Provider Manual - Amerigroup

1 IA-PM-0013-18 Provider ManualIA Health Link and Hawki 1-800-454-3730 The master copy of this document is available online. Hard copies are for information purposes only and are not subject to document control. ii August 2019 Table of Contents CHAPTER 1: INTRODUCTION .. 10 Welcome .. 10 About This Manual .. 10 Third-Party Websites .. 12 CHAPTER 2: LEGAL AND ADMINISTRATIVE REQUIREMENTS .. 13 Proprietary Information .. 13 Updates and Changes .. 13 CHAPTER 3: 14 Overview .. 14 Amerigroup Contacts .. 14 CHAPTER 4: COVERED AND NONCOVERED SERVICES .. 18 Covered Services .. 18 Covered Services: Medicaid Services .. 18 Noncovered Services: Medicaid Services .. 24 Covered Services: 25 Noncovered Services: Hawki .. 28 Covered Services: Iowa Health and Wellness Plan .. 29 Noncovered Services: Iowa Health and Wellness Plan .. 34 Covered Services: Substance Use Disorder Services .. 34 Covered Services: Home and Community Based Services (HCBS).

2 36 Chiropractic Services .. 36 Covered Services: Value-Added 36 Covered Services: Tobacco 37 Covered Services: Healthy Rewards Program .. 38 State-Covered Services .. 38 Noncovered Services .. 39 Pharmacy .. 39 Services Requiring Precertification .. 39 Dental Services .. 40 Vision Services .. 43 Nonemergent Transportation Services .. 43 CHAPTER 5: LONG-TERM SERVICES AND SUPPORTS .. 44 Overview .. 44 Waiver Descriptions .. 44 Facility Information .. 46 Precertification Requirements .. 48 Person-centered Case Management Model .. 49 Initial Discovery, Assessments and Informed Consent .. 50 Person-Centered Service Planning .. 50 Incorporating Member Choice in Funding Decisions .. 50 Identification .. 51 Processing Referrals to LTSS Services .. 51 Transition and Discharge Planning .. 52 Responsibilities of the LTSS 53 Self-Direction (Consumer Choices Option and Consumer-Directed Attendant Care) .. 53 Electronic Visit Verification .. 54 Client Participation.

3 55 iii Nursing Facility Preadmission Screening and Resident Review .. 56 LTSS Continuity of Care .. 56 Critical Incident Reporting and Management .. 58 Nonemergency Medical Transportation (NEMT) .. 59 CHAPTER 6: BEHAVIORAL HEALTH SERVICES .. 60 Overview of Behavioral Health at Amerigroup .. 60 Goals .. 60 Values .. 60 Principles .. 60 Objectives .. 61 Recovery and Resiliency .. 61 General Provider Information .. 63 Health Home Services .. 64 Services Requiring Precertification .. 66 Member Records and Treatment Planning .. 66 Adverse Incident Reporting (including PMIC, CMH Waiver and Habilitation Program Services) .. 68 Psychotropic Medication .. 68 Utilization Management 69 Behavioral Health Authorization Time Standards .. 69 Notification or Request Preauthorization .. 69 Clinical Criteria .. 70 Behavioral Health Medical Necessity Determination and Peer Review .. 70 Nonmedical Necessity Adverse Decisions .. 71 Appeals, Grievance and Payment Disputes.

4 71 Avoiding an Adverse Decision .. 71 Behavioral Health Drug Utilization Review Program .. 73 Post-Discharge Outreach, Diversion Plans and Crisis Assessments .. 73 Clinical Practice Guidelines .. 74 Provider Training .. 75 Critical Incident Reporting and Management .. 75 Psychiatric Medical Institutions for Children (PMIC) .. 76 Behavioral Health Waivers .. 77 1915(i) Habilitation Services Program .. 78 CHAPTER 7: MEMBER ELIGIBILITY .. 79 Overview .. 79 How to Verify Member Eligibility .. 79 Identification Cards .. 79 CHAPTER 8: MEDICAL MANAGEMENT .. 81 Overview .. 81 Availability of UM Criteria .. 82 Access to UM Staff .. 82 Precertification .. 82 Services Requiring Precertification .. 83 Services Not Requiring Precertification .. 84 Starting the Process .. 84 Information Needed for Medical Necessity Determination .. 85 Requests with Insufficient Clinical Information .. 86 Urgent Requests .. 86 Routine Requests .. 86 Emergency Medical Services .. 86 iv Emergency Stabilization and Post-Stabilization.

5 86 Concurrent Review: Hospital Admissions .. 87 Concurrent Review: Clinical Information for Continued-Stay Review .. 87 Concurrent Review: Second Opinions .. 88 Denial of Service and Peer-to-Peer Review .. 88 Referrals to Specialists .. 88 Additional Services: Behavioral Health .. 89 Chronic Condition Health Home and Integrated Health Home .. 89 Additional Services: Vision Care .. 91 CHAPTER 9: HEALTH SERVICES PROGRAMS .. 92 Overview .. 92 Preventive Care: Initial Health Assessments .. 92 Preventive Care: Well Woman .. 93 Preventive Care: Taking Care of Baby and Me .. 93 Preventive Care: Long-acting Reversible Contraception .. 94 Health Management: Disease Management Centralized Care Unit .. 95 Health Management: Healthy Families .. 96 Health Management: Women, Infants and Children .. 96 Health Education: Amerigroup on Call .. 97 Health Education: Drug Lock-In Initiative .. 97 Health Education: Smoking Cessation .. 97 Provider Assessment of Smoking Use.

6 98 CHAPTER 10: CLAIMS SUBMISSION AND GUIDELINES .. 98 Overview .. 98 Submitting Clean Claims .. 99 Methods for Submission .. 99 Web Portal 99 Electronic Claims .. 99 Paper Claims .. 100 National Provider Identifier .. 101 Atypical Providers .. 102 Enrollment in Iowa Medicaid .. 102 ICD-10 Clinical Modification (CM) .. 102 Claim Filing Limits .. 103 Claim Forms and Filing Limits .. 104 Other Filing Limits .. 104 Claims from Noncontracted Providers .. 105 Balance Billing .. 105 Client Participation/Member Liability .. 106 Coordination of Benefits .. 106 Subrogation .. 107 Claims Filed With the Wrong Plan .. 107 Payment of Claims .. 108 Monitoring Submitted Claims .. 108 Electronic Fund Transfer .. 108 Electronic Remittance Advice .. 108 Claims Overpayment Recovery Procedure .. 108 Third-Party Recovery .. 109 Claim Resubmissions .. 109 Claims Returned for Additional Information .. 109 v Reference: Covered Services .. 110 Reference: Clinical Submissions Categories.

7 110 Reference: Common Reasons for Rejected and Returned Claims .. 111 Reimbursement Policies .. 112 Acute Care Hospitals/Critical Access Hospitals .. 114 Ambulatory Service Center .. 116 Behavioral Health Facility .. 116 Federally Qualified Health Center (FQHC) and Rural Health Clinics (RHC).. 116 Intermediate Care Facility .. 116 Intermediate Care Facility for Individuals Who Are Intellectually 116 Skilled Nursing Facility .. 116 Hospice .. 116 CHAPTER 11: BILLING PROFESSIONAL AND ANCILLARY CLAIMS .. 117 Overview .. 117 Coding .. 117 Initial Health Assessments .. 118 Adult Preventive Care .. 118 Preventive Medicine Services: New Patient .. 118 Preventive Medicine Services: Established Patient .. 119 Behavioral Health .. 119 Emergency and Related Professional Services .. 119 Family Planning 120 Immunizations Covered by the Vaccines for Children (VFC) Program .. 121 Immunizations Coding .. 122 Maternity Services .. 122 Maternity Services: Newborns .. 123 Newborns: Circumcision.

8 123 Sensitive 123 Sterilization .. 124 Hysterectomy .. 125 Termination of Pregnancy .. 126 Billing Members for Services Not Medically Necessary .. 127 Recommended Fields for CMS-1500 .. 127 CHAPTER 12: BILLING INSTITUTIONAL CLAIMS .. 128 Overview .. 128 Basic Billing Guidelines .. 128 Emergency Room Visits .. 129 Urgent Care Visits .. 129 Maternity Services .. 130 Termination of Pregnancy .. 130 Inpatient Acute Care .. 131 Inpatient Sub-acute Care .. 132 Outpatient Laboratory, Radiology and Diagnostic Services .. 132 Outpatient Surgical Services .. 132 Outpatient Infusion Therapies and Pharmaceuticals .. 133 Ancillary Billing Overview .. 134 Ambulance Services .. 134 Ambulatory Surgical Centers .. 134 Physical, Speech and Occupational Therapies .. 134 Durable Medical Equipment .. 134 vi Durable Medical Equipment: Rentals .. 135 Durable Medical Equipment: Purchase .. 135 Durable Medical Equipment: Wheelchairs and Wheeled Mobility Aids .. 135 Dialysis.

9 136 Home Infusion Therapy .. 136 Laboratory and Diagnostic Imaging .. 136 Skilled Nursing Facilities .. 136 Home Health Care .. 136 Hospice .. 136 Additional Billing Resources .. 136 CMS-1450 Claim Form .. 137 CMS-1450 Revenue Codes .. 137 Institutional Inpatient Coding .. 137 Institutional Outpatient Coding .. 137 Recommended Fields for CMS-1450 .. 137 Consumer-Directed Attendant Care (CDAC) Provider Billing .. 138 CHAPTER 13: MEMBER TRANSFERS AND DISENROLLMENT .. 139 Overview .. 139 PCP-Initiated Member Transfers .. 139 PCP-Initiated Member Disenrollment .. 140 State Agency-Initiated Member Disenrollment .. 140 Member-Initiated PCP Reassignment .. 141 Member-Initiated Disenrollment Process .. 141 Member Transfers to Other Plans .. 142 Amerigroup -Initiated Member Disenrollment .. 143 CHAPTER 14: RECONSIDERATIONS, DISPUTES, GRIEVANCES AND APPEALS .. 145 Overview .. 145 Members: Filing a Grievance .. 146 Members: Resolution .. 147 Confidentiality .. 147 147 Providers: Claim Payment Dispute Process.

10 148 Providers: Claim Inquiries .. 151 Providers: Claim Correspondence .. 151 Medical Necessity Appeals .. 152 Providers: Nonmedical Necessity Claims Determinations .. 153 Providers: Mediation and Arbitration .. 153 Members: Appeals .. 154 Members: Time Frames .. 155 Members: Response to Standard Appeals .. 155 Members: Resolution of Standard Appeals .. 156 Members: Extensions .. 156 Members: Expedited .. 156 Members: Timeline for Expedited Appeals .. 156 Members: Response to Expedited Appeals .. 157 Members: Resolution of Expedited Appeals .. 157 Members: State Fair Hearing .. 157 Confidentiality .. 158 Continuation of Benefits during Appeal .. 158 CHAPTER 15: CREDENTIALING AND RECREDENTIALING .. 159 vii Overview .. 159 Council for Affordable Quality Healthcare .. 159 Approved Provider Types .. 160 Approved Health Delivery Organizations .. 160 CAQH/ProView Registration: First Time Users .. 160 CAQH/ProView Registration: Completing the Application Process.