Provider Manual Effective July 1, 2014 AHCA 062514 PHC MMA Form 400.0
Provider Manual Effective July 1, 2014 AHCA 062514 PHC MMA Form 400.0 Table of Contents Part 1: Introduction ......................................................................................................................................... 1 Part 2: Program Description ........................................................................................................................ 2 Part 3: How to Contact Us............................................................................................................................ 3 Part 4: Member ID Card ................................................................................................................................ 4 Part 5: Primary Care Provider Information ............................................................................................ 5 Responsibilities ............................................................................................................................................. 5 Emergency Care ............................................................................................................................................ 6 Out-of-Area Emergency Care ................................................................................................................. 6 Emergency Transportation ....................................................................................................................... 7 Emergency Behavioral Health Conditions .......................................................................................... 7 Domestic Violence Screening ................................................................................................................. 7 Alcohol and Substance Abuse Screening ........................................................................................... 7 Smoking Cessation ...................................................................................................................................... 8 Family Planning Services ........................................................................................................................... 8 Making Member Medical Decisions Known to Providers............................................................ 9 Five Wishes Advance Directive..............................................................................................................10 Clinical Access Standards ........................................................................................................................10 After-Hours Care ........................................................................................................................................10 Missed Appointments ..............................................................................................................................11 Non-Covered Services .............................................................................................................................11 Provider Incident Reporting Requirements .....................................................................................11 Reporting Unusual Incidents on Providers Premises...................................................................11 Other Provider Requirements ...............................................................................................................13 Part 6: Specialist Information....................................................................................................................14 Specialist Responsibilities .......................................................................................................................14 Pregnancy-Related Requirements.......................................................................................................14 Hysterectomies, Sterilizations and Abortions .................................................................................17 Diagnosis and Treatment of Tuberculosis .......................................................................................17 Clinical Access Standards ........................................................................................................................18 After-Hours Care ........................................................................................................................................18 Missed Appointments ..............................................................................................................................18 Non-Covered Services .............................................................................................................................18 Provider Incident Reporting Requirements .....................................................................................18 Reporting Unusual Incidents on Providers Premises...................................................................19 Other Provider Requirements ...............................................................................................................20 Part 7: Provider Notification Requirements ........................................................................................21 Office Relocation ........................................................................................................................................21 Leave of Absence .......................................................................................................................................21 -i- Provider Termination ................................................................................................................................21 Part 8: Provider Services .............................................................................................................................23 Provider Relations Department ............................................................................................................23 Provider Manual .........................................................................................................................................23 Training and Education ............................................................................................................................23 Provider and Pharmacy Directory........................................................................................................24 Part 9: Medical Records ..............................................................................................................................25 Transfers ........................................................................................................................................................25 Medical Records Copies ..........................................................................................................................25 Part 10: Delegated Entities ........................................................................................................................26 Part 11: Community Outreach Activities ..............................................................................................27 Part 12: Preventive Care Guidelines .......................................................................................................28 Child Health Check-Ups ..........................................................................................................................28 CHCUP Components ................................................................................................................................28 CHCUP Exam Frequency..........................................................................................................................28 CHCUP/Well-Child Codes .......................................................................................................................29 Referrals .........................................................................................................................................................29 Blood Lead Level Testing ........................................................................................................................30 Immunization Schedule ...........................................................................................................................30 Transportation Assistance ......................................................................................................................30 Healthy Behaviors Program ...................................................................................................................30 Part 13: Members with Special Health Care Needs ....................................................................31 Part 14: Adult Health Screenings ............................................................................................................32 Adult Preventive Health Exam ..............................................................................................................32 Part 15: Covered Services ...........................................................................................................................35 Covered Services and Limitations .......................................................................................................35 Behavioral Health Services .....................................................................................................................40 Dental Services ............................................................................................................................................40 Optometric and Vision Services ...........................................................................................................41 Hearing Services .........................................................................................................................................41 Transportation Services ...........................................................................................................................41 Part 16: Pharmacy..........................................................................................................................................42 Prescription Drug Prior Authorization ...............................................................................................42 Non-Formulary and Non-Covered Medications ...........................................................................42 Smoking Cessation ....................................................................................................................................42 Covered Medications................................................................................................................................43 Coverage Limitations ................................................................................................................................43 Hemophilia Medications .........................................................................................................................43 Member Co-Payments .............................................................................................................................43 Prescription Limits .....................................................................................................................................43 - ii - Prescriber Request for Non-Formulary Medications ...................................................................43 Over-the-Counter Pharmacy Benefit .................................................................................................45 Part 17: Member Rights and Responsibilities ....................................................................................46 Member Rights ...........................................................................................................................................46 Member Responsibilities .........................................................................................................................47 Part 18: Member Complaints, Grievances and Appeals .................................................................48 Filing a Complaint or Grievance ...........................................................................................................49 Filing an Appeal ..........................................................................................................................................50 Continuation of Benefits .........................................................................................................................51 Expedited Appeal Process ......................................................................................................................51 Medicaid Fair Hearing Process .............................................................................................................52 Appealing to the Beneficiary Assistance Program (BAP) ...........................................................53 Exhaustion of the Grievance and Appeal Process.........................................................................54 Part 19: Member Satisfaction ...................................................................................................................55 Part 20: Eligibility ...........................................................................................................................................56 Part 21: Claim Submission and Payment Guidelines.......................................................................57 Claim Definitions ........................................................................................................................................57 Initial Claim Submission ..........................................................................................................................57 Standard Code Sets ...................................................................................................................................58 Encounter Data Submission and Acceptance by State Medicaid ...........................................59 Information for Obtaining an NPI .......................................................................................................59 Claims Submission Protocols and Standards..................................................................................59 Claims Receipt Verification and Status..............................................................................................59 Claims Processing ......................................................................................................................................59 Coordination of Benefits .........................................................................................................................60 Prohibition of Billing Plan Members ..................................................................................................60 Provider Claim Disputes ..........................................................................................................................61 Overpayment of Claims ...........................................................................................................................62 Part 22: Clinical Practice Guidelines .......................................................................................................64 Part 23: Disease Management .................................................................................................................65 Part 24: Prior Authorization and Referral Procedures ....................................................................67 Prior Authorization ....................................................................................................................................67 Referrals .........................................................................................................................................................69 Referral Form ...............................................................................................................................................70 Referral to Non-Participating Providers............................................................................................71 Second Medical/Surgical Opinion.......................................................................................................72 Prior Authorization Time Standards ...................................................................................................73 Provider Referral Tracking System ......................................................................................................73 Part 25: Admission Review .........................................................................................................................74 Notification of Admissions .....................................................................................................................74 - iii - Concurrent/Continued Stay Review ...................................................................................................74 Discharge Planning Review ....................................................................................................................74 Retrospective Review of Inpatient Stay.............................................................................................74 Ancillary Services (Home Health, Durable Medical Equipment, Hospice)...........................75 Skilled Nursing or Rehabilitation Facility Review ..........................................................................75 Part 26: Continuity of Care ........................................................................................................................76 Part 27: Chronic and Complex Conditions ..........................................................................................77 Comprehensive Diabetes Care .............................................................................................................77 Nephropathy ................................................................................................................................................77 Congestive Heart Failure .........................................................................................................................78 Asthma ...........................................................................................................................................................78 Hypertension................................................................................................................................................78 HIV/AIDS ........................................................................................................................................................78 Part 28: Quality Improvement Program ...............................................................................................80 Quality Improvement Requirements ..................................................................................................80 Quality Improvement Overview ...........................................................................................................80 Clinical Performance Measures ............................................................................................................81 Part 29: Medical Record Requirements ................................................................................................86 Part 30: Credentialing and Recredentialing ........................................................................................87 Credentialing Program.............................................................................................................................87 Criteria for Practitioner Selection ........................................................................................................87 Credentials Documentation ...................................................................................................................89 Recredentialing ...........................................................................................................................................90 Part 31: Cultural Competency...................................................................................................................91 Part 32: Compliance and Regulations ...................................................................................................92 Provider Contract Requirements .........................................................................................................92 Part 33: Provider Grievances and Appeals ..........................................................................................95 Part 34: Anti-Fraud and Abuse Program ..............................................................................................97 Fraud ...............................................................................................................................................................97 Waste ..............................................................................................................................................................98 Abuse ..............................................................................................................................................................98 Education and Training ............................................................................................................................99 Reporting Fraud, Waste and/or Abuse..............................................................................................99 Anti-Retaliation Policy ........................................................................................................................... 100 Part 35: Community Based Resources ............................................................................................... 101 Part 36: Definitions..................................................................................................................................... 103 Part 37: Forms .............................................................................................................................................. 110 - iv - Part 1: Introduction Thank you for your participation in PHC Florida (formerly Positive Healthcare Florida), a Medicaid HIV specialty care program. As a provider, you play a critical role in the delivery of health care services to our members. This manual contains information to help you and your staffs provide appropriate covered services to our members when they are needed. The manual outlines provider requirements and describes what you can expect from PHC Florida. This manual is provided for the convenience of providers participating in PHC Florida. Nothing in this manual shall guarantee coverage of any service, treatment, drugs or supplies, because coverage is governed exclusively by the member coverage document. As a PHC Florida participating provider, you are required to comply with applicable Florida Medicaid policies, procedures, laws and regulations. The contents of this manual are supplemental to your Florida Medicaid agreement and its addendums. Should the contents of PHC Florida’s provider manual conflict with your Florida Medicaid agreement, the agreement supersedes the manual. We look forward to working with you and your staff to provide quality managed health care services to PHC Florida members. -1- Part 2: Program Description The Florida Medicaid Program implemented a new system through which Medicaid enrollees receive services. This program is called the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) program. Most Medicaid recipients must enroll in the MMA program. The Goals of the Florida MMA program are to provide: Coordinated health care across different health care settings A choice of the best managed care plans to meet recipient’s needs The ability for health care plans to offer different, or more services The opportunity for recipients to become more involved in their health care PHC FL is an MMA specialty plan providing services specific to the needs of people living with HIV/AIDS (PLWHA). All enrollees with PHC FL have a diagnosis of HIV or AIDS. In entering into a contract with AHCA to provide services to Medicaid beneficiaries, PHC Florida has agreed to comply with the provisions of the Medicaid Contract (the “Contract”) as well as with all applicable AHCA rules relating to the Contract and the applicable provisions in the Florida Medicaid Handbooks (“Handbooks”). PHC’s obligations under the Contract include, but are not limited to: Maintaining a quality improvement program aimed at improving the quality of patient outcomes Maintaining quality management and utilization management programs Furnishing AHCA with data as required under the Contract and as may be required in additional ad hoc requests Collecting and submitting encounter data in the format and in the timeframes specified by AHCA -2- Part 3: How to Contact Us Member Services: Tel: (888) 997-0979 Fax: (323) 436-5034 Administrative Office: PHC Florida 110 SE 6th St., Ste. 1960 Ft. Lauderdale, FL 33301 Tel: (954) 522-3132 Fax: (954) 522-3260 Mental Health Services (provided through Psychcare): Tel: (855) 765-9698 After-Hours Nursing Advice Line: Tel: (866) 228-8714 Over-the-Counter Pharmacy Benefit Line Tel: (877) 764-3781 Case Management: Tel: (866) 990-9322 Fax: (888) 972-5340 Pharmacy Benefit Line Tel: (866) 763-9103 Fax: (888) 972-5340 Claims Department: Tel: (855) 318-4387 Fax: (323) 337-9146 Provider Relations and Contracting: Tel: (855) 318-4387 Fax: (954) 522-3260 Claim Submissions: Attn: Claims PHC Florida P.O. Box 7490 La Verne, CA 91750 Quality Management: Tel: (954) 522-3132 Fax: (954) 522-3260 Transportation Services: Tel: (855) 318-4387 Credentialing: Tel: (855) 318-4387 Fax: (323) 436-5034 Utilization Management: Tel: (866) 990-9322 Fax: (888) 972-5340 Eligibility: Tel: (855) 318-4387 Fax: (323) 436-5034 Vision Care Services (VSP) Tel: (800) 877-7195 -3- Part 4: Member ID Card PHC Florida members receive an ID card containing information that helps you process claims accurately. A sample card is shown below. Be sure to check each member’s ID card at each visit. Front Back -4- Part 5: Primary Care Provider Information Responsibilities Below is a summary of responsibilities specific to primary care providers (PCPs) who provide services to plan members. Please refer to these responsibilities and the responsibilities outlined for all physicians: Accept and manage patients who have chosen that physician as their primary care physician Perform services normally in his or her scope of practice Utilize a standardized formal assessment instrument for HIV, during initial and subsequent patient assessments to: - Identify members who require behavioral health and substance abuse services - Determine the types of behavioral health and substance abuse services that should be furnished Accept Care Management responsibilities Coordinate/manage patient’s care for specialty physicians or other healthcare services Inform members of all testing/screenings due in accordance with the periodicity schedule specified in the Medicaid Child Health Check-Up Services Coverage and Limitations Handbook Contact members to encourage them to obtain health assessment and preventative care Participate and abide by all decisions regarding member complaints, peer reviews, quality improvement, and utilization management programs Agree to provide or arrange coverage of services, consultation or approval for referrals 24 hours/day, seven (7) days /week by Medicaid enrolled providers, who will accept Medicaid reimbursement. Coverage must be provided by a Medicaid eligible PCP with demonstrated experience in the provision and management of medical and psychosocial health care for persons with HIV/AIDS. This coverage must consist of an answering service with call forwarding or provider call arrangements. The 24-hour coverage must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. The after-hours coverage must be available using the medical office’s daytime telephone number. The call must be returned by the PCP or covering medical professional within 30 minutes of the initial contact. Provide direction and follow-up care for those members who have received emergency services Accept and participate in peer review -5- Emergency Care If a member has an emergency medical condition, call 911 or advise him or her to go to the nearest hospital emergency room. Members may access emergency care anytime. They may go to a hospital out of network for emergencies if necessary. An emergency is defined as a condition that the member believes will cause any of the following if he or she does not receive treatment at once: Serious harm to his or her health Serious injury to the body Serious damage of a body part Serious damage of an organ Some examples of emergencies may include: Heavy blood loss Heart attack Severe cuts requiring stitches Loss of consciousness Poisoning Severe chest pains Loss of breath Broken bones For pregnant women, these medical problems may be considered emergencies: Serious harm to her health or the health of her unborn baby If the member thinks there is not enough time to go to her doctor’s regular hospital If the member thinks that going to another hospital may cause harm to her and/or her baby Out-of-Area Emergency Care If the member becomes ill while traveling, he or she should seek care and then call PHC Florida’s Member Services Department at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. PHC Florida will cover follow-up care to emergency treatment that is medically necessary. Prior authorization is not required to receive this care regardless of whether the member receives this care within or outside of the PHC Florida provider network. -6- Emergency Transportation Members should call 911 if they need emergent transportation to a hospital. Emergency Behavioral Health Conditions Emergency behavioral health conditions are sudden and often serious medical conditions. These conditions may require admission to a hospital. PHC Florida has contracted with Psychcare to provide behavioral health services to members. To access a behavioral health provider, call (855) 765-9698. Providers and members may call this number anytime to reach Psychcare. Emergency behavioral health conditions include behaviors that may cause: Danger to the member and to others Substantial harm to the member’s wellbeing The inability to carry out basic actions of daily life. A PHC Florida member may go to any hospital for emergency care. He or she does not need approval for this service. If a member presents to a hospital, hospital staff should contact Psychcare at (855) 765-9698. This number is answered 24 hours a day. Domestic Violence Screening Primary care providers should screen members for signs of domestic violence, also known as domestic abuse, spousal abuse, battering, family violence, dating abuse, and intimate partner violence (IPV), and offer referral services to applicable community agencies if needed. Community agencies for domestic violence referrals are located in Part 35 (Community Based Resources) of this manual. A short domestic violence screening tool is available at: http://www.orchd.com/violence/documents/HITS_eng.pdf Should a member need assistance accessing domestic violence resources, please direct him or her to contact PHC Florida Member Services at (888) 997-0979, TTY 711 for assistance. Member Services is available Monday through Friday, 8:00 am to 8:00 pm. Alcohol and Substance Abuse Screening Primary care providers should screen members for signs of alcohol and substance abuse and offer referral services to applicable community agencies if needed as part of preventative evaluation at the following times: Upon initial contact with member During routine physical examinations During initial prenatal contact -7- When the member evidences serious over-utilization of medical, surgical, trauma or emergency services When documentation of emergency room visits suggests the need Should a member need assistance accessing alcohol and/or substance abuse resources, please direct the member to contact PHC Florida Member Services at (888) 997-0979 TTY 711, for assistance. Member Services is available Monday through Friday, 8:00 am to 8:00 pm. Smoking Cessation PHC Florida offers a smoking cessation program that will help members break both the physical and psychological addiction to cigarettes. Primary care providers (PCPs) should screen and educate members regarding smokingcessation by: Making members aware of and recognizing dangers of smoking Teaching members how to anticipate and avoid temptation Provide basic information to the member about smoking and successful quitting Encourage the member to quit Encourage the patient to talk about the quitting process PCPs should direct members who smoke or desire to quit smoking to contact Member Services at (888) 997-0979 TTY 711 Monday through Friday, 8:00 am to 8:00 pm. Family Planning Services Family planning services may be provided by any Florida Medicaid provider. PHC Florida members do not need an authorization for these services and they do not need to use a PHC Florida provider. These services include: Information and referral for learning and counseling Diagnostic procedures Contraceptive drugs and supplies Medically needed sterilization and follow-up care Family planning services must also include HIV-primary and secondary prevention and risk reduction services that include the following: Education and counseling regarding reduction of perinatal transmission Harm reduction education and services Education for members regarding STDs -8- Services available for STD treatment and prevention Education and counseling specific to HIV prevention and transmission Counseling and supportive services for partners/spouses Partner/spouse notification pursuant to Section 381.004, F.S. and in accordance with protocol established by the Florida Department of Health, Bureau of HIV/AIDS and Hepatitis Making Member Medical Decisions Known to Providers The Patient Self Determination Act of 1990 mandates that patients have a right to refuse medical treatment, which includes life-prolonging care. The Act also mandates that health plans educate its members how to exercise that right with the help an advance directive, such as a living will or power of attorney. A living will shows the type and extent of care the patient wants if he/she is not conscious and is unable to regain consciousness. It may be used if the patient has a condition that will lead to death. It also tells the patient’s physician when to stop care that is extending his/her life. A durable power of attorney for health care decision names a person chosen by patient to make decisions. It will be used if and when the patient is not able to make decisions for himself/herself. It will also be used in order to make the patient’s decisions known to his/her physician. A living will or durable power of attorney for health care decisions is used when and only when patients cannot make decisions on their own or make their health care decisions know to their physicians. A patient may change or cancel his/her advance directive decisions at any time. Patients should be encouraged to make their changes to their advance directives known to their physicians and family members. Individuals may contact an attorney, a local legal aid office, or the Florida Medical Association for advance directive forms, or use the Five Wishes form that PHC Florida supplies to new enrollees in their new member welcome packet. PHC Florida enrollees are advised in the plan’s Evidence of Coverage that they may file a complaint with the Florida Agency for Health Care Administration Consumer Complaint Hotline if they believe a provider has not complied with advance directive laws and regulations. -9- Five Wishes Advance Directive PHC Florida provides its enrollees at the time of enrollment with Five Wishes, an advance directive form. Five Wishes gives enrollees a way to control something very important — how they would like to be treated if they get seriously ill. It is an easy form to complete and allows enrollees to articulate exactly what they want. When completed, it provides the enrollee’s wishes for the following questions: The person he/she wants to make care decisions when he/she cannot The kind of medical treatment the enrollee wants or does not want How comfortable he/she want to be How the enrollee wants people to treat him/her What the enrollee wants his/her loved ones to know about his/her health condition PHC also provides an ongoing class, Five Wishes, to all members about advance care planning. The Five Wishes Workshops provide our clients with a safe and informative small group setting to ensure that the documents are completed correctly and completely. Please contact Provider Relations at (855) 318-4387, Monday through Friday, 8:30 a.m. to 5:30 p.m. for more information. Clinical Access Standards PHC Florida is committed to timely access to care for all members. Access standards are developed to ensure that all health care services are provided in a timely manner. These standards are based on community norms. PHC Florida monitors providers’ compliance to the standards. The access standards below must be observed by all network providers. Type of Care Emergency care Urgent care Non-urgent but needs attention Routine/preventive care Office waiting time Appointment Standards Immediate Within 24 hours Within one (1) week of request Within 30 days of request Should not exceed 60 minutes After-Hours Care Providers must be available 24 hours a day, seven days a week. PHC Florida requires a practitioner or a registered nurse under his/her supervision to maintain a 24-hour phone service, seven days a week. This access may be through an answering service after office - 10 - hours. The service should instruct members with an emergency to hang-up and call 911 or go immediately to the nearest emergency room. Missed Appointments Providers are responsible for the follow up of missed appointments. Providers must have a process in place to follow-up on missed appointments that includes written policy and procedure and documentation of all provider efforts. Non-Covered Services PHC Florida members may be billed for non-covered services, such as cosmetic procedures and items of convenience if the provider informs the member that the service is not covered, the member agrees to pay for the service and the provider documents the member’s agreement to pay for such services. Provider Incident Reporting Requirements In the event of an adverse or untoward incident, defined as a Code 15 case by the Agency for Health Care Administration (AHCA), that occurs to a PHC Florida member whether occurring in a facility of one of the plan’s providers or arising from health care prior to admission to a facility, which may result in: The death of a member Fetal death Severe brain or spinal damage to a member A surgical procedure being performed on the wrong member/wrong site Surgical procedure to remove foreign objects remaining from a surgical procedure Surgical repair of injuries from a planned surgical procedure The incident must be reported to the PHC Florida’s Quality Improvement Department on the Incident Report form located in Part 37 (Forms) of this manual. Reporting Unusual Incidents on Providers Premises Unusual incidents that occur on the property of the provider must be reported to the designated risk manager at that location. The following are examples: In the event of an incident/injury to a member or visitor at a plan provider: Report the occurrence to the Office Administrator or risk management contact person in the office immediately - 11 - If injury has occurred, obtain immediate medical assistance for visitor by physician or offer ambulance to nearest contracted Emergency Room Medical record will be completed and documented in compliance with the plan’s medical record keeping as for other members In the event, a patient or visitor becomes abusive (physically or verbally) at the plan’s participating provider premises: Report occurrence to the Office Administrator or risk management contact person in the office immediately. Attempt to calm patient or visitor. Do not argue or disagree with the abusive individual(s). Notify police if patient/visitor is physically threatening Remove other patients or visitors from the immediate area Do not attempt to restrain abusive individual unless another person is placed in danger. If restraint must be used, every effort must be made to keep the abusive person from physical harm (it is recommended that two individuals be present to assist with abusive individual). In the event the abusive individual is a member, the attending physician should also be notified immediately The provider’s office notifies the plan’s Member Service Department of the incident, if appropriate Other incidences that are required to be communicated to the plan include: A slip or fall by a patient or family member Medication error Reaction requiring treatment A theft or loss from provider’s office Malfunction or damage of equipment during treatment Accusations of malpractice by a patient or family member Non-compliance with potential to be life threatening An incident report form should be used to report all incidents to the plan’s risk manager. Further reporting to the plan’s insurance carrier and governmental agencies, as appropriate, shall be arranged within the prescribed time frames by the plan’s risk manager. Physicians are reminded that serious negative events or incidences that occur in a provider’s office or facility must be reported to AHCA directly by the provider. - 12 - Other Provider Requirements Provider is required to have a unique Florida Medicaid Provider number in accordance with the guidelines of the Agency for Health Care Administration (AHCA). As of May 2007, each provider is required to have a National Provider Identifier (NPI) in accordance with Section 1173 (b) of the Social Security Act, as enacted by Section 4707 (a) of the Balanced Budget Act of 1997. - 13 - Part 6: Specialist Information Specialist Responsibilities The following is a list of specialist responsibilities: Accept and manage patients who have been referred by the member’s primary care provider (PCP) Communicate treatment plans to the member’s PCP in a timely fashion Perform services normally in his or her scope of practice Participate and abide by all decisions regarding member complaints, peer reviews, quality improvement and utilization management programs Accept and participate in peer review Obtain prior authorizations as outlined by PHC Florida’s Utilization Management Department. See Part 15 (Covered Services) for a list of services requiring prior authorization by either the PCP or by PHC Florida. Pregnancy-Related Requirements Providers treating members who are pregnant shall offer Florida’s Healthy Start prenatal risk screening to each pregnant member as part of her first prenatal visit. Providers conducting such screening must use the Florida Department of Health prenatal risk form (DH Form 3134) that may be obtained from the local County Health Department (CHD). One copy of the completed screening form shall be kept in the member’s medical record and another copy shall be provided to the member. Within ten (10) business days from completion, the provider must submit the screening form to the CHD in the county in which the prenatal screen was completed. Providers shall also complete the Florida Healthy Start Infant Postnatal Risk Screening Instrument (DH Form 3135) with the Certificate of Live Birth and transmit both documents to the CHD in the county in which the infant was born within ten (10) business days from completion. Copies of Form 3135 shall be maintained by the provider, included in the member’s medical record and furnished to the member. Pregnant members or infants who do not score high enough to be eligible for Healthy Start care coordination may be referred for services, regardless of their score on the Healthy Start risk screen, in the following ways: If the referral is to be made at the same time the Healthy Start risk screening is administered, the provider may indicate on the risk screening form that the member or infant is invited to participate based on factors other than score; or - 14 - If the determination is made subsequent to risk screening, the provider may refer the member or infant directly to the Healthy Start care coordinator based on assessment of actual or potential factors associated with high risk, such as HIV, hepatitis, hepatitis B, substance abuse or domestic violence PHC Florida shall refer all pregnant women, breast-feeding and postpartum women, infants and children up to age five (5) to the local Women Infants and Children (WIC) office. The provider will provide: 1. A completed Florida WIC program Medical Referral Form with the current height or length and weight taken within 60 calendar days of the WIC appointment; 2. Hemoglobin or hematocrit; and 3. Any identified medical/nutritional problems For subsequent WIC certifications, providers shall coordinate with the local WIC office to provide the above referral data from the most recent Child Health Check-Up (CHCUP). Each time the provider completes a WIC referral form, the provider shall give a copy of the form to the member and retain a copy in the member’s medical record. Providers must provide all women of childbearing age HIV counseling and offer them HIV testing.1 In accordance with Florida law, providers shall offer all pregnant women counseling and HIV testing at the initial prenatal care visit and again at 28 to 32 weeks. Providers must attempt to obtain a signed objection if a pregnant woman declines an HIV test.2 All pregnant women who are infected with HIV shall be counseled about and offered the latest antiretroviral regimen recommended by the U.S. Department of Health & Human Services.3 Providers must screen all pregnant members receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during the first prenatal visit. Providers must perform a second HBsAg test between 28 and 32 weeks of pregnancy for all pregnant members who tested negative at the first prenatal visit and are considered high-risk for Hepatitis B infection. This test shall be performed at the same time that other routine prenatal 1 Chapters 381, F.S., 2004 Sections 384.31, F.S., 2004 and 64D-3.019, F.A.C., 2004 3 U.S. Department of Health & Human Services, Public Health Service Task Force Report entitled Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal 2 - 15 - screening is ordered. All HBsAg-positive women shall be reported to the local CHD and Healthy Start, regardless of their Healthy Start screening score. Participating Providers shall ensure that infants born to HBsAg-positive members shall receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once they are physiologically stable, preferably within 12 hours of birth and shall complete the Hepatitis B Maxine series according to the recommended vaccine schedule established by the Recommended Childhood Immunization Schedule for the United States. Providers shall test infants born to HBsAg-positive members for HBsAg and Hepatitis B surface antibodies (anti-HBs) six (6) months after the completion of the vaccine series to monitor the success or failure of the therapy. Providers must report to the local CHD a positive HBsAg result in any child aged 24 months or less within 24 hours of receipt of the positive test results. Providers shall ensure that infants born to members who are HBsAg-positive are referred to Healthy Start regardless of their Healthy Start screening score. Providers shall report to the Perinatal Hepatitis B Prevention Coordinator at the local CHD all prenatal or postpartum members who test HBsAg-positive. Providers shall also report said members’ infants and contacts to the Perinatal Hepatitis B Prevention Coordinator at the local CHD. The provider shall report the following information: name, date of birth, race, ethnicity, address, infants, contacts, laboratory test performed, date the sample was collected, the due date or EDC, whether or not the member received prenatal care and immunization dates for infants and contacts. The provider shall use the Perinatal Hepatitis B Case and Contact Report (DH Form 1876) for reporting purposes. PCPs must maintain all documentation of Healthy Start screenings, assessments, findings and referrals in the members’ medical records. Providers shall provide the most appropriate and highest level of quality care for pregnant members, including, but not limited to, the following: 1. Prenatal Care – PHC Florida providers are expected to: a. Require a pregnancy test and a nursing assessment with referrals to a physician, PA or ARNP for comprehensive evaluation b. Require case management through the gestational period according to the needs of the member c. Require any necessary referrals and follow-up d. Schedule return prenatal visits at least every four (4) weeks until the thirtysecond (32nd) week, every two (2) weeks until the thirty-sixth (36th) week, and - 16 - every week thereafter until delivery, unless the member’s condition requires more frequent visits e. Contact those members who fail to keep their prenatal appointments as soon as possible, and arrange for their continued prenatal care f. Assist members in making delivery arrangements, if necessary g. Ensure that all pregnant members are screened for tobacco use and make available to the pregnant members smoking cessation counseling and appropriate treatment as needed 2. Nutritional Assessment/Counseling – PHC Florida providers shall supply nutritional assessment and counseling to all pregnant members. In addition, providers are expected to: a. Ensure the provision of safe and adequate nutrition for infants by promoting breastfeeding and the use of breast milk substitutes b. Offer a mid-level nutrition assessment c. Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a nurse or physician following the nutrition assessment d. Document the nutrition care plan in the medical record by the person providing counseling Hysterectomies, Sterilizations and Abortions Providers must maintain a log of all hysterectomy, sterilization and abortion procedures performed on PHC Florida members. The log must include, at a minimum, the member’s name and identifying information, date of procedure, and type of procedure. Providers shall provide abortions only in the following situations: If the pregnancy is a result of an act of rape or incest The physician certifies that the woman is in danger of death unless an abortion is performed Hysterectomies, sterilizations and abortions may be performed only after meeting the Florida Medicaid guidelines, outlined in the Provider Handbooks. Necessary forms are included in Part 37 (Forms) of this manual. Diagnosis and Treatment of Tuberculosis Providers are required by law to report all tuberculosis suspects and/or cases within 72 hours of diagnosis to the health department in the county in which the patient lives or your office is located. For reporting codes, see Florida Administrative Code 64D-3. - 17 - Clinical Access Standards PHC Florida is committed to timely access to care for all members. Access standards are developed to ensure that all health care services are provided in a timely manner. These standards are based on community norms. PHC Florida monitors providers’ compliance to the standards. The access standards below must be observed by all network providers. Type of Care Emergency care Urgent care Non-urgent but needs attention Routine/preventive care Office waiting time Appointment Standards Immediate Within 24 hours Within one (1) week of request Within 30 days of request Should not exceed 60 minutes After-Hours Care Providers must be available 24 hours a day, seven days a week. PHC Florida requires a practitioner or a registered nurse under his/her supervision to maintain a 24-hour phone service, seven days a week. This access may be through an answering service after office hours. The service should instruct members with an emergency to hang-up and call 911 or go immediately to the nearest emergency room. Missed Appointments Providers are responsible for the follow up of missed appointments. Providers must have a process in place to follow-up on missed appointments that includes written policy and procedure and documentation of all provider efforts. Non-Covered Services PHC Florida members may be billed for non-covered services, such as cosmetic procedures and items of convenience if the provider informs the member that the service is not covered, the member agrees to pay for the service and the provider documents the member’s agreement to pay for such services. Provider Incident Reporting Requirements In the event of an adverse or untoward incident, defined as a Code 15 case by the Agency for Health Care Administration (AHCA), that occurs to a PHC Florida member whether occurring in a facility of one of the plan’s providers or arising from health care prior to admission to a facility, which may result in: - 18 - The death of a member Fetal death Severe brain or spinal damage to a member A surgical procedure being performed on the wrong member/wrong site Surgical procedure to remove foreign objects remaining from a surgical procedure Surgical repair of injuries from a planned surgical procedure The incident must be reported to the PHC Florida’s Quality Improvement Department on the Incident Report Form located in Part 37 (Forms) of this manual. Reporting Unusual Incidents on Providers Premises Unusual incidents that occur on the property of the provider must be reported to the designated risk manager at that location. The following are examples: In the event of an incident/injury to a member or visitor at a plan provider: Report the occurrence to the Office Administrator or risk management contact person in the office immediately If injury has occurred, obtain immediate medical assistance for visitor by physician or offer ambulance to nearest contracted Emergency Room Medical record will be completed and documented in compliance with the plan’s medical record keeping as for other members In the event, a patient or visitor becomes abusive (physically or verbally) at the plan’s participating provider premises: Report occurrence to the Office Administrator or risk management contact person in the office immediately. Attempt to calm patient or visitor. Do not argue or disagree with the abusive individual(s). Notify police if patient/visitor is physically threatening Remove other patients or visitors from the immediate area Do not attempt to restrain abusive individual unless another person is placed in danger. If restraint must be used, every effort must be made to keep the abusive person from physical harm (it is recommended that two individuals be present to assist with abusive individual). In the event the abusive individual is a member, the attending physician should also be notified immediately The provider’s office notifies the plan’s Member Service Department of the incident, if appropriate Other incidences that are required to be communicated to the plan include: - 19 - A slip or fall by a patient or family member Medication error Reaction requiring treatment A theft or loss from provider’s office Malfunction or damage of equipment during treatment Accusations of malpractice by a patient or family member Non-compliance with potential to be life threatening An incident report form should be used to report all incidents to the plan’s risk manager. Further reporting to the plan’s insurance carrier and governmental agencies, as appropriate, shall be arranged within the prescribed time frames by the plan’s risk manager. Physicians are reminded that serious negative events or incidences that occur in a provider’s office or facility must be reported to AHCA directly by the provider. Other Provider Requirements Provider is required to have a unique Florida Medicaid Provider number in accordance with the guidelines of the Agency for Health Care Administration (AHCA). As of May 2007, each provider is required to have a National Provider Identifier (NPI) in accordance with Section 1173 (b) of the Social Security Act, as enacted by Section 4707 (a) of the Balanced Budget Act of 1997. - 20 - Part 7: Provider Notification Requirements All provider changes must be submitted in writing to PHC Florida’s Provider Relations Department sixty (60) days in advance for the following: Office Relocation Primary care providers (PCPs) changing office locations require a facility site review. Once the site is approved, the provider’s address is updated and members are transferred to the new site. If the PCP moves outside of PHC Florida’s geographic service area, PHC Florida will reassign the members to the PCP of the member’s choosing within the service area. Written notification must be submitted to the Provider Relations Department for all telephone, fax number and tax identification number changes. Prior notice to the plan is required for any of the following changes: 1099 mailing address Tax identification number or entity affiliation (W-9 required) Group name or affiliation Physical or billing address Telephone and/or fax number Leave of Absence Primary care providers (PCPs) must provide adequate coverage for leave of absence or vacation. Absences more than 90 days require transfer of members to another PHC Florida PCP. Specialty care providers must provide a written notification to PHC Florida’s Provider Relations Department for absences more than 30 days. Provider Termination Providers must send written notification to PHC Florida’s Provider Relations Department 60 days in advance of a withdrawal or termination. For continuity of care, PHC Florida reserves the right to obligate the provider to provide medical services for existing members until the effective date of termination according to the terms of your contract with PHC Florida. PHC Florida may administratively suspend or terminate a provider for reasons such as, but not limited to: - 21 - No response to inquiries regarding the expiration of license, malpractice or other credentialing requirements Deficiencies in quality of care. PHC Florida will provide at least 60 days written notification of an administrative suspension or termination. A provider may be terminated immediately in cases in which a member’s health is subject to imminent danger or a provider’s ability to practice medicine is impaired. PHC Florida is responsible for transitioning member care for all terminated providers. Provider fair hearing and appeal rights will be issued at the time of termination. In addition to the provider termination information included in your provider agreement with the plan, you must adhere to the following items: Any contracted provider must ensure at least written notice before “without cause” termination of a contracted provider’s participation. Please refer to your contract for the details regarding specific required days for providing termination notice. Unless otherwise provided in the termination notice, termination occurs on the last day of the month. For example, required notice in 60 days; a termination letter dated October 15; since required notice is 60 days, the effective date of termination is December 31. Providers who receive a termination notice from the plan may submit an appeal. PHC Florida will notify all appropriate agencies and/or members in writing of a provider termination as required by regulations and statutes. - 22 - Part 8: Provider Services Provider Relations Department The Provider Relations Department acts as the liaison between PHC Florida and the external provider network to promote positive communication, conduct trainings, facilitate the exchange of information and seek efficient resolution of provider issues. Provider Manual A provider manual is distributed to all new contracted providers upon execution of an agreement with PHC Florida. PHC Florida will request and maintain documented receipt of all provider manuals distributed. Training and Education Provider Relations representatives will conduct provider orientations to educate new providers on PHC Florida’s guidelines, policies and procedures. Contracted providers may request additional training by scheduling an in-service from the Provider Relations Department. Call (855) 318-4387 Monday through Friday, 8:30 am to 5:30 pm. Provider orientations and in-services include, but are not limited to, the following: Administration overview and contact information Enrollment and eligibility Quality management and access standards Authorizations and referrals Utilization management and case management Claim submission and payment guidelines Health education Credentialing and provider services Grievances and appeals Pharmacy and formulary - 23 - Provider and Pharmacy Directory The PHC Florida Provider and Pharmacy Directory is printed at least annually and is updated as necessary. The directory is solely used as a member handbook referencing participating primary care providers, specialists, hospitals, ancillary, vision and dental providers. All providers are encouraged to review their information in the directory and are responsible for submitting any changes to PHC Florida’s Provider Relations Department. - 24 - Part 9: Medical Records Transfers If a member requests copies of medical records to be sent to another medical professional because of a transfer to another primary care provider (PCP), there will be no charge to the member. When a member, or the member’s representative, presents a written request to a provider’s office requesting copies of medical records for reasons other than stated above, the office may charge a fee not to exceed the amount allowed by state law. In addition to assuring medical records are maintained in a confidential manner, members’ medical records must also be available at the time of an appointment. Medical record documentation facilitates communication, coordination, and continuity of care, which promotes the most efficient and effective treatment of the member. The medical records of PHC Florida members must be available to PHC Florida representatives upon request. In addition, members may access their medical records at any time, by contacting their health care provider. Medical Records Copies The primary care provider (PCP) office shall bear the cost of duplicating and shipping the member’s medical records when referring the member to a consulting physician. The provider’s office shall not charge the member for the cost of copying medical records that will be used during the member’s course of treatment with a referral provider. - 25 - Part 10: Delegated Entities All participating providers or entities delegated for network management and network development should meet all applicable standards and are held to the same standards whether delegation of these functions have occurred to providers or entities or is retained by the plan. Reviews are performed on delegated entities and compliance is monitored on a regular basis. If you would like a copy of all applicable standards, please contact our Provider Relations Department at (855) 318-4387 Monday through Friday, 8:30 am to 5:30 pm. Credentialing and recredentialing standards are outlined in Part 30 (Credentialing and Recredentialing). - 26 - Part 11: Community Outreach Activities Carefully read the following “Dos” and “Don’ts” related to Community Outreach for Medicaid members: Providers may display health-plan specific materials in their own offices Providers cannot orally or in writing compare benefits or provider networks among health plans, other than to confirm health plan network participation Providers may announce a new affiliation with a health plan or give a list of health plans with which they are affiliated to their patients Providers may co-sponsor events, such as health fairs, and advertise with the health plan in indirect ways such as through television and radio commercials, posters, fliers and print advertisements Providers shall not furnish lists of their Medicaid recipients to health plans with which they contract, or any other entity, nor can providers furnish other health plans’ membership lists to any other health plan Providers cannot assist with health plan enrollment Providers may distribute information about non-health-plan-specific care services and the provision of health, welfare and social services provided by the State of Florida or local communities as long as any inquiries from prospective members are referred to the member services section of the health plan or the Agency for Health Care Administration’s (AHCA’s) Choice Counselor/Enrollment Broker - 27 - Part 12: Preventive Care Guidelines Child Health Check-Ups Child Health Check-Up (CHCUP) is a Medicaid child health program of early and periodic screening, diagnosis and treatment services for beneficiaries under the age of 21. All PHC Florida members who are under the age of 21 should receive an exam. The program ensures access to necessary health resources and assists parents and guardians in appropriately using those resources. CHCUP Components The screening component of the CHCUP includes a general health screening most commonly known as a periodic well-child exam. The required CHCUP screening guidelines are based on the American Academy of Pediatrics’ recommendations for preventive health care include: Comprehensive health and developmental history Developmental/behavioral assessment Age-appropriate unclothed physical examination Height and weight measurements and age-appropriate head circumference Blood pressure for children 3 and older Immunization review and administration of appropriate immunizations Health education including anticipatory guidance Nutritional assessment Hearing, vision and dental assessment Blood lead level testing for children younger than six years of age Interpretive conference and appropriate counseling for parents and guardians Objective testing for developmental behavior, hearing and vision must be performed in accordance with the Medicaid periodicity schedule Laboratory services as appropriate See the Medical Records section – Pediatric Health Screening for detailed requirements and/or the Medicaid Child Health Check-Up Services Coverage and Limitation Handbook. CHCUP Exam Frequency The recommended schedule for Well-Child exams is as follows: Birth (2 Weeks) One (1) month, two (2) months, four (4) months, six (6) months, nine (9) months, and 12 months - 28 - 15 months (must occur on/or before the 15th month birthday to count as a wellchild visit) 18 months, 24 months Annually after age 2 through 21 At the beginning of each month, primary care providers (PCPs) will receive a list of eligible members who have chosen or been assigned to the PCP as of that date. CHCUP/Well-Child Codes Exams should be coded on claim forms using CPT codes 99381 through 99395, whichever is applicable for new patients, as indicated in the following chart. Correct codes are required for timely and accurate claims payment and documentation of services provided. New Patient/Initial Exam CPT Code 99381 99382 99383 99384 99385 Description Infant (age under 1 year) Early Childhood (1-4 years of age) Late Childhood (5-11 years of age) Adolescent (12-17 years of age) 18-20 years of age Established Patient/Periodic Exam CPT Code 99391 99392 99393 99394 99395 Description Infant (age under 1 year) Early Childhood (1-4 years of age) Late Childhood (5-11 years of age) Adolescent (12-17 years of age) 18-20 years of age These codes should be used along with appropriate ICD-9 codes, i.e., V20.2, V70.0, V70.3, V70.5, V70.6, V70.8 or V70.9 codes. When updating routine CHCUP status at the time of an acute care visit, the next-higher level E&M CPT code may be submitted if the appropriate ICD-9 code is also submitted as a secondary diagnosis. Referrals If a primary care provider (PCP) is unable to provide all the components of the WellChild/CHCUP exam or if screenings indicate a need for evaluation by a specialist, a - 29 - referral must be made to another participating provider in accordance with PHC Florida’s referral procedures. The PCP shall refer members to appropriate service providers within four (4) weeks of the examination for further assessment and treatment of conditions found during the examination. The member’s medical record must indicate to where the member was referred. Blood Lead Level Testing The Centers for Medicare and Medicaid Services (CMS) and the State of Florida Medicaid Program require that all children be blood lead tested at 12 months and again at 24 months of age, or between 36 and 72 months of age, if not previously tested. Filter paper testing is an accepted method to obtain blood lead levels. If the blood level is elevated, the primary care provider (PCP) will provide additional diagnostic and treatment services determined to be medically necessary. Immunization Schedule Immunizations are an important part of preventive care for children and should be administered during the Well-Child/CHCUP exam as needed. PHC Florida endorses the same recommended childhood immunization schedule that is recommended by the Center for Disease Control and approved by the American Academy of Pediatrics. Transportation Assistance Primary care providers (PCPs) shall offer transportation scheduling assistance to members in order to assist them to keep, and travel to medical appointments. See “Transportation Services” in Part 15 (Covered Services) of this manual. Healthy Behaviors Program PHC FL encourages and rewards members for taking part in activities that promote healthy behaviors. Current programs that are medically approved or directed include: Smoking Cessation (Quit-for-Life, p.6) PHC FL will offer programs to our members who want to lose weight, or address any drug abuse problems. We will reward members who join and meet certain goals. These programs will be ready October 1, 2014. We will send more information to you later. - 30 - Part 13: Members with Special Health Care Needs Members with special needs are defined as adults, children and adolescents who face physical, mental or environmental challenges daily that place their health at risk and ability to fully function in society. They include for example: Members with mental retardation or related conditions Members with serious chronic illnesses such as HIV, schizophrenia or degenerative neurological disorders Members with disabilities resulting from years of chronic illness, such as arthritis, emphysema or diabetes; and adults, children and adolescents with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care The following is a summary of responsibilities specific to physicians who render services to PHC Florida members identified as having special health care needs: 1. Assess the member and develop a plan of care for those members determined to need a course of treatment or regular care 2. Coordinate a treatment plan with member’s family and/or specialist caring for the member 3. Insure the plan of care adheres to community standards and any applicable agency quality assurance and utilization review standards 4. Allow the members needing a course of treatment or regular care monitoring to have access through standing referrals or approved visits, as appropriate for the member’s condition or needs 5. Coordinate with the health plan, if appropriate, to ensure that each member has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the member 6. Members may request a specialist as primary care provider (PCP) through PHC Florida’s Member Services Department. If the medical director agrees the specialist is appropriate as a PCP and the specialist agrees to act as the PCP, the member will be assigned to that specialist by the Member Services Department. 7. Coordinate services with other managed care organizations to prevent duplication of services - 31 - Part 14: Adult Health Screenings Providers should perform an adult health screening to assess the health status of members age 21 or older. The adult member should receive an appropriate assessment and intervention as indicated or upon request. Adult Preventive Health Exam Elements of a preventive health exam include: 1. Risk Screening Guidelines Screening to identify high-risk individuals, assessing family medical and social history is required. Screening for the following risks are included as a minimum: cardiovascular disease, hepatitis, HIV/AIDS, STDs and TB. 2. Interval History Interval histories are required with preventive health care. Changes in medical, emotional, and social status are documented. 3. Immunizations Immunizations are documented and current. If immunization status is not current, this is documented with a catch up plan. Immunizations are required as follows: Influenza, annually beginning at age 65 years Tb booster every 10 years Pneumococcal vaccine beginning at age 65. When an individual has received a Pneumococcal vaccination prior to the age of 65 years and five (5) years has passed since the vaccination, he or she should be revaccinated. 4. Height and Weight Documented height and weight is required for all preventive health care visits and at least every five (5) years, ages 21-40 years, and every two (2) years beginning at age 41 years. 5. Vital Signs Pulse and blood pressure are required for all preventive health care visits and at least every five (5) years, ages 21-40 years, and every two (2) years beginning at age 41 years. 6. Physical Exam Appropriate evaluation for inclusion in the baseline physical examination of an asymptomatic adult are: - 32 - general appearance skin gums/dental/oral eyes/ears/nose/throat neck/thyroid chest/lungs cardiovascular breasts abdomen/GI genital/urinary musculoskeletal neurological lymphatic If non-compliance or refusal is documented, the risk associated with the noncompliance must be documented as well. 7. Cholesterol Screening Screening required every five (5) years for men beginning age 35, and women beginning age 45, earlier if any risk factor for cardiovascular disease. 8. Visual Acuity Testing Visual acuity testing, at a minimum, documents the patient’s ability to see at twenty feet. Referrals for testing must be documented. 9. Hearing Screening Test or inquire about hearing periodically/once a year. 10. Electrocardiogram Periodically after age 40-50, or as primary care deems medically appropriate. 11. Colorectal Cancer Colorectal cancer screening must be documented. Screening should begin at age 50 years. Risk factors: first-degree relatives or personal history of colorectal cancer, Gardner’s syndrome, hereditary non-polyposis colon cancer, and chronic inflammatory bowel disease. 12. Pap Smear Baseline pap smears annually for three consecutive years until three consecutive normal exams are obtained, then every two to three (2-3) years. May stop at age 65 if patient has had regularly normal smears up to that age. 13. Mammography Required as appropriate for age: baseline between ages 35 and 40. Every one to two (1-2) years for women age 40 or older. Earlier and/or more frequent for women at high-risk. - 33 - 14. Prostate exam/screening U.S. Preventive Services Task Force, December 2002 The evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal examination. The USPSPTF found good evidence that PSA can detect early-stage prostate cancer but mixed inconclusive evidence that early detection improves health outcomes. Insufficient evidence to determine whether the benefits outweigh the harms (of biopsies, complications and anxiety), especially in a cancer that may have never affected the patient’s health. American College of Physicians 2004 Recommendations are for selected testing in 50-69 year olds, if the risks, benefits and uncertainties are understood. With the current available evidence, it is difficult to ever justify routine screening of men 70 and older. 15. Education/anticipatory Health education and guidance must be documented. Guidance: educational needs are based on risk factors identified through personal and family medical history, social and cultural history and current practices. 16. Osteoporosis Screening for women age 65 and older; begin at age 60 if at increased risk for osteoporotic fractures. Perform DEXA Scan for serial monitoring every two (2) years; special conditions may need more frequent monitoring. All perimenopausal women should have a DEXA Scan after a fracture if test has not been performed recently. - 34 - Part 15: Covered Services Covered Services and Limitations A summary of the benefits and limits is provided below. Non-pregnant adults have up to 45 days of inpatient care and up to 365 days of emergency inpatient coverage, including behavioral health. Any limitations in the table below do not apply to children and pregnant women. Medicaid Services Provided Limitations Advanced Registered Nurse Covered when medically necessary; limited Practitioner/Physician Assistant Services to one (1) visit per day; no co-pay; requires prior authorization Ambulance Services For emergencies; covered when medically necessary; no limits; no co-pay Ambulatory Surgery at an Ambulatory Covered when medically necessary; no Surgery Center limits; no co-pay; requires prior authorization Behavioral Health Inpatient Hospital Covered; up to 45 days per year; no co-pay; Services requires prior authorization unless emergency. Behavioral Health Outpatient Services Covered; no limits; no co-pay; certain services require prior authorization Child Health Check-Up Services Covered; no limits; no co-pay (CHCUP) Chiropractic Services Members may self-refer to a network chiropractor; covered when medically necessary; limited to one (1) visit per day; limited to 24 visits per year; no co-pay; procedures require prior authorization Clinical Services from Federally Covered; limit of one (1) visit per day; no coQualified Health Care Centers pay; certain services require prior authorization Clinical Services from County Health Covered; limit of one (1) visit per day; no coDepartment pay; certain services require prior authorization Clinical Services from Rural Health Covered; limited to one (1) visit per day; no Clinics co-pay; certain services require prior authorization - 35 - Dental Services for Adults Dental Services for Children (members under the age of 21) Dermatology Services Dialysis Services (hospital-based and free standing) Durable Medical Equipment and Medical Supplies Emergency Room Services Family Planning Services and Supplies including: Education and Counseling Initial Examination Diagnostic Procedures and Lab Studies Contraceptive Drugs/Supplies Hearing Services Emergency dental procedures covered when medically necessary. Full and partial denture services covered. Limitations apply; see a network dentist for details. No co-pay. See the Expanded Benefits table for “Dental Services for Adults. The plan has enhanced adult dental services to provide routine and restorative dental care. Comprehensive preventive, restorative and emergency treatments and orthodontics covered when medically necessary. See a network dentist for details. No co-pay. Members may self-refer to a network dermatologist; covered when medically necessary; no co-pay; procedures require prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no copay; certain items and services require prior authorization. Covered when medically necessary; no limits; no co-pay Covered; no co-pay; certain services require prior authorization. Diagnostic testing, cochlear implants and hearing aids covered when medically necessary. Diagnostic testing may be limited to once every three (3) years. Hearing aids limited to once every three (3) years. Newborn hearing screening covered. No co-pay; certain services require prior authorization. - 36 - Healthy Start/Maternity Services including: Prenatal Care and Screening Obstetrical Delivery and Hospital Care Birthing Center Services Postnatal Risk Screening Physician Care for Mother and Newborn Nutrition Assessment and Counseling Members may self-refer to a network OB/Gyn provider; covered when medically necessary; no co-pay; certain services require prior authorization. See Expanded Benefits table for “Prenatal/Perinatal Services.” The plan has enhanced prenatal/perinatal services to remove doctor visitation limits. Home Health Care Services (See page 23 for more information about Home Health Care Services.) Covered when medically necessary; limited to four (4) intermittent visits per day; limited to 60 visits in a lifetime; no co-pay; requires prior authorization Covered; enrollee must be certified by a physician as terminally ill with life expectancy of six (6) months or less; no copay. Covered; no limits; no co-pay Covered; up to 45 days per year; no co-pay; requires prior authorization unless emergency Covered for pregnant substance abusers; up to 28 days per year; no co-pay; requires prior authorization. Covered when medically necessary; no limits; no co-pay; certain services require prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Hospice Services Immunizations Inpatient Hospital Services Inpatient Hospital Substance Abuse Treatment Program Laboratory/X-Ray/Imaging Services Medical/Drug Therapies Outpatient Hospital Services Outpatient Surgery (Hospital) - 37 - Optometric and Vision Services Physician Primary Care Services Physician Specialty Care Services Podiatry Services Prescription Drugs Therapy Services (Hospital- and Community-Based) including: Occupational Therapy Physical Therapy Respiratory Therapy Speech Therapy Transplant Services Exams, eyeglass frames, eyeglass lenses, repairs to eyeglasses covered. Contact lenses covered if medically necessary. Eyeglass frames limited to one (1) pair every two (2) years. Eyeglass lenses limited to replacement once every year. For members under the age of 21, eyeglass frames and lenses limited to replacement two (2) times a year. No co-pay; additional services require prior authorization. See Expanded Benefits table for “Vision Services.” Plan has enhanced this service to provide members with an enhanced eyeglass frame benefit. See Expanded Benefits table for “Physician Primary Care Services.” Plan has enhanced this service to remove doctor visitation limits. Covered when medically necessary; limited to one (1) visit per day per specialist; no copay; referral and/or prior authorization required. Members may self-refer to network podiatrist; covered when medically necessary; limit of 24 visits per year; no copay; procedures require prior authorization Covered when medically necessary; no limits; no co-pay; prior authorization required on certain drugs Covered when medically necessary; no limits; no co-pay; requires prior authorization. No occupational or speech therapy coverage for adults. Covered when medically necessary; no limits; no co-pay; requires prior authorization. Heart, liver and lung transplant services covered under Medicaid fee-for-service and requires disenrollment from the plan. - 38 - Transportation (Non-Emergency) Tuberculosis Diagnosis and Treatment Services Expanded Benefits Dental Services for Adults Meal Service after Hospital Discharge Newborn Circumcision Nutritional Counseling Over-the-Counter (OTC) Pharmacy Items Physician Primary Care Services Prenatal/Perinatal Care Vaccines: Influenza Pneumonia Shingles Covered; no limits; no co-pay. Plan must arrange transportation to and from planapproved locations. Covered; no limits; no co-pay. Tuberculosis directly observed therapy (TB/DOT) covered through Medicaid fee-for-service providers. Limitations Limit of $1,000 per year to cover exams, cleanings, certain fillings, and X-rays. See a network dentist for details. No co-pay. Note that emergency dental procedures are covered under the plan’s medical benefit with no limits. Limited to two (2) meals per day for up to 14 days per year delivered to member after hospital discharge; no co-pay Covered for a newborn male in the first 30 days of life. No co-pay. Up to three (3) visits per year with a registered dietician, nutritionist or other qualified provider covered. No co-pay. Limit of $25 per member per month; no co-pay Covered; no limits to primary care doctor visits; no co-pay Covered; no limits to prenatal/perinatal care doctor visits; no co-pay Influenza vaccine covered once every year; pneumonia vaccine covered when ordered by a provider and limited to once every five (5) years; shingles vaccine covered when ordered by a HIV provider only; no co-pay - 39 - Expanded Benefits Vision Services Limitations One (1) pair of eyeglasses frames every two (2) years; one (1) pair of eyeglasses lenses per year; contact lenses may be substituted for eyeglasses if medically necessary. Behavioral Health Services PHC Florida provides behavioral health (mental health) services for members and enrolled household member(s). Inpatient and outpatient hospital services are covered. To access behavioral health services, the provider or member may call (855) 765-9698 24 hours a day, seven days a week. Referrals are not required to use this service. The behavioral health benefit is administered by Psychcare. If a member is exhibiting any of the following symptoms, he or she should call: Constantly feeling sad Feeling hopeless and/or helpless Feelings of guilt Worthlessness Difficulty sleeping Poor appetite Weight loss Loss of interest Difficulty concentrating Irritability Constant pain such as headaches, stomach and back aches PHC Florida, though Psychcare has licensed providers who will help with mental health problems. When members call, they will be given the names of several providers in their local community. Members may choose who to call for an appointment. An approval for services will be given at the time the member or provider calls Psychcare. If a member uses a behavioral health provider without getting an approval, he or she will be responsible for the cost. These rules do not apply for emergencies. Dental Services PHC Florida covers children’s dental services that include: Diagnostic exams X-rays needed to make a diagnosis Preventive services - 40 - Restorations Endodontics/periodontal treatment Dentures, complete and partial Oral surgery Limited Orthodontic treatment If a child is in need of orthodontia treatment, the member should contact Member Services at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. TTY users call 711. In addition to the adult emergency dental and denture services provided under the Florida Medicaid Program, PHC Florida provides an additional $1,000 benefit that may be used toward annual exams, X-rays, cleanings, fillings, or deep cleaning and periodontal scaling. For more details, members should contact a PHC Florida dentist. Members must receive these services from a plan dentist. A list of plan dentists is in the PHC Florida Provider and Pharmacy Directory. Optometric and Vision Services PHC Florida covers exams, eyeglass frames (one pair every two years), eyeglass lenses (once every year) and contact lenses (if medically necessary). Additional vision services must be authorized by PHC Florida. Hearing Services PHC Florida covers the following hearing services. Some of these services require prior authorization. Cochlear implants Diagnostic testing (may be limited to once every three [3] years) Hearing aids and/or hearing aid fitting and dispensing (once every three [3] years) Hearing aid repairs and accessories Newborn hearing screening Transportation Services PHC Florida provides transportation to and from provider offices for visits and other medical appointments if members need it. Members should call (855) 318-4387 TTY 711, to schedule a ride. This service is not for emergencies. - 41 - Part 16: Pharmacy The management of outpatient prescription drugs is an integral part of the medical management program to improve the health and well-being of PHC Florida members. Prescriber and member involvement is critical to the success of the pharmacy program. To help your patient get the most out of his or her pharmacy benefit, please be cognizant of the following guidelines when prescribing: 1. Follow national standards-of-care guidelines for treating conditions i.e., NIH Asthma guideline, JNC VII Hypertension guidelines, etc. 2. Prescribe drugs from the formulary 3. Prescribe generic drugs when therapeutic equivalent drugs are available 4. Evaluate medication profile for appropriateness and duplication of therapy Generic drugs are equally effective and generally less costly than the brand medication. Generic drug use can contribute to cost-effective therapy and must be dispensed by the pharmacist when a therapeutically equivalent to a brand name drug is available. Prescription Drug Prior Authorization PHC Florida has a “Prior Authorization and Exceptions” process in place to provide for coverage of non-formulary medications and for those medications listed in the formulary as requiring prior authorization (PA). The Pharmacy Services staff will adhere to PHC Florida Pharmacy & Therapeutics Committee-approved criteria, National Pharmacy and Therapeutics (NPTC) practice guidelines and other professionally recognized standards in reviewing each case, rendering a decision based on established protocols and guidelines, and referring cases to clinical pharmacists or physicians in accordance with standing procedures. Non-Formulary and Non-Covered Medications PHC Florida covers all drug categories currently available through the Florida Medicaid fee-for-service program. The exceptions process applies to all non-formulary medications. Smoking Cessation Medicaid members are allowed one course of nicotine replacement therapy of 12 weeks duration per year or the manufacturer’s recommended duration. - 42 - Covered Medications All dosage forms and strengths of drugs listed on the formulary are eligible for coverage unless specified otherwise. The formulary applies only to medications obtained through outpatient community pharmacies and does not apply to drugs used in the hospital or while in a skilled nursing facility. Coverage Limitations Non-covered (excluded) drugs and/or their categories include drugs for the treatment of infertility and drugs used for weight loss. Hemophilia Medications PHC Florida is not responsible for covering hemophilia medications. The member must contact the State Medicaid Agency directly at (888) 419-3456 to receive this benefit from an Agency for Health Care Administration (AHCA)-approved organization. Member Co-Payments There is no member co-pay for prescribed and over the counter drug products. Prescription Limits PHC Florida has a monthly 16-prescription limit. Prescriptions provided for the treatment of HIV and AIDS, chemotherapy and birth control are not included in this limit. Prescriber Request for Non-Formulary Medications The physician or a designated employee or individual must: 1. Under the direction and control of the physician may only make the request for a non-formulary drug 2. Be located in the physician’s office or other site where the member is receiving medical services 3. Not delegated the prior authorization function to a third party who is not located at the physician’s office or other site where the member is receiving medical services 4. Included specific information related to the member’s medical condition in the prior auth request 5. Provide all of the information requested for the non-formulary drug before PHC Florida can approve the exception - 43 - PHC Florida will communicate with the physician or a designated employee or other individual under the direction and control of the physician, regarding whether or not the non-formulary drug will be covered. The determination will be made within 48 hours of receipt of all of the necessary information requested. If a member is stabilized on a non-formulary drug previously approved for coverage by the plan, the physician can continue the therapy without further prior authorization if the drug is medically necessary. Non-formulary medications may be authorized when one of the following criteria is met: The requested non-formulary prescription has limited efficacy and relatively high incidence of side effects but indication for specific disease management meets criteria outlined in the National Pharmacy and Therapeutics Committee (NPTC) Guidelines Documented failure of a therapeutic trial of a formulary agent(s) The formulary alternative(s) is/are contraindicated for treatment The member is currently maintained and stabilized on a non-formulary medication previously approved by the plan that is not excluded from coverage The member experienced allergic reaction(s) to the formulary alternative(s) (e.g. rash, urticaria, drug fever, anaphylactic type, or established adverse effects as published in the package insert(s) of respective product(s) relating to the pharmacological properties of the medication(s), formulations or differences in absorption, distribution, or elimination of the medication(s) The prescriber provides compelling medical evidence supporting the use of the requested non-formulary medication over the formulary agent(s) where the requested therapeutic class is necessary for medical management The following information is required to evaluate each case prior to issuance of an authorization: 1. Member Name 2. Member ID# 3. Member Birth date 4. Member Gender 5. Prescriber Name 6. Prescriber Specialty 7. Prescriber Address 8. Prescriber Phone/Fax Number 9. Name and dosage strength of the requested medication 10. Directions for use 11. Diagnosis 12. Date patient started on the non-formulary medication - 44 - 13. Name of specific drugs tried and failed 14. Documentation of patient chart notes in accordance with the specifications outlined 15. in the NPTC Guidelines or, where appropriate, as the community standard of 16. practice 17. Any other compelling medical information that would support the use of the non- formulary medication over a formulary alternative A written communication of case resolution is faxed to the provider for each case serviced. If prior authorization is approved, the medication will be covered. If prior authorization is denied the member is responsible for paying the cost of the prescription. A copy of the PHC Florida Authorization Request Form is included in Part 37 (Forms) of this manual. Please make additional copies of the Authorization Request Form as needed for your use. To request prior authorization for a non-formulary drug, please call the PHC Florida Utilization Management Department at (866) 990-9322, or fax the completed Authorization Request form to PHC Florida at (888) 972-5340. Over-the-Counter Pharmacy Benefit PHC Florida has an over-the-counter (OTC) pharmacy benefit program for its members. Each member household may receive up to $25 worth of approved OTC items every month. Items include vitamins, medicines, and health supplies. The OTC items are at no cost to the member. Please encourage your patients to use this benefit. A member can order their OTC items by mail, fax or phone. To order by mail, the member must complete the “Over-the-Counter Pharmacy Benefit Order Form” that is in their new member welcome packet and mail it in the self-addressed, postage-paid envelope provided. The form can also be mailed to: Attn: PHC Florida OTC Benefit Fulfillment AHF Pharmacy 1785 E. Sunrise Blvd. Fort Lauderdale, FL 33304 The form can also be faxed to PHC Florida OTC Benefit Fulfillment at (954) 462-9793. To place an order by phone, the member can call (954) 462-9223 Monday through Saturday, 10:00 am to 7:00 pm. TTY users call 711. - 45 - Part 17: Member Rights and Responsibilities You should be aware of PHC Florida member rights and responsibilities as prescribed by Florida Law. Member Rights PHC Florida member rights as published in the Membership Guide are as follows: Be provided with facts about benefits, services, and use of the health plan Receive kind, respectful care and be treated with human dignity Know the names and titles of all doctors and other health care providers involved in your medical treatment Understand your medical condition and health status, suggested course of treatment, alternatives, and risks involved Actively participate in decisions regarding your medical care Be informed of continuing health care requirements following discharge from the hospital or provider office Refuse treatment, providing you choose to accept responsibility and the possible results of such a decision Refuse to participate in any medical research projects Have all complaints and grievances forwarded to the health plan’s Member Services Department for appropriate response Access to your medical records and have the privacy and confidentiality of these records maintained Complete an advance directive Make suggestions for improvement to PHC Florida Appeal unfavorable medical or administrative decisions by following the established appeal procedures of PHC Florida and the State Have all the above rights apply to the person having legal authority to make decisions regarding your health care Have all health plan personnel observe your member rights Exercise these rights without regard to sex, age, race, ethnic, economic, educational, or religious background - 46 - Member Responsibilities PHC Florida member responsibilities as published in the Membership Guide are as follows: Understand how PHC Florida works by reading the plan’s Membership Guide Carry your PHC Florida ID card and Medicaid card with you at all times. Present them to each provider (doctor, lab, hospital, pharmacy, etc) at the time services are being provided. Select and seek all non-emergency care by appointment through your assigned primary care provider (PCP), obtain a referral from your PCP for specialty care, and cooperate with all persons providing your care and treatment Be on time for appointments Notify the doctor’s office well in advance if you need to cancel or reschedule an appointment Be respectful of the rights, property, and environment of all providers, employees, other patients and not be disruptive Understand and follow medical advice concerning your treatment and ask questions if you do not understand or need an explanation Understand the medications you take, know what they are, what they are for, and how to take them properly. Provide accurate and complete medical information to all providers as may be required in the course of your treatment Make sure your current doctor has been provided with copies of all previous medical records Notify PHC Florida within 48 hours or as soon as possible, if you are hospitalized or receive emergency room care - 47 - Part 18: Member Complaints, Grievances and Appeals This section describes what steps members may take to file a complaint or grievance or to appeal a decision made by the plan. Members who have questions, concerns or complaints about the health plan should call Member Services at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. TTY users should call 711. A “complaint” is the lowest level of challenge and provides the health plan an opportunity to resolve a problem without it becoming a formal grievance. Complaints must be resolved by the close of business the day following receipt, or be moved into the grievance system. A “grievance” is an expression of dissatisfaction about any matter other than an “action.” For example, member would file a grievance if he or she has a problem with issues such as: The quality of care Waiting times for appointments Waiting time to be seen while in a doctor’s office The way a doctor or his or her staff behave Unable to reach a provider or the health plan by phone Inability to receive the information you need Cleanliness or condition of a provider’s office An “action” is the denial or limit by the plan of services requested by member or provider. Examples of an action are: Changing level of service, i.e., outpatient instead of inpatient hospital care Reduction, suspension or termination of a service that was already authorized for you Denial of all or part of the payment for a service or failure to provide the service in a timely manner The health plan’s failure to act on a grievance or appeal you requested within 90 days of receiving your request An “appeal” is a request for a review of an action. For example: If PHC Florida refuses to cover or pay for services member thinks the health plan should cover, he or she may file an appeal If the health plan or one of its contracted providers refuses to give member a service he or she thinks should be covered, he or she may file an appeal - 48 - If the health plan or one of its contracted providers reduces or cuts back on services member has been receiving, he or she may file an appeal If member thinks PHC Florida is stopping his or her coverage of a service too soon, he or she may file an appeal With member’s permission, provider may also file an appeal on behalf of member. The health plan is required to keep track of all appeals and grievances so it can report data to the State on a quarterly and annual basis. This information is also used to improve the plan’s service to its members. Filing a Complaint or Grievance If member is dissatisfied with PHC Florida for any reason he or she can file a complaint or grievance. Member cannot be disenrolled or penalized in any way if he or she files a grievance. Member may file a complaint or grievance by calling Member Services at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. TTY users call 711. If member files a complaint and the health plan cannot resolve it by the end of the following business day, the complaint will become a grievance. If member chooses not to notify PHC Florida by phone, he or she will then need to put his or her grievance in writing and must sign it. The health plan can assist with this. Member may also file a grievance in writing. The grievance should explain in detail what happened to make member dissatisfied, the names and titles of people involved, and the date, time and location of the incident(s). When filing a grievance, member should include his or her name, his or her PHC Florida ID number, and current address, and telephone number. Grievances go to: Attn: Member Services PHC Florida P.O. Box 46160 Los Angeles, CA 90046 With member’s written permission, provider may also file a grievance on behalf of member. PHC Florida will send each member who files a grievance a letter stating that the health plan received the grievance. The health plan must resolve the grievance within 90 - 49 - calendar days from receipt. Member may file a grievance any time up to one (1) year following the date of an incident. Member or his or her provider may request an extension, if necessary; if this is in his or her best interest. An extension can be made for up to 14 days. PHC Florida is required to send each member who files a grievance a written response to his or her grievances within 90 calendar days from the date it was filed. This resolution letter will tell the member what actions the health plan took to address his or her grievance, and what additional steps he or she can take. PHC Florida members should call the Member Services Department if they have questions or need any help with grievances. They can also call Member Services if they have more information to add about grievances after they filed them. Member Services can be reached at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. TTY users call 711. Filing an Appeal Member may file an appeal of a decision by PHC Florida within 30 calendar days of receipt of the health plan’s notice to him or her about its action. An appeal can be filed orally or in writing. Member Services staff can assist members with this. Oral appeals must be followed by a written, signed appeal within 30 calendar days of the oral filing. PHC Florida will send members a notice to remind them that they must file a written appeal within 10 business days of receiving their oral request for appeal. If a member needs help completing his or her written appeal, he or she should call Member Services at (888) 997-0979 Monday through Friday, 8:00 am to 8:00 pm. TTY users call 711. Translators and interpreters are available at no cost to members if they need help. The health plan’s timeframe to resolve appeals begins on the date that it receives an oral request. Provider may file an appeal on member’s behalf, with his or her written consent. PHC Florida will resolve appeals within 45 calendar days from the date the health plan received the initial request, unless an “expedited” appeal is requested. This timeframe can be extended up to 14 calendar days if requested by member. The timeframe may also be extended if PHC Florida finds there is a need for additional information, and the delay is in member’s best interest. PHC Florida will notify member in writing within five (5) business days if it needs an extension. The health plan will notify member within two (2) weeks of the decision. - 50 - If the decision to member appeal is in member’s favor, PHC Florida will provide the services as quickly as conditions require. Continuation of Benefits Benefits will continue while member’s appeal is pending, if: 1. He or she files a request for continuation or reinstatement of benefits in a timely manner on or before the later of: Ten (10) days from the date of PHC Florida’s notice of action to the member (or 15 days, if the notice is sent via US mail) Prior to the intended effective date of the health plan’s proposed action; 2. The Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; 3. The services must have been ordered by an authorized provider; 4. The authorization period has not expired; and/or 5. Member requests an extension of benefits PHC Florida will continue member’s benefits during this time until one (1) of the following occurs: Member withdraws his or her request for the appeal Ten (10) calendar days pass from an oral request or 15 calendar days pass from a written (mailed) request from the date of the plan’s adverse decision and member has not requested a Medicaid Fair hearing with continuation of benefits An adverse appeal decision is made The authorization expires or authorized service limits are met If the final resolution of the appeal is in member’s favor, PHC Florida will pay for the disputed services as required. If the final resolution of the appeal is not in member’s favor, member may be liable for all costs accrued while the appeal was pending. PHC Florida may recover the cost of the services furnished while the appeal was pending. Expedited Appeal Process Member can ask for an “expedited or urgent” appeal if the time it takes for a standard resolution could seriously jeopardize member’s life, health or ability to attain, maintain or regain maximum function. - 51 - Member can file an "expedited” appeal orally or in writing. Member’s doctor may file one on his or her behalf, with member’s written consent. Member does not need to follow up this request in writing. If member files an “expedited” appeal, PHC Florida will: 1. Inform member of the limited time available to present member’s evidence and allegation of fact or law, in person or in writing; 2. Resolve each expedited appeal and give member notice as quickly as member’s condition requires, but within 72 hours after PHC Florida receives member appeal; 3. Provide member with a written notice of the decision; and 4. Try to provide member with oral notice of the decision If PHC Florida denies member’s request for an “expedited” appeal, the health plan will: 1. Transfer member appeal to the standard timeframe. The standard timeframe is no longer than 45 calendar days from date when PHC Florida received member’s request for an expedited appeal. A 14-day extension may be granted if it is in member’s best interest. 2. Try to call member to notify member of the denial of member’s request; and 3. Provide member with written notice of the denial within two (2) calendar days Medicaid Fair Hearing Process Member has the right to ask for a Medicaid Fair Hearing at any time within ninety (90) days of the date on PHC Florida’s letter about the results of member’s appeal. Member may do this in addition to, and at the same time as, pursuing resolution through PHC Florida’s appeals process. To request a Medicaid Fair Hearing, contact: Department of Children and Families Office of Appeal Hearings Bldg. 5, Room 255 1317 Winewood Blvd. Tallahassee, FL 32399-0700 (50) 488-1429 Member or someone member appoints to represent member may request a Medicaid Fair Hearing. Provider (with written consent) may also request a Medicaid Fair Hearing on member’s behalf. The parties to a Medicaid Fair Hearing include member, member’s representative or a representative of a deceased member and representatives from PHC Florida. - 52 - If member chooses to have a Medicaid Fair Hearing, member gives up his or her right to a review by the State’s Beneficiary Assistance Program. Member benefits will continue while the Medicaid Fair Hearing is pending, if: 1. Member files request for a Medicaid Fair Hearing in a timely manner on or before the later of: Ten (10) days from the date of PHC Florida’s notice of action to member (or 15 days, if the notice is sent via US mail) Prior to the intended effective date of our proposed action; 2. The Medicaid Fair Hearing involves the termination, suspension, or reduction of a previously authorized course of treatment; 3. The services must have been ordered by an authorized provider; 4. The authorization period has not expired; and/or 5. Member requests an extension of benefits If PHC Florida continues member’s benefits during this time, the health plan will until one (1) of the following occurs: Member withdraws request for Medicaid Fair Hearing Ten (10) calendar days pass from an oral request or 15 calendar days pass from a written (mailed) request from the date of the plan’s adverse decision and member has not requested a second appeal A Medicaid Fair Hearing decision adverse to member is made The authorization expires or authorized service limits are met If the final resolution of the Medicaid Fair Hearing is in member’s favor, PHC Florida will pay for the disputed services as required. If the final resolution of the Medicaid Fair Hearing is not in member’s favor, member may be liable for all costs accrued while the Medicaid Fair Hearing was pending. PHC Florida may recover the cost of the services furnished while the Medicaid Fair Hearing was pending. If the services were not provided during the time the Medicaid Fair Hearing was pending and PHC Florida’s decision is reversed, the health plan will authorize or provide the services as quickly as required by member’s condition. Appealing to the Beneficiary Assistance Program (BAP) If member completed PHC Florida’s appeals process, and he or she is still dissatisfied, member may file an appeal with the BAP. The notice of resolution letter from PHC - 53 - Florida will tell member how to start a review by BAP. It will also include BAP’s address and telephone number. The BAP can also be contacted at anytime during the appeal process. Member must request a hearing within 365 calendar days or one (1) year. The BAP will only hear member’s case if it involves the availability of health care services, the coverage of benefits, a benefit action/denial made by the health plan, claim payment, handling, or paying for benefits. If member takes his or her concern to a Medicaid Fair Hearing, member may not also request a BAP review. Submit appeals to: Agency for HealthCare Administration Beneficiary Assistance Program Bldg. 3, MS# 26 2727 Mahan Drive Tallahassee, Florida 32308 Tel (850) 412-4502 Toll Free (888) 419-3456 Exhaustion of the Grievance and Appeal Process Member must complete the grievance and appeal process described here before bringing action by way of arbitration or court action against PHC Florida. The State’s Consumer Call Center is available to Medicaid recipients. If member has any questions or concerns about quality of medical care he or she receives from PHC Florida, call (888) 419-3456; TTY 711. - 54 - Part 19: Member Satisfaction PHC Florida uses several mechanisms to measure member satisfaction with the plan, providers, care and service such as: Satisfaction Surveys – PHC Florida conducts an annual assessment of member satisfaction. Members rate their satisfaction in multiple areas including perceptions of the health plan, health care, providers, access, referral process, specialty care, benefits, and customer service. Complaints – PHC Florida codes all complaints received from members, both oral and verbal, and enters the information into a centralized system to identify trends and opportunities for improvement related to care and service. - 55 - Part 20: Eligibility A member’s eligibility status can change at any time; therefore, all providers should consider requesting and copying a member’s identification card, along with additional proof of identification, such as a photo ID, and file them in the patient’s medical record. Primary care providers (PCPs) receive a list of eligible members at the beginning of each month who have chosen or been assigned to the PCP as of that date. Providers may do one of the following to verify member eligibility: Check member eligibility through the Medicaid verification program Call PHC Florida’s Member Services Department at (855) 318-4387 Monday through Friday, 8:00 am to 8:00 pm - 56 - Part 21: Claim Submission and Payment Guidelines This section of the Provider Manual describes PHC Florida’s requirements for provider claims settlement practices and provider disputes applicable to claims. Claim Definitions Clean Claim — A “clean claim” is defined as a claim for services submitted by a practitioner that is complete and includes all information reasonably required by PHC Florida, and as to which request for payment there is no material issue regarding PHC Florida’s obligation to pay under the terms of a managed care plan. Timely Filing Limit — The claim’s “Timely Filing Limit” is defined as the calendar day period between the claim’s last date of service, or payment/denial by the primary payer, and the date by which PHC Florida must first receive the claim. Received Date — The “Received Date” is the oldest PHC Florida date stamp on the claim. Acceptable date stamps include any of the following: PHC Florida Claims department date stamp, Primary payer claim payment/denial date Initial Claim Submission Claims for services provided to members assigned to PHC Florida must be submitted on the appropriate billing form (CMS1500, UB04, etc.) within ninety (90) calendar days, or as stated in the written service agreement with PHC Florida. The provider is responsible to submit all claims to PHC Florida within the specified timely filing limit. PHC Florida may deny any claim billed by the provider that is not received within the specified timely filing limit. The following information must be included on every claim: 1. Provider name 2. Provider address 3. Name 4. Date of birth 5. ID 6. Date(s) of service 7. All ICD9 diagnosis code(s) present upon visit 8. Revenue, CPT, HCPCS code for service or item provided 9. Billed charges 10. Place of service or UB04 bill type code - 57 - 11. Tax ID number 12. NPI number 13. Name and state license number of rendering provider Claims that do not meet the criteria described above will be returned to the provider indicating the necessary information that is missing. PHC Florida will process only legible claims received on the proper claim form that contains the essential data elements described above. Only current standard procedural terminology is acceptable for reimbursement per the following coding manuals: Current Procedural Terminology (CPT) for physician procedural terminology International Classification of Diseases (ICD9-CM) for diagnostic coding Health Care Procedure Coding System (HCPC) CMS-1500 paper claim submissions must be submitted on form OMB-0938-0999(08-05) as noted on the document’s footer. The Plan accepts the revised CMS-1500 and UB-04 forms printed in Flint OCR Red, J6983, (or exact match) ink. To ensure timely claim processing, PHC Florida requires that adequate and appropriate documentation be submitted with each claim filed. Documentation required with a CMS1500 or UB04 claim form: Documentation Other coverage explanation of benefits Dialysis log Doctor’s orders, nursing or therapy notes Full medical record with discharge summary Consult, procedures report Emergency room report Operative report Minimum Data Set (MDS) Assessment Applies to All Providers Dialysis Service Home Health Hospital Physician Emergency Medicine Physician Surgeon Skilled Nursing Facility Standard Code Sets Standard Code Sets as required by HIPAA are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms. All providers are required to submit claims and encounters using current HIPAA compliant codes, which include the standard CMS codes for ICD9, CPT, HCPCS, NDC and CDT, as appropriate. - 58 - Encounter Data Submission and Acceptance by State Medicaid If a provider is capitated, the provider agrees to submit encounter data in the prescribed HIPAA-compliant format as specified by PHC Florida and Agency for Health Care Administration. Providers submitting encounters and claims agree that PHC Florida is authorized to take whatever steps are necessary to ensure that the provider is recognized by the state Medicaid program, including its choice counseling/enrollment broker contractor(s) as a participating provider of the health plan and that the provider’s submission of encounter data is accepted by the Florida MMIS and/or the state’s encounter data warehouse. Information for Obtaining an NPI To obtain a national provider identifier (NPI) you may: Telephone: (800) 465-3203 or TTY: (800) 692-2326 E-mail [email protected] Mail to NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059 Answers to frequently asked questions regarding NPI are available at www.cms.gov Claims Submission Protocols and Standards Paper claims should be submitted to the address listed on the back of the members’ ID cards or to: Attn: Claims PHC Florida P.O. Box 7490 La Verne, CA 91750 For claim payment inquiries and information regarding electronic claim submission, please contact PHC Partners Florida Claims at (855) 318-4387, fax (323) 337-9146. Claims Receipt Verification and Status For verification of claims receipt by PHC Florida, please contact the Claims Department at (855) 318-4387. Claims Processing Claims will be paid to contracted providers in accordance with the timeliness provisions set forth in the provider’s contract and/or by applicable Florida Law. Unless the subcontracting provider and contractor have agreed in writing to an alternate payment schedule, claims will be adjudicated as follows: - 59 - For clean claims, expect reimbursement within 45 days of PHC Florida’s receipt of the claim if submitted on paper You will receive an Explanation of Benefits (EOB) that details how each service is paid You will receive an Explanation of Payment and Recovery Detail (EOPRD) when PHC Florida identifies a previous claim overpayment Coordination of Benefits Coordination of benefits (COB) is the procedure used to process health care payments when a member has coverage with more than one insurer. Prior to submitting a claim to PHC Florida, providers must identify if any other payer has primary responsibility for payment of a claim. If determination is made that, another payer is primary: 1. The primary payer should be billed prior to billing PHC Florida; 2. Any balance due after receipt of payment from the primary payer should be submitted to the PHC Florida for consideration; and 3. The claim must include information verifying the payment amount received from the primary plan as well as a copy of the explanation of benefits (EOB) Upon receiving the claim, PHC Florida will review it using the COB rule or the Medicaid/Medicare Crossover rule, whichever is applicable. PHC Florida shall reimburse provider for members who are Medicare primary for their Medicare deductibles and coinsurance payments according to the lesser of the following: The rate negotiated with the provider The reimbursement amount as stipulated in Section 409.908 F.S. Prohibition of Billing Plan Members A provider or its agent, trustee, assignee, or any subcontractor rendering covered medical services to Plan Members may not bill, charge, collect a deposit or other sum; or seek compensation, remuneration or reimbursement from, or maintain any action at law or have any other recourse against, or make any surcharge upon, a Plan Member or other person acting on a Plan Member’s behalf to collect sums owed by Plan. Should PHC FL receive notice of any surcharge upon a Plan Member, the Plan shall take appropriate action including but not limited to terminating the provider agreement for cause. The Plan will require that the provider give the Plan Member an immediate refund of such surcharge. - 60 - Your agreement with PHC Florida requires providers to accept payment directly from the health plan. Payment from the health plan constitutes payment in full, with the exception of applicable co-payments and any other amounts listed as member responsibility on the Explanation of Benefits/Provider Remittance Advice. This means providers cannot bill PHC Florida members for: The difference between actual charges and the contracted reimbursement amount Services denied due to timely filing requirements Covered services for which a claim has been returned and denied for lack of information Remaining or denied charges for those services where the provider fails to notify the health plan of a service that required prior authorization – payment for that service will be denied Covered services that were not medically necessary, in the judgment of the health plan, unless prior to rendering the service the provider obtains the member’s informed written consent and the member receives information that he/she will be financially responsible for the specific services Provider Claim Disputes A provider dispute is a provider’s written notice challenging, appealing or requesting reconsideration of a claim (or a bundled group of similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract disputes or disputing a request for reimbursement of an overpayment of a claim. Each provider claim dispute must contain the following information at a minimum: 1. Provider’s name 2. Provider’s identification number 3. Provider’s contact information 4. If the provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from PHC Florida to a provider, the request must include: a. A clear identification of the disputed item b. The date of service - 61 - c. A clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect. Providers may submit disputes on a Provider Dispute Resolution Form, which is included in Part 37 (Forms) of this manual. The form is also available on the plan’s website at www.positivehealthcare.org. Providers may initiate a claims dispute no later than 365 days from the date of the plan’s action on a claim. PHC Florida sends written acknowledge of receipt of a Provider Claim Dispute within 15 business days for hard copy submission, and two (2) business days for electronic submission. The plan returns provider claim disputes to submitting providers that do not include the required information as described on the previous page. Providers have 30 calendar days from receipt of a returned provider claim dispute to submit an amended dispute. If a provider does not submit an amended provider claim dispute within the 30-day timeframe, the plan closes the dispute. PHC Florida issues a written determination regarding a provider claim dispute within 60 calendar days after receipt of the dispute. For those provider claim disputes that require amending by the provider, the plan issues a written determination within 60 calendar days after receipt of an amended dispute. Provider claim disputes and appeals should be faxed to (323) 337-9146 or mailed to: Attention: Claims Department PHC Florida P.O. Box 7490 La Verne, CA 91750 Overpayment of Claims If PHC Florida determines that a claim was overpaid, then the health plan will notify the provider in writing within 365 calendar days of the date of the payment. Notification of an overpaid claim to the provider requires the following information: 1. Name and ID number 2. Date of service - 62 - 3. An explanation why PHC Florida believes the claim was overpaid The provider has 30 working days to dispute an overpayment notification, which then becomes a provider dispute and follows the applicable procedures listed above under Provider Disputes. - 63 - Part 22: Clinical Practice Guidelines These are evidence-based guidelines utilized by PHC Florida to help practitioners and members make decisions about specific clinical situations. Nationally recognized guidelines and standards are utilized as major sources in the development of PHC Florida Clinical Guidelines including: The US Preventive Services Task Force The American Diabetes Association Guidelines The American Cancer Society Guidelines The American Academy of Pediatrics Agency for Healthcare Research & Quality (AHRQ) guidelines DHHS (Department of Health & Human Services) HRSA-HAB (Health Resources and Services Administration HIV/AIDS Bureau guidelines such as “A Guide to Primary Care for People with HIV/AIDS, 2004 edition & “A Guide to the Clinical Care of Women with HIV/AIDS, 2005 edition & Centers for Disease Control (CDC) HIV/AIDS guidance All such guidelines are formally reviewed & approved for use by PHC Florida’s Utilization Management Committee and/or Medical Policy and Procedure Committee. In addition, PHC Florida utilizes McKesson’s InterQual Criteria in the issuance of authorizations for services requiring PHC Florida’s express pre-service or concurrent service authorization. PHC Florida contracted providers may obtain copies of these guidelines by calling our Provider Relations Department at (855) 318-4387. - 64 - Part 23: Disease Management As a specialty care plan managing HIV positive members and their families, PHC has implemented a disease management program that includes the following: Coordinating care through all levels of practitioner care (primary care to specialist) Usage of the most recent clinical practice guidelines for HIV/AIDS treatment by our providers. To receive a copy of the guidelines, contact the Florida Department of Health, Bureau of HIV/AIDS at (800) 245-4334 or go to www.aids.gov/treatment/guidelines/index.html. The Florida/Caribbean AIDS Education and Training Center (F/C AETC), funded by the US Public Health Services’ Health Resources Service Administration, has a HIV/AIDS Primary Care Guide for Florida and the Caribbean. To receive a copy of the guidelines, contact F/C AETC at USF Center for HIV education and Research, University of South Florida at (866) 352-2382 or go to www.faetc.org/Guide. Conducting severity risk and case management needs assessments for our members with reassessments completed no less than every six (6) months and more frequently when warranted by a significant change in the member’s medical condition or behavioral health status Offering patient education to assist members in better management of their disease as well as transmission prevention, risk-reduction services and secondary prevention of associated conditions and illnesses Conducting screenings to verify the member’s initial diagnosis, any complications and the severity of the member’s illness Providing outreach programs, which make a reasonable effort to locate and/or engage a member who has been lost to follow-up care for 180 days or more Coordinating support services with the Project AIDS Care (PAC) Waiver case manager/agencies as well as other public or private organizations that provide services to HIV/AIDS patients, their families and their caregivers Developing interventions designed to improve compliance and prevent acute events, which may include: - Implementation of standard clinical guidelines for recommended treatments for each disease process - Provider education focusing on HIV primary and secondary prevention of associated illnesses and conditions and risk reduction services - Focusing on process and outcomes measurement, evaluation and management - Creating a routine reporting and feedback loop that includes all provider and the patient - 65 - - HIV treatment adherence services. - 66 - Part 24: Prior Authorization and Referral Procedures Utilization management (UM) is an on-going process of assessing, planning, organizing, directing, coordinating, monitoring, and evaluating the utilization of health care services for PHC Florida’s members. UM staff performs assessments of referrals and authorization of services through evaluation and review of all pertinent clinical indications and medical records necessary to justify the medical necessity of the request. UM staff utilizes clinical guidelines of InterQual and state/federal standards. In addition, referrals or services that are beyond the UM staff scope of practice are forwarded to the health plan’s Medical Director for review. The UM/Case Management Department staff is responsible for identification of potential or actual quality-of-care issues, and cases of over- or under-utilization of health care services for PHC Florida’s members during all components of review and authorization. PHC does not provide incentives to PHC staff for UM decision-making. The comprehensive methods of review and authorization include the following processes: Prior Authorization Prior authorization is designed to promote the medical necessity of service, to prevent unanticipated denials of coverage and ensure that participating providers are utilized and that all services are provided at the appropriate level of care for the member’s needs. The primary care provider (PCP) is always the initial source of care for members. A member may see the PCP without a referral and the PCP may perform essential services in the office environment. Prior authorization is required for necessary services ordered by the PCP, which cannot be performed in the office. - 67 - The following services typically require prior authorization: Elective inpatient admissions Emergency hospital admissions require notification of admission within one (1) business day Outpatient surgeries (except where otherwise specified, i.e., abortions, minor office procedures) Major diagnostic tests, e.g., MRI, CT scan, angiography Endoscopies Hospice care Durable medical equipment New medical technology (considered investigational or experimental), including drugs, treatment, procedures, equipment, etc. Pharmacy drug formulary overrides Home health care Non-participating practitioners/non-contracted facilities PHC Florida does not require referral or prior authorization for the following services: Emergency services Family planning services Treatment of sexually transmitted diseases Confidential HIV testing and counseling Obstetrical care Sensitive and confidential services, e.g., services related to sexual assault, drug and alcohol abuse for children age 12 and over Therapeutic and elective pregnancy termination Annual “Well Woman” visit Dental and vision services Chiropractic (limited to treatment of the spine by means of manual manipulation and to a maximum of two (2) services per calendar month) Initial and one (1) follow-up consultation with a specialist Submit requests for prior authorization of services to PHC Florida’s UM/Case Management Department by filling out the prior authorization form in Part 37 (Forms) of this manual. You may do so by electronic medical records system (if available), fax, or telephone: Attn: UM/Case Management PHC Florida 110 SE 6th St., Ste. 1960 Ft. Lauderdale, FL 33301 - 68 - Tel (866) 990-9322 Fax (888) 972-5340 Referrals Referrals are made when medically necessary services are beyond the scope of the primary care provider’s (PCP’s) practice or when complications or unresponsiveness to an appropriate treatment regimen necessitates the opinion of a specialist. In referring a patient, the PCP should forward pertinent patient information/findings to the specialist. Upon initiation of the referral, the PCP is responsible for initiating the referral tracking system. If the PCP determines that a specialist is necessary for consultation or care of the patient, the PCP must complete a Referral Form — see Part 37 (Forms) — and obtain a prior authorization number for that referral, unless the service does not require prior authorization as described in the previous section. The PCP will specify the type of referral: Consultation for diagnostic purposes Consultation to recommend treatment plan Consultation and request to assume care When the member is referred for “Consultation to Recommend Treatment Plan” the PCP will specify on the referral form if: The referral is for a consultation visit only, or The referral is for consultation plus one follow-up visit. When a member is referred for consultation and subsequent care, the PCP will so specify. For diagnostic procedures and tests which are specifically related to the requested consultation, and which are not listed in the services/referral guidelines, prior authorization is required. This authorization is obtained by the PCP following PHC Florida’s Prior Authorization policies and procedures. Such tests, procedures, and treatments must be performed in network facilities. This referral is valid for 90 days, unless otherwise specified on the Referral Form. If the specialist determines that a secondary specialist who is out of the PHC Florida network is required, a medical review is required. PHC Florida is financially responsible only for those services that are medically necessary and specified in the Referral Form by the PCP to the specialist (or referred specialist to secondary specialist), and have been prior authorized by PHC Florida. Only those diagnostic procedures, tests, and treatments specifically related to the consultation and not defined in the services/referral guidelines, may be performed by - 69 - the specialist. This authorization is obtained directly by the specialist following PHC Florida prior authorization policies and procedures. Tests, procedures, and treatments must be performed in network facilities. This type of referral is valid for a 90-day period. Procedures not related to the admitting diagnosis (or presenting symptom/diagnosis in the specialist’s office) require prior authorization by PHC Florida. The health plan retains the right to retrospectively review inpatient and specialist claims to identify inappropriate consultations and procedures. PHC Florida also reserves the right to deny such consultations and procedures. Referral appointments to specialists must be on the same day for emergency care, within three (3) days for urgent care and within 30 days for routine care. Verbal communication from the PCP should be provided on any urgent referrals. If there is any question regarding the scope of the referral, the PCP should be contacted for clarification. Referrals are only made to specialists in the PHC Network. Exceptions will be made only in rare circumstances and then only with the prior approval of the Medical Director. Complete referrals are essential, stating exactly what is to be done and including any clinical information and previous diagnostic testing for the specialty provider/practitioner’s review. A system within the PCP’s practice should be developed to assure that written responses from specialty referrals are received and incorporated into the member’s medical record, e.g. a specialty referral log. A specialist may see a PHC Florida member only upon an initial referral from the member’s assigned PCP or as a secondary consultant from the primary referred specialist, except in a medical emergency. A written response from the specialist should be provided to the PCP within three (3) weeks of care for inclusion in the member’s medical record. All inpatient services must have an approval number issued by PHC Florida’s UM/Case Management Department. Inpatient admission notification may be made by telephone at (866) 990-9322 or fax (888) 972-5340. Prior authorization numbers must be clearly written on all bills submitted to PHC Florida. Referral Form Primary care providers (PCPs) and referring specialists must complete the Referral Form in Part 37 (Forms) and obtain an authorization from PHC Florida for all services - 70 - described previously as requiring prior authorization before such services are provided, except in emergencies. For a referral to be valid, the following conditions must be met: 1. The member must be currently enrolled in PHC Florida 2. The member must be assigned to a PCP initiating the primary referral 3. The member must receive initial services within 90 days from the referral date Providers are required to supply the following information, if applicable, for the requested service: 1. Demographic information (name, date of birth, etc.) 2. Provider demographic information, i.e., referring provider and referred to provider 3. Requested service/procedure, including specific CPT/HCPCS codes 4. Diagnosis, including ICD-9 code and description 5. Clinical indications necessitating service or referral 6. Pertinent medical history, treatment, and laboratory data 7. Location where service will be performed 8. Requested length of stay (for inpatient requests) Pertinent data and information is required by the Utilization Management (UM) staff to enable a thorough assessment for medical necessity and assign appropriate diagnosis and procedure codes to the authorization. A thoroughly completed Referral Form is essential to assure a prompt authorization. To assure maximum benefit from a referral, the PCP must clearly state the purpose of the referral and desired services. Patient progress notes, labs, and imaging should be attached to the referral. A copy of pertinent clinical notes may be attached and substituted for the Clinical History segment of the Referral Form if the required information is present on those clinical notes. Fax the completed Referral Form to the UM/Case Management Department for an assignment of an authorization number at (888) 972-5340. Referral to Non-Participating Providers Except in true emergencies, PHC provides coverage for only those services rendered by contracted providers and facilities. The exceptions are: PHC is notified, approves, and authorizes the referral in advance. In these instances, the Utilization Management (UM)/Case Management Department will issue an authorization number for the services to be provided. The provider recommending an out-of-plan referral must obtain approval for those services - 71 - before arrangements can be made for those services. To obtain an authorization number, contact the PHC Florida UM/Case Management Department at (866) 990-9322 or fax (888) 972-5340. The patient’s medical needs require specialized or unique service available only through a non-contracted provider or facility. In this case, PHC Florida will assist the referring provider in identifying specialists or facilities with the needed capabilities. PHC Florida must authorize any such referral. Second Medical/Surgical Opinion A member may request a second medical/surgical opinion at any time during the course of a particular treatment in the following manner: PHC Florida members may request a second opinion through their primary care provider or PHC Florida Utilization Management (UM)/Case Management Department. The UM/Case Management Department will assist the member in coordinating the second opinion request with the member’s PCP and specialist. PHC Florida’s Medical Director will review member’s second opinion requests Second opinion requests will be reviewed and provided written approval or denial within 48 hours of request receipt. In cases where the request identifies an urgent or emergent need, formal approval or denial will be provided within one (1) working day. If the request for second medical/surgical opinion is denied, both the member and provider have the opportunity to appeal the decision through the appeals process If the requested specialty-care provider or service is not available within the PHC Florida network, an approval to an out of network provider will be facilitated by the UM/Case Management Department Only one request for a second medical/surgical opinion will be approved for the same episode of treatment. This applies to both the in-network and out-ofnetwork requests for second medical/surgical opinion. Under the authorization process used by the UM/Case Management Department, any medical or surgical procedure that does not meet medical policy criteria (refer to on-line InterQual criteria) is reviewed by the health plan’s Medical Director. The Medical Director may request a second opinion at any time on any case deemed to require specialty practitioner advisor review. The UM review criteria may be obtained by request to the UM/Case Management Department. Upon approval of the request for a second medical/surgical opinion, the PCP’s office staff will assist the member in scheduling an appointment with the second opinion - 72 - practitioner. The PCP or his staff will instruct the member to take a copy of the authorization form and pertinent medical records to the second opinion practitioner. Prior Authorization Time Standards Determinations regarding requests for elective services/procedures are made within 14 days of request and receipt of medical record information required to evaluate medical necessity and appropriateness. Determinations regarding urgent service/procedures are made within 24 hours of receipt of medical record information required to evaluate medical necessity and appropriateness. Providers will be notified of the decision within one (1) calendar day of the decision. A list of resources used to make utilization and clinical decisions includes but is not limited to: InterQual Milliman and Robertson Medicaid Policies and Procedures Medicare Policies and Procedures Hayes Directory of New Medical Technology American Institute of Preventive Medicine Protocols American College of Obstetrics and Gynecology (ACOG) Guidelines for Perinatal Care American College of Radiology Providers who wish to discuss denial or modification of services may contact the health plan’s Medical Director at (954) 522-3132. Provider Referral Tracking System Providers may track and monitor referrals requiring prior authorization. Staff model providers may access the electronic medical records, which contains in detail the status of the referral. Contracted providers may contact the UM/Case Management Department directly at (866) 990-9322. - 73 - Part 25: Admission Review The Utilization Management representative obtains either telephonic or on-site medical record review within 24 hours of notification of admission (or next business day) to ensure the admission to an acute care hospital is appropriate/medically indicated in accordance with the illness or condition and confirm information obtained during prior authorization of elective admissions. Admission review is also required on all emergency admissions to determine medical necessity and appropriateness. Notification of Admissions All elective and emergency inpatient admissions must be reported to PHC Florida within 24 hours of the admission (or the next business day). Notifications should be submitted by faxing the patient’s admission face sheet to PHC Florida, Utilization Management (UM)/Case Management Department, at (888) 972-5340 or by telephoning the UM/Case Management Department at (866) 990-9322. Concurrent/Continued Stay Review Concurrent/continued stay review is a process coordinated by the Utilization Management (UM) representative during a member’s course of hospitalization to assess the medical necessity and appropriateness of continued confinement at the requested level of care. Hospital UM staff should phone in continued stay updates to PHC Florida, UM/Case Management Department at (866) 990-9322. Discharge Planning Review Discharge planning begins as early as possible during an inpatient admission. Such planning is designed to identify and initiate cost-effective, quality-driven treatment intervention for post-hospital care needs. It is a cooperative effort between the attending physicians, hospital discharge planner, PHC Florida’s UM staff, including its Medical Director, ancillary providers, and community resources to coordinate care and services. Retrospective Review of Inpatient Stay Retrospective review is a review process performed by the PHC Florida UM staff and Medical Director, after services have been rendered, to determine: If unauthorized services were medically necessary/appropriate If services were rendered at the appropriate level of care and in a timely manner If any quality-of-care issues exist - 74 - The attending physician, and/or hospital/facility are notified in writing of the claim payment determinations via the “Explanation of Benefits.” Ancillary Services (Home Health, Durable Medical Equipment, Hospice) Referrals for any ancillary services including home health and durable medical equipment require prior-authorization from the Utilization Management (UM)/Case Management Department. Skilled Nursing or Rehabilitation Facility Review When a member is transferred or admitted to a skilled nursing facility (SNF) or rehab facility, PHC Florida uses Title 22 SNF criteria and guidelines to determine appropriate level of care. All admissions to SNF and Rehab facilities require authorization by the Utilization Management (UM)/Case Management Department. - 75 - Part 26: Continuity of Care PHC Florida and its contracted providers must ensure that members receive medically necessary health care services in a timely manner without undue interruption. PHC shall allow enrollees to continue receiving medically necessary services for from a nonparticipating provider(s) for up to ninety (90) days of enrollment. PHC shall process nonparticipating provider claims for services rendered to such recipients until the enrollee selects another provider and/or transition to an in-network provider. The cornerstone of continuity of care is the maintenance of a single, confidential medical record for each patient. This record includes documentation of all pertinent information regarding medical services rendered in the primary care provider’s (PCP) office or other settings, such as, hospital emergency departments, inpatient and outpatient hospital facilities, specialist offices, the patient’s home (home health), laboratory and imaging facilities. Providers must have systems in place to ensure the following: 1. Maintenance of a confidential medical record 2. Monitoring of patients with ongoing medical conditions 3. Appropriate referral of patients in need of specialty services 4. Documentation of referral services in the member’s medical record 5. Forwarding of pertinent information or findings to specialist 6. Entering findings of specialist in the member’s medical record 7. Documentation of care rendered in the emergency or urgent care facility in the medical record 8. Documentation of hospital discharge summaries and operative reports in the medical record 9. Coordination of post-hospital follow-up, discharge planning, and after-care - 76 - Part 27: Chronic and Complex Conditions Comprehensive Diabetes Care Diabetic Retinal Examinations — PHC Florida is committed to reducing the incidence of diabetes-induced blindness in its members. Early intervention and continual monitoring of diabetic eye disease could reduce the incidence of diabetes-related blindness. Based on guidelines proposed by the American College of Physicians, the American Diabetic Association, and the American Academy of Ophthalmology, the health plan’s primary care providers (PCPs) will provide or manage services such that recipients with a history of diabetes will receive at least one fundoscopic exam every 12 months. Glycohemoglobin Levels — PHC Florida acknowledges that tight control of blood glucose levels can delay the onset and slow the progression of many of the side effects from diabetes. Glycohemoglobin is one laboratory indicator of how well a person’s blood sugar is controlled. Consistent with the American Diabetic Association recommendations, the health plan’s PCPs will provide or manage services such that members with a history of diabetes will receive glycohemoglobin determinations at least twice a year. Lipid Levels — PHC Florida recognizes the direct link between hyperlipidemia, secondary hyperlipoproteinemias and diabetes mellitus. By closely monitoring lipids and lipoprotein levels in diabetics, better control and maintenance of diabetes is possible. Consistent with the recommendations of the American Diabetes Association, the health plan’s PCPs will provide or manage services such that members with a history of diabetes will receive lipid and lipoprotein determination annually. If any anomalies are found in the annual baseline, additional studies should be conducted as medically necessary. Nephropathy Primary care provider (PCP) will for nephropathy so as to delay or prevent loss of renal function through early detection and initiation of effective therapies, and to manage complications in those identified with a renal disease. PCPs will manage members who have a positive test for protein in the urine (micro-albuminuria testing). Members are to be monitored for the disease, including end stage renal, chronic renal failure and renal insufficiency or acute renal failure and referred to a nephrologist as deemed medically appropriate. - 77 - Congestive Heart Failure PHC Florida is aware that today there is effective options for treating congestive heart failure (CHF) and its symptoms. It also recognizes that with early detection, symptoms can be reduced and many heart failure patients are able to resume normal active lives. To further these goals, the health plan’s primary care providers (PCPs) will provide or manage care of the CHF member by prescribing and monitoring an ace inhibitor, angiotensin II receptor blockers (ARB), and diuretic, and reviewing the contraindications of those medications prescribed. An echocardiogram should be performed annually and member should be instructed on nutrition and education ongoing of his or her disease. Asthma PHC Florida recognizes that asthma is a common chronic condition that affects children and adults. Primary care providers (PCPs) are expected to measure members’ lung function, assess the severity of asthma, and monitor the course of therapy based on: Comprehensive pharmacologic therapy for long-term management designed to reverse and prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma exacerbations Member education about the contributing environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations Education that fosters a partnership amongst the member, his or her family and clinicians Hypertension PHC Florida recognizes that primary care providers (PCPs) can assist members by checking blood pressure at every opportunity and counseling them and their families about preventing hypertension. Members benefit from general advice on healthy lifestyle habits, in particular a healthy body weight, moderate consumption of alcohol and regular exercise. PCPs are expected to document the confirmation of hypertension and identify if the member is at risk for hypertension in the member’s medical record. HIV/AIDS PHC Florida requires that primary care providers (PCPs) assist members in obtaining necessary care in coordination with health plan’s staff. Providers must utilize a standardized formal assessment instrument for HIV members, during initial and subsequent patient assessments, to identify members who require behavioral health and substance abuse services and determine the types of behavioral health and substance abuse services that should be furnished. Copies of appropriate guidelines can be - 78 - accessed through: www.mentalhealth.samhsa.gov/cmhs/HIVAIDS and www.aids.gov. Please contact Provider Relations at (855) 318-4387 or more details. - 79 - Part 28: Quality Improvement Program Quality Improvement Requirements Positive Health Care Florida will monitor and evaluate the quality and appropriateness of care and service delivery (or the failure to provide care or deliver services) to members through: Performance improvement projects (PIPs) - Ongoing measurements and interventions, significant improvement to the quality of care and service delivery, sustained over time, in both clinical care and non-clinical care areas that are expected to have a favorable effect on health outcomes & member satisfaction Medical record audits - Annual medical record review to evaluate the quality outcomes concerning timeliness of and member access to covered services Performance measures - Data on patient outcomes as defined by the Healthcare Effectiveness Data & Information Set (HEDIS) or otherwise defined by the Florida Agency for Health Care Administration (AHCA) Surveys - Consumer Assessment of Health Plans Survey (CAHPS) & Provider Satisfaction Survey Peer Review - Conducted by the plan to review a provider's practice methods, patterns and appropriateness of care If the PIPs, CAHPS, performance measures, annual medical record audits, or the EQRO indicate that health plan performance is not acceptable, then the AHCA may impose penalties. Quality Improvement Overview PHC Florida is committed to providing quality health care to its members. To that end, the health plan has implemented a comprehensive Quality Improvement Program (QI Program) that is built on the concept of continuous quality improvement and incorporates clinical care and service activities. The QI Program is developed with practitioner, provider, and member input to address the specific needs and demographics of the enrolled population. The health plan requires contracting providers to participate and cooperate in the quality improvement program emphasizing change through education. Active involvement includes, but is not limited to, participating on committees, collecting data and providing access to medical records, identifying barriers when opportunities for improvement are identified, and implementing targeted interventions. - 80 - Clinical Performance Measures PHC Florida reports clinical performance measures annually to AHCA, the National Committee for Quality Assurance (NCQA) and other agencies. Some of the clinical performance measures include but are not limited to the following: Clinical Performance Measures 1. Childhood Immunization Status – (CIS) 2. Well-Child Visits in the First 15 Months of Life – (WC15) 3. Lead Screening in Children - (LSC) 4. Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – (WC34) 5. Adolescent Well Care Visits – (AWC) 6. Follow-up Care for Children Prescribed ADHD Medication (ADD) Description Percent of children who turned two (2) years old and received four (4) doses of DTP or DTaP, three (3) doses of OPV or IPV, one (1) dose of MMR, two (2) doses of Hib, three (3) doses of hepatitis B and one (1) dose of VZV. Percent of children who turn 15 months old and received at least six (6) well-care visits (to include physical and developmental history, physical exam, and health education/anticipatory guidance) with a PCP during first 15 months of life. Percent of children who received at least one capillary or venous lead screening test on or before their second birthday. Percent of children 3-6 years old who received a comprehensive well-care visit (to include physical and developmental history, physical exam, and health education/anticipatory guidance) by a PCP during the measurement year. Percent of enrollees 12-21 years old who received a comprehensive well-care visit (to include physical and developmental history, physical exam, and health education/anticipatory guidance) by a PCP or OB/GYN during the measurement year. Percent of children newly prescribed ADHD medication who had at least three (3) follow-up care visits within a 10-month period, one (1) of which is within 30 days of when the first ADHD medication was dispensed. - 81 - Clinical Performance Measures 7. Breast Cancer Screening – (BCS) Description Percent of women between 40 and 69 years old who had a least one mammogram in the past two (2) years. 8. Cervical Cancer Screening – (CCS) Percent of women ages 21 to 64 who had a least one (1) Pap test in the past three years. 9. Follow-Up after Hospitalization Percent of enrollees six (6) years and older who for Mental Illness – (FHM) were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner within seven (7) days and within 30 days. 10. Mental Health Readmission Rate - Percent of enrollees who were hospitalized for a (RER) mental health diagnosis and were discharged to the community from an acute care facility and were readmitted for a mental health diagnosis within 30 days. 11. Antidepressant Medication Percent of enrollees who were diagnosed with a Management – (AMM) new episode of major depression and received: Effective Acute Phase Treatment: Were treated with an antidepressant medication and remained on the antidepressant drug during the entire 84-day Acute Treatment Phase. Effective Continuation Phase Treatment: Were treated with an antidepressant medication and remained on the antidepressant drug for at least 180 days. 12. Use of Appropriate Medications Percent of enrollees five (5)-56 years of age for People with Asthma – (ASM) during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. 13. Controlling High Blood Pressure – Percent of hypertensive adults ages 18 to 85 (CBP) whose blood pressure was controlled. Adequate control is defined as a blood pressure reading less than 140/90 mmHg during the past year. 14. Comprehensive Diabetes Care – Percent of enrollees 18-75 years of age with (CDC) – Without Blood Pressure diabetes who had a hemoglobin A1C (HbA1c) Measure testing and LDL-C screening. - 82 - Clinical Performance Measures 15. Adults Access to Preventive /Ambulatory Health Services – (AAP) 16. Ambulatory Care – (AMB) Description Percent of enrollees of the designated ages (20– 44 years, 45–64 years, 65 years and older) who had an ambulatory or preventive care visit. Percent of enrollees age <1 - ≥85 years in who received services in the following categories: Outpatient visits, Emergency Department visits, Ambulatory Surgery/procedures; and, Observation Room stays. 17. Annual Dental Visits – (ADV) Percent of enrollees two (2)-21 years of age who had at least one (1) dental visit during the measurement year. 18. Prenatal and Postpartum Care – (PPC) Percent of women who gave live births who received prenatal care visit between 176 and 280 days before delivery and who received postpartum visit between 21 and 56 days after delivery. 19. Frequency of Ongoing Prenatal Care – (FPC) Percent of women who gave live births who received prenatal care visit than 21%, 21% to 40%, 41% to 60%, 61% to 80%, or greater than or equal to 81% of the expected number of prenatal care visits. 20. Mental Health Utilization – Inpatient, Intermediate, & Ambulatory Services – (MPT) Percent of enrollees receiving mental health services during the measurement year in the following categories of care: Any mental health services Inpatient Day/Night (Intermediate Care) Ambulatory 21. Persistence of Beta-Blocker Treatment After a Heart Attack Percent of persons age 18 and older hospitalized for a heart attack who received beta blockers medication through 6 months period post event. 22. BMI Assessment (BAA) Percent of enrollees 18–74 years of age who had an outpatient office visit and who had their body mass index (BMI) documented. - 83 - Clinical Performance Measures 23. Percentage of Enrollees Participating in Disease Management Program Description Percent of health plan enrollees with a specified disease state who are enrolled in the plan’s disease management program. Congestive Heart Failure Disease Management 24. Use of Angiotensin-Converting Percent of enrollees 18 years and older during Enzyme (ACE) Inhibitors / the measurement year who were diagnosed with Angiotensin Receptor Blockers congestive heart failure, and who have at least (ARB) Therapy (ACE) one prescription filled for angiotensinconverting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) during the measurement year. Hypertension Disease Management 25. Lipid Profile Annually (LPA) Percent of enrollees 18 to 85 years of age who had a diagnosis of hypertension and who had a lipid profile during the measurement year that includes total cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglycerides. Asthma Disease Management 26. Use of Beta Agonist (UBA) Percent of enrollees 5 to 56 years of age during the measurement year who were identified as having persistent asthma and who had prescriptions for beta agonist medications filled during the measurement year. HIV/AIDS Disease Management 27. Frequency of HIV Disease The frequency of HIV disease monitoring lab test Monitoring Lab Tests - (CD4 and for CD4 and viral load performed in a calendar VL) year. 28. Highly Active Anti-Retroviral Percent of enrollees with an AIDS diagnosis that Treatment – (HAART) have been prescribed a Highly Active AntiRetroviral Treatment drug. 29. HIV-Related Medical Visits (HIVV) Percent of enrollees with HIV/AIDS who were seen by a physician, physician assistant or advanced nurse practitioner for an HIV-related medical visit within the measurement year. PHC Florida requires access to all primary care provider (PCP) medical records for the purpose of collecting and reporting data to AHCA, NCQA and other agencies regarding - 84 - performance in these measures. PHC Florida will coordinate any necessary medical record reviews with PCPs’ offices. In addition, PHC Florida also is required to offer quality enhancements (QEs) to enrollees pursuant to the Medicaid Plan contract. PHC Florida operates a variety of QEs to benefit its Medicaid members, including the following. Some of these are listed in Parts 5 and 6 of the Provider Manual as Primary Care Physician and Specialist Physician responsibilities. To obtain more information regarding these QEs please, call Member Services at (855) 318-4387 Monday through Friday, 8:00 am to 8:00 pm. Children’s programs – Regular general wellness programs targeted specifically toward enrollees from birth to age five (5). These programs promote increased use of prevention and early interventions for at-risk enrollees. Domestic violence – Primary care provider (PCP) screening and referral for domestic violence Pregnancy prevention – Pregnancy prevention programs open to all enrollees; however, targeted to teens Prenatal and postpartum pregnancy programs – Home visits by a home health nurse or aide and counseling and education materials to enrollees not compliant with prenatal and postpartum programs Smoking cessation – Regularly scheduled smoking cessation programs and counseling as an option for all enrollees. For a quick reference guide on identifying tobacco users and supporting and delivering effective smoking cessation interventions, please call Member Services. Substance abuse screenings – PCP screenings for substance abuse as part of the PCP’s prevention evaluation. These screenings shall be conducted at initial visits, routine physicals, the initial prenatal visit, and when enrollees show evidence of over-utilization of ER and other services. - 85 - Part 29: Medical Record Requirements For each Medicaid member, providers shall maintain detailed and legible medical records that include the following: 1. Member’s identifying information including name, member ID, date of birth, sex and legal guardianship (if any) 2. A summary of significant surgical procedures, past and current diagnoses or problems, allergies, untoward reactions to drugs and current medications 3. Description of chief complaint or purpose of visit, the objective diagnosis, medical findings of the impression of the provider 4. Identification of any studies ordered and any referral reports 5. Identification of any therapies administered and prescribed 6. Name and profession of the provider rendering services, including the signature or initials of the provider 7. The record is legible to someone other than the writer 8. Disposition, recommendations, instructions to the member, evidence of whether there was follow up and outcome of services 9. Up to date immunization history 10. Information relating to the member’s use of tobacco products and alcohol/substance abuse 11. Summaries of all emergency services and care and hospital discharges with appropriate follow up 12. Documentation of referral services and members medical records 13. All services provided by provider (family planning services, preventive services, etc.) 14. Primary language spoken by the member and any translation needs of member 15. Identify members needing communication assistance in the delivery of healthcare services 16. Documentation that the member was provided written information concerning the member’s rights regarding advance directives and whether or not the member has executed an advanced directive - 86 - Part 30: Credentialing and Recredentialing Credentialing Program PHC Florida has a comprehensive credentialing program that has been established in accordance with the standards of the National Committee for Quality Assurance (NCQA) and applicable state, and federal regulatory requirements that are reviewed and revised at least annually. Additionally, since PHC Florida is a specialty plan under Florida Medicaid MMA Program there are specific requirements relating to HIV/AIDS training and experience. PHC Florida maintains the confidentiality of all information obtained about physicians and other practitioners in the credentialing/recredentialing process as required by law. Criteria for Practitioner Selection All practitioners who fall under the scope of PHC Florida’s Credentialing Program must meet the following minimum credentials, qualifications and criteria established by PHC Florida as applicable. 1. For physicians, graduation from a school of medicine, or osteopathy, that is accredited by the Liaison Committee on Medical Education and completion of a residency. Graduates of foreign medical schools must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) or must have completed a fifth pathway. For other practitioners, graduation from an appropriate accredited professional school and/or completion of a formal training program. 2. A current valid unrestricted state license to practice his or her specialty in the state in which the applicant will provide services. For categories of practitioners for which licensure is not required by any state board/agency, PHC Florida’s Credentialing Committee and/or Medical Director will review the education, training and additional criteria to verify practitioner competence. 3. A current valid Drug Enforcement Agency (DEA) certificate 4. For physicians, board certification by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) in physician’s practicing specialty. If the physician states that he or she is board-certified on the application, or, for those physician applicants who are not board certified, evidence that the applicant has completed required residency/fellowship programs that meet all ABMS or AOA training prerequisites to be considered “board eligible” in practicing specialty. 5. Current and unrestricted clinical and admitting privileges in good standing at a PHC Florida contracted hospital, or evidence and Medical Director approval that - 87 - the applicant does not require hospital privileges in order to deliver satisfactory professional services. For PCPs without hospital privileges at a contracted facility, the physician must provide a mechanism for continuity of care. Physicians who do not have hospital privileges must have a formal inpatient coverage arrangement through a physician with clinical and admitting privileges at a PHC Floridacontracted hospital and who is a PHC Florida participating practitioner. 6. Current professional liability insurance that meets or exceeds PHC Florida’s minimum limits for each type of practitioner 7. Absence of a history of involvement in a malpractice suit, arbitration, or settlement; or, in the case of applicant with such history, evidence that the history does not demonstrate probable future sub-standard professional performance 8. Must demonstrate continuous personal development 9. Must demonstrate experience as an HIV-qualified provider. A person should show continuous professional development through clinical, behavioral or case management of at least 20 HIV-infected patients in the last two (2) years with a minimum of eight (8) contact hours annually of HIV-specific continuing medical education (CME) that includes information on the use of antiretroviral therapy. 10. Absence of a history of denial, suspension, restriction, or termination of hospital privileges; or in the case of an applicant with such history, evidence that this history does not currently affect applicant’s ability to perform professional duties for which the applicant contracted or does not demonstrate probable future substandard 11. Absence of a history of disciplinary actions affecting applicant’s professional license, DEA or other required certifications; or, for applicants with such history, evidence that this history does not currently affect applicant’s license, DEA, or any other required certification 12. Absence of history of felony convictions; or for an applicant with such history, evidence that the nature of the conviction does not affect applicant’s current ability to perform the professional duties for which applicant contracted, or does not demonstrate probable future substandard care 13. Absence of a history of sanctions by regulatory agencies, including Medicare/Medicaid sanctions; or for an applicant with such history, evidence that applicant is not currently sanctioned or prevented by a regulatory agency from participating in any federal or state sponsored programs 14. Absence of a history of chemical dependency/substance abuse; or for those applicants who have such history, evidence that the applicant is participating in, or has completed, a prescribed, monitored treatment program and that no current chemical dependency or substance abuse exists that would affect applicant’s ability to adequately perform the professional duties for which applicant is contracted - 88 - 15. Absence of a physical or mental health condition that would impair or would be likely to impair applicant’s ability to competently and safely perform the professional duties for which applicant is contracted and that could not be reasonably accommodated without undue hardship to PHC Florida 16. Evidence of the capability to provide 24 hour coverage as required by PHC Florida 17. Ability to work cooperatively with others 18. Appropriate and complete work history for at least the past five (5) years 19. Successful completion of an office survey, which includes a structured review of the office site and evaluation of the medical record keeping practices 20. PHC Florida will conduct a background check with the Florida Department of Law Enforcement for all providers not currently enrolled in the Medicaid Fee-ForService program. Credentials Documentation The applicant must provide a completed, signed and dated credentialing application to PHC Florida and any additional information requested by the health plan in order to properly verify and evaluate the practitioner’s qualifications. All questions listed on the application must be answered, and explanations given for all “yes” answers. The credentialing application requests documentation of the following information from the practitioner: 1. A valid state professional license number 2. Clinical privileges in good standing at a PHC Florida-contracted hospital(s) designated by the practitioner as the primary admitting facility, as applicable 3. A valid Federal Drug Enforcement Agency (DEA) number or certificate and whether such certificate has ever been suspended, revoked or limited 4. Graduation from professional school and completion of a formal residency or fellowship-training program, as applicable 5. Board certification, if the practitioner states that he or she is board certified on the application (American Board of Medical Specialties or American Osteopathic Association for physicians) 6. Work history for at least the past five (5) years. Work history will be verified by review of the Provider’s Curriculum Vitae and application. Any gaps exceeding one year will be verified in writing; six months for non-physicians. 7. Current, adequate malpractice insurance in the minimum amounts required by PHC Florida 8. Professional liability claims history for, at a minimum, the past seven (7) years, with details of any claims/lawsuits that resulted in settlements or judgments paid by or on behalf of the practitioner, as well as the outcome (if the suit or claim has been resolved) - 89 - 9. A statement by the practitioner regarding lack of a physical or mental health condition that would substantially impair the practitioner’s ability to competently and safely carry out the scope of his or her duties on behalf of PHC Florida, and a statement by the practitioner regarding lack of impairment due to chemical dependency/substance abuse 10. A statement by the practitioner regarding history of loss or limitation of professional license and/or felony convictions 11. A statement by the practitioner regarding history of loss or limitation of privileges or disciplinary activity 12. Three peer-reference verification letters are required and must come directly from the source. These letters will be placed in the credentialing file. 13. A signed and dated consent and release form completed by the applicant authorizing PHC Florida to obtain confidential information for credentialing purposes Copies of the following documents must accompany the application: 1. Valid, current and unrestricted professional license 2. Evidence of current malpractice coverage (face sheet) at PHC Florida required limits 3. Evidence of board certification, if applicable, or certificate of completion of a formal residency or fellowship training program 4. Current federal DEA 5. Evidence of eligibility for payment under Medicare Other documents may be required for certain types of practitioners to meet specific license-type requirements and documents relating to the education, experience, prior training and ongoing training regarding HIV/AIDS. The applicant must submit a signed and dated attestation certifying the correctness and completeness of the information provided on and with the application. This attestation must be signed within 30 days of receipt of application by PHC Florida. Recredentialing Every three (3) years, a recredentialing application will be sent to the practitioner. The recredentialing application will request that the practitioner update the same information as was required on the initial credentialing application form. If applicable, a site review and medical records review will be completed during the course of the recredentialing process. - 90 - Part 31: Cultural Competency PHC Florida is committed to be respectful of and responsive to the cultural and linguistic needs of our members. The US Department of Health & Human Services, Office of Minority Health, has issued national culturally and linguistically appropriate services (CLAS) standards. PHC Florida is committed to a continuous effort to perform according to those standards. PHC Florida uses Language Line Services for interpreter services as needed to communicate with members who have limited English proficiency. Providers are expected to have access to interpretive services. If a provider does not have access, PHC Florida can provide such access for use with our members by calling Member Services at (855) 318-4387. Providers may request a “Cultural Competency Checklist,” approved by the Centers for Medicare & Medicaid Services (CMS), from PHC Florida to assess their cultural competency in the delivery of health care services. The health plan will arrange for follow-up assistance and/or training to providers who report a need for technical assistance. If PHC Florida receives any member grievance related to the delivery of culturally or linguistically appropriate care by providers, it will immediately assess the provider’s competency and require corrective action where necessary. Contracted providers are expected to provide services in a culturally competent manner that includes, but is not limited to, removing all language barriers to service, and accommodating the special needs of the ethnic, cultural, and social circumstances of the patient. Providers must also meet the requirements of all applicable state and federal laws and regulations as they pertain to provision of services and care including, but not limited to, Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, and the Rehabilitation Act of 1973. PHC Florida operates the Medicaid MMA health plan pursuant to a Cultural Competency Plan. To obtain a copy of the plan at no charge, you may request one by calling Member Services at (855) 318-4387 Monday through Friday, 8:00 am to 8:00 pm. - 91 - Part 32: Compliance and Regulations Provider Contract Requirements PHC Florida contracts with physicians, facilities and ancillary providers to provide health care services to its members. PHC Florida provider contracts or subcontracts must include the following provisions: 1. Utilization/Medical Management Policies and Procedures All parties contracted directly or indirectly with PHC Florida must abide by the health plan’s Utilization Management Department's policies and procedures. 2. Quality Management Compliance PHC Florida requires that all providers participate in periodic audits and/or site surveys for evaluating compliance with PHC Florida quality management standards and regulatory requirements, i.e., National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS). These audits include, but are not limited to, site review and medical record reviews. 3. Medical Records Contracted providers must provide the PHC Florida Medical Director or designee access to all plan members' charts and medical records for the purpose of determining or resolving eligibility, liability or appropriate care issues. Providers, as prescribed by State and federal law, will maintain confidentiality of this information at all times. In addition, a random sampling of medical records for all primary care providers (PCPs) with more than 50 members will be reviewed for compliance with accreditation standards a minimum of every two (2) years but more frequently at the discretion of the PHC Florida. 4. No Billing of Members PHC Florida contracted providers agree not to impose any charges on any plan member for covered benefits. Further, contracted providers agree to accept the PHC Florida payment as payment in full and agree not to seek compensation from a PHC Florida member for services provided to that member, even in the event of non-payment by the health plan. 5. Retention of Records Contracted providers agree to retain financial and medical records relating to PHC Florida members for a period of 10 years from the termination of the - 92 - contract or such time period as may be required by applicable law, regulation or customary practice. 6. Liability Coverage PHC Florida requires all contracted providers to maintain professional liability insurance and primary general liability coverage in the minimum amount of two hundred fifty thousand dollars $250,000 per occurrence and seven hundred fifty thousand dollars ($750,000) annual aggregate. 7. Non-Solicitation of Members During the initial and any succeeding term of a provider contract and one (1) year following the termination date of the contract, a contracted provider agrees not to knowingly advise a PHC Florida member to disenroll from PHC Florida and will not solicit any member or employer to seek enrollment with any other health maintenance organization or provider of health services. Further, the contracted provider will not make any derogatory remarks regarding PHC Florida to any member. 8. No Contact with Members All contracted providers acknowledge that PHC Florida has expended significant time and resources in developing its business and enrolling members. Therefore, the PHC Florida eligibility list is an important corporate asset containing valuable proprietary information. All contracted providers agree to rely exclusively on the health plan’s communication to its members regarding changes in the contractual relationship between PHC Florida and the provider. 9. Use of the Plan’s Trade Secrets A trade secret refers to information, including but not limited to programs, techniques and processes that has independent economic value by not being generally known to either the public or to other persons or parties who could obtain economic value from its disclosure or use. PHC Florida contracted providers agree not to use or divulge PHC Florida trade secrets to anyone. 10. Contact with Members PHC Florida and its participating providers shall maintain a physician-patient relationship with each member. Nothing contained in the agreement is intended to interfere with such physician-patient relationship. Nothing in the agreement should be interpreted to discourage or prohibit participating physicians from discussing treatment options or providing other medical advice or treatment deemed appropriate by the participating physician. The participating physician - 93 - shall have the sole responsibility for the medical care and treatment of members. PHC Florida contracts or subcontracts could also include additional sections or provisions not discussed in this section. In addition, the description of the contract provisions listed in this section does not constitute a complete disclosure of all requirements placed on providers contracted with PHC Florida. Contracted providers should refer to their PHC Florida contract for further information. - 94 - Part 33: Provider Grievances and Appeals Any provider who renders service to PHC Florida enrollees may file a grievance about any aspect of the plan’s operations and performance, or behavior of its members or staff within 365 calendar days from the date of the incident that precipitated the dissatisfaction. Note that grievances/disputes regarding claims are addressed in Part 21 (Claim Submission and Payment Guidelines), section “Provider Claim Disputes.” To submit a grievance, providers should complete a Provider Grievance Form and submit it to the plan. A Provider Grievance Form is included in Part 37 (Forms) of this manual. The form is also available on the plan’s website at www.positivehealthcare.org. PHC Florida also accepts grievances over the telephone. Call Provider Relations at (855) 318-4387 Monday through Friday, 8:30 am to 5:30 pm. Upon receipt of a grievance in writing or over the telephone, the plan sends written acknowledgement of the grievance within five (5) business days to the submitting provider. The plan resolves grievances within 30 calendar days from the date of receipt of the grievance and sends a resolution letter to the provider who submitted the grievance. If a provider is dissatisfied with the plan’s resolution to his or her grievance, he or she may submit an appeal within 180 calendar days from receipt of the plan’s resolution letter. A provider may also file an appeal if PHC Florida fails to resolve his or her grievance with the 30-day timeframe described above. To submit an appeal, a provider should submit the following documentation to the plan. Appeal submissions must be in writing. 1. Letter requesting appeal and/or review of the grievance resolution 2. Copy of the Provider Grievance Form or letter used to submit the grievance to the plan, if the grievance was submitted in writing 3. Copy of the documents submitted with the grievance if applicable 4. Copy of the plan’s grievance resolution letter, if applicable 5. Copy of any other correspondence between PHC Florida and the provider Upon receipt of an appeal, the plan sends written acknowledgement of the appeal within 15 calendar days to the provider who submitted it. The plan sends a written report of its investigation and conclusions to the appeal within 45 business days of receipt of the appeal. - 95 - Grievances and appeals should be faxed to (954) 522-3260 or mailed to: Attention: Provider Relations PHC Florida 110 SE 6th St., Suite 1960 Fort Lauderdale, FL 33301 - 96 - Part 34: Anti-Fraud and Abuse Program PHC Florida is committed to conducting its business ethically and lawfully, and with integrity. It has created a compliance program as an expression of its commitment to ethical behavior, which operates in accordance with federal law and the health plan’s policies and procedures. The health plan’s Compliance Officer, Compliance Committee, and a Compliance hotline are available to providers and their employees, agents, and contractors to receive reports of suspected violations and when, appropriate, oversee corrective actions. As a provider in PHC Florida’s network, you and, as applicable, your employees, agents, and contractors, have a duty to act ethnically and lawfully when rendering services to health plan members. In carrying out those duties, you are required take measures to prevent, detect, report, and correct fraud, waste, and abuse. Fraud Fraud, generally involves a person’s or entity’s intentional use of false statements or fraudulent schemes, such as kickbacks, to obtain payment for, or to cause another person or entity to obtain payment for, items or services payable under a federal health care program. Some examples of fraud are: Billing for services not furnished Soliciting, offering, or receiving a kickback, bribe, or rebate Violations of the physician self-referral (“Stark”) prohibition Using an incorrect or inappropriate provider identifier in order to be paid, i.e., using a deceased individual’s provider identifier Signing blank records or certification forms that are used by another entity to obtain Medicare or Medicaid payment Selling, sharing, or purchasing Medicare/Medicaid Health Insurance Claim (HIC) numbers in order to bill false claims to the Medicare/Medicaid Program Offering incentives to Medicare/Medicaid beneficiaries that are not offered to other patients, i.e., routinely waiving or discounting Medicare/Medicaid deductibles, coinsurance, or co-payments Falsifying information on applications, medical records, billing statements, cost reports, or on any statement filed with the government or its agents Using inappropriate procedure or diagnosis codes to misrepresent the medical necessity or coverage status of the services furnished Consistently using billing or revenue codes that describe more extensive services than those actually performed (upcoding) - 97 - Misrepresenting himself or herself as a Medicare/Medicaid beneficiary for the purpose of securing Medicare/Medicaid payment for their health care by presenting a Medicare/Medicaid health insurance card or Medicare/Medicaid HIC number that rightfully belongs to another person. Waste Waste involves using or expending carelessly, extravagantly, or to no purpose. Abuse Abuse may be intentional or unintentional, and directly or indirectly results in unnecessary or increased costs to the Medicaid Program. Some of the significant anti-fraud, waste, and abuse laws are: The False Claims Act (31 USC §§ 3729-3733) prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval. Additionally, it prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by the federal government or its agents, like a carrier, other claims processor, or state Medicaid program. Because your payments from PHC Florida ultimately derive from federal funds, you may not submit any false or fraudulent claims or other records to PHC Florida for payment or approval. If you find that a claim you originally believed was correct was not, you have a continuing obligation to disclose that to PHC Florida. The Anti-Kickback Statute (42 USC § 1320a-7b) provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward business payable (or reimbursable) under the Medicare or other Federal health care programs. In addition to applicable criminal sanctions, an individual or entity may be excluded from participation in the Medicare and other Federal health care programs and subject to civil monetary penalties. For purposes of the anti-kickback statute, “remuneration” includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind. The Physician Self Referral (“Stark”) Statute (42 USC §1395nn) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Florida also has state-law counterparts to these laws, which prohibit similar conduct as it relates to state-regulated government healthcare programs. Penalties for violating - 98 - these state or federal laws can be significant – for example, $10,000 per violation and exclusion from federal health care programs, including Medicare and Medicaid. Education and Training Additionally, as a person who contracts with PHC Florida, you and, as applicable, your employees, agents, and contractors must comply with CMS education and training requirements related to fraud, waste, and abuse (“FWA”). (See 42 CFR §§ 422.503(b)(4)(vi)(C) and 423.504(b)(4)(vi)(C).) You are required to maintain evidence of your education and training (i.e., training materials, logs, and sign-in sheets) and provide certifications of completion to PHC Florida upon request. You may fulfill your FWA training requirements by either (a) using materials provided by PHC Florida (such as this section of the Provider Manual, or other materials that may be made available from time to time), (b) using your own FWA materials, or (c) taking training from Medicaid plan or organization, as long as the training program complies with federal and state guidelines. If you have contracted with other entities or persons to provide health and/or administrative services for PHC Florida beneficiaries, you will need to obtain attestations from those entities that they have completed FWA training and copies of their training logs. Reporting Fraud, Waste and/or Abuse If you or, as applicable, your employees, agents, or contractors identify potential fraud, waste, or abuse, contact PHC’s Compliance Officer at (323) 436-5023 or by writing to: Attn: Compliance Officer PHC Florida 10001 N Martel Ave Los Angeles, CA 90028 Alternatively, you may use PHC Florida’s compliance hotline at (800) 243-7448. As situations require, we may also refer the case to Centers for Medicare and Medicaid Services (CMS), Agency for Health Care Administration (AHCA), appropriate law enforcement and federal or state agencies. Suspected health care fraud or program abuse may also be reported directly to AHCA’s Bureau of Medicaid Program Integrity (MPI) at (888) 419-3456, or you may file an on-line complaint through http://ahca.myflorida.com/Executive/Inspector_General/medicaid.shtml - 99 - Anti-Retaliation Policy PHC Florida has a strict policy against retaliating against anyone who, in good faith, makes a report, complaint, or inquiry regarding a compliance issue. Providers must follow this same policy with respect to their employees. Under the Whistle Blower or qui tam provision of the False Claim Act, any individual who has knowledge of a false claim may file a civil suit on behalf of the U.S. Government and may share a percentage of the recovery realized from a successful action. - 100 - Part 35: Community Based Resources PHC Florida has a network of information and referral organizations linking members to appropriate assistance in their community. Providers and members are encouraged to access the resources below or contact PHC Florida’s Utilization Management/Case Management Department for further assistance with member specific resource needs at (866) 990-9322, Monday through Friday, 8:30 am to 5:30 pm. Resource Contact Information Smoking CessationFlorida Quit-for-Life Line 1-877-U-CAN-NOW (877) 822-6669 Freedom From Smoking Online Tool www.ffsonline.org Children’s Medical Service www.cms-kids.com Women, Infants and Children (WIC) Healthy Start Program (800) 342-3556 (800) 451-2229 - 101 - Description This toll-free cessation hotline is a service of the Florida Department of Health and the American Cancer Society. It provides counseling, self-help materials and pharmacotherapy (medication) assistance. Adults (18 or older) living in Florida who are ready to attempt to quit can use the hotline. A free online smoking cessation program sponsored by the American Lung Association. A website that provides information for children with special health care needs. A nutrition program for women, infants and children. A program for women and teenagers to obtain medical services, social services and instructional support in the areas of pregnancy, family planning, substance abuse, mental health and counseling. Resource Contact Information National Domestic Violence Hotline (800) 799-7233 New LifeStyles www.newlifestyles.com (800) 869-9549 www.flairs.org Florida Alliance for Information and Referral Services HIV/AIDS Treatment Guidelines Description A 24-7 hotline that provides facts and information about domestic violence. An area guide to senior residences and care options. A website that provides information on domestic violence, mental health, substance abuse, grief, pregnancy, crisis, housing assistance, disability, cancer and HIV. www.aids.gov www.cdc.gov/hiv www.aidsinfo.nih.gov www.mentalhealth.samhsa.gov/cmhs/HIVAIDS www.floridashealth.com/Disease_ctrl/aids/index.html - 102 - Part 36: Definitions The following are definitions that are specific this publication: Advance Directive — A written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State),relating to the provision of health care when the individual is incapacitated. AHCA or Agency — State of Florida, Agency for Health Care Administration. AIDS — The Centers for Disease Control and Prevention (CDC) definition of Acquired Immune Deficiency Syndrome includes all HIV-infected persons who have been less than 200 CD4+ T-lymphoctes/uL (or CD4+ T-lymphoctes/uL percentage of total lymphocytes of less than 14) or one of the clinical conditions as provided in the CDC’s most currently published Classification System for HIV Infected and Expanded Surveillance Case Definition for AIDS that can be found at www..cdc.gov/hiv. Appeal — A request for review of an Action, pursuant to 42 CFR 438.400(b). Benefits — A schedule of health care services to be delivered to member covered by the health plan set forth in Part 15 (Covered Services) in this publication. Child Health Check-Up Program (CHCUP) — A comprehensive and preventative health examinations provided on a periodic basis that are aimed at identifying and correcting medical conditions in Children/Adolescents. Policies and procedures are described in the Child Health Check-Up Services Coverage and Limitations Handbook. Children/Adolescents — Members under the age of 21. Clinical Guidelines for HIV/AIDS Care – The latest antiretroviral regimen and treatments recommended by the U.S. Department of Health & Human Services. To receive a copy of the guidelines contact the DOH, Bureau of HIV/AIDS at (800) 245-4334, or www.aidsinfo.nih.gov/guidelines or go to The Florida/Caribbean AIDS Education and Training Center at www.faetc.org/Guidelines. County Health Departments (CHD) — CHDs are organizations administered by the Department of Health for the purpose of providing health services as defined in Chapter - 103 - 154, F.S., which include the promotion of the public’s health, the control and eradication of preventable diseases, and the provision of primary health care for special populations. Covered Services — Those services provided by the health plan in accordance with Health Plans Medicaid Contract, and as outlined in Part 15 (Covered Services) of this publication. Demonstrated Experience in the Treatment of HIV/AIDS – To demonstrate experience as an HIV-qualified provider a person should show continuous professional development through clinical, behavioral or case management of at least 20 HIVinfected patients in the last two (2) years with a minimum of eight (8) contact hours annually of HIV specific continuing medical education (CME) that includes information on the use of antiretroviral therapy. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could reasonably be expected to result in any of the following: Serious jeopardy to the health of a patient, including a pregnant woman or fetus Serious impairment to bodily functions Serious dysfunction of any bodily organ or part With respect to a pregnant woman: That there is inadequate time to affect safe transfer to another Hospital prior to delivery; That a transfer may pose a threat to the health and safety of the patient or fetus; That there is evidence of the onset and persistence of uterine contractions or rupture other membranes, Section 395.002.F.S. Emergency Services and Care — Medical screening, examination and evaluation by a physician or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an Emergency Medical Condition exists. If an Emergency Medical Condition exists, Emergency Services and Care includes the care or treatment that is necessary to relieve or eliminate the Emergency Medical Condition within the service capability of the facility. Member — A Medicaid Recipient currently enrolled in the health plan. - 104 - Expanded Services — A health plan covered service for which it receives no direct payment from the Agency. External Quality Review (EQR) — The analysis & evaluation by an EQRO of aggregated information on quality, timeliness and access to the health care services that are furnished to Medicaid recipients by a health plan. External Quality Review Organization (EQRO) — An organization that meets the competence and independence requirements set forth in federal regulation 42 CFR 438.354, and performs EQR, other related activities as set forth in federal regulations or both. Grievance — An expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to, the quality of care, the quality of services provided and aspects of interpersonal relationships such as rudeness of a Provider or employee or failure to respect the member’s rights. Health Plan — An entity that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with an organized system of Providers, which deliver services and frequently shares financial risk. For the purposes of this Contract, a health plan has also contracted with the Agency to provide Medicaid services under the Florida Medicaid MMA program, and includes health maintenance organizations authorized under chapter 641 of the Florida Statutes, exclusive provider organizations as defined in chapter 627 of the Florida Statutes, health insurers authorized under chapter 624 of the Florida Statutes, and Provider Service Networks as defined in Section 409.912, Florida Statutes. HIV/AIDS Algorithm — A step by step process for using Medicaid claims to identify members with HIV/AIDS. HIV/AIDS Specialist Physician — A physician who is licensed in the State of Florida and who meets any one of the following criteria: (1) Is credentialed as an AAHIVM HIV Specialist by the American Academy of HIV Medicine; (2) Is board certified in the field of infectious diseases and, if not certified in the last year through the American Board of Medical Specialties, has clinically managed a minimum of 25 patients in the preceding 12 months, as well as successfully completed a minimum of 10 hours of continuing medical education (CME) with at least five (5) hours related to antiretroviral therapy in the last year; (3) meets the criteria of an HIV-qualified physician as defined by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America; and (4) is recognized by the Florida/Caribbean AIDS Education and Training Center as having - 105 - sufficient clinical experience and additional on-going training in HIV/AIDS to be considered a specialist. HIV Infected Member — All eligible members who are HIV-positive but asymptomatic; individuals with symptomatic HIV disease; and individuals with CDC-defined AIDS. Licensed — A facility, equipment, or an individual that has formally met state, county, and local requirements, and has been granted a license by a local, state or federal government entity. Medicaid — The medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., and regulations there under, as administered in the State of Florida by the Agency under 409.901 et seq., F.S. Medicaid Recipient — Any individual whom DCF, or the Social Security Administration on behalf of the DCF, determines is eligible, pursuant to federal and State law, to receive medical or allied care, goods or services for which the Agency may make payments under the Medicaid program, and who is enrolled in the Medicaid program. Medical Record — Documents corresponding to medical or allied care, goods or services furnished in any place of business. The records may be on paper, magnetic material, film or other media. In order to qualify as a basis for reimbursement, the records must be dated, legible and signed or otherwise attested to, as appropriate to the media. Medically Necessary or Medical Necessity — Services that include medical or allied care, goods or services furnished or ordered that must meet the following conditions: 1. Be necessary to protect life, to prevent significant illness or significant disability or to alleviate severe pain 2. Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under treatment and not in excess of the patient’s needs 3. Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not be experimental or investigational 4. Be reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide 5. Be furnished in a manner not primarily intended for the convenience of the member, the member’s caretaker or the provider - 106 - Medically Necessary or Medical Necessity for those services furnished in a Hospital on an inpatient basis cannot, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. The fact that a provider has prescribed, recommended or approved medical or allied goods or a service does not, in itself, make such care, goods or services Medically Necessary, a Medical Necessity or a Covered Service/Benefit. Medicare — The medical assistance program authorized by Title XVIII of the Social Security Act. Newborn — A live child born to a member, who is a member of the health plan. Non-Covered Service — A service that is not a Covered Service/Benefit. Nursing Facility — An institutional care facility that furnishes medical or allied inpatient care and services to individuals needing such services. Outpatient — A patient of an organized medical facility, or distinct part of that facility, who is expected by the facility to receive, and who does receive, professional services for less than a twenty-four (24) hour period, regardless of the hours of admission, whether or not a bed is used and/or whether or not the patient remains in the facility past midnight. Participating Specialist — A physician, licensed to practice medicine in the State of Florida, who contracts with the health plan to provide specialized medical services to the health plan’s members. Primary Care — Comprehensive, coordinated and readily-accessible medical care including: health promotion and maintenance; treatment of illness and injury; early detection of disease; and referral to specialists when appropriate. Primary Care Provider (PCP) — A health plan staff or contracted physician practicing as a general or family practitioner, internist, pediatrician, obstetrician, gynecologist, advanced registered nurse practitioners, physician assistants or other specialty approved by the Agency, who furnishes Primary Care and patient management services to an member. Prior Authorization — The act of authorizing specific services before they are rendered. - 107 - Project AIDS Care (PAC) – The Project AIDS Care (PAC) waiver is a Medicaid program that provides home and community-based services to eligible recipients living at home. PAC waiver recipients must demonstrate a deterioration in functions that places them at risk of hospitalization or nursing facility admission were it not for the provision of waiver services. Protocols — Written guidelines or documentation outlining steps to be followed for handling a particular situation, resolving a problem or implementing a plan of medical, nursing, psychosocial, developmental and educational services. Provider — A person or entity that has a Medicaid provider agreement in effect with the Agency, and a contractual agreement with the health plan. Provider Contract — An agreement between the health plan and a health care provider as described above. Quality — The degree to which a health plan increases the likelihood of desired health outcomes of its members through its structural and operational characteristics and through the provision of health services that are consistent with current professional knowledge. Quality Improvement (QI) —The process of monitoring and assuring that the delivery of health care services are available, accessible, timely, medically necessary, and provided in sufficient quantity, of acceptable quality, within established standards of excellence, and appropriate for meeting the needs of the members. Quality Improvement Program (QIP) — The process of assuring the delivery of health care is appropriate, timely, accessible, available and medically necessary. Sick Care — Non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated (e.g., chronic disease). Special Supplemental Nutrition Program for Women, Infants & Children (WIC) — Program administered by the Department of Health that provides nutritional counseling; nutritional education; breast-feeding promotion and nutritious foods to pregnant, postpartum and breast-feeding women, infants and children up to the age of five (5) who are determined to be at nutritional risk and who have a low to moderate income. An individual who is eligible for Medicaid is automatically income eligible for WIC benefits. Additionally, WIC income eligibility is automatically provided to a member’s family that includes a pregnant woman or infant certified eligible to receive Medicaid. - 108 - State — State of Florida. Subcontract — An agreement entered into by the health plan for provision of administrative services on its behalf. Subcontractor — Any person or entity with which the health plan has contracted or delegated some of its functions, services or responsibilities for providing services under this Contract. Transportation — An appropriate means of conveyance furnished to a member to obtain Medicaid authorized/covered services. Urgent Care — Services for conditions, which, though not life-threatening, could result in serious injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe pain, etc.) or do substantially restrict a member’s activity (e.g., infectious illnesses, flu, respiratory ailments, etc.). Well Care Visit — A routine medical visit for one (1) of the following: CHCUP visit, family planning, routine follow-up to a previously treated condition or illness, adult physicals or any other routine visit for other than the treatment of an illness. - 109 - Part 37: Forms The following forms follow: 1. Abortion Certification Form 2. Sterilization Consent Form 3. Hysterectomy Acknowledgement Form 4. Exception to Hysterectomy Acknowledgement 5. Code 15 Incident Report Form 6. Direct Referral Form 7. Authorization Request Form 8. Prescription Drug Authorization Request Form 9. Provider Dispute Resolution Form 10. Provider Grievance Form - 110 - Form Approved: OMB No. 0937-0166 Expiration date: 11/30/2009 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION STATEMENT OF PERSON OBTAINING CONSENT I have asked for and received information about sterilization from . When I first asked doctor or clinic Before signed the name of individual consent form, I explained to him/her the nature of sterilization operation for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal Funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a , the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure. . The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on: Month Day Year I, , hereby consent of my own free will to be sterilized by by a method called . My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services, or Employees of programs or projects funded by the Department but only for determining if Federal laws were observed. I have received a copy of this form. Date: Signature Month Day Year You are requested to supply the following information, but it is not required: (Ethnicity and Race Designation) (please check) Ethnicity: Hispanic or Latino Not Hispanic or Latino Race (mark one or more): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White INTERPRETER’S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. Interpreter’s Signature HHS-687 (11/2006) Facility Address Date Date PHYSICIAN’S STATEMENT Shortly before I performed a sterilization operation upon on name of individual date of sterilization . I explained to him/her the nature of the sterilization operation doctor Signature of person obtaining consent , the fact that it is specify type of operation intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual’s signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least thirty days have passed between the date of the individual’s signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual’s signature on this consent form because of the following circumstances (check applicable box and fill in information requested): Premature delivery Individual’s expected date of delivery: Emergency abdominal surgery (describe circumstances) : Physician’s Signature Date PSC Graphics (301) 443-1090 EF PAPERWORK REDUCTION ACT STATEMENT A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Respondents should be informed that the collection of information requested on this form is authorized by 42 CFR part 50, subpart B, relating to the sterilization of persons in federally assisted public health programs. The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization procedures in federally assisted public health programs. Although not required, respondents are requested to supply information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted public health programs. All information as to personal facts and circumstances obtained through this form will be held confidential, and not disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations. HHS-687 (11/2006) STATE OF FLORIDA EXCEPTION TO HYSTERECTOMY ACKNOWLEDGEMENT REQUIREMENT State of Florida Physicians Certification Statement for Exception to Hysterectomy Acknowledgement Requirement SECTION I I ______________________________, __________________ certify that (PRINT PHYSICIAN NAME) (PROVIDER NUMBER) the condition(s) marked below existed at the time a hysterectomy was performed for _________________________, ______________________. (PRINT RECIPIENT’S NAME) (MEDICAID I.D. NUMBER) ______ A. The recipient was already sterile at the time of the hysterectomy. Specify cause of sterility: ______ Postmenopausal ______ Congenital disorder: Specify___________________ _________________________________________ ______ Previously surgically sterilized: Specify method _________________________________________ ______ B. The recipient requires an emergency hysterectomy because of a life threatening emergency situation. (The emergency situation must render the recipient incapable of understanding or responding to the information pertaining to the acknowledgement agreement because of the emergency nature of her admission). Please describe the nature of the emergency below. 1 2 3 4 5 6 7 8 SECTION II Physician Statement of Certification For the above reason(s), I am requesting an exception to the hysterectomy acknowledgement requirement for the hysterectomy services indicated on the attached claim for (CMS-1500 or UB 04). _____________________________ (Physician Signature) _______________________ _____________________________ Fiscal Agent Screening (Date) Supervisor ETA 07/2008 9 10 Confidential Code 15 Report Florida Center for Health Information & Policy Analysis 2727 Mahan Drive • Mail Stop # 16 Tallahassee, Florida 32308 Phone: (850) 414-9475; Fax: (850) 921-5459 I. Facility Information (Form Must Be Typed) Risk Manager Name of Facility or Campus Address State Zip Code Telephone Number Fax Number II. City Title County 55 License Number E-mail Address Patient Information Medicaid Patient Name Age Patient Identification Number Date of Admission Patient Address City III. County State Medicare Sex Admitting Diagnosis Zip Code ICD-9 Code for Admit Diagnosis Incident Information Incident Date Time Location of Incident: Facility Unit: Blood Bank CCU Endoscopy Emergency Room ICU Labor/Delivery Facility Campus Laboratory Operating Room Outpatient Services Patient Room Radiology Recovery Room Other Note: If the incident involved a death, was the Medical Examiner notified? Was an autopsy performed? Yes Other Health Care Provider: Abortion Clinic Ambulatory Surgical Center Assisted Living Facility Doctor’s Office Home Health Nursing Home Name of Other Provider Yes No No Name and contact number of the Medical Examiner Name Telephone Number A) Describe circumstances of the incident (narrative) (Use additional sheets as necessary for complete response) B) ICD-9-CM Codes Surgical, diagnostic, or treatment procedure being performed at time of incident (ICD-9 Codes 01-99.9) Accident, event, circumstances, or specific agent that caused the injury or event. (ICD-9 E-Codes) Resulting injury (ICD-9 Codes 800-999.9) C) List any equipment used if directly involved in the incident D) Outcome of Incident (Please check) Death Surgical procedure performed on the wrong patient Fetal death Wrong surgical procedure performed Brain damage Surgical procedure unrelated to the patient’s diagnosis Spinal damage Surgical procedure to remove foreign objects remaining from a surgical procedure Surgical procedure performed on the wrong site Surgical repair of injuries from a planned surgical procedure E) List license numbers of personnel and the capacity in which they were directly involved with this incident, i.e., ER physician, attending physician, surgeon, etc. (List social security numbers and capacity of unlicensed personnel) F) IV. List license numbers of witnesses (List social security numbers and capacity of unlicensed personnel) Analysis and Corrective Action A) Analysis (apparent cause) of this incident (Use additional sheets as necessary for complete response) B) Describe corrective or proactive action(s) taken (Use additional sheets as necessary for complete response) V. Signature of Risk Manager AHCA Form 3140-5001-09/07/07 (Rev) Title Date DIRECT REFERRAL No authorization number is required for payment. Send a copy of this form with billing to: Claims Department, Positive Healthcare, P.O. Box 7490, La Verne, CA 91756 Patient Name: DOB: Current Address: Phone Number: ( ) Member ID: Diagnosis: Diagnosis Code: Address & Telephone Number Provider/Specialist PCP Name: Signature: Appointment Date & Time Date: The specialty consult services listed below can be referred directly to the specialist without a prior authorization number. Your patients must see in-network providers/physicians and utilize contracted facilities shown on your current provider roster. Please give this direct referral form to your patient to make the appointment and ask that he or she bring this form to the requested specialist/facility. Procedures such as, but not limited to, surgeries, colonoscopies, imaging guided procedures and device placements will require prior authorization. Cardiology Office Evaluation Follow-Up Visit(s) x EKG Treadmill Stress Test Nuclear Stress Test Dermatology Office Evaluation Follow-Up Visit(s) x Biopsy Gastroenterology Office Evaluation Follow-up Visit(s) x General Surgery Office Evaluation, including X-rays in office, if required Follow-Up Visit(s), including X-rays in office, if required x Hemetology/Oncology Office Evaluation Follow-Up Visit(s) x Neurology Office Evaluation Follow-Up Visit(s) x Ob/Gyn In Network, no referral required Out of Network, prior auth required Ophthalmology Office Evaluation, Yearly Diabetic Eye Exam Follow-Up Visit(s) x Other Office Evaluation Follow-Up Visit(s) x NOTE: All lab work must be referred to LabCorp. Optometry (verify benefits) Office Evaluation Routine Eye Exam – one per year or change in Rx (verify benefits) Glasses/Frames/Lens (verify benefits) 92015 Refraction (verify benefits) Z2930 Dispensing (verify benefits) Orthopedic Office Evaluation, including X-rays in office, if required Follow-Up Visit(s), including X-rays in office, if required x Pain Management Office Evaluation Follow-up Care Requires Prior Authorization Podiatry Office Evaluation, including X-rays in office, if required Follow-Up Visit(s), including X-rays in office, if required x Psychiatry/Psychology Office Evaluation O/P Follow-Up Visit(s) x Urology Office Evaluation Follow-Up Visit(s) x Radiology* – Must use contracted facilities only. X-Ray of: Ultrasound of: Mammogram Bone Density * CT scans, MRI, PET scans and nuclear imaging require prior authorization. Eligibility: Member must be eligible at the time of visit. To verify eligibility for Positive Healthcare Partners (HMO SNP) (Medicare Advantage and Prescription Drug Plan) or Positive Healthcare Florida (Medicaid Reform HMO plan), call (866) 990-9322 or fax to (888) 972-5340 Benefits: Member must have appropriate benefit level at the time of visit. Provider of service must verify benefits. Signature: Direct Referral Form must be signed by the referring primary care provider. Provider: The provider to whom member is referred must be an in-network provider and utilize contracted facilities. Time: This referral is effective for one (1) month from date above. 8SWRURXWLQHIollow-up visits SHUHSLVRGHafter initial evaluation2IILFH WUHDWPHQWVSURFHGXUHVRUDGGLWLRQDOYLVLWVZLWKLQPRQWKVIURPWKHUHIHUUDOZRXOGUHTXLUHSULRUDXWKRUL]DWLRQ. ATTACH THIS FORM WHEN SUBMITTING CLAIM ALL CLAIMS WILL BE REVIEWED FOR APPROPRIATENESS Rev. 11052013 Authorization Request Instructions Prior authorizations are not required for referrals to network specialists for initial consultations and follow-up appointments. Prior authorizations are required all procedures and medical services listed in the table below. Use a Referral Request form to make a referral for initial consultations and all follow-up appointments. Authorization Request Instructions Prior authorizations are required for all procedures and medical services listed in the table below, and for any specialist visits beyond initial and follow-up appointments. Providers and facilities must be in network. Complete this form and fax it to Utilization Management at (888) 972-5340. Routine authorization requests are processed within 14 days. Please call (866) 9909322 for authorization status. Claim(s) will be paid if a prior authorization has been granted. Patient eligibility should be verified at time of service, see below. Eligibility Verification For PHP (HMO SNP) (Medicare Advantage Part D plan) eligibility verification, please call (888) 456-4751. For PHC Florida (Medicaid Managed Care Plan) please call (888) 997-0979. Specialty Services Requiring Prior Authorization x x x All inpatient care (acute, subacute, SNF, and long term) Home health care, including skilled nursing, rehab, and home infusion Imaging studies (excluding mammography, x-ray and ultrasounds or single/flat view studies) and nuclear medicine x x x x x Interventional radiology Outpatient surgery, rehabilitation including PT/OT/ST and chemotherapy Photo and radiation therapy Wound care Injectables (Part B) administered in physician’s office other than Immunizations administered by a PCP Durable medical equipment (DME) Dialysis in service area Colonoscopy and endoscopy EMG, nerve conduction studies Hearing aids Orthotics and prosthetics Cardiac testing (excluding EKG) and catheterization x x x x x x x Date of Request:______________________________________________ Patient Information Check if Urgent _______________________________________________________________________________________________ Patient Name Select Plan Option: _________________________________________________________ _____________________________________ Member ID Number Birth Date PHP (Medicare) PHC Florida (Medicaid) _____________________________________________ ______________________ _____________________ ______________________ Primary Care Provider Name Contact Phone Fax Referring Provider Information _____________________________________________ ______________________ _____________________ ______________________ Provider Name Contact Phone Fax Indication for Referral Diagnosis(es) Code ______________________________________________________________________________________________________________________ CPT Code(s):_____________________________________________________________________________________________________________________________ List Patient’s Clinical Condition, Lab Data, or Other Diagnostic Data ___________________________________________________________________ ___________________________________________________________________________________________________________________________________________ Requested Consultation or Service _____________________________________________________________________________________________________ Requested (Refer to) Provider Information _____________________________________________ ______________________________ ______________________________ Requested Provider/Facility Name Phone Fax Fax authorization requests to Utilization Management at (888) 972-5340. Routine authorization requests are processed within 14 days. Please call (866) 990-9322 for authorization status. Rev. 120913 Prescription Drug Authorization Request Fax Completed Form to (888) 238-2244 o Please complete all sections legibly. Request will be processed within normal timeframes unless noted as an urgent request and the request meets urgent criteria. o Include all pertinent clinical documentation. Failure to do so will result in a delay in processing. Plan Option: PHP (HMO SNP) • • All requests: processed within 1 business day PHC Florida • All requests: processed within 1 business day Member Information Member Name Routine requests: processed within 72 hrs PHC California AHF Birth Date (Eligibility check?) Member ID Number Drug Information Drug _____________________________________________________________________ Strength _______________________________________ Quantity _______________________Directions for Use Diagnosis Duration of Therapy New Refill Date drug Initiated: Patient Allergies Previous Therapies: Include Drug, Dose, and Duration Rationale for Exception Request or Prior Authorization* Alternate drug contraindicated or previously tried, but with adverse outcome (toxicity, allergy, therapeutic failure): Contraindication(s) (list conditions):________________________________________________________________________________________________________ Drug Interaction(s) (please specify):________________________________________________________________________________________________________ Medical need for higher dosage - explain medical reason below _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ *Please provide lab data, discharge summaries, or progress notes as applicable Prescriber Information Prescriber Name (Print) Signature Prescriber Office Contact Date Phone Fax Pharmacy Information Pharmacy Name Phone Fax For Health Plan Use Only Approved Denied Inquiry Date of Action Approved Duration_________________ through __________________ Reason for Auth Request PA Required Non-Formulary Comments: _____________________________________________________________________________________________ Early Refill; Reason________________ __________________________________________________________________________________________________________ Quantity Limit Other______________________________ __________________________________________________________________________________________________________ Completed By Reviewed By____________________________________________ Positive Healthcare Pharmacy Services / Phone (888) 554-1334 / Fax (888) 238-2244 MA-input CONFIDENTIALITY NOTICE: This fax transmission, and any documents, attached to it, may contain confidential information that is legally privileged. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify the sender by phone and destroy the original fax and its attachments without reading or saving in any manner PROVIDER DISPUTE RESOLUTION FORM • • • • • INSTRUCTIONS Please complete the below form. Fields with an asterisk ( * ) are required. Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME. Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed. For routine follow-up status, instead of the Provider Dispute Resolution Form, please [indicate whether your organization uses a Claims Follow-Up Form or indicate how providers should inquire on claims status, e.g., customer service phone number]. Mail the completed form to: PHC FLORIDA P.O. Box 7490 La Verne, CA 91750 *PROVIDER NAME: *PROVIDER TAX ID # / NPI #: PROVIDER ADDRESS: PROVIDER TYPE SNF DME MD Mental Health Professional Mental Health Institutional Hospital ASC Rehab Home Health Ambulance Other ____________________________ (please specify type of “other”) CLAIM INFORMATION Single Multiple “LIKE” Claims (complete attached spreadsheet) Number of claims:___ Date of Birth: * Patient Name: * Health Plan ID Number: Patient Account Number: Original Claim ID Number: (If multiple claims, use attached spreadsheet) Service “From/To” Date: ( * Required for Claim, Billing, and Reimbursement Of Overpayment Disputes) Original Claim Amount Billed: DISPUTE TYPE Claim Original Claim Amount Paid: Seeking Resolution Of A Billing Determination Appeal of Medical Necessity / Utilization Management Decision Contract Dispute Disputing Request For Reimbursement Of Overpayment Other: * DESCRIPTION OF DISPUTE: EXPECTED OUTCOME: Contact Name (please print) Title ( ) Phone Number Signature Date ( ) Fax Number [ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED (Please do not staple) For Health Plan/RBO Use Only TRACKING NUMBER ________________________ PROV ID# __________ CONTRACTED _____ NON-CONTRACTED _____ AHCA 050610 PHC Form 410.0 Last First [ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED (Please do not staple) 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Number * Patient Name Date of Birth Number * Health Plan ID From/To Date Page ______ of ______ Original Claim ID Number * Service Original Claim Amount Billed PROVIDER DISPUTE RESOLUTION REQUEST (For use with multiple “LIKE” claims) Original Claim Amount Paid Expected Outcome Provider Grievance Form Provider Name: Date of Complaint: Address: Complaint Filed by: Member Information (if applicable): Member Name: Telephone: ID#: DOB: Fax: Description of the Grievance/Complaint: Action Requested by Provider: Supporting Documentation: Provider or Representative Signature: Date: Submit form to Provider Relations, Positive Healthcare Florida, 110 SE 6th St., Ste. 1960, Ft. Lauderdale, FL 33301, or fax to Provider Relations at (954) 522-3260. AHCA 050610 PHC Form 411.0
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