Provider Manual - Providers - AmeriHealth Caritas Delaware

1 DIAMOND STATE HEALTH PLAN (DSHP) Delaware HEALTHY CHILDREN PROGRAM (DHCP) DIAMOND STATE HEALTH PLAN PLUS (DSHP PLUS) AND DIAMOND STATE HEALTH PLAN (DSHP PLUS ltss ) Provider Manual PUBLICATION: AUGUST 13, 2018 DMMA Approved Changes after 08 13 18 AmeriHealth Caritas Delaware Version 4; Updated August 13, 2018 Page 2 AmeriHealth Caritas Delaware Version 4; Updated August 13, 2018 Page 3 Table of Contents WELCOME .. 9 SHARING OUR MISSION .. 9 I. GETTING STARTED .. 11 WHO WE ARE .. 11 ABOUT OUR PROGRAM .. 11 PLAN AND Delaware DHSS CONTACT INFORMATION.

2 12 AmeriHealth Caritas Delaware .. 12 Delaware DMMA .. 12 MEMBER ENROLLMENT & HEALTH PLAN SELECTION .. 12 ACCEPTING AmeriHealth Caritas Delaware MEMBERS .. 13 PRIMARY CARE SELECTION & 13 VERIFYING MEMBER ELIGIBILITY .. 13 MEMBER SERVICES AND MEMBER ADVOCATES .. 14 AmeriHealth Caritas Delaware MEMBER ID CARDS .. 16 MEMBER RIGHTS AND RESPONSIBILITIES .. 17 Member Rights .. 17 Member Responsibilities .. 18 PLAN PRIVACY AND SECURITY PROCEDURES .. 19 II. Provider AND NETWORK INFORMATION .. 21 BECOMING A PLAN Provider .. 21 EXAMPLES OF PARTICIPATING NETWORK Provider TYPES.

3 21 Provider CREDENTIALING AND RE-CREDENTIALING .. 21 COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE (CAQH) AND ONLINE CREDENTIALING .. 23 PRACTITIONER CREDENTIALING RIGHTS .. 24 CREDENTIALING/RE-CREDENTIALING FOR PRACTITIONERS .. 24 Practitioner Re-Credentialing .. 25 Presentation to the Medical Director or Credentialing Committee: .. 26 CREDENTIALING/RE-CREDENTIALING FOR ANCILLARY/HOSPITAL Providers .. 26 Presentation to the Medical Director or Credentialing Committee: .. 27 SITE VISITS RESULTING FROM RECEIPT OF A COMPLAINT AND/OR ON-GOING MONITORING.

4 28 STANDARDS FOR PARTICIPATION .. 29 Access to Care .. 30 Missed Appointment Tracking .. 33 After-Hours Accessibility .. 33 Monitoring Appointment Access and After-Hours 33 Panel Capacity & Notification .. 34 PRACTITIONER & Provider RESPONSIBILITIES .. 34 Responsibilities of All Providers .. 34 Primary Care Provider (PCP) Responsibilities .. 36 OB/GYN Practitioner as a PCP .. 38 Specialist Responsibilities .. 39 COMPLIANCE RESPONSIBILITIES .. 39 The Americans with Disabilities Act (ADA) and the Rehabilitation Act .. 40 Health Insurance Portability and Accountability Act (HIPAA).

5 40 AmeriHealth Caritas Delaware Version 4; Updated August 13, 2018 Page 4 Program Integrity .. 40 False Claims Act .. 41 The Fraud Enforcement and Recovery Act .. 41 Program Integrity Operations Team .. 41 Claims Cost Containment Unit .. 42 Refunds for Claims Overpayments or Errors .. 43 Special Investigations Unit Preventing, Detecting, and Investigating Fraud, Waste and Abuse .. 43 The Delaware False Claims and Reporting Act (DFCRA), 6 Del. Code Ann. 1201-1211 .. 45 Reporting and Preventing FWA .. 47 What to Expect as a Result of SIU Activities.

6 48 ADVANCED DIRECTIVES .. 49 Provider MARKETING ACTIVITIES GUIDELINES .. 49 Provider SUPPORT & ACCOUNTABILITY .. 50 Provider Network Management .. 50 New Provider Orientation .. 51 Orientation Training .. 51 Mandatory Provider Trainings & Meetings .. 52 Provider Education and On-Going Training .. 52 Plan-to- Provider Communications .. 52 Provider Complaint System .. 52 Provider Contract Terminations .. 53 Mutual Terminations .. 55 Continuity of Care .. 55 III. PROVISION OF SERVICES .. 58 BASIC COVERED SERVICES .. 58 NON-COVERED SERVICES .. 65 PRIVATE PAY FOR NON-COVERED SERVICES.

7 65 EMERGENCY SERVICES .. 65 OUT-OF-NETWORK USE OF NON-EMERGENCY SERVICES .. 66 SECOND OPINIONS .. 67 INPATIENT AT TIME OF ENROLLMENT .. 67 NEWBORN COVERAGE .. 67 STERILIZATIONS .. 68 PREVENTIVE CARE/IMMUNIZATIONS .. 68 Immunization Schedules (Childhood, Adolescent and Adult) .. 69 Vaccines for Children (VFC) Program .. 69 EPSDT .. 69 Screening Timeframes .. 70 PHARMACY SERVICES .. 70 Formulary .. 71 Pharmacy Prior Authorization .. 71 Emergency Supply .. 72 Over-the-Counter Medications .. 72 Durable Medical Equipment (DME) and Pharmacy Claims .. 72 Pharmacy Copays.

8 73 Pharmacy and PCP Lock-In Programs .. 74 Delaware Prescription Monitoring Program (PMP) .. 75 VISION SERVICES .. 75 Comprehensive Eye Care Administrator .. 75 AmeriHealth Caritas Delaware Version 4; Updated August 13, 2018 Page 5 LABORATORY SERVICES .. 75 HOSPICE SERVICES .. 76 Hospice Services in a Nursing Facility .. 77 Notification and Coverage for Hospice Benefits .. 77 INTERPRETATION AND TRANSLATION SERVICES .. 77 BEHAVIORAL 77 LONG TERM SERVICES AND SUPPORTS ( ltss ) .. 78 MONEY FOLLOWS THE PERSON (MFP) .. 78 IV. MEDICAL MANAGEMENT PROGRAMS.

9 80 INTEGRATED HEALTH CARE MANAGEMENT 80 INTEGRATED HEALTH CARE MANAGEMENT COMPONENTS .. 80 Pediatric Preventive Health Care Care for Kids .. 81 Bright Start (Maternity Management) .. 81 Rapid Response and Outreach Team (RROT) .. 81 Transitions of Care .. 82 Complex Care Management (CCM) .. 82 Community-Based Care Management Team (CCMT) .. 82 Program Participation .. 83 Let Us Know Program .. 83 CARE COORDINATION WITH THE PCP .. 84 CARE COORDINATION WITH OTHER Providers .. 84 INTEGRATING BEHAVIORAL AND PHYSICAL HEALTH CARE .. 84 MEMBER-CENTERED PLAN OF CARE.

10 85 COORDINATING CARE THROUGH TRANSITIONS AND DISCHARGE PLANNING .. 85 IDEA & CARE COORDINATION FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS .. 86 Identifying Children with Special Health Care Needs .. 87 HEALTH & LIFESTYLE EDUCATION .. 90 V. UTILIZATION MANAGEMENT .. 93 PRIOR AUTHORIZATION POLICY AND PROCEDURE .. 93 Prior Authorization Contact Information .. 95 Physical Health Services Requiring Prior Authorization .. 96 ALL LONG TERM SERVICES AND SUPPORTS ( ltss ) SERVICES .. 99 Physical Health Services that Do Not Require Prior Authorization .. 99 Physical Health Services that Require Notification.