Care Improvement Plus. Provider Manual

Transcription

1 Care Improvement Plus Provider Manual

2 Contact Information PROVIDER SERVICES General Information Claims Questions Appeals Credentialing PROVIDER RELATIONS AND CONTRACTING ELIGIBILITY VERIFICATION VRU available: press option 3 Online eligibility at OUTPATIENT SERVICES AND SKILLED NURSING FACILITY PREAUTHORIZATION Missouri, Arkansas, and Texas Georgia and South Carolina LTAC HH SNF/REHAB OT/PT/ST DME: Specific DME Items HOSPITAL ADMISSIONS AUTHORIZATION: Missouri, Arkansas, and Texas Georgia and South Carolina AFTER HOURS QUESTIONS CLAIMS Submit EDI claims via Emdeon: Payer ID Submit Paper Medical Claims to: Care Improvement Plus P.O. Box 488 Linthicum, MD Attention: Claims Department Submit Pharmacy Claims to: Medco Health Solutions, Inc. PO BOX Lexington, KY i

3 Submit Vision and Dental Claims to: Avesis Third Party Administrators P.O. Box 7777 Phoenix, AZ Attention: Claims Department Or electronically PHARMACY BENEFITS SERVICES (Medco Health Solutions) TELEPHONE FOR DEAF AND DISABLED (TTY) ii

4 Table of Contents SECTION A WELCOME... 1 WELCOME... 1 OVERVIEW OF CARE IMPROVEMENT PLUS... 1 SECTION B ELIGIBILITY & PLAN DESCRIPTION... 1 ELIGIBILITY VERIFICATION PROCEDURE... 1 SECTION C PROVIDER REQUIREMENTS... 2 STANDARDS OF CARE... 2 DISCRIMINATION... 3 ACCESSIBILITY... 3 MEDICAL RECORDS... 3 CONFIDENTIALITY...3 LICENSE, CERTIFICATIONS & PRIVILEGES... 3 POLICIES & PROCEDURES... 4 NETWORK PROVIDERS... 4 PHARMACEUTICAL PRESCRIPTIONS... 4 ADVANCE DIRECTIVES... 4 REPORTING AND DISCLOSURE/ENCOUNTER DATA... 4 NO BILLING OF MEMBERS... 4 SECTION D PROVIDER RIGHTS AND RESPONSIBILITIES... 5 SECTION E BILLING & CLAIMS PAYMENT... 8 BILLING... 8 SECTION F CREDENTIALING PROGRAM... 9 PROGRAM OVERVIEW... 9 SECTION G USE OF ANCILLARY PROVIDERS... 9 ANCILLARY SERVICES... 9 SECTION H BEHAVORIAL HEALTH SERVICES SECTION I PHARMACY FOUR-TIER AND FIVE-TIER CO-PAY STRUCTURE SECTION J VISION AND DENTAL COVERAGE SECTION K UTILIZATION AND CASE MANAGEMENT CHRONIC CARE MANAGEMENT SECTION L QUALITY IMPROVEMENT PROGRAM OVERVIEW CLINICAL PRACTICE GUIDELINES PREVENTIVE SERVICES GUIDELINES MEDICAL RECORDS SECTION M MEMBER RIGHTS AND RESPONSIBILITIES MEMBER RIGHTS MEMBER RESPONSIBILITIES OUT OF AREA SERVICES PRIMARY CARE PHYSICIAN SELECTION PROVIDER TERMINATIONS GRIEVANCE PROCEDURE MEMBER APPEALS SECTION N ADVANCED DIRECTIVE ADVANCE DIRECTIVES APPENDIX A SAMPLE MEMBER IDENTIFICATION CARD B ELECTRONIC BILLING iii

5 C UM AUTHORIZATION FACT SHEET iv

6 SECTION A WELCOME WELCOME Welcome to Care Improvement Plus! This provider manual was developed as a guide to assist you and your office staff with providing services to our members, your patients. We are confident that this provider manual will be an important resource for your office. The provider manual contains essential information, and will be updated on a regular basis as policies and procedures are created and/ or modified and placed online. We also encourage you to utilize other tools and information available on our website ( through our provider portal, specifically designed to make working with Care Improvement Plus easy for our providers. Your review and understanding of the provider manual is essential. Any questions, issues, and/or suggestions concerning the provider manual or our website are encouraged and should be directed to Care Improvement Plus Provider Services department at or contact us through our regional mailboxes: [email protected] [email protected] [email protected] [email protected] [email protected] Once again, thank you for your participation with Care Improvement Plus. OVERVIEW OF CARE IMPROVEMENT PLUS Care Improvement Plus is a Medicare Advantage Special Needs Plan for those with diabetes, heart failure, chronic obstructive pulmonary disease (COPD) and/or end stage renal disease (ESRD) *. We provide all Medicare benefits, including prescription drug coverage (Part D). All of our services are specifically designed to help manage chronic illness, and help patients understand and follow your advice and treatment plans. You can rely on us to follow through with recommendations and keep you informed according to your direction. The plan is available to Medicare beneficiaries, who are eligible for Medicare Part A and are enrolled in Medicare Part B, who reside in Texas, Missouri, Arkansas, Georgia, or South Carolina and have one of the following chronic conditions: diabetes, heart failure, COPD, and/or ESRD. As a contracted MAPD plan with Medicare, Care Improvement Plus abides by all CMS regulations pertaining to MAPD plans, including ensuring that payment and incentive arrangements with providers are specified in the contract, ensuring providers meet all downstream CMS requirements, and ensuring that the plan and its providers follow all laws subject to federal funds, including fraud, waste, abuse and anti-kickback statutes. SECTION B ELIGIBILITY & PLAN DESCRIPTION ELIGIBILITY VERIFICATION PROCEDURE Members should present a Care Improvement Plus ID card (or temporary proof of coverage envelope, if they have not yet received their ID card) upon arrival for services. Providers are * Beneficiaries with ESRD can only join the Silver Rx Plan. 1

7 encouraged to validate the identity of the person presenting an ID card by requesting some form of photo identification, such as a driver s license, in addition to the ID card. Please see Appendix 1 for an example of our ID card. The ID card does not guarantee eligibility. Member eligibility must be verified at each visit. Failure to verify eligibility may result in delay or non-payment of claims. Care Improvement Plus also offers a Verification Telephone Line to confirm member eligibility, as well as online eligibility available at: To speak with a provider service representative, please dial toll-free Monday through Friday from 8:00 AM to 8:00 PM EST. Care Improvement Plus: Has an open access network, which means Members may use any Medicare approved provider that will accept payment from our plan Does not require referrals Requires preauthorization for home health services, therapies, certain Part B medications, and selected DME items. Please see Appendix C for the current listing of services requiring preauthorization, or go online to and access the Provider Authorization Requirements fact sheet Does NOT require a qualifying 3-day hospital stay before admission to a Skilled Nursing Facility (as does Medicare). This allows the physician to admit to this level of care if that is the most appropriate care for the patient Encourages the use of preventive services, including an annual physical exam Offers additional benefits, such as transportation, routine vision and routine dental services SECTION C PROVIDER REQUIREMENTS Providers may include physicians, facilities, and ancillary providers that provide care to Care Improvement Plus members. In some instances, Providers may include Physician Hospital Organizations and Independent Physician Associations who may subcontract with other Care Improvement Plus approved Providers to render care to Care Improvement Plus members as well. In all cases, Care Improvement Plus Providers are required to acknowledge and adhere to the following: STANDARDS OF CARE Providers are required to render medically necessary covered services to members in an appropriate, timely, and cost effective manner and in accordance with Care Improvement Plus s policies and procedures; including adherence to Care Improvement Plus s appointment wait time standards. Providers are required to support an open communication relationship with members regarding appropriate treatment alternatives without regard to cost or benefit coverage. Providers are required to accept and render service to members at the same level, scope, and quality of care rendered to all members and other patients. Providers must accept responsibility for the advice and treatment given to members and for the performance of all medical services in accordance with accepted professional standards. Providers must render service as applicable within the scope of their specialty. 2

8 Providers should make a concerted effort to educate and instruct members about the proper utilization of the practitioner s office in lieu of hospital emergency rooms. Providers shall not refer or direct members to hospital emergency rooms for nonemergent medical services at any time. Providers must meet all applicable requirements of the Americans with Disabilities Act (ADA), the Civil Rights Act of 1974, the Age Discrimination Act of 1975 and any other applicable laws or rules when rendering services to members with disabilities who may request special accommodations such as interpreters, alternative formats, or assistance with physician accessibility. At all times providers must preserve and enhance the member s dignity. DISCRIMINATION Providers are required to refrain from discriminating against any member on any basis prohibited by law, by the frequency or extent of services; Providers shall not discriminate because of member s religion, race, color, national origin, age, sex, weight, height, marital status, economic status, health status, sexual preference, or physical handicaps as further prohibited by law. Providers are further required to refrain from segregating a member or treating a member in a location or manner different from other members or other patients. ACCESSIBILITY Physician Providers are required to provide or arrange for urgent care, including emergency medical services on a 24-hour per day basis, 7 days per week. MEDICAL RECORDS Providers are required to create and maintain a health record-keeping system through which all pertinent information relating to the health care of members is accumulated and readily available to persons authorized to review these records, including Care Improvement Plus and its designee, subject to laws regarding patient confidentiality. CONFIDENTIALITY Providers are required to maintain and safeguard the privacy, confidentiality, and accuracy of member personal health information and records, consistent with state and federal laws and other regulatory bodies. Providers are required to adhere to the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements relating to the exchange of personal health information. HIPAA The privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L ), and their implementing regulations at 45 CFR Part 160, and Part 164, Subparts A and E (collectively the HIPAA Privacy Rule ), protect the confidentiality of personally identifiable medical information, known as protected health information (PHI), by limiting the use and disclosure of such information without the beneficiary s authorization. Care Improvement Plus and its Participating Providers must adhere to the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements. LICENSE, CERTIFICATIONS & PRIVILEGES Providers are required to maintain all licenses, certifications, permits, or other prerequisites required by law to render covered services, and submitting evidence that each is current and in good standing upon the request by Care Improvement Plus; including but not limited to Medicare certification. Providers are further required, as applicable, to maintain staff membership and 3

9 admission privileges in good standing at the network hospital stipulated in Provider s credentialed approval. Any changes in hospital privileges should be reported to Care Improvement Plus s Credentialing Department in writing. Care Improvement Plus 351 West Camden Street, Suite 100 Baltimore, MD Attention: Credentialing Department [email protected] POLICIES & PROCEDURES Providers must comply with applicable written policies and procedures as established or modified by Care Improvement Plus, which are available online through our Provider Portal at NETWORK PROVIDERS Providers are encouraged to utilize Care Improvement Plus network hospitals, physicians, and ancillary providers. A network directory may be found at However, providers may refer members to any Medicare approved provider as long as the provider agrees to accept payment from Care Improvement Plus. PHARMACEUTICAL PRESCRIPTIONS Providers are encouraged to prescribe and authorize the substitution of generic pharmaceuticals and otherwise abide by the Care Improvement Plus Formulary available upon request and found online at ADVANCE DIRECTIVES Providers are required to give adult members (age 21 and older) written information about their right to have an advance directive; advance directives are oral or written statements either outlining a member s choice for medical treatment or naming a person who should make choices if the member loses the ability to make decisions. For more information reference the Advance Directives Section. REPORTING AND DISCLOSURE/ENCOUNTER DATA Providers are required to submit data and other information, including medical records, as needed when necessary to characterize the content and purpose of each encounter with a member. Providers are required to certify to the accuracy of such information. NO BILLING OF MEMBERS Except for applicable coinsurance, co-payments or deductibles, providers may not seek any further out-of-pocket expenses from members for covered services. In order to bill a Care Improvement Plus member for a non-medically necessary service or noncovered service, the member must have prior written notice stating the specific service was not covered. 4

10 SECTION D PROVIDER RIGHTS AND RESPONSIBILITIES PRIMARY CARE PHYSICIAN Care Improvement Plus recognizes the important role that specialists have in the health care needs of our members. We also recognize the need for a Primary Health Care Provider to coordinate and monitor the overall clinical care needs of the patient (the physician primarily focuses on clinical aspects related to their chronic illness). As such, we encourage the member to identify a Primary Care Physician who will be willing to act in that capacity. A Primary Care Physician (PCP) is defined as a physician with a specialty of: family practice, general practice, internal medicine, and gerontology. When a Provider consents to act as Primary Care Physician for a member, it is the role of the Primary Care Physician to coordinate all health care and when medically necessary, refer Care Improvement Plus members to other specialists if needed. Primary Care Physicians responsibilities include but are not limited to: Notify Care Improvement Plus of all hospital admissions, if aware. Discuss and consider requests from members who have chosen that physician as their Primary Care Physician Perform services normally in his or her scope of practice Coordinate the provision of covered services to members by: (1) counseling members and their families regarding members medical care needs, including family planning and advance directives; (2) initiating medically necessary referrals; and (3) monitoring progress, care, and managing utilization of specialty services Render preventive health services; such services shall include, but are not limited to, periodic health assessments, immunizations, and other measures for the prevention and detection of disease Render immunization services without assessing a co-pay Participate and abide by all decisions regarding member complaints, peer reviews, quality improvement and utilization management Give direction and follow-up care to those members who have received emergency services Accept and participate in peer review Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) medical care Provide clinical documentation as requested SPECIALTY CARE PHYSICIANS All specialty care physicians have responsibilities that include, but are not limited to: Providing covered specialty care services to members (referrals are not required) Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) medical care Provide clinical documentation as requested FACILITY PROVIDERS All facility providers have responsibilities that include, but are not limited to: Providing covered services to members Obtain authorizations as appropriate 5

11 Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) Provide clinical documentation as requested ANCILLARY PROVIDERS All ancillary providers have responsibilities that include, but are not limited to: Providing covered services to members Obtain authorizations as appropriate Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) Provide clinical documentation as requested UPDATES TO PERTINENT INFORMATION Providers must give Care Improvement Plus written notification 30-days prior to any change in: address telephone number tax identification number (including a W-9 form) license status certification status Medicare certification status professional liability coverage other information supplied in the credentialing application. All updates should be directed to: Care Improvement Plus 351 W Camden Street, Suite 100 Baltimore, MD Attention: Credentialing Department [email protected] Failure to notify Care Improvement Plus may result in delay of or denial of payment for services rendered and the provider must hold the member harmless. APPEALS Providers may appeal claims where Care Improvement Plus has denied all or part of a claim. All appeals must be submitted within 60 days, or as stipulated in the provider s contract, from the date that the provider s payment was denied in whole or in part. The appeal case will undergo investigation and review by designated appeals staff who will work with a licensed physician for the plan to review cases of medical necessity and appropriateness of care. The provider must cooperate in sending all necessary medical documentation to support the case for the Plan s review. Care Improvement Plus will send a written decision within 60 days. If the initial decision is overturned, in whole or in part, a check will be sent following the decision. In making the decision, Care Improvement Plus follows Medicare coverage requirements, the benefit package applicable to the member, and Milliman Guidelines where needed. The Plan is also guided by the Provider Contract. If Care Improvement Plus upholds the initial denial, then the contracted provider is notified. At this point the contracted provider s appeal process is closed and the member cannot be balanced billed. Provider and Member Appeals: Members have appeal rights that begin with plan-level reconsideration and extend through four (4) additional levels of external review. Providers may appeal on behalf of a member, but only in the limited circumstances as allowed by federal law, as follows: 6

12 Expedited Appeals: Physicians may request an expedited appeal on behalf of the member. Expedited appeals (also known as reconsiderations) are cases where denied medical services or prescription drug(s) are of an urgent nature. That is, a delay in obtaining the medical services or prescription drug(s) could jeopardize the member s health, life, or ability to regain maximum function. Expedited appeals do not have to be in writing and may be initiated by calling for medical and for prescription drug appeals. Authorized Representative: Providers may serve as the official representative of the member by signing, along with the member, a CMS Form A letter that includes the same designation of authority and co-signed with the member may also be used. Once activated, an authorized representative has the same rights as a member in the Medicare member appeals process. Except for expedited appeals, all appeals should be in writing and mailed to the following address: Care Improvement Plus 351 West Camden Street, Suite 100 Baltimore, MD Attention: Appeals Department For more information on how to file an appeal, please call the Compliance Department at ; TTY users should call For prescription drug appeals, please call , or fax to MEMBER SOLICITATION Providers may announce new affiliations and repeat affiliation announcements for specific Plans through general advertising. An announcement to patients of a new affiliation which names only one Plan may occur once when such announcement is conveyed through direct mail and/ or . Providers contracted with Care Improvement Plus may: Provide the names of plans with which they contract and or participate Provide information and assistance in applying for the limited income subsidy Provide objective information on specific Plan formularies, based on a particular patient s medications and health care needs Provide objective information regarding specific plans, such as covered benefits, cost sharing, and utilization management tools Distribute Care Improvement Plus marketing materials, excluding enrollment applications Refer their patients to other sources of information, such as the State Health Insurance Assistance Programs, Plan marketing representatives, their State Medicaid Office, local Social Security Administration Office, CMS s website at or calling MEDICARE. Print out and share information with patients from CMS s website. Providers contracted with Care Improvement Plus may not: 7

13 Direct, urge or attempt to persuade, any prospective enrollee to enroll in a particular Plan or to insure with a particular company based on financial or any other interest of the provider. Collect enrollment applications Offer inducements to persuade beneficiaries to enroll in a particular plan or organization Offer anything of value to induce Plan enrollees to select them as their provider Expect compensation in consideration for the enrollment of a beneficiary Expect compensation directly or indirectly from the Plan for beneficiary enrollment activities. SECTION E BILLING & CLAIMS PAYMENT BILLING Care Improvement Plus follows Medicare payment policies and guidelines as directed in the Medicare Advantage Payment Guide. Providers must submit their claim on the current and appropriate Medicare billing form, with all required fields and documentation complete. Care Improvement Plus accepts both paper and electronically submitted claim forms from providers. Care Improvement Plus encourages providers to submit claims electronically whenever possible. There are many advantages to submitting claims electronically. Elimination of paper and associated expenses, more timely claims payment by Care Improvement Plus, and the ability to track submitted claims are just a few of the benefits. Care Improvement Plus utilizes Emdeon as our clearinghouse. The unique Electronic Payor ID is: Call for more information on Emdeon Business Services EDI Solutions. For more detailed information regarding Care Improvement Plus claims payment policies, please go online to to our provider portal and access the quick links for more information For claims status information, you can go to and log into the Provider Portal, call Provider Services at , or contact your Provider Relations Department at: [email protected] [email protected] [email protected] [email protected] [email protected] Medical Claims may also be submitted via paper to: Care Improvement Plus P.O. Box 488 Linthicum, MD Attention: Claims Department Pharmacy Claims may be submitted via paper to: Medco Health Solutions, Inc. PO BOX Lexington, KY

14 Dental and Vision Claims may be submitted via paper or electronically to: Avesis Third Party Administrators P.O. Box 7777 Phoenix, AZ Attention: Claims Department SECTION F CREDENTIALING PROGRAM PROGRAM OVERVIEW Care Improvement Plus maintains a comprehensive credentialing program, developed in accordance with CMS and the National Committee for Quality Assurance (NCQA) standards The credentialing process involves several steps including application, primary source verification, Credentialing Committee review and provider notification. All providers applying to the Care Improvement Plus network have the right to: Review information obtained in support of their credentialing application except for references, recommendations or other information peer review protected by law. Respond to information obtained during the credentialing process that is discrepant with the information submitted on their credentialing application. Correct erroneous information that may have been submitted. Be informed of the status of their credentialing or re-credentialing application upon request. The credentialing program is periodically reviewed by the Credentialing Committee and revised when necessary. All information obtained during the credentialing process is held in the strictest confidence. All providers shall be notified in writing of any denial, suspension or termination. RE-CREDENTIALING Providers are re-credentialed between 2 and 3 years of the date of their last credentialing cycle. The basic process is the same as the initial credentialing process. Additional criteria that may be used during the re-credentialing process include, but are not limited to: Compliance with health plan policies and procedures. Sanctions related to utilization management, administrative or quality of care issues. Member complaints Member satisfaction survey results Participation in quality improvement activities SECTION G USE OF ANCILLARY PROVIDERS ANCILLARY SERVICES Laboratory Services Any Medicare certified laboratory provider may be used. Physicians may do limited lab work in their offices some services will be considered bundled charges and will not be paid in addition to an office visit. For a listing of contracted laboratory facilities in your area, search our online provider directory or contact our Provider Services department. 9

15 Radiology Services Any Medicare certified radiology provider may be used. For a listing of contracted radiology facilities in your area, search our online provider directory or contact our Provider Services department. Physical Therapy Any Medicare certified therapy provider may be used. For a listing of contracted physical therapy facilities in your area, search our online provider directory or contact our Provider Services department. Home Health and Durable Medical Equipment Any licensed Home Health and/or DME supplier may be used. Select DME items require preauthorization. For a listing of contracted Home Health and DME suppliers in your area, search our online provider directory or contact our Provider Services department. SECTION H BEHAVORIAL HEALTH SERVICES PROGRAM OVERVIEW Care Improvement Plus recognizes that members with chronic medical illness may also have symptoms requiring behavioral health services for psychiatric or substance abuse treatment. Care Improvement Plus clinical staff will assist in accessing providers and facilities for treatment when these needs are identified. Members and providers can make routine requests for this assistance by calling the Care Improvement Plus Care Coordination Department from 8:00 am until 8:00 pm EST Monday through Friday at Emergency care needs should always be directed to the nearest Emergency Department or Local Hospital. SECTION I PHARMACY List of Prescriptions/Medications The Care Improvement Plus Formularies: Contain at least 2 drugs from each class Provide a framework and relative cost information for the management of drug costs Require generic drug prescription usage whenever possible. These drugs are listed with the generic name on the Formularies. If a member requests a brand name drug when a generic drug is available, the member may be responsible for additional charges Include quantity, form, dosage and preauthorization restrictions for certain drugs (Clinical and/or coverage determinations); and, Will be updated, reprinted and distributed to physician offices upon request. Physician offices needing additional copies of the list should contact Care Improvement Plus Provider Services at The formulary and any recent changes are also available online at: Preauthorization Some medications as noted on the Care Improvement Plus Formulary require preauthorization from Care Improvement Plus (clinical (PA), quantity limit (QL) or Part B/D coverage determination (B/D)). Prescriptions requiring preauthorization should be called in to (TTY: ). 10

16 Exceptions Members may request an exception when they wish to receive a drug that is not on the formulary or to receive a drug at a lower coinsurance/ co-pay/ tier. The Care Improvement Plus Pharmacy department reviews the request and may contact the prescriber to obtain information necessary to approve or deny the request. The decision to approve or deny the request will be made within 72 hours of receiving complete information for a standard request or within 24 hours of receiving complete information for an expedited request. Members may request a re-determination of any denial of coverage (See Section M- Members Rights and Responsibilities, page 26 for more detailed information on pharmacy appeals, including the right to an expedited appeal). More information on requesting an exception (including provider and member forms to request an exception) is available online at careimprovementplus.com Transition All new enrollees may receive a one time refill of any non-formulary medication for up to a 90 day period after enrollment. Providers and patients should consider switching to a formulary option in advance to the next refill of medication. A notification will be sent to the provider and member regarding the need to transition to a formulary medication. Four-Tier and Five-Tier Co-pay Structure Care Improvement Plus has set up two co-pay structures within the Formulary. There is a fourtier and a five-tier co-pay structure. The five-tier copay structure applies only to beneficiaries who have enrolled in the Plus Gold and Platinum plans. Most drugs are covered (with the exception of exclusions as listed in the member s Certificate of Insurance). Co-payments vary depending on the tier in which the prescription drug falls. To access a copy of our Tier 4 or Tier 5 formulary or to access our online formulary search tool, go to select the appropriate state from the Provider Portal dropdown list, and click Submit. Once inside the Provider Portal, select Medicare Part D from the left-hand navigation. Tiers include: Generic (Tier 1) Preferred Brand (Tier 2) Non-Preferred Brand (Tier 3) Specialty Drugs (Tier 4) Formulary Zero Copayment Drugs (Tier 5) Generic drugs rated AB products by the FDA. Care Improvement Plus covers all generics (including those not listed on the printed formulary) that are not excluded by Medicare. Agents approved by the FDA as safe and effective, not available as AB rated generics. These drugs have been reviewed by the Pharmacy and Therapeutic Committee as drugs that are standards of care to be used for reasons of increased safety, efficacy and cost-effectiveness over other available FDA approved drugs. Non-Preferred brand drugs process at a higher copay level than preferred brand medications. They are often injectable or infused medications, but may also include oral agents. Centers of Medicare Medicaid Services defines specialty medications as medications that may cost at least $600 per month. Select generic and brand name formulary medications specific to certain disease states such as diabetes, heart failure (HF), and COPD, are available with a $0 co-pay for the life of the benefit including the coverage gap. This benefit is available only to beneficiaries in the Gold Rx Plus and Platinum Rx Plus Plans. 11

17 Preauthorization Exceptions Transition Some medications as noted on the Care Improvement Plus Formulary require pre-authorization from Care Improvement Plus (clinical (PA), quantity limit (QL) or Part B/D coverage determination (B/D)). Preauthorization may be requested by calling Medco Health Solutions Preauthorization Department at Members may request an exception when they wish to receive a drug that is not on the formulary or to receive a drug at a lower coinsurance/co-pay/tier. The Care Improvement Plus Pharmacy department reviews the request and may contact the prescriber (as necessary) to obtain information necessary to make a coverage decision. The decision to approve or deny the request will be made within 72 hours of receiving complete information for a standard request or within 24 hours of receiving complete information for an expedited request. Members may request a redetermination of any denial of coverage (See Section M- Members Rights and Responsibilities, page 26 for more detailed information on pharmacy appeals, including the right to an expedited appeal). More information on requesting an exception (including provider and member forms to request an exception) is available online at careimprovementplus.com All new enrollees are eligible to receive a one time refill of any non-formulary medication (as long as it is not excluded by Medicare) for up to a 90 day period after enrollment. Providers and patients should consider switching to a formulary option in advance of the next refill of the nonformulary medication. A notification will be sent to the member regarding the need to transition to a formulary medication. Members who are experiencing a level of care change to or from a long term care facility may be eligible for additional transition supplies after the initial 90 day period. SECTION J VISION AND DENTAL COVERAGE Care Improvement Plus covers medical services for vision care as well as routine vision screening services that are typically not covered by Medicare. Care Improvement Plus offers routine eye exams and a materials benefit to purchase frames, lenses or contacts. A list of contracted routine vision service providers is located in the provider directory. Care Improvement Plus also offers a routine dental benefit, which includes cleaning, exam and x-rays. Some plans offer comprehensive coverage as well. A list of contracted routine dental service providers is located in the provider directory. This is a general description only. Please refer to members Evidence of Coverage and summary of benefits for benefit information. In the event of any conflict between the Evidence of Coverage and this provider manual, the Evidence of Coverage shall prevail. 12

18 SECTION K UTILIZATION AND CASE MANAGEMENT COMPLEX CASE MANAGEMENT Care Improvement Plus Complex Case Management program is a customized/case-specific approach to managing complex, resource-intensive cases, and provides education and counseling for our members. Our Case Managers develop and implement proactive care plans designed to reduce or eliminate barriers to care, especially those in the realm of psychosocial or socioeconomic barriers, our goal is to maximize participation with the chronic care management approaches proven to be successful in enhancing health outcomes. Care Managers collaborate with Primary Care Physicians, discharge planners, social workers, community outreach programs, family and caregivers. We encourage providers to make referrals to our Case Management Department at , Monday -Friday, 8:00 a.m. - 5:00 p.m. EST. CHRONIC CARE MANAGEMENT Care Improvement Plus offers fully integrated chronic care management programs for high prevalence, high cost conditions that encompass the full continuum of disease management interventions from low-risk through high-risk. We take a comprehensive focus on care issues surrounding diabetes, heart failure, chronic obstructive pulmonary disease and end stage renal disease. The programs are proactive, criteria and risk-based with targeted clinical outcomes, focused on meeting the health needs of members. UTILIZATION REVIEW Utilization Management staff will perform review services telephonically and/or onsite and review the member s admissions, services and continued stays for medical necessity and appropriateness of the level of care. Utilization Management staff may also screen for quality and/or risk management issues, participate in and coordinate the discharge planning process, and identify member s post-discharge needs. Care Improvement Plus medical director may, from time to time, ask to speak with a member s provider to discuss a plan of care or institutional stay. SERVICES REQUIRING PREAUTHORIZATION: Services requiring preauthorization can be found in Appendix C of this manual. In addition, certain Part B Drugs provided in the physician s office require an administrative authorization as noted on the website, For any experimental or other service where provider are uncertain of coverage, e.g. transplants, weight loss (bariatric surgery), etc. you may call the preauthorization line for a predetermination. Generally we follow Medicare guidelines. However, a provider or member always has the right to request a predetermination. SECTION L QUALITY IMPROVEMENT PROGRAM OVERVIEW Care Improvement Plus s Quality Improvement program aims to ensure that timely, efficient and quality clinical care and services are rendered to our members. We participate in all CMS reporting and survey requirements, including all Quality Assurance Performance Indicators (QAPI) reporting requirements to CMS as well as the annual HEDIS, NCQA, CAHPS, and HOS surveys. The program seeks to demonstrate value and improve quality through the elimination of over, under, and misuse of services by: 13

19 Measuring, assessing, and coordinating the quality of clinical care across Care Improvement Plus delivery system. Promoting members health through health promotion, disease management, and condition pathways. Assisting members to engage in healthy behaviors and encourage active selfmanagement. Implementing interventions to improve the safety, quality, availability, and accessibility of, and member satisfaction with, care and services. Care Improvement Plus has a long-term commitment to quality improvement initiatives that encompass the full spectrum of care and services provided to our members. The Quality Improvement Program is dedicated to fulfilling that commitment by working with the provider community to establish evidence-based clinical guidelines and service standards. The guidelines and measures are used to develop tools for the purpose of providing feedback to members and providers, to encourage improvement. CLINICAL PRACTICE GUIDELINES The Quality Improvement Committee (QIC) is responsible for identifying appropriate nationally recognized clinical guidelines for use in Care Improvement Plus clinical programs. Care Improvement Plus s guidelines outline specific, well accepted clinical treatments for these medical conditions. All guidelines are evidence-based so as to achieve optimum, high-quality health outcomes. The complete set of guidelines is reviewed annually by Care Improvement Plus Medical Advisory Board comprised of community based physicians and clinical experts. PREVENTIVE SERVICES GUIDELINES When providers consistently offer preventive services, patients are able to maintain or improve their health, while avoiding more costly and invasive medical procedures. With prevention, everybody wins. These guidelines are evidence-based, offering only recommendations that are well supported in the medical literature. Every year the guidelines are reviewed and updated as needed. HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS) Care Improvement Plus is required by CMS to submit data annually that measures health plan performance for HEDIS reporting. During annual HEDIS preparation, Care Improvement Plus may request medical files which will be reviewed for record-keeping practices and adherence with HEDIS clinical performance indicators. The HEDIS quality indicators may be obtained at the National Committee for Quality Assurance website at: MEDICAL RECORDS Care Improvement Plus requires all affiliated providers to abide by the medical record standards established by Care Improvement Plus policy as well as state and federal regulations. These standards are based on the requirements of NCQA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and other regulatory bodies. Care Improvement Plus s Quality Improvement department routinely audits all provider sites for medical record-keeping practices during the credentialing process and re-credentialing process, when applicable. 14

20 SECTION M MEMBER RIGHTS AND RESPONSIBILITIES MEMBER RIGHTS Care Improvement Plus members have the right to understand their health conditions and to participate in health care decisions. To ensure that members attain the maximum benefits, we encourage members to exercise their rights, including but not limited to: Receive considerate and respectful care, regardless of nationality, race, creed, color, age, economic status, sex, lifestyle or severity of illness Be treated with respect and to have their dignity and personal privacy recognized Obtain complete and current information about their treatment alternatives without regard to cost or benefit coverage Understand their health conditions and to participate in health care decisions Receive all information needed to give informed consent prior to the start of any procedure or treatment including an explanation of procedures and any potential risks Be informed of the Care Improvement Plus affiliated providers available to deliver medical care Access to complete and current information about Care Improvement Plus, its services, practitioners and providers Receive prompt treatment in an emergency Voice an opinion or to file a grievance or appeal MEMBER RESPONSIBILITIES Care Improvement Plus is committed to treating its members in a manner that respects their rights and addresses their responsibility for cooperating with Care Improvement Plus staff and Care Improvement Plus affiliated practitioners and providers. Member responsibilities include but are not limited to: Make a full and complete disclosure of their medical history and symptoms before and during the course of treatment Follow the agreed upon plan and instruction from their health care provider Treat Care Improvement Plus staff, Care Improvement Plus affiliated providers and their personnel, and other Care Improvement Plus members or patients respectfully and courteously Keep scheduled appointments or give adequate notice of delay or cancellation of appointments Notify their health care provider of any unexpected health changes Understand and follow Care Improvement Plus policies and procedures Provide pertinent information to Care Improvement Plus and its affiliated providers in order to render health care benefits and health care services OUT OF AREA SERVICES Emergency and urgent care services, as well as renal dialysis services, are covered when an enrollee is out of the Care Improvement Plus service area temporarily. Care Improvement Plus also covers ambulance services for medical emergencies. PRIMARY CARE PHYSICIAN SELECTION All members are encouraged to identify a Primary Care Physician (PCP), and Care Improvement Plus s Member Services department will assist with that process if needed. The process begins with a new member s enrollment application. A member may identify their PCP at enrollment into Care Improvement Plus, or Members can also select a PCP by contacting Care Improvement Plus s telephone line, or going online at 15

21 PROVIDER TERMINATIONS While Care Improvement Plus does not require members to be assigned to a Primary Care Physician (PCP), when known, we will notify affected members 30 days before the effective date of a Primary Care Physician termination. The notification will include information that will assist the member in selecting a new PCP, if requested. It will also identify resources for additional physician selection assistance. Reasons for terminations will remain confidential. GRIEVANCE PROCEDURE The purpose of the member grievance process is to provide a mechanism by which a Care Improvement Plus member who is dissatisfied with any aspect of the health plan may file a formal grievance and have the complaint investigated. A grievance is any complaint other than an adverse decision with regard to a service or claim (e.g., denied authorizations and denied claims are appeals, not grievances). Timeframes for responding to grievances are as follows: 30 days for regular grievance, but may extend 14 calendar days if additional information is required 24 hours for an expedited grievance MEMBER APPEALS Members or their authorized representatives may request in writing an appeal of a denied service, such as a disapproved authorization or admission, or a denied claim. The member has 60 days from the date of the denial to file an appeal. Care Improvement Plus conducts these reconsiderations, or first level appeals, according to federal requirements. There are standard timeframes for medical appeals and claims appeals. There also are expedited appeals for medical services. The timeframes are as follows: Standard medical reconsiderations: Up to 30 calendar days, with a possible extension of 14 calendar days Expedited reconsiderations: 72 hours or less based on need, with a possible extension of 14 calendar days Medical claim reconsiderations: No more than 60 days. With the prescription drug benefit, there are also appeals, or redeterminations. Appeals related to the drug benefit may occur when a formulary drug is denied, a member s drug claim is denied, a request for an exception to the tiering structure of the formulary is rejected, a request for an exception to a drug utilization management tool is rejected, or a request for a non-formulary drug is denied (See Section I: Pharmacy Services). As with medical services, there are expedited appeals in addition to the standard timeframes: Standard drug redeterminations: Up to 7 days Expedited drug redeterminations: 72 hours or less There are several sources of information on how an enrollee may file an appeal, such as in their Evidence of Coverage, on the plan website, and on denial notices. Questions may be directed to Provider Services at If Care Improvement Plus upholds Part C denial, the case is then sent to an external, Independent Review Organization (Maximus). The enrollee may keep appealing through two additional levels of federal review and ultimately seek Judicial Review. 16

22 SECTION N ADVANCED DIRECTIVE ADVANCE DIRECTIVES Every competent adult and emancipated minor has the right to execute an Advance Directive. The Patient Self-Determination Act requires that a provider of services must document in the individual s medical record whether or not the individual has executed an Advance Directive. Participating providers must demonstrate compliance with all applicable state and federal laws and regulations. Care Improvement plus routinely provides information on Advance Directives to members upon enrollment. Provider Relations may conduct provider staff education on Advance Directives along with regular updates and reminders. Providers seeking information on Advance Directives and/or forms can contact the Provider Relations Department at Care Improvement Plus. 17

23 A Sample Member Identification Card APPENDIX 18

24 B Electronic Billing 19

25 C UM Authorization Fact Sheet 20

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