1. health and fitness

PACE 2014
PROVIDER OFFICE MANUAL
1
TABLE OF CONTENTS
INTRODUCTION..............................................................................................................5
PARTICIPANT BILL OF RIGHTS ................................................................................8
PARTICIPANT IDENTIFICATION CARD ................................................................12
REFERRALS & PRIOR AUTHORIZATIONS ...........................................................13
URGENT & EMERGENCY CARE ..............................................................................14
CREDENTIALING & RECREDENTIALING ............................................................15
•
•
•
•
•
•
•
•
•
•
•
Physician & Healthcare Providers .................................................................................... 15
Facility .............................................................................................................................. 15
Skilled Nursing Facility .................................................................................................... 15
Delegated credentialing .................................................................................................... 16
Medical Record Review .................................................................................................... 16
Provider Information......................................................................................................... 17
Adverse Credentialing Determination ............................................................................. 17
Request for Additional Information .................................................................................. 17
Appeals ............................................................................................................................. 18
Provider Termination ........................................................................................................ 19
Private Contract “Opt Out” ............................................................................................... 20
ADVERSE REIMBURSEMENT CHANGE.................................................................21
SANCTIONS ....................................................................................................................21
REINSTATEMENT ........................................................................................................21
RESOLUTION OF DISPUTES ......................................................................................22
ARBITRATION ...............................................................................................................22
BILLING/CLAIMS SUBMISSION ...............................................................................23
• Payment/Participant Held Harmless ......................................................................23
• General Billing .......................................................................................................24
• NPI (National Provider Identifier) .........................................................................24
• Paper Claims Submission ......................................................................................24
• Present on Admission ............................................................................................26
2
•
•
•
•
•
•
Facility claims ........................................................................................................26
Late Claims ............................................................................................................27
Reconsiderations ....................................................................................................28
Explanation of Payment .........................................................................................28
Claims Inquiries .....................................................................................................29
Notice of Overpayment ..........................................................................................31
MEDICAL RECORD KEEPING ..................................................................................33
• Access to Medical Records ....................................................................................33
• Record Retention ...................................................................................................33
• Access and Audit of Records .................................................................................34
• HITECH Act ..........................................................................................................36
FRAUD WASTE & ABUSE ...........................................................................................37
HIPAA COMPLIANCE & RELEASE OF INFORMAITON.....................................38
QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT ...................................... 38
PARTICIPANT APPEALS & GRIEVANCE ...............................................................40
Grievance Procedure ..........................................................................................................40
Appeals Procedure .............................................................................................................41
Expedited Appeals Process ................................................................................................41
Additional Appeal Rights under Medicare & Medicaid ....................................................41
Provider Demographic Change Form............................................................................42
DEFINITIONS .................................................................................................................43
3
How to Contact ArchCare Senior Life/ PACE
Administrative Office/Plan Address
33 Irving Place
11th Floor
New York, NY 10003
Customer Service
(866) 263-9083:
24 hour answering service available after business hours and weekends
TTY/TDD (Teletype) should dial 711
Provider Services:
Telephone
Fax Inquiries
1-866-263-9083
1-646-417-7157
Provider Services can provide Authorizations, Credentialing information, Contract Status,
Provider Information Changes, Training and Orientations.
Compliance Hotline
Telephone
(Fraud and Abuse Prevention)
1-800-443-0463
Claims:
Telephone
1-866-263-9083
All services must be prior authorized and billed through ArchCare Senior Life. Services may
be provided by network providers ONLY and must be pre-authorized. Failures to contact
ArchCare Senior Life prior to the provision of non-emergency services will forfeiture of
billing rights for all unauthorized services. In an Emergency, Prior Authorization is not
required. If the patient is presenting in an emergency room, please contact ArchCare Senior
Life immediately at (866) 263-9083.
Claims Submission Address
TriState Benefit Solutions
C/o ArchCare Senior Life / PACE
619 Oak Street
Cincinnati, OH 45206
Electronic Claims (Payer ID 31144)
TriState Benefits Solution
Claims Inquiry Telephone
4
1-513-569-5049
Introduction
To
ArchCare Senior Life (PACE)
Provider Manual
5
Introduction
Welcome to ArchCare Senior Life.
ArchCare Senior Life is a community based model of care for nursing home eligible participants
sponsored by ArchCare, the continuing care community of the Archdiocese of New York.
As a provider of services, you have a special place in our program. Through effective use of
services that focus on enhancing our participants’ quality of life and functional capacity, we can
achieve our program goal of managing the frail elderly in their homes and community as long as
it is socially, medically, and economically feasible.
ArchCare Senior Life is a PACE Model of Care
The PACE program is based on a successful long-term care model developed in San Francisco
known as On Lok. Nationally known as PACE (Program of All-Inclusive Care for the Elderly),
it was developed as a special health plan for senior citizens that helps them stay as independent
as possible for as long as possible.
The PACE is a unique model of managed care service delivery for a small number of very frail
community-dwelling elderly, most of whom were dually eligible for Medicare and Medicaid
coverage and all of whom were assessed as being eligible for nursing home placement
according to the standards established by the State.
The model of care includes as core services the provision of adult day health care and
multidisciplinary team case management, through which access to and allocation of all health
services was controlled. Physician, therapeutic, ancillary and social support services are
furnished in the participant’s residence or on-site at the adult day health center, unless those
locations were not feasible. Hospital, nursing home, home health, and other specialized services
are furnished under contract. Financing of this model is accomplished through prospective
capitation of both Medicare and Medicaid payments.
6
Eligibility
To be eligible to enroll as an ArchCare Senior Life participant, an individual must be:
1.
55 years of age or older
2.
A resident of New York (Manhattan), Bronx or Richmond counties
3.
Eligible for nursing home level of care based on an established criterion for New
York State
4.
Eligible for Medicare and/or Medicaid and/or willing to pay privately
5.
Able to live safely in the community with the services of the plan
6.
Expected to need the long term care services of the plan for at least 120 days
The ArchCare Senior Life Intake Enrollment department assesses all potential participants prior
to enrollment and verifies that all persons meet nursing home eligibility requirements.
When the participant is enrolled, their care is planned and directed by ArchCare Senior Life’s
interdisciplinary team. Care is focused on preventive services and maintenance or improvement
of functional status as well as ongoing medical care. Periodic assessment by the interdisciplinary
team keeps the care plan and service delivery on track.
ArchCare Senior Life offers a full range of services, including primary medical care and
rehabilitative therapy services at our PACE center, home care, inpatient services; both acute care
through local hospitals and nursing home care through affiliated providers, drugs, and durable
medical equipment and supplies.
When a participant is enrolled in ArchCare Senior Life, we become the sole provider and payer
of services. This ensures a coordinated, comprehensive approach to our participants’
care. Services are available 24 hours a day, 7 days a week, and 365 days a year. Most of these
services will be provided in ArchCare Senior Life’s PACE center. Those services that cannot be
provided at the center will be provided in the home, or by our network of contracted providers,
such as you, in consultation with our interdisciplinary team. This Provider manual is meant to
assist you in working with our participant’s within the framework of ArchCare Senior Life’s
policies and procedures. Familiarizing yourself with and adhering to the procedures outlined in
this Manual will help to ensure a mutually beneficial, productive relationship in caring for our
enrolled participants.
7
Participant Rights
Participant’s Rights in the Program of All-inclusive Care for the Elderly (PACE)
The Program of All-inclusive Care for the Elderly, (PACE) is a Special program that combines
medical and long-term care services in a community setting.
When enrolled in a PACE program participants have certain rights and protections.
The PACE program must fully explain the rights to all participants or someone acting on their
behalf in a way that they can understand at the time they join. As a provider, you have the
responsibility to respect every participant’s rights.
The PACE Participant Bill of Rights follows:
1.
They have the right to be treated with dignity and respect at all times and to have
all of their care kept private, and to get compassionate, considerate care.
2.
They have the right:
• To get all of their health care in a safe, clean environment.
• To be free from harm. This includes physical or mental abuse, neglect,
physical punishment, being placed by themselves against their will, and
any physical or chemical restraint that is used on them for discipline or
convenience of staff and that they do not need to treat their medical
symptoms or to prevent injury.
• To be encouraged to use their rights in the PACE program.
• To get help, if they need it, to use the Medicare and Medicaid complaint
and appeal processes, and their civil and other legal rights.
• To be encouraged and helped in talking to PACE staff about changes in
policy and services they think should be made.
• To use a telephone while at the PACE Center.
• To not have to do work or services for the PACE program.
8
3.
You have a right to protection against discrimination.
Discrimination is against the law. Every company or agency that works with
Medicare and Medicaid must obey the law. They cannot be discriminated against
because of their:
• Race /Ethnicity and National Origin
• Religion
• Age
• Sex
• Mental or physical ability
• Sexual Orientation
• Source of payment for your health care (For example, Medicare or Medicaid)
If they think you have been discriminated against for any of these reasons,
contact a staff member at the PACE program to help them resolve your
problem. If they have any questions, they can call the Office for Civil
Rights at 1-800-368-1019. TTY users should call 1-800-537-7697.
4.
They have a right to information and assistance.
They have the right to get accurate, easy-to-understand information and to have
someone help you make informed health care decisions. They have the right:
• To have someone help them if they have a language or communication
barrier so they can understand all information given to them.
• To have the PACE program interpret the information into their preferred
language in a culturally competent manner, if their first language is not
English and they can’t speak English well enough to understand the
information being given to them.
• To get marketing materials and PACE rights in English and in any other
frequently used language in their community. They can also get these
materials in Braille, if necessary.
• To get a written copy of their rights from the PACE program. The PACE
program must also post these rights in a public place in the PACE center
where it is easy to see them.
• To be fully informed, in writing, of the services offered by the PACE
program. This includes telling you which services are provided by
contractors instead of the PACE staff. You must be given this information
before you join, at the time you join, and when you need to make a choice
about what services to receive.
• To look at, or get help to look at, the results of the most recent review of
their PACE program. Federal and State agencies review all PACE
programs. They also have a right to review how the PACE program plans
to correct any problems that are found at inspection.
5.
They have a right to a choice of providers.
They have the right to choose a health care provider within the PACE program’s
network and to get quality health care. Women have the right to get services from
a qualified women’s health care specialist for routine or preventive women’s
health care services.
6.
They have a right to access emergency services.
9
They have the right to get emergency services when and where they need them
without the PACE program’s approval. A medical emergency is when they think
their health is in serious danger—when every second counts. They may have a bad
injury, sudden illness or an illness quickly getting much worse. They can get
emergency care anywhere in the United States.
7.
They have a right to participate in treatment decisions.
They have the right to fully participate in all decisions related to their health care.
If they cannot fully participate in their treatment decisions or they want to have
someone they trust help them, they have the right to choose that person to act on
their behalf. They have the right:
•
•
•
•
8.
To have all treatment options explained to them in a language they
understand, to be fully informed of their health status and how well they
are doing, and to make health care decisions. This includes the right not to
get treatment or take medications. If they choose not to get treatment, they
must be told how this will affect their health.
To have the PACE program, help them create an advance directive. An
advance directive is a written document that says how they want medical
decisions to be made in case they cannot speak for themselves. They
should give it to the person who will carry out their instructions and make
health care decisions for them.
To participate in making and carrying out their plan of care. They can ask
for their plan of care to be reviewed at any time.
To be given advance notice, in writing, of any plan to move them to another
treatment setting and the reason they are being moved.
They have a right to have your health information kept private.
They have the right to talk with health care providers in private and to have their
personal health care information kept private as protected under State and Federal
laws. They have the right to look at and receive copies of their medical records.
They can also be assured that:
• All of the information in their health record, including information
contained in an automated data bank is treated in a confidential manner at
all times.
• Their written consent will be required and obtained before any information
is released to any person not otherwise authorized under law to receive it.
• They have the right to provide written consent that limits the degree of
information and the persons to whom information may be given.
10
There is a patient privacy rule that gives them more access to their own medical
records and more control over how their personal health information is used. If
they have any questions about this privacy rule, please call the Office for Civil
Rights at 1-800-368-1019. TTY users should call 1-800-537-7697. They also
have the right to confidentiality in the treatment, payment, and health care
operations, provided that such use or disclosure is consistent with other applicable
requirements of the HIPPA Privacy Rule.
9.
They have a right to file a complaint.
They have a right to complain about the services they receive or that they need and
don’t receive, the quality of their care, or any other concerns or problems they have
with their PACE program. They have the right to a fair and timely process for
resolving concerns with their PACE program. They have the right:
•
•
•
10.
11
To a full explanation of the complaint process.
To be encouraged and helped to freely explain their complaints to PACE
staff and outside representatives of their choice. They must not be harmed
in any way for telling someone their concerns. This includes being
punished, threatened, or discriminated against.
To appeal any treatment decision by the PACE program, staff, or
contractors.
They have a right to leave the program.
If, for any reason, they do not feel that the PACE program is what they want, they
have the right to leave the program at any time.
Participant ID Card
Every ArchCare Senior Life participant will receive an identification card that will detail the
participant’s name and identification number. This card, which identifies them as an ArchCare
Senior Life participant should be presented to physicians and other providers when seeking
health care services. If the participant does not have an identification card, but they represent
that they are an ArchCare Senior Life participant, please contact customer service at 1-866-2639083 for member eligibility.
Medicare and Medicaid will not be responsible for claims for the participant while they are
enrolled as a participant of ArchCare Senior Life. All claims for services provided to ArchCare
Senior Life participants need to be submitted to ArchCare Senior Life at the address listed on
the “How to Reach Us” page.
Below is a sample of the ArchCare Senior Life participant identification card:
THIS CARD IS NOT CURRENT.
JANET TO SHOW NAZIA FOR INSERTING
Front of the card:
12
Back of the card:
Referrals and Prior Authorization
When ArchCare Senior Life participants need services that cannot be provided at our center, our
interdisciplinary team will make all of the arrangements, including calling for the appointment and
arranging transportation. As a provider, you will receive a “Service Authorization” form via fax
or email with instructions regarding where to send the report of services rendered.
This process ensures our participants receive all of the care they need and that all care is
coordinated within our network. Providers must only provide services as authorized by the
ArchCare Senior Life interdisciplinary team, on the “Service Authorization” form. Any services
that may be necessary need to be authorized by ArchCare Senior Life’s Medical Director/
interdisciplinary team. Services not authorized or arranged for by the ArchCare Senior Life
Interdisciplinary team will not be paid for unless it is an emergency. Authorizations for urgently
needed care or post stabilization services should be obtained by calling 866-263-9083. ArchCare
Senior Life will respond to an authorization request as quickly as possible and not to exceed three
days. The interdisciplinary team may conduct a re-assessment as the members condition requires.
All services must be prior authorized and billed through ArchCare Senior Life. Services may be
provided by network providers ONLY and must be pre-authorized. Failures to contact ArchCare
Senior Life prior to the provision of non-emergency services will forfeiture of billing rights for
all unauthorized services. In an Emergency, Prior Authorization is not required. If the patient is
presenting in an emergency room, please contact ArchCare Senior Life immediately at (866) 2639083.
13
Urgent and Emergency Care
ArchCare Senior Life provides coverage for the treatment of an emergency medical condition,
which is defined by CMS as a condition that manifests itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in:
• Placing the health of the individual in serious jeopardy
• Serious impairment to bodily functions, or
• Serious dysfunction of any bodily organ or part
Inpatient and outpatient emergency health services are covered both inside and outside the
ArchCare Senior Life service area. In the event of an emergency, the participant should seek
immediate care, or call 911 for assistance. Prior authorization is not required for emergency care,
and ArchCare Senior Life may not deny payment if an ArchCare Senior Life contracted health
care provider instructs a participant to seek emergency services.
Enrollment in ArchCare Senior Life includes coverage for post-stabilization care, defined as nonemergency services needed to ensure that the participant remains stabilized after an
emergency. Providers must only provide services as authorized by ArchCare Senior Life
Interdisciplinary Team. Any additional services needed must be discussed with the ArchCare
Senior Life Interdisciplinary Team. Unauthorized services will not be paid by ArchCare Senior
Life unless it is an emergency or ArchCare Senior Life fails to respond to an authorization request
within one hour of being contacted for urgently needed or post-stabilization services.
Urgently needed services are defined as those conditions which require immediate medical
attention due to unexpected illness or injury. Fevers, abdominal pain, nausea and vomiting and
difficulty urinating are some examples of situations requiring urgently needed services.
Urgent care services are covered for participants when they are temporarily outside of the
ArchCare Senior Life service area. Providers must notify ArchCare Senior Life within 24 hours
or the next business day of providing emergency or urgent services to an ArchCare Senior Life
participant, or if the participant is admitted to a hospital.
Participants are encouraged to carry their ArchCare Senior Life identification card at all times
and to notify their care manager or provider should they need urgent or emergency care.
14
Credentialing/Recredentialing
All physician and health care providers providing health services to ArchCare Senior Life
participants must be credentialed in accordance with ArchCare Senior Life policies and
procedures. Under CMS regulation, the credentialing process and approval must be completed
by any network provider administering care to an ArchCare Senior Life participant. Recredentialing will occur every three years thereafter for all contracted physicians, other health
care providers, facilities, and hospitals.
The following items are required along with the provider credentialing applications in order to
complete the credentialing process:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
15
Physician and Health Care Providers
Current Curriculum Vitae
Work history past five years
Current valid State license to practice
Valid DEA & CDS (controlled dangerous substances) certificates
Education and Training
Copy of Insurance Certificate
Board Certification status
Hospital admitting privileges
Disclosure Statement and Signed Attestation
Verification of “Opt Out” or Private Contract from Medicare
participation
History of professional liability claims that resulted in settlements
or judgments paid by the or on behalf of practitioner
Facility Credentialing
Medicare and/or Medicaid license
Copy of New York State Operating License
Copy of Insurance Certificate
Copy of any accreditations and/or surveys
A copy of any notice of disciplinary actions taken within the past
five years by the New York State Department of Health or other
government agency that regulates the services by the provider;
A copy of any notice of sanctions imposed upon the provider within
the past five years by the Medicare or Medicaid program;
Skilled Nursing Facility Credentialing
Medicare, Medicaid or JCAHO accreditation
Copy of License
Copy of Insurance Certificate
Copy of last 3 years of federal and state surveys including any
sanctions
•
•
A copy of any notice of disciplinary actions taken within the past
five years by the New York State Department of Health or other
government agency that regulates the services by the provider;
A copy of any notice of sanctions imposed upon the provider within
the past five years by the Medicare or Medicaid program;
The credentialing process is considered complete when the credentialing committee approves
the credentialing application. Once the credentialing process has been completed, and an
executed contract is received and countersigned, the physician or health care provider will be
considered participating. The physician or health care provider will use their NPI (National
Provider Identification) number as their “provider number”.
Delegated Credentialing
ArchCare Senior Life offers delegated credentialing for large groups of health care providers.
ArchCare Senior Life delegates the credentialing function to groups that meet ArchCare Senior
Life and National Committee for Quality Assurance (NCQA) standards and state and federal
law. The decision by ArchCare Senior Life to delegate the credentialing function results from a
review of the group’s credentialing policies and procedures and an on-site audit of the group’s
credentialing files. The ArchCare Senior Life Credentialing Committee reviews the resulting
delegation report and makes a determination to approve, defer or grant provisional delegated
status for the group. If provisional status is granted, this is followed by a reassessment within a
specified period of time and a final decision to approve or defer. Groups granted “delegated
status” are required to sign a delegated credentialing agreement with ArchCare Senior Life.
Medical Record
• As part of the re-credentialing process ArchCare Senior Life will
review on a quarterly basis medical quality and utilization management data on
an aggregate basis. This tracking and reporting of data supports analysis of trends
and outliers across sites and within specific service areas. Pharmaceutical
management and utilization practices is tracked and discussed quarterly by the
Medical Director. ArchCare Senior Life newly hired PCP’s and mid-level
practitioners receive competency and orientation checklist which is reviewed and
signed off by the Medical Director. The ASL PACE Medical Director administers
and completes the competency evaluation initially and is on-going.
Prior to the physician date for recredentialing, a provider relations representative will contact
the Medical Director of PACE to determine current performance evaluations and job
competencies meet standards for re-credentialing.
16
Provider Information
Providers are responsible for contacting ArchCare Senior Life to report any changes in their
practice. It is essential that ArchCare Senior Life maintain an accurate provider database in
order to ensure proper payment of claims and capitation, to comply with provider information
reporting requirements mandated by governmental and regulatory authorities, and to provide the
most up-to-date information on provider choices to our participants. Any changes to the
following list of items must be reported to ArchCare Senior Life within 30 (thirty) days of the
change, using our Provider Change Request Form attached in the appendix of this manual:
• Provider’s name and Tax ID number(s)
• Provider’s address, zip code, telephone or fax
• Provider’s billing address
• Languages spoken in the provider’s office
• Wheelchair accessibility
• Provider’s NY license (e.g., revocation, suspension)
• National Provider Identification Number (if applicable)
• Provider’s board eligibility/board certification status
• Hospital affiliation status
Please use the “Provider Addition/Change Request” form found on page 39.
Adverse Credentialing Determination Appeals
As a network provider, you have the right to:
• Review information submitted to your credentialing application.
• Correct erroneous information collected during the credentialing
process.
• Be informed of the status of your credentialing or re-credentialing
application.
• Be notified of these rights.
Requests for Additional Information
If ArchCare Senior Life receives information from an outside source that differs
substantially from information you have provided us, we will contact you directly
as soon as the discrepancy is noted and request your clarification in writing within
10 business days. Requests should be made in writing to:
ArchCare Senior Life
Attention: Credentialing Department
33 Irving Place, 11th Floor
New York, NY 10003
17
Appeals Process for Providers Terminated or Rejected from the ArchCare Senior Life
Provider Network
A provider has the right to appeal a Peer Review and Credentialing Sub-Committee decision that
has negatively impacted the provider. ArchCare Senior Life complies with all state and federal
mandates with respect to appeals for providers terminated or rejected from the ArchCare Senior
Life Provider Network. ArchCare Senior Life notifies the provider in writing of the reason for
the denial, suspension and termination. Terminated or rejected providers may submit a request
for an appeal as outlined in the letter of rejection/termination sent by ArchCare Senior Life. In
addition, the request for appeal must be received by ArchCare Senior Life within ten (10) days
of the date of the rejection/termination letter. Upon receipt of the letter by ArchCare Senior Life,
the appeal is forwarded to the ArchCare Senior Life Peer Review Committee for review and
further processing ArchCare Senior Life will ensure that the majority of the hearing panel
members are peers of the affected physician.
Provider Monitoring & Evaluation
ArchCare Senior Life, DOH, CMS and their designees shall each have the right, during
provider's normal operating hours, and at any other time a contractor function or activity is being
conducted, to monitor and evaluate, through inspection or other means, provider's performance,
including, but not limited to, the quality, appropriateness, access to service and timeliness of
services provided under the provider contract.
All providers are required to cooperate with and provide reasonable assistance to ArchCare
Senior Life, DOH, CMS and their designee in the monitoring and evaluation of the services
provided under the provider contract.
18
Physician or Health Care Provider Termination
ArchCare Senior Life or its participating providers may decide to terminate or elect not to renew
a provider agreement. Termination procedures are subject to the provisions of the provider
agreement. If there are conflicts between the provisions in this Provider Manual and any provider
agreement, the terms of the provider agreement will apply.
All providers who wish to terminate their contractual relationship with ArchCare Senior Life are
bound by the applicable provisions of the individual or group provider agreement or hospital
agreement that may govern the termination of an ArchCare Senior Life provider. All providers
voluntarily terminating their participation with ArchCare Senior Life must give ninety (90) days
prior written notice of the termination. ArchCare Senior Life will not accept any verbal
notification as sufficient to initiate the termination process.
Provider shall complete any course of treatment to any individual Member, in accordance with the
terms of his/her agreement, for whom treatment was ongoing on the date of termination, unless
ArchCare Senior Life makes reasonable and medically appropriate provision for the assumption
of such services by another participating provider. For those members confined to an inpatient
facility, provider shall also complete any course of treatment in progress until a medically
appropriate discharge or transfer is made, or completion of the course of treatment is made,
whichever first occurs, provided that the confinement or course of treatment was commenced
during the paid premium period.
For information, regarding contracted physicians or health care providers including facilities
termination; please refer to your provider agreement. Requests should be made in writing to:
ArchCare Senior Life
Attention: Credentialing Department
33 Irving Place, 11th Floor
New York, NY 10003
You may also contact Provider Relations at 1-800-373-3177 or fax 646-417-7157.
19
Private Contract “Opt Out”
ArchCare Senior Life will not pay, directly or indirectly, on any basis, for services (other than post
stabilization, emergency or urgently needed services) furnished to a Medicare enrollee by a
physician or other health care provider who has filed an affidavit with the Medicare carrier
agreeing to furnish Medicare covered services to Medicare beneficiaries only through private
contracts with the beneficiaries. ArchCare Senior Life verifies, with the local Medicare
intermediary, the Opt Out or Private Contract list during credentialing and re-credentialing to
ensure that our contracted providers are not included on the list.
Upon written notification from the carrier of a physician’s or other health care provider’s decision
to “opt out” of the Medicare program, Provider Relations will send a letter to the physician or
other health care provider stating that the physician or provider will be removed from the list of
ArchCare Senior Life contracted physicians and providers. No payments will be made to the
physician or provider for two years after the effective date of the affidavit.
In addition, ArchCare Senior Life will send a letter to each ArchCare Senior Life participant
assigned to the physician or provider notifying the enrollee that the physician or provider is no
longer contracted and advising the enrollee to select a new Primary Care Physician, if appropriate.
Participants with claims pending for services from a physician or provider who has “opted out” of
Medicare, or participants submitting claims from physicians or providers who have “opted out” of
Medicare will receive a letter containing the following information:
• The participant is accessing a physician or provider who has “opted
out” of Medicare.
• Payments by ArchCare Senior Life are prohibited.
• The services are not covered, the current claim(s) will not be paid
by ArchCare Senior Life and the physician or provider must have
entered into a private contract with the participant in order to receive
payment from the participant.
• Payments will not be made for items or services rendered after the
date of the physician “opt out.”
Physicians and health care provider are responsible for notifying
ArchCare Senior Life when their affidavit has expired if they desire
to apply for reinstatement.
20
Adverse Reimbursement Change
ArchCare Senior Life will provide ninety (90) days’ notice to providers of an adverse
reimbursement change. Providers have the opportunity to terminate their contract by providing
ArchCare Senior Life with written notice within 30 days of receipt of the notice of the change.
This provision is not applicable to reimbursement/rates changes mandated by New York State
or the federal government. This provision is not applicable to hospitals, diagnostic and treatment
centers, home care agencies, or other institutions.
Sanctions
Upon written notification from CMS – by letter or the lists published by the Office of Inspector
General (OIG) and Government Accountability Office (GAO) – of a physician’s or other health
care provider’s exclusion from original Medicare, ArchCare Senior Life will send a letter to the
physician or provider stating the physician or provider will be removed from the ArchCare
Senior Life list of contracted physicians and providers. Except for post stabilization, emergency
and urgently needed care; no payments will be made to the physician or provider after the
exclusion effective date. Members are notified that the physician or other health care provider
is no longer contracted and are advised to select a new Primary Care Physician or health care
provider, if appropriate.
Members with claims pending for items or services from an excluded physician or provider, or
member’s submitting claims for items or services from an excluded physician or provider for
the first time, will receive a letter notifying the enrollee of the following:
•
•
•
The enrollee is accessing a sanctioned physician or provider.
Payments to a Medicare-excluded physician or provider are
prohibited.
Payments will not be made for items or services rendered after the
date of exclusion or after notification to the enrollee (whichever date
is later).
Participating physicians and other healthcare providers are also prohibited from employing or
contracting with an individual who is excluded from participation in Medicare, or with an entity
that employs or contracts with such an individual, for the provision of health care, utilization
review, medical social work or administrative services.
Reinstatement
Upon reinstatement by CMS, the physician or provider is responsible for notifying ArchCare
Senior Life and apply for reinstatement.
21
Resolution of Disputes
Contract concern or complaint
The services you provide are essential to our ability to serve our participants. If you have a
concern or complaint about any aspect of our relationship with you, please let us know about
it. You can send a letter outlining the details of your complaint to ArchCare Senior Life Provider
Relations Department or call our toll free number (866) 263-9083. The Provider Relations staff
will seek to address and resolve your concerns as quickly as possible.
• Acknowledge your complaint within 5 business days of receipt.
• Investigate your complaint and arrive at a mutually satisfactory
resolution within 30 days.
If there is no resolution to the complaint after following the above procedures, arbitration
proceeding may be filed as described below and in our provider services agreement.
Arbitration
ArchCare Senior Life will conduct arbitration proceedings under your agreement under the
auspices of the American Arbitration Association, as further described in our provider services
agreement. For more information on the American Association guidelines, visit their website at
www.adr.org.
22
Billing Procedures
All participant ArchCare Senior Life providers are required to submit claims/encounters for
services reimbursed fee-for-service and for services provided under a capitation model of care.
Agreement. Encounter data is essential for claims processing and utilization reporting as well as
for complying with the reporting requirements of CMS, New York State and other governmental
and regulatory agencies. It is essential that this information be submitted in a timely and accurate
manner.
Payment for services rendered is subject to verification that the participant was enrolled in
ArchCare Senior Life at the time the service was provided and the provider’s compliance with
ArchCare Senior Life medical management and prior authorization policies at the time of service.
•
•
Providers should verify participant eligibility at the time of service to ensure that
the participant is enrolled in ArchCare Senior Life. Failure to do so may affect
claims payment. Note, however, that participant’s may retroactively lose their
eligibility with ArchCare Senior Life after the date of service. Therefore,
verification of eligibility is not a guarantee of payment by ArchCare Senior Life.
Claims submitted for services rendered without proper authorization (as
appropriate) will be denied for ‘failure to obtain authorization’. No payment will
be made.
Payment is made directly to the participating hospital for all employed providers who are covered
by the hospital’s participation agreement with ArchCare Senior Life and who practice in hospital
outpatient departments and hospital owned community-based sites. For all other providers,
payment is made directly to the provider or to the designated payee.
In certain cases, a managed care plan participant may change health plans during the course of a
hospital stay. When this occurs, provider should bill the health plan to which the participant
belonged at the time of admission to the hospital.
ArchCare Senior Life Payment in Full / Participant Held Harmless
Pursuant to the provider contract, participating providers are prohibited from seeking payment,
billing or accepting payment from any participant for fees that are the legal obligation of ArchCare
Senior Life, including in the event that ArchCare Senior Life becomes insolvent or denies
payment on a claim, regardless of the reason. Participating providers must refund all amounts
incorrectly collected from ArchCare Senior Life participants or from others on behalf of the
participant. ArchCare Senior Life is not financially responsible for reimbursing non-covered
services provided to participants.
23
General Billing Requirements:
Submitting Claims Electronically
For all electronic claims, ArchCare utilizes the Emdeon clearinghouse and MD On-line, a free
online service for non-facility providers who do not have claims submission software. Claims
submitted electronically receive a status report indicating the claims are accepted, rejected
and/or pending.
Claims submitted electronically must include:
1. The ArchCare Payer ID Number 31144 on each claim.
2. A complete ArchCare Senior Life Participant ID Number.
3. A National Provider Identifier (NPI).
To sign up for electronic billing with Emdeon, providers must contact their software vendor
and request that their ArchCare claims be submitted through Emdeon. Providers can also direct
their current clearinghouse to forward claims to Emdeon. To sign up for electronic billing with
Emdeon or for more information visit www.emdeon.com or call 1-866-924-4634, #4.
To enroll your office for Online Claim submission with MD On-line, visit www.tbsmdol.com
to register on line or call 1-888-499-5465 (A representative is available to assist you between
the hours of 8:30AM to 6PM / EST.)
Submitting Claims on Paper
All paper claims should be submitted to:
ArchCare Senior Life
C/o TriState Benefit Solutions
619 Oak Street
Cincinnati, OH 45206
All paper claims should include the National Provider Identifier (NPI) as well as the ArchCare
Provider ID Number (the latter is not required for electronic claims). The ArchCare Provider
ID is a unique provider number.
Note for group practices and facilities: When submitting claims, please ensure separate
billing NPI and provider NPI numbers are entered in the appropriate fields. Office visit claims
submitted for the group practice, with the group practice NPI number instead of the individual
NPI number for the servicing provider, cannot be processed.
24
Required Data elements and Claim Forms
Prior to being adjudicated, all claims are reviewed within the ArchCare Claims Department for
completeness and correctness of the data elements required for processing payments, reporting
and data entry into the ArchCare Senior Life claims processing system. If the following
information is missing from the claim, the claim is not ‘clean’ and will be rejected:
Data Element
CMS 1500
UB-04
Patient Name
X
X
Patient Date of Birth
X
X
Patient Address
X
X
Patient Gender
X
X
ArchCare Senior Life Participant ID Number
X
X
Coordination of Benefits (COB / other insured’s medical
insurance coverage information.)
X
X
Date(s) of Service
X
X
ICD – 9 Diagnosis Code(s) including 4 and 5 digit, when
required
X
X
CPT- 4 Procedure Code(s)
X
X
HCPCS Code(s)
X
X
Service Code Modifier(s), when required
X
X
Place of Service
X
Service Units
X
X
Charges per Service and total charges
X
X
Provider Name
X
X
Provider Address / Phone Number
X
X
National Provider Identifier - NPI
X
X
Tax ID Number
X
X
ArchCare Senior Life Provider Number – for Paper Claims
Only
X
X
ArchCare Senior Life Payer ID Number 31144 – for EDI
Claims Only
X
X
th
th
Hospital / Facility Name and Address
X
Type of Bill
X
Admission Date and Type
X
Patient Discharge Status Code
X
Condition Code(s)
X
25
Data Element
CMS 1500
UB-04
Occurrence Codes and Dates
X
Value Code(s)
X
Revenue Code(s) and corresponding CPT / HCPCS Code(s)
X
Health Insurance Prospective Payment System (HIPPS)
Rate Code(s), when required
X
Principal, Admitting, and Other ICD – 9 Diagnosis Codes
including 4th and 5th digit, when required
X
Present on Admission (POA) indicator, as applicable
X
Present on Admission (POA)
The POA indicator applies to diagnosis codes for certain health care claims. POA indicator
reporting is mandatory for claims involving inpatient admissions to general acute care hospitals
or other facilities. It clarifies whether a diagnosis was present at the time of admission.
ArchCare requires POA indicators for all primary and secondary diagnosis codes as well as the
external cause of injury codes, regardless of the manner in which claims are submitted (i.e.,
paper or electronic). Please refer to the instructions provided by CMS regarding identification
of the POA for all diagnosis codes for inpatient claims submitted on the UB-04 and ASCX12N
837 Institutional (837I) forms.
Requirements for Billing by Facilities
Facilities, including hospitals, must submit inpatient and outpatient facility claims on the UB04 or on electronic media:
•
Report the name, NPI and ArchCare Senior Life provider ID number of the attending
provider in Field 76 (ArchCare Senior Life’s provider ID number is not required on
electronic transactions)
Professional services that are not part of the facility claim should be billed on a CMS 1500
form.
26
Time Frames for Claim Submission, Adjudication and Payment
Timely Claim Submission
Providers should submit all claims within thirty (30) days of the date of service for prompt
adjudication and payment. When claims are submitted later than the time period set forth in
the provider’s agreement with ArchCare Senior Life, the claim will not be paid except under
certain circumstances. In no event will ArchCare Senior Life pay claims submitted more than
one hundred eighty (180) calendar days from the date of service.
Late Claim Submission
In certain circumstances, ArchCare Senior Life will process claims submitted after the time
period required under the provider’s agreement with ArchCare Senior Life. Please note that
‘unclean’ claims that are returned to the provider for necessary information are adjudicated
according to the original date of service. They do not fall into the category of exceptions to the
time period required.
The following situations allow for special handling of claims. Claims must be submitted with
a written explanation and appropriate documentation showing the date the claim came within
the provider’s control:
Reason for Delay
Litigation involving payment of
the claim
Within ninety (90) calendar days from the time the
Medicare or other third party
processing delays affecting the
claim
Within ninety (90) calendar days from the time the
Delay in member eligibility
determination
Within ninety (90) calendar days from the time of
notification of eligibility (submit with
documentation substantiating the delay)
Member’s Enrollment with
ArchCare Advantage was not
known on the date of service
Within ninety (90) days from the time the
member’s enrollment is verified. Providers must
make diligent attempts to determine the member’s
coverage with the Plan.
submission came within the provider’s control
submission came within the provider’s control
Coordination of Benefits (COB)
Coordination of Benefits (COB) ensures that the proper payers are held responsible for the cost
of healthcare services and is one (1) of the factors that can help hold down co-payments.
ArchCare Senior Life follows all standard guidelines for COB. Participants are asked to
provide information about other medical health insurance plans under which they are covered.
27
ArchCare Senior Life is Always the secondary Payer in the Following
Circumstances
•
Workers compensation
•
Automobile medical
•
No-fault or liability auto insurance
ArchCare Senior Life Does Not Pay for Services Provided Under the
Following Circumstances When There is COB
•
The Department of Veterans Affairs (VA) or other VA facilities (except for certain
emergency hospital services)
•
When VA-authorized services are provided at a non-VA hospital or by a non-VA
provider
ArchCare Senior Life will use the same guidelines as Medicare for the determination of
primary and secondary payer. As a result, ArchCare Advantage is the secondary payer for all
of the cases listed above as well as for the following:
•
Most Employer Group Health Plans (EGHP)
•
Most EGHPs for disabled members
•
All benefits payable under an EGHP in the case of individuals who are entitled to
benefits solely or partly on the basis of end stage renal disease (ESRD) during a period
of thirty (30) months. (This applies to all services, not just ESRD. If the individual
entitlement changes from ESRD to over sixty-five [65] or disability, the coordination
period will continue.)
Explanation of Payment (EOP)
The EOP describes how claims for services rendered to ArchCare Senior Life Participants were
reviewed. It details the adjudication of claims, describing the amounts paid or denied and
indicating the determinations made on each claim.
The EOP includes the following elements (see Appendix A for a sample of the EOP):
•
Payer’s Name
•
Vendor Name and Identification (ID) Number
•
Provider Name and Identification (ID) Number
•
Patient’s Name
•
Member’s Identification (ID) Number
•
Claim Date of Service
•
Service
•
Total Billed Charges
•
Allowed Amount
28
•
Explanation for Denied Charges
•
Amount Applied to Deductible
•
Co-payment/Co-insurance Amount
•
Total Payment Made and to Whom
The EOP is arranged by vendor by provider. Each claim represented on an EOP may be
comprised of multiple rows of text. The line number indicated to the left of the date of service
identifies the beginning and end of a particular claim. Key fields that indicate payment amounts
and denials are as follows:
•
Paid Claim Lines: If the Paid Amount field reads greater than zero (0), the claim line
was paid in the amount indicated.
•
Denied Claim Lines: If the Not Covered field is greater than zero (0) and equal to the
charged amount, the service was denied.
•
Claim Processed as a Capitated Service: If the Paid Amount field is zero (0), but the
EOP Explanation Codes is ‘171’ – Capitated Covered Services, the service was
processed as a Capitated Service.
•
End of Claim: Each claim is summarized by a claim total. If there are multiple claims
for a single member, the EOP also summarizes the total amount paid for that member.
Claim Inquiries, claim Reconsideration and Appeal Process
Claim Inquiries
Providers may call Provider Services at 1-800-373-3177 to request claim status.
Requests for Review and Reconsideration of a Claim
Please note that the process described here does not apply to utilization management
determinations concerning medical necessity. See appropriate section (page XX) for
information on medical management appeals.
A provider may be dissatisfied with a decision made by ArchCare Senior Life regarding a claim
determination. Some of the common reasons include, but are not limited to:
•
Claim was incorrectly processed
•
Denial of a service / claim
•
Denial for the untimely submission of claim(s)
•
Failure to obtain prior authorization
29
Providers who are dissatisfied with a claim determination made by ArchCare Senior Life must
submit a written request for review and reconsideration with all supporting documentation
within sixty (60) business days from ArchCare Senior Life’s initial date of action that led to the
dispute, to the following address:
ArchCare Senior Life
33 Irving Place, 11th Floor
New York, NY 10003
Attention: Provider Disputes
Provide a clear explanation of the basis upon which you believe the initial
determination/action is incorrect along with all supporting documentation and a copy of the
Explanation of Payment (EOP) or include:
•
•
•
•
•
•
•
The provider’s full name
The provider’s identification number
The provider’s contact information
The Participant’s name and ArchCare Senior Life’s Participant identification number
Date(s) of service
The ArchCare Senior Life claim(s) number
A copy of the original claim or corrected claim, if applicable
ArchCare Senior Life will investigate all written requests for review and reconsideration and
issue a written explanation stating that the claim has been either reprocessed or the initial denial
has been upheld within 45 calendar days from the date of receipt of the provider’s request for
review and reconsideration.
ArchCare Senior Life will not review or reconsider claim determinations which are not
appealed according to the procedures set forth above. If a provider submits a request for
review and reconsideration after the 60 business day time frame, the request is deemed ineligible
and will be dismissed. Providers will not be paid for any services irrespective of the merits of
the underlying dispute if the request for review and reconsideration is not timely filed. In such
cases providers may not bill members for services rendered.
All questions concerning request for review and reconsideration should be directed to the
ArchCare Senior Life Provider Relations Department at 1-800-373-3177.
30
Corrected Claim Submission
If you need to correct and re-submit a claim and reduce the risk that your corrected claim is
rejected by ArchCare Senior Life as a ‘duplicate’ of the first claim, submit the CMS-1500 or UB04 and written clearly ‘Corrected Claim Re-submission’ in bold at the top of the claim form and
specify the ArchCare Senior Life claim number to the right of the re-submission statement on the
CMS-1500 or UB-04, as appropriate.
Over payments
ArchCare Senior Life periodically reviews payments made to providers to ensure the accuracy
of claim payment pursuant to the terms of the provider contract or as part of its continuing
utilization review and fraud control programs. In doing so, ArchCare Senior Life may
identify instances when we have overpaid a provider for certain services. When this happens,
ArchCare Senior Life provides notice to the provider and recoups the overpayment consistent with
Section 3224-b of the New York Sate Insurance Law.
ArchCare Senior Life will not pursue overpayment recovery efforts for claims older than twentyfour (24) months after the date of the original payment to a provider unless the overpayment is:
•
•
•
Based upon a reasonable belief of fraud, intentional misconduct or abusive billing;
Required or initiated by the request of a self-insured plan or,
Required by a state or federal government program.
In addition, if a provider asserts that ArchCare Senior Life has underpaid any claim(s) to a provider,
ArchCare Senior Life may offset any underpayments that may be owed against past
overpayments made by ArchCare Senior Life dating as far back as the claim underpayment.
Notice of Overpayments Before Seeking Recovery
If ArchCare Senior Life has determined that an overpayment has occurred, ArchCare Senior
Life will provide thirty (30) days written notice to the provider of the overpayment and request
repayment. This notice will include the Participant’s name, service date(s), payment
amount(s), proposed adjustment and a reasonably specific explanation of the reason for the
overpayment and the adjustment. In response to this notice, the provider may dispute the finding
or remit payment as outlined below.
31
If you Agree That We Have Overpaid You
Upon receipt of a request for repayment, providers may voluntarily submit a refund check made
payable to ArchCare Senior Life within 30 calendar days from the date the overpayment
notice was mailed by ArchCare Senior Life. Providers should further include a statement
in writing regarding the purpose of the refund check to ensure the proper recording and
timely processing of the refund.
Refund check should be mailed to:
ArchCare Senior Life
33 Irving Place, 11th Floor
New York, NY 10003
Attention: Provider Disputes
If You Disagree that We Overpaid You
If a provider disagrees with ArchCare Senior Life’s determination concerning the
overpayment, the provider must submit a written request for an appeal within 30 calendar days
from the date the overpayment notice was mailed by ArchCare Senior Life and include all
supporting documentation in accordance with the provider appeal procedure.
If upon reviewing all supporting documentation submitted by a provider, ArchCare Senior
Life determines that the overpayment determination should be upheld, providers may initiate
arbitration pursuant to their provider agreement. ArchCare Senior Life will proceed to offset
the amount of the overpayment prior to any final determination made pursuant to binding
arbitration.
If You Fail to Respond to Our Notice of Overpayment
If a provider fails to dispute a request for repayment concerning an overpayment
determination made by ArchCare Senior Life within 30 calendar days from the date the
overpayment notice was mailed by ArchCare Senior Life, the provider will have
acknowledged and accepted the amount requested by ArchCare Senior Life.
ArchCare Senior Life will offset the amount outstanding against current and future claim
remittance(s) until the full amount is recovered by ArchCare Senior Life.
32
Medical Records
1.
Access to Medical Records
a. Provider shall maintain adequate medical records for all participants treated by
Provider. Subject to all applicable statutory and legal privacy and confidentiality
requirements, such medical records shall remain available to each physician and
other health professionals treating the Participant, and upon request to any
ArchCare Senior Life committee for review to determine whether the medical
record and quality of services provided are acceptable, as well as for peer review
and incident and grievance review and investigation.
b. During normal business hours, ArchCare Senior Life, New York State Department
of Health, CMS, or the Comptroller of the State of New York or the authorized
representatives have the right, upon request, to inspect the accounting,
administrative, and medical records maintained by Providers pertaining to
ArchCare Senior Life, the participant, and to the Provider's participation hereunder
during the term of this agreement and for ten (10) years thereafter. Provider shall
comply with all applicable state and federal law regarding access to books and
records.
2.
Record Retention
a. Provider shall keep and maintain all records relating to ArchCare Senior Life in
compliance with applicable requirements of DOH and CMS. These records include
but are not limited to:
1) Records related to services provided to Participants, including separate
Medical Record for each Participant;
2) all financial records and statistical data that DOH and any other state or
federal agency may require including books, accounts, journals, ledgers,
and all financial records relating to capitation payments, third party health
insurance recovery, and other revenue received and expenses incurred
under this Agreement;
3) appropriate financial records to document fiscal activities and
expenditures, including records relating to the sources and application of
funds and to the capacity of Provider or its subcontracts, if relevant, to
bear the risk of potential financial losses; and
4) Personnel records.
b. ArchCare Senior Life shall maintain all financial records and statistical data
according to generally accepted accounting principles.
33
c. Provider agrees to preserve records related to their contract with ArchCare Senior
Life for the term the agreement is in effect and for ten (10) years thereafter, with
disposal by Provider of any records during said period permitted only upon prior
written approval by ArchCare Senior Life and DOH. Records involving matters in
litigation shall be kept for a period permitted only upon prior written approval by
ArchCare Senior Life and DOH. Records involving matters in litigation shall be
kept for a period of not less than three (3) years following the termination of the
litigation, in addition to the previously specified ten years, Microfilm or Electronic
copies of records may be substituted for the originals with the prior written approval
of ArchCare Senior Life and DOH, provided that the microfilming procedures are
accepted by ArchCare Senior Life and DOH as reliable and are supported by an
adequate retrieval system.
d. All provisions of this Agreement relating to maintaining and retaining records shall
survive the termination of your Agreement with ArchCare Senior Life and shall
bind Provider until the expiration of the records retention period.
3.
Access and Audit of Records
a. At all times during the period that our ArchCare Senior Life is in force and for a
period of ten (10) years thereafter, Provider shall provide ArchCare Senior Life and
all authorized representatives of the state and federal governments with full access
to its records which pertain to services performed, and determination of amounts
payable under this agreement, including access to appropriate individuals with
knowledge of financial records (including providers independent public auditors)
and full access to any additional records they may process which pertain to services
performed and determination of amounts payable under this Agreement, permitting
such representatives to examine, audit and copy such records at the site at which
they are located. Such access shall include both announced and unannounced
inspections and on-site audits.
b. All records and information obtained by ArchCare Senior Life pursuant to the
provision of their agreement with providers, whether by audit or otherwise, shall
be usable by ArchCare Senior Life in any manner, in its sole discretion, it deems
appropriate and provider shall have no right of confidentiality or proprietary interest
in such records or information.
c. Notwithstanding the preceding sentence, ArchCare Senior Life agrees, in those
instances in which it has discretion, not to disclose outside of its agency the
following data:
•
•
•
•
34
any resume or other description of qualification which includes the name of
an individual;
any individual’s actual salary;
provider’s indirect rates including labor, overhead, G&A and fee; and,
the methodology for calculating those indirect rates including the allocation
base.
d. ArchCare Senior Life will use or disclose Medicaid recipient identifiable
information obtained only as authorized under applicable provisions of federal and
state law.
•
Provider shall promptly notify ArchCare Senior Life of any
request for access to any records maintained pursuant to their
contract with ArchCare Senior Life.
•
All provisions of your Agreement with ArchCare Senior Life
relating to access and audit of records shall survive the
termination of the Agreement and shall bind provider until the
expiration of the record retention period.
HITECH Act
The Health Information Technology for Economic and Clinical Health (HITECH) Act was passed
as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and
meaningful use of health information technology. Subtitle D of the HITECH Act addresses the
privacy and security concerns associated with the electronic transmission of health information, in
part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA
rules.
Enacted in part to assist healthcare providers who are, or will be, utilizing electronic health
records (EHR) systems, the HITECH Act addresses consumer access to their EHR, increases
application of HIPAA privacy standards to business associates of covered entities, and
implements a tiered system of civil monetary penalties for HIPAA violations.
Under the HITECH Act, business associates are now responsible for complying with the provisions
and regulations of HIPAA and are directly answerable to the government for HIPAA breaches.
Business associates are now also directly liable for civil and criminal penalties. This increased
statutory liability for business associates under HIPAA will likely result in the necessity of
updating business associate and vendor lists as well as renegotiating business associate
agreements. In addition, business associates will most likely incur costs associated with
bringing themselves into direct HIPAA compliance. The Secretary of the Department of Health
and Human Services (HHS) will ultimately issue guidance regarding these safeguards.
The HITECH Act also expands the notification requirements due to breaches of an individual’s
PHI. Both covered entities and business associates are now obligated to notify individuals of
breaches of their PHI. In cases where more than 500 “residents of a State or jurisdiction” have
had their PHI breached, “prominent media outlets” serving that area must also be notified.
Individuals should be notified in writing or e-mail if that is their preferred method of contact,
and be provided with basic information about the breach, such as:
• when the breach happened, when the event was discovered, and a brief statement
about what happened;
• what type of PHI was breached;
• things that the individual can do in order “to protect themselves from potential harm
resulting from the breach”;
35
•
what corrective actions and investigation the covered entity is doing to prevent future
breaches and mitigate losses; and contact information for the individual to use in case
of any questions.
In addition to disclosure accounting, the individual is also entitled to receive a copy of his or her
electronic health record, if they request; this information may be sent to the individual, or
another person designated by individual.
For more information about the HITECH Act, please visit the CMS website at www.cms.gov.
36
Fraud Waste & Abuse
ArchCare Senior Life operates a comprehensive compliance program that actively investigates
allegations of fraud, abuse and waste on the part of providers and participants. Fraud and abuse
are broadly defined as intentional deception or misrepresentation that results in an
unauthorized benefit, payment or inappropriate care. The following are some examples of
fraudulent, abusive, and unacceptable practices that are prohibited by ArchCare Senior Life:
•
•
•
•
•
•
•
Submission of false information for the purpose of obtaining greater
compensation than that to which the provider is legally entitled (i.e. up coding
or unbundling of charges).
Billing for services not rendered or billing in advance of care.
Knowingly demanding or collecting any compensation in addition to claims
submitted for covered services (except where permitted by law).
Ordering or furnishing inappropriate, improper, unnecessary or excessive care
services or supplies.
Failing to maintain or furnish, for audit and investigative purposes, sufficient
documentation on the extent of care and services rendered to participants.
Offering or accepting inducements to influence participants to join the plan or
to use or avoid using a particular service.
Submitting bills or accepting payment for care, services or supplies rendered by
a provider who has been disqualified from participation in the Medicare or
Medicaid programs.
Providers must comply with federal laws and regulations designed to prevent fraud, waste and
abuse, but not limited to, applicable provisions of federal criminal law, the False Claims Act,
the anti-kickback statute, and the Health Insurance Portability and Accountability Act
administrative simplification rules, applicable state and federal law, including, but not limited
to, Title VI of The Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, the Americans with Disabilities Act and all other laws applicable
to recipients of federal funds from which payments to providers under this Agreement are made
in whole or in part, and all applicable Medicare laws, regulations, reporting requirements, and
CMS instructions.
Confirmed cases of fraud and abuse are reported to the appropriate state agency.
Providers who suspect fraud, waste and abuse on the part of another provider
or a participant should contact the ArchCare Compliance Hotline at 1-800-4430463. Remember, you may report anonymously as ArchCare Senior Life abides
by a zero-tolerance against non-compliance.
37
HIPAA and Releasing Information
ArchCare Senior Life is concerned with protecting participant privacy and is committed to
complying with the Health Insurance and Portability Act (HIPAA) privacy regulations. Generally,
covered health plans and covered providers are not required to obtain individual participant
consent or authorization for use and disclosure of Protected Health Information (PHI) for
treatment, payment and health care operations. Activities such as: care coordination, reviewing
the competence of health care professionals, billing/claims management, and quality improvement
fall into this category. If you have further concerns, please contact Customer Service at 1-866263-9083.
QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT (QAPI)
A. ArchCare Senior Life's Quality Management Committee performs a critical element of
quality assessment performance improvement through audits of authorized services,
review of incidents, investigation of service delivery failures, and participant
satisfaction surveys. The process of service delivery in the PACE model requires the
team to identify participant problems, determine appropriate treatment goals, select
interventions, and evaluate efficiencies of care on an individual basis. This activity is
the foundation for all subsequent QAPI and utilization review activities.
B. ArchCare Senior Life maintains a written QAPI Plan provides a system of ongoing
assessment, implementation, evaluation, and revision of activities related to overall
program administration and services. The QAPI plan identifies specific and
measurable activities to be undertaken. The QAPI plan includes, at the minimum, the
following essential elements:
•
•
•
38
Standards that are performance benchmarks, established in conjunction with the
Provider, and are incorporated into the Provider Manual as appropriate. Such
performance benchmarks may include measures of access and availability of
service including response time to referrals, timelines of treatment/ implementation
of plan of care
Performance goals provide a framework for QAPI activities, evaluation, and
corrective action.
Performance Improvement indicators need to be single outcome measurable
variables related to the required services provided by ArchCare Senior Life. The
methodology should assure that all care settings (e.g., ArchCare Senior Life’s
contracted Providers, PACE Center, and home health care settings) are included in
the scope of services being measured and monitored. Quality performance
indicators should be selected for review on the basis of high volume, high risk,
diagnoses or clinical procedures, adverse outcomes, functional outcomes, or other
problem related to the health and welfare of the participants.
•
•
•
•
•
•
•
•
Process to review the effectiveness of ArchCare Senior Life’s interdisciplinary
team in its ability to assess participant’s care needs, identify the participant’s
treatment goals, assess the effectiveness of interventions, evaluate adequacy and
appropriateness of service utilization and reorganize a plan of care as necessary.
Process for aggregating data for purposes of conducting overall program utilization
analysis and provider performance analysis. Contracted Providers are asked to
complete and communicate feedback via the Contract Providers Survey and
provide written summaries of participant care and service delivery.
Policies and procedures related to establishing quality committees that:
Evaluate data collected pertaining to quality indicators;
include contracted service provider MDS reports, NYS DOH survey results and
quarterly care conference per contract request.
address the process and outcomes of the QAPI plan; and
provide input related to ethical decision making including end-of-life issues and
implementation of the Patient Self-Determination Act.
Participant, contracted service providers and caregiver involvement in the QAPI
plan and evaluation of Participant satisfaction with services.
39
Participant Grievances and Appeals
ArchCare Senior Life promotes open communication with its participants, and is committed to
addressing any complaints, either written or verbal regarding dissatisfaction with service delivery,
quality of care, and non-coverage or nonpayment of services being provided by ArchCare Senior
Life. A participant or designated representative may make a complaint at any time, or an appeal
when there has been a denial, reduction or termination of services. It is policy that ArchCare
Senior Life continues to provide care to the participant during the grievance or appeal process
without fear of any reprisal. A grievance or appeal will be kept confidential and in no way will
the grievance or appeal adversely affect a person's care or services. ArchCare Senior Life
investigates grievances and appeals, and informs participants of their complaint and appeal rights
at each juncture of the process. We hope that grievances and appeals are addressed to one's
satisfaction in a prompt and courteous manner.
The right to file a grievance or appeal is made known to the participant in writing upon enrollment,
and annually thereafter.
For persons who do not speak English, a bilingual staff member, or translation service are available
to help with the grievance and appeal processes.
GRIEVANCE PROCEDURES:
Definition: A grievance is a complaint, either written or verbal, expressing dissatisfaction with
service delivery or quality of care.
Each time there is an expression of dissatisfaction with service delivery or quality of care a
participant has a grievance. The participant will be provided with, and will have an opportunity to
discuss, a written explanation of the specific steps that will be taken or already have been taken to
resolve the grievance. Participants are encouraged to give complete information regarding their
grievance so that appropriate staff can resolve grievances in a timely manner. Participants may
designate a representative to file a grievance on their behalf. Contractors receiving complaints
from participants must report them to the ArchCare Senior Life Director of Quality Management
or the Executive Director.
When a participant files a grievance you may contact ArchCare Senior Life staff in person or call
(866) 263-9083. Our 24 hour answering service is available after business hours and on the
weekends.
If a solution is immediately found regarding a grievance and agreed to by the participant (or
designated representative), the grievance is considered resolved. ArchCare Senior Life staff seeks
to address and resolve grievances as quickly as possible to ensure satisfaction. A participant may
request reconsideration of a grievance decision if they are dissatisfied with the outcome of the
grievance process. To do so, they may contact the ArchCare Senior Life Quality Management
Department or Executive Director within thirty (30) days of the team’s written decision.
40
APPEAL PROCEDURES:
Definition: An appeal is a participant’s action taken with respect to noncoverage of or
nonpayment for a service including denials, reduction or termination of services.
A
participant has up to 45 days to request an appeal from the date of notification of noncoverage.
Participants or designated representatives may make an appeal with any staff member.
Participants are encouraged to give complete information so following up on an appeal can be
completed in a timely manner. Participants may designate a representative to file an appeal on
their behalf. Contractors receiving complaints must report them to ArchCare Senior Life.
The Director of Clinical Services coordinates appeals. Clinical aspects of appeals are reviewed
by qualified clinical personnel not involved in the decision.
During the appeals process, ArchCare Senior Life may not reduce or terminate disputed services
while an appeal is pending if the participant has requested continuation of the services. If the
decision is not in the participant’s favor, the participant may be held liable for the cost of
services.
EXPEDITED APPEALS PROCESS:
An expedited appeal may be requested should a participant believe that his or her life, health, or
ability to regain or maintain maximum function could be seriously jeopardized absent the
provision of a service. ArchCare Senior Life will respond in writing to confirm receipt of appeal
within 24 hours of receipt. An expedited appeal must be resolved within 72 hours. Notification
of the resolution will be shared with the participant (or designated representative) verbally and
in writing immediately upon resolution. Care will continue until notification of this resolution.
ADDITIONAL APPEAL RIGHTS UNDER MEDICARE AND MEDICAID:
The appeal processes are reviewed with participants upon enrollment and annually thereafter by
the social worker. The social worker is responsible for informing participants or designated
representatives of their additional appeal rights under Medicare or Medicaid managed care, or
both, and a right to having a Fair Hearing. The social worker may assist the participant in
choosing which to pursue if both are applicable. In the event that Medicaid is applicable,
ArchCare Senior Life's social worker can offer a Fair Hearing notice to the participant to exercise
an external appeal to the New York State Office of Hearing and Appeals. When Medicare is
involved, an external appeal, if elected, will be forwarded to the Medicare Designated Review
Agent.
State and Federal Complaint Options:
A participant or designated representative may file a complaint at any time. To pursue
complaints with the New York State Department of Health Managed Long Term Care hotline
call 1-866-712-7197.
41
APPENDIX – A
ArchCare Senior Life Provider Addition/Change Request Form
INSTRUCTIONS: Type or print your information on this form. If a question does not apply, write "N/A" in the field. A separate
form will be needed for each Provider.
Check the appropriate box:
o
Change of Information*
o
Credentialing Request
Date of Request
Practice Name
Provider Name
Specialty
Board Certification
o Yes
oNo
Tax ID
NPI
Primary Office Location
Secondary
Office Location
Provider Signature
*Requests for change of demographic information will be reflected in ArchCare Senior Life within 48 hours.
representative will contact you within that time frame to advise when the change has taken effect.
A
In receiving this form from the physician or entity, ArchCare Senior Life relies on the truth of all
the following statements:
�
�
�
42
All information entered is accurate and complete, and that if any of
that information changes, Provider will notify ArchCare Senior Life of
any such change within 30 days.
By submitting this form, Provider agrees to abide by all Medicare
statutes, rules, and policies.
Please submit request form to:
ArchCare Senior Life / PACE
Attention: Credentialing Department
33 Irving Place, 11th Floor
New York, NY 10003
Fax: 646-417-7157
Definitions
I. Enrollment Agreement is defined as the Enrollment Agreement issued by
ArchCare Senior Life that describes its obligations to arrange for the delivery of
medical care to ArchCare Senior Life participants who are eligible for such
services pursuant to the terms of Plan's contract with the New York State
Department of Health and Department of Health and Human Services (DHHS),
Centers for Medicare and Medicaid Services.
II. Covered Service is defined as those services which are medically indicated and
which Participants are entitled to receive under the terms of the Enrollment
Agreement.
III. DOH is defined as the New York State Department of Health.
IV. An Emergency medical condition is defined as a condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) such that a prudent
lay person, with an average knowledge of health and medicine, could reasonably
expect the absence of immediate attention to result in:
a. Serious jeopardy to the health of the individual;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any organ or part.
V. CMS is defined as the Centers for Medicare and Medicaid Services.
VI. Medically Indicated Services is defined as those health care services or items
defined by the Plan's medical director and
a) provide for the diagnosis, prevention, or direct care of a medical
condition;
b) are appropriate and necessary, for the diagnosis, prevention, or treatment
of a medical condition and could not be omitted without adversely
affecting the Participant’s condition;
c) are within standards of good medical practice recognized within the
organized medical community;
d) are appropriate to and consistent with the Participant’s diagnosis and,
(except for Emergency Services or Urgent Services) their plan of care;
e) would be likely to materially improve or to help in maintaining the
Participant’s physical condition; or
f) would be likely to materially improve or to help in maintaining the
Participant’s ability to engage in essential activities of daily living
g) are not primarily for the convenience of the Participant or his/ her family,
his/ her physician, or another care provider; and
h) are the most appropriate and economical level and source of care or
supply that can be provided safely. The foregoing provisions shall be
determined by the Plan's medical director or designee.
43
VII. Participant is defined as any person who is eligible to receive Covered Services
under the eligibility criteria set by DOH and is enrolled in ArchCare Senior Life.
VIII. Interdisciplinary Team is defined as a group of health professionals or care
givers composed of the primary care physician, registered nurse, social worker,
physical therapist, occupational therapist, recreational therapist, activity
coordinator, dietitian, PACE Center manager, home health care coordinator, home
health aides/ personal care attendants, and drivers.
IX. PACE is defined as the Program of All-Inclusive Care for the Elderly. It offers a
benefit plan to frail seniors who are nursing home eligible who live at home with
the support of PACE services. PACE is an integrated comprehensive program that
combines the services of an adult day center, home health care, medical outpatient
clinic on-site, and network of specialty care providers including inpatient hospital
and nursing home care when needed. Funding combines both Medicare and
Medicaid capitated payments in paying for the services.
X. Participating Agency is defined as an agency or health care provider that has
signed an ArchCare Senior Life Service Agreement.
XI. Primary Physician is defined as any physician, professional service corporation
or partnership who or which has agreed to provide specific primary health services
to Participants and to coordinate the overall health care of Participants as their
primary care physician.
XII.
A Provider is defined as those individual providers of individual services who
are contracted vendors. The Provider must meet applicable New York state
licensure, certification, or registration requirements in which they practice, and
meet ArchCare Senior Life’s credentialing criteria.
XIII. Quality Assurance Performance Improvement (QAPI): ArchCare Senior Life
has a quality assurance performance improvement committee consisting of its
program director, director of participant services, medical director and other
clinical and non-clinical professional staff as deemed appropriate. All Contracted
Service Providers are encouraged to participate in Quality Assessment.
CENTERS FOR MEDICARE & MEDICAID SERVICES
44
Quick Facts about Programs of All-inclusive
Care for the Elderly (PACE)
What are Programs of All-inclusive Care for the Elderly
(PACE)?
PACE is a Medicare program for older adults and people over age 55 living with disabilities. This
program provides community-based care and services to people who otherwise need nursing home level
of care. PACE was created as a way to provide you, your family, caregivers, and professional health
care provider’s flexibility to meet your health care needs and to help you continue living in the
community.
An interdisciplinary team of professionals will give you the coordinated care you need. These
professionals are also experts in working with older people. They will work together with you and
your family (if appropriate) to develop your most effective plan of care.
PACE provides all the care and services covered by Medicare and Medicaid, as authorized by the
interdisciplinary team, as well as additional medically-necessary care and services not covered by
Medicare and Medicaid. PACE provides coverage for prescription drugs, doctor care, transportation,
home care, check ups, hospital visits, and even nursing home stays whenever necessary. With
PACE, your ability to pay will never keep you from getting the care you need.
Who can join a PACE Plan?
You can join PACE if you meet the following conditions:
• You are 55 years old or older.
• You live in the service area of a PACE organization.
• You are certified by the state in which you live as meeting the need for the nursing
•
home level of care.
You are able to live safely in the community when you join with the help of PACE
services.
- Note: You can leave a PACE program at any time.
45
PACE services include but aren’t limited to the
following:
� Primary Care
(including doctor and nursing services)
�
Adult Day Care
�
Hospital Care
�
Recreational Therapy
�
Medical Specialty Services
�
Meals
�
Prescription Drugs
�
Dentistry
�
Nursing Home Care
�
Nutritional Counseling
�
Emergency Services
�
Social Services
�
Home Care
�
Laboratory / X-Ray
Services
�
Physical Therapy
�
Social Work Counseling
�
Occupational Therapy
�
Transportation
PACE also includes all other services determined necessary by your team of health
care professionals to improve and maintain your overall health.
You should know this about PACE:
PACE Provides Comprehensive Care
PACE uses Medicare and Medicaid funds to cover all of your medically-necessary care and
services. You can have either Medicare or Medicaid or both to join PACE.
The Focus is on You
You have a team of health care professionals to help you make health care decisions. Your team is
experienced in caring for people like you. They usually care for a small number of people. That way,
they get to know you, what kind of living situation you are in, and what your preferences are.
You and your family participate as the team develops and updates your plan of care and your
goals in the program.
PACE Covers Prescription Drugs
PACE organizations offer Medicare Part D prescription drug coverage. If you join a PACE program,
you’ll get your Part D-covered drugs and all other necessary medication from the PACE program.
Note: If you are in a PACE program, you don’t need to join a separate Medicare drug plan. If you
do, you will lose your PACE health and prescription drug benefits.
46
You should know this about PACE: (continued)
PACE Supports Family Caregivers
PACE organizations support your family members and other caregivers with caregiving
training, support groups, and respite care to help families keep their loved ones in the
community.
PACE Provides Services in the Community
PACE organizations provide care and services in the home, the community, and the
PACE center. They have contracts with many specialists and other providers in the
community to make sure that you get the care you need. Many PACE participants get
most of their care from staff employed by the PACE organization in the PACE center.
PACE centers meet state and Federal safety requirements and include adult day programs,
medical clinics, activities, and occupational and physical therapy facilities.
PACE is Sponsored by the Health Care Professionals Who Treat You
PACE programs are provider sponsored health plans. This means your PACE doctor and
other care providers are also the people who work with you to make decisions about your
care. No higher authorities will overrule what you, your doctor, and other care providers
agree is best for you. If you disagree with the interdisciplinary team about your care
plan, you have the right to file an appeal.
Preventive Care is Covered and Encouraged
The focus of every PACE organization is to help you live in the community for as long as
possible. To meet this goal, PACE organizations focus on preventive care. Although all
people enrolled in PACE are eligible for nursing home care, only 7% live in nursing
homes.
PACE Provides Medical Transportation
PACE organizations provide all medically-necessary transportation to the PACE center for
activities or medical appointments. You can also get transportation to appointments in the
community.
What You Pay for PACE Depends on Your Financial Situation
If you qualify for Medicare, all Medicare-covered services are paid for by Medicare. If you also qualify
for your State’s Medicaid program, you will either have a small monthly payment or pay nothing for the
long-term care portion of the PACE benefit. If you don’t qualify for Medicaid you will be charged a
monthly premium to cover the long-term care portion the PACE benefit and a premium for Medicare Part
D drugs. However, in PACE there is never a deductible or copayment for any drug, service, or care
approved by the PACE team.
47
For more information about PACE do the following:
•
Visit www.npaonline.org on the web. This website is sponsored by the National
PACE Association.
•
Visit www.medicare.gov/Nursing/Alternatives/PACE.asp on the web.
•
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-4862048.
CMS Publication No. 11341
January 2008
48