Provider Manual
Provider Manual New for 2014! Soundpath Health now has a Provider Portal that allows contracted providers to check Eligibility and the status of paid claims! Email us for more information at: [email protected]. Soundpath Health Provider Manual v3.1.14 Page 1 Contents Soundpath Health Mission Statement Introduction Your Role As a Soundpath Health Provider Statement of Non-Discrimination Non-interference with Patient/Provider Relationship Directory of Services & Contact Information Product Overview List of Entities - SPH “POD” structure Sample Member ID Card Responsibilities of All Providers Definitions Changes in Provider Status Discharging a Patient from Your Practice Participating Provider Access Standards Member Rights and Responsibilities Advance Directives Responsibilities of Soundpath Health Significant Health Risk Assessment Findings Member Transfers Between PCPs Involuntary Member Disenrollment Change In Residence Loss of Entitlement to Medicare Part A or Loss of Enrollment in Part B Member is Deceased Disruptive Behavior Member Fraud and Abuse Contract Termination Medical Management Division Care Management Pharmacy Services Quality Improvement (QI) Delegation Oversight Provider Cooperation Adverse Incident Reporting Referrals and Prior Authorization Process Soundpath Health Provider Manual v3.1.14 Page 2 Facility Admissions Out of Area Notice of Medicare Non-Coverage Credentialing Process Re-credentialing Process Appeals and Grievances Provider Reconsideration and Dispute Processes Provider Appealing on the Member’s Behalf Expedited Appeal Quality Improvement Organization Who are QIO Physicians? Immediate Review of Hospital Discharges Special expedited appeal, if missed QIO deadline QIO complaints process Grievance Procedures Fraud, Waste, and Abuse Billing and Claims Payment Electronic Claims Submission Where To Send Paper Claims HCCM Claims Process & Payment Timeframes for Submission Provider Remittance Member Eligibility and Retroactive Disenrollment COB Co-Payments and Coinsurance Checking Claims Status Denial of Claims NPI Compensation Site of Service Payment Differential Soundpath Health Provider Manual v3.1.14 Page 3 Medicare Part D Pharmacy Management Examples of UM tools P & T Committee Pharmacy Benefits and Covered Drugs What Is Coverage Determination? Can the Formulary Change? Drug Utilization Review Medication Therapy Management Programs Mail Order Pharmacy Vendor Partners Behavioral Health Routine Vision Care Complementary Alternative Medicine rider (if purchased by member) Routine Hearing Exams and Hearing Devices SilverSneakersFitness Program & Network Discount Programs o NutriSystem o QuickMedical o Mayo Clinic CMS Regulations Soundpath Health Provider Manual v3.1.14 Page 4 Soundpath Health Mission Statement Be the local industry leader in supporting health care delivery Promote our Members’ health through local Provider innovation Be responsible stewards of health care resources Be an active partner in improving the health of our communities Introduction Soundpath Health is a unique, independent local health plan founded by doctors who have taken a fresh approach by forming a licensed Medicare Advantage (MA) Plan which assures a partnership between patient, Provider and health plan. Our purpose is to promote the Memberphysician relationship, provide the highest level of treatment in the most appropriate setting, and improve health and wellness through this partnership. This Provider Manual is designed to assist you and your staff and to provide information regarding Soundpath Health policies and procedures that encompass patient/Member needs, Provider standards, and Soundpath Health reporting. This makes it possible to deliver appropriate and cost-effective care using the full continuum of services, which includes services through delegation to highly qualified Independent Physician Associations. Your Role as a Soundpath Health Provider As a Soundpath Health-contracted Provider, you have agreed to provide care to members of Soundpath Health. We look forward to supporting you in providing accessible, quality health care that meets the needs of your patients – our members. Statement of Non-Discrimination Soundpath Health agrees to adhere to the principles of affirmative action and equal opportunity. Our Organization will not discriminate on the basis of age, ethnicity, national origin, marital status, race, religion, sexual orientation, sex, mental or physical disability, genetic information, or source of payment in the enrollment of Members, the delivery of covered services or items, or the credentialing or contracting of Providers. This Organization will not accept or disregard behavior demonstrated by employees or Providers that discriminate and follows CMS regulations S422.200, S422.202, S422.204, S422.205. Soundpath Health Provider Manual v3.1.14 Page 5 Non-interference with Patient/Provider relationship Soundpath Health encourages a strong Provider-Member relationship, and therefore does not interfere, prohibit, or otherwise restrict contracted Providers from freely communicating with or advising Members concerning their health status, medical care or treatment options. Therefore, Soundpath Health serves as an advocate on behalf of a Member regarding the care or treatment options, regardless of benefit coverage limitations, including, any information that is determined to be in the Member’s best interests concerning: Alternative treatments, medication options and any other medical care and treatment options The opportunity to decide among all relevant treatment options The risks, benefits and consequences of treatment or non-treatment The opportunity to refuse treatment and express preferences about future treatment decisions Soundpath Health Provider Manual v3.1.14 Page 6 Directory of Services & Soundpath Health Contact Information Soundpath Health Headquarters 32129 Weyerhaeuser Way South, Suite 201 Federal Way, WA 98001 Phone: 1-253-779-8830 Toll Free: 1-866-789-7747 Fax: 1-253-779-8829 Member Services Claims Information Claims Submission Eligibility Hours of Operation: 8:00 A.M. – 8:00 P.M. Monday –Sunday. You may receive a voicemail on weekends and holidays from March 2 through October 14. Please leave a message and your call will be returned the next business day. Submit electronic claims to: Emdeon Claims Submission Payer ID #42172. Submit paper claims to: Phone: 1-866-789-7747 TDD/TTY: 1-866-264-4141 Fax: 1-253-779-8829 Website: www.SoundpathHealth.com Soundpath Health Attn: Claims P.O. Box 4537 Federal Way, WA 98063 Medical Affairs Utilization Management – Prior Authorization Case Management Quality Improvement Appeals and Grievances Phone: 1-253-779-8830 Toll Free: 1-866-352-7086 Fax: 1-866-362-0627 Provider Relations Phone: 1-253-517-4342 Toll Free: 1-866-789-7747 Fax: 1-253-345-5538 Sales & Marketing Phone: Fax: Soundpath Health Provider Manual v3.1.14 1-866-789-7747 1-253-779-8829 Page 7 Language Assistance Soundpath Health provides Member’s access to interpretive services, if the Member does not speak English. In such cases, the Provider may call Member Services at 1-866-789-7747 on behalf of the Member. Product Overview We feel the best healthcare is accomplished in partnership between the member, doctor and health plan; because of this we are proud that our benefit designs are the result of input from our contracted providers and members. We provide plans that offer an array of benefits beyond Original Medicare. We offer various plans to fit every budget; all of which provide comprehensive coverage, predictable costs, and robust benefits. Find out more about these programs in the Evidence of Coverage (EOC) or on our website, www.SoundPathHealth.com. List of Entities – SPH “Pool of Doctor (POD)” structure Pod Physicians of SW Washington (“Pod 1”) 319 Seventh Avenue S.E., Suite 201 Olympia, WA 98501 Phone: (360) 943-4337 Fax: (360) 754-4324 Northwest Physicians Network (“Pod 2”) PO Box 2117 Tacoma, WA 98401 Phone: (253) 573-1880 Fax: (253) 573-9511 Medical Management Claims Processing Credentialing Delegated Delegated Delegated NonDelegated NonDelegated Delegated Pod 3 is not in use at this time. Soundpath Health Provider Manual v3.1.14 Page 8 Physicians Care Network (“Pod 4”) 1401 Harvard Ave., Suite 300 Seattle, WA 98122 Phone: (206) 860-2220 Fax: (206) 860-2283 Delegated Delegated Delegated Pod 5 is SPH’s directly-contracted providers. All administrative functions performed by SPH. All inquiries to SPH Customer Service: 1-866-789-7747. Pod 6 is not in use at this time. Central Washington Area – CWA (“Pod 7”) including: Confluence Health Independent providers throughout Grant, Chelan, and Douglas counties Family Care Network (“Pod 8”) 709 W Orchard Dr, #4 Bellingham, WA 98225 (360) 318-8065 Fidelis Senior Care (“Pod 9”) 1412 SW 34th ST Ste 315 Renton, WA 98056 Phone: (425) 272-4600 Fax: (425) 289-3103 Confluence Health is delegated for credentialing its employed providers. N/A N/A NonDelegated NonDelegated Delegated Delegated NonDelegated NonDelegated NonDelegated NonDelegated Delegated Franciscan Medical Group (“Pod 10”) All inquiries to SPH Customer Service: 1866-789-7747. Soundpath Health Provider Manual v3.1.14 Page 9 Sample Member Identification Card Responsibilities of All Providers To maintain current licensure in the State of Washington To maintain participation in Medicare under Sections 1128 or 1128A of the Social Security Act To comply with Washington State Statute regarding maintaining malpractice insurance deemed sufficient by Soundpath Health To maintain the requirements for Continuing Medical Education (CME) Provide notification if there are any changes to your licensure status, sanctions or business information. (Tax ID number, address, etc.) To maintain confidentiality with the Members’ records, correspondence, and discussions in accordance with state and federal laws and regulations To maintain Members’ medical records in a form that is consistent with the requirements of state and federal laws and regulations To provide coverage by a contracted Soundpath Health Physician and/or Mid-Level Provider twenty-four (24) hours a day, seven (7) days a week Applicable to PCPs, to provide, coordinate, monitor, and supervise the delivery of health care services for assigned-Members and to provide appropriate referrals to participating specialists Applicable to specialists, to provide the Members’ PCP with a written report within 14 days of the date of service regarding the proposed plan of treatment, including any proposed hospitalization or surgery. This report should also be provided to a member’s PCP for self-referred services such as women’s health care services. Failure to provide the PCP with this report may result in nonpayment for services and the Provider cannot bill the member. With the exception of Urgent or Emergent Care, specialists should see Soundpath Health Provider Manual v3.1.14 Page 10 members only upon a referral from the PCP (for services not on the current Prior Authorization list). For services on the current Prior Authorization list, specialists should only see members upon approval by Soundpath Health or its delegate. Applicable to acute facilities, to provide notification of all inpatient admissions as described in this Manual and have inpatient and emergency services available 24 hours a day, 7 days a week Maintain active admitting privileges at an in-network hospital or designate coverage such as an associate or hospitalist To collect the appropriate co-payment in accordance with the Members benefit plan To provide copies of medical records to the Member upon request at no cost consistent with Revised Code of Washington (RCW) 70.02.080 To provide services in a manner consistent with standards of care To encourage a Member to participate in their treatment planning and course of care To provide clear and understandable information to the Member regarding treatment options, including interpretive services for members who are hearing impaired or whose primary language is not English To provide Members with written information about advance directives and the right to make anatomical gifts To maintain an environmentally safe practice facility To meet Safety Standards in accordance with the Occupational Safety Health Administration, ADA, and regulatory requirements To comply with Utilization Management/Quality Improvement activities, including but not limited to, HEDIS, Medical Record reviews, Utilization Management Reviews, audits and corrective action plans To comply with the Plan’s Quality Improvement Plan To comply with Plan’s audits, including but not limited to, retrospective Hierarchical Condition Category audits at no cost to Plan To ensure that Members are not discriminated against based on race, ethnicity, national origin, religion, sex, sexual orientation, age, mental or physical disability, or source of payment To ensure that the hours of operation are convenient for Members so services may be provided with reasonable promptness To make an exception, as per written authorization from the Member, to allow their medical records or medical condition(s) disclosed to others To maintain safe storage of inactive medical records for a minimum of ten years (or the extent required by federal regulations) and have them easily retrievable when needed To allow Members to directly access screening mammography and influenza vaccination services Soundpath Health Provider Manual v3.1.14 Page 11 To provide female Members with direct access to a women’s health specialist for routine and preventive health care services You may not distribute marketing materials or forms to Members without CMS approval You must ensure that any payment and incentive arrangements with subcontractors are specified in writing, that such arrangements do not encourage reductions in medically necessary services, and that any physician incentive plans comply with applicable CMS standards You must cooperate with our processes to disclose to CMS all information necessary for CMS to administer and evaluate the Medicare Advantage Program, and all information determined by CMS to be necessary to assist members in making an informed choice about Medicare coverage You must cooperate with our processes for notifying members of provider agreement terminations You must comply with our medical policies, quality improvement programs and medical management procedures, including Participating Provider Access Standards You must cooperate with Soundpath Health in fulfilling its responsibility to disclose to CMS quality, performance and other indicators, as specified by CMS You must cooperate with our procedures for handling grievances, appeals, and expedited appeals You must provide full disclosure to members before providing a health service if you feel that such service will not be covered by a member’s benefit plan. The member may assume additional financial responsibility in accordance with the member’s benefit plan and the contract language. A document similar to the Medicare Advanced Beneficiary Notice (ABN) must be signed by the member before liability for payment can be passed to the member. If the service is performed and there is no signed advance notice on record, the claim will be denied and you may not bill the member You must abide by all State and Federal rules, regulations, and statutes You must abide by all provisions of your Participant Agreement with Soundpath Health You are required to refer all services to a participating provider in our network, except as otherwise authorized by Soundpath Health Soundpath Health Provider Manual v3.1.14 Page 12 Definitions: Soundpath Health provides Emergency Services as required by law and in accordance with the enrollee’s benefits, limitations, and exclusions based on our contract with Centers for Medicare and Medicaid Services. Soundpath Health ensures that enrollees have the right to access emergency health care services, consistent with the enrollee’s determination of the need for such services as a prudent layperson without prior authorization. Pursuant to the member’s Evidence of Coverage, a “medical emergency” is when the member, or any other prudent layperson with an average knowledge of health and medicine, believes that they have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Emergency Services and Care means medical screening, examination, and evaluation by a physician or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician. It is to determine if an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of a hospital. No Plan referral or prior authorization request is necessary for emergency care services. Members have been instructed to call 911 or go to the nearest emergency room for emergency care services. In addition, the Member should inform the PCP about the emergency care so the PCP may coordinate any follow-up care and services. Urgent Care Urgent care is when the Member requires medical attention right away for an unforeseen illness or injury; however the health of the Member is not in serious danger. The main difference between an urgent need for care and a medical emergency is in the danger to the Member’s health. The Members should consider contacting the Primary Care Physician (PCP) if they have sudden illness or injury that is not a medical emergency. They may seek services without a referral, but are advised to remain in the Network. Please refer to the EOC for additional information. Changes in Provider Status All Soundpath Health providers are responsible for giving notice at least 30 days in advance of provider changes such as Tax ID, billing address, and practice locations. This ensures time for Soundpath Health to update its systems, notify members, and prevent payment delay. Soundpath Health Provider Manual v3.1.14 Page 13 PCPs are also responsible for notifying Soundpath Health when their practice reaches capacity and they can no longer accept new patients. This notice should be in writing and will be effective the first day of the month following 30 days from receipt of notice. Discharging a Patient from your Practice Occasionally, you may encounter patients who you no longer wish to treat. Reasons for ending the physician-patient relationship may include chronic non-compliance, rudeness to office staff, or non-payment of bills. While these patient behaviors can affect the interactive care-giving process, they may also identify patients with a propensity to file a claim against you. To help reduce the risk of a future claim, a physician may terminate or discharge a patient from the practice. There are, however, certain exceptions that apply to terminating a patient: You may not terminate your professional relationship for any discriminatory purpose Or in violation of any laws or rules prohibiting discrimination such as the Americans with Disabilities Act. You also are not permitted to terminate a patient where you know, or reasonably should know, that no other healthcare provider is currently able to provide the patient the type of care or services that you are providing to the patient. Reduce the Risk of Abandonment for the patient: Abandonment occurs when a physician suddenly terminates a patient relationship without giving the patient sufficient time to locate another practitioner. A patient, however, may withdraw from a physician’s care at any time without notifying the physician. To reduce the risk of allegations of abandonment, it is recommended that you discuss with the patient, in-person, the difficulties in the physician-patient relationship and your intention to discharge the patient from the practice. Be sure to document the discussion fully in the patient’s medical record, also noting the presence of any witnesses such as a patient’s family member or a member of your office staff. Soundpath Health Provider Manual v3.1.14 Page 14 Write a Formal Discharge Letter to the patient: You are required to notify the patient and Soundpath Health, in writing, of the termination. The letter must state that you will no longer provide care to the patient as of a date certain. The date must be at least 30 days from the date of the letter. You must also state in the letter that you will be available to provide emergency care or services, including provision of necessary prescriptions, during the 30-day notice period. The discharge letter should also include: A description of any urgent medical problems the patient may have, An offer to forward copies of the patient’s medical records to the subsequent treating Physician. Soundpath Health’s Member Services contact information to assist the patient in locating a physician who is accepting new patients. The care of a patient is a mutual agreement and is in many ways a team between you, the provider, and the patient, but when that relationship is strained and you can no longer feel that you are able to provide quality care to the patient, at that point it is time to end that patientprovider interaction. Make sure you have attempted all you can do to help and when you realize there is no more to do, discharging the patient may be the only course of action. Soundpath Health Provider Manual v3.1.14 Page 15 Participating Provider Access Standards: New & Established Patients (not seeking Behavioral Health Care) Routine, Wellness & Physical Appointment within 30 days of request Routine, Primary Care Appointment within 7 days of request Urgent Care Same day appointment or within 24 hours Emergency Care 24 hour availability of appropriate triage Waiting time for scheduled appt Should not exceed 30 minutes Patients Seeking Behavioral Health (BH) Care Urgent Appointment with BH provider within 6 hours Appointment with BH provider within 48 hours Emergency 24 hour availability of appropriate triage Routine Office Visit Appointment with BH provider within 10 business days Waiting time for scheduled appt Should not exceed 30 minutes Care for non-life threatening emergency Behavioral Health Telephone Access Standards Triage calls Answered by a live voice within 30 seconds Triage abandonment rate Within 5% Preventative Care: No symptomatic clinical concerns, complete physicals or other preventative services, i.e. flu inoculations. Routine Primary Care: Stable conditions that require a visit but are not considered urgent. Urgent Care: Conditions that require medical intervention on the same day or within 24 hours to prevent serious deterioration in health. Emergency Care: Conditions that require emergent, possibly lifesaving, intervention that must be referred immediately for medical intervention. After-Hours Care: Care required after the provider’s scheduled closing time and before their scheduled opening time or on a day the clinic is closed. Soundpath Health Provider Manual v3.1.14 Page 16 Office Waiting Time: Amount of time between the time a patient checks in and the time they see a provider, starting no earlier than their scheduled appointment time. Member Rights and Responsibilities Below are Member rights and responsibilities in accordance with CMS requirements. The following is in the Member Handbook: AS A SOUNDPATH HEALTH MEMBER, YOU HAVE A RIGHT TO: Receive information about the organization, its services, its practitioners and Providers and Member rights and responsibilities Be treated with respect and recognition of your dignity and right to privacy Participate with practitioners in making decisions about your health care A candid discussion of appropriate or medically necessary treatment option(s) for your condition, regardless of cost or benefit coverage Voice complaints or appeals about the organization or the care it provides Make recommendations regarding the organization’s Member rights and responsibilities policy Supply information (to the extent possible) that the organization and its practitioners and Providers need in order to provide care Understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible AS THE MOST IMPORTANT MEMBER OF YOUR HEALTH CARE TEAM, IT IS YOUR RESPONSIBILITY TO: Provide complete and correct facts about your health history, current health status, and changes in your symptoms Make informed decisions about treatments and procedures before they are performed Follow the treatment plan that you and your Provider agree on Tell your Provider if you do not understand your treatment plan, or if you believe you cannot follow through with it Accept the risks of refusing treatment Treat health care professionals, staff, other Members, and their property in a kind and respectful manner Seek medical services only through your PCP, except in a life threatening emergency Make and keep appointments. Tell your PCP if you are going to be late or need to cancel an appointment Request a referral from your PCP before going to a specialist Soundpath Health Provider Manual v3.1.14 Page 17 Call Soundpath Health if you do not understand how your health plan works Tell us about your suggestions for improvements, concerns and complaints Use emergency room services only for injury or illness that, in the judgment of a reasonable person, requires immediate treatment to avoid jeopardy to life or health Pay any necessary copayment at the time you receive treatment Protect against the wrongful use of your ID card by another person Verify that the physician or health care professional you receive services from is participating in the Soundpath Health network. Notify Soundpath Health of any change in address. Identify yourself as a Member of Soundpath Health when you seek care and carry your identification card with you Notify Soundpath Health if you are injured as a result of actions of a third party and are entitled to recovery from the third party as a result of your injury for medical expenses. As such, you are obligated to reimburse Soundpath Health for the value of the medical services paid on your behalf by Soundpath Health. Let us know if you have a living will, durable power of attorney for health care, or other advance directives. Advance Directives Soundpath Health is required to provide members with information regarding their health care rights under Washington law. Washington State law recognizes a member’s right to accept or refuse health care by using documents called Advance Directives. If a patient is no longer able to make medical decisions, the Advance Directive takes effect when the provider determines the patient’s medical condition is terminal. The Directive may also go into effect if the patient’s provider and another provider agree that the patient is in a permanently unconscious state. Health Care Directives (also known as Living Wills) and Durable Power of Attorney for Health Care are the two types of Advance Directives that can be used to set forth in writing one’s wishes regarding medical treatment in the event of the inability to clearly communicate due to incapacitating injury or illness. Federal law requires hospitals to ask patients if they have Advance Directives when they are admitted. Other health care providers should document Advance Directives in the patient’s medical record. Hospitals and providers must also inform patients of their own policies regarding Advance Directives and end-of-life treatment, as well as any conflict between the patient’s Directive and their own policies. If there is a conflict, a written plan of action must be agreed upon and included in the patient’s medical record. Soundpath Health Provider Manual v3.1.14 Page 18 All hospital and primary care providers are required to provide adult members with written information about Advance Directives and the right to make anatomical gifts. Specialists must inform members of these rights when deemed appropriate based on the treatment or care they are providing. In addition, a member has the right to be informed and educated about the opportunity to express his/her wishes concerning future care, including choosing a person to make medical decisions on the patients behalf if the patient is unable to do so. Responsibilities of Soundpath Health To offer a Provider Network that provides care and services to enrollees To supply the Provider and the office staff with any revisions to Policy/Procedure in accordance with Regulatory and applicable Accreditation Agencies To offer training and support to the Provider and their staff To ensure that Member Health Risk Assessments received will be forwarded to the Member’s PCP To offer support in the provision of language services To ensure that the Provider Relations staff will be available for the Providers To supply the Provider with any changes, revisions, additions, deletions and other modifications to the Provider agreement To conduct Oversight Reviews in compliance with state and federal regulatory requirements To conduct reviews to assess content, legibility, organization and completeness of the enrollee’s records as well as assess compliance concerning confidentiality of medical and health information To ensure the compliance of Providers for Site Audits, Medical Record Review, Access Audits, QI Reviews, and other requirements as determined by Soundpath Health Publicly acknowledge Providers with high positive satisfaction scores and address Providers with low scores To maintain and provide access to accurate Provider Directory information To maintain current Membership records for Providers To ensure non-discriminatory practices for prospective and current enrollees or to enrollees with physical, mental disability and/ or chronic illnesses To conduct Member satisfaction surveys regarding the Provider’s services and share the reports with the Provider Soundpath Health will send each Member a Health Risk Assessment within the first 30 days after selection of a Primary Care Physician. The objectives of the assessment tools are: To proactively identify conditions that requires attention by a health care Provider To promote continuity and coordination of care Soundpath Health Provider Manual v3.1.14 Page 19 To identify conditions that may qualify for disease management programs or case management To provide Members with appropriate educational materials Significant Health Risk Assessment Findings New members will be offered a Health Risk Assessment (HRA) tool to complete and return to the health plan. In response to the HRA, members that indicate they are depressed and need help will be connected on an urgent basis with their Primary Care Provider. This is done by faxing a copy of the HRA to the PCP with a letter encouraging them to see their patient at the earliest availability. Referrals are made Case Management from as appropriate. Plan may intervene on behalf of the Member to facilitate appointments, education, and assistance with resources available through the Plan and/or the community. Member Transfer Between Soundpath Health-contracted PCPs The following guidelines apply to the transfer of a Soundpath Health Member, upon his/her request, from one PCP to another: The Member’s decision to transfer should be strictly voluntary. The Member must not have been directly recruited by phone or in person by anyone involved with either primary care office. The Member must not have been influenced to transfer PCP due to improper or incorrect information, or for medical reasons. Upon a Member’s request, the primary care office must send his/her medical records to the newly selected primary care office. Any Provider who violates these guidelines is subject to corrective action. Involuntary Member Disenrollment A beneficiary may be involuntarily disenrolled from a Medicare Advantage Plan under the following circumstances: Change in residence outside the plan’s service area or temporary absence for more than 6 consecutive months Loss of entitlement to Medicare Part A or loss of enrollment in Part B Member is deceased Disruptive behavior Member fraud and abuse Soundpath Health Provider Manual v3.1.14 Page 20 Contract termination Change in residence outside the plan’s service area or temporary absence for more than 6 consecutive months The Eligibility Coordinator (EC) will document receipt of a verbal request for disenrollment and will document and stamp the date of receipt of written requests. When a member or legal representative contacts Soundpath Health with an address change that is outside the service area, the EC will determine the effective date of disenrollment and mail the member a Disenrollment Due to Permanent Move letter. The EC will notify CMS of this action. When Soundpath Health receives a member’s address change from a source other than the member or the member’s representative, the EC cannot disenroll until the member or member’s representative has confirmed that this out-of-area move is permanent or that six consecutive months have passed. The EC will attempt to call the member to verify the address change. If the EC cannot contact the member via telephone, the EC will mail the member a Verification of Change in Address letter. If the EC does not receive a response by the beginning of the sixth month after sending the letter, the EC will mail an Upcoming Disenrollment Due to Out of Area Six Months letter. The EC will determine the disenrollment effective date and send a Disenrollment Transaction to CMS. Upon receipt by CMS, a Final Confirmation of Disenrollment Due to Out of Area Six Months letter will be sent to the member. Loss of Entitlement to Medicare Part A or Loss of Enrollment in Part B When the EC receives a CMS Reply Listing that indicates a member has lost Medicare Part A or Part B benefits, the EC will mail to the member a Disenrollment Due to Loss of Part A or Part B Coverage letter. If a member subsequently contacts Soundpath Health regarding an erroneous disenrollment, the EC will use the Enrollment Reinstatement procedure. Member is Deceased When the EC receives a CMS Reply Listing that indicates a member is deceased, the EC will mail a Disenrollment Due to Death letter to the estate of the member. If a member subsequently contacts Soundpath Health regarding an erroneous disenrollment, the EC will use the Enrollment Reinstatement procedure. Soundpath Health Provider Manual v3.1.14 Page 21 Disruptive Behavior This language is from the MA Regulations: 42 CFR 422.74 Disenrollment by the MA organization regarding disruptive behavior. (i) Definition of disruptive behavior. An MA plan enrollee is disruptive if his or her behavior substantially impairs the plan's ability to arrange for or provide services to the individual or other plan Members. An individual cannot be considered disruptive if such behavior is related to the use of medical services or compliance (or noncompliance) with medical advice or treatment. (ii) Basis of disenrollment for disruptive behavior. An organization may disenroll an individual whose behavior is disruptive as defined in 422.74(d)(2)(i) only after it meets the requirements described in this section and CMS has reviewed and approved the request. (iii) Effort to resolve the problem. The MA organization must make a serious effort to resolve the problems presented by the individual, including providing reasonable accommodations, as determined by CMS, for individuals with mental or cognitive conditions, including mental illness and developmental disabilities. In addition, the MA organization must inform the individual of the right to use the organization's grievance procedures. The beneficiary has a right to submit any information or explanation that he or she may wish to the MA organization. (iv) Documentation. The MA organization must document the enrollee's behavior, its own efforts to resolve any problems, as described in paragraph (iii), and any extenuating circumstances. The MA organization may request from CMS the ability to decline future enrollment by the individual. The MA organization must submit this information and any documentation received by the beneficiary to CMS. (v) Effective date of disenrollment. If CMS permits an MA organization to disenroll an individual for disruptive behavior, the termination is effective the first day of the calendar month after the month in which the MA organization gives the individual notice of the disenrollment that meets the requirements set forth in paragraph (c) of this section, unless otherwise determined by CMS. Member fraud and abuse Examples include: When a member submits fraudulent information on an enrollment form. When a member allows another person to use his/her enrollment card to obtain services or a prescription drug. When Soundpath Health receives information that a member has committed fraud and abuse, the EC will call CMS to discuss the issue with the CMS Plan Manager. If the CMS Plan Manager advises Soundpath Health to disenroll the member, the EC will determine the effective date of disenrollment and send a Disenrollment for Fraud and Abuse letter to the member. The EC will Soundpath Health Provider Manual v3.1.14 Page 22 then send a Disenrollment Transaction to CMS as well as send all supporting documentation to the Inspector General in the CMS Regional Office. Contract Termination If Soundpath Health determines not to renew its contract with CMS, the EC will mail to the member a Contract Non-Renewal Notification letter at least 90 calendar days before the effective date of the non-renewal. If Soundpath Health receives a contract termination notice from CMS, the EC will mail to the member a Contract Termination by CMS Notification Letter at least 30 calendar days before the effective date of the termination. If Soundpath Health terminates the contract with CMS due to CMS substantially not carrying out the terms of its contract, members will be sent the Contract Termination by Soundpath Health Notification 60 days prior to the effective date of the termination. Soundpath Health’s Medical Management Division Medical Management is designed to assure and deliver consistent, high quality, cost-effective, medically necessary care and services for all members. Medical Management promotes evidence-based, efficient and effective care and drug utilization and effective oversight of all delegated entities. All care and services delivered to the members will be compliant with CMS regulatory requirements and evidence-based criteria. The Board of Directors has delegated the ongoing oversight and administration of the Medical Management program to the Quality Improvement Committee (QIC). The Medical Advisory Committee, an advisory subcommittee to the QIC, provides community physician input into the Medical Management program. The Medical Management Division provides: Care Management o Utilization Management o Case Management o Population Health/Chronic Disease Management Pharmacy Services Quality Improvement Delegation Oversight Soundpath Health Provider Manual v3.1.14 Page 23 Care Management Care Management is the set of processes that manages utilization of medical services, promotes equal access for members to their benefits, and promotes cost effective, high quality care across the continuum. The Care Management Program has two key areas: Utilization Management Population Health/Case Management Key functions of Care Management include, but are not limited to: Pre-Service Authorization and management for services on the Prior Authorization List and for all services provided by a non-contracted provider (The Prior Authorization List is available in the member’s Evidence of Coverage document and on the Plan’s website.) Concurrent Review Retrospective or Post-Service Review Home Health/Ambulatory Review Out of Area Review and management Referral management between contracted PCPs and contracted specialists Discharge Planning Appeals and Operations Interface Coordination and oversight of Delegated Care Management/Utilization Management Entities Case Management Population Health/Chronic Disease Management Transplant Coordination Behavioral Health Coordination Pharmacy Services Pharmacy Services provides drug utilization and quality oversight. In partnership with the Pharmacy Benefit Manager (PBM) partner, Pharmacy Services assures member access to Part D benefits, promotes evidenced-based management of the drug formulary, assures regular review of therapeutic classes of drugs, and promotes cost-effective drug utilization. Working with the delegated Pharmacy Benefits Management Company, the Chief Medical Officer and the Quality Soundpath Health Provider Manual v3.1.14 Page 24 Improvement Committee, Pharmacy Services has the accountability to assure that this process is performing at expected standards and costs. The Medication Therapy Management Program is a program of Drug Management managed by the PBM that identifies at-risk members with defined chronic diseases. The interventions are focused on compliance with evidence-based guidelines for medication use. The MTM Program works with the member and their PCP to assure compliance and cost effective drug use. Quality Improvement (QI) Under the oversight of the QIC, the QI Department identifies opportunities for improvement in service and clinical care, while promoting the evidence-based clinical practices. QI develops appropriate metrics for Quality Improvement initiatives, facilitates HEDIS reporting, and tracks and directs initiatives to improve Star Rating measures. Performance measurement is fundamental to Quality Improvement and is a critical tool that guides improvement. The QI program: Establishes the criteria for all activities related to care and services in accordance with state and federal regulatory requirements. Ensures that improvements initiated are of value to the members and are implemented and sustained through ongoing monitoring. Develops specific, measurable Quality Improvement goals and timelines in alignment with RiverLink Health’s strategic goals. Collaborates with delegated groups and partners to improve clinical and service quality that results in improvement of processes and outcomes. Focuses on identifying opportunities for improvement through systematic internal quality processes and working with the providers to develop appropriate action plans, when indicated. Identifies studies that address meaningful, relevant clinical issues that are relevant to the population served and uses them to develop improvement initiatives. Promotes physician use of nationally recognized practice guidelines to improve the process and outcome of chronic and acute disease management. The intent of the QI department is to continuously improve the quality of care provided to members with the intent of optimizing their health outcomes. QI activities and initiatives include but are not limited to - Medicare Star Rating Improvement; Healthcare Effectiveness and Data Information Set (HEDIS) Reporting; HEDIS Compliance Audit; Consumer Assessment of Healthcare Providers and Systems (CAHPS), Health Outcomes Survey (HOS), Health Risk Assessments (HRA), Chronic Care Improvement Program (CCIP), Quality Improvement Soundpath Health Provider Manual v3.1.14 Page 25 Program (QIP), Data Analytics and Physician Engagement – Actionable Reports and Closing Gaps in Care. Delegation Oversight Delegation oversight is the process to assure that all delegated entities are performing at the expected and contracted level; that performance is consistent with the policies and procedures of Soundpath Health; and that all members have equal access to their benefits across the service areas. Soundpath Health can delegate the performance of specific services, such as care management/utilization management, behavioral health, drug management and claims management, to outside entities. To assure the highest level of service and satisfaction to all members, it is necessary to monitor and audit the performance of delegated services. Policies and procedures are established to assess the initial and ongoing compliance of delegated functions with Soundpath Health standards. Soundpath Health will perform an initial or PreDelegation Audit to ensure the Medical Groups/IPA/PHO complies with Soundpath Health standards for delegation of Care Management. At least annually thereafter, Soundpath Health will audit the Medical Groups/IPA/PHO to ensure continued compliance. Soundpath Health may initiate a focused audit based on specific activities at the Medical Groups/IPA/PHO that warrants such an audit. The Medical Groups/IPA/PHO is required to provide specific documents/evidence to the auditor as applicable. Pre-Delegation, Annual Audit, corrective action plans, and Dedelegation may occur with any delegated responsibilities from Soundpath Health to the entity. The Medical Management goals are to: Facilitate medical care and services based on contractual agreement with CMS for assigned eligible Medicare Advantage Members Provide equitable and fair access to care and timeliness of care demonstrated through audits, reporting and evaluation of quality Improve coordination of care by facilitating communication Improve quality of healthcare services through the identification and communication of quality indicators Identify Members considered to be high-risk for complicated, long-term continuous care in order to assure appropriate coordination of care and case management intervention Identify and monitor key indicators for tracking potential over-and-under utilization of specific healthcare services and report findings to the QIC for corrective action Soundpath Health Provider Manual v3.1.14 Page 26 Care Management uses the following industry and nationally-recognized criteria in assisting decision-making: Guidelines Function Review of medical necessity, priorauthorization, preadmission review, concurrent review, discharge planning, InterQual and/or other nationally recognized medical necessity criteria CMS Coverage Determinations and Manual Guidelines Independent and peer medical reviews Medical necessity reviews. Provider Cooperation In support of Soundpath Health’s care management program and quality initiatives, including but not limited to, Healthcare Effectiveness Data and Information Set (HEDIS), quality improvement projects, prior-authorization requirements, concurrent review activities, providers and facilities are required to give access to: (1) facilities, including the emergency room; (2) our members and their medical records; and (3) hospital and medical staff for purposes of obtaining necessary clinical information regarding our member’s condition or treatment plan. In addition, providers and facilities are expected to participate in discharge planning activities. This protocol also applies when providing continued care to our members following termination of a provider agreement. Adverse Incident Reporting Serious Reportable Adverse Events (SRAEs) Soundpath Health adopts the most current version of the Serious Reportable Adverse Events (SRAEs), as published by the National Quality Forum (www.qualityforum.org). SRAEs are serious patient safety incidents that, by definition, should never happen and include events such as surgery on the wrong part of the body or surgical instruments left in the body after an operation. This Incident Reporting System is one of the components of Soundpath Health’s Risk Management Program. All employees, agents and Providers of Soundpath Health are required to report to Soundpath Health’s Director of Quality Improvement any “adverse” or “sentinel” incident involving a Member. Soundpath Health Provider Manual v3.1.14 Page 27 An “adverse” or “sentinel” incident means any incident that: Is associated, in whole or in part, with any action of any health care facility or personnel in the provision of health care to a Member (referred to as a “medical intervention”) rather than the condition for which such intervention occurred. Is not consistent with or expected to be a consequence of such medical intervention. Occurs as a result of medical intervention to which the Member has not given his informed consent. Occurs as a result of any other action or lack thereof on the part of the facility or personnel of the facility. Results in a surgical procedure being performed on the wrong Member. Results in a surgical procedure unrelated to the Member’s diagnosis or medical needs being performed on any Member (including the surgical repair of injuries or damage resulting from the planned surgical procedure, wrong site or wrong procedure surgeries and procedures to remove foreign objects remaining from surgical procedures); and causes injury to a Member. Per Medicare guidelines, if a SRAE occurs on a Soundpath Health patient, the provider, hospital or healthcare facility must immediately report it to Soundpath Health’s Director of Quality and Care Management at 1-866-352-7086. Soundpath Health Provider Manual v3.1.14 Page 28 Referrals & Prior Authorizations Process Soundpath Health Care Management is responsible for managing Plan level referrals to noncontracted providers and services on the Prior Authorizations list. The Prior Authorization List is available in the member’s Evidence of Coverage document and on the Plan’s website. The PCP is responsible for initiating and submitting requests for authorization to the Care Management Department of Soundpath Health or the Delegated Entity, where appropriate. Services performed without authorization are subject to review and denial of payment. Member eligibility and benefits must be checked prior to authorizing services. Coverage for medical services is subject to the limits and conditions of the Member benefit plan. Members and their Providers should consult the Members Summary of Benefits and/or Evidence of Coverage or contact a Customer Service representative to determine whether there are any applicable benefit limitations. While the current Prior Authorization list can be located at www.SoundpathHealth.com, Soundpath Health will provide its contracted providers with the most current Prior Authorization list upon return of the initial contract signature and/or as it is updated by the Soundpath Health Utilization Management Department. The Prior Authorization list is subject to change. When a Plan Referral or Authorization request is received, Soundpath Health determines the level of urgency and follows Medicare Part C turnaround time requirements, as follows. These are the Plan’s minimum standards: Soundpath Health Provider Manual v3.1.14 Page 29 Service Type Decision Timeframe Notification Timeframes (approvals & denials) Extensions Allowed (Pending status) Standard Pre-Service (non urgent) Up to 14 calendar days from date of receipt Written notification 14 calendar days from date of receipt Up to 14 calendar days Expedited PreService (urgent) 72 hours from date of receipt of request (including weekends and holidays) VERBAL Notification within 72 HOURS FROM receipt of request. Up to 48 hours WRITTEN Notification required within 3 days of verbal notification Concurrent Decision & notification within 24 hours of receiving all the necessary information to make a determination. Extension for decision Decision & notification is NOT Allowed (verbal) within 24 hours of receiving the request. Written notification will follow. PostService/Retrospective (Pre Claim) 30 calendar days from date of receipt Written notification within Up to 14 calendar days 30 calendar days of receipt of request, with adverse determination notification within business 5 days Soundpath Health Provider Manual v3.1.14 Page 30 Pre-Service Non-Urgent (Standard) received without adequate information to make a medical necessity determination will be placed on requested status and a Lack of Documentation (LOD) letter will be sent to the Provider and Member which initiates a fourteen (14) day extension process. Review will be pended until necessary information is received. If the information is not received within the required timeframe, an administrative denial will be issued in accordance with Medicare Part C requirements. Requested information will be documented and forwarded for medical review within the Medicare Part C turnaround time requirements. When a determination is made, the data will be entered into our system and the specialist, Provider or Member (if the service has not been approved) will be notified via fax, or mail. For an Expedited Request, all parties will be notified via telephone in addition to a letter sent via electric transmission and/or mail to the PCP, Specialist and, if denied, to the Member. Delegated Entities will follow the referral process as approved by Soundpath Health. Facility Admissions All Member Acute Hospital and Skilled Nursing Facility Admissions must be approved by the Prior Authorization Request Process. The Care Management Department telephone number is 1866-352-7086 and the fax is 1-866-362-0627. Pertinent medical records and supporting documentation will be required on a periodic basis and may involve on-site review at the hospital or Skilled Nursing Facility (SNF) by the Chief Medical Officer, Medical Director, or CM Nurse. The request will be reviewed against the designated medical review criteria. Requests not meeting the medical review criteria will be reviewed by the Chief Medical Officer and / or Medical Director for final decision. Emergency Admissions/Admissions after ER Visit require notification to Soundpath Health within 24 hours of the admission. Pre-scheduled acute and SNF admissions must be pre-certified and approved. Concurrent review is performed by the Utilization Management Nurse who will monitor the necessary services in Member related cases as well as any discharge planning services. Soundpath Health Provider Manual v3.1.14 Page 31 Out of Area (OOA) Soundpath Health provides coverage for emergent services for Members worldwide. For purposes of CMS compliance, Soundpath Health defines out of area services as being those services received by an Enrollee outside the approved service area. Soundpath Health Care Management requires notification of all out-of-area Inpatient admissions if PCP is made aware of such admission. The Care Management staff will conduct concurrent review and assist in discharge planning. Soundpath Health staff will assist in coordination of the Member discharge/transfer with the appropriate delegated group when necessary. Currently, only the Apex+Rx plan, available to residents of Thurston and Lewis counties, offers a supplemental benefit visitor/traveler program outside of the Plan’s service area, but within the continental United State and its territories. Under this benefit plan, member’s may receive all plan covered services at in-network cost sharing. Members are still required to select a local PCP and obtain the necessary referrals and prior authorizations, as required. Members should contact the Plan for assistance in locating a provider who accepts original Medicare when using the visitor/traveler benefit. As with all plans, members can stay enrolled while out of the service area for up to 6 months. Members who have not returned to the plan’s service area within 6 months will be disenrolled from the Plan. Notice of Medicare Non-Coverage (NOMNC) A written Notice of Medicare Non-Coverage/Generic Notice is given to all beneficiaries whose skilled services are being terminated by: Home Health Agencies (HHA’s) Skilled Nursing Facilities (SNF’s) Comprehensive Outpatient Rehabilitation Facilities (CORF’s) Hospice Copies of all letters issued by the SNF, HHA or CORF to a Member or Member’s representatives will be sent to Soundpath Health, or delegated medical group. Soundpath Health Provider Manual v3.1.14 Page 32 Credentialing Process This section represents the Soundpath Health process for Credentialing and Recredentialing. Please read through all the criteria as listed. 1. Established criteria for practitioners will be maintained and required in order to participate in the Soundpath Health Provider network. Any exceptions are at the discretion of the Board of Directors. 2. The health care practitioner must be registered with Provider Source through One Health Port pursuant to Washington State Senate Bill 5346. Senate Bill 5346 requires a statewide data collection process be setup for all credentialing and privileging data to reduce hassles for the provider community and simplify access to data for health plans and hospitals. The service is free for practitioners inputting data. 3. The health care practitioner must possess a current, valid, and unrestricted license to practice in the state where he or she provides services to Soundpath Health’s Members. 4. The health care practitioner must have clinical privileges and be in good standing at a hospital participating in the Provider network of Soundpath Health. If the health care practitioner is a primary care physician, he or she must have admitting privileges and be in good standing at a hospital participating in the Provider network of Soundpath Health. Exceptions may be granted if: A. The health care practitioner’s practice does not require admitting or clinical privileges at a hospital participating in the Provider network of Soundpath Health. This type of practice may include, but is not limited to: anesthesiology, dentistry, chiropractic, pathology, occupational medicine, optometry, physical therapy, and podiatry. B. The health care practitioner’s practice is exclusively office-based and the health care practitioner provides documentation that another practitioner or hospitalist will provide inpatient services for the health care practitioner’s patients at a hospital participating in the network of Soundpath Health. 5. The health care practitioner must provide all information regarding any current or past limitations, restrictions, terminations or other disciplinary actions taken with respect to his or her medical staff appointment or clinical or admitting privileges. The health care practitioner must never have had his or her medical staff appointment or clinical or admitting privileges denied, revoked or terminated by any hospital or other health care facility. Exceptions may be granted if Soundpath Health has identified an access, adequacy or other need in the practice area in which the health care practitioner practices, and the health care practitioner’s history and present circumstances do not indicate a Soundpath Health Provider Manual v3.1.14 Page 33 probable future substandard practitioner performance or competency concern in the opinion of Soundpath Health’s Chief Medical Officer or Credentialing Committee. 6. The health care practitioner must never have been convicted of, pled guilty to or no contest to, or have been sanctioned for, any offense or action involving Medicare, Medicaid or other governmental or private third party payor fraud or program abuse, and must not be listed on the Office of Inspector General (OIG) “Sanction List”. 7. The health care practitioner must never have been sanctioned, debarred, excluded or precluded from participation in Medicare or Medicaid programs. 8. The health care practitioner must possess and maintain, in the proposed practicing contracted specialty, Board Certification; completion of an approved and accredited residency-training program, awaiting certification results; or equivalent training and/or experience acceptable to the Soundpath Health Chief Medical Officer or Credentialing Committee. 9. The health care practitioner must provide a minimum of five (5) years of malpractice history. If the health care practitioner has a history of liability suits, claims, arbitration or settlements, this history must not demonstrate probable future substandard practitioner performance as determined by the Soundpath Health Chief Medical Officer or Credentialing Committee. 10. The health care practitioner must provide evidence of and maintain practitioner liability insurance coverage in such minimum amounts as are required by Soundpath Health from to time. Currently, the health care practitioner must maintain practitioner liability insurance coverage, on occurrence basis, in the amount of at least $1,000,000 million dollars per occurrence and $3,000,000 million dollars in the aggregate. 11. The health care practitioner must never have been indicted or convicted of, pled guilty to or no contest to, a felony, any offense involving moral turpitude or fraud, or any offense related to the practice of healing arts, other health care related matters, third-party reimbursement, controlled substances violations, child or adult abuse, or any other matter that in the opinion of Soundpath Health’s Chief Medical Officer or the Credentialing Committee, would adversely affect the ability of the applicant to participate. Exceptions may be granted if Soundpath Health has identified an access, adequacy or other need in the practice area in which the health care practitioner practices and the health care practitioner’s history and present circumstances do not indicate a probable future substandard practitioner performance in the opinion of Soundpath Health’s Chief Medical Officer or Credentialing Committee. 12. The health care practitioner must possess a valid, current and unrestricted state and federal Drug Enforcement Agency Certificate (DEA number) applicable to his or her specialty. Exceptions may be granted if the health care practitioner does not need to prescribe narcotics or other controlled substances in his or her practice (e.g., pathologist Soundpath Health Provider Manual v3.1.14 Page 34 or non-invasive radiologist) in the opinion of Soundpath Health’s Chief Medical Officer or Credentialing Committee. 13. The health care practitioner must permit Soundpath Health representatives to conduct onsite office reviews and the results of such review must not demonstrate a probable substandard practitioner performance in the opinion of Soundpath Health’s Chief Medical Officer or Credentialing Committee. 14. The health care practitioner must have no current abuse of illegal substances or chemical dependency. 15. The health care practitioner must not be experiencing physical or mental health problem(s), which impair the health care practitioner’s ability to practice within the scope of his or her license. Proof of ability will be based upon the nature of the impairment and other information obtained. 16. The health care practitioner’s financial and legal status history must not demonstrate probable future substandard practitioner performance or lack of financial capability and must demonstrate that the practitioner has authority to provide health care services to Soundpath Health’s Members. 17. The health care practitioner must not be restricted from participating in the Provider network of Soundpath Health by an exclusive or other arrangement with any person or entity other than Soundpath Health. 18. In certain geographic areas, the health care practitioner must participate in the Provider network of Soundpath Health through an intermediary with whom Soundpath Health has an exclusive or other restrictive arrangement. 19. The health care practitioner must execute, and enter into with Soundpath Health (or any required intermediary), the then current template of Soundpath Health’s written practitioner agreement, and must abide by and comply with all terms and conditions of the practitioner agreement and fulfill all obligations imposed on the health care practitioner under such practitioner agreement. 20. The number of existing practitioners who participate in Soundpath Health’s Provider network in the practice area of the health care practitioner must not exceed the number determined necessary by Soundpath Health’s Chief Medical Officer or Credentialing Committee to meet the needs of Soundpath Health’s Members. Soundpath Health Provider Manual v3.1.14 Page 35 Re-Credentialing Process Practitioners are re-credentialed at a minimum every three (3) years. Approximately 120 days before the re-credentialing date, Soundpath Health will review the provider’s Provider Source record. The Provider Source record must be up-to-date and include: Reason for any inability to perform the essential functions of the position, with or without accommodation Lack of present illegal drug use History of loss of license and felony convictions History of loss or limitation of privileges or disciplinary action Current malpractice insurance coverage The correctness and completeness of the application If the Provider Source record is not up-to-date, the provider will be notified in writing and requested to update his/her information. 3 attempts will be made to obtain up-to-date information. If the provider is unresponsive it may be cause for suspension or termination of Network participation. Incomplete re-credentialing may also result in Network suspension or termination as determined by the Chief Medical Officer and in accordance with the established Network Agreement and participation criteria. Soundpath Health may also elect to obtain updated copies of those practitioner and Provider documents that expire. This includes but is not limited to the state license, business license, professional liability coverage, DEA certificate if applicable, board certification and accreditation. Soundpath Health Provider Manual v3.1.14 Page 36 Appeals and Grievances Provider Claim Reconsideration and Provider Claim Dispute Processes 1st Level: Provider Reconsideration If you believe an item or service was denied in error by Soundpath Health, the first step in addressing your concern is to request a Claim Reconsideration. You may submit a Claim Reconsideration request via fax or mail. Mail to: Soundpath Health Attn: Provider Reconsiderations PO Box 4397 Federal Way, WA 98063 Fax to: (253) 517-4364 Your reconsideration request must be submitted to us within twelve (12) months from the date of the organization determination on the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA) and should include any supporting documentation. Please identify the specific claim(s) in “paid” or “denied” status which you believe should be adjusted, including any necessary supporting documentation. If you are submitting a Claim Reconsideration Request for a claim which was denied due to untimely filing: 1. Electronic claims – include confirmation that Soundpath Health or one of our delegated groups received and accepted your claim. 2. Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim to Soundpath Health or one of our delegated groups. Note: All proof of timely filing must also include documentation that the claim is for the correct patient and the correct visit. Soundpath Health Provider Manual v3.1.14 Page 37 2nd Level: Provider Dispute If you believe you were underpaid or feel an item or service was denied in error by us, the first step in resolving your concern is to submit a Claim Reconsideration as described above. If you do not agree with the outcome of the Claim Reconsideration decision made at the 1st level review, you may submit a formal dispute. Mail to: Soundpath Health Attn: Provider Reconsiderations PO Box 4397 Federal Way, WA 98063 Fax to: (253) 517-4364 Your dispute must be submitted to us within sixty (60) days from the date of the reconsideration decision shown on the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). Attach all supporting materials such as member specific treatment plans or clinical records to the formal dispute letter, based on the reason for the request. Include information which supplements your previous reconsideration submission that you wish to have included in the dispute review. Our decision will be rendered based on the materials available at the time of the formal dispute review. If you are disputing a claim that was denied because filing was not timely: 1. Electronic claims – include confirmation that Soundpath Health or one of our delegated groups received and accepted your claim. 2. Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim to Soundpath Health or one of our delegated groups. Note: All proof of timely filing must also include documentation that the claim is for the correct patient and the correct visit. Soundpath Health will provide a response to your dispute in writing within thirty (30) calendar days for pre-service disputes and sixty (60) calendar days for post-service disputes. Soundpath Health Provider Manual v3.1.14 Page 38 Note: The second level dispute decision rendered is final and not subject to further appeal. If you are disputing a refund request, please send your letter of appeal to the address noted on the refund request letter. Your appeal must be received within thirty (30) calendar days of the date of the refund request letter, or as required by law or your participation agreement, in order to allow sufficient time for processing the appeal, and to avoid possible offset of the overpayment against future claim payments to you. When submitting the appeal, please attach a copy of the refund request letter and a detailed explanation of why you believe we have made the refund request in error. Send Reconsiderations and Provider Disputes to: Soundpath Health Attn: Provider Reconsiderations PO Box 4397 Federal Way, WA 98063 Fax to: (253) 517-4364 For assistance, please call the Member Services Department seven days a week, from 8:00 a.m. to 8:00 p.m. from October 1 through March 1. Monday through Friday from 8:00 a.m. to 5:00 p.m. from March 2 through September 30. Toll free: 1-866-789-7747 or for TTY users: 1-866-264-4141 Provider Appealing on the Member’s behalf In the event that a member has authorized you to appeal a clinical or coverage determination on his/her behalf, such an appeal will follow the process governing member appeals as outlined in the member’s Evidence of Coverage (EOC) benefit handbook. Expedited Appeal Expedited appeal – for organizational determinations that resulted in a denial The Provider may request that the appeal be expedited if he/she believes the service or the discontinued service is a medically necessary covered service and is time-sensitive. As per the Member’s request, the Provider may submit a seventy-two (72) hour appeal on the Member’s behalf. Soundpath Health will make a decision on an expedited appeal within twenty-four (24) hours to determine the need for expedition. Requests for expedition will be considered when a Soundpath Health Provider Manual v3.1.14 Page 39 standard resolution could seriously jeopardize the Member’s life, health, or the ability to attain, maintain, or regain maximum function. Soundpath Health must make a decision as expeditiously as the health of the Member requires, but no later than the end of any extension period of fourteen (14) calendar days. The following are samples of expedited appeals that the Provider may believe are time-sensitive: Member is being discharged from a Hospital early and the Provider has missed the deadline for a Peer Review Organization (PRO) review. Member is being discharged from a Skilled Nursing Facility early. Member’s Home Health care is being discontinued early. How to request an expedited seventy-two (72) hour appeal Call, write, fax or visit the Soundpath Health Corporate Office at 32129 Weyerhaeuser Way South, Suite 201, Federal Way, WA 98001. The Provider needs to specify that this is an expedited appeal or urgent appeal. Mail to: Soundpath Health Attn: Appeals Department PO Box 4397 Federal Way, WA 98063 Phone: (253) 779-8830 or toll-free: (866) 789-7747 Fax to: (253) 517-4364 The following are possible dispositions for the Provider to request an expedited determination/appeal: The request to expedite our determination/appeal decision is approved, Soundpath Health will make a decision in seventy-two (72) hours and notify the Provider that Soundpath Health will provide or continue the service. The request to expedite our determination/appeal decision is not approved, and Soundpath Health informs the Provider that the request will be handled under the standard fourteen (14) day determination/appeal process. If the Provider does not hear Soundpath Health Provider Manual v3.1.14 Page 40 back from Soundpath Health within 72 hours of the request, please call the Utilization Management department or request a copy of the expedited determination/appeal decision. Quality Improvement Organization (QIO) The Provider has the right to provide all the Hospital or Skilled Nursing care necessary for the proper diagnosis and treatment of the Member’s illness or injury. The Member’s discharge date must be determined solely by medical needs as per the Federal law. The Provider and Members will receive a written notice of explanation called a “Detailed Notice of Discharge” or “Notice of Medicare Non-Coverage” when discharging a Member from the hospital or skilled nursing facility. This document outlines the Member’s rights. Soundpath Health or the Hospital is required to issue this notice to the Provider. Who are QIO Physicians? QIOs are groups of doctors who are paid by the Federal Government to review Medical Necessity, appropriateness and quality of Hospital treatment furnished to Medicare patients, including those enrolled in a managed care plan such as Soundpath Health. There is a QIO in every state. QIOs have different names, depending on which state they are in. The QIO in Washington State is called Qualis Health. You may contact Qualis Health toll free at 1-877-290-4346 or write to: Qualis Health P.O. Box 33400 Seattle, WA 98133-0400 Immediate Review of Hospital Discharges The Provider will be entitled to this process instead of the standard appeals process if the Provider asks for immediate review by the QIO by noon on the workday following a Detailed Notice of Discharge/Notice of Medicare Non-Coverage. Before the QIO makes its decision, the Provider will be protected from liability for hospital services the Member received. The Provider may appeal the Detailed Notice of Discharge/Notice of Medicare Non-Coverage as previously discussed by requesting that Soundpath Health reconsider the decision instead of a QIO review. If the Provider requests the review on time, the advantage of the QIO review is that the Provider will get the results within three working days. During the QIO review process, the Member will Soundpath Health Provider Manual v3.1.14 Page 41 not be financially liable for hospital charges incurred. This same protection for the Member does not apply in the case of Soundpath Health’s reconsideration process. Special expedited appeal, if missed QIO deadline If the Provider has missed the deadline for requesting the QIO review, they may only file an oral or written request for an expedited seventy-two (72) hour Soundpath Health appeal. If the original determination to discharge the Member is not approved through the appeal process and the Provider does not seek QIO review, however seeks an expedited reconsideration of the Organization Determination, the Member will be financially responsible for the hospital costs incurred from the date the Detailed Notice of Discharge/Detailed Explanation of Non-Coverage is issued. QIO complaints process The Provider or Member may file a complaint with the QIO in their local area if they are concerned about the quality of care provided to a Member. Grievance Procedures A “Complaint” is an Informal Grievance that is any expression of dissatisfaction with the administration, claim practices, or provision of services relating to quality of care and services provided. The Provider should use Soundpath Health’s Grievance Procedure for complaints that do not involve coverage decisions. Please call Member Services if you have a question about what type of complaint process to use. The Provider has the right to file a complaint/grievance about problems the Member and/or Provider may observe or experience. The Provider may file a grievance (a written complaint) submitted on behalf of the Member. The following are some examples of a grievance: complaints regarding Member issues, adequacy of facilities, or other similar Providers; quality of care; claims payment, handling, or reimbursement for health care services; or any matter pertaining to the contractual relationship between you and Soundpath Health. If the Provider feels the standard of time frame for our decision could seriously jeopardize the life or health of the enrollee or regain maximum function, he or she may request an expedited seventy-two (72) hour review. Soundpath Health Provider Manual v3.1.14 Page 42 Who to call for a complaint? Soundpath Health will attempt to resolve any complaints and encourages the informal resolution of complaints since some of the complaints may arise from misinformation, misunderstanding or lack of information. By calling Soundpath Health, the Provider may utilize the informal resolution of the complaint process. Formal grievance For issues involving quality of care and services, the formal grievance procedure is the submission of the Provider’s issue in writing to Soundpath Health within 45 days of the incident. To use the formal grievance procedure, submit your grievance in writing to: Soundpath Health Attn: Appeals Department PO Box 4397 Federal Way, WA 98063 Fax to: (253) 517-4364 If Soundpath Health requires additional time to address the concern, Soundpath Health may have a 30-calendar day extension. Soundpath Health shall resolve a grievance within sixty (60) days after receipt of the grievance, or within a maximum of ninety (90) days if the grievance involves the collection of information outside the service area. Fraud, Waste, and Abuse Definitions: Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347) Waste is over-utilization of services or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather misuse of resources. Soundpath Health Provider Manual v3.1.14 Page 43 Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. (Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.) Pertinent Laws and Regulations: False Claims Act The Federal False Claims Act creates liability for the submission of a claim for payment to the government that is known to be false – in whole or in part. Several states have enacted false claims laws as well. A “claim” is broadly defined to include any submissions that results, or could result, in payment. Under the False Claims Act, ‘knowing’ or ‘known’ means that a person: Has actual knowledge Acts in deliberate ignorance of truth or falsity or Acts in reckless disregard of truth or falsity (Proof of specific intent to defraud is not required to fall within the definition of “knowing” or “known.”) Claims submitted to the government include claims submitted to intermediaries such as state agencies, managed care organizations and other subcontractors under contract with the government to administer health care benefits. Liability can also be created by improper retention of an overpayment. The Affordable Care Act of 2010 (ACA) expanded a provision of the False Claims Act referred to as a reverse false claim. Overpayments or any funds received or retained under Medicare or Medicaid that a person or organization is not entitled to must be reported and returned within sixty (60) days of identification. Soundpath Health Provider Manual v3.1.14 Page 44 Whistleblower and Whistleblower Protections: The False Claims Act and some state false claims laws permit private citizens with knowledge of fraud against the U.S. or state governments to file suit on behalf of the government against the person or business that committed the fraud. Individuals who file such suits are known as ‘whistleblowers’. The federal False Claims Act and some state false claims acts prohibit retaliation against individuals for investigating, filing or participating in a whistleblower action. Soundpath Health expressly prohibits retaliation against employees – including employees of first tier, downstream and related entities – who, in good faith, report or participate in the investigation of compliance concerns. Examples of FWA include: A physician who submits a bill to Medicare for medical services not provided. A government contractor who submits records that he/she knows (or should know) are false and that indicate compliance with certain contractual or regulatory requirements. An agent who submits a forged or falsified enrollment application to receive compensation from a Medicare Plan Sponsor. Anti-Kickback Statute The Anti-Kickback law makes it a crime for individuals or entities to knowingly and willfully offer, pay, solicit or receive something of value to induce or reward business referrals under Federal health care programs. The Anti-Kickback law is intended to ensure that referrals for health care services are based on medical need and not financial or other types of incentives to individuals or groups. The Affordable Care Act (sometimes referred to as the Health Care Reform law) has added a provision to the Anti-Kickback statute where “knowingly and willfully” does not mean the individual had the intent to specifically violate the statute. In addition, violations of the AntiKickback statute can now be considered a false and fraudulent claim under the False Claims Act. Soundpath Health Provider Manual v3.1.14 Page 45 Examples include: A frequent flyer campaign in which a physician may be given airline frequent flier mileage rewards for questionnaires completed for new patients put on a drug company's product. Free laboratory testing offered to health care providers, their families and their employees to induce referrals. In addition to criminal penalties, violation of the Federal Anti-Kickback statute could result in civil monetary penalties and exclusion from federal health care programs, including the Medicare and Medicaid programs. Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA contains provisions and rules related to protecting the privacy and security of protected health information (PHI) as well as provisions related to prevention of health care fraud and abuse. HIPAA Privacy The Privacy Rule outlines specific protections for use and disclosure of PHI. It also grants rights to members. HIPAA Security The Security Rule outlines specific protections and safeguards for electronic PHI. If you become aware of a potential breach or inappropriate disclosure of protected information, you must comply with the security breach and disclosure provisions under HIPAA and, if applicable, with any business associate agreement. Examples of HIPAA provisions related to the prevention of health care fraud and abuse: Creation of the Fraud Abuse and Control Program for coordination of state and federal health care fraud investigation and enforcement activities. Expansion of the exclusion authority so that any health care fraud conviction, even if the fraud is not related to Medicare or Medicaid, results in mandatory exclusion from participation in the Medicare or Medicaid programs. Creation of a new series of federal crimes, together referred to as “health care fraud,” which make it a federal crime to defraud health care benefit programs – any benefit program, not just Medicare or Medicaid. Soundpath Health Provider Manual v3.1.14 Page 46 Criminal Health Care Fraud Statute The Criminal Health Care Fraud statute (18 U.S.C. Section 1347) prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice: To defraud any health care benefit program; or To obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program in connection with the delivery of or payment for health care benefits, items or services. Proof of actual knowledge or specific intent to violate the law is not required. Penalties for violating the Criminal Health Care Fraud statute may include fines, imprisonment, or both. Examples of Member Fraud, Waste and Abuse: Doctor Shopping – Consumer or other individual consults with a number of doctors for the purpose of inappropriately obtaining multiple prescriptions for narcotic painkillers or other drugs. Doctor shopping might be indicative of an underlying scheme, such as stockpiling or resale. Prescription Diversion and Inappropriate Use – Consumers obtain prescription drugs from a provider, possibly for a condition from which they do not suffer, and give or sell this medication to someone else. Also can include the inappropriate consumption or distribution of a consumer’s medications by a caregiver or anyone else. Identity Theft or Medical Identity Theft – A person uses another person’s Medicare card to obtain services or prescriptions – OR – another person’s information is used to bill for procedures never done or for supplies never received. Examples of Pharmacy Fraud, Waste and Abuse: Prescription Drug Switching – The pharmacy or pharmacy benefit manager (PBM) receives a payment to switch a consumer from one drug to another or influences the prescriber to switch the patient to a different drug. Prescription Drug Shorting or Splitting – A pharmacy or PBM’s mail order pharmacy intentionally provides less than the prescribed quantity and does not inform the patient or make arrangements to provide the balance, but bills for the Soundpath Health Provider Manual v3.1.14 Page 47 fully-prescribed amount. The pharmacy splits the original prescription to receive additional dispensing fees. Inappropriate billing practices such as: Billing for brand when generics are dispensed. Billing for non-covered prescriptions as covered items. Billing for prescriptions that are never picked up. Prescriber Fraud, Waste and Abuse: Script Mills – Provider writes prescriptions for drugs that are not medically necessary, often in mass quantities, and often for patients that are not theirs. These scripts are usually written, but not always, for controlled drugs for sale and might include improper payments to the provider. Illegal Remuneration Schemes – Prescriber is offered, paid, solicits or receives unlawful remuneration (payment or items of value) to induce or reward the prescriber to write prescriptions for drugs or products. Prescription Drug Switching – Drug switching involves offers of cash payments or other benefits to a prescriber to induce them to prescribe certain medications rather than others. Examples of Sales Agent Fraud, Waste and Abuse: Marketing Schemes Enrollment of a consumer in a Medicare Plan without the consumer’s knowledge or consent. Offering consumers a cash payment or other reward as encouragement to enroll in a Medicare, Medicaid, or health care benefit plan. Selling or marketing insurance without a license. Using consumer information supplied through a third-party (another agent, friend, etc.) to market Medicare plans. Agents splitting commissions or agent referral fees. Misrepresenting themselves as a representative of the government (Medicare/Social Security/Federal Government). If you identify or are made aware of potential misconduct or a suspected fraud, waste or abuse situation, it is your right and responsibility to report it. Please call our Compliance/Fraud, Waste and Abuse Hotline at 253-779-8830. Soundpath Health Provider Manual v3.1.14 Page 48 State and the federal government regulations have very clear guidelines on the mandatory reporting of claims that are suspicious. In addition Soundpath Health policy states that any person who knowingly and with intent to defraud or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. As a result of our legal obligations, Soundpath Health has established an anti-fraud program. We routinely audit, and when necessary, investigate claims submitted to us for payment of services. Common errors in billing include: Billing for non-chargeable or non-covered services. Reciprocal billing – billing for services rendered for another Provider. Submitting duplicate claims for services rendered. Any other unsound fiscal practices, i.e., up-coding, unbundling. Upon investigation, it may be necessary to elicit your cooperation in an effort to resolve questions regarding suspicious claims. While it is important to follow policies and procedures and internal controls to prevent fraud and abuse, Soundpath Health is committed to balancing prompt claims processing adjudication with effective claims control at all times. Healthcare fraud, waste and abuse affects us all and causes an increase in health care costs. If you suspect any person, provider or company of defrauding or attempting to defraud Soundpath , please call us at (253) 779-8830. All calls are confidential and you may report your suspicions anonymously via our toll free hotline. For more information about health care fraud, visit http://www.stopmedicarefraud.gov/. Resources: CMS’ Prescription Drug Benefit Manual – Chapter 9 CMS’ Medicare Managed Care Manual – Chapter 21 http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf CMS’ Prescription Drug Benefit Manual http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/PartDManuals.html CMS’ Medicare Managed Care Manual http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html Soundpath Health Provider Manual v3.1.14 Page 49 Code of Federal Regulations (see 42 CFR 422.503 and 42 CFR 423.504) http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR Office of the Inspector General – Fraud Information http://oig.hhs.gov/fraud/ Medicare Learning Network (MLN) Fraud & Abuse Job Aid http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/Fraud_and_Abuse.pdf Billing and Claims Payment Electronic Claims Submission Soundpath Health strongly prefers electronic claims submission for a variety of reasons: less manual work means less human error resulting in faster payment with minimal rework. Soundpath Health uses Emdeon as the primary clearinghouse for claims. The clearinghouse’s use of specific system edits ensures the accuracy of all claims forwarded. If you are a physician, other health care professional or facility you may use electronic transactions. Please use the Emdeon Claims Submission payer ID #42172. Where to Send Paper Claims If you are not currently set up to bill Soundpath Health electronically, paper claims need to be submitted on the appropriate claim form (CMS-1500 for professional claims and the UB-04 for facility claims). Please send claims to: Soundpath Health Attn: Claims PO Box 4537 Federal Way, WA 98063-9346 Hierarchical Condition Category Model (HCCM) Documentation must support the diagnosis and coding of the highest specificity. Medicare payment to Soundpath Health is based on the most severe manifestation of disease when less severe manifestation is present. Soundpath Health will not accept any claims that do not have a 5-digit code. Soundpath Health Provider Manual v3.1.14 Page 50 Claims Process & Payment Soundpath Health standard is to process 95% of clean claims from non-contracted Providers within thirty (30) days of receipt and will pay interest on claims that do not meet this standard. 95% of unclean claims from non-contracted Providers will be paid in sixty (60) days. Reimbursement to non-contracted Providers will be the amount the Provider would have received under original Medicare. A clean claim an uncontested, complete, accurate, and valid claim, submitted on a CMS 1500 or UB92 or successors as appropriate, which has all mandatory entries and truthfully represents Medically Necessary services provided to a Member as documented in the Members medical record and which complies with standards established by Soundpath Health. It is also defined as a claim that has no defect or impropriety, including lack of required substantiating documentation for non-contracting Providers and suppliers, or particular circumstances requiring special treatment that prevents timely payment for being made on the claim. 95% of claims from contracted Providers will be paid in sixty (60) days or as required by the Participant Agreement. All facility claims must be submitted on a UB-04 Form All ancillary services claims must be submitted on a CMS 1500 Form All coding must conform to National Coding Standards (HIPAA) The “UNIT” submitted will vary according to the type of service authorized. All “UNITS” must be submitted as whole numbers. Decimal numbers are not acceptable. The following are examples of UNITS: A day A visit An hour A dose of medication A piece of equipment Soundpath Health does not count the day of discharge as a covered day for purposes of reimbursement. Claims for services that have not been authorized by Soundpath Health or the appropriate delegate will be denied. Soundpath Health Provider Manual v3.1.14 Page 51 An Explanation of Benefits/Remittance Advice will be provided for each claim line that is denied. Claims received with missing and/or invalid codes or with the use of any corrective material will be denied and returned to the Provider for re-submission. An Explanation of Benefits/Remittance Advice will accompany the claim. Timeframes for Submission Providers shall make best efforts to submit claims within thirty (30) days of the date of authorized service. Under no circumstances will claims be paid for services billed more than 365 days from the date of service. Soundpath Health will make payment within the timeframes required by the Participant Agreement, or the State and /or Federal mandate and the timeframe for payment is based on the receipt of a complete, “clean” claim. Provider Remittance (Explanation of Benefits) All claim payments are sent with a Provider Remittance that includes the claims payment calculations and benefit codes that explain why a service was paid, modified, or denied. Member Eligibility and Retroactive Disenrollment Soundpath Health verifies Member eligibility and benefit availability at the time services are requested, at the time the claims are adjudicated, and when notified by CMS of a retroactive disenrollment. Payments will be made only when the Member is eligible on the dates the service is provided. Occasionally, Soundpath Health is notified of a retroactive disenrollment by CMS after a claim has been paid. In this event, Soundpath Health will notify the Provider of the overpayment, and will request an immediate refund. If such monies are not received, the overpayment will be deducted from the Provider’s next remittance. Soundpath Health will assist the Provider in identifying the Member’s other coverage. Soundpath Health Provider Manual v3.1.14 Page 52 Coordination of Benefits (COB) Soundpath Health adheres to CMS regulations to determine primary insurance carrier and appropriate reimbursement process. The Soundpath Health Provider is responsible for identifying all insurance coverage held by the Member by obtaining a copy of the Member’s identification card at the time of admission or service initiation. Any coverage information obtained (in excess of that provided by Soundpath Health at the time of service authorization) should be forwarded immediately to Soundpath Health. This information will help expedite payment. If the additional coverage is “primary,” the claim first must be submitted to that carrier for payment. Soundpath Health will review the admission record or intake form to identify possible COB, and will relay such information to the Soundpath Health Claims Department. If other coverage is determined to be primary, Soundpath Health will deny payment and return the claim to the Provider. If Soundpath Health is the secondary payor an EOB from the primary carrier must be submitted to Soundpath Health in order for Soundpath Health to process any secondary coverage payment. All COB claims over $25,000 will be reviewed for case management. Co-Payments and Coinsurance Soundpath Health Providers are responsible for collection of all co-payments and co-insurance. Such co-payments and co-insurance are generally reflected on the Member’s Soundpath Health identification card. To obtain or verify the information, please contact Soundpath Health Member Services at 1-866-789-7747. Checking Claims Status Soundpath Health Providers may contact the Member Services to check the status of a claim at 1- 866-789-7747. Contracted providers who have enrolled in the Soundpath Health Provider Portal can look up certain claims payments online. More info at [email protected]. Providers must have the following information available: Member Identification number Member name Date of service Soundpath Health Provider Manual v3.1.14 Page 53 Denial of Claims Soundpath Health will deny a claim for the following reasons: Member is not eligible on dates of service Non-covered services or services which exceed benefit limits No prior authorization (if service requires prior authorization) Services billed are in excess of services authorized Non-timely filing of claim COB review determines that primary liability is not with Soundpath Health contracted payor but rather with other health Insurance Incomplete claim Alteration of claim with corrective material (whiteout /corrective tape, etc Duplicate claim National Provider Identification (NPI) The Health Insurance Portability and Accountability Act (HIPAA), federal Medicare regulations, and many state Medicaid agencies mandate the adoption and use of a standardized National Provider Identifier (NPI) for all health care professionals. In compliance with HIPAA, all covered health care providers and organizations must obtain an NPI for identification purposes in standard electronic transactions. HIPAA defines a covered health care provider as any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. These covered health care providers must obtain an NPI and use this number in all HIPAA transactions. To avoid payment delays or denials, Soundpath Health requires a valid Billing NPI and Taxonomy Code(s) be submitted on both paper and electronic claims. Please continue to submit your Tax Identification Number (TIN) as well. Compensation Additional fees: You may not charge members fees for covered services beyond copayments, coinsurance or deductibles as described in the Member’s benefit plans. You may not charge members retainer, membership, or administrative fees, voluntary or otherwise. This includes, but is not limited to, concierge/boutique practice fees, as well as fees to cover increases in malpractice insurance and office overhead, any taxes, or fees for services you provide that are denied or otherwise not paid due to your failure to notify us, to file a timely claim, to submit a Soundpath Health Provider Manual v3.1.14 Page 54 complete claim, to respond to our request for information, or based on our reimbursement policies or methodologies. Please note that CMS does not allow a provider to charge for “missed appointments” unless the provider has previously disclosed that policy, in writing, to the member. Charges for non-covered services: A Notice of Denial of Medical Coverage must be provided to the Member advising them when a service is not covered. You should know or have reason to know that a service may not be covered if 1) we have provided general notice through an article in a newsletter or bulletin, or information provided on our website (www.SoundpathHealth.com), including clinical protocols, medical and drug policies, either that we will not cover a particular service or that a particular service will be covered only under certain circumstances not present with the member, or we have made a determination that planned services are not covered services and have communicated that determination to you on this or a previous occasion. Financial incentives: Soundpath Health notifies its members that the treatment decisions are made between physicians and members and coverage decisions on health care services are based on the member’s benefit contract. Therefore, 1) coverage decisions are made based on the existence of coverage as defined with the Member’s benefit contract, 2) The staff of Soundpath Health, its delegates, and the physicians and other health care professionals making these decisions are not rewarded for issuing non-coverage decisions, and 3) Soundpath Health and its delegates do not offer incentives to physicians or other health care professionals to encourage underutilization of care or services. Medicare Advantage risk adjustment data: The risk adjustment data you submit to Soundpath Health must be accurate and complete. Note that 1) risk adjustment is based on ICD-9-CM (or its successor) diagnosis codes, not CPT codes. Thus it is critical for your office to refer to an ICD-9CM (or its successor) coding manual and code accurately, specifically and completely when submitting claims to Soundpath Health, 2) diagnosis codes must be supported by the medical record. If it is not documented in the medical record, the Soundpath Health will not recognize it as occurring. Medical records must be clear and complete, 3) be sure to distinguish between acute vs. chronic conditions in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit, 4) always carry the diagnosis code all the way through to the correct digit for specificity. For example, do not use a 3-digit code if a 5-digit code more accurately describes the Member’s condition, 5) be sure that the diagnosis code is appropriate for the Member’s gender. You shall cooperate with any Soundpath Health audits and/or external audits mandated by federal or state law or regulations, and shall make all records available to appropriate federal and state authorities, subject to applicable federal and state laws and regulations relating to the privacy of an individual’s health care information. You will allow and fully cooperate with Soundpath Health Provider Manual v3.1.14 Page 55 inspection, audit and duplication by Soundpath Health of any and all data and other records maintained on Soundpath Health’s Members which relate to the Provider Agreement to the extent necessary to perform the audit or inspection. Such data and other records include, but are not limited to, billing, payment, assignment, utilization review, medical and medical abstract records maintained on Members pursuant to this Agreement, and charge and reimbursement data maintained by you related to charges made and payments received by you from other payors. Such inspection, audit verification and duplication will be allowed upon reasonable notice during regular business hours. In addition, you shall make such data and other records available to appropriate state and federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Members, subject to applicable state and federal laws related to the confidentiality of medical records. Plan, the Secretary of Health and Human Services (the “Secretary”), the Comptroller General or their designees shall have the right to audit, evaluate, inspect and copy any books, contracts, medical records, patient care documentation and other records that pertain to: (1) the services performed under the Provider Agreement; (2) reconciliation of benefit liabilities (3) determination of amounts payable; or (4) other relevant matters as such person conducting the audit, evaluation or inspection deems necessary. The right described above shall extend through 10 years from the final date of the applicable Plan Contract period or completion of audit, whichever is later; provided, however, that such access may be required for a longer time period if: (1) CMS determines that there is a special need to retain a particular record or group of records for a longer period and CMS provides notice at least 30 days before the normal disposition date; (2) CMS determines that there has been a termination, dispute, fraud or similar fault, in which case the retention may be extended to 10 years from the date of any resulting final resolution of the matter; or (3) CMS determines that there is a reasonable possibility of fraud, in which case it may perform the inspection, evaluation or audit at any time. (42 CFR §§ 422.504(e)(2); 422.504(e)(3); 422.504(i)(2)(i) and (ii); 422.504(e)(4)). For the purpose of conducting the above activities, you shall make available their premises, physical facilities and equipment, records relating to Soundpath Health Members, and any additional relevant information that CMS may require. Site of Service Payment Differential The site of service differential is based on CMS‘s payment policy. Soundpath Health will pay professional services at the RBRVS rates for facility and non-facility settings based on where the Soundpath Health Provider Manual v3.1.14 Page 56 service was performed. It is important to include a valid 2-digit place of service code on your bill. Professional services will be paid at the RBRVS rate for facility settings when Soundpath Health also makes a payment to a facility. The following codes will be paid at the rate for facility settings: Place of Service Code Place of Service Description 05 Indian health service free-standing facility 06 Indian health service provider-based facility 07 Tribal 638 free-standing facility 08 Tribal 638 provider-based facility 21 Inpatient hospital 22 Outpatient hospital 23 Emergency room-hospital 24 Ambulatory surgery center 25 Birthing center 26 Military treatment facility 31 Skilled nursing facility 34 Hospice 41 Ambulance (land) 42 Ambulance (air or water) 51 Inpatient psychiatric facility 52 Psychiatric facility partial hospitalization 56 Psychiatric residential treatment center 61 Comprehensive inpatient rehabilitation facility 62 Comprehensive outpatient rehabilitation facility 99 Other unlisted facility (none) (Place of service code not supplied) Soundpath Health Provider Manual v3.1.14 Page 57 When services are provided in non-facility settings, the professional provider typically bears the costs of labor, medical supplies and medical equipment. These costs are included in the RBRVS rate for non-facility settings. Professional services will be paid at the RBRVS rate for nonfacility settings when Soundpath Health does not make a separate payment to a facility. The following place of service codes will be paid at the rate for non-facility settings: Place of Service Code Place of Service Description 01 Pharmacy 03 School 04 Homeless shelter 09 Correctional facility 11 Office 12 Home 13 Assisted living facility 14 Group home 15 Mobile unit 16 Temporary lodging 17 Walk-in retail health clinic 20 Urgent care facility 32 Nursing facility 33 Custodial care facility 49 Independent clinic 50 Federally qualified health center 53 Community mental health center 54 Intermediate care facility/mentally retarded 55 Residential substance abuse treatment center 57 Nonresidential substance abuse treatment center 60 Mass immunization center 65 End stage renal disease treatment facility Soundpath Health Provider Manual v3.1.14 Page 58 71 State or local public health clinic 72 Rural health clinic 81 Independent laboratory Facilities will be paid at the RBRVS rate for non-facility settings when Soundpath Health does not make a separate payment directly to the provider of the service. Medicare Part D Soundpath Health is an approved Medicare Advantage Prescription Drug Plan (MAPD); and therefore, as an approved Part D contracted Provider, have met specific guidelines that apply to drug formulary and network development, drug management programs, and benefits design. By law, certain types of drugs or categories of drugs are not covered by Medicare Drug Plans. These include, but are not limited to: Most non-prescription drugs Drugs used for anorexia, weight loss, or weight gain Drugs used to promote fertility Drugs used to treat erectile dysfunction Drugs used for cosmetic purposes or hair growth Drugs used for the symptomatic relief of cough or colds Prescription vitamins (with the exception of pre-natal vitamins) and mineral products Pharmacy Management For certain prescription drugs, we have additional requirements which may include requirements for “step therapy,” quantity limits, or limits on our coverage. These requirements and limits ensure that our Members use these drugs in the most effective way and also help us control drug plan costs. The Pharmacy and Therapeutic (P&T) Committee developed these requirements and limits for Soundpath Health to help to provide cost effective coverage to our Members. Soundpath Health Provider Manual v3.1.14 Page 59 Examples of utilization management tools are described below: Prior Authorization: Soundpath Health requires Providers to get prior authorization for certain drugs. This means that the Member, the physician, or pharmacist will need to get approval from Soundpath Health before the prescription is filled. The formulary identifies which drugs require prior authorization and quantity limits. The Formulary Exception Request Form is available on the website as a PDF file (in progress, contact Member Services for the form). Quantity Limits: For certain drugs, Soundpath Health limits the amount of the drug that is covered per prescription or for a defined period of time. Generic Substitution: When there is a generic version of a brand-name drug available, Soundpath Health network pharmacies will automatically give the Member the generic version, unless the Provider has informed Soundpath Health that a brandname drug should be dispensed. Pharmacy & Therapeutics (P&T) Committee Soundpath Health benefits from MedImpact’s, our Pharmacy Benefit Manager partner’s, P&T Committee. This committee meets regularly and its Members include primary care and specialty physicians, pharmacists and pharmaceutical consultants. Responsibilities include but are not limited to review and analysis of the covered drug list, the pharmacy benefits, requests for new technologies and therapeutics, development of drug safety studies, and potential quality issues regarding medications. Physicians are encouraged to participate in the process. The physicians and pharmacists who serve on the Pharmacy and Therapeutics Committee are responsible for reviewing all medications as they come to market. They consider whether each medication should be covered under the prescription benefit. When making a recommendation, the P&T Committee focuses on the medication’s overall health benefit as well as the cost. They consider FDA recommendations, manufacturer package labeling instructions, and published clinical recommendations. Pharmacy Benefits and Covered Drugs Pharmacy benefits are filed with CMS (Center for Medicare and Medicaid Services) on an annual basis. The benefits include a list of covered drugs and corresponding co-payments, dispensing limits, and other restrictions. For additional information regarding pharmacy benefits please refer to the Soundpath Health member’s Evidence of Coverage or contact Customer Services at 1-866-789-7747. Soundpath Health Provider Manual v3.1.14 Page 60 What is a Coverage Determination? The coverage determination made by Soundpath Health is the starting point for dealing with requests Members may have about exceptions to cover or pay for a Part D prescription drug. The following are examples of coverage determinations: Members may ask us to pay for a prescription drug they have already received. This is a request for a coverage determination about payment Members may ask for a Part D drug that is not on the plan's list of covered drugs ("formulary"). This is a request for a formulary exception. Members may ask for an exception to our plan’s utilization management tools - such as step therapy requirements, dosage limits, or quantity limits. Requesting an exception to a utilization management tool is a type of formulary exception. Members may ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tier exception. Generally, Soundpath Health will only approve a request for an exception if the alternative drug included on the plan’s formulary or the low-tiered drug would not be as effective in treating the Member’s condition and/or would cause the Member to experience adverse medical effects. Can the formulary change? Soundpath Health and the PBM will add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much Members will have to pay when filling a prescription. If drugs are removed from the formulary, a tier change occurs, prior authorizations are added, and/or quantity limits change on a drug, Soundpath Health will notify Members and Providers of the change at least sixty (60) days before the date that the change becomes effective. However, if a drug is removed from our formulary because the drug has been recalled from the market, Soundpath Health will not give sixty (60) days notice before removing the drug from the formulary. Instead, Soundpath Health will remove the drug from our formulary immediately and notify Members and Providers about the change as soon as possible. Soundpath Health Provider Manual v3.1.14 Page 61 Drug Utilization Review Soundpath Health and the PBM conduct drug utilization reviews for all Members to make sure that they are getting safe and appropriate care. These reviews are especially important for Members who have more than one doctor who prescribe their medications. If we identify a problem during the drug utilization review, we will work with the physician(s) to correct the problem. These reviews serve to look for problems such as: Possible prescription drug errors Duplicate drugs that are unnecessary because another drug is prescribed to treat the same medical condition Drugs which are inappropriate because of age or gender or possible harmful interactions between drugs Drug allergies and drug dosage errors Medication Therapy Management Programs Soundpath Health and the PBM offer medication therapy management programs at no additional cost for Members who have multiple medical conditions, are taking many prescription drugs, or have high drug costs. In compliance with the Centers for Medicaid and Medicare (CMS), the MTMP program is outlined below, and the purpose of the program is to ensure appropriate utilization of drugs, reduce the potential for adverse effects, and improve the opportunities for optimal Member outcomes. Members will be designated for participation based on meeting all three of the following criteria if they choose to Opt In to the MTMP Program: Chronic Diseases: (two chronic conditions from the following list): diabetes, asthma, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, or congestive heart failure. Multiple Covered Part D Drugs: more than two. Total incurred cost: covered Part D drugs, if the Member is likely to incur annual costs of at least $3,017 for all covered Part D drugs. Soundpath Health Provider Manual v3.1.14 Page 62 Interventions and programs by the PBM and Soundpath Health for those Members who Opt-In include: targeted quarterly mailings and educational materials to Members who are determined to be non-adherent to prescribed medication therapy for identified disease states; targeted quarterly mailings and educational materials to Members determined to be users of medications that are potentially inappropriate for use in an elderly population due to the high potential for adverse effects. Mail Order Pharmacy Service This program is provided through MedImpact and is a great convenience for Members. Please refer to the website at www.SouthpathHealth.com for a program description and order forms. MedImpact: (800) 788-2949 Vendor Partners Behavioral Health Soundpath Health has partnered with Reliant Behavioral Health (RBH) for the provision of behavioral health and substance abuse services, including treatment review and payment authorization for Members receiving behavioral health treatment. RBH offers clients over 10 years of experience as an independent, regional, managed behavioral healthcare organization (MBHO). Fully accredited by the National Committee for Quality Assurance (NCQA), RBH offers reliable, quality care management. Their goal is to direct members to the right care at the right time to ensure individuals receive appropriate care for their unique needs at the greatest possible savings for the plan and/or employer. Please note, the PCP must refer the member for non-emergent BH services. Phone: 1-866-750-1327 Fax: 1 -877- 730-5113 www.MyRBH.com 1221 S.W. Yamhill St., Suite 200 Portland, Oregon 97205 Soundpath Health Provider Manual v3.1.14 Page 63 Routine Vision Care* Access to routine vision services is an important benefit to most people on Medicare. In support of this, Soundpath Health has partnered with Vision Service Plan (VSP) to provide access to routine vision care for our Members. VSP is dedicated to offering affordable, high-quality eye care plans that promote visual wellness and improve Members’ quality of life. As the nation’s largest provider of eye care coverage, thousands of companies rely on them to provide a range of vision plans to meet overall eye health and wellness. For our Members with a hardware (lenses, frames, and/or contact lenses) benefit, they may elect to access this benefit through the VSP network or out-of-network and is payable up to the benefit limit. Out-of-network benefits require the Member to pay upfront and submit a receipt for reimbursement. Vision Service Plan 1-800-877-7195 Complementary Alternative Medicine rider (if purchased by member)* Soundpath Health is pleased to offer a unique benefit of chiropractic and acupuncture services to Members. These services are provided through American Specialty Health (ASH). ASH is one of the nation’s leading complementary health care benefits organizations, providing benefit programs, health education programs, and health-related products, administering benefit programs for 12.1 million members and affinity discount programs for over 80 million members. American Specialty Health 1-800-972-4226 Routine Hearing Exams and Hearing Devices* Through a special arrangement with Hearing Care Solutions (HCS), members are now eligible for a valuable new hearing care program. Hearing Care Solutions offers Soundpath Health members an annual hearing exam at no charge. Members can choose from a wide selection of hearing aids at fixed prices, from $825 to $1,750, depending on level of technology. HCS works with several major manufacturers to offer a wide variety in products. We offer a 3-year warranty, 1 year of free batteries and routine in-office servicing. Call Hearing Care Solutions today to schedule your complete hearing exam at no charge 1-866-344-7756 or visit www.hearingcaresolutions.com. Soundpath Health Provider Manual v3.1.14 Page 64 Fitness Benefit* The SilverSneakers program offered by Healthways provides no-cost fitness club memberships to fitness clubs and exercise centers. In addition to a standard fitness club/exercise center membership, Members may have access to senior-oriented fitness classes at participating fitness clubs. SilverSneakers 1-888-423-4632 [email protected] Discount Programs* NutriSystem. Members have access to NutriSystem products at a discount off of retail prices. Members should contact Soundpath Health Customer Service who can provide the online discount code. QuickMedical. Members have access to Omron blood pressure monitoring products at a discount off of retail prices. Members should contact Soundpath Health Customer Service who can provide the online discount code. Mayo Clinic. Members have access to Mayo Foundation for Medical Education and Research products at a discount off of retail prices. Members should contact Soundpath Health Customer Service who can provide the online discount code. *The products and services described above are neither offered nor guaranteed under Soundpath Health’s contract with the Medicare program. In addition, these programs are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Soundpath Health grievance process. Soundpath Health Provider Manual v3.1.14 Page 65 CMS Regulations § 422.501(i)(3)(i) and 422.504 (g)(1)(i) For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for Medicare Part A and B cost sharing when the State is responsible for paying such amounts. Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. First Tier or Downstream Entities may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under title XIX if the individual were not enrolled in such a plan. Providers will: (1) accept the MA plan payment as payment in full, or (2) bill the appropriate State source. § 422.200 Basis and scope. This subpart is based on sections 1852(a)(1), (a)(2), (b)(2), (c)(2)(D), (j), and (k) of the Act; section 1859(b)(2)(A) of the Act; and the general authority under 1856(b) of the Act requiring the establishment of standards. It sets forth the requirements and standards for the MA organization's relationships with providers including physicians, other health care professionals, institutional providers and suppliers, under contracts or arrangements or deemed contracts under MA private fee-for-service plans. This subpart also contains some requirements that apply to non-contracting providers. § 422.202 Participation procedures. (a) Notice and appeal rights. An MA organization that operates a coordinated care plan or network MSA plan must provide for the participation of individual physicians, and the management and members of groups of physicians, through reasonable procedures that include the following: (1) Written notice of rules of participation including terms of payment, credentialing, and other rules directly related to participation decisions. (2) Written notice of material changes in participation rules before the changes are put into effect. (3) Written notice of participation decisions that are adverse to physicians. (4) A process for appealing adverse participation procedures, including the right of physicians to present information and their views on the decision. In the case of termination or suspension of a provider contract by the MA organization, this process must conform to the rules in §422.202(d). (b) Consultation. The MA organization must establish a formal mechanism to consult with the physicians who have agreed to provide services under the MA plan offered by the organization, regarding the organization's medical policy, quality improvement programs and medical management procedures and ensure that the following standards are met: (1) Practice guidelines and utilization management guidelines— Soundpath Health Provider Manual v3.1.14 Page 66 (i) Are based on reasonable medical evidence or a consensus of health care professionals in the particular field; (ii) Consider the needs of the enrolled population; (iii) Are developed in consultation with contracting physicians; and (iv) Are reviewed and updated periodically. (2) The guidelines are communicated to providers and, as appropriate, to enrollees. (3) Decisions with respect to utilization management, enrollee education, coverage of services, and other areas in which the guidelines apply are consistent with the guidelines. (c) Subcontracted groups. An MA organization that operates an MA plan through subcontracted physician groups must provide that the participation procedures in this section apply equally to physicians within those subcontracted groups. (d) Suspension or termination of contract. An MA organization that operates a coordinated care plan or network MSA plan providing benefits through contracting providers must meet the following requirements: (1) Notice to physician. An MA organization that suspends or terminates an agreement under which the physician provides services to MA plan enrollees must give the affected individual written notice of the following: (i) The reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed by the MA organization. (ii) The affected physician's right to appeal the action and the process and timing for requesting a hearing. (2) Composition of hearing panel. The MA organization must ensure that the majority of the hearing panel members are peers of the affected physician. (3) Notice to licensing or disciplinary bodies. An MA organization that suspends or terminates a contract with a physician because of deficiencies in the quality of care must give written notice of that action to licensing or disciplinary bodies or to other appropriate authorities. (4) Timeframes. An MA organization and a contracting provider must provide at least 60 days written notice to each other before terminating the contract without cause. [64 FR 7981, Feb. 17, 1999, as amended at 65 FR 40324, June 29, 2000; 68 FR 50857, Aug. 22, 2003; 70 FR 4724, Jan. 28, 2005] § 422.204 Provider selection and credentialing. (a) General rule. An MA organization must have written policies and procedures for the selection and evaluation of providers. These policies must conform with the credential and recredentialing requirements set forth in paragraph (b) of this section and with the antidiscrimination provisions set forth in §422.205. (b) Basic requirements. An MA organization must follow a documented process with respect to providers and suppliers who have signed contracts or participation agreements that— Soundpath Health Provider Manual v3.1.14 Page 67 (1) For providers (other than physicians and other health care professionals) requires determination, and redetermination at specified intervals, that each provider is— (i) Licensed to operate in the State, and in compliance with any other applicable State or Federal requirements; and (ii) Reviewed and approved by an accrediting body, or meets the standards established by the organization itself; (2) For physicians and other health care professionals, including members of physician groups, covers— (i) Initial credentialing that includes written application, verification of licensure or certification from primary sources, disciplinary status, eligibility for payment under Medicare, and site visits as appropriate. The application must be signed and dated and include an attestation by the applicant of the correctness and completeness of the application and other information submitted in support of the application; (ii) Re-credentialing at least every 3 years that updates information obtained during initial credentialing, considers performance indicators such as those collected through quality improvement programs, utilization management systems, handling of grievances and appeals, enrollee satisfaction surveys, and other plan activities, and that includes an attestation of the correctness and completeness of the new information; and (iii) A process for consulting with contracting health care professionals with respect to criteria for credentialing and re-credentialing. (3) Specifies that basic benefits must be provided through, or payments must be made to, providers and suppliers that meet applicable requirements of title XVIII and part A of title XI of the Act. In the case of providers meeting the definition of “provider of services” in section 1861(u) of the Act, basic benefits may only be provided through these providers if they have a provider agreement with CMS permitting them to provide services under original Medicare. (4) Ensures compliance with the requirements at §422.752(a)(8) that prohibit employment or contracts with individuals (or with an entity that employs or contracts with such an individual) excluded from participation under Medicare and with the requirements at §422.220 regarding physicians and practitioners who opt out of Medicare. [65 FR 40324, June 29, 2000, as amended at 66 FR 47413, Sept. 12, 2001; 70 FR 4724, Jan. 28, 2005] § 422.205 Provider antidiscrimination rules. (a) General rule. Consistent with the requirements of this section, the policies and procedures concerning provider selection and credentialing established under §422.204, and with the requirement under §422.100(c) that all Medicare-covered services be available to MA plan enrollees, an MA organization may select the practitioners that participate in its plan provider networks. In selecting these practitioners, an MA organization may not discriminate, in terms of participation, reimbursement, or indemnification, against any health care professional who is Soundpath Health Provider Manual v3.1.14 Page 68 acting within the scope of his or her license or certification under State law, solely on the basis of the license or certification. If an MA organization declines to include a given provider or group of providers in its network, it must furnish written notice to the effected provider(s) of the reason for the decision. (b) Construction. The prohibition in paragraph (a)(1) of this section does not preclude any of the following by the MA organization: (1) Refusal to grant participation to health care professionals in excess of the number necessary to meet the needs of the plan's enrollees (except for MA private-fee-for-service plans, which may not refuse to contract on this basis). (2) Use of different reimbursement amounts for different specialties or for different practitioners in the same specialty. (3) Implementation of measures designed to maintain quality and control costs consistent with its responsibilities. [65 FR 40324, June 29, 2000] Additional CMS language requirements. For this section Soundpath Health will be represented by “SPH” and “SPH’s.” 1.01 Participation Requirements. Participant represents and warrants that Participant is not excluded, and will not employ or contract with any individual who is excluded from participation in any federal or state program, including, without limitation, Medicare under Sections 1128 or 1128A of the Social Security Act. 1.02 Medicare Members. Participant agrees to provide Health Services to Enrollees who are enrolled in a Benefit Contract for Medicare recipients. Participant acknowledges that SPH’s agreements for Medicare Advantage products with Facilities and Participants are subject to review and approval by the Center for Medicare and Medicaid Services (CMS) 1.03 Quality and Utilization Management. Participant agrees to participate in the SPH’s internal Quality Management and Utilization Management activities. This participation includes, but is not limited to, (1) providing access to on-site office and medical record review, (2) providing copies of medical records, (3) participating in focused studies and/or committees, and (4) cooperation with complaint resolution. Participant authorizes SPH’s Medical Director, or his/her designee, to obtain from internal and external sources, information which is relevant to quality and utilization management programs. Participant agrees that he or she shall not bring any suit, claim or other action which he or she may otherwise be entitled to bring against SPH or any of their respective employees or agents as a result of any communication, report, recommendation or disclosure made or received by SPH if such information is provided responsibly, in good Soundpath Health Provider Manual v3.1.14 Page 69 faith and without malice or carelessness, and for the purpose of achieving and maintaining quality, cost effective care of Enrollees. Participant acknowledges that SPH must report certain information and actions to the National Practitioner Data Bank, Healthcare Integrity and Protection Data Bank, and/or the appropriate regulatory entity. SPH is bound by law to report such incidents. 1.04 Access to Care. Participant shall cooperate with SPH’s written standards for adequate access to covered services to meet the needs of the population served and should be offered in a culturally competent manner by SPH and its Participants. Where a Benefit Contract requires certain services to be provided only upon the referral of a primary care Participant, the following Health Services may be provided to SPH Enrollees without such a referral: (1) screening mammography and influenza vaccination Health Services; and (2) for women, routine and preventive Health Services from a Participant that is a women’s health specialist. No Enrollee expenses shall apply to influenza and pneumococcal vaccines. 1.05 Cooperation with Procedures and Programs. Participant shall cooperate and comply with the following: (1) all credentialing and re-credentialing processes and all utilization management, quality assessment and performance improvement, medical, peer review, on site review, and advance directives; (2) SPH’s Enrollee grievance and appeal/expedited appeal processes, including gathering and forwarding information to SPH on a basis that will permit SPH to meet CMS required timeframes for disposition of grievances and appeals; (3) the activities of any independent quality review and improvement organization approved by CMS that is under contract with SPH; (4) as applicable, SPH processes for identifying SPH Enrollees with complex or serious medical conditions, assessment of those conditions, and establishment and implementation of a treatment plan appropriate to those conditions; and (5) Participant process to include conducting an initial assessment of each SPH Enrollee’s health care needs within 90 days of the effective date of their enrollment. 1.06 Accordance with SPH’s Contractual Obligations. Participant agrees that all services performed under this Agreement will be done so in a manner that is consistent and complies with SPH’s contractual obligations. 1.07 Accordance with SPH’s Policies and Procedures. Participant agrees that all services performed under this Agreement will be done so in a manner that is consistent and complies with CMS and SPH’s policies and procedures. 1.08 Accountability Provisions. Participant agrees that SPH retains the right to approve, suspend or terminate the delegated activities and reporting requirements in instances Soundpath Health Provider Manual v3.1.14 Page 70 where CMS or SPH determines that Contractor or a Participant has not performed satisfactorily; (a) (b) (c) (d) Reporting Responsibilities. Participant agrees to comply with CMS and SPH reporting requirements. Revocation. Participant agrees that this Agreement may be revoked in the event CMS or SPH determines that Participant has not performed it’s duties in a satisfactory manner. Monitoring. Participant agrees that SPH has the right and responsibility to monitor performance under this Agreement on an ongoing basis. Credentialing. Participant agrees that the credentials of medical professionals affiliated with the party or parties will either be reviewed by SPH; or the credentialing process will be reviewed and approved by SPH; or SPH must audit the credentialing process on an ongoing basis. 1.09 Data Collection Requirements. Participant acknowledges that SPH is required by CMS to maintain a health information system that collects, analyzes and integrates all data necessary to compile, evaluate and report certain statistical data related to costs, utilization and quality, and such other matters as CMS may require from time to time. Participant hereby agrees to submit to SPH within the timeframes specified by SPH to meet CMS requirements, upon request, all data necessary for SPH to fulfill these obligations.. Contractor and each Participant hereby represent and warrant, and to the extent required by SPH, hereby agree to certify in writing at the time of submission to SPH or its designee, that all data including, but not limited to, encounter data and other information that CMS may specify, shall be truthful, reliable, accurate and complete. 1.10 Payment. (a) Provision of Health Services. For the provision of Health Services to SPH Enrollees, Participants shall be paid in accordance with their Participant Agreement. Enrollee expenses, if any, may be collected directly from the SPH Enrollee. If Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, then the Participant shall make such payments in accordance with the CMS and State of Washington regulations. Participant shall ensure that payment and incentive arrangements with subcontractors, if any, are specified in a written agreement and comply with CMS and State of Washington laws and regulations. Additional information regarding payment and incentive payments to subcontracting Participants must be made available to the subcontracted Participants upon request. Soundpath Health Provider Manual v3.1.14 Page 71 (b) Prompt Payment. For covered services provided to Enrollees, SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, shall pay Contractor or Participant as soon as practical but subject to the following minimum standards: 1) Ninety-five percent (95%) of the monthly volume of Clean Claims shall be paid within thirty (30) days of receipt; and 2) Ninety-five percent (95%) of the monthly volume of all claims shall be paid or denied within sixty (60) days of receipt, except as agreed to in writing on a claim by claim basis. The receipt date of a claim shall be the date SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, receives either written or electronic notice of the claim. SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, shall pay Contractor or Participant interest on un-denied and unpaid Clean Claims more than sixty-one (61) days old. Interest shall be assessed at the rate required by applicable state or federal law, or as otherwise agreed by contract between Contractor and Participant, and shall be calculated monthly as simple interest prorated for any portion of a month. SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, shall add the interest payable to the amount of unpaid claims without the necessity of the Contractor or Participant submitting an additional claim. SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, shall not apply any interest to an Enrollee’s deductible, copayment, coinsurance or any similar obligation of the Enrollee. SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, shall reimburse Contractor or Participant for covered services following receipt of a clean claim in accordance with Medicare Secondary Payer rules. Claim denials shall include the specific reason why the claim was denied. If the denial is based upon Medical Necessity or similar grounds, SPH or Soundpath Health Provider Manual v3.1.14 Page 72 Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, upon request from Contractor or Participant shall promptly disclose the supporting basis for the decision. These standards do not apply to claims about which there is substantial evidence of fraud or misrepresentation by Contractor, Participant or Enrollee or instances where SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, has not been granted reasonable access to information under Contractor or Participant’s control. (c) Hold Harmless Provisions. Participant shall hold SPH Enrollees harmless for payment of fees that are the legal obligation of SPH and its contract to fulfill. Such provision will apply but not be limited to insolvency of SPH, or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, contract breach and provider billing; Participant hereby agrees that they will not bill, charge, collect a deposit from, seek compensation, remuneration from or have any recourse against an Enrollee or other person acting on an Enrollee’s behalf, other than SPH, for services provided pursuant to this Agreement. This provision shall not prohibit collection of deductible, copayments, coinsurance and/or non-covered services which have not otherwise been paid by a primary or secondary carrier in accordance with regulatory standards for coordination of benefits, from Enrollees in accordance with the terms of the Enrollee’s Subscriber Agreement. 1.11 Private Contracts. SPH or Participant, if Participant is responsible for making payment to subcontracting Participants for Health Services provided to SPH Enrollees, may not pay, directly or indirectly, on any basis, for services rendered by a Participant to a SPH Enrollee if Participant files or is required to file an affidavit with a Medicare carrier agreeing to furnish Medicare covered services to any Medicare beneficiary through a private contract, except that payment may be made by SPH for emergency and urgent care services. Such payment shall be limited to the Medicare allowable charge. 1.12 Excluded Individuals. Participant is prohibited from employing or contracting with an individual who is excluded from participation in Medicare under Section 1128 or 1128A of the Social Security Act (or with an entity that employs or contracts with such an individual) for the provision of any of the following: (1) health care; (2) utilization review; (3) medical social work; or (4) administrative services. Soundpath Health Provider Manual v3.1.14 Page 73 1.13 Laws and Regulations. Participants and SPH shall each maintain, without material restriction, all applicable federal, state and local licenses, certifications and permits which are required to fulfill their obligations under this Attachment and this Exhibit in the applicable jurisdiction. Participant shall comply with all applicable Medicare laws, regulations, reporting requirements, and CMS instructions (and shall cooperate, assist and provided information, as requested), and shall comply with all other applicable federal, state and local laws, rules and regulations including, but not limited to, Title VII of the Civil Rights Act of 1964, The Age Discrimination Act of 1975, and The Americans With Disabilities Act. Facilities and Participants shall also cooperate with SPH in its efforts to comply with the laws, regulations and other requirements of applicable regulatory authorities. Participant shall require that all health care professionals employed by or under contract to render Health Services to SPH Enrollees, including covering Participants, comply with this provision. 1.14 Records: (a) Maintenance and Accuracy of Records. Participant will assure that adequate medical, financial and administrative records related to the services rendered under this Agreement are maintained in an accurate and timely manner, including prominent documentation of an executed Advance Directive, if any. (b) Access to Records. (i) SPH, The Secretary of Health and Human Services (the “Secretary”), the Comptroller General or their designees shall have the right to audit, evaluate or inspect any books, contracts, medical records, patient care documentation and other records of Facilities and Participants that pertain to: (1) the services performed under this Agreement; (2) reconciliation of benefit liabilities (3) determination of amounts payable; or (4) other relevant matters as such person conducting the audit, evaluation or inspection deems necessary. (ii) The right described above shall extend through 10 years from the final date of the applicable SPH Contract period or completion of audit, whichever is later; provided, however, that such access may be required for a longer time period if: (1) CMS determines that there is a special need to retain a particular record or group of records for a longer period and CMS provides notice at least 30 days before the normal disposition date; Soundpath Health Provider Manual v3.1.14 Page 74 (2) CMS determines that there has been a termination, dispute, fraud or similar fault, in which case the retention may be extended to 10 years from the date of any resulting final resolution of the matter; or (3) CMS determines that there is a reasonable possibility of fraud, in which case it may perform the inspection, evaluation or audit at any time. (iii) For the purpose of conducting the above activities, Participants shall make available their premises, physical facilities and equipment, records relating to SPH Enrollees, and any additional relevant information that CMS may require. (c) Enrollee Access to Records. Participant agrees to establish procedures to ensure timely access by SPH Enrollees to medical records and other health and enrollment information that pertains to them. (d) Confidentiality of Records. SPH and each Participant shall safeguard the privacy and confidentiality of any SPH Enrollee information consistent with all federal and state laws. SPH and Participant shall also abide by all federal and state laws regarding confidentiality and disclosure of medical records and other health and enrollee information. 1.15 Rules of Participation. SPH’s rules of participation are set forth in this Agreement, and in the Participant manual, which shall be made available to Participant. Written notice of material changes to the rules of participation shall be provided prior to the effective date of such changes. 1.16 Additional Termination Provisions. Notwithstanding any provision in this Attachment to the contrary, the following provisions shall apply to SPH’s network of Participants only: (a) Participant’s participation in the SPH Medicare Advantage network of Participants may be terminated by SPH immediately upon written notice due to: (1) loss or suspension of licensure or certification; (2) sanction by Medicare; or (3) Participant entering into a private contract with any Medicare beneficiary; or (b) If this Attachment contains any provision permitting termination of this Attachment without cause, notice of such termination shall be given by either party in accordance with the applicable provision of this Attachment, but in no such case shall the notice period be less than 60 days prior to the termination date. Soundpath Health Provider Manual v3.1.14 Page 75 1.17 that: (c) Any written notice to Participant by SPH regarding its, his or her suspension or termination shall include the following, to the extent applicable: (1) the reason for the suspension or termination; (2) the standards and profiling data used by SPH to evaluate the Participant; (3) the numbers and mix of applicable Participants needed in the network; (4) right to appeal the action; and (5) the process and timing for requesting a hearing. (d) Participant shall provide SPH with a list of its, his or her patients who are SPH Enrollees within fifteen (15) business days of the date that Participant either gives or receives notice of termination. SPH will make a good faith effort to notify all affected SPH Enrollees of the termination of this Attachment, within the time period required by applicable law, after notice of termination is given. Acknowledgements and Delegated Activities. Participant acknowledges and agrees (a) Agreements with Participants are subject to review and approval by CMS; (b) Participant agrees to adhere to CMS marketing provisions. (c) SPH receives payments in whole or in part from federal funds. Contractors and subcontractors, including Participant, are subject to certain laws that are applicable to individuals and entities receiving federal funds. Participant agrees that any services or activity performed by him or her in connection with this Agreement and its attachment will be consistent with and comply with SPH’s contractual obligations to CMS and other applicable state and federal laws and regulations; and (d) SPH oversees and is accountable to CMS for any functions or responsibilities that are contained in the SPH Contract, including those that SPH may delegate to others. Activities or responsibilities under the SPH Contract that are delegated by SPH to Contractor or a Participant must be set forth in a written agreement that contains, at a minimum, the following CMS delegation requirements: (1) the specific delegated activities and reporting requirements; (2) the right of revocation in the event CMS or SPH determines that Participant has not performed the delegated duties in a satisfactory manner; (3) a right to approve, suspend or terminate the delegated activities and reporting requirements in Soundpath Health Provider Manual v3.1.14 Page 76 instances where CMS or SPH determines that Contractor or a Participant has not performed satisfactorily; (3) a provision specifying that the performance of Contractor and Participant is monitored by SPH on an ongoing basis; (4) a provision specifying that the credentialing processes must be reviewed and approved by SPH, and SPH shall audit the credentialing process on an ongoing basis; and (5) a requirement that Contractor and each Participant must comply with all applicable Medicare laws, regulations, reporting requirements and CMS instructions. Any written delegation agreement between SPH and Contractor or a Participant is hereby amended to include these requirements. 1.18 Regulatory Amendment. SPH may amend this Agreement to comply with the requirements of state and federal regulatory authorities, and shall give written notice to Participant of such amendment and its effective date. Unless such regulatory authorities direct otherwise, the signature of Participant will not be required. 1.19 Non-interference with Advice to SPH. Nothing in this Attachment and this Exhibit is intended to prohibit or restrict Participant from advising or advocating on behalf of a SPH Enrollee about (1) the SPH Enrollee’s health status, medical care, or treatment options (including alternative treatments that may be self-administered), including providing sufficient information to the SPH Enrollee to provide an opportunity to decide among all relevant treatment options, (2) the risks, benefits and consequences of treatment or nontreatment, and (3) the opportunity for the SPH Enrollee to refuse treatment and express preferences about future treatment decisions. Participant must assure that individuals with disabilities are furnished with effective communications in making decisions regarding treatment options. 1.20 Individual Participants and Facilities. (a) If Contractor is a Participant, Participant or other entity whose staff of health care professionals consists wholly or partially of employees, Contractor represents and warrants that it has the unqualified authority to bind all such employees to the terms of this Attachment and this Exhibit. If Contractor or a Participant has any arrangements with subcontractors, as defined in subsection (b), below, to render Health Services to SPH Enrollees, they shall ensure that all such subcontracts are duly amended to incorporate the terms contained in this Agreement through one of the methods described in subsections (b)(i) and (b)(ii), below. Soundpath Health Provider Manual v3.1.14 Page 77 (b) If Contractor is an independent practice association, physician hospital organization, or other network organization contracting on behalf of health care Participants and/or facilities, Contractor shall ensure that all arrangements with subcontractors for participation in SPH’s network of Participants are in writing and duly executed. A “subcontractor” is defined as a person or entity that is contracted by Contractor or a Participant, directly or through another person or entity, to provide Health Services to SPH Enrollees, and that does not hold a direct contract with SPH. Contractor and each Participant shall ensure that all agreements with subcontractors are duly amended to incorporate the terms contained in this Exhibit through one of the following methods: (i) Contractor and each Participant shall ensure that the terms of this Agreement are included in all future and pending agreements with subcontractors who agree to provide services to SPH. (ii) Contractor and each Participant shall promptly amend the agreements with subcontractors to meet any additional CMS requirements. Refusal of any subcontractor to agree to the terms in this Exhibit, and any subsequent amendments, shall be grounds for the termination of such subcontractor from the SPH network of Participants. Soundpath Health Provider Manual v3.1.14 Page 78
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