2019 Florida Healthy Kids Provider Manual

1 Aetna Better Health of Florida 2019 Florida Healthy Kids Provider Manual Provider Relations Department: 1-844-528-5815. FL-19-01-10. Proprietary Table of Contents Introduction to Aetna Better Health of Florida .. 5. Welcome .. 5. Healthy Kids Key Contact Information .. 8. Administrative 10. Provider tools ..10. Translation IVR (Integrated Voice Response System) .. 11. Forms and reference documents ..11. Designated liaison ..11. Member responsibility ..11. Direct access and cost-sharing ..12. Compliance and Ethics Program ..12. Provider subcontractor responsibilities.

2 13. Independent contractor relationship .. 13. Florida Healthy Kids 13. Listing of Healthy Kids Covered Services*..14. Eligibility and 16. Eligibility ..16. Member identification Continuity of care in Community Outreach and Marketing 18. Provider Responsibilities and Programs .. 21. Provider Selection Requirements regarding background screening .. 23. Changes to Provider Information or 24. Staff/administration changes and training .. 24. Continuity of care (COC) ..25. Unique identifier/national Provider identifier (NPI) .. 25. Verifying member eligibility.

3 25. Aetna Better Health of Florida Healthy Kids Provider Manual Provider Relations 1-844-528-5815, TTY 711 Proprietary 1. Educating members on their own health 27. Acceptance of Managing the member's health care ..28. Authorizing treatment for members ..28. Timeliness of Weather and emergency-related closings .. 29. Membership assigned to PCPs ..29. Individuals with disabilities ..30. Hospitalist Specialist physicians ..31. Obstetricians ..32. Hospital services ..32. Child Health checkup ..33. Early and periodic screening, diagnosis, and treatment.

4 33. Family planning Hysterectomies, sterilizations and 34. Cultural 35. Fraud, Waste and 37. Abuse, Neglect and Exploitation .. 44. Identifying Victims of Human Trafficking .. 45. Access to Care and Service 46. Member Rights and Responsibilities .. 51. Medical Records Guidelines .. 54. Medical records Utilization Management Program .. 57. Our utilization management Medically necessary or medical Out of network ..58. Behavioral Skilled Nursing admissions ..59. Rehabilitation admissions ..59. Discharge Aetna Better Health of Florida Healthy Kids Provider Manual Provider Relations 1-844-528-5815, TTY 711 Proprietary 2.

5 Second opinions ..60. New Medical Care 60. Care management Diabetes Clinical Practice Asthma Clinical Practice Congestive Heart Failure Clinical Practice Guidelines .. 65. Quality Improvement .. 67. Quality Improvement (QI) Program ..67. Risk Management Program .. 70. Fee Schedule Maintenance and Reimbursement 72. Claims and Encounter Submission Protocols and 76. Clean How to file a claim ..77. Claim Correct coding Coordination of Claim Remittance Advice ..82. Editing Guidelines ..83. Anesthesia Unit Billing Guidelines ..84. HCPCS Codes for Drugs and National Drug Code (NDC) Requirements.

6 85. Retroactive Eligibility Changes ..86. Balance Billing ..86. Electronic Data Interchange (EDI) Claim .. 86. Monitoring your EDI reports ..87. Corrected or voided EDI claims ..88. EDI Electronic remittance advice ..89. Electronic fund transfer ..89. Billing Encounters and Claims Overview .. 90. Member Grievances and 92. Aetna Better Health of Florida Healthy Kids Provider Manual Provider Relations 1-844-528-5815, TTY 711 Proprietary 3. Member Appeal Rights ..92. Member Complaint Rights ..93. Medical Necessity Reconsideration.

7 94. Provider Complaint System .. 95. Provider Non-claim related complaints ..96. Provider claim related complaints ..97. Overpayment Oversight of the Provider complaint system processes .. 99. Credentialing and Recredentialing .. 100. Pharmacy .. 102. The Formulary ..102. Prior Authorization ..104. Generic Substitution/Therapeutic Specialty Pharmacy benefit Aetna Better Health of Florida Healthy Kids Provider Manual Provider Relations 1-844-528-5815, TTY 711 Proprietary 4. Introduction to Aetna Better Health of Florida Welcome Welcome to Aetna Better Health of Florida .

8 Our ability to provide excellent service to our members is dependent on the quality of our Provider network. By joining our network, you are helping us serve those Floridians who need us the most. As a Florida Healthy Kids Professional, you play a very important role in the delivery of healthcare and support services to our members. The Provider Manual is intended to be used as an orientation tool and guideline for the provision of covered services to members. This Manual contains policies, procedures, and general reference information including minimum standards of care which are required of Plan providers.

9 As a Network Provider , we hope this information will help you better understand Aetna Better Health of Florida . Should you or anyone on your staff have any questions about any information contained in this Manual or anything else about Aetna Better Health of Florida , please feel free to contact our Provider Relations department. We look forward to working with you and your staff to provide quality managed healthcare service to our members. Our vision is to benefit all stakeholders while considering consumer choice and outcomes, Provider qualifications, and Aetna Better Health of Florida 's requirements.

10 FHK or FHKC . may be used herein to reference the Florida Healthy Kids Corporation. History Coventry Health Care of Florida Inc., Coventry Health Plan of Florida Inc., Coventry Summit Health Plan and Coventry Health and Life Insurance Company are subsidiaries of Coventry Health Care, Inc.. acquired by Aetna Health Insurance May 2013 operating insurance companies, network rental and workers' compensation services companies. Aetna Better Health of Florida offers a full range of risk and fee-based managed care products and services including HMO, PPO and POS, Medicare Advantage, Medicaid, Healthy Kids, Workers' Compensation and network lease products to a broad cross-section of employer and government-funded groups, government agencies, individuals and other insurance carriers and administrators in all 50 states, as well as, the District of Columbia and Puerto Rico.