Gateway Health Medicare Assured SM

Transcription

1 Gateway Health Medicare Assured SM 2015 PROVIDER POLICY AND PROCEDURE MANUAL Corporate Address: Four Gateway Center 444 Liberty Avenue, Suite 2100 Pittsburgh, PA For inquiries, please call Provider Services at (KY) (NC) (OH) (PA) Please visit our website at

2 QUICK REFERENCE... 7 IMPORTANT PHONE NUMBERS... 7 PLAN CO-PAYMENTS... 8 IMPORTANT ADDRESSES... 9 INTRODUCTION ABOUT THIS MANUAL OVERVIEW OF GATEWAY HEALTH MEDICARE ASSURED SM Corporate Overview Philosophy History Mission Products Continuing Quality Care Wellness & Disease Management Health Care Disparities Community Involvement Benefits of Gateway Health Medicare Assured SM HOW DOES GATEWAY WORK? Gateway Health Medicare Assured SM Provider Network Gateway s Provider Relations Role Primary Care Practitioner s Role CONTRACTS/NO GAG CLAUSE QUALITY IMPROVEMENT Purpose of the Quality Improvement/Utilization Management Program Goal of the Quality Improvement/Utilization Management Program Objectives of the Quality Improvement/Utilization Management Program Scope of the Quality Improvement/Utilization Management Program Quality Improvement Manual PATIENT SAFETY PREVENTABLE SERIOUS ADVERSE EVENTS/HOSPITAL ACQUIRED CONDITIONS AND NEVER EVENTS LIVING WILL DECLARATION Advance Directives MEMBER OUTREACH MEMBER ENROLLMENT ELIGIBILITY DUAL ELIGIBLE CATEGORIES THE ENROLLMENT/DISENROLLMENT PROCESS MEMBER ID CARDS DETERMINING ELIGIBILITY PRIMARY CARE PRACTITIONER S ROLE IN DETERMINING ELIGIBILITY BENEFITS Medical Benefits Summary of Benefits Table of Contents 1

3 Care Management Programs General Exclusions Prescription Drug Benefits Prescription Drug Coverage Drugs Covered Drug Exclusions: Self-Referred Services MEMBERS RIGHTS AND RESPONSIBILITIES COVERAGE ARRANGEMENTS PRIMARY CARE PRACTITIONER PRIMARY CARE PRACTICE DASHBOARD REPORTS ENCOUNTERS Accurate Submission of Encounter Data TRANSFER OF NON-COMPLIANT MEMBERS TRANSFER OF MEDICAL RECORDS APPOINTMENT STANDARDS SPECIALTY CARE PRACTITIONER VERIFYING ELIGIBILITY COORDINATION OF CARE EMERGENCY SERVICES TRANSFER OF MEDICAL RECORDS APPOINTMENT STANDARDS OB/GYN SERVICES GENERAL INFORMATION OBSTETRICAL NEEDS ASSESSMENT FORM DIAGNOSTIC TESTING APPOINTMENT STANDARDS BEHAVIORAL HEALTH SERVICES VERIFYING ELIGIBILITY AUTHORIZATIONS AND REFERRALS EMERGENCY SERVICES APPOINTMENT STANDARDS HOSPITAL SERVICES INPATIENT ADMISSIONS EMERGENCY ROOM AMBULANCE SERVICES DRG POST-PAYMENT AUDITS CONTINUITY AND COORDINATION OF CARE POLICIES AND PROCEDURES POLICY CHANGES PRACTITIONER EDUCATION AND SANCTIONING Table of Contents 2

4 PRACTITIONER DUE PROCESS TITLE VI OF THE CIVIL RIGHTS ACT OF ACCESS AND INTERPRETERS FOR MEMBERS WITH DISABILITIES CONFIDENTIALITY FRAUD AND ABUSE ENVIRONMENTAL ASSESSMENT STANDARDS Environmental Assessment Standards PROVIDER CHANGES CMS GUIDANCE ON MEDICARE MARKETING ACTIVITIES REFERRALS AND AUTHORIZATIONS OUT OF PLAN REFERRALS Referrals for Second Opinions Self-Referral AUTHORIZATIONS Process for Requesting Prior Authorizations Speech Therapy Services Physical and Occupational Therapy Durable Medical Equipment Services Requiring Authorization Prior Authorization Decision Timeframes and Notification Home Infusion Pharmacy Services MANAGING CARE TRANSITIONS NEW TECHNOLOGY CLAIMS AND BILLING CLAIMS General Information Timely Filing Electronic Claims Submission Requirements for Submitting Claims to Gateway Through Emdeon and RelayHealth HIPAA Electronic Remittance Advice/Electronic Funds Transfer Claims Review Process Administrative Claims Review Coordination of Benefits Claim Coding Software BILLING Billing Procedures Family Planning Services Surgical Procedure Services Hospital Services UB-04 Data Elements for Submission of Paper Claim Forms CMS-1500 (08-05) Data Elements for Submission of Paper Claim Forms.. 89 Table of Contents 3

5 APPEALS AND GRIEVANCES INTRODUCTION WHAT ARE APPEALS AND GRIEVANCES? ACTING AS AN AUTHORIZED REPRESENTATIVE APPEALS REGARDING HOSPITAL DISCHARGE SKILLED NURSING FACILITY (SNF), HOME HEALTH (HHA) OR COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) SERVICES QUALITY IMPROVEMENT ORGANIZATION (QIO) REVIEW APPEALS FOR COVERAGE OF OTHER MEDICAL SERVICES IRE REVIEW ADMINISTRATIVE LAW JUDGE REVIEW MEDICARE APPEALS COUNCIL FEDERAL COURT APPEALS FOR COVERAGE OF PART D DRUGS INDEPENDENT REVIEW ENTITY (IRE) ADMINISTRATIVE LAW JUDGE (ALJ) REVIEW MEDICARE APPEALS COUNCIL FEDERAL COURT AMOUNT IN CONTROVERSY, FEDERAL MINIMUM REQUIREMENTS FOR FILING MEMBER GRIEVANCES Grievances Expedited Grievances QUALITY IMPROVEMENT ORGANIZATION REVIEW How to File a Quality of Care Complaint with the QIO PROVIDER APPEALS First Level Appeal (The Informal Dispute Resolution Process) Second Level Appeal (The Informal Dispute Resolution Process) MODEL OF CARE OVERVIEW SNP MODEL OF CARE ELEMENTS HOW THE MODEL OF CARE WORKS FOR A MEMBER OTHER IMPORTANT INFORMATION ABOUT GATEWAY S MODEL OF CARE PREVENTIVE HEALTH, DISEASE AND CARE MANAGEMENT PREVENTIVE HEALTH PROGRAM GATEWAY TO LIFESTYLE MANAGEMENT PROGRAMS Cardiac Program COPD Program Diabetes Program MOM Matters Program CARE MANAGEMENT General Information Criteria for Referrals to the Care Management Department Complex Care Management Transitions from Hospital to Home Table of Contents 4

6 INTRODUCTION TO CREDENTIALING WHO IS CREDENTIALED? PURPOSE OF CREDENTIALING CREDENTIALING STANDARDS ONGOING AND PERFORMANCE MONITORING PRACTITIONER ABSENCES DENIAL AND TERMINATION DELEGATED CREDENTIALING FORMS AND REFERENCE MATERIALS Table of Contents 5

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8 QUICK REFERENCE Important Phone Numbers Call to Inquire About: Telephone Number Hours of Operation Provider Services (Benefit & Claim Inquiries, Eligibility Verification) (KY) (NC) (OH) (PA) Monday-Friday 8:00 AM to 4:30 PM Davis Vision Provider Servicing Monday-Friday 8:00 AM to 6:00 PM United Concordia Companies, Inc Monday-Friday 8:00 AM to 8:00 PM Digital Voice Assistant (DIVA) (Eligibility Check) Hotline to report Fraud and Abuse or Compliance Concerns Utilization Medical & Behavioral Health Management hours a day/7 days a week 24 hours a day/7 days a week (412) or (KY) (NC) (OH) (PA) Monday-Friday 8:30 AM to 4:30 PM (Calls received during non-business hours are referred to ) Member Services Pharmacy Care Management Due to lower call volumes, the best time to call is between 8:30 AM and 11:30 AM. For urgent requests, please stay on the line to have your call serviced (KY) (NC) (OH) (PA) (KY) (NC) (OH) (PA) Fax (KY) (NC) (OH) (PA) Selection Option 1 to speak to a care manager Monday-Friday 8:00 AM to 8:00 PM Monday-Friday 8:30 AM to 4:30 PM Monday-Friday 8:30 AM to 4:30 PM Part D Prescriber Appeals hours a day/7 days a week Quick Reference 7

9 Call to Inquire About: Telephone Number Hours of Operation TTY/TDD 711 or 24 hours a day/7 days a (for all departments) (KY) week (NC) (OH) (PA) Forever Fit MTM (Transportation Services) Voiance Language Services (Offers bilingual interpreters at a special Gateway rate) go to Plan Co-Payments (KY, NC, OH) (PA) (TTY 711) (KY, NC, OH) (PA) (TTY ) Monday-Friday 8:00 AM to 8:00 PM (EST) Monday-Friday 8:00 AM 5:00 PM, Saturday 9:00 AM to 1:00 PM ext-1 24 hours a day/7 days a week A member s out of pocket expense or cost sharing will vary depending upon the level of assistance they may be receiving from the State, Medicare, as well as which Gateway Health Medicare Assured SM plan they have chosen to join. For more benefit information a copy of the Summary of Benefits for all Gateway Health Medicare Assured SM plans is an attachment to this Provider Policy & Procedure Manual. For your convenience co-pays* for frequently used services are provided below: Dual Eligible Special Needs Plans (D-SNP) Gateway Health Medicare Assured Diamond SM (HMO SNP): PCP-$0, SCP-$0, ER-$0** Gateway Health Medicare Assured Ruby SM (HMO SNP): PCP-$0 or $15, SCP-$0 or $30, ER-$0 or $65** *Please note: All members enrolled on Gateway Health Medicare Assured Diamond SM and Gateway Health Medicare Assured Ruby SM also have Medicaid (Medical Assistance) or receive some assistance from the state. Some members will be eligible for Medicaid coverage to pay for cost sharing (deductibles, copayments, coinsurance). They may also have coverage for Medicaid covered services, depending on their level of Medicaid eligibility. Please follow Medicaid coverage and claims processing guidelines. Please contact Gateway Health Medicare Assured SM Provider Services for member specific information. Chronic Condition Special Needs Plans (C-SNP) Gateway Health Medicare Assured Gold SM (HMO SNP) : PCP-$20, SCP-$40, ER-$65** Quick Reference 8

10 Gateway Health Medicare Assured Platinum SM (HMO SNP) : PCP-$15, SCP- $30, ER-$65** MA-PD Plans (Non-Pennsylvania Only) Gateway Health Medicare Assured Choice SM (HMO): PCP-$25, SCP-$40, ER- $65** Gateway Health Medicare Assured Prime SM (HMO): PCP-$5, SCP-$25, ER- $65** Gateway Health Medicare Assured Select SM (HMO): PCP-$5, SCP-$45, ER- $65** Employer Group Name (Kentucky, North Carolina and Ohio Only) Gateway Health Medicare Assured Flex SM (HMO) *This list does not represent every service covered or every applicable co-pay and/or co-insurance. **Not covered outside the U.S. except under limited circumstances. Important Addresses Corporate Office: Gateway Health SM Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Claims Office PA: Gateway Health SM Claims Processing Center P.O. Box Birmingham, AL Claims Office KY, NC & OH: Gateway Health SM Claims Processing Center P.O. Box Birmingham, AL Reason for Mailing Claims (Medical and Behavioral Health) Claims Inquiries and Administrative Address PA: Gateway Health Medicare Assured SM Claims Processing Department P.O. Box Birmingham, AL KY, NC & OH: Gateway Health Medicare Assured SM Claims Processing Department P.O. Box Birmingham, AL Gateway Health Medicare Assured SM Quick Reference 9

11 Reviews Member Appeals Provider Appeals Initial Applications for Credentialing Recredentialing Applications Practice Change Information Practice Change Information for Behavioral Health Providers: Vision Claims Dental Claims PA Medicaid Claims Attention: Claims Review Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Gateway Health Medicare Assured SM Attention: Medicare Complaints Administrator Appeals & Grievances P.O. Box Pittsburgh, PA Gateway Health Medicare Assured SM Attention: Medical Review Appeals & Grievances P.O. Box Pittsburgh, PA Gateway Health Medicare Assured SM Attention: Network Development Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Gateway Health Medicare Assured SM Attention: Credentialing Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Gateway Health Medicare Assured SM Attention: Provider Relations Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Fax: Gateway Health Medicare Assured SM Attention: BH Contracting Specialist Four Gateway Center 444 Liberty Ave., Suite 2100 Pittsburgh, PA Davis Vision Attention: Vision Card Processing Unit P.O. Box 1525 Latham, NY United Concordia Companies, Inc. Claims Processing PO Box Harrisburg, PA Follow claims processing instructions provided to you by PA Medicaid Quick Reference 10

12 INTRODUCTION About This Manual Gateway Health Medicare Assured SM s success, as measured by the benefits received by the healthcare providers, members, the Centers for Medicare and Medicaid Services (CMS) and Gateway Health SM ( Gateway ), is dependent upon strong educational processes. Understanding Gateway s policies and procedures is essential. Gateway s Provider Relations, Provider Services, Member Services, and Member Outreach staff, among others, is committed to providing accurate, up-to-date, and comprehensive information to our member and practitioner populations through prompt and dedicated service. The Provider Policy and Procedure Manual is one way of providing participating practitioner offices, hospitals and ancillary providers with information regarding Gateway s policies and procedures and is considered part of your contractual agreement with the health plan. This manual should be considered as a general guideline for Gateway s provider network. The manual is a ready reference and is designed to be updated as needed. Please retain all updates with your manual. This Manual and any updates are available on our website under the Providers section: Overview of Gateway Health Medicare Assured SM Corporate Overview Gateway Health SM delivers quality and affordable healthcare for its members. With more than 20 years of service to the community, Gateway strongly believes in doing things A better way. We don t believe in just fulfilling members health insurance needs. At Gateway, we also assist our members in many aspects of their daily lives that affect their health and well-being. Gateway understands that overall health is more than a factor of genetics and lifestyle and that where one lives shouldn t matter about the quality of care received. That s why Gateway offers a variety of health plan options for beneficiaries eligible for Medicaid and Medicare. Our large network provides access to top-notch physicians, hospitals and health providers to make sure our members have access to the care they deserve. When communities are healthier, everybody wins. Philosophy Research shows that with resources and support, people with chronic conditions can improve their health and well-being. In an effort to meet our members unique needs, to address the challenges faced by members in accessing medical and social support services, Gateway developed an enhanced healthcare management model called Prospective Care Management (PCM ). This model is a proactive holistic approach that addresses the Behavioral, Environmental, Economic, Medical, Social and Spiritual (BEEMS SM ) issues a member faces that may be barriers to care. Using state of the art techniques, the PCM model of Introduction 11

13 care helps design a plan to ensure the member receives the individualized services needed. Some of our no-cost programs include smoking cessation and managing chronic conditions, such as asthma, depression, diabetes and heart disease. History In 1992, Gateway Health SM, Inc. was established as an alternative to Pennsylvania s Department of Public Welfare s Medical Assistance Program. For over two decades, members have benefited from services such as disease management, health and wellness programs and preventive care. Today, Gateway Health SM is a top-ranked managed care organization that serves more than 300,000 members. Gateway Health SM is a NCQA accredited health plan. The National Committee for Quality Assurance (NCQA) is an independent, notfor-profit organization dedicated to assessing and improving health care quality. Since 2006, Gateway has also offered a Medicare product that is geared toward vulnerable Medicare beneficiaries residing in select Pennsylvania counties. Gateway Health Medicare Assured SM (HMO SNP) is a Dual Eligible Special Needs Plan (D-SNP) Coordinated Care plan with a Medicare contract and a contract with the Pennsylvania Medicaid Program. In 2015, Gateway will operate in thirty-nine (39) Pennsylvania counties: Introduction 12

14 Gateway will operate in fifty-nine (59) Ohio counties: Gateway will operate in seventy (70) Kentucky counties: Introduction 13

15 Gateway will operate in forty-one (41) North Carolina counties: Gateway Health Medicare Assured SM is one of the nation s largest Medicare programs for the dual-eligible population with more than 47,000 members. For individuals who qualify, there is NO monthly premium, and they receive healthcare coverage, PLUS prescription drug coverage, dental, transportation, vision, hearing services, fitness center membership, and bathroom safety products all from ONE plan! Mission Gateway emphasizes the development and delivery of innovative programs to positively affect the personal health of its members. Gateway maintains a healthcare delivery system that ensures the availability of high quality medical care for the Gateway member, based upon access, quality and financial soundness. Products In Kentucky, North Carolina, Ohio and Pennsylvania Gateway s product offerings include four Special Needs Plans (SNP) serving those with Medicare Parts A and B; among other qualifying factors. These four plans are: Gateway Health Medicare Assured Diamond SM (HMO SNP) A Dual Eligible Special Needs Plan, (D-SNP); serving those who have BOTH Medicare Parts A and B and who receive full assistance from the state. Gateway Health Medicare Assured Ruby SM (HMO SNP) A Dual Eligible Special Needs Plan, (D-SNP); serving those who have BOTH Medicare Parts A and B and who receive specified levels of assistance from the state. Introduction 14

16 Gateway s two Chronic Condition Special Needs Plans (C-SNP) serve those who have BOTH Medicare Parts A and B, along with one of the following chronic conditions: diabetes, cardiovascular disorders or chronic heart failure. The two C- SNP plans will be known as: Gateway Health Medicare Assured Gold SM (HMO SNP) Gateway Health Medicare Assured Platinum SM (HMO SNP) In addition, in non-pennsylvania markets, Gateway offers three Medicare Advantage Part D (MAPD) plans serving those who have both Medicare Parts A and B and live within the county service areas. Gateway Health Medicare Assured Choice SM (HMO SNP) Gateway Health Medicare Assured Prime SM (HMO SNP) Gateway Health Medicare Assured Select SM (HMO SNP) Gateway offers the following benefits to members enrolled in Gateway Health Medicare Assured SM : All the benefits of Original Medicare Prescription drug coverage Hearing, vision, and dental benefits (including dentures)* Health and wellness education, such as heart disease, diabetes and smoking cessation Bathroom safety products* Forever Fit, a fitness program to help members stay active (including Pak for home-bound members)* Transportation* *Benefit coverage varies by product. Refer to the Summary of Benefits attachments. Gateway is dedicated to providing benefits to the Medicare and Medicaid populations to meet their medical and social needs. The specific needs of our membership have led to Gateway s development of wellness, education and outreach programs to improve immunization compliance, to identify and provide effective case management for members with chronic conditions such as asthma, diabetes, cardiovascular disorders, chronic heart conditions, and HIV/AIDS. Continuing Quality Care Healthcare is an ever-changing field and Gateway strives to stay on top of its members needs. Gateway is committed to continuous improvement and providing high standards of quality in every aspect of service. This commitment is led by Gateway s 15-member Quality Improvement/Utilization Management committee, made up of experts in a wide variety of medical fields. The QI/UM Introduction 15

17 Committee evaluates Gateway s ongoing efforts as well as new protocols and quality initiatives in order to improve service and care for its members. Wellness & Disease Management Gateway is committed to improving the life of its members and working to find new ways to promote wellness, illness prevention and health education as demonstrated by the following: Preventive health care guidelines o Annual Wellness Visit o Diabetes tests HBA1C, LDL-C and microalbumin (Diabetic members) o Glaucoma screening (65 and older or high risk members) o Low-density lipoprotein (LDL) test (Members with heart disease) o Colorectal cancer screening ifobt (55-75 years old) o Colorectal cancer screening colonoscopy or Flex Sigmoidoscopy (50-75 years old) o Mammogram breast cancer screening (Women years old) Tobacco cessation education and benefits Pediatric and adult immunization reminders Gateway to Lifestyle Management o Cardiac Program o COPD Program o Diabetes Program o MOM Matters Maternity Program Health Care Disparities Gateway understands that in order to help improve our members quality of life, we must take into account their cultural and linguistic differences. For this reason, addressing disparities in health care is high on our leadership s agenda. We believe a strong patient-provider relationship is the key to reducing the gap in unequal health care access and health care outcomes due to cultural and language barriers. Gateway is continuously working to close the gap in health outcomes by focusing on education and prevention. One example of how we are working to close the quality gap can be seen in our culturally sensitive diabetes disease management programs. In order to improve information based interventions at the point of care, Gateway pays for primary care practitioners to perform in-office HbA1c tests. Test results are available in five minutes and can be administered by a non-clinician. For more information, please contact your Provider Relations Representative. In addition, Gateway has cross-cultural education programs in place to increase awareness of racial and ethnic disparities in health care among our employees, members and providers. Community Involvement Gateway is an active partner in the community through many outreach and community based activities. Gateway strives to improve the health and quality of life of its members as well as the community-at-large. Introduction 16

18 Gateway participates in community events and sponsorships and provides assistance to community and social agencies that also serve a high-risk, vulnerable population. Gateway continually develops a variety of outreach programs for adults and children to provide education on health, wellness and safety issues. These programs are offered to the community at no cost. Gateway informs and partners with individuals and organizations through the Health Literacy Initiative. The goal of the initiative is to develop and implement programs that positively impact health and well-being by helping people better understand and navigate the healthcare system. Benefits of Gateway Health Medicare Assured SM Gateway is a win-win situation for all: the member, the healthcare provider and applicable state and federal agencies. Benefits to the Gateway Health Medicare Assured SM member: In addition to receiving added benefits currently not covered by Medicare, Gateway members enjoy improved access to primary medical care, health and wellness programs. Benefits to the Healthcare Provider: Timely payments, simplified administrative procedures and dedicated provider servicing are benefits of being a Gateway Health Medicare Assured SM provider. Benefits to Gateway: Gateway benefits by fulfilling our mission, which ensures the availability of high quality medical care for the dual eligible population to positively affect the personal health of our members. How Does Gateway Work? Gateway Health Medicare Assured SM Provider Network Gateway contracts directly with primary and specialty care practitioners, hospitals, and ancillary providers to provide care for our membership. Gateway s provider network includes more than 135 hospitals, over 12,200 providers, and over 2,000 ancillary locations a network of pharmacies, home healthcare agencies and other related healthcare providers. Practitioners and other healthcare providers are chosen in such a manner that existing patterns of care, including patterns of hospital admissions, can be maintained. Participating practitioners treat patients in their offices as they do their non-gateway patients, and agree not to discriminate in the treatment of or in the quality of services delivered to Gateway s members on the basis of race, sex, age, religion, place of residence, or health status. Because of the cultural diversity of our membership, participating providers must be culturally sensitive to the needs of our members. Participation in Gateway Health Medicare Assured SM in no way precludes participation in any other program with which the provider may be affiliated. To Introduction 17

19 find a provider go to to access Gateway s On-Line Provider Directory. Gateway s Provider Relations Role We are keenly aware that, to provide exceptional access and quality health care to our members, it is essential that our providers and their staff have a solid understanding of the member s needs, our contract requirements and other protocols, as well as applicable contract standards and Federal and/or State regulations. Within 30 calendar days of successful completion of provider credentialing and approval to participate in our network our Provider Relations Department provides introductory training to providers and their office staff. The Provider Manual is delivered and reviewed in detail at this on-site orientation. This provider training familiarizes new providers and their staff with Gateway s policies and procedures. Each participating primary care practice, specialty care practice and hospital is assigned a Provider Relations Representative, who is responsible for ongoing education in their assigned Service Region. As a follow-up to the initial orientation session, the assigned Provider Relations Representative regularly contacts each provider and their staff to ensure that they fully understand the responsibilities outlined in the Provider Agreements and Manual. Primary Care Practitioner s Role The definition of a primary care practitioner is a specific practitioner, practitioner group or a CRNP operating under the scope of his/her licensure, who is responsible for supervising, prescribing, and providing primary care services; locating, coordinating, and monitoring other medical care and rehabilitative services and maintaining continuity of care on behalf of a member. The primary care practitioner is responsible for the coordination of a member s healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary services and other healthcare services. To ensure continuity and coordination of care, when a member obtains care outside of the primary care practice, a report should be forwarded by the rendering provider to the designated primary care practitioner. By focusing all of a member s medical decisions through the primary care practitioner, Gateway is able to provide comprehensive and high quality care in a cost-effective manner. Our goal is to work together with a dedicated group of practitioners to make a positive impact on the health of our membership and truly make a difference. Introduction 18

20 Contracts/No Gag Clause Gateway allows open practitioner-patient communication regarding appropriate treatment alternatives without penalizing practitioners for discussing medically necessary or appropriate care for the patient. All of Gateway s contracts with practitioners and providers include an affirmative statement indicating that the practitioner can freely communicate with patients regarding the treatment options available to them, including medication treatment options available to them, regardless of benefit coverage limitations. There is no language in Gateway s contracts that prohibits open clinical dialogue between practitioner and patient. Quality Improvement Purpose of the Quality Improvement/Utilization Management Program The Quality Improvement/Utilization Management (QI/UM) Program s purpose is to assure the quality, safety, appropriateness, timeliness, availability and accessibility of care and services provided to Gateway members. The comprehensive evaluation and assessment of clinical, demographic, and community data in conjunction with current scientific evidence is paramount to understanding the membership and developing effective programs to meet the identified needs. The development of health care programs must be done in collaboration with all partners including members, practitioners, community agencies, regulators, and staff, not only to meet the current health care needs of the members served but to begin to address the future needs of the members. Essential to the success of these partnerships and programs is the establishment of meaningful data collection and measurement of outcomes to assess the improvements in the quality of care and to identify where opportunities exist for improvement. As a participating provider Gateway asks that you cooperate with QI activities to improve the quality of care and services members receive. This may include the collection and evaluation of data, participation in various QI initiatives and programs and allowing the plan to use and share your performance data. Goal of the Quality Improvement/Utilization Management Program The goal of the QI/UM Program is to ensure the provision and delivery of high quality medical and behavioral health care, pharmaceutical, and other covered health care services and quality health plan services. The QI/UM Program focuses on monitoring and evaluating the quality and appropriateness of care provided by the Gateway health care provider network, and the effectiveness and efficiency of systems and processes that support the health care delivery system. Utilizing quality improvement concepts and appropriately recognized quality measurement tools and reports, such as qualitative, quantitative and root/cause barrier analyses, Gateway focuses on assessing its performance outcomes to identify opportunities for improvement in the provision and delivery of health care and health plan services, patient safety, satisfaction with care and services, and achieving optimum member health outcomes. Introduction 19

21 Of specific importance, the QI/UM Program focuses on three key areas: (a) preventive health care, (b) prevalent chronic health care conditions and (c) service indicators. The Program strives to improve members compliance with preventive care guidelines and disease management strategies, therapies that are essential to the successful management of certain chronic conditions, and identify opportunities to impact racial and ethnic disparities and language barriers in healthcare. Also, the QI/UM Program strives to improve patient safety by educating members and practitioners in regard to safe practices, by assessing and identifying opportunities to improve patient safety throughout the practitioner/provider network and by communicating to members and practitioners safety activities and provisions that may be in place throughout the network. By considering population demographics and health risks, utilization of health care resources, and financial analysis, Gateway ensures that the major population groups are represented in QI/UM activities and health management programs chosen for assessment and monitoring. This information, along with high-volume/high-cost medical and pharmaceutical/drug reports, health risk appraisal data, disease management and care management data, satisfaction survey information, and other utilization reports, is used to identify members with special needs and/or chronic conditions to develop programs and services to assist in managing their conditions. Objectives of the Quality Improvement/Utilization Management Program The objectives of the QI/UM Program are consistent with Gateway s mission, commitment to effective use of healthcare resources, and to continuous quality improvement. To ensure that the current needs of the population are being evaluated, changes noted, programs implemented to address the needs of members, and to ensure continuous quality improvement, an annual QI/UM Work Plan is developed. The QI/UM Program is assessed on an annual basis to determine the status of all activities and identify opportunities that meet the QI/UM Program objectives. Objectives are as follows: Implement a QI/UM Work Plan that identifies and assures completion of planned activities for each year: Assure processes are in place using Total Quality Management values to assess, monitor, and implement actions when opportunities are identified regarding the utilization of healthcare resources, quality of care, and access and availability to services; Based on assessment of the population, develop and update guidelines that address key healthcare needs, which are based on scientific evidence and recommendations from expert and professional organizations and associations; Introduction 20

22 Conduct studies to measure the quality of care provided, including established guideline studies, evaluate improvements made, barriers, opportunities and develop actions to address those opportunities; Evaluate the utilization and quality performance of Gateway practitioners and vendors to assure Gateway standards are met and to identify both opportunities and best practices. In a group effort with practitioners and vendors, identify barriers, opportunities and apply interventions as needed; Conduct satisfaction surveys to determine member and provider satisfaction with Gateway services and programs, organizational policies, and the provision of healthcare. Review results for barriers, opportunities and apply interventions to increase satisfaction and to improve the quality of care and services provided. Scope of the Quality Improvement/Utilization Management Program Implementation and evaluation of the QI/UM Program is embedded into Gateway s daily operations. The QI/UM Program has available and uses appropriate internal information systems, practitioners, and community resources to monitor and evaluate use of healthcare services, the continuous improvement process and to assure implementation of positive change. The scope of the Program includes: Enrollment Members Rights and Responsibilities Network Accessibility and Availability, including those related to Special Needs Healthcare Disparities Network Credentialing/Recredentialing Medical Record Standards Member, Provider and Employee Education Member and Provider Services Claims Administration Fair, Impartial and Consistent Utilization Review Evaluating the Healthcare Needs of Members Preventive Health, Disease Management, and Care Management Services including Complex Case Management Clinical Outcomes Oversight of Delegated Activities Patient Safety Model of Care Continuous Quality Improvement using Total Quality Management Principles To request a copy of the Quality Improvement Program, Work Plan or Annual Evaluation please contact Gateway s Provider Services Department at, (KY), (NC), (OH) or (PA), Introduction 21

23 Quality Improvement Manual The Quality Improvement Manual is designed as a resource to assist practitioners in caring for Gateway members. The manual consists of clinical practice and preventive guidelines that are developed using evidence-based clinical guidelines from recognized sources or through involvement of boardcertified practitioners from appropriate specialties when the guidelines are not from recognized sources. The guidelines are evaluated on an ongoing basis and are developed based on the prevalent diseases or conditions and relevance to Gateway members. The use of guidelines permits Gateway Health Plan to measure the impact of the guidelines on outcomes of care and may reduce interpractitioner variation in diagnosis and treatment. Clinical practice and preventive guidelines are not meant to replace individual practitioner judgment based upon direct patient contact. The manual consists of an introductory page, along with the following guidelines: Adult HIV Clinical Practice Guideline, Adult Preventive, Care of Adults with Diabetes Mellitus, Child Preventive, Cardiac Medical Management, Hypertension, Lead Screening and Follow-up Guideline, Management of the Patient with Asthma, Chronic Obstructive Lung Disease Guideline, Major Depression in Adults in Primary Care, Schizophrenia, Bipolar Disorders and Routine and High Risk Prenatal Care. In addition to the guidelines, the Medical Record Review procedure and standards are included. To facilitate distribution of the most current version of these guidelines and standards, they have been added to Gateway s web site at A paper copy of the Quality Improvement Manual and individual guidelines are available upon request. For a paper copy, please contact the Quality Improvement Department at Patient Safety Patient safety is the responsibility of every healthcare professional. Health care errors can occur at any point in the health care delivery system and can be costly in terms of human life, function, and health care dollars. There is also a price in terms of lost trust and dissatisfaction experienced by both patients and health care practitioners. There are ways practitioners can develop a Patient Safety Culture in their practice. Clear communication is key to safe care. Working in collaboration with members of the multidisciplinary care team, hospitals, other patient care facilities and including the patient as an important member of his care team are critical. Examples of safe practices include providing instructions to patients in terms they can easily understand, writing legibly when documenting orders or prescribing, and avoiding abbreviations that can be misinterpreted. Read all communications from specialists and send documentation to other providers, as necessary, to assure continuity and coordination of care. When calling in orders over the telephone, have the person on the other end repeat the information back to you. Introduction 22

24 Collaborate with hospitals and support their safety culture. Bring patient safety issues to the committees you attend. Report errors to your practice or facility s risk management department. Offer to participate in multidisciplinary work groups dedicated to error reduction. Ask Gateway s Quality Improvement Department how you can support compliance with our safety initiatives. Gateway also works to ensure patient safety by monitoring and addressing quality of care issues identified through pharmacy utilization data, continuity and coordination of care standards, sentinel/adverse event data, Never Events, Care Management Program follow-up, and member complaints. If you would like to learn more about patient safety visit these web sites: Institute of Medicine Report: To Err is Human-Building a Safer Health Care System: JCAHO National Patient Safety Goals: National Patient Safety Foundation: The Leapfrog Group for Patient Safety: Agency for Healthcare Research and Quality: Medical Record Reviews Gateway performs several different medical record reviews to: Help ensure quality services are provided Allow for proper disease management Respond to regulator s requests Facilitate accurate and complete data is sent to CMS Allow for proper risk scoring by CMS of each member Complete and accurate coding is essential for Gateway to accomplish the above objectives and our mission. Preventable Serious Adverse Events/Hospital Acquired Conditions and Never Events Potential Preventable Serious Adverse Events, Hospital Acquired Conditions and Never Events are identified by several internal and external mechanisms such as, but not limited to, claims payment retrospective review, utilization management case review, complaint and grievance review, fraud and abuse investigations, practitioner/providers, delegates, and state and/or federal agencies. Introduction 23

25 Once a potential event has been identified an extensive review is conducted by the Quality Improvement and Medical Management Departments at Gateway. The process includes a medical record review and possible telephonic or mail communication with the practitioner/provider. Upon final determination if an actual event has been discovered, Gateway will notify the practitioner/provider by mail that payment denial or retraction will occur. Should you have any questions, please contact Gateway s Provider Services Department at (KY), (NC), (OH) or (PA). Living Will Declaration Advance Directives The Omnibus Budget Reconciliation Act (OBRA) of 1990 included a new law that has come to be known as the Patient Self-Determination Act. It became effective on December 1, The Patient Self-Determination Act applies to hospitals, nursing facilities, providers of home health care or personal care services, hospice programs and health maintenance organizations that receive Medicare or Medicaid funds. The primary purpose of the act is to make sure that the beneficiaries of such care are made aware of advance directives and are given the opportunity to execute an advance directive if they so desire. The Act also prevents discrimination in health care if the member chooses not to execute an advance directive. As a participating provider within the Gateway Health Medicare Assured SM network, you are responsible for determining if the member has executed an advance directive and for providing education about advance directives when it is requested. While there is no specific governmentally mandated form, you can request a copy of a Living Will form from Gateway s Quality Improvement Department by calling A copy of the Living Will form should be maintained in the member s medical record. Gateway s Medical Record Review Standards state that providers should ask members age 21 and older whether they have executed an advance directive and document the member s response in their medical records. Providers will receive educational materials regarding a member s right to advance directives upon entering the Gateway practitioner network. Member Outreach Gateway practitioners can request assistance from the Member Services Department to provide additional education to members who need further explanation on such issues as the importance of keeping scheduled appointments. Introduction 24

26 Practitioners can refer non-adherent members for additional education regarding their benefits and services by completing a Member Outreach Form, which can be found in the Forms and Reference Material Section of this Manual. A Gateway representative will contact the member and follow-up with the practitioner at the practitioner s request. For more information, or to request member outreach, please call Gateway s Care Management Department at (KY), (NC), (OH) or (PA) and press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form. Introduction 25

27 This page intentionally left blank. GATEWAY HEALTH MEDICARE ASSURED SM Introduction 26

28 MEMBER Enrollment Eligibility Gateway Health Medicare Assured SM offers a variety of Medicare plans designed to provide more than healthcare for those who qualify. Gateway Health Medicare Assured SM offers medical and prescription drug coverage, and all the benefits of Original Medicare, PLUS more benefits. Healthcare Options: Dual Eligible Special Needs Plans: Gateway Health Medicare Assured Diamond SM (HMO SNP) and Gateway Health Medicare Assured Ruby SM (HMO SNP) are Dual Eligible Special Needs Plans, (D-SNP); serving those who have BOTH Medicare Parts A and B and Medical Assistance or assistance from the State Chronic Condition Special Needs Plans: Gateway Health Medicare Assured Gold SM (HMO SNP) and Gateway Health Medicare Assured Platinum SM (HMO SNP) are Chronic Condition Special Needs Plans (C-SNP) serving those who have BOTH Medicare Parts A and B, along with one of the following chronic conditions: diabetes, cardiovascular disorders or chronic heart failure. Non-Pennsylvania Medicare Advantage Prescription Drug Plans: Gateway Health Medicare Assured Choice SM (HMO) and Gateway Health Medicare Assured Prime SM (HMO), Gateway Health Medicare Assured Select SM (HMO), are Medicare Advantage plans that also offer prescription drug coverage, serving those who have BOTH Medicare Parts A and B and live within the 70 county Kentucky service area, 41 county North Carolina service area or 59 county Ohio service area. Member 27

29 Refer to the chart below for eligibility criteria. GATEWAY HEALTH MEDICARE ASSURED SM Enrollment Criteria Must be entitled to Medicare Part A Must be enrolled in Medicare Part B Medicare eligibility may be due to either disability or age Must be eligible for either: full Medicaid/ QMB/ QMB plus/ SLMB plus Must receive one of the following levels of assistance from the state: SLMB only/ QDWI/ QI Must have one of the following conditions: Diabetes/ Chronic Heart Failure/ Cardiovascular Disorder Medicare Assured Diamond SM Medicare Assured Ruby SM Medicare Assured Gold SM Medicare Medicare Assured Assured Platinum SM Choice SM Medicare Assured Prime SM YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO YES NO NO NO NO NO NO NO YES YES NO NO NO Medicare Assured Select SM Dual Eligible Categories Medicaid only ( Full Dual ) - Individual who is eligible for full Medicaid benefits. Medicaid does not pay out-of-pocket costs for Part D cost-share. QMB Only- Individual who is eligible for Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay out-of-pocket costs for Part D costshare. QMB plus- Individual eligible for full Medicaid benefits and Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay for Part D costshare. QDWI (Qualified Disabled and Working Individual) - An individual who works and eligible to purchase Medicare Part A. Individual is eligible for Medicaid payment of Part A premium only. Medicaid does not pay out-ofpocket costs for Part D cost-share. SLMB only (Special Low-Income Medicare Beneficiary) - An individual eligible for Medicaid payment of Medicare Part B premium only. Medicaid does not pay out-of-pocket costs for Part D cost-share. Member 28

30 SLMB plus- Individual eligible for full Medicaid benefits and Medicaid payment of Medicare Part B premium only) QI (Qualifying Individual) - An individual eligible for Medicare Part A. Individual is eligible for Medicaid payment of Medicare Part B premium only. Medicaid does not pay out-of-pocket costs for Part D cost-share. The Enrollment/Disenrollment Process The Centers for Medicare and Medicaid Services (CMS) has periods when beneficiaries can enroll or disenroll with/from Medicare. These times are known as election periods. Please contact or direct the member to contact Gateway Health Medicare Assured SM for additional information about election periods. Members can enroll into our plan by using any of these methods: Mailing in a paper enrollment form Enrolling on-line through Medicare s website Enrolling on-line through Gateway s website, Downloading an enrollment form from Gateway s website at - click on Become a Member and mailing it in. By calling Gateway Health Medicare Assured SM at GATEWAY (TTY users should call 711 or in PA or in OH). Working with their sales agent Members of Special Needs Plans must meet specific eligibility requirements. Gateway confirms the beneficiary s eligibility during the enrollment process. For the Chronic Condition Special Needs Plans, Gateway obtains permission from the beneficiary to contact his/her physician in order to confirm the beneficiary has one of the qualifying conditions. Gateway attempts to reach the physician by telephone or fax. CMS permits Gateway to confirm the condition with a member of the physician s office staff. The confirmation can be given over the phone, on a recorded line. It is important that the physician s office respond promptly to any requests for confirmation of chronic condition. If the confirmation is not received within 21 days, the beneficiary s enrollment must be denied. Members can disenroll from our plan by: Completing a paper disenrollment form or sending a letter/fax to Gateway Health Medicare Assured SM requesting disenrollment. Contacting Medicare at MEDICARE (TTY: ) or By enrolling in another HMO or Part D plan. Members should call Gateway Health Medicare Assured SM or visit for additional information. Member 29