Government Programs Provider Manual

Transcription

1 Government Programs Provider Manual July 2013 Website: Provider Services: Dallas Service Area

2 Table of Contents I. I. Introduction 4 Quick Reference Contact List 5 Role and Responsibilities of the Primary Care Physician (PCP) 6 Role and Responsibilities of the Specialty Care Physician (SCP) 7 Access to OB/GYN 8 Hospital Responsibilities 8 Ancillary Provider Responsibilities 9 Network Limitations 9 Specialty Care Provider as a Primary Care Provider 9 General Responsibilities for all Providers 10 Changes in Provider Addresses or Contact Information 10 Access Standards 11 After-Hours Care 12 Referrals 12 Emergency Care 13 Termination of Provider Participation 13 PCP requested removal of a member from panel 14 II. Eligibility and Benefits 15 Verifying Eligibility 15 Texas Health Steps 16 III. Prior Authorization and Utilization Management 17 Medical Management 17 Pre-Authorization 18 When to Initiate Prior Authorization 18 What Requires Notification 18 Prior Authorization Response 18 Referral to an Out-of-Network Specialist 18 Authorization is Not Obtained for Specialty Referral 18 Second Opinion 19 Quality Improvement 19 Clinical Practice Guidelines 19 Advance Directives 20 IV. Billing and Claims 21 Claim Forms 21 Billing Codes 22 1

3 Claims Processing and Payment Requirements 23 Appeal Submission Timeframes 23 Claim Submissions 23 Claims Questions 24 Private Pay Form 24 Member Acknowledgement Statement 24 V. Complaints and Appeals 25 Member Complaint and Appeal Process 25 Adverse Determinations 26 Provider/Member Complaints 27 Independent Review Organization Appeal 27 No Retaliation 28 VI. Fraud, Waste, and Abuse 29 Fraud Information 29 How to report Fraud, Abuse, and Waste 29 VII. HIPAA Regulations 31 Confidentiality 30 Medical Records 31 Electronic Medical Records 32 CMCHP Requests for Medical Records 32 HIPAA Privacy Regulations 33 HIPAA Security Rule 33 HIPAA Transactions and Code Sets 33 Breach Notification Rule 34 VIII. Credentialing 35 IX. Cultural Competency 36 Translation Services 36 Cultural Sensitivity 36 X. Out-of-Network Providers 37 Out-of-Network Referrals 37 Claim Submission 37 XI. Pharmacy Services 38 Role of a Pharmacy 38 Formulary and Preferred Drug List 38 Emergency Prescription Supply 38 Pharmacy Prior Authorization 39 Pharmacy Claim Submission 39 2

4 Claims Payment to Pharmacies 39 XII. Physician and Provider Economic Profiling 41 XIII. Forms 42 3

5 I. Introduction Children s Medical Center Health Plan (CMCHP) is committed to providing high quality, accessible health care. In collaboration with Children s Medical Center of Dallas, one of the most distinguished providers of pediatric health care, CMCHP is built on and expands upon Children s existing network of providers and services. CMCHP is focused on maintaining Children s long-standing relationships with patients, their doctors, and the community. CMCHP is applying for our Texas Department of Insurance license with the end goal of becoming a Medicaid/CHIP HMO in the seven counties (Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwall) that comprise the Dallas Service Area. The CMCHP s mission is to operate a community focused managed care company with an emphasis on the public sector health care market. CMCHP will coordinate our members physical and behavioral health care, by offering a continuum of care, education, and outcome programs, resulting in lower cost, improved quality and better health for our community. CMCHP welcomes you as a participating provider in our network. The Provider Manual is designed to provide you with information you will need when caring for a CMCHP Member. This manual will be updated periodically. The most current Provider Manual for providers will also be available on our website: Thank you and welcome to Children's Medical Center Health Plan. 4

6 Quick Reference Contact List General Mailing Address Children s Medical Center Health Plan Attn: Director of Network Management 1935 Medical District Drive Dallas, TX Departments Member Services Main Number Toll free Fax Please call the Member Services Department for member eligibility, benefits, or general questions. Claim Inquiries Main Number Toll free Fax Please call the Claims Department for claims status, payments, appeals or questions. Medical Management Main Number Toll free Fax Please call the Medical Management Department for more information regarding prior authorization for certain services, patient notification, and catastrophic case management. Network Development Main Number Toll free Fax Please call the Network Development Department for general questions, complaints, an orientation or a current provider directory. 5

7 Role and Responsibilities of the Primary Care Physician (PCP) The following CMCHP network provider types are eligible to serve as a PCP: Pediatrician Family or General Practitioner Internist Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Pediatric and Family Nurse Practitioners (PNP and FNP) Physician Assistants (PA) (under the supervision of a licensed practitioner) Obstetricians/Gynecologists (OBGYN) electing to be a PCP Specialty Care Physicians, as approved by CMCHP, willing to provide a medical home for specific members with certain special health care needs or illnesses (see below). Each CMCHP member will have a designated PCP. The role of the PCP is to provide the following minimum set of primary care services in his/her practice, in conjunction with providing a medical home: Routine office visits Care for colds, flu, rashes, fever, and other general problems Urgent Care within the capabilities of the provider s office Periodic health evaluations, including Texas Health Steps examinations Well baby and child care Vaccinations, including tetanus toxoid injections Allergy injections Venipuncture and other specimen collection Eye and ear examinations Preventive care and education Nutritional counseling Other covered services within the scope of the provider s medical practice based on evaluation and assessment, coordinate referrals to in network specialty care Behavioral health screening and help to access care at the request of the member Provide behavioral health related services within the scope of his/her practice Coordinate all medically necessary care with other CMCHP network providers as needed for each CMCHP member, including, but not necessarily limited to: outpatient surgery dental care hospital admission other medical services 6

8 Follow CMCHP procedures with regard to non-network provider referrals (see below) and applicable aspects of the CMCHP medical management program as outlined in this manual Be available to Members for urgent or emergency care, either directly or through on-call physician arrangement on a 24 hours-a-day/7 day-a-week basis Have admitting privileges at an in-network hospital Maintain a confidential medical record for each patient Educate members concerning their health conditions and their needs for specific medical care regimens or specialty care physician referral Help CMCHP in identifying members who would benefit from disease management programs and notify CMCHP of such members Cooperate with CMCHP s case management program when members are determined appropriate for case management services, e.g. asthma or diabetes Participate in the State of Texas Vaccines for Children Program for the provision of immunization services to pediatric members EXCEPTION OB/GYN physicians are not required but encouraged to participate with the Texas Vaccines for Children Program Maintain an open panel and accept new members unless prior arrangements have been made with CMCHP Be a Texas Health Steps provider and have an acceptable rate of completed Texas Health Steps exams and an acceptable immunization rate evidenced in the state s immunization registry EXCEPTION OB/GYN physicians are not required but encouraged to be Texas Health Steps providers Refer member to Women, Infant, Children (WIC) program and Early Childhood Intervention (ECI) programs as appropriate If the PCP employs physician assistants, advanced practice nurses, or other individuals who assess the health care needs of the members, the PCP must have written policies in place that are implemented, enforced, and describe the duties of all such individuals in accordance with statutory requirements for licensure, delegation, collaboration, and supervision as appropriate. Role and Responsibilities of the Specialty Care Physician (SCP) The Specialty Care Physician collaborates with the PCP to deliver specialty care to members. A key component of the Specialty Care Physician s responsibility is to maintain ongoing communication with the member s PCP. Specialty Care Physicians also ensure necessary referrals / authorizations have been obtained prior to provision of services. When providing services pursuant to a valid referral (except for services that do not require a referral), the Specialty Care Physician should: Provide the services requested in the referral Educate the member with regard to findings and/or next steps in treatment 7

9 Coordinate further services with the referring physician or provider and provide such services as authorized Send a written report to the member s PCP no later than seven (7) working days after the date of service Consult with member s PCP concerning any additional specialty care or service needed by the member that is not pre-certified by CMCHP and/or included with the referral, during or after the member s visit to the Specialty Care Physician, prior to providing any additional specialty care or service If the Specialty Care Physician employs physician assistants, advanced practice nurses, or other individuals who assess the health care needs of the members, the Specialty Care Physician must have written policies in place that are implemented, enforced, and describe the duties of all such individuals in accordance with statutory requirements for licensure, delegation, collaboration, supervision as appropriate. Access to OB/GYN Members have the right to pick an OB/GYN without a referral from their PCP. An OB/GYN can give the member: one (1) well woman checkup each year, care related to pregnancy, care for any female medical condition, and if needed, a referral to a specialist provider within the network. Hospital Responsibilities Routine, Elective and Urgent hospital admissions must be pre-authorized. Admissions will be coordinated by the member s PCP or a network Specialty Care Physician involved in the member s care. Hospital admission for Emergent services should be communicated to CMCHP within twentyfour (24) hours of the admission by calling the Medical Management Department. They may request certain information be faxed for review. Ancillary Provider Responsibilities Ancillary providers such as home health agencies, rehabilitative services providers, durable medical equipment providers, and similar providers may only provide services as authorized by CMCHP. It is the responsibility of the referring physician to provide any required physician orders to the ancillary provider. Network Limitations CMCHP has an open network. Providers can refer to the CMCHP website or the current Provider Directory for a list of primary care providers, specialists, OB/GYN physicians, behavioral health providers, and facilities. CMCHP members must seek services from a 8

10 CMCHP contracted provider, unless a provider is not accessible within the network, to ensure continuity of care for a newly enrolled member. Specialty Care Provider as a Primary Care Provider From time to time, at the request of a member or the request of a provider with the member s permission, and subject to the approval of the Medical Director, a Specialty Care Physician may serve as a PCP for members with specific health conditions generally cared for by the Specialty Care Physician. Requests for a Specialty Care Physician to be a PCP must be submitted in writing, signed by the member (or parent/guardian if member is a child), and approved by the Medical Director. A decision will be given to the requesting Specialty Care Physician and member in writing, within thirty (30) days of original request. If approved, the Specialty Care Physician may serve as a PCP for specific members and must be willing to provide all the services outlined above in The Role and Responsibilities of the PCP paragraph of this section, and if they meet the criteria stated below. If denied, the member may appeal the decision following the Complaints and Appeals procedures in this manual. The Specialty Care Physician that has been chosen as a PCP by the member must meet and agree to the following criteria: 1. The Specialty Care Physician must be board certified or board eligible in their specialty and licensed to practice medicine or osteopathy in the State of Texas. (Board certification/eligibility may be waived in certain circumstances for Significant Traditional Providers or providers who have functioned long term in a field that is appropriate for the diagnosis of the member with special health care needs.) 2. The Specialty Care Physician must have admitting privileges at a network hospital. 3. The Specialty Care Physician must agree to be the PCP for the member. He/she will be contacted and informed of the member s selection. 4. The Specialty Care Physician must then sign the Agreement for Specialist to function as a PCP form (available by calling Provider Services) for the member with special needs that has made the request. 5. The Specialty Care Physician must agree to abide by all the requirements and regulations that govern a PCP, including but not limited to: a. Being available 24 hours-a-day/7 day-a-week b. Administering immunizations as required, and c. Acting as the medical home and coordinating care for this member When a member changes from a regular PCP to a Specialty Care Physician acting as a PCP the effective date of the Specialty Care Physician functioning as the member s PCP will be the first of the month following the date the Agreement for Specialist to Function as a Primary Care Physician form is signed by the Medical Director. The original PCP s compensation owed before the effective date will not be reduced by CMCHP. General Responsibilities for all Providers Be aware of culturally sensitive issues with members 9

11 Abide by the ethical principles of your profession Participate in Children s Medical Center Health Plan Quality Improvement Program Initiatives Notify Children s Medical Center Health Plan if there is a change in your office address, tax identification number, or any other demographic changes Verify member eligibility or authorizations for services Abide by the terms of your Children s Medical Center Health Plan Participation Agreement Changes in Provider Addresses or Contact Information All network providers are required to notify CMCHP in writing of any changes in office address or in relevant contact information. Changes in office address should be received by CMCHP thirty (30) days prior to the change. This includes notifying CMCHP when a provider is leaving a group practice or joining another group practice or if an employed provider is leaving a group practice. In addition, all network providers must notify CMCHP upon opening of new offices where CMCHP members may be treated or upon engaging new physician or mid-level practitioners who may be involved in the treatment of CMCHP members. New PCP office locations are subject to site review before they are eligible to receive reimbursement. Access Standards Access to Primary Care Providers, Specialty Care Providers, Ancillary Providers, and Network Facilities must be available to members as follows: Service Access Standard Emergency Urgent care, including urgent specialty care Upon member presentation at service delivery site, including non-network and out-of-area facilities Provided within 24 hours of request Routine primary care Routine specialty care referrals Provided within 14 days of request Provided within 30 days of request Initial outpatient behavioral health visit Provided within 14 days of request 10

12 Routine prenatal care Prenatal care for high-risk pregnancies or new members in third trimester Preventive health care for adults Provided within 14 days of request or immediately if an emergency exists Appointment offered within 5 days, or immediately if an emergency exists Offered within 90 days of request Preventive health care services for children For newly enrolled Members from birth through age 20 or for those overdue for Texas Health Steps checkups Newborns Offered following Texas Health Steps periodicity schedule Offered no later than 90 days of enrollment In no case later than 14 days of enrollment After-hours care Providers are required to provide 24 hours-a-day/7 day-a-week on-call coverage. The answering service or paging mechanism must provide a response to a member call within thirty minutes. Emergent is defined as a condition if left untreated could be potentially life threatening. All Emergent after hour calls should be returned within 30 minutes. Urgent is defined as a condition that is not imminently life threatening but requiring care within twenty-four (24) hours. All Urgent after hour calls should be returned within 30 minutes. Routine includes non-emergency check-ups, physicals, tests or non-urgent surgeries. All Routine after hour calls should be returned within twenty-four (24) hours. Referrals The PCP may arrange for a referral to a specialist provider when a member requires specialty care services. A specialist may refer to another specialist if the PCP is notified and concurs with the referral. Referral documentation should be included in the member medical record. Any referral from an in-network primary care physician to an in- network specialist (for evaluation only), facility, or contractor does not require prior authorization. Some treatment(s) may require a prior authorization when performed by an in-network provider. 11

13 The provider is responsible for initiating the prior authorization process when a member requires medical services or inpatient admission. All out-of-network referrals must receive prior authorization from CMCHP Medical Management. Out-of-network referrals are required when services are unavailable from a CMCHP in-network provider, facility or contractor. CMCHP s members do not need a referral from the PCP for the following: Emergency services Family planning OB/GYN Care (One well woman checkup each year, care related to pregnancy, care for any female condition) Texas Health Steps medical and dental checkups Case Management for Children and Pregnant Women Vision Dental Behavioral health (Behavioral Health related services may be provided by the PCP if it is within their scope) Emergency Care CMCHP pays for emergency care in and out of the area. Emergency care is defined as health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: Placing the patient s health in serious jeopardy Serious impairment to bodily functions Serious dysfunction of any bodily organ or part Serious disfigurement In the case of a pregnant woman, serious jeopardy to the health of the fetus The provider should direct the member to call 911 or go to the nearest emergency room or comparable facility if the provider determines an emergency medical condition exists. If an emergency medical condition does not exist, the provider should direct the member to a CMCHP participating office. CMCHP does not require that the member receive approval from the health plan or the PCP prior to accessing emergency care. To facilitate continuity of care, CMCHP instructs members to notify their PCP as soon as possible after receiving emergency care. Providers are not required to notify CMCHP Medical Management about emergency care services. If the provider receives a request for authorization of post-stabilization treatment, the provider must respond to the emergent/urgent facility within one (1) hour. If the facility does not receive a response within one (1) hour, the post-stabilization services shall be considered authorized 12

14 in accordance with Texas Department of Insurance statutes. The provider shall notify CMCHP of all post-stabilization treatment requests. Termination of Provider Participation Provider Requested Termination- As outlined in each provider s CMCHP contract, a provider retains the right to terminate his/her participation in the CMCHP network. If a provider desires to terminate his/her participation agreement with CMCHP, a written notice to CMCHP is required either ninety (90) days prior to the desired effective date of the termination or in accordance with the time frames outlined in the provider s contract with CMCHP. CMCHP will honor requests for termination, but may work with the provider to see if some other alternative can be identified to prevent network termination. In the event of a conflict between this rule and the provider s contract, the contract will prevail. CMCHP Requested Termination- CMCHP may terminate a network provider s contract pursuant to relevant state and federal laws, rules and regulations related to provider termination, the CMCHP Credentialing and Re-credentialing Policy or as set forth in the provider s or group s contract with CMCHP. PCP requested removal of a member from panel PCPs may request the removal of a member from their panel in select situations. CMCHP will work to resolve problems between the member and the PCP before making the change. The following may be reasons for a PCP to request that a member be removed from his/her panel: Member is consistently non-compliant with the PCP s medical advice Member is consistently disruptive in the office Member consistently misses scheduled appointments without cause and/or without notice to the office 13

15 II. Eligibility and Benefits Verifying Eligibility Providers may call CMCHP Member Services Monday through Friday, 8 a.m. to 5 p.m. to verify members eligibility and primary care provider selection 24 hours-a-day/7 day-a-week at CMCHP s website: The CMCHP member ID card identifies the CMCHP and PCP that has been selected by the member. The ID card also has the following: Member Name Member Identification Number CMCHP s phone numbers Primary Care Physician s name While the ID card does identify the member, it does not confirm eligibility. 14

16 Texas Health Steps Texas Health Steps is a comprehensive preventive care program that combines diagnostic screenings, communication and outreach, and medically necessary follow up care, including dental, vision and hearing examinations for Medicaid eligible children, adolescents and young adults under the age of 21. CMCHP is committed to the wellness of each member and encourages providers to follow the steps outlined in the Texas Medicaid Provider Procedures Manual, Volume 2: Children s Services Handbook and in subsequent Medicaid Bulletins at: 15

17 III. Prior Authorization and Utilization Management Medical Management CMCHP Medical Management Department works with its network providers to facilitate quality care through its Medical Management Program. The information provided and the recommendation of the patient s physician or provider will be used to make precertification determinations. Services will be approved as proposed or referred to a Medical Management Medical Director in the event there are questions about the clinical aspects for the recommended services, including appropriateness of level of care. CMCHP Medical Management makes decisions based on the appropriateness of care and service. Requests for coverage are reviewed to determine if the service requested is a covered benefit and is delivered in accordance with established guidelines. If a request for coverage is denied, the member (or a physician acting on behalf of the member) may appeal this decision through the complaint and appeal process. CMCHP has adopted screening criteria and established review procedures which are periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians and other health care providers. Utilization review decisions are made in accordance with currently accepted medical or health care practices, taking into account special circumstances of each case. Screening criteria is used to determine only whether to approve the requested service. Flexibility may be utilized when applying screening criteria in determining utilization review decisions for members with special health care needs. Concurrent Reviews are performed to ensure that the care provided in the acute level setting is medically necessary, assure that goals for length of stay are appropriate, identify potential quality of care issues, implement discharge planning, and capture data for claims payment. Concurrent reviews will be performed on all hospitalized patients and initiated within one (1) business day of admission. On-site review will be performed, if necessary. On-site review will be done in accordance with all hospital policies. Reviewers will identify themselves appropriately and follow hospital guidelines for review of patient records, etc. Pre-Authorization A prior authorization is a formal medical necessity determination request submitted to CMCHP by a provider prior to a service being rendered. Upon receipt, the prior authorization request is screened for eligibility and benefit coverage and assessed for medical necessity and appropriateness of the health services proposed, including the setting in which the proposed care will take place. When to Initiate a Prior Authorization 16

18 Requesting providers must initiate a prior authorization of non emergency services (i.e. inpatient admissions, elective/outpatient services) request at least five (5) business days prior to the requested date of service by contacting CMCHP s Medical Management Department. If you have an urgent request that requires immediate attention after normal business hours, or on the weekend, please leave a message and the call will be returned by the next business day. What Requires Notification Hospitals must notify CMCHP Medical Management of all emergent admissions no later than the close of the next business day. Prior authorization is not required for emergency services, urgent care services, and if applicable, some post stabilization services. All non emergency, elective inpatient admissions require a prior authorization. In order to notify CMCHP regarding an urgent/emergent admission, please contact the following: Phone: Fax: Prior Authorization Response Prior authorization requests will be responded to within three (3) business days, after receipt of the request for authorization of services. Urgent requests for services required within twenty-four (24) hours may be submitted with a signed acknowledgement of the requesting provider. Those requests will be completed by close of the next business day after receipt. Referral to an Out of Network Specialist CMCHP recognizes that there may be instances when an out of network referral is justified. CMCHP s Medical Management Department will work with CMCHP s Medical Director and the provider to determine the medical necessity of the out of network referral, and to reach a decision that is in the best interest of the member. Please note: All out of network services require an authorization. Authorization is Not Obtained for a Specialty Referral If an authorization for referral to a Specialist requiring authorization is not obtained prior to the service being rendered, the claim will be denied. Retrospective authorizations are not given without documentation of the reason for not obtaining the authorization prior to rendering the service. In these cases, the denial does not have appeal rights, since the denial decision was not based on medical review prior to services. These instances only have complaint rights. The complaint must include information as to why prior authorization was not obtained. Second Opinion 17

19 A second opinion may be requested when there is a question concerning diagnosis, options for surgery, other treatment of a health condition, or when requested by any member of the member s health care team, including the member, parent, and/or, guardian, or a social worker exercising a custodial responsibility. Authorization for a second opinion shall be granted to a network provider, or an out of network provider, if there is not an in network provider available. The second opinion will be provided at no cost to the member. If the provider who is going to see the member for a second opinion is not in-network, an authorization is required. Quality Improvement CMCHP, through its quality improvement program, strives to see that members, regardless of their source of eligibility, are provided with high-quality health care and services. Through the continuous, objective, and systematic process of measuring and analyzing key clinical and service indicators against regional and national benchmarks, taking action and re-measuring, CMCHP and its participating network of providers pursue opportunities for improvement in clinical health care and non-clinical service outcomes. The scope of the quality improvement program provides for the review of the entire range of care provided by ensuring that all demographic groups, care settings, and services are included. CMCHP monitors clinical and service measures including, but not limited to, quality of care, preventative care, acute and chronic care, accessibility and availability of care, efficient utilization of resources, and member/provider satisfaction. HEDIS is designed to measure Plan and Provider performance on a number of measures to produce a consumer report card. The information collected from managed care health plans is published to assist consumers in choosing a health plan, physicians and other health care providers. Specific HEDIS measures may change annually to reflect medical advances and to identify new areas in which to focus improvement efforts. CMCHP prepares information based on data obtained from participating providers in the form of claims or encounter records. For example, one HEDIS measure is to determine if member with diabetes receive an annual dilated eye examination. The percent of diabetic members that meet HEDIS criteria and have an encounter reported for a dilated retinal eye examination is reported. If there is no report of such an examination, the member is identified as needing an examination. An annual reminder may be generated to members who have not met the HEDIS criteria for certain measures. Clinical Practice Guidelines 18

20 CMCHP approves, adopts, and promotes Clinical Practice Guidelines to providers in an effort to improve health care quality and reduce unnecessary variation in care for its enrolled membership. All guidelines are reviewed annually for updating, and/or when new scientific evidence or national standards are published. CMCHP Quality Improvement Program assures that Clinical Practice Guidelines are: Adopted guidelines approved by CMCHP s Quality Improvement Committee that is comprised of participating board certified providers from appropriate specialties Evidence based and include preventive health services Reviewed on an annual basis and updated accordingly, but no less than bi annually Disseminated to providers in a timely manner via the following appropriate communication settings: Provider orientations and other group sessions Provider E Blasts Provider Newsletters Targeted mailings Advance Directives Advance directives are legal documents signed by a competent person giving direction to health care providers about treatment choices in certain circumstances. There are two (2) types of advance directives. A durable power of attorney for health care (DPOA) allows the member to name a patient advocate to act on behalf of the member. A living will allows the member to state his or her wishes in writing but does not name a patient advocate. CMCHP encourages members to request education about advance directives and ask for an advance directive form from their PCP at their first appointment. Members over age eighteen (18) and emancipated minors are able to make an advance directive. His or her response is to be documented in the medical record. CMCHP will not discriminate or retaliate based on whether a member has or has not executed an advance directive. CMCHP notes the presence of advance directives in the medical records when conducting medical chart audits. 19

21 IV. Billing and Claims Claim Forms Claims must be submitted on a standard CMS 1500 Form or UB-92/UB-04 (or their successor) to the address designated on the member s card within ninety-five (95) days of the date of service. Emergency service claims are required to follow all claims billing procedures. Required Information for CMS 1500 Claims: Member name Member date of birth Member s ID number Member s relationship to insured Information on any other coverage applicable to the member If there is any other insurance on member, provide policy and/or group number Insurance plan name Claims for treatment of an injury must include injury date Referring physician s name, if applicable ICD-9/10 diagnosis codes Provider s NPI number TPI number Date of service(s) Place of service CPT-4 or HCPCS procedure codes with modifiers where appropriate Diagnosis code by specific service Tax ID number of the physician for the service Number of days or units Charge for each listed service Total charge Signature of treating physician for the services Name and address of facility where service(s) rendered Billing name and address of physician/provider When submitting a claim, please follow the guidelines below: A separate claim must be completed for each member and each provider. Please allow 30 days for claim processing prior to submitting a duplicate claim. If you need to refile a claim, please note in red Resubmission or Corrected claim. If submitting electronically, mark the electronic field for corrected claims. You may also drop your claim(s) to paper and submit to Children's Medical Center Health Plan by mail. Required Information for UB-92/UB-04 Claim Forms: Name and address of facility providing the service Member control number (member account number) 20

22 Bill type Tax ID number of the facility providing the service Coverage period Member s name and address Member s date of birth and sex Admission date, admission hour, discharge hour, and discharge status Medical record number Value codes Four digit revenue code Description of service HCPCS codes (outpatient claims) Individual service dates (outpatient claims) Number of units Billed charge(s) for each revenue code Total charge(s) Member s name Member s ID number Authorization number, if applicable ICD-9/10 diagnosis codes DRG code, if applicable Billing Codes It is important that providers bill with codes applicable to the date of service on the claim. Billing with obsolete codes will result in a potential denial of the claim and a subsequent delay in payment. Claims should be billed using the following coding: Submit professional claims with current and valid CPT 4, HCPCS, or ASA codes and ICD-9/10 codes. Submit institutional claims with valid Revenue Codes and CPT 4 or HCPCS (when applicable), ICD-9/10 codes and DRG codes (when applicable). Claims must comply with the requirements of Section 6507 of the Patient Protection and Affordable Care Act of 2010 (P.L ), regarding "Mandatory State Use of National Correct Coding Initiatives," including all applicable rules, regulations, and methodologies implemented as a result of this initiative. Claim Processing and Payment Requirements CMCHP will pay all clean claims within thirty (30) days from the date of receipt or the date that the claim is deemed clean. Should CMCHP fail to pay the provider within the thirty days, the provider will be reimbursed the interest on the unpaid claim at a rate of 1.5% per month for every month the claim remains unpaid. 21

23 Payment is considered to have been paid on the date of: (1) the date of issue of a check for payment and its corresponding Explanation of Payment (EOP) to the provider by CMCHP or (2) electronic transmission, if payment is made electronically. Providers have 120 days from the date of disposition (receipt of the EOP) to appeal. CMCHP will process appeals and adjudicate the claim within thirty (30) days from the date of receipt. A provider may appeal any disposition of a claim. Appeal Submission Timeframes All requests for reconsideration or adjustment to processed claims must be received within one hundred and twenty (120) days from the date of the EOP. To submit an appeal regarding claim payment, please submit a completed claim form, a copy of the EOP with the claim in question, and a written explanation of your appeal. Claim Submissions You can file your claims several ways: Regular or certified paper claims can be mailed to: Children s Medical Center Health Plan Attn: Claims Department 1935 Medical District Drive Dallas, Texas Electronic filing through Children s Medical Center Health Plan s secure Provider Portal: Electronic filing does not require use of a clearinghouse. Claims are submitted directly to Children s Medical Center Health Plan for claims payment. There is no cost for this service. Providers can also use this website to review status of claim payments. Claim Questions For all questions related to claim filing, claim status and claim appeals, call the Provider Services Department at Private Pay Form There are instances when the PCP may bill the member. For example, if the provider accepts the member as a private pay patient and informs the member at the time of service that the member will be responsible for paying for all services. In this situation, it is recommended that the provider use a Private Pay Form. It is suggested that the provider use the Member Acknowledgement Statement provided below as the Private Pay Form, or use a Provider Pay Form (see Forms section of this manual). Without written, signed documentation that the 22

24 member has been properly notified of their private pay status, the provider cannot ask for payment from a member. Member Acknowledgement Statement The only occasion when a provider may bill a member is when the member has completed the Member Acknowledgement Statement. A provider may bill a member for a claim denied as not being medically necessary or not a part of a covered service if both of the following conditions are met: A specific service or item is provided at the request of the patient The provider has obtained and kept a written Member Acknowledgement Statement signed by the client The Member Acknowledgment Statement must read as follows: I understand that, in the opinion of (Provider s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the CMCHP as being reasonable and medically necessary for my care. I understand that CMCHP determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care. Nothing contained in the Agreement or this manual is intended by CMCHP to be a financial incentive or payment which directly or indirectly acts as an inducement for Providers to limit medically necessary services. 23

25 V. Complaints and Appeals Member Complaint and Appeal Process Members (or their authorized representatives) who are not satisfied with their health care services can file a complaint with Children s Medical Center Health Plan (CMCHP). Members should call CMCHP Member Services. If a member needs assistance with filing a complaint, a Member Services Representative will help them file a complaint. You may also send your complaint in writing to CMCHP at: Children s Medical Center Health Plan Attn: Complaint Department 1935 Medical District Drive Dallas, Texas CMCHP will send the member a letter within five (5) working days telling them that we have received their complaint. We will also include a complaint form with the letter if the complaint was filed orally. Within thirty (30) days of receiving your written complaint, CMCHP will mail you a letter with the outcome of the complaint. The resolution letter must include an explanation of CMCHP s resolution of the complaint, a statement of the specific medical and contractual reasons for the resolution; and the specialization of any physician or other provider consulted. The resolution letter must also contain a full description of the process for appeal, including the deadlines for the appeals process and the deadlines for the final decision on the appeal. CMCHP will investigate and resolve a complaint concerning an emergency or a denial of continued hospitalization in accordance with the medical immediacy of the case and not later than one (1) business day after CMCHP receives the complaint. If the member does not like the response to their complaint, they can contact CMCHP and request an "appeal" by asking for a hearing with the Complaint Appeal Panel (CAP). Every oral appeal received must be confirmed by a written, signed appeal by the member, or his or her representative, unless the Member asks for an expedited appeal. The complainant has the right to appear before a CAP where they normally receive health care or at another site agreed to by the complainant. The CAP is a group of people that includes equal numbers of: CMCHP Staff Physicians or other providers with experience in the area of care that is in dispute and must be independent of any physician or provider who made the prior determination Members If specialty care is in dispute, the panel must include a specialist in the field of care related to the dispute 24

26 Not later than the fifth (5th) business day before the scheduled meeting of the panel, unless the complainant agrees otherwise, CMCHP will provide to the complainant or the complainant's designated representative: Any documentation to be presented to the panel by the CMCHP staff The specialization of any physicians or providers consulted during the investigation The name and affiliation of each CMCHP representative on the panel The complainant or designated representative if the member is a minor or disabled is entitled to: Appear in person before the CAP Present alternative expert testimony Request the presence of and question any person responsible for making the disputed decision that resulted in the appeal Appeals relating to ongoing emergencies or denials of continued stays for hospitalization will be completed in accordance with the medical or dental immediacy of the case but in no event to exceed one (1) business day after the request for appeal is received. At the request of the complainant, CMCHP shall provide, in lieu of a CAP, a review by a specialist of the same or similar specialty as the physician or provider who would typically manage the medical condition, procedure or treatment and who has not previously reviewed the case. The physician or provider reviewing the appeal may interview the patient or the patient s designated representative and shall decide on the appeal. Initial notice of the decision may be delivered orally if followed by written notice not later than three (3) days after the date of the decision. The CAP only serves in an advisory role to CMCHP. CMCHP will consider the findings of panel and render our final decision. The appeals process must be completed no later than thirty (30) calendar days after receipt of the written request for appeal. Adverse Determinations If the request for a service is denied for not meeting medical necessity criteria, it is considered an adverse determination. CMCHP will make its best efforts to obtain all necessary information, including pertinent clinical information, and consult with the treating physician as appropriate in making Medical Management determinations. 25

27 A peer to peer discussion is available to the ordering physician at any time during the prior authorization, denial or appeal process. CMCHP s Medical Director will review all potential medical necessity denials and render a final decision on them. The review may include a discussion with the ordering physician in order to obtain any information that may not have been submitted with the request. If the final decision is to deny the service request, then a denial is rendered. CMCHP is required to notify the member and ordering provider of the denial, in writing. The notification describes the services that are being denied and the steps a member or authorized member representative can take to appeal the decision and how to access subsequent steps of the appeal process. Provider/Member Complaints CMCHP requires that all complaints received from providers be submitted to CMCHP in writing. CMCHP offers a number of ways to file a written complaint as listed below: Filing a Complaint Form that can be printed, completed and faxed or mailed to Children s Medical Center Health Plan for a resolution response. Mailing or faxing a written complaint through USPS, Courier or Facsimile to the following: Independent Review Organization Appeal Children's Medical Center Health Plan ATTN: Complaint Department 1935 Medical District Drive Dallas, Texas Fax: An Independent Review Organization (IRO) is an external organization that is selected by the Texas Department of Insurance (TDI) to review the request for appeal and render a decision on the request. An IRO appeal may be requested by the member, member s representative, or health care provider. Immediate access to an IRO review is available for appeals relating to presently occurring emergencies, care for life-threatening conditions, or denials of continued stays for hospitalization without completion of the CMCHP Medical Necessity Appeals Process. IRO Request Forms are included in all adverse determination letters or can be obtained by calling the Medical Management Department. The IRO makes its determination no later than: 26

28 The 15th day after the date the IRO receives the information necessary to make the determination The 20th day after the date the IRO receives the request that the determination be made In the case of a life-threatening condition, not later than the 5th day after the IRO received the information necessary to make the determination The 8th day after the date the IRO receives the request that the determination be made If you are not satisfied with the outcome of the CMCHP Appeal Process, you can file a complaint with: Texas Department of Insurance Attention: Mail Code 103-6A P.O. Box Austin, TX Phone: No Retaliation CMCHP will not retaliate against any person filing a complaint against CMCHP or appealing a decision made by CMCHP. CMCHP is required to comply with the complaint and appeal procedures as defined by the Texas Department of Insurance. 27

29 VI. Fraud, Waste, and Abuse Fraud Information CMCHP wants to work with all providers to ensure that CMCHP is doing everything possible to prevent waste, fraud or abuse. Please notify CMCHP if you think a provider, dentist, pharmacist at a drug store, other health care providers, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse or fraud, which is against the law. For example, tell us if you think someone is: Getting paid for services that weren t given or necessary Not telling the truth about a medical condition to get medical treatment Letting someone else use their Medicaid ID Using someone else s Medicaid ID Not telling the truth about the amount of money or resources he or she has to get benefits How to report Fraud, Abuse, and Waste To report waste, abuse or fraud, choose one of the following: Call the OIG Hotline at ; Visit and pick Click Here to Report Waste, Abuse, and Fraud to complete the online form; or You can report directly to CMCHP: Children s Medical Center Health Plan Attn: Compliance Department 1935 Medical District Drive Dallas, TX Phone: To report waste, abuse or fraud, gather as much information as possible. When reporting a Provider (a doctor, dentist, counselor, etc.), include: Name, address, and phone number of Provider Name and address of the facility (hospital, nursing home, home health agency, etc.) Type of Provider (doctor, dentist, therapist, pharmacist, etc.) Names and phone numbers of other witnesses who can help in the investigation Dates of events 28

30 Summary of what happened When reporting about someone who gets benefits, include: The person s name The person s date of birth, Social Security number, or case number if you have it The city where the person lives Specific details about the waste, abuse or fraud 29

31 VII. HIPAA Regulations Protecting the confidentiality and privacy of members personal health information (PHI), should be done in compliance with both federal and state laws regarding the privacy and security of members PHI. Providers must maintain policies and practices to comply with all state and federal healthcare privacy laws including the following: 1. The Health Insurance Portability and Accountability Act (HIPAA); 2. Medicare and Medicaid Rules and Regulations, where applicable; and 3. Texas Medical Privacy Laws and Regulations. Providers should be aware that Texas state law may be more stringent in some areas than HIPAA and should consult legal counsel to ensure compliance with all applicable laws. The Office for Civil Rights administers and enforces the Privacy Rule and the Security Rule. The Enforcement Rule provides standards for the enforcement of all the Administrative Simplification Rules. A summary of the HIPAA Administrative Simplification Rules can be found on: Confidentiality All providers must maintain written policies and procedures with regard to maintaining the confidentiality of medical records in a manner consistent with federal, state and local laws, rules and regulations, including HIPAA and HITECH provisions of the American Recovery and Reinvestment Act. CMCHP will maintain complete confidentiality with regard to medical records that may be requested from providers. CMCHP s policies and procedures for confidentiality shall at all times be compliant with federal, state and local laws, rules and regulations, including HIPAA and HITECH. Medical Records Maintenance of Records All CMCHP providers are required to maintain a written or electronic medical record that complies with the standards of the health care industry and with the requirements of 30