Provider and Billing Manual - Peach State Health Plan

1 2018 Provider and Billing September 18, 2017 OVERVIEW .. 6 KEY CONTACTS AND IMPORTANT PHONE NUMBERS .. 7 MEDICARE REGULATORY REQUIREMENTS .. 9 SECURE WEB PORTAL .. 12 Functionality .. 12 Disclaimer .. 13 CREDENTIALING AND RE-CREDENTIALING .. 14 Credentialing Committee .. 15Re-credentialing .. 16 Practitioner Right to review and Correct Information .. 16 Practitioner Right to Be Informed of Application Status .. 16 Practitioner Right to appeal Adverse Re-credentialing Determinations .. 17 Provider Anti-Discrimination .. 17 ACCOUNT MANAGMENT .. 18 Primary Care Providers .. 18 Specialist as the Primary Care Provider .. 18 Specialty Care 19 Hospitals .. 19 Ancillary Providers .. 20 APPOINTMENT AVAILABILITY .. 21 Telephone Arrangements .. 23 Training Requirements .. 24 ALLWELL BENEFITS.

2 25 Missed Appointments and Other Charges .. 25 VERIFYING MEMBER BENEFITS, ELIGIBILITY, and COST SHARES .. 26 Member Identification Card .. 26 Preferred Method to Verify Benefits, Eligibility, and Cost Shares .. 26 Other Methods to Verify Benefits, Eligibility and Cost Shares .. 27 MEDICAL MANAGEMENT .. 282 September 18, 2017 Care Management .. 28 HMO Special Needs Plan (SNP) Model of Care (MOC) and Care Management .. 29 Utilization Management .. 32 Utilization Determination Timeframes .. 35 Utilization review Criteria .. 36 Pharmacy .. 37Se cond Opinion .. 40 Women s Health Care .. 40 Emergency Medical Condition .. 40 ENCOUNTERS AND CLAIMS .. 41 Encounter Reporting .. 41 CLAIMS .. 42 Verification Procedures .. 42 Upfr ont Rejections vs. Denials .. 44 Timely Filing .. 44 Who Can File Claims?.

3 45 Electronic Claims Submission .. 45 Online Claim Submission .. 49 Paper Claim Submission .. 49 Corrected Claims, Requests for Reconsideration or Claim Disputes .. 50 Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) .. 53 Risk Adjustment and Correct Coding .. 54 Coding Of Claims/ Billing Codes .. 55 CODE EDITING .. 56 CPT and HCPCS Coding Structure .. 56 International Classification of Diseases (ICD-10) .. 57 Revenue Codes .. 57 Edit Sources .. 57 Code Editing Principles .. 59 Invalid Revenue to Procedure Code Editing .. 62 Inpatient Facility Claim Editing .. 63 Administrative and Consistency Rules .. 633 September 18, 2017 Prepayment Clinical Validation .. 64 Claim Reconsiderations Related To Code Editing .. 66 Viewing Claims Coding 66 Automated Clinical Payment Policy Edits.

4 67 Clinical Payment Policy Appeals .. 69 THIRD PARTY LIABILITY .. 70 Billing THE MEMBER .. 71 Failure to obtain 71No Balance Billing .. 71 Non -Covered Services .. 71 MEMBER RIGHTS AND RESPONSIBILITIES .. 72 Member Rights .. 72 Member Responsibilities .. 74 Provider RIGHTS AND RESPONSIBILITIES .. 76 Provider Rights .. 76 Provider Responsibilities .. 76 Interference with Health Care Professionals Advice .. 79 CULTURAL COMPETENCY .. 80 Interpreter Services .. 81 Americans with Disabilities Act .. 82 MEMBER GRIEVANCES AND APPEALS .. 85 Grievances .. 85 Appeals .. 85 Member Grievance and Appeals Address .. 86 Provider COMPLAINT AND APPEALS PROCESS .. 87 Allwell Complaint .. 87 Authorization and Coverage Appeals .. 87 QUALITY IMPROVEMENT PLAN .. 88 Overview .. 88 QAPI Program Structure.

5 884 September 18, 2017 Practitioner Involvement .. 89 Qual ity Assessment and Performance Improvement Program Scope and Goals .. 89 Practice Guidelines .. 91 Patient Safety and Level of Care .. 92 Performance Improvement Process .. 93 Office Site Surveys .. 93 MEDICARE STAR RATINGS .. 95 How can providers help to improve Star Ratings? .. 95 Healthcare Effectiveness Data and Information Set (HEDIS) .. 96 Consumer Assessment of Healthcare Provider Systems (CAHPS) Survey .. 97 Medicare Health Outcomes Survey (HOS) .. 98 REGULATORY MATTERS .. 99 Medical Records .. 99 Federal and State Laws Governing the Release of Information .. 101 Section 1557 of the Patient Protection and Affordable Care Act .. 102 Health Insurance Portability and Accountability Act .. 103 WASTE, ABUSE, AND FRAUD .. 107 False Claims Act.

6 109 Physician Incentive Programs .. 109 First -Tier and Downstream Providers .. 110 APPENDIX .. 111 Appendix I: Common Causes for Upfront Rejections .. 111 Appendix II: Common Cause of Claims Processing Delays and Denials .. 112 Appendix III: Common EOP Denial Codes and Descriptions .. 112 Appendix IV: Instructions for Supplemental Information .. 115 Appendix V: Common HIPAA Compliant EDI .. Rejection Codes117 Appendix VI: Claim Form Instructions .. 121 Appendix VII: Billing Tips and Reminders .. 154 Appendix VIII: Reimbursement Policies .. 157 Appendix IX: EDI Companion Guide Overview .. 160 INTRODUCTION 5 September 18, 2017 Welcome to Allwell from Peach State Health Plan (Allwell). Thank you for participating in our network of participating physicians, hospitals and other healthcare professionals. This Provider Manual is a reference guide for providers and their staff providing services to members who participate in our Medicare Advantage and/or our Medicare Advantage Special Needs Program, Allwell.

7 6 September 18, 2017 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 dual-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 Case 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 member s Health information seriously. We have processes, policies, and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIP AA) and CMS regulations.

8 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. The PCP is responsible for coordinating our member s Health services, maintaining a complete medical record for each member under their care, and ensuring continuity of care. The PCP advises the Member about their Health status, medical treatment options, which include the benefits, consequences of treatment or non-treatment, and the associated risks. Members are expected to share their preferences about current and future treatment decisions with their PCP.

9 7 September 18, 2017 KEY CONTACTS AND IMPORTANT PHONE NUMBERS The following table includes several important telephone and fax numbers available to providers and their office staff. When calling, it is helpful to have the following information available. 1. The Provider s NPI number 2. The practice Tax ID Number 3. The member s ID number Health PLAN INFORMATION Website Health Plan Address Allwell Attn: Medicare 1100 Circle 75 Parkway Suite 1100 Atlanta, GA 30339 Phone Numbers Phone TTY/TDD Allwell HMO: 1- 844- 890-2326 HMO SNP: 1-877- 725-7748 1- 800- 659-7487 Department Phone Fax Provider Services HMO: 1-844- 890-2326 HMO SNP: 1-877- 725-7748 1- 800- 659-7492 Member Services 1- 800- 659-7518 Medical Management Inpatient and Outpatient Prior Authorization 1- 877- 689-1055 Concurrent review /Clinical Information 1- 844- 359-0328 Admission/Census Reports/Facesheets na Care Management na Behavioral Health Outpatient Prior Authorization 1- 877- 725-7751 24/7 Nurse Advice Line na Interpreter Services na 8 September 18, 2017 Pharmacy Services Inquiries.

10 1- 888- 865-6567 Prior Authorization: 1- 888- 865-6567 na NIA 1- 877- 807-2363 Envolve Vision 1- 888- 642-4723 To report suspected fraud, waste and abuse 1- 866- 685-8664 na EDI Claims Assistance 1- 800-225-2573 ext. 6075525 e- mail: 9 September 18, 2017 MEDICARE REGULATORY REQUIREMENTS As a Medicare contracted Provider , you are required to follow a number of Medicare regulations and CMS requirements. Some of these requirements are found in your Provider agreement. Others have been described throughout the body of this Manual . A general list of the requirements can be reviewed below: Providers may not discriminate against Medicare members in any way based on the Health status of the member. Providers may not discriminate against Medicare members in any way on the basis of race, color, national origin, sex, age, or disability in accordance with subsection of Section 1557 of the Patient Protection and Affordable Care Act.