2021 Provider Manual - SWHP.org

1 2021 Provider Manual Provider Relations 1-855-TX-RIGHT ( ) RCSWHP 21233 05/21 Contents CHAPTER 1. INTRODUCTION .. 1 Welcome to RightCare from Scott and White health Plan .. 1 Who is RightCare? .. 2 Program Objectives .. 2 Our Mission, Vision, and Values .. 3 Phone List .. 4 Primary care Providers (Medical Home) .. 6 Specialty care Providers .. 6 Role of Pharmacy .. 7 Role of Main Dental Home .. 7 Network Limitations .. 8 CHAPTER 2. TEXAS health STEPS SERVICES .. 9 Texas health Steps .. 9 Becoming a Texas health Steps Provider .. 9 More about Texas health Steps .. 9 Texas health Steps Medical Checkups and Screenings .. 10 Documentation of Completed Texas health Steps Components and Elements .. 11 Texas health Steps Billing 13 Timing of Texas health Steps Checkups .. 14 Performing Newborn Screenings .. 14 Newborn Testing .. 15 Performing Adolescent Screenings .. 15 Performing Pregnant Adolescent Screenings .. 15 Exceptions to Periodicity Allowed .. 16 RightCare Provider Manual Page i Texas health Steps Environmental Lead Investigation (ELI).

2 17 Lead Screening and Testing .. 17 Texas health Steps Laboratory Testing .. 18 Immunizations .. 19 Vaccines for Children .. 19 Vaccine Administration and Preventive E/M Visits .. 20 Texas health Steps Dental Checkups .. 20 Oral Evaluation and Fluoride Varnish (OEFV) .. 21 Vision Exams and 22 Hearing Exams and Services .. 22 Comprehensive care Program .. 23 Children of Migrant Farmworkers .. 23 Refusal of Services .. 24 Referrals for Conditions Identified During a Texas health Steps Medical Checkup .. 24 CHAPTER 3. COVERED SERVICES AND EXTRA BENEFITS .. 25 Medicaid Covered Services for STAR .. 25 Covered Services (Core Medicaid services covered by RightCare) .. 25 Prescribed Pediatric Extended care Centers and Private Duty Nursing .. 27 Adoption Assistance and Permanency care Assistance .. 27 Medicaid Program Exclusions .. 28 CHAPTER 4. COORDINATION WITH NON-MEDICAID MANAGED care COVERED SERVICES .. 29 Texas School health and Related Services (SHARS) .. 30 DSHS Case Management for Children and Pregnant Women.

3 30 Women, Infants and Children (WIC) .. 30 DARS Case Management for the Visually Impaired .. 31 Tuberculosis (TB) Services Provided by DSHS-Approved Providers .. 32 RightCare Provider Manual Page ii DADS Hospice Services .. 32 CHAPTER 5. BEHAVIORAL health .. 33 Behavioral health Services Explained .. 33 Behavioral health Covered Services .. 33 Behavioral health Authorizations .. 34 Primary care Provider Requirements .. 34 Member Access to Behavioral health Services .. 35 Routine Access .. 35 Urgent Access .. 35 Emergent Access .. 36 Attention Deficit Hyperactivity Disorder (ADHD) .. 36 Follow-up care for Children Prescribed ADHD Medication .. 37 Reimbursement for ADHD .. 37 Referrals .. 37 Coordination of care .. 37 Medical Records Documentation .. 38 Consent for Disclosure .. 38 Court Ordered Commitments .. 38 Coordination with the Local Mental health Authority (LMHA) & State Psychiatric Facilities .. 39 Assessment Instruments for Behavioral health .. 40 Focus Studies and Utilization Reporting Requirements.

4 40 Missed Appointments .. 40 Member Discharged from Inpatient Psychiatric Facilities .. 40 Behavioral health Value-Added Services .. 41 Behavioral health Case Management .. 41 Mental health Rehabilitation (MHR) Services, Targeted Case Management and care Coordination .. 41 care Coordination .. 42 RightCare Provider Manual Page iii Severe and Persistent Mental Illness (SPMI) .. 43 Severe Emotional Disturbance (SED) .. 43 Member Access & Benefits of MHR Services and TCM .. 43 Provider Requirements .. 44 Psychosocial Rehabilitative Services .. 44 Initial Encounters .. 44 Laboratory Services .. 45 CHAPTER 6. ADDITIONAL COVERED BENEFITS .. 46 Family Planning .. 46 Breast Pump Coverage in Medicaid .. 46 CHAPTER 7. QUALITY IMPROVEMENT (QI) .. 49 Goals and Objectives .. 49 Quality Assessment and Performance Improvement .. 50 Clinical Practice Guidelines .. 51 Monitoring Guideline Compliance .. 51 RightCare Staff .. 52 Medical Record Standards .. 52 Patient Visit Data .. 54 Medical Record Confidentiality.

5 55 CHAPTER 8. Provider ADVISORY GROUPS .. 56 Chapter 9. UTILIZATION MANAGEMENT REPORTING REQUIREMENTS .. 57 CHAPTER 10. Provider ROLES AND RESPONSIBILITIES .. 58 The Primary care Provider .. 58 Who Can Serve as a Primary care Provider ? .. 58 Availability and Accessibility .. 59 Primary care Provider Responsibilities .. 60 RightCare Provider Manual Page iv Notification of Changes in Medical Office Staffing, Addresses, and Provider 61 Provider Termination from health Plan .. 62 OB/GYN as a Primary care Provider .. 62 Specialist as a Primary care Provider .. 63 Direct Access Services .. 63 Medications from any Network pharmacy .. 63 Advance Directives .. 63 Referrals to Specialist .. 64 How to Help a Member Find Dental care .. 64 Primary care Provider & Behavioral health .. 64 Referral to Network Facilities & Contractors .. 64 Second Opinion .. 64 Eligibility Report .. 65 Specialty care Provider Responsibilities .. 65 Availability and Accessibility .. 65 Verify Member Eligibility or Authorizations.

6 66 Continuity of care .. 66 Pregnant Women .. 66 Member Moves Out of Service Area .. 67 Pre-existing Conditions .. 68 Network Limitations .. 69 Medical Records .. 69 Reporting Abuse, Neglect, or Exportation (ANE) .. 69 Notification to MCO .. 71 Out of Network Referrals .. 71 Physician Selection/Primary care Provider Changes .. 71 Marketing .. 72 RightCare Provider Manual Page v CHAPTER 11. PHARMACY Provider RESPONSIBILITIES .. 74 The Role of Pharmacy .. 74 General Information .. 74 Prior Authorizations .. 74 Billing Guidelines for Compounded Prescription Drugs .. 75 Chapter 12. COORDINATION WITH TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES (DFPS) .. 76 CHAPTER 13. ROUTINE, URGENT, AND EMERGENCY SERVICES .. 77 Routine, Urgent and Emergency Services Defined .. 77 Routine Services .. 77 Urgent care .. 77 Emergency care .. 77 Access to Routine, Urgent and Emergent care .. 78 Non-Emergency Services .. 79 Hospital Emergency Department Claims .. 79 Emergency Room Visit after Hours.

7 79 Emergency Room Reimbursement Reduction for Non-Emergency Visits .. 80 Emergency Admission .. 80 Emergency Prescription Supply .. 80 Urgent/Emergent Hospital-to-Hospital Transportation .. 81 Emergency Ambulance Services .. 81 Emergency Air Services .. 81 Non-Emergency Transportation .. 82 Non Emergency Medical Transportation (NEMT ) .. 83 Emergency Dental Services .. 85 Non-Emergency Dental Services .. 85 Durable Medical Equipment & Other Products Normally Found in a Pharmacy .. 86 RightCare Provider Manual Page vi CHAPTER 14. CREDENTIALING AND RE-CREDENTIALING .. 88 Criteria .. 88 Credentialing & Re-credentialing .. 90 Physician/Physician Group .. 90 Professional Practitioners .. 90 Availity/Aperture Credentialing .. 90 Hospital Privileges .. 91 Full Residency Requirement .. 91 Board Certification .. 91 Medicaid Providers .. 92 Institutional Providers .. 92 Expedited Credentialing .. 93 Mid-level Providers .. 93 Credentialing Decisions .. 93 Rights of Applicants to the Scott and White health Plan.

8 94 On-Going Monitoring .. 95 Changes in Address or Practice Status .. 95 CHATPER 15. Provider COMPLAINT AND APPEAL 96 Complaints .. 96 Filing Complaints to RightCare .. 96 Coverage Determinations & Appeals .. 97 Provider Complaint Process to HHSC .. 97 Provider Appeal Process to HHSC .. 98 CHAPTER 16. MEMBER COMPLAINTS & APPEALS .. 99 Member Coverage Determination and Appeals .. 100 Member Expedited Appeal Process to RightCare .. 102 State Fair Hearing Information .. 103 RightCare Provider Manual Page vii Enrollment and Eligibility Determination .. 104 Enrollment Process .. 105 Verifying Member Medicaid Eligibility .. 105 RightCare Identification Card .. 106 Coordination of Benefits (Dual Coverage) .. 107 CHAPTER 17. ADDED BENEFITS .. 108 Value-Added Services .. 108 VAS Sport Physical Billing .. 110 CHAPTER 18. MEMBER RIGHTS AND RESPONSIBILITIES .. 111 MEMBER RIGHTS: .. 111 Member Responsibilities: .. 113 CHAPTER 19. MEMBER S RIGHT TO DESIGNATE AN OB/GYN: .. 114 CHAPTER 20.

9 FRAUD INFORMATION .. 115 REPORTING WASTE, ABUSE, OR FRAUD BY A Provider OR CLIENT .. 115 CHAPTER 21. CLAIMS .. 117 Claim Requirements .. 117 Electronic Claim Filing .. 117 Paper Claims .. 117 Filing Limits .. 118 Inpatient Admission Prior To Enrollment .. 119 Inpatient Admissions after Enrollment .. 119 Discharge after Voluntary Disenrollment from RightCare and Re-Enrollment into a New MCO .. 119 Member Acknowledgement Statement/Private Pay Form .. 119 Medicaid Third Party Recovery .. 119 Claim Forms .. 121 Claim Appeal .. 123 RightCare Provider Manual Page viii Corrected Claim .. 124 Capitated Services .. 124 Emergency Services .. 124 National Drug Code (NDC) Requirements .. 125 Hospital Transfers .. 125 CHAPTER 22. REFERRALS .. 126 In-Network Referrals .. 126 Out-of-Network Referrals .. 127 Referrals to Ancillary Services .. 127 CHAPTER 23. PRIOR AUTHORIZATION .. 128 Submission Process .. 128 Authorization for Newborn Deliveries .. 129 Requests for Therapy .. 129 Requests for Durable Medical Equipment.

10 129 Request for Behavioral health .. 130 Submission Process .. 130 Review Process .. 131 Transplants .. 132 CHAPTER 24. HOSPITAL ADMISSIONS .. 133 Physician Obligations for Hospital Admissions .. 133 Facility Obligations for Admission .. 134 Admission to Out-Of-Network Facilities .. 135 Concurrent Review .. 135 CHAPTER 25. MEMBER ENROLLMENT AND DISENROLLMENT FROM MCO .. 136 Newborn Enrollment .. 136 Automatic Re-Enrollment .. 136 RightCare Provider Manual Page ix Member Disenrollment .. 136 CHAPTER 26. SPECIAL ACCESS REQUIREMENTS .. 138 Ambulance Transportation .. 138 Interpreter/Translation Services .. 138 MCO/ Provider Coordination .. 139 Reading/Grade Level Consideration .. 140 Cultural Sensitivity .. 140 RightCare Provider Manual Page 1 CHAPTER 1. INTRODUCTION Welcome to RightCare from Scott and White health Plan HHSC contracts with Managed care Organizations (MCOs) to provide STAR services to Medicaid recipients throughout the state of Texas. HHSC s goal is to achieve five main objectives: improved access to care , improved quality of care , improved client and Provider satisfaction, improved cost effectiveness and improved health status.