sunflower health plan,

1 sunflower health plan ,". June 16, 2021. Current as of June 16, 2021. Please see for updates. 1-877-644-4623. TTY: 711 Su nflowerHealth plan .com an are I. 9 ,;unflower health plan . Table of Contents Welcome .. 3 Benefit Explanation and 27. About sunflower health plan ..3 sunflower health plan Benefits ..27. Our Mission ..3 Early and Periodic Screening, Diagnosis, and How to Use This Provider Treatment (KAN Be Healthy) ..32. Key Contacts and Important Phone Numbers ..4 Emergency Care sunflower Women's Kansas Medicaid Program Summary ..5 Family Contracting and Network 7 Sterilization Provider Network Development ..7 Obstetrical Credentialing ..8 Identifying Pregnant Members ..35. Credentialing Prenatal Care from Out-of-Network Recredentialing.

2 9 High-Risk Pregnancy Provider Rights to Review and Correct Information ..10 Home monitoring for High-Risk Provider Right to Be Informed of Application Value-Added Services for 36. Provider Right to Appeal Adverse 24-Hour Nurse Advice Line ..36. Credentialing Determinations ..10 My health Pays Program ..36. Provider Network Community health Support from Provider Relations Start Smart for Your Baby ..37. Provider and Practitioner Change Requests ..11 SafeLink Provider Network Termination ..12 Telemonitoring ..38. Member Impact from Provider Termination ..12 More Value-Added Services ..39. Provider Rights and Responsibilities .. 13 Medical Management .. 41. sunflower Provider sunflower Provider Responsibilities ..13 Utilization Beneficiary and Attorney Requests and Subpoenas.

3 14 Prior Authorization and Notifications ..41. Provider Types That May Serve as Radiology and Diagnostic Imaging Services ..44. Primary Care Provider (PCP) Responsibilities ..15 Therapy Services ..44. PCP Member Behavioral health Outpatient Treatment Request (OTR) ..45. PCP Member Panel Authorization Determination PCPs Can Be Specialists ..17 Second Opinion ..46. PCP Referrals to Clinical Information Needed for Specialist Provider Prior Authorization Hospital Responsibilities and Tertiary Care ..17 Clinical 24-Hour Access to Lock-In ..47. Provider Phone Call Pharmacy Travel Distance and Access Medical Appointment Availability and Wait Utilization Review Criteria ..48. Dismissing a Member from Your Practice ..21 Physician Peer-to-Peer (P2P).

4 49. Cultural Competency .. 22 Benefit Determination: New Technology ..49. Concurrent Review and Discharge Planning ..50. Verifying Member Eligibility .. 24 Retrospective Member Eligibility Verification ..24 Retrospective Review Due to Member Identification Card ..24 Members Awarded Retroactive Member Rights and 25 Clinical Practice 51. sunflower Member Care Management Program .. 52. sunflower Member Responsibilities ..25 Disease Management Member Interpreter Services ..26 Integrated Care Teams (IC Teams) ..52. Member Self-Referral Options ..26. Advance Directives ..26. 061621 | 1. sunflower Customer Service Department: 1-877-644-4623 (TTY 711). Medical Records .. 53 Quality Improvement 78. Medical Records Management and Records Retention ..53 Required QAPI Program Medical Records Release.

5 54 Practitioner Medical Records Transfer for New Quality Assessment and Performance Medical Records Audits ..54 Improvement Program Scope and Goals ..79. Access to Records and Audits by sunflower health plan ..54 Patient Safety and Quality of Electronic Medical Record Access ..54 Performance Improvement Process ..80. Billing and Claims Submission .. 55 Healthcare Effectiveness Data and Information Set (HEDIS) ..81. Clean Claim Definition ..55 HEDIS Rate Calculations ..81. Non-Clean Claim Definition ..55 Who Conducts Medical Record Reviews (MRR) for HEDIS? ..81. Timely Filing ..55 How Can Providers Improve Their HEDIS Scores?..81. Who Can File Claims? ..56 Provider Satisfaction How to File a Claim ..56 Consumer Assessment of Healthcare Online Claims Provider Systems (CAHPS) Survey.

6 82. Electronic Claims Submission ..59 Provider Performance monitoring and Incentive Paper Claims Physician Incentive Code auditing and Editing ..62 85. Rejections vs. Denials ..62 Appendix I: Common Causes of Upfront Rejections ..85. Corrected Appendix II: Common Causes of Claim Electronic Funds Transfers (EFT) and Processing Delays and Denials ..85. Electronic Remittance Advices (ERA) ..63 Appendix III: Common EOP Denial Codes and Descriptions ..86. Prospective and Retrospective Claim Reviews ..64 Appendix IV: Instructions for Supplemental Information Refunds and CMS-1500 (8/05) Form, Shaded Field 24A-G ..87. Third-Party Liability ..65 Appendix V: Common HIPAA-Compliant Claims vs. Encounter Data ..66 EDI Rejection Codes ..88. Procedures for Filing Claims and Encounter Appendix VI: Coordination of Benefits (COB)/.

7 Electronic Visit Verification (EVV) Kansas Third-Party Liability (TPL)..89. Billing the Appendix VII: Claim Form Instructions ..93. Anti-Fraud, Waste and 68 Appendix VIII: HCBS programs Billing 113. compliance Authority and Responsibility ..68 Appendix IX: Electronic Visit Verification (EVV) . Ways to Report Potential Fraud, Waste and Kansas 119. False Claims Act ..68 Appendix X: Billing Tips and Reminders .. 121. Grievance and Appeal 69 Appendix XI: 837 Companion Guide (October 2016) .. 127. Grievance Process ..69 Appendix XII: Provider Manual Updates .. 133. Appeal Process ..70. Member/Pre-Service Appeals ..70. Where to Send Member or Pre-Service Member Standard Appeal Process Provider Appeals ..73. Reconsideration External Independent Third-Party Review (EITPR).

8 73. State Fair Hearing for Provider Provider Appeal Process Steps and Timelines ..75. Where to Send Provider or Post-Service Appeals ..77. 2 | PROVIDER MANUAL | Published June 16, 2021. an are I. 9 ,;unflower health plan . Welcome Welcome organization committed to building collaborative partnerships with Provide medical coverage in a cost-effective manner. Welcome to sunflower health providers throughout Kansas. We All of our programs , policies, and plan ( sunflower ). We thank you for were selected by KDHE and KDADS. procedures are designed with these joining our network of participating due to our unique expertise and goals in mind. We trust that you, our physicians, hospitals, and other dedication to serving persons enrolled valued network provider, share our healthcare professionals.

9 Our in Medicaid programs to improve commitment to serving KanCare number-one priority is the promotion their health status and quality of life. members and will assist sunflower of healthy lifestyles through the sunflower will serve our members in in reaching these goals. We look provision of preventive healthcare a manner consistent with our core forward to your active involvement in services for persons who are enrolled philosophy that quality healthcare is improving access to care for the State in sunflower . By partnering with best delivered locally. of Kansas's most vulnerable citizens. providers like you, we can reach this goal together. Our Mission How to Use This About sunflower sunflower strives to provide improved health status, successful outcomes, Provider Manual health plan and member and provider satisfaction sunflower is committed to serving in an environment focused on our Kansas State provider community sunflower is a Medicaid Managed coordination of care.

10 As an agent of and supporting their efforts to Care Organization (MCO) contracted KDHE and KDADS and partner with deliver high-quality healthcare to with the Kansas Department of health local healthcare providers, sunflower our members. We are committed and Environment (KDHE) Division seeks to achieve the following goals to disseminating comprehensive of health Care Finance (DHCF) and for our clients, KDHE, KDADS, and and timely information to providers the Kansas Department for Aging and members: through this Provider Manual as Disability Services (KDADS) to serve Ensure access to primary and it relates to sunflower operations, Medicaid-eligible members through preventive care services in benefits, policies, and procedures. the KanCare program.