NEMS Medical Group Provider Manual

Transcription

1 NEMS Medical Group Provider Manual Revised October 2011 NEMS-MSO 1520 Stockton Street San Francisco, CA Tel: Fax:

2 I. Introduction TABLE OF CONTENTS I. INTRODUCTION 1-1 II. IMPORTANT QUESTIONS AND ANSWERS 2-1 III. MEMBER ELIGIBILITY VERIFICATION & ENROLLMENT 3-1 Verifying Eligibility 3-1 Sample Identification Cards 3-4 Determining Medi-Cal Eligibility 3-8 Managed Care Plan Hold Status 3-10 Determining Healthy Families Eligibility 3-11 Determining Healthy Kids Eligibility 3-12 Medi-Cal Member SFHP Enrollment 3-13 Healthy Families Member SFHP Enrollment 3-15 Healthy Kids Member SFHP Enrollment 3-19 IV. BENEFITS AND EXCLUSIONS 4-1 Medical Necessity 4-1 Medi-Cal Covered Benefits 4-2 Medi-Cal Limitations and Exclusions 4-8 Healthy Families Covered Benefits 4-11 Healthy Families Limitations and Exclusions 4-20 Healthy Families Program Co-payment 4-23 Healthy Kids Covered Benefits 4-24 Healthy Kids Limitations and Exclusions 4-33 Healthy Kids Program Co-payment 4-36 V. PCP REFERRAL/ AUTHORIZATION POLICY 5-1 Primary Care Physician and Service Provider Responsibilities 5-1 Initial Health Assessment 5-2 Authorizations to Medical Services 5-5 Referral Authorization Form (RAF) 5-6 Specialist Extension Form 5-8 Treatment Authorization Request (TAR) 5-9 Turn Around Time (TAT) 5-10 Approval / Denial Procedure 5-10 Appeals Process 5-10 Emergency Care Procedures 5-11 After-Hours Availability 5-12 Emergency Services Out-of-Area 5-13 Hospital Utilization 5-14 NEMS-MSO Authorization Listing 5-16 Revised October

3 I. Introduction VI. SENSITIVE SERVICES 6-1 Abortion Services 6-1 Family Planning Services 6-1 Sterilization 6-2 Sterilization Consent Form Instructions 6-5 VII. COORDINATION OF CARE & SERVICES 7-1 Case Management 7-1 Facility Site and Medical Record Review 7-4 Medical Group Credentialing 7-7 Provider Orientation and Training 7-9 Second Opinions and Independent Medical Review 7-11 Cultural and Linguistic Services 7-14 Community Resources 7-16 VIII. QUALITY IMPROVEMENT PROGRAM 8-1 Quality Improvement Committee & Program Activities 8-1 Quality Indicator Collection and Case Management Review 8-2 Case Management Review Process 8-2 Quality Improvement Method and Peer Review 8-3 Quality Improvement Plan 8-4 IX. CLAIMS PROCESSING AND PAYMENT DISPUTE 9-1 Timely Filing Limit 9-1 Turn Around Time (TAT) 9-2 Claims Processing 9-2 Reimbursement Rate and UCR Pricing Methodology 9-4 Claims Payment Dispute Resolution Mechanism 9-5 X. PROVIDER COMPLAINT AND MEMBER GRIEVANCE 10-1 Provider Grievance Process 10-1 Member Grievances 10-6 XI. ATTACHMENTS A. UM Authorization Grid and RAF / TAR forms B. Provider Dispute Form / Member Grievance Form C. SFHP Reimbursable Immunization List D. CHDP Periodicity and Immunization Schedule E. California Children Services F. Reportable Diseases and Conditions G. Medi-Cal Aid Codes Master Chart H. Glossary of Terms Revised October

4 I. Introduction I. INTRODUCTION NEMS-MSO (North East Medical Services-Management Services Organization) performs administrative services for Managed Care members (including Medi-Cal, Healthy Families and Healthy Kids members) who have selected the San Francisco Health Plan (SFHP) as their Health Maintenance Organization (HMO). Our Primary Care Providers (PCP) include North East Medical Services clinics, the Family Healthy Center at California Pacific Medical Center, Bayview Child Health Center, and some contracted private practices. San Francisco Health Plan is a City-sponsored health plan providing health insurance to more than 55,000 San Franciscans. For over 10 years, NEMS Medical Group and its partner hospital, California Pacific Medical Center (CPMC), have contracted with SFHP to provide quality medical services to Medi-Cal Managed Care, Healthy Families, and Healthy Kids members. Members assigned to NEMS Medical Group are able to access our broad physician network in the city and county of San Francisco. Medi-Cal Managed Care Program The Medi-Cal Managed Care Division (MMCD) provides high quality, accessible, and costeffective health care through managed care delivery systems. MMCD contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care. Managed care plans are a costeffective use of health care resources that improve health care access and assure quality of care. Today, approximately 3.4 million Medi-Cal beneficiaries in 25 counties receive their health care through three models of health care plans: Two-Plan, County Organized Health Systems (COHS) and Geographic Managed Care (GMC). Medi-Cal providers who wish to provide services to managed care enrollees must participate in the managed care plan s provider network. In San Francisco, a Two-Plan model is established by Blue Cross California (BCC) and San Francisco Health Plan which is sponsored by the San Francisco Health Authority. BCC has been operating Medi-Cal health plan business since July 1, 1996; San Francisco Health Plan has been in operation since January 1, Mandatory Medi-Cal Managed Care participants will be automatically assigned to a PCP in one of these two plans even if they do not choose one for themselves. Healthy Families Program The Healthy Families Program is administered by the Managed Risk Medical Insurance Board (MRMIB). It is a low cost insurance for children ages 18 years or younger. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for nocost Medi-Cal. It is a State Children s Health Insurance Program (SCHIP) for children whose family income is between 100% and 250% of the Federal Poverty Level. SFHP is the Community Provider Health Plan for the Healthy Families program in San Francisco County. The monthly premium for children is determined by income category, which includes family size, family income, and the health plan is chosen. In addition to the monthly premium, member pays a $5 co-payment for non-preventive services. Revised October

5 I. Introduction Healthy Kids Program Healthy Kids Program is jointly administered by the California Department of Health Services and the Managed Risk Medical Insurance Board (MRMIB). Children under the age of 19 years, family income does not exceed 300% of the federal poverty level may enroll into this program. Provider Resources Information related to Medi-Cal Managed Care, Healthy Families, and Healthy Kids may be found at the Department of Health Care Services website or the Department of Health and Human Services website. Providers may visit these websites to retrieve background information and/or obtain updates to enrollment eligibilities and requirements. Medi-Cal Managed Care: Healthy Families: Healthy Kids: Provider may also access the San Francisco Health Plan website at to find information related to member enrollment information in the City and County of San Francisco. San Francisco Health Plan has also provided our physicians many useful resources through the SFHP website such as: SFHP Drug Formulary: Clinical Guidelines: Community Resources: Health Education for Providers and patients: San Francisco Health Plan also provides periodic group trainings to deliver updates related to the different lines of businesses. The training schedule can be found by visiting the website at: Additionally, Primary Care Physicians may register with San Francisco Health Plan to download the monthly member roster from the website. For information on how to use the SFHP secure provider website, please visit: Revised October

6 I. Introduction Important Telephone Numbers Membership Eligibility SFHP General questions about member benefits, eligibility, covered services, etc. Automated Verification System or NEMS-MSO Christina Ng x 5860 PCP Assignment San Francisco Health Plan Medical Director Daniel Chan, MD Referral and Authorization Suzanne Lee Dorothy Fung Case Management Olin Lau, FNP Claim Payment and Dispute Provider Credentialing Provider Contracting Patricia Tse Wendy Miao Winnie Choy Wendy Miao Sandy Chiang NEMS-MSO Address: 1520 Stockton Street San Francisco, CA Telephone: Fax: Hours: Monday to Friday: 8:30 a.m. to 5:30 p.m. San Francisco Health Plan (SFHP) Address: 201 Third Street, 7th Floor San Francisco, CA Telephone: Fax: Revised October

7 II. Important Questions and Answers II. IMPORTANT QUESTIONS AND ANSWERS 1. How do I know if a patient is eligible for the San Francisco Health Plan (SFHP) benefits and if I am the Primary Care Provider? You must verify the following information when seeing SFHP members: Eligibility: Is the patient eligible for Medi-Cal / Healthy Families / Healthy Kids benefits for the present month? Health Plan Enrollment: Is the patient enrolled in SFHP? PCP Assignment: Is the member assigned to you (if you are a PCP) or do you have a referral from the member s PCP (if you are a specialist)? Medical Group Assignment: Which medical group is the PCP affiliated with? The SFHP Eligibility Verification & Fax Back System verifies Eligibility, SFHP Enrollment, PCP Assignment and Medical Group Affiliation. Information can be accessed 24 hours a day by calling (415) (Please also refer to Section III -- Member Eligibility Verification & Enrollment) 2. How do I find out if a service is covered? Please refer to the Benefits and Exclusions section in this manual for detailed information on the scope of benefits. The scope of benefits for Medi-Cal beneficiaries enrolled in SFHP is identical to Fee-for-Service Medi-Cal recipients. However, there are several benefits and diseases carved out by the Medi-Cal Managed Care Program, such as Chiropractic and Acupuncture services. Medi-Cal members may also be disenrolled from the Managed Care Program to receive Fee-for-Service benefits, such as Long Term Care and Major Organ Transplant services. Pharmacy and Optometry benefits are covered and provided by SFHP directly. Mental Health benefits are covered through the San Francisco Mental Health Plan. Benefits and service exclusions for the Healthy Families and Healthy Kids program are set according to the regulations set forth by the Managed Risk Medical Insurance Board (MRMIB). Co-payments are required for non-preventive services. See Section 4-11 for more detail. (Please also refer to Section IV -- Benefits and Exclusions) 3. Which doctor should I refer my patients to when they need specialty care? SFHP PCPs must refer members for specialty care within their affiliated Medical Group network. For members who have selected a NEMS Medical Group s affiliated PCP, a Specialist provider must be selected from the SFHP Provider Directory. Please visit the SFHP website at for a detail provider listing and their specialties. 4. What are the referral/authorization guidelines? PCPs may authorize consultations with specialists by filling out a Referral Authorization Form (Attachment A). Specialists may request additional visits for the patient from the PCP by completing the Specialist Extension Form (Attachment A). Certain services require prior authorization from the NEMS-MSO Utilization Management Department. Services Revised October

8 II. Important Questions and Answers providers will need to submit a Treatment Authorization Request (Attachment A) form and obtain approval before the procedure can be performed. A listing of procedures requiring the TAR form is in this Provider Manual, including the method of submission of the TAR form. Extra supplies of RAFs, TARs and Specialist Extension Forms may be requested from the NEMS-MSO UM Department, or by visiting the NEMS MSO Portal at (Please also refer to Section V -- PCP Referral/ Authorization Policy) 5. What kinds of services do not require a referral or prior authorization? Under federal and state law, Medi-Cal beneficiaries may access certain services (family planning, diagnosis/treatment of sexually transmitted diseases, HIV testing, sexual abuse counseling) in or out of network, without referral or prior authorization. Though abortion services are not considered family planning services; they do not require PCP or Medical Group prior authorization. Medi-Cal members may access these services through any willing providers. Healthy Families and Healthy Kids subscribers may access these services within network without referral or prior authorization. The provider shall document the service(s) provided in a treatment record and then bill the members medical group for the above services using the HCFA-1500 form. A copy of the treatment record must accompany the claim for payment. (Please also refer to Section VI -- Sensitive Services) 6. How do I submit a claim? NEMS Medical Group encourages all providers to submit claims for services rendered as soon as practical using a HCFA-1500 or UB-92 form. Hard copy claims should be mailed to the NEMS-MSO Claims Department at 1520 Stockton Street, San Francisco, California NEMS MSO does not accept electronic claims submission at the current moment. 7. How soon will I received payment after submitting claims? In general, the turn around time (TAT) for a clean claim is thirty (30) calendar days; the TAT for an unclean claim is forty-five (45) business days (63 calendar days). (Please also refer to Section IX -- Claims Submission and Payment Dispute.) 8. Which hospital should I admit my patient to? Patients should be referred to the California Pacific Medical Center (CPMC) for hospital care. In certain emergency care situations, the provider should direct the member to the nearest or most appropriate hospital facilities. Revised October

9 III. Eligibility Verification & Enrollment III. MEMBER ELIGIBILITY VERIFICATION & ENROLLMENT VERIFYING ELIGIBILITY When a SFHP member seeks medical care, it is essential that the provider office verify the member s eligibility, assigned PCP, and medical group. Failure to verify eligibility may result in non-payment of claims. SFHP makes final determination of a member s eligibility for the date of service at the time of receipt of the claim. Note: Possession of a SFHP ID Card does not guarantee eligibility. However, once eligibility is confirmed, the SFHP ID Card can identify the member s assigned PCP and medical group. The following table provides a summary of the methods to verify eligibility. TO VERIFY ELIGIBILITY AND ENROLLMENT: Ask for the member s SFHP ID Card Check eligibility using the Provider Secure Website at OR Call the SFHP Interactive Voice Response system (IVR) at (415) , 24 hours a day 7 days a week. OR Call the SFHP Member Services Department at (415) Monday-Friday, 8:30 a.m.-5:30 p.m. SFHP systems will report: SFHP Enrollment Status Medical Group Affiliation PCP Assignment Note: Do not rely upon POS or other non-sfhp systems to determine member assignment, as they will not identify medical group or designated PCP. Revised October

10 III. Eligibility Verification & Enrollment How to Verify Member Eligibility On-line THE SFHP SECURE PROVIDER WEB SITE San Francisco Health Plan s Provider Secure Website, is a fast and sure way for providers and their staffs to verify a member s eligibility, download member rosters, and check claims status for their practice. To access the web site, follow these easy steps to creating a unique user ID and password. DESIRED ACTION Go to Select Provider Secure Login Registration for User ID and Password Basic Feature you can Verify Member Eligibility & PCP and Search for Claims: Additional Features you can: View Current Member Roster Download Current Member rosters in Excel format To obtain access to these features, submit the form at the bottom of page with additional feature requests. Checking Member Eligibility Click on Sign up here Fill in requested information for steps 1-6 Choose a USERNAME for step 7 Click Finish. Your password will be sent to you via the e- mail that you submitted in the registration process. Enter Username and Password Click on Login Click on Verify member Eligibility & PCP Choose Search by ID or Search by Last name and Date of Birth Complete requested information Click on Check Eligibility Download Patient Roster in Excel Format Enter Username and Password Click on Login Click on View Current Patient Roster Click on Download Excel Spreadsheet If you have questions regarding this web site please contact Rebecca Lim, SFHP Provider Relations at (415) ; If you are experiencing technical difficulties, please contact Ying Li, SFHP Information Systems at (415) Revised October

11 III. Eligibility Verification & Enrollment How to Use the Interactive Voice Response (IVR) System The SFHP Interactive Voice Response (IVR) system allows 24-hour access to member eligibility, medical group and PCP assignment. Provider may access the IVR system by dialing the SFHP Automated Verification of Coverage (AVC) line at (415) , 24 hours a day, 7 days a week. To verify eligibility, providers must provide: Member s first and last name. ID Number from the front of the member s SFHP ID card; if SFHP ID Card is not available, use the member s Social Security number, client index number (CIN) or Medi- Cal ID number. Provider name and contact telephone number. Note: Each SFHP member receives an ID card to present to providers as a means of verifying eligibility for covered services. In addition, Medi-Cal members are issued a state Basic Identification Card (BIC). As neither card guarantees eligibility, SFHP recommends that where possible providers first use the SFHP ID card to determine eligibility. Point of Service (POS) Swipe Devices Use of a Point of Service (POS) swipe device will only alert the provider that the member has enrolled into San Francisco Health Plan as a Managed Care member, and will not indicate member s medical group and/or PCP assignment. San Francisco Health Plan does not issue or participate in the use of POS Swipe devices for verifying eligibility. Revised October

12 III. Eligibility Verification & Enrollment SAMPLE IDENTIFICATION CARDS Medi-Cal Benefits Identification Card (BIC) The BIC is a small plastic card, similar to a credit card, which is issued to every Medi-Cal beneficiary. Only one permanent BIC is issued, although it may be replaced through the county welfare department if lost or stolen. Cards are not sent monthly. The following fields are present on the BIC: 1. Recipient ID Number a 10-character client index number (CIN), a unique identifier assigned to each beneficiary by the state, followed by a check digit. The check digit should be ignored for eligibility purposes. 2. Beneficiary s first name, middle initial and last name. 3. Gender Code male or female. 4. Beneficiary s date of birth. 5. BIC issue date required for access to the beneficiary eligibility information via the computerized point of service (POS) network. Note: Payment will not be guaranteed for care provided if eligibility is not verified. Providers, Professionals, and Institutions must use their best judgment in deciding whether to provide treatment for an individual whose eligibility could not be verified. Revised October

13 III. Eligibility Verification & Enrollment SFHP Member Identification Card for Medi-Cal Members Each SFHP member receives a member card to present as identification when requesting services. This card must be shown in addition to the State Medi-Cal Benefits Identification Card (BIC) shown previously. Medi-Cal members are instructed to keep both cards with them. Member Name: Jane Doe Effective Date: Jan. 1, 1997 SFHP ID #: Member Medi-Cal #: Member SSN #: Primary Care Provider: John Williams, MD Provider Phone #: Clinic Name: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS Members: Call your Primary Care Provider (PCP) when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. If you lose Medi-Cal eligibility or disenroll from SFHP, your Membership is invalid. Prescription Plan: To get a prescription filled, take your doctor s written prescription to a SFHP-PCN participating pharmacy. Vision Plan: To find a SFHP Vision Service Plan (VSP) doctor and get an eye exam or glasses call FRONT OF CARD (Actual card has blue logo.) FRONT OF CARD WITH FOLD Members: For Urgent Care call your Primary Care Provider (PCP) 24 hours a day 7 days a week. For Emergency Care when you are in extreme pain or there is threat of death or disability, go to the nearest hospital or call 911. Members and Providers: Please notify the SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Emergency services rendered by non-affiliated providers will be reimbursed by SFHP/affiliated contractor. BACK OF CARD Providers: This card is for identification only. Use member BIC card for verifying eligibility or call SFHP at Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. Pharmacy Provider Questions: Call PCN at Use Account Number 00670, BIN Number , SFHP Member Services Call or BACK OF CARD WITH FOLD Independent Physician Associate/Medical Group (IPA/MG) Codes CHN = Community Health Network CHI = Chinese Community Health Care Association KSR = Kaiser Permanente NEMS = North East Medical Services Medical Group STL = Integrated Medical Group at St. Luke s Hospital UCS = UCSF Medical Group San Francisco Revised October

14 III. Eligibility Verification & Enrollment SFHP Member Identification Card for Healthy Families Members Each SFHP member receives a member card to present as identification when requesting services. LISA LEWIS Healthy Families ID# SFHP ID #: Effective date: Primary care provider: John Smith, MD #11809 Provider Phone #: Clinic: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS *co-payments: $5 office visit, waived for preventive visits and children under 24 months; $5 emergency room visit; $5 prescription medicine Pharmacy: use account # 00671, bin # FRONT OF CARD (Actual card has red logo.) SUBSCRIBERS: Call your PCP when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. PRESCRIPTIONS To get a prescription filled, take your doctor's written prescription to an SFHP participating pharmacy. FOR URGENT CARE: Call your PCP 24 hours a day, 7 days a week. FRONT OF CARD WITH FOLD EMERGENCY CARE Go to the nearest hospital or call 911 if you are in extreme pain or there is threat of death or disability. Prior Authorization is not required. If you are outside of San Francisco, go directly to the nearest hospital emergency room for treatment and notify your medical group and physician as soon as possible. SUBSCRIBERS AND PROVIDERS Please notify SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Providers: This card is for identification only. To verify member eligibility, call SFHP at Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. PHARMACY PROVIDER QUESTIONS: Call PCN at SFHP MEMBER SERVICES Call or BACK OF CARD BACK OF CARD WITH FOLD *Members will not have to pay more than $250 in co-payments during the course of one benefit year (July 1 to June 30). SFHP sends a new ID card to each Healthy Families subscriber who meets his or her co-payment maximum for the benefit year. The co-payments field in the new ID card will state none. Revised October

15 III. Eligibility Verification & Enrollment SFHP Member Identification Card for Healthy Kids Members Each SFHP member receives a member card to present as identification when requesting services. LISA LEWIS Healthy Kids ID# SFHP ID #: Effective date: Primary care provider: John Smith, MD #11809 Provider Phone #: Clinic: North East Medical Service Address: 1520 Stockton Street IPA/MG code: NEMS *co-payments: $5 office visit, waived for preventive visits and children under 24 months; $15 emergency room visit; $5 prescription medicine Pharmacy: use account # 00671, bin # FRONT OF CARD (Actual card has red logo.) SUBSCRIBERS: Call your PCP when you need medical care. Keep this card with you at all times and present to all doctors and hospitals that treat you. PRESCRIPTIONS: To get a prescription filled, take your doctor's written prescription to an SFHP participating pharmacy. FOR URGENT CARE: Call your PCP 24 hours a day, 7 days a week. FRONT OF CARD WITH FOLD EMERGENCY CARE Go to the nearest hospital or call 911 if you are in extreme pain or there is threat of death or disability. Prior Authorization is not required. If you are outside of San Francisco, go directly to the nearest hospital emergency room for treatment and notify your medical group and physician as soon as possible. SUBSCRIBERS AND PROVIDERS Please notify SFHP of all emergency related care or admissions within 24 hours or as soon as possible. Providers: This card is for identification only. To verify member eligibility, call SFHP at Contact your IPA/MG for pre-authorization for required services and referrals. Prior authorization for emergency services is not required. PHARMACY PROVIDER QUESTIONS: Call PCN at SFHP MEMBER SERVICES Call or BACK OF CARD BACK OF CARD WITH FOLD **Members will not have to pay more than $250 in co-payments during the course of one benefit year (July 1 to June 30). SFHP sends a new ID card to each Healthy Families subscriber who meets his or her co-payment maximum for the benefit year. The co-payments field in the new ID card will state none. Revised October

16 III. Eligibility Verification & Enrollment Electronic Eligibility Verification Options for Medi-Cal Members To obtain eligibility information, you may use the information on the BIC to verify eligibility through the computerized point of service (POS) network. In addition, the POS network can be used to clear share of cost and report Medi-Services. Listed below are the services available to access the POS Network: CERTS A claims and eligibility real-time software system which allows access to the POS when the card is swiped or the card number is input. You can also print results on a receipt. A sample POS readout will read like this: Sample Readout Meaning John Recipient Patient name A EVC# - (Verification #) 38 County code 82 Primary aid code Medi-Cal for dental Dental coverage Medi-Cal eligible - Health Plan enrollment Call Health Plan phone number AEVS the Automated Eligibility Verification System allows access using a touch-tone telephone. A computerized voice will guide the caller through the transactions and provide the most current Medi-Cal eligibility information available. Note: The above listed systems are free to qualified Medi-Cal providers. Access to these devices must be approved by the DHS through insurance of two authorization numbers. Call the San Francisco Health Plan customer service for more information on AEVS, CERTS or the POS Devise. Determining Medi-Cal Eligibility Individuals apply for Medi-Cal in person through the Department of Health Care Services (DHCS). Children and pregnant women may also apply through the joint Medi-Cal and Healthy Families on-line One-E-App system. The State creates a computer record for each eligible Medi-Cal member in the FAME system. The County Welfare Department supplies eligibility information on the Medi-Cal population to the State, and the Social Security Administration supplies eligibility information on the SSI/Fiscal Intermediary Access to the Medi-Cal eligible population. These agencies are responsible for correcting any discrepancies regarding Medi-Cal eligibility information. FAME information is the basis for the computerized point of service (POS) network that you may access directly to verify member eligibility, and it is updated on a daily basis. Revised October

17 III. Eligibility Verification & Enrollment What is Contained in a FAME Record The FAME system identified a Medi-Cal beneficiary by Social Security number, Medi-Cal ID number, and a unique Client Index number (CIN). The CIN has replaced the SSN as the primary beneficiary identifier. The Medi-Cal ID number is a 14-digit number as listed below: Digit What they designate 1 st & 2 nd County of responsibility; SF is 38 3 rd & 4 th Aid category code; identifies the assistant program; 5 th 11 th County case number, a 7 digit number; 12 th Family budget number; 13 th & 14 th Person number Most Medi-Cal eligible family members have the same number from 1-12, except for SSI beneficiaries who have individualized numbers based on their SSN as listed: 1 st & 2 nd 3 rd & 4 th 5 th 6 th to 14th County Code Aid code Always 9 SSN or MEDS pseudo number FAME Monthly Update Every month, approximately five days prior to the end of the month, FAME is modified to reflect eligibility for the following month. Health Care Options (HCO) enrollment information is matched against MEDS eligibility to produce health plan enrollment files for Medi-Cal members throughout the State. A member s enrollment that is processed by HCO by the 25 th of the month will be enrolled into a health plan on the first day of the next month that they are eligible. If a form is entered after the FAME cut-off date, the beneficiary will not be enrolled until the first of the second following eligible month. Eligibility data received from the state is processed by SFHP before distribution to IPA/MGs and other contracted providers. Medi-Cal Mandatory Aid Codes Aid codes are indicators of Medi-Cal eligibility and are used by the DHCS to classify beneficiaries by the type of Medi-Cal services for which they qualify. In San Francisco County, Medi-Cal beneficiaries with the following aid codes must enroll in a managed care plan, either SFHP or the Commercial Managed Care plan (Blue Cross): Mandatory Aid Category Codes: 0A, 0I, 3L, 01, 02, 08, 30, 32, 33, 34, 35, 38, 39, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 54, 59, 5X, 7A, 7X, 82. Exceptions in the mandatory aid categories include: Individuals who have been approved by the Medi-Cal Field Office or the California Children s Services Program for bone marrow, heart, heart-lung, liver, lung, combined liver and kidney, or combined liver and small bowel transplants; Individuals who elect and are accepted to participate in the following Medi-Cal waiver programs: In-Home Medical Care Waiver Program, Skilled Nursing Facility Waiver Program, AIDS or AIDS-Related Conditions Waiver Program. Revised October

18 III. Eligibility Verification & Enrollment Individuals determined by the Medi-Cal Field Office to be in need of long-term care who have been residing in a Skilled Nursing Facility (SNF) for thirty (30) days past the month of admission; and Individuals who have received a Medical Exemption. Managed Care Plan Hold Status Each month FAME renewal re-evaluates current and pending health plan enrollments to determine if beneficiaries qualifications for enrollment have changed. If a beneficiary still qualifies for health plan enrollment, he or she will appear on the health plan s monthly eligibility reports as a capitated member. However, if a beneficiary s qualifications for health plan enrollment have changed, he or she will appear on the health plan s report with a hold status. Capitation is not paid for a health plan member with hold status. The following changes would cause a hold on enrollment: 1. Change in aid code to one not covered by the managed care plan; 2. Change in county code not covered by the health plan. These individuals are disenrolled once brought to the attention of DHCS; 3. Loss of Medi-Cal eligibility; or 4. Hold placed on Medi-Cal eligibility In the first two cases (change in aid code or change in county code), the beneficiary may still be entitled to benefits under the Medi-Cal fee-for-service program. Under the last two cases (loss of Medi-Cal eligibility and hold placed on Medi-Cal eligibility), the beneficiary would not be entitled to Medi-Cal benefits. An enrollee may remain in hold status for up to two months. If enrollment is not reinstated within two consecutive months, FAME will automatically disenroll the beneficiary from the health plan. If the beneficiary again becomes eligible, he or she will be processed as a new eligible. Supplemental Eligibility (Retroactive Enrollment) Enrollments are effective on the first of a future month. Supplemental eligibility enrollments are the only enrollments applied retroactively. Supplemental eligibility is the reinstatement of a member for the month(s) when the member was on hold or lost eligibility. If the enrollment was placed on hold because of a change in aid code or county code, health plan eligibility can only be reinstated for a future month. This occurs because once eligibility has been established for a given month. It cannot be changed until the following month. The effective month in which an enrollment is reinstated is determined by the process date. If supplemental eligibility is reinstated before the FAME cut-off date, the enrollment is effective the first of the current month. Example: On hold for August, reinstated August 20, enrollment effective August 1. In this example, the health plan is responsible for all services provided to the enrollee during August, and receives later capitation for the full month. If supplemental eligibility is reinstated after the FAME cut-off date, but before the end of the month, enrollment is for the current month and future month. Example: On hold for August, reinstated August 28, enrollment for August and September. Revised October

19 III. Eligibility Verification & Enrollment Determining Healthy Families Eligibility Electronic Data Systems Healthy Families (HF) provides health, dental and vision insurance at low cost to eligible children who do not have insurance and are not eligible for no-cost Medi-Cal. Once deemed eligible by HF enrollment contractor Electronic Data Systems (EDS), the child is covered for at least 12 months. Even if family circumstances change during this period, eligibility continues unless the applicant requests disenrollment or fails to pay the monthly premium. For requests to add additional children to the program, an applicant must complete a new application and forward it to EDS. The HF application may be used to apply for either HF or Medi-Cal. If an applicant is eligible for no-cost Medi-Cal, the application is forwarded to Medi-Cal for review. Help in completing the document is available by calling the NEMS Member Services Department at (415) for application assistance from our Member Services representatives. Once an application is received, EDS determines eligibility for the Healthy Families program within twenty (20) business days. The applicant is then notified in writing of the application status. The notice tells the date on which coverage begins for each enrolled child. The first day of insurance coverage begins 10 days from the date that EDS determines the child s eligibility. If an applicant wants an update on the status of an application, he or she can call toll free (800) , between 8 a.m. and 8 p.m., Monday through Friday. If a child is found to be ineligible, the applicant will be informed in writing of the reason. If the applicant gave permission to forward the application to Medi-Cal, EDS will forward the application, without the payment for the first month s premium, to Medi-Cal. If not, the application and money order will be returned to the applicant. Healthy Families Premiums The HF program requires subscribers to pay a monthly fee to retain insurance coverage. The monthly premium is determined by income category, which in turn includes family size, family income, and the health plan chosen. Subscribers pay a monthly premium between $4 and $15 for each child, up to a maximum of $45 for all children in the family enrolled in the program. The first month s premium must be mailed with the application and paid with a cashiers check or money order. Once a child is enrolled in the program, the subscriber is billed monthly. Subscribers have two methods of saving money on the payment of insurance premiums: 1. Choosing the Community Provider Plan saves the subscriber $3 per child on the monthly premium. The Community Provider Plan includes the most traditional and safety net providers in its network. SFHP is the Community Provider Plan in San Francisco County. 2. After paying in advance for three consecutive months of premiums, the fourth month of coverage is free. If a premium payment is sixty (60) days late, the child s insurance coverage ends. Coverage termination is effective at the end of the last month in which the premium was paid in full. The subscriber is then responsible for any health care received by the covered child in the last Revised October

20 III. Eligibility Verification & Enrollment month after coverage ended. Partial payments of the premium are not allowed, and are considered non-payment and will be returned to subscriber. In addition to monthly premiums, the subscriber must pay a co-payment for certain services. Although some services, such as preventive care, are free, the usual individual charge is $5 per visit. There is a $250 maximum co-payment limit for a family during each benefit year (July 1 to June 30). After the $250 maximum is met, no more co-payments are required for the benefit year. At this point, SFHP will send the subscriber a new ID card noting that the maximum copayment has been met. Annual Eligibility Review Each year the subscriber is asked to renew the child s eligibility for Healthy Families (HF). The HF program notifies the subscriber by mail of the Annual Eligibility Review (AER) process. The subscriber will receive a notice about sixty (60) calendar days before the end of the family s anniversary date in the Healthy Families Program. If the enrolled child still qualifies for the Program, coverage will continue for another twelve (12) months. Each time the subscriber enrolls a new child in the Program, the subscriber re-qualifies all the children who are enrolled in the Healthy Families for another twelve (12) months. The AER date for all children will be twelve (12) months from the date the last child is enrolled. The monthly premium will be recalculated. The new premium may change depending on the household income. Subscribers may contact the Healthy Families Program by: Phone: Call (800) Monday to Friday 8:00am to 8:00pm, Saturday 8:00am to 5:00pm. Send question by to HealthyFamilies@MAXIMUS.com, or Write to: P.O. Box , Sacramento, CA Determining Healthy Kids Eligibility The Healthy Kids Program offers complete medical, dental and vision insurance to children at a very affordable cost, regardless of immigration status. Subscribers must be under the age of 19 years, not eligible for no-cost, full-scope Medi-Cal or the Healthy Families Program, with family income within 300% of Federal Poverty Level (FPL). Depending on income and family size, Healthy Kids members pay an annual premium ranging from $48 to $126. Each member will be re-evaluated annually prior to his or her anniversary date in the program to determine continued eligibility for the Program. The continued eligibility of each member is contingent upon the availability of public funds from the City and County of San Francisco ( CCSF ) to pay the premium costs of the program. At or before each member s anniversary date, SFHP shall determine whether funds are available from CCSF to cover the premiums for the member s next year of enrollment. Applicants shall be notified of the annual eligibility review process at least sixty (60) days prior to the anniversary date. It is the member s, or where the member is a minor, the applicant s, responsibility to notify SFHP within thirty-one (31) days of all changes in eligibility affecting member s enrollment in the Healthy Kids Program. Contact the SFHP Healthy Kids renewal team at (800) Revised October

21 III. Eligibility Verification & Enrollment SFHP ENROLLMENT AND DISENROLLMENT Throughout the State, families with children under the age of 19 who may be eligible for no-cost Medi-Cal or low-cost Healthy Families Program may complete a mail-in application to enroll into a managed care health plan. Trained application assistants may include SFHP staff, providers and community-based organizations. These qualified sites offer assistance to families with the applications. Applications can be ordered through Richard Health and Associates, by calling (888) , or call SFHP for help in ordering applications. Medi-Cal Member SFHP Enrollment All enrollments and disenrollments are handled by the State Department of Health Services (DHS) Health Care Options (HCO) contractor. Health Care Options can be reached at (800) How a Medi-Cal beneficiary Choose a Health Plan In San Francisco, current Medi-Cal beneficiaries in the mandatory aid code categories (those who must choose a managed card plan) receive an enrollment packet in the mail from the HCO contractor. New applicants and beneficiaries re-determining Medi-Cal eligibility are also informed of the health plan enrollment process. Beneficiaries receive enrollment materials through the mail or from an enrollment presentation conducted by the HCO contractor. Medi-Cal health plan enrollment requirements for the mandatory population differ from the enrollment requirements for the voluntary population. The mandatory population is informed that they must enroll in a health plan unless specific exemption criteria are met. NOTE: DHS no longer allows providers to distribute Medi-Cal managed care enrollment materials and Medi-Cal Health Plan Choice Forms. Exemption from Medi-Cal Health Plan Enrollment In certain cases, the State allows a beneficiary in a mandatory aid category to avoid enrollment, or allows dis-enrollment from a health plan. The beneficiary may be allowed to remain in the fee-for-service program for the duration of the treatment, if the beneficiary has a complex medical problem and is in the middle of a treatment program with a provider that is not participating anywhere within the health plan s provider network. The doctor must verify in writing that changing providers would be harmful, and state the duration of the treatment. Medical conditions that fall into this category include: Complex cancer treatment; Organ transplant (when certified for organ transplant except for kidney member would be disenrolled from SFHP even if he or she did not request enrollment exemption); HIV - positive status; or Participation in any Medi-Cal Waiver Program (i.e. AIDS Waiver Program) In addition, certain Medi-Cal beneficiaries, including Native Americans, Alaska Natives and non-indians currently receiving services from an Indian Health Service Program, may request Revised October

22 III. Eligibility Verification & Enrollment an alternative to plan enrollment and continue to receive services from that facility through regular Medi-Cal. Members and providers may contact SFHP at (415) or (800) for additional details and/or assistance. Problems with Health Care Options (HCO) DHS has established an Office of the Ombudsman. The Office handles the full range of problems that Medi-Cal managed care members/providers experience, and is one avenue that providers and the health plans may use to address enrollment and disenrollment problems. You can call the Office of the Ombudsman at In addition, providers are encouraged to contact SFHP customer Service at about enrollment/disenrollment problems. Member Disenrollment Members may leave San Francisco Health Plan (SFHP) at any time and switch to another Medi-Cal managed care health plan. In these cases, the member must complete a Medi-Cal Choice Form, provided by the HCO Contractor, not SFHP, processes disenrollments. Members should obtain a Choice Form through the health plan according to State policy, or call Health Care Options at to request a Medi-Cal Health Plan Choice Form. Disenrollments based upon DHS Criteria In some cases, members may be involuntarily disenrolled from the Health Plan based upon DHS State guidelines. Reasons why members may be disenrolled include: A move out of San Francisco County (our health plan area); Loss of State Medi-Cal eligibility (the Plan does not determine Medi-Cal eligibility); A change in Medi-Cal aid code category to one that is not eligible for Medi-Cal Managed Care; When a member s condition meets criteria for excluded services such as major organ transplants, waiver programs, and long term care; Enrollment was in violation of State regulations; The contract between the State DHS and SFHP ends; Services Requiring Disenrollment. There are certain medical conditions that may meet the criteria for disenrollment (i.e., major organ transplants, waiver programs and long-term care). These situations warrant member disenrollment. These disenrollments become effective on the first day of the second months following receipt by DHS of all documentation necessary to process the disenrollment. Disenrollments related to major organ transplants will be effective the beginning of the month in which the transplant is approved. Disenrollment for any of the above reasons will not affect the individual s Medi-Cal eligibility. Re-enrollment with the San Francisco Health Plan is at the discretion of the California Department of Health Services and the San Francisco Health Plan. Effective Date of Disenrollment Except as described above for excluded service disenrollment, if a member loses eligibility, coverage will terminate at midnight on the day specified by the Department of Health Services, but no later than the last day of the month in which Medi-Cal eligibility is lost. If a member moves out of the county, coverage will terminate at midnight on the last day of the month for Revised October

23 III. Eligibility Verification & Enrollment which the State Department of Health Services has paid monthly premiums to the San Francisco Health Plan on the member s behalf. SFHP initiated disenrollments that are approved by DHS will become effective on the first day of month following the approval of the disenrollment request. Member initiated disenrollment from the San Francisco Health Plan, for whatever reason, takes fifteen (15) to forty-five(45) days for the HCO Contractor to process. Emergency Disenrollments SFHP can request emergency disenrollments. The HCO Contractor will process emergency disenrollments within two (2) working days of receipt. Emergency disenrollment guidelines are being finalized by DHS and in draft form include the following circumstances: Members who were assigned to SFHP and contact the Plan or the HCO Contractor within 60 days of enrollment who meet criteria for Exemption from Health Plan enrollment; Members who are in foster care; Members enrolled while in a long term care facility; Members enrolled that are incarcerated; Members that have moved out of the county; or Other reasonable cause (i.e. breakdown in doctor-patient relationship). Contact SFHP Customer Service at (415) to initiate/report appropriate member emergency disenrollments. SFHP staff will work with providers, the HCO enrollment contractor and DHS staff to the greatest extent possible to ensure appropriate and timely emergency disenrollments. Foster Care Disenrollments SFHP works with the County s Department of Human Services to identify members placed in the Foster Care system. These members must be disenrolled from Managed Medi-Cal to Feefor-service Medi-Cal. However, until such disenrollment becomes effective, it is the appropriate IPA/MG s responsibility to authorize and pay for emergency services and medically necessary urgent services. (This includes the medical screening examination, a requirement of every child in San Francisco County who is removed from his or her home.) Healthy Families Member SFHP Enrollment Electronic Data Systems (EDS), the Healthy Families contractor, reviews all applications for Healthy Families eligibility. Information on Healthy Families eligible members who choose San Francisco Health Plan (SFHP) as their health insurance plan is then electronically transmitted to SFHP on a nightly basis. Transfer between Health Plans Subscribers can request that their children be transferred from one health, dental and vision insurance plan combination to another. They can transfer in any of the following instances: Applicant requests in writing (one time for any reason) within the first 30 days of the original effective date of coverage in HF; Applicant requests in writing (one time for any reason) within the first 30 days of the effective date of coverage in a new insurance plan following open enrollment; Revised October