2018 Florida Provider Manual - lmchealthplans.com

1 2018 . Florida Provider Manual We are Ladies and Gentlemen, serving Ladies and Gentlemen . ACKNOWLEDGEMENT OF RECEIPT OF. LEON MEDICAL CENTERS HEALTH PLANS. Provider Manual . Dear Provider : Enclosed you will find the 2018 Leon Medical Centers Health Plans (LMCHP) Provider Manual . Upon receipt of this Manual , please sign below and return this form to LMCHP by fax or mail to the following: Leon Medical Centers Health Plans Network Operations Department 8600 NW 41st Street, Suite 201. Doral, FL 33166. 305-646-3776 or 305-631-5242. Fax: 305-646-3781. Centers Health Plans Provider Manual .

2 I. I acknowledge receipt of the Leon Medical Manual along with all updates. agree to the terms and provisions of the _____. Signature of Provider Date _____. Print Name of Provider INTRODUCTION. Leon Medical Centers Health Plans' (LMCHP) Provider Manual is designed to provide Primary Care Physicians (PCP), Specialty providers, Ancillary providers and Facility administrators and their staff with a source of readily available information regarding the administration of our plan. The Manual contains an overview of the product offered by LMCHP and provides administrative procedures for claims processing, referrals, prior authorizations and the Quality Management program.

3 This Manual is intended for use by the staff of participating primary care physicians (PCP), specialists, hospitals and ancillaries, and the information contained herein should not be shared with anyone not directly related to the daily function of the above described entities. Participating PCPs, Specialists, Hospitals and Ancillaries are considered to be those providers which have contracted with LMCHP to provide services to our members. Any comments or questions regarding the information contained in this Manual should be directed to the Provider Relations Department at (305) 646-3776 or (305) 631-5242.

4 Provider Manual UPDATES: LMCHP may update this Provider Manual periodically. Please be sure to check our Provider website at for the most updated version. A paper copy can be requested by contacting the Provider Relations Department. Medicare Medicare is the federal program established by Title XVIII of the Social Security Act of 1965, as amended from time to time, which provides health care coverage for the aged and disabled. During the three months prior to an American citizen's 65th birthday, the Social Security Office will send the individual information concerning enrollment in Medicare.

5 There are four types of Medicare insurance: Medicare Part A: Provides inpatient hospital insurance Medicare Part B: Provides medical and outpatient hospital insurance, doctor visits Medicare Part C: Medicare Advantage Plans, LMCHP. Medicare Part D: Prescription Drug plans Medicare Part A is made available to individuals who are at least 65 years old, certain disabled persons, persons with End Stage Renal Disease (if diagnosed after enrollment), and person who meet Medicare eligibility requirements. Part A is the basic part of the health insurance program covering inpatient hospital benefits, post hospital care in skilled nursing facilities, home health care in the patient's home, or hospice care for terminally ill patients.

6 Medicare Part B is the medical insurance part of the program which provides coverage for medical services and supplies furnished by physicians or others in connection with physician services, outpatient hospital care, outpatient physician therapy services, and home health care. Medicare Part C allows the Centers for Medicare and Medicaid Services (CMS) to contract with Medicare Advantage Plans, like LMCHP. Plans must cover all Medicare Part A and Part B health care benefits. Some managed care plans cover extras, like prescription drugs and fitness programs.

7 Everyone who has Medicare Parts A and B is eligible, except those who have end stage renal disease. Medicare Part D is the prescription drug coverage that provides members with a prescription drug benefit and may be part of the Medicare Advantage Plan benefits. This benefit became available to Medicare recipients effective January 1, 2006. Leon Medical Centers Health Plans is an HMO plan with a Medicare contract. Enrollment in Leon Medical Centers Health Plans depends on contract renewal. LMCHP is a Medicare replacement plan that contracted with CMS (Centers for Medicare and Medicaid Services) in June, 2005.

8 LMCHP is a Cigna-HealthSpring Company. ADDITIONAL LMCHP BENEFITS. Benefit LMCHP Original Medicare Routine Transportation Covered Not Offered Routine Vision Exam Covered Not Offered Routine Hearing Exam Covered Not Offered Routine Physical Exam Covered Not Offered Dental Covered Not Offered Vitamins Covered Not Offered Provider Manual . Table of Contents I. Telephone Numbers and Addresses .1-3. II. Member ID Card and Eligibility ..4-5. III. Primary Care Physician (PCP) Responsibilities .6-15. IV. Specialty Care Physician (SCP) Responsibilities .16-25. V. Office Administration.

9 26-27. VI. Medical Records Guidelines .28-32. VII. Member Access to Care 33-34. VIII. Rights and Responsibilities (Member and Provider ) 35-38. IX. Claims ..39-41. X. EDI & HIPAA ..42-44. XI. Credentialing 45-48. XII. Advance Directives 49. XIII. Quality Improvement Program .50-55. XIV. Utilization Management Program 56-58. XV. Referrals and Authorizations 59-66. XVI. Risk Management .67-69. XVII. Provider Appeals 70. XVIII. Plan Benefits .71-82. XIX. Forms .83. a. Medical Records Release ..84. b. Claims Inquiry Request ..85. c. Provider Appeal Request.

10 86. d. Grievance/Complaint Form ..87-88. e. Advance Directives ..89-99. f. Referral/Pre-Authorization ..100-101. Additional Medicare Advantage Terms and Conditions of Participation XX. and Accreditation Requirements ..102-111. SECTION I: KEY CONTACTS & PHONE NUMBERS. Chief Medical Officer/Medical Director Chief Medical Officer/Medical Director 8600 NW 41st Street, Suite 201. Doral, FL 33166. (305) 631-4459. (305) 229-7467 Fax Member Services Member Services 8600 NW 41st Street, Suite 201. For member eligibility and benefit Doral, FL 33166. verification (305) 559-5366.