2021 Provider Manual - PA Health & Wellness

1 2021 Provider Manual Last updated date:1 September 15, 2020 Table of Contents INTRODUCTION .. 6 OVERVIEW .. 7 KEY CONTACTS AND IMPORTANT PHONE NUMBERS .. 8 MEDICARE REGULATORY REQUIREMENTS .. 10 SECURE WEB PORTAL .. 13 Functionality .. 13 Disclaimer .. 14 CREDENTIALING AND RE-CREDENTIALING .. 15 Credentials Committee .. 16 Re-credentialing .. 16 Practitioner Right to Review and Correct Information .. 17 Practitioner Right to Be Informed of Application Status .. 17 Practitioner Right to Appeal Adverse Re-credentialing Determinations .. 17 Provider Non-Discrimination .. 18 Provider ADMINISTRATION AND ROLE OF THE Provider .. 19 Primary Care Providers.

2 19 Specialist as the Primary Care Provider .. 19 Specialty Care Provider .. 20 Mental Health Providers .. 20 Independently Practicing Psychologists (IPP) Hospitals .. 21 Ancillary Providers .. 21 Member Selection or Assignment of PCP .. 23 APPOINTMENT AVAILABILITY .. 24 Telephone Arrangements .. 26 Training Requirements .. 27 ALLWELL BENEFITS .. 28 2 September 15, 2020 Missed Appointments and Other Charges .. 28 VERIFYING MEMBER BENEFITS, ELIGIBILITY, and COST SHARES .. 29 Member Identification Card .. 29 Preferred Method to Verify Benefits, Eligibility, and Cost Shares .. 31 Other Methods to Verify Benefits, Eligibility and Cost Shares.

3 31 MEDICAL MANAGEMENT .. 33 Care Management .. 33 HMO Special Needs Plan (SNP) Model of Care (MOC) and Care Management .. 34 Utilization Management .. 37 Utilization Determination Timeframes .. 40 Utilization Review Criteria .. 41 Pharmacy .. 42 Second Opinion .. 44 Health Care .. 45 Emergency Medical Condition .. 45 ENCOUNTERS AND CLAIMS .. 46 Encounter Reporting .. 46 CLAIMS .. 47 Verification Procedures .. 47 Upfront Rejections vs. Denials .. 49 Timely Filing .. 49 Who Can File Claims? .. 49 Electronic Claims Submission .. 50 Online Claim Submission .. 54 Paper Claim Submission .. 54 Corrected Claims, Requests for Reconsideration or Claim Disputes.

4 55 Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) .. 58 Risk Adjustment and Correct Coding .. 59 Coding Of Claims/ Billing Codes .. 60 CODE EDITING .. 61 CPT and HCPCS Coding Structure .. 61 3 September 15, 2020 International Classification of Diseases (ICD-10) .. 62 Revenue Codes .. 62 Edit Sources .. 62 Code Editing Principles .. 64 Invalid Revenue to Procedure Code Editing .. 66 Co-Surgeon/Team Surgeon Edits .. 66 Inpatient Facility Claim Editing .. 67 Administrative and Consistency Rules .. 67 Prepayment Clinical Validation .. 68 Claim Reconsiderations Related To Code Editing .. 70 Viewing Claims Coding 71 Automated Clinical Payment Policy Edits.

5 71 Clinical Payment Policy Appeals .. 73 THIRD PARTY LIABILITY .. 75 BILLING THE MEMBER .. 76 Failure to Obtain Authorization .. 76 No Balance Billing .. 76 Non-Covered Services .. 76 Qualified Medicare Beneficiaries (QMB) Billing .. 76 MEMBER RIGHTS AND RESPONSIBILITIES .. 78 Member Rights .. 78 Member Responsibilities .. 80 Provider RIGHTS AND RESPONSIBILITIES .. 82 Provider Rights .. 82 Provider Responsibilities .. 82 Interference with Health Care Professionals Advice .. 84 CULTURAL COMPETENCY .. 86 Language Services .. 88 Interpreter Services .. 89 Americans with Disabilities Act .. 90 MEMBER GRIEVANCES AND APPEALS .. 97 4 September 15, 2020 Grievances.

6 97 Appeals .. 98 Member Grievance and Appeals Address .. 98 Provider COMPLAINT AND APPEALS PROCESS .. 99 Allwell Complaint .. 99 Authorization and Coverage Appeals .. 99 QUALITY IMPROVEMENT PLAN .. 101 Overview .. 101 QAPI Program Structure .. 101 Practitioner Involvement .. 102 Quality Assessment and Performance Improvement Program Scope and Goals .. 102 Practice Guidelines .. 104 Patient Safety and Quality of Care .. 105 Performance Improvement Process .. 106 Office Site Surveys .. 107 MEDICARE STAR RATINGS .. 108 How Can Providers Help to improve Star Ratings? .. 108 Healthcare Effectiveness Data and Information Set (HEDIS) .. 110 Consumer Assessment of Healthcare Provider Systems (CAHPS) Survey.

7 111 Medicare Health Outcomes Survey (HOS) .. 112 REGULATORY MATTERS .. 113 Medical Records .. 113 Federal and State Laws Governing the Release of Information .. 116 Section 1557 of the Patient Protection and Affordable Care Act .. 117 Health Insurance Portability and Accountability Act .. 118 Fraud, Waste and Abuse .. 122 False Claims Act .. 124 Physician Incentive Programs .. 124 First- tier and Downstream Providers .. 125 Member Notifications .. 126 Detailed Explanation of Non-Coverage .. 126 Required Notification to members for Observation 127 5 September 15, 2020 Provider -Preventable Conditions .. 127 APPENDIX .. 129 Appendix I: Common Causes for Upfront Claim Rejections.

8 129 Appendix II: Common Cause of Claims Processing Delays and Denials .. 130 Appendix III: Common EOP Denial Codes and Descriptions .. 130 Appendix IV: Instructions for Supplemental Information .. 133 Appendix V: Common HIPAA Compliant EDI Rejection Codes .. 135 Appendix VI: Claim Form Instructions .. 139 Appendix VII: Billing Tips and Reminders .. 183 Appendix VIII: Reimbursement Policies .. 186 Appendix IX: EDI Companion Guide Overview .. 190 6 September 15, 2020 INTRODUCTION Welcome to Allwell from PA Health & Wellness . Thank you for participating in our network of high quality physicians, hospitals and healthcare professionals.

9 This Provider Manual is a reference guide for you and your staff servicing members who are enrolled in our Medicare Advantage program for HMO, PPO, or Dual Special Needs (D-SNP) plans. 7 September 15, 2020 OVERVIEW Allwell is a licensed Health maintenance organization (HMO) contracted with the Centers for Medicare and Medicaid Services (CMS) to provide medical and behavioral Health services to eligible members . CMS also contracts Allwell to provide Part D prescription medications to members enrolled in certain Health plans which include a Part D benefit. Allwell is designed to achieve four main objectives: Full partnership between the member, their physician and their Allwell Care Manager Integrated case management (medical, social, behavioral Health , and pharmacy) Improved Provider and member satisfaction Quality of life and Health outcomes Allwell takes the privacy and confidentiality of our members Health information seriously.

10 We have processes, policies, and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and CMS regulations. The services provided by the contracted Allwell network providers are a critical component in terms of meeting the objectives above. Our goal is to reinforce the relationship between our members and their primary care physician (PCP). We want our members to benefit from their PCP having the opportunity to deliver high quality care using contracted hospitals and specialists. PCPs are responsible for coordinating our members Health services, maintaining a complete medical record for each member under their care, and ensuring continuity of care.