Transcription of Health Care Professional and Provider Manual
1 Health care Professional and Provider ManualiTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 ContentsIntroduction ..1 Our Vision .. 1 Our Mission .. 1 Our Values .. 1 Practice and Facility Changes .. 1 Medicaid Managed care Overview .. 1 Quality Assurance and Performance Improvement Program .. 2 Quality Assessment Performance Improvement Committee .. 2 Quality Clinical care Committee 2 Quality of Service Committee 2 Pharmacy and Therapeutics Committee 3 Compliance Committee 3 Credentialing Committee 3 Administrative Appeal and Grievance Committee 3 Appeals Committee
2 3 Practitioner Involvement 3 QAPI Activities .. 3 Performance Improvement Projects 3 Ensuring Appropriate Utilization of Resources 3 Chronic care Improvement Programs 3 Measuring Member and Provider Satisfaction 3 Participant and Provider Dissatisfaction 3 Member Safety Programs 4 NCQA HEDIS Reporting Measures.
3 4 Important Phone Numbers .. 4 Select Health Credentialing Requirements .. 4 Required Credentialing Documentation .. 5 Collaborative Agreements ( for PA s) .. 6 Nurse Practitioners (NP s) Protocols .. 7 Licensed Dietitian (LD) Enrollment 7 Ancillary Providers .. 7 Ancillary Providers Organizational 7 Ancillary Providers Non Organizational 8 Non-accredited Organizational Providers 10 Ongoing Monitoring Of Sanctions & Complaints 10 Required Re-credentialing Documentation 10 Select Health Credentialing/Re-credentialing Actions 10 Delegated Credentialing Requirements
4 11 Disclosure of Ownership and Control Interest Statement 11 Health care Professional / Provider Site Visit Requirements 11 Prohibition on Payments to Excluded/Sanctioned Persons 11 Credentialing Health care Professional / Provider Rights 12 Provider Network Credentialing Appeals Process 12 Termination 13 Specialist Termination 13 Health care Professional / Provider s Bill of Rights.
5 13 Select Health of South Carolina Provider Manual Table of ContentsiiTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 Fraud and Abuse .. 14 Fraud and Abuse Contact Information 14 False Claims Act 15 Culturally and Linguistically Appropriate Services (CLAS) ..16 Advances in Medicine .. 16 Bariatric Surgery Centers .. 16 Medical Management Department .. 17 Utilization Management Program ..17 Adverse Benefit Determinations 17 Medical Record Review Standards 17 Medical Record Documentation Standards 18 Medical Record Retention 20 Referral and Authorization for Specialists, Hospitals and Ancillary Health care Professionals/Providers.
6 21 Participating Specialty care Health care Professionals/Providers 21 Specialty care Access Standards: 21 Non-Participating Health care Professionals/Providers 21 Services That Require Prior Authorization 21 Services That DO NOT Require Authorization 22 Services That Require Notification 23 Clinical Guidelines ..23 Ancillary Services .. 23 Authorization for Ancillary Services.
7 23 Children s Rehabilitative Services and Baby Net ..23 Durable Medical Equipment .. 24 Home Health care /Family Support Services .. 24 Home Infusion/Specialty Pharmacy .. 24 Speech, Physical and Occupational Therapies .. 24 Behavioral Health Under First Choice .. 24 Rehabilitative Behavioral Health Services (RBHS) ..25 Prior authorization requirements 26 Autism Spectrum Disorder (ASD) ..27 Psychiatric Residential Treatment Facilities (PRTF) .. 28 Psychotherapy Supervision Guidelines .. 28 Licensed Independent Practitioners (LIPs) .. 29 Emergency/Urgent care Services .. 29 Hysterectomy ..29 Inpatient Admissions/Outpatient Admissions or Procedures .. 30 Extension of Authorization Time frames .. 30 Administrative Days ..31 Sterilization .. 31 Telemedicine Services .. 32 Therapeutic and Non-elective Abortion.
8 32 Therapeutic Abortions ..32 Non-elective Abortions ..32 Billing Notes ..32 Well-Woman Exam .. 33 Health care Professional / Provider Disputes .. 33 Medical Review Determinations .. 34 Denials .. 34 Medical Director Availability (Peer-to-Peer) .. 34 Appeal of Utilization Management Decisions ..35iiiTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 Extension of Grievance and Appeal Resolution Time Frames .. 36 Expedited Appeal .. 36 Continuation of Benefits .. 36 Integrated Health care Management Program ..37 Complex care Management 37 Disease Management Programs 37 Emergency Room Outreach Program 38 Rapid Response/Episodic care Program 38 Maternal Child Management (Bright Start ) Program 38 First Choice Member Information.
9 40 Member Access Guidelines .. 40 Enrollment ..41 Eligibility Verification ..41 Member Eligibility ..41 Member Disenrollment ..41 Member Transfer .. 42 Member No Shows .. 43 Medicaid Hotline Number .. 43 Member Rights and Responsibilities .. 43 Members and Potential Members Bill of Rights 43 Member Responsibilities 44 Advance Directives .. 44 Living Will and Power of Attorney 44 Outreach Services .. 45 EPSDT/Immunizations Outreach .. 45 Foreign Language Interpretation Services .. 45 Primary care Providers .. 45 Patient-Centered Medical Home .. 45 Member Assignment .. 46 Primary care Access Standards: .. 46 After-Hours care .. 46 Billing for After-Hours care .
10 46 Use of Network Health care Professionals/Providers ..47 Covered Benefits ..47 Benefits include, but are not necessarily limited to, the following: 47 Services Not Covered 47Co-payments .. 48 Member Grievances .. 48 Quality of Service Grievances .. 49 Clinical Practice Guidelines .. 49 EPSDT and Adult Health Screenings .. 49 Adult Vaccines .. 50 Adult Vaccine Claims 50 Topical Fluoride Varnish .. 50 Blood Lead Testing ..51 Immunizations ..51 Synagis ..51 Pharmacy Services .. 51 Monthly Prescription Limits ..5290-day medication supply ..52ivTable of ContentsSelect Health of South Carolina Health care Professional and Provider Manual | Updated March 2018 Coverage of Generic Products.
