Aetna Better Health of Illinois - Medicaid Health Plans

1 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Aetna Better Health of Illinois Provider Manual Provider services : 1-866-329-4701 Aetn aB etterHealth .com/I llin ois- Medicaid 1 Provider Manual Version 1 (2/07/2022) IL-22-02-05 2 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Table of contents Table of contents .. 2 C H A PT ER 1: I NT RO DU CTI ON TO AE TN A BE TT ER HE ALT H O F 7 Welcome .. 7 About Aetna Better Health of Illinois .. 7 Experience and 7 About the Medicaid Managed care Program .. 7 About this Provider Manual .. 7 C H A PT ER 2: Im po r tan t CON TA CT I N FOR MA TI CH APTER 3 : PROV I DER SER VI CE 11 Provider 11 W eb po r tal tr ain in 12 C H A PT ER 4 : PR OVI DER RE SPONSIBI LITIE S & I MPOR TANT INFORMATION.

2 13 Provider responsibilities overview .. 13 Clinical 13 Appointment availability 13 Behavioral Health appointment 14 Telephone accessibility standards .. 15 Co v er in g p ro v id er s .. 17 Verifying member eligibility .. 17 Provider Secure Web Portal .. 17 Preventive or screening services .. 19 Educating members on their own Health care .. 19 Emergency 19 Urgent care services .. 19 Primary care providers (PCPs) .. 20 Provider Financial Incentives (P4P) M BR in cen tiv e p ro gr am s ..22 Updates to preventive and screening Specialty Specialty providers or primary care sites acting as PCPs .. 23 PCP panel size .. 23 Self-referrals/direct 23 Skilled Nursing Facility (SNF)/Nursing Facility (NF) providers .. 24 Out-of-network providers .. 25 Pr o v id er-requested member transfer .. 26 3 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Medical records 26 Medical record audits.

3 27 Documenting member appointments ..27 Missed or cancelled appointments ..27 Documenting referrals .. 28 Self-referrals/direct 28 Confidentiality and accuracy of member records .. 28 Health Insurance Portability and Accountability Act (HIPAA) of 1996 .. 28 Member privacy rights .. 29 Member privacy requests .. 30 Advance 30 Cultural competency and Health 30 Inclusive patient 31 I n di v i du als with disabilities .. 32 Clinical 32 Office administration .. 32 Continuity of 32 Credentialing/recredentialing .. 33 Interested 33 Discrimination laws .. 36 Financial liability for payment for services .. 36 CH A PT ER 5 : COV ERE D AN D N ON-COVERED SERV I CE S .. 38 Value-added benefits .. 38 42 Spenddown .. 42 Medical necessity .. 44 Emergency 44 Emergency transportation .. 44 Non-emergent 45 Laboratory services Lab 45 Pharmacy services .

4 45 Vision services M a r ch Vision .. 45 Dental services D en t a Qu e s t .. 45 Interpretation services .. 45 C H A PT ER 6 : BEH AV IOR AL H EALTH .. 46 Mental Health /Substance Use Disorder (MH/SUD) 46 46 4 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Referral process for members needing mental Health /substance use disorder 47 PCP role in behavioral Health services .. 47 Coordination between behavioral Health and physical Health services .. 48 CH APTER 7: MEMB ER R IGH TS AND R ESPONSIB I LI TI 49 Member rights .. 49 Member responsibilities .. 50 Member rights under Rehabilitation Act of 1973 .. 50 C H A PT ER 8 : E LI GIB I LI T Y AN D ENR O L LM EN T .. 52 Open Enrollment .. 52 ID 52 Sample ID card .. 53 Verifying eligibility .. 53 CH APTER 9: E AR LY PER IODI C SCR EENING , DI AGNOSIS, AND TR EATME NT.

5 54 Handbook for Providers of Healthy Kids services E PS D T-specific requirements .. 54 EPSDT 54 Identifying barriers to 55 Educating members about EPSDT services .. 56 Provider responsibilities in providing EPSDT 56 Provider monitoring .. 57 PCP 57 Direct-access 57 Vision services .. 57 Dental services .. 58 Mental Health /substance use disorder .. 58 CH APTER 10: MEMBE RS WI TH SPE CI AL NEE DS .. 59 Members with special 59 CHAPTER 11: care coo r d in atio n .. 61 care coordination .. 61 T r an si tio n-of- care coordination functions .. 61 Integrated care teams .. 61 care Plans .. 62 Transplants .. 62 Model o f care .. 62 Integrated care coordination and disease 64 CH APTER 12: CONCURRE NT R EVI EW AN D DI SCH ARG E PLANNI 66 Concurrent review overview .. 66 Discharge planning coordination .. 66 5 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Discharge from a Skilled Nursing Facility.

6 66 CHAPTER 13: PRIOR AUTHORIZATION .. 67 Emergency 67 Post-stabilization 67 services requiring prior authorization .. 67 E xceptio ns to prior authorizations .. 68 Provider requirements .. 68 Ways to request prior authorizations .. 68 Medical necessity criteria (physical and behavioral Health ) .. 68 Timeliness of decisions and notifications to providers and members .. 69 Prior authorization period of validation .. 70 Out-of-network providers .. 70 Notice of Adverse Benefit Determination requirements .. 70 Continuation of Prior authorization and coordination of benefits ..72 CH A PT ER 14 : Q UA LIT Y M AN AG EME 74 Overview .. 74 Identifying opportunities for improvement .. 75 Potential Quality of care (PQoC) concerns .. 76 Performance Improvement Projects (PIPs) .. 76 Peer review ..77 Satisfaction survey ..77 M e m b er s a t i s f a c t i o n su r v ey s.

7 77 Provider satisfaction surveys ..77 External Quality Review (EQR) .. 78 Provider feedback .. 78 CHAPTER 15: PHARMACY 79 Pharmacy management 79 79 Fo rm u lary /Pr efer r ed Dru g List (PDL) .. 79 Quantity Level Limits (QLL).. 79 Prior authorization process .. 79 CHAPTER 16: ADVANCE DIRECTIVES (THE PATIENT SELF-DETERMINATION ACT).. 81 Advance 81 Proxy 82 Instruction directive .. 82 Patient Self-Determination Act (PSDA) .. 83 6 Provider Manual Version 1 (2/07/2022) IL-22-02-05 Physician Orders for Life Sustaining Treatment (POLST) .. 83 C H A PT ER 1 7 : B I L LI NG an d C LA IM S OV ERV IEW .. 84 Billing and claims 84 Information on billing and claim submission .. 84 Coding overview .. 89 Claim 90 Remittance 91 C H A PT ER 18 : APPEAL AND GR IEV ANCE SYSTEM .. 94 Enrollee appeal and grievance system overview.

8 94 Enrollee complaint process .. 94 E nro llee grievance 95 Enrollee appeal 95 Provider appeal and grievance on behalf of the member system overview .. 98 Provider co mp l a i n t s .. 100 Department 101 CHAPTER 19: FRAUD, WASTE AND ABUSE ..102 Fraud, Waste and Abuse ..102 Special investigations Reporting suspected fraud and abuse ..102 Fraud, Waste and Abuse 103 Elements to a compliance 104 Relevant laws .. 105 Administrative sanctions .. 106 Remediation .. 106 Exclusion lists and death master report .. 106 CH APTER 20: MEMB ER ABUSE AND NEG LE CT ..107 Mandated reporters ..107 C h i l d r en ..107 Vulnerable adults ..107 R epo r tin g i d en ti fy in g in for m atio n ..107 Examinations to determine abuse or 108 Examples, behaviors and signs .. 108 7 Provider Manual Version 1 (2/07/2022) IL-22-02-05 CHAPTER 1: INTRODUCTION TO Aetna Better Health OF Illinois B a c k to Ta ble of Contents Welcome Welcome to Aetna Better Health of Illinois .

9 We rely on the quality of our provider network to provide excellent service to our members. By joining our network, you re helping us serve those Illinoisans who need us most. About Aetna Better Health of Illinois For over 30 years, Aetna Medicaid has honed our approach to serving high-acuity, medically frail and low-income populations with diverse benefits. Our goal is to improve the functional status and quality of life for members, while providing budget predictability to our state partners. Our experience in implementing, managing, and caring for high-acuity Medicaid beneficiaries results in improved access to care , higher quality care in appropriate settings, and a simplified consumer experience in a culturally competent manner. We take seriously our responsibility as a steward of public programs. Today, Aetna Medicaid serves more than 3 million members through Medicaid managed care Plans .

10 In partnership with providers, community resources, and other key stakeholders, we offer an extensive suite of programs and services that work in concert to meet the individual needs of our most vulnerable members. While our programs and services continue to evolve and expand, our mission remains the same building a healthier world by improving the lives and well-being of every member we are privileged to serve. Experience and innovation We enhance member and provider satisfaction by using tools such as predictive modeling, care coordination, and state of the art technology to achieve cost savings and help members attain the best possible Health through a variety of service models. We work closely and cooperatively with physicians, hospitals, and all other providers to achieve demonstrable improvements in service delivery. We re committed to building on the dramatic improvements in preventive care by facing the challenges of Health literacy and personal barriers to healthy living.