicare can get this coverage that may help lower
UpdatedDecember2012
Page 2
America’s 1st Choice Provider Manual – South Carolina
prescription drug costs and help protect against higher costs in the future. Medicare Prescription
Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the
drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in
a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
UpdatedDecember2012
Page 3
America’s 1st Choice Provider Manual – South Carolina
2. PHYSICIAN RESPONSIBILITIES
Introduction
This section of the Provider Manual addresses the respective responsibilities of participating
Physicians. Our expanding network of primary care Providers, as well as the growing list of
specialty Providers, makes it more convenient to find America’s 1st Choice Providers in your
neighborhood.
America’s 1st Choice does not prohibit or restrict Plan Providers from advising or advocating on
behalf of a Plan Member about:
1. The Plan Member’s health status, medical care or treatment options (including alternative
treatments that may be self-administered), including providing sufficient information to
the Plan Member to provide an opportunity to decide among all relevant treatment options;
2. The risks, benefits and consequences of treatment or non-treatment; and
3. The Plan Member’s right to refuse treatment and express preferences about future
treatment decisions. A Provider must provide information regarding treatment options in a
culturally competent manner, including the option of no treatment. A Provider must ensure
that individuals with disabilities are presented with effective communication on making
decisions regarding treatment options.
Practitioners may freely communicate with patients about their treatment, regardless of benefit
coverage limitations. As applicable, the Plan shall not prohibit the participating Provider from
providing inpatient services to a Member in a contracted hospital if such services are determined
by the Participating Provider to be medically necessary covered services under the Plan and/or
Medicare Contract.
A Physician’s responsibility is to provide or arrange for medically necessary covered services for
Members without regard to race, ethnicity, national origin, religion, sex, age, mental or physical
disability, sexual orientation, genetic information or source of payment. A Physician is further
responsible to render medically necessary covered services to Plan Members in the same manner,
availability and in accordance with the same standards of the profession as offered to the
Physician’s other patients.
Primary Care Physician (PCP) Responsibilities
The following is a summary of responsibilities specific to Primary Care Physicians who render
services to Plan Members:

Coordinate, monitor and supervise the delivery of health care services to each Member who
has selected the PCP for Primary Care services.

Assure the availability of Physician services to Members in accordance with Section 2,
“Appointment Scheduling”.

Arrange for on-call and after-hours coverage.
UpdatedDecember2012
Page 4
America’s 1st Choice Provider Manual – South Carolina

Submit a report of an encounter for each visit where the Provider services the Member or
the Member receives a Health Plan Employer Data and Information Set (HEDIS) service.
Encounters should be submitted on a CMS 1500 form.

Accommodate Members who request to be seen for an initial office visit and assessment
within 90 days.

A Physician/Provider will consider Member input into proposed treatment plans.
Specialist Responsibilities
Specialists are responsible for communicating with the PCP in supporting the medical care of a
Member. Specialists are also responsible for treating Plan Members referred to them by the PCP.
Responsibilities of All Plan Providers
The following is an overview of responsibilities for which all Plan Providers are accountable. Please
refer to your contract or contact your Provider Relations Representative for clarification of any of
the following:

All Providers must comply with the appointment scheduling requirements as stated in the
Appointment Scheduling Section.

Provide or coordinate health care services that meet generally recognized professional
standards and the Plan guidelines in the areas of operations, clinical practice guidelines,
medical quality management, customer satisfaction and fiscal responsibility.

Use Physician extenders appropriately. Physician Assistants (PA) and Nurse Practitioners
(NP) may provide direct Member care within the scope of practice established by the rules
and regulations of the State of licensure and Plan guidelines.

The sponsoring Physician will assume full responsibility to the extent of the law when
supervising PAs and NPs whose scope of practice should not extend beyond statutory
limitations.

NPs and PAs should clearly identify their titles to Members, as well as to other health care
professionals.

A request by a Member to be seen by a Physician, rather than a Physician extender, must
be honored at all times.

Refer Plan Members with problems outside of his/her normal scope of service for
consultation and/or care to appropriate Specialists.

Respond promptly to Plan requests for medical records in order to comply with regulatory
requirements and to provide any additional information about a case in which a Member
has filed a grievance or appeal.

Not bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement
from or have any recourse against any Plan Member, subscriber or enrollee other than for
supplemental charges, co-payments or fees for non-covered services furnished on a “feefor-service” basis. Non-covered services are benefits not included by the Plan in a
UpdatedDecember2012
Page 5
America’s 1st Choice Provider Manual – South Carolina
Member’s healthcare policy, are excluded by the Plan, are provided by an ineligible
Provider or are otherwise not eligible to be Covered Services, whether or not they are
Medically Necessary.

Treat all Member records and information confidentially and not release such information
without the written consent of the Member, except as indicated herein, or as needed for
compliance with State and Federal law.

Apply for a Clinical Laboratory Improvement Amendments (CLIA) certificate, if applicable.

Maintain quality medical records and adhere to all Plan policies governing the content of
medical records as outlined in the Plan’s quality improvement guidelines. All entries in the
Member record must identify the date and the Provider.

Maintain an environmentally safe office with equipment in proper working order in
compliance with city, State and Federal regulations concerning safety and public hygiene.

Communicate clinical information with treating Providers timely. Communication will be
monitored during medical/chart review. Upon request, provide timely transfer of clinical
information to the Plan, the Member or the requesting party at no charge, unless otherwise
agreed to.

Preserve Member dignity and observe the rights of Members to know and understand the
diagnosis, prognosis and expected outcome of recommended medical, surgical
and medication regimen.

Not to discriminate in any manner between Plan Members and non-Plan Members.

Fully disclose to Members their treatment options and allow them to be involved in
treatment planning.

A Physician/Provider will consider Member input into proposed treatment plans.
Provider Licensure, Credentials and Demographic Information Changes

Inform the Plan, in writing, within five business days of any revocation or suspension of
his/her DEA number, and/or suspension, limitation or revocation of his/her license,
certification or other legal credential authorizing him/her to practice in the State.

Inform the Plan immediately of changes in licensure status, tax identification numbers,
telephone numbers, addresses, status at participating hospitals, loss of liability insurance
and any other change which would affect his/her status with the Plan.
Physician Availability & Accessibility
In accordance with the Provider’s contract with the Plan, Physicians agree to make necessary and
appropriate arrangements to ensure the availability of services to Members on a 24-hour per day,
7-day per week basis, including arrangements for coverage of Members after hours or when the
Physician is otherwise unavailable.
UpdatedDecember2012
Page 6
America’s 1st Choice Provider Manual – South Carolina
In the event participating Providers are temporarily unavailable to provide care or referral services
to Plan Members, they should make arrangements with another Physician to provide these
services on their behalf.
Additionally, Physicians are to establish an appropriate appointment system to accommodate the
needs of Plan Members, and shall provide timely access to appointments to comply with the
following schedule:

Urgent care within one day of an illness;

Sick care within one week of an illness; and

Well care within one month of an appointment request.
The Physician will ensure that Members with an appointment receive a professional evaluation
within one hour of the scheduled appointment time. If a delay is unavoidable, the patient shall be
informed and provided with an alternative.
Appointment Scheduling
The following criteria comply with access standards:
1. Primary Care Providers should:

Provide medical coverage 24-hours a day, seven days a week;

See a scheduled appointment within 30 minutes;

Schedule an emergent referral appointment immediately;

Schedule routine sick care within one week; and

Schedule well care within one month.
2. Specialty Care Providers should:

Schedule well care within one month;

Schedule routine sick care within one week;

Schedule an urgent referral within 24 hours; and

Schedule an emergent referral appointment immediately.
After-Hours Services
The Primary Care Physician or covering Physician should be available after regular office hours
to offer advice and to assess any conditions which may require immediate care. This includes
referrals to the nearest Urgent Care Center or Hospital Emergency Room in the event of a serious
illness.
To assure accessibility and availability, the Primary Care Physician should provide one of the
following:

24-Hour answering service;
UpdatedDecember2012
Page 7
America’s 1st Choice Provider Manual – South Carolina

Answering system with an option to page the Physician; or

An advice nurse with access to the PCP or on-call Physician.
PCP-Initiated Member Transfer
A Participating Primary Care Provider (PCP) may not seek or request to terminate their relationship
with a Member or transfer a Member to another Provider of care based upon the Member’s medical
condition, amount or variety of care required or the cost of covered services required by the Plan’s
Member.
Reasonable efforts should always be made to establish a satisfactory Provider/Member
relationship. The PCP should provide adequate documentation in the Member’s medical record to
support his/her efforts to develop and maintain a satisfactory Provider/Member relationship.
If a satisfactory relationship cannot be established or maintained, the PCP must continue to
provide medical care for the Plan Member until such time that the Member can be transitioned to
another PCP.
The PCP must mail a certified letter to the Member dismissing the Member from the PCP’s care
and directing the Member to contact the Plan’s Member Services Department to coordinate
selection of a new PCP.
Closing Physician Panel
When closing Membership panel to new Plan Members, Providers must:

Submit a request in writing 60 days prior to closing the Membership panel.
Maintain an open panel to all Plan Members who were provided services prior to the closing
of panel.

Submit a written notice of the re-opening of the panel, to include a specific effective date.
America’s 1st Choice will assist Physicians in providing communication to Members with disabilities
or language services. Please contact America’s 1st Choice Member Services to arrange services
for the deaf, blind or those who need a language interpreter.
Provider Information Changes
Prior notice to your Provider Relations Representative is required for any of the following changes:

Tax identification number (may require a new contract to be signed)

Group name or affiliation

Physical or billing address

Telephone or facsimile number

National Provider Identifier (NPI)
UpdatedDecember2012
Page 8
America’s 1st Choice Provider Manual – South Carolina
Participation & Credentialing
Providers are accepted for participation if they meet the Plan’s credentialing requirements and
business needs, in its sole discretion. America’s 1st Choice does not discriminate against race,
creed or national origin of the Provider.
Participating Providers are required to notify the Plan immediately when a new Provider joins their
practice. Notify the local Provider Relations Representative and the representative will send an
application for completion. Please see the Credentialing Section to learn more about our
credentialing requirements.
Provider Termination
In addition to the Provider termination information included in your contractual agreement with the
Plan, the Provider must adhere to the following terms:

Any contracted Provider must provide at least 60 days prior written notice before a “without
cause” termination;

Terminations occur on the last day of the month. For example, if a termination letter is
dated January 15, the termination will be effective March 31; and

Providers who receive a termination notice from the Plan may submit an appeal. Please
refer to the Credentialing section of this manual for specific guidelines.
Please Note: The Plan must provide written notification to all appropriate agencies and/or
Members upon a Provider suspension or termination, as required by regulations and statutes.
Continuity of Care – Terminated Provider
America’s 1st Choice will provide continued services to Members undergoing a course
of treatment by a Provider that no longer participates with the Plan. The Member’s applicable
co-payment shall be the same as it would be for a participating Provider if the following conditions
exist at the time of contract termination:
a. Such care is medically necessary. Continued care is allowed through the completion of
treatment, until the Member selects another treating Provider, or until the next Open
Enrollment period – not to exceed six months after the termination of the Provider’s
contract.
b. Continuation of care through the postpartum period for Members who have initiated a
course of prenatal care, regardless of the trimester in which care was initiated with a
terminated treating Provider.
For continued care under this subsection, the Plan and terminated Provider continue to abide by
the same terms and conditions as existed in the terminated contract. However, a terminated
Provider may refuse to continue to provide care to a Member who is abusive or noncompliant.
This subsection does not apply to Providers terminated from the Plan for cause.
UpdatedDecember2012
Page 9
America’s 1st Choice Provider Manual – South Carolina
Utilization Management & Quality Management Programs (UM/QM)
The Plan has UM/QM programs that include consultation with requesting Providers when
appropriate. Under the terms of the contract for participation with the Plan’s network, Providers
agree, in addition to complying with State and Federal mandated procedures, to cooperate and
participate in the Plan’s UM/QM programs, including quality of care evaluation, peer review
process, evaluation of medical records, Provider or Member grievance procedures, external audit
systems and administrative review.
Further, to comply with all final determinations rendered pursuant to the proceedings of the UM/QM
programs, all participating Providers or entities delegated for Utilization Management are to use the
same standards as defined in this section.
Compliance is monitored on an ongoing basis and formal audits are conducted annually.
Preferred Drug List
Please refer to the Pharmacy section of this manual for a description of the Plan’s Preferred Drug
List and prescribing criteria. Please contact your Provider Relations Representative for a copy of
the Preferred Drug List or you may locate it on our website at www.americas1stchoice.com.
Confidential Member Information & Release of Medical Records
All consultations or discussions involving the Member or his/her case should be conducted
discreetly and professionally in accordance with the HIPAA Privacy and Security Rules established
on April 14, 2003. All Physician practice personnel must be trained on privacy and security rules.
The Practice should ensure that there is a Privacy Officer on staff, that policies and procedures are
in place for the confidentiality of Member’s protected health information and that the Practice is
following procedure or obtaining appropriate authorization from Members to release protected
health information.
All Members have a right to confidentiality. Any health care professional or person who directly or
indirectly handles the Member or his/her medical record must honor this right. Every Provider is
required to post their Notice of Privacy Practice in the office or provide a copy to Members.
Employees who have access to Member records and other confidential information are required to
sign a “Confidentiality Statement.”
Confidential Information includes:
a) Any communication between a Member and a Physician; and
b) Any communication with other clinical persons involved in the Member’s health, medical
and mental care.
Included in this category are:
1) All clinical data, i.e., diagnosis, treatment and any identifying information such as name,
address, Social Security Number, etc.;
UpdatedDecember2012
Page 10
America’s 1st Choice Provider Manual – South Carolina
2) Member transfer to a facility for treatment of drug abuse, alcoholism, mental or psychiatric
problem; and
3) Any communicable disease (such as AIDS) or HIV testing protected under Federal or State
law.
When a Member enrolls in the Plan, his/her signature on the “Enrollment Form” automatically gives
the health care Provider permission to release his/her medical record to the Plan, other Physicians
in the Plan network who are directly involved with the Member’s treatment plan and agencies
conducting regulatory or accreditation reviews.
Before any individual not working for the Plan can gain access to the Member’s medical record,
written authorization must be obtained from the Member, Member’s guardian or his/her legally
authorized representative (except when there is a statute governing access to the record, a
subpoena or a court order involved). Disclosures without authorization or consent may include, but
are not limited to Armed Services Personnel, Attorneys, Law Enforcement Officers, Relatives, Third
Party Payers and Public Health Officials.
Adult Health Screening Services
An adult health screening is performed by a Physician to assess the health status of a patient age
21 and older. It is used to detect and prevent disease, disability and other health conditions or
monitor their progression. This is an all-inclusive service. The Plan does not allow separate billing
for required or recommended components.
America’s 1st Choice reimburses adult health screening services for recipients ages 21 and older,
with the following procedure codes and no modifier:

99385 for new patient screenings ages 21-39;

99386 for new patient screenings ages 40-64;

99387 for new patient screenings ages 65 years and older;

99395 for established patient screenings ages 21-39;

99396 for established patient screenings ages 40-64; or

99397 for established patient screenings ages 65 years and older.
(Actual financial reimbursement is according with the terms of the Provider’s contract.)
Required Service Components
A Physician who provides adult health screenings must be able to provide or refer and coordinate
the provision of all required screening components. These components must be documented in the
Member’s medical record.
Required components:
1. Health History
At a minimum, the following items must be documented in the Member’s medical record:


Present history;
Past history;
UpdatedDecember2012
Page 11
America’s 1st Choice Provider Manual – South Carolina



Family history;
A list of all known risk factors, allergies and medications; and
Nutritional assessments.
2. Physical Examination
At a minimum, the following items must be documented in the Member’s medical record:

Measurements of height, weight, blood pressure and pulse; and

Physical inspection to include: assessment of general appearance, skin, eyes, ears, nose,
throat, teeth, thyroid, heart, lungs, abdomen, breasts, extremities; and a pelvic, testicular,
rectal and prostate exam, per gender, as appropriate.
3. Visual Acuity Testing
At a minimum, the testing must document a recipient’s ability to see at 20 feet.
4. Hearing Screen
At a minimum, the screen must document a recipient’s ability to hear by air conduction.
5. Required Laboratory Testing
At a minimum, the following are required and are included in the reimbursement of an adult
health screening:


Urinalysis dipstick for blood, sugar and acetone; and
Hemoglobin or hematocrit.
Manual or automated dipstick urine, hemoglobin and hematocrit tests performed during an
adult health screening are not reimbursable as separate services from the adult health
screening.
Recommended service components:
1. Mammography Screening Referral
The American Cancer Society recommends referral for routine screening mammography for all
females ages 35 and older. Mammography screening guidelines are as follows:


Ages 35 to 39, one screening baseline mammogram; and
Ages 40 and older, one mammogram screening every year.
A screening mammogram is limited to one per year. A diagnostic mammogram used to
evaluate or monitor an abnormal finding may be performed more than once a year.
Mammograms performed by a mobile x-ray Provider are not reimbursable.
2. Laboratory Procedures
The following laboratory procedures are recommended, when indicated:





Stool for occult blood;
Tuberculin skin test (can be reimbursed in addition to the adult health screening);
Collection of cervical pap smear for sexually active females or all females 18 years old
and older;
Collection of prostatic surface antigen (PSA), if indicated for males 50 years old and older;
and
Collection of specimens for sexually transmitted diseases.
UpdatedDecember2012
Page 12
America’s 1st Choice Provider Manual – South Carolina
Cultural Competency
America’s 1st Choice has a strong commitment to diversity in its workforce, customer base and
communities it serves. When health care services are delivered without regard for cultural
differences, patients are at risk for sub-optimal care. Patients may be unable or unwilling to
communicate their health care needs in a culturally insensitive environment, reducing the
effectiveness of the health care process.
Understanding the fundamental elements of culturally and linguistically appropriate services is
necessary when striving for cultural competency in health care delivery. Implementing a strong
cultural competency program in health care delivery allows America’s 1st Choice to:




Respond to demographic changes;
Eliminate disparities in the health status of people of diverse backgrounds;
Improve the quality of health care services and health outcomes;
Gain a competitive edge in the health care market and decrease liability/malpractice claims;
and
Increase both Member and staff satisfaction.
Cultural Competency is defined as a set of congruent behaviors, attitudes and policies that come
together in a system, agency or among professionals and enable that system, agency or those
professionals, to work effectively in cross-cultural situations.
Cultural Competency occurs in both clinical and non-clinical areas. In the clinical area, it is based
on the Patient-Provider relationship. In the non-clinical area, it involves organizational policies and
interactions that impact health care services.
Member Rights & Responsibilities
America’s 1st Choice strongly endorses the rights of Members as supported by State and Federal
laws. America’s 1st Choice also expects Members to be responsible for certain aspects of the care
and treatment they are offered and receive.
All Member rights and responsibilities are to be acknowledged and honored by America’s 1st
Choice staff and all contracted Providers. Contracted Providers are provided with a declaration of
America’s 1st Choice Member rights and responsibilities in their Provider Manual. In addition,
Providers are given a handout of these rights and responsibilities and are urged to post them in
their respective offices.
Members are afforded a listing of their rights and responsibilities as a Plan Member in their
America’s 1st Choice materials. See the Sample Forms and Documents section for rights and
responsibilities that America’s 1st Choice endorses and expects Providers and Members to
acknowledge and reinforce.
Advance Medical Directives
Members have the right to control decisions relating to their medical care including the decision
to have withheld or taken away the medical or surgical means or procedures to prolong their lives.
The law provides that each Plan Member (age 18 years or older of sound mind) should receive
information concerning this provision and have the opportunity to sign an Advance Directive
Acknowledgement Form to make their decisions known in advance. This allows Members to
UpdatedDecember2012
Page 13
America’s 1st Choice Provider Manual – South Carolina
designate another person to make a decision should they become mentally or physically unable
to do so.
Fraud and Abuse Reporting
Under the Centers for Medicare and Medicaid Services (CMS) guidelines, the health plan is
required to have an effective fraud, waste and abuse (FWA) program in place. America’s 1st
Choice has implemented an FWA program to prevent, detect and report health care fraud and
abuse according to applicable federal and State statutory, regulatory and contractual requirements.
America’s 1st Choice will use a number of processes and procedures to identify and prevent fraud
and abuse. Providers engaged in fraud and abuse may be subject to disciplinary and corrective
actions, including but not limited to, warnings, monitoring, administrative sanctions, suspension or
termination as an authorized Provider, loss of licensure, civil and/or criminal prosecution, fines and
other penalties.
In December 2007, CMS published a final rule that requires these organizations to apply certain
training and communication requirements to all entities they partner with to provide benefits or
services in the Part C or Part D programs.
To meet CMS requirements for Medicare Advantage Organizations and Part D Sponsors, this
section covers general fraud, waste and abuse training guidelines for the Plan’s first-tier,
downstream, and related entities.
Provider Requirements

All Providers and their employees must complete training annually.

Please maintain records of all training – this is to include dates, methods of training,
materials used for training, identification of trained employees via sign-in sheets or other
methods, etc.

The Plan may request such records to verify that training occurred.

If the organization has contracted with other entities to provide health and/or administrative
services on behalf of our Plan Members, you must provide this training material to your
subcontractor for training and ensure that the subcontractor and any other entity they may
have contracted with to provide the service also maintain records of training.

All contracted entities should have policies and procedures to address fraud, waste and
abuse – including effective training, reporting mechanism and methods to respond to
detected offenses.
Definitions
First Tier Entity - Any party that enters into a written agreement with the health plan to provide
administrative or health care services for the health plan’s enrollees.

Examples include, but are not limited to, pharmacy benefit manager (PBM), contracted
hospitals or Providers.
UpdatedDecember2012
Page 14
America’s 1st Choice Provider Manual – South Carolina
Downstream Entity - Any party that enters into a written agreement below the level of the
arrangement between a sponsor and a first tier entity for the provision of administrative or health
care services for a Medicare eligible individual under Medicare Advantage or Part D programs.

Examples include, but are not limited to, pharmacies, claims processing firms or billing
agencies.
Related Entity - Any entity that is related to the health plan by common ownership or control and:
1. performs some of the sponsor’s management of functions under contract of delegation,
2. furnishes services to Medicare enrollees under an oral or written agreement, or
3. leases real property or sells materials to the sponsor at a cost of more than $2,500 during a
contract period.
Fraud - Federal health care fraud generally involves a person’s or entity’s intentional use of false
statements or fraudulent schemes (such as kickbacks) to obtain payment for or to cause another to
obtain payment for items or services payable under Federal and State health care programs.
Some examples of fraud:

Billing for services not furnished;

Soliciting, offering or receiving a kickback, bribe or rebate; or

Violations of the physician self-referral (“Stark”) prohibition.
Waste - Generally, means over-use of services or other practices that result in unnecessary costs.
In most cases, waste is not considered caused by reckless actions but rather the misuse of
resources.
Abuse - In general, program abuse, which may be intentional or unintentional, directly or indirectly
results in unnecessary or increased costs to the Medicaid and Medicare Programs.
Some examples of abuse:

Charging in excess for services or supplies;

Providing medically unnecessary services; or

Providing services that do not meet professionally recognized standards.
Training:



The plan’s Providers, including first-tier, downstream and related entities, must complete
fraud, waste and abuse training annually.
Providers are required to maintain records of all training, to include dates of training,
methods of training, training curriculum, identification of trained employees via sign in
sheets or other methods. The plan may request such records to ensure training has
occurred.
Providers should have policies and procedures to address fraud, waste and abuse,
including effective training, reporting mechanisms and methods to respond to detected
offenses.
UpdatedDecember2012
Page 15
America’s 1st Choice Provider Manual – South Carolina
Pertinent Statues, Laws and Regulations
False Claims Act
The federal False Claims Act of 1985 permits a person with knowledge of fraud against the United
States Government, referred to as the "qui tam plaintiff," to file a lawsuit on behalf of the
Government against the person or business that committed the fraud (the defendant). If the action
is successful, the qui tam plaintiff is rewarded with a percentage of the recovery.
Violations of Medicare laws and the Medicare Fraud and Abuse Statute also constitute violations of
the False Claims Act. Since Medicaid is indirectly funded by the Federal Government, violations of
Medicaid laws will also be covered under the False Claims Act.
The federal False Claims Act creates liability for the submission of a claim for payment to the
government that is known to be false – in whole or in part. Several States have also enacted false
claims laws modeled after the federal False Claims Act.
A “claim” is broadly defined to include any submissions that result, or could result, in payment.
Claims “submitted to the government” include claims submitted to intermediaries such as State
agencies, managed care organizations and other subcontractors under contract with the
government to administer health care benefits.
Liability can also be created by the improper retention of an overpayment.
Examples include:

A physician who submits a bill for medical services not provided.

A government contractor who submits records that he knows (or should know) are false and
that indicate compliance with certain contractual or regulatory requirements.

An agent who submits a forged or falsified enrollment application to receive compensation
from a Medicare Plan Sponsor.
Whistleblower and Whistleblower Protections
The False Claims Act and some State false claims laws permit private citizens with knowledge of
fraud against the U.S. Government or State government to file suit on behalf of the government
against the person or business that committed the fraud.
Individuals who file such suits are known as “whistleblowers”. The Federal False Claims Act and
some State false claims acts prohibit retaliation against individuals for investigating, filing or
participating in a whistleblower action.
Anti-Kickback Statute
The Anti-Kickback law makes it a crime for individuals or entities to knowingly and willfully offer,
pay, solicit or receive something of value to induce or reward referrals of business under Federal
health care programs.
The Anti-Kickback law is intended to ensure that referrals for health care services are based on
medical need and not based on financial or other types of incentives to individuals or groups.
UpdatedDecember2012
Page 16
America’s 1st Choice Provider Manual – South Carolina
Examples include:

A frequent flier campaign in which a physician may be given a credit toward airline frequent
flier mileage for each questionnaire completed for a new patient placed on a drug
company’s product.

Free laboratory testing offered to health care Providers, their families and their employees
to induce referrals.
In addition to criminal penalties, violation of the Federal Anti-Kickback Statute could result in civil
monetary penalties and exclusion from federal health care programs, including Medicare and
Medicaid programs.
Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA contains provisions and rules related to protecting the privacy and security of protected
health information (PHI).
HIPAA Privacy - The Privacy Rule outlines specific protections for the use and disclosure of PHI.
It also grants rights specific to Members.
HIPAA Security - The Security Rule outlines specific protections and safeguards for electronic PHI.
If you become aware of a potential breach of protected information, you must comply with the
security breach and disclosure provisions under HIPAA and, if applicable, with any business
associate agreement.
Potential FWA committed by:
Pharmaceutical Manufacturer

Illegal Off-label Promotion - Illegal promotion of off-label drug usage through marketing,
financial incentives or other promotion campaigns;

Illegal Usage of Free Samples - Providing free samples to physicians knowing and
expecting those physicians to bill the federal health care programs for the sample;

Billing for items or services not rendered or not provided as claimed;

Submitting claims for equipment or supplies and services that are not reasonable and
necessary;

Double billing resulting in duplicate payment;

Billing for non-covered services as if covered;

Knowing misuse of Provider identification numbers, which results in improper billing;

Unbundling (billing for each component of the service instead of billing or using all inclusive
code);

Altering medical records;
UpdatedDecember2012
Page 17
America’s 1st Choice Provider Manual – South Carolina

Improper telemarketing practices;

Compensation programs that offer incentives for items or services ordered and revenue
generated; or

Routine waivers of deductibles/coinsurance.
Potential FWA committed by:
Skilled Nursing Facility (SNF)

SNFs improperly up-coding resident Resource Utilization Group (RUG) assignments to gain
higher reimbursement;

SNF improperly utilizing therapy services to inflate the severity of the RUG classification to
obtain additional reimbursement; and

DME or supplies offered by DME Provider that are covered by the Medicare Part A benefit
in the SNF’s payment.
Potential FWA committed by:
Hospital

Failure to follow the same day rule;

Abuse of partial hospitalization payments;

Same day discharges and readmissions;

Improper billing for observation services;

Improper reporting of pass through costs;

Billing on an outpatient basis for “inpatient only” procedures;

Submitting claims for medically unnecessary services by failing to follow local policies;

Improper claims for cardiac rehabilitation services; and

Improper DRG Coding for increased revenue.
Potential FWA committed by:
Physician and Others

Chiropractor intentionally billing Medicare for physical therapy and chiropractic treatments
that were never actually rendered for the purpose of fraudulently obtaining Medicare
payments;

A psychiatrist billing Medicare, Medicaid, the Plan, and private insurers for psychiatric
services that were provided by nurses rather than him or herself;

Physician certifies on a claim form that he performed laser surgery on a Medicare
beneficiary when he knew that the surgery was not actually performed on the patient;
UpdatedDecember2012
Page 18
America’s 1st Choice Provider Manual – South Carolina

Physician instructs his employees to tell the OIG investigators that the physician personally
performs all treatments when, in fact, medical technicians do the majority of the treatment
and the physician is rarely present in the office;

Physician, who is under investigation by the FBI and the Plan, alters records in an attempt
to cover up improprieties;

Neurologist knowingly submits electronic claims to the Medicare carrier for tests that were
not reasonable and necessary and intentionally up-coded office visits and electromyograms
to Medicare;

Podiatrist knowingly submits claims to the Medicare and Medicaid programs for non-routine
surgical procedures when he actually performed routine, non-covered services such as the
cutting and trimming of toenails and the removal of corns and calluses; and

Performing tests on a beneficiary to establish medical necessity.
Potential FWA committed by:
Durable Medical Equipment, Prosthetics, Orthotics and Suppliers (DMEPOS)

DME Provider billed for items or services not provided to the beneficiary;

Continued billing for rental items after they are no longer medically necessary;

Resubmission of denied claims with different information in an attempt to be improperly
reimbursed;

Providing and/or billing for substantially excessive amounts of DME items or supplies;

Up-coding a DME item by selecting a code that is not the most appropriate;

Providing a wheelchair and billing for the individual parts (unbundling);

Delivering or billing for certain items or supplies prior to receiving a physician’s order and/or
appropriate certificate of necessity;

Completing portions of the certificate of necessity that is reserved for completion by the
treating physician only;

Cover letters to encourage physicians to order medically unnecessary items or services;

Improper use of KX modifier;

Providing false information on the DMEPOS supplier enrollment form;

Knowing misuse of a supplier number, which results in improper billing;

Duplicate billing for the same service; and

Providing services at no charge to an assisted living center.
Plan’s Processes for Identification of Fraud, Waste and Abuse
The Plan has software and monitoring programs designed to identify indicators for fraud, waste
and abuse, including, but not limited to:

Multiple billing: Several payers billed for the same services (e.g. billing medications under
Part A or Part B and then billing again under Part D);

Billing for non-covered services;

Duplicate Billing;
UpdatedDecember2012
Page 19
America’s 1st Choice Provider Manual – South Carolina

Unbundling of charges;

Up-coding;

Fictitious Providers;

Billing of unauthorized services;

Billing with the wrong place of service in order to receive a higher level of reimbursement;

Claims data mining to identify outliers in billing;

Billing for services or supplies not provided;

Improper use of KX modifier;

Failure to follow the same day rule (hospital);

Abuse of partial hospitalization payments; or

Billing on an outpatient basis for “inpatient only” procedures.
Reporting Obligation and Mechanisms
If you identify or are made aware of potential misconduct or a suspected fraud, waste or abuse
situation, it is your right and responsibility to report it.
Providers, Vendors and Delegates can call the Plan’s Compliance Hotline at 1-888-548-0095.
Callers are encouraged to provide contact information should additional information be needed.
However, you may report anonymously and retaliation is strictly prohibited if a report is made in
good faith. The Plan will notify the CMS Regional Office of any issues that involve Medicare
Members.
Cooperation with the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
As a Medicare provider contracted with the Plan, you have a contractual and compliance obligation
to cooperate with the Federal government in its ongoing efforts to combat fraud, waste and abuse.
CMS contracts with the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
to investigate potential fraud, waste and abuse matters, and relies on providers like you to provide
certain information.
Health Integrity, LLC (the NBI MEDIC) routinely mails to Medicare prescribers a Prescription
Verification Form containing the beneficiary’s name, the name of the medication, the date
prescribed and the quantity given. The form also asks the prescriber to check “yes” or “no” to
indicate whether the prescriber wrote the prescription. The prescriber is asked to respond within
2 weeks. If no response is received, then the investigator follows up with a second request.
The Health Plan encourages you to review your current process and ensure that your office staff is
aware of the MEDIC’s requests and is prepared to respond to the MEDIC in a timely manner and
completely.
Resources
CMS’ Prescription Drug Benefit Manual – Chapter 9:
http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PDBManual_Chapter9_FWA.pdf
UpdatedDecember2012
Page 20
America’s 1st Choice Provider Manual – South Carolina
Code of Federal Register (see 42 CFR 422.503 and 42 CFR 422.504)
http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms4124fc.pdf
Office of the Inspector General
http://www.oig.hhs.gov/fraud.asp
Medicare Learning Network (MLN) Fraud & Abuse Job Aid
http://www.cms.hhs.gov/MLNProducts/downloads/081606_Medicare_Fraud_and_Abuse_brochure.
pdf.
Marketing Prohibitions
Providers shall comply with all Medicare Marketing Guidelines as set forth by the Centers for
Medicare and Medicaid Services (CMS).
At minimum, participating Physicians and Providers should observe the following:
1. Providers or Provider groups are prohibited from distributing printed information comparing
benefits of different health plans, unless the materials have consent from all of the Plans
listed, and received prior approval from the Centers for Medicare and Medicaid Services
(CMS);
2. Providers shall not accept enrollment applications or offer inducement to persuade
beneficiaries to join plans;
3. Providers may not offer anything of value to induce plan enrollees to select them as a
Provider; and
4. Provider offices or other places where health care is delivered shall not accept applications
for health plans, except in the case where such activities are conducted in common areas in
the health care setting.
UpdatedDecember2012
Page 21
America’s 1st Choice Provider Manual – South Carolina
3. CREDENTIALING
Introduction
The credentialing process is mandatory for network Provider participation. During this process,
the Provider’s credentials are verified and the complete application is reviewed against the Plan’s
policies and procedures. Any issue identified such as malpractice claims history, licensure or
Medicare or Medicaid sanction is reviewed by the Credentialing Committee, which is the Peer
Review Committee of the Plan. It is the Provider’s responsibility to fill out the entire credentialing
application and supply a written explanation to any item of negative information. Acceptable
credentialing applications include the Plan’s own applications as well as the Council for Affordable
Quality Healthcare (CAQH) application. The CAQH application must have a current attestation and
be updated with all supporting documents. An application cannot be processed until all areas are
completed and all documents are provided to the Plan.
Please note that Providers have the following rights in connection with the credentialing process:
The right to review information submitted to support their credentialing applications;

Upon request to Credentialing, a Provider has the right to review information that is
obtained by the Plan from outside sources and which it uses to evaluate the credentialing
application. The exception to the information that may be reviewed is peer references and
information that is peer review protected.
The right to correct erroneous information;

When information is obtained by the Plan from other sources, and the information
substantially varies from that supplied by the Provider, the Plan will notify the Provider of
the right to correct the erroneous information; the timeframe for making the changes; the
format for submitting the changes; and the person to whom and the location where the
corrected information must be sent.
The right to receive the status of their credentialing or re-credentialing applications upon request;

The Plan will respond to a Provider’s request for status on their credentialing application
within 15 business days. The information provided will advise of any items still needed, or
any difficulty or non-response in obtaining a verification response.
The application is then taken through the initial credentialing process and brought to
the Credentialing Committee (composed of practicing Providers credentialed by the Plan).
Any committee need for additional information will, without delay, be requested from the Provider.
Providers are initially credentialed for a three-year period, after which re-credentialing is required.
Periodically, the Plan may request updates for expired documentation such as professional liability
insurance. If there are changes to any of the information/documentation submitted in support of
the application, such as board certification status, it is important to let the Plan know.
The Plan has a defined Provider appeal process for cases in which it chooses to alter the
conditions of a Provider’s participation, based on issues of quality of care or service. Providers
are notified of any instances where there is an impending action related to a Provider’s
participation status. The notification will include an explanation of the appeal process.
UpdatedDecember2012
Page 22
America’s 1st Choice Provider Manual – South Carolina
Credentialed Providers
For network Provider participation, the following is a list of licensed Providers types required to be
credentialed in order to provide medical services to Plan Members:

Medical Doctors (MD);

Osteopathic Doctors (DO);

Podiatric Doctors (DPM);

Chiropractic Doctors (DC);

Optometric Doctors (OD);

Oral Surgeons (DDS/DMD)

Psychologists (Psych.D/PhD);

Dentists (DDS/DMD)

Audiologists

Diabetes Educators – Outpatient

Dietitians/Nutritionists

Advanced Registered Nurse Practitioners (ARNP);

Physician Assistants (PA);

Certified Physician Assistants (PAC);

Certified Nurse Midwifes (CNM);

Physical Therapists (PT) - if contracting directly with us. If through a facility, then only the
facility needs to be credentialed;

Occupational Therapists - Same as PT;

Speech Therapists - Same as PT;

Licensed Psychologists (non-doctoral)

Licensed Psychoanalysts

Licensed Professional Counselors

Clinical Social Workers (CSW);

Masters in Social Work (MSW);

Licensed Mental Health Counselors (LMHC);

Licensed Marriage & Family Therapists (LMFT).
Credentialing must be approved before a Provider begins to deliver health care services to
Members. Services delivered to Plan Members before a Physician or Provider has completed the
credentialing process and are billed to the Plan directly will be processed as Out of Network.
The Plan also reviews certain facilities and ancillary Providers. A Data Collection Form is required
including, but not limited to, the following supporting documents:

State operating certificate;
UpdatedDecember2012
Page 23
America’s 1st Choice Provider Manual – South Carolina

JCAHO or other acceptable accreditation; and

Certificate of Insurance.
These facilities are:

Hospitals;

Ambulatory Surgery Centers (ASC);

Skilled Nursing Facilities (SNF);

Diagnostic Imaging Facilities;

Hospice Facilities;

Dialysis/ESRD Centers;

Home Health Agencies;

Durable Medical Equipment (DME) Providers;

Comprehensive Outpatient Rehabilitation Facilities; and

Outpatient Physical, Occupational & Speech Therapy (PT, OT, ST) Facilities.
NOTE: Hospital and accredited facility-based Practitioners do not require credentialing and
re-credentialing by the Plan.
Initial Credentialing Process
The Initial Credentialing Process is as follows:
Step 1. The Provider fully completes the initial credentialing application and submits the required
documents to the Plan. A CAQH application is acceptable provided that all the
information and documents are up to date. If a Provider has signed a Medicare contract,
the Plan will verify the Provider’s name does not appear on the listing of Medicare Opted
Out Providers.
Step 2. Primary source verification is performed.
Step 3. The Medical Director/Chairperson of the Credentialing Committee reviews applications
prior to each scheduled meeting. He/she may ask for additional explanations if deemed
necessary.
Step 4. The Provider’s application is presented to the Credentialing Committee.
Step 5. If approved, the application is noted accordingly and proceeds to step 6. If additional
information is requested by the Credentialing Committee, the request is conveyed to the
Provider and the file is placed in a pending status, awaiting the requested information.
Once received, the committee re-evaluates the application.
Step 6. Upon approval, the Provider information is loaded into the Plan’s main database for
purposes of claims payment and directory listing.
UpdatedDecember2012
Page 24
America’s 1st Choice Provider Manual – South Carolina
Step 7. The Provider is notified in writing of their status and the effective date of their contract
following approval. Contractual terms are effective the 1st day of the following month.
Example: A contract effective date is January 1, 2013 but the Provider is not credentialed
until January 25, 2013. The Provider will be loaded effective February 1, 2013.
Step 8. The assigned Provider Relations Representative will conduct an in-service visit with the
Provider and selected staff.
The credentialing process takes approximately 90 days from receipt of a complete application
through credentialing approval and loading.
Re-Credentialing
Credentialed Providers must be re-credentialed every three years. The Credentialing Department
establishes this date as 36 months following the Provider’s approval date. The Provider will be
notified approximately 120 days prior to the expiration of credentialing. The re-credentialing review
process involves the following:

Completion of a re-credentialing application or CAQH application that includes a statement
regarding:
1) Correctness and completeness of the application;
2) Physical or mental health problems;
3) History of chemical dependency/substance abuse;
4) History of loss of license or felony convictions;
5) History of loss or limitation of privileges; or
6) State or federal disciplinary activity;

Verification of current license;

Evidence of current professional liability insurance coverage;

Verification of current DEA Certificate (as applicable);

Verification of current State issued Controlled Substance Registration (as applicable);

Verification of Board Certification Status (as applicable);

History of professional liability claims that resulted in settlement or judgment paid by or on
behalf of the practitioner;

Review of the National Practitioner Data Bank (NPDB);

Review for any sanctions imposed by Medicare;

Evidence of good standing privileges at a participating hospital; and

Internal evaluations from Provider Services, Member Services and Quality Management, if
applicable.
If a Provider fails to submit a re-credentialing application in a timely fashion and the credentialing
period lapses, the Provider’s contract may be terminated.
In the rare event that the committee denies a Provider credentialed status, the Provider has the
right to appeal the decision within 30 days of receiving the denial notice. The appeal rights are
provided by the Medical Director, as Chairman of the Credentialing Committee. Any provider
UpdatedDecember2012
Page 25
America’s 1st Choice Provider Manual – South Carolina
denied credentialing will be reported to the appropriate state agency if this is required by state
regulation.
Professional Liability Insurance
The Plan’s credentialing policies concerning liability insurance coverage conform to State and
Federal guidelines. Upon request, a provider must provide the Plan with evidence of coverage and
any renewals, replacements or changes.
Updated Documents
The Plan is required to maintain verification of certain documents that expire throughout the
Provider’s participation with the Plan. These documents include, but are not limited to, Medical
License, DEA Certification and Board Certification. The Plan will maintain expiration dates and
notify Providers if updated documentation should be submitted.
UpdatedDecember2012
Page 26
America’s 1st Choice Provider Manual – South Carolina
4. MEMBER ELIGIBILITY & SERVICES
Member Services
The primary purpose of the America’s 1st Choice Member Services Department is to answer
questions and attempt to resolve issues, problems and concerns raised by Members.
Our office is open Monday through Friday from 8:00 a.m. until 8:00 p.m. EST, from February 15
through October 14. For all remaining dates, the office is open Monday through Sunday from 8:00
a.m. until 8:00 p.m. EST.
The Member Services Department can be contacted at: 1-866-321-3947. Members with hearing
and/or speech impairments should call our toll-free TTY line at 1-800-735-8583. We also
encourage the use of our website at www.americas1stchoice.com.
Members and Physicians may contact Member Services to:

Change a Primary Care Physician;

Receive educational materials;

Learn about pre-certification;

Disenroll from the Plan;

Obtain a new identification card;

Find participating pharmacies;

Verify Member eligibility;

Ask co-payment, co-insurance and deductible questions;

Inquire about claims payment;

Learn more regarding Member benefits;

File a Member complaint/grievance;

Notify the Plan of a change in information – new address, phone number or other personal
information; and

Receive Member assistance with the Appeals & Grievance process.
Staff Selection and Training
The Member Services Department is committed to hiring highly qualified individuals, providing
superior training and monitoring activities to achieve America’s 1st Choice’s service commitments.
Telephone calls are monitored to maintain standards regarding information accuracy, professional
demeanor and timely follow-up.
Service Standards
America’s 1st Choice Member Services Department is designed to address issues, solve problems,
answer questions and listen to concerns from Members and Physicians or Providers. Our service
commitments are to:
UpdatedDecember2012
Page 27
America’s 1st Choice Provider Manual – South Carolina
1. Answer calls within 30 seconds;
2. Respond to voice mail messages within 24 business hours; and
3. Respond to urgent calls within one hour.
America’s 1st Choice will track the types of issues that you and your staff bring to our attention so
that we may correct any underlying problems.
Member Identification Card
Each Member will receive an identification card that allows them access to receive services from
the America’s 1st Choice network of participating Physicians/Providers. A sample of the America’s
1st Choice identification card for each product is available in the Sample Forms and Documents
section of this manual. Physicians/Providers should ask to see the Member Identification Card at
each scheduled appointment.
Some important points to remember:

The practice should make a copy of both sides of the identification card for their Member
medical record;

For purposes of privacy, the identification card has a unique Member number used for most
transactions;

The identification card lists the most common co-payments, co-insurance and deductible
amounts;

The identification card lists the toll-free Member Service telephone number;

The identification card has the address to mail claims;

The identification card does not reflect the effective date of the Provider; it is the date the
Member became effective with the Plan; and

The Physician/Provider can always verify eligibility by requesting to see the Member
identification card each time the Member has an appointment. The Member should also be
asked if there have been any changes since his/her previous appointment.
Methods of Eligibility Verification
Providers have the following methods to verify Member eligibility:
1. Provider Portal - Our Provider Portal is a fast and easy way to search eligibility. It enables
you to verify basic information within seconds, minimizing the time spent on administrative
functions so that patient care can remain your primary focus.
2. Member Services – Member Services Department staff are available to verify Member
eligibility toll free at 1-866-321-3947, from February 15 through October 14, Monday
through Friday from 8:00 a.m. until 8:00 p.m. EST and for all remaining dates, Monday
through Sunday from 8:00 a.m. until 8:00 p.m. EST.
UpdatedDecember2012
Page 28
America’s 1st Choice Provider Manual – South Carolina
3. Application Form – For new Members who have not yet received their identification card
with the New Member Packet, a copy of their application form will suffice as a form of
eligibility verification. We do encourage that network Physicians/Providers use a second
form of verification under these circumstances for “non-urgent” medical services.
UpdatedDecember2012
Page 29
America’s 1st Choice Provider Manual – South Carolina
5. UTILIZATION MANAGEMENT DEPARTMENT
Introduction
The Utilization Management (UM) Department is involved in the coordination of care for our
Members. The roles of the department include utilization review of those services on the PPO
Plan which require pre-service requests and Disease Management for Members enrolled in the
Chronic Care Improvement Program (CCIP).
The UM Department is also available to assist your office regarding any questions related to the
pre-certification process and disease management.
Department Philosophy
The Utilization Management Department’s goal is to create partnerships with health care
Physicians, Providers and Members that result in the following:
1. Avoidance of acute illnesses and diseases through prevention and/or early detection of
medical problems;
2. Enhancement and improvement of general levels of health and fitness;
3. Enabling of Members through education to develop awareness of the importance of
prevention and health maintenance as key to general health and fitness; and
4. Assistance for Members in understanding their partnership role with health Providers.
The UM department will strive to achieve these objectives through two methods:
1. Development of an efficient utilization management program as outlined below; and
2. Developing strong disease management and lifestyle change programs.
UM Staff Availability
The Utilization Management (UM) department will be available for all pre-certification requests from
8:00 a.m. to 5:00 p.m. EST on weekdays (excluding holidays). After routine business hours, the
UM department can be reached by calling the department’s regular telephone number. This
number will lead to the on-call clinical staff that will be able to assist with any UM functions.
Contact Information
The Plan’s Utilization Management (UM) department may be contacted at:
America’s 1st Choice
Utilization Management
Telephone: 1-888-211-9912
Fax: 1-888-211-9919
UpdatedDecember2012
Page 30
America’s 1st Choice Provider Manual – South Carolina
General Information
The Utilization Management Program is for Medicare Members enrolled in the PPO product.
The time frames for response for pre-certification requests are as follows:

Standard Requests: Requests are processed as quickly as possible and the department’s
current turnaround time is 1-2 days.

Expedited/STAT Requests: Our department goal is to respond within 24 hours of the request.
Expedited/STAT requests are those where a delay would jeopardize the Member’s life, health,
or ability to regain maximum function. These requests require the Physician or Physician’s
representative to call the UM Department and request to speak to the Medical Director.
Members calling into Member Services will be re-directed back to their Physician to make certain
the service is requested, and Member Services will also send the information to UM in order to
track the request.
Status of a Pre-Service Request
A Provider may call the UM department during normal business hours, 8:00 a.m. to 5:00 p.m. EST
on weekdays, to check the status of a request. Members should contact Member Services
to receive information regarding a requested service. If further information is needed, Member
Services will contact the UM department.
Pre-Certification Process
The Plan requires pre-certification on the following procedures/services:
1. Bariatric Surgery
2. Septoplasty
3. Mammoplasty
4. Rhinoplasty
5. Varicose Vein Treatment
6. Power Operated Vehicles or Wheelchairs
7. Plastic/Cosmetic Procedures
All other procedures/services other than those mentioned above can be arranged without prior
authorization from the Plan.
For a copy of the Pre-Certification Request form for the PPO Plan, please see Section 10
of this manual or you may locate it on our website at www.americas1stchoice.com.
The UM department utilizes the following criteria when making a determination:

CMS National Coverage Determinations;

Local Carrier Coverage Determinations;

Federal and State Statutes; and
UpdatedDecember2012
Page 31
America’s 1st Choice Provider Manual – South Carolina

Hayes Medical Technology, along with other resources to determine medical necessity, as
appropriate.
For a copy of the UM Review Criteria, please contact the UM department, Monday through Friday,
from 8:00 a.m. to 5:00 p.m. EST.
The Plan’s Medical Director also has access to board-certified specialists for consultation on issues
that fall outside of his/her expertise.
Approved Requests
When a pre-service authorization request is approved, an Authorization Notification will be faxed to
the requesting Provider(s). This notice will contain the valid time frame of the authorization, the
date of the decision, who requested the authorization, who is authorized to provide the services
and which services were authorized.
Pended Requests
When the pre-service authorization request is pended, the UM department will contact the Provider
to gather additional information if needed. The requests will be either verbal or faxed to the
Provider’s office, labeled:


1st Request for Information
2nd Request for Information
Each request has a specific time frame for response and will also inform the Provider of what is
required. If the Provider does not respond to both requests, then the UM department will send the
Medicare approved denial letter to the Member and will fax a copy to the requesting Provider.
The Provider may contact the Medical Director by calling 1-888-211-9912 at any time during the
review process or immediately after the receipt of the denial letter in order to discuss the decision.
The Plan will comply with all Federal and State requirements concerning denial of services. The
Plan’s Medical Director and UM staff are available during normal business hours to assist
Providers with inquiries regarding a service denial.
Emergency and Urgent Care Services
An emergency medical condition is a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent layperson, with an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in:

Serious jeopardy to the health of the individual or, in the case of a pregnant woman,
the health of the woman or her unborn child;

Serious impairment to bodily functions; or

Serious dysfunction of any bodily organ or part.
Emergency services are covered inpatient and outpatient services that are:
UpdatedDecember2012
Page 32
America’s 1st Choice Provider Manual – South Carolina

Furnished by a Provider qualified to perform emergency services; and

Needed to evaluate or stabilize an emergency medical condition.
Urgently needed services are covered services that:

Are not emergency services as defined in this section;

Are provided when a Member is temporarily absent from the Plan’s service area or, if
applicable, continuation area. (Note that urgent care received within the service area is an
extension of primary care services); and

Are medically necessary and immediately required, meaning that:
o The urgently needed services are a result of an unforeseen illness, injury or
condition; and
o Given the circumstances, it was not reasonable to obtain the services through the
Plan’s participating Provider network.
Note that under unusual and extraordinary circumstances, services may be considered urgently
needed when the Member is in the service or continuation area, but the Plan’s Provider network is
temporarily unavailable or inaccessible.
Pharmacy and Provider Access During a Federal Disaster or Other
Public Health Emergency Declaration
The Plan will consult the U.S. Department of Homeland Security's Federal Emergency
Management Agency’s (FEMA) website (see http://www.fema.gov/hazard/dproc.shtm) for
information about the disaster or emergency declaration process and the distinction between types
of declarations.
The Plan will also consult the Department of Health and Human Services (DHHS) or Centers for
Medicare & Medicaid Services (CMS) websites for any detailed guidance.
In the event of a Presidential emergency declaration, a Presidential (major) disaster declaration,
a declaration of emergency or disaster by a Governor or an announcement of a public health
emergency by the Secretary of Health and Human Services Cost & MA plans - absent an 1135
waiver by the Secretary - the Plan will:

Allow Part A/B and supplemental Part C plan benefits to be furnished at specified noncontracted facilities (note that Part A/B benefits must, per 42 CFR § 422.204(b)(3), be
furnished at Medicare-certified facilities);

Waive in full, or in part, requirements for authorization or pre-notification;

Temporarily reduce plan approved out-of-network cost sharing amounts; and

Waive the 30-day notification requirement to Members provided all the changes (such as
reduction of cost sharing and waiving authorization) benefit the enrollee.
UpdatedDecember2012
Page 33
America’s 1st Choice Provider Manual – South Carolina
Concurrent Review & Discharge Planning
No prior authorization is required for inpatient services whether planned or emergent admissions
except for the procedures mentioned under Pre-Certification Process. Upon discharge from an
acute care facility, the Member (through the PPO Plan) has the ability to utilize either a
participating or non-participating Provider of their choosing.
Second Opinions
In accordance with State requirements, a Member may request and is entitled to a second
medical/surgical opinion when:

The Member feels he/she is not responding to the current treatment plan in a satisfactory
manner, after a reasonable lapse of time for the condition being treated;

The Member disagrees with the opinion of a physician regarding the reasonableness or
necessity of a medical/surgical procedure; or

The treatment is for a serious injury or illness related to the medical need for surgery or for
major non-surgical diagnostic and therapeutic procedures (e.g. diagnostic techniques such
as cardiac catheterization and gastroscopy).
The Member will select the Provider from whom he/she is seeking a second opinion. The Member
may choose:

A Participating Physician listed in a directory provided by the Plan; or

A non-participating Physician located in the same geographical service area of the Plan.
Covered Services
America’s 1st Choice Members are eligible for all Medicare covered services, as appropriate. The
Plan also offers a variety of added benefits to its Members. To learn more about an individual
Member’s covered benefits, please use one of these two resources:
1. America’s 1st Choice: For eligibility, contact Member Services to find Member-specific
benefits.
2. Medicare: Search the CMS Medicare Coverage Database available online at:
http://www.cms.hhs.gov/mcd/overview.asp. Below is a summary of covered services by
Medicare.
Summary of Medicare Part A Covered Services (Inpatient Care – see restrictions in Medicare
coverage database)

Anesthesia

Chemotherapy

Room and board

All meals and special diets
UpdatedDecember2012
Page 34
America’s 1st Choice Provider Manual – South Carolina

General nursing

Medical social services

Physical, occupational and speech-language therapy

Drugs with the exception of some self-administered drugs

Blood transfusions

Other diagnostic and therapeutic items and services

Medical supplies and use of equipment

Respite care in hospice

Transportation services

Inpatient alcohol or substance abuse treatment

Part A blood (see the restrictions under non-covered services)

Clinical Trials (Inpatient)

Kidney Dialysis (Inpatient)
Summary of Medicare Part B Covered Services (Medically-Necessary Outpatient Services – see
restrictions in Medicare coverage database)

Durable medical equipment (DME)

Home health services

Outpatient physical, speech and occupational therapy services

Chiropractic care

Outpatient mental health services

Part B blood

Physician services

Prescription drugs

Preventive care services

X-rays and lab tests
Podiatry Services
Medicare Members are covered through the Medicare guidelines.
Chiropractic Services
Medicare Members are covered through the Medicare guidelines.
UpdatedDecember2012
Page 35
America’s 1st Choice Provider Manual – South Carolina
Vision Services
The Plan has a vision benefit for routine eye exams and discounted frames, lenses and contact
lenses. The Vision Vendor may be contacted directly for coordination of these services. The
number is on the Quick Reference Guide in Section 10 of this Provider Manual.
Behavioral Health Services
Behavioral health services are available through a statewide contract. Members may self-refer to
a participating Behavioral Health Provider and schedule an appointment by calling the toll-free
number available in the Plan’s Provider Directory. Providers who want to coordinate care on behalf
of the Member may call the toll-free number for these services.
Well Woman – Routine & Preventive Services
Members have direct access to network women’s health Specialists for routine and preventive
services.
Initial Health Assessment Tool (HAT)
Members receive an Initial Health Assessment Tool in their New Member Enrollment Packet along
with a self-addressed stamped envelope for return. The answers on this assessment provide the
Plan with important health information regarding the membership.
Disease Specific Health Assessment Tool (DS HAT)
When a Member states that he/she has one of the diseases listed below, a Disease Specific
Health Assessment Tool is sent to the Member in order to determine the level of wellness in each
of the specific diseases. There are Disease Specific Assessments for the following:

Chronic Heart Failure

Cardiovascular Disease

Chronic Obstructive Pulmonary Disease

Asthma

Diabetes
The responses to these assessments allow the Plan to risk stratify the Member for enrollment into
the Disease Management Program associated with the Plan.
Clinical Practice Guidelines
The UM Program is based on evidence-based medicine. To support this premise, the Plan has
adopted a set of Clinical Practice Guidelines which:

Are based on valid and reliable clinical evidence or a consensus of health care
professionals in a particular field;
UpdatedDecember2012
Page 36
America’s 1st Choice Provider Manual – South Carolina

Consider the needs of the Members;

Are adopted in a consultation with Providers; and

Are reviewed and updated periodically, as appropriate.
The guidelines are available on the Plan’s website. If you would like a copy of a particular
guideline, you may call the UM Department number and place a request or fax the request to the
UM fax number including which guideline you need and the address where it should be sent.
Disease Management Programs
Disease Management Programs manage a population of individuals who share a common
diagnosis. The Plan has determined the following diseases to be indicative of the needs of the
Plan’s population:

Diabetes

Cardiovascular Disease
Members may be enrolled in these programs through several avenues:

Information from the Initial Health Assessment Tool;

Information from the Disease Specific Health Assessment Tool;

Member self-referral;

Physician or Provider referral; and/or

Evaluation of Plan data.
The responses from the Disease Specific Health Assessments allow the Plan to risk stratify the
Member’s needs and place the Member into the ongoing monitoring of crucial data and
interventions.
This program is voluntary to Members, who may or may not choose to participate in the program.
To request enrollment or an evaluation for possible enrollment in a Disease Management Program,
call the UM Department number and ask for Case/Disease Management or you can fax a
Case/Disease Management Provider Referral to 1-888-314-0794.
Outcome Evaluation
Outcome evaluation is designed to determine the effectiveness of the targeted Disease
Management Program relative to the following outcome measures:

Hospital bed days;

Hospital re-admissions;

Emergency room visits;

Lifestyle health behaviors;

Self-care management;
UpdatedDecember2012
Page 37
America’s 1st Choice Provider Manual – South Carolina

Provider/Member interactions;

Medication and treatment compliance;

Member quality of life;

Compliance with evidence-based practice guidelines among PCPs; and

Disease complications and co-morbid conditions.
The Plan offers all Members the opportunity to participate voluntarily in a Disease Management
Program if they exhibit chronic conditions. Potential candidates for these programs are identified
through the administration of the Health Assessment Tool (HAT), by their PCP, family members,
the Utilization Management Department and through Claims and Pharmacy Utilization data.
The Quality Management Department is responsible for coordinating all study/evaluation activities
related to the Disease Management Program and for drafting all interim and final study reports.
Preventive Health Guidelines
The Plan has adopted the U.S. Preventive Services Taskforce Guidelines. The Plan annually
reviews preventive health guidelines to reflect any changes in recommendations regarding
screening, counseling and preventive services. These guidelines can be referenced on the
website for the Agency of Health Care, Research and Quality at www.ahrq.gov.
Financial Incentives
The Plan makes Utilization Management decisions based only on appropriateness of care and
service, in conjunction with Member benefits and coverage. The Plan does not reward
practitioners or other individuals for issuing denials of coverage or care. The Plan does not
encourage Utilization Management decisions that result in underutilization of health care services.
UpdatedDecember2012
Page 38
America’s 1st Choice Provider Manual – South Carolina
6. MEDICATION MANAGEMENT
Introduction
The Plan developed a Preferred Drug List (PDL) to promote clinically appropriate utilization of
medication in a cost-effective manner.
The drugs on the Plan’s PDL are set up in a tier system that offers Providers and Members a
choice of medications. Generic medications listed will have the widest choice and the least copayment. Brand medication options could be limited in certain classes or may not be available
on the Plan.
The Plan’s Pharmacy and Therapeutics Committee meets quarterly to review and recommend
medications for PDL consideration. The Pharmacy and Therapeutics Committee is comprised of
the Plan’s Medical Director, Pharmacy Director, a clinical pharmacist representing the Plan’s
Pharmacy Benefits Manager and Physicians from the Plan’s Provider network. Providers can
request the addition of a drug to the PDL by writing to the Plan’s Medical or Pharmacy Director.
Physicians interested in participating in our Pharmacy and Therapeutics Committee should contact
our Medical Director.
Preferred Drug List
The Plan maintains its own Preferred Drug List (PDL), a listing of medications intended to assist
the Plan’s Physicians and pharmacy Providers in delivering comprehensive, high quality and costeffective pharmaceutical care.
The Pharmacy and Therapeutics Committee reviews all therapeutic classes and selects
medications based on effectiveness, safety and cost. The PDL is posted on the Plan’s website at
www.americas1stchoice.com. Printed copies are also available by calling the Plan’s Provider
Relations department at 1-866-321-3947.
The Preferred Drug List only applies to outpatient medications filled at network pharmacies and
does not apply to inpatient medications or those obtained from or administered by a Physician.
Typically, most injectable drugs, except those listed on the PDL, are not covered by the pharmacy
benefit. These must be approved through the Utilization Management department.
Generic Substitution
Generic drugs, excluding those with a narrow therapeutic index, should be dispensed when
available. The FDA has approved a selection of “generic equivalents” for branded medications.
Generic substitution is mandatory when an “A” or “AB” rated generic drug is available. Drugs listed
on the State Negative Formulary are exempt from generic substitution requirements.
Drugs Not on the Preferred Drug List
Medications not on the Plan’s Preferred Drug List (PDL) are not a covered benefit. A drug override
can be requested when a medication is not on the PDL by using the Prior Authorization/Drug
Exception Request Form and providing the related clinical information. Approval is based on the
UpdatedDecember2012
Page 39
America’s 1st Choice Provider Manual – South Carolina
Member’s medical and prescription benefit coverage, acceptable medical standards of practice and
FDA-approved uses.
A Provider or a Member may request the addition of a drug to the PDL by sending a letter to the
Plan’s Medical Director that specifies which medication and why it should be added. These
requests are reviewed by the Pharmacy and Therapeutics Committee. Physicians interested in
participating in our Pharmacy and Therapeutics Committee should contact our Medical Director.
Prior Authorization (PA)
Some drugs on the Preferred Drug List may have a designation of PA. These are drugs that will
require the Provider to send in a request to cover this medication. Medical documentation,
including any labs, tests, diagnosis and/or previous medications failed, is needed for the request to
be considered. The PA criteria can be found in Section 10 of this manual.
Step Therapy (ST)
There are some drugs that would require the use of first line drugs before the drug being
prescribed will be approved. This is called Step Therapy. Documentation that the first line drugs
have been tried and failed or are not tolerated by the patient needs to be submitted along with the
Prior Authorization/Drug Exception Request before the request can be considered. Step Therapy
Criteria can be found in Section 10 of this manual.
Quantity Limits
Many drugs contain quantity limits, which restrict the amount of the particular medicine dispensed
as a benefit from the Plan. These are typically limited to a one month supply. Some categories of
drugs include:

Sedative/hypnotics;

Impotence medication;

Certain antihypertensive medication; and

Other type of quantities limits which address medical issues.
If the Provider needs to override quantity limits because of medical necessity, he/she should follow
the process described in the “Drugs Not on the Preferred Drug List” section.
Co-payments
The Preferred Drug List is categorized into 4 Tiers as described below. The co-payment varies
with each category where the preferred generic has the lowest co-payment and the non-preferred
brands have the highest. Brands not appearing on the Preferred Drug List are not covered.

Tier 1: Generic and Brand

Tier 2: Non Preferred Generic and Preferred Brand

Tier 3: Non Preferred Generic and Non Preferred Brands

Tier 4: Specialty Drugs
UpdatedDecember2012
Page 40
America’s 1st Choice Provider Manual – South Carolina
Injectables
Most Injectables of all types require authorization through the Prior Authorization/Drug Exception
Request Form process with the following exceptions:

One-time antibiotics;

Intra-articular injections of steroids; and

Intravenous or intra-muscular injection of steroids.
Pharmacy Use
All Members should use network pharmacies. A list of participating pharmacies is in the Provider
directory. If a Member uses a non-network pharmacy, the medication may not be covered.
Members may use out-of-area pharmacies for emergencies only.
Medication/Treatment Compliance Surveillance is designed to:

Monitor and enhance medication treatment compliance among Members;

Monitor and evaluate medication treatment patterns among Providers; and

Identify potential negative effects of medication treatment, to include drug-to-drug
interactions, contraindications and medication side effects.
Drug Utilization Review Program
To promote safe and cost-effective utilization, selected high-risk, high cost, specialized use
medications, or medications not included on the Plan’s Preferred Drug List (PDL) require a Prior
Authorization/Drug Exception Request. A designated form for this request is in Section 10 of this
manual. Approval is granted for medically necessary requests and/or when PDL alternatives have
demonstrated ineffectiveness.
When these exceptional needs arise, the Physician should fax a completed Prior
Authorization/Drug Exception Request Form to the Plan. Approval for use is based on the
Member’s medical and prescription benefit coverage, acceptable medical standards of practice and
FDA-approved uses. Additional forms may be obtained by sending your request to the Plan’s
Utilization Management Department at 1-888-407-9977.
UpdatedDecember2012
Page 41
America’s 1st Choice Provider Manual – South Carolina
7. QUALITY MANAGEMENT PROGRAMS
Overview
America’s 1st Choice has established a Quality Management (QM) Program designed to comply
with State and Federal regulations and to promote quality care and service for America’s 1st Choice
Members. The QM Program also provides a system for improving organizational processes.
Provider contracts require participation in the America’s 1st Choice QM Program.
The QM Program includes the use of performance data available through standardized measures,
including State and national information, performance measures, benchmarks and root cause
analyses that relate to measuring outcomes and identifying opportunities for improvement.
A copy of the QM Program is available to America’s 1st Choice Providers and Members upon
request.
Goals & Objectives
Program goals are to:

Improve and maintain America’s 1st Choice Members’ physical and emotional status;

Promote health, risk identification and early interventions;

Empower Members to develop and maintain healthy lifestyles;

Involve Members in treatment and care management decision-making;

Facilitate the use of evidence-based medical principles, standards and practices;

Promote accountability and responsiveness to Member concerns and grievances;

Coordinate utilization of medical technology and other medical resources efficiently and
effectively for Member welfare;

Facilitate accessibility and availability of care to Members in a timely manner; and

Promote Member safety in conjunction with effective medical care.
Primary objectives of the America’s 1st Choice Quality Management Program include:

Proactively pursue methods to improve care and service for Members;

Develop interventions to improve the overall health of Members;

Develop systems to enhance coordination and continuity of care between medical and
behavioral health services;

Maintain systematic identification and follow-up of potential quality issues;

Educate Members, Physicians, hospitals and ancillary Providers regarding America’s 1st
Choice’s quality management goals, objectives, structure and processes; and

Promote open communication and interaction between and among Providers and
Members.
UpdatedDecember2012
Page 42
America’s 1st Choice Provider Manual – South Carolina
America’s 1st Choice Quality Management Program components include:

Member rights and responsibilities;

Confidentiality of Member information;

Member satisfaction, including grievance and appeals;

Access and availability of care and services;

Medical record keeping practices;

Preventive health and HEDIS measures;

Clinical quality improvement initiatives;

Quality of care evaluation;

Peer review;

Grievances and appeals;

Medical management, disease management and case management initiatives;

Coordination and continuity of care, including medical and behavioral health;

Credentialing and re-credentialing activities;

Monitoring of delegated services;

Member safety;

Risk management;

Delegation oversight;

Provider and enrollee communication; and

Behavioral health.
The America’s 1st Choice Quality Management Program is evaluated and updated at least annually
with input from America’s 1st Choice staff, network Providers and Members.
The America’s 1st Choice Quality Management Program includes a committee structure that
incorporates committees designed to review and monitor medical management, quality
management, pharmacy and therapeutics, credentialing, peer review and grievances/appeals
activities.
Providers who wish to participate in any of these committees are encouraged to notify the Plan for
consideration. A company-wide quality committee oversees all quality related activities and reports
to the Board of Directors.
Provider Notification of Changes
America’s 1st Choice will notify Physicians and Providers of material changes in writing, 30 days
prior to putting those changes into effect. These changes are communicated via the America’s 1st
Choice website (Americas1stchoice.com), the Provider Manual and/or the Provider Newsletter.
A “material change” is a change that may influence a Physician or Provider’s decision to remain in
the Plan’s network. Examples of material changes are those that affect the organization’s payment
UpdatedDecember2012
Page 43
America’s 1st Choice Provider Manual – South Carolina
structure, the size of Member panels or the scope of a Physician and/or Provider’s administrative
responsibilities.
Please contact your local America’s 1st Choice Provider Relations Representative should you have
questions related to a change notification.
Medical Health Information
Participating Providers are expected to provide information to Plan Members regarding their health
status and treatment options, including self-treatment. Information provided includes the risk,
benefits and consequences of treatment or non-treatment. Providers should also allow Members
to participate in treatment decisions and to refuse treatment.
Medical Record Standards
In accordance with the America’s 1st Choice Physician Service Agreement, the Physician shall
ensure medical records are accurately maintained for each Member. It shall include the quality,
quantity, appropriateness and timeliness of services performed under this contract.
Medical records shall be maintained for a period of no less than ten years, including after
termination of this Agreement and retained further if records are under inspection, evaluation or
audit, until such is completed.
Upon request, the Plan or any Federal or State regulatory agency, as permitted by law, may obtain
copies and have access to any medical, administrative or financial record of Physician-related and
Medically Necessary Covered Services to any Member. The Physician further agrees to release
copies of medical records of Members discharged from the Physician to the Plan for retrospective
review and special studies.
A medical record documents an America’s 1st Choice Member’s medical treatment, current and
past health status and current treatment plans. A Member’s medical record is an essential
component in the delivery of quality health care. America’s 1st Choice has established medical
record standards available to all participating practitioners. Providers are required to comply with
these standards.
Medical Record Standards
Plan Providers must comply with the following medical record standards:

Each and every page in the record contains the Member’s name (or ID/chart number) and
birth date;

Includes personal/biographical data including age, date of birth, sex, address, employer,
home and work telephone numbers, marital status and legal guardianship;

The record reflects the primary language spoken by the Member and any translation needs
of the Member;

All entries are signed and dated;
UpdatedDecember2012
Page 44
America’s 1st Choice Provider Manual – South Carolina

All entries include the name and profession of the Provider rendering services (e.g., MD,
DO, OD), including the signature or initials of the Provider;

All entries in the medical record contain legible author identification. Author identification is
a handwritten signature, stamped signature or a unique electronic identifier. Signature is
accompanied by the author’s title (MD, DO, ARNP, PA, MA);

The record is legible to someone other than the writer;

The record is maintained in detail;

Medication allergies and adverse reactions are prominently noted in the record. If the
Member has no known allergies or history of adverse reactions, this is noted in the record
(no known allergies = NKA);

Past medical history (for members seen three or more times) easily identified and include
serious accidents, significant surgical procedures and illnesses;

Medical record includes previous physicals;

The immunization history has been made in the medical record;

Diagnostic information, consistent with findings, is present in the medical record;

A treatment plan, including medication information, is reflected in the medical record;

A problem list including significant illnesses, medical conditions, health maintenance
concerns and behavioral health issues are indicated in the medical record;

Medical record includes a medication list;

Notation concerning the use of cigarettes and alcohol use and substance abuse is present
(for Members seen three or more times, query substance abuse history);

If a consultation is requested, a note from the consultant is in the record;

Emergency Room discharge notes and hospital discharge summaries (hospital admissions
which occur while the Member is enrolled in America’s 1st Choice, and prior admissions, as
necessary) appropriately indicated in the medical record;

The record includes all services provided including, but not limited to, family planning
services, preventive services and services for sexually transmitted diseases;

There is evidence that preventive screening and services are offered in accordance with the
America’s 1st Choice preventive services policies, procedures and guidelines;

There is no evidence that the patient is placed at inappropriate risk by a diagnostic or
therapeutic procedure;

The record contains evidence of risk screenings;
UpdatedDecember2012
Page 45
America’s 1st Choice Provider Manual – South Carolina

The record contains documentation that the Member was provided with written information
concerning Member’s rights regarding advance directives, and whether or not the individual
has executed an advance directive;

The record contains copies of any advance directives executed by the Member;

The record documents when Members seek assistance with special communications needs
for health care services;

There is review for under- or overutilization of consultants;

Documentation of individual encounters provides adequate evidence of:

o
The history and physical expression of subjective and objective presenting complaints,
including the chief complaint or purpose of the visit;
o
The objective;
o
Working diagnoses are consistent with findings;
o
Medical findings or impressions of the Provider, as well as Provider’s evaluation of the
Member;
o
Treatment plans are consistent with diagnoses;
o
Laboratory and other diagnostic studies used or ancillary services ordered, as
appropriate;
o
Therapies, home health and prescribed regimens;
o
Encounter forms or notes have notation, regarding follow-up care, calls or visits, when
indicated. The specific time of return is noted in weeks, months or as needed;
o
Unresolved problems from previous office visits are addressed in subsequent visits;
o
Consultation, lab, imaging and other diagnostic reports filed in the chart initialed by the
PCP to signify review. If the reports are presented electronically or by some other
method, there is also representation of review by the ordering practitioner. Consultation
and abnormal laboratory and imaging study results have an explicit notation in the
record of follow-up plans;
o
Disposition, recommendations, instructions to the enrollee, evidence of whether there
was follow-up and outcome of services;
o
Reports from specialists and other consultative services referred by PCP; and
o
Discharge reports from hospitalizations.
Medical records are secured in a safe place to promote confidentiality of Member
information;
o
Records are maintained in a location with access limited to authorized staff; and
UpdatedDecember2012
Page 46
America’s 1st Choice Provider Manual – South Carolina
o
Records are readily available for provision of care.

Medical records and all Member information are maintained in a confidential manner;

Additional medical record recommendations include:
o
All entries are neat, legible, complete, clear and concise, written in black ink;
o
Entries are dated and recorded in a timely manner;
o
Records are not altered, falsified or destroyed;
o
Incorrect entries are corrected by:
o

Drawing a single line through the error;

Avoiding correction fluid or markers that will obscure writing;

Dating and initialing each correction; and

Making no additions or corrections to a medical record entry if a medical chart
has been provided to outside parties for possible litigation; and
All telephone messages and consent discussions are documented.
Assessing the Quality of Medical Record Keeping
America’s 1st Choice will assess practitioner compliance with these standards and monitor the
processes used in practitioner’s offices. America’s 1st Choice establishes performance goals for
compliance with our medical record documentation standards.
Improving Medical Record Keeping
If a Provider does not meet medical record standards, both Provider Relations and Quality
Management staff will work with the Provider to improve medical record keeping. Practitioners with
identified deficiencies may receive suggestions of how to improve their medical record-keeping
practices, record-keeping aids or examples of best practices that meet the Plan’s record-keeping
standards.
Medical Record Review
The Plan adheres to the Privacy Rule established by the Health Insurance and Portability Act of
1996 (HIPAA), which outlines national standards to protect individuals’ medical records and other
personal health information. The rule requires appropriate safeguards to protect the privacy of
personal health information and sets limits and conditions on the uses and disclosures that may be
made of such information without patient authorization. It also gives patient’s rights over their
health information, including rights to examine and obtain copies of their health records and to
request corrections.
To ensure HIPAA compliance, the Plan performs on-site medical record audits at the time of recredentialing and during routine medical record evaluations. Medical records are reviewed for
compliance with documentation requirements as outlined by regulatory and accreditation agencies.
UpdatedDecember2012
Page 47
America’s 1st Choice Provider Manual – South Carolina
They are also evaluated for compliance with preventive, chronic and acute health care standards.
Providers who do not meet America’s 1st Choice standards for medical record documentation will
be referred to the Medical Director for follow-up or to the Quality Management Committee for
further action.
Medical Record Privacy & Confidentiality Standards
Medical Record Privacy and Confidentiality Standard 1
All America’s 1st Choice Members’ individually identifiable information whether contained in the
Member’s medical record or otherwise is confidential. Such confidential information, whether verbal
or recorded, in any format or medium, includes, but is not limited to, a Member’s medical history,
mental or physical condition, diagnosis, encounters, referrals, authorization, medication or
treatment, which either identifies the Member or contains information that can be used to identify
the Member.
Medical Record Privacy and Confidentiality Standard 2
In general, medical information regarding an America’s 1st Choice Member must not be disclosed
without obtaining written authorization. The Member, the Member’s guardian or conservator must
grant the authorization. If the Member signs the authorization, the Member’s medical record must
not reflect mental incompetence. If authorization is obtained from a guardian or conservator,
evidence such as a Power of Attorney, Court Order, etc., must be submitted to establish the
authority to release such medical information.
Medical Record Privacy and Confidentiality Standard 3
To release Member medical information, the entity must use a valid and completed Medical
Information Disclosure Authorization Form, prepared in plain language.
The form must include the following:

Name of the person or institution providing the Member information;

Name of the person or institution authorized to receive and use the information;

The Member’s full name, address and date of birth;

Purpose or need for information and the proposed use thereof;

Description, extent or nature of information to be released identified in a specific and
meaningful fashion, including inclusive dates of treatment;

Specific date or condition upon which the Member’s consent will expire, unless earlier
revoked in writing, together with Member’s written acknowledgment that such revocation
will not affect actions taken prior to receipt of the revocation;

Date that the consent is signed, which must be later than the date of the information to be
released;

Signature of the Member or legal representative and his or her authority to act for the
Member;
UpdatedDecember2012
Page 48
America’s 1st Choice Provider Manual – South Carolina

The Member’s written acknowledgment that Member may see a copy the information
described in the release and obtain a copy of the release itself, at reasonable cost to the
Member;

The Member’s written acknowledgment that information used or disclosed to any recipient
other than a health plan or Provider may no longer be protected by law;

Except where the authorization is requested for a clinical trial, it must contain a statement
that it will not condition treatment or payment upon the Member providing the requested use
or disclosure authorization; and

A statement that the Member can refuse to sign the authorization.
Medical Record Privacy and Confidentiality Standard 4
Pursuant to laws that allow disclosure of confidential medical information in certain specific
instances, the Plan may release such information without prior authorization from the Member, the
Member’s guardian or conservator for the following reasons:

Diagnosis or treatment, including emergency situations;

Payment or for determination of Member eligibility for payment;

Concurrent and retrospective review of services;

Claims management, claims audits, billing and collection activities;

Adjudication or subrogation of claims;

Review of health care services with respect to medical necessity, coverage,
appropriateness of care or justification of charges;

Coordination of benefits;

Determination of coverage, including pre-existing conditions investigations;
Peer review activities;

Risk management;

Quality assessment, measurement and improvement, including conducting Member
satisfaction surveys;

Case management and discharge planning;

Managing preventive care programs;

Coordinating specialty care, such as maternity management;

Detection of health care fraud and abuse;

Developing clinical guidelines or protocols;

Reviewing the competency of health care Providers and evaluating Provider performance;
Preparing regulatory audits and regulatory reports;

Conducting training programs;

Auditing and compliance functions;

Resolution of grievances;

Provider contracting, certification, licensing and credentialing;
UpdatedDecember2012
Page 49
America’s 1st Choice Provider Manual – South Carolina

Due diligence;

Business management and general administration;

Health oversight agencies for audits, administrative or criminal investigations, inspections,
licensure or disciplinary actions, civil, administrative or criminal proceedings or actions;

In response to court order, subpoena, warrant, summons, administrative request or similar
legal processes;

To comply with applicable law relating to workers’ compensation;

To County coroner, for death investigation;

To public agencies, clinical investigators, health care researchers and accredited non-profit
educational or health care institutions for research, but limited to that part of the information
relevant to litigation or claims where Member’s history, physical condition or treatment is an
issue, or which describes functional work limitations, but no statement of medical cause
may be disclosed;

To organ procurement organizations or tissue banks to aid Member medical
transplantation;

To State and federal disaster relief organizations, but only basic disclosure information,
such as Member’s name, city of residence, age, sex and general condition;

To agencies authorized by law, such as the FDA; and

To any chronic disease management programs provided Member’s treating Physician
authorizes the services and care.
Medical Record Privacy and Confidentiality Standard 5
All individual America’s 1st Choice Member records containing information pertaining to alcohol or
drug abuse are subject to special protection under Federal Regulations (Confidentiality of Alcohol
and Drug Abuse Member Records, Code 42 of Federal Regulation, Chapter 1, Subchapter A. Part
2). An additional and specific consent form must be used prior to releasing any medical records
that contain alcohol or drug abuse diagnosis.
Medical Record Privacy and Confidentiality Standard 6
Special consent for release of information is needed for all Members with HIV/AIDS and mental
health disorders. In general, medical information for Members who exhibit HIV/AIDS and/or mental
health disorders will always be reported in compliance with State and federal law. Additional
information will be released regarding a Member infected with the HIV virus only with an authorized
consent.
Information released to authorized individuals/agencies shall be strictly limited to the information
required to fulfill the purpose stated in the authorization. Any authorization specifying “any and all
medical information” or other such broadly inclusive statements shall not be honored and release
of information that is not essential to the stated purpose of the request is specifically prohibited.
UpdatedDecember2012
Page 50
America’s 1st Choice Provider Manual – South Carolina
8. CLAIMS
General Payment Guidelines
Claims should be submitted in one of three formats:

Electronic claims submission,

CMS 1500 Form, or

UB04 Form.
Physicians/Providers are required to use the standard CMS codes for ICD9, CPT, and HCPCS
services, regardless of the type of submission. Claims processing is subject to change based upon
newly promulgated guidelines and rules from CMS.
Medicare General Payment Guidelines
For payment of Medicare claims, America’s 1st Choice has adopted all guidelines and rules
established by CMS. America’s 1st Choice Medicare Members may only be billed for their
applicable co-payments, co-insurance, deductibles and non-covered services.
Mail Medicare claims to:
America’s 1st Choice Health Plans, Inc.
P.O. Box 210769
Columbia, SC 29221-0769
Professional and Technical Component Payments
America’s 1st Choice covers the professional and technical components of global CPT procedures.
Therefore, the appropriate professional component modifiers and technical component modifiers
should be included on the claim form.
Member Responsibility
The Physician/Provider should collect the following payments from the Member based upon the
terms of your contract and the benefit plan design:

Co-payments

Deductibles

Co-insurance
Charges that can be billed and collected from the Member will be indicated on the Explanation of
Benefits (EOB) notice from the Plan. The Provider gets an explanation of payment (EOP).
UpdatedDecember2012
Page 51
America’s 1st Choice Provider Manual – South Carolina
Prohibition on Billing Members
As a participating Physician/Provider you have entered into a contractual agreement to accept
payment directly from America’s 1st Choice. Payment from the Plan constitutes payment in full,
with the exception of applicable co-payments, deductibles and/or co-insurance as listed on the
EOB.
You may not “balance bill” Members for the difference between actual billed charges and your
contracted reimbursement rate. A Member cannot be “balance billed” for covered services denied
for “lack of information”. Failure to notify the Plan of a service that requires prior authorization will
result in payment denial. In this scenario, Plan Members may not be “balance billed” and are
responsible only for their applicable co-payments, deductibles and/or co-insurance.
A Member cannot be billed for a covered service that is not medically necessary unless the
Member’s informed written consent is obtained prior to rendering a non-covered service. This
consent must include information regarding their financial responsibility for the specific services
received.
Maximum Out-of-Pocket Expenses (MOOP)
The term Maximum Out-of-Pocket (MOOP) refers to the limit on how much a Medicare
Advantage Plan enrollee has to pay out-of-pocket each year for medical services that are
covered under Medicare Part A and Part B. Co-payments, co-insurance and deductibles comprise
Member expenses for purposes of MOOP. MOOP is not applicable to the Member’s Medicare
Part B Premium.
All of our health plans have a MOOP. If a Member reaches a point where they have paid the
MOOP during a calendar year (coverage period), the Member will not have to pay any out-ofpocket costs for the remainder of the year for covered Medicare Part A and Part B services. If a
Member reaches this level, the Plan will no longer deduct any applicable Member expenses from
the Provider’s reimbursement.
The MOOP can vary by Plan and may change from year to year. Please refer to the Summary of
Benefits available online at our website www.americas1stchoice.com. You may confirm that a
Member has reached their MOOP by contacting the Member Services Department.
Timely Submission of Claims
The Plan abides by CMS guidelines for Medicare timely submission of claims.
Plan Members cannot be billed for services denied due to a lack of timely filing. Claims appealed
for “timely filing” should be submitted with “proof” along with a copy of the EOB and the claim.
Acceptable proof of timely filing will be in the form of a registered postal receipt signed by a
representative of the Plan or a similar receipt from other commercial delivery services.
Physician and Provider Reimbursement
Reimbursement for covered services is based on the negotiated rate as established in the
Physician or Provider Agreement. Services that require pre-certification will be denied if services
UpdatedDecember2012
Page 52
America’s 1st Choice Provider Manual – South Carolina
were rendered prior to approval. Please refer to your Physician or Provider Agreement to
determine the method that applies to your contract.
Completion of Paper Claims
Paper claims should be completed in their entirety including but not limited to the following
elements:

The Plan Member’s name and their relationship to the subscriber;

The subscriber’s name, address and insurance ID as indicated on the Member’s
identification card;

The subscriber’s employer group name and number (if applicable);

Information on other insurance or coverage;

The name, signature, place of service, address, billing address and telephone number of
the Physician/Provider performing the service;

The tax identification number and NPI number for the Physician or Provider performing the
service;

The appropriate ICD-9 codes at the highest level of specificity;

The standard CMS procedure or service codes with the appropriate modifiers;

The number of service units rendered;

The billed charges;

The name of the referring Physician;

The dates-of-service;

The place-of-service;

The referral and/or authorization number;

The NDC for drug therapy; and

Any job-related, auto-related or other accident-related information, as applicable.
Electronic Claims Submission
Electronic data filing requires billing software through which you can electronically send claims
data to a clearinghouse. Since most clearinghouses can exchange data with one another, you
can continue to use your existing clearinghouse even when it is not the clearinghouse selected
by America’s 1st Choice.
Prior to submitting claims through a clearinghouse exchange, you must check with your existing
clearinghouse to make sure they can complete the transaction with the America’s 1st Choice
vendor. If you do not have a clearinghouse or have been unsuccessful in submitting claims to your
clearinghouse, please contact your Provider Relations Representative for assistance.
Our trading partner, EMDEON, can help establish electronic claims submissions connectivity with
our Plan. You will need our Payer ID (distinct for each plan), which is 20553 for America’s 1st
Choice Health Plans, Inc.
UpdatedDecember2012
Page 53
America’s 1st Choice Provider Manual – South Carolina
Tips on successfully submitting electronic claims:

Ensure your clearinghouse can remit information to our trading partner, EMDEON. You may
reach EMDEON at 1-800-845-6592.

Use the billing name and address on the electronic billing format that matches our records.
Please notify our office of any name and address changes in writing.

For all electronic claims transmissions and 837s, LOOP 2010 AA relates to box 33 (Billing
Provider) of a CMS1500 or the UB04 and LOOP 2010 AB relates to the Pay to Address
field.

The Member/subscriber number should not include the suffix.
Ex. For Member N00001234-01, the -01 is not included.

The Payer ID is based on the State that the Member resides.

Contact EMDEON with any transmission questions at 1-800-845-6592.
*Currently not available for dual specialty Providers, PCPs with IPA affiliations, anesthesiology or
ambulance Providers.
Electronic Transactions and Code Sets
To improve the efficiency and effectiveness of the health care system, Congress enacted the
Health Insurance Portability and Accountability Act (HIPAA). HIPAA includes a series of
administrative simplification provisions including the adoption of national standards for electronic
health care transactions.
On October 16, 2003, the Electronic Transaction and Code Set provision of HIPAA went into effect.
Law requires payers to have the capability to send and receive all applicable HIPAA-compliant
transactions and code sets.
One requirement is that the payer must be able to accept a HIPAA-compliant 837 electronic claim
transaction, in standard format, using standard code sets and standard transactions. Specifically,
claims submitted electronically must comply with the following Provider-focused transactions:

270/271 – Health Insurance Eligibility/Benefit Inquiry & Response;

276/277 – Health Care Claim Status Request & Response;

278 – Health Care Services Review – Request for Review and Response;

835 – Health Care Claim Payment/Advice; and

The X12N-837 claims submission transactions replace the manual CMS 1500/UB92 forms.
All files submitted must be in the ANSI v5010 format, as applicable.
Encounter Data
Encounter Data is a record of covered services provided to our Members. An Encounter is an
interaction between a patient and Provider (health plan, rendering physician, pharmacy, lab, etc.)
who delivers services or is professionally responsible for services delivered to a patient. America’s
1st Choice requires the submission of claims for all encounters in order for the Plan to achieve
State and federal reporting requirements.
UpdatedDecember2012
Page 54
America’s 1st Choice Provider Manual – South Carolina
Coordination of Benefits (COB)
Coordination of Benefits (COB) is the procedure used to process health care payments for a
patient with one or more insurers providing health care benefit coverage. Prior to claims
submission, it is important to identify if any other payer has primary responsibility for payment.
If another payer is primary, that payer should be billed prior to billing America’s 1st Choice.
When a balance is due after receipt of payment from the primary payer, a claim should be
submitted to America’s 1st Choice for payment consideration. The claim should include information
verifying the payment amount received from the primary payer as well as a copy of their
explanation of payment statement. Upon receipt of the claim, America’s 1st Choice will review
its liability using the COB rules and/or the Medicare/Medicaid “crossover” rules—whichever is
applicable.
Correct Coding
America’s 1st Choice has adopted a policy of reviewing claims to ensure “correct coding”. The Plan
utilizes a corrective coding, re-bundling/unbundling software, which will be integrated with our
payment system IKA Solutions. Services that should be bundled and paid under a single procedure
code will be subject to review.
Claims Appeals
Claims appealed for the denial “no authorization” or “other medical reasons” should be submitted
to the attention of the Appeals and Grievance Department. Please include documentation
explaining why an authorization was not obtained, any pertinent medical records, a copy of the
claim(s) and a copy of the denial statement received.
Claim appeals for denial of timely filing, incorrect payment or denied in error should be submitted to
the attention of the Claims Department at the Plan’s claims address.
The time frame for appealing a claim denial is 90 days from the date of the denial on the
explanation of benefits/payment. Cases appealed after the 90-day time limit will be denied for
“untimely filing”. There is no “second level” consideration for appeals outside the timely filing
requirement. Acceptable proof of timely filing will be in the form of a registered postal receipt
signed by a representative of the Plan or a similar receipt from other commercial delivery services.
The Plan has up to 60 days to review it for medical necessity and conformity to Plan guidelines.
The Plan is not responsible for payment of medical records generated as a result of a claims
appeal. Cases received for lack of necessary documentation will be denied. The Physician or
Provider is responsible for providing the requested documentation within 60 days of the denial in
order to re-open the case. Records and documents received after that time frame will not be
reviewed and the case will be closed.
In the case of a review in which the Physician or Provider has complied with Plan guidelines and
services are determined to be medically necessary, the denial will be overturned. The Physician or
Provider will be notified in writing to re-file the claim for payment. If the claim was previously
submitted and denied, the Plan will adjust it for payment after the decision is made to overturn the
denial.
UpdatedDecember2012
Page 55
America’s 1st Choice Provider Manual – South Carolina
Fee Schedule Updates
America’s 1st Choice updates fee schedules at the time they are made publicly available by
Medicare. Most negotiated reimbursement rates are based upon “prevailing” rates of Medicare.
UpdatedDecember2012
Page 56
America’s 1st Choice Provider Manual – South Carolina
9. GRIEVANCE & APPEALS
Introduction
America’s 1st Choice provides for Member and Provider grievances and appeals, as established by
the Medicare Managed Care Manual, Chapter 13, and the “Medicare Managed Care Beneficiary
Grievances, Organization Determinations and Appeals Applicable to Medicare Health Plans”
publication.
Definitions
Adverse Determination – An adverse determination is a decision regarding admission, care,
continued stay or other health care services to deny, reduce or terminate services based on
America’s 1st Choice’s approved criteria for medical necessity, appropriateness, health care
setting, level of care or effectiveness and coverage for the requested service.
Appeal – An appeal is a request to review a decision made regarding health care services or
payment.
Complaint – A complaint is an expression of dissatisfaction and can be classified as either a
grievance or an appeal. A complaint can be made to America’s 1st Choice or any America’s 1st
Choice Provider.
Grievance – A grievance is any complaint, other than one involving an organizational
determination (appeal), expressing dissatisfaction with health care services received from or
through America’s 1st Choice. Both verbal and written complaints are considered grievances.
Grievance & Appeals System
America’s 1st Choice Members have the right to express verbal or written grievances and appeals,
as outlined in Member Rights & Responsibilities. These rights are provided in the Evidence of
Coverage Document sent to all of our Members. America’s 1st Choice has developed a system to
receive, process and resolve Member grievances and appeals to support these rights. All
grievances and appeals are handled by the America’s 1st Choice Grievance and Appeals
Department.
America’s 1st Choice will provide assistance with the grievance and appeals filing processes.
Providers may also contact America’s 1st Choice to file or support a Member’s filing of an appeal
or a grievance. Members may also contact America’s 1st Choice to file an appeal or request a
grievance form. Appeals and grievances are filed with America’s 1st Choice by mail, telephone
or fax at:
America’s 1st Choice Health Plans, Inc.
C/O Grievance and Appeals Coordinator
P. O. Box 210769
Columbia, SC 29221-0769
Telephone: 1-866-321-3947
Fax: 1-803-748-4907
Member Services staff and the Grievance and Appeals Coordinator are available from 8:00 am to
5:00 pm to assist with questions regarding grievances and appeals.
UpdatedDecember2012
Page 57
America’s 1st Choice Provider Manual – South Carolina
Members may be assisted or represented by an outside legal advisor, practitioner, or other
designated representative during the appeal or grievance processes. America’s 1st Choice
requires written documentation of such representation and advanced notice in the event that the
representative needs to attend any scheduled meetings or hearings.
Providers who want to file an Appeal or request additional information regarding pre-service
denials, grievances or pre-service denial appeals may contact the Grievance and Appeals
Coordinator. If the appeal or request is submitted in writing, Providers should include what is
requested and any additional information to support the request.
America’s 1st Choice grievance and appeals policies are available upon request to America’s 1st
Choice Members and Providers.
Grievance & Appeals
This section of the Provider Manual provides guidance to participating Providers on the Plan’s
appeal process. Member appeals are detailed in the Explanation of Coverage (EOC). The
appeals process for Members of a Medicare Advantage plan is the same regardless of the type
of plan in which the Member is enrolled.
Member Grievance & Appeals
All participating Providers or entities delegated for Network Management and Network
Development are to use the same standards as defined in this section. Compliance is monitored
on an ongoing basis and formal audits are conducted annually.
Participating Provider Claims Appeals
This section explains the appeal process for denied claims only. The appeals process for
pre-service denials can be found in the Utilization Management Section of this manual.
The terms and conditions of payment to participating Providers follow the mutual obligations of
the Plan and Providers per our Provider Agreement. Per our Agreement, Physicians and Providers
may not bill our Members, except for any co-payments or co-insurance. Any claims disputes for
services provided to our Members have to be resolved per the contract’s terms and conditions.
Balance billing Members is also prohibited by Medicare regulations. Claims may be denied for
reasons including, but not limited to:

Lack of pre-certification;

Billing with an incorrect code; or

Place of service billed incorrectly.
The specific reason for denial of the claim will be provided in the explanation of payment document
that is sent to Providers along with all paid/denied claims.
Once a claim is denied, the Provider may request a reconsideration regarding the Plan’s decision.
Providers must make this request in writing within 90 days of receipt of the initial claims denial and
send the request to the Grievance and Appeals address provided. Additional information to support
the request may be sent at this stage. Please also see the Claims Appeals Section in Chapter 8 of
this manual.
UpdatedDecember2012
Page 58
America’s 1st Choice Provider Manual – South Carolina
Submit written claims appeals for denials related to “no pre-certification” or other medical reasons
to:
America’s 1st Choice Health Plans, Inc.
C/O Grievance and Appeals Coordinator
P. O. Box 210769
Columbia, SC 29221-0769
Fax: 1-803-748-4907
Submit written claims appeals for denials related to denial of timely filing, incorrect payment or
denied in error to:
America’s 1st Choice Health Plans, Inc.
C/O Claims Processing
P. O. Box 210769
Columbia, SC 29221-0769
Fax: 1-803-748-4907
Non-participating Provider Appeals
A non-par Provider must follow these steps:
Step 1. If a claim is denied, the non-par Provider can file an appeal. However, all non-par
Providers must sign a Waiver of Liability Form in order for the claim to be reconsidered
for payment. The Waiver of Liability Form is attached to the Appeal Acknowledgement
Letter. If the Waiver of Liability Form is not completed and returned, the case is prepared
and sent to Maximus Federal Services (the Independent Review Entity) for dismissal.
Step 2. Upon receipt of the Waiver of Liability Form, the claim and reason for the denial are
reviewed. The Grievance and Appeals staff either pays the claim or presents the
case for administrative review.
Step 3. Providers and Members are notified in writing of approved or denied claims. Claims
approved for payment on appeal are processed and paid within established time frames
to either the Provider or Member—whichever is appropriate.
Step 4. Claims denied for payment after the appeal review are processed and forwarded to
Maximus Federal Services, the Independent Review Entity (IRE) contracted by CMS.
Expedited Claims Appeals
Providers can request an expedited appeal for pre-service requests only. There is not an
expedited appeal for post-service denials.
Medicare Grievance Process
Providers cannot file a grievance but are able to submit a complaint. Please see the Provider
Complaint Process that appears further in this section. Medicare Members may file a grievance
within 60 days of the event that initiated the grievance. America’s 1st Choice will resolve the
grievance within 30 days of receipt but may extend the resolution period by up to 14 days if
additional information is required.
UpdatedDecember2012
Page 59
America’s 1st Choice Provider Manual – South Carolina
Provider Complaint Process
Initial Complaint
A Provider Relations Representative is assigned to each contracted Provider to assist in the
administration of services to Plan Members. Any Provider who has a complaint may call the
Provider Services Department at 1-866-321-3947. A Provider Relations Representative will assist
the Provider to resolve the complaint.
Complaint Procedures
Formal complaints will be handled by the Grievance Department with the cooperation
of other departments involved with the complainant’s concerns—should the Provider Relations
Representative be unable to resolve the issue.

All issues with medical management will be reviewed confidentially by the Plan’s Utilization
Management Department.

A resolution to the Provider’s complaint will be due within 60 days from the receipt of the
formal complaint, except when information is needed from non-participating Providers or
Providers outside of the Plan’s service area. In such cases, this period may be extended
an additional 30 days, if necessary.

The complainant will receive a written notice when an extension is necessary. The time
limitations requiring completion of the grievance process within 60 days will be paused after
the Plan has notified the complainant in writing that additional information is required to
review the complaint properly. Upon receipt of the additional information required, the time
for completion of the grievance process will resume. The Plan will communicate with the
complainant during the formal grievance process.

A resolution letter with the Plan’s findings and/or decision will be sent to the Provider by
mail.
The Plan will provide to the complainant written notice of the right to appeal upon completion of the
full complaint review process.
The Plan will maintain an accurate record of each Provider complaint. Each record will include the
following:

Complete description of the complaint;

Complainant’s name and address;

Complete description of factual findings and conclusions after the completion of the formal
complaint process; and

Complete description of the Plan’s conclusions pertaining to the complaint, as well as the
Plan’s final disposition of the grievance.
UpdatedDecember2012
Page 60
America’s 1st Choice Provider Manual – South Carolina
10. SAMPLE FORMS & DOCUMENTS
The following sample forms and documents are included in this manual:
1. Asthma Disease Management Assessment
2. Cardiovascular Assessment
3. Case / Disease Management Referral
4. Congestive Heart Failure Assessment
5. COPD Assessment
6. Diabetes Health Assessment
7. Health Assessment Tool (HAT)
8. Member Rights & Responsibilities
9. Pre-Certification Request
10. Pre-Service Determination
11. Prior Authorization / Step Therapy Criteria (Pharmacy)
12. Provider Information Change
13. Quick Reference Guide
14. Sample Member ID Cards UpdatedDecember2012
Page 61
153178,
Tampa 33684-9846
P.O.PO
BoxBox
210459,
Columbia,
SC
29221-0459
P.O.
Box
153178,
Tampa, FL
33684
Asthma Disease Management Assessment
Health and Wellness Material
<Member Name>
<Member Address>
<City> <State> <Zip>
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Date <Date>
Date of Birth <DOB>
Phone #
<Phone #>
ID # <ID # >
From your first Health Assessment you completed at enrollment, you stated you have Asthma. To ensure you are
properly managing your disease, please complete the following and return to us in the supplied envelope. These
answers will help us determine your disease status.
Have you been admitted to or been to a clinic at a VA (Veteranʼs Affairs) Hospital in the last 12 months? Yes No
If you received this form in error and don't have this disease, check the box and return the form to us in the
supplied envelope without answering any of the questions below.
No, I don't have Asthma.
1. How often do you experience shortness of breath?
(check one) Daily
1-2 times a week
2-4 times a month
Never
2. How often do you experience wheezing?
(check one) Daily
1-2 times a week
2-4 times a month
Never
3. In the past 4 weeks, how often did your Asthma interfere with your daily activities?
(check one) Never
Rarely
Sometimes
Very Often
Always
4. Does your Asthma prevent you from getting a good nightʼs sleep?
(check one) Never
Rarely
Sometimes
Very Often
Always
5. How many medications do you take for your Asthma?
(check one) None
1
2-3
4 or more
6. How often do you use a rescure inhaler? (ex. Albuterol or ProAir)
(check one) Daily
1-2 times a week
2-4 times a month
Never
7. Are you on a daily inhaled steroid? (ex. Advair or Pulmocort)
Yes
No
8. How many times in the past year did you need to take steroids by mouth (ex. Prednisone)
B. (check
Activities
Daily Living
one) of
Daily
1-2 times a week
2-4 times a month
Never
9. How many pills do you take for your asthma?
(check one) 0
1-2 pills
2-3 pills
3-4 pills
More than 4 pills
10. What doctor takes care of your Asthma?
(check all that apply)
Primary Care Doctor
Allergist
Pulmonologist
11. How many times in the past year have you seen your doctor for your Asthma?
(check one) None
1-2 times
3-4 times
5 times or more
12. How many times in the past year have you been to the emergency room due to your Asthma?
(check one) None
1-2 times
3-4 times
5 times or more
13. How many times in the past year have you been hospitalized due to your Asthma?
(check one) None
1-2 times
3-4 times
5 times or more
14. How often do you use your peak flow meter?
(check one) Never
Rarely
Sometimes
Very Often
Always
15. How often do you have to give yourself a breathing treatment with a nebulizer?
(check one) Never
Rarely
Sometimes
Very Often
Always
16. Do you smoke?
Yes
No
17. Does someone in your household smoke?
Yes
No
18. Do you think your Asthma has become better or worse over the past year?
(check one) Better
Worse
Stayed the same
19. Do you have a written plan from your doctor of what to do when you start to wheeze?
Yes
20. How many days of work/school have you missed in the past year due to asthma?
(check one) NA/retired
1-5 days
5-10 days
10-20 days
More than 20 days
AFC Form 1039
No
Asthma Disease Management Assessment
Cardiovascular Assessment Form
153178,
Tampa 33684-9846
P.O. PO
BoxBox
210459,
Columbia,
SC33684
29221-0459
P.O.
Box
153178,
Tampa, FL
Date <Date>
Health and Wellness Material
Date of Birth <DOB>
Phone #
<Member Name>
<Member Address>
<City> <State> <Zip>
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
<Phone #>
ID # <ID # >
From your first Health Assessment you completed at enrollment, you stated you have Coronary Artery Disease. To
ensure you are properly managing your disease, please complete the following and return to us in the supplied
envelope. These answers will help us to determine your disease status.
Have you been admitted to or been to a clinic at a VA (Veteranʼs Affairs) Hospital in the last 12 months?
Yes
No
If you received this form in error and don't have this disease, check the box and return the form to us in the
supplied envelope without answering any of the questions below.
No, I don't have Coronary Artery Disease.
1. Do you experience shortness of breath?
If yes, then how often do you get short of breath?
(check one)
Rarely
Sometimes
2. Do you experience chest pain?
If yes, how often do you have chest pain?
(check one)
Rarely
Sometimes
Yes
No
Yes
No
Very Often
Always
Very Often
Always
Yes
No
3. Do you have swelling of your feet, ankles, or legs?
If yes, then how often do your feet, ankle or legs swell?
(check one)
Rarely
Sometimes
Very Often
Always
4. Have
you everofhad
a Heart
Attack?
B.
Activities
Daily
Living
(check one) Yes
No
5. If yes, how long ago was your Heart Attack?
2-3 years ago
(check one) Less than 1 year
More than 3 years ago
6. Have you ever had any of the following surgeries?
(check all that apply) Bypass Surgery
Stent Placement
7. Have you had to have your bypass surgery redone?
No
(check one) Yes
Valve Replacement Surgery
None
8. Have you had to have your stents replaced or additional stents placed?
No
(check one) Yes
9. If you had valve replacement, how many valves did you have replaced?
Two
Three or more
(check one) One
10. Does your Blood Pressure usually run more than 130/80?
No
Donʼt Know
(check one) Yes
AFC Form 1041
Page 1 of 2 (See Reverse Side)
CVD Assessment Form
Cardiovascular Assessment Form
11. Do you have any of the following?
High Cholesterol
Diabetes
12. What type of diet are you on?
Low Fat
(check one) Low Salt
13. Do you smoke?
Yes
No
14. Do you use Oxygen at home?
(check one) 1-2 liters
2-3 liters
(continued)
High Cholesterol & Diabetes
Diabetic
Problems with circulation in your legs
No specific diet
3-4 liters
More than 4 liters
15. How many medicines do you take for your heart condition?
(check one) 1-2 Medications
2-3 Medications
More than 4 medicines
16. Does your heart condition prevent you from enjoying your life?
(check one) Never
Rarely
Sometimes
Very Often
17. Does your heart condition prevent you from getting a good nightʼs sleep?
(check one) Never
Rarely
Sometimes
Very Often
Always
18. How often have you seen your PCP in the last year for your Heart condition?
(check one) 0
1-2 times
2-3 times
3-4 times
19. How often have you seen your Cardiologist in the last year?
(check one) 0
1-2 times
2-3 times
3-4 times
Donʼt use
None for my heart
Always
More than 4 times
More than 4 times
20. How often in the past year have you been to the Emergency Room due to your Heart Condition?
(check one) 0
1-2 times
2-3 times
More than 3 times
21. How often in the past year have you been hospitalized due to your Heart Condition?
(check one) 0
1-2 times
2-3 times
More than 3 times
22. Do you think your Heart Condition has become better or worse over the past year?
(check one) Better
Worse
Stayed the same
AFC Form 1041
Page 2 of 2
CVD Assessment Form
Case/Disease Management Referral Form
Please complete all applicable sections of this form, indicating whether the member is being
referred to a Nurse, Social Worker, or both.
Referral Date: ___________
Referred by: ______________________
(Provider Name)
(Provider Phone No.)
Member Name: _________________________
Member DOB: __________
Phone: _________________________
ID #: _________________________
Member Phone No.: _________________________
Reason for Referral:
I.
Nursing Needs
_____ Uncontrolled Diabetes
_____ COPD/Asthma Complications
_____ Transplant
_____ CAD
_____ CHF
_____ Wounds (unhealed over 30 days.)
_____ OB/Pediatrics
_____ HIV/AIDS
_____ Multiple Events (3 ≥ hospital admissions in 6 months, multiple ER visits, etc.
_____ Multiple Co morbidities
_____ Other _______________________________________________________
Additional Comments:
II.
Social Services Needs
_____ Financial (Utilities, etc.)
_____ Food Assistance
_____ Member is in coverage gap
_____ Copay Assistance
_____ Behavioral Health
_____ Transportation Barriers
_____ Other ________________________________________________________
Additional Comments:
Please Fax this form and any supporting documentation to 1-888-314-0794.
Revised 1/19/2012
153178,
Tampa 33684-9846
P.O.PO
BoxBox
210459,
Columbia,
SC33684
29221-0459
P.O.
Box
153178,
Tampa, FL
Congestive Heart Failure Assessment Form
Date <Date>
Health and Wellness Material
Date of Birth <DOB>
Phone #
<Member Name>
<Member Address>
<City> <State> <Zip>
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
ID #
<Phone #>
<ID # >
From your first Health Assessment you completed at enrollment states, you stated you have Congestive Heart
Failure. To ensure you are properly managing your disease, please complete the following and return to us in the
supplied envelope. These answers will help us to determine your disease status.
Have you been admitted to or been to a clinic at a VA (Veteranʼs Affairs) Hospital in the last 12 months?
Yes
No
If you received this form in error and don't have this disease, check the box and return the form to us in the
supplied envelope without answering any of the questions below.
No, I don't have Congestive Heart Failure.
1. Do you experience shortness of breath?
(check one) Never
Rarely
Sometimes
2. Do you have swelling of your feet, ankles, or legs?
Very Often
Yes
3. If you answered yes to #2, how deep a print does it leave?
½ inch
More than ½"
(check one) ¼ inch
4. Do you experience abdominal pain or swelling?
(check one) Never
Rarely
Sometimes
Very Often
5. Have you ever had an echocardiogram (ultrasound of the heart)?
No
Donʼt Know
(check one) Yes
6. Do you know your ejection fraction ?
B. (check
Activities
Daily
Living
Less
than
20%
one) of
20%-40%
7. Does your Blood Pressure usually run > 130/80?
No
Donʼt Know
(check one) Yes
8. Do you weigh yourself Daily?
If no, do you have access to a scale?
Yes
Yes
9. How much does your weight change in a week?
2-3 lbs.
3-4lbs.
(check one) 1 lb.
10. Do you take a Diuretic ? i.e: water pill
Twice a day
(check one) Once a day
No
40-50%
Always
None
Always
More than 50%
Donʼt know
No
No
More than 4 lbs.
More than twice a day
None
11. How often in the past year have you been to the Emergency Room due to your CHF?
1-2 times
2-3 times
More than 3 times
(check one) 0
12. How often in the past year have you been hospitalized due to your CHF?
1-2 times
2-3 times
More than 3 times
(check one) 0
AFC Form 1043
Page 1 of 2 (See Reverse Side)
CHF Assessment Form
Congestive Heart Failure Assessment Form
13. What type of diet are you on?
(check one) Low Salt
Low Fat
14. Do you smoke?
15. Do you use Oxygen at home?
If yes:
1-2 liters
Yes
2-3 liters
Diabetic
No
Yes
3-4 liters
No
16. How often have you seen your PCP in the last 6 months?
1-2 times
2-3 times
(check one) 0
(continued)
No specific diet
> 4 liters
3-4 times
17. How often have you seen your Cardiologist in the last year?
1-2 times
2-3 times
3-4 times
(check one) 0
18. Does your Congestive Heart Failure interfere with your daily activities?
(check one) Never
Rarely
Sometimes
Very Often
More than 4 times
More than 4 times
Always
19. Do you think your Congestive Heart Failure has become better or worse over the past year?
Worse
Stayed the same
(check one) Better
20. How far can you walk before getting short of breath and you have to rest?
10-15 minutes
30 minutes
More than 1 hour
(check one) Less than 6 minutes
21. Who treats you for your Congestive Heart Failure?
Cardiologist
(check all that apply) PCP
AFC Form 1043
Page 2 of 2
Cannot walk must use wheelchair
Internal Medicine Specialist
CHF Assessment Form
COPD Assessment Form
153178,
Tampa 33684-9846
P.O. PO
BoxBox
210459,
Columbia,
SC33684
29221-0459
P.O.
Box
153178,
Tampa, FL
Date <Date>
Health and Wellness Material
Date of Birth <DOB>
Phone #
<Member Name>
<Member Address>
<City> <State> <Zip>
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
<Phone #>
ID # <ID # >
From your first Health Assessment you completed at enrollment , you stated you have COPD. To ensure you are
properly managing your disease, please complete the following and return to us in the supplied envelope. These
answers will help determine your disease status.
Have you been admitted to or been to a clinic at a VA (Veteranʼs Affairs) Hospital in the last 12 months? Yes No
If you received this form in error and don't have this disease, check the box and return the form to us in the
supplied envelope without answering any of the questions below.
No, I don't have COPD.
1. How often do you experience shortness of breath?
(check one) Never
Rarely
Sometimes
2. Do you have an ongoing cough?
(check one) Never
Rarely
Sometimes
3. Has the doctor ordered Oxygen for you to use at home?
Very Often
Always
Very Often
Always
Yes
No
4. If you said yes that you have been ordered Oxygen, then how often do you use your Oxygen?
During the day
All the time
(check one) Never
Occasionally
5. If you said yes that you have been ordered Oxygen, do you use it as your doctor ordered?
6. How many liters of Oxygen do you use?
(check one) 1-2 liters
2-3 liters
7. Do you use a hand-held nebulizer at home?
3-4 liters
Yes
8. Do
you get short
of breath
when having a conversation?
B.
Activities
of Daily
Living
No
More than 4 liters
Yes
No
(check one) Never
Rarely
Sometimes
Very Often
Always
9. How many inhalers do you use?
(check one) 1 inhaler
2-3 inhalers
More than 3 inhalers
Donʼt use an inhaler
10. Do you take any of the following oral medications for your COPD?
(check one) Singulair
Prednisone/Steroids (every day)
Theophylline
Other
None
11. Do you smoke?
Yes
No
12. Does anyone in your household smoke?
Yes
No
13. How many times in the past year have you seen your doctor for your COPD?
(check one) 0
1-2 times
3-4 times
More than 4 times
14. How many times in the past year have you been to the Emergency Room due to your COPD?
(check one) 0
1-2 times
3-4 times
More than 4 times
15. How many times in the past year have you been hospitalized due to your COPD?
(check one) 0
1-2 times
3-4 times
More than 4 times
16. Does your COPD prevent you from enjoying your life?
(check one) Never
Rarely
Sometimes
Very Often
Always
17. Does your COPD prevent you from getting a good nightʼs sleep?
(check one) Never
Rarely
Sometimes
Very Often
Always
18. Do you think your COPD has become better or worse over the past year?
(check one) Better
Worse
Stayed the same
19. How far can you walk before getting short of breath and you have to rest?
(check one) Less than 6 minutes 10-15 minutes 30 minutes
More than 1 hour Must use wheelchair
AFC Form 1040
COPD Assessment Form
Diabetes Health Assessment Form
153178,
Tampa 33684-9846
P.O. PO
BoxBox
210459,
Columbia,
SC33684
29221-0459
P.O.
Box
153178,
Tampa, FL
Date <Date>
Health and Wellness Material
Date of Birth <DOB>
Phone #
<Member Name>
<Member Address>
<City> <State> <Zip>
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
<Phone #>
ID # <ID # >
From your first Health Assessment you completed at enrollment, you stated that you have Diabetes. To ensure you
are properly managing your disease, please complete the following and return to us in the supplied envelope. These
answers will help us determine your disease status.
Have you been admitted to or been to a clinic at a VA (Veteranʼs Affairs) Hospital in the last 12 months?
Yes
No
If you received this form in error and don't have this disease, check the box and return the form to us in the
supplied envelope without answering any of the questions below.
No, I don't have Diabetes.
1. Which type of medication do you take for your Diabetes?
Insulin only
Both pills and insulin
Pills only
(check one)
2. If you take insulin, how often do you take it:
2-3 times a day
1 time a day
(check one)
Other medicine by shot
More than 3 times a day
None
On an insulin pump
3. How many times in the past year have you had to go to the hospital due to your diabetes?
1 time
2-3 times
More than 3 times
0
(check one)
B. Activities of Daily Living
4. How often do you see your doctor about your diabetes?
1 time a year
0
(check one)
5. How often do you have your HgbA1C checked?
1 time a year
0
(check one)
2 times a year
2 times a year
6. What was your last HgbA1C result?
between 6.5 and 7.5
6.5 or less
(check one)
7. Do you have a glucometer (blood sugar testing device)?
8. How often do you check your blood sugar every day?
3 times
2 times
One time
(check one)
7.5 to 9.0
Yes
Never
No
4-5 times
3 times a year or greater
Donʼt know what this is?
More than 9.0
More than 5 times
9. What does your fasting (first one in the morning) blood sugar usually run?
110-120
120-140
More than 140
110 or less
(check one)
10. What does your blood sugar usually run if taken 2 hours after eating?
120-140
140-180
More than 180
110 -120
(check one)
AFC Form 1037
Page 1 of 2 (See Reverse Side)
Donʼt know
Never
Donʼt know
Donʼt know
Diabetes Health Assessment Form
Diabetes Health Assessment Form
(continued)
11. During a week, how often does your blood sugar drop below 70?
Never 1-2 times a week 2-3 times a week
(check one)
More than 3 times a week
12. How do you change your diet in order to control your blood sugar?
control only my sugar intake
Control my carbohydrate intake
(check one)
13. When was the last time you attended a Diabetes Management Class?
Less than 1 year ago
1-2 years ago
2-5 years ago
(check one)
Yes
14. Do you have any wounds that are not healing properly?
Donʼt know
Donʼt follow a diet
More than 5 years
No
Never
15. Do you have any of the following problems with your legs? (Check all that apply)
cramping/pain in legs or buttocks after walking
pins/needles/burning to legs and/or feet
redness/swelling in legs
16. How often do you have your feet checked?
17. How often do you have a dilated eye exam?
18. How often do you have your urine checked?
1 time a year
1 time a year
1 time a year
Never
2 times a year
Never
2 times a year
Never
19. Does having Diabetes keep you from being active or socializing as much as you would like?
Yes
20. Does having Diabetes make you feel depressed?
21. How often do you exercise?
1-3 days a week
(check one)
3-5 days a week
22. Do you take any medicine for high blood pressure?
Yes
23. Does your blood pressure usually run higher than 130/80?
24. Do you take any medicine for high cholesterol?
25. Do you take any medicine for chest pain?
Yes
Yes
26. If yes, has your chest pain been getting worse or more often?
No
5-7 days a week
No
Yes
No
No
No
Yes
Yes
No
Not routinely
Donʼt know
No
27. Do you think your diabetes has become better or worse over the past year?
Worse
Stayed the same
Better
(check one)
AFC Form 1037
Page 2 of 2
Diabetes Health Assessment Form
SC12HATP1
Health Assessment Tool (HAT)
This assessment is designed to provide us with
some important health information that will help us in
understanding your unique healthcare needs. We ask that
you please complete all questions on the assessment and
return it in the envelope provided. Your answers to these
questions will in no way affect your insurance coverage
and may be shared with your primary care providers.
If you have any questions regarding this form,
please call 1-866-321-3947 TTY/TDD 1-800-735-2962.
If you have already mailed the Health Assessment Tool
form, please disregard this letter.
PO Box 15804, Tampa FL 33684-9846
Health & Wellness Material
<date>
<Name> <Last Name>
<Address>
<City> <State> <Zip>
<phone number> <Member ID>
A. Physical Health Rating
1. On a usual basis, how do you rate your health?
(check one) o Excellent o Good o Fair o Poor
2a. How many times were you admitted to the hospital in the past 12 months?
(check one) o 0
o 1 time o 2-3 times o More than 3 times
2b. How you been in a Skilled Nursing Facility within the past 12 months?
o Yes o No
3. How many times were you in Emergency Room in the past 12 months?
(check one) o 0
o 1 time o 2-3 times o More than 3 times
4a. When did you last see your Primary Care Physician?
(check one) o Less than 6 months o More than 6 months o 12 months ago or greater
4b. Have you seen any of the below specialists in the past 6 months? (check all that apply)
o Heart Doctor/Cardiologist o Endocrinologist (Diabetes specialist) o Ophthalmologist (Eye doctor)
o Podiatrist (Foot doctor o Hematologist/Oncologist (Cancer doctor) o Mental Health Provider o Nephrologist (Kidney doctor)
If you have not seen your Primary Care Physician (PCP) in the last 6 months, we highly encourage you to contact your PCP to
set up an appointment so that we can maintain your good health and coordinate your health care needs.
B. Activities of Daily Living
5. How much help do you need with the following? (check one box for each activity)
Activity
No Help Needed
Some Help Needed
Can’t Do At All
Bathing
o
o
o
Dressing
o
o
o
Eating
o
o
o
Using the Bathroom
o
o
o
Walking
o
o
o
Preparing Meals
o
o
o
Taking your medicine
o
o
o
Getting out of bed or chair
o
o
o
6a. If you need help, do you have someone close by who helps you? o Yes
o No
6b. Where do you currently live?
(check one) o Private home o Assisted Living o Nursing Home
AFS_HAT
page 1 of 2
www.americas1stchoice.com
SC12HATP2
C. Health Conditions
Please check if you have or have had had any of the conditions or problems listed below (check all that apply):
o Asthma
o Depression
o Kidney Problems or Failure
o Amputation/limb removed o Diabetes (On dialysis o Yes o No)
o BiPolar Disorder o Frequent Falls o Organ Transplant
o Cancer currently being treated o Heart Attack or blocked arteries o Schizophrenia
o Congestive Heart Failure o High Blood Pressure
o Skin ulcer or Unhealing wound
o COPD or Emphysema or o HIV/AIDS o Stroke
Chronic Bronchitis
7. Other health conditions or problems? (Be Specific) __________________________________________________
_____________________________________________________________________________________________ 8a. Do you currently have any medical equipment such as an electric bed or wheelchair in your home? o Yes o No
If yes, what kind___________________________ What company?____________________________ 8b. Do you currently use or have oxygen in your home? o Yes o No
If yes, what company brings you your oxygen?____________________________________________
9. Are you receiving any nursing, therapy or home health aide care in your home? o Yes o No
If yes, from what Home Health Company?________________________________________________ D. Medications:
What medicine do you take? (Please list all including over the counter medicines, vitamins, etc. Use additional sheet and attach).
Medication:
____________________________ __________________________ ____________________________
____________________________ __________________________ ____________________________
____________________________ __________________________ ____________________________
10. Have you received a flu shot in the past year? o Yes
o No
o Unsure
11. Have you received a pneumonia shot in the past 5 years? o Yes
o No
o Unsure
12. Have you received a tetanus shot in the past 10 years? o Yes
o No
o Unsure
13. Have you had your cholesterol checked in the past 5 years? o Yes
o No
o Unsure
14. Have you had a pap smear in the past 2 years? o Yes
o No
o Unsure
o N/A
15. Have you a mammogram in the past 2 years? o Yes
o No
o Unsure
o N/A
16. Have you had a colonoscopy in the past 10 years, or sigmoidoscopy/barium
enema in the last 5 years or do you do yearly stool card checks for blood? o Yes
o No
o Unsure
17. Do you have glaucoma (elevated pressure in the eye) in the past year?
o Yes
o No
o Unsure
18. Have you been checked for diabetes in the past 3 years?
o Yes
o No
o Unsure
19. Have you experienced any of the following often (more than twice a week)?
Feeling sad, irritable or anxious
o Yes
o No
Changed sleep patterns or changed appetite
o Yes
o No
Feeling hopeless, helpless, or worthless
o Yes
o No
Lost interest in activities you enjoy
o Yes
o No
If you have any of the above symptoms and feel that you are depressed, please set up an appointment with your PCP.
20. Do you have:
A Living Will
o Yes o No
Health Care Surrogate o Yes
o No
21. Is English your main language?
o Yes
o No
If no, what language are you most confortable with? ____________________________________
AFS_HAT
page 2 of 2
www.americas1stchoice.com
Your Rights and Responsibilities as a Member of our Plan
Introduction to Your Rights and Protections
Since you have Medicare, you have certain rights to help protect you. In this section,
we explain your Medicare rights and protections as a member of our Plan and we explain
what you can do if you think you are being treated unfairly or your rights are not being
respected.
Your Right to be Treated with Dignity, Respect and Fairness.
You have the right to be treated with dignity, respect, and fairness at all times. Our Plan
must obey laws that protect you from discrimination or unfair treatment. We don’t
discriminate based on a person’s race, disability, religion, sex, sexual orientation, health,
ethnicity, creed, age, or national origin. If you need help with communication, such as
help from a language interpreter, please call Member Services. Member Services can also
help if you need to file a complaint about access (such as wheel chair access).
You may also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800537-7697 or your local Office for Civil Rights.
Your Right to the Privacy of Your Medical Records and Personal Health
Information.
There are federal and state laws that protect the privacy of your medical records and
personal health information. We protect your personal health information under these
laws. Any personal information that you give us when you enroll in this plan is protected.
We will make sure that unauthorized people don’t see or change your records. Generally,
we must get written permission from you (or from someone you have given legal power
to make decisions for you) before we can give your health information to anyone who
isn’t providing your care or paying for your care. There are exceptions allowed or
required by law, such as release of health information to government agencies that are
checking on quality of care.
The laws that protect your privacy give you rights related to getting information and
controlling how your health information is used. We are required to provide you with a
notice that tells about these rights and explains how we protect the privacy of your health
information.
Page 1 of 6
You have the right to look at medical records held at the Plan, and to get a copy of your
records (there may be a fee charged for making copies). You also have the right to ask us
to make additions or corrections to your medical records (if you ask us to do this, we will
review your request and figure out whether the changes are appropriate). You have the
right to know how your health information has been given out and used for non-routine
purposes. If you have questions or concerns about privacy of your personal information
and medical records, please call Member Services.
Your Right to See Medicare Approved Providers, Get Covered Services Within a
Reasonable Period of Time.
As explained in this booklet, you will get most or all of your care from Medicare
approved providers, that is, from doctors and other health providers who are part of our
Plan. You have the right to choose a Medicare approved provider (we will tell you which
doctors are accepting new patients). You have the right to go to a women’s health
specialist in our Plan (such as a gynecologist) without a referral. You have the right to
timely access to your providers and to see specialists when care from a specialist is
needed. “Timely access” means that you can get appointments and services within a
reasonable amount of time.
Your Right to Know Your Treatment Options and Participate in Decisions About
Your Health Care.
You have the right to get full information from your providers when you go for medical
care, and the right to participate fully in decisions about your health care. Your providers
must explain things in a way that you can understand. Your rights include knowing about
all of the treatment options that are recommended for your condition, no matter what they
cost or whether they are covered by our Plan. You have the right to be told about any
risks involved in your care. You must be told in advance if any proposed medical care or
treatment is part of a research experiment, and be given the choice of refusing
experimental treatments. You have the right to receive a detailed explanation from us if
you believe that a provider has denied care that you believe you were entitled to receive
or care you believe you should continue to receive.
In these cases, you must request an initial decision called an organization determination.
Organization determinations are discussed in Section 5. You have the right to refuse
treatment. This includes the right to leave a hospital or other medical facility, even if your
doctor advises you not to leave. This includes the right to stop taking your medication. If
you refuse treatment, you accept responsibility for what happens as a result of your
refusing treatment.
Page 2 of 6
You Have The Right To Use Advance Directives (such as a living will or a power of
attorney).
You have the right to ask someone such as a family member or friend to help you with
decisions about your health care. Sometimes, people become unable to make health care
decisions for themselves due to accidents or serious illness. If you want to, you can use a
special form to give someone the legal authority to make decisions for you if you ever
become unable to make decisions for yourself. You also have the right to give your
doctors written instructions about how you want them to handle your medical care if you
become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance in these
situations are called “advance directives.” There are different types of advance directives
and different names for them. Documents called “living will” and “power of attorney for
health care” are examples of advance directives. If you want to have an advance
directive, you can get a form from your lawyer, from a social worker, or from some
office supply stores. You can sometimes get advance directive forms from organizations
that give people information about Medicare. Regardless of where you get this form,
keep in mind that it is a legal document. You should consider having a lawyer help you
prepare it. It is important to sign this form and keep a copy at home. You should give a
copy of the form to your doctor and to the person you name on the form as the one to
make decisions for you if you can’t. You may want to give copies to close friends or
family members as well.
If you know ahead of time that you are going to be hospitalized, and you have signed an
advance directive, take a copy with you to the hospital. If you are admitted to the
hospital, they will ask you whether you have signed an advance directive form and
whether you have it with you. If you have not signed an advance directive form, the
hospital has forms available and will ask if you want to sign one. Remember, it is your
choice whether you want to fill out an advance directive (including whether you want to
sign one if you are in the hospital). According to law, no one can deny you care or
discriminate against you based on whether or not you have signed an advance directive.
If you have signed an advance directive, and you believe that a doctor or hospital hasn’t
followed the instructions in it, you may file a complaint with Medicare at 1-800MEDICARE (1-800-633-4227), visit Medicare online at www.medicare.gov, TTY users
should call 1-877-486-2048; or North Carolina SHIP 1-800-443-9354.
Your Right to Get Information About Our Plan.
You have the right to get information from us about our Plan. This includes information
about our financial condition, and how our Plan compares to other health plans. To get
any of this information, call Member Services.
Page 3 of 6
Your right to get information in other formats. You have the right to get your questions
answered. Our plan must have individuals and translation services available to answer
questions from non-English speaking beneficiaries, and must provide information about
our benefits that is accessible and appropriate for persons eligible for Medicare because
of disability. If you have difficulty obtaining information from your plan based on
language or a disability, call 1-800-MEDICARE (1-800-633-4227). TTY users should
call 1-877-486-2048.
Your Right to Get Information About Medicare Approved Providers.
You have the right to get information from us about our network providers and their
qualifications and how we pay our doctors. To get this information, call Member
Services.
Your Right to Get Information About Your Part C Medical Care or Services and
Costs.
You have the right to an explanation from us about any Part C medical care or service not
covered by our Plan. We must tell you in writing why we will not pay for or approve a
Part C medical care or service, and how you can file an appeal to ask us to change this
decision. You also have the right to this explanation even if you obtain the Part C medical
care or service from a provider not affiliated with our organization.
Your Right to Make Complaints.
You have the right to make a complaint if you have concerns or problems related to your
coverage or care. If you make a complaint, we must treat you fairly (i.e., not retaliate
against you) because you made a complaint. You have the right to get a summary of
information about the appeals and grievances that members have filed against our Plan in
the past. To get this information, call Member Services.
How to get more information about your rights. If you have questions or concerns about
your rights and protections, you can:
1. Call Member Services at the number on the cover of this booklet.
2. Get free help and information from your State Health Insurance Assistance Program (SHIP). Contact SHIP at 1-800-443-9354. 3. Visit www.medicare.gov to view or download the publication “Your Medicare
Rights & Protections.”
4. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-4862048.
Page 4 of 6
What can you do if you think you have been treated unfairly or your rights are not being
respected? If you think you have been treated unfairly or your rights have not been
respected, you may call Member Services or:

If you think you have been treated unfairly due to your race, color, national origin,
disability, age, or religion, you can call the Office for Civil Rights at 1-800-3681019 or TTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.

If you have any other kind of concern or problem related to your Medicare rights
and protection described in this section, you can also get help from your SHIP.
Your Responsibilities as a Member of Our Plan Include:

Getting familiar with your coverage and the rules you must follow to get care as a
member.

You can use your Evidence of Coverage to learn about your coverage, what you
have to pay, and the rules you need to follow. Call Member Services if you have
questions.

Using all of your insurance coverage. If you have additional health insurance
coverage besides our Plan, it is important that you use your other coverage in
combination with your coverage as a member of our Plan to pay your health care
expenses. This is called “coordination of benefits” because it involves
coordinating all of the health benefits that are available to you.

You are required to tell our Plan if you have additional health insurance. Call
Member Services.

Notifying providers when seeking care (unless it is an emergency) that you are
enrolled in our Plan and you must present your plan membership card to the
provider.

Giving your doctor and other providers the information they need to care for you
and following the treatment plans and instructions that you and your doctors agree
upon. Be sure to ask your doctors and other providers if you have any questions
and have them explain your treatment in a way you can understand.

Acting in a way that supports the care given to other patients and helps the smooth
running of your doctor’s office, hospitals, and other offices.
Page 5 of 6

Paying your coinsurance or co-payment for your covered services. You must pay
for services that aren’t covered.

Notifying us if you move. If you move within our service area, we need to keep
your membership record up-to-date. If you move outside of our plan service area,
you cannot remain a member of our plan, but we can let you know if we have a
plan in that area.
Letting us know if you have any questions, concerns, problems or suggestions. If
you do, please call Member Services.

Page 6 of 6
PRE-CERTIFICATION REQUEST FORM PPO PLAN ONLY
Requires Medical Records
Phone: (888) 211-9912
Fax: (888) 211-9919
Instructions:
This form is for pre-service determinations which will be processed as quickly as possible depending on the member’s needs.
IMMEDIATE OR EXPEDITED REQUESTS: Do not write STAT, ASAP, Immediate on this form. Please follow below instructions.
Medicare’s definition of expedited is defined as one where “applying the standard time for making a determination could seriously
jeopardize the life or health of an enrollee’s ability to regain maximum function.” Applies to PPO Plan Only.
ONLY COMPLETE THIS SECTION FOR EXPEDITED REQUESTS
If your PHYSICIAN feels the member meets this definition please either:
1. Have your physician call 888-796-0947 to speak with our Medical Director to expedite your request or
2. Have your physician document the reason he/she feels the member meets the Medicare definition of expedited and sign below.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Signature:____________________________________________________ Date:____________________________________________________
Date of Request:
Date of Service: Member Information
ICD-9 Code(s):
Requesting Provider
Name:___________________________________________
Name: ___________________________________________
Plan ID#: _________________________________________
TIN#: ____________________________________________
Date of Birth:______________________________________
Phone: (_____)___________ Fax: (_____)______________
Office Contact Person:_______________________ Ext._____
Facility Requested (No Abbreviations)
Provider Requested (No Abbreviations)
Name: __________________________________________
Name: __________________________________________
TIN#: _________________________
TIN#: _________________________
Phone: (_____)__________________
Phone: (_____)__________________
Fax:
Fax:
(_____)__________________
(_____)__________________
Comments
(Please provide concise statement of medical necessity to assist in determination. Medical records must be attached.)
Service Requested: Check appropriate request(s)
□ Blepharoplasty (check CPT code)
□ 15820-15821 □ 15822-15823
□ Septoplasty (CPT code 30520)
□ Mammaplasty
□ 19324-19325
□ Rhinoplasty
□ 30400-30420
□ 19318
□ 30430-30450
AFC PPO Pre-Certification Form 7/2012
□ Bariatric Surgery
□ 43644-43645
□ 43770-43775
□ 43842-43848
□ 43886-43888
□ Vein Treatment
□ 36475-36479
□ 37765-37785
□ 37735-37761
□ Power operated vehicle
□ K0800-k0812
□ Power wheelchair
□ K0813-K0899
□ Plastic Surgery/Cosmetic procedure
(List requested codes)
______________________________
______________________________
______________________________
www.americas1stchoice.com
PFFS ADVANCED PRE-SERVICE DETERMINATION REQUEST FORM
Please Attach All Medical Records to Request
Phone: (888) 211-9912
Fax: (888) 211-9919
Instructions:
America’s 1st Choice is a PFFS Plan and prior authorization is not required. A provider may request to have a pre-service review to determine
if this is a covered service under Medicare or a Plan benefit. Please complete this form and attach any pertinent medical records and fax
to the number stated above.
This form is for pre-service determinations which will be processed as quickly as possible depending on the member’s needs.
IMMEDIATE OR EXPEDITED REQUESTS: Do not write STAT, ASAP, Immediate on this form. Please follow below instructions.
Medicare’s definition of expedited is defined as one where “applying the standard time for making a determination could seriously
jeopardize the life or health of an enrollee’s ability to regain maximum function.”
ONLY COMPLETE THIS SECTION FOR EXPEDITED REQUESTS
If your PHYSICIAN feels the member meets this definition please either:
1. Have your physician call 888-796-0947 to speak with our Medical Director to expedite your request or
2. Have your physician document the reason he/she feels the member meets the Medicare definition of expedited and sign below.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Signature:____________________________________________________ Date:____________________________________________________
Date of Request:
Date of Service: Member Information
ICD-9 Code(s):
Requesting Provider
Name:___________________________________________
Name: ___________________________________________
Plan ID#: _________________________________________
TIN#: ____________________________________________
Date of Birth:______________________________________
Phone: (_____)___________ Fax: (_____)______________
Office Contact Person:_______________________ Ext._____
Facility Requested (No Abbreviations)
Provider Requested (No Abbreviations)
Name: __________________________________________
Name: __________________________________________
TIN#: _________________________
TIN#: _________________________
Phone: (_____)__________________
Phone: (_____)__________________
Fax:
Fax:
(_____)__________________
□ Inpatient
□ Outpatient Hospital
Service Requested
(_____)__________________
□ Ambulatory Surgery Center
□ Other __________________________
CPT or HCPCS Code(s)Description# of Visits/Injections
Comments:
AFC Pre-Determination Form 7/2012
www.americas1stchoice.com
America’s 1st Choice Health Plans, Inc.
PRIOR AUTHORIZATION/STEP THERAPY
INSTRUCTIONS:
■
PLEASE FAX THE COMPLETED PRIOR AUTHORIZATION/NON-FORMULARY
REQUEST TO PHARMACY DEPARTMENT: FAX: (727) 451-6820
■
NOTE: ANY MEMBER OF THE PHYSICIAN’S STAFF MAY COMMUNICATE THIS INFORMATION
TO AMERICA’S 1ST CHOICE HEALTH PLANS. EXPEDITED REQUEST CALL: PHONE: (888) 407-9977
PATIENT INFORMATION
LAST NAME:
FIRST NAME:
MI:
AMERICA’S 1ST CHOICE PATIENT ID NUMBER:
DATE OF BIRTH:
PHARMACY:
PHARMACY PHONE:
DRUG REQUESTED
NAME:
STRENGTH:
QUANTITY:
1. HAS THIS PATIENT PREVIOUSLY RECEIVED THIS DRUG?
YES
DURATION:
NO IF YES, HOW LONG? ____________________
2. HAS PATIENT HAD A DOCUMENTED ALLERGY/INTOLERANCE TO THE FORMULARY MEDICATION?
YES
NO
N/A
3. LIST THERAPY FAILURE ON ONE OR MORE FORMULARY DRUGS WITHIN THE SAME THERAPEUTIC CLASS:
4. PATIENT DIAGNOSIS:
Please send all relevant documentation to support your request for this drug.
PHYSICIAN NAME:
PHYSICIAN PHONE #:
SPECIALTY:
DATE:
ADDRESS:
PHYSICIAN FAX: # (FOR FAXED NOTIFICATION):
CONTACT:
FOR AMERICA’S 1ST CHOICE USE ONLY
Approved By: ____________
Denied By: _____________
More Information Needed______
COMMENTS: _______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Coverage Determination: ________
Date________________ Valid for______________ Expires____________
Redetermination: ________
NOTE: This facsimile transmission is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from discloser under applicable law. In the event that you are not the intended recipient, any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify America’s 1st Choice at (888) 407‐9977. Provider Information Change Form
Provider Name:
Contact Name:
Contact Phone #:
Provider ID#:
Contact Fax#:
Provider ID#:
Provider ID#:
Type of Change Requested:
_____ Name Change
_____ Add Physician/Group*
_____ Office Address Change
_____ Office Phone/Fax Change
_____ Billing Address Change
_____ New Service Location*
_____ 1099 Address Change
_____ Other
Attach letter, W9 form, or other supporting documentation as required. Change
cannot be processed without attached paperwork. Requests received on or before the
15th of the month will be effective retroactive to the first of the month. Requests
received after the 15th will be effective the first day of the following month.
*Requests received to add Physician/Group/Location will follow the Health Plan
Credentialing Process and will be effective the first day of the month following the
completion of the Credentialing Process.
Return the completed form to a Provider Relations Representative
or fax it to 1-803-509-5035.
FOR INTERNAL USE ONLY:
Provider Relations Representative Effective Date of Change
Department Manager Date
Configuration Department Staff Date
Credentialing Department Staff Date
Updated 8/2012
North and South Carolina Medicare
Quick Reference Guide
January 2013
IMPORTANT TELEPHONE NUMBERS
Provider Relations Columbia Office
Toll Free: (866) 321-3947
CORPORATE OFFICE
Phone: (803) 748-4533
TTY/TDD: (800) 735-2962 (NC)
(800) 735-8583 (SC)
Fax: (803) 748-4907
Address:
America’s 1st Choice
250 Berryhill Rd, Suite 311
Columbia, SC 29210
Web: www.americas1stchoice.com
Provider Relations Fax Numbers:
Main ...................................................................... (803) 509-5035
Secondary ............................................................ (803) 748-4534
Additional Health Plan Numbers:
Utilization Management ........................................ (888) 211-9912
Member Services.................................................. (866) 321-3947
PHARMACY
Pharmacy Technical Help..(888) 706-0421 Authorization Required
Spectral Solutions..............(888) 407-9977 • Drugs not listed on the Formulary
Assured RX (mail-order).....(888) 987-9977 • Some drugs on the Formulary require a Coverage Determination Request
• Duplication of drug therapy
Assured RX Fax.................(727) 451-6821 • Dosing that exceeds the FDA daily or monthly quantity maximum
Web-Based Information
• Formulary
• Coverage Determination Request
Forms
• Most self-injectable and infusion drugs that require a Part B vs Part D determination
• Brand name requests when a generic exists
• Drug that has a step edit and the first line therapy is inappropriate
• Prescriptions that exceed $2,000/prescription (some exceptions apply) and/or plan
limitations
CLAIMS
America’s 1st Choice Insurance Company of North Carolina
America’s 1st Choice Health Plans (SC)
Submit Medical Paper Claims to:
America’s 1st Choice Insurance Company of North Carolina
Claims Department
P.O. Box 210459, Columbia, SC 29221
Submit Medical Paper Claims to:
America’s 1st Choice Health Plans
Claims Department
P.O. Box 210769, Columbia, SC 29221
EDI Information:
Payor ID: 26078
Clearinghouse - EMDEON
EDI Information:
Payor ID: 20553
Clearinghouse - EMDEON
Claims Department – (866) 321-3947
Claims Department – (866) 321-3947
Claim Disputes: Please send to the address below for claim denials regarding untimely filing, incidental procedures, bundling,
unbundling, unlisted procedure codes, non-covered codes, etc. Claims must be submitted to America’s 1st Choice Health Plans and
America’s 1st Choice Insurance Company of North Carolina within 90 days of date of denial from EOB.
America’s 1st Choice Insurance Company
of North Carolina
Attn: Claims Department
P.O. Box 210459, Columbia, SC 29221
America’s 1st Choice Health Plans (SC)
Attn: Claims Department
P.O. Box 210769
Columbia, SC 29221
NOTE: Claims should be filed to the address for the State that the member resides in. When filing claims that require additional information or attachments (i.e. Medical
Records, CLIA Updates, EOPs, invoices...) please mail the information to one of the addresses listed above.
APPEALS & GRIEVANCES
A provider may file an appeal or grievance on behalf of the member with the member’s written consent. A provider may also seek an
appeal through the Appeals Department within 60 calendar days when a claim is denied for lack of prior authorization, the service
exceeds authorization, has insufficient supporting documentation or late notification. Mail an appeal or grievance with supporting
clinical documentation to:
America’s 1st Choice Insurance Company of North Carolina
Appeals & Grievances
P.O. Box 210459, Columbia, SC 29221
America’s 1st Choice Health Plans (SC)
Appeals & Grievances
P.O. Box 210769, Columbia, SC 29221
North and South Carolina Medicare
Reference Guide
January 2013
AMERICA’S 1ST CHOICE PROVIDER WEB PORTAL
HHH As a participating provider you have access to the America’s 1st Choice Provider Portal. HHH
HHH Log on to www.americas1stchoice.com to register today! HHH
UTILIZATION MANAGEMENT (UM) DEPARTMENT - AUTHORIZATIONS (PPO Only)
Telephone: (888) 211-9912 • Fax: (888) 211-9919
Authorization Requests - 8:00 a.m. to 5:00 p.m. on weekdays (excluding holidays).
Standard: The Plan’s average time to completion is one day if all information is complete.
Expedited: A request can only be expedited if it is felt that waiting up to the standard timeframe would place the patient’s life, health
or ability to regain maximum function in serious jeopardy. If this is the case, please call the UM Department and make a request to
speak with the Medical Director about an expedited review.
The Plan requires pre-certification on the following procedures/services for PPO only:
1. Bariatric Surgery
5. Vein Treatment
2. Septoplasty
6. Power Operated Vehicles or Wheelchairs
3. Mammaplasty 7. Plastic/Cosmetic Procedures
4. Rhinoplasty 8. Blepharoplasty
PRIVATE FEE FOR SERVICE (PFFS)
No pre-certification/authorization is required for Medicare covered services. The Provider may request an Advanced Pre-Service Determination if
there is a question that the requested service would be covered by Medicare. The request can be submitted to the UM Department utilizing the
“PFFS Advanced Pre-Service Determination Form” and faxing the form and information to the number stated above for Utilization Management.
PROVIDER COMPLAINTS & GRIEVANCES
Provider complaints related to any administrative issue such as America’s 1st Choice Health Plans and America’s 1st Choice
Insurance Company of North Carolina policies and procedures or authorization/referral process must be submitted within 45 calendar
days from the date of the occurrence. Please submit your complaint in writing by mail or fax to:
America’s 1st Choice Insurance Company of North Carolina
America’s 1st Choice Health Plans (SC)
Attn: Provider Relations
Attn: Provider Relations
PO Box 210469
P.O. Box 210759
Columbia, SC 29221
Columbia, SC 29221
Fax: (803) 509-5035
Fax: (803) 509-5035
CONTRACTED NETWORKS
Behavioral Health - PsychCare.............................(800) 221-5487 Dental - Argus.................................................. (877) 864-0625
Gym
Silver and Fit (NC/SC only).....................................(877) 427-4788
(Gym benefit excluded for Presidential and
Presidential Plus members)
Chiropractic - Palladian
(AFC Member Services)..........................................(866) 321-3947
Hearing - HearUSA/HearX.............................. (800) 333-3389
Optometry - Advantica Eye Care.................... (866) 425-2323
Laboratory Services
Solstas Lab Partners.......................................... (888) 664-7601
Quest.................................................................. (866) 697-8378
LabCorp.............................................................. (800) 762-4344
OTC Diabetic Supplies (Member Services)................................................................................................................(866) 321-3947
• 0% Co-Insurance for Medicare-covered diabetic monitors, lancets, and test strips through the plan’s mail order program.
• 20% Co-Insurance for retail and all other diabetes monitoring supplies.
Updated 12/11/12
NOTE: This guide is not designed to be an all-inclusive list of covered services under America’s 1st Choice Health Plans and America’s 1st Choice Insurance Company of NC, but it does provide current referral and prior
authorization instructions. Authorization does not guarantee payment of claims. All services/procedures are subject to benefit coverage, limitations and exclusions as described in the applicable plan coverage guidelines.
SamplleIDCarrds
Call Toll Free: 1-866-321-3947
TTY/TDD: 1-800-735-8583
Dates
October 1, 2012 to February 14, 2013
Days
7 days a week
February 15, 2013 to September 30, 2013 Monday through Friday
October 1, 2013 to December 31, 2013
7 days a week
www.americas1stchoice.com
Times
8 a.m. to 8 p.m.
8 a.m. to 8 p.m.
8 a.m. to 8 p.m.