PROVIDER HANDBOOK - Clear Health Alliance - …

1 PROVIDER HANDBOOK Medicaid Specialty Program 2013 Page 2 of 92 Prov Hand CHA January 2013 Dear PROVIDER : Please allow us to extend a personal greeting in welcoming you to Clear Health Alliance . Attached you will find your Clear Health Alliance , Inc. (CHA) PROVIDER HANDBOOK that has been written to specifically meet the requirements to administer the Plan s products, services, policies and procedures and to supplement the PROVIDER agreement. Clear Health Alliance is a Health maintenance organization (HMO) that has a contract with the State of Florida to provide the Health needs of Medicaid beneficiaries enrolled with our plan. Florida Medicaid is the state and Federal partnership that provides Health coverage for Florida residents with low income so that there is access to medical care for themselves and their children.

2 To qualify for Medicaid, Florida residents must be US nationals, US citizens, permanent residents, or legal aliens, in need of Health care/insurance assistance, whose financial situation would be characterized as low income or very low income. These residents also must be either pregnant, a parent or relative caretaker of a dependent child(ren) under age 19, blind, have a disability or a family member in their household with a disability, or be 65 years of age or older. CHA offers an appropriate and accessible range of preventive, primary care, and specialty services to meet the needs of its Medicaid enrollees, and maintains a sufficient number, mix and geographic distribution of providers. It is a prepaid, comprehensive system of Health care delivery. We have designed this HANDBOOK to assist you in the processes that include your responsibilities as a Primary Care Physician (PCP), as a specialist or vendor, as well as protocols for prior authorization and referrals, medical necessity standards and practice protocols, including guidelines that address treatment of chronic and complex conditions, covered and emergency services, claims and encounter submissions, member rights and responsibilities and many other important functions and information.

3 It is all outlined for you in the Table of Contents. There are times when updates to this HANDBOOK may be required, due to regulatory changes or internal policy revisions/updates. When this occurs we will advise you if it is a new (add) or revised (replace) change - you will simply have to add or replace the specific information in the HANDBOOK . You may request additional copies of the HANDBOOK at no charge from your PROVIDER Relations representative. Thank you for actively participating in the delivery of quality Health care services to our members. We encourage you to contact us if you have any suggestions for improving the services that we provide. Sincerely, Clear Health Alliance , Inc. Page 3 of 92 Prov Hand CHA January 2013 Clear Health Alliance PROVIDER HANDBOOK Table of Contents Section 1: Important Plan Contact Information.

4 6 Section 2: Member Enrollment, Eligibility and Disenrollment .. 8 Member Eligibility and 8 Effective Date of Enrollment .. 8 Newborn Enrollment .. 8 Inpatient at Time of Enrollment .. 9 Member Eligibility .. 9 Clear Health Alliance Member Identification Card ..10 Section 3: PROVIDER Responsibilities ..11 Non-discrimination ..11 Access to Care ..11 Support from CHA ..11 Primary Care Physician (PCP) Responsibilities ..12 Adult Health Screening ..13 Child Health Check-Ups Program (CHCUP) ..13 Components ..13 Referrals ..14 Blood Lead Level Testing ..14 Immunizations ..15 Domestic Violence and Abuse Screening ..16 Smoking Cessation.

5 16 Members with Special Healthcare Needs ..17 Children Medical Services (CMS) ..17 Living Will and Advance Directives ..17 After-Hours, Weekends and Holiday Services ..18 PCP Coverage ..18 Physician Panel Changes ..18 PCP s Request to Disenroll a Member from their Panel ..19 Family Diagnosis and Treatment of Responsibilities of All Providers ..20 Health Care Extenders (ARNPs and Pas) ..21 Additional Specialist Responsibilities ..22 Member Information and Confidentiality ..22 Changes in PROVIDER Information ..23 PROVIDER Termination ..23 PROVIDER -Required Incident Reporting ..23 Community Outreach ..24 Delegated Providers.

6 25 Section 4: Utilization Management Department ..26 Notifications and Referrals: Quick Authorization Form and Prior Authorization ..27 Emergency Services ..29 Post-stabilization Care ..31 Page 4 of 92 Prov Hand CHA January 2013 Hospital In-patient Services ..31 In-patient Hospital Care Limits ..31 Obstetrical Admissions ..32 Dental Services in the Hospital ..32 Hospice ..32 Observation Services ..32 Pregnancy ..33 Global OB Authorizations ..33 Florida Healthy Start and WIC Referrals ..34 Newborn Deliveries ..34 Out-of-Network Requests for Non-emergency Services ..34 County Health Departments (CHD) ..34 Mental Health .

7 34 Requests for Second Medical Opinions ..36 Referrals for Members with Chronic Conditions ..36 Continuity and Transition of Care Needs ..37 Post Discharge Planning/Transition of Care ..37 Care Management Services ..37 Utilization and Medical Criteria Resources ..38 Adverse Determinations ..38 Section 5: Pregnancy-Related Requirements ..39 Florida s Healthy Start Prenatal and Postnatal Risk Screenings and Referrals ..39 WIC Referrals ..39 HIV Testing, Counseling, Screening and Treatment ..40 Hepatitis B ..40 Other Prenatal Requirements ..40 Nutritional Assessment/Counseling ..41 Obstetrical Deliveries ..41 Newborn Care ..41 Postpartum Care ..41 Section 6: Covered Services.

8 42 Medical Necessity ..42 Covered Services Summary .. 42-45 Section 7: Members Rights and Responsibilities ..46 Summary of Members Rights and Responsibilities ..46 Services for Translations and the Hearing Impaired ..47 Advance Directives ..47 Section 8: Preventative Care and Clinical Practice Guidelines ..48 Links to Guidelines .. 48-50 Section 9: Medical Records Standards ..51 Requirements .. 51-53 Medical Records Audits and Compliance ..53 Section 10: Quality Improvement ..54 Program Goals ..54 Care Management and Prevention/Wellness Programs ..55 Resources: on Tobacco and Substance Abuse, Domestic Violence, Pregnancy Prevention ..55 Providers Right to Corrective Action, Fair Hearing and Reporting to Regulators.

9 55 Page 5 of 92 Prov Hand CHA January 2013 Section 11: Cultural Competency Program ..57 Overview, Standards, Program Goals and Components .. 57-58 Section 12: Credentialing ..59 Overview and Required Information ..59 Site Reviews ..59 Credentialing Review Committee ..59 Verification Process ..60 Re-credentialing ..60 Medicaid Program ..60 PROVIDER s Right to Review, Notify and Correct Information ..60 PROVIDER s Right to be Informed ..60 Section 13: PROVIDER Complaints ..62 Definitions of Grievance and Appeal ..62 Submission of a Formal Appeal or Grievance .. 62-64 Section 14: Member Grievances and Appeals ..65 Overview and Process.

10 65 To Request Continuation of Services while an Appeal is in Process .. 65-67 Expedited Reviews ..67 Section 15: Claims ..68 Overview ..68 Claims Submission ..68 Filing Electronically ..68 Timely Claim Submission ..69 Clean Claim ..69 Timely Claims Processing and Payment ..69 Claims for Emergency Services ..69 Coordination of Benefits ..69 Third Party Liability ..70 Retroactive Eligibility Changes ..70 Section 16: Compliance & Fraud, Waste and Abuse ..71 Section 17: Forms ..73 1. Referral and Authorization Form ..74 2. Quick Authorization Form ..74 3. Psych Care Referral Form ..75 4. Pregnancy Notification Form ..76 5. State of Florida Acknowledgment of Receipt of Hysterectomy Information.