Washington Apple Health - Amerigroup

1 WA-PM-0026-19 provider ManualWashington Apple Health1-800-454-3730 WA-PM-0026-19 All rights reserved. This publication or any part thereof may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without prior written permission. Providers must acknowledge this provider manual and any other written materials provided by Amerigroup Washington , Inc. as proprietary and confidential. Apply for network participation Interested in participating in the Amerigroup Washington , Inc. network? Visit or call our provider Services team at 1-800-454-3730. ii Table of Contents 1. INTRODUCTION .. 5 Who We Are .. 5 Nondiscrimination Statement .. 5 Updates and Changes .. 6 Quick Reference Contact Information .. 7 2. provider TYPES, ACCESS AND AVAILABILITY .. 13 Primary Care Providers .. 13 PCP Responsibilities.

2 13 3. provider PROCEDURES, TOOLS AND 23 Core provider Agreement required .. 23 Medical Necessity Appeals .. 23 Expedited Appeals .. 24 Administrative Hearing Process .. 25 Continuation of Benefits During Appeals or Administrative Hearings .. 25 Clinical Practice Guidelines .. 26 Covering Physicians .. 26 Critical Incidents .. 26 Cultural Competency and Considerations .. 26 Research, Evidence-Based and Promising Practices .. 28 Fraud, Waste and Abuse .. 28 Privacy, Confidentiality and Compliance .. 31 Lab Requirements: Clinical Laboratory Improvement Amendments .. 33 Marketing: Prohibited provider Activities .. 33 Records Standards: Member Medical Records .. 34 Member Rights .. 35 Member Responsibilities .. 38 Rights of Our Providers .. 39 Satisfaction Surveys .. 40 Support and Training for Providers .. 40 4. TOOLS TO HELP YOU MANAGE OUR MEMBERS .. 41 Availity Portal .. 41 Identification Cards .. 42 Members with Special Needs.

3 42 Missed Appointments .. 43 Noncompliant Members .. 43 Second Opinions .. 44 Member Grievances .. 44 Member Self-Referrals .. 45 5. HOW WE SUPPORT OUR MEMBERS .. 46 Health Home Program .. 46 24-Hour Nurse HelpLine .. 46 Automatic Assignment of PCPs .. 46 Case Management Services .. 47 iii Disease Management .. 48 Member Enrollment .. 50 Interpreter Services .. 50 provider 50 Well-child Visits Reminder Program .. 51 6. COVERED SERVICES FOR MEMBERS .. 52 Health Care Authority and Integrated Managed Care .. 52 Services Covered under the State Plan or Fee-For-Service Medicaid .. 52 Services Covered Under Amerigroup .. 54 Amerigroup Special Services and Value-Added Benefits .. 70 Blood Lead Screenings .. 75 Immunizations .. 75 Medically Necessary Services .. 75 Pharmacy Services .. 76 Taking Care of Baby and Me Pregnancy Support Program .. 79 7. PRIOR AUTHORIZATION AND PRIOR NOTIFICATION PROCESSES .. 80 Confidentiality of Information During the Process.

4 80 Interactive Care Reviewer .. 80 Coverage Guidelines .. 81 Nonemergent Outpatient and Ancillary Services .. 89 Prenatal Ultrasounds .. 90 Urgent Care/After-Hours Care .. 91 Emergency Services .. 91 Medical and Behavioral Health Inpatient Admissions .. 92 Inpatient Reviews .. 93 Extenuating Circumstances .. 93 Discharge Planning .. 94 8. QUALITY MANAGEMENT .. 96 Quality Management Program .. 96 Quality of Care .. 96 Quality Management Committee .. 96 Medical Necessity and Clinical Review Criteria .. 97 Medical Advisory Committee .. 98 Credentialing .. 99 Initial Credentialing .. 102 103 Health Delivery Organizations .. 104 Ongoing Sanction Monitoring .. 104 Appeals Process .. 105 Reporting Requirements .. 105 Anthem Credentialing Program Standards .. 105 Delegated Credentialing .. 118 Peer Review .. 118 9 CLAIM SUBMISSION AND ENCOUNTERS PROCEDURES .. 119 Claims Submissions .. 119 Clearinghouse Submissions.

5 120 Electronic Claims 120 Paper Claims Submission .. 120 iv Encounter Data .. 121 Claims Adjudication .. 123 International Classification of Diseases, 10th Revision (ICD-10) .. 123 Clean Claim Payments .. 123 Claims Status .. 124 Coordination of Benefits and Third-party Liability .. 124 Reimbursement Policies .. 125 Reimbursements by provider Type .. 126 Overpayment Process .. 133 Documentation of Claim Receipt .. 134 Billing Members .. 135 Client Acknowledgment Statement .. 135 10 provider CLAIM PAYMENT DISPUTE PROCEDURES .. 137 Claim Inquiries .. 137 Claim Correspondence .. 137 provider Claim Payment Dispute Process .. 138 Claims Payment Reconsideration .. 139 Claim Payment Appeal .. 140 How to Submit a Claim Payment Dispute .. 140 Required Documentation for Claims Payment Disputes .. 141 5 1. INTRODUCTION Welcome to our network. We re glad you ve decided to join us. We recognize hospitals, physicians, behavioral Health practitioners and other providers play a pivotal role in integrated managed care.

6 Earning your respect and gaining your loyalty are essential to a successful collaboration in the delivery of quality Health care. Our manual contains information you need to know about us, our programs and how we work with you. And we want to hear from you! Participate in one of our quality improvement committees or call our provider Services team at 1-800-454-3730 with any suggestions, comments or questions. Together, we can make a difference in the lives of our members your patients. Who We Are As a leader in integrated managed Health care services for the public sector, Amerigroup Washington , Inc. helps adults, low-income families, children, pregnant women, those with disabilities and special needs plans get the Health care they need. We help coordinate physical and behavioral Health care and offer education, access to care and disease management programs. As a result, we lower costs, improve quality and encourage better Health status for our members.

7 We: Improve access to preventive primary care services. Ensure selection of a primary care provider who will serve as provider , care manager and coordinator for all basic medical services. Improve Health status outcomes for members. Educate members about their benefits, responsibilities and appropriate use of care. Utilize community-based enterprises and community outreach. Integrate physical and behavioral Health care. Encourage: o Stable relationships between our providers and members. o Appropriate use of specialists and emergency rooms. o Member and provider satisfaction. In a world of escalating Health care costs, we work to educate our members about the appropriate use of our managed care system and their involvement in all aspects of their Health care. Nondiscrimination Statement Amerigroup does not engage in, aid or perpetuate discrimination against any person by providing significant assistance to any entity or person that discriminates on the basis of race, color or national origin in providing aid, benefits or services to beneficiaries.

8 Amerigroup does not utilize or administer criteria having the effect of discriminatory practices on the basis of gender or gender identity and does not select site or facility locations that have the effect of excluding individuals from, denying the benefits of or subjecting them to discrimination on the basis of gender or gender identity. In addition, in compliance with the Age Act, Amerigroup does not discriminate against any person on the basis of age or aid or perpetuate age discrimination by providing significant assistance to any agency, organization or person that discriminates on the basis of age. Amerigroup provides Health coverage to our members on a 6 nondiscriminatory basis, according to state and federal law, regardless of gender, gender identity, race, color, age, religion, national origin, physical or mental disability, or type of illness or condition. Members who contact us with an allegation of discrimination are informed immediately of their right to file a grievance.

9 This also occurs when an Amerigroup representative working with a member identifies a potential act of discrimination, we advise the member to submit a verbal or written account of the incident and is assisted in doing so if he or she requests assistance. We document, track and trend all alleged acts of discrimination. Members are also advised to file a civil rights complaint with the Department of Health and Human Services Office for Civil Rights (OCR): Through the OCR complaint portal at By mail to Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington , DC 20201. By phone at 1-800-368-1019 (TTY/TDD: 1-800-537-7697). Complaint forms are available at Amerigroup provides tools and services at no cost to those with disabilities to communicate effectively with us. Amerigroup also provides no-cost language services to people whose primary language isn t English ( , qualified interpreters and information written in other languages).

10 These services can be obtained by calling the customer service number on the member s ID card. If you or your patient believe that Amerigroup has failed to provide services or discriminated in any way on the basis of race, color, national origin, age, disability, gender or gender identity, you can file a grievance with our grievance coordinator via: Mail: 705 Fifth Ave. S., Suite 300, Seattle, WA 98104 Phone: 1-800-600-4441 (TTY 1-800-855-2880) Fax: 1 877 271 2409 Equal Program Access on the Basis of Gender Amerigroup provides individuals with equal access to Health programs and activities without discriminating on the basis of gender. Amerigroup must also treat individuals consistently with their gender identity and is prohibited from discriminating against any individual or entity on the basis of a relationship with, or association with, a member of a protected class ( , race, color, national origin, gender, gender identity, age or disability). Amerigroup may not deny or limit Health services that are ordinarily or exclusively available to individuals of one gender, to a transgender individual based on the fact that a different gender was assigned at birth or because the gender identity or gender recorded is different from the one in which Health services are ordinarily or exclusively available.