1. health and fitness

PROVIDER MANUAL
Provider Manual
1. ABOUT BEHEALTHY AMERICA ...................................................................................................... 1
Introduction ................................................................................................................................................. 1
Mission & Vision Statement .........................................................................................................................1
BeHealthy America Service ......................................................................................................................... 2
Service Areas ............................................................................................................................................... 2
Medicare ..................................................................................................................................................... 2
2. PHYSICIAN RESPONSIBILITIES................................................................................................................. 3
Introduction ................................................................................................................................................. 3
Primary Care Physician (PCP) Responsibilities ............................................................................................. 3
Specialist Responsibilities ............................................................................................................................ 4
Responsibilities of All Plan Providers ........................................................................................................... 4
Provider Licensure, Credentials and Demographic Information Changes ................................................... 6
Physician Availability & Accessibility ............................................................................................................ 6
Vacations ...................................................................................................................................................... 7
Appointment Scheduling .............................................................................................................................. 7
After-Hours Services .................................................................................................................................... 7
Closing Initiated Member Transfer .............................................................................................................. 8
Provider Participation with the Florida Medicare Program ......................................................................... 9
Provider Information Changes ................................................................................................................... 10
Participation & Credentialing ..................................................................................................................... 11
Provider Termination ................................................................................................................................. 11
Continuity of Care – Terminated Provider ................................................................................................. 11
Utilization Management & Quality Management Programs (UMQ) ......................................................... 12
Preferred Drug List ..................................................................................................................................... 12
Confidential Member Information & Release of Medical Records ............................................................ 12
Adult Health Screening Services ................................................................................................................ 13
Cultural Competency ................................................................................................................................. 14
Consumer Assistance & Complaints .......................................................................................................... 14
Member Rights & Responsibilities ............................................................................................................. 14
Fraud and Abuse Reporting ....................................................................................................................... 15
Marketing Prohibitions .............................................................................................................................. 22
Environment of Care and Safety ............................................................................................................... 22
3. CREDENTIALING………………………………………………………………………………….…………..……………….………….……….24
Introduction……………………………………………………………………………………….…………………………………….…………. 24
Credentialed Providers ............................................................................................................................... 25
Initial Credentialing Process........................................................................................................................ 26
Credentialing ............................................................................................................................................... 27
Professional Liability Insurance................................................................................................................... 28
Updated Documents ................................................................................................................................... 28
Appeal Rights .............................................................................................................................................. 28
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4. MEMBER ELIGIBILITY & SERVICES.…………………………………………………………………………………………….. 29
Member Services…………………………………………………………………………………………………………………………………. 29
Staff Selection and Training…………………………………………………………………………………………………………………. 29
Services Standards……………………………………………………………………………………………………….………………………. 30
Member Identification Card………………………………………………………………………………………….……………………… 30
Member Transfers………………………………………………………………………………………………………….……………………. 31
Methods of Eligibility Verification………………………………………………………………………………….…………………….. 31
5. Health Services Department…………………………….…………………………………………………………..…………… 32
Introduction…………………………………………………..…………………………………………………………………………………… 32
Department Philosophy……………………………………..………………………………………………………………………………. 32
Health Services Staff Availability……………………………..…………………………………………………………………………. 32
Contact Information……………………………………………………..……………………………………………………………………. 33
General Information…………………………………………………………………………………………..………………………………. 33
Status of a Pre-Service Request……………………………………………………………………………..…………………………… 34
Referrals……………………………………………………………………………………………………………..……………………………… 34
Pre-Certifications………………………………………………………………………………………………..……………………………… 36
Criteria……………………………………………………………………………………………………………….……………………………… 43
Emergency and Urgent Care Services…………………………………………………………………….………………………….. 43
Pharmacy and Provider Access During a Federal Disaster or Other Public Health
Emergency Declaration…………………………………………………………………………………………..…………………………. 44
Concurrent Review & Discharge Planning…………………………………………………………………..……………………… 44
Second Opinions……………………………………………………………………………………………………………..………………….45
Covered Services…………………………………………………………………………………………………………………..…………… 45
Direct Access Programs…………………………………………………………………………………………..…………………..……. 46
Dermatology Services…………………………………………………………………………………………………………………….…. 47
Podiatry Services…………………………………………………………………………………………………………………….………… 47
Chiropractic Services…………………………………………………………………………………………………………….………….. 47
Vision Services…………………………………………………………………………………………………………………….……………. 47
Behavioral Health Services………………………………………………………………………………………………….……....………. 47
Well Woman – Routine & Preventive Services……………………………………………………………....………....………… 48
Case Management Program…………………………………………………………………………………………….………………. 48
Preventive Health Guidelines…………………………………………………………………………………………….…………….. 49
Financial Incentives…………………………………………………………………………………………………………….……....………. 49
6. MEDICATION MANAGEMENT……………………………………………………………………..………………...…………. 50
Introduction…………………………………………………………………………………………………………..…………………....……… 50
Preferred Drug List………………………………………………………………………………………………....………………....………. 50
Generic Substitution……………………………………………………………………………………………..…..…………....…………. 50
Drugs Not on the Preferred Drug List……………………………………………………………………....…………………....…… 51
Prior Authorization (PA)/Step Therapy (ST)…………………………………………………………….……………………….. 51
Quantity Limits………………………………………………………………………………………………………….…………………….. 51
Co-payments………………………………………………………………………………………………………………….…………………. 51
Injectables………………………………………………………………………………………………………………………….……………. 52
Pharmacy Use……………………………………………………………………………………………………………………….…………. 52
Drug Utilization Review Program……………………………………………………………………………………………….…...… 52
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7. QUALITY MANAGEMENT PROGRAMS………………………………………………………….….……………..…...…… 53
Overview…………………………………………………………………………………………………………………………………………. 53
Goals/Objectives……………………………………………………………………………………………………………………………… 53
Provider Notification of Changes……………………………………………………………………………………………………… 55
Medical Health Information…………………………………………………………………………………………………………..… 55
Medical Record Standards……………………………………………………………………………………………………………….. 55
Medical Record Review……………………………………………………………………………………………………………………. 59
Medical Record Privacy & Confidentiality Standards……………………………………………………………………....…. 59
8. CLAIMS…………………………………………………………………….………..……………………….………………....………... 63
General Payment Guidelines………………………………………………………..…………………………………………………. 63
Prohibition on Billing Members……………………………………………………..……………………………………………….. 64
Timely Submission of Claims……………………………………………………………..……………………………………………. 64
Maximum Out-of-Pocket Expenses (MOOP)……………………………………………………………………………………. 64
Physician and Provider Reimbursement………………………………………………..….…………………………………….. 65
Completion of “Paper” Claims…………………………………………………………………..……………………………………. 66
Electronic Claims Submission………………………………………………………………………………………………………….. 66
Electronic Transactions & Code Sets……………………………………………………………………………………………….. 66
Encounter Data………………………………………………………………………………………………..…………………………….. 67
Coordination of Benefits (COB)…………………………………………………………………………..………………………….. 68
Correct Coding……………………………………………………………………………………………………..………………………… 68
Claims Appeals……………………………………………………………………………………………………………………………….. 68
Reimbursement for Covering Physicians……………………………………………………………………..…………………. 69
Fee Schedule Updates…………………………………………………………………………………………………..……………….. 69
Online Claims Information……………………………………………………………………………………………..………....………. 69
9. GRIEVANCE & APPEALS………………………..………………………………………………….………....…………….….… 70
Introduction…………………………………………………………………………………………………………………………………....… 70
Definitions………………………………………………………..…………………………………………….…………….……………......... 70
Grievance & Appeals System……………………………..…………………………………………….……….……………..……. 70
Member Grievance & Appeals……………………………..…………………………………………..……………………………. 71
Participating Provider Claims Appeals……………………..…………………………………………..………………………… 72
Non-participating Providers Appeal…………………………..…………………………………………..………………………. 73
Expedited Claims Appeals…………………………………………..…………………………………………..……………………… 73
Medicare Grievance Process……………………………………………………………………………………..……………………. 73
Provider Complaint Process………………………………………………………………………………………..…………....….……. 73
10. SAMPLE FORMS & DOCUMENTS…………………………………………….…....……………………………….……….. 75
2014 Quick Reference Guide….....…………………………..…………………………………………….……….……………..……. 76
2014 Pre-Cert Request Form…………........…………………..…………………………………………..……………………………. 78
2014 Referral Form.............................…….....………………..…………………………………………..………………………… 79
Consumer Assistance Notice................…………………………..…………………………………………..………………………. 80
Member Rights & Responsibilities…………………………………..…………………………………………..……………………… 81
PCP Member Transfer Request Form……………………………………………………………………………..……………………. 83
Sample Member ID Cards..........................................................................................................................84
Procedures and J Codes That Do Not Need Authorization.........................................................................85
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1. ABOUT BEHEALTHY AMERICA
Introduction
BeHealthy America, Inc. is an independently owned Florida MAPD Health Plan, with
corporate headquarters in Sarasota, Florida. The company was founded with the
primary goal of designing and offering outstanding healthcare products to Floridians.
Vision:
To be the highest rated and most prominent healthcare leader in our communities by
radically changing the way our healthcare system delivers care and services while
improving overall members' healthcare experience
Mission:
Our mission is to be the premier, community-centric, 5 star Medicare Advantage
Health Plan serving our geographic area.
As the premier health plan we will:
Recruit and manage physicians and providers that want to coach, educate and
navigate our members through the healthcare system.
Values:
Our Management Team of Community Leaders have instilled a core set of values into our
culture which will guide our organization in our pursuit to be the preeminent health plan in
our geographic area.
What makes BeHealthy America Different?
• BeHealthy America is committed to pay “clean” claims promptly and accurately,
meeting all regulatory guidelines.
• BeHealthy America's focus is on providing the most efficient methods to obtain
referrals and authorizations.
• BeHealthy America is committed to operating state-of-the-art information
technology for claims processing, member services, enrollment management,
Physician profiling and data analysis.
• BeHealthy America has exceptionally trained Physician and Provider
representatives available to answer all provider inquiries.
• BeHealthy America will set itself above others with a high level of service
orientation that our physician and provider offices deserve
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BeHealthy America Service
Provider Manual
BeHealthy America, Inc. is adamant about service. We will accomplish our goal of superior
service to Members and Physicians/Providers through:
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Outstanding telephone customer service,
Easy, intuitive web portal access, for both members and providers,
Dedicated Provider Relations “field” staff,
Highly trained marketing staff,
State-of-the-art claims processing software,
Recruiting only the most highly qualified staff, and
Dedication to training.
Service Areas
In 2014 we will service the following counties: Manatee and Sarasota
What is Medicare?
Medicare is a health insurance program for people:
• age 65 or older,
• under age 65 with certain disabilities, and
• of all ages with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a kidney transplant).
Medicare has:
Part A Hospital Insurance - Most people don't pay a premium for Part A because they or
a spouse already paid for it through their payroll taxes while working. Medicare Part A
(Hospital Insurance) helps cover inpatient care in hospitals, including critical access
hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover
hospice care and some home health care. Beneficiaries must meet certain conditions to
get these benefits.
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part
B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers
some other medical services that Part A does not cover, such as some of the services of
physical and occupational therapists, and some home health care. Part B helps pay for
these covered services and supplies when they are medically necessary.
Prescription Drug Coverage - Most people will pay a monthly premium for this coverage.
Starting January 1, 2006, new Medicare prescription drug coverage was available to
everyone with Medicare. Everyone with Medicare can get this coverage. Medicare
Prescription Drug Coverage is insurance. Beneficiaries choose a drug plan and pay a
monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan
when they are first eligible, they may pay a penalty if they choose to join later. The
BeHealthy America includes Part D coverage. The provider beneficiary can refer to the
formulary for specific coverage and co-payment details.
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2. PHYSICIAN RESPONSIBILITIES
Introduction
This section of the Provider Manual addresses the respective responsibilities of
participating Physicians. Our expanding network of primary care providers, as well as the
growing list of specialty providers, makes it more convenient to find BeHealthy America in
your neighborhood.
BeHealthy America does not prohibit or restrict Plan Providers from advising or advocating
on behalf of a Plan Member about:
1) The Plan Member’s health status, medical care or treatment options (including
alternative treatments that may be self-administered), including providing sufficient
information to the Plan Member to provide an opportunity to decide among all relevant
treatment options;
2) The risks, benefits and consequences of treatment or non-treatment; and
3) The Plan Member’s right to refuse treatment and express preferences about future
treatment decisions. A Provider must provide information regarding treatment options in a
culturally competent manner, including the option of no treatment. A Provider must ensure
that individuals with disabilities are presented with effective communication on making
decisions regarding treatment options.
Practitioners may freely communicate with patients about their treatment, regardless of
benefit coverage limitations. As applicable, the Plan shall not prohibit the participating
Provider from providing inpatient services to a Member in a contracted hospital if such
services are determined by the Participating Provider to be medically necessary covered
services under the Plan, and/or Medicare Contract.
A Physician’s responsibility is to provide or arrange for Medically Necessary Covered
Services for Members without regard to race, ethnicity, national origin, religion, sex, age,
mental or physical disability, sexual orientation, genetic information or source of payment.
A Physician is further responsible to render Medically Necessary Covered Services to Plan
Members in the same manner, availability and in accordance with the same standards of
the profession as offered to the Physician’s other patients.
Primary Care Physician (PCP) Responsibilities
The following is a summary of responsibilities specific to Primary Care Physicians who
render services to Plan Members:
•
•
•
Coordinate, monitor and supervise the delivery of health care services to each Member
who has selected the PCP for Primary Care services.
Assure the availability of Physician services to Members in accordance with Section 2,
“Appointment Scheduling” on pages 6 and 7 of this manual.
Arrange for on-call and after-hours coverage.
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Submit a report of an encounter for each visit where the Provider services the Member
or the Member receives a Health Plan Employer Data and Information Set (HEDIS)
service. Encounters should be submitted on a CMS 1500 form.
Ensure Members utilize network Providers. If unable to locate a participating Provider
for services required, contact Provider Relations or Health Services for assistance.
Ensure Members are seen for an initial office visit and assessment within the first 90
days of being assigned to the PCP panel.
Physician/Provider will consider Member input into proposed treatment plans.
Specialist Responsibilities
Specialists are responsible for communicating with the PCP in supporting the medical care
of a Member. Specialists are also responsible for treating Plan Members referred to them
by the PCP; and communicating with the PCP for authorizations. These requests must be
coordinated through the Member’s PCP in most instances.
Responsibilities of All Plan Providers
The following is an overview of responsibilities for which all Plan Providers are
accountable. Please refer to your contract, or contact your Provider Relations
Representative for clarification of any of the following:
•
All Providers must comply with the appointment scheduling requirements as stated in
the Appointment Scheduling Section.
•
Provide or coordinate health care services that meet generally recognized professional
standards and the Plan guidelines in the areas of operations, clinical practice
guidelines, medical quality management, customer satisfaction and fiscal responsibility.
•
Use Physician extenders appropriately. Physician Assistants (PA) and Advanced
Registered Nurse Practitioners (ARNP) may provide direct Member care within the
scope or practice established by the rules and regulations of the State of Florida and
Plan guidelines. The sponsoring Physician will assume full responsibility to the extent
of the law when supervising PA’s and ARNP’s whose scope of practice should not
extend beyond statutory limitations. ARNP’s and PA’s should clearly identify their titles
to Members, as well as to other health care professionals.
•
•
A request by a Member to be seen by a Physician, rather than a Physician extender,
must be honored at all times.
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• Refer Plan Members with problems outside of his/her normal scope of service for
consultation and/or care to appropriate Specialists contracted with Plan (PCP’s only).
• Refer Members to participating Physicians or Providers, except when they are not
available, or in an emergency. Providers should contact the Health Services department in
the event it is medically necessary to refer a Member to a non-participating Provider for
continuity of care purposes.
• Admit Members only to participating Hospitals, Skilled Nursing Facilities (SNF’s) and other
inpatient care facilities, except in an emergency.
• Respond promptly to Plan requests for medical records in order to comply with regulatory
requirements, and to provide any additional information about a case in which a Member
has filed a grievance or appeal.
• Not bill, charge, collect a deposit from, seek compensation, remuneration or
reimbursement from or have any recourse against any Plan Member, subscriber or
enrollee other than for supplemental charges, co-payments or fees for non-covered
services furnished on a “fee-for-service” basis. Non-covered services are benefits not
included by the Plan in a Member’s healthcare policy, are excluded by the Plan, are
provided by an ineligible Provider, or are otherwise not eligible to be Covered Services,
whether or not they are Medically Necessary.
• Treat all Member records and information confidentially, and not release such information
without the written consent of the Member, except as indicated herein, or as needed for
compliance with State and Federal law.
• Apply for a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver, if
applicable.
• Maintain quality medical records and adhere to all Plan policies governing the content of
medical records as outlined in the Plan’s quality improvement guidelines. All entries in the
Member record must identify the date and the Provider.
• Maintain an environmentally safe office with equipment in proper working order in
compliance with city, state and federal regulations concerning safety and public hygiene.
• Communicate clinical information with treating Providers timely. Communication will be
monitored during medical chart review. Upon request, provide timely transfer of clinical
information to the Plan, the Member or the requesting party, at no charge, unless
otherwise agreed to.
•
Preserve Member dignity, and observe the rights of Members to know and understand the
diagnosis, prognosis and expected outcome of recommended medical, surgical and
medication regimen.
•
Not to discriminate in any manner between Plan Members and non-Plan Members.
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•
Fully disclose to Members their treatment options and allow them to be involved in
treatment planning.
•
A Physician/Provider will consider Member input into proposed treatment plans.
Provider Licensure, Credentials and Demographic Information Changes
•
Inform the Plan, in writing, within 24 hours of any revocation or suspension of his/her
DEA number, and/or suspension, limitation or revocation of his/her license,
certification, or other legal credential authorizing him/her to practice in the State of
Florida.
•
Inform the Plan immediately of changes in licensure status, tax identification numbers,
telephone numbers, addresses, status at participating hospitals, loss of liability
insurance and any other change which would affect his/her status with the Plan.
Physician Availability & Accessibility
In accordance with the BeHealthy America Physician Service Agreement, Physicians
agree to make necessary and appropriate arrangements to ensure the availability of
services to Members on a 24-hour per day, 7-day per week basis, including arrangements
for coverage of Members after hours or when the Physician is otherwise unavailable.
In the event participating Providers are temporarily unavailable to provide care or referral
services to Plan Members, they should make arrangements with another Plan-contracted
and credentialed Physician to provide these services on their behalf.
If a covering Physician is not contracted and credentialed with the Plan, he/she must first
obtain approval to treat Plan Members. The Physician should be credentialed by the Plan,
he/she must sign an agreement accepting the Participating Provider’s negotiated rate and
agree not to balance bill Plan Members. For additional information, please contact your
local Provider Relations Department.
Additionally, Physicians are to establish an appropriate appointment system to
accommodate the needs of Plan Members, and shall provide timely access to
appointments to comply with the following schedule:
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Urgent Care within one (1) day of an illness;
Routine sick care within one (1) week of an illness; and
Well Care within one (1) month of an appointment request.
The Physician will ensure that Members with an appointment receive a professional
evaluation within one (1) hour of the scheduled appointment time. If a delay is unavoidable,
the patient shall be informed and provided with an alternative.
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Vacations
Primary Care Physicians should notify the Plan, in writing, of any extended vacation/ timeoff of (1) one week or more, and disclose the provisions made for Provider coverage in the
PCP’s absence. The Provider covering for the PCP must be a Participating Provider with
our Plan.
Appointment Scheduling
The following criteria comply with access standards:
1. Primary Care Providers should:
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Provide medical coverage 24-hours a day, seven days a week;
Scheduled appointments should be seen within 30 minutes;
Schedule emergent referral appointments immediately;
Schedule routine sick care within one (1) week; and
Schedule well care within one (1) month.
2. Specialty Care Providers should:
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Schedule well care within one (1) month;
Schedule routine sick care within one (1) week;
Schedule urgent referral within 24 hours; and
Schedule emergent referral appointments immediately.
BeHealthy America collects and performs an annual analysis of access and availability
data, and measures compliance to required thresholds. The analysis can include access
to:


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well care;
sick care; · urgent care; and/or
after hours care.
After-Hours Services
The Primary Care Physician or covering Physician should be available after regular office
hours to offer advice and to assess any conditions, which may require immediate care.
This includes referrals to the nearest Urgent Care Center or Hospital Emergency Room in
the event of a serious illness.
To assure accessibility and availability, the Primary Care Physician should provide one of
the following:
• 24-Hour answering service;
• Answering system with an option to page the Physician; or
• An advice nurse with access to the PCP or on-call Physician.
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Closing Physician Panel
Provider Manual
When closing Membership panel to new Plan Members, Providers must:
• Submit a request in writing, 60 days prior to closing the Membership panel.
• Maintain the panel open to all Plan Members who were provided services prior to
closing the panel.
• Submit a written notice of the re-opening of the panel, to include a specific effective
date.
BeHealthy America will assist Physicians in providing communication to Members with
disabilities or language services. Please contact BeHealthy America Member Services to
arrange services for the deaf, blind, or those who need a language interpreter.
PCP Initiated Member Transfer
A Participating Primary Care Provider (PCP) may not seek or request to terminate their
relationship with a Member, or transfer a Member to another Provider of care based upon
the Member’s medical condition, amount or variety of care required, or the cost of covered
services required by the Plan’s Member.
Reasonable efforts should always be made to establish a satisfactory Provider/Member
relationship. The PCP should provide adequate documentation in the Member’s medical
record to support his/her efforts to develop and maintain a satisfactory Provider/Member
relationship.
If a satisfactory relationship cannot be established or maintained, the PCP must continue
to provide medical care for the Plan Member until such time that the member can be
transitioned to another PCP.
The PCP may request that a member be assigned to another practice if his/her behavior is
disruptive to the extent that his/her continued assignment to the PCP substantially impairs
the PCP’s ability to arrange for or provide services to either that particular member or other
patients being treated by the PCP. The PCP may request transfer of the member only after
it has met the requirements of this section and only with the Plan’s approval. The PCP may
not request transfer of a member because he/she exercises the option to make treatment
decisions with which the PCP disagrees, including the option of no treatment and/or
diagnostic testing. The PCP may not request transfer of a member because he/she
chooses not to comply with any treatment regimen developed by the PCP or any health
care professionals associated with the PCP.
Before requesting transfer of a member, the PCP must make a serious effort to resolve the
problems presented by the member. Such efforts must include providing reasonable
accommodations for individuals with mental or cognitive conditions, including mental
illnesses and developmental disabilities. The PCP must also inform the member of his/her
right to use the Plan’s grievance procedures.
The PCP must submit documentation of the specific case to Plan for review. This includes
documentation:
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Provider Manual
Of the disruptive behavior;
Of the PCP’s serious efforts to provide reasonable accommodations for individuals with
disabilities, if applicable in accordance with the Americans with Disabilities Act;
Establishing that the member’s behavior is not related to the use, or lack of use, of
medical services;
Describing any extenuating circumstances cited under 42CFR 422.74(d)(2)(iii) and (iv);
That the PCP provided the member with appropriate written notice of the
consequences of continued disruptive behavior;
That the PCP then provided written notice of its intent to request transfer of the
member.
The PCP must submit to the Plan:
The above documentation;
The thorough explanation of the reason for the request detailing how the individual’s
behavior has impacted the providers ability to arrange for or provide services to the
individual or other patients in the PCP’s practice;
Member information, including age, diagnosis, mental status, functional status, a
description of his/her social support systems and other relevant information;
Statements from providers describing their experiences with the member; and any
information provided by the member.
A PCP Request for Transfer Form, a copy of which may be found in the Forms Section of
this manual. Copies are also available from our Provider Relations Department.
The request for transfer must be complete, as described above. The Plan will review this
documentation and render a determination regarding the request for transfer. The Plan will
make the determination within thirty (30) days of receipt of the request for transfer and will
notify PCP within three (3) days of the determination.
Except in extreme circumstances, the transfer to a new PCP will not occur until the first of
the month following Plan’s determination of approval of transfer.
Once the Plan has approved the transfer, the PCP must mail a certified letter to the
member dismissing the member from the PCP’s care and directing the member to contact
the Plan’s Member Service Department to coordinate selection of a new PCP.
The PCP will also be responsible for notifying their Plan Provider Representative so that
the Plan can ensure the member selects a new PCP in a timely manner.
Provider Participation with the Florida Medicare Program
Providers not already enrolled with the Florida Medicare program, and who wish to
perform services for BeHealthy America Members with Medicare coverage, may submit a
Managed Care Treating Provider Registration form to the Plan. BeHealthy America will
then submit the form on a Provider’s behalf to the Agency for Health Care Administration
(AHCA) and a provider ID will be assigned solely for the submission of encounter data.
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The form submission is a formal request to obtain a Florida Medicare provider ID that is
only valid to treat BeHealthy America Medicare Members. This form is available through
our Provider Relations staff.
The Medicare Provider ID will then be used to submit encounter data to BeHealthy
America for the services rendered to the Plan’s Members. Providers must follow the Plan’s
encounter data submission requirements to ensure acceptance of said information by
Florida MMIS and/or the state’s encounter data warehouse.
A Provider who is granted a Medicare ID to treat Plan Members may also be an option for
assignments in the choice counseling process.
It is important to note that the form may not be used to apply to the Medicare program as a
fee-for-service Provider. If a Provider plans to submit claims directly to Florida Medicare for
fee-for-service reimbursement, they must submit the full Florida Medicare Provider
Enrollment Application, available at http://www.medicare.gov.
Provider participating with telemedicine
If the health plan has approved a provider to provide telemedicine services to BeHealthy
America members, the provider is required to have protocols in place to prevent fraud
waste and abuse. The provider must implement telemedicine fraud waste and abuse
protocols that address the following:
(1)
Authentication and authorization of users;
(2)
Authentication of the origin of the information;
(3)
The prevention of unauthorized access to the system or information;
(4)
System security, including the integrity of information that is collected, program
integrity and system integrity; and
(5)
Maintenance of documentation about system and information usage.
Provider Information Changes
Prior notice to your Provider Relations Representative is required for any of the following
changes:
•
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•
•
Tax identification number
Group name or affiliation
Physical or billing address
Telephone or facsimile number
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Participation & Credentialing
Provider Manual
Providers are accepted for participation if they meet the Plan’s credentialing requirements
and business needs, at its sole discretion. BeHealthy America, Inc. does not discriminate
against race, creed, age, gender or national origin of the Provider.
Participating Providers are required to notify the Plan immediately when a new Provider
joins their practice. Notify the local Provider Relations Representative and the
representative will send an application for completion. Please see the Credentialing
Overview Section to learn more about our credentialing requirements. The new Provider
should not treat BeHealthy America members until the credentialing has been completed
and approved.
Provider Termination
In addition to the Provider termination information included in your contractual agreement
with the Plan, the Provider must adhere to the following terms:
•
•
•
•
•
Any contracted Provider must provide at least 60 days prior written notice before a
“without cause” termination;
Terminations occur on the last day of the month. For example, if a termination letter is
dated
January 15, the termination will be effective March 31; and
Providers who receive a termination notice from the Plan may submit an appeal.
Please Note: The Plan must provide written notification to all appropriate agencies
and/or Members upon a Provider suspension or termination, as required by regulations
and statutes.
Continuity of Care – Terminated Provider
BeHealthy America will provide continued services to Members undergoing a course of
treatment by a provider that no longer participates with the Plan, if the following conditions
exist at the time of contract termination:
a. Such care is medically necessary. Continued care is allowed through the completion of
treatment, until the Member selects another treating provider, or until the next Open
Enrollment period – not to exceed six (6) months after the termination of the provider’s
contract.
b. Continuation of care through the postpartum period for Members who have initiated a
course of prenatal care, regardless of the trimester in which care was initiated with a
terminated treating provider.
For continued care under this subsection, the Plan and terminated provider continue to
abide by the same terms and conditions as existed in the terminated contract. However, a
terminated provider may refuse to continue to provide care to a Member who is abusive or
noncompliant. This subsection does not apply to providers terminated from the Plan for
cause.
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Utilization Management & Quality Management Programs (UM/QA)
The Plan has UM/QM programs that include consultation with requesting providers when
appropriate. Under the terms of the contract for participation with the Plan’s network,
Providers agree, in addition to complying with state and federal mandated procedures, to
cooperate and participate in the Plan’s UM/QM programs, including quality of care
evaluation, peer review process, evaluation of medical records, Provider or Member
grievance procedures, external audit systems and administrative review.
Further, to comply with all final determinations rendered pursuant to the proceedings of the
UM/QM programs, all participating Providers or entities delegated for Utilization
Management are to use the same standards as defined in this section.
Compliance is monitored on an ongoing basis and formal audits are conducted annually.
Preferred Drug List
Please refer to the Pharmacy Section of this manual for a description of the Plan’s
Preferred Drug List and prescribing criteria. Please contact your Provider Relations
Representative or go to the member portal link at www.behealthyus.com for a copy of the
Preferred Drug List.
Confidential Member Information & Release of Medical Records
All consultations or discussions involving the Member or his/her case should be conducted
discreetly and professionally in accordance with the HIPAA Privacy and Security Rules
established on April 14, 2003. All Physician practice personnel must be trained on privacy
and security rules. The Practice should ensure that there is a Privacy Officer on staff, that a
policy and procedure is in place for confidentiality of Member’s protected health information
and that the Practice is following procedure or obtaining appropriate authorization from
Members to release protected health information.
All Members have a right to confidentiality. Any health care professional or person who
directly or indirectly handles the Member or his/her medical record must honor this right.
Every practice is required to post their Notice of Privacy Practice in the office or provide a
copy to Members.
Employees who have access to Member records and other confidential information are
required to sign a “Confidentiality Statement.”
Confidential Information includes:
a) Any communication between a Member and a Physician; and
b) Any communication with other clinical persons involved in the Member’s health,
medical and mental care.
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Included in this category are:
Provider Manual
1) All clinical data, i.e., diagnosis, treatment and any identifying information such as name,
address, Social Security Number, etc.;
2) Member transfer to a facility for treatment of drug abuse, alcoholism, mental or
psychiatric problem; and
3) Any communicable disease (such as AIDS) or HIV testing protected under federal or
state law.
When a Member enrolls in the Plan, his/her signature on the “Enrollment Form”
automatically gives the healthcare Provider permission to release his/her medical record to
the Plan, other Physicians in the Plan network who are directly involved with the Member’s
treatment plan and agencies conducting regulatory or accreditation reviews.
Before any individual not working for the Plan can gain access to the Member’s medical
record, written authorization must be obtained from the Member, Member’s guardian or
his/her legally authorized representative (except when there is a statute governing access
to the record, a subpoena or a court order involved). Disclosures without authorization or
consent may include, but are not limited to Armed Services Personnel, Attorneys, Law
Enforcement Officers, Relatives, Third Party Payers, and Public Health Officials.
Initial and Annual Wellness Visits
An annual wellness visit is performed by a Physician to assess the health status of a
patient.
BeHealthy America reimburses initial and annual wellness visits for our members including,
but not limited to the following procedures:
•
•
•
G0402 - for initial preventative physical examination; face to face visits, services limited
to new beneficiary during the first 12 months of Medicare enrollment.
G0438 - for annual wellness visit, including PPPS, first visit.
G0439 - for annual wellness visit, including PPPS, Subsequent visit.
Screening Schedule
BeHealthy America will reimburse for one annual wellness exam every 11 months.
Cultural Competency
BeHealthy America has a strong commitment to diversity in its workforce, customer base
and communities it serves. When health care services are delivered without regard for
cultural differences, patients are at risk for sub-optimal care. Patients may be unable or
unwilling to communicate their health care needs in a culturally insensitive environment,
reducing the effectiveness of the health care process.
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Understanding the fundamental elements of culturally and linguistically appropriate
services is necessary when striving for cultural competency in health care delivery.
Implementing a strong cultural competency program in health care delivery allows
BeHealthy America to:
o
o
o
o
o
Respond to demographic changes;
Eliminate disparities in the health status of people of diverse backgrounds;
Improve the quality of health care services and health outcomes;
Gain a competitive edge in the health care market and decrease liability/malpractice
claims; and
Increase both Member and staff satisfaction.
Cultural Competency is defined as a set of congruent behaviors, attitudes and policies that
come together in a system, agency or among professionals and enable that system,
agency or those professionals, to work effectively in cross-cultural situations.
Cultural competency occurs in both clinical and non-clinical areas. In the clinical area, it is
based on the Patient-Provider relationship. In the non-clinical arena, it involves
organizational policies and interactions that impact health care services.
Evaluation of the Cultural Competency Program will be performed on an annual basis as
part of the Quality Management Program Evaluation.
Providers may obtain a full copy of the Cultural Competency plan, by contacting their local
Provider Relations Representative.
Consumer Assistance & Complaints
Please refer to section 10, the Forms Section of this Manual, for the Plan’s related forms.
Member Rights & Responsibilities
BeHealthy America strongly endorses the rights of Members as supported by State and
Federal laws. BeHealthy America also expects Members to be responsible for certain
aspects of the care and treatment they are offered and receive.
All Member rights and responsibilities are to be acknowledged and honored by BeHealthy
America staff and all contracted Providers. Contracted Providers are provided with a
declaration of BeHealthy America Member rights and responsibilities in section 10 of this
Provider Manual. In addition, Providers are given a handout of these rights and
responsibilities and are urged to post them in their respective offices.
Members are afforded a listing of their rights and responsibilities as a Plan Member in their
BeHealthy America Member Handbook. See the Forms section for rights and
responsibilities that BeHealthy America endorses and expects Providers and Members to
acknowledge and reinforce.
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Advance Medical Directives
Provider Manual
Members have the right to control decisions relating to their medical care; including the
decision to have withheld or taken away the medical or surgical means or procedures to
prolong their life. The law provides that each Plan Member (age 18 years or older of sound
mind) should receive information concerning this provision and have the opportunity to sign
an Advance Directive Acknowledgement Form to make their decisions known in advance.
This allows members to designate another person to make a decision should they become
mentally or physically unable to do so. Please refer to the Forms Section of this manual.
Fraud and Abuse Reporting
Under the Centers for Medicare and Medicaid Services (CMS) and Agency for Health Care
Administration (AHCA) guidelines, the health plan is required to have an effective fraud,
waste and abuse (FWA) program in place. BeHealthy America has implemented a FWA
program to prevent, detect and report health care fraud and abuse according to applicable
federal and state statutory, regulatory and contractual requirements. BeHealthy America
will use a number of processes and procedures to identify and prevent fraud and abuse.
Providers engaged in fraud and abuse may be subject to disciplinary and corrective
actions, including but not limited to, warnings, monitoring, administrative sanctions,
suspension or termination as an authorized provider, loss of licensure, civil and/or criminal
prosecution, fines and other penalties.
To report suspected fraud and/or abuse in Florida Medicare, call the Consumer complaint
Hotline toll-free at 1-800-Medicare or complete a Medicare Fraud and Abuse Complaint
Form, which available online at: http://www.medicare.gov/forms-help-and-resources/reportfraud-and-abuse/ report-fraud/reporting-fraud.html and if you report suspected fraud and
your report results in a fine, penalty, or forfeiture of property from a doctor or other health
care provider, you may be eligible for a reward through the Attorney General's Fraud
Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to
25 percent of the amount recovered, or a maximum of $500,000 per case) Florida statutes
Chapter 409.9203). You can talk to the Attorney General's Office about keeping your
identity confidential and protected.
In December 2007, CMS published a final rule that requires these organizations to apply
certain training and communication requirements to all entities they partner with to provide
benefits or services in the Part C or Part D programs.
To meet CMS requirements for Medicare Advantage Organizations and Part D Sponsors,
this section covers general fraud, waste and abuse training guidelines for the Plan’s first
tier, downstream, and related entities.
FWA Provider Requirements
• All providers and their employees must complete training within thirty (30) calendar
days of new hire and annually thereafter.
• Please maintain records of all training – this is to include dates, methods of training,
materials used for training, identification of trained employees via sign-in sheets or
other method, etc.
• The Plan may request such records to verify that training occurred.
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•
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If the organization has contracted with other entities to provide health and/or
administrative services on behalf of our Plan Members, you must provide this training
material to your subcontractor for training and ensure the subcontractor and any other
entity they may have contracted with to provide the service, also maintains records of
training.
All contracted entities should have policies and procedures to address fraud, waste,
and abuse – including effective training, reporting mechanism, and methods to respond
to detected offenses.
FWA Related Definitions:
First Tier Entity - Any party that enters into a written agreement with the health plan to
provide administrative or health care services for the health plan’s enrollees.
•
Examples include, but are not limited to, pharmacy benefit manager (PBM), contracted
hospitals or providers.
Downstream Entity - Any party that enters into a written agreement below the level of the
arrangement between a sponsor and a first tier entity for the provision of administrative or
health care services for a Medicare eligible individual under Medicare Advantage or Part D
programs.
•
Examples include, but are not limited to, pharmacies, claims processing firms, billing
agencies.
Related Entity - Any entity that is related to the health plan by common ownership or
control and,
1) Performs some of the sponsor’s management of functions under contract of delegation;
2) Furnishes services to Medicare enrollees under an oral or written agreement; or 3)
leases real property or sells materials to the sponsor at a cost of more than $2500
during a contract period.
Fraud - means an intentional deception or misrepresentation made by a person with the
knowledge that the deception results in unauthorized benefit to herself or himself or
another person. The term includes any act that constitutes fraud under applicable federal
or state law.
Some examples of fraud:
•
•
Billing for services not furnished;
Soliciting, offering or receiving a kickback, bribe or rebate; or · Violations of the
physician self-referral (“Stark”) prohibition.
Waste - Generally, means over-use of services, or other practices that result in
unnecessary costs. In most cases, waste is not considered caused by reckless actions but
rather the misuse of resources.
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Abuse - means provider practices that are inconsistent with generally accepted business
or medical practices and that result in an unnecessary cost to the Medicare program or in
reimbursement for goods or services that are not medically necessary or that fail to meet
professionally recognized standards for health care.
Some examples of abuse:
•
•
•
Charging in excess for services or supplies;
Providing medically unnecessary services; or
Providing services that do not meet professionally recognized standards.
Pertinent Statues, Laws and Regulations
False Claims Act
The federal False Claims Act of 1985 permits a person with knowledge of fraud against the
United States Government, referred to as the "qui tam plaintiff," to file a lawsuit on behalf of
the Government against the person or business that committed the fraud (the defendant). If
the action is successful, the qui tam plaintiff is rewarded with a percentage of the recovery.
Violations of Medicare laws and the Medicare Fraud and Abuse Statute also constitute
violations of the False Claims Act.
The federal False Claims Act creates liability for the submission of a claim for payment to
the government that is known to be false – in whole or in part. Several states have also
enacted false claims laws modeled after the federal False Claims Act.
A “claim” is broadly defined to include any submission that results, or could result, in
payment.
Claims “submitted to the government” includes claims submitted to intermediaries such as
state agencies, managed care organizations, and other subcontractors under contract with
the government to administer healthcare benefits.
Liability can also be created by the improper retention of an overpayment.
Examples of false claims include:
•
A physician who submits a bill for medical services not provided.
•
A government contractor who submits records that he knows (or should know) are false
and that indicate compliance with certain contractual or regulatory requirements.
•
An agent who submits a forged or falsified enrollment application to receive
compensation from a Medicare Plan Sponsor.
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Whistleblower and Whistleblower Protections
The False Claims Act and some state false claims laws permit private citizens with
knowledge of fraud against the U.S. Government or state government to file suit on behalf
of the government against the person or business that committed the fraud.
Individuals who file such suits are known as ‘whistleblowers’. The federal False Claims Act
and some state false claims acts prohibit retaliation against individuals for investigating,
filing, or participating in a whistleblower action.
Anti-Kickback Statute
The Anti-Kickback law makes it a crime for individuals or entities to knowingly and willfully
offer, pay, solicit, or receive something of value to induce or reward referrals of business
under Federal health care programs.
The Anti-Kickback law is intended to ensure that referrals for healthcare services are
based on medical need and not based on financial or other types of incentives to
individuals or groups.
Examples include:
•
A frequent flier campaign in which a physician may be given a credit toward airline
frequent flier mileage for each questionnaire completed for a new patient placed on a
drug company’s product.
•
Free laboratory testing offered to health care providers, their families and their
employees to induce referrals to that laboratory.
In addition to criminal penalties, violation of the Federal Anti-Kickback Statute could result
in civil monetary penalties and exclusion from federal health care programs, including
Medicare and Medicaid programs.
Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA contains provisions and rules related to protecting the privacy and security of
protected health information (PHI).
HIPAA Privacy - The Privacy Rule outlines specific protections for the use and disclosure
of PHI. It also grants rights specific to members.
HIPAA Security - The Security Rule outlines specific protections and safeguards for
electronic PHI.
If you become aware of a potential breach of protected information, you must comply with
the security breach and disclosure provisions under HIPAA and, if applicable, with any
business associate agreement.
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Examples of Fraud, Waste and Abuse
Pharmaceutical Manufacturer Potential FWA committed by:
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•
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•
Illegal Off-label Promotion - Illegal promotion of off-label drug usage through marketing,
financial incentives, or other promotion campaigns;
Illegal Usage of Free Samples - Providing free samples to physicians knowing and
expecting those physicians to bill the federal health care programs for the sample;
Billing for items or services not rendered or not provided as claimed;
Submitting claims for equipment or supplies and services that are not reasonable and
necessary;
Double billing resulting in duplicate payment;
Billing for non-covered services as if covered;
Knowing misuse of provider identification numbers, which results in improper billing;
Unbundling (billing for each component of the service instead of billing or using all
inclusive code);
Failure to properly code using coding modifiers;
Altering medical records;
Improper telemarketing practices;
Compensation programs that offer incentives for items or services ordered and
revenue generated;
Inappropriate use of place of service codes;
Routine waivers of deductibles/ coinsurance;
Clustering; and
Upcoding the level of service provided.
Potential FWA committed by Skilled Nursing Facility (“SNF”):
SNFs improperly upcoding resident RUGs assignments to gain higher reimbursement;
SNF improperly utilizing therapy services to inflate the severity of the RUG
classification to obtain additional reimbursement; and
DME or supplies offered by DME provider that are covered by the Medicare Part A
benefit in the SNF’s payment.
Potential FWA Committed by Hospital:
•
•
•
•
•
•
•
•
Failure to follow the same day rule;
Abuse of partial hospitalization payments;
Same day discharges and readmissions;
Improper billing for observation services;
Improper reporting of pass through costs;
Billing on an outpatient basis for “inpatient only” procedures;
Submitting claims for medically unnecessary services by failing to follow local policies;
and Improper claims for cardiac rehabilitation services.
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Potential FWA committed by Physician and Other Providers:
•
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Chiropractor intentionally billing Medicare for physical therapy and chiropractic
treatments that were never actually rendered for the purpose of fraudulently obtaining
Medicare payments;
A psychiatrist billing Medicare, the Plan, and private insurers for psychiatric services
that were provided by his nurses rather than himself;
Physician certifies on a claim form that he performed laser surgery on a Medicare
beneficiary when he knew that the surgery was not actually performed on the patient;
Physician instructs his employees to tell the OIG investigators that the physician
personally performs all treatments when, in fact, medical technicians do the majority of
the treatment and the physician is rarely present in the office;
Physician, who is under investigation by the FBI and the Plan, alters records in an
attempt to cover up improprieties;
Neurologist knowingly submits electronic claims to the Medicare carrier for tests that
were not reasonable and necessary and intentionally upcoded office visits and
electromyograms to Medicare;
Podiatrist knowingly submits claims to the Medicare programs for non-routine surgical
procedures when he actually performed routine, non-covered services such as the
cutting and trimming of toenails and the removal of corns and calluses; and
Performing tests on a beneficiary to establish medical necessity.
Potential FWA committed by Durable Medical Equipment, Prosthetics, Orthotics and
Suppliers (DMEPOS):
DME provider billed for items or services not provided to the beneficiary;
Continued billing for rental items after they are no longer medically necessary;
Resubmission of denied claims with different information in an attempt to be improperly
reimbursed;
Providing and/or billing for substantially excessive amounts of DME items or supplies;
Upcoding a DME item by selecting a code that is not the most appropriate;
Providing a wheelchair and billing for the individual parts (unbundling);
Delivering or billing for certain items or supplies prior to receiving a physician’s order
and/or appropriate certificate of necessity;
Completing portions of the certificate of necessity that is reserved for completion by the
treating physician only;
Cover letters to encourage physicians to order medically unnecessary items or
services;
Improper use of ZX modifier;
Providing false information on the DMEPOS supplier enrollment form;
Knowing misuse of a supplier number, which results in improper billing;
Furnishing more visits than as medically necessary;
Duplicate billing for the same service;
Submission of claims for home health aide services to beneficiaries that did not require
any skilled qualifying service;
Provision of personal care services by aides in assisted living facilities when such is
required by the assisted living’s State licensure;
Providing services at no charge to an assisted living center.
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Plan’s Processes for Identification of Fraud Waste and Abuse
The Plan has software and monitoring programs designed to identify indicators for fraud,
waste and abuse, including, but not limited to:
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Multiple billing: Several payers billed for the same services (e.g. billing medications
under Part A or Part B and then billing again under Part D;
Billing for non-covered services;
Duplicate Billing;
Unbundling of charges;
Up-coding;
Fictitious providers;
Billing of unauthorized services;
Billing with the wrong place of service in order to receive a higher level of
reimbursement;
Claims data mining to identify outliers in billing;
Billing for services or supplies not provided;
Improper use of ZX modifier;
Failure to follow the same day rule (hospital);
Abuse of partial hospitalization payments; or
Billing on an outpatient basis for “inpatient only” procedures.
Reporting Obligation and Mechanisms
If you identify or are made aware of potential misconduct or a suspected fraud, waste, or
abuse situation, it is your right and responsibility to report it.
Providers, Vendors and Delegates can call the Plan’s Compliance Hotline at 1-855-5222970, the Medicare Program Integrity line at 1-888-419-3456 or the Florida Attorney
General’s Office at 1-866-966-7226.
Callers are encouraged to provide contact information should additional information be
needed. However, you may report anonymously and retaliation is strictly prohibited if a
report is made in good faith.
The Plan will notify the CMS Regional office of any issues that involve Medicare members.
Resources
CMS’ Prescription Drug Benefit Manual – Chapter 9:
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/
downloads/pdbmanual_chapter9_fwa.pdf
Code of Federal Register (see 42 CFR 422.503 and 42 CFR 422.504)
http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms4124fc.pdf
Office of the Inspector General http://www.oig.hhs.gov/fraud.asp
Medicare Fraud, Waste and Abuse Training
http://www.capcms.com/publicfiles/Medicare%20Fraud%20%20Abuse%20Compliance%
20Training.pdf
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Marketing Prohibitions
Provider Manual
Providers shall comply with all Medicare Marketing Guidelines as set forth by the Centers
for Medicare and Medicaid Services (CMS).
At minimum, participating Physicians and Providers should observe the following:
1. Providers or Provider groups are prohibited from distributing printed information
comparing benefits of different health plans, unless the materials have consent from all
of the Plans listed, and received prior approval from the Centers for Medicare and
Medicaid Services (CMS);
2. Providers shall not accept enrollment applications or offer inducement to persuade
beneficiaries to join plans;
3. Providers may not offer anything of value to induce plan enrollees to select them as a
provider; and
4. Provider offices or other places where healthcare is delivered shall not accept
applications for health plans, except in the case where such activities are conducted in
common areas in the health care setting.
Environment of Care and Safety
Infection Control and Safety Practices
Providers must adhere to safety and infection control practices for members and all others.
Providers must maintain ongoing programs designed to (1) prevent infections, and (2)
provide a safe and sanitary environment of care as evidenced by the following
characteristics:
A.
The provider must establish a program for identifying and preventing infections and
maintaining a sanitary practice environment. Providers are responsible for reporting
any untoward events to the proper authorities
B.
The Provider must have an established safety program that addresses the
environment of care and the safety of members and others, and must meet or exceed
local, state, or federal safety requirements. The elements of the safety program
include, but are not limited to:
1. Processes for the management of identified hazards, potential threats, near
misses, and other safety concerns.
2. An awareness of, and a process for, the reporting of known adverse incidents to
appropriate state and federal agencies when required by law to do so.
3. Processes to reduce and avoid medication errors.
4. Prevention of falls or physical injuries involving patients, staff, and all others.
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C. The provider must have a written emergency and disaster preparedness plan to address
internal and external emergencies. The written plan must include a provision for the
safe evacuation of individuals during an emergency.
D. The Provider ensures its sites where health care services are provided to members
comply with the following:
1. Applicable state and local building codes and regulations.
2. Applicable state and local fire prevention regulations.
3. Applicable federal regulations.
E. The provider must ensure that practice sites:
1. Contain fire-fighting equipment to control a limited fire, including appropriately
maintained and placed fire extinguishers of the proper type for each potential type
of fire.
2. Have prominently displayed illuminated signs with emergency power capability at
all exits, including exits from each floor or hall.
3. Have emergency lighting, as appropriate to the facility, to provide adequate
illumination for evacuation of members and staff, in case of an emergency.
4. Have stairwells protected by fire doors, when applicable.
5. Provide examination rooms, dressing rooms, and reception areas that are
constructed and maintained in a manner that ensures member privacy during
interviews, examinations, treatment, and consultation.
6. Are operated in a safe and secure manner.
7. Have provisions to reasonably accommodate disabled individuals.
8. Have a process for the proper identification, management, handling, transport, and
disposal of hazardous materials and waste.
F. Providers must have the necessary personnel, equipment, supplies and procedures to
deliver safe care, and to handle medical and other emergencies that may arise, and
have periodic instruction of all staff in the proper use of safety, emergency and fireextinguishing equipment. Provider must hold at least two drills of its internal emergency
and disaster preparedness plan annually.
The plan will monitor its owned and contracted facilities for compliance with the above
requirements, and will initiate interventions for any identified areas for improvement.
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3. CREDENTIALING
Introduction
The credentialing process is mandatory for network provider participation. During this
process, the provider’s credentials are verified and the complete application is reviewed
against the Plan’s policies and procedures. Any issue identified such as malpractice claims
history, licensure or Medicare or Medicaid sanction is reviewed by the Credentialing
Committee, which is the Peer Review Committee of the Plan. It is the provider’s
responsibility to fillout the entire credentialing application and supply a written explanation
to any item of negative information. Acceptable credentialing applications include the
Plan’s own applications as well as the Council for Affordable Quality Healthcare (CAQH)
application. The CAQH application must have a current attestation and be updated with all
supporting documents. An application cannot be processed until all areas are completed
and all documents are provided to the Plan. Further, a site visit is required for all Primary
Care Providers and OB/GYN specialists.
Please note that providers have the following rights in connection with the credentialing
process:
The right to review information submitted to support their credentialing application;
•
Upon request to Credentialing, a provider has the right to review information that is
obtained by the Plan from outside sources and which it uses to evaluate the
credentialing application. The exception to the information that may be reviewed is peer
references and information that is peer review protected.
The right to correct erroneous information;
•
When information is obtained by the Plan from other sources, and the information
substantially varies from that supplied by the provider, in accordance with Policy CR 1
the Plan will notify the provider of the right to correct the erroneous information; provide
the timeframe for making the changes; the format for submitting the changes; and the
name of the person to whom, and the location where the corrected information must be
sent.
The right to receive the status of their credentialing or re-credentialing application upon
request;
•
The Plan will respond to a provider’s request for status on their credentialing
application within fifteen (15) business days. The information provided will advise of
any items still needed, or any difficulty or non-response in obtaining a verification
response.
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Once received and reviewed for completeness, the application is then taken through the
initial credentialing process and brought to the credentialing committee, (composed of
practicing Providers credentialed by the Plan). Any committee need for additional
information will be immediately requested from the Provider. Providers are initially
credentialed for a thirty-six month credentialing period, after which re-credentialing is
required. Periodically, the Plan may request updates for expired documentation such as
malpractice insurance. If there are changes to any of the information/documentation
submitted in support of the application such as board certification status, please let the
Plan know.
BeHealthy America has a defined provider appeal process for cases in which it chooses to
alter the conditions of a provider’s participation, based on issues of quality of care or
service. Providers are notified of any instances where there is an impending action related
to a provider’s participation status. The notification will include an explanation of the
appeal process.
Credentialed Providers
The following licensed provider types are required to be credentialed. Following is a list
Providers who must be credentialed in order to provide medical services to BeHealthy
America Members:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
Medical Doctors (MD’s);
Osteopathic Doctors (DO’s);
Podiatric Doctors (DPM’s);
Chiropractic Doctors (DC’s);
Optometric Doctors (OD’s);
Psychologists (Psych.D’s);
Advanced Registered Nurse Practitioners (ARNP);
Physician Assistants (PA);
Certified Physician Assistants (PAC);
Certified Nurse Midwifes (CNM);
Physical Therapists (PT) - if contracting directly with us. If through a facility, then only
the facility needs to be credentialed;
Occupational Therapists - Same as PT;
Speech Therapists - Same as PT;
Licensed Clinical Social Workers (LCSW); · Masters in Social Work (MSW);
Licensed Mental Health Counselors (LMHC); · Licensed Marriage & Family Therapists
(LMFT’s).
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The Credentialing Committee must approve practitioners before they begin to deliver
health care services to Members. Physicians and Providers who deliver services before
they have completed the credentialing process and bill directly for these services will not
receive payment unless an authorization was obtained to perform the services as a nonparticipating provider. BeHealthy America also credentials certain facilities and ancillary
Providers. An application and the following supporting documents are required but not
limited to: AHCA certificate; CMS Certificate Accreditation certificate; and Commercial and
Professional insurances. These facilities are:
•
•
•
•
•
•
•
•
•
•
Hospitals;
Freestanding Ambulatory Surgery Centers (ASC);
Skilled Nursing Facilities (SNF);
Diagnostic Facilities;
Inpatient Hospice Facilities;
Dialysis Centers;
Home Health Agencies;
Durable Medical Equipment (DME) Providers; and
Comprehensive Outpatient Rehabilitation Facilities;
Outpatient Physical, Occupational & Speech Therapy (PT, OT, ST) Facility Groups.
NOTE: Hospital and other facility-based Physicians and Providers do not require
credentialing and re-credentialing by the Plan.
Initial Credentialing Process
The Initial Credentialing Process is as follows:
Step 1. The Physician/Provider fully completes all necessary sections of the initial
credentialing application and submits the required documents to BeHealthy
America. A CAQH application is acceptable provided that all the information and
documents are up to date. PCP and OB/ GYN Specialists will need to participate
in a Site Survey. If a provider has signed a Medicare contract, the Plan will verify
the provider’s name does not appear on the Medicare exclusion database.
Step 2. Primary source verification is performed concerning education, licenses and other
submitted documents.
Step 3. The Physician Chairperson of the Credentialing Committee reviews the file prior to
the next scheduled meeting. The Chairperson of Credentialing Committee may
ask for additional explanations if needed before the application is presented to the
Credentialing Committee.
Step 4. The Provider’s file is then presented to the Credentialing Committee.
Step 5. If approved, the file is noted accordingly and proceeds to step six. If additional
information is requested by the Committee, the request is conveyed to the
Provider and the file is placed in a pending status, awaiting the requested
information. Once received, the committee will re-evaluate the application.
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Step 6. Upon approval, the provider information is loaded into the BeHealthy America
database for purposes of claims payment and directory listing.
Step 7. The Physician/Provider is notified in writing of their status and the effective date of
their contract within 60 calendar days following the Committee’s decision.
Step 8. The assigned Provider Relations Representative will conduct an in-service visit with
the Physician/Provider and selected staff.
The credentialing process typically takes approximately 30-90 days from receipt of
complete application through presentation to the Credentialing Committee.
Re-Credentialing
Credentialed Providers must be re-credentialed every thirty-six months. The Credentialing
Department establishes this date as 36 months following the provider’s approval. The
Physician/ Provider will be notified approximately 120 days prior to the expiration of
credentialing. The re-credentialing review process involves the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
Completion of a re-credentialing application or CAQH application that includes a
statement regarding: 1) correctness and completeness of the application; 2) physical or
mental health problems, 3) history of chemical dependency/substance abuse, 4) history
of loss of license or felony convictions, 5) history of loss or limitation of privileges; or
6)state or federal disciplinary activity;
Verification of current license;
Evidence of current malpractice/liability insurance coverage;
Verification of current DEA Certificate (as applicable);
Verification of Board Certification Status (as applicable);
History of professional liability claims that resulted in settlement or judgment paid by or
on behalf of the practitioner;
Review of the National Practitioner Data Bank (NPDB);
Review for any sanctions imposed by Medicare or Medicaid;
Evidence of good standing privileges at a participating hospital;
Participation in a subsequent Site Survey by Primary Care and Obstetrics and
Gynecology Physicians;
Medical record review as indicated, by specialty; and Internal evaluations from Provider
Services, Member Services (Complaints/Grievances) and Quality Management, if
applicable.
If a Provider fails to return the re-credentialing application in a timely fashion and their
credentialing period lapses, the Provider may not render services to a Plan Member
until the re-credentialing process is completed.
In the rare event that the committee denies a Provider credentialed status, the Provider
has the right to appeal the decision within 30 days of receiving the denial notice. The
appeal rights are provided by the Medical Director, as Chairman of the Credentialing
Committee. Any Provider denied credentialing will be reported to the appropriate State
agency as required by Florida Statute.
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Professional Liability Insurance
Provider Manual
BeHealthy America credentialing policies concerning liability coverage conform to Florida
Statutes Providers will be asked to sign a financial responsibility form as part of their
credentialing packet. This will allow BeHealthy America to confirm compliance with these
guidelines.
Upon request, a Provider must provide the Plan with evidence of coverage and any
renewals, replacements or changes.
Updated Documents
BeHealthy America is required to maintain verification of certain documents that expire
throughout the Provider’s participation with the Plan. These documents include but are not
limited to Medical License, and Board Certification.
Practitioner Appeal Rights – Quality of Care or Conduct
In the event the Plan makes an adverse participation decision against a practitioner for the
reasons noted above, the affected practitioner will be notified in writing within 30-days of
the adverse decision, and will be provided notice of rights to appeal. The letter will specify
the reason for the restriction, suspension or termination, and will include if relevant the
data used to evaluate the practitioner. The letter will include the timeframe of 30-days from
the practitioners receipt of the Plan’s letter for an appeal request to be submitted to the
Plan; the name of the person to whom the appeal should be submitted; the practitioner’s
right to submit any additional information in support of the appeal; the right to
representation by an attorney; and if an appeal is requested, the appeal hearing will be
held via teleconference.
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4. MEMBER ELIGIBILITY & SERVICES
Member Services
The primary purpose of the BeHealthy America Member Services Department is to answer
questions and attempt to resolve issues, problems and concerns raised by Members.
Beginning October 1, 2013 through February 14, 2014 our office is open seven days a
week from 8:00 a.m. until 8:00 p.m. EST. From February 14 through September 30, 2014
the office is open Monday through Friday from 8:00 a.m. until 8:00 p.m. On October 1st,
2014 through February 15th, 2015, we will return to being open seven days per week from
8 a.m. to 8 p.m. Eastern.
The Member Services Department can be contacted at 1-855-522-2870; Members with
hearing and/or speech impairments should call our toll-free TTY line at 1-855-522-2973.
We also encourage the use of our website at www.BeHealthyus.com.
Members and Physicians may contact Member Services to:
•
•
•
•
•
•
•
•
•
•
•
•
•
Change a Primary Care Physician;
Receive educational materials;
Learn about referrals and authorizations;
Disenroll from the Plan;
Obtain a new identification card;
Find participating pharmacies;
Verify Member eligibility;
Ask co-payment, co-insurance and deductible questions;
Inquire about claims payment;
Learn more regarding Member benefits
File a Member complaint/grievance;
Notify the Plan of a change in information – new address, phone number or other
personal information; and
Receive Member assistance with the Appeals & Grievance process.
Staff Selection and Training
The Member Services Department is committed to hiring highly qualified individuals,
providing topnotch training and monitoring activities to support attainment of BeHealthy
America's service commitments. Telephone calls are monitored to maintain standards
regarding information accuracy, timely follow-up and Member Service Representatives
attitudes and responses to plan members.
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Service Standards
Provider Manual
The BeHealthy America Member Services Department is designed to address issues,
solve problems, answer questions and listen to concerns from Members and Physicians or
Providers. Our service commitments are to:
1.
2.
3.
Answer calls within 30 seconds;
Respond to voice mail messages within 24 business hours, and
Respond to urgent calls within (1) hour.
BeHealthy America will track the types of issues that you and your staff bring to our
attention so that we may correct any underlying problems.
The Plan also maintains written case management and continuity of care protocols that
include appropriate referral and scheduling assistance of Members needing specialty
health care or transportation services.
Member Identification Card
Each Member will receive an identification card that allows them access to receive services
from the BeHealthy America network of participating Physicians/Providers. A sample of
the BeHealthy America identification card for each product is available in the Sample
Forms section of this manual. Physicians/Providers should ask to see the Member
identification card at each scheduled appointment.
Some important points to remember:
•
The practice should make a copy of both sides of the identification card for their
Member medical record;
•
For purposes of privacy, the identification card has a unique Member number used for
most transactions;
•
The identification card lists the most common co-payments, co-insurance, and
deductible amounts.
•
The identification card lists the toll-free Member Service telephone number;
•
The identification card has the address to mail claims;
•
The identification card does not reflect the effective date of the provider; it is the
effective date the Member became effective with the Plan; and
•
The Physician/Provider can always verify eligibility by requesting to see the Member
identification card each time the Member has an appointment. The Member should
also be asked if there have been any changes since their previous appointment. On
line verification is also available through the provider portal.
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Member Transfers
Provider Manual
The following guidelines apply to the transfer of a Member, upon his/her request, from one
Primary Care office to another:
•
The Member’s decision to transfer should be strictly voluntary;
•
The Member must not have been directly recruited by phone or in person by anyone
involved with the Primary Care office;
•
The Member must not have been influenced to transfer to or out of the office due to
improper/incorrect information or for medical reasons; and
•
Upon the Member’s request and completion of a Medical Record Release Form, the
office is required to send his/her medical records to the newly selected Primary Care
office.
Methods of Eligibility Verification
Providers will have up to four (4) methods to verify Member eligibility:
1. Member Services – Member Services Department staff are available to verify Member
eligibility toll free at 1-855-522-2865, from February 15 through September 30, Monday
through Friday from 8:00 a.m. until 8:00 p.m. EST and from October 1 through February
15, Monday through Sunday from 8:00 a.m. until 8:00 p.m. EST.
2. Monthly Roster – The Primary Care Physician will receive a “Monthly Roster” of
Members assigned to their practice. However, the Plan cannot guarantee that a
Member who appears on the Monthly Roster will not be "retroactively" terminated,
although this is rare.
3. Application Form – For new Members who have not yet received their identification card
with the New Member Packet, a copy of their application form will suffice as a form of
eligibility verification. We do encourage that network Physicians/Providers use a second
form of verification under these circumstances for “non-urgent” medical services.
4. Provider Portal – BeHealthy America has a Web portal to verify Member eligibility,
benefits and claims status quickly and efficiently. You can go to www.BeHealthyus.com
to register/ log on to the Provider Portal. Please be aware that the confirmation e-mail
containing the log on ID could be in your spam folder. Online Member information is
available to Physicians/Providers in “real-time” and will meet current Federal privacy
guidelines. We encourage Physicians to verify Member eligibility prior to the
appointment and ensure that the Member is eligible for covered benefits with the Plan.
Eligibility can be gained or lost within a month’s time frame.
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5. HEALTH SERVICES DEPARTMENT
Introduction
The Health Services Department is involved in the coordination of care for our Members.
The roles of the department include utilization review of pre-service requests, concurrent
review of Members in hospitals and skilled nursing facilities and Case Management.
The Health Services Department works closely with Provider offices and Members to help
coordinate care and enhance Member adherence to the treatment plan. This includes
gathering clinical information from Provider offices. All hospitalized Members receive a call
following discharge to ensure they have all post-discharge medication, equipment and
nursing assistance, if required. The Health Services Department is also available to assist
your office regarding any questions related to the precertification process and case
management.
Department Philosophy
The Health Services Department’s goal is to create partnerships with Physicians, Providers
and Members that result in the following:
1. Avoidance of acute illnesses and diseases through prevention and/or early detection
of medical problems;
2. Enhancement and improvement of general levels of health and fitness;
3. Enabling of Members through education, to develop awareness of the importance of
prevention and health maintenance as key to general health and fitness; and
4. Assistance for Members in understanding their partnership role with health Providers.
The Department will strive to achieve these objectives through these methods:
1. Development of an efficient Health Services program as outlined below and;
2. Establishing effective case management programs focused on interventions for
potential or existing catastrophic medical situations.
Health Services Staff Availability
The Health Services (HS) department will be available for all pre-certification requests from
8:00 a.m. to 5:00 p.m. on weekdays (excluding holidays). After routine business hours, HS
can be reached by calling the department’s regular telephone number to arrange hospital
admissions or emergent needs. This number will lead to the on-call clinical staff that will be
able to assist with any HS functions.
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Contact Information
Provider Manual
The BeHealthy America Health Services department may be contacted at:
BeHealthy America
Health Services Dept.
6948 Professional Pkwy. East, Sarasota, FL 34240
Telephone: 1-855-522-2865 Fax: 888-972-4750
General Information
The Health Services Program is for all BeHealthy America Members. The Plan practices
the “Medical Home Office” model. Enrolled Members are encouraged but not required to
obtain a referral from the Primary Care Physician (PCP) before receiving services from a
Specialist or other medical Provider. Once the initial referral is generated, the Specialist
must coordinate most additional services through the PCP. The PCP is responsible for
submitting all Pre-Certification Requests to the Plan except in specific circumstances (see
the section on pre-certifications).
The time frames for response for requests are as follows:
Standard Requests: The department processes authorization requests as quickly as
possible. It is our goal to process over 50% of our requests the same day we receive them
with an average turnaround time for all requests for service at 1.5 - 2 days.
Expedited/STAT Requests: Expedited requests are defined by Medicare as one where
“applying the standard time for making a determination could seriously jeopardize the life
or health of an enrollee or the enrollee’s ability to regain maximum function". These
requests must be completed and the member notified within 72 hours from the time we
receive the request at the Plan. In order for our Precertification staff to continue to process
all requests for service quickly, we ask that you please review all requests your office
submits before you write STAT, URGENT, ASAP or EXPEDITED. You can obtain an
expedited determination for all services that meet the above definition in one of two ways:
1. You can use the Pre-certification form. There is a section for the Physician to confirm
the request meets the definition of Expedited. The confirmation will be the Physician’s
signature and a brief note indicating his/her reason why the service requested meets
the above Expedite definition; or
2. Your Physician can contact the Plan Medical Director anytime to discuss a case by
calling 1-855-522-2967 and asking to speak to the Medical Director.
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Status of a Pre-Service Request
Provider Manual
A Provider may determine the status of an authorization in two ways:
•
•
Call the Health Services department during normal business hours, 8:00 a.m. to 5:00
p.m. on weekdays, to check the status of a request or;
Access the Plan’s Provider Portal. Here you can review the status of an authorization
request. If you have questions regarding the Provider Portal or would like access,
please contact your Provider Relations Representative for assistance.
A Member should contact Member Services or go to the Member Portal through the
BeHealthy America website to receive information regarding a requested service.
Referral Process
BeHealthy America allows beneficiaries to go to a participating specialist without a referral
from the PCP; however, the plan has a strong belief in the value of the Patient Centered
Medical Home Model and encourages our members to seek advice from their PCP prior to
self-referring to a specialist.
Primary Care Physicians (PCP’s) are not required but are encouraged to provide a referral
for Specialist office visits using the on-line Provider Portal or using the Plan Referral Form.
ATTENTION SPECIALISTS: With the exception of simple X-rays, Ultrasounds and CT
Scans, all procedures beyond an office visit will need a Referral from the PCP in order to
be eligible for payment. Some procedures may require pre-certification or notification; the
type of referral given to you by the PCP will determine who can obtain the pre-certification.
If the on-line referral process is used, copies will be automatically forwarded to the plan
and the specialist via fax or email. If the Referral Form is used, one copy of the form will be
placed in the member’s chart, one copy faxed to the Provider or Facility getting the referral
and one copy faxed to the plan. Please note, no referral number will be provided on this
form and the referral will not be returned to the PCP office by the plan.
The Referral Process may be utilized by the Primary Care Physician (PCP) to order
the following allowable services with Participating Providers:
Office Visits performed in place of service -11
•
The PCP may order a consult for any participating specialist with the referral process.
This includes the specialties of Pain Management, Oncology, Plastic Surgery, etc. for
the initial evaluation. These specialties and others may require pre-certification for
certain services done in their office beyond the initial evaluation (see following precertification list).
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The PCP may refer to a specialist or ancillary provider for:
•
an office visit only,
•
an office visit and specific procedures/codes*, or
•
an office visit and any treatment performed in a place of service 11 that does not
require pre-certification.
*The specialist or ancillary facility will need to go back to the PCP for additional referral if
additional procedures are needed beyond those indicated on the initial referral.
Radiology Procedures performed at a participating free standing radiology facility in
place of service – 11
Simple X-rays, Ultrasounds and CT Scans can be ordered on a script by either a PCP or a
specialist. MRI’s, MRA’s and Nuclear Radiology should be performed only with a Referral
from the PCP unless the Specialist was given a referral to “evaluate and treat” from the
PCP, in which case either the specialist office or the PCP may complete the referral for the
MRI, MRA or Nuclear Radiology.
All PET scans, virtual endoscopies and pill endoscopies require pre-certification which
should only be obtained through the PCP. All radiology services done in an out-patient
hospital setting (POS 22) need to be pre-certified. This request should also come through
the PCP.
Durable Medical Equipment (DME) and Orthotics/Prosthetics
All DME and Orthotics/Prosthetics under $500 Medicare Allowable can be by referral from
the PCP or from the specialist that was given a referral for evaluation and treat or
evaluation and the specific DME or orthotics/ prosthetics that are being ordered.
Physical, Occupational or Speech Therapies in place of service 11
All Physical, Occupational or Speech Therapy can be done by referral from the
participating PCP or treating specialist.
The following are excluded from the Referral Process and need to be sent to the plan for
pre-certification by the PCP:
•
•
Rehab therapy performed in an out-patient hospital setting
Therapies done in a member’s home (Home Health Care)
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Procedures performed in an Ambulatory Surgery Center (POS 24)
The PCP should initiate the referral to the ASC except in cases where the specialist
received an evaluation and treat referral to the specialist. A common example would be a
PCP sending a member to a participating gastroenterologist for a colonoscopy. If the PCP
writes for Evaluate and Treat, the gastroenterologist can initiate the referral to the ASC.
The following procedures done at an ASC do require plan pre-certification: blepharoplasty,
septoplasty, reduction mammoplasty, rhinoplasty, vein surgeries, podiatry surgeries, ocular
surgeries, plastic surgery procedures, TMJ joint treatment, surgery or splinting, and pain
management injections.
Pre-Certification Process
The Pre-Certification Process must be used when the services being ordered require
review for medical necessity or Medicare coverage. Medical records are required for this
process. The Primary Care Physician (PCP) may request pre-certification directly from the
plan through the on-line portal or by faxing in a plan Pre-Certification form. The following
services require Pre-Certification:
Acute Rehabilitation Facility
Hyperbaric O2 Therapy
ASC for certain procedures
(see list)
Implantable Device/
Stimulator
Chemotherapy
Injectable/Infusion
Therapy
In-Patient Hospital
MOHS Procedure
Non-Par Provider
DME and Orthotics/
Prosthetics
> $500 Medicare
allowable
Out-Patient Hospital
Clinical Trials
Cosmetic Procedures
Dialysis
Experimental/Investigational
Procedures
Genetic Testing/Non-Par
Lab
Home Health
Radiation Therapy
Radiology: PET Scan, Pill
or Virtual Endoscopy
(PCP must request precert)
Skilled Nursing Facility
TMJ Joint Treatment
Transplant
Wound Care
Certain Part B Drug
Codes (See list for those
that do not require precert)
Medical Nutrition Education
Pain Management
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The following services require the plan to be notified via the Provider Portal or by using the
Plan’s Pre-Certification/Notification form:
Diabetic Education
Hospice Enrollment
Obstetrical Care
Rehabilitation:
Cardiac,
Pulmonary,
Respiratory
Physical,
Occupational or
Speech Therapy
Pre-Certification or notification for the above services should be requested through the
Provider Portal or faxed to the plan with the medical records attached. Typically this
request will come directly from the PCP office unless the PCP has given a referral to the
specialist for an all-inclusive “Evaluate and Treat” or “Evaluate and treat the specific
procedure(s) that need pre-certification;” in these cases the Specialist may come directly to
the plan to request the pre-certification.
Pre-Certification Requests will be processed within the following timeframes:
Expedited: An expedited request is defined by Medicare as being when a physician or
member feels that by waiting the standard time frame, the wait places the member’s life,
health, or ability to regain maximum function in serious jeopardy.
STAT/Expedited requests should be called to the plan for immediate Medical Director
review after completing the request on-line or faxing the form and medical records to the
plan. STAT/ Expedited requests must be completed no later than 72 hours from the time
the Plan receives the request. The Plan’s goal is to process all Expedited Pre-Certification
requests within 24 hours.
Standard: A standard request for service that does not meet the above definition of
Expedited as described above. The majority of the pre-certification requests should fall into
this category. The HS Department’s goal for average response time is two days for a
standard request.
The table on the following pages clarifies which services are allowed to be ordered
as a Referral, which services require a Pre-Certification and for which services the
plan simply needs notification. Please note that any service in any hospital setting,
In-Patient, Out-Patient or Observation, needs Pre-Certification.
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SPECIALTY
Allergist
Cardiology
Provider Manual
FOLLOW REFERRAL
PROCESS
-All treatment codes POS
11
-All treatment codes POS
11 Inc. Nuclear Stress
Tests, EKG’s, and
approved labs
Cardiothoracic Surgeon
-See Cardiology
Colorectal Specialist
-All treatment codes POS
11
-Procedures at
participating
ASC’s
-Open Access for first 5
visits, after 5 visits obtain
referral from PCP
-All treatment codes POS
11
-Approved labs
-All treatment codes POS
11
-Approved labs
-Office diagnostics
including scoping
-Procedures at par ASC
-All treatment codes POS
11 except vein treatments
-Approved labs
-Procedures at par ASC
-All treatment codes POS
11
-Procedures at par ASC
-All treatment codes POS
11 including colposcopy &
ultrasound
-Approved labs
-Procedures at an ASC
-All treatment codes POS
11
-Approved labs
Dermatology
Endocrinologist
Ear, Nose, Throat
(Otolaryngology)
Gastroenterology
General Surgeon
GYN Oncology
Hematology/ Oncology
FOLLOW
PRE-CERTIFICATION
PROCESS
-Cardiac caths in any
location
-MOHS procedures All Cosmetic
procedures
-Urea breath test
-Virtual Endoscopy
-Pill Endoscopy
-Vein treatments in
office or ASC or
Hospital
-PET Scan (through
PCP)
-PET Scan(through
PCP)
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SPECIALTY
Provider Manual
FOLLOW REFERRAL
PROCESS
FOLLOW
PRE-CERTIFICATION
PROCESS
-All treatment codes POS
11
-Approved labs
-All treatment codes POS
11
-Approved labs -Stress
test, EKG, ultrasounds,
etc.
-All treatment codes POS
11
-Certain J codes
-Port insertion at OP
Hospital setting
Neuropsychology
-Consalt codes Pos 11
-Neuro-psych testing
OB/GYN
-Open access for annual
well woman visit
-All treatment codes POS
11 Pelvic ultrasounds,
colposcopy, etc.
-Approved labs
Oncology
-Approved lab codes Treatment codes except
as noted in next column
-Sterilizations ̀
-Abortions
-Obstetrical Care
(Notification only for
OB Care- no medical
records
needed)
-Certain J codes
-Chemotherapy
Orthopedics
-Fracture treatment codes
–X-rays (PCP or
Specialist can refer)
-MRI (PCP must refer)
-Simple DME, splints,
slings, casting supplies
-All treatment codes POS
11
-Certain J Codes
Pain Management
-Consalt codes Pos 11
Plastic Surgery
-Consalt codes Pos 11
Podiatry
-Open access for 10 for
covered services
-All treatment codes POS
11
-Pain Management
injections in office or
ASC
-All treatment codes in
office or ASC
-Podiatric Surgery at
an ASC or IP or OP
setting
Infectious Disease
Internal Medicine Specialist
Neurology
Ophthalmologist
-Certain J codes
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SPECIALTY
Provider Manual
FOLLOW REFERRAL
PROCESS
FOLLOW
PRE-CERTIFICATION
PROCESS
-Sleep studies
Radiation Oncology
-All treatment codes POS
11 including pulmonary
function test and blood
gases.
Approved lab codes
Rheumatology
- All treatment codes
Pulmonary
Therapy & Rehab:
PT/OT/ST/Cardiac/
Pulmonary/Respiratory
-Certain J codes Radiation Therapy
-Certain J codes
-Hospital based
therapies
-Notification (no
medical records): for
evaluation and
therapies done at an
office or par freestanding facility
Thoracic Surgeon
Office procedures
-Inpatient or Outpatient
Hospital procedures
Urology
Approved
lab
codes
Treatment in POS 11
-Certain J codes
Vascular Surgeon
-Vein Treatment in
office or ASC or
hospital
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Member Request to Plan for Decision on Services
Medicare mandates that all members have the right to contact the Health Plan directly to
request a decision on a service they believe the Health Plan (or Medicare) should provide
or pay for. This request is considered a request for an organization determination and the
Plan must review and respond to this request as it would from any provider.
Plan procedures based on various scenarios of the member requesting Specialist visits,
diagnostic procedures, or therapeutic treatments:
•
Member has not spoken to PCP: If a member informs the Plan they want to have a
service and they have not spoken with their PCP about this request, Member Services
will direct the member to make an appointment with your office to discuss this service.
•
Member has spoken with PCP: If the member informs the Plan they have already
spoken with you or your office about this service, our Member Services Department will
send this information to the HS Department in order to begin the decision process.
•
HS will call and fax your office twice about this request and let your office know what
service(s) the member is requesting. Your office must respond within 2 calendar days
for a standard request and same day if the request is expedited. A final decision will be
made on standard requests within 5 calendar days or for expedite requests within 2
calendar days. The decision will be based on information provided and the Plan
Medical Director will make a determination of whether to approve or deny the service.
•
The final determination will be communicated to the member and your office either
orally or in writing depending on the decision.
Specialist or Provider Requests to Plan for Decision on Services
When HS receives a request for services directly from Specialist or Provider:
•
HS will call PCP offfice, inform the staff of the request and fax PCP office all the
information received from the Specialist or Provider.
•
PCP office will be advised you will have 5 calendar days for standard requests and
same day for expedited requests to respond back to the HS department with your
recommendation on the request.
•
HS will call and fax your office again on calendar day 3 for standard to make certain
you are processing the request, if no response has been received.
If no information is received by the required timeframe, the request and information will be
forwarded to the Plan’s Medical Director for a final decision.
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Criteria
Provider Manual
The HS department utilizes the following criteria when making a determination:
•
•
•
•
Center for Medicare and Medicaid (CMS) National Coverage Determinations
CMS Local Coverage Determinations
InterQual Criteria
Health Plan Coverage Guidelines
Local Health Plan Coverage Guidelines For a copy of the specific HS Review Criteria,
please contact the HS department, Monday through Friday, from 8:00 a.m. to 5:00 p.m.
The Plan’s Medical Director also has access to an external independent review agency
consisting of board-certified specialists for consultation on issues that fall outside of his/her
expertise. Medically Necessary Services or Medical Necessity – are services provided in
accordance with 42 CFR Section 440.230 and as defined in Section 59G-1.010(166),
F.A.C., to include that medical or allied care, goods or services furnished or ordered must:
A. 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 confirmed 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 Medicare program, and not experimental or investigational;
4. Be reflective of the level of service that can be safely furnished, and for which no
equally effective and more conservative or less costly treatment is available,
statewide; and
5. Be furnished in a manner not primarily intended for the convenience of the recipient,
the recipient's caretaker, or the provider.
B. "Medically necessary" or "medical necessity" for inpatient hospital services requires that
those services furnished in a hospital on an inpatient basis could not, 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.
C. The fact that a Provider has prescribed, recommended, or approved medical or allied
goods or services, does not make such care, goods or services medically necessary, a
medical necessity or a covered service.
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Approved Requests
Provider Manual
When a Pre-Service authorization request is approved, an Authorization Notification will be
faxed or emailed to the PCP and the requesting Provider(s) in addition to being entered on
the Provider and Member Portals. This notice will contain the valid time frame of the
authorization, the date of the decision, who requested the authorization, who is authorized
to provide the services and which services were authorized. The PCP or Provider are
delegated the responsibility of notifying the member of the approval and arranging the
needed services. Please note that the member will have access to the authorization
information on the Member Portal and should be encouraged to utilize this web based
access.
Pended Requests
When the Pre-service authorization request is Pended, the HS department may contact the
Provider to gather additional information. The requests will be verbal, faxed and/or noted
on the Provider Portal to the Provider’s office, labeled:
1st Request for Information
2nd Request for Information
Each request has a specific time frame for response and will also inform the Provider of
what is required. If the Provider does not respond to either request and the Medical
Director is unable to make a decision, the appropriate Denial Letter will be mailed to the
member and faxed to the Providers.
Denied Requests
If a service is denied, the member, PCP and provider will receive a CMS developed letter
informing everyone in detail the reason for the denial, the criteria on which the decision
was based, how to access a copy of the criteria and the Appeal rights. This letter will also
provide contact information for the Plan Medical Director if the provider would like to
discuss the case further. If two business days have elapsed since the initiation of the
denial letter, any further action on the request will be handled through the Appeals Process
explained in this manual.
The Plan will comply with all Federal and State requirements concerning denial of services.
The Plan’s Medical Director and Health Services staff are available during normal business
hours to assist Providers with inquiries regarding a service denial or to provide a copy of
the criteria used to make the determination Providers should contact the Health Services
department by calling the number listed at the beginning of this section.
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Emergency and Urgent Care Services
An emergency medical condition is a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent layperson, with
an average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in:
•
Serious jeopardy to the health of the individual or, in the case of a pregnant woman,
the health of the woman or her unborn child;
•
Serious impairment to bodily functions; or
•
Serious dysfunction of any bodily organ or part.
•
Emergency services are covered inpatient and outpatient services that are:
•
Furnished by a Provider qualified to perform emergency services and needed to
evaluate or stabilize an emergency medical condition.
Urgently needed services are covered services that:
•
Are not emergency services as defined in this section;
•
Are provided when a Member is temporarily absent from the Plan’s service area (or, if
applicable, continuation). (Note that urgent care received within the service area is an
extension of primary care services); and
•
Are medically necessary and immediately required, meaning that:
•
The urgently needed services are a result of an unforeseen illness, injury or condition;
and
•
Given the circumstances, it was not reasonable to obtain the services through the
Plan’s participating provider network.
Note that under unusual and extraordinary circumstances, services may be considered
urgently needed when the Member is in the service or continuation area, but the Plan’s
provider network is temporarily unavailable or inaccessible.
Pharmacy and Provider Access During a Federal Disaster or Other
Public Health Emergency Declaration
The Plan will consult the U.S. Department of Homeland Security's Federal Emergency
Management Agency’s (FEMA) website (see http://www.fema.gov/hazard/dproc.shtm) for
information about the disaster or emergency declaration process and the distinction
between types of declarations.
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The Plan will also consult the Department of Health and Human Services (DHHS) or
Centers for Medicare & Medicaid Services (CMS) websites for any detailed guidance.
In the event of a Presidential emergency declaration, a Presidential (major) disaster
declaration, a declaration of emergency or disaster by a Governor, or an announcement of
a public health emergency by the Secretary of Health and Human Services Cost & MA
plans - absent an 1135 waiver by the Secretary, the Plan will:
•
•
•
•
Allow Part A/B and supplemental Part C plan benefits to be furnished at specified
noncontracted facilities (note that Part A/B benefits must, per 42 CFR § 422.204(b)(3),
be furnished at Medicare-certified facilities);
Waive in full, or in part, requirements for authorization or pre-notification;
Temporarily reduce plan approved out-of-network cost sharing amounts; and
Waive the 30-day notification requirement to Members provided all the changes (such
as reduction of cost sharing and waiving authorization) benefit the enrollee.
Concurrent Review & Discharge Planning
The Health Services Department maintains an active hospital management program
comprised of concurrent review and discharge planning. Key to the success of these
efforts is the involvement of the Member’s Primary Care Physician.
Upon notification of an emergency admission, and receipt of the necessary clinical
information, the Plan will establish medical necessity and notify the appropriate Provider.
The Plan will also notify the member’s PCP via fax of the member’s admission (if the PCP
is not the admitting physician).
Discharge planning is key to achieving the best outcomes for our Members and requires
active participation of the facility and Physicians involved in their care. To discharge any
Member to a Skilled Nursing Facility, approval must first be obtained from the Plan’s HS
department. Patients can be admitted to a Skilled Nursing Facility directly from the
Emergency Department, their home or from an inpatient or observation stay in an acute
care facility.
The HS department staff will assist in coordinating any post-discharge services with
participating ancillary Providers, including enrollment of Members into a Case Management
Program.
Second Opinions
In accordance with state requirements, a Member may request and is entitled to a second
medical/surgical opinion when:
•
The Member feels he/she is not responding to the current treatment plan in a
satisfactory manner, after a reasonable lapse of time for the condition being treated;
•
The Member disagrees with the opinion of a physician regarding the reasonableness or
necessity of a medical/surgical procedure; or
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•
Provider Manual
The treatment is for a serious injury or illness related to the medical need for surgery or
for major non-surgical diagnostic and therapeutic procedures (e.g. diagnostic
techniques such as cardiac catheterization and gastroscopy).
The Member will select the provider from whom he/she is seeking a second opinion. The
Member may choose:
•
•
•
A Participating Physician listed in a directory provided by the Plan; or
A non-participating Physician located in the same geographical service area of the
Plan.
Any tests or procedures deemed necessary by a non-participating physician should be
performed within the Plan’s network.
The Plan Physician’s professional judgment concerning the treatment of a Member after
review of a second opinion shall be controlling as to the treatment obligations of the Plan.
Treatment not authorized by the Plan shall be at the Member’s expense.
Provider Request for Second Opinion
All Providers requesting a second opinion must utilize the Plan’s existing network unless
the required specialist is not available. All second opinion requests for non-participating
providers must be submitted through the pre-certification process.
Covered Services
BeHealthy America Members are eligible for all Medicare covered services, as appropriate.
The Plan also offers a variety of added benefits to its Members. To learn more about an
individual Member’s covered benefits, please use one of these resources:
1. Search the Plan’s Web eligibility verification tool or contact Member Services to find
Member-specific benefits. Website: www.behealthyus.com
2. Medicare: Search the CMS Medicare Coverage Database available online at:
http://www.cms.hhs.gov/mcd/overview.asp. Below is a summary of covered services by
Medicare.
Summary of Medicare Part A Covered Services (Inpatient Care – see restrictions in
Medicare coverage database)
•
•
•
•
•
•
•
Anesthesia
Chemotherapy
Room and board
All meals and special diets
General nursing
Medical social services
Physical, occupational, and speech-language therapy
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•
•
•
•
•
•
•
•
Provider Manual
Drugs with the exception of some self-administered drugs
Blood transfusions
Other diagnostic and therapeutic items and services
Medical supplies and use of equipment
Respite care in hospice · Transportation services
Inpatient alcohol or substance abuse treatment
Part A blood (see the restrictions under non-covered services) · Clinical Trials
(Inpatient)
Kidney Dialysis (Inpatient)
Summary of Medicare Part B Covered Services (Medically-Necessary Outpatient
Services – see restrictions in Medicare coverage database)
•
•
•
•
•
•
•
•
•
•
Durable medical equipment (DME)
Home health services
Outpatient physical, speech, and occupational therapy services
Chiropractic care
Outpatient mental health services
Part B blood
Physician services
Prescription drugs
Preventive care services
X-rays and lab tests
Direct Access Programs
The Plan maintains written case management and continuity of care protocols that include
a mechanism for direct access to specialists for Members identified as having special
health care needs, as is appropriate for their condition and identified needs.
Members have direct access to dermatologists, podiatrists, chiropractors,
ophthalmologists, optometrists, and behavioral health providers, among others. Our
Member Services department will provide assistance on how to find the appropriate
provider.
Dermatology Services
Members have direct access without a referral to network dermatologists for the first five
(5) visits each calendar year. In order to receive payment, services must be both medically
necessary and covered benefits. Dermatologists are expected to utilize participating
laboratories unless otherwise established in the Provider’s contract. Members are covered
through the Medicare guidelines. Plan needs to pre-certifiy MOHS procedures only for
Dermatology.
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Podiatry Services
Provider Manual
Medicare Members have direct access without a referral to network Podiatrists. In order to
receive payment, services must be both medically necessary and a covered benefit.
Podiatrists are listed in the Plan’s Provider Directory. Refer to the Statute for visit
limitations. The Plan follows Medicare guidelines for coverage determination.
Chiropractic Services
Chiropractic services are available to Members. Members may contact the network
Provider directly to access services that are both medically necessary and covered
benefits. A list of network chiropractors is in the Plan’s Provider Directory.
Optometric Services
Optometry services are available to Members through a statewide contract. Members may
contact the network optometrist directly for routine vision screening and medically
necessary covered benefits. If the optometrist determines that the Member needs to be
seen by an ophthalmologist, the optometrist should contact the PCP and request a referral
for a network Ophthalmologist.
If a PCP determines that there is a medical eye problem, and deems it medically
necessary for the Member to be seen immediately by an ophthalmologist, the PCP should
call BeHealthy America’s Customer Service line at 1-855-522-2870, TTY: 1-855-522-2973,
Monday through Friday from 8:00 a.m. until 8:00 p.m. EST. The PCP may also have the
Member call Member Services to find the nearest ophthalmologist to handle the Member’s
care.
Vision Services
Medicare Advantage has a discounted vision benefit for frames, lenses, and contact
lenses. A list of network vision Providers is in the Plan’s Provider Directory.
Behavioral Health Services
Behavioral health services are available through a statewide contract. Members may selfrefer to a participating Behavioral Health Provider and schedule an appointment by calling
the toll-free number available in the Plan’s Provider Directory. Providers who want to
coordinate care on behalf of the Member may call the toll-free number for these services.
Well Woman – Routine & Preventive Services
Members have direct access to network women’s health Specialists for routine and
preventive services. The Plan will reimburse network Physicians for procedure codes
99385 and 99397 when billed with diagnosis code V72.3 without prior authorization or
Physician referral.
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Initial Health Risk Assessment Tool (HRA)
Medicare Members receive an Initial Health Risk Assessment Tool in their New Member
Enrollment Packet along with a self-addressed stamped envelope for return. The answers
on this assessment perform the following:
•
•
•
•
Identify where early interventions may be appropriate.
Identify members which may be eligible for referral to case management.
Assist in care coordination for beneficiaries.
Provide the Case Management Department a report of Members identified as requiring
either short or long-term intervention to optimize their health.
Case Management Program
The purpose of the Case Management Program is to achieve and maintain member
wellness through a program of advocacy, communication, education, identification and
facilitation of services. The Plan has a developed a Case Management Program that
assists members who may have the following disease processes or other similarly complex
health issues:
Complex Case Management of Wounds
•
•
•
•
•
•
•
Transplants
Multiple admissions for same or related diagnosis
Major system failure
Multiple trauma
Head or spine injuries with severe deficits
Severe burns greater than 20% surface area
Cancer with extensive treatment
Members are identified for Case Management Programs through several sources,
including, but not limited to:
•
•
•
•
•
•
•
Information from Health Risk Assessment Tool responses;
Discharge Planning from acute or skilled services;
Claim or Encounter Data
Pharmacy Data
Information through HS services
Member Self-Referral; and/or
Physician or Provider Referral.
Member participation in the Case Management Program is on a voluntary basis and a
Member may choose to opt out of participation.
The Case Manager works closely with the Member, Member’s family and professional staff
in the development of a mutually agreed Care Plan. The Case Manager will monitor and
assist the Member in reaching the goals and outcomes developed in this plan of care and
will be in constant communication with the Member’s physician regarding the Member’s
progress.
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To request enrollment or an evaluation for possible enrollment into Case Management; call
the Health Services Department Number, 1-855-522-2870, and ask for Case Management
or you can fax a “Case Management Referral” to 1- 888-972-4750.
Preventive Health Guidelines
BeHealthy America has adopted the U.S. Preventive Services Taskforce Guidelines.
BeHealthy America annually reviews preventive health guidelines to reflect any changes in
recommendations regarding screening, counseling, and preventive services. These
guidelines can be referenced on the website for the Agency of Health Care, Research and
Quality at www.ahrq.gov.
Financial Incentives
BeHealthy America makes Health Services decisions based only on appropriateness of
care and service, in conjunction with Member benefits and coverage. The Plan does not
reward practitioners or other individuals for issuing denials of coverage or care. BeHealthy
America does not encourage or provide incentives regarding Health Services decisions
that result in underutilization of health care services.
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6. MEDICATION MANAGEMENT
Provider Manual
Introduction
BeHealthy America has developed a Preferred Drug List (PDL) to promote clinically
appropriate utilization of medication, in a cost-effective manner. The drugs on the Plan’s
PDL are set up in a tier system that offers Providers and Members a choice of medications.
Generic medications listed will have the widest choice and the least copayment. Brand
medication options could be limited in certain classes, or may not be available on the Plan.
BeHealthy America Pharmacy and Therapeutics Committee meets quarterly to review and
recommend medications for PDL consideration. The Pharmacy and Therapeutics
Committee, is comprised of the Plan’s Medical Director, Pharmacy Director, a clinical
pharmacist representing the Plan’s Pharmacy Benefits Manager, and Physicians from
BeHealthy America Provider Network. Providers or members can request the addition of a
drug to the PDL by writing to the Plan’s Medical or Pharmacy Director. Physicians
interested in participating in our Pharmacy and Therapeutics Committee should contact our
Medical Director.
Preferred Drug List
BeHealthy America maintains its own Preferred Drug List (PDL), a listing of medications
intended to assist the Plan’s Physicians and Pharmacy Providers in delivering
comprehensive, high quality, and cost effective pharmaceutical care.
The Pharmacy and Therapeutics Committee reviews all therapeutic classes and selects
medications based on effectiveness, safety, and cost. The PDL is posted on
BeHealthy America’s website at www.behealthyus.com when updated. Printed copies
are also available by calling the Plan’s Provider Services department at
1-855-522-2967.
The Preferred Drug List only applies to outpatient medications filled at network pharmacies
and does not apply to inpatient medications or those obtained from or administered by a
Physician. Typically, most injectable drugs, except those listed on the PDL, are not
covered by the pharmacy benefit. These must be approved through the Health Services
Department.
Generic Substitution
Generic drugs, excluding those with a narrow therapeutic index, should be dispensed when
available. The FDA has approved a selection of ‘generic equivalents’ for branded
medications. Generic substitution is mandatory when an “A” or “AB” rated generic drug is
available. Drugs listed on the State Negative Formulary are exempt from generic
substitution requirements.
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Drugs Not on the Preferred Drug List
Medications not on the BeHealthy America's Preferred Drug List (PDL) are not a covered
benefit. A drug override can be requested when a medication is not on the PDL by using
the Prior Authorization / Drug Exception Request Form and providing the related clinical
information. Approval is based on the Member’s medical and prescription benefit
coverage, acceptable medical standards of practice and FDA-approved uses.
Prior Authorization (PA)/ Step Therapy (ST)
Some drugs on the Preferred Drug List may have a designation of PA. These are drugs
that will require the provider to send in a request to cover this medication. Medical
documentation, including any labs, tests, diagnosis and/or previous medications failed, are
needed for the request to be considered. There are some drugs that would require the use
of first line drugs before the drug being prescribed will be approved. This is called Step
Therapy. Documentation that the first line drugs have been tried and failed or are not
tolerated by the patient needs to be submitted with the Prior Authorization/Step Therapy
Request before the request can be considered.
Quantity Limits
Many drugs contain quantity limits, which restrict the amount of the particular medicine
dispensed as a benefit from BeHealthy America. These are typically limited to a one (1)
month supply. Some categories of drugs include:
•
•
•
•
Sedative/hypnotics;
Impotence medication;
Certain antihypertensive medication; and
Other type of quantities limits which address medical issues.
If the Provider needs to override quantity limits because of medical necessity, he/she
should follow the process described in the “Drugs not on the Preferred Drug List” section.
Co-payments
The Preferred Drug List is categorized into 5 Tiers as described below. The co-payment
varies with each category where the preferred generic has the lowest co-payment and the
non-preferred brands have the highest. Brands not appearing on the Preferred Drug List
are not covered.
•
•
•
•
•
Tier 1: Preferred Generic
Tier 2 : Non-Preferred Generic
Tier 3: Preferred Brand
Tier 4: Non Preferred Brands
Tier 5: Specialty Drugs
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Injectables
Provider Manual
Most Injectables of all types require authorization through the Prior Authorization / Drug
Exception Request Form process with the following exceptions:
• One time Antibiotics;
• Intra-articular injections of steroids; and
• Intravenous or intra-muscular injection of steroids.
Pharmacy Use
All Members should use network pharmacies. A list of participating pharmacies is found at
www.envisionrx.com/resources/pharmacymap.aspx and in the Provider directory.
If a Member uses a non-network pharmacy, the medication may not be covered. Members
may use out-of-area pharmacies for emergencies only.
Medication Treatment Compliance Surveillance is designed to:
•
Monitor and enhance medication treatment compliance among Members;
•
Monitor and evaluate medication treatment patterns among Providers; and
•
Identify potential negative effects of medication treatment, to include drug-to-drug
interactions, contraindications, and medication side effects.
Drug Utilization Review Program
To promote safe and cost effective utilization, selected high-risk, high cost, specialized use
medications, or medications not included on the BeHealthy America’s Preferred Drug List
(PDL) require a Prior Authorization Drug Exception Request. A designated form for this
request is in Section 10 of this manual. Approval is granted for medically necessary
requests and/or when PDL alternatives have demonstrated ineffectiveness.
When these exceptional needs arise, the Physician should fax a completed Prior
Authorization Drug Exception Request Form to the Plan. Approval for use is based on the
Member’s medical and prescription benefit coverage, acceptable medical standards of
practice and FDA-approved uses. Additional forms may be obtained by sending your
request to the BeHealthy America Health Services Department at 1-855-522-2865 or
1-855-522-2969.
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7. QUALITY MANAGEMENT PROGRAMS
Overview
BeHealthy America has established a Quality Management (QM) Program designed to
comply with state and federal regulations and to promote quality care and service for
BeHealthy America Members. The QM Program also provides a system for improving
organizational processes. Provider contracts require participation in the BeHealthy America
QM Program.
The QM Program includes the use of performance data available through standardized
measures, including State and national information; performance measures, benchmarks
and root cause analyses that relate to measuring outcomes and identifying opportunities
for improvement.
Analytical resources are available through Quality Management staffing, and through the
employment of project-specific consultants. Our staff has access to end-user datasystems for claims/encounter data, enrollment and Health Services data; grievance and
administrative services, to provide information for performance measures and quality
improvement activities.
The annual QM Program is available through the Plan website under the quality
management section. This section includes information about the plan’s progress toward
meeting quality management goals. Providers are encouraged to review the website
regularly for current program information and updates. A printed copy of the QM Program
is available, upon request, to BeHealthy America Providers and Members.
Goals/Objectives
Program goals are to:
•
•
•
•
•
•
•
•
•
Improve and maintain BeHealthy America Members’ physical and emotional status;
Promote health through risk identification and early interventions;
Empower Members to develop and maintain healthy lifestyles;
Involve Members in treatment and care management decision-making;
Facilitate the use of evidence-based medical principles, standards and practices;
Promote accountability and responsiveness to Member concerns and grievances;
Coordinate utilization of medical technology and other medical resources efficiently and
effectively for Member welfare;
Facilitate accessibility and availability of Members to care in a timely manner; and
Promote Member safety in conjunction with effective medical care;
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Primary objectives of the BeHealthy America Quality Management Program include:
•
•
•
•
•
•
•
Proactively pursue methods to improve care and service for Members;
Develop interventions to improve the overall health of Members;
Develop systems to enhance coordination and continuity of care between medical and
behavioral health services;
Maintain systematic identification and follow-up of potential quality issues;
Educate Members, Physicians, Hospitals and Ancillary Providers BeHealthy
America’s quality management goals, objectives, structure and processes; and
Promote open communication and interaction between and among Providers and
Members.
BeHealthy America Quality Management Program components include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Member rights and responsibilities;
Confidentiality of Member information;
Member satisfaction, including grievance and appeals;
Access and availability of care and services;
Medical record keeping practices;
Preventive health and HEDIS measures;
Clinical quality improvement initiatives;
Quality of care evaluation;
Peer review;
Grievances and appeals;
Medical management, disease management and case management initiatives;
Coordination and continuity of care, including medical and behavioral health;
Credentialing re-credentialing activities;
Monitoring of delegated services;
Member safety;
Risk management;
Delegation oversight;
Provider and enrollee communication; and ·
Behavioral health.
The BeHealthy America Quality Management Program is evaluated and updated at least
annually, with input from BeHealthy America staff, network Providers, and Members.
The BeHealthy America Quality Management Program includes a committee structure that
incorporates committees designed to review and monitor medical management, quality
management, pharmacy and therapeutics, credentialing, peer review, and grievances/
appeals activities.
Providers who wish to participate in any of these committees are encouraged to notify the
Plan for consideration. A company-wide quality committee oversees all quality related
activities and reports to the Board of Directors.
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Provider Notification of Changes
Provider Manual
BeHealthy America will notify Physicians and Providers of material changes in writing, 30
days prior to putting the change into effect. These changes are communicated via
BeHealthy America's website (www.behealthyus.com), the Provider Manual, the Provider
Newsletter and/or letter mailed to the physician or provider.
A “material change” is a change that may influence a Physician or Provider’s decision to
remain in the Plan’s network. Examples of material changes are those that affect the
organization’s payment structure, the size of member panels, or the scope of a Physician
and/or Provider’s administrative responsibilities.
Please contact your local BeHealthy America Provider Relations Representative should
you have questions related to a change notification.
Medical Health Information
Participating Providers are expected to provide information to Plan Members regarding
their health status and treatment options, including self-treatment. Information provided
includes the risk, benefits and consequences of treatment or non-treatment. Providers
should also allow Members to participate in treatment decisions and to refuse treatment.
Medical Record Standards
In accordance with the BeHealthy America Physician Service Agreement, the Physician
shall ensure medical records are accurately maintained for each Member. It shall include
the quality, quantity, appropriateness and timeliness of services performed under this
contract.
Medical records shall be maintained for a period of no less than ten years, including after
termination of this Agreement and retained further if records are under inspection,
evaluation or audit, until such is completed.
Upon request, the Plan or any Federal or State regulatory agency, as permitted by law,
may obtain copies and have access to any medical, administrative or financial record of
Physician-related and Medically Necessary Covered Services to any Member. The
Physician further agrees to release copies of medical records of Members discharged from
the Physician to the Plan for retrospective review and special studies.
A medical record documents a BeHealthy America Member’s medical treatment, current
and past health status, and current treatment plans. A Member’s medical record is an
essential component in the delivery of quality health care. BeHealthy America has
established medical record standards available to all participating practitioners. Providers
are required to comply with these standards:
•
Every page in the record contains the member’s name, member ID number and birth
date;
•
Includes personal/biographical data including age, date of birth, sex, address,
employer, home and work telephone numbers, marital status and legal guardianship;
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•
The record reflects the primary language spoken by the member and any translation
needs of the member.
•
All entries are signed and dated;
•
All entries include the name and profession of the provider rendering services (e.g.,
MD, DO, OD), including the signature or initials of the provider;
•
All entries in the medical record contain legible author identification. Author
identification is a handwritten signature, stamped signature, or a unique electronic
identifier. Signature is accompanied by the author’s title (MD, DO, ARNP, PA, MA);
•
The record is legible to someone other than the writer;
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The record is maintained in detail;
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Medication allergies and adverse reactions are prominently noted in the record. If the
member has no known allergies or history of adverse reactions, this is noted in the
record (no known allergies = NKA);
•
Past medical history easily identified and includes serious accidents, significant
surgical procedures, and illnesses. For children and adolescents (21 years and
younger), past medical history relates to prenatal care, birth, operations, and childhood
illnesses;
•
Medical record includes previous physicals;
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The immunization record is up to date;
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Diagnostic information, consistent with findings, is present in the medical record;
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A treatment plan, including medication information, is reflected in the medical record;
•
A problem list including significant illnesses, medical conditions, health maintenance
concerns and behavioral health issues are indicated in the medical record;
•
Medical record includes a medication list;
•
A notation concerning the use of cigarettes and alcohol use and substance abuse is
present;
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If a consultation is requested, a note from the consultant is in the record;
•
Emergency Room discharge notes and hospital discharge summaries (hospital
admissions which occur while the member is enrolled in BeHealthy America, and prior
admissions, as necessary) with appropriate medically indicated in the medical record;
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•
The record includes all services provided including, but not limited to, family planning
services, preventive services and services for the sexually transmitted diseases;
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There is evidence that preventive screening and services are offered in accordance
with the BeHealthy America Care preventive services policies, procedures, and
guidelines;
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The record contains evidence of risk screenings;
•
The record contains documentation that the member was provided with written
information concerning member’s rights regarding advance directives, and whether or
not the individual has executed an advance directive;
•
The record contains copies of any advance directives executed by the member;
•
The record documents members seeking assistance with special communications
needs for health care services;
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Documentation of individual encounters provides adequate evidence of:
•
The history and physical expression of subjective and objective presenting complaints,
including the chief complaint or purpose of the visit.
•
The objective;
•
Diagnoses;
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Medical findings or impressions of the provider, as well as provider’s evaluation of the
member;
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Treatment plan;
•
Laboratory and other diagnostic studies used or ancillary services ordered; o Therapies
and prescribed regimens;
•
Encounter forms or notes regarding follow-up care, calls, or visits; o Unresolved
problems from previous visits;
•
Consultation, lab, and imaging reports filed in the chart initialed by the PCP to signify
review;
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Disposition, recommendations, instructions to the enrollee, evidence of whether there
was follow up and outcome of services;
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Medical records are secured in a safe place to promote confidentiality of member
information;
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•
Medical records and all member information are maintained in a confidential manner;
•
Minor members’ consultations, examinations, and treatment for sexually transmissible
diseases are maintained confidentially;
Additional medical record recommendations include:
•
All entries are neat, legible, complete, clear, and concise, written in black ink;
•
Entries are dated and recorded in a timely manner;
•
Records are not altered, falsified or destroyed;
•
Incorrect entries are corrected by drawing a single line through the error;
•
Avoiding correction fluid or markers that will obscure writing;
•
Dating and initialing each correction;
•
Making no additions or corrections to a medical record entry if a medical chart has
been provided to outside parties for possible litigation; and
•
All telephone messages and consent discussions are documented.
Assessing the Quality of Medical Record Keeping
BeHealthy America will assess practitioner compliance with these standards, and monitor
the processes used in practitioner’s offices. BeHealthy America establishes performance
goals for compliance with our medical record documentation standards.
Improving Medical Record Keeping
If a Provider does not meet Medical Record standards, both Provider Relations and Quality
Management staff will work with the Provider to improve medical record keeping.
Practitioners with identified deficiencies may be sent suggestions of how to improve their
medical recordkeeping practices, record-keeping aids, or examples of best practices that
meet the Plan’s recordkeeping standards.
Medical Record Review
The Plan adheres to the Privacy Rule established by the Health Insurance and Portability
Act of 1996 (HIPAA), which outlines national standards to protect individuals’ medical
records and other personal health information. The rule requires appropriate safeguards to
protect the privacy of personal health information, and sets limits and conditions on the
uses and disclosures that may be made of such information without patient authorization.
It also gives patients’ rights over their health information, including rights to examine and
obtain a copy of their health records, and to request corrections.
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To ensure HIPAA compliance, the Plan performs on-site medical record audits at the time
of re-credentialing and during routine medical record evaluations. Medical records are
reviewed for compliance with documentation requirements as outlined by regulatory and
accreditation agencies. They are also evaluated for compliance with preventive, chronic
and acute health care standards. Providers who do not meet BeHealthy America
standards for medical record documentation will be referred to the Medical Director for
follow-up, or to the Quality Management Committee for further action.
Medical Record Privacy & Confidentiality Standards
Medical Record Privacy and Confidentiality Standard 1
All BeHealthy America Members’ individually identifiable information whether contained in
the Member’s medical record or otherwise is confidential. Such confidential information,
whether verbal or recorded, in any format or medium, includes but is not limited to, a
Member’s medical history, mental or physical condition, diagnosis, encounters, referrals,
authorization, medication or treatment, which either identifies the Member, or contains
information that can be used to identify the Member.
Medical Record Privacy and Confidentiality Standard 2
In general, medical information regarding a BeHealthy America Member must not be
disclosed without obtaining written authorization. The Member, the Member’s guardian, or
conservator must grant the authorization. If the Member signs the authorization, the
Member’s medical record must not reflect mental incompetence. If authorization is
obtained from a guardian or conservator, evidence such as a Power of Attorney, Court
Order, etc., must be submitted to establish the authority to release such medical
information.
Medical Record Privacy and Confidentiality Standard 3
To release Member medical information, the entity must use a valid and completed Medical
Information Disclosure Authorization Form, prepared in plain language.
The form must include the following:
•
•
•
•
•
•
Name of the person or institution providing the Member information;
Name of the person or institution authorized to receive and use the information;
The Member’s full name, address, and date of birth;
Purpose or need for information and the proposed use thereof;
Description, extent or nature of information to be released identified in a specific and
meaningful fashion, including inclusive dates of treatment;
Specific date or condition upon which the Member’s consent will expire, unless earlier
revoked in writing, together with Member’s written acknowledgment that such
revocation will not affect actions taken prior to receipt of the revocation;
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•
•
•
•
•
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Provider Manual
Date that the consent is signed, which must be later than the date of the information to
be released;
Signature of the Member or legal representative and his or her authority to act for the
Member;
The Member’s written acknowledgment that Member may see and copy the information
described in the release and a copy of the release itself, at reasonable cost to the
Member;
The Member’s written acknowledgment that information used or disclosed to any
recipient other than a health plan or Provider may no longer is protected by law;
Except where the authorization is requested for a clinical trial, it must contain a
statement that it will not condition treatment or payment upon the Member providing the
requested use or disclosure authorization; and
A statement that the Member can refuse to sign the authorization.
Medical Record Privacy and Confidentiality Standard 4
Pursuant to laws that allow disclosure of confidential medical information in certain specific
instances, the Plan may release such information without prior authorization from the
Member, the Member’s guardian, or conservator for the following reasons:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Diagnosis or treatment, including emergency situations;
Payment or for determination of Member eligibility for payment;
Concurrent and retrospective review of services;
Claims management, claims audits, billing and collection activities;
Adjudication or subrogation of claims;
Review of health care services with respect to medical necessity, coverage,
appropriateness of care, or justification of charges;
Coordination of benefits;
Determination of coverage, including pre-existing conditions investigations;
Peer review activities;
Risk management;
Quality assessment, measurement and improvement, including conducting Members
satisfaction surveys;
Case management and discharge planning;
Managing preventive care programs;
Coordinating specialty care, such as maternity management;
Detection of health care fraud and abuse;
Developing clinical guidelines or protocols;
Reviewing the competency of health care Providers and evaluating Provider
performance;
Preparing regulatory audits and regulatory reports;
Conducting training programs;
Auditing and compliance functions;
Resolution of grievances;
Provider contracting, certification, licensing and credentialing;
Due diligence;
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•
•
•
•
•
•
•
•
•
•
Provider Manual
Business management and general administration;
Health oversight agencies for audits, administrative or criminal investigations,
inspections, licensure or disciplinary actions, civil, administrative, or criminal
proceedings or actions;
In response to court order, subpoena, warrant, summons, administrative request, or
similar legal processes;
To comply with Florida law relating to workers’ compensation;
To County coroner, for death investigation;
To public agencies, clinical investigators, health care researchers, and accredited nonprofit educational or health care institutions for research, but limited to that part of the
information relevant to litigation or claims where Member’s history, physical condition or
treatment is an issue, or which describes functional work limitations, but no statement
of medical cause may be disclosed;
To organ procurement organizations or tissue banks, to aid Member medical
transplantation;
To state and federal disaster relief organizations, but only basic disclosure information,
such as Member’s name, city of residence, age, sex and general condition;
To agencies authorized by law, such as the FDA; and
To any chronic disease management programs provided Member’s treating Physician
authorizes the services and care.
Medical Record Privacy and Confidentiality Standard 5
All individual BeHealthy America Member records containing information pertaining to
alcohol or drug abuse are subject to special protection under Federal Regulations
(Confidentiality of Alcohol and Drug Abuse Member Records, Code 42 of Federal
Regulation, chapter 1, Subchapter A. Part 2). An additional and specific consent form must
be used prior to releasing any medical records that contain alcohol or drug abuse
diagnosis.
Medical Record Privacy and Confidentiality Standard 6
Special consent for release of information is needed for all Members with HIV/AIDS and
mental health disorders. In general, medical information for Members who exhibit
HIV/AIDS and/or mental health disorders will always be reported in compliance with Florida
state law. Additional information will be released regarding a Member infected with the HIV
virus only with an authorized consent.
Information released to authorized individuals/agencies shall be strictly limited to the
information required to fulfill the purpose stated in the authorization. Any authorization
specifying “any and all medical information” or other such broadly inclusive statements
shall not be honored and release of information that is not essential to the stated purpose
of the request is specifically prohibited.
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8. CLAIMS
Provider Manual
General Payment Guidelines
Claims should be submitted in one of three formats:
•
•
•
Electronic claims submission,
CMS 1500 Form, or
UB04 Form.
Physicians/Providers are required to use the standard CMS codes for ICD9, CPT, and
HCPCS services, regardless of the type of submission.
Claims processing is subject to change based upon newly promulgated guidelines and
rules from CMS and AHCA.
Medicare General Payment Guidelines
For payment of Medicare claims, BeHealthy America has adopted all guidelines and rules
established by CMS. BeHealthy America Medicare Members may only be billed for their
applicable co-payments, co-insurance, deductibles, and non-covered services.
Mail claims to:
BeHealthy America, Inc.
C / O Claims
Processing P.O. Box
25492 Sarasota, FL
34240
Or, preferably, submit claims electronically through either EMDEON, our
clearinghouse, using Payer # 06080, or through our Provider Portal. Please note
there is no charge for claims submitted through our Provider Portal.
Member Responsibility
The Physician/Provider should collect the following payments from the Member based
upon the terms of your contract and the benefit plan design:
•
•
Deductible
Co-payments
Charges that can be billed and collected from the Member will be indicated on the
Explanation of Benefits (EOB) notice from the Plan. The provider will receive an
explanation of payment (EOP) from the plan.
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Prohibition of Billing Members
Provider Manual
As a participating Physician/Provider you have entered into a contractual agreement to
accept payment directly from BeHealthy America. Payment from the Plan constitutes
payment in full, with the exception of applicable co-payments, deductibles, and/or coinsurance as listed on the EOB/ EOP.
You may not “balance bill” Members for the difference between actual billed charges and
your contracted reimbursement rate. A Member cannot be “balance billed” for covered
services denied for “lack of information”. Failure to notify the Plan of a service that requires
prior authorization will result in payment denial. In this scenario, Plan Members may not be
“balance billed” and are responsible only for their applicable co-payments, deductibles,
and/or co-insurance.
A Member cannot be billed for a covered service that is not medically necessary. Unless
the Member’s informed written consent is obtained prior to rendering a non-covered
service. This consent must include information regarding their financial responsibility for
the specific services received.
Timely Submission of Claims
The Plan abides by CMS guidelines for Medicare timely submission of claims.
Timely submission is subject to statutory changes. Therefore, claims should be submitted
within the timely filing period established by regulatory statute, unless your contract
stipulates something different. Plan Members cannot be billed for services denied due to a
lack of timely filing. Claims appealed for “timely filing” should be submitted with “proof”
along with a copy of the EOP and the claim. Acceptable proof of timely filing will be in the
form of a registered postal receipt signed by a representative of the Plan, or a similar
receipt from other commercial delivery services.
Maximum Out-of-Pocket Expenses (MOOP)
The term Maximum Out-of-Pocket (MOOP) refers to the limit on how much a Medicare
Advantage Plan enrollee has to pay out-of-pocket each year for medical services that are
covered under Medicare Part A and Part B. Co-payments, co-insurance and deductibles
comprise member expenses for purposes of MOOP. MOOP is not applicable to the
member’s Medicare Part B Premium.
Our health plan has a MOOP. If a member reaches a point where they have paid the
MOOP during a calendar year (coverage period), the member will not have to pay any outof-pocket costs for the remainder of the year for covered Medicare Part A and Part B
services. If a member reaches this level, the Plan will no longer deduct any applicable
member expenses from the provider’s reimbursement.
The MOOP can change from year to year. Please refer to the Summary of Benefits
available online at our website: www.behealthyus.com. You may confirm that a member
has reached their MOOP by contacting the Member Services Department.
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Physician and Provider Reimbursement
Reimbursement for covered services is based on the negotiated rate as established in the
Physician or Provider Agreement. Services that require a referral and/or prior authorization
will be denied if services were rendered prior to approval. Please refer to your Physician or
Provider Agreement to determine the method that applies to your contract. Capitation
payments, based upon the number of assigned Members, will be made by or before the
20th day of the month.
The preferred method of claim submission is through an electronic format.
Physicians and Providers can submit claims directly through our provider portal,
individually or in a batch. The portal also interfaces with multiple practice management
systems that can create an 837 file; enabling claims to also be submitted directly to the
plan. Additionally the provider can submit claims electronically through EMDEON, which is
the clearinghouse for BeHealthy America. These claims submission processes will be
described in detail on the following page.
Electronic Claims Submission
BeHealthy America gives physicians and providers three ways to send claims
electronically.
The first way to submit claims electronically is to input the claim information directly into our
ClaimScape provider portal. There is no fee associated with this claim submission.
The second way to submit claims electronically is from your practice management system.
If your system can produce an 837 file, you will also be able to submit electronically
through the provider portal, there is no fee associated with the submission of claims in this
format.
Lastly, the physician or provider may submit claims to our clearinghouse, which is
EMDEON. The BeHealthy America Payer ID for EMDEON is 06080.
Unless you file your claims directly through our BeHealthy America Provider Portal,
electronic data filing requires billing software through which you can electronically send
claims data to a clearinghouse. Since most clearinghouses can exchange data with one
another, you can continue to use your existing clearinghouse even when it is not the
clearinghouse selected by BeHealthy America.
Prior to submitting claims through a clearinghouse exchange, you must check with your
existing clearinghouse to make sure they can complete the transaction with the BeHealthy
America's vendor. Our trading partner, EMDEON, can help establish electronic claim
submissions connectivity with our plan. The payer number for EMDEON is 060808 for
BeHealthy America.
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Tips on successfully submitting electronic claims:
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•
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•
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
Use the billing name and address on the electronic billing format that matches our
records.
Please notify our office of any name and address changes in writing.
Field NM1 relates to box 33 of a CMS1500 or the UB04 for all electronic claims
transmissions and 837’s.
Contact EMDEON with any transmission questions for claims submitted to them at 1800-845-6592
Ensure your clearinghouse can remit information to our trading partner, EMDEON.
You may reach EMDEON at 1-800-845-6592.
The Plan Member’s name;
The Plan Members, address, and insurance ID as indicated on the Member’s
identification card;
Information on other insurance or coverage;
The name, signature, place of service, address, billing address, and telephone number
of the Physician/Provider performing the service;
The tax identification number, NPI number, for the Physician or Provider performing the
service;
The appropriate ICD-9 codes at the highest level;
The standard CMS procedure or service codes with the appropriate modifiers;
The number of service units rendered;
The billed charges;
The name of the referring Physician;
The dates-of-service;
The place-of-service;
The referral and/or authorization number;
The NDC for drug therapy; and
Any job-related, auto-related, or other accident-related information, as applicable.
Completion of “Paper” Claims
Paper claims should be completed in their entirety including but not limited to the
previously listed elements above.
Electronic Transactions and Code Sets
To improve the efficiency and effectiveness of the health care system, Congress enacted
the Health Insurance Portability and Accountability Act (HIPAA). HIPAA includes a series
of administrative simplification provisions including the adoption of national standards for
electronic health care transactions.
On October 16, 2003, the Electronic Transaction and Code Set provision of HIPAA went
into effect. Law requires payers to have the capability to send and receive all applicable
HIPAA-compliant transactions and code sets.
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One requirement is that the payer must be able to accept a HIPAA-compliant 837
electronic claim transaction, in standard format, using standard code sets and standard
transactions. Specifically, claims submitted electronically must comply with the following
Provider-focused transactions:
•
270/271 – Health Insurance Eligibility/Benefit Inquiry & Response;
•
276/277 – Health Care Claim Status Request & Response;
•
278 – Health Care Services Review – Request for Review and Response; and
•
835 – Health Care Claim Payment/Advice
The X12N-837 claims submission transactions replaces the manual CMS 1500/UB92
forms. All files submitted must be in the ANSI ASC X12N format, version 4010A, as
applicable.
Encounter Data
Encounter Data is a record of covered services provided to our Members. An Encounter is
an interaction between a patient and Provider (health plan, rendering physician, pharmacy,
lab, etc.) who delivers services or is professionally responsible for services delivered to a
patient. BeHealthy America requires the submission of claims for all encounters in order
for the Plan to achieve state and federal reporting requirements.
Providers reimbursed on a capitation basis must file claims for all services.
Claims submitted under a capitation contract are referred to as “encounter data”.
Encounter data can be submitted on a “paper claim” format or through Electronic Data
Interface (EDI) following the same rules as submitting claims. BeHealthy America
recognizes these services as paid under the capitation contract and not paid to the
Physician or Provider directly. These services become an integral part of the BeHealthy
America claims history database and are used for analysis and reporting.
Capitated Physicians and Providers who do not submit encounter data could be terminated
from the Plan.
Coordination of Benefits (COB)
Coordination of Benefits (COB) is the procedure used to process health care payments for
a patient with one or more insurers providing health care benefit coverage. Prior to claims
submission, it is important to identify if any other payer has primary responsibility for
payment. If another payer is primary, that payer should be billed prior to billing BeHealthy
America.
When a balance is due after receipt of payment from the primary payer, a claim should be
submitted to the BeHealthy America for payment consideration. The claim should include
information verifying the payment amount received from the primary payer as well as a
copy of their explanation of payment statement. Upon receipt of the claim, BeHealthy
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America will review its liability using the COB rules and/or the Medicare/Medicaid
“crossover” rules— whichever is applicable.
Correct Coding
BeHealthy America has adopted a policy of reviewing claims to ensure "correct coding".
The Plan utilizes a corrective coding re-bundling/unbundling software, which is integrated
with our claims payment system, ClaimScape. Services that should be bundled and paid
under a single procedure code will be subject to review.
Claims Appeals
Claims appealed for the denial “no authorization” or other medical reasons” should be
submitted to the attention of the Appeals and Grievance Department. Please include
documentation explaining why an authorization was not obtained, any pertinent medical
records, a copy of the claim(s), and a copy of the denial statement received.
Claim appeals for denial of timely filing, incorrect payment, or denied in error, should be
submitted to the attention of the Claims Department at the Plan’s claims address. The time
frame for appealing a claim denial is 90 days from the date of the denial on the explanation
of benefits/payment. Cases appealed after the 90-day time limit will be denied for “untimely
filing”.
There is no “second level” consideration for appeals outside the timely filing requirement.
Acceptable proof of timely filing will be in the form of a registered postal receipt signed by a
representative of the Plan, or a similar receipt from other commercial delivery services.
The Plan has up to 60 days to review it for medical necessity and conformity to Plan
guidelines.
The Plan is not responsible for payment of medical records generated as a result of a
claims appeal. Cases received for lack of necessary documentation will be denied. The
Physician or Provider is responsible for providing the requested documentation within 60
days of the denial in order to re-open the case. Records and documents received after that
time frame will not be reviewed and the case will be closed.
In the case of a review in which the Physician or Provider has complied with Plan
guidelines and services are determined to be medically necessary, the denial will be
overturned. The Physician or Provider will be notified in writing to re-file the claim for
payment. If the claim was previously submitted and denied, the Plan will adjust it for
payment after the decision is made to overturn the denial.
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Reimbursement for Covering Physicians
Covering Physicians for Primary Care Physicians must agree to abide by Utilization
Management and Quality Management guidelines. The payment rate is according to the
Physician Agreement between the contracted PCP and the Plan – unless other
arrangements are in place. In the case of a capitated PCP, the covering Physician will
seek payment for services from the contracted Physician. The covering Physician shall not
seek payment from the Plan or the Plan Member with the exception of those services for
which the assigned PCP would have been permitted to collect, i.e., co-payments,
deductibles, and/or co-insurance from the Member.
Fee Schedule Updates
BeHealthy America updates fee schedules at the time they are publicly available by
Medicare.
Most negotiated reimbursement rates are based upon “prevailing” rates of Medicare.
Online Claims Information
BeHealthy America encourages Physicians and Providers to check the status of their
claims on the Provider Portal of BeHealthy America’s website at www.behealthyus.com. In
addition to checking claims status, you can also verify eligibility and benefit information.
You will need your log in ID number and password to access this information.
To learn more about using our website, please contact your local Provider Relations
representative.
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9. GRIEVANCE & APPEALS
Provider Manual
Introduction
BeHealthy America provides for Member and Provider grievances and appeals, as
established by Florida Statutes, Chapter 641, the Medicare Managed Care Manual,
Chapter 13, and the “Medicare Managed Care Beneficiary Grievances, Organization
Determinations, and Appeals Applicable to Medicare Health Plans” publication.
Definitions
Adverse Determination – An adverse determination is a decision regarding admission,
care, continued stay or other health care services to deny, reduce, or terminate services
based on BeHealthy America’s approved criteria for medical necessity, appropriateness,
health care setting, level of care or effectiveness and coverage for the requested service.
Appeal – An appeal is a request to a review a decision made regarding health care
services or payment.
Complaint – A complaint is an expression of dissatisfaction and can be classified as either
a grievance or an appeal. A complaint can be made to BeHealthy America or any
BeHealthy America Provider.
Grievance – A grievance is any complaint, other than one involving an organizational
determination (appeal), expressing dissatisfaction with health care services received from
or through BeHealthy America. Both verbal and written complaints are considered
grievances.
Grievance & Appeals System
BeHealthy America Members have the right to express verbal or written grievances and
appeals, as outlined in Member Rights and Responsibilities. These rights are provided in
the Evidence of Coverage Document sent to all of our Members. BeHealthy America has
developed a system to receive process and resolve Member grievances and appeals to
support these rights. All grievances and appeals are handled by the BeHealthy America
Grievance and Appeals Department.
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BeHealthy America will provide assistance with the grievance and appeals filing processes.
Providers may also contact BeHealthy America to file or support a Members’ filing of an
appeal or a grievance. Members may also contact BeHealthy America to file an appeal or
request a grievance form. Appeals and grievances are filed with BeHealthy America by
mail, telephone or fax at:
BeHealthy America, Inc.
C/O Grievance and Appeals Coordinator
P. O. Box 25492
Sarasota, FL 34277
Telephone/Fax: 855-522-2870 Fax: 888-972-4746
Member Services staff and the Grievance and Appeals Coordinator are available from 8:00
am to 8:00 pm to assist with questions regarding grievances and appeals.
Members may be assisted or represented by an outside legal advisor, practitioner, or other
designated representative during the appeal or grievance processes. BeHealthy America
requires written documentation of such representation, and advanced notice in the event
that the representative needs to attend any scheduled meetings or hearings.
Providers who want to file an Appeal or request additional information regarding preservice denials, grievances or pre-service denial appeals, may contact the Grievance and
Appeals Coordinator. If the appeal or request is submitted in writing, Providers should
include what is requested and any additional information to support the request.
BeHealthy America grievance and appeals policies are available to BeHealthy America
Members and Providers upon request.
Grievance & Appeals - BeHealthy America Medicare
This section of the Provider Manual provides guidance to participating Providers on the
Plan’s appeal process. Member appeals are detailed in the Explanation of Coverage
(EOC). The appeals process for Members of a Medicare Advantage plan is the same
regardless of the type of plan in which the Member is enrolled.
Member Grievance & Appeals
All participating Providers or entities delegated for Network Management and Network
Development are to use the same standards as defined in this section. Compliance is
monitored on an ongoing basis and formal audits are conducted annually.
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Participating Provider Claims Appeals
This section explains the appeal process for denied claims only. The appeals process for
pre-service denials can be found in the Health Services Section of this manual.
The terms and conditions of payment to participating Providers follow the mutual
obligations of the Plan and Providers per our Provider Agreement. Per our Agreement,
Physicians and Providers may not bill our Members, except for any co-payments or coinsurance. Any claims disputes for services provided to our Members have to be resolved
per the contract’s terms and conditions. Balance billing Members is also prohibited by
Medicare regulations. Claims may be denied for reasons including, but not limited to:
•
•
•
•
•
Lack of authorization;
Services not billed as authorized;
Billing with an incorrect code;
Place of service billed wrong; or
Provider not member’s PCP on date of service.
The specific reason for denial of the claim will be provided in the Evidence of Payment
document that is sent to Providers along with all paid/denied claims.
Once a claim is denied, the Provider may request a reconsideration regarding the Plan’s
decision. Providers must make this request in writing within 60 days of receipt of the initial
claims denial and send the request to the Grievance and Appeals address provided.
Additional information to support the request may be sent at this stage. Please also see the
Claims Appeals Section in Chapter 8 of this manual.
Submit written claims appeal for denials related to “no authorizations” or other medical
reasons to:
BeHealthy America, Inc.
C/O Grievance and Appeals Coordinator
P.O. Box 25492
Sarasota, Florida 34277
Submit written claims appeals for denials related to denial of timely filing, incorrect
payment, or denied in error to:
Medicare Claims appeals should be sent to:
BeHealthy America, Inc.
C/O Claims Processing
P.O. Box 25492
Sarasota, Florida 34277
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Non-participating Providers Appeal
BeHealthy America encourages the use of participating Providers but when a
nonparticipating Provider is used, the non-par Provider must follow these steps:
Step 1. Contact the PCP for all pre-service authorization requests. All claims of non-par
providers for services provided without a proper authorization will be denied.
Step 2. If a claim is denied, the non-par provider can file an appeal. However, all non-par
providers must sign a Waiver of Liability Form in order for the claim to be
reconsidered for payment. The Waiver of Liability form is attached to the Appeal
Acknowledgement Letter. If the Waiver Form is not completed and returned, the
case is prepared and sent to the Maximus CHDR (the Independent Review Entity)
for dismissal.
Step 3. Upon receipt of the Waiver Form, the claim and reason for the denial are reviewed.
The Grievance and Appeals staff either pays the claim or presents the case for
administrative review.
Step 4. Providers and Members are notified in writing of approved or denied claims.
Claims approved for payment on appeal are processed and paid within
established time frames to either the Provider or Member—whichever is
appropriate.
Step 5. Claims denied for payment after the appeal review, are processed and forwarded
to Maximus Federal Services, the Independent Review Agency (IRE) contracted
by CMS.
Expedited Claims Appeals
Providers can request an expedited appeal for pre-service requests only. There is not an
expedited appeal for post-service denials.
Medicare Grievance Process
Providers cannot file a grievance but are able to submit a complaint. Please see the
Provider Complaint Process that appears further in this section. Medicare Members may
file a grievance within 90 days of the event that initiated the grievance. BeHealthy America
will resolve the grievance within 30 days of receipt but may extend the resolution period by
up to 14 days if additional information is required.
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Provider Complaint Process
Provider Manual
Initial Complaint
A Provider Relations Representative is assigned to each contracted Provider to assist in
the administration of services to Plan Members. Any Provider who has a complaint may
call the Provider Services Department at 855-522-2967. A Provider Relations
Representative will assist the Provider to resolve the complaint.
Complaint Procedures
Formal complaints will be handled by the Grievance Department with the cooperation of
other departments involved with the complainant’s concerns—should the Provider
Relations Representative be unable to resolve the issue.
•
•
•
•
All issues with medical management will be reviewed confidentially by the Plan’s
Health Services Department.
A resolution to the Provider’s complaint will be due within 60 days from the receipt of
the formal complaint, except when information is needed from non-participating
providers or providers outside of the Plan’s service area. In such cases, this period
may be extended an additional 30 days, if necessary.
The complainant will receive a written notice when an extension is necessary. The time
limitations requiring completion of the grievance process within 60 days will be paused
after the Plan has notified the complainant in writing that additional information is
required to review the complaint properly. Upon receipt of the additional information
required, the time for completion of the grievance process will resume. The Plan will
communicate with the complainant during the formal grievance process.
A resolution letter with the Plan’s findings and/or decision will be sent to the Provider by
mail.
The Plan will provide to the complainant written notice of the right to appeal upon
completion of the full complaint review process.
The Plan will maintain an accurate record of each provider complaint. Each record will
include the following:
•
•
•
Complete description of the complaint;
Complainant’s name and address;
Complete description of factual findings and conclusions after the completion of the
formal complaint process; and
Complete description of the Plan’s conclusions pertaining to the complaint, as well as the
Plan’s final disposition of the grievance.
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10. SAMPLE FORMS & DOCUMENTS
The following sample forms and documents are included in this manual:
•
2014 Quick Reference Guide
•
2014 Pre-Cert Request Form(s)
•
2014 Referral Form
•
Consumer Assistance Notice
•
Member Rights & Responsibilities
•
PCP Member Transfer Request Form
•
Sample Member ID Cards
•
Procedures and J Codes That Do Not Need Authorization
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Quick Reference Guide Oct-13
Important Telephone Numbers
Corporate Office
Provider Relations Representatives:
Paige Flanders
Fax
Philip Boyd
Fax
Executive
Phone:
Fax:
941.587.6630
888.972.4749
941.444.6767 Ext. 104
888.972.4749
Director Provider Relations
DeeAnn Garey-Roy 941.308.7884
888.972.4749
Fax
Address:
BeHealthy America Member Services: 855.522.2870
855.522.2969
Health Services Phone
Health Services Fax
888.972.4750
TTY/TDD
855.522.2973
Web Site:
855.522.2865
888.972.4617
BeHealthy America, Inc.
6948 Professional Pkwy. East
Sarasota, FL 34240
www.behealthyus.com
Pharmacy
1.855.889.0045
Pharmacy Services
Envision Rx Options -Pharmacy Benefit Manager
Web-Based Information
* Formulary
* Coverage Determination Request Forms
BeHealthy America, Inc.
Claims Department
855.972.4757
Submit Claims to:
BeHealthy America, Inc.
Claims Department
P.O. Box 25492
Sarasota, FL 34277
EDI Information:
Payor ID:
06080
Clearing House- EMDEON
800.845.6592
Authorization Required
• Drugs not listed on the Formulary
• Some drugs on the Formulary require a Coverage
Determination Request
• Duplication of drug therapy
• Dosing that exceeds the FDA daily or monthly
quantity maximum
• Most self-injectable and infusion drugs
• Brand name requests when a generic exists
• Drug that has a step edit and the first line therapy is
inappropriate
• Prescriptions that exceed $ 1,000/prescription (some
exceptions apply) and/or plan limitations
Claims
Claims Appeals
Please send appeals to the address for claims
regarding untimely filing, incidental procedures,
bundling, unbundling, unlisted procedure codes,
non-covered codes, etc. Claims must be
submitted to BHA within 90 days of date of denial
from EOP.
Appeals & Grievances
A provider may file an appeal or grievance on behalf of
Mail an appeal or grievance with supporting
the member with the member's written consent. A
clinical documentation to:
provider may also seek an appeal through the Appeals
department within 60 calendar days when a claim is
BeHealthy America, Inc
ATTN: Appeals & Grievances
denied for lack of prior authorization, the service exceeds
P.O. BOX 25492
authorization has insufficient supporting documentation
Sarasota, FL 34277
or late notification.
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BeHealthy America Provider Web Portal
Website: www.behealthyus.com, look for Provider Portal link
1. Submit claims
2. Submit and view Referral And Pre-Certification Requests, upload documents
3. 24 hour access to eligibility and claim status
4. Contact customer service via e-mail
For help with the use of the portal, you may contact Provider Services @ 855.522.2870
Health Services Department- Authorizations
Authorization Requests Standard: Medicare allows up to 14 days to make a decision regarding a request for a service.
Urgent: Service is requested and date of service is within 3-5 days.
Expedited: A request can only be expedited if it is felt that waiting up to 14 days for a decision would
place the patient's life, health or ability to regain maximum function in serious jeopardy. If this is the case,
please call the Health Services Department and make a request for an expedited review.
Provider Complaints & Grievances
Provider complaints related to any administrative issue such as BeHealthy America's policies and
procedures or authorization/referral process must be submitted within 60 calendar days from the date of
the occurrence. Please submit your complaint in writing by mail or fax to:
Provider Services:
Phone: 855.522.2967
Fax: 888.972.4749
Contracted Networks
Behavioral Health- CompCare
800.458.6139
Contact CompCare directly for all
member Behavioral Health Services such
as: Hospital Services, PHP, Observation,
Substance Abuse and Behavioral Health
Counseling.
Dental- Argus
Optometry - Argus
Hearing - Argus
Laboratory Services: Labcorp (Clinical)
Argus Customer
Care Toll-Free
1.877.864.0625
Mon-Fri 8:30AM-5PM
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PRE-CERTIFICATION REQUEST FORM
Phone: 855.522.2969
Fax: 888.972.4750
Date: _________________________________
Standard
Urgent: Service is requested and date of service is within 3-5 days.
Expedited: A request can only be expedited if it is felt that waiting up to 14 days for a
decision would place the patient's life, health or ability to regain maximum function in
serious jeopardy. If this is the case, please call the UM Department and make a request
for an expedited review.
Member Information
Requesting Physician: PCP________ Specialist_________
Name: ______________________________________
Name: ________________________________________________________________
ID#: ________________________________________
Provider # or TIN# __________________ Contact Person:_______________________
Date of Birth:_________________________________
Phone: __________________________
Fax: ______________________________
Facility Requested (no abbreviations)
Provider Requested (no abbreviations)
Name: _______________________________________________________
Name: ___________________________________________________
TIN# _________________________________
TIN #__________________
Non-Par
Phone: ____________________ Fax:_____________________
Pre- Cert Service Requested
Check appropriate request(s)
Non-Par
Phone: ___________________ Fax: ___________________________
These services require medical records to be submitted with this request form
Experimental/Investigational Procedures
Genetic Testing/Non par Laboratory
Hepatitis B Vaccine
Home Health(__RN, __PT, __OT, __MSW,
__ ST, ___HHA)
Acute Rehabilitation Facility
ASC for Blepharoplasty,
Podiatric Surgery, Reduction
Mammoplasty, Rhinoplasty,
Septoplasty, Vein Treatments,
Ocular Surgery, Plastic surgery
only. Other procedures by par
providers may be done on
Referral.
Cardiac Catheterization (any
location)
Clinical Trials
Cosmetic Procedures
Dialysis
DME - > $500.00 / POS
Hyperbaric Oxygen Therapy
Injectables/Infusion Therapy
Inpatient Hospital or Outpatient Hospital
Implantable pumps/devices/stimulators
Medical Nutrition Education
MOHS Procedure (Dermatology)
Non-Participating Provider
Outpatient Hospital
Pain Management
Radiation Therapy
Radiology: PET Scan, Pill or Virtual
Endoscopy (PCP must request
pre-cert)
Skilled Nursing Facility/ CORF
Sleep Studies
TMJ Joint Treatment
Transplant
Transportation
Wound Care
Certain Part B Drug Codes (See
list for those that do not require
pre-cert)
Other______________________
The following services require the plan to be notified via fax: 888.972.4750
Diabetic Education
Rehabilitation: Cardiac, Pulmonary, Respiratory
Hospice Enrollment
Service Code
Obstetrical Care
Physical, Occupational or Speech Therapy > 10 visits
NO MEDICAL RECORDS ARE NEEDED FOR THE ABOVE SIX SERVICES THAT ONLY REQUIRE NOTIFICATION
Description
# of Units/Visits/Injections
Date of Service:
Comments or additional codes:
ICD-9 Code(s):
BeHealthy America Pre-Certification Form 1-2014
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Referral Form
Date:______________
Referral Start Date:_________________
End Date:__________________
(Dates left blank will default to 60 days)
MEMBER INFORMATION
REFERRING PHYSICIAN INFORMATION
Name:__________________________________________________Name:________________________________________________
Date of Birth:________________ ID# ________________________Phone:______________________ Fax:______________________
Phone:_________________________________________________ Point of Contact:____________________________ Ext.__________
REFERRED TO
(Check One)
Physician
Radiology Center
DME Provider
Therapy
(Must be a participating provider)
Name:__________________________________________________Phone:______________________ Fax:_______________________
Address:________________________________________________Tax ID#_______________________________________________
_____________________________________________________ ICD-9:_______________Description:________________________
Office Visit: ____________ visit(s)
Office Visit and treatment ____________ visit(s)
Office Visit and Treatment: ______________ visits with the below services only
PT
OT
ST
________visit(s)
Code:______________ Description________________________
Code:______________ Description_________________________
Code:______________ Description________________________
Code:______________ Description_________________________
FACILITY
Ambulatory Surgery Center only (Inpatient and Outpatient Hospital require Pre-Certification)
Name of Facility:________________________________________________________________ (Must be a participating provider)
Address: _______________________________________________ Phone:______________________ Fax:_______________________
________________________________________________Tax ID#_______________________________________________
Comments or additional codes:
Addition to existing Referral
FAX to 888.972.4750
Note to receiving Provider/Facility. This referral form is only for services listed above. If you are an out of network provider,
Inpatient Facility or Outpatient Hospital provider, an authorization is required for your services. This is not an authorization form and
payment is not guaranteed. If you have any questions please call Health Services at 855-522-2969.
INSTRUCTIONS- this referral is for the following only:
·
·
·
Participating specialists for office visit and treatments
in the office that do not require pre-Certification
Free-Standing (not hospital-based) radiology center for
MRAs, MRIs and Nuclear Medicine.
Ambulatory Surgery Centers- except for excluded
procedures (see Pre-Certification list)
BHA Referral Form 1/2014
·
·
DME and Orthotics/Prosthetics – oxygen, c-pap,
nebulizers (rentals only) and any DME/orthotic/
prosthetic purchase less than $500.00
Physical, Occupational or Speech Therapy, in free-standing
office for Evaluation plus 9 visits (10 total), home therapy or
outpatient therapy and visits more than 10 require
Pre-Certification
www.BeHealthyus.com
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Consumer Assistance Notice
(Posted in compliance with s.641.511(11), Florida Statutes and the Patient’s Bill of Rights)
Patient Grievances may be filled with the following government agencies:
Agency for Health Care Administration, Consumer Hotline
888.419.3456
2727 Mahan Drive, Bldg. 1, Suite 339
Tallahassee, FL 32308
Statewide Provider and Subscriber Assistance Program
888.419.3456
2727 Mahan Drive, Bldg. 1, Suite 339
Tallahassee, FL 32308
Florida Department of Financial Services-Offices of Insurance Regulation
850.413.3140
200 E. Gains Street, Larson Building
Tallahassee, FL 32399-0300
The address and toll-free number of the organization’s grievance department shall be provided upon
request.
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SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES
Florida law requires that your health care provider or health care facility recognize your rights while you
are receiving medical care and that you respect the health care provider’s or health care facility’s right
to expect certain behavior on the part of patients. You may request a copy of the full text of this law
from your health care provider or health care facility. A summary of your rights and responsibilities
follows:
A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual
dignity, with protection of his or her need for privacy.
A patient has the right to a prompt and reasonable response to questions and requests.
A patient has the right to know who is providing medical services and who is responsible for his or her
care.
A patient has the right to know what patient support services are available, including whether an
interpreter is available if he or she does not speak English.
A patient has the right to know what rules and regulations apply to his or her conduct.
A patient has the right to be given by the health care provider information concerning diagnosis,
planned course of treatment, alternatives, risks and prognosis.
A patient has the right to refuse any treatment, except as otherwise provided by law.
A patient has the right to be given, upon request, full information and necessary counseling on the
availability of known financial resources for his or her care.
A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment,
whether the health care provider or health care facility accepts the Medicare assignment rate.
A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for
medical care.
A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and,
upon request, to have the charges explained.
A patient has the right to impartial access to medical treatment or accommodations, regardless of race,
national origin, religion, handicap, or source of payment.
A patient has the right to treatment for any emergency medical condition that will deteriorate from
failure to provide treatment.
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A patient has the right to know if medical treatment is for purposes of experimental research and to give
his or her consent for refusal to participate in such experimental research.
A patient has the right to express grievances regarding any violation of her or his rights as stated in
Florida law, through the grievance procedure of the health care provider or health care facility which
served her or him and to the appropriate state licensing agency.
A patient is responsible for providing to the health care provider, to the best of her or his knowledge,
accurate and complete information about present complaints, past illnesses, hospitalizations,
medications and other matters relating to his or her health.
A patient is responsible for reporting unexpected changes in her or his condition to the health care
provider.
A patient is responsible for reporting to the health care provider whether she or he comprehends a
contemplated course of action and what is expected of her or him.
A patient is responsible for following the treatment plan recommended by the health care provider.
A patient is responsible for keeping appointments and, when she or he is unable to do so for any reason,
for notifying the health care provider or health care facility.
A patient is responsible for her or his actions if she or he refuses treatment or does not follow the health
care provider’s instructions.
A patient is responsible for assuring that the financial obligations of her or his health care are fulfilled as
promptly as possible.
A patient is responsible for following health care facility rules and regulations affecting patient care and
conduct.
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PCP REQUEST FOR MEMBER TRANSFER
Physician:
ID#:
Telephone:
Fax:
Member:
ID#:
Telephone:
Please include detailed reason for request:
Disruptive Behavior
Missed Appointment:
Date:
Other:
Description:
Date:
Medical Records #
Non Compliance with treatment
Date:
PLEASE SUBMIT A COPY OF THE PROGRESS NOTES FROM THE MEMBER’S MEDICAL RECORD THAT
DOCUMENTS YOUR CONCERN.
Physician Signature:
Instructions:
Date:
Please complete this request in its entirety and attach all supporting documentation, including pertinent medical records and
office notes. Dot not discuss your request to transfer a member from your care until you receive approval from BeHealthy
America. Submit your request to:
BeHealthy America, Inc
P.O. Box 25492
Sarasota, FL 34277
-orYou may fax back the completed form and documentation to 888.972.4746
Section to be completed by the Health Plan
Medical Director:
Signature:
Date Received:
Approved or
Disapproved
Date Closed:
New PCP Assignment: Yes or No
Effective Date:
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BeHealthy America Member ID Card
Front:
<2014>
Plan: <H2758BHA002>
ID: <XXXXXX>
Effective Date: <XX/XX/XXXX>
RxBin: <012312>
RxPCN: <PARTD>
RxGroup: <H2758002>
Name: <First MI Last>
PCP Name: <Dr. First Last>
PCP Phone: <XXX-XXX-XXXX>
24/7 Nurse Line: <855-522-2969>
<$0>
<$35>
<$30>
<$65>
PCP
Specialist
Urgent Care
ER
Back:
Members: See your Summary of Benefits for covered services.
Possession of this card does guarantee eligibility for benefits.
For members:
For providers:
Questions about your medical services?
• Call BeHealthy America at <855-522-2870>
<(TTY/TDD: 855-522-2973)>
Questions about your prescription drug coverage?
• Call <EnvisionRx Options> at <855-889-0045>
Questions about your <Dental, Vision or Hearing
services?>
• Call <Argus> at <877-864-0625>
Questions about Behavioral Health services?
Call <CompCare> at <877-224-7504>
PROVIDERS MUST NOT BILL MEDICARE
<www.behealthyus.com>
Provider Services: <855-522-2967>
Submit medical claims to:
BeHealthy America – Claims
<PO Box 25492
Sarasota, FL 34277>
<Payor ID: 06080>
Submit prescription claims to:
<Envision/Rx Options, Inc.
2181 E. Aurora Road, #201
Twinsburg, OH 44087>
H2758_MemIDCard V114
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Procedures and JCodes that do not need Authorization
HCPCS
Code Short Description
90740
Hepatitis b vaccine, dialysis/immunosuppressed, 3 dose sched, IM
90371
90375
Hepatitis B immune globulin, IM
90743
Hepatitis b vaccine, adol, 2 dose scheduled IM
Rabies immune globulin, IM/SC
90744
Hepatitis b vaccine, ped/adol, 3 dose IM
90376
Rabies immune globin, heat treated, IM/SC
90746
Hepatitis b vaccine, adult, IM
90385
Rho(D) immune globulin, mini-dose, IM
90747
Hepatitis b vaccine, dialysis/immunosuppressed, 4 dose sched, IM
90585
BCG vaccine, percutaneous
J0130
Abciximab (Repro), 10 mg
90586
BCG vaccine, intravesical
J0278
Amikacin sulfate (Amikin), 100 mg
90632
Hepatitis A vaccine, adult IM
J0280
Aminophyllin, to 250 mg
90633
Hepatitis A vaccine, ped/adol, 2 dose schedule, IM
J0282
Amiodarone HCL (Cordarone), 30 mg
90647
Hemophilus influenza b vaccine, 3 dose schedule, IM
J0290
Ampicillin, 500 mg
90655
Flu vaccine no prsrv, 6-35m, IM
J0295
Ampicillin sodium/sulbactam (Unasym), per 1.5 gm
90656
Flu vaccine no prsrv, 3 yo & >, IM
J0330
Succinylcholine chloride (Anectine, Quelicin), to 20 mg
90657
Flu vaccine, 6-35 mo, IM
J0360
Hydralazine HCL, to 20 mg
90658
Flu vaccine, age 3 yo & over, IM
J0456
Azithromycin (Zithromax), 500 mg
90660
Flu vaccine, nasal
J0461
Atropine (AtroPen), 0.01 mg
90669
Pneumococcal vaccine, 7 valent, IM
J0500
Dicyclomine (Bentyl), to 20 mg
90675
Rabies vaccine, IM
J0515
Benztropine mesylate (Cogentin), per 1 mg
90691
Typhoid vaccine, IM
J0583
Bivalirudin (Angiomax), 1 mg
90703
Tetanus vaccine, IM
J0592
Buprenorphine HCL (Buprenex), 0.1 mg
90714
Tetanus and diphtheria vaccine, no prsrv, >/ 7 yo, IM
J0595
Butorphanol tartrate (Stadol), 1 mg
90715
Tetanus, diphtheria, and pertussis vaccine (Tdap), = > 7 J0610
yo, IM
90717
Yellow fever vaccine, SC
J0636
Calcitriol (Calcijex), 0.1 mcg J1094 Dexamethasone acetate, 1 mg
90732
Pneumococcal vaccine, SC/IM
J0670
Mepivacaine HCL, per 10 mg
90733
Meningococcal vaccine, SC
J0690
Cefazolin (Ancef, Kefzol), 500 mg
90735
Encephalitis vaccine, SC
J0692
Cefepime (Maxipime), 500 mg
J0694
J0696
J0697
J0698
J0702
Cefoxitin sodium, 1 g
Ceftriaxone (Rocephin), per 250 mg
Cefuroxime (Zinacef), per 750 mg
Cefotaxime (Claforan), per g
Betamethasone acetate 3 mg & Betamethasone sodium
phosphate 3 mg (Celestone Soluspan)
J1240
J1245
J1250
J1265
J1327
Dimenhydrinate, up to 50 mg
Dipyridamole (persantine), per 10 mg
Dobutamine HCL, per 250 mg
Dopamine HCL, 40 mg
Eptifibatide (Integrilin), 5 mg
J0706
J0713
J0720
J0735
J0744
J0760
J0780
J0795
J1000
J1020
J1030
J1040
J1070
J1080
J1094
J1100
Caffeine citrate (Cafcit), 5 mg
Ceftazidime (Ceptax, Fortaz, Tazicef), per 500 mg
Chloramphenicol (Chlormycetin), to 1 mg
Clonidine HCL (Clorpres, Duraclon, Iopidine), 1 mg
Ciprofloxacin (Cipro), 200 mg
Colchicine, per 1 mg
Prochlorperazine (Compazine Ultrazine-10), to 10 mg
Corticoreln ovine triflutate (Acthrel), 1mcg
Depo-estradiol cypionate, to 5 mg
Methylprednisolone (Depo-Medrol), 20 mg
Methylprednisolone, 40 mg
Methylprednisolone, 80 mg
Testosterone cypionate, 100 mg
Testosterone cypionate, 200 mg
Dexamethasone acetate, 1 mg
Dexamethasone sodium phosphate, 1 mg
J1364
J1410
J1450
J1457
J1580
J1610
J1626
J1630
J1631
J1642
J15644
J1700
J1720
J1790
J1800
J1815
Erythromycin lactobionate, 500 mg
Estrogen conjugate, per 25 mg
Fluconazole (Diflucan), 200 mg
Gallium nitrate (ganite), 1 mg
Garamycin, Gentamicin, to 80 mg
Glucagon HCL, per 1 mg
Granisetrn HCL (Kytril), 100 mcg
Haloperidol (Haldol), up to 5 mg
Haloperidol decanoate, per 50 mg
Heparin sodium (Heparin lock flush), per 10 U
Heparin sodium, per 1,000 U
Hydrocortisone acetate, to 25 mg
Hydrocortisone sodium succinate (solu-Cprtef), to 100 mg
Droperidol (Inderal), to 5 mg
Propranolol HCL (Inderal), to 1 mg
Insulin, per 5 U
PtBDrugNoAuth
Page 1 of 2
Calcium gluconate, per 10 ml
Rev.110113
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Procedures and JCodes that do not need Authorization (cont.)
J1110
J1160
J1165
J1200
J1956
Dihydroergotamine mesylate (D.H.E. 45), per 1 mg
Digoxin (Lanoxin), to 0.5 mg
Phenytoin sodium (Dilantin), per 50 mg
Diphenhydramine HCL, to 50 mg
Levofloxacin (Levaquin), 250 mg
J1817
J1840
J1885
J1940
J2675
Insulin for use in pump, per 50 U
Kanamycin (Kantrex), to 500 mg
Ketorolac tromethamine (Toradol), per 15 mg
Furosemide (Lasix), to 20 mg
Progesterone, per 50 mg
J2001
Lidocaine HCL IV infusion, 10 mg
J2680
Fluphenazine decanoate, to 25 mg
J2010
Lincomycine HCL (Lincocin), to 300 mg
J2690
Procainamide HCL (Pronestyl), to 1 mg
J2060
Lorazepam (Ativan), 2 mg
J2700
Oxacillin sodium (Bactocill), to 250 mg
J2150
Mannitol, 25% in 50 ml
J2710
Neostigmine methylsulfate (Prostigmin), to 0.5 mg
J2175
Meperidine (Demerol), per 100 mg
J2720
Protamine sulfate, per 10 mg
J2210
Methylrgonovin malate, to 0.2 mg
J2765
Metoclopramide HCL (Reglan), to 10 mg
J2250
Midazolam HCL (versed), per 1 mg
J2680
Ranitidine HCL (Zantac), 25 mg
J2270
Morphine sulfate, to 10 mg
J2785
Regadenoson (Lexiscan), 0.1 mg
J2271
Morphine sulfate, 100 mg
J2795
Ropivacaine HCL (Naropin), 1 mg
J2275
Morphine sulfate, per 10 mg
J2800
Methocarbamol (Robaxin), to 10 ml
J2300
Nalbuphine HCL (Nubain), per 10 mg
J2805
Sincalide (Kinevac), 5 mcg
J2310
Naloxone HCL (Narcan), per 1 mg
J2920
Methylprednisolone sodium succinate (Solu-Medrol), to 40 mg
J2360
Orphenadrine citrate (Norflex), to 60 mg
J2930
Methylprednisolone sodium succinate (Solu-Medrol), to 125 mg
J2370
Phenylephrine HCL, to 1 ml
J2993
Reteplase (Retavase), 18.1 mg
J2405
Ondansetron HCL (Zofran), per 1 mg
J3000
Streptomycin, to 1 mg
J2410
Oxymorhpone HCL, to 1 mg
J3030
Sumatriptan succinate (Imitrex), 6 mg
J2510
Penicillin G procaine, up to 600,000 U
J3105
Terbutaline sulfate, to 1 mg
J2515
Pentrobarbital sodium, per 50 mg
J3120
Testosterone Enanthate (Delatestryl), to 100mg
J2540
Penicillin G potassium, to 600,000 U
J3130
Testosterone Enanthate (Delatestryl), to 200mg
J2543
Piperacill sodium/tazobactam sodium, 1g/0.125g
(1.125 g)
J3250
Trimethobenzamide HCL, to 200 mg
J2550
Promethazine HCL (Phenergan), to 50 mg
J3260
Tobramycin sulfate (Nebcin), to 80 mg
J2560
Phenobarbital sodium, to 120 mg
J3300
Triamcinolone acetonide, 1 mg
J2590
Oxytocin, to 10 U
J3301
Triamcinolone acetonide, 10 mg
J2650
Predinsolone acetate, to 1 mg
J3302
Triamcinolone diacetate, per 5 mg
J3303
Triamcinolone hexacetonide, per 5 mg
J7674
Methacholine chloride, inhalation sln, per 1 mg
J3310
Perphenazine (Trilafon), to 5 mg
J8540
Dexamethasone, oral, 0.25 mg
J3360
Diazepam (Valium), to 5 mg
J9017
Arsenic trioxide, 1 mg
J3370
Vancomycin HCL, 500 mg
J9260
Methotrexate sodium, 50 mg
J3410
Hydroxyzine HCL, to 25 mg
S0020
Bupivacaine HCL, 30 mg
J3411
Thiamine HCL, 100 mg
S0077
Clindamycin phosphate, 300 mg
J3415
Pyridoxine HCL, 100 mg
J7050
NS solution, 250 cc
J3420
Vitamin B-12 cyanocabalamin, to 1,000 mcg
J7060
D5W, 1,000 cc
J3430
Phytonadione (Vit.K), per 1 mg
J7100
Dextran 40, 500ml
J3475
Magnesium sulfate, per 500 mg
J7110
Dextran 75, 500ml
J3480
Potassium chloride, per 2 mEq
J7120
Ringers lactate, to 1,000 cc
J7030
NS solution, 1,000 cc
J7609
Albuterol, inhalation sln, compounded, unit dose, 1 mg
J7040
NS solution, 500ml = 1 U
J7611
J7042
D5 NS, 500ml = 1 U
Albuterol, inhalation sln, noncompounded, concentrated form,
1 mg
J7613
Albuterol, inhalation sln, noncompounded, unit dose,
1 mg
J7642
Glycopyrrolate, inhalation sln, compounded, concentrated, per mg
J7620
Albuterol, to 2.5 mg and ipatropium bromide, to 0.5
mg, noncompounded, via DME
J7644
Ipratropium bromide, inhalation sln, noncompounded, unit dose,
per mg
PtBDrugNoAuth
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Rev.110113
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