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Provider Handbook - betterhealthflorida.com

Provider Handbook Medicaid Program 2016 (AHCA Acknowledgement Date: 010416)3 Dear Doctor, Welcome to Better Health s statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Provider Network. We are pleased that you have decided to participate in our plan specifically for Medicaid Members. Better Health takes a positive approach toward managing Medicaid Members by working collaboratively with their Primary Care Physician to support a system of optimal utilization management and clinical quality. We believe that this system of management is the formula for our mutual success. This Provider Manual highlights the key points related to Medicaid MMA and Better Health. The Provider Manual does not constitute a contract.

3 Dear Doctor, Welcome to Better Health’s Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Provider Network. We are pleased that you have decided to participate in our plan specifically for Medicaid

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Transcription of Provider Handbook - betterhealthflorida.com

1 Provider Handbook Medicaid Program 2016 (AHCA Acknowledgement Date: 010416)3 Dear Doctor, Welcome to Better Health s statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Provider Network. We are pleased that you have decided to participate in our plan specifically for Medicaid Members. Better Health takes a positive approach toward managing Medicaid Members by working collaboratively with their Primary Care Physician to support a system of optimal utilization management and clinical quality. We believe that this system of management is the formula for our mutual success. This Provider Manual highlights the key points related to Medicaid MMA and Better Health. The Provider Manual does not constitute a contract.

2 It is intended to be a guideline to facilitate and inform you and your staff of what the Florida Medicaid MMA Program is about, what we need from you, and what you can expect from Better Health. By following the guidelines outlined in this manual, we can assist you in providing caring, responsive service for your Medicaid Members. We look forward to a lasting, productive future with you and your staff. If you need assistance, we are only a telephone call away. Sincerely, Lourdes T. Rivas, Chief Executive Officer Simply Healthcare Plans, Inc. Table of Contents Section 1. Important Contact Information ..8-11 Section 2. Medicaid MMA Program ..12 Overview and Better Health Cultural Competency ..12-13 Sensitivity Training ..13 Websites ..13 Section 3. Enrollment, Eligibility, and Disenrollment.

3 14 Member Eligibility and Enrollment ..14-15 Effective Date of Enrollment ..15-16 Newborn Enrollment ..16 Inpatient at Time of Enrollment ..16 Member Better Health Member Identification Card ..17 Section 4. Provider Overview ..18 Access to Support from the Plan to PCP Offices ..18 Primary Care Physician (PCP) Responsibilities ..18-19 Adult Health Screening ..20 CDC Guidelines for HIV Screening and Treatment Administration ..20 Recommendations for Adults and Adolescents ..20 Screening for HIV Infection ..20 Repeat Consent and Pretest Diagnostic Testing for HIV Recommendations for Pregnant Women ..22 HIV Screening for Pregnant Women and Their Infants ..22 Timing of HIV Testing ..22-23 Rapid Testing during Labor ..23 Postpartum/Newborn Confirmatory Testing ..23-24 Additional Considerations for HIV Rapid HIV Test.

4 24 Participants in HIV Vaccine Documenting HIV Test Clinical Care for HIV-Infected Persons ..25 Partner Counseling and Referral ..25 Special Considerations for Screening Adolescents ..25 Prevention Services for HIV-Negative Persons ..25 Preventative HIV/AIDS Surveillance Risk Factor Ascertainment for HIV-infected Persons ..26 HIV/AIDS Case Reporting ..26 Pediatric Exposure Reporting ..26 Monitoring and Evaluation ..26 Child Health Check-Ups Program (CHCUP) ..26-28 Child Health Check-Up Visits Coding Requirements ..28-29 Referrals ..29 Blood Lead Level Testing ..29 Immunizations ..29-30 Vaccines Excluded from the VFC Program ..30 Domestic Violence and Abuse Screening ..30-31 Smoking Cessation ..31 Members with Special Health Care Needs ..31-32 Children Medical Services (CMS) ..32 Living Will and Advance Directives.

5 32 After-Hours, Weekends and Holiday Services ..32-33 PCP Coverage ..33 Physician Panel Changes ..33 PCP s Request to Disenroll a Member from their Family Planning ..34 Diagnosis and Treatment of Tuberculosis ..34 Responsibilities of All Providers ..34-36 Physician Use of Health Care Extenders (ARNP s and PA s) ..36 Additional Specialist Responsibilities ..36 Member Information and Confidentiality ..36-37 Changes in Provider Information ..37 Provider Termination ..37-38 Provider -Required Incident Reporting ..38 Adverse Incidents ..38-39 How to Report ..39 Community Outreach ..39-40 Plan Responsibility ..40 Permissible and non-permissible activity ..40 Delegated Providers ..40-42 Observations/Recommendations ..42 Corrective Actions ..42-43 Delegation Oversight Committee (DOC) ..43-44 Quality Enhancement Programs.

6 44 Children s Programs ..44 Domestic Violence ..44 Pregnancy Prevention ..44 Prenatal/Postpartum Pregnancy Programs ..44 Behavioral Health Programs ..44 Section 5. Utilization Management Department ..45 Overview ..45 Medical Notification ..45 Referrals or Prior Notifications ..45-46 Prior Authorization or Notification Process ..47-48 Emergency Services ..49-50 Emergencies at Out-of-State Hospitals ..50 Post-stabilization Care Services ..50 Hospital Inpatient Services ..50 Prior Notification for Hospital Admissions ..50 Inpatient Hospital Care Limits ..51 Obstetrical Admissions ..51 Dental Services in the Hospital ..51 Hospice ..51 Observation Services ..51 Pregnancy ..52 Global Obstetric (OB) Florida Healthy Start and WIC Referrals ..52-53 Newborn Deliveries ..53 Out-of-Network Requests for Non-Emergency Services.

7 53 County Health Departments (CHD) ..53 Behavioral Health ..53-54 Behavioral or Mental Health Services not Covered by the Plan ..54 Emergency Mental Health Services In and Outside of the Service area ..54 Requests for a Second Medical Opinion ..54-55 Standing Referrals for Members with Chronic and/or Disabling Continuity and Transition of Care Needs ..55 Post Discharge Planning/Transition of Care Management Services ..56 Disease Management ..56-57 The Plan s Utilization and Medical Criteria Resources ..57 Adverse Section 6. Pregnancy-Related Requirements ..58-61 Section 7. Covered Family Planning Services ..63 Home Health Hysterectomy ..63 Sterilization ..63-64 Peritoneal Dialysis ..64 Section 8. Member Rights and Overview ..65 Member s Rights & Services for Translations and the Hearing Impaired.

8 66 Advance Directives ..66-67 Section 9. Preventative Care and Clinical Practice Guidelines ..68 Overview ..68-70 Section 10. Medical Record Overview ..71 Medical Records Audits and Section 11. Quality Improvement ..75 Overview ..75 Program Goals ..75-76 Providers Rights, Corrective Action, Fair Hearing and Reporting to the Florida Division of Medical Quality Department of Health and the Satisfaction Section 12. Cultural Competency Program Goals ..80 Program Section 13. Credentialing ..81 Overview ..81 Required Information ..81 Additional Considerations ..81-82 Medicaid Background Site Reviews ..82 Credentialing Review Committee (CRC) ..82 Verification Re-credentialing ..82-83 Ongoing Medicaid Program ..83 Provider s Right to Provider s Right to Notify and Correct Information.

9 83 Provider s Right to be Informed ..83 Section 14. Provider Complaints and How to Submit a Complaint ..85 How to Submit a Dispute ..85 For an Administrative Appeal ..85-86 Section 15. Claims ..87 Overview ..87 Claims Submission ..87 Filing a Claim Electronically ..88 Timely Claim Clean Claim ..88 Timely Claims Processing and Payment ..88 Claims for Emergency Coordination of Benefits ..88-89 Third Party Liability ..89 Retroactive Eligibility Changes ..89 Section 16. Information on Fraud and Abuse ..90 How to Report Fraud or Abuse ..91-92 Reward Program ..92 HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Rule ..92 Breach Section 17. Recommended Immunization Schedules for Persons Aged 0 through 18 Years ..93-95 Section 18. Infection Control and Prevention Plan.

10 96-97 Section 19. Safety and Health Program ..98-100 Section 20. Highlights of Practitioner Services Coverage and Limitations ..101-103 Section 21. Healthy Behaviors ..103-109 . Section 22. Care Coordination/Case Management Process ..110-112 Section 23. Section 1. Important Contact Information Websites: Departments Contact Information Provider Relations/Credentialing Department 9250 W. Flagler Street, Suite 600 Miami, FL 33174-3460 Toll-Free Phone Number: 1-877-915-0551 Fax Number: 786-441-4601 Member Services Department 9250 W. Flagler Street, Suite 600 Miami, FL 33174-3460 Toll-Free Phone Number: 1-800-514-4561 Toll-Free Fax Number: 1-877-577-0114 Health Services: Referrals/Pre-Certification Information: You may call us when you have a true URGENT/EXPEDITED request, but you must enter it in the portal or fax it Please provide all documentation for medical necessity determination available when making a request 9250 W.


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