Provider Manual - CareCentrix

1 Provider Manual Provider Manual Contents 1-1 KEY CONTACTS .. 6. GENERAL .. 6. KEY PHONE NUMBERS: AUTHORIZATION, RE-AUTHORIZATION, AUTHORIZATION CORRECTIONS .. 7. NETWORK MANAGEMENT KEY CONTACTS .. 7. 1-2 8. ABOUT THIS Provider Manual .. 8. 1-3 ABOUT CareCentrix .. 9. ABOUT CareCentrix .. 9. EMPLOYEES AND OFFICE LOCATIONS .. 10. 1-4 CORPORATE COMPLIANCE PROGRAM .. 10. COMPANY OBJECTIVES AND PURPOSE OF THE COMPLIANCE PROGRAM .. 10. REPORTING SYSTEM .. 12. RESPONSE AND CORRECTIVE ACTION TO PROMOTE PROGRAM 13. COMPLIANCE WITH CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) NOTICE OF MEDICARE NON-COVERAGE. REQUIREMENT .. 13. 2-1 PERFORMANCE STANDARDS .. 15. 2-2 USE OF OFFSHORE VENDORS .. 17. 3-1 Provider COMMUNICATIONS .. 17. Provider Manual .. 18. OUR CUSTOMERS .. 18. Provider ORIENTATION CONFERENCE CALL .. 19. THE CareCentrix Provider PORTAL .. 19. CareCentrix NEWSFLASHES .. 20. 3-2 NATIONAL CREDENTIALING COMMITTEE .. 20. PURPOSE .. 20. COMMITTEE ATTENDANCE.

2 20. 2|Page EDRC 746 - 03222018. Provider Manual COMMITTEE MEETING SCHEDULE .. 21. 3-3 Provider QUALIFICATION AND QUALITY MANAGEMENT .. 21. CREDENTIALING .. 21. RE-CREDENTIALING .. 22. Provider PROFILING .. 23. CREDENTIALING REQUIREMENTS FOR A NEW 23. CREDENTIALING REQUIREMENTS FOR ADDING A SERVICE CATEGORY .. 24. QUALITY 24. SATISFACTION 24. SATISFACTION MEASUREMENT REPORT TO PROVIDERS .. 25. 4-1 CHANGES IN YOUR ORGANIZATION .. 25. 5-1 HEALTHCARE DELIVERY PROCESS INTRODUCTION .. 26. 5-2 COORDINATION OF SERVICES AND AUTHORIZATIONS .. 26. Provider RECEIVES REFERRAL FROM PRIMARY REFERRAL SOURCE .. 26. CareCentrix RECEIVES REFERRAL FROM PRIMARY REFERRAL SOURCE .. 29. REQUESTS FOR ADDITIONAL SERVICES .. 31. RETROACTIVE SERVICE REQUESTS .. 32. SERVICE REQUEST INQUIRIES .. 33. 5-3 UTILIZATION MANAGEMENT .. 34. THE CareCentrix AND SLEEP MANAGEMENT SOLUTIONS (SMS) UTILIZATION MANAGEMENT PROCESS .. 34. UTILIZATION MANAGEMENT RESPONSIBILITIES .. 36. RETROSPECTIVE CLAIMS REVIEW.

3 37. APPEALING A DENIED REQUEST .. 38. 6-1 SERVICE DELIVERY .. 38. THE Provider 'S RESPONSIBILITY .. 38. THE Provider 'S DISCHARGE 40. 3|Page EDRC 746 - 03222018. Provider Manual 6-2 GUIDELINES SPECIFIC TO Provider 41. TRADITIONAL HOME HEALTH (THH) .. 41. INFUSION NURSING SERVICES .. 43. HOME INFUSION THERAPY (HIT) .. 45. DURABLE MEDICAL EQUIPMENT AND PROSTHETICS AND ORTHOTICS (DMEPOS) .. 47. SPECIALTY PROGRAMS .. 51. DOCUMENTATION .. 51. 6-3 GENERAL CLAIMS AND REIMBURSEMENT INFORMATION .. 52. CLAIMS PROCESS .. 52. CHECKING REIMBURSEMENT STATUS .. 53. EXPLANATION OF PAYMENT (EOP) .. 54. 6-4 GENERAL BILLING REQUIREMENTS .. 55. CLAIMS SUPPORT CENTER .. 55. CLAIM FORM AND CLEAN CLAIM REQUIREMENTS .. 56. TIMELY FILING .. 59. BILLING WHEN ANOTHER PAYOR IS PRIMARY .. 61. MEDICARE PRIMARY CLAIMS .. 61. RECOUPMENT AND ADJUSTMENTS .. 62. 6-5 COMPLAINTS, CLAIMS PAYMENT RECONSIDERATIONS, AND APPEALS .. 63. INTRODUCTION TO COMPLAINT, CLAIMS PAYMENT RECONSIDERATION, AND APPEALS PROCESS.

4 63. COMPLAINTS .. 63. CREDENTIALING .. 63. 6-6 CLAIMS PAYMENT ISSUES .. 64. CORRECTED CLAIMS .. 64. CLAIMS 65. RECONSIDERATION .. 65. 4|Page EDRC 746 - 03222018. Provider Manual APPEALS .. 68. DISPUTE RESOLUTION .. 69. BINDING ARBITRATION .. 69. 6-7 CONTRACT TERMINATION .. 70. 7-1 CUSTOMER ACKNOWLEDGEMENT AND RESOLUTION MANAGEMENT .. 71. 5|Page EDRC 746 - 03222018. Provider Manual 1-1 KEY CONTACTS. GENERAL. Reason for Contact Resource Contact Information Authorizations Initial Authorization Add-On Requests CareCentrix Provider Re-Authorization Portal Authorization Edits Authorization Status Aetna: 888-999-9641. Amgen: 888-571-6027. Beech Street and Cofinity: 877-466-0164. Cigna: 844-457-9969. Coventry: 877-415-7864. Other Care & Service Center Fallon: 866-827-2469. Florida Blue: 877-561-9910. Horizon Healthcare Services, Inc.: 855-243-3321. Neighborhood Health Plan (NHP): 866-827-5861. Public Employee Insurance Agency (PEIA): 888- 497-5337. CareCentrix Provider CareCentrix Direct Portal Claims and Payment Claims Questions Claims Support Team For 844-457-9969.

5 Cigna Appeal & Reconsideration Status Claims Support Team for 877-725-6525. all other plans Rejection Questions EDI Support Team Claims Inquiries Claims Status Reconsideration & Appeals CareCentrix Provider Forms Portal Register for EDI. EFT & ERA Enrollment CareCentrix Provider Portal Admin Accounts: Create or Network Management Unlock User Accounts: Create , Reset, Provider Portal Admin at Provider Portal Admin at your agency or Unlock your agency Provider Portal Questions Portal Info Box 6|Page EDRC 746 - 03222018. Provider Manual Other Patient Transitions Transition Team 1-866-776-4617. Provider Information Updates Credentialing Department Compliance Concerns Compliance Hotline 877-848-8229. Policies and Processes Provider Manual Click Provider Manual . Contractual Questions Network Management Reference Network Management Contact Sheet . Patient Financial Responsibility Patient Services Team 800-808-1902. Infusion Nursing Services Infusion Nursing Team 844-457-9973.

6 KEY PHONE NUMBERS: Authorization, Re-authorization, Authorization Corrections Plan Phone Number Aetna FL 888-999-9641. Aetna GA 888-999-9641. Amgen 888-571-6027. Beech Street 877-466-0164. CIGNA 844-457-9969. Cofinity 877-466-0164. Coventry 877-415-7864. Fallon 866-827-2469. Florida Blue 877-561-9910. Horizon Healthcare Services, Inc. 855-243-3321. Humana 888-428-4282. Neighborhood Health Plan (NHP) 866-827-5861. Public Employees Insurance Agency (PEIA) 888-497-5337. Walmart Specialty Pharmacy Reauthorization 877-453-4566. Authorization Edits NETWORK MANAGEMENT KEY CONTACTS. 7|Page EDRC 746 - 03222018. Provider Manual 1-2 WELCOME. Congratulations and welcome to the CareCentrix Provider Network. We are proud to work with you as we strive to meet high quality of care standards and provide and manage cost-effective health care solutions for the customers and patients served by our integrated healthcare network. As a Provider within our network, we value your services and are committed to making your experience with us as easy as possible.

7 To demonstrate this commitment, we have dedicated resources to support your participation in our network, and those resources are discussed further in this Manual . About This Provider Manual This Manual , as updated from time to time, serves as the basis for providing services within our network. It contains both general and Health Plan specific information. Please read this Manual carefully. It explains your rights and responsibilities as a CareCentrix Network Provider . As indicated in your Provider Agreement, you are obligated to comply with the terms of this Manual . Since this Manual is updated regularly, we encourage you to visit our Provider portal frequently at to find the most recent information. CareCentrix does not own the various third party websites referenced in this Manual and makes no representation relating to the content or accuracy of the information contained therein. You are solely responsible for your interaction with such third parties, and we encourage you to read the terms of use and privacy policies before accessing any third-party websites.

8 8|Page EDRC 746 - 03222018. Provider Manual 1-3 ABOUT CareCentrix . About CareCentrix CareCentrix is the leader in managing the transition of care to the home. For nearly 20 years, we have worked with health plans to support patients and providers make healing at home attainable and sustainable while lowering costs and improving outcomes. CareCentrix works with health plans to manage care in the home for their 23 million members. We connect providers with patients, help leverage best practices, and help patients navigate the complex home health care system. Our Core Services include: Durable Medical Equipment consisting of four subcategories home medical equipment, disposables, respiratory supplies and orthotics/prosthetics. Home Infusion This includes coordination for both specialty pharmacy products and acute services required for post discharge such as enteral nutrition, anti-infective and hydration. Home Health including nursing services for recuperative care typically following a period of hospitalization.

9 Wound Care Management Our Wound Care program tracks post-acute healing for wounds and offers intervention when patients are not healing as expected. Our Specialty products and services include: Sleep Management Our wholly owned subsidiary, Sleep Management Solutions (SMS), collaborates with health plans to help manage their patients' sleep disorders in the most cost effective way, offering diagnostic sleep testing in the home, as well as remote patient monitoring. 9|Page EDRC 746 - 03222018. Provider Manual HomeSTAR (Successful Transitions and Recovery at Home) HomeSTAR is designed to identify patients at risk for hospital readmission. The program provides telephonic coaching and coordination with home health care with the goal of avoiding costly hospital readmissions. Employees and Office Locations CareCentrix operates nationally with employees primarily located in Tampa, Florida; Hartford, Connecticut; Overland Park, Kansas; and Phoenix, Arizona.

10 For more information, visit the CareCentrix web site, 1-4 CORPORATE COMPLIANCE PROGRAM. Company Objectives and Purpose of the Compliance Program CareCentrix is committed to complying with all applicable legal requirements in the course of conducting its operations and expects each of its associates and network Providers to do the same. CareCentrix 's Corporate Compliance Program was developed with that commitment in mind. One purpose of the CareCentrix Corporate Compliance Program (the Program ) is to help prevent and detect fraudulent, noncompliant or unethical conduct and to take appropriate corrective actions upon detection of any such conduct. One activity that the Program is intended to help prevent and detect is the submission of improper, false or fraudulent claims for payment to the United States government or other health care payors as prohibited by such payors and/or as prohibited under applicable state and federal law, including applicable fraud, waste and abuse laws such as False Claims Act(s), Anti-Kickback Act(s), and the Civil Monetary Penalties law.