Cenpatico Provider Manual www.cenpatico.com Kansas KanCare Plan v. 4/2014 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Table of Contents Welcome To Cenpatico ..................................................................................................................................... 3 About Cenpatico ....................................................................................................... ........................................3 MISSION ........................................................................................................................ ........................................3 VISION ........................................................................................................................... ........................................3 GOAL ............................................................................................................................ ........................................3 History and Structure of Cenpatico ........................................................................ ........................................4 Managed Care Philosophy ...................................................................................... ........................................4 Quick Reference Guide ...................................................................................................................................... 6 The Cenpatico Provider Network ...................................................................................................................... 7 Network Provider Selection Process .................................................................................... ........................................8 The Network Provider’s Office ............................................................................................ ........................................9 Network Provider Concerns ..................................................................................... ......................................10 Verifying Member Enro ment .................................................................................. ......................................10 Eligibility Screening For SUD Service ....................................................................... ......................................10 Network Provider Standards of Practice ............................................................... ......................................10 Credentialing ...................................................................................................................................................... 12 Re-Credentialing Requirements and Schedule.................................................... ......................................16 Council for Affordable Quality HealthCare (CAQH) ........................................... ......................................17 Right to Review and Correct Information .............................................................. ......................................17 Cenpatico Credentialing Policies and Procedures ............................................. ......................................17 Cenpatico Credentialing Committee & Approval of Applications.................. ......................................18 Status Change Notification ...................................................................................... ......................................18 Network Provider Demographic/Information Updates ...................................... ......................................18 Network Provider Request to Terminate................................................................. ......................................19 Cenpatico’s Right to Terminate .............................................................................. ......................................19 Cultural Competency ....................................................................................................................................... 20 Understanding the Need for Culturally Competent Services .................................................................... 21 Facts about Health Disparities ................................................................................. ......................................22 Access and Coordination of Care ................................................................................................................. 23 Quality Improvement......................................................................................................................................... 28 Monitoring Clinical Quality........................................................................................ ......................................28 Network Provider Participation in the QI Process ................................................. ......................................29 Confidentiality and Release of Member Information .......................................... ......................................29 Communication with the Primary Care Physician................................................ ......................................29 Consent for Disclosure ............................................................................................... ......................................30 Critical Incident Reporting ........................................................................................ ......................................31 Abuse and Neglect Reporting ................................................................................ ......................................31 Member Concerns about Network Providers ....................................................... ......................................31 Records and Documentation .................................................................................. ......................................32 Cenpatico Compliance Program ................................................................................................................... 33 1 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Waste, Abuse and Fraud (WAF) System................................................................. ......................................33 Federal and States Laws Governing the Release of Information...................... ......................................34 Treatment Record Guidelines .................................................................................. ......................................35 Preventative Behavioral Health Programs ............................................................ ......................................36 Complaints, Grievances and Appeals Member Grievances and Provider Complaints .............................. 37 Member Rights and Responsibilities ............................................................................................................... 40 Customer Service ............................................................................................................................................... 42 The Cenpatico Customer Service Department ................................................... ......................................42 Verifying Member Enrollment ................................................................................... ......................................42 Sunflower Health Plan Member ID Cards ...................................................................................................... 43 Interpretation/Translation Services .......................................................................... ......................................44 NurseWise ..................................................................................................................... ......................................44 Specialty Therapy and Rehabilitative Services (STRS) ................................................................................. 65 Utilization Management.................................................................................................................................... 66 The Utilization Management Program ................................................................... ......................................66 Member Eligibility................................................................................................................................................ 67 Outpatient Treatment Request (OTR)/ Requesting Additional Sessions .......... ......................................67 Disease Management ....................................................................................................................................... 74 Claims ................................................................................................................................................................... 74 Cenpatico Billing Policies .................................................................................................................................. 78 Resolving Claims Issues ...................................................................................................................................... 80 Claim Reconsideration .............................................................................................. ......................................80 UB-04 Claim Form Instructions .......................................................................................................................... 91 2 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Welcome to Cenpatico Welcome to the Cenpatico Behavioral Health, LLC (Cenpatico) Provider network. We look forward to a long and mutually rewarding partnership as we work together in the delivery of behavioral health and substance use disorder services to Sunflower Health Plan Members in Kansas. The Cenpatico Provider Manual is designed to answer your questions about our behavioral health program and to explain how we manage the delivery of behavioral health and substance use disorder services to the Members we serve. This Manual provides a description of Cenpatico and Sunflower Health Plan’s treatment philosophy and the policies and procedures administered in support of this philosophy. It also describes the requirements established by Cenpatico and its clients and the performance standards for Network Providers in the delivery of services to Members. Cenpatico will provide bulletins as needed to incorporate any needed changes to this Manual online at www.cenpatico.com. Additionally, we offer a wealth of resources for our Kansas Providers on our website including this Manual and Provider forms. We look forward to working with you and providing you with support and assistance. We hope you find your relationship with Cenpatico a satisfying and rewarding one. About Cenpatico MISSION Creating innovative solutions that drive quality health care for vulnerable populations. VISION To establish a national presence as an industry leading health solutions organization for children, Medicaid, and specialty therapies. GOAL To improve outcomes and deliver savings through innovation. 3 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 History and Structure of Cenpatico Cenpatico is a wholly-owned subsidiary of CenCorp Health Solutions, Inc. (CenCorp). CenCorp is a wholly-owned subsidiary of Centene Corporation (Centene). Sunflower Health Plan (http://www.sunflowerstatehealth.com), a Centene health plan, delegates the provision of covered behavioral health and substance use disorder services to Cenpatico. Cenpatico has provided comprehensive managed behavioral healthcare services for more than eleven (11) years, and currently operates in Arizona, California, Florida, Georgia, Illinois, Indiana, Kansas, Massachusetts, Mississippi, Missouri, New Hampshire, Ohio, South Carolina, Texas, Washington and Wisconsin. As an integral part of our core philosophy we believe quality behavioral healthcare is best delivered locally. Cenpatico is a clinically driven organization that is committed to building collaborative partnerships with Providers. Cenpatico defines "behavioral health” as inclusive of acute and chronic psychiatric and substance use disorders as referenced in the most recent International Statistical Classification of Diseases and Related Health Problems (ICD-9). Cenpatico provides quality, cost effective behavioral healthcare services for Members of Sunflower Health Plan through a comprehensive Provider Network of qualified behavioral health Providers. An experienced Provider Network is essential to provide consistent, superior services to our Members. To achieve our goals, Cenpatico builds strong, long-term relationships with our Provider Network. This Provider Manual was designed to assist you with the administrative and clinical activities required for participation in our system. Cenpatico prefers and encourages a partner relationship with our Provider Network. Member care is a collaborative effort that draws on the expertise and professionalism of all involved. Managed Care Philosophy Cenpatico is strongly committed to the philosophy of providing appropriate treatment at the least restrictive level of care that meets the Member’s needs. We believe careful case-by-case consideration and evaluation of each Member’s treatment needs are required for optimal medical necessity determinations. We believe Members need to be fully involved in their care and participate in decisions regarding treatment needs. Outpatient treatment is generally considered the first choice treatment approach, with the exception of when medical necessity is met for a higher level of care. Many factors support this position: Outpatient treatment allows the Member to maximize existing social strengths and supports, while receiving treatment in the setting least disruptive to normal everyday life. Outpatient treatment maximizes the potential of influences that may contribute to treatment motivation, including family, social, and occupational networks. Allowing a Member to continue in occupational, scholastic, and/or social activities increases the potential for confidentiality of treatment and its privacy. Friends and associates need not know of the Member’s treatment unless the Member chooses to tell them. Outpatient treatment encourages the Member to work on current individual, family, and job-related issues while treatment is ongoing. Problems can be examined as they occur and immediate feedback can be provided. Successes can strengthen the member’s confidence so that incremental changes can occur in treatment. 4 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 The use of appropriate outpatient treatment helps the Member preserve available benefits for potential future use. Benefits are maximized for the Member’s healthcare needs. At Cenpatico, we take privacy and confidentiality seriously. We have processes and policies and procedures in place to comply with applicable Federal and State regulatory requirements. We appreciate your partnership with Cenpatico in maintaining the highest quality and most appropriate level of care for Sunflower Health Plan Members. 5 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Quick Reference Guide Cenpatico Contact Information: Cenpatico 866-896-7293 www.cenpatico.com Health Plan Contact Information: Sunflower Health Plan 877-644-4623 http://www.sunflowerstatehealth.com/ Eligibility Verification: Phone: 866-896-7293 Web: www.cenpatico.com (you must have a Provider log-on to verify eligibility on this site) ERA/EFT Enrollment: Please call PaySpan Health at 877-331-7154 or visit www.payspanhealth.com Cenpatico Customer Service: Please call Customer Service at 866-896-7293 to assist with eligibility determinations and Provider referrals Claims Guidelines: Claims must be submitted within 180 days of the date of service. Claim Submission: Claims can be submitted on the Cenpatico website at www.Cenpatico.com EDI Vendors: Emdeon (866-369-8805) Availity (800-282-4548) Gateway EDI (800-969-3666) Cenpatico’s Payor ID Number is 68068 For further information regarding electronic submission, contact the Cenpatico EDI Department at 800-225-2573, ext. 25525 or email at [email protected] Paper Claims Address: KanCare Office of Fiscal Agent PO Box 3571 Topeka, KS 66601-3571 Claims Customer Service: 866-896-7293 6 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Claim Appeals Address: Cenpatico Appeals PO Box 6000 Farmington, MO 63640-3809 Benefits/ Covered Services: Please refer to your fee schedule and the Kansas Covered Services & Authorization Guidelines document within the Provider Manual. Prior Authorization: Call Medical Management at 866-896-7293 Download and complete an Outpatient Treatment Request (OTR) online at www.cenpatico.com After-Hours Admissions: Please notify Cenpatico of after-hours or weekend admissions on the next business day. Medical Necessity and Administrative Appeals: Cenpatico Attn: Appeals Coordinator 12515-8 Research Blvd. Suite 400 Austin, TX 78759 or Fax to: 866-714-7991 Provider Relations: Cenpatico Telephone: 866-944-7588 Fax: 866-263-6521 Email: [email protected] The Cenpatico Provider Network Cenpatico Service Area Cenpatico reimburses claims for the covered behavioral health and substance use disorder benefits for Sunflower Health Plan Members throughout the State of Kansas. 7 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Provider Selection Process The Cenpatico Network includes, but is not limited to the following provider types: Community Mental Health Centers (CMHCs) Licensed Psychiatrists Licensed Psychologists Licensed Psychiatric Advance Practice Nurses Licensed Clinical Professional Counselors Licensed Specialist Clinical Social Workers Licensed Clinical Marriage and Family Therapists Licensed Clinical Psychotherapists Licensed Master’s Level Psychologists* Licensed Mental Health Professionals* Physician Assistants Kansas Licensed Substance Abuse Counselors Autism Waiver Providers State Licensed Behavioral Health or Substance Use Disorder Programs Federally Qualified Health Centers Rural Health Clinics Psychiatric Residential Treatment Facilities Psychiatric Hospitals General Hospitals offering psychiatric and/or substance use disorder services *Supervision is required in accordance with the Kansas Behavioral Sciences Regulatory Board or its equivalent We work with Providers that consistently meet or exceed Cenpatico clinical quality standards and are comfortable practicing within the managed care arena, including those Providers that demonstrate and support Sunflower Health Plan’s integrated care approach to Member care. Network Providers should support a brief, solution-focused approach to treatment and should be engaged in a collaborative approach to the treatment of Sunflower Health Plan’s Members. Cenpatico consistently monitors network adequacy. Network Providers are selected based on the following standards; Clinical expertise; Geographic location considering distance, travel time, means of transportation, and access for Members with physical disabilities; Potential for high volume referrals; 8 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Specialties and accessibility standards, including meeting the Americans with Disabilities Act (ADA) requirements, to best meet our Members’ needs; Ability to accept new Members; Ability to act as the Member’s medical home; and Experience in utilizing evidence-based practices in working with seriously mentally ill (SMI) and developmentally delayed/disabled (DD) populations. This includes but is not limited to Assertive Community Treatment (ACT), Trauma Informed Cognitive Behavioral Therapy, IMR, etc. Cenpatico contracts its Provider Network to support and meet the linguistic, cultural and other unique needs of every individual Member, including the capacity to communicate with Members in languages other than English and communicate with those Members who are deaf or hearing impaired. The Network Provider’s Office Cenpatico reserves the right to conduct Network Provider site visit audits. Site visits may be conducted as a result of Member dissatisfaction or as part of a chart audit. The site visit auditor reviews the quality of the location where care is provided. The review assesses the accessibility and adequacy of the treatment and waiting areas. General Network Provider Office Standards Cenpatico requires the following: Office must be professional and secular; Offices and facilities must be easily accessible with accommodations for Members with disabilities as required and covered by titles II and III of the Americans with Disabilities Act (ADA) of 1990; Provide designated accessible parking spaces; Appropriate door sizes for clear openings with easy opening mechanism; Provide adequate space in clinic rooms to turn a wheelchair; Signs identifying office must be visible; Display all marketing and health education materials provided by contracted health plans in an equal fashion; Office must be clean, and free of clutter with unobstructed passageways; Office must have a separate waiting area with adequate seating; Clean restrooms must be available; Office environment must be physically safe; Network Providers must have a professional and fully-confidential telephone line and twenty-four (24) hour availability; Member records and other confidential information must be locked up and out of sight during the work day; and Medication prescription pads and sample medications must be locked up and inaccessible to Members. 9 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Provider Concerns Network Providers who have concerns about Cenpatico should contact the Network/Provider Relations department at 866-944-7588 or Quality Improvement department at 866-896-7293 to register these complaints. All concerns are investigated, and resolution is provided to the Network Provider on a timely basis. Verifying Member Enro ment Network Providers are responsible for verifying eligibility every time a Member schedules an appointment, and when they arrive for services. Network Providers should use either of the following options to verify Member enrollment: Access the Kansas Medical Assistance program (KMAP) website at https://www.kmap-state-ks.us/Public/Provider.asp or call 800-933-6593 Contact Cenpatico Customer Service at 866-896-7293 Verify online at www.cenpatico.com Until the actual date of enrollment with Sunflower Health Plan, Cenpatico is not financially responsible for services the prospective Member receives. In addition, Cenpatico is not financially responsible for services Members receive after their coverage has been terminated. Eligibility Screening For SUD Service The Provider shall use the AAPS funding source as the payor of last resort. To this end, Providers shall conduct eligibility screenings for all Members that present to their location to determine the appropriate funding stream for the Member. Eligibility screenings shall include verification of possible funding through the Kansas Medical Assistance Program (KMAP) prior to admission and a minimum of monthly while the Member is in treatment. When appropriate, this shall include the facilitation of Medicaid enrollment activities, up to and including referral of a Member to an SRS Office and/or a Medicaid enrollment entity. As part of the eligibility determination Providers shall obtain proper documentation on each Member for whom an eligibility screening is conducted and place it in the Member file. Documentation must confirm that the Member’s income and residency meet the most recent AAPS (Addiction and Prevention Services) eligibility guidelines. This section of the contract is meant to address deviations from the standard course of provider practice. Network Provider Standards of Practice Network Providers are required to: Refer Members with known or suspected physical health problems or disorders to the Member’s PCP for examination and treatment; Send initial and bi-annually (or more frequently if clinically indicated) summary reports of a Member's behavioral health status to the PCP, with the Member's or the Member's legal guardian's consent; Only provide physical health services if such services are within the scope of the Network Provider’s clinical licensure; 10 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Providers must ensure Members that are discharging from inpatient care are scheduled for outpatient follow-up and/or continuing treatment prior to the Member’s discharge. Cenpatico strives to meet the National Committee for Quality Assurance (NCQA) Health Care Effectiveness Data and Information Set (HEDIS) guidelines for follow up and/or continuing treatment after an inpatient visit. To that end, Cenpatico requires Network Providers offering inpatient psychiatric services to ensure that outpatient treatment is scheduled within seven (7) days following the date of discharge; Attempt to outreach to Members who have missed appointments within twenty-four (24) hours to reschedule; Comply with State of Kansas appointment access standards; Ensure all Members receive effective, understandable and respectful treatment provided in a manner compatible with their cultural health beliefs and practices and preferred language (which can be accomplished by engaging professional interpreter services at the onset of treatment); Comply with all State and Federal requirements governing emergency, screening and post-stabilization services; Provide Member’s clinical information to other providers treating the Member, as necessary, to ensure proper coordination and treatment of Members who express suicidal or homicidal ideation or intent, consistent with State law; Exchange information with Member’s PCP and/ or other behavioral health providers upon Member consent; Comply with all Cenpatico non-discrimination and cultural competency requirements; Accommodate the needs of Members with disabilities; Ensure behavioral health treatment plans are developed with the Member and Member’s family involvement; Submit all documentation in a timely fashion; Comply with Cenpatico’s Case Management and UM processes; Cooperate with and participate in all Cenpatico’s Quality Improvement (QI) activities as requested; Use appropriate Medical Necessity and Evidence-Based Best Practices when formulating treatment plans and requesting ongoing care; Assist Members in identifying and utilizing community support groups and resources; Maintain confidentiality of records and treatment and obtain appropriate written consents from Members when communicating with others regarding Member treatment; Notify Cenpatico of any critical incidents; Notify Cenpatico of any changes in licensure, any malpractice allegations and any actions by your licensing board (including, but not limited to, probation, reprimand, suspension or revocation of license); Notify Cenpatico of any changes in malpractice insurance coverage; Notify Cenpatico of any change of address/location within thirty (30) days of the change; Complete credentialing and re-credentialing materials as requested by Cenpatico; and, Maintain an office that meets all standards of professional practice. 11 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Credentialing Credentialing Requirements The Cenpatico Provider Network includes but is not limited to: Community Mental Health Centers (CMHCs), Licensed Psychiatrists, Licensed Psychologists, Licensed Psychiatric Advance Practice Nurses, Licensed Clinical Professional Counselors, Licensed Master Social Workers, Licensed Clinical Social Workers, Licensed Clinical Workers, Licensed Clinical Marriage and Family Therapists, Licensed Clinical Psychotherapists, Licensed Master’s Level Psychologists, Licensed Mental Health Professionals, Physician Assistants, Kansas Licensed Substance Abuse Counselors, Autism Waiver Providers, State Licensed Behavioral Health or Substance Use Disorder Programs, Federally Qualified Health Centers, Rural Health Clinics, Psychiatric Residential Treatment Facilities and Psychiatric Hospitals. Cenpatico Network Providers must adhere to the following requirements: Adhere to Cenpatico’s Clinical Practice Guidelines and Medical Necessity Criteria. Consistently meet our credentialing standards and Cenpatico guidelines on Primary Care Physician (PCP) notification. Failure to adhere to guidelines and standards at any time can lead to termination from our network. Notify Cenpatico immediately upon receipt of revocation or suspension of the Network Provider’s State License by the State of Kansas. All solo and group Network Providers must be licensed to practice independently in compliance with Cenpatico’s credentialing standards and guidelines. Licensed Master’s Level Psychologists and Licensed Mental Health Professionals must meet the supervision requirements established by the Kansas Behavioral Sciences Review Board. License/Certification must be current, active and in good standing. MDs and DOs must have hospital privileges and/or a coverage plan. Hospital privileges must be current and active. All Network Providers’ graduate degrees must be from an accredited institution. All Network Providers are subject to the completion of primary source verification of the Network Provider through our Credentialing Department located in Austin, Texas. The Network Provider agrees to complete and provide appropriate documentation for this primary source verification in a timely manner. The Network Provider further agrees to provide all documentation in a timely manner required for credentialing and/or re-credentialing. The Network Provider agrees to maintain adequate professional liability insurance as set forth in the Provider Agreement with Cenpatico. 12 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 All credentialing applications are subject to consideration and review by the Cenpatico Credentialing Committee which meets monthly. Providers Providers must submit at a minimum the following information when applying for participation with Cenpatico: Properly completed, signed and dated Kansas Provider Application; Signed attestation of the correctness and completeness of the application, history of loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions; lack of current illegal substance registration and/or alcohol abuse; mental and physical competence, and ability to perform the essential functions of the position, with or without accommodation; Copy of W-9 form; Statement regarding history of loss or limitation or privileges or disciplinary activity; A statement from each Network Provider applicant regarding the following: any physical or behavioral health problems that may affect the Provider’s ability to provide healthcare; any history or chemical dependency/substance use disorder problems; any history of loss of license and/or felony conviction; A copy of current and unrestricted license to practice in the State of Kansas; Malpractice face sheet: Network Providers must carry $1/$3M in coverage, or such other amounts as required by State law; Proof of the highest level of education—a copy of certificate or letter certifying formal postgraduate training; For MDs and DOs, Cenpatico will require proof of the Network Provider’s medical school graduation, completion of residency and other postgraduate training. Evidence of board certification shall suffice in lieu of proof of medical school graduation, residency and other postgraduate training, as applicable and a copy of the Educational Commission for Foreign Medical Graduates (ECFMG) certificate, if applicable; MDs and DOs are also asked to supply Drug Enforcement Administration (DEA) registration, and Board Certification(s); For MDs and DOs, good standing of privileges at the hospital designated as the primary admitting facility; Providers licensed as LMFT, LPC, LMSW, LMLP and LAC must provider a Supervising Physician Statement indicating that they are following the supervision standards as set forth by The Kansas Behavioral Sciences Regulatory Board; Valid Drug Enforcement Administration (DEA) certificates (where applicable); A completed Kansas Disclosure of Ownership & Control Interest Statement; 13 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Current curriculum vitae, which includes at least five (5) years of work history with explanation in writing for a six (6) month, or more, gap; Completed Cenpatico Provider Specialty Profile; and, Any sanction or exclusion imposed on the Provider by Medicare or Medicaid. Facilities Facilities must submit at a minimum the following information when applying for participation with Cenpatico: A complete signed and dated Cenpatico facility application; List of current professional Behavioral Health/Substance Use Disorder staff privileged to admit and/or treat patients in your facility, (include license type, address, telephone numbers and social security numbers) that you would recommend that we contact for membership on Cenpatico’s Individual Provider Panel; Copy of The Joint Commission/CARF/COA/AOA accreditation letter with dates of accreditation in addition to a list of all practice locations covered under the applicable accreditation body; Copy of the State or local license(s) and/or certificate(s) under which your facility operates; Copy of Clinical Laboratory Improvement Amendments (CLIA), if applicable; Copy of current Drug Enforcement Administration (DEA) registration certificate, if applicable; Copy of professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate, name of liability carrier, and insurance effective date and expiration date (Month/Day/Year); Listing of satellite locations and services offered at each location (include copies of accreditation, license, insurance, CLIA, and DEA certificate, if applicable); Kansas Disclosure of Ownership and Controlling Interest Statement; and, Facilities contracted under a Cenpatico Facility Agreement that list a rendering NPI in box 24-J of the claim form that is different than the Facility’s billing NPI (box 33-A), must submit a facility roster of clinicians rendering covered services with their credentialing materials. This information should be submitted in the Cenpatico Facility Roster Format, which can be obtained from the Provider Relations Specialists. Any changes or updates to this list must be submitted to [email protected] 14 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Non-Accredited Facilities must include the following in addition to the items above: Copy of State or local Fire/Health Certificate Copy of Quality Assurance Plan Description of Aftercare or Follow-up Program Organizational Charts including staff to patient ratio It is the Provider’s responsibility to notify Cenpatico of any of the following within ten (10) days of the occurrence: Lawsuits related to professional role; Licensing board actions ; Changes to NPI and TIN; Malpractice claims or arbitration; Disciplinary actions before a State agency and Medicaid/Medicare sanctions; Cancellation or material modification of professional liability insurance; Member complaints against Practitioner; Changes in physical address and fiscal/billing address; and Any situation that would impact a Provider’s ability to carry out the provisions of their Behavioral Health Provider Agreement (“Agreement”) with Cenpatico, including the inability to meet Member accessibility standards, changes or revocation with DEA certifications, hospital staff changes or NPDB or Medicare sanctions. Please notify Cenpatico immediately of any updates to your Tax Identification Number, service site address, phone/fax number and ability to accept new referrals in a timely manner so that our systems are current and accurately reflect your practice. In addition, we ask that you please respond to any questionnaires or surveys submitted regarding your referral demographics, as may be requested from time to time. Credentialing of Health Delivery Organizations (CMHCs and other Behavioral Health Providers/Facilities) Prior to contracting with Health Delivery Organizations (HDO), Cenpatico verifies that the following organizations have been approved by a recognized accrediting body or meet Cenpatico standards for participation, and are in good standing with State and Federal agencies: Hospital or Facility Community Mental Health Center (CMHC) Psychiatric Residential Treatment Facility (PRTF) Kansas Facilities/Health Delivery Organizations are required to utilized the Cenpatico facility application and provide information on accreditation, license, regulatory status and certificate of insurance. In addition, the facility must complete the Kansas Disclosure 15 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 of Ownership & Control Interest Statement. Cenpatico recognizes the following accrediting bodies:* CARF - Commission on Accreditation of Rehabilitation Facilities COA - Council on Accreditation JCAHO - Joint Commission on Accreditation of Healthcare Organizations. NCQA - National Committee for Quality Assurance URAC - Utilization Review Accreditation Commission Council on Accreditation of Services for Family & Children *This list may not be inclusive of all accrediting organizations For those organizations that are not accredited, an on-site evaluation will be scheduled to review the scope of services available at the facility, physical plant safety, the Quality Improvement program, and Credentialing and Re-credentialing Policies and Procedures. Cenpatico may substitute a Center for Medicare and Medicaid Services (CMS) or State review in lieu of the site visit. Cenpatico would require the report from the organization to verify that the review has been performed and the report meets its standards. Also acceptable is a letter from CMS or the applicable State agency which shows that the facility was reviewed and indicates that it passed inspection. Re-Credentialing Requirements and Schedule Kansas Network Providers will be re-credentialed every 36 months from the initial credentialing date in accordance with the current NCQA guidelines, unless otherwise dictated by State law. Providers will receive notice that they are due to be re-credentialed well in advance of their expiration date and, as such, are expected to submit their updated information in a timely fashion. Failure to do so could result in suspension and/or termination from the Network. Quality indicators including but not limited to, complaints, appointment availability, critical incidents, and compliance with discharge appointment reporting will be taken into consideration during the re-credentialing process. Cenpatico will verify the following information submitted for Credentialing and/or Re-Credentialing: License through appropriate licensing agency; Board certification, or residency training, or medical education; National Practitioner Data Bank (NPDB) and HIPDB claims; Five years of work history; and Sanction or exclusion activity including Medicare/Medicaid services (OIG-Office of Inspector General and EPLS – Excluded Parties Listing). Once the application is completed, the Cenpatico Credentialing Committee will render a final decision on acceptance following its next regularly scheduled meeting. 16 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Council for Affordable Quality HealthCare (CAQH) Cenpatico subscribes to the CAQH to streamline the Credentialing/Re-credentialing process. If you are interested in having Cenpatico retrieve your credentialing/re-credentialing application from CAQH, or if you are not enrolled with CAQH, Cenpatico can assist you with contacting CAQH for enrollment. Once a CAQH Provider ID number is assigned, you can visit the CAQH website or call the help desk, to complete the credentialing application. There is no cost for Providers to participate with CAQH and submit their credentialing applications. CAQH Website: www.caqh.org Phone Number: 1-888-559-1717 Right to Review and Correct Information All Network Providers participating with Cenpatico have the right to review information obtained by Cenpatico to evaluate their credentialing and/or re-credentialing application. This includes information obtained from any outside primary source such as malpractice insurance carriers and the licensing/certification agencies. This does not allow a provider to review references, personal recommendations or other information that is peer review protected. Should a Provider believe any of the information used in the credentialing/re-credentialing process is erroneous, or should any information gathered as part of the primary source verification process differ from that submitted, Providers have the right to correct any erroneous information submitted by another party. To request release of such information, a written request must be submitted to the Credentialing Department. Upon receipt of this information, the Provider will have fourteen (14) days to provide a written explanation detailing the error or the difference in information to Cenpatico. The Cenpatico Credentialing Committee will then include this information as part of the credentialing/re-credentialing process. Cenpatico Credentialing Policies and Procedures Cenpatico maintains written credentialing and re-credentialing policies and procedures that include the following: Formal delegation and approvals of the credentialing process; A designated credentialing committee; Identification of Network Providers who fall under its scope of authority; A process which provides for the verification of the credentialing and recredentialing criteria; Approval of new Network Providers and imposition of sanctions, termination, suspension and restrictions on existing Network Providers; Identification of quality deficiencies which result in Sunflower Health Plan or Cenpatico’s restriction, suspension, termination or sanctioning of a Network Provider; and A process to implement an appeal procedure for Network Providers whom Cenpatico has terminated. 17 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Cenpatico Credentialing Committee & Approval of Applications The Cenpatico Credentialing Committee has the responsibility to establish and adopt, as necessary, criteria for Provider participation and termination and direction of the credentialing procedures, including Provider participation, denial and termination. The Cenpatico Credentialing Committee meets monthly, at a minimum ten (10) times per year. Cenpatico has delegated the approval of credentialing applications that meet all the credentialing standards/criteria to the Medical Director who reviews files on a weekly and or bi-weekly basis. Status Change Notification Network Providers must notify Cenpatico immediately of any change in licensure and/or certifications that are required under federal, State, or local laws for the provision of covered behavioral health services to Members, or if there is a change in Network Provider’s hospital privileges. All changes in a Network Provider’s status will be considered in the re-credentialing process. Network Provider Demographic/Information Updates Network Providers should advise Cenpatico with as much advance notice as possible for demographic/ information updates. Network Provider information such as address, phone and office hours are used in our Provider Directory, and having the most current information accurately reflects our Kansas Provider Network. Please use the Cenpatico Provider Information Update Form located on our website at www.cenpatico.com. Completed Provider Information Update Forms should be sent to Cenpatico using one of the following methods; Fax: 866-263-6521 Email: [email protected] Mail: Cenpatico|Att: Provider Data Management 12515-8 Research Blvd., Suite 400 |Austin, Texas 78759 Provider Rosters Cenpatico requires a listing of rendering employed professional Behavioral Health/Substance Use Disorder staff privileged to admit and/or treat patients. This list must include the Provider’s license type, address, telephone numbers, NPI number, and social security numbers. Cenpatico must be notified of any updates to this listing to ensure data accuracy. In addition, please note that the information provided may be accessed by Cenpatico for network accessibility and Member referral services. Providers should submit the updates to this listing to [email protected] 18 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Provider Request to Terminate Network Providers requesting to terminate from the network must adhere to the Termination provisions set forth in their Provider Agreement with Cenpatico. This notice can be sent to the following: Email: [email protected] Fax: 866-263-6521 Mail: Cenpatico|Attn: Provider Data Management 12515-8 Research Blvd., Suite 400 |Austin, Texas 78759 The notification will be acknowledged by Cenpatico in writing and the Network Provider will be advised on procedures for transitioning Members if indicated. Cenpatico fully recognizes that a change in a Network Provider’s participation status is difficult for Members. Cenpatico will work closely with the terminating Network Provider to address the Member’s needs and ensure a smooth transition as necessary. A Network Provider who terminates the contract with Cenpatico must notify all Cenpatico Members who are currently in care at the time and who have been in care with that Network Provider during the previous six (6) months. Treatment with these Members must be completed or transferred to another Cenpatico Network Provider within three (3) months of the notice of termination, unless otherwise mandated by State law. The Network Provider needs to work with the Cenpatico Care Management Department to determine which Members might be transferred, and, which Members meet Continuity of Care Guidelines to remain in treatment. Cenpatico’s Right to Terminate Please refer to your Provider Agreement with Cenpatico for a full disclosure of causes for termination. As stated in your Provider Agreement, Cenpatico shall have the right to terminate the Provider Agreement by giving written notice to the Network Provider upon the occurrence of any of the following events: Termination of Cenpatico’s obligation to provide or arrange behavioral health/ substance use disorder treatment services for Members of Sunflower Health Plan, or any other health plan or agency in the State of Kansas with which Cenpatico is the behavioral health vendor; Restriction, qualification, suspension or revocation of Network Providers’ license or certification; Network Provider's loss of liability insurance required under the Provider Agreement with Cenpatico; Network Provider’s exclusion from participation in the Medicare or Medicaid program; Network Provider’s insolvency or bankruptcy or Network Provider’s assignment for the benefit of creditors; Network Provider’s conviction, guilty plea, or plea of nolo contendere to any felony or crime involving moral turpitude; Network Provider’s ability to provide services has become impaired, as determined by Cenpatico, at its sole discretion; 19 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Provider’s submission of false or misleading billing information; Network Provider’s failure or inability to meet and maintain full credentialing status with Cenpatico; Network Provider’s breach of any term or obligations of the Provider Agreement; Network Provider’s breach of Cenpatico Policies and Procedures. Any occurrence of serious misconduct which brings Cenpatico to the reasonable interpretation that a Network Provider may be delivering clinically inappropriate care; or Network Provider Appeal of Suspension or Termination of Contract Privileges If a Network Provider has been suspended or terminated by Cenpatico, contact the Cenpatico Provider Data Management department at 866-896-7293 to request further information or discuss how to appeal the decision. For a formal appeal of the suspension or termination of contract privileges, the Network Provider should send a written reconsideration request to Cenpatico to the attention of the Quality Improvement Department: Cenpatico Attn: Quality Improvement Department 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Please note that the written request should describe the reason(s) for requesting reconsideration and include any supporting documents. This reconsideration request must be postmarked within thirty (30) days from the receipt of the suspension or termination letter to comply with the appeal process. Cenpatico will use the Provider Dispute Policy to govern its actions. Details of the Provider Dispute Policy will be provided to the Network Provider with the notification of suspension/ termination. To request a copy of Cenpatico’s Provider Dispute Policy, please contact the Quality Improvement Department at 866-896-7293. Each Network Provider will be provided with a copy of their fully-executed Provider Agreement with Cenpatico. The Provider Agreement will indicate the Network Provider’s Effective Date in the network and the Initial Term and Renewal Term provisions in Cenpatico’s Provider Network. The Provider Agreement will also indicate the cancellation/ termination policies. There is no “right to appeal” when either party chooses not to renew the Provider Agreement. Cultural Competency Cultural Competency within the Cenpatico Network is defined as described below: “Davis (1997) defines cultural competence as the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual's culture and increase the quality and appropriateness of behavioral health care and outcomes. 20 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Cultural competence occurs in behavioral health service delivery when cultural issues are acknowledged and addressed at all levels of an organization administration, service delivery, and clinician.” Cenpatico is committed to the development, strengthening, and sustaining of healthy Provider/ Member relationships. Members are entitled to dignified, appropriate and quality care. When healthcare services are delivered without regard for cultural differences, Members are at risk for sub-optimal care. Members may be unable or unwilling to communicate their healthcare needs in an insensitive environment, reducing effectiveness of the entire healthcare process. The Cenpatico vision for culturally competent care is: Care is given with the understanding of, and respect for, the Member’s health-related beliefs and cultural values. Cenpatico staff respect health related beliefs, interpersonal communication styles and attitude of the Members, families and communities they serve. Each functional unit within the organization applies a trained, tailored approach to culturally sensitive care in all Member communications and interactions. All Cenpatico Network Providers support and implement culturally sensitive care models to Sunflower Health Plan Members. The Cenpatico goal for culturally sensitive care is: To support the creation of a culturally sensitive behavioral health system of care that embraces and supports individual differences to achieve the best possible outcomes for individuals receiving services. Network Providers must ensure the following: Members understand that they have access to medical interpreters, signers, and TTY services to facilitate communication without cost to them. Care is provided with consideration of the Members’ race/ ethnicity and language and its impact/ influence on the Members’ health or illness. Office staff that routinely come in contact with Members have access to and participate in cultural competency training and development. The office staff responsible for data collection makes reasonable attempts to collect race and language specific Member information. Treatment plans are developed and clinical guidelines are followed with consideration of the Member’s race, country of origin, native language, social class, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics that may result in a different perspective or decision-making process. Office sites have posted and printed materials in English, Spanish, or other prevailing languages within the region. Understanding the Need for Culturally Competent Services: Research indicates that a person has better health outcomes when they experience culturally appropriate interactions with Providers. The path to developing cultural competency begins with self-awareness and ends with the realization and acceptance that the goal of cultural competency is an ongoing process. Network Providers should note that the experience of a Member begins at the front door. 21 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Failure to use culturally competent and linguistically competent practices could result in the following: Member’s feelings of being insulted or treated rudely; Member’s reluctance and fear of making future contact with the Network Provider’s office; Member’s confusion and misunderstanding; Non-compliance by the Member; Member’s feelings of being uncared for, looked down upon and devalued; Parents’ resistance to seek help for their children; Unfilled prescriptions; Missed appointments; Network Provider’s misdiagnosis due to lack of information sharing; Wasted time for the Member and Network Provider; and/or Increased grievances or complaints. The road to developing a culturally competent practice begins with the recognition and acceptance of the value of meeting the needs of your patients. Cenpatico is committed to helping you reach this goal. Take the following into consideration when you provide services to Members: What are your own cultural values and identity? How do/can cultural differences impact your relationship with your patients? How much do you know about your patient’s culture and language? Does your understanding of culture take into consideration values, communication styles, spirituality, language ability, literacy, and family definitions? Facts about Health Disparities Government-funded insurance consumers face many barriers to receiving timely care. Households headed by Hispanics are more likely to report difficulty in obtaining care. Consumers are more likely to experience long wait times to see healthcare providers. African American Medicaid consumers experience longer waits in emergency departments and are more likely to leave without being seen. Consumers are less likely to receive timely prenatal care, more likely to have low birth weight babies and have higher infant and maternal mortality. Consumers that are children are less likely to receive childhood immunizations. Patient race, ethnicity, and socioeconomic status are important indicators of the effectiveness of healthcare. Health disparities come at a personal and societal price. 22 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Access and Coordination of Care Provider Access Standards Sunflower Health Plan Members may access behavioral health and substance use disorder services through several mechanisms. Members do not need a referral from their Primary Care Physician (PCP) to access covered behavioral health and covered substance use disorder services. Caregivers or medical consenters may self-refer Members for behavioral health and substance use disorder services. Cenpatico adheres to National Committee for Quality Assurance (NCQA) and State of Kansas accessibility standards for Member appointments. Network Providers must make every effort to assist Cenpatico in providing appointments within the following timeframes: Type of Care Office Wait Time Appointment Availability Not to exceed 45 minutes from the scheduled appointment time Emergent Care An assessment and/or treatment shall be provided within 3 hours for outpatientbehavioral health services, and within 1 hour from referral for an emergent concurrent utilization review screen. Urgent Care An assessment and/or treatment within 48 hours from referral for outpatient behavioral health services, and within 24 hours from referral for an urgent concurrent utilization review screen. Routine Outpatient Assessment and/or treatment within 9 working days from referral; 10 working days from previous treatment Inpatient Psychiatric An assessment and/or treatment within 5 working days from referral Discharge from Inpatient Aftercare appointments within seven (7) calendar days after hospital discharge Emergency Care Provided immediately at the nearest facility available. 23 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Post Stabilization An assessment and/or treatment within 1 hour from referral for poststabilization services (both inpatient and outpatient) in an emergency room. Substance Use Disorder Services Emergent services, for Members who are unsafe or whose condition is deteriorating, must be available immediately or Member referred to a hospital. For urgent (non-emergent) care, An assessment must be given within 24 hours of initial contact and services delivered within 24 hours from assessment. Pregnant women shall be placed in the urgent category. In routine situations, Members shall receive an assessment within 14 days of initial contact and treatment within 14 days from the assessment, without resultant deterioration in the Member’s functioning or condition. IV Drug User Members who have used IV drugs within the last 6 months and who are not considered Emergent or Urgent, shall receive treatment within 14 days of initial contact. Urgent Pregnant Substance Users IVDU Pregnant & Pregnant women are considered Urgent. This population must be assessed in 24 and offered treatment within 24 hours of the assessment. If the program lacks capacity, SAPT interim services should be offered. 24 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 “Screening" defined as the process performed by a participating community behavioral health center, to determine whether a person, under either voluntary or involuntary procedures, can be evaluated or treated, or can be both evaluated and treated, in the community or should be referred to the appropriate inpatient psychiatric hospital or state psychiatric hospital for such treatment or evaluation or for both treatment and evaluation. Urgent-already admitted to a hospital with a psych unit (24 hrs) Post stabilization-at a hospital without a psych unit (1 hr) Emergency-anywhere else (3 hours) PRTF initial (7 days) PRTF extension (7 days) PRTF emergency exception- (48 hours) If you cannot offer an appointment within these timeframes, please refer the Member to Cenpatico at 866-896-7293 so that the Member may be rescheduled with an alternative provider who can meet the access standards and Member’s needs. Network Providers shall ensure that services provided are available on a basis of twenty-four (24) hours a day, seven (7) days a week, 365 days a year as the nature of the Member’s behavioral health condition dictates. These services include all covered behavioral health services provided by Cenpatico’s Network Providers that are congruent with the Member’s treatment plan and presenting behavioral health issues. Network Providers will offer hours of operation that are no less than the hours of operation offered to commercial insurance members and shall ensure Members with disabilities are afforded access to care by ensuring physical and communication barriers do not inhibit Members from accessing services. Network Providers should call the Cenpatico Provider Relations department at 866-944-7588 if they are unable to meet these access standards on a regular basis. Please note that the repeated inability to accept new Members or meet the access standards can result in suspension and/or termination from the network. All changes in a Network Provider’s status will be considered in the re- credentialing process. 25 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Cenpatico Access Standards Cenpatico ensures network adequacy and promotes quality of care and service to Members in part, by establishing, implementing, and evaluating standards for Member geographic access to Network Provider and facility services. Cenpatico will strive to meet the following accessibility requirements: For all behavioral health services, including substance use disorder services, members will travel no more than 30 miles for urban areas, 45 miles for densely settled rural areas and 60 miles for rural and frontier areas. Exceptions to these standards will be in the western and southwestern regions of Kansas, where health care providers and services are scarce overall, and travel distance standards would default to the closest available providers or community standards. After Hours Access Standards Network Providers must have coverage for their practice twenty-four (24) hours per day, seven (7) days per week, 365 days a year. This type of coverage may include a published after hours telephone number, pager, or answering service. Members must be given instructions for what to do and whom they can call after hours; voicemail alone after hours is not acceptable. No Show Appointments A “no show” is defined as a failure to appear for a scheduled appointment without notification to the Provider with at least twenty-four (24) hours advance notice. No show appointments must be recorded in the Member record. A “no show” appointment may never be applied against a Member’s benefit maximum. Sunflower State Health Plan Members may not be charged a fee for a “no show” appointment. Network Providers may contact Cenpatico via email or telephone to inform Cenpatico about Members who do not keep appointments. Cenpatico Care Coordinators will contact the Member to reinforce the importance of attending appointments; assess and help address barriers such as transportation; and assist in rescheduling if needed. 26 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 No New Referral Periods Network Providers are required to notify Cenpatico when they are not available for appointments. Network Providers may place themselves in a “no referral” hold status for a set period of time without jeopardizing their overall network status. “No referral” is set up for Network for the following reasons: Vacation Full practice Personal leave Other personal reasons Network Providers must call or write to the Cenpatico Provider Relations department to set up a “no referral” period. The Cenpatico Provider Relations department can be reached as follows: Fax: 866-263-6521 Email: [email protected] Network Providers must have a start date and an end date indicating when they will be available again for referrals. A “no referral” period will end automatically on the set end date. Coordination between Sunflower Health Plan and Cenpatico Sunflower Health Plan and Cenpatico work together to assure quality behavioral health services, including substance use disorder services, are provided to all Members. This coordination includes participation in Quality Improvement (QI) activities for both organizations and planned focus studies conducted conjointly for physical and behavioral healthcare services. In addition, Cenpatico works to educate and assist physical health and behavioral health providers in the appropriate exchange of medical information. Behavioral health utilization reporting is prepared and provided to Sunflower Health Plan on a monthly basis and is shared with Sunflower Health Plan’s management and executive leadership quarterly. Provider performance is compared to state and national performance thresholds and benchmarks to assess for over and underutilization of services, quality of service provision, and areas for improvement. Performance on any standard that does not meet performance thresholds and/or exhibits continued poor performance will result in a corrective action plan (CAP). Cenpatico works with its Providers on CAP development and interim reporting to resolve performance issues and improve Member quality of care. 27 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Quality Improvement Cenpatico’s Quality Improvement (QI) Program is based on the principles of Continuous Performance Improvement (CPI) and utilizes the Plan, Do, Study Act (PDSA) model of CPI in the development and evaluation of quality activities. All quality activities are designed to improve the quality of care to Sunflower Health Plan Members. The QI Program is data driven and incorporates data feeds from all Cenpatico functional units, creating a culture of quality throughout the organization. The Cenpatico QI Program includes clinical, network, customer service, and service utilization and provider complaints as core business metrics. Further, the Cenpatico QI program coordinates with the Sunflower Health Plan QI program to support continuity, coordination and improved integration of Member care. Cenpatico is committed to providing quality care and clinically appropriate services for our Members. In order to meet our objectives, Network Providers must participate and adhere to our programs and guidelines. Monitoring Clinical Quality What does Cenpatico monitor? Access to care standards; Adherence to Clinical Practice Guidelines; Communication with PCPs and other behavioral health providers; Critical Incidents; Quality of Care (QOC) concerns; Member confidentiality; High-risk Member identification, management and tracking; Inpatient discharge follow-up care; Inpatient admissions, readmissions and lengths of stay; Member grievances; Provider grievances; Service utilization patterns; Provider satisfaction; and, Member satisfaction How does Cenpatico monitor quality? Cenpatico evaluates available administrative data (claims and service authorizations) along with Member and Provider surveys as methods to monitor quality. Hybrid methods (those that include administrative as well as medical record review) occur as a result of trends in critical incidents, Provider complaints and QOCs. 28 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Results of ongoing quality monitoring are communicated to Network Provider groups for technical assistance and in the development of performance improvement and Corrective Action Plan (CAPs). Trends in performance and results of CAPs are evaluated and reviewed by Cenpatico during the re- credentialing process. Network Provider Participation in the QI Process Cenpatico Providers are expected to monitor and evaluate their own compliance with performance requirements to assure the quality of care and service provided. Providers are expected to meet Cenpatico’s performance requirements and ensure Member treatment is efficient and effective by: • Cooperating with medical record reviews and reviews of telephone and appointment accessibility; • Cooperating with Cenpatico’s complaint review process; • Participating in Provider satisfaction surveys; and • Cooperating with reviews of quality of care issues and critical incident reporting. In addition, Providers are invited to participate in Cenpatico’s QI Committees and in local focus groups. Confidentiality and Release of Member Information Cenpatico abides by applicable Federal and State laws which govern the use and disclosure of behavioral health information and alcohol/ substance use disorder treatment records. Similarly, Cenpatico Network Providers are independently obligated to comply with applicable laws and shall hold confidential all Member records and agree to release them only when permitted by law, including but not limited to 42 CFR et seq., when applicable. Communication with the Primary Care Physician Sunflower Health Plan encourages primary care physicians (PCPs) to consult with their patients’ behavioral health Network Providers. In many cases the PCP has extensive knowledge about the Member's medical condition, mental status, psychosocial functioning, and family situation. Communication of this information at the point of referral or during the course of treatment is encouraged with Member consent, when required. Network Providers should communicate not only with the Member’s PCP whenever there is a behavioral health problem or treatment plan that can affect the Member’s medical condition or the treatment being rendered by the PCP, but also with other behavioral health clinicians who may also be providing service to the Member. Network Providers are encouraged to complete a health status screen, at the initial point of contact and as part of the re-assessment process for Members in treatment. Network Providers must refer Members with physical health conditions (as indicated by the screen) to their primary care provider for evaluation and treatment of the physical health condition. Cenpatico developed a PCP Communication template that may be used by Network Providers in coordination of care activities for a Member, if the Provider does not have an existing form. The form is a template that incorporates key clinical information that should be shared with each Member’s PCP. The PCP Communication template is located on our website at 29 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 www.cenpatico.com. Network Providers can identify the name and number for a Member’s PCP on the front-side of the Member ID Card. Network Providers should screen for the existence of co-occurring behavioral health and substance use disorder conditions and make appropriate referrals. Network Providers should refer Members with known or suspected untreated physical health problems or disorders to the PCP for examination and treatment. If the Members’ assigned PCP is not local (e.g. in the event of a RTC/PRTF facility) and the Member is in need of medical assistance, Sunflower Health Plan staff will be able to assist the Network Provider with linking the Member to provider closer geographically. Cenpatico requires that Network Providers report specific clinical information to the Member's PCP in order to preserve the continuity of the treatment process. With appropriate written consent, when required under State and/or Federal law, it is the Network Provider's responsibility to keep the Member's PCP abreast of the Member's treatment status and progress in a consistent and reliable manner. If the Member requests this information not be given to their PCP, the Network Provider must document this refusal in the Member’s treatment record. Such consent shall meet the requirements set forth in 42 CFR et seq., when applicable. If the Member requests this information not be given to their PCP, the Network Provider must document this refusal in the Member’s treatment record, and if possible, the reason why. The following information is valuable to include in the report to the PCP: A copy of the behavioral health intake assessment; Identified barriers to Member’s success with current treatment plan, if applicable; The results of an initial psychiatric evaluation; Current psychotropic medications, including initiation of and major changes in medication regime, within fourteen (14) days of the visit or medication order; The results of functional assessments; and Member’s functional and clinical status upon completion of treatment. Consent for Disclosure Cenpatico recognizes communication as the link that unites all the service components and a key element in any program’s success. To further this objective, Network Providers shall obtain consent from Members or their authorized representatives when required by state and/or federal law to exchange confidential information, including but not limited to the disclosures to behavioral health providers and between the behavioral health provider and the Member’s physical health provider. Anytime consent to release information is required and the Member whose information is the subject of the release refuses to provide consent for the release, the Network Provider shall document the refusal along with the reasons for declination in the medical record. Cenpatico monitors compliance by its Network Providers with medical record documentation requirements, including but not evidence of a note in a Member’s record if he/she declined to give consent for a release, and whether the Network Provider sends regular to the primary care provider (PCP) or other behavioral health providers for treatment and care coordination. 30 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Critical Incident Reporting A Critical Incident is defined as any occurrence which is not consistent with the routine operation of a Network Provider. It includes, but is not limited to: injuries to Members, a suicide/ homicide attempt by a Member while in treatment, death due to suicide/ homicide, sexual battery, medication errors, Member escape or elopement, altercations involving medical interventions or any other unusual incident that has high risk management implications. A Critical Incident Report must be completed for any Cenpatico Member by the Network Provider within twenty four (24) hours of, or notification of, such an occurrence. The Critical Incident Report Form is located on Cenpatico’s website at www.cenpatico.com/providers/forms/kansas. Submit completed Critical Incident Reports to the following address: Cenpatico Attn: Quality Improvement Department 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Fax: 866-694-3649 Abuse and Neglect Reporting Providers are required to report all incidents that may include abuse and neglect consistent with the Department of Human Services Act, the Adults with Disabilities Domestic Abuse Intervention Act and the Abused and Neglect Child Reporting Act. Reports regarding elderly Members who are over the age of 60 with domestic/community abuse will be reported to Kansas Department for Aging and Disability Services at 800-922-5330. Reports regarding elderly Members for abuse by a nursing home, hospital, home health agency, etc., abuse or neglect should call the Kansas Department of Health and Environment Bureau of Health Facilities, Phone: 800-842-0078. Reports concerning children and adults should be directed to the Kansas Protection Report Center, Phone: 800-922-5330, The Kansas Protection Report Center staffs this hotline 24 hours a day, 7 days a week, 365 days a year. Cenpatico will offer training to Providers about the signs of abuse or neglect. Member Concerns about Network Providers Members who have concerns about Cenpatico Network Providers should contact Sunflower Health Plan to register their concern. All concerns are investigated, and feedback is provided on a timely basis. It is the Network Provider’s responsibility to provide supporting documentation to Cenpatico if requested. Any validated concern will be taken into consideration when re-credentialing occurs, and can be cause for termination from Cenpatico’s Provider Network. This process is referenced in your Provider Agreement with Cenpatico. Cenpatico alerts a Network Provider through written and oral communication when a complaint has been lodged against a Provider. Cenpatico asks for the Network Provider to submit any and all documentation to support or refute the complaint as part of the complaint investigation process. Cenpatico provides documentation with the complaint resolution to the Provider. 31 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Records and Documentation Network Providers need to retain all books, records and documentation related to services rendered to Members as required by law and in a manner that facilitates audits for regulatory and contractual reviews. The Network Provider will provide Cenpatico, Sunflower Health Plan and other regulatory agencies access to these documents to assure financial solvency and healthcare delivery capability, to investigate complaints and grievances, and to meet the reporting requirements specified in the contract between Sunflower Health Plan and KanCare, subject to regulations concerning confidentiality of such information. Access to documentation must be provided upon reasonable notice for all inpatient care. This provision shall survive the termination and or non-renewal of a Provider Agreement with Cenpatico. Reporting and Metric Requirements Network Providers may be required to submit timely to Cenpatico reports or performance metrics as required by Sunflower Health Plan’s contract with KanCare, and/or Cenpatico’s requirements for NCQA accreditation. Such metrics shall include but not be limited to provider rosters by service location, average number of days to receive an emergent appointment, average number of days to receive a routine appointment, network adequacy and complaint trends. Cenpatico and Network Providers shall work together to find solutions when performance standards are not met. Record Keeping and Retention The clinical record is an important element in the delivery of quality treatment because it documents the information to provide assessment and treatment services. Sample forms are located on our website at www.cenpatico.com and Network Providers are encouraged to use for Members. As part of our ongoing Quality Improvement program, clinical records may be audited to assure the quality and consistency of Network Provider documentation, as well as the appropriateness of treatment. Before charts can be reviewed or shared with others, the Member must sign an authorization for release. Chart Audits of Member records will be evaluated in accordance with these criteria. Clinical records require documentation of all contacts concerning the Member, relevant financial and legal information, consents for release/ disclosure of information, release of information to the Member’s PCP, documentation of Member receipt of the Statement of Member’s Rights and Responsibilities, the prescribed medications with refill dates and quantities, including clear evidence of the informed consent, and any other information from other professionals and agencies. If the Network Provider is able to dispense medication, the Network Provider must conform to drug dispensing guidelines set forth in the Sunflower Health Plan drug formulary. Network Providers shall retain clinical records for Members for as long as is required by applicable law. These records shall be maintained in a secure manner, but must be retrievable upon request. 32 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Cenpatico Compliance Program The Cenpatico President/CEO and Compliance Department share responsibility and authority for carrying out the provisions of the compliance program. In collaboration with Sunflower Health Plan, Cenpatico is committed to conducting activities in an ethical manner consistent with applicable laws, contracts and regulatory requirements. The Network Providers shall cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations by Sunflower Health Plan. The Cenpatico Compliance Program includes a system for identifying and reporting waste, abuse and fraud and for safeguarding the privacy of confidential information as follows; Waste, Abuse and Fraud (WAF) System Cenpatico is committed to the detection, investigation and prosecution of waste, abuse and fraud (WAF). WAF is defined as follows: Waste – Use of healthcare benefits or dollars without a real need. For example, prescribing a medication for thirty (30) days with a refill when it is not known if the medication will be needed. Abuse – Practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the health plan program, including, but not limited to practices that result in unnecessary cost to the Health Care program for services that are not Medically Necessary, or that fail to meet professionally recognized standards for healthcare. It also includes Member practices that result in unnecessary cost to the health plan program. Fraud – An intentional deception or misrepresentation made by a person or corporation with the knowledge that the deception could result in some unauthorized benefit under the health plan program to himself, the corporation, or some other person. It also includes any act that constitutes fraud under applicable federal orsState healthcare fraud laws. Examples of Provider fraud include: lack of referrals by PCPs to specialists, improper coding, billing for services never rendered, inflating bills for services and/or goods provided, and Providers who engage in a pattern of providing and/or billing for medically unnecessary services. Examples of Member fraud include improperly obtaining prescriptions for controlled substances and card sharing. Reporting Provider or Member Waste, Abuse or Fraud If you suspect a Member (a person who receives benefits) or a Provider (e.g., doctor, counselor, etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it. 33 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Network Providers can report Providers and Members to Cenpatico by mailing or contacting Cenpatico’s Special Investigations Unit (SIU) at: Cenpatico Attn: Special Investigations Unit 7711Carondelet Ave. St. Louis, MO 63105 Phone: 866-685-8664 When reporting a Provider (e.g., doctor, dentist, counselor, etc.) please provide the following: Name, address, and phone number of Provider; Name and address of the facility (hospital, nursing home, home health agency, etc.); Type of Provider (physician, physical therapist, pharmacist, etc.); Names and phone numbers of other witnesses who can aide in the investigation; Summary of what happened Dates of events; and When reporting a Member (a person who receives benefits through Sunflower Health Plan) please provide the following: The Member’s name; The Member’s date of birth, social security number, or case number (if available); The city where the Member resides; and Specific details about the waste or abuse. To report waste, abuse or fraud, gather as much information as possible. Federal and States Laws Governing the Release of Information The release of certain information is governed by a myriad of federal and/or state laws. These laws often place restrictions on how specific types of information may be disclosed, including, but not limited to, behavioral health, alcohol/substance use disorder treatment and communicable disease records. For example, the federal Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities, such as health plans and providers, release protected health information only when permitted under the law, such as for treatment, payment and operations activities, including care management and coordination. However, a different set of federal rules place more stringent restrictions on the use and disclosure of alcohol and substance use disorder treatment records (42 CFR Part 2 or ―Part 2). These records generally may not be released without consent from the individual whose information is subject to the release. Still other laws at the state level place further restrictions on the release of certain information, such as behavioral health, communicable disease, etc. 34 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 For more information about any of these laws, refer to following: HIPAA - please visit the Centers for Medicare & Medicaid Services (CMS) website at: www.cms.hhs.gov and then select ―Regulations and Guidance and ―HIPAA – General Information‖; Part 2 regulations - please visit the Substance Abuse and Mental Health Services Administration (within the U.S. Department of Health and Human Services) at: http://www.samhsa.gov/ State laws - consult applicable statutes to determine how they may impact the release of information on patients whose care you provide. Cenpatico Network Providers are independently obligated to know, understand and comply with these laws. Cenpatico takes privacy and confidentiality seriously. We have established processes, policies and procedures to comply with HIPAA and other applicable federal and/or state confidentiality and privacy laws. Please contact the Cenpatico Privacy Officer at 512-406-7200 or in writing (refer to address below) with any questions about our privacy practices. Cenpatico Compliance Department 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Please instruct any Member to contact our Customer Services team with any questions about our privacy practices. Treatment Record Guidelines Cenpatico requires treatment records to be maintained in a manner that is current, detailed and organized and which permits effective and confidential patient care and quality review. Treatment record standards are adopted that are consistent with the National Committee for Quality Assurance. The adopted standards facilitate communication, coordination and continuity of care and promote efficient, confidential and effective treatment. Medical records must be prepared in accordance with all applicable State and Federal rules and regulations and signed by the medical professional rendering the services. Cenpatico’s minimum standards for Provider medical record keeping practices include medical record content, medical record organization, ease of retrieving medical records, and maintaining confidentiality of patient information. The following thirteen (13) elements reflect a set of commonly accepted standards for behavioral health treatment record documentation: 1. 2. Each page in the treatment record contains the patient’s name or ID number. Each record includes the patient’s address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, appropriate consent forms and guardianship information, if relevant. 35 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. All entries in the treatment record are dated and include the responsible clinician’s name, professional degree and relevant identification number, if applicable. The record is legible to someone other than the writer. Medication allergies, adverse reactions and relevant medical conditions are clearly documented and dated. If the patient has no known allergies, history of adverse reactions or relevant medical conditions, this is prominently noted. Presenting problems, along with relevant psychological and social conditions affecting the patient’s medical and psychiatric status and the results of a mental status exam, are documented. Special status situations, when present, such as imminent risk of harm, suicidal ideation or elopement potential, are prominently noted, documented and revised in compliance with written protocols. Each record indicates what medications have been prescribed, the dosages of each and the dates of initial prescription or refills. A medical and psychiatric history is documented, including previous treatment dates, Provider identification, therapeutic interventions and responses, sources of clinical data and relevant family information. For children and adolescents, past medical and psychiatric history includes prenatal and perinatal events, along with a complete developmental history (physical, psychological, social, intellectual and academic). For patients 12 and older, documentation includes past and present use of cigarettes and alcohol, as well as illicit, prescribed and over-the-counter drugs. A DSM- diagnosis is documented, consistent with the presenting problems, history, mental status examination and/or other assessment data. Treatment plans are consistent with diagnoses, have both objective, measurable goals and estimated timeframes for goal attainment or problem resolution, and include a preliminary discharge plan, if applicable. Continuity and coordination of care activities between the primary clinician, consultants, ancillary providers and health care institutions are included, as appropriate. Informed consent for medication and the patient’s understanding of the treatment plan are documented. Progress notes describe patient strengths and limitations in achieving treatment plan goals and objectives and reflect treatment interventions that are consistent with those goals and objectives. Documented interventions include continuity and coordination of care activities, as appropriate. Dates of follow-up appointments or, as applicable, discharge plans are noted. Preventative Behavioral Health Programs Cenpatico, in conjunction with Sunflower Health Plan, offers the Perinatal Depression Screening Program as a preventative behavioral health program for our Members. The Perinatal Depression Screening Program offers depression screening to Members who are pregnant via a brief, easy to answer survey, in order to identify Members who would benefit from behavioral health services. Members can complete the surveys in their PCP offices, CMHC, or submit the survey directly to Cenpatico. If completed at a Provider’s office, the Provider submits the screening to Cenpatico for scoring and analysis. Each Member who participates receives communication from Cenpatico regarding the outcome of their survey answers and resources 36 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 available to them. If a Member screens positive for depression while pregnant or after delivery, a Cenpatico clinical staff person will call to attempt to outreach and engage the Member in services and/or finding community resources. Cenpatico communicates the survey findings and outreach attempts to the Member’s medical provider as well to support coordination of care. Cenpatico appreciates your assistance in promoting this preventative behavioral health program. You can refer your Members to the program directly when you assess a Member is at risk for, or screened positive for, depression while pregnant or post-delivery. If you would like more information about the program or if you have suggestions as to how we can improve our preventative behavioral health program, please contact the Quality Improvement department at 512-406-7200. Complaints, Grievances and Appeals Member Grievances and Provider Complaints Grievances A Member grievance is defined as any Member expression of dissatisfaction about any matter other than an “adverse action”. A Provider complaint is any Provider expression of dissatisfaction about any matter other than a claims dispute. Note: Throughout this Manual, we will consider the term “grievance” to refer to both Member grievances and Provider complaints as the resolution processes are the same. Provider complaints include disputes regarding policies, procedures or any aspect of Sunflower Health Plans’ administrative functions including proposed actions. The grievance process allows the Member, or the Member’s authorized representative (Provider, family Member, etc.) acting on behalf of the Member, to file a grievance either orally or in writing within 180 calendar days of the event covering the dissatisfaction. Sunflower State Health Plan shall acknowledge receipt of each grievance in writing within 5 working days of receipt of the grievance. A Provider MAY NOT file a grievance or appeal on behalf of a Member without written consent by the Member or the Member’s representative. Any individual who makes a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Sunflower Health Plan shall ensure that the decision makers are health care professionals with the appropriate clinical expertise in treating the Member’s condition or disease. Sunflower Health Plan values its Providers and will not take punitive action against Providers who file a grievance on a Member’s behalf. To file a complaint, please call: 866-896- 7293. A Cenpatico Customer Service Representative will assist you in filing a grievance. Acknowledgement Staff receiving grievances orally will acknowledge the grievance and attempt to resolve them immediately. Staff will document the substance of the grievance. For informal grievances, defined as those received orally and resolved immediately to the satisfaction of the Member, representative or Provider, the staff will document the resolution details. Member notification of the grievance resolution shall be made in writing within two business days of the resolution. The Grievance and Appeals Coordinator (GAC) will date stamp written grievances upon initial receipt and send an acknowledgment letter, which includes a description of the grievance procedures and resolution time frames, within five business days of receipt of the written grievance. 37 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Grievance Resolution Time Frame Grievance Resolution will occur as expeditiously as the Member’s health condition requires, not toexceed thirty (30) calendar days from the date of the initial receipt of the grievance. Grievances will be resolved by the GAC, in coordination with other Sunflower State Health Plan staff as needed. In our experience, most grievances are resolved at the staff level to the satisfaction of the Member, representative or Provider filing the grievance. Expedited grievance reviews will be available for Members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 24 hours. Sunflower Health Plan may extend the resolution of a grievance by up to 14 calendar days if the Member or a Member representative requests the extension or if Sunflower Health Plan determines that there is a need for additional information and the extension is in the Member’s interest. For any extension not requested by the Member, Sunflower Health Plan will give the Member written notice of the reason for the extension within two working days of the decision to extend the timeframe. Notice of Resolution The GAC will provide written resolution to the Member, representative or Provider within 30 calendar days of receipt. The letter will include, but need not be limited to: all information considered in investigating the grievance, findings and conclusions, the deposition of the grievance, and the right to a second level review by the Grievance Appeal Committee (GAC) if the Member is not satisfied. The grievance response shall include, but not be limited to, the decision reached by Sunflower Health Plan, the reason(s) for the decision, the policies or procedures which provide the basis for the decision, and a clear explanation of any further rights available to the Member. A copy of verbal complaints logs and records of disposition or written grievances shall be retained for five years. Grievances may be submitted by written notification to: Cenpatico Attn: Quality Improvement Department 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Fax: 866-704-3063 Appeals An appeal is the request for review of a “Notice of Adverse Action”. A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a Member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Cenpatico/Sunflower Health Plan Network. The review may be requested in writing or orally within thirty (30) calendar days of receiving the Notice of Adverse Action; an oral request, must be followed up with a written, signed appeal. Requests for appeals within the standard timeframe must be resolved within fourteen (14) days of receipt of the appeal, with a fourteen (14) day extension possible if additional information is required. The legal guardian of the Member (for minors or 38 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 incapacitated adults), a representative of the minor designated in writing, or a Provider acting on behalf of the Member with the Member’s written consent, has the right to file an appeal of an action on behalf of the Member. Sunflower Health Plan shall provide written notice that the appeal has been received within three business days of its receipt, including the expected date of resolution. Members may request that Sunflower State Health Plan review the Notice of Adverse Action to verify if the right decision has been made. Cenpatico ensures that the Cenpatico decision makers on grievance and appeals were not involved in previous levels of review or decision making and are health care professionals with clinical expertise in treatment of the Member’s conditions. If a Member is receiving authorized services that are now denied and wishes to keep getting these services, an appeal must be submitted in writing within 10 calendar days of the denial letter. The request must clearly state that the Member wishes to keep getting the denied services. The Member can keep getting these services until the appeal decision is rendered. If the appeal decision upholds Sunflower Health Plan’s denial, the Member may have to pay for the services. Expedited Appeals Expedited appeals may be filed when either Sunflower Health Plan or the Member’s Provider determines that the time expended in a standard resolution could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum functioning. No punitive action will be taken against a Provider that requests an expedited resolution or supports a Member’s appeal. In instances where the Member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals. Decisions for expedited appeals are issued as expeditiously as the Member’s health condition requires, not exceeding three working days from the initial receipt of the appeal. Sunflower Health Plan may extend this timeframe by up to an additional 14 calendar days if the Member requests the extension or if Sunflower Health Plan provides evidence satisfactory to the State that a delay in rendering the decision is in the Member’s interest. For any extension not requested by the Member, Sunflower Health Plan shall provide written notice to the Member of the reason for the delay. Sunflower Health Plan shall make reasonable efforts to provide the Member with prompt verbal notice of any decisions that are not resolved wholly in favor of the Member and shall follow-up within two calendar days with a written notice of action. Written notice shall include the following information: (a) The decision reached by Sunflower Health Plan; (b) The date of decision; (c) For appeals not resolved wholly in favor of the Member, the right to request a State fair hearing and information as to how to do so; and (d) The right to request to receive benefits while the hearing is pending and how to make the request, explaining that the Member may be held liable for the cost of those services if the hearing decision upholds the Sunflower Health Plan decision; (e) Notification that in the State Fair Hearing the member may represent him/herself or use legal counsel, a relative, a friend, or a spokesperson; (f) Any other information required by Kansas Statute that relates to a managed care organization’s notice of disposition of an appeal. 39 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Grievances may be submitted verbally or in writing to: Cenpatico Grievance and Appeals Coordinator 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Phone: 866-896-7293 Fax: 866-714-7991 State Fair Hearing Process Sunflower Health Plan will include information in the Member Handbook, online and via the appeals process to Members of their right to appeal directly to the State. The Member has the right to appeal to the State at the same time they appeal to Sunflower Health Plan, after exhausting appeal rights with Sunflower Health Plan, or instead of appealing to Sunflower Health Plan. Any adverse action or appeal that is not resolved wholly in favor of the Member by Sunflower Health Plan may be appealed by the Member or the Member’s authorized representative to the State for a fair hearing. Sunflower Health Plans denial of payment for Kansas Medicaid covered services and failure to act on a request for services within required timeframes may also be appealed. Appeals must be requested in writing by the Member or the Member’s representative within 90 days of the Member’s receipt of notice of adverse action. Sunflower Health Plan shall comply with the State’s Fair hearing decision. The State’s decision in these matters shall be final and shall not be subject to appeal by Sunflower Health Plan. Reversed Appeal Resolution If Sunflower Health Plan or the State fair hearing decision reverses a decision to deny, limit, or delay services, where such services were not furnished while the appeal was pending, Sunflower Health Plan will authorize the disputed services promptly and as expeditiously as the Member’s health condition requires. Additionally, in the event that services were continued while the appeal was pending, Sunflower Health Plan will provide reimbursement for those services in accordance with the terms of the final decision rendered by the States and applicable regulations. To request a State Fair Hearing, you must file a written request with the Office of Administrative Hearings, 1020 S. Kansas Avenue, Topeka, KS 66612 within 30 days of the written notice. If KDHEDHCF mailed the notice of denial to you, K.S.A. 77- 531 allows you an additional three days to file such a request. Or the request for fair hearing can be faxed to: Office of Administrative Hearings Phone: 785-296-2433 Fax: 785-296-4848 40 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Member Rights and Responsibilities Sunflower Health Plan Member Rights and Responsibilities Sunflower Health Plan Members have the right to: 1. Respect, dignity, privacy, confidentiality and nondiscrimination; 2. 3. 4. 5. 6. Receive information on available treatment options and alternatives; Consent for or refusal of treatment and active participation in decision choices; Assistance with Medical Records in accordance with applicable federal and state laws; Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation; and, Freely exercise these rights without adversely affecting the way the Sunflower Health Plan and its Providers or the State agency treat the Member. It is the responsibility of Sunflower Health Plan Members to: 1. Provide, to the extent possible, information needed by Providers in caring for the Member; 2. Contact their Primary Care Provider (PCP) as their first point of contact when needing medical care; 3. 4. Follow appointment scheduling processes; and Follow instructions and guidelines given by Providers. In addition to the Member Rights and Responsibilities provided by Sunflower Health Plan, Cenpatico believes that members also have the following Rights and Responsibilities: Cenpatico Member Rights and Responsibilities Member Rights 1. A right to receive information about the organization, its services, its Providers and Member rights and responsibilities. 2. A right to participate with providers in making decisions about their health care. 3. A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. 4. A right to voice complaints about the organization or the care it provides. 5. A right to make recommendations regarding the organization's Member Rights and Responsibilities Policy. Member Responsibilities 1. A responsibility to supply information (to the extent possible) that the organization and its providers need in order to provide care. 2. A responsibility to follow plans and instructions for care that they have agreed to with their providers. 3. A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible. 41 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Civil Rights Cenpatico provides covered services to all eligible Members regardless of: Age, Race, Religion, Color, Disability, Sex, Sexual Orientation, National Origin, Marital Status, Arrest or Conviction Record, or Military Participation. All Medically Necessary covered services are available to all Members. All services are provided in the same manner to all Members. All persons or organizations connected with Cenpatico who refer or recommend Members for services shall do so in the same manner for all Members. Customer Service The Cenpatico Customer Service Department Cenpatico operates a toll free emergency and routine Behavioral Health Services Hotline, answered by a live voice and staffed by trained personnel, Monday through Friday 8:00 a.m. to 5:00 p.m. Central Time. After hours services are available during evenings, weekends and holidays. The after-hours service is staffed by customer service representatives with registered nurses and behavioral health clinicians available 24/7 for urgent and emergent calls. The Cenpatico Customer Service Department supports the Mission Statement in providing quality, cost-effective behavioral health services to our customers. We strive for customer satisfaction on every call by doing the right thing the first time and we show our integrity by being honest, reliable and fair. The Customer Service department’s primary focus is to facilitate the authorization of covered services for Members for treatment with a specific clinician or clinicians. The Cenpatico Customer Service department assists Network Providers with the following: Verifying Member eligibility; Verifying Member benefits; Providing authorization information; Referrals; and, Troubleshooting any issues related to eligibility, authorizations, referrals, or researching prior services. Verifying Member Enrollment Network Providers are responsible for verifying eligibility every time a Member schedules an appointment, and when they arrive for services. Network Providers should use either of the following options to verify Member enrollment: Access the Kansas Medical Assistance program (KMAP) website at https://www.kmap-state-ks.us/Public/Provider.asp or call 800-933-6593 Contact Cenpatico Customer Service at 866-896-7293 Access the Cenpatico Provider Website at www. cenpatico.com 42 Cenpatico Provider Manual www.cenpatico.com Call us toll free: 866-896-7293 Until the actual date of enrollment with Sunflower Health Plan, Cenpatico is not financially responsible for services the prospective Member receives. In addition, Cenpatico is not financially responsible for services Members receive after their coverage has been terminated. The Provider must implement a policy prior to providing non-emergency services to an adult KanCare Member that requests and inspects the adult Member’s KanCare identification card (or other documentation provided by the state agency demonstrating KanCare eligibility) and health plan membership card. If the adult Member does not produce their health plan membership card, and the Provider verifies eligibility and health plan enrollment, the Provider may provide service. Sunflower Health Plan Member ID Cards Cenpatico Provider Manual www.cenpatico.com Page 43 Call us toll free: 866-896-7293 Interpretation/Translation Services Cenpatico is committed to ensuring staff are educated, aware and sensitive to the linguistic needs and cultural differences of its Members. In order to meet this need, Cenpatico’s Customer Service team is staffed with Spanish and English bilingual personnel. Trained professional language interpreters, including those proficient in American Sign Language, can be made available face-to-face at your office. Interpreters are also available telephonically to assist Providers with discussing technical, medical, or treatment information with Members as needed. Cenpatico requests a five-day prior notification for face-to-face services. To access TDD access for Members who are hearing impaired, contact Kansas Relay Customer Service: TTY: 800-766-3777 Voice: 800-766-3777 Key Information: To access interpreter services for Sunflower Health Plan Members, contact Customer Service at 866-896-7293. NurseWise NurseWise is Cenpatico’s after-hours nurse referral line which is a bilingual care line consisting of both Customer Service Representatives and Registered Nurses who respond to inquiries from eligible individuals and their eligible dependents. Verification of eligibility for service, demographic information verification and administrative questions may be answered by NurseWise representatives. NurseWise provides after-hours phone coverage seven (7) days per week including holidays. NurseWise provides after hours assistance with the following: emergency and urgent care matters; health questions and identification and treatment of health issues; eligibility verification; notification of primary care and other Providers when warranted; coordination of appropriate transportation for health services; and questions regarding participating status of Providers. Benefit Overview Cenpatico covers all behavioral health services, including substance use disorder services, defined in the KanCare comprehensive benefit package. Services for Sunflower Health Plan Members include, but are not limited to the following; Inpatient Mental Health Hospitalization & Medical Detoxification Observation Intensive Outpatient Program (IOP) Partial Hospitalization Program (PHP) Electroconvulsive Therapy (ECT) Crisis Intervention Cenpatico Provider Manual www.cenpatico.com Page 44 Call us toll free: 866-896-7293 Outpatient Mental Health Services including medication management Community Mental Health Center services Substance Use Disorder (SUD) Services HCBS SED Waiver Services Autism Waiver Services 1915 (b) 3 Services Federally Qualified Health Center (FQHC) and Rural Health Center (RHC) behavioral health services Positive Behavioral Support (PBS) Services Screening, Brief Intervention and Referral for Treatment (SBIRT) for Alcohol and Drug Use Services For a listing of service codes and authorization requirements, please refer to the Covered Professional Services & Authorization Guidelines located in this Manual. Network Providers should refer to their Provider Agreement with Cenpatico to identify which services they are contracted and eligible to provide. Please note that all services performed must be medically necessary. Behavioral Health Covered Services & Authorization Guidelines Please note that the listing below may not fully comprise all Cenpatico KanCare covered services. Please refer to your Provider Agreement with Cenpatico to identify additional services you are contracted and eligible to provide. All services provided by non-participating providers require prior authorization. Covered diagnoses codes are generally in the ICD range of 290 through 319. V codes cannot be billed as primary diagnosis codes in most situations, but may be used as secondary diagnosis. Diagnosis code 780.99 is allowed for home and community based services (HCBS) waiver services and Screening, Brief Intervention and Referral for Treatment for Alcohol and Drug Use (SBIRT) only. Facility Behavioral Health Services Service Description Inpatient Admission – Behavioral Health Billable Provider Type(s) Billing Codes Auth Required Hospital 100, 101, 114, 124, 134, 144, 154, 204 Yes Hospital 116, 126, 136, 146, 156 Yes Inpatient admissions to an Institute for Mental Disorders (IMD) is only covered for age 21 and under or over age 65 Inpatient Admission – Substance use Disorder/Detox Cenpatico Provider Manual www.cenpatico.com Page 45 Call us toll free: 866-896-7293 Service Description Inpatient Admission – Eating Disorders Billable Provider Type(s) Billing Codes Auth Required 120, 130, 140, 150 Yes T2048 Yes Hospital Hospital 901 760, 761, 762 Yes No Hospital 905, 906 Yes Hospital 912, 913 Yes Hospital 513 No Hospital Primary diagnosis must be in the following range: 307.1 through 307.19, 307.50 through 307.59. Psychiatric Residential Hospital Treatment Facility Admission Service must be billed on a CMS-1500 claim form with the HCPCS code T2048. ECT Observation Covered up to 2 consecutive days.. Intensive Outpatient Program (IOP) Service must be billed on a CMS-1450 claim form and must include the HCPCS code H0015. Partial Hospitalization Program (PHP) Service must be billed on a CMS-1450 claim form and must include the HCPCS code H0018. Discharge Consultation Appointment Service must be billed on a CMS-1450 claim form and must include the HCPCS code 99366. Cenpatico Provider Manual www.cenpatico.com Page 46 Call us toll free: 866-896-7293 Professional Behavioral Health Services Professional services provided by a Psychiatrist or Nurse Practitioner in an inpatient setting do not require prior authorization. Only Psychiatrists and Nurse Practitioners are allowed to bill for inpatient services. Please see covered services below to determine which services are allowed in an inpatient setting. Services listed with GT modifier as allowed are also covered as telemedicine services. *Benefit table reflects the 2013 CPT coding changes in effect January 1, 2013. New codes are subject to approval or modification by the Kansas KanCare Program. Service Description Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required Psychiatric diagnostic interview – no medical services MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP 90791 Blank No MD/DO, ARNP 90792 Unlimited benefit based on medical necessity. Maximum of 1 unit per rolling 6 months without authorization. Only 1 unit per day allowed. 1 unit = 1 visit 90791 also allowed with GT modifier *90801 and 90802 have been terminated Psychiatric diagnostic interview – with medical services Blank No 90792 also allowed with GT modifier Unlimited benefit based on medical necessity. Maximum of 1 unit per rolling 6 months without authorization. Only 1 unit per day allowed. 1 unit = 1 visit *90801 and 90802 have been terminated Interactive Complexity Add-on service subject to meeting interactive complexity criteria Billable in combination with 90791, 90792, 90832, 90834, 90837, 90833, 90836, 90838, 90853 Cenpatico Provider Manual www.cenpatico.com MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP Page 47 90785 Blank No Call us toll free: 866-896-7293 Service Description Individual psychotherapy Unlimited benefit based on medical necessity. Maximum of 1 unit of 90832, 90833, 90834, 90836, 90837, 90838 per day. 1 unit = 1 visit. Amount of time spent per visit is specified by standard coding definitions. Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP 90832, 90834, 90837 Blank No MD/DO, ARNP 90833, 90836, 90838 90832, 90834, and 90837 are also allowed with GT modifier *90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828 have been terminated Individual psychotherapy with medication management – add on services Unlimited benefit. Must be billed in combination with the appropriate E&M code. Time billed represents time spent in psychotherapy separately and distinctly from time spent in medication and medical examination. Blank No 90833, 90836, and 90838 also allowed with GT modifier Maximum of 1 unit of 90832, 90833, 90834, 90836, 90837, 90838 per day. 1 unit = 1 visit. Amount of time spent per visit is specified by standard coding definitions. *90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829 have been terminated. Family psychotherapy Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit Group Psychotherapy Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit. Electroconvulsive therapy MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP MD/DO 90846, 90847, 90849 Blank No 90853 90847 also allowed with HK and GT modifier Blank No 90870 Blank Yes Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit Cenpatico Provider Manual www.cenpatico.com Page 48 Call us toll free: 866-896-7293 Service Description Psychological testing Unlimited benefit based on medical necessity. Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required MD/DO, PhD, LCP, LMLP, ARNP 96101 Blank Yes – if more than 6 hours per member lifetime Maximum of 6 units per day. 1 unit = 1 hour Psychological testing PhD, LCP, LMLP, ARNP 96102, 96103 Blank Unlimited benefit based on medical necessity. Maximum of 6 units per day. 1 unit = 1 hour Assessment of Aphasia (includes assessment of expressive/repetitive speech/language) ARNP 96105 Blank Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit Developmental testing ARNP 96110, 96111 Blank Unlimited benefit based on medical necessity. Maximum of 2 units per day. 1 unit = 1 hour Neurobehavioral status exam MD/DO, PhD, LCP, LMLP, ARNP Unlimited benefit based on medical necessity. Blank Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime Note: 6 hours is a combined count with all testing codes *96116 effective for dates of service as of 1/20/2014 and after Cenpatico Provider Manual www.cenpatico.com 96116 Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime Page 49 Call us toll free: 866-896-7293 Service Description Neuropsychological testing Unlimited benefit based on medical necessity. Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required MD/DO, PhD, LCP, LMLP, ARNP 96118 Blank Yes – if more than 6 hours per member lifetime Maximum of 6 units per day. 1 unit = 1 hour Neuropsychological testing Unlimited benefit based on medical necessity. MD/DO, PhD, LCP, LMLP, ARNP 96119, 96120 Blank Maximum of 6 units per day. 1 unit = 1 hour Health and behavioral assessment Unlimited benefit. Maximum of 1 unit per day. 1 unit = 1 visit Injection MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP 96150 Blank Note: 6 hours is a combined count with all testing codes No MD/DO, ARNP 96372 Blank No Blank Not payable with J2794 on same date of service No Unlimited benefit. Maximum of 1 unit per day. 1 unit = 1 visit Risperidone, long acting, 0.5 mg MD/DO, ARNP J2794 Not payable with 96372 on same date of service Unlimited benefit. Max of 1 per day. Must include NDC# and # of units. Office emergency care Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime ARNP 99058 Blank No Unlimited benefit. Maximum of 1 unit per day. 1 unit = 1 visit. Cenpatico Provider Manual www.cenpatico.com Page 50 Call us toll free: 866-896-7293 Service Description Office visits/Medication Management – new patient Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required MD/DO, ARNP 99201 – 99205 Blank or GT No MD/DO, ARNP 99211 – 99215 Blank or GT No MD/DO, ARNP 99221 99223, 99231 99233, 99238, 99239 9921799220, 9923499236 Blank No Blank No PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHP 99510 Blank No MD/DO, ARNP 90839, 90840 Blank No Unlimited benefit. No more than 3 units per 3 years Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. New 2013 coding replaces 90862 Office visits/ Medication Management – established patient Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. New 2013 coding replaces 90862 Hospital care Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. Observation care MD/DO, ARNP Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. Home visit Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. Crisis Psychotherapy Unlimited benefit based on medical necessity 90840 is 30 minute add-on service New CPT code for 2013, subject to modification by KanCare program Cenpatico Provider Manual www.cenpatico.com Page 51 Call us toll free: 866-896-7293 Community Mental Health Center (CMHC) Services Providers at the CMHCs shall only perform services in accordance with regulations of their licensure or certification. Community Based Services (Billing Codes H0036-HA, H2017, H2017-TJ, H2011, H2011-HK, H2011-HO, H0038 & H0038-HQ) delivered to children (under the age of 19) are interventions intended for Members with a behavioral health and/or substance use disorder diagnosis or children with significant functional impairments resulting from an identified behavioral health and/or substance use disorder diagnosis. In order to qualify for Community Based Services, a Member must have a behavioral health and/or substance use use disorder diagnosis, and/or exhibit functional impairments. Evidence of this determination of SED, SPMI, or PRE must be in the Members medical record. Community Based Services must be medically necessary as determined by Cenpatico’s Medical Necessity Criteria for Community Based Services. Service Description Psychiatric diagnostic interview – no medical services Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC 90791 Blank No 90791 also allowed with GT modifier Unlimited benefit based on medical necessity. Maximum of 1 unit per rolling 6 months. Only 1 unit per day allowed. 1 unit = 1 visit *90801 and 90802 have been terminated Psychiatric diagnostic interview – with medical services CMHC 90792 Blank No 90792 also allowed with GT modifier Unlimited benefit based on medical necessity. Maximum of 1 unit per rolling 6 month. Only 1 unit per day allowed. 1 unit = 1 visit *90801 and 90802 have been terminated Interactive Complexity CMHC 90785 Blank No Add-on service subject to meeting interactive complexity criteria Billable in combination with 90791, 90792, 90832, 90834, 90837, 90833, 90836, 90838, 90853 Cenpatico Provider Manual www.cenpatico.com Page 52 Call us toll free: 866-896-7293 Service Description Outpatient individual psychotherapy Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC 90832, 90834, 90837 Blank No Unlimited benefit based on medical necessity. Maximum of 1 unit of 90832, 90833, 90834, 90836, 90837, 90838 per day. 1 unit = 1 visit. Amount of time spent per visit is specified by standard coding definitions. 90832, 90834, and 90837 are also allowed with GT modifier *90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828 have been terminated Outpatient individual psychotherapy with medication management – add on services CMHC 90833, 90836, 90838 Unlimited benefit. Must be billed in combination with the appropriate E&M code. Time billed represents time spent in psychotherapy separately and distinctly from time spent in medication and medical examination. Blank No 90833, 90836, and 90838 also allowed with GT modifier Maximum of 1 unit of 90832, 90833, 90834, 90836, 90837, 90838 per day. 1 unit = 1 visit. Amount of time spent per visit is specified by standard coding definitions. *90805, 90807, 90809, 90811, 90813, 90815, 90817, 90819, 90822, 90824, 90827, 90829 have been terminated. Family psychotherapy CMHC 90847 Blank or GT No Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit Cenpatico Provider Manual www.cenpatico.com Page 53 Call us toll free: 866-896-7293 Service Description Family psychotherapy in the home Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC 90847 HK No CMHC 90853 Blank No CMHC 96101, 96102, 96118, 96119 Blank Yes – if more than 6 hours per member lifetime Unlimited benefit based on medical necessity. Home family therapy requirements must be completed in advance Maximum of 2 units per day. 1 unit = 1 visit. May bill 2 units per day for extended sessions (>90 minutes). Group Psychotherapy Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit. Psychological and neuropsychological testing Unlimited benefit. Maximum of 6 units per day. 1 unit = 1 hour Psychological and neuropsychological testing CMHC 96103, 96120 Blank Note: 6 hours is a combined count with all testing codes Yes – if more than 6 hours per member lifetime Unlimited benefit. CMHC 96150 Blank Note: 6 hours is a combined count with all testing codes No CMHC 96372 Blank No Maximum of 1 unit per day. 1 unit = 1 session Health and behavioral assessment Unlimited benefit. Maximum of 1 unit per day. 1 unit = 1 visit. Injection Unlimited benefit. Not payable with J2794 on same date of service Maximum of 1 unit per day. 1 unit = 1 visit. Cenpatico Provider Manual www.cenpatico.com Page 54 Call us toll free: 866-896-7293 Service Description Risperidone, long acting, 0.5 mg Billable Provider Type(s) MD/DO, ARNP Billing Codes Allowed Modifiers Auth Required J2794 Blank No Not payable with 96372 on same date of service Unlimited benefit. Max of 1 per day. Must include NDC# and # of units. Office visits/Medication Management – new patient CMHC 99201 – 99205 Blank or GT No CMHC 99211 – 99215 Blank or GT No CMHC Blank No CMHC 99221 99223, 9923199233, 99238, 99239, 99304 99310 H0036 HA, HB, HH, HJ, or HK Effective11/1/2013, CBH’s benefit for CPST (H0036) will be changing from “no auth required” to “auth required if > 48 units over 3 calendar months.” See note*. CMHC H0038 Blank, GT, or HQ Yes – if more than 1,000 units per member lifetime CMHC H2011 Blank Yes – if more than 288 units per episode Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. New 2013 coding replaces 90862 Office visits/Medication Management – established patient Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. New 2013 coding replaces 90862 Inpatient or nursing facility care/consultation Unlimited benefit. Maximum of 1 unit of any 99xxx code per day. 1 unit = 1 visit. Community psychiatric support and treatment Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Peer support Unlimited benefit. 1 unit = 15 minutes. Crisis intervention Unlimited benefit based on medical necessity. Maximum of 96 units per day. 1 unit = 15 minutes Cenpatico Provider Manual www.cenpatico.com Page 55 Call us toll free: 866-896-7293 Service Description Comprehensive community support services (consolidated FSS) Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC H2015 Blank Yes CMHC H2017 Blank, HQ, or TJ Yes – if more than 3,000 units per member lifetime CMHC T1017 Blank Yes – if more than 60 units in one calendar quarter CMHC T1023 Blank No CMHC H0032 HA No Benefit limited to 400 units per fiscal year. Maximum of 12 units per day. 1 unit = 15 minutes. Psychosocial rehabilitation, Individual or Group Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Targeted case management Unlimited benefit based on medical necessity. 1 unit = 15 minutes. State Hospital Screening Assessment Unlimited benefit based on medical necessity. 1 unit = 1 visit. Community Based Services Team (CBST) Assessment/screening Unlimited benefit based on medical necessity. 1 unit = 1 visit Note*: Effective 11/1/2013, Cenpatico Behavioral Health’s benefit for Community Psychiatric Support and Treatment (H0036) will be changing from “no authorization required” to “authorization required if more than 48 units over 3 calendar months.” Additional units (over the 48 units every 3 calendar months) would then be available based on the review and approval of an Outpatient Authorization Treatment Request. If it is determined that the Member meets medical necessity criteria for continued CPST services, past the 48 units available every three calendar months, Cenpatico will authorize additional services up to 3 months at a time. The number of units being authorized past the 48 units will be based on the Member’s individualized needs. If an OTR is not submitted, and an authorization is not obtained, claims for units beyond the 48 per three calendar months will be denied for ‘no authorization on file.’ CPST services Cenpatico Provider Manual www.cenpatico.com Page 56 Call us toll free: 866-896-7293 provided prior to 10/1/2013 will not count towards the member’s totals. This benefit will mirror processes already in place for Targeted Case Management. This decision was made after obtaining input from KDADS and is expected to bring our benefit limits in line with other expectations pertaining to KanCare benefits for behavioral health services. Positive Behavioral Support (PBS) Services Providers of PBS services will be enrolled as provider type 11 (Mental Health Provider) and (new) provider specialty 239 (Positive Behavior Support). Providers of PBS services must have successfully completed Kansas Institute for Positive Behavior Support (KIPBS) training and have received a certificate of completion and PBS Facilitator identification number. A PBS Prior authorization form can be located on the Cenpatico Website and must be submitted prior to rendering services. Services prior to 4/1/2014 must be billed to Sunflower. Service Description PBS Environmental Assessment Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required Must be PBS certified H2027 Blank Yes Must be PBS certified H2027 U3 Yes Must be PBS certified 90882 22 Yes 1 unit = 15 minutes Maximum of 120 units PBS Treatment 1 unit = 15 minutes Maximum of 240 units PBS Person-Centered Planning 1 unit = 1 hour Maximum of 40 units Screening, Brief Intervention and Referral for Treatment (SBIRT) for Alcohol and Drug Use Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels, with the goal of reducing and preventing related health consequences, disease, accidents and injuries. The goal of SBIRT is not Cenpatico Provider Manual www.cenpatico.com Page 57 Call us toll free: 866-896-7293 to identify alcohol or other drug dependent individuals. SBIRT is intended to meet the public health goal of reducing the harms of societal costs associated with risky use. Approved providers must have a certificate of completion with a score of 70% or greater from an approved SBIRT training in order to provide SBIRT services. The State of Kansas will maintain an approved SBIRT training list. Service Description Alcohol and /or drug screening Limited to 1 annual screening Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required Must be SBIRT certified H0049 Blank No Must be SBIRT certified H0050 Blank No Must be SBIRT certified 99408 Blank No Must be SBIRT certified 99409 Blank No Maximum of 1 unit. 1 unit = 1 hour Alcohol and/or drug service, brief intervention, per 15 minutes 1 Unit = 15 mins. Limited to four (4) units or one (1) hour of service per day. Limited to sixteen (16) per enrollment year or rolling 12 months based on plan type Alcohol and/or substance use disorder structured screening, and brief intervention services 15-30 minutes Limited to 1 annual screening Maximum of 1 unit. 1 unit = 15-30 minutes Intervention counts as 1 toward the 16 per enrollment year limit Alcohol and/or substance use disorder structured screening, and brief intervention services; greater than 30 minutes (Full Screen) Limited to 1 annual screening Maximum of 1 unit. 1 unit = > 30 minutes Intervention counts as 1 toward the 16 per enrollment year limit Cenpatico Provider Manual www.cenpatico.com Page 58 Call us toll free: 866-896-7293 Substance Use Disorders Services Licensed Clinical Addictions Counselors are only eligible to bill independently for places of service 11 (office) and 12 (home). Any practitioner providing and billing substance use disorder services must meet the Behavioral Sciences Review Board (BSRB) requirements for such services. Any staff performing substance use disorder services at a facility such as a Substance Abuse Treatment Facility/Substance Use Disorder Facility (SATF), a Community Mental Health Center (CMHC), or similar, may provide these services within their scope of practice. Any reference to CMHC below is intended for facilities that may hold multiple licensures within Kansas and under one of their licensures they are eligible to offer these services below. As of 1/1/2014, H0004 and H0005 no longer require prior authorization but must be entered in to the KCPC system for tracking purposes. Service Description Assessment /referral Billable Provider Type(s) CMHC, SATF, LCAC Billing Codes H0001 Allowed Modifiers Blank or GT Unlimited benefit based on medical necessity. Auth Required Yes -if more than 1 in 6 rolling months V71.09 will be accepted as a primary diagnosis. LAC must practice within a facility. Maximum of 1 unit per day. 1 unit = 1 visit. Individual counseling Unlimited benefit based on medical necessity. CMHC, SATF, LCAC H0004 Blank or GT No CMHC, SATF, LCAC H0005 Blank or GT No Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC, SATF, LCAC H0006 Blank or GT Yes LAC must practice within a facility. 1 unit = 15 minutes. Group counseling Unlimited benefit based on medical necessity. LAC must practice within a facility. 1 unit = 15 minutes. Service Description Case management Cenpatico Provider Manual www.cenpatico.com Page 59 Call us toll free: 866-896-7293 Unlimited benefit. LAC must practice within a facility. 1 unit = 15 minutes. Crisis intervention Unlimited benefit. CMHC, SATF, LCPC, LCAC H0007 Blank or GT Yes – if more than 288 units per episode SATF H0011 Blank Yes –if more than 5 days CMHC, SATF, LCAC H0015 Blank or HA Yes – if more than 45 days over 15 weeks SATF H0018 Blank Yes – if more than 14 days SATF H0019 Blank Yes – if more than 30 days CMHC, SATF (rendering practitioners must meet AAPS requirements) H0038 HF or HQ-HF Yes –if more than 1000 units LAC must practice within a facility. 1 unit = 15 minutes. Acute detoxification Unlimited benefit. 1 unit = 1 day. Intensive outpatient program (IOP) Unlimited benefit based on medical necessity. LAC must practice within a facility. Maximum of 1 unit per day.1 unit = 1 day. Intermediate (short term residential) Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 day. Reintegration (long term residential) Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 day. Peer support Unlimited benefit. 1 unit = 15 minutes. Cenpatico Provider Manual www.cenpatico.com Page 60 Call us toll free: 866-896-7293 HCBS SED Waiver Services “CMHC” in the table below represents any facility, clinic, community health center, etc. that is eligible by their licensure to conduct the SED waiver services. Service Description Parent support and training Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required CMHC S5110 Blank or TJ Yes – If more than 8 units per member lifetime CMHC T2038 Blank Yes – If more than 2 units per member lifetime CMHC S5150 Blank Yes – If more than 12 units per member lifetime CMHC H2021 Blank Yes – If more than 12 units per member lifetime CMHC S9485 Blank Yes – If more than 1 unit per member lifetime CMHC T1019 HK Yes – If more than 12 units per member lifetime Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Independent living/skills building Unlimited benefit based on medical necessity. 1 unit = 1 service. Short term respite care Benefit limited to 1,200 units per calendar year. Not covered on same day as professional resource family care. 1 unit = 15 minutes. Wrap around facilitation Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Professional resource family care Unlimited benefit based on medical necessity. Not covered on same day as short term respite care. Maximum of 1 unit per day. 1 unit = 1 day. Attendant care [1915(c)] Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Please note that the Targeted Case Management Service will continue to be provided within the Community Mental Health Center, however, authorizations for services above the stated limits for TCM must be approved by Cenpatico. Sunflower Health Plan Members who are recipients of HCBS SED Waiver services will have access to the MCO’s Care Coordination/Intensive Care Coordination program as an additional resource for the coordination of care and access to Member resources. Cenpatico Provider Manual www.cenpatico.com Page 61 Call us toll free: 866-896-7293 Upon the initiation of HCBS SED Waiver Services, the provider should submit the Member’s Interim Budget and any other supporting documentation for initial approval of continued services over the limits referenced in the SED Waiver Services Section of this Manual. Ongoing services related to the HCBS SED Waiver will be authorized based medical necessity and guidance outlined in the HCBS SED Waiver Manual. All SED waiver services are to be requested via the Outpatient Treatment Request form and faxed into Cenpatico; the plan of care is to be entered into the Lucidity System. 1915(b)(3) Services Only Members who have been determined to be part of the target population, SPMI or SED, can access 1915 (b) (3) services. Service Description Billable Provider Type(s) Attendant care Billing Codes Allowed Modifiers Auth Required CMHC T1019 HE CMHC-non hospital based or non CMHC provider 99366, 99367, 99368 Blank or GT Yes – if more than 2,000 units per member lifetime Yes – if more than 32 units per member lifetime Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Case conference Unlimited benefit based on medical necessity. Maximum of 1 unit per day. 1 unit = 1 visit. HCBS Autism Waiver Services Speech/language services for Interpersonal Communication Therapy provided under the HCBS Autism Waiver should be billed to Sunflower Health Plan for reimbursement. The STRS OTR is available on the Cenpatico website. Service Description Consultative clinical and therapeutic services Unlimited benefit based on medical necessity. Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required Autism specialist, CMHC H2015 Blank Yes – if more than 200 units per calendar year KMAPenrolled provider for parent support and T1027 Blank or HQ Yes 1 unit = 15 minutes. Parent support and training Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Cenpatico Provider Manual www.cenpatico.com Page 62 Call us toll free: 866-896-7293 Service Description Family Adjustment Counseling Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Intensive individual supports Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Respite Unlimited benefit based on medical necessity. 1 unit = 15 minutes. Billable Provider Type(s) training, CMHC KMAPenrolled provider for family adjustment counseling, CMHC KMAPenrolled provider for intensive individual supports, CMHC KMAPenrolled provider for respite care, CMHC Billing Codes Allowed Modifiers Auth Required S9482 Blank or HQ Yes H2019 Blank Yes T1005 Blank Yes Please note that members on the Autism Waiver will continue to receive their Targeted Case Management services through their Autism Specialist as well as an assigned care coordinator through Cenpatico. Sunflower Heath Plan will ensure completion of the Health Risk Assessment. Kan-be-Healthy Services Service Description Evaluation and assessment Unlimited benefit. Maximum of 1 unit per day. 1 unit = 1 visit. Service plan development Unlimited benefit. 1 unit = 15 minutes. Cenpatico Provider Manual www.cenpatico.com Billable Provider Type(s) Billing Codes Allowed Modifiers Auth Required MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHPCMHC MD/DO, ARNP, PhD, LSCSW, LCPC, LCP, LCMFT, LMLP, LMHPCMHC H0031 Blank No H0032 Blank No Page 63 Call us toll free: 866-896-7293 Federally Qualified Health Center and Rural Health Clinic Services Service Description Encounter Billable Provider Type(s) Clinic Maximum of 1 unit per day. Billing Codes Allowed Modifiers Auth Required Regular Service Codes Blank No Modifier Definitions: The modifier list below contains commonly billed modifiers. Please refer to Covered Services and Authorization Grid to identify required/accepted modifiers for each covered service. Modifier GT HA HB HF HH HJ HK HQ TJ Definition/State Use Telehealth Services Child/adolescent program Adult program Substance use disorder program Integrated behavioral health/substance use disorder program Employee assistance program Specialized behavioral health program for high-risk populations Group setting Program group, child and/or adolescent Location Definitions: The location list below contains commonly billed locations. Please refer to Covered Services and Authorization Grid to identify accepted locations for each covered service. Code 3 4 11 12 13 14 Description School Homeless shelter Provider’s office Home Assisted living facility Group home 15 Mobile unit 20 Urgent care facility 21 Inpatient hospital 22 Outpatient hospital 23 Emergency room – hospital 31 Skilled nursing facility 32 Nursing facility Cenpatico Provider Manual www.cenpatico.com Page 64 Call us toll free: 866-896-7293 33 Custodial care facility 49 Independent clinic 50 Federally qualified health center 51 Inpatient psychiatric facility 52 Psychiatric facility partial hospitalization 53 Community mental health center 54 Intermediate care facility/mentally retarded 55 Residential substance use disorder treatment center 56 Psychiatric residential treatment center 57 Non-residential substance use disorder treatment facility 61 Comprehensive inpatient rehab facility 62 Comprehensive outpatient rehab facility 71 State or local public health clinic 72 Rural health clinic 99 Other place of service Specialty Therapy and Rehabilitative Services (STRS) Cenpatico offers Sunflower Health Plan Members access to all covered, medically necessary outpatient home health, physical, occupational and speech therapy services. Prior authorization is required for outpatient home health, physical, occupational, or speech therapy services and prior authorization requests should be submitted to Cenpatico Specialty Therapy and Rehabilitative Services (STRS) using the Outpatient Treatment Request (OTR) form located at www.cenpatico.com. Cenpatico STRS Outpatient Therapies Prior Authorization Fax: 1-866-264-4452 Cenpatico STRS created and applies medical necessity criteria developed using Clinical Practice Guidelines of the physical, occupational and speech Professional Associations, as well as InterQual Criteria for both adult and pediatric guidelines. The criteria can be found on the Cenpatico website at: www.cenpatico.com. Cenpatico STRS utilizes Physical, Occupational and Speech Therapists to process Outpatient Treatment Requests. Our specialized approach allows for interaction in real time with the Provider to best meet the overall therapeutic needs of the Members. In the event that the Provider is unable to provide timely access for a Member, Cenpatico will assist in securing authorization to a Provider to meet the Member’s needs in a timely manner. For more detailed information about Specialty Therapy and Rehabilitative Services, please read the provider manual on the Sunflower Health Plan website at www.sunflowerhealthplan.com . For additional questions, please contact Cenpatico STRS at 877-644-4623. Cenpatico Provider Manual www.cenpatico.com Page 65 Call us toll free: 866-896-7293 Utilization Management The Utilization Management Program The Cenpatico Utilization Management department’s hours of operation are Monday through Friday (excluding holidays) from 8:00 a.m. to 5:00 p.m., local time. Additionally, clinical staff is available after hours if needed to discuss urgent UM issues. UM staff can be reached via our toll-free number at 866-896-7293. The Cenpatico Utilization Management team is comprised of qualified behavioral health professionals whose education, training and experience are commensurate with the Utilization Management reviews they conduct. Cenpatico is committed to compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and the Interim Final Rule and subsequent Final Ruling. Cenpatico will ensure compliance with MHPAEA requiring parity of both quantitative limits (QTLS) applied to MH/SUD benefits and non-quantitative limits (NQTLS). Cenpatico administers benefits for Substance Use Disorder (SUD) and/or behavioral health conditions as designated and approved by the State contract and Plan benefits. MHPAE does not preempt state law, unless law limits application of the act. We support access to care for individuals seeking treatment for behavioral health conditions as well as Substance Use Disorders and believe in a “no wrong door” approach. Our strategies, evidentiary standards and processes for reviewing treatment services are no more stringent than those in use for medical/surgical benefits in the same classification when determining to what extent a benefit is subject to NQTLs. The Cenpatico Utilization Management Program strives to ensure: Member care meets Medical Necessity Criteria; Treatment is specific to the Member’s condition, is effective and is provided at the least restrictive, most clinically appropriate level of care; Services provided are of high clinical quality; Utilization Management policies and procedures are systematically and consistently applied; and Focus on Member and family recovery, resiliency and hope. Cenpatico’s utilization review decisions are made in accordance with currently accepted behavioral healthcare practices, taking into account special circumstances of each case that may require deviation from the norm stated in the screening criteria. Medical Necessity Criteria are used for the review and approval of treatment. Plans of care that do not meet Medical Necessity guidelines are referred to a licensed physician advisor or psychologist for review and peer to peer discussion. Cenpatico conducts utilization management in a timely manner to minimize any disruption in the provision of behavioral healthcare services. The timeliness of decisions adheres to specific and standardized time frames yet remains sufficiently flexible to accommodate urgent situations. Utilization Management files includes the date of receipt of information and the date and time of notification and resolution. Cenpatico’s Utilization Management Department is under the direction of our licensed Medical Director. The Utilization Management Staff regularly confer with the Medical Director or physician designee on any cases where there are questions or concerns. Cenpatico Provider Manual www.cenpatico.com Page 66 Call us toll free: 866-896-7293 Member Eligibility Establishing Member eligibility for benefits and obtaining an authorization before treatment is essential for the claims payment process. It is the responsibility of the Network Provider to monitor the Member’s ongoing eligibility during the course of treatment. Network Providers should use either of the following methodologies to verify Member eligibility; Contact Cenpatico Customer Service at 866-896-7293 Access the Provider web portal at www.cenpatico.com Outpatient Notification Process Network Providers need to adhere to the Covered Professional Services & Authorization Guidelines set forth in this Manual when rendering services. Please refer to the Covered Professional Services & Authorization Guidelines to identify which services require prior authorization. Cenpatico does not retroactively authorize treatment. Please see the Covered Professional Services and Authorization Guidelines grid to get detailed information about the authorization limits. Outpatient Treatment Request (OTR)/ Requesting Additional Sessions When requesting additional sessions for those outpatient services that require authorization, the Network Provider must complete an Outpatient Treatment Request (OTR) form and fax the completed form to Cenpatico at 866-694-3649, The OTR is located on our website at www.cenpatico.com. Network Providers may call Customer Service at 866-896-7293, Network Providers should allow up to two (2) to fourteen (14) calendar days to process non-urgent requests. IMPORTANT: The OTR must be completed in its entirety. The diagnosis (es), as well as all other clinical information, must be evident. Failure to complete an OTR in its entirety can result in authorization delay and/or denials. Retro Authorization Retrospective review is an initial review of both inpatient and outpatient services provided to a Member, but for which authorization and/or timely notification to Cenpatico was not obtained. If this is due to extenuating circumstances (i.e. Member was unconscious at time of presentation, Member did not have their Medicaid card or otherwise indicated Medicaid coverage, services authorized by another payer who subsequently determined Member was not eligible at the time of service), the requests for retrospective review must be within 30 business days of the Network Provider knowing that the Member had Sunflower Health Plan coverage. For those services, both inpatient and outpatient, where the Member was given Medicaid coverage after the service occurred, the requests for retrospective review must be submitted to Cenpatico within thirty (30) business days of the Medicaid card issue date. A decision on retrospective reviews will be made within thirty (30) calendar days following receipt of the request. Cenpatico Provider Manual www.cenpatico.com Page 67 Call us toll free: 866-896-7293 Network Providers must submit their Retroactive Authorization request to: Cenpatico Attn: Appeals Department 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Fax: 866-714-7991 Retro Authorizations will only be granted in rare cases, such as eligibility issues. All requests for retro authorizations must be submitted within 180 days of the date of service and should include a cover letter explaining why authorization was not obtained. You should provide medical records that will be used to determine if medical necessity was met for the services provided. Repeated requests for Retro Authorizations will result in termination from the Cenpatico Provider Network due to inability to follow policies and procedures. Failure to submit a completed OTR can result in delayed authorization and may negatively impact your ability to meet the timely filing deadlines which will result in payment denial. Guidelines for Psychological Testing Prior authorization is required for psychological testing must be prior-authorized, for either inpatient or outpatient services. Testing, with prior- authorization, may be used to clarify questions about a diagnosis as it directly relates to treatment. It is important to note that; Testing will not be authorized by Cenpatico for ruling out a medical condition. Testing is not used to confirm previous results that are not expected to change. A comprehensive initial assessment (90791 and 90792) may be conducted by the requesting Psychologist prior to requesting authorization for testing. No authorization is required for this assessment if the provider is contracted and credentialed with Cenpatico. Network Providers should submit a request for Psychological Testing that includes the specific tests to be performed. Cenpatico’s Psychological Testing Authorization Request form is located on our website at www.cenpatico.com. Guidelines for Requesting SED Waiver Services When a Member qualifies for the SED Waiver Services the Network Provider is to submit the budget and all required components into Lucidity prior to service delivery. Network Providers must also fax the Member’s Plan of Care (POC) including signature page the same day. The number of units allowed prior to submission of the POC is outlined in the Covered Services and Authorization Guideline Grid, located within the Provider Manual. In the event that an SED Waiver Services Member was not assigned to an MCO at the time of their clinical eligibility determination, but was later assigned to Sunflower Health Plan, Cenpatico would perform a retrospective review back to the date of Medicaid eligibility. If a Member is already Cenpatico Provider Manual www.cenpatico.com Page 68 Call us toll free: 866-896-7293 assigned to Sunflower Health Plan, Cenpatico would require the Network Provider to follow the Covered Services and Authorization Guidelines Grid to determine when the request needs to be submitted. SED WAIVER PROCESSING UPDATES Member participation in treatment planning is a very important part of the treatment process. It greatly enhances treatment success because it guarantees that the Member has a voice. The ability to be heard increases the Member’s engagement in their treatment and healing process. Cenpatico and the State of Kansas expect that all Members, age 5 years and above, shall attend treatment planning sessions unless there is a mitigating reason why such Member should not be present for their Plan of Care reviews. (Reference SED Waiver Manual page 19). In order to facilitate successful treatment planning sessions, Cenpatico recommends: Meetings should take place during times and at specific locations that are convenient for the Member. Natural support systems will be identified by the facilitator and those supports will be incorporated into the meetings. If a member presents with challenging behaviors, Cenpatico suggests that the CMHC’s explore the following options in an effort to increase the Member’s participation in treatment planning meetings. These may include: Provision of natural supports Attendant care Allowing the member to attend part of the meeting to verbalize what will help them be successful in their treatment and help to individualize the goals If a member is unable to attend treatment planning after reasonable accommodations have been provided, there must be documentation on the signature line of the treatment plan and also documented in the progress notes as to why the member was unable to participate. Inability of a member to participate may include: Illness of the member Documentation that indicates participation in treatment planning would be emotionally harmful to the member. Note the risk of this should be evaluated on a continued basis to assess readiness to participate in future treatment planning. The Plan of Care (POC) update must be submitted within 2 weeks of the meeting date in order to be considered for approval of the entire timeframe. The POC should be faxed the same day that the budget is entered into Lucidity along with supporting documentation. Cenpatico will only backdate fourteen (14) calendar days. This timeframe excludes the initial plan of care which remains the same. If the budget has been entered into Lucidity and if all required documentation has been submitted timely, then backdating guidelines would not apply when there are financial eligibility issues. Cenpatico Provider Manual www.cenpatico.com Page 69 Call us toll free: 866-896-7293 Plans of Care should be completed at least every 90 days. If it is greater than ninety (90) days since the last review, a request for authorization will not be approved for days where there is no an active Plan of Care. Cenpatico does not require a signature page or Plan of Care review for SED Waiver Services if the provider is only seeking an increase in the number of units of a service. Please indicate in the note section of Lucidity what types of units are being increased (monthly, crisis, post crisis budget etc.). Also, specify the type of additional services that are being requested. This process is not to be used if there is an addition or deletion of a service as this would be a significant clinical change. Cenpatico will process the request and add the units in to the existing authorization. Guidelines for SUD Authorizations Network Providers requesting authorization for SUD services must utilize the KCPC system. The Network Provider will request the services and units via KCPC, and Cenpatico staff will review the authorization in the KCPC system. Beginning January 1, 2014, H0004 and H0005 no longer require prior authorization but must be entered in to the KCPC system for tracking. Guidelines for the Autism Waiver Services Providers who are requesting authorization for Autism Waiver Services are to request these services via the Autism Waiver Outpatient Treatment Request Form, located on the Cenpatico website. Guidelines for Inpatient Screening and Admission to PRTF Members who are in need of inpatient hospitalization are to receive an inpatient screening from the local CMHC. The Network Provider conducting the screening is to arrange the hospitalization and submit the screening to Cenpatico by the next business day. Once the Member arrives at the facility, the facility is to notify Cenpatico within 24 hours of admission. Concurrent reviews will occur with the Cenpatico Utilization Manager. The screening for inpatient hospitalization will be honored for up to five (5) days post the date of the screen. Members who are in need of PRTF placement are to receive a screening assessment from the CMHC. The CMHC will notify Cenpatico of the outcome of the screen and invite Cenpatico case management staff to participate in the CBST meeting. Screenings for PRTF placement will be honored for up to fifteen (15) days post the date of the screen. Medical Necessity Member coverage is not an entitlement to utilization of all covered benefits, but indicates services that are available when medical necessity criteria (MNC) are satisfied. Network Providers are expected to work closely with Cenpatico’s Utilization Management Department in exercising judicious use of a Member’s benefit and to carefully explain the treatment plan to the Member in accordance with the Member’s benefits offered by Sunflower Health Plan. Utilization management will review OTR’s based on MNC, and will outreach to the Provider for further clinical information as needed. Cenpatico uses InterQual Criteria for behavioral health services, both adult and pediatric guidelines. InterQual is a nationally recognized instrument that provides a consistent, evidencebased platform for care decisions and promotes appropriate use of services and improved health outcomes. Cenpatico utilizes the American Society of Addiction Medicine Patient Placement Criteria (ASAM) for substance use disorder Medical Necessity Criteria. For Substance Cenpatico Provider Manual www.cenpatico.com Page 70 Call us toll free: 866-896-7293 Use Disorder (SUD) Providers who are currently utilizing KCPC, Cenpatico will continue to utilize the KCPC system. Additionally, Cenpatico has adopted the Kansas State Medicaid Manual service descriptions and medical necessity guidelines for all community based services. ASAM and the InterQual criteria sets are proprietary and cannot be distributed in full; however, a copy of the specific criteria relevant to any individual need for authorization is available upon request. Community-Based Services criteria can be found on the Cenpatico website at: www.cenpatico.com. ASAM, InterQual and our Community Based Services criteria are reviewed on an annual basis by the Cenpatico Provider Advisory Committee that is comprised of Network Providers as well as Cenpatico clinical staff. Cenpatico is committed to the delivery of appropriate service and coverage, and offers no organizational incentives, including compensation, to any employed or contracted UM staff based on the quantity or type of utilization decisions rendered. Review decisions are based only on appropriateness of care and service criteria, and UM staff is encouraged to bring inappropriate care or service decisions to the attention of the Medical Director. Concurrent Review Cenpatico’s Utilization Management Department will concurrently review the treatment and status of all Members in inpatient (including crisis stabilization units) and partial hospitalization through contact with the Member’s attending physician or the facility’s Utilization and Discharge Planning departments. The frequency of review for all higher levels of care will be determined by the Member’s clinical condition and response to treatment. The review will include evaluation of the Member’s current status, proposed plan of care and discharge plans. Peer Clinical Review Process If the Utilization Manager is unable to certify the requested level of care based on the information provided, they will initiate the peer review process. For continued stay requests, the physician or treating provider is notified about the opportunity for a telephonic peer-to-peer review with the Peer Reviewer to discuss the plan of treatment. The Peer Reviewer initiates at least three (3) telephone contact attempts within twenty-four (24) hours prior to issuing a clinical determination. All attempts to reach the requestor are documented in the Utilization Management Record. If the time period allowed to provide the information expires without receipt of additional information, a decision is made based on the information available. When a determination is made where no peer-to-peer conversation has occurred, a Provider can request to speak with the Peer Reviewer who made the determination within one (1) business day. Providers should contact Cenpatico at 866-896-7293 to discuss UM denial decisions. The Peer Reviewer consults with qualified board certified sub-specialty psychiatrists when the Peer Reviewer determines the need, when a request is beyond his/ her scope, or when a healthcare provider submits good cause in writing. As a result of the Peer Clinical Review process, Cenpatico makes a decision to approve or deny authorization for services. Cenpatico Provider Manual www.cenpatico.com Page 71 Call us toll free: 866-896-7293 Notice of Action (Adverse Determination) When Cenpatico determines that a specific service does not meet criteria and will therefore not be authorized, Cenpatico will submit a written notice of action (or denial) notification to the treating Network Provider, Providers rendering the service(s) and the Member. The notification will include the following information/ instructions: 1. The reason(s) for the proposed action in clearly understandable language; 2. A reference to the criteria, guideline, benefit provision, or protocol used in the decision, communicated in an easy to understand summary; 3. A statement that the criteria, guideline, benefit provision, or protocol will be provided upon request; 4. Information on how the Provider may contact the Peer Reviewer to discuss decisions and proposed actions. When a determination is made where no peer-to-peer conversation has occurred, the Peer Reviewer who made the determination (or another Peer Reviewer if the original Peer Reviewer is unavailable) will be available within one (1) business day of a request by the treating Provider to discuss the determination; 5. Instructions for requesting an appeal including the right to submit written comments or documents with the appeal request; the Member’s right to appoint a representative to assist them with the appeal, and the timeframe for making the appeal decision; 6. For all urgent precertification and concurrent review clinical adverse decisions, instructions for requesting an expedited appeal; and 7. The right to have benefits continues pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services. Discharge Planning Follow up after hospitalization is one of the most important markers monitored by Cenpatico to help Members remain stable and to reduce preventable readmissions into acute levels of care. Follow up after discharge is monitored closely by the National Committee for Quality Assurance (NCQA), which has developed and maintains the Health Care Effectiveness Data Information Set (HEDIS). Even more importantly, increased compliance with this measure has been proven to minimize no-shows in outpatient treatment, thereby improving Member engagement in behavioral health services. While a Member is in an inpatient facility receiving acute care services, Cenpatico’s Utilization and Case Managers work with the facility’s treatment team to make arrangements for continued care with outpatient Network Providers. Every effort is made to collaborate with the outpatient Network Providers to assist with transition back to the community and a less restrictive environment as soon as the Member is stable. Discharge planning should be initiated on admission. Prior to discharge from an inpatient setting, an ambulatory follow-up appointment must be scheduled within seven (7) days after discharge. Cenpatico Coordination/Case Management staff will follow-up with the Member prior to this appointment to remind him/her of the appointment. If a Member does not keep his/her outpatient appointment after discharge, Network Providers should inform Cenpatico as soon as possible. Upon notification of a no-show, Cenpatico Provider Manual www.cenpatico.com Page 72 Call us toll free: 866-896-7293 Care Coordination staff will follow up with the Member and assist with rescheduling the appointment and provide resources as needed to ensure appointment compliance. Continuity of Care When Members are newly enrolled and have previously received behavioral health services, Cenpatico will authorize care as needed to minimize disruption and promote continuity of care. Cenpatico will work with non-participating Providers (those that are not contracted and credentialed in Cenpatico’s Provider Network) to continue treatment or create a transition plan to facilitate the transfer of a Member’s care to a participating Network Provider. In addition, if Cenpatico determines that a Member is in need of services that are not covered benefits, the Member will be referred to an appropriate Provider and Cenpatico will continue to coordinate care including discharge planning. Cenpatico will ensure appropriate post-discharge care when a Member transitions from a State institution, and will ensure appropriate screening, assessment and crisis intervention services are available in support of Members who are in the care and custody of the State. Clinical Practice Guidelines Cenpatico has adopted many of the clinical practice guidelines published by the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry as well as evidence-based practices for a variety of services. Clinical practice guidelines adopted include but are not limited to: Treatment of Bipolar Disorder, Treatment of Major Depressive Disorder, Treatment of Schizophrenia, and Post Traumatic Stress Disorder. Clinical practice guidelines may be accessed through our web site, www.cenpatico.com, or you may request a paper copy of the guidelines by contacting your network representative or by calling 866-8967293. Copies of our evidence based practices can be obtained in the same manner. .Cenpatico uses associated HEDIS measures for assessing Provider compliance with the Treatment of Major Depressive Disorder and Treatment of ADHD clinical practice guidelines. Cenpatico encourages Network Providers to review the full suite of Cenpatico clinical practice guidelines to support the Network Provider’s clinical treatment strategy. Advance Directives Cenpatico is committed to ensuring that Sunflower Health Plan Members know of, and are able to avail themselves of their rights to execute Advance Directives. Cenpatico is equally committed to ensuring that its Network Providers and office staff are aware of, and comply with their responsibilities under federal and State law regarding Advance Directives. Network Providers must ensure Members or Member representatives over the age of eighteen (18) years receive information on Advance Directives and are informed of their right to execute Advance Directives. Network Providers must document such information in the permanent Member medical record. Case Management Program The Cenpatico/ Sunflower Health Plan case management model uses an integrated team of registered nurses, licensed behavioral health professionals, social workers and non-clinical staff. The model is designed to help Members obtain needed services and assist them in coordination of their healthcare needs whether they are covered within the Sunflower Health Plan or Cenpatico Provider Manual www.cenpatico.com Page 73 Call us toll free: 866-896-7293 Cenpatico array of covered services, from the community, or from other non-covered venues. We recognize that multiple co-morbidities will be common among our membership. The goal of our program is to collaborate with the Member and all treating Providers to assist our Members to achieve the highest possible levels of wellness, functioning, and quality of life. The program includes a systematic approach for early identification of members’ needs through screening and assessment. In partnership with our Members, we will develop and implement an individualized care plan that is comprehensive and will incorporate the full range of needed services we identify with our Members. Our teams will engage Members to be fully participatory in their health decisions and offer education as well as support for achieving Member goals. Care plans will be shared with all treating Providers and our Care Coordinators will serve to facilitate exchange of information between Providers and with Members. Members who are eligible for the waiver programs and have either an SED TCM through the community mental health center, or a TCM through Sunflower Health Plan are eligible for this care coordination/intensive care coordination program as appropriate and the Cenpatico staff will work collaboratively with the Community TCM or the Sunflower Health Plan TCM. We look forward to hearing from you about any Sunflower Health Plan Members you think can benefit from outreach by a case management team member. To contact a case manager please call Cenpatico at 866-896-7293. Disease Management Cenpatico offers Disease Management programs to Sunflower Health Plan Members with depression to provide a coordinated approach in managing the disease and improve the health status of the Member. This is accomplished by identifying and providing the most effective and efficient resources, enhancing collaboration between medical and behavioral health providers and ongoing monitoring of outcomes of treatment. Cenpatico’s Disease Management programs are based on clinical practice guidelines and include research evidence-based practices. Multiple communication strategies are used in Disease Management programs to include written materials, telephonic outreach, and web-based information, in person outreach through MemberConnections program and case managers, and participation in community events. Claims Cenpatico Claims Department Responsibilities Cenpatico’s claims processing responsibilities are as follows: Reimburse Clean Claims (see Clean Claim section below) within the timeframes outlined by the Prompt Payment Statute. Reimburse interest on claims in accordance with the guidelines outlined in the Prompt Pay Statute. Cenpatico Provider Manual www.cenpatico.com Page 74 Call us toll free: 866-896-7293 Claims eligible for payment must meet the following requirements: The Member is effective (eligible for coverage through Sunflower Health Plan) on the date of service; The service provided is a covered service (benefit of Sunflower Health Plan) on the date of service; and Cenpatico’s prior-authorization processes were followed. Cenpatico’s reimbursement is based on clinical licensure, covered service billing codes and modifiers, and the compensation schedule set forth in the Network Provider’s Agreement with Cenpatico. Reimbursement from Cenpatico will be accepted by the Network Provider as payment in full, not including any applicable copayments or deductibles. It is the responsibility of the Network Provider to collect any applicable copayments or deductibles from the Member. CENPATICO DOES NOT ACCEPT BLACK OR COPIED FORMS. Providers need to use only original forms that meet CMS requirements. The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, the copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. Clean Claim A clean claim is a claim submitted on an approved or identified claim format (CMS-1500 or CMS-1450 [“UB-04”] or their successors or electronic equivalents) that contains all data fields required by Cenpatico and the State, for final adjudication of the claim. A clean claim has no defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment. The required data fields must be complete and accurate. A Clean Claim must also include Cenpatico’s published requirements for adjudication, such as: NPI Number, Tax Identification Number, or medical records, as appropriate. Clean Claims do not include claims submitted by or on behalf of a Provider who is under investigation for fraud or abuse, or a claim that is under review for medical necessity. Claims lacking complete information are returned to the Network Provider for completion before processing or information may be requested from the Provider on an Explanation of Benefit (EOB) form. This will cause a delay in payment. Explanation of Payment (EOP) An Explanation of Payment (EOP) is provided with each claim payment or denial. The EOP will detail each service being considered, the amount eligible for payment, copayments/ deductibles deducted from eligible amounts, and the amount reimbursed. If you have questions regarding your EOP, please contact Cenpatico’s Claims Customer Service department at 866-896-7293. Cenpatico Provider Manual www.cenpatico.com Page 75 Call us toll free: 866-896-7293 Network Provider Billing Responsibilities Please submit claims immediately after providing services. Claims must be received within one hundred and eighty (180) days of the date the service(s) are rendered. Claims submitted after this period will be denied payment for untimely filing. Claim Submission Options Network Providers are strongly encouraged to utilize our available electronic means for claim submission. Electronic claim submission results in improved processing accuracy as well as quicker claim adjudication and payment. Web Portal Claim Submission Cenpatico’s website provides an array of tools to help you manage your business needs and to access information of importance to you. The following information is available on www.cenpatico.com: Provider Directory Frequently Used Forms EDI Companion Guides Billing Manual Secure Web Portal Manual Provider Manual Managing EFT Cenpatico also offers our all Providers and their office staff the opportunity to register for our Secure Web Portal. You may register by visiting www.cenpatico.com and creating a username and password. Once registered you may begin utilizing these additional available services: Submit Professional and Institutional claims individually or as batches Submit corrected claims View and check claim status View and download payment history View and print Member eligibility Contact us securely and confidentially We are continually updating our website with the latest news and information. Be sure to bookmark www.cenpatico.com to you favorites and check back often. EDI Clearinghouses Cenpatico’s network Providers may choose to submit their claims through a clearinghouse. Cenpatico accepts EDI transactions through the following vendors: Emdeon (866-369-8805) Cenpatico’s Payor ID Number is 68068 Cenpatico Provider Manual www.cenpatico.com Page 76 Call us toll free: 866-896-7293 For further information regarding electronic submission, contact the Cenpatico EDI Department at 800-225-2573, ext. 25525 or email at [email protected] Paper Claim Submission All paper claims and encounters or claims that have been corrected for resubmission, or claims for which the Provider is requesting reconsideration should be mailed or submitted to the below address. All claims must be filed on a CMS-1500 Form or a CMS-1450 Form (“UB-04”) or their successors. KanCare Office of the Fiscal Agent P.O. Box 3571 Topeka, KS 66601-3571 Imaging Requirements for Paper Claims Cenpatico uses an imaging process for claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules: Do: Use original red claim forms Submit all claims in a 9” x 12” or larger envelope Complete forms correctly and accurately with black or blue ink only (or typewritten) Ensure typed print aligns properly within the designated boxes on the claim form Submit on a proper form; CMS-1500 or CMS-1450 (“UB04”) Whenever possible refrain from submitting hand written claims Do Not: Use red ink on claim forms Circle any data on claim forms Add extraneous information to any claim form field Use highlighter on any claim form field Submit carbon copied claim forms Submit claim forms via fax Common Claim Processing Issues It is the Network Provider’s responsibility to obtain complete information from Cenpatico and the Member and then to carefully review the CMS-1500, or its successor claim form and/or CMS1450 (“UB-04”), or its successor claim form, prior to submitting claims to Cenpatico for payment. This prevents delays in processing and reimbursement. Cenpatico Provider Manual www.cenpatico.com Page 77 Call us toll free: 866-896-7293 Some common problem areas are as follows: Failure to obtain prior-authorization Federal Tax ID number not included Provider’s NPI number not included in field 24J (CMS-1500) or field 56 (CMS-1450) Insufficient Member ID Number. Network Providers are encouraged to call Cenpatico to request the Member’s Medicaid ID prior to submitting a claim Visits or days provided exceed the number of visits or days authorized Date of service is prior to or after the authorized treatment period Network Provider is billing for unauthorized services, such as the using the wrong CPT Code Insufficient or unidentifiable description of service performed Member exceeded benefits Claim form not signed by Network Provider Multiple dates of services billed on one CMS-1500 claim form are not listed on separate claim detail lines Diagnosis code is incomplete or not specified to the highest level available – be sure to use 4th and 5th digit when applicable Hand written claims are often illegible and require manual intervention, thereby increasing the risk of error and time delay in processing claims. Services that require prior-authorization may be denied if authorization was not obtained. Cenpatico reserves the rights to deny payment for services provided that are not medically necessary. Electronic Funds Transfer and Electronic Remittance Cenpatico and PaySpan Health are in a partnership to provide an innovative web based solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). This service is provided at no cost to Providers and allows online enrollment. Using this free service, Providers can take advantage of EFTs and ERAs to settle claims electronically, without making an investment in additional software. Following a fast online enrollment, you will be able to receive ERAs and import the information directly into your Practice Management or Patient Accounting System, eliminating the need to key remittance data off of paper advices. Visit www.payspanhealth.com to enroll, or call PaySpan Health at 1-877-331-7154. Cenpatico Billing Policies Member Hold Harmless Under no circumstances is a Member to be balance billed for covered services or supplies. If the Network Provider uses an automatic billing system, bills must clearly state that they have Cenpatico Provider Manual www.cenpatico.com Page 78 Call us toll free: 866-896-7293 been filed with the insurer and that the participant is not liable for anything other than specified un-met deductible or copayments (if any). Please Note: A Network Provider’s failure to authorize the service(s) does not qualify/ allow the Network Provider to bill the Member for service(s). Sunflower Health Plan Members may not be billed for missed sessions (“No-Show”). Non-Covered Services If a Network Provider renders a non-covered service to a Member, the Network Provider may bill the Member only if he/ she has obtained written acknowledgement from the Member, prior to rendering such non-covered service, that the specific service is not a covered benefit under Sunflower Health Plan or Cenpatico, and that the Member understands they are responsible for reimbursing the Network Provider for such services. Claims Payment and Member Eligibility Cenpatico’s Network Providers are responsible for verifying Member eligibility for each referral and service provided on an ongoing basis. When Cenpatico refers a Member to a Network Provider, every effort has been made to obtain the correct eligibility information. If it is subsequently determined that the Member was not eligible at the time of service (Member was not covered under Sunflower Health Plan or benefits were exhausted), a denial of payment will occur and the reason for denial will be indicated on the Explanation of Payment (EOP) accompanying the denial. In this case, the Network Provider should bill the Member directly for services rendered while the Member was not eligible for benefits. It is the Member’s responsibility to notify the Network Provider of any changes in his/her insurance coverage and/or benefits. Coordination of Benefits Coordination of benefits will be done for all Members with two or more types of insurance coverage. The insurance plan that is primary pays its full benefits first. The primary insurance carrier’s explanation of payment (EOP) or explanation of benefits (EOB) is then sent to the secondary carrier (Cenpatico) for coordination of benefits. The EOP or EOB will explain the primary’s payment or denial process. Cenpatico will coordinate benefits for Members as the secondary payer. Claims requiring coordination of benefits must be submitted to Cenpatico within 365 calendar days from the date of disposition (final determination) of the primary payer. Claims received outside of this timeframe will be denied for untimely submission. For Medicare cross-over claims, Cenpatico shall coordinate benefits for dual eligible Members by paying the lesser amount of: Cenpatico’s allowed amount minus the Medicare payment, or the Medicare co-insurance and deductible up to Cenpatico’s allowed amount. For services that are not covered by Medicare, or other primary payer, Cenpatico will process claims as primary payer so long as other insurance information has been supplied on the claim. Cenpatico follows KMAP TPL policy. All KMAP TPL billing requirements still apply. Please refer to KMAP General TPL Payment Provider manual. Cenpatico Provider Manual www.cenpatico.com Page 79 Call us toll free: 866-896-7293 Claim Status Please do not submit duplicate bills for previously submitted services. If your Clean Claim has not been adjudicated within thirty (30) days, please call Cenpatico’s Claims Customer Service department at 866-896-7293 to determine status of the claim. To expedite your call, please have the following information available when you contact Cenpatico’s Claims Customer Service department: Member Name Member Date of Birth Member ID Number Date of Service Procedure Code Billed Amount Billed Cenpatico Authorization Number Network Provider’s Name Network Provider’s NPI Number Network Provider’s Tax Identification Number Resolving Claims Issues Claim Reconsideration If a claim discrepancy is discovered, in whole or in part, the following action may be taken: 1. Call Cenpatico Customer Service at 866-896-7293. The majority of issues regarding claims can be resolved through Customer Service. 2. When a Provider has submitted a claim and received a denial due to incorrect or missing information, a corrected claim should be submitted within 180 days from date of original EOP either electronically or on paper. If submitting a paper claim for review or reconsideration of the claims disposition, the claim must clearly be marked as RESUBMISSION along with the original claim number written at the top of the claim. Failure to mark the claim may result in the claim being denied as a duplicate. Corrected paper claim resubmissions should be sent to the following address: KanCare Office of the Fiscal Agent P.O. Box 3571 Topeka, KS 66601-3571 3. For cases where authorization has been denied because the case does not meet the necessary criteria, the Appeals Process, described in the denial letter is the appropriate means of resolution. If a claim was denied due to no authorization on file, please send a request in writing for a retro- active authorization, explaining in detail the reason for providing services without an authorization. Cenpatico contracts with physicians who are Cenpatico Provider Manual www.cenpatico.com Page 80 Call us toll free: 866-896-7293 not Network Providers to resolve claims disputes related to denial on the basis of medical necessity that remain unresolved subsequent to a Provider appeal. The physician resolving the dispute will hold the same specialty or a related specialty as the appealing Provider. Mail requests to the following address: Cenpatico Care Management 12515-8 Research Blvd. Suite 400 Austin, TX 78759 Retro authorizations will only be granted in rare cases. Repeated requests for retro authorizations will result in termination from the network due to inability to follow policies and procedures. If the authorization contains unused visits, but the end date has expired, please call Cenpatico Customer Service and ask the representative to extend the end date on your authorization. 4. If a resubmission has been processed and the Network Provider is dissatisfied with Cenpatico’s response, an appeal of this decision may be filed by writing to the address listed below. Note: Appeals must be filed in writing. Place APPEAL within the request. In order for Cenpatico to consider the appeal it must be received within 90 days of the date on the EOP which contains the service line(s) being appealed, unless otherwise stated in the Network Provider’s contract. Cenpatico Appeals PO Box 6000 Farmington, MO 63640-3809 5. Network Providers unable to resolve specific claims issues through these avenues may initiate the Payment Dispute Process. Please contact the Cenpatico Provider Relations Representative about the specific issue. Provide detailed information about efforts to resolve the payment issue. Making note of which staff spoken with will help Cenpatico assist you. Steps 1-4 should be followed prior to initiating the Payment Dispute Process. After contacting Provider Relations at the address below, the dispute will be investigated. Network Providers can contact their Cenpatico Provider Relations Specialist as follows: Telephone: 866-944-7588 Fax: 866-263-6521 Email: [email protected] National Provider Identifier (NPI) Cenpatico requires all claims be submitted with a Network Provider’s National Provider Identifier (NPI). This will be required on all electronic and paper claims. Network Providers must ensure Cenpatico has their correct NPI Number loaded in their system profile. Typically, each Network Provider’s NPI Number is captured through the credentialing process. Cenpatico Provider Manual www.cenpatico.com Page 81 Call us toll free: 866-896-7293 Applying for an NPI Providers can apply for an NPI via the web or by mail. To Register Online: To register for an NPI using the web-based process, please visit the following website www.nppes.cms.hhs.gov/NPPES Click on the link that says “If you are a healthcare provider, the NPI is your unique identifier. ”Then click on the link that says “Apply online for an NPI.” This should be the first link. Follow the instructions on the web page to complete the process. To Register By Mail To obtain an NPI paper application, please call 800-465-3203 (NPI Toll- Free). Submitting Your NPI to Cenpatico Please visit www.cenpatico.com to submit your NPI number. Network Providers may elect to contact the Cenpatico Provider Relations Representative by telephone or email to submit their NPI. Taxonomy Codes Network Providers that submit Cenpatico claims through KMAP should include their Taxonomy Code. Claims billed without a Taxonomy Code may be routed to Sunflower Health Plan and subsequently denied payment. Cenpatico Provider Manual www.cenpatico.com Page 82 Call us toll free: 866-896-7293 CMS 1500 (2/12) Claim Form Instructions Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. NOTE: Claims with missing or invalid Required (R) field information will be rejected or denied. FIELD# FIELD DESCRIPTION 1 Insurance Program Identification 1a INSURED I.D. NUMBER 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) 3 PATIENT’S BIRTH DATE / SEX 4 INSURED’S NAME 5 PATIENT'S ADDRESS (Number, Street, City, State, Zip code) Telephone (include area code) 6 PATIENT’S RELATION TO INSURED Cenpatico Provider Manual www.cenpatico.com INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL Check only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Select "D", other. The 10-digit Medicaid identification number on the Member’s CENPATICO I.D. card. Enter the patient's name as it appears on the member's Cenpatico I.D. card. Do not use nicknames. Enter the patient’s 8-digit date of (MMDDYYYY) and mark the appropriate box to indicate the patient’s sex/gender. M = male F = female Enter the patient's name as it appears on the member's Cenpatico I.D. card. Enter the patient's complete address and telephone number including area code on the appropriate line. First line – Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Second line – In the designated block, enter the city and state. Third line – Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)5551414). Note: Patient’s Telephone does not exist in the electronic 837 Professional 4010A1. Always mark to indicate self. Page 83 Not Required R R R R R C Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION 7 INSURED'S ADDRESS (Number, Street, City, State, Zip code) Telephone (include area code) 8 RESERVED FOR NUCC USE OTHER INSURED'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) 9 *OTHER INSURED’S POLICY OR GROUP NUMBER RESERVED FOR NUCC USE RESERVED FOR NUCC USE INSURANCE PLAN NAME OR PROGRAM NAME 9a 9b 9c 9d 10a, b, c 10d 11 11a 11b 11c 11d INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL Enter the patient's complete address and telephone number including area code on the appropriate line. First line – Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Second line – In the designated block, enter the city and state. Third line – Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)551414). Note: Patient’s Telephone does not exist in the electronic 837 Professional 4010A1. Please leave blank Refers to someone other than the patient. REQUIRED if patient is covered by another insurance plan. Enter the complete name of the insured. NOTE: COB claims that require attached EOBs must be submitted on paper. REQUIRED if # 9 is completed. Enter the policy of group number of the other insurance plan. Not Required Not Required C C Please leave blank Please leave blank REQUIRED if # 9 is completed. Enter the other insured’s (name of person listed in box 9) insurance plan or program name. Enter a Yes or No for each category/line (a, b, and c). Do not enter a Yes and No in the same category/line. Not Required Not Required CLAIM CODES (DESIGNATED BY NUCC) Please leave blank Not Required INSURED’S POLICY GROUP OR FECA NUMBER INSURED’S DATE OF BIRTH / SEX OTHER CLAIM ID (DESIGNATED BY NUCC) INSURANCE PLAN NAME OR PROGRAM NAME IS THERE ANOTHER HEALTH BENEFIT PLAN REQUIRED when other insurance is available. Enter the policy, group, or FECA number of the other insurance. C IS PATIENT'S CONDITION RELATED TO: Cenpatico Provider Manual www.cenpatico.com Same as field 3. R C Please leave blank Not Required Enter name of the insurance Health Plan or program. Mark Yes or No. If Yes, complete # 9a-d and #11c. Page 84 C C R Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION INSTRUCTION OR COMMENTS 12 PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE Enter “Signature on File”, “SOF”, or the actual legal signature. The Provider must have the Member’s or legal guardian’s signature on file or obtain their legal signature in this box for the release of information necessary to process and/or adjudicate the claim. 13 INSURED OR AUTHORIZED PERSON’S SIGNATURE DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (ACCIDENT) OR PREGNANCY (LMP) 14 15 REQUIRED OR CONDITIONAL Not Required. Enter the 6-digit (MMDDYY) or 8-digit (MMDDYYYY) date reflecting the first date of onset for the: Present illness Injury LMP (last menstrual period) if pregnant OTHER DATE 16 17 17a 17b DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION NAME OF REFERRING PROVIDER OR OTHER SERVICE ID number of referring PROVIDER NPI number of referring physician HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ADDITIONAL CLAIM INFORMATION (DESIGNATED FOR NUCC) OUTSIDE LAB / CHARGES 18 19 20 21 A-L DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. Cenpatico Provider Manual www.cenpatico.com Required C C Not Required Enter the name of the referring physician or professional (First name, middle initial, last name, and credentials). Required if 17 is completed. Use ZZ qualifier for Taxonomy code. Required if 17 is completed. If unable to obtain referring NPI, servicing NPI may be used. C C C Not Required Please leave blank Not Required Not Required Enter the diagnosis or condition of the patient using the appropriate release/update of ICD-9CM Volume 1 for the date of service. Diagnosis codes submitted must be a valid ICD-9 codes for the date of service and carried out to its highest digit – 4th or“5”. "E" codes are NOT acceptable as a primary diagnosis. NOTE: Claims missing or with invalid diagnosis codes will be denied for payment. Page 85 R Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION RESUBMISSION CODE / ORIGINAL REF.NO. 22 Prior authorization number 23 24A-J Gener al Inform ation 24A-G Shade d 24A Unshade d INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL For re-submissions or adjustments, enter the 12character DCN (Document Control Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with “RESUBMISSION” to avoid denials for duplicate submission. NOTE: Resubmissions may NOT currently be submitted via EDI. Enter the Cenpatico authorization or referral number. Refer to the Cenpatico Provider Manual for information on services requiring referral and/or prior authorization. C Not Required Box 24 contains 6 claim lines. Each claim line is split horizontally into shaded and un-shaded areas. Within each un-shaded area of a claim line there are 10 individual fields labeled A-J. Within each shaded area of a claim line there are 4 individual fields labeled 24A-24G, 24H, 24J and 24J. Fields 24A through 24G are a continuous field for the entry of supplemental information. Instructions are provided for shaded and un-shaded fields. The shaded area for a claim line is to accommodate the submission of supplemental information, EPSDT qualifier, Provider Medicaid Number qualifier, and Provider Medicaid Number. Shaded boxes a-g is for line item supplemental information and is a continuous line that accepts up to 61 characters. Refer to the instructions listed below and in Appendix 4 for information on how to complete. The un-shaded area of a claim line is for the entry of claim line item detail. The shaded top portion of each service claim line is used to report supplemental information for: NDC Anesthesia Start/Stop time & duration supplemental Unspecified, miscellaneous, or unlisted CPT C information and HCPC code descriptions. HIBCC or GTIN number/code. DATE(S) OF SERVICE Cenpatico Provider Manual www.cenpatico.com For detailed instructions and qualifiers refer to Appendix 4 of this manual. Enter the date the service listed in 24D was performed (MMDDYY). If there is only one date enter that date in the “From” field. The “To” field may be left blank or populated with the “From” date. If identical services (identical CPT/HCPC code(s)) were performed within a date span, enter the date span in the “From” and “To” fields. The count listed in field 24G for the service must correspond with the date span entered. Page 86 R Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION 24B Unshade d PLACE OF SERVICE 24C Unshade d EMG INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL Enter the appropriate 2-digit CMS standard place of service (POS) code. A list of current POS codes may be found on the CMS website or the following link: http://www.cms.hhs.gov/PlaceofServiceCodes/ Downloads/placeofservice.pdf Enter Y (Yes) or N (No) to indicate if the service was an emergency. R R Enter the 5-digit CPT or HCPC code and 2character modifier– - if applicable. Only one CPT or HCPC and up to 4 modifiers may be entered per claim line. Codes entered must be valid for date of service. Missing or invalid codes will be denied for payment. 24D Unshade d PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS MODIFIER Only the first modifier entered is used for pricing the claim. Failure to use modifiers in the correct position or combination with the procedure code, or invalid use of modifiers, will result in a rejected, denied, or incorrectly paid claim. R The following modifiers are recognized as modifiers that will impact the pricing of your claim. Modifiers that indicate licensure level must be placed in the first modifier position for correct pricing. 24E Unshade d DIAGNOSIS CODE 24F Unshade d CHARGES Cenpatico Provider Manual www.cenpatico.com HA HE HN HO HQ HR HT SA TF TG Enter the numeric single digit diagnosis pointer (1,2,3,4) from field 21. List the primary diagnosis for the service provided or performed first followed by any additional or related diagnosis listed in field 21 (using the single digit diagnosis pointer, not the diagnosis code.) Do not use commas between the diagnosis pointer numbers. Diagnosis codes must be valid ICD-9 codes for the date of service or the claim will be rejected/denied. Enter the charge amount for the claim line item service billed. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e. 10.00), enter 00 in the area to the right of the vertical line. Page 87 R R Call us toll free: 866-896-7293 FIELD# 24G Unshade d 24H Shade d 24H Unshade d 24I Shade d FIELD DESCRIPTION INSTRUCTION OR COMMENTS DAYS OR UNITS Enter quantity (days, visits, units). If only one service provided, enter a numeric value of 1. R EPSDT (CHCUP) Family Planning Leave Blank Not Required EPSDT (CHCUP) Family Planning ID QUALIFIER 24Ja Shade d Non-NPI PROVIDER ID# 24Jb Unshade d NPI PROVIDER ID 26 FEDERAL TAX I.D. NUMBER SSN/EIN PATIENT’S ACCOUNT NO. 27 ACCEPT ASSIGNMENT? 28 TOTAL CHARGES 25 Cenpatico Provider Manual www.cenpatico.com REQUIRED OR CONDITIONAL Enter the appropriate qualifier for EPSDT visit C Use ZZ qualifier for Taxonomy C Enter as designated below the Medicaid ID number or taxonomy code. Typical Providers: Enter the Provider taxonomy code or Medicaid Provider ID number that corresponds to the qualifier entered in 24I shaded. Use ZZ qualifier for taxonomy code. Atypical Providers: Enter the 6-digit Medicaid Provider ID number. Typical Providers ONLY: Enter the 10-character NPI ID of the provider who rendered services. Providers that are contracted with Cenpatico under a “Facility Provider Agreement” should enter the organization’s NPI number, not the NPI number of the Provider rendering the service. Enter the Provider or supplier 9-digit Federal Tax ID number and mark the box labeled EIN. Enter the Provider's billing account number. Enter an X in the YES box. Submission of a claim for reimbursement of services provided to a Medicaid recipient using Medicaid funds indicates the Provider accepts Medicaid assignment. Refer to the back of the CMS 1500 (12-90) form for the section pertaining to Medicaid Payments. Enter the total charges for all claim line items billed – claim lines 24F. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e. 10.00), enter 00 in the area to the right of the vertical line. Page 88 R R R Not Required R R Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL REQUIRED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing Cenpatico. Medicaid programs are always the payers of last resort. 29 AMOUNT PAID 30 RSVD FOR NUCC USE Please leave blank 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. Note: does not exist in the electronic 837P. REQUIRED if the location where services were rendered is different from the billing address listed in field 33. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($). If the dollar amount is a whole number (i.e. 10.00), enter 00 in the area to the right of the vertical line. C Not Required R Enter the name and physical location. (P.O. Box #’s are not acceptable here.) First line – Enter the business/facility/practice name. Second line– Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line – In the designated block, enter the city and state. Fourth line – Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Typical Providers ONLY: REQUIRED if the location where services were rendered is different from the billing address listed in field 33. 32 SERVICE FACILITY LOCATION INFORMATION 32a NPI – SERVICES RENDERED C C Enter the 10-character NPI ID of the facility where services were rendered. Cenpatico Provider Manual www.cenpatico.com Page 89 Call us toll free: 866-896-7293 FIELD# FIELD DESCRIPTION INSTRUCTION OR COMMENTS REQUIRED OR CONDITIONAL REQUIRED if the location where services were rendered is different from the billing address listed in field 33. Typical Providers Enter the 2-character qualifier ZZ followed by the taxonomy code (no spaces). Atypical Providers Enter the 2-character qualifier 1D followed by the 6-character Medicaid Provider ID number (no spaces). Enter the billing Provider’s complete name, address (include the zip + 4 code), and phone number. 32b OTHER PROVIDER ID First line – Enter the business/facility/practice name. Second line– Enter the street address. Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Third line – In the designated block, enter the city and state. Fourth line – Enter the zip code and phone number. When entering a 9-digit zip code (zip+4 code), include the hyphen. Do not use a hyphen or space as a separator within the telephone number (i.e. (803)551414). Typical Providers ONLY: REQUIRED if the location where services were rendered is different from the billing address listed in field 33. C 33 BILLING PROVIDER INFO & PH # 33a GROUP BILLING NPI 33b GROUP BILLING OTHER ID Cenpatico Provider Manual www.cenpatico.com Enter the 10-character NPI ID. Enter as designated below the Billing Group Medicaid ID number or taxonomy code. Typical Providers: Enter the Provider taxonomy code. Use ZZ qualifier. Atypical Providers: Enter the 6-digit Medicaid Provider ID number. Page 90 R R R Call us toll free: 866-896-7293 UB-04 Claim Form Instructions Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. NOTE: Claims with missing or invalid Required (R) field information will be rejected or denied. FIELD FIELD Description Required or Conditional * Instructions and Comments Line 1: Enter the complete provider name. Line 2: Enter the complete mailing address. 1 (UNLABELED FIELD) Line 3: Enter the City, State, and zip+4 code (include hyphen). NOTE: the 9-digit zip (zip + 4 code) is a requirement for paper and EDI claims. R Line 4: Enter the area code and phone number. 2 (UNLABELED FIELD) Enter the facility patient account/control number 3a PATIENT CONTROL NO. MEDICAL RECORD NUMBER Enter the facility patient medical or health record number. 3b Not Required Enter the Pay-To Name and Address. Not Required R Enter the appropriate 3-digit type of bill (TOB) code as specified by the NUBC UB-04 Uniform Billing Manual minus the leading “0” (zero). A leading “0” is not needed. Digits should be reflected as follows: 4 TYPE OF BILL 1st digit - Indicating the type of facility. R 2nd digit - Indicating the type of care 3rd digit - Indicating the billing sequence. Enter the 9-digit number assigned by the federal government for tax reporting purposes. 5 FED. TAX NO. 6 Enter begin and end or admission and discharge dates for the services billed. Inpatient STATEMENT and outpatient observation stays must be billed using the admission date and discharge R COVERS PERIOD date. Outpatient therapy, chemotherapy, laboratory, pathology, radiology and dialysis FROM/THROUGH may be billed using a date span. All other outpatient services must be billed using the actual date of service. (MMDDYY) Cenpatico Provider Manual www.cenpatico.com Page 91 R Call us toll free: 866-896-7293 FIELD 7 FIELD Description (UNLABELED FIELD) Required or Conditional * Instructions and Comments Not Not Used Required 8a – Enter the patient’s 13-digit Medicaid identification number on the member’s Sunflower I.D. card. 8 a-b PATIENT NAME Not Required 8b – Enter the patient’s last name, first name, and middle initial as it appears on the Sunflower Health Plan ID card. Use a comma or space to separate the last and first names. Titles (Mr., Mrs., etc.) should not be reported in this field. Prefix: No space should be left after the prefix of a name e.g. McKendrick. H Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. Enter the patient’s complete mailing address of the patient. Line a: Street address R R 9 a-e PATIENT ADDRESS Line b: Line c: Line d: Line e: 10 BIRTHDATE Enter the patient’s date of birth (MMDDYYYY) R 11 SEX Enter the patient's sex. Only M or F is accepted. R 12 Enter the date of admission for inpatient claims and date of service for outpatient ADMISSION DATE claims. 13 ADMISSION HOUR City State ZIP code Country Code (NOT REQUIRED) (except line 9e) Enter the time using 2-digit military time (00-23) for the time of inpatient admission or time of treatment for outpatient services. 00-12:00 midnight to 12:59 12- 12:00 noon to 12:59 01- 01:00 to 01:59 13- 01:00 to 01:59 02- 02:00 to 02:59 14- 02:00 to 02:59 03- 03:00 to 03:39 15- 03:00 to 03:59 04- 04:00 to 04:59 16- 04:00 to 04:59 05- 05:00 to 05:59 17- 05:00 to 05:59 06- 06:00 to 06:59 07- 07:00 to 07:59 08- 08:00 to 08:59 09- 09:00 to 09:59 10- 10:00 to 10:59 11- 11:00 to 11:59 R R 18- 06:00 to 06:59 19- 07:00 to 07:59 20- 08:00 to 08:59 21- 09:00 to 09:59 22- 10:00 to 10:59 23- 11:00 to 11:59 Required for inpatient admissions (TOB 11X, 118X, 21X, 41X). Enter the 1-digit code indicating the priority of the admission using one of the following codes: 14 15 1 ADMISSION TYPE 2 3 4 5 ADMISSION SOURCE Emergency Urgent C Elective Newborn Trauma Enter the 1-digit code indicating the source of the admission or outpatient service using one of the following codes: For Type of admission 1,2,3 or 5 1 2 Cenpatico Provider Manual www.cenpatico.com Physician Referral Clinic Referral Page 92 Call us toll free: 866-896-7293 FIELD FIELD Description Required or Conditional * Instructions and Comments 3 4 5 6 7 8 9 Health Maintenance Referral (HMO) Transfer from a hospital Transfer from Skilled Nursing Facility (SNF) Transfer from another healthcare facility Emergency Room Court/Law enforcement Information not available For type of admission 4 (newborn): 1 2 3 4 5 16 DISCHARGE HOUR Normal Delivery Premature Delivery Sick Baby Extramural Birth Information not available Enter the time using 2-digit military time (00-23) for the time of inpatient or outpatient discharge. Do not enter a dis charge hour if patient status is “30 – Still a patient”. 00-12:00 midnight to 12:59 12- 12:00 noon to 12:59 01- 01:00 to 01:59 13- 01:00 to 01:59 02- 02:00 to 02:59 14- 02:00 to 02:59 03- 03:00 to 03:39 15- 03:00 to 03:59 04- 04:00 to 04:59 16- 04:00 to 04:59 C 05- 05:00 to 05:59 17- 05:00 to 05:59 06- 06:00 to 06:59 07- 07:00 to 07:59 08- 08:00 to 08:59 09- 09:00 to 09:59 10- 10:00 to 10:59 11- 11:00 to 11:59 18- 06:00 to 06:59 19- 07:00 to 07:59 20- 08:00 to 08:59 21- 09:00 to 09:59 22- 10:00 to 10:59 23- 11:00 to 11:59 REQUIRED for inpatient claims. Enter the 2-digit disposition of the patient as of the “through” date for the billing period listed in field 6 using one of the following codes: 01 Routine Discharge 2 Discharged to another short-term general hospital 3 Discharged to SNF 04 Discharged to ICF 5 Discharged to another type of institution 6 Discharged to care of home health service organization 07 Left against medical advice 8 Discharged/transferred to home under care of a Home IV provider 9 Admitted as an inpatient to this hospital (only for use on Medicare outpatient hospital claims) 20 Expired or did not recover 17 Cenpatico Provider Manual www.cenpatico.com C Page 93 Call us toll free: 866-896-7293 PATIENT STATUS 30 Still patient (To be used only when the client has been in the facility for 30 consecutive days if payment is based on DRG) 40 Expired at home (hospice use only) 41 Expired in a medical facility (hospice use only) 42 Expired—place unknown (hospice use only) 43 Discharged/Transferred to a federal hospital (such as a Veteran’s Administration [VA] hospital) 50 Hospice—Home 51 Hospice—Medical Facility 61 Discharged/ Transferred within this institution to a hospital-based Medicare approved swing bed 62 Discharged/ Transferred to an Inpatient rehabilitation facility (IRF), including rehabilitation distinct part units of a hospital Cenpatico Provider Manual www.cenpatico.com Page 94 Call us toll free: 866-896-7293 FIELD FIELD Description Required or Conditional * Instructions and Comments 63 Discharged/ Transferred to a Medicare certified long-term care hospital (LTCH) 64 Discharged/ Transferred to a nursing facility certified under Medicaid but not certified under Medicare 65 Discharged/ Transferred to a Psychiatric hospital or psychiatric distinct part unit of a hospital 66 Discharged/transferred to a critical access hospital (CAH) 18-28 CONDITIO N CODES REQUIRED when applicable. Condition codes are used to identify conditions relating to the bill that may affect payer processing. Each field (18-24) allows entry of a 2-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). C For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. 29 30 31-34 a-b 35-36 a-b ACCIDENT STATE Not Required Not Required (UNLABELED FIELD) Not Used OCCURRENCE CODE and OCCURENCE DATE Occurrence Code: REQUIRED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows entry of a 2-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing C Manual. Occurrence Date: REQUIRED when applicable or when a corresponding Occurrence Code is present on the same line (31a-34a). Enter the date for the associated occurrence code in MMDDYYYY format. OCCURRENCE SPAN CODE and OCCURRENCE DATE Occurrence Span Code: REQUIRED when applicable. Occurrence codes are used to identify events relating to the bill that may affect payer processing. Each field (31-34a) allows entry of a 2-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. Cenpatico Provider Manual www.cenpatico.com Page 95 C Call us toll free: 866-896-7293 FIELD FIELD Description Required or Conditional * Instructions and Comments Occurrence Span Date: REQUIRED when applicable or when a corresponding Occurrence Span code is present on the same line (35a-36a). Enter the date for the associated occurrence code in MMDDYYYY format. 37 38 39-41 a-d (UNLABELED FIELD) REQUIRED for re-submissions or adjustments. Enter the DCN (Document Control Number) of the original claim. A resubmitted claim MUST be marked using large bold print within the body of the claim form with “RESUBMISSION” to avoid denials for duplicate submission. RESPONSIBLE PARTY NAME AND ADDRESS VALUE CODES CODES and AMOUNTS C Not Required Code: REQUIRED when applicable. Value codes are used to identify events relating to the bill that may affect payer processing. Each field (39-41) allows entry of a 2-character code. Codes should be entered in alphanumeric sequence (numbered codes precede alphanumeric codes). Up to 12 codes can be entered. All “a” fields must be completed before using “b” fields, all “b” fields before using “c” fields, and all “c” fields before using “d” fields. For a list of codes and additional instructions refer to the NUBC UB-04 Uniform Billing Manual. Amount: REQUIRED when applicable or when a Value Code is entered. Enter the dollar amount for the associated value code. Dollar amounts to the left of the vertical line should be right justified. Up to 8 characters are allowed (i.e. 199,999.99). Do not enter a dollar sign ($) or a decimal. A decimal is implied. If the dollar amount is a whole number (i.e. 10.00), enter 00 in the area to the right of the vertical line. C General Informatio SERVICE LINE n DETAIL Fields 42-47 The following UB-04 fields – 42-47: Have a total of 22 service lines for claim detail information. Fields 42, 43, 45, 47, 48 include separate instructions for the completion of lines 1-22 and line 23. 42 REV CD Line 1-22 Enter the appropriate revenue codes itemizing accommodations, services, and items furnished to the patient. Non-covered revenue codes listed in the KanCare Hospital Provider Manual will be denied. Refer to the NUBC UB-04 Uniform Billing Manual for a R complete listing of revenue codes and instructions. Enter accommodation revenue codes first followed by ancillary revenue codes. Enter codes in ascending numerical value. Cenpatico Provider Manual www.cenpatico.com Page 96 Call us toll free: 866-896-7293 FIELD FIELD Description Instructions and Comments Required or Conditional * Rev CD Enter 0001 for total charges. R DESCRIPTION Enter a brief description that corresponds to the revenue code entered in the service line of field 42. R 42 Line 23 43 Line 1-22 43 Line 23 44 PAGE OF HCPCS/RATES Enter the number of pages. Indicate the page sequence in the “PAGE” field and the total number of pages in the “OF” field. If only one claim form is submitted enter a “1” in R both fields (i.e. PAGE “1” OF “1”). REQUIRED for outpatient claims when an appropriate CPT/HCPCS code exists for the service line revenue code billed. The field allows up to 9 characters. Only one CPT/HCPC and up to two modifiers are accepted. When entering a CPT/HCPCS with a modifier(s) do not use a spaces, commas, dashes or the like between the CPT/HCPC C and modifier(s) Refer to the NUBC UB-04 Uniform Billing Manual for a complete listing of revenue codes and instructions. Please refer to the Kansas Hospital Provider Manual. 45 Line 1-22 45 Line 23 46 SERVICE DATE REQUIRED on all outpatient claims. Enter the date of service for each service line C billed. (MMDDYY) Multiple dates of service may not be combined for outpatient claims CREATION DATE Enter the date the bill was created or prepared for submission on all pages submitted. (MMDDYY) R SERVICE UNITS Enter the number of units, days, or visits for the service. A value of at least “1” must be entered. For inpatient room charges, enter the number of days for each accommodation listed. R 47 Line 1-22 47 Line 23 TOTAL CHARGES Enter the total charge for each service line. R TOTALS Enter the total charges for all service lines. R Enter the non-covered charges included in field 47 for the revenue code listed in field 42 of the service line. Do not list negative amounts. C TOTALS Enter the total non-covered charges for all service lines. C (UNLABELED FIELD) Not Used 48 NON-COVERED Line 1-22 CHARGES 48 Line 23 49 Cenpatico Provider Manual www.cenpatico.com Not Required Page 100 Call us toll free: 866-896-7293 FIELD 50 A-C 51 A-C FIELD Description PAYER Required or Conditional * Instructions and Comments Enter the name for each Payer from which reimbursement is being sought in the order of the Payer liability. Line A refers to the primary payer; B, secondary; and C, tertiary. HEALTH PLAN IDENTIFICATION NUMBER R Not Required REL. INFO REQUIRED for each line (A, B, C) completed in field 50. Release of Information Certification Indicator. Enter “Y” (yes) or “N” (no). Providers are expected to have necessary release information on file. It is expected that all released invoices contain "Y”. R 53 ASG. BEN. Enter “Y" (yes) or "N" (no) to indicate a signed form is on file authorizing payment by the payer directly to the Provider for services. R 54 PRIOR PAYMENTS Enter the amount received from the primary payer on the appropriate line when Medicaid/ Sunflower Health Plan is listed as secondary or tertiary. C 55 EST. AMOUNT DUE 56 NATIONAL PROVIDER IDENTIFIER or PROVIDER ID Required: Enter Provider’s 10-character NPI ID. R 57 OTHER PROVIDER ID a. Enter the numeric Provider Medicaid identification number assigned by the Medicaid program. b. Enter the TPI number (non -NPI number) of the billing Provider R 58 For each line (A, B, C) completed in field 50, enter the name of the person who carries INSURED'S NAME the insurance for the patient. In most cases this will be the patient’s name. Enter the name as last name, first name, middle initial. R 59 PATIENT RELATIONSHIP Not Required 60 INSURED’S UNIQUE ID 61 GROUP NAME Not Required 62 INSURANCE GROUP NO. Not Required 63 TREATMENT Enter the Prior Authorization or referral when services require pre-certification. AUTHORIZATION CODES C 52 A-C 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME Not Required REQUIRED: Enter the patient's Insurance/Medicaid ID exactly as it appears on the patient's ID card. Enter the Insurance /Medicaid ID in the order of liability listed in field 50. R Enter the 12-character Document Control Number (DCN) of the paid HEALTH claim when submitting a replacement or void on the corresponding A, B, C line reflecting Cenpatico from field 50. C Applies to claim submitted with a Type of Bill (field 4) Frequency of “7” (Replacement of Prior Claim) or Type of Bill Frequency of “8” (Void/Cancel of Prior Claim). * Please refer to reconsider/corrected claims section Cenpatico Provider Manual www.cenpatico.com Not Required Page 101 Call us toll free: 866-896-7293 FIELD FIELD Description 66 DX VERSION QUALIFIER Required or Conditional * Instructions and Comments Not Required Enter the principal/primary diagnosis or condition using the appropriate release/update of ICD-9/10-CM Volume 1& 3 for the date of service. 67 PRINCIPAL DIAGNOSIS CODE Diagnosis code submitted must be a valid ICD-9/10 code for the date of service and R carried out to its highest level of specificity– 4th or“5” digit. "E" and most “V” codes are NOT acceptable as a primary diagnosis. Please refer to the Covered Diagnosis section of this manual for more information. Note: Claims with missing or invalid diagnosis codes will be denied 67 A-Q OTHER DIAGNOSIS CODE Enter additional diagnosis or conditions that coexist at the time of admission or that develop subsequent to the admission and have an effect on the treatment or care received using the appropriate release/update of ICD-9/10-CM Volume 1& 3 for the date of service. Diagnosis codes submitted must be a valid ICD-9 codes for the date of service and C carried out to its highest level of specificity – 4th or“5” digit. "E" and most “V” codes are NOT acceptable as a primary diagnosis. Please refer to the Covered Diagnosis section of this manual for more information. Note: Claims with incomplete or invalid diagnosis codes will be denied. 68 69 (UNLABELED) ADMITTING DIAGNOSIS CODE Not Required Not Used Enter the diagnosis or condition provided at the time of admission as stated by the physician using the appropriate release/update of ICD-9/10-CM Volume 1& 3 for the date of service. Diagnosis codes submitted must be a valid ICD-9/10 codes for the date of service and R carried out to its highest level of specificity – 4th or“5” digit. "E" codes and most “V” are NOT acceptable as a primary diagnosis. Please refer to the Covered Diagnosis section of this manual for more information. Note: Claims with missing or invalid diagnosis codes will be denied. 70 PATIENT Enter the ICD-9/10-CM code that reflects the patient’s reason for visit at the time of outpatient registration. 70a requires entry, 70b-70c are conditional. Diagnosis codes submitted must be valid ICD-9/10 codes for the date of service and Cenpatico Provider Manual www.cenpatico.com Page 102 R Call us toll free: 866-896-7293 a,b,c REASON CODE FIELD FIELD Description carried out to its highest digit – 4th or“5”. "E" codes and most “V” are NOT acceptable as a primary diagnosis. Please refer to the Covered Diagnosis section of this manual for more information. Required or Conditional * Instructions and Comments Note: Claims with missing or invalid diagnosis codes will be denied 71 PPS / DRG CODE Not Required 72 a,b,c EXTERNAL CAUSE CODE Not Required 73 (UNLABELED) Not Required 74 PRINCIPAL PROCEDURE CODE / DATE REQUIRED on inpatient claims when a procedure is performed during the date span of the bill. CODE: Enter the ICD-9/10 procedure code that identifies the principal/primary procedure performed. Do not enter the decimal between the 2nd or 3rd digits of code. It C is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). REQUIRED for EDI Submissions. 74 a-e OTHER PROCEDURE CODE DATE 75 (UNLABELED) REQUIRED on inpatient claims when a procedure is performed during the date span of the bill. CODE: Enter the ICD-9 procedure code(s) that identify significant a procedure(s) performed other than the principal/primary procedure. Up to 5 ICD-9 procedure codes C may be entered. Do not enter the decimal between the 2nd or 3rd digits of code. It is implied. DATE: Enter the date the principal procedure was performed (MMDDYY). Not Required Enter the NPI and Name of the physician in charge of the patient care: NPI: Enter the attending physician 10-character NPI ID. 76 ATTENDING PHYSICIAN Taxonomy Code: Enter valid taxonomy code QUAL: Enter one of the following qualifier and ID number 0B – State License # 1G – Provider UPIN G2 – Provider Commercial # ZZ – Taxonomy Code R LAST: Enter the attending physician’s last name FIRST: Enter the attending physician’s first name. REQUIRED when a surgical procedure is performed: NPI: Enter the operating physician 10-character NPI ID. Taxonomy Code: Enter valid taxonomy code 77 OPERATING PHYSICIAN QUAL: Enter one of the following qualifier and ID number 0B – State License # 1G – Provider UPIN G2 – Provider Commercial # ZZ – Taxonomy Code C LAST: Enter the operating physician’s last name FIRST: Enter the operating physician’s first name. Cenpatico Provider Manual www.cenpatico.com Page 103 Call us toll free: 866-896-7293 78 & 79 OTHER PHYSICIAN Enter the Provider Type qualifier, NPI, and Name of the physician in charge of the patient care: (Blank Field): Enter one of the following Provider Type Qualifiers: DN – Referring Provider C ZZ – Other Operating MD Cenpatico Provider Manual www.cenpatico.com Page 104 Call us toll free: 866-896-7293 FIELD FIELD Description Required or Conditional * Instructions and Comments 82 – Rendering Provider NPI: Enter the other physician 10-character NPI ID. QUAL: Enter one of the following qualifier and ID number 0B – State License # 1G – Provider UPIN G2 – Provider Commercial # LAST: Enter the other physician’s last name. FIRST: Enter the other physician’s first name. 80 Not REMARKS Required 81 CC A: Taxonomy of billing Provider. Use ZZ qualifier Cenpatico Provider Manual www.cenpatico.com Page 105 C Call us toll free: 866-896-7293
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