Provider Quick Reference - INTotal Health

1 Important Phone Numbers precertification /Notification Requirements Revenue CodesProvider Quick Important Contact Information Our Service Partners Claims ServicesTimely filing is within 180 calendar days from the date of the clearinghouse with any accept claims through four clearinghouses: Emdeon (payer 10262) Gateway (payer IHP01) Capario (payer IHP01) Availity (payer IHP001 - professional claims only) Availity (payer IHP002 - institutional claims only)Paper ClaimsSubmit claims on original claim forms (CMS 1500 or CMS 1450) printed with dropout red ink or typed (not handwritten) in large, dark font. AMA- and CMS-approved modifiers must be used appropriately based on the type of service and procedure code. Mail to:Claims INTotal Health Box 5446 Richmond, VA 23220-0446 Payment DisputesClaims payment disputes must be filed within 90 days of the adjudication date on your explanations of payment.

2 Forms for Provider appeals are available on our website. Mail to: Payment Dispute Unit INTotal Health 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 Medical AppealsMedical appeals, or medical administrative reviews, can be initiat-ed by members or providers on behalf of members and must be submitted within 30 calendar days from the dates of the notices of proposed actions. A Provider submitting on behalf of a member can write a letter or use the Provider Appeals form on our website. Submit in writing to: Medical Appeals INTotal Health 2600 Park Tower Drive, Suite 600 Vienna, VA 22180 Health ServicesCare Management Services offer care management services to members who are likely to have extensive Health care needs. Our nurse care managers work with you to develop individualized care plans, including identify-ing community resources, providing Health education, monitoring compliance, assisting with transportation, Management Services management services include educational information like local community support agencies and events in the Health plan s service area.

3 Services are available for members with the following medical conditions: asthma, bipolar disorder, COPD, CHF, CAD, diabetes, HIV/AIDS, hypertension, obesity, major depressive disorder, schizophrenia and transplants. 24/7/365 Nurse HelpLine can call our 24-hour Nurse HelpLine for nursing advice 7 days a week, 365 days a year. When a member accesses this service, a report will be faxed to your office within 24 hours of receipt of the Services (Pharmacy Services) Prior Authorization (PA): Fax: Specialty: Vision (Vision Services) (CAT, CT, MRA, MRI and PET scans, and nuclear cardiology) for Children (Dental Services; administered by DentaQuest Dental) (Nonemergent Transportation Services)Reservation line: status of a ride: Surgery (Including Oral Maxillofacial Services) No precertification is required for coverage of E&M codes. precertification is required for services related to trauma to the teeth, oral maxillofacial, and medical and surgical conditions, including TMJ.

4 Services considered cosmetic in nature or services related to previous cosmetic procedures ( , scar revision, keloid removal resulting from pierced ears) are not covered. Reduction mammoplasty requires an INTotal Health medical director s review. Podiatry No precertification is required for coverage of E&M, testing and procedures. precertification requirement is based on the service performed. See the Durable Medical Equipment section of this QRC for more information. Private Duty NursingPrecertification and a medical director s review are TherapyNo precertification is required for coverage of radiation therapy procedures when performed in a Provider s office, an outpatient hospital or an ambulatory surgery center. RadiologySee the Diagnostic Testing section of this QRC. Rehabilitation Therapy (Short Term): Occupational, Physical, Rehabilitation and Speech Therapies precertification is not required Early Intervention Services are covered under the DMAS FFS Program.

5 Notification is not required for initial evaluation. precertification is required for coverage of subsequent visits. You may fax your requests to All children of school age should be evaluated for school-based speech therapy prior to precertification at a nonschool-based Nursing Facility Medicaid/FAMIS Moms: Skilled nursing facility services are covered through the FFS Medicaid Program. For assistance, call FAMIS: precertification is required for coverage. Medically necessary services provided in a skilled nursing facility are covered for up to 180 days per Study precertification is Physicals Sports physicals are a value-added benefit for FAMIS and Medicaid members. Coverage is limited to one sports physical exam per year for members between ages 10 and 18. There is a maximum allowable reimbursement of $30 with no applicable member copayments. Sterilization No precertification or notification is required for coverage of sterilization procedures, including tubal ligation and vasectomy.

6 Sterilization services are a covered benefit for members age 21 and older and require a 30-day waiting period. Reversal of sterilization is not covered. Sterilization Consent Form is required for claims submission. Transportation Services Medicaid/FAMIS Moms: Unlimited nonemergent transport to medically necessary appointments is provided through LogistiCare. FAMIS: As a value-added benefit, FAMIS members receive 10 round trips per year to medically necessary appointments through LogistiCare. Providers and members may contact LogistiCare for assistance in scheduling transportation with three days prior notice. Members may call to make a reservation. To check the status of a ride, members may call Where s My Ride? at No precertification or notification is required except for coverage of air transportation (airplane or helicopter). Urgent Care Center: No notification or precertification is required for participating facility.

7 Vision Care (Routine) Make this paragraph say Members may self-refer for these services and can call Block Vision at Exam Members may self-refer for these services. Well-woman exams are covered once per calendar year when performed by a PCP or in-network GYN. Exam includes routine lab work, STD screening, Pap smear and mammogram (age 35 or older). Revenue (RV) Codes To the extent the following services are covered benefits, precertification or notification is required for all services billed with the following revenue codes: All inpatient and behavioral Health accommodations 0023: Home Health prospective payment system 0240 through 0249: All-inclusive ancillary psychiatric 0632: Pharmacy multiple source 3101 through 3109: Adult day care and foster careEasy access to precertification /notification requirements and other important informationFor more information about requirements, benefits and services, visit our Provider website to get the most recent, full version of our Provider manual.

8 If you have questions about this Quick Reference Card (QRC) or recommendations to improve it, call your local Provider Relations representative. We want to hear from you and improve our service so you can focus on serving your patients! precertification /notification instructions and definitionsRequest precertifications and give us notifications: Online: By phone: By fax: code-specific requirements for all services, visit listed are for network providers. In many cases, out-of-network providers may be required to request precertification for services when network providers do not. precertification - The act of authorizing specific services or activities before they are rendered or - Telephonic, fax or electronic communication received from a Provider to inform us of your intent to render covered medical services to a member. Give us notification prior to rendering services outlined in this document.

9 For emergency or urgent services, give us notifications within 24 hours or the next business day. There is no review against medical necessity criteria; however, member eligibility and Provider status (network and non-network) are Rehabilitation precertification is required for all services. Chemotherapy precertification is required for coverage of inpatient chemotherapy services. No precertification is required for the coverage of chemotherapy procedures when performed in outpatient settings by a participating facility, Provider office, outpatient hospital or ambulatory surgery center. For information on coverage of and precertification requirements for chemotherapy drugs, please see the Pharmacy section of this Services precertification is required. Medicaid/FAMIS Plus/FAMIS Moms: Not covered unless recommended at an EPSDT visit. FAMIS: Covered up to $500 per calendar year. Dental Services We cover medically necessary services resulting from a dental accident or for medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures.

10 precertification is required for coverage of trauma to the teeth and oral maxillofacial medical and surgical conditions, including Temporomandibular Joint (TMJ) disorder. Dental services are administered through the Smiles For Children program. The toll-free number for the Smiles For Children program is INTotal Health precertification /Notification Coverage GuidelinesBehavioral Health /Substance Abuse ServicesPrecertification is required. The MCO is not required to cover services rendered in a freestanding psychiatric facility; however, based upon review criteria, services may be MomsFAMISNoteInpatient (IP) freestanding psychiatric facilityCovered only for members under age 21 and over age 64 Not covered*If a member has been prescribed drugs for opioid treatment and the member obtains such drugs through an independent pharmacy, the drugs are the responsibility of INTotal Health . If the opioid treatment is administered by the substance abuse Provider and that Provider obtains the drugs for the member, such drugs will be covered by the Department of Medical Assistance Services (DMAS).