Provider Orientation for: Meridian Advantage Plan Meridian Prime Meridian Complete

Transcription

1 Provider Orientation for: Meridian Advantage Plan Meridian Prime Meridian Complete

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3 Table of Contents Welcome Letter About Meridian Service Area Key Features Eligibility Member Benefits Quality Improvement Bonus Program Behavioral Health Laboratories Diabetic Supplies Healthy Living Diabetic Supply Form Prescription Drugs Medicare Prescription Drug Prior Authorization Form Model of Care Model of Care Goals Interdisciplinary Care Team (ICT) Chronic Care Improvement Program (CCIP) Annual Training Program Referral Pre-Service Clinical Review Program Prior Authorization Overview Claims Information Billing Information Fraud, Waste and Abuse Find us Online! Contact Information Representative Territory Map

4 Welcome Letter Dear Provider, It is my pleasure to introduce you to the Meridian Family of health plans. We are excited to offer our products to the Medicare-eligible community and work with providers to offer the best managed care to this population. We know our success is based on the relationships we have with our providers. Meridian cultivates those relationships by offering several distinct services that differentiate it from others. Thank you for joining our growing network. Sincerely, David B. Cotton, MD President/CEO Meridian Health Plan 2

5 About Meridian Our Mission To continuously improve the quality of care in a low resource environment Our Vision To be the premier service organization in healthcare To be the #1 Medicare Program based on quality, innovative technology and service to our members Corporate History The Meridian Medicare plans were established in 2011 through a contract with the Centers for Medicare and Medicaid Services (CMS). Meridian Advantage Plan, Meridian Prime, Advantage Plus Meridian and Meridian Complete are part of the Meridian Health Plan Family. Meridian Health Plan is a Medicaid health plan contracted with the Michigan Department of Community Health (MDCH) to provide healthcare services. Meridian was formed from the merger of two clinic plans, Central Michigan Health Plan (CMHP) and American Preferred Provider Plan of Michigan (APPPM). CMHP was founded by physicians at the Jackson Northwest Clinic located in Jackson, Michigan in December In August 1997, Dr. David B. Cotton acquired a majority position in CMHP and assumed fiscal and administrative responsibility for the plan, which had approximately 1,400 members. CMHP acquired APPPM in January 1999 and ultimately became operational as Health Plan of Michigan (HPM) in May In January 2000, HPM acquired the Michigan membership of Family Health Plan of Ohio. Operating as a full service HMO since January 2000, HPM obtained NCQA accreditation in May 2002 and URAC accreditation in March On January 1, 2012, Health Plan of Michigan became Meridian Health Plan. Meridian Health Plan remains a family-owned and family-operated health plan. Meridian Health Plan is growing throughout the Midwest and beyond. In 2008, MHP established a new plan in Illinois, Meridian Health Plan of Illinois. In 2011, MeridianRx, a pharmacy benefit manager, was launched. Soon after, Meridian Advantage Plan was established to coordinate Medicare and Medicaid benefits for the dual-eligible population. On March 1, 2012, Meridian began providing services to members in eastern Iowa. 3

6 Service Area Meridian Advantage Plan (HMO SNP) A Medicare Advantage Prescription Drug Dual Special Needs Plan (MAPD-SNP) for people who have both Medicare and Medicaid. This plan provides members with Part C (A and B) and Part D prescription drug benefits and includes additional benefits not covered by Original Medicare. Service area: Barry, Genesee, Kalamazoo, Kent, Macomb, Muskegon, Oakland, Ottawa, Saginaw, Wayne Ohio: Lucas Meridian Prime (HMO) A Medicare Advantage Prescription Drug Plan (MAPD) in select counties of Michigan and Ohio. MAPDs are a type of Medicare health plan that provide Part C (A and B) and Part D prescription drug benefits and include additional benefits that are not covered by Original Medicare. Service area: Barry, Genesee, Kalamazoo, Kent, Macomb, Muskegon, Oakland, Ottawa, Saginaw, Wayne Ohio: Lucas Meridian Complete (Medicare-Medicaid Plan) Integrates managed care for individuals who are eligible for both Medicare and Medicaid under one plan under a demonstration program with CMS and the State of Michigan. (Coming soon in 2015). Service area: Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph, Van Buren Member Name: Member ID: Health Plan (80840): Copays: $0 H RxBin: RxPCN: MHPMICOMP Advantage-Plus Meridian (PDP) A Medicare Prescription Drug Plan (PDP) in all counties in Michigan and Ohio which adds only Part D prescription drug coverage to Original Medicare and some Medicare Cost Plans, Medicare Private Fee-for-Service Plans and Medicare Medical Savings Account Plans. These Plans do not include any Part A or Part B coverage. 4

7 Michigan Service Area Members are encouraged to utilize in-network Meridian providers. Service Area Plan Product Antrim Emmet Charlevoix Cheboygan Presque Isle Montmorency Alpena Otsego Meridian Advantage Plan Meridian Prime Meridian Complete Advantage-Plus Meridian serves ALL counties in Michigan, including those in the Upper Peninsula. Benzie Leelanau Grand Traverse Kalkaska Crawford Oscoda Alcona Manistee Wexford Missaukee Roscommon Ogemaw Iosco Mason Lake Osceola Clare Gladwin Arenac Bay Huron Oceana Newaygo Mecosta Isabella Midland Muskegon Montcalm Gratiot Saginaw Tuscola Sanilac Ottawa Kent Ionia Clinton Shiawassee Genesee Lapeer St. Clair Macomb Allegan Barry Eaton Ingham Livingston Oakland Van Buren Kalamazoo Calhoun Jackson Washtenaw Wayne Berrien Cass St. Joseph Branch Hillsdale Lenawee Monroe 5

8 Ohio Service Area Members are encouraged to utilize in-network Meridian providers. Williams Defiance Fulton Henry Lucas Wood Ottawa Sandusky Erie Lorain Cuyahoga Lake Geauga Ashtabula Trumbull Huron Paulding Seneca Medina Putnam Hancock Van Wert Ashland Wyandot Crawford Wayne Allen Richland Hardin Mercer Auglaize Marion Morrow Holmes Logan Knox Shelby Union Delaware Coshocton Darke Champaign Miami Licking Franklin Muskingum Clark Madison Montgomery Preble Fairfield Greene Perry Pickaway Fayette Morgan Hocking Butler Warren Clinton Ross Athens Vinton Hamilton Highland Meigs Clermont Pike Jackson Brown Adams Scioto Gallia Lawrence Summit Stark Tuscarawas Guernsey Noble Washington Service Area Portage Carroll Harrison Belmont Monroe Mahoning Columbiana Plan Product Jefferson Meridian Advantage Plan Meridian Prime Advantage-Plus Meridian serves ALL counties in Ohio. 6

9 Key Features Timely Claims Processing Meridian Advantage Plan and Meridian Prime pay clean claims within 10 business days Electronically billed claims are paid even faster Majority of claims processed in 2-5 days Incentive Programs Meridian provides bonus opportunities to our contracted providers to cover the costs associated with treating this delicate population, as well as opportunities based on administering preventive care measures For more information, see page 12 Hassle-Free Policies and Procedures Comprehensive drug formulary and licensed pharmacists available at MeridianRx for consultation Assigned local Provider Network Development Representative to handle all questions and concerns Primary Differences Between Medicaid and Medicare Use of contracted providers by Meridian Advantage Plan or Meridian Prime members With few exceptions, Medicare covered services should be provided by contracted providers and approved in advance by the contracted provider and by Meridian Advantage Plan or Meridian Prime Exceptions: Emergent/urgent services Dialysis when member is temporarily outside the plan s service area When care from non-contracted provider is arranged/approved by Meridian Advantage Plan or Meridian Prime Referral notification is required for all specialist visits Meridian Advantage Plan and Meridian Prime coordinate comprehensive behavioral health and substance abuse services (including inpatient mental health, substance abuse and outpatient visits) for eligible members 7

10 Eligibility Meridian Advantage Plan is a Special Needs Plans (SNP) Members eligible for Meridian Advantage Plan benefits must be entitled to full Medicaid benefits, be entitled to Medicare Part A, enrolled in Medicare Part B and must reside in one of our current service areas Under the Medicare Modernization Act (MMA, Section 231), Congress created a new type of Medicare Advantage (Part C) Coordinated Care Plan focused on individuals with special needs Special needs individuals were identified by Congress as: Institutionalized beneficiaries Dual-Eligible (DE) Beneficiaries with severe or disabling chronic conditions Dual-Eligibles (DE) Are a fragile and/or disabled population Have multiple chronic and/or complex conditions with higher medical expenditures than other populations Include working age adults, the elderly and people with chronic illnesses, developmental disabilities, physical disabilities and/or psychiatric disabilities Have the option to receive coordination of their Medicaid (FFS) and Medicare services administered by a Dual-Eligibile Special Needs Plan (D-SNP), like Meridian Advantage Plan Meridian Prime (MAPD) A Medicare Advantage Prescription Drug Plan Provides Part A, Part B, and Part D prescription drug benefits and additional benefits not covered by Original Medicare Meridian Complete (MMP) A Medicare-Medicaid Plan For those eligible for both Medicare and Medicaid Adds Medicare, Medicaid, and prescription drug coverage all under one plan Advantage-Plus Meridian (PDP) A Medicare Prescription Drug Plan Adds Part D prescription drug coverage to Original Medicare and some Medicare Cost Plans, Medicare Private Fee-for-Service Plans and Medicare Medical Savings Account Plans 8

11 Member Benefits Meridian has several programs that support both members and providers: Care Coordination for Meridian Advantage Plan Members Each member is assigned a Care Coordinator responsible for coordinating their care Care Coordinators ensure these members receive all services available to them through coordination of their Medicare and Medicaid benefits Care Coordinators assist with scheduling medical appointments, providing appointment reminders, reviewing medication regimens (in conjunction with pharmacy staff) and providing assistance to members and their caregivers in locating and utilizing community resources Care Coordinators communicate important benefit and coverage information to providers, members and caregivers Health Risk Assessments All members receive a Health Risk Assessment within the first 90 days of enrollment to assess their needs and determine the level of resources necessary to effectively manage their medical care Interdisciplinary Care Teams (ICT) analyze initial, subsequent and annual results of Health Risk Assessments and incorporate the results into the member s plan of care Model of Care Program (see page 14) Pharmacy (Part D) Benefits (see page 12) Medicaid FFS currently pays Medicare premiums Our Meridian Advantage Plan members have no premiums, deductibles or co-insurance Supplemental Benefits Meridian s supplemental benefits package includes dental and vision services. Dental One oral exam every 6 months One cleaning every 6 months One dental x-ray every year Vision Vision coverage is available for Meridian Advantage Plan and Meridian Prime members. Coverage levels differ by plan Meridian Advantage Plan Members Have $0 Co-Pays For All Services, Including: Annual wellness visits X-rays Immunizations (flu and pneumonia) Durable medical equipment Primary Care Provider office visits Diabetes supplies Specialist office visits Mental health services Inpatient hospitalization Outpatient surgery and hospital services Urgent care Ambulance services Emergency care Home health care Skilled nursing facility care Lab services (cardiovascular and HIV screenings; all other lab services) Diagnostic testing (AAA and EKG screenings; all other lab services) Meridian Prime members have copays for covered services ranging from $5-$150. 9

12 Quality Improvement Quality Improvement Program Meridian maintains a commitment to members through a Quality Improvement Program (QIP).This program includes processes to assess and improve the quality and safety of clinical care, as well as the quality of services provided to members. This process is embraced by within the entire organization and each department is accountable for their respective procedures included in the QIP. The Quality Improvement Program at Meridian has established standards to coordinate, monitor and guarantee accuracy of all required reporting data to the State of Michigan, CMS, NCQA, HOS and CAHPS. Due to the nature of the population served by Meridian, the QIP is evaluated annually to respond to the changing needs of its members. Meridian s commitment to quality ensures the monitoring and reporting of all HEDIS performance measures, CAHPS, HOS, Star Ratings, Chronic Care Improvement Program and the Model of Care. Quality Improvement activities are conducted externally and internally to meet designated goals with interventions, such as education and outreach to members and providers. Star Ratings The Medicare Five-Star Quality Rating System was implemented by the Centers for Medicare and Medicaid Services (CMS). It was put in place to educate consumers on quality and make quality more transparent. The 2015 Stars Rating System for Medicare health and drug plans consists of more than 50 measures from the following data sources: HEDIS : Healthcare Effectiveness Data and Information Set CAHPS : Consumer Assessment of Healthcare Provider Systems Medicare Reviews: Conducted by CMS HOS: Health Outcomes Survey IRE: Independent Review Entity There are five categories for Star Ratings, including: 1. Staying Healthy: Screenings, Tests, and Vaccines 2. Managing Chronic (Long-Term) Conditions 3. Member Experience with Health Plan 4. Member Complaints, Problems Getting Services, and Improvement in the Health Plan's Performance 5. Health Plan Customer Service Meridian works closely with providers and members to improve our Star Ratings in order to better the health of current members and attract new members. Meridian has many quality improvement initiatives focused around the Star Ratings categories and values support from providers to improve quality and service for our members. Bonus Program To assist our primary care providers (PCPs) in coordination of care for members, Meridian offers the following bonus opportunities: $50 bonus for completing the important Welcome to Medicare visit, payable one time (billing code: G0402) $5 PMPM to support additional administrative costs For further program details, please contact your Provider Network Development Representative. 10

13 Behavioral Health Members have unlimited outpatient visits and do not require prior authorization for these visits Inpatient behavioral health visits are coordinated by Meridian Contact the Meridian Behavioral Health department by: Phone: Fax: Laboratories Meridian has entered into Preferred Provider Agreements with Quest Diagnostics and JVHL for laboratory services. Meridian has partnered with Quest Diagnostics and JVHL in this Preferred Provider relationship to capture laboratory results to support quality initiatives. Meridian does not require prior authorization for routine laboratory tests for in- or out-of-network providers. JVHL: Quest Diagnostics: Diabetic Supplies All Meridian Advantage Plan and Meridian Prime members with diabetes are eligible to receive a new Advocate Redi-Code Meter through our exclusive diabetic supply company, Healthy Living Medical Supply. Features of the Advocate Redi-Code meter include: Small blood sample size (0.6 microliter) No coding of test strips Six second test time, with a 450-test memory Talking meter providing results in both English and Spanish Alternate site testing Advocate Redi-Code Healthy Living Medical Supply should be utilized for any Meridian Advantage Plan or Meridian Prime member who is newly diagnosed or needs a new glucometer. Please call Healthy Living Diabetic at for coordination. If a Meridian member has questions or needs assistance using the new Advocate Redi-Code meter, please instruct the member to contact Healthy Living Medical Supply. Meridian will not reimburse for other glucometers or testing supplies provided by any other durable medical equipment vendor. 11

14 Date: 1095 Crooks Rd Troy MI Phone #: Please send all faxes to: Diabetic Supply Prescription /21/1 Referred by: Name: Date of Birth: Male Female Address: City: Phone #: Phone #2: State: MI Zip Code: Insurance Meridian Health Plan ID: Contract/Policy: Other: Group: DURATION of need: Duration of need: Lifetime Other: (The maximum allowed duration is 12 months. The duration will default to this unless specified otherwise.) Diagnosis Code: Estimated Due Date: Pre Existing New (please check one) Is patient treated with insulin? Yes No I have seen this patient within the last six (6) months to evaluate their diabetes control and have noted the reason(s) for a testing frequency of more than 6x a day. Recommended Testing frequency: Diabetes Testing Supplies: 1 time a day 4 times a day Glucose Monitor Alcohol Wipes 2 times a day 5 times a day Battery Lancing Device 3 times a day 6 times a day Control Solution Other: Other: times a day Reason: Insulin Pump: Yes / No HEDIS Data: Please fill in the result within the Last 6 months for the following tests: Test (most recent) Date of Test Score/Result Test (most recent) Date of Test Score/Result LDL Dilated Eye Exam HbA1c Micro albumin Blood Pressure BMI Physician Name: Physician Signature: Address: Phone#: Date: UPIN: NPI: Fax#: 12

15 Prescription Drugs Meridian is contracted with MeridianRx to administer all pharmacy benefits. The formulary is available on our website ( Surescripts also allows our providers the opportunity to eprescribe for Meridian members while integrating our policies and procedures. In order to enjoy the benefits of eprescribe, a provider must have an appropriate Electronic Medical Record System (EMR) or eprescribing system. If you are currently using EMR or eprescribe software, it is likely that your software is already certified by Surescripts. To find out if your software is certified or to find out more about eprescribing, visit the Surescripts website at eprescribing allows providers to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point of care. This is an important element in improving the quality of patient care. eprescribing has been instrumental in reducing medication errors. MeridianRx Support: MeridianRx Fax:

16 Plan Name Phone # Fax # Medicare Part D Coverage Determination Request Form This form cannot be used to request: Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Biotech or other specialty drugs for which drug-specific forms are required. [See <Part D plan website.>] OR [See links to plan websites at Patient Name: Patient Information Prescriber Information Prescriber Name: Member ID#: Address: NPI# (if available): Address: City: State: City: State: Home Phone: Zip: Office Phone #: Office Fax #: Zip: Sex (circle): M F DOB: Contact Person: Diagnosis and Medical Information Medication: Strength and Route of Administration: Frequency: New Prescription OR Expected Length of Therapy: Qty: Date Therapy Initiated: Height/Weight: Drug Allergies: Diagnosis: Prescriber s Signature: Date: Rationale for Exception Request or Prior Authorization FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, toxicity, allergy, or therapeutic failure) Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s); Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change Specify below: Anticipated significant adverse clinical outcome Medical need for different dosage form and/or higher dosage Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason Request for formulary tier exception Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome Other: Explain below REQUIRED EXPLANATION: Request for Expedited Review REQUEST FOR EXPEDITED REVIEW [24 HOURS] BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER S ABILITY TO REGAIN MAXIMUM FUNCTION Information on this form is protected health information and subject to all privacy and security regulations under HIPAA. 14

17 Model of Care - Meridian Advantage Plan Purpose To improve Meridian member access to and coordination of care. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 includes: New policies to reduce racial and ethnic health disparities within the Medicare population New accountability measures for Medicare Advantage Plans to increase access to preventive and mental health services A plan for delivering care coordination and services for Medicare Advantage Plan members with special needs Guidelines for assessment and care coordination of members, uses an interdisciplinary team of health professionals, integrates the primary care physician and measures individual and program outcomes The Focused Model of Care Program Targets dual-eligible members enrolled in our Dual-Eligible Special Needs Plan (D-SNP) Affects improvement of: Care Coordination (a Care Coordinator will be assigned to each D-SNP member) Transitions of care across healthcare settings and providers Access to preventive health, including medical, social and behavioral health services, to improve member health outcomes Provider Participation Ongoing participation from members and providers is essential to the success of the Model of Care program. Meridian Advantage Plan requests your ongoing participation. Please: Review the faxed individualized plan of care for each Meridian Advantage Plan member for whom you provide care Update each plan of care with any changes and fax back to Meridian Advantage Plan Discuss the individualized plan of care with each Meridian Advantage Plan member for whom you provide care Communicate with the Interdisciplinary Care Team (ICT) to ensure optimal coordination of care and transition of care for the member. You will receive written notice of ICT meetings and are invited to participate in person or by phone You will receive a plan of care, including a Transition of Care report, throughout the year for existing and new members each time the Meridian Advantage Plan member has an inpatient or skilled nursing home admission. You can expect communication in the following ways: Mailings Telephone calls Faxes Your participation ensures the member understands their plan of care and receives needed care. Care Coordinators will facilitate regular communication with you on behalf of the members. You may reach Meridian s Care Coordination department by calling or you can contact the Care Coordinator directly by calling the number included on the fax cover sheet of the plan of care. 15

18 Model of Care Goals - Meridian Advantage Plan SNP Model of Care goals are as follows: 1) Improve access to medical, mental health and social services 2) Improve access to affordable care 3) Improve coordination of care through an identified point of contact 4) Improve transitions of care across healthcare settings and providers 5) Improve access to preventive health services 6) Ensure appropriate utilization of services 7) Ensure cost-effective service delivery 8) Improve beneficiary health outcomes a) Reduce hospitalizations and SNF placements b) Improve self-management and independence c) Improve mobility and functional status d) Improve pain management e) Improve quality of life f) Improve satisfaction with health status and health services Interdisciplinary Care Team (ICT) Key Participants The ICT is responsible for establishing and implementing the individualized plan of care for each Meridian member. Members and providers are encouraged to attend DCT meetings either in person or by phone. The ICT is composed of: Member/caregiver Member s Primary Care Physician (PCP) Meridian s internal staff, including, but not limited to: Member s Medicare Care Coordinator MeridianRx Pharmacist Behavioral Health Clinician Director of Utilization Management Administrative Coordinator of Utilization Management Medical Director Disease Management Coordinator Member Services Representative Provider Services Representative Registered Dietitian Based upon the member s needs, other healthcare professionals may be invited to join the ICT. 16

19 Chronic Care Improvement Program (CCIP) The Meridian Advantage Plan Chronic Care Improvement Program (CCIP) is a clinical program that is incorporated into the Quality Improvement Program (QIP). This includes elements of the Model of Care and is disease management based. The CCIP includes multiple health initiatives with regards to nationally mandated requirements per CMS. The Chronic Care Improvement Program supports physician and patient plan of care with an emphasis on prevention. It also includes designated outcomes, which are reportable and measurable health improvement outcomes in Meridian Advantage Plan s targeted population. The targeted populations within Meridian Advantage Plan are identified through data produced from HRAs, medical claims, encounter data and pharmacy claims. Interventions are created for members in targeted populations that relate to specific diseases. The goal of these interventions is to improve health outcomes. A positive impact must be measurable based on the discussed elements of the CCIP with the ability to empower, educate and support members and in-network providers. This evidence-based program is a multidisciplinary and continuum based system developed to identify, stratify and monitor populations with specific, highly prevalent, targeted health conditions. Annual Training Program Meridian follows the Centers for Medicare and Medicaid Services (CMS) guidelines to deliver the appropriate educational pieces to its provider network. Together, we can achieve outstanding quality and increased value in the care provided to our members. Model of Care (MOC) Our MOC training module outlines the role of contracted providers in delivering our Special Needs Plan (SNP) Model of Care. MOC training is required to be completed annually. Fraud, Waste and Abuse (FWA) Our FWA training module assists providers in participating in fraud, waste and abuse prevention and detection. CMS requires the completion of FWA training by all Meridian network providers on an annual basis. The Model of Care (MOC) and Fraud, Waste and Abuse (FWA) training modules are easily accessible on the Meridian website ( 17

20 Referral Pre-Service Clinical Review Program Referral processing is the primary activity performed by our Utilization Management Specialist staff. Meridian encourages in-network referrals. Meridian offers three easy ways to submit referrals: 1. Electronically: Through Meridian s Managed Care System (MCS) 2. Fax: Please include pertinent clinical documentation with the request, if needed 3. Phone: Urgent requests must always be submitted by calling. Make sure you identify the request as urgent to expedite the pre-service review process Pre-Service Clinical Review Program Meridian s clinical staff must review select services before they are provided. Clinical review determines whether services are clinically appropriate, performed in the appropriate setting and a covered benefit. Please forward the pertinent clinical information with your request via fax to expedite a response. Please see page 18 for the services that require clinical review. Utilization Management clinical staff use plan documents for benefit determination and Medical Necessity Coverage Guidelines to support Utilization Management decision-making. All utilization review decisions to deny coverage are made by Meridian Medical Directors. In certain circumstances, external reviews of service requests are conducted by qualified, licensed physicians with the appropriate clinical expertise. In the instance of a pre-service denial, a Meridian nurse reviewer contacts the provider office by phone to inform them of the denied decision and the reason for the denial. The nurse reviewer also provides contact information to discuss the denial with a Meridian Medical Director. Written denial notification is sent via fax to the provider and mailed to the member. Providers who would like to discuss a utilization review determination with the decision-making Medical Director may contact the Utilization Management department at The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based and directions on how to obtain a copy of the reference. You may contact the Utilization Management department at to request a copy of Meridian s medical necessity guidelines. 18

21 Prior Authorization Overview MEDICARE PRIOR AUTHORIZATION PROCEDURES OVERVIEW You may forward your request to Meridian via Fax: You may also contact Meridian by Phone: For more information, providers and members can visit our website at Outpatient Services/Procedures 23-Hour Observations Clinical Trials Elective Outpatient Surgeries/Procedures Invasive Diagnostic Procedures Maternity Care and Delivery Neurology and Neuromuscular Diagnostics Pain Management Sleep Studies Therapy Cardiac Rehabilitation Outpatient Infusion Therapy Physical, Occupational and Speech Therapy Pulmonary Rehabilitation Other SERVICES THAT REQUIRE PRIOR AUTHORIZATION *All services provided by out-of-network providers* Inpatient Services All Elective and Emergent Admissions Inpatient Rehabilitation Skilled Nursing Facility Behavioral Health Services Inpatient Detoxification Admissions Inpatient Mental Health Admissions Outpatient Behavioral Health (after initial 10 visits) Outpatient Substance Abuse Partial Hospitalization In-Home Services DME/Prosthetics and Orthotics Home Infusion Therapy Nursing and Therapy Services Parenteral and Enteral Feedings Ambulance Transportation (Non-Emergent) Anesthesia (when performed with Radiology Testing) Audiology Services and Testing (excludes hearing aids) Chemotherapy Chiropractic Services Dialysis (when outside plan service area and provided by Medicare-certified facility) Hereditary Blood Testing or Genetic Testing (e.g. BRCA Testing for Breast and Ovarian Cancer) Hospice (notification only) Injectables and Other Drugs Podiatry for Treatment of Injuries and Disease of Foot Specialty Drugs Covered Under the Medical Benefit Weight Management NON-COVERED BENEFITS Non-covered benefits include long term custodial care, cosmetic surgery, hearing aids, personal care items, alternative care and most non-emergent ambulance transport. For a comprehensive list of services and conditions not covered by Meridian, please refer to our Provider Manual or call If the member is enrolled in a Medicare SNP program, the member should present both Medicare and Medicaid ID cards at the time of service. For Medicare Part D benefits, contact MeridianRx: Phone: Fax: By requesting prior authorization, the provider is representing that the services to be provided are medically necessary. As a condition of authorization of those services, the servicing provider agrees to accept no more than 100% of Medicare rates. At no time will Meridian Advantage Plan pay more than 100% of Medicare rates for any services. In the event that these services are deemed not to be medically necessary, Meridian will not reimburse the provider for those services. 19

22 Prior Authorization Overview Clinical information should be provided at least 14 days prior to the service. The facility is responsible for ensuring authorization. Meridian provides a reference number on all referrals. Referral Makes Decision Fax/Phone Notification Written Notification (Denials) Non-urgent pre-service review Within 14 days of receipt of request Within 14 days of receipt of request Within 14 days of receipt of request Urgent pre-service review Within 72 hours of receipt of request Within 72 hours of receipt of request Within 72 hours of receipt of request Urgent concurrent Within 24 hours of receipt of request. 48 hours if clinical is not included Within 24 hours of receipt of request. 48 hours if clinical is not included Within 72 hours of decision Retrospective Within 30 days of receipt of request. N/A for members. N/A Within 30 days of receipt of request Meridian believes that there are very few situations that justify requesting retrospective authorization and most often will be denied. Claims Information Claims Payments and Status Meridian is dedicated to processing your claims in under 10 days. You may status claims by calling the Meridian Claims department or by mail: 20 Meridian Advantage Plan - Claims Department 1001 Woodward Ave, Suite 510 Detroit, MI Meridian Prime - Claims Department 1001 Woodward Ave, Suite 510 Detroit, MI Phone: Claims Appeal Process Meridian makes every reasonable effort to partner with our providers. In cases where a claim has been denied, providers may submit an appeal in writing within 30 days of the denial. Please include the following: Patient name and ID# Reason for appeal Any relevant clinical information to support your appeal The Meridian Appeals Committee meets regularly to review these appeals. You will receive a response within 30 days. Meridian is continually making efforts to improve the efficiency of its claim payments by increasing automation of its processes. The two measures of claims efficiency are electronic claims submission and auto-adjudication. These automated processes support timely claims payment. The following chart demonstrates the level of automation and correlated improvements of Meridian claims processing.

23 Billing Information Meridian follows the Medicare billing guidelines unless otherwise noted. Mail to: Meridian Advantage Plan 1001 Woodward Avenue, Suite 510 Detroit, MI Meridian Prime 1001 Woodward Avenue, Suite 510 Detroit, MI Meridian Electronic Claim Submission (EDI) Vendors Availity Customer Support: 800-Availity Claim Types: Professional/Facility Payer ID: PayerPath Customer Support: Claim Types: Professional Payer ID: Blue Cross Blue Shield of MI Customer Support: Claim Types: Professional Payer ID: Office Number: 2936 Emdeon (WebMD) Customer Support: Claim Types: Professional/Facility Payer ID: Per-Se Customer Support: Claim Types: Professional/Facility Payer ID: Relay Health Customer Support: Claim Types: Professional/Facility Payer ID: NDC Customer Support: Claim Types: Facility Payer ID: SSI Group Customer Support: Claim Types: Professional/Facility Payer ID: Netwerkes Customer Support: Claim Types: Professional/Facility Payer ID: A0915 ZirMed Customer Support: Claim Types: Professional/Facility Payer ID: Z

24 Fraud, Waste and Abuse Medicare fraud, waste and abuse is a serious and expensive problem in health care. It is estimated to account for 3-10% of the annual healthcare expenditure in the United States. Penalties for Medicare fraud include fines, restitution, loss of license, disbarment from participation in state/federal programs and/or jail time. Meridian is dedicated to educating our provider community and assisting in the prevention, detection and reporting of healthcare fraud, waste and abuse. Examples of fraud, waste and abuse are: Billing for services not provided Providing medical services or prescriptions that are inappropriate and/or medically unnecessary Providing or accepting kickbacks, or anything of value, in return for the referral of patients and/or insurance billing information Billing for more expensive services than are actually provided Billing for the same service more than once and/or unbundling services into multiple claims Patients altering information on a prescription Patients using insurance ID cards belonging to individuals other than themselves Patients going to multiple physicians to receive prescriptions for the same medication Patients displaying threatening or offensive behavior at a provider s office, hospital or pharmacy Patients utilizing the emergency room for non-emergent conditions or to obtain certain medications Report Fraud, Waste and Abuse Meridian encourages the reporting of fraud, waste and abuse. If you learn of any providers, pharmacies and/or members who have committed fraud, waste and abuse you can report them to Meridian at: Mail: Attn: Compliance Officer Meridian Advantage Plan 777 Woodward Avenue, Suite 600 Detroit, MI Attn: Compliance Officer Meridian Prime 777 Woodward Avenue, Suite 600 Detroit, MI Phone: To report to Medicare directly, you can use the following contact information: Mail: Office of Inspector General HHS TIPS Hotline PO Box Washington DC, Phone: 800-HHS-TIPS ( ) Fax: [email protected] Reports of fraud, waste and abuse can be made anonymously. 22

25 Fraud, Waste and Abuse The False Claims Act The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the government. Under the False Claims Act, those who knowingly submit or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud. The Act permits a person with knowledge of fraud against the United States government to file a lawsuit on behalf of the government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15% and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer. For more information on the False Claims Act, please contact the Meridian Corporate Compliance Officer at Find us Online! The Meridian website has been updated with the following features: Provider manual Provider directory Formulary Bulletins Forms Useful links and information Plus much more 23

26 Contact Information Utilization Management (UM) Phone: Fax: Process referrals Perform corporate pre-service review of select services Collect supporting clinical information for select services Conduct inpatient review and discharge planning activities Care Coordination Appeals Phone: Care Coordination Phone: Member Services Phone: Fax: Verify member eligibility Obtain member schedule of benefits Obtain general information and assistance Determine claims status Encounter inquiry Record member personal data change Obtain member benefit interpretation File complaints and grievances Verify / record newborn coverage Coordination of Benefit questions Provider Services Phone: Fax: Fee schedule assistance Contractual issues Primary care administration Discuss recurring problems and concerns Provider education assistance Initiate physician affiliation, disaffiliation and transfer Quality Improvement Phone: Fax: Requests and questions about Clinical Practice Guidelines Requests and questions about Preventive Healthcare Guidelines Questions about Quality Initiatives Questions about QI regulatory requirements Questions about Disease Management programs Other Important Phone and Fax Numbers Pharmacy Benefit Manager Main Fax Non-Emergent Transportation (LogistiCare) Administration Fax Behavioral Health Behavioral Health Fax Claims

27 Representative Territory Map Provider Network Development Representatives Muskegon Kent Ottawa Barry Kalamazoo Saginaw Genesee Oakland Macomb Wayne Lauren Arnold Laura Champine Amanda Dubyk Crystal Klier Melissa Kuiper Denal Nelson Jennifer Peyerk Jessica Roybal Anne Marie Salliotte Amanda Woebbeking Oakland County Wixom Farmington Roseville Novi Hills Southfield Center Line St. Clair South Lyon Eastpointe Shores Farmington Harper Woods Northville Highland Park Grosse Pointe Woods Northville Twp. Grosse Pointe Farms Livonia Hamtramck Grosse Pointe City Plymouth Dearborn Grosse Pointe Park Westland Heights Canton Twp. Garden City Dearborn Inkster Allen Park Van Buren Twp. Lincoln Park Taylor Romulus Wyandotte Belleville Southgate Brownstown Twp. Riverview Sumpter Twp. Grosse Ile Twp. Huron Twp. Woodhaven Flat Rock Rockwood Detroit Wayne County Macomb County Lucas MICHIGAN Director of Provider Network Development Kellie Rice: Manager of Provider Network Development Jacqueline DuPuy: OHIO Director of Network Development Michael Dieterich:

28 PSOR01 MAP MP MI Provider Orientation May 2015