Mercy Care Provider Manual

1 Mercy Care Provider ManualVisit: CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 1 of 17 Last Update: November 2018 Proprietary Mercy Care Provider Manual Table of Contents Content highlighted in yellow represents changes since the last Provider Manual iteration. CHAPTER 100 Mercy CARE Provider Manual GENERAL TERMS MC Chapter 1 Introduction to Mercy Care Welcome About Mercy Care Disclaimer MC Policies and Procedures Eligibility Hospital Presumptive Eligibility MC Chapter 2 Mercy Contact Information Mercy Care Contact Information Provider Credentialing and Contracting for all Plans Health Plan Authorization Services Table Community Resources Contact Information Table MC Chapter 3 Provider Relations Overview Provider Relations Overview MC Chapter 4 Provider Responsibilities - Provider Responsibilities Overview AHCCCS Registration Appointment Availability Standards Telephone Accessibility Standards Covering Physicians Locum Tenens Verifying Member Eligibility Preventive or Routine Services Well-Woman

2 Preventative Care Services Provider Requirements Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 2 of 17 Last Update: November 2018 Proprietary Educating Members on their own Heath Care Urgent Care Services Emergency Services Primary Care Providers (PCPs) Specialist Providers Second Opinions Provider Assistance Program for Non-Compliant Members Member s Medical Records Advance Directives - Documenting Member Appointments Missed or Cancelled Appointments Documenting Referrals Respecting Member Rights Consent to Treat Minors or Disabled Members under Guardianship Health Insurance Portability and Accountability Act of 1997 (HIPAA) Cultural Competency, Health Literacy and Linguistic Services Individuals with Disabilities Primary Care Provider (PCP) Assignments Plan Changes Cost Sharing and Coordination of Benefits Copayments Clinical Guidelines Office Administration Changes and Training Requirements Consent Forms Contract Additions or Terminations Continuity of Care Contract Changes or Updates Credentialing/Recredentialing Licensure and Accreditation Contract Enforcement Duty to Report Abuse, Neglect or Exploitation Duty to Warn Marketing Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 3 of 17 Last Update.

3 November 2018 Proprietary Provider Policies and Procedures Health Care Acquired Conditions and Abuse Mercy Care Web Portal Provider Directory MC Chapter 5 EPSDT EPSDT Program Overview Requirements for EPSDT Providers Health Education Periodic Screenings Nutritional Assessment and Nutritional Therapy Developmental Screening Tools PCP Application of Fluoride Varnish Pediatric Immunizations/Vaccines for Children Program Body Mass Index (BMI) Blood Lead Screening Eye Examinations and Prescriptive Lenses Hearing/Speech Screening Behavioral Health Screening Dental Screening and Referrals Tuberculin Skin Testing Metabolic Medical Foods Arizona Early Intervention Program MC Chapter 6 Children s Rehabilitative Services - Children s Rehabilitative Services (CRS) Overview - Integration Initiatives - CRS Qualifying Medical Conditions - Who is Eligible for CRS MC Chapter 7 Family Planning Family Planning Overview Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 4 of 17 Last Update.

4 November 2018 Proprietary Provider Responsibilities for Family Planning Services Covered and Non-Covered Services Prior Authorization Requirements MC Chapter 8 Maternity Maternity Overview High Risk Maternity Care OB Care Management OB Incentive Program Obstetrical Care Appointment Standards General Obstetrical Care Requirements Additional Obstetrical Physician and Practitioner Requirements Provider Requirements for Medically Necessary Termination of Pregnancy Reporting High Risk and Non-Compliant Behaviors Outreach, Education and Community Resources Providing EPSDT Services to Pregnancy Members under Age 21 Loss of AHCCCS Coverage during Pregnancy Pre-Selection of Newborn s PCP Newborn Notification Process MC Chapter 9 Non-Emergency Transportation Non-Emergency Transportation Covered Services Program Specific Requirements Documentation Requirements Data and Reporting Professional Standards and Responsibilities Vehicle Requirements Performance Improvement Performance Outcome Measures Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 5 of 17 Last Update.

5 November 2018 Proprietary MC Chapter 10 Behavioral Health Assessments and Treatment/Service Planning Behavioral Health Assessments and Service Planning Overview Assessments Minimum Elements of the Behavioral Health Assessment Provider Submits a Complex Case Request Update to Assessment and Service Plan Transfer Assessments MC Chapter 11 Care Management and Disease Management Care Management and Disease Management Overview Referrals Care Management HIV/AIDS High Risk OB Behavioral Health Disease Management Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Diabetes Active Health MC Chapter 12 Concurrent Review Concurrent Review Overview MILLIMAN Care Guidelines Discharge Planning Coordination Physician Medical Review MC Chapter 13 Pharmacy Management Pharmacy Management Overview Updating the Preferred Drug Lists (PDLs) Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 6 of 17 Last Update: November 2018 Proprietary Notification of PDL Updates Prior Authorization Required Over the Counter (OTC) Medications Generic vs.

6 Brand Diabetic Supplies Injectable Drugs Exclusions Family Planning Medications and Supplies Behavioral Health Treatment of Attention Deficit Hyperactivity Disorder (ADHD), Anxiety, Depression and/or Opioid Use Disorder RBHA Covered Services Medication Management Program Request for Non-PDL Drugs Discarded Physician-Administered Medications MC Chapter 14 Quality Management Quality Management Overview Quality Management Plan Quality of Care, Peer Review and Fair Hearing Process Escalation Process Ambulatory Medical Record Review Quality Management Studies Data Collection and Reporting Reports Credentialing/Re-Credentialing Streamlining Process Incident, Accident, Death Reporting Processes MC Chapter 15 Partnership Requirements with Families and Family Run Organizations Peer and Family Support Services Incorporating Peer and Family Voice and Choice in Integrated Care Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 7 of 17 Last Update.

7 November 2018 Proprietary MC Chapter 16 Referrals and Authorizations Referral Overview Referring Provider s Responsibilities Receiving Provider s Responsibilities Period of Referral Maternity Referrals Ancillary Referrals Member Self-Referrals Prior Authorization Types of Requests Medical Prior Authorization Complex Radiology Service Authorization Bariatric Surgery Approval Process Pharmacy Prior Authorization Nutritional Assessment and Nutritional Therapy Metabolic Medical Foods Extensions and Denials Prior Authorization and Referrals for Services Prior Authorization and Coordination of Benefits Prior Authorization Contacts MC Chapter 17 Billing Encounters and Claims Billing Encounters and Claims Overview When to Bill a Member Prior Period Coverage Encounter Overview When to File an Encounter How to File an Encounter When to File a Claim Timely Filing of Claim Submissions MC as Secondary Insurer Dual Eligibility MCA Cost Sharing and Coordination of Benefits Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 8 of 17 Last Update.

8 November 2018 Proprietary Injuries due to an Accident How to File a Claim Correct Coding Initiative Correct Coding Incorrect Coding Modifiers Medical Claims Review Checking Status of Claims Payment of Claims Claim Resubmission or Reconsideration Overpayments MC General Claims Payment Information Inpatient Claims Federally Qualified Health Centers (FQHCs) Skilled Nursing Facilities (SNFs) Dental Claims Durable Medical Equipment (DME) Family Planning Claims Complete Obstetrical Package Trimester of Entry into Prenatal Care Provider Remittance Advice Program Integrity MC Chapter 18 Fraud, Waste and Abuse Fraud and Abuse Overview Deficit Reduction Act and False Claims Act Compliance Requirements False Claims Training Requirements Administrative Remedies for False Claims and Statements State Laws Relating to Civil or Criminal Penalties or False Claims and Statements MC Chapter 19 Workforce Development General Information Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 9 of 17 Last Update.

9 November 2018 Proprietary Contract Requirements CHAPTER 200 Mercy CARE COMPLETE CARE Provider Manual PLAN SPECIFIC TERMS mccc Chapter 1 Mercy Care Complete Care Overview Mercy Care Complete Care Overview mccc Chapter 2 Covered and Non-Covered Services Coverage Criteria Covered Services Non-Covered Services mccc Chapter 3 Behavioral Health Behavioral Health Overview Behavioral Health Provider Types Alternative Living Arrangements Emergency Services Behavioral Health Consults Behavioral Health Screening Behavioral Health Appointment Standards Behavioral Health Provider Coordination of Care Responsibilities PCP Coordination of Care General and Informed Consent Family Involvement Members with Diabetes and the Arizona State Hospital Pre-Petition Screening, Court Ordered Evaluation and Court Ordered Treatment Behavioral Health Treatment Plans and Daily Documentation SMI Eligibility Determination mccc Chapter 4 General Mental Health/Substance Use (GMH/SU) About General Mental Health/Substance Use (GMH/SU) Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 10 of 17 Last Update.

10 November 2018 Proprietary Funding Referral and Intake Process Outreach, Engagement, Reengagement and Closure Serious Mental Illness Determination Special Populations Crisis Intervention Services Training Requirements mccc Chapter 5 Dental and Vision Services Dental Services Vision Services mccc Chapter 6 Grievances, Appeals and Claim Disputes Grievances Provider Claim Disputes Appeals Mercy CARE Provider Manual TABLE OF CONTENTS Table of Contents Page 11 of 17 Last Update: November 2018 Proprietary CHAPTER 300 Mercy CARE LONG TERM CARE Provider Manual PLAN SPECIFIC TERMS MCLTC Chapter 1 Mercy Care Long Term Care Overview Mercy Care Long Term Care Overview MCLTC Chapter 2 Network Provider Service Delivery Requirements MCLTC Overview MCLTC Program Contractor Changes Home and Community Based Services (HCBS) Agency with Choice Providers Attendant Care Services Interruption in Service Attendant Care Modifiers Attendant Care Out of Area Care Direct Care Worker Database Non-Provision of Service Log (NPS) Prior Period Coverage for Home and Community Based Services (HCBS)