ADVICARE A Managed Care Organization for the Entire Family Provider Manual 2013-2014 Table of Contents INTRODUCTION AND WELCOME TO ADVICARE .......................................................................... 1 ADVICARE VALUES ....................................................................................................................... 1 ADVICARE COMMITTMENT .......................................................................................................... 1 ADVICARE AT A GLANCE ............................................................................................................. 2 II. ID CARD AND ELIGIBILITY ................................................................................................................ 3 NEW MEMBER INFORMATION ............................................................................................................. 3 ELIGIBILITY VERIFICATION .................................................................................................................. 3 MEMBER IDENTIFICATION CARD ............................................................................................... 4 VISIT PROCEDURES ..................................................................................................................... 4 III. PROVIDER RESPONSIBILITIES .................................................................................................... 4-5 PRIMARY CARE PROVIDER (PCP) ............................................................................................... 5 PANEL LIST .................................................................................................................................... 6 PCP ASSIGNMENT ........................................................................................................................ 6 PCP AVAILABILITY ......................................................................................................................... 6 PCP ACCESSIBILITY 6 MEMBER STATUS CHANGE ......................................................................................................... 7 24-HOUR ACCESS ......................................................................................................................... 7 APPOINTMENT ACCESS STANDARDS ........................................................................................ 7 OFFICE WAIT TIMES ...................................................................................................................... 7 LABORATORY SERVICES ............................................................................................................. 7 IN OFFICE LAB PROCEDURES..................................................................................................... 7 HOSPITAL ADMITTING PRIVILEGES ............................................................................................ 8 IV. REFERRAL AND AUTHORIZATIONS .............................................................................................. 8 REFERRAL GUIDELINES ............................................................................................................... 8 AFTER HOURS AND EMERGENCY CARE ................................................................................... 8 AUTHORIZATION GUIDELINES ..................................................................................................... 8 UTILIZATION MANAGEMENT INPATIENT .................................................................................... 9 CONCURRENT REVIEW…………………………………………………………………………………..9 SECOND OPIONIONS…………………………………………………………………………………......9 DISCHARGE PLANNING………………………………………………………………………………….10 AUTHORIZATION GRID…..……………………………………………........................................ 11-13 UTILIZATION MANAGEMENT INPATIENT………………………………………………………….....13 REFERRALS INTO THE WOMEN, INFANT AND CHILDRENS (WIC) PROGRAM ..................... 14 OBSTETRICAL REGISTRATION ................................................................................................. 14 PROVIDER TERMINATION .......................................................................................................... 14 V. MEDICAL RECORDS ...................................................................................................................... 15 REQUIRED INFORMATION ..................................................................................................... 15-16 MEDICAL RECORDS RELEASE .................................................................................................. 16 MEDICAL RECORDS TRANSFER FOR NEW MEMBERS .......................................................... 16 VI. ADVICARE CASE AND DISEASE MANAGEMENT SERVICES .................................................. 17 CASE MANAGEMENT INTRODUCTION...................................................................................... 17 SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT)………........17 CASE MANAGEMENT PROGRAM............................................................................................... 18 COMPONENTS OF CASE MANAGEMENT ................................................................................. 18 DISEASE MANAGEMENT INTRODUCTION ................................................................................ 18 DISEASE MANAGEMENT STATES ............................................................................................. 18 DISEASE MANAGEMENT PROGRAM .................................................................................... 19-20 CASE AND DISEASE MANAGEMENT PROCESS ................................................................. 20-21 PREVENTIVE AND CLINICAL PRACTICE GUIDELINES ............................................................ 21 VII. ROUTINE, URGENT AND EMERGENCY SERVICES ................................................................... 21 ROUTINE, URGENT AND EMERGENCY CARE SERVICES DEFINED ................................. 21-22 ELIGIBILITY AND ENROLLMENT ................................................................................................. 22 VIII. Advicare Provider Manual 2013-2014 V.1 I. IX. X. XI. XII. XIII. XIV. XV. XVI. ELIGIBILITY FOR THE ADVICARE PROGRAM ..................................................................... 22-23 VERIFYING ELIGIBILITY .............................................................................................................. 22 ENROLLMENT/MARKETING GUIDELINES FOR ADVICARE PROVIDERS .............................. 23 NON-COMPLIANT MEMBERS .................................................................................................. 23-24 NURSE RESPONSE® ................................................................................................................... 24 NON-EMERGENCY TRANSPORTATION SERVICES ................................................................. 24 EPSDT ............................................................................................................................................ 25 SOUTH CAROLINA EPSDT SERVICES AND STANDARDS .................................................. 25-26 IMMUNIZATIONS .......................................................................................................................... 27 BLOOD LEAD SCREENING ......................................................................................................... 27 BILLING AND CLAIMS ............................................................................................................. 27-30 GENERAL BILLING GUIDELINES ................................................................................................ 27 CLAIM FILING GUIDELINES ........................................................................................................ 28 BILLING A MEDICAID ADVICARE MEMBER .............................................................................. 29 MAILING ADDRESSES ................................................................................................................. 29 TIMELY FILING ............................................................................................................................. 29 ELECTRONIC FUNDS TRANSFER (EFT) ................................................................................... 29 QUALITY IMPROVEMENT .............................................................................................................. 30 QUALITY IMPROVEMENT PROGRAM ........................................................................................ 30 QUALITY IMPROVEMENT PROGRAM STRUCTURE ................................................................. 30 QUALITY IMPROVEMENT PROGRAM GOALS AND OBJECTIVES........................................... 31 QUALITY IMPROVEMENT PROGRAM SCOPE ..................................................................... 31-32 PRACTITIONER INVOLVEMENT ................................................................................................. 32 HEALTH CARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) ........................... 32 CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) SURVEY........ 33 PROVIDER SATISFACTION SURVEY ......................................................................................... 33 AUTHORITY AND RESPONSIBILITY ........................................................................................... 34 Provider Initiated Grievance………………………………………………………………………………34 MEMBER SERVICES ...................................................................................................................... 35 MEMBER SERVICES .................................................................................................................... 35 MEMBER MATERIALS .................................................................................................................. 35 MEMBER RIGHTS & RESPONSIBILITIES .............................................................................. 36-37 CORE BENEFITS .......................................................................................................................... 38 CO-PAYMENTS............................................................................................................................. 38 SERVICES COVERED BY ADVICARE ................................................................................... 39-42 SERVICES COVERED BY MEDICAID FEE FOR SERVICE .................................................. 43-46 MEMBER GRIEVANCES .............................................................................................................. 46 APPEALS....................................................................................................................................... 47 EXPEDITED RESOLUTION OF APPEALS ................................................................................... 47 CONTINUATION OF BENEFITS .............................................................................................. 47-48 ASSISTANCE AND CONTACTING ADVICARE ........................................................................... 48 MEMBERS RIGHT TO STATE FAIR HEARING ........................................................................... 48 INTERPRETER/TRANSLATION SERVICES ................................................................................ 48 PROVIDER RELATIONS ASSISTANCE ........................................................................................ 49 PROVIDER RELATIONS AND CONTRACTING DEPARTMENTS .............................................. 49 PROVIDER RIGHTS ...................................................................................................................... 50 CREDENTIALING AND RECREDENTIALING ............................................................................... 51 ANNUAL REVIEWS ....................................................................................................................... 52 PROVIDER SANCTIONS .............................................................................................................. 52 PHARMACY .................................................................................................................................... 52 COVERED PHARMACY SERVICES ............................................................................................ 52 DEFINITIONS ........................................................................................................................... 53-54 FORMS AND OTHER KEY INFORMATION .............................................................................. 55-70 Advicare Provider Manual 2013-2014 V.1 I. INTRODUCTION AND WELCOME TO ADVICARE Advicare, Corp. (Advicare) is pleased to welcome you to its participating provider network. Advicare is a Managed Care Organization (MCO) contracted with the South Carolina Department of Health and Human Services (SCDHHS) to serve Medicaid members. At Advicare our sole mission is to improve the health care status of the Medicaid population in the state of South Carolina. We believe this under-served population is entitled to the same quality health care as the commercially-insured population, but requires a focused approach that is specifically designed to meet their unique needs. It is the policy of Advicare to conduct its business affairs in accordance with the standards and rules of ethical business conduct and to abide by all applicable federal and state laws. Advicare takes the privacy and confidentiality of our members’ health information seriously. We have processes, policies and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state privacy law requirements. ADVICARE VALUES Relationships Members are the reason we are in the business of health care in a partnership with providers, government officials & leaders and community based stakeholders/organizations. Providers, government officials & leaders and community based stakeholders/organizations are our partners in the service to our members. Respect All associates must act in good faith and show consistent levels of respect and demonstrate a high level of integrity that earns the trust of internal and external customers. Responsibility All associates must act in good faith and be responsible for the commitments made to members, providers, government officials & leaders, community based stakeholders/organizations and fellow associates. Results We must produce positive results and get things done for our members, providers, government officials & leaders and community and community based stakeholders/organizations. ADVICARE COMMITTMENT • • • • • • Serve and support the South Carolina Medicaid eligible population Meet the health care needs of our members Empower our members through education and member-focused services Effectively integrate managed care administration and health care services Support doctor/patient relationships by fostering strong provider relationships Abide by all ethical standards and demonstrate integrity and quality in all business practices 1 ADVICARE AT A GLANCE For your ease, we have included this reference guide to assist you in the day-to-day operations of your office. Contact Physical Address Advicare Advicare, Inc. 531 S ou th Main Street, Suite RL-1 Greenville, SC 29601 Mailing Address Advicare, Inc. 531 South Main Street, Suite RL-1 Greenville, SC 29601 Phone Numbers (toll free) (888) 781-4371 (Provider/Member Services) Provider Relations (toll free) (888) 781-4371 24-hour Nurse Line (toll free) (888) 781-4371 Claims Inquiries Claims Address (toll free) (888) 781-4371, Fax (646) 417-5836 Advicare PO Box 5547 Hauppauge, NY 11788 EMDEON: PAYOR ID 45423 Website Address Contracting Medical Management (Authorizations) Transportation ( www.Advicarehealth.com (toll free) (888) 781-4371 (toll free) (888) 781-4371 or (855) 303-2427 Fax Region 1: 866-910-7688 Region 2: 866-445-6860 Region 3: 866-445-9954 TTY: 866-288-3133 2 II. ID Cards and Eligibility New Member Information Advicare members are sent a New Member Packet that includes helpful guidelines and instructions on how to access their health benefits. This packet includes: • • • • • • • • • • • Welcome Letter Member Handbook Evidence of Coverage which details: After hours care Appropriate use of the Emergency Room Benefits Summary How to make appointments Specialist Information Primary Care Physician Information Member Identification Card Health Education Materials Eligibility Verification Each new member enrolled in Advicare will receive an individual member identification card. It is important to remember that a member’s eligibility could change on a month-to-month basis. Consequently, you should verify your patient’s eligibility each time they present for services. Participating primary care physicians (PCPs) can verify eligibility through the monthly enrollment listing. Other providers may call for verification of eligibility. For eligibility verification for Advicare members, call Member Services at (888) 781-4371 (toll free). 3 Member Identification Card Patients should be asked to present their Member ID card at each visit. Remember that possession of an ID card does not guarantee eligibility for benefits coverage or payment. The ID card includes valuable information, as displayed below: Medicaid Plan Name: [member name] Medicaid ID: [State Medicaid #] Plan ID: [AVC plan ID#] Eff Date: [eff date] ecti : [member DOB] ve DO Medical Group Name: Primary Care Provider (PCP): [Provider Name] PCP Contact #: [Provider Phone] Member Reminder: Show this card along with your SC Healthy Connections ID card at each medical visit RxBIN: 004336 RxPCN: ADV RxGrp: RX4266 If you have an emergency, call 911, or go to your nearest Emergency Room. For your convenience, Advicare members and providers may call the toll free number: 1-888-781-4371 for the following services: • Member Care (Eligibility & Benefits) • Provider Inquiry • Utilization Management • 24 Hour Nurse Line TTY Line: 1-888-357-7188 Mail Claims to: Advicare Corp. Electronic Claims Attn: Claims Department Emdeon Payer ID: 45423 PO Box 5547 Hauppauge, NY 11788 CVS Caremark: 1-855-383-9430 Pharmacy Help Desk: 1-800-364-6331 (For Members) (For Pharmacy) SC Healthy Connections Choices at 1-877-552-4642 VISIT PROCEDURES In order to work effectively with our members and to ensure prompt and accurate reimbursement for services, we recommend the following visit procedures: • • • • • • Identify the patient’s health insurance at the time of appointment scheduling. Remind the patient to bring their Member ID card to their appointment. Call Advicare Member Services to verify eligibility in advance if possible. When the patient arrives, ask them to present their ID card Verify eligibility, benefits and PCP assignment. You may want to make a copy of the ID card for your files. 4 PCP offices should check their member enrollment listing. In a specialist’s office, make sure that appropriate authorizations have been completed prior to rendering services. III. PROVIDER RESPONSIBILITIES Participating physicians are responsible for fulfilling certain obligations and commitments as participants in our provider network. Contracted providers agree to abide by all rules and guidelines stated in the contract between Advicare and the South Carolina Department of Health and Human Services (SCDHHS). Responsibilities include, but are not limited to, the following: • • • • • • • • • • • • Provider shall provide Core Benefits to Members when such services are ordered by a licensed physician or other Participating Provider and are within the scope of Provider’s license. Provider is a Participating Provider and a Medicaid Provider at all locations listed in the Participating Provider Application and under all taxpayer identification numbers utilized by Provider. Provider may not refuse to provide Medically Necessary or covered preventive services to Members for non-medical reasons. Provider shall not discriminate against Members for any reason and shall provide the same standard of care and access to medical services as are offered to Provider’s other patients. Provider agrees that Members shall not be subject to discrimination regardless of race, creed, color, religions, physical/mental handicap, sexual orientation, marital status, national origin/ancestry, health status as a Member, or type of coverage provided to Member (i.e., Medicaid, Medicare, commercial). Provider shall verify the current status of a Member’s eligibility by contacting Advicare during normal office hours; or utilizing the SCDHHS Web Tool or prior to providing services. Provider agrees to provide services related to Core Benefits in accordance with the applicable terms and conditions of the Advicare Provider Manual, SCDHHS ADVICARE Policy and Procedure Guide and CMS guidelines. Provider agrees to comply with the SCDHHS Quality Assurance and Utilization Review (QA/UR) Requirements contained in the SCDHHS ADVICARE Policy and Procedure Guide, and any future amendments to such requirements. Provider further agrees to cooperate with Advicare compliance with the SCDHHS QA/UR Requirements and CMS guidelines. Provider shall prescribe drugs to Members that are contained in the Advicare Prescription Drug Formulary. Provider shall ensure that all of Provider’s Health Care Professionals, if any, have and shall maintain in good standing, all licenses, permits, registrations and/or certifications required by law. Evidence of maintaining such licenses permits, registrations and/or certifications shall be provided to Advicare and/or CMS or SCDHHS upon request. Provider shall ensure that persons with limited English skills receive free of charge the language assistance necessary to afford them meaningful and equal access to the benefits and services provided under the Provider Agreement with Advicare. Provider shall comply with all applicable state and federal laws, regulations and guidelines applicable the confidentiality of medical records (such as regulations implementing the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, laws addressing advanced directives, and state and federal anti-discrimination laws (such as the Civil Rights Act of 1964 and the Americans with Disabilities Act.) Provider shall submit to Advicare all reports and clinical information required by Advicare contract with SCDHHS, including Early and Periodic Screening, Diagnosis and Treatment (EPSDT) if applicable. PRIMARY CARE PROVIDER (PCP) Primary Care Physicians (PCPs) in the Advicare network include Board Certified or Board Eligible practitioners in the fields of Internal Medicine, General Practice, Family Practice and Pediatrics. Each Advicare member chooses a PCP, who assumes responsibility for the management of our member’s health 5 care needs. An Obstetrician may assume care for members during pregnancy, but generally will refer back to the PCP for health care issues unrelated to the pregnancy. The PCP is the key to managing the member’s overall health and wellbeing. The PCP’s role includes: • • • • Performing an initial health assessment for new members assigned to their panel to begin establishing the physician patient relationship. Direct provision or coordination of all healthcare services for the member to include 24-hour coverage. Contacting Advicare to obtain necessary prior authorization for designated services (e.g., out of network referrals, specified diagnostic tests). Complying with all established Advicare policies and procedures as documented in this provider manual. PANEL LIST Each month, Primary Care Physicians will receive a list of all patients paneled to that provider. This listing provides important information and should be reviewed by your office staff, as it may be used to verify eligibility. Please refer to this list before providing services or referring members to specialists. PCP ASSIGNMENT • • • • • New members are asked to select a Primary Care Physician at the time of enrollment. Members may select any Advicare participating provider whose panel is open to accepting new members and who matches the member’s age category. If the member does not select a PCP, Advicare will select one on their behalf. We will consider all available information related to any prior relationship the patient may have had with a PCP, special clinical needs, age category, language requirements, as well as geographic proximity to the provider. Advicare will notify the member of their PCP assignment and will issue a Member Identification Card with the PCP’s name and phone number. The PCP will receive a Member List each month, reflecting all Advicare members paneled to that provider. Members may request a change to their PCP assignment at any time. PCP AVAILABILITY Availability is defined as the extent to which Advicare contracts with the appropriate type and number of PCPs necessary to meet the needs of its members within defined geographical areas. Advicare has implemented several processes to monitor its network for sufficient types and distribution of PCPs. PCP availability is analyzed annually by the Advicare’ Provider Relations (PR) Department. At least annually, the PR department computes the percentage of PCPs with panels open for new members versus those PCPs accepting only members who are already- existing patients in their practice. The Member Services Department analyzes member surveys and member grievance data to address SCDHHS and federal requirements regarding the cultural, ethnic, racial, and linguistic needs of the membership. The Quality Improvement Department tracks and trends member and provider grievances quarterly and monitors other data (such as appointment availability audits, after hours use of the member hotline and member and provider satisfaction surveys) that may indicate the need to increase network capacity. PCP ACCESSIBILITY Accessibility is the extent to which a patient can obtain available services at the time they are needed. Such service refers to both telephone access and ease of scheduling an appointment, if applicable. The Plan monitors access to services by performing access audits, tracking applicable results of the Healthcare Effectiveness Data and Information Set/Consumer Assessment of Health 6 Plans Survey (HEDIS/CAHPS), and analyzing member grievances regarding access, and reviewing telephone access. MEMBER STATUS CHANGE Advicare members may be dis-enrolled from Advicare by the South Carolina Department of Health and Human Services (DHHS) if the member no longer meets DHHS’ eligibility requirements for Managed Care enrollment. PCPs are responsible for notifying Advicare’s Member Services Department if they know of a member’s change in eligibility status (e.g., admission to an extended care facility). 24-HOUR ACCESS Each PCP is responsible to maintain sufficient facilities and personnel to provide covered physician services and shall ensure that such services are available as needed twenty-four (24) hours a day, 365 days a year. PCPs must provide members with an after-hours telephone number. The after-hours number must connect the member to an answering service, a call center system, a recording that directs the caller to another number to reach the PCP or PCP- authorized medical practitioner, or a system that automatically transfers the call to another telephone line that is answered by a person who will contact the PCP. A hospital may be used for the 24-hour telephone coverage requirement if the 24-hour access is not answered by the emergency department staff. The PCP must establish a communication and reporting system with the hospital and the PCP must review the results of all hospital-authorized services. Advicare will monitor physicians’ offices through scheduled and unscheduled visits through our Provider Relations staff. APPOINTMENT ACCESS STANDARDS The following schedule should be followed regarding appointment availability: • Routine well care visits should be scheduled within 4 to 6 weeks of presentation • Urgent care visits should be performed within 48 hours of presentation or notification at the delivery site • Emergency care visits should be performed immediately upon presentation or notification at the delivery site • Wait Time shall not exceed forty-five (45) minutes for a scheduled appointment of a routine nature. Advicare will monitor appointment and after-hours availability on an ongoing basis through its Quality Improvement Program. LABORATORY SERVICES Advicare has a network of contracted laboratory providers to provide outpatient laboratory services for our members. Participating physicians should contact a network lab to arrange for specimen pick-up, supplies, results and general information. IN-OFFICE LAB PROCEDURES Lab procedures performed in office must be performed according to your CLIA certification level. These in office lab procedures performed in the office will be covered. 7 HOSPITAL ADMITTING PRIVILEGES PCPs or specialist must establish and maintain hospital admitting privileges or enter into a formal arrangement with another physician or group practice for the management of inpatient hospital admissions of Advicare members. This requirement must be met prior to the PCP or specialist providing medical services to members. An attestation must be signed by the PCP or specialist attesting that a formal arrangement exists. By signing the attestation, the physician/group agrees to accept responsibility for admitting and coordinating medical care for the member throughout the member’s inpatient stay. The following arrangement is acceptable: • • • IV. A physician, a group practice, a hospital group, a physician call group (not necessarily a ADVICARE provider) that is enrolled with the South Carolina Medicaid program, and has admitting privileges or formal arrangements at a hospital that is within 30 miles or 45 minutes’ drive time from the PCP’s or specialist office. If there is no hospital which meets this geographic criterion, the closest hospital to the PCP or specialist practice is acceptable. Hospital admitting agreements with unassigned call doctors are unacceptable. Exceptions may be granted in cases where it is determined the benefits of a PCP’s or specialist participation outweighs the PCP’s or specialist inability to comply with the admitting privileges requirement. Advicare is responsible for ensuring that all enrolled Providers are eligible to participate in the Medicaid Program. If a Subcontractor is not accepting new Medicaid Members, the Subcontractor cannot be listed on the Spreadsheet. Additionally if a PCP or specialist does not have admitting privileges to at least one of the contracted Hospital (s) listed on the Spreadsheet, the ADVICARE must provide a detailed description of the mechanisms that will be used to provide services to Medicaid ADVICARE Members. SCDHHS reserves the right to disapprove any Provider Network submission based on the information provided. REFERRALS AND AUTHORIZATIONS Advicare Referral Authorization Process Referral Guidelines In order to reduce the administrative burden on providers, Advicare does not require notification or completion of referral forms. PCPs may simply refer members to specialists, provided that such referrals are in-network specialists. Any referrals to out-of-network providers will require prior authorization from Advicare. When referring a member for specialty care, the PCP must document the referral in the member’s medical record. After Hours and Emergency Care Members are not required to contact their PCP in emergent/urgent situations. The emergency room staff will triage the member to determine whether or not an emergency exists. However, the PCP must provide telephone coverage 24 hours per day/7 days a week Authorization Guidelines Advicare requires prior authorization for all inpatient admissions and certain outpatient services. To request prior authorization, the admitting or referring physician, or the facility or provider rendering the service can submit the request in one of the following ways: • • Via telephone at toll free (888)-781-4371. Via fax to toll free (888) 781-4316. 8 • Soon you will also be able to submit via our website at www.Advicarehealth.com Upon receipt of a prior authorization request, Advicare will verify member eligibility and benefits. We will make case-by-case determinations based on the individual’s health care needs and medical history, in conjunction with nationally-recognized standards of medical care. If medical necessity criteria are not met on the initial review, the referring provider may discuss the case with an Advicare physician who is in the same or similar specialty prior to the determination. If the request is denied, the appropriate denial letter (including the member’s Fair Hearing appeal rights) will be mailed to the requesting provider, member’s PCP, and the member. To ensure timeliness of prior authorization requests, the requesting provider should include the following information: • • • • • • • • • Member name and plan ID Name, telephone and fax of the facility or provider who will be rendering the service Proposed date(s) of service Diagnosis with ICD9 code Name of procedure(s) with CPT-4 code Medical information to support the request Signs and symptoms Past and current treatment plans, including response to treatment plans Medications, along with frequency and dosage Inpatient Admission Review Advicare reviews inpatient admissions within one business day of notification. We determine the member’s status through: • • Onsite review, when indicated Communication with the hospital’s utilization review department We then document the appropriateness of stay and refer specific diagnoses to our Health Services department for care coordination or case management. Inpatient Concurrent Review To determine the authorization of coverage, we conduct a concurrent review of the hospital medical record: • • At the hospital when indicated Via telephone or fax We conduct select continued stay reviews daily and review discharge plans. Our Utilization management (UM) clinician will also try to meet with the member and/or family to: • • Discuss any discharge planning needs Verify they know the PCP’s name and address We authorize the covered length of stay one day at a time. Our medical director can make exceptions for severe illness and course of treatment or when it is pre-determined by state law. Examples include: • • ICU, CCU C-section or vaginal deliveries We will communicate approved days and bed level coverage to the hospital for any continued stay. 9 Discharge Planning Advicare’s utilization management (UM) clinician coordinates our members’ discharge planning needs with: • • • Hospital utilization review/discharge planning staff The attending physician The Advicare Services department The attending physician, in concert with our UM clinician or Health Services Representative, coordinates the member’s follow up care with the member’s PCP. For ongoing care, we work with the provider to plan discharge to an appropriate setting such as: • • • • Hospice Convalescent care Home health care program Skilled nursing facility 10 Authorization Grid Please visit www.Advicarehealth.com, or call toll free (888) 781-4371 for the most current version of prior authorization guidelines. Service Allergy Audiology Bariatric Surgery Cardiology Cardiac Catheterization Chemotherapy Circumcision Prior Authorization Guidelines No prior authorization required. Not covered for adults 21 years of age or older Prior authorization is required. No prior authorization is required. No prior authorization is required for outpatient procedures No prior authorization is required No prior authorization is required Clinical Trials Dermatology Prior authorization is required No prior authorization is required for E&M or Testing Some procedures may require prior authorization Diagnostic Testing Prior authorization is required for MRIs, MRAs, PET, EEG, Nuclear Testing, MEG, CT Angiogram Diabetic supplies Diabetic shoes Durable Medical Equipment No prior authorization required No prior authorization required No prior authorization is required for DME below $500 Prior authorization is required for all DME that exceeds $500 DME rentals are capped at the purchase price Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Visit No prior authorization is required PCPs are required to use the EPSDT schedule and to document the visits Note: vaccine serum is received under the Vaccines for Children (VFC) program Emergency Room No prior authorization is required Note: Advicare must be notified by the next business day if a member is admitted to the hospital through the emergency room ENT Services (Otolaryngology) No prior authorization is required for out-patient services Endocrinology Family Planning No prior authorization is required No prior authorization required Members may self-refer for family planning services Gastroenterology General Surgery No prior authorization is required for outpatient services No prior authorization is required for outpatient or ambulatory surgery center Gynecology Hearing Aids Hearing Screening No prior authorization is required for outpatient services Covered by the State for <21 Not A Covered Benefit for >21 years of age 11 Service Prior Authorization Guidelines Covered by the State for <21 years of age per EPSDT Guidelines Hematology Home Health Care No prior authorization is required Prior authorization is required DME and Supplies are covered per authorization guidelines Hospital Admissions Prior authorization is required for all elective admissions Advicare must be notified by the next business day of any admissions Medical Supplies No prior authorization is required for disposable medical Supplies Nephrology Neurology Observation No prior authorization required, including dialysis No prior authorization is required No prior authorization is required for observation services Advicare must be notified by the next business day of any admissions that resulted from observation services. Obstetrical Care No prior authorization is required Please notify Advicare within one business day following the first OB visit for referral to case management Occupational Therapy Prior authorization is required for adults over 21 years of age. Covered by the State for children under 21 years of age. Oncology Ophthalmology No prior authorization is required No prior authorization is required for out-patient services Services that are considered cosmetic are not covered benefits Orthopedics Out of Area/Out of Network Care No prior authorization is required Prior authorization is required except for emergency care and DHMH self-referred services Outpatient/Ambulatory Surgery (ASC) No prior authorization is required Pain Management No Authorization required: E&M All other services will require a prior authorization No prior authorization is required Prior authorization is required Perinatology Plastic Reconstructive Surgery Podiatry No prior authorization for Podiatry Services for: Medically necessary services for members younger than 21 years old; Diabetes care services specified in COMAR 10.09.67.24; and Routine foot care for members, 21 years old or older with vascular disease affecting the lower extremities 12 Service Pulmonology Physical Rehabilitation (inpatient) Prior Authorization Guidelines No prior authorization is required Prior authorization is required Physical Therapy (outpatient) Prior authorization is required for adults over 21 years of age Radiology Rheumatology Skilled Nursing Facility Sleep Studies Sterilization See Diagnostic Testing No prior authorization is required Prior authorization is required Prior authorization is required No prior authorization is required for outpatient services or services provided in an ambulatory surgery center Provider must submit a completed consent form and Medicaid Form (MA-30) for sterilizations Reversal of sterilization is not a covered benefit Substance Abuse Services (Outpatient) Member Self-Refer (no authorization required) Substance Abuse Services (Inpatient) Prior authorization requirements are consistent with SCDHHS’s Substance Abuse Initiative. For a complete description of the SCDHHS Substance Abuse Initiative and prior authorization requirements, please visit: https://www.scdhhs.gov/pressrelease/alcohol-and-other-drug-abuse-treatment-servicesauthorized-or-provided-state-agencies Urology No prior authorization is required Second Opinions If a member requests a second opinion, Advicare will provide the second opinion from a qualified health care professional within our network at no additional cost to the member. If necessary we will arrange for the member to obtain one outside of our network. UTILIZATION MANAGEMENT INPATIENT Concurrent Review To determine the authorization of coverage, we conduct a concurrent review of the hospital medical record: • • At the hospital when indicated Via telephone or fax We conduct select continued stay reviews daily and review discharge plans. Our Utilization management (UM) clinician will also try to meet with the member and/or family to: • • Discuss any discharge planning needs Verify they know the PCP’s name and address We authorize the covered length of stay one day at a time. Our medical director can make exceptions for severe illness and course of treatment or when it is pre-determined by state law. Examples include: • • ICU, CCU C-section or vaginal deliveries 13 We will communicate approved days and bed level coverage to the hospital for any continued stay. Advicare adheres to all notification and turn-around time requirements according to NCQA and COMAR regulations. Discharge Planning Advicare Utilization Management clinician coordinates our members’ discharge planning needs with: • • • Hospital utilization review/discharge planning staff The attending physician The Advicare Services department The attending physician, in concert with our Utilization Management clinician or Health Services Representative, coordinates the member’s follow up care with the member’s PCP. For ongoing care, we work with the provider to plan discharge to an appropriate setting such as: • • • • • Hospice Convalescent care Home health care program Skilled nursing facility Member’s home REFERRALS INTO THE WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM Advicare PCPs are required to refer potentially eligible members to the WIC program. The WIC program helps women, infants and children protect their health and well-being through nutrition. The program is run by the South Carolina Department of Health and Environmental Control (SCDHEC). Those who qualify receive vouchers to redeem for food items such as fruits, vegetables, dairy products and cereal. For more information please call SCDHEC at 1-800-868-0404. OBSTETRICAL REGISTRATION FORM Submit completed OB Registration Form (Attachment A) for expectant mothers within 5 days of first prenatal visit via fax at toll free (888) 781-4316 or email at [email protected] PROVIDER TERMINATION Providers should refer to their Advicare contract for specific information about terminating provider agreement. 14 V. MEDICAL RECORDS MEDICAL RECORDS Advicare providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. They will also enable Advicare to review the quality and appropriateness of the services rendered. To ensure the member’s privacy, medical records should be kept in a secure location. Advicare requires providers to maintain all records for members for at least ten years for adult patients and at least thirteen years for minors. See Member Rights section of this manual for policies on member access to medical records. REQUIRED INFORMATION Medical records means the complete, comprehensive member records including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the member’s participating primary care physician or provider, that document all medical services received by the member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable SCDHHS rules and regulations, and signed by the medical professional rendering the services. Providers must maintain complete medical records for members in accordance with the following standards: • Member’s name, and/or medical record number on all chart pages; • Personal/biographical data is present (i.e. employer, home telephone number, spouse, next of kin, etc.); • All entries must be legible; • All entries must be dated and signed, or dictated by the provider rendering the care; • Significant illnesses and/or medical conditions are documented on the problem list; • Medication, allergies, and adverse reactions are prominently documented in uniform location in the medical record; if no known allergies, NKA or NKDA is documented; • An up-to-date immunization record is established for pediatric members or an appropriate history is documented in adult members’ charts; • Evidence that preventive screening and services are offered in accordance with Advicare’ practice guidelines; • Appropriate subjective and objective information pertinent to the member’s presenting grievances is documented in the history and physical; • Past medical history (for members seen three or more times) is easily identified and includes any serious accidents, operations and/or illnesses, discharge summaries, and ER encounters; for children and adolescents (18 years and younger) past medical history relating to prenatal care, birth, any operations and/or childhood illnesses; • Working diagnosis is consistent with findings; • Documented treatment prescribed, therapy prescribed and drug(s) administered or dispensed; • Documentation of prenatal risk assessment for pregnant women or infant risk assessment for newborns; • Signed and dated required consent forms; a 15 • Unresolved problems from previous visits are addressed in subsequent visits; • Laboratory and other studies ordered as appropriate; • Abnormal lab and imaging study results have explicit notations in the record for follow up plans; all entries should be initialed by the primary care provider (PCP) to signify review; • Referrals to specialists and ancillary providers are documented including follow up of outcomes and summaries of treatment rendered elsewhere; • Health teaching and/or counseling is documented; • For members ten (10) years and over, appropriate notations concerning use of tobacco, alcohol and substance use (for members seen three or more times, a substance abuse history should be queried); • Documentation of failure to keep an appointment; • Encounter forms or notes have a notation, when indicated, regarding follow-up care calls or visits. The specific time of return should be noted as weeks, months or as needed; • Evidence that the member is not placed at inappropriate risk by a diagnostic or therapeutic problem; • Confidentiality of member information and records protected; • Evidence that an advance directive has been offered to adults 18 years of age and older; • Pre-birth selection form. • Records must be secured and accessible only by authorized personnel. • Records must be made available to South Carolina Department of Health and Human Services or their designee. MEDICAL RECORDS RELEASE All member medical records shall be confidential and shall not be released without the written authorization of the covered person or a responsible covered person’s legal guardian. When the release of medical records is appropriate, the extent of that release should be based upon medical necessity or on a need to know basis. Written authorization is required for the transmission of the medical record information of a current Advicare member or former Advicare member to any physician not connected with Advicare. MEDICAL RECORDS TRANSFER FOR NEW MEMBERS All PCPs must transfer the member’s medical record to the receiving provider upon the change of the member’s PCP and as authorized by the member within 30 days of the date of the request. All PCPs are required to document in the member’s medical record attempts to obtain historical medical records for all newly assigned Advicare members. If the member or member’s guardian is unable to remember where they obtained medical care, or they are unable to provide addresses of the previous providers then this should also be noted in the medical record. 16 VI. ADVICARE CASE AND DISEASE MANAGEMENT CASE MANAGEMENT INTRODUCTION Case Management at Advicare is done in conjunction with the Disease Management program. Individuals not meeting the identified disease entities (i.e. Cardiovascular Disease, Diabetes, Asthma, HIV/AIDS and Cancer) are placed in the Case Management Program. Disease Management is a comprehensive, integrated approach to care and reimbursement based on a disease’s natural course (population based, disease focused). The Case Management Society of America defines Case Management as a collaborative process which assesses plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communications and available resources to promote quality, cost effective outcomes.” Health care issues commonly placed in case management include but are not limited to: • • • • • • • • High Risk OB Children with Special Needs Sickle Cell Anemia Behavioral Health Chronic Debilitating Illnesses Transplants Renal Failure Spinal Cord Injuries These diagnoses will be evaluated on an individual basis to identify the need for case management. Not all diagnosed patients will require case management. An expanded program description of each disease state follows at the end of this section. SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT) What is SBIRT? SBIRT is an evidenced based, integrated and comprehensive approach to the Identification, Intervention and Treatment of Substance (Drug and Alcohol) Usage, Domestic Violence, Depression, and Tobacco Usage. The SBIRT program in South Carolina is specific to pregnant women to include 12 months postpartum. What are the core clinical components of SBIRT? Screening - Brief process of identifying substance use, behavioral health issues, domestic violence and tobacco use Brief Intervention - 5-10 minute session to raise awareness of risks and motivate the patient toward acknowledging there is a problem Referral - When risk is identified and treatment is needed Treatment - Cognitive behavioral work for member to acknowledge risks and change behavior Why is SBIRT important? Research indicates SBIRT may: 1. 2. 3. 4. Stem progression to independence Improve medical conditions Prevent medical conditions related to substance use, abuse and dependence Decrease trauma related mortality: Alcohol alone is a factor in up to 70% of homicides, 40-50% of fatal motor vehicle accidents, 60% of fatal burns and 40% of fatal falls . 17 How do I learn more about the SBIRT process? Please click on SBIRT Tool Kit for the full provider tool kit, which includes (1) Screening Tools, (2) Referral Forms, (3) Referral Resource Information and (4) Other information which can be accessed at www.Advicarehealth.com under the Provider tab. CASE MANAGEMENT PROGRAM The goals of the Case Management Program are to: • • • • Facilitate the delivery of individualized, coordinated care Process ongoing or future service needs Empower our members Identify, assess, design, control and manage the care of our members to ensure optimum outcomes COMPONENTS OF CASE MANAGEMENT The identification and monitoring of members needing case management includes: • • • • • • Intake and Screening Assessment and Reassessment Care Plan Development Care Coordination of services Monitoring outcomes Ongoing Documentation/Communication DISEASE MANAGEMENT INTRODUCTION Disease Management at Advicare is a program aimed at: • • • • • Understanding the course of identified diseases Targeting members most likely to benefit from our interventions Cost containment Prevention Member education. The goal of disease management is to identify a member’s illness or condition to prevent the exacerbation of that disease and the corresponding need for high cost resources. Warren Todd, in his book Disease Management, A Systems Approach to Improving Patient Outcomes, defines disease management as a comprehensive, integrated approach to care and reimbursement based on a disease’s natural course. In contrast to case management with its emphasis on individualized patient management, the impetus for disease management is a population-based, disease focused, preventative approach. DISEASE MANAGEMENT STATES At Advicare, we have identified the following four disease states as the most prevalent to address in this population: • • Asthma/COPD Diabetes 18 • • Cardiovascular Disease HIV/Oncology Each disease state is managed by a licensed professional that is responsible for establishing, updating and maintaining their disease management program and identifying their population base. To assist our disease case managers in the managing of patients, we have developed applicable assessment tools, are utilizing extensive patient education literature, the most current clinical guidelines and are continually working to establish the necessary community and health care relationships. An expanded program description of each disease state follows at the end of this section. DISEASE MANAGEMENT PROGRAM Our program aims to identify individuals at risk or suffering from specific disease states and stratify them by severity of illness or their health risk. Once identified, members are evaluated to assess their specific needs and deficits. There are four (4) acuity levels that a member may be placed in depending on the severity of illness: • • • • Level I – Member is receiving preventative services, member is functioning independently. Level II – Member is receiving home health care services, continuous or special order DME, or requiring consistent monitoring of needs. Level III – Member is in an inpatient setting, high-cost, high utilization of resources, and/or noncompliant. Level IV – Catastrophic use of resources, multiple admission, multiple use of emergency services, and/or noncompliant. The assessment tools used are disease specific so Disease Managers can readily identify what a member will need. Clinical guidelines from the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and the Evidenced Based Medicine Resource Center will be adopted to ensure that members are doing all the necessary things to keep them at an optimum level of health. Clinical guidelines adopted by Advicare include but are not limited to: • • • • • Asthma Cholesterol Hypertension Obesity HIV The Disease Management program strives to ensure that there is open team dialogue between the Disease Manager, patient, Primary Care Physician, and Specialist (as needed). This collaborative relationship helps the patient to take an active part in their care and allows the other team members to assist the patient to participate in care plan development and compliance. The members move through a continuum of care and can be discharged from disease management. Members can be discharged for the following reasons: • • • • • • • Member is disenrolled No response from the member after multiple phone and outreach attempts Member expired Criteria not met for placement in the program Goals met and no further targets are needed Member declines services Member is non-compliant after exhausting all avenues. 19 We have developed outcome measures to evaluate our program and measure the effects of our disease management. Outcome measures are under development for each disease state managed. Some examples of outcome measures are: Hospital Admission/ Readmissions • Medication Compliance • Emergency Room Visits • Blood Pressure Screening • Annual Eye Examination • Annual Podiatry Examination • Annual Physical Examination • Annual Dental Examination • Annual Lipid Profile • Semi-annual CD4 count • Semi-annual HBA1c • Compliance with the Care Plan • Verbalizes Understanding of Disease Condition • Appropriate DME in the Home • Verbalizes Understanding of DME usage To track these outcomes and patient encounters, the Disease/Management Database is utilized. CASE AND DISEASE MANAGEMENT PROCESS Submit completed Disease/Case Management Request form (Attachment B) via fax toll free at (855) 303-2427or email at [email protected] for any of your Advicare that you would like to be enrolled into a case or disease management program. Referrals to Case or Disease Management Case Managers will act on the receipt of all appropriate external and internal referrals to the Case Management Program. Referrals for case management can be made directly to the Medical Management Department via telephone or the Case Management Referral Form. Internal referrals may be received from: • • • • • • • Providers Nurse Advice Line Advicare Members Outreach Department Utilization Review Nurses Quality Management Department Customer Services External referrals may be received from: • • • • • • • Primary Care Providers Provider Specialists Social Workers Community Organizations Hospital Outpatient Clinics Government Agencies Admission to Case or Disease Management 20 Once the member has been accepted into the Case or Disease Management Program, the Case Manager will: • Verify member eligibility • Determine if the member has been a part of case management previously, if not, create a new chart • Enter member data into Case Management database. • Determine current medical status through medical record review, PCP, therapist, or skilled nursing assessment. • Contact member/member representative (parent, guardian, etc.). • Obtain verbal permission to be entered into case management and document consent/refusal in chart. • Complete case management assessment. • Identify problem areas or needs. • Determine how the case management team can manage the case to improve outcomes in cost and quality of care. PREVENTIVE AND CLINICAL PRACTICE GUIDELINES Advicare contractually requires network providers to deliver services in accordance with nationally recognized clinical protocols and guidelines when available and established clinical guidelines when providing care to our beneficiaries. The Medical Director facilitates the review and adoption of these guidelines for the Plan through the Quality Improvement infrastructure. In addition, the Provider Manual will address provider practices; the Provider Relations staff updates the Manual annually to reflect newly adopted or modified protocols and post it on Advicare’s web site. Use of the protocols will also be included in Provider training sessions. The Plan Administrative and Medical Management Teams will monitor utilization reports at the network provider level to assure application of nationally recognized clinical practice guidelines. The Medical Director and Medical Management team are responsible for the annual MOC training, which will include distribution of network profiles for discussion with providers. The Director of Medical Management will also report these results to the QIC, which will evaluate the results and assign corrective action plans to address opportunities for improvement. Clinical guidelines will also inform the Care Management program. Advicare’s Case Managers are Registered Nurses specifically trained in the complex needs of the population and Licensed Clinical Social Workers with experience in chronic care management. Clinical staff will have access to InterQual for supplemental guidelines outside of the system. Advicare will also draw on the National Guideline Clearinghouse maintained by the Agency for Healthcare Research and Quality as an additional resource for the Care Management unit. Care Coordinators will also have access to condition-specific evidence-based guidelines in embedded in the Advicare information system. The Care Management staff at Advicare will apply the National Guideline Clearinghouse™ (NGC) evidencebased clinical practice guidelines criteria. Online access to guidelines is at http://www.guideline.gov/index.aspx.The NGC guidelines will be used in efforts to execute on case and disease management and will also be used in decisions to limit or reduce referrals. The Medical Director may refer cases to peer reviewers or other physician specialist to assist in decisionmaking process. All requests not meeting NGC criteria, or when criteria do not exist for that category of services, will be referred to the Medical Director for review Advicare will have the link to the National Guidelines Clearinghouse (NGC) website on its company website in 21 efforts for providers to access the guidelines or providers can go directly to the NGC site at http://www.guideline.gov/index.aspx. VII. ROUTINE, URGENT AND EMERGENCY SERVICES ROUTINE, URGENT AND EMERGENCY CARE SERVICES DEFINED Members are encouraged to contact their PCP prior to seeking care, although it is not required in an emergency. The following are definitions for routine, urgent, and emergency services. Routine - Services to treat a condition that would have no adverse effects if not treated within twenty-four (24) hours or could be treated in a less acute setting (e.g., physician’s office) or by the patient. Examples include treatment of a cold, flu, or mild sprain. Urgent - Services furnished to treat a medical condition that requires attention within forty eight hours. If the condition is left untreated for 48 hours or more, it could develop into an emergency condition. Emergency* Medical Condition - An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Emergency Services area covers inpatient and outpatient services that are as follows: (1) furnished by a provider that is qualified to furnish these services under this title; and (2) needed to evaluate or stabilize an emergency medical condition. An emergency medical condition shall not be defined or limited based on a list of diagnoses or symptoms. *Emergency Care is not subject to prior authorization or pre-certification. Urgent care provided in an urgent care facility does not require authorization. Emergency Services must be provided by a qualified Provider regardless of network participation. The PCP plays a major role in educating members about appropriate and inappropriate use of hospital emergency rooms. The PCP is responsible to follow up on members who receive emergency care from other providers. VIII. ELIGIBILITY AND ENROLLMENT ELIGIBILITY FOR THE ADVICARE PROGRAM The State of South Carolina has the sole responsibility for determining eligibility for Medicaid for all coverage groups except for Supplemental Security Income (SSI). The Social Security Administration (SSA) determines eligibility for SSI. VERIFYING ELIGIBILITY 22 Providers are responsible for verifying eligibility every time a member schedules an appointment, and when they arrive for services. PCPs should also verify that a member is their assigned member. Call toll free 1-888-781-4371 to reach Member Services for eligibility verification Or check online at: https://portal.scmedicaid.com (Must have provider login and password from SCDHHS) ENROLLMENT/MARKETING GUIDELINES FOR ADVICARE PROVIDERS Advicare’ contract with SCDHHS defines how the ADVICARE and its providers market and advertise the program. Accordingly, providers may not include any reference to their affiliation with SCDHHS or Advicare, in their marketing or advertising without prior approval from Advicare and SCDHHS. SCDHHS requires providers to submit to Advicare samples of any marketing materials they intend to distribute, and to obtain state approval prior to distribution or display. Advicare Provider Relations staff will submit these materials to SCDHHS within five (5) business days of receipt, and will send providers written notice of approval or of any changes required by SCDHHS within five (5) business days of receiving notice from SCDHHS Advicare Provider Relations staff will give an overview of the marketing plan to all network physicians and their staff and present them with the SCDHHS ADVICARE Policy and Procedure Guidelines on General Marketing and Enrollment. This will define what a provider may or may not do in regards to marketing to our members. Provider communication tools will include brochures, directories, booklets, handbooks, newsletters, letters and videos. Some specific examples of the tools Advicare might use include: • • • • • • IX. Provider orientation meetings/town hall meetings Provider newsletters Provider manual Provider directory Informational letters, flyers and other mailings Interactive Web portal NON-COMPLIANT MEMBERS NON-COMPLIANT MEMBERS There may be instances when a PCP feels that a member should be removed from his or her panel. A PCP may request a member be transferred to another practice for any of the following reasons: • • • Repeated disregard of medical advice Repeated disregard of member responsibilities Personality conflicts between physician and/or staff with member Examples of reasons that a PCP may request to remove a member from their panel could 23 include, but not be limited to: A member is disruptive, unruly, threatening, or uncooperative to the extent that the member seriously impairs the provider’s ability to provide services to the member or to other members and the member’s behavior is not caused by a physical or behavioral condition. All requests to remove a member from a panel must be made in writing, contain detailed documentation and must be directed to: Advicare Attention: Director, Customer Services 531 South Main Street, Suite RL-1 Greenville, SC 29601 Upon receipt of such request, Member Services may: • • • • Interview the provider or their staff that are requesting the disenrollment, as well as any additional relevant providers Interview the member Review any relevant medical records Involve other Advicare departments as appropriate to resolve the issue A PCP should never request a member be disenrolled for any of the following reasons: • • Adverse change in the members health status or utilization of services which are medically necessary for the treatment of a member’s condition On the basis of the member’s race, color, national origin, sex, age, disability, political or religion. NURSE RESPONSE® Our members have many questions about their health, their primary care provider and access to emergency care. Our health plan offers a nurse line service to encourage members to talk with their physician and to promote education and preventive care. Nurse Response is our 24-hour nurse line for members. The registered nurses provide basic health education, nurse triage and answer questions about urgent or emergency access, all day long. The staff often answers questions about pregnancy and newborn care. In addition, members with chronic problems, like asthma or diabetes, are referred to case management for education and encouragement to improve their health. Members may use Nurse Response to request information about providers and services available in your community after the health plan is closed. Providers can use it to verify eligibility any time of the day. The Nurse Response staff is conversant in both English and Spanish and can offer the Language Line for additional translation services. The nurses document their calls in a webbased data system We provide this service to support your practice and offer our member’s access to an RN every day. If you have any additional questions, please call Care Management or Nurse Response toll free at 1-888-781-4371. NON-EMERGENCY TRANSPORTATION SERVICES Advicare members may need transportation to or from a Medicaid covered service to receive medically necessary care. Non-emergency transportation is only available to eligible recipients who cannot obtain transportation on their own through other available means, such as family, friends or community resources. 24 South Carolina Medicaid Transportation program provides non-emergency transportation for members. If a member needs to schedule a ride for non-emergency reason, the member is to call Logisticare. They will schedule the ride for the member. The member or provider can also call the Member/Provider Services Department toll free at 1-888-781-4371 if they are having difficulty scheduling their ride for a medical appointment. Member Services can assist the member in contacting the transportation broker to arrange transportation. LOGISTICARE REGIONS and CONTACT NUMBER Region 1: 866-910-7688 Abbeville Cherokee Greenville Laurens Oconee Saluda Anderson Edgefield Greenwood McCormick Pickens Spartanburg Region 2: 866-445-6860 Aiken Bamberg Calhoun Clarendon Kershaw Lee Newberry Richland Union Allendale Barnwell Chester Fairfield Lancaster Lexington Orangeburg Sumter York Region 3: 866-445-9954 Beaufort Charleston Colleton Dillon Florence Hampton Jasper Marlboro Berkeley Chesterfield Darlington Dorchester Georgetown Horry Marion Williamsburg TTY: 866-288-3133 X. EPSDT SOUTH CAROLINA EPSDT SERVICES AND STANDARDS The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, is a program of comprehensive preventive health services available to Advicare recipients through the month of their 21st birthday. The program is designed to maintain health by providing early intervention to discover and treat health problems. EPSDT is a preventive program that combines diagnostic screening and medically necessary follow-up care for dental, vision and hearing examinations for eligible members. EPSDT services include: • • Outreach and informing Screening in accordance with the SCDHHS periodicity schedule 25 • • Tracking compliance with EPSDT requirements Diagnostic and treatment services Standards for providing EPSDT services are described and are included in the state ADVICARE Policies and Procedures Manual. PCPs are required to perform EPSDT medical check-ups in their entirety and at the required intervals. All components of exams must be documented and included in the medical record of each EPSDT eligible member. Initial well-child exams are to be completed within ninety days of the initial effective date of membership and within twenty-four (24) hours of birth for all newborns. The components of these visits are as follows: • • • • • • • • • • Comprehensive health and developmental history -- (including assessment of both physical and mental health development); Comprehensive unclothed physical exam; Appropriate immunizations -- (according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines); Laboratory tests -- including blood level assessments appropriate for age and risk factors; Lead Toxicity Screening- according to established guidelines Anticipatory Guidance/Health Education -- Health education is a required component of screening services and includes anticipatory guidance. At the outset, the physical and/or dental screening provides the initial context for providing health education. Health education and counseling to both parents (or guardians) and children is required and is designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention; Vision Screening – Vision should be assessed at each screening. In infants, the history and subjective findings of the ability to regard and reach for objects, the ability to demonstrate an appropriate social smile, and to have age appropriate interaction with the examiner is sufficient. At ages four and above, objective measurement using the age- appropriate Snellen chart, Good lite Test, or Titmus Test should be done and recorded. If needed, a referral should be made to an ophthalmologist or optometrist; Dental Screening – A general assessment of the dental condition (teeth and/or gums) is obtained on all children, including fluoride treatments. As indicated and beginning at age 2 years old a referral should be made to a dentist; Hearing Screening – A hearing test is required appropriate to the child’s age and educational level. For the child under age four, hearing is determined by whatever method is normally used by a provider, including, but not limited to, a hearing kit. For the child over age four, an audiometer, if available is recommended. If needed, an appropriate referral should be made to a specialist. It is recommended that high-risk neonates be evaluated with objective measures, such as brain stem evoked response testing, prior to discharge from the hospital nursery; Other Necessary Healthcare – States must provide other necessary healthcare, diagnosis services, treatment, and other measures described in section 1905(a) of the Social Security Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services. Periodic Screening - EPDST beneficiaries are eligible to receive 20 screenings in 21 years of life. Screening ranges are determined according to age of the child and, in some circumstances, when last screened. The following is a general guide for the ranges in which screenings should occur (refer also refer to the American Academy of Pediatrics website at http://www2.aap.org/immunization/IZSchedule.html). • • • • Neonatal exam (identified from hospital claim and not billable as an EPSDT screening) Birth to 1 month 1 month through 2 months 3 months through 4 months 26 • • • • • • • 5 months through 7 months 8 months through 11 months 12 months through 14 months 15 months through 17 months 18 months through 20 months 21 months through 24 months (when the child passes age 2, another screening is not due until age 3) 3 years through month of 21st birthday (screenings are recommended annually) Note: The codes for reporting screening services for new and established patients are as follows: • • 99381 - New Patient under one year 99382 - New Patient (ages 1-4 years) • • • • • • • • • • 99383 - New Patient (ages 5-11 years) 99384 - New Patient (ages 12-17 years) 99385 - New Patient (ages 18-39 years) 99391 - Established patient under one year 99392 - Established patient (ages 1-4 years) 99393 - Established patient (ages 5-11 years) 99394 - Established patient (ages 12-17 years) 99395 - Established patient (ages 18-39 years) 99431 - Newborn care (history and examination) 99432 - Normal newborn care Screenings for children 17 years and under should be billed with Diagnosis code V20.2 and for children 18-21 V70.0 Preventive health is a major principal on which managed care organizations are based, measured and held accountable. Advicare supports its PCPs to encourage their Advicare patients to participate in the State of South Carolina preventive care program, EPSDT. Advicare will send reminders of the need for a well-child examination to all EPSDT eligible members. For newborns, parents/guardians will receive a letter explaining the EPSDT schedule through 2 years old. For the child’s second birthday, an EPSDT reminder postcard will be sent advising of the two suggested exams before the child turns three. For ages 3 through 20, reminders will be sent annually based on the month of the birth. Providers must demonstrate compliance with the EPSDT periodicity schedule and screening requirements (including blood lead screening) for at least 80% of their eligible members, in accordance with the methodology prescribed by the Centers for Medicare and Medicaid Services. IMMUNIZATIONS Children must be immunized during medical checkups according to the EPSDT Routine Immunization Schedule by age and immunizing agent. Advicare encourages all members under the age of 18 to be immunized by their PCP unless medically contraindicated or against parental religious beliefs. Providers shall report all immunizations to the State Immunization Information System (SIIS) administered by the South Carolina Department of Health and Environmental Control (DHEC), effective with the implementation of SIIS. Since immunizations are a required component of EPSDT screening services, an assessment of the child’s immunization status should be made at each screening and immunizations administered as appropriate. If the child is due for an immunization, it must be administered at the time of the screening. However, if illness precludes immunization, the reason for delay should be 27 documented in the child’s record. An appointment should be given to return for administration of immunization at a later date. Immunization of children should be provided according to the guidelines recommended by the Department of Health and Environmental Control (DHEC), the Centers for Disease Control (CDC), the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, and South Carolina State Law. PCPs should participate with the Vaccine for Children Program (VFC). If a provider does not routinely administer immunizations as part of his/her practice, they should refer the child to the county health department but must maintain a current record of the child’s immunization status. BLOOD LEAD SCREENING Advicare EPSDT guidelines include Blood Lead Level Screenings for children from the ages of nine months through 72 months. A Lead Screening Questionnaire should be completed at the time of each routine office visit for children in this age group. All Medicaid children are considered at increased risk for having elevated blood lead levels (BLLs). A blood lead test must be used when screening Medicaid-eligible children. An elevated BLL is considered anything >10 ug/dl. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (finger stick) must be confirmed using a venous blood sample. According to CMS policy, all Medicaid children require a screening blood lead test at 12 and 24 months of age. Children between the ages of 36 and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. XI. BILLING AND CLAIMS GENERAL BILLING GUIDELINES For additional information concerning core services and limitations, please refer to the Advicare Policy and Procedures manual, or provider manuals for the applicable area (Physicians, Hospitals, etc.) Provider agrees to accept as payment in full for Medically Necessary Core Benefits to Members the applicable reimbursement schedules(s) set forth in their agreement with Advicare, or Provider’s actual billed charges, which is less. Unless otherwise specified by in writing by the parties, Advicare shall submit payment to the name and address of Provider specified on the signature page of this Agreement. Provider shall bill Advicare at the address noted on the Member’s ID card for Core Benefits to Advicare within three hundred sixty-five (365) days of performing the Core Benefits. Claim Filing Guidelines Advicare is required by State and Federal regulations to capture and report specific data regarding services rendered to its members. All services rendered, including capitated encounters and Fee-ForService claims, must be submitted on the CMS 1500 (HCFA 1500) or UB-04 claim form, or via electronic submission in a HIPAA compliant 837 or NCPDP format. Advicare follows South Carolina Medicaid billing requirements. Advicare prefers that claims are filed electronically and this will ensure that claims are paid as quickly as possible. 28 Claims for billable services provided to Advicare members must be submitted by the provider that rendered the services. Claims filed with Advicare are subject to the following procedures: • Verification that all required fields are completed on the claim • Verification that all diagnosis codes, modifiers and procedure codes are valid for the date of service • Verification of member's eligibility for services under Advicare during the time period in which services were provided • Verification that the provider has been given approval for services that require prior authorization by Advicare • Advicare is the "payer of last resort" on all claims submitted for members of its health plan. Providers must verify whether the member has Medicare coverage or any other third party resources and, if so, submit an EOB from the primary and/or secondary payer as appropriate • Prior authorization is required for all out of network office visits When data elements are missing, incomplete, invalid or coded incorrectly, Advicare cannot process the claim. NOTE: Rejected claims are defined as claims with invalid or missing data elements, such as the National Provider Identification Number (NPI), that are returned to the submitter or EDI source without registration in the claim processing system. Since these claims are not recorded in the claim system, the provider must resubmit corrected claims within 180 calendar days from the date of service. This guideline applies to claims submitted on paper or electronically. Rejected claims are different than denied claims, which are registered in the claim processing system but, do not meet requirements for payment under Advicare guidelines. BILLING A MEDICAID ADVICARE MEMBER Provider may only bill a Medicaid Advicare Member under the following conditions: 1. When Provider renders services that are non-covered services and are not Additional Services, as long as the Provider: • Provides to the Medicaid Advicare Member a written statement of the services prior to rendering said services, which must include: The cost of each service(s) - • 2. An acknowledgement of Medicaid Advicare Member’s payment responsibility, and Obtains Medicaid Advicare Member’s signature on the statement. When the service provided has a co-payment, as allowed by the Advicare, Provider may charge the Medicaid Advicare Member only the amount of the allowed co-payment, which cannot exceed the co-payment amount allowed by SCDHHS. 29 Mailing Addresses Submit claims, or claim appeals, oral or written for all medical services to Advicare: Advicare Attention: Claims Dept., P O Box 5547, Hauppauge, NY 11788 Requests for appeals or adjustments may be submitted by telephone by calling toll free (888) 7814371 or sent via fax toll free (888) 781-4316. NOTE: Please be sure to use the Advicare Adjustment and Appeal Form (Exhibit H1) for all requested appeals. This form can be found on the website under the “Provider Communication and Forms” link at www.Advicarehealth .com. Administrative appeals must be submitted in writing to: Advicare Attention: Appeals 531 South Main Street, Suite RL-1 Greenville, SC 29601 Medical appeals must be submitted in writing to: Advicare Attention: Appeals 531 South Main Street, Suite RL-1 Greenville, SC 29601 NOTE: Be sure to include the member's Advicare Identification Number on all claims, this number is also the member’s Medicaid identification number. TIMELY FILING GUIDELINES Original claims must be submitted to Advicare within 365 calendar days from the date of service. Resubmission of previously denied claims with corrections and requests for adjustments must be submitted within 180 calendar days from the date of remittance. ELECTRONIC FUNDS TRANSFER (EFT) Advicare and Emdeon Business Services have partnered to offer you direct deposit for your claims payment. Health care professionals/providers interested in receiving electronic payments through Emdeon may get additional information through the Emdeon website, www.Emdeon.com/epayment or by contacting Advicare Provider Relations Department toll free at (888) 781- 4371 . XII. QUALITY IMPROVEMENT QUALITY IMPROVEMENT PROGRAM Advicare has designed a provider centric system and quality-based program for the support of the provider network and the monitoring and evaluation of proper quality and utilization of services. This program is the Quality Improvement Plan (QIP) and is also designed to comply with applicable quality standards, including those of the Centers for Medicare and Medicaid Services’ (CMS) Quality Improvement System for Managed Care (QISMC), and the need and requirements of Federal and State authorities that conduct oversight. The purpose of the QIP is to develop a systematic process to monitor and evaluate provider service utilization and progress on the Managed Care Organization program. In addition, the QIP will identify quality indicators, monitor, and measure, evaluate, and then provide a quantitative basis for continuous improvement of outcomes and the care process through which these 30 outcomes are achieved. The QIP seeks to define the quality of services by assessing the following components deemed integral to the quality of all healthcare services: • • • • • • • • • • Appropriateness and Necessity of Services Access to and Availability of Care Timeliness of Service Case and Disease Management Utilization Management / Use of Services Health Education for Members Preventative Services Health Care System Stability Prudent Management of Healthcare Resources Member and Provider Satisfaction QUALITY IMPROVEMENT PROGRAM STRUCTURE To ensure continuity of operations within Advicare and ensure the execution of the QIP, the following guidelines apply: • The Executive Manager’s appointment by the Board of Directors will be reflected in the Board of Director’s proceeding and minutes • The Board of Directors will be apprised of the absences of the Executive Manager in writing and the temporary appointment of a designee as the acting Executive Manager for Advicare. • The Medical Director shall be licensed in South Carolina. Through participation as chairman of the Quality Management and its subcommittees, the Medical Director will demonstrate active participation in the development of related policies and procedures. • In the absence of the Medical Director, a duly licensed physician, authorized to practice in South Carolina will be designated in writing to fulfill the role and obligations of the Medical Director with the approval of the President and the Board of Directors. • The Quality Management Committee and all subordinate committees will perform under the supervision of the Medical Director. QUALITY IMPROVEMENT PROGRAM GOALS AND OBJECTIVES • To provide and maintain the highest standard and quality of healthcare. • To assure compliance with all local, federal, and contractual regulations. • To continuously identify new areas for improvement of the delivery of healthcare and services for our members. • To assess the impact of Case and Disease Management and health education on the quality of for our members as well as sound resource management practices for Advicare. • To ensure that the quality of care and healthcare services provided meets professionally recognized standards of practice. • To promote the advancement of quality management and delivery of services through continued analysis, education, and resource management. life 31 • To provide a systematic approach for monitoring the appropriateness of the delivery of care so to ensure that the healthcare provided results in optimal outcomes for the members of Advicare. • To assess the medical necessity of all care as well as ensuring optimal utilization practices. • To evaluate and ensure significant community, consumer, and provider satisfaction. • To communicate the results of our quality activities with the employees and providers of Advicare Health. • To assess the impact of wellness programs and preventative care on the prevention of disease resource management. • To identify member specific needs, taking into consideration unique demographics, assessed special and cultural needs, and preference. • To evaluate and improve accessibility and timeliness of all care and services provided to Advicare members. confidence as and and QUALITY IMPROVEMENT PROGRAM SCOPE The Quality Improvement Program is integrated into clinical and non-clinical services involved with care for Advicare patients. The QIP will assess the impact of Case and Disease Management and health education on the quality of life for our members as well as sound resource management practices for Advicare patients, health care providers and affiliated providers. The program is designed to monitor, evaluate, and continually improve all care and services delivered by Advicare providers. These services include: • • • • • • • • • Primary Care Services Specialist Physicians Advanced Practice Nurses Pharmacy Services Home Health Services EPSDT Pregnancy Related services (all family planning, prenatal, perinatal and postpartum care) Case Management Services Diabetes Care Services • • • • • • • • • • • • • • • • Dental Services for Children Inpatient Hospital Services Outpatient Hospital Services Diagnostic Testing Laboratory Testing Nursing Facility Services Outpatient Rehabilitation Services Inpatient Rehabilitation Services Dialysis Blood and Blood Products Mental Health Services Substance Abuse Services Emergency Services Services for speech, language, and hearing for children less than 21 years old Health Education Programs Transportation Services (non-emergency and emergency) 32 • • • • • • • • Podiatry Services Vision Services Day Treatment Services Personal Care Services Durable Medical Equipment (DME) Disposable Medical Supplies (DMS) Long Term Care Services Transplants PRACTITIONER INVOLVEMENT Advicare recognizes the integral role practitioner involvement plays in the success of its quality improvement program. Practitioner involvement in various levels of the process is highly encouraged through provider representation. Advicare encourages PCP, Behavioral Health, Pediatrics, OB/GYN representation on key quality committees and select ad-hoc committees. HEALTH CARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of the SCDHHS contract. SCDHHS holds Advicare accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc.) delivered to its diverse membership. HEDIS consists of 20+ Effectiveness of Care type measures as well as Access to Care and Use of Services measures for which the health plan contractually reports rates to the State of South Carolina based on claims and/or medical record review data. As both the State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a Health Insurance Company’s ability to demonstrate an improvement in Preventive Health outreach to its members. Physician specific scores are being used as evidence of preventive care from primary care office practices. The rates then serve as a basis for physician incentive programs such as ‘pay for performance’ and ‘quality bonus funds’. These programs pay providers an increased premium based on scoring of such quality indicators used in HEDIS. How are HEDIS rates calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of highblood pressure, immunizations, prenatal care, and well-child care. What can be done to improve my HEDIS scores? Understand the specifications established for each HEDIS measure. Submit claim/encounter data for each and every service rendered. All providers must bill (or 33 report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation. Chart documentation must reflect the services provided. If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact Advicare’ Quality Improvement Department toll free at (888)-781-4371. CONSUMER ASSESSMENT (CAHPS) SURVEY OF HEALTHCARE PROVIDERS AND SYSTEMS This is a member satisfaction survey that is included as a part of HEDIS and NCQA accreditation. It is a standardized survey administered annually to members by an NCQA certified survey vendor. The adult CAHPS survey provides information on the experiences of Medicaid members with the Advicare services and gives a general indication of how well the Advicare meets members’ expectations. Global rating questions reflecting overall satisfaction include rating of personal doctor and rating of specialist seen most often. Composite scores summarize responses in key areas such as getting care quickly, getting needed care, how well doctors communicate, and shared decision making. The child CAHPS survey looks at the same global and composite areas but provides information on parents’ experience with Advicare services. Member responses to the CAHPS survey are used in various aspects of the quality program including monitoring of practitioner access and availability. PROVIDER SATISFACTION SURVEY Advicare conducts an annual provider satisfaction survey which includes questions to evaluate provider satisfaction with our services such as claims, communications, utilization management, and provider services. The survey is conducted by an external vendor. Participants are randomly selected by the vendor, meeting specific requirements outlined by Advicare, and the participants are kept anonymous. We encourage you to respond timely to the survey as the results of the survey are analyzed and used as a basis for forming provider related quality improvement initiatives. AUTHORITY AND RESPONSIBILITY The Advicare Compliance Officer has overall responsibility and authority for carrying out the provisions of the compliance program. Advicare is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse. The Advicare provider network must 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. These are the primary agencies to which incidents or practices of abuse and/or fraud are to be reported: ADVICARE Attention: Compliance Officer 531 South Main Street, Suite RL1 Greenville, SC 29601 Toll free 1-888-781-4371 SCDHHS 34 Department of Fraud P.O. Box 8206 Columbia, SC 29202-8206 Toll free 1-888-364-3224 Provider Initiated Grievance Providers may file a grievance if the Provider has a concern regarding issues such as: • • • • General dissatisfaction Difficulty getting through on the telephone Complaints about a member Claims resolution A provider may file a grievance both orally or in writing by contacting Advicare at the number listed below or by sending a written grievance to Advicare at the address listed below: ADVICARE Attention: Manager, Appeals and Grievances 531 South Main Street, Suite RL1 Greenville, SC 29601 Toll free 1-888-781-4371 XIII. MEMBER SERVICES MEMBER SERVICES Advicare is committed to providing its members with information about the health benefits that are available to them through the Advicare program. Advicare encourages members to take responsibility for their healthcare by providing basic information to assist with making decisions about their healthcare choices. Other functions of the member services department: • • • Provide additional information about Advicare providers, Facilitate referrals to providers; and Assist in the resolution of service and/or medical delivery concerns or problems. Advicare has developed targeted programs to address the needs of its members. Members receive specific disease management bulletins and treatment updates, appointment reminder cards, and informational mailings. As a provider for Advicare, please remember that it is your obligation to identify any member who 35 requires translation or interpretation language services. Advicare will pay for these services whenever you need them to effectively communicate with an Advicare member. Advicare members are not to be held liable for these services. To arrange for any of the above services, please call the Advicare Member Services Department: Toll Free 1-888-781-4371 MEMBER MATERIALS Members will receive various pieces of information from Advicare through mailings and through face-to-face contact. The Member Handbook is printed in English and Spanish and can be requested in other languages identified by the state. These materials include: • • • • • • Quarterly Newsletters Targeted Case and Disease Management Brochures Provider Directory Nurse Response Information Emergency Room Information Member Handbook which includes Member rights and responsibilities Providers interested in receiving any of these materials may contact: Member Services Department Toll Free 888-781-4371 Fax Toll Free 888-781-4316 TDD/TTY Toll Free 888-357-7188 www.Advicarehealth.com MEMBER RIGHTS & RESPONSIBILITIES Members are informed of their rights and responsibilities through the Member Handbook. Advicare providers are also expected to respect and honor member’s rights. Below are the member rights that are given to Advicare member’s upon enrollment: 1. To be treated with respect and with due consideration for his or her dignity and privacy. 2. To participate in decisions regarding his or her healthcare, including the right to refuse treatment, as well as, the right to receive information on available treatment options. 3. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in the federal regulations on the use of restraints and seclusion. 4. To be able to request and receive a copy of his or her Medical Records, and request that they be amended or corrected. 5. To receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid FFS and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished. 36 6. To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition. 7. To receive all information including but not limited to Enrollment notices, informational materials, instructional materials, available treatment options, and alternatives in a manner and format that may be easily understood. 8. To receive assistance from both SCDHHS and Advicare in understanding the requirements and benefits of the plan. 9. To receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent. 10. To be notified that oral interpretation is available and how to access those services. 11. As a potential member, to receive information about the basic features of managed care; which populations may or may not enroll in the program and Advicare’s responsibilities for Coordination of Care in a timely manner in order to make an informed choice. 12. To receive information on Advicare’s services, to include, but not limited to: a) Benefits covered b) Procedures for obtaining benefits, including any authorization requirements c) Any cost sharing requirements d) Service Area e) Names, locations, telephone numbers of and non-English language spoken by current contracted Providers, including at a minimum, primary care physicians, specialists, and hospitals. f) Any restrictions on member’s freedom of choice among network Providers. g) Providers not accepting new patients. h) Benefits not offered by Advicare but available to members and how to obtain those benefits, including how transportation is provided. 13. To receive a complete description of Disenrollment rights at least annually. 14. To receive notice of any significant changes in the Benefits Package at least thirty (30) days before the intended effective date of the change. 15. To receive information on the Grievance, Appeal and Fair Hearing procedures. 16. To receive detailed information on emergency and after-hours coverage, to include, but not limited to: a) What constitutes an Emergency Medical Condition, emergency services, and PostStabilization Services? b) That Emergency Services do not require Prior Authorization. c) The process and procedures for obtaining Emergency Services. d) The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered under the contract. e) Member’s right to use any hospital or other setting for emergency care. f) Post-Stabilization care Services rules as detailed in 42 CFR §422.113(c). 17. To receive Advicare’s policy on referrals for specialty care and other benefits not provided by the member’s PCP. 18. To have his or her privacy protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are applicable. 19. To exercise these rights without adversely affecting the way Advicare, its Providers, or SCDHHS treat the members. Advicare members are expected to do the following: ♦ Be familiar with Advicare’s procedures to the best of your ability ♦ Call or contact Advicare to obtain information and/ or have questions clarified. ♦ Choose a personal doctor from the Advicare Network of Primary Care Physicians (PCP). ♦ Get your primary medical care through the Advicare list of participating primary doctors 37 ♦ Carry your SC Healthy Connections (Medicaid) card along with your Advicare ID card with you when obtaining health care services. ♦ Give Advicare and your personal doctor the information they need to care for you and provide participating network providers with accurate and complete medical information. ♦ Inform Advicare of any changes such as: Change of address or telephone number. Change of name Death of a family Member. New additions to their family, such as a baby. Availability of other insurance coverage. A move to somewhere outside of the South Carolina. ♦ Inform Advicare how we can work better for you. ♦ Inform Advicare of the loss or theft of your Advicare or SC Healthy Connections ID cards. ♦ Keep your doctor’s appointments or call to cancel at least 24 hours in advance; make every effort to keep any agreed upon appointments. ♦ Whenever you visit the doctor’s office, tell the doctor you are a Member of Advicare. Ask questions and talk with your doctor about your health, and listen to what the doctor tells you ♦ Follow the prescribed treatment plan recommended by the provider or letting the provider know the reasons the treatment cannot be followed, as soon as possible. ♦ Access Preventive Care services ♦ Know what an emergency is, how to keep emergencies from happening, and what to do if one does happen. ♦ Know the difference between a true emergency and a condition needing urgent care. ♦ Treat Advicare employees and providers with respect. CORE BENEFITS Co-Payments Some adult members will need to pay a small amount (co-payment) for the following services. Amount Type of Service $1.15 per date of service Chiropractor $3.30 per date of service Ambulatory Surgical Center Federally Qualified Health Center (FQHC) Home Health Optometrist Physician Office Visit- (Physician/Nurse Practitioner) Rural Health Clinic (RHC) $3.40 per date of service *Durable Medical Equipment and Supplies Dental 38 Pharmacy (per prescription/refill) (Copay will apply to ages 19 and above only) $3.40 per claim Outpatient Hospital (Non-emergency) $25.00 per admission Inpatient Hospital There will be no co-payment for children less than 19 years of age, pregnant women, and individuals receiving emergency services or federally recognized Native Americans. * Includes: doctors, nurse practitioners, licensed midwifes and optometrists. A Medicaid beneficiary may not be denied services if they are unable to pay the co-payment at the time the service is rendered, however this does not relieve the beneficiary of the responsibility for the co-payment. It is the provider’s responsibility to collect the co-payment from the beneficiary to receive full reimbursement for a service. Pursuant to federal regulations, the following beneficiaries are excluded from copayment requirements: children under the age of 19, pregnant women, institutionalized individuals (such as persons in a nursing facility or ICF-MR), and members of a Federally Recognized Indian Tribe (for services rendered by the Catawbas Service Unit in Rock Hill, SC and when referred to a specialist or other medical provider by the Catawbas Service Unit). Additionally, the following services are not subject to a copayment: Medical equipment and supplies provided by DHEC; Orthodontic services provided by DHEC; Family Planning services, End Stage Renal Disease (ESRD) services, Infusion Center services, Emergency services in the hospital emergency room, Hospice benefits and Waiver services. Please call member Services at toll free 888-781-4371 if you questions concerning co-payments. Services Covered by Advicare: Some of the covered services may require a Prior Authorization, if you have any questions, please contact Provider Services toll free (888) 781- 4371. Covered Service Ambulance Transportation Ancillary Medical Services Description These trips may be routine or non-routine transports and will provider stretcher trips, air ambulance, and Medivac transportation These services include, but are not limited to: * Pathology * Radiology * Emergency Medicine * Anesthesia Actions Call 911 if there is an emergency 39 Audiological Services Services include diagnostic testing, screening, preventive and/or corrective services for hearing disorders or for determining if you have a hearing disorder under the direction of an Audiologist. Get a referral from your PCP or other Licensed Health Care Professional of the Healing Arts (LPHA). This benefit only covers members under the age of 21. Chiropractic Care Chiropractic services are available to all members. Make an appointment with a participating an Advicare partipating chiropractor. Services are limited to 6 visits each year. Communicable Disease Services include services to help control and prevent diseases such as tuberculosis (TB), syphilis, other sexually transmitted diseases (STDs) and HIV/AIDS. Services include exams, assessments, diagnostic procedures, health education/counseling, treatment, and contact tracing. Seek care from any public health agency or make an appointment with your PCP Disease Management Disease management is comprised of all activities for members with special healthcare needs to coordinate and monitor their treatment for specific identified chronic/complex conditions and diseases, as well as educate members to maximize appropriate selfmanagement. Covered Service Description Durable Medical Equipment Durable Medical Equipment (DME) is equipment that provides therapeutic benefits and enables a member to perform certain task he or she would otherwise be unable to undertake due to certain medical conditions and/or illness. Services include medical products, surgical supplies and equipment when ordered by a physician as medically necessary in the treatment of a specific medical condition. Early & Periodic Screening, diagnosis, and Treatment (EPSDT) /Well-child) Visit Visits for your regular medical checkups from birth to age 21 at your assigned Primary Care Physician (PCP) that you chose from the Advicare Provider Directory. These visits may include immunizations (shots). Actions Make an appointment with your PCP. 40 Family Planning This service is a health care service available to help prevent unplanned pregnancies. This service provides any examinations, assessments, diagnostic procedures, health education and counseling services related to alternative birth control and prevention prescribed by physician, pharmacies, hospitals, and clinics. As a member, you have the freedom to receive Family Planning Services from any appropriate Medicaid Providers without restrictions, this includes your PCP. Hearing Aids and Hearing Aid Accessories The Hearing Aids and accessories will be considered a DME This benefit only covers members under the age of 21. Home Health Services Healthcare services that are delivered to your home. Home health services include intermittent skilled nursing, home health aides, physical, occupational, and speech therapy. Get a referral from your PCP. You must visit an in-network provider. These services are not cover when given in nursing homes and institutions. Adult members age 21 years and older are limited to 50 visits per year. Independent Lab and x-rays Services Services ordered by a doctor and provided by independent laboratories and x-ray facilities. Inpatient Services Services that are rendered via medical and/or behavioral services provided under the direction of a doctor if you are admitted to a hospital when the stay is expected to last more than 24 hours. Includes room and board, miscellaneous hospital services, medical supplies and equipment. All Inpatient Services will require prior approval 41 Covered Service Description Outpatient Pediatric Aids Clinics Services (OPAC) OPAC operates exclusively for the purpose of providing specialty care, consultation and counseling services for HIV infected and exposed Medicaid children and their families. Outpatient Services Services include preventive diagnostic, therapeutic, rehabilitative, surgical and emergency services received for the treatment of a disease or injury at an outpatient/ambulatory care facility for a period of time under 24 hours Physician Services Physician services include the full range of preventive care services, Primary care medical services, and physician specialty services. Prescriptions Prescriptions and Over-the-counter drugs are limited to 4 medicines per month (There is a maximum 31-day supply for each medicine). An additional 3 medicines (per month) can be covered. To get additional medicines a prescription override will have to be approving by Advicare. Generic medicine and supplies will be provided when available. For adults ages 21 and older, there is no limits applied to certain drugs, insulin syringes and associated supplies. Please refer to the PDL for a list of Advicare's approved medications. Some medicines on the list will require Prior Approval. Preventive and Rehabilitative Services for Primary Care Enhancement (PSPCE/RSPCE) These services are available to Medicaid member that has medical risk factors. PSPCE/RSPCE includes activities related to medical/dental plan of care to promote changes in behavior, improve health status, develop healthier practices by building client and/or care giver self-sufficiency, and promote appropriate use of primary medical care. Psychiatric Services These services include assessments, treatment plan development, and modification, and therapy services. Actions Comprehensive neurodevelopment and/or psychological development assessment and testing services are covered for children under the age of 21. Take your prescription(s) to an Advicare participating pharmacy. Present your Advicare and Medicaid ID cards. Call Member Services for complete information about covered medicines, the appeal process, or a complete list of participating pharmacies. These services are limited to a maximum of 1 assessment per member every 6 months. 42 Covered Service Description Rehabilitative Therapies for Children- Non-Hospital Based Under these services, Advicare provides a wide range of therapeutic services available to individuals under the age 21 who have sensory impairments, mental retardation, physical disabilities, and/or developmental disabilities or delays. This benefit covered Private Providers that are rendering Rehabilitative Therapy Services to include: (1) Speech-language Pathology (2) Audiology (3) Physical and Occupational Therapies (4) Nursing Services for children under 21 years of age. Transplant and Transplant Related Services This service will require approval before being performed. Depending on the service and transplant, coverage may be provided by Advicare or by Medicaid. Advicare Transplant benefits covers: * All services for corneal transplants * Services before and after a kidney transplant and other transplants. Vision Care Children under 21 years can get 1 comprehensive eye exam each year and one pair of eyeglasses with no co-pay. Call Member Services for a list of Advicare providers. Substance Abuse Services Covers services administered through Department of Alcohol and Other Drug Abuse Services (DAODAS) Actions Advicare providers do not require prior authorization. Providers NOT in the Advicare network require prior authorization Please contact Provider Services toll free (888) 781-4371 for a complete list of services provided by either Advicare or Medicaid. Services not covered by Advicare or Medicaid are non-covered services. 43 Services Covered by Medicaid Fee-for-Service: The services detailed below are those services which will continue to be provided and reimbursed by the current Medicaid program and are consistent with the outline and definition of covered services in the Title XIX SC State Medicaid Plan. Payment for these services will remain fee-for-service. MCOs are expected to be responsible for the Continuity of Care for all Medicaid MCO Members by ensuring appropriate referrals and linkages are made for the Medicaid MCO Member to the Medicaid fee-for-service Provider. Covered Service by Medicaid FFS Description Actions Mental Health Authorized or Provided by State Agencies Mental health services authorized or provided by a state agency are reimbursed by Medicaid fee-for-service. Such services require a unique authorization number issued by the state agency to ensure the claim is appropriately adjudicated by SCDHHS. Advicare will coordinate the referral of Members for services that are outside of the required Core Benefits. Medicaid Providers. These services are consistent with the outline and definition of Covered Services in the Title XIX SC State Medicaid Plan. These services include, but are not limited to, Targeted Case Management services, intensive family treatment services, therapeutic day services for children, out-of-home therapeutic placement services for children, inpatient psychiatric hospital and residential treatment facility services. 44 Covered Service by Medicaid FFS Description Actions Medical (Non-Ambulance) Transportation Medical non-ambulance transportation is defined as transportation of the Beneficiary to or from a Medicaid Covered Service to receive medically necessary care. This transportation is only available to Eligible Beneficiaries who cannot obtain transportation on their own through other available means, such as family, friends or community resources. Advicare staff will communicate directly with the brokers to ensure services are arranged, scheduled, and fulfilled as required for a Medicaid MCO Member’s access to Medicaidcovered services. These services are paid fee-for-service. Advicare shall assist the Member in obtaining medical transportation services through the SCDHHS Enrollment broker system as part of its Care Coordination responsibilities, as detailed below. BrokerBased Transportation (Routine NonEmergency Medicaid Transportation) These are transports of Medicaid MCO Members to Covered Services as follows: • Urgent transportation for Medicaid MCO Member trips and urgent transportation for follow-up medical care when directed by a medical professional • Unplanned or unscheduled requests for immediate transportation to a medical service when directed by a medical professional (i.e., pharmacy, hospital discharge) Routine non-Emergency transportation to medical appointments for Eligible Medicaid MCO Members (Any planned and/or scheduled transportation needs for Medicaid Beneficiaries must be prearranged via direct contact with the regional brokers) • Non-Emergency transports requiring BLS that are planned/scheduled transports to a scheduled medical appointment (i.e., transport from nursing home to physician’s office, nursing home to dialysis center or hospital to residence) • Non-Emergency wheelchair transports that require use of a lift vehicle and do not require the assistance of medical personnel on board at the time of transport to medical appointments for Eligible Beneficiaries (These transports do not require the use of an ambulance vehicle.) Vision Care Services Advicare Members age 21 and older may only receive vision services when those services are identified as being Medically Necessary and not routine care. 45 Covered Service by Medicaid FFS Description Actions Dental Services Routine and emergency dental services are available to Medicaid MCO Members under the age of 21. The dental program for Medicaid MCO Members under age 21 is administered by the SCDHHS dental broker, DentaQuest. Dental services are a non-covered benefit for Advicare Members age 21 and over. Dental services for Medicaid MCO Members age 21 and over covered by SCDHHS on a fee-forservice basis are limited to dental procedures performed for the following medical reasons; Organ Transplants, Oncology: Radiation of the head and/or neck for cancer treatment, Chemotherapy for cancer treatment, Total Joint Replacement and Heart Valve Replacement Targeted Case Management (TCM) Services Targeted Case Management (TCM) consists of services which will assist an individual eligible under the State plan in gaining access to needed medical, social, educational, and other services. Home- and CommunityBased Waiver Services Home- and community-based waiver services target persons with long-term care needs and provide Beneficiaries access to services that enable them to remain at home rather than in an institutional setting. Pregnancy Prevention Services – Targeted Populations The Medicaid program provides reimbursement for pregnancy prevention services for targeted populations through state and community Providers. The Medicaid Program will reimburse fee-forservice directly to enrolled Medicaid Providers for these services. 46 MAPPS Family Planning Services Medicaid Adolescent Pregnancy Prevention Services (MAPPS) provide Medicaid funded Family Planning Services to at-risk youths. Covered Service by Medicaid FFS Description Actions Developmental Evaluation Services (DECs) Developmental Evaluation Services (DECs) are defined as Medically Necessary comprehensive neurodevelopment and psychological developmental, evaluation and treatment Services for Beneficiaries between the ages of 0 to 21 years. DECs are provided by one of the three tertiary level facilities located within the Departments of Pediatrics at the Greenville Hospital System, Greenville, SC; The University of South Carolina School of Medicine, Columbia, SC; or the Medical University of South Carolina a Charleston, SC. Pediatric day treatment, when rendered by DECs, is considered as one of the DEC treatment services. Please contact Provider Services at 888-781-4371 for a complete list of services provided by either Advicare or Medicaid. Services not covered by Advicare or Medicaid are non-covered services. MEMBER GRIEVANCES A grievance is an expression of dissatisfaction about any matter other than an “action” with any aspect of Advicare or a provider's operation. Examples: • Quality of care issues • Rudeness of a provider or employee • Failure to respect the member’s rights Who has the authority to file? • • A member or member’s authorized representative A provider, acting on behalf of the member (must obtain written authorization from the member) Grievances may be filed either orally or in writing with Advicare. Advicare will notify the member or authorized representative that the grievance has been received in writing within 5 business days of receipt of the grievance. Members or their authorized representative may file a grievance by contacting Member Services toll free-888-781-4371 or by submitting written notification to: Advicare Appeals/Grievances Coordinator 531 South Main Street, Suite RL-1 Greenville, SC 29601 47 Advicare will resolve all grievances within 90 calendar days from the receipt of the grievance. A member, provider, authorized representative, or Advicare can request an extension for up to 14 calendar days. Advicare will have to submit the extension request to SCDHHS. If approved, Advicare will send a letter to the requestor advising the extension. Once the grievance has been resolved, Advicare will send a resolution letter to the requestor advising of Advicare’s actions taken within 5 days of the determination. APPEALS An appeal is the request for review of an “action”. An “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 • the failure to provide services in a timely manner, as defined by the State • the failure of an ADVICARE or PIHP to act within the timeframes stated in the Code of regulations • for a resident of a rural area with only one ADVICARE, the denial of a Medicaid enrollee’s request to exercise his or her right, to obtain services outside the network. An appeal review may be requested orally or in writing in which both are handled in the same manner and is resolved within 30 calendar days Who may file an Appeal? • Advicare members • Authorized representative of an Advicare member • Provider acting on behalf of member Requests for an Appeal must be made within ninety (90) calendar days from the date of the Notice of Proposed Action. A member, provider, authorized representative, or Advicare can request an extension for up to 14 calendar days. Advicare will submit extension request to SCDHHS for approval. If approved, Advicare will send a letter to the requestor advising the extension. Advicare will send a written decision within thirty (30) calendar days from the date of receipt of an appeal. EXPEDITED RESOLUTION OF APPEALS If a decision on an appeal is required immediately due to the member’s health needs which cannot wait with the standard resolution time, an expedited appeal may be requested. Advicare’ decision on the expedited resolution will be provided within 3 business days of receipt of the request for the review. ***NOTE** Under certain circumstances, members have the right to request, within 10 days of the date of the Notice of Action, that benefits be continued while an appeal is pending. CONTINUATION OF BENEFITS Advicare members may continue receiving services or items until a decision is made about his/her appeal or fair hearing process if the member was receiving ongoing services that were suspended, reduced or terminated. Advicare must continue the member’s benefits if: • The member or the provider files the appeal timely 48 • • • • The appeal involves the termination, suspension, or reduction of a previously authorized course treatment The services were ordered by an authorized provider The original period covered by the original authorization has not expired; or The member requests an extension of benefits of If the member request to continue his/her benefits while the appeal is pending, Advicare will continue or reinstate the member’s benefits until one of the following occurs: • The member withdraw the appeal • Ten (10) calendar days pass after Advicare mails the notice providing the resolution of the Appeal against the member • A State Fair hearing officer issues a hearing decision adverse to the member • The time period or service limits of a previous authorized services has been met. Member’s responsibility for services furnished while the appeal is pending • If the final resolution of the appeal is adverse to the member and Advicare’s decision is upheld, Advicare may recover the cost of the services furnished to the member while the Appeal was pending ASSISTANCE AND CONTACTING ADVICARE Advicare Appeals and Grievance Coordinator is available to assist members who need help in filing a grievance or request for appeal or in completing any element in the grievance or appeal process. Members may seek assistance or initiate a grievance or request for appeal by calling toll free-888-781-4371 (or TDD/TTY toll free-888-357-7188). MEMBERS RIGHT TO STATE FAIR HEARING If the member has exhausted Advicare’s level appeal process, Advicare must notify the member by certified mail, return receipt of his or her right to request a State Fair hearing. . A member or member's authorized representative may request in writing a State Fair Hearing within thirty (30) calendar days from the date of the certified mail return receipt. The parties to the State Fair Hearing shall include Advicare, as well as the member, Member's Authorized Representative, or representative of a deceased member's estate. A provider can, with written consent from the member, request a State Fair Hearing on behalf of a member. The request for the State Fair Hearing should be mailed to: South Carolina Department of Health and Human Services Division of Appeals and Hearings P.O. Box 8206 Columbia, SC 29202-8206 1-803-898-2600 INTERPRETER/TRANSLATION SERVICES Advicare is committed to ensuring that staff and subcontractors are educated about, remain aware of, and are sensitive to the linguistic needs and cultural differences of its members. In order to meet this need, Advicare is committed to the following: • • Providing Language Line services that will be available twenty-four (24) hours a day, seven(7) Days a week in 140 languages to assist providers and members in communicating with each other when there are no other translators available for the language TDD/TTY access for hearing impaired members through toll free 888-357-7188. 49 • Advicare medical advice line, Nurse Response, provides 24 hour access, seven days a week for interpretation of Spanish or the coordination of non- English/Spanish needs via the Language Line • Providing or making available Member Services and Health Education materials in alternative formats as needed to meet the needs of the members, such as language translation; all alternative methods must be requested by the member or designee • Providers must call Member Services toll free 888-781-4371 if interpreter services are needed. Please have the member’s ID number; date/time service is requested and any other documentation that would assist in scheduling interpreter services. XIV. PROVIDER RELATIONS ASSISTANCE PROVIDER RELATIONS & CONTRACTING DEPARTMENTS The Provider Relations Department at Advicare is designed around the concept of making your experience with Advicare a positive one by being your advocate within Advicare. Provider Relations is responsible for providing the services listed below which include but are not limited to: • • • • • Contracting Maintenance of existing Advicare Provider Manual Eligibility distribution Development of alternative reimbursement strategies PMPM and shared savings updates/status • • • • Network performance profiling Individual physician performance profiling Physician and office staff orientation Ongoing provider education, updates, and training The goal of this department is to furnish you and your staff with the necessary tools to provide the highest quality of healthcare to Advicare enrolled membership. To contact the provider relations specialist for your area contact: Director of Provider Relations and/or designee will receive notification from Credentialing/Contracting Department of new Providers. Upon notification, The PR Department shall provide education for the provider. Provider Relations Department Toll Free 888-781-4371 Provider Relations staff is available to you and your staff to answer questions, listen to your concerns, assist with members, and respond to your Advicare inquiries New Provider Orientation Orientations for new offices must be scheduled within ten (10) days of the provider’s effective date. Orientations shall be completed within thirty (30) days of the effective date of the contract. In the event a new provider orientation cannot be completed within the thirty (30) day timeframe, it shall be documented in the contracting file and new provider orientation must be completed no later than sixty (60) days after the effective date of the contract. Ongoing Education and Training Primary Care Physicians (PCPSs) shall be trained on a quarterly basis or as requested by the PCP. Facilities, Hospitals and Specialists shall be trained on a yearly basis or as requested by the entity. Provider and their office staff will be educated on the following: Network contractual obligations as prescribed 50 in the Provider Service Agreement. Regulatory requirements and utilization management protocol as detailed in the Orientation presentation Provider Rights • Each Advicare care professional/provider shall be assured of the following rights: • A healthcare professional, acting within the lawful scope of practice, shall not be prohibited from advising or advocating on behalf of a member who is his/her patient, for the following: o o o o The member’s health status, medical care or treatment options, including any alternative treatment that may be self-administered. Any information the member needs in order to decide among all relevant treatment options. The risks, benefits and consequences of treatment or non-treatment. The member’s right to participate in decisions regarding his/her healthcare, including the right to refuse treatment and to express preferences about future treatment decisions. • To receive information on the grievance, appeal and fair hearing procedures. • To have access to Advicare’s policies and procedures covering the authorization of services. • To be notified of any decision by Advicare to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. • To challenge, on behalf of the Advicare members, the denial of coverage of, or payment for, medical assistance. • Advicare’s health care professional/provider selection policies and procedures must not discriminate against particular health care professionals/providers that serve high-risk populations or specialize in conditions that require costly treatment • To be free from discrimination for the participation, reimbursement, or indemnification of any Provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Right to review information • The organization must have written policies and procedures for notifying practitioners of their right to review information it has obtained to evaluate their credentialing application, attestation or CV. Evaluation of the credentialing application includes information obtained from any outside source (e.g., malpractice insurance carriers, state licensing boards), with the exception of references, recommendations or other peer-review protected information. Right to correct erroneous information • The organization must have written policies and procedures for notifying practitioners when credentialing information obtained from other sources varies substantially from that provided by the practitioner. • The organization is not required to reveal the source of information if the information is not obtained to meet organization credentialing verification requirements or if law prohibits disclosure. • Policies and procedures must state the practitioner's right to correct erroneous information submitted by another source, and include the following: o The time frame for changes. o The format for submitting corrections. o The person to whom corrections must be submitted. o Documentation of receipt of the corrections. o How practitioners are notified of their right to correct erroneous information. 51 Right to be informed of application status • The organization must have written policies and procedures for notifying practitioners of their right to be informed of the status of their application upon request, and must describe the process for responding to such requests, including information that the organization may share with practitioners. Credentialing and Recredentialing Program Description Overview of Program The Credentialing and Recredentialing Program of Advicare shall be comprehensive to ensure that its practitioners and providers meet the standards of professional licensure and certification. The process enables Advicare to recruit and retain a quality network of practitioners and providers to serve its members. It consistently and periodically assesses and evaluates a practitioner’s or provider’s ability to deliver quality care between credentialing or re-assessment cycles, and it emphasizes and supports a practitioner’s and provider’s ability to successfully manage the health care of network members in a cost-effective manner. The Credentialing Program enables Advicare to ensure that all practitioners and providers are continuously in compliance with Advicare policies and procedures, the SC Department of Health and Human Services (SCDHHS) policies and procedures, the Utilization Review Accreditation Commission (URAC) standards, the National Committee for Quality Assurance (NCQA) standards and any other applicable regulatory or accreditation entity. Advicare’s Board of Directors (the “Board”) has ultimate authority, accountability and responsibility for the credentialing evaluation process (the “Credentialing Program”). The Board has delegated full oversight of the Credentialing Program to the Credentialing Committee. The Credentialing Committee accepts the responsibility of administering the Credentialing Program, having oversight of operational activities, which include, but are not limited to making the final approval or denial decision on all practitioners and providers, as applicable. Credentialing Committee Structure & Activities The Medical Director is responsible for the oversight and operation of the Credentialing Program, and serves as Chairperson or may appoint a Chairperson, with equal qualifications. The Credentialing Committee is a peer-review body that includes representation from a range of participating practitioners including primary care (i.e., family practice, internal medicine, pediatrics, general medicine, obstetrics and gynecology) and specialty practice. Allied health representatives include mental health, rehabilitation, etc., and may be appointed to serve as non-voting members, on an ad hoc basis. Members may be appointed or requested to attend the meeting representing Advicare’s internal staff. • Receive and review the credentials of all practitioners being credentialed or recredentialed who do not meet the organization's established criteria, and to offer advice, which the organization considers. This includes evaluating practitioner files that have been identified as problematic (e.g., malpractice cases, licensure issues, quality concerns, missing documentation, etc.). • Review practitioner credentials and give thoughtful consideration to the credentialing elements before making recommendations about a practitioner's ability to deliver care. • Establish, implement, monitor, and revise policies and procedures for Advicare credentialing and recredentialing. • Report to the QIC and CQIC and other proper authorities, as required. • Annual Review of the credentialing program description, and other related objectives. • Credentialing activities can be performed by Advicare staff or a third party credentialing 52 organization at the discretion of Advicare with SCDHHS approval. ANNUAL REVIEWS Advicare conducts an annual review of the credentialing process to assess compliance with policies and procedures in accordance with Advicare standards, DHHS standards, and the standards set forth by URAC, NCQA and other applicable regulatory bodies. Additionally, Advicare conducts annual reviews on delegated vendors to assure that they are in compliance with Advicare, regulatory and accreditation standards and other applicable regulatory bodies. PROVIDER SANCTIONS Advicare has developed policies and procedures for credentialing activities including sanctioning practitioners or providers on issues of quality of care and service. Sanctions may include mandated continuing education, corrective action planning, probationary periods, and re-evaluation of the contract and/or the termination of the practitioner or provider from the network. The policies include an appeal process for practitioners and providers, which are communicated to them through a variety of media. Advicare also maintains procedures to guide reporting of serious quality concerns to the appropriate authorities. XV. PHARMACY COVERED PHARMACY SERVICES Prescription drug benefits are managed and administered through CVS Caremark. Monthly Prescription Limit Override Criteria for Adult Beneficiaries Pharmacists may utilize an override code to exceed the monthly prescription limit for adult Medicaid beneficiaries if the prescription limit override criteria are met. Pharmacists should submit the prescription limit override code, a “5” in the Prior Authorization Type Code (PATC) field, if all of the following criteria are met. Adult Medicaid beneficiaries are entitled to four prescriptions per month and up to three overrides for prescriptions that meet the following criteria. Pharmacists should submit the prescription limit override code on the claim if: • • • The monthly prescription limit has been met, and The adult patient has one of the following conditions, and The prescription is for an essential drug used in the adult patient’s treatment plan for one of these conditions: o o o o o o o o o o o o Acute sickle cell disease Behavioral health disorder Cancer Cardiac disease (including hyperlipidemia) Diabetes End stage lung disease End stage renal disease (ESRD) HIV/AIDS Hypertension Life-threatening illness (not otherwise specified) Organ transplant Terminal stage of an illness “If a pharmacist is uncertain as to the appropriateness of a prescription limit override for a particular medication, the pharmacist should contact the prescriber to obtain additional clinical information so that an 53 informed Medicaid coverage decision may be made”. DEFINITIONS Care Coordination – The manner or practice of planning, directing and coordinating health care needs and services of Medicaid ADVICARE Program Members. Coordination of Benefits – The method of determining primary responsibility for payment of Core Benefits under the terms of the applicable Evidence of Coverage and laws and regulations, when more than one payer may have liability for payment for services rendered to a Medicaid ADVICARE Member. Core Benefits – Schedule of health care benefits provided to Medicaid ADVICARE Members enrolled in plan as specified under the terms of this Agreement. Designated Provider means those subcontracted arrangements, capitated or otherwise, whereby certain specialty service or ancillary vendors and/or providers have assumed financial risk for the provision of certain Core Benefits rendered to Medicaid ADVICARE Members. Designated Services means that certain category or set of Core Benefits within a certain medical specialty that are made available by a Designated Provider. Evidence of Coverage – The term which describes services and supplies provided to Medicaid ADVICARE Members, which includes specific information on benefits, coverage limitations and services not covered. Healthcare Professional – A physician or any of the following: a podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech-language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse midwife), licensed certified social worker, registered respiratory therapist, certified respiratory therapy technician, or any other provider of healthcare services or products; with appropriate licensure or certification with the state of South Carolina. Imminent Harm – Circumstances involving (i) imminent harm to a Medicaid ADVICARE Member's health; (ii) fraud or misfeasance; or (iii) action by a state medical or other licensing board or other government agency that effectively impairs the ability of Provider to provide Core Benefits. Medicaid – The medical assistance program authorized by Title XIX of the Social Security Act. Other Payer – An entity or individual, other than PPC, that is financially responsible for payment for health care services provided to a Medicaid ADVICARE Member. Other Payer is applicable only when third party liability is appropriate. Participating Provider – A Healthcare Medicaid Provider which has entered into an agreement with PPC to provide Core Benefits to Medicaid ADVICARE Members. Post-stabilization services – Core Benefits, related to an emergency medical condition that are provided after a Medicaid ADVICARE Member is stabilized in order to maintain the stabilized condition, or improve or resolve the Medicaid ADVICARE Member’s condition. Prior Authorization – The act of authorizing specific approved services by the Provider before they are rendered. Advicare Provider Manual –The operational manual that serves as a source of information for Core Benefits, utilization review requirements and other policies, procedures and other information that will assist in ensuring contractual and regulatory compliance with the program. Provider Network–Advicare’s network of Participating Providers. 54 Quality – As related to external quality review, the degree to which an ADVICARE increases the likelihood of desired health outcomes of its members through structural and operational characteristics and the provision of health services consistent with current professional knowledge. Quality Assessment – The measurement and evaluation of success of care and services offered to individuals, groups or populations. SCDHHS – The South Carolina Department of Health and Human Services. SCDHHS ADVICARE Policy and Procedure Guide -The South Carolina Department of Health and Human Services guide that documents the medical and program policies and requirements implemented by the SCDHHS for ADVICAREs wishing to conduct business in South Carolina. Utilization Review – The functions, including Case Management, performed by PPC or any entity acting on behalf of PPC that has been duly authorized and/or licensed, as applicable, to review and determine whether Core Benefits provided, or to be provided, were or are Medically Necessary. 55 XVI. FORMS AND OTHER KEY INFORMATION Attachment A – Obstetrical Registration Form Attachment B – Disease/Case Management Request Form Attachment C – WIC Referral Form Attachment D – Medical Record Release Attachment E – Grievance Form Attachment F – Member Primary Care Provider Attachment G – Logisticare Information (Non-Emergent Transportation) Attachment H – Pharmacy Prior Authorization Form Attachment I – Immunization Schedule for Ages 0 – 18 Attachment J – Change Control Record 56 Attachment A – Obstetrical Registration Form Obstetrical Registration Form (please fax or email) Instructions 1. Complete the demographics section. : 2. Complete the clinical/social section. Check the trimester a condition or risk identified by the provider office (an unchecked box indicates that the risk was not identified). 531 South Main Street, Suite RL-1 3. Fax or Email to Care Management Dept at (888) 781-4316 or [email protected] Greenville, South Carolina 29601 Phone: (888)781-4371 Fax: (888) 781-4316 Member/Enrollee Name (First, Middle, Last) Date of Birth Provider Name (First, Last) Member/Enrollee ID# NPI or Provider Number Alternate Phone Home Phone Phone # Fax # Language Spoke Date of 1st Prenatal Visit Gravida Gestational age Para TAB Live Births wks EDC Hospital/Birthing Center for Delivery Past OB Complications Gestational Diabetes Incompetent cervix DIUGR Preeclampsia/Eclampsia Premature ROM Preterm delivery <32 wks Preterm delivery 32-36 wks Preterm labor <32 wks Previous C-Section Prior fetal loss (1 st )(2 nd)(3 rd) Infant or child death Current Risk Factors 2 nd/3 rd trimester bleeding Trimester 1st 2nd 3rd Current Risk Factors Anemia Hb <10 Abnormal placenta Asthma Gestational diabetes Cardiac ______________________________ Missed Prenatal Care Chronic hypertension Perinatal depression Oral problems: _________________ or N Dental visit past 6 mos? Y Excessive Weight gain Poor Disability ______________________________ Premature ROM Clotting disorder _____________________ Preterm dilation of cervix (>1.5cm) Previous delivery within 1 year Underweight BMI<19 Renal disease __________________________________ STI _______________________________ Preeclampsia/Eclampsia Sickle cell disease Tobacco Use HIV Hepatitis _________________________________ Thyroid disease ____________________________ Mental health disorder or Preterm Labor <32 weeks) Cessation Services Offered Domestic violence Street / Rx drug abuse History of chronic depression Depression screening Eating disorder _______________________________ Housing problems Diabetes Seizure disorder Obese BMI>30, Overweight BMI>25, Current Medication _______________________________________ ______________ Other medical issues: _______________________________________ _______________ List Referrals Made by Provider Teen pregnancy WIC Y Head of Household Aware Others: Transportation problems Other risks: N Trimester 1st 2nd 3rd Disease/Case Management Referral Form Medical record or most recent visit summary and SBIRT may be attached. Please fax completed form to 1-855-303-2427 or email to [email protected] Date: _________________Referred By: ___________________________________________________ Phone/Fax:__________________________________________ Member Name: _________________________________ DOB: ______________________________________ Member ID: ____________________________________ Phone: ____________________________________ Address: ___________________________________________________________________________________ Reason for Referral High Risk Obstetrics EDD: ________________ Pregnancy-induced hypertension Diabetes History of complication:__________________________ Confirmed psychosocial issues: _________________________ Other: _____________________________ Substance abuse, including tobacco use: __________________________________________________________ Screening Brief Intervention Referral Treatment (SBIRT) Please complete and submit with this referral. Catastrophic/Complex Events More than 3 ER visits per month More than 3 inpatients in 6 months Bariatric Surgery Readmission within 30 days for the same or similar diagnosis Transplant (type): ____________________________________________________________________________ Non-controlled lab data (attach labs):____________________________________________________________ Major trauma (MVA, TBI, GSW, etc.):_____________________________________________________________ Four or more chronic conditions (specify):________________________________________________________ Polypharmacy-30 or more prescriptions per quarter Suicide/Homicide risk within the last 6 months Psychosocial Risks-Check all that applies: Access to care Undomiciled Transportation Cost of Care Self-care deficit Fall risk Disease Management Asthma/COPD Pregnancy Diabetes Hypertension ESRD Behavioral Health (specify diagnosis):________________________ Orthopedic Substance Abuse (type): __________________________________ Special needs HIV/AIDS Vascular (specify diagnosis):_____________________ Cardiovascular (specify diagnosis): ______________ Oncology (stage, type): ________________________ Other: ____________________________________ 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 Attachment C – WIC Referral Form WIC REFERRAL FORM PL103-448, §204(e) requires States using managed care arrangements to serve their Medicaid beneficiaries to coordinate their WIC and Medicaid Programs. This coordination should include the referral of potentially eligible women, infants, and children and the provision of medical information to the WIC Program. To help facilitate the information exchange process, please complete this form and send it to the address listed below. Thank you for your cooperation. Name of Person being referred: Address: Phone: The following classifications describe the populations served by the WIC program. Please check the category that most appropriately describes the person being referred: Pregnant woman Woman who is breast feeding her infant(s) up to one year postpartum Woman who is non-breast feeding up to six months postpartum Infant (age 0-1) Child under age 5 States may consider using this space to either include specific medical information or to indicate that such information can be provided if requested by the WIC Program. Provider's Name: Provider's Phone: I, the undersigned, give permission for my provider to give the WIC Program any required medical information. _ (Signature of the patient being referred or, in the case of children and infants, signature and printed name of the parent/guardian) Send completed form to: WIC Program Contact Address Phone Number Please go to http://www.scdhec.gov/health/mch/wic/map.htm for the WIC Program Contact name, address and phone number for the Regional WIC site in your area. 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 Attachment D – Medical Record Release MEDICAL RECORD RELEASE I, the undersigned, give permission for my provider, acting on my behalf, to refer my name for WIC services and to release necessary medical record information to the WIC agency. Signature (Signature of patient being referred or, in case of children and infants, the signature and printed name of the parent/guardian) Date 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 Attachment E – Grievance Form ADVICARE GRIEVANCE FORM *Note: For reporting grievances regarding ADVICARE Providers ONLY Mail the completed, signed form to: Advicare 531 South Main Street, Suite 307 Greenville, SC 29601 Name of Person Completing this Form: (may be ADVICARE member, designated friend/family member, medical provider, hospital, community member, etc.) Relationship to Member: ADVICARE Member Name: Medicaid ID: Date Form Completed: DOB: County of Residence: Address: Telephone Number: Name of Doctor: Practice: Please describe your grievance in detail including dates/names. Please attach any additional documentation. 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 Continued (See Consent Statement and Signature) 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 ADVICARE GRIEVANCE FORM (Page 2) Advicare staff reviews all grievances that come to our office. We take each grievance seriously and have a process in place for addressing each one. It is not necessary for us to use your name when investigating a grievance. However, it is more effective to have your name when describing the concern to the provider. Therefore, we have included a place to sign your name on this form that will let us use your name when investigating your grievance. Please do not sign both statements. If you agree to allow us to use your name in investigating this grievance, please sign the following: I give the SC ADVICARE Managed Care staff permission to use my name when sharing my grievance with the Primary Care Provider (PCP) named in my grievance. The PCP has my permission to respond to the SCADVICARE staff concerning my grievance and release medical records regarding the patient when necessary. Signature of Complainant Date Signature of Patient/Parent/Legal Guardian Date of Birth OR If you would like your name to remain confidential and you do not want us to use your name in the investigation of this grievance, please sign below: Signature of Complainant Date Signature of Patient/Parent/Legal Guardian Date of Birth If you have any questions regarding the use of this form or the ADVICARE Grievance Process, please contact the Advicare office at Toll-free (888) 781-4371. Thank you for giving us this opportunity to serve you better. Please Do Not Write Below This Line ADVICARE PCP Name: ADVICARE PCP#: ADVICARE Practice Name: Location: Comments:_ 531 South Main Street, Suite RL-1 Greenville, South Carolina 29601 Phone 1(888) 781-4371 Fax 1(888)781-4316 Attachment F – Member Primary Care Provider Transfer Member Primary Care Provider Transfer (please fax or email) Instructions 1. For Provider Use Only 2. Please complete form and provide documentation to support your request to transfer PCP. 3. Fax or Email to the Palmetto Physician Connections Member Services Department at: 531 South Main Street, Suite RL-1 (888) 781-4316 or [email protected] Greenville, South Carolina 29601 Phone: (888)781-4371 Fax: (888) 781-4316 The member is enrolled with the following practice: ______________________________________________________________ The member(s) listed are to be transferred to Primary Care Provider: ________________________________________________ List reason for transfer: ________________________________________________________________________________________ PRINT NAME OF EACH FAMILY MEMBER TO BE TRANSFERRED DOB MEDICAID NUMBER IS MEMBER AWARE OF TRANSFER? Family Address: _______________________________________________________________ City: __________________________ State:___________ Zip: ________________ Phone number: (______) _______________________________ Member Signature: _____________________________________________________________(MEMBER MUST SIGN IF PRESENT) Provider Name: ________________________________________________ Medicaid Provider number: _____________________ Phone: (____) _______________________ Title: ________________________________________ Name: _______________________________Signature:____________________________________ Date: _______________ Attachment G – Logisticare (Non-Emergent Transportation) LOGISTICARE Transportation Beneficiary Information Transportation is available for doctor appointments, dialysis, x-rays, lab work, drug store or other medical appointments. To ask for a ride call at least 3 days before your appointment. Call Monday – Friday 8:00am to 5:00pm. To cancel a ride call at least 24 hours in advance. To reach Region 1, call (866) 910-7688, Region 2, call (866) 445-6860, Region 3, call (866) 4459954. Region 1 Region 2 Region 3 •Abbeville •Aiken •York •Laurens •Lancaster •Beaufort •Anderson •Allendale •Florence •McCormick •Lee •Berkeley •Cherokee •Bamberg •Georgetown •Oconee •Lexington •Charleston •Edgefield •Barnwell •Hampton •Pickens •Newberry •Chesterfield •Greenville •Calhoun •Horry •Saluda •Orangeburg •Colleton •Greenwood •Chester •Jasper •Spartanburg •Richland •Darlington •Clarendon •Marion •Sumter •Dillon •Fairfield •Marlboro •Union •Dorchester •Kershaw •Williamsburg Attachment H – Pharmacy Prior Authorization Form Attachment I – Immunization Schedule for Ages 0 - 18 Attachment J – Change Control Record Advicare Provider Manual Manual Updated CHANGE CONTROL RECORD Date Section Page(s) Change
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