Welcome to American Eldercare, Inc.

Transcription

1 PROVIDER HANDBOOK

2 Welcome to American Eldercare, Inc. Thank you for joining our provider network. We look forward to working with you to provide quality, accessible services to our members. American Eldercare, Inc. is committed to distributing comprehensive and timely information to providers through this Provider Handbook. This handbook will assist you with information on: Care Management services Claims submission Covered Services Authorization process You will be notified of updates to this handbook via bulletins and notices posted on our website at If you need further explanation on any topics discussed in this handbook, please contact your local Provider Relations Specialist. A complete listing of our offices is located in Section 8, Appendix. Sincerely, Provider Relations Department ii

3 TABLE OF CONTENTS Section 1 Introduction... Page 6 Long Term Care Managed Care Program.. Page 7 Practice Guidelines... Page 8 Mission Statement.. Page 8 Office Hours Page 9 AEC Website. Page 9 Confidentiality Statement Page 9 Section 2 Covered Services... Page 10 Medical Necessary/Necessity.. Page 11 Emergency Service Responsibilities Page 11 Adult Day Care. Page 12 Assistive Care.. Page 12 Assisted Living Page 12 Behavioral Management Page 14 Home Adaptations Accessibility. Page 14 Home Delivered Meals. Page 15 Home Health Care... Page 15 Hospice.... Page 17 Medical Supplies (Consumable Medical)... Page 18 Medical Supplies (Durable Medical Equipment).. Page 18 Nursing Facility Services. Page 19 Nutritional Assessment/Risk Reduction Page 20 Personal Emergency Response Systems. Page 20 Pharmacy Benefits Page 21 Transportation.. Page 21 Quality Enhancements Page 21 Section 3 Eligibility.. Page 22 Conditions of Enrollment.. Page 22 Medicaid Pending. Page 23 Membership Identification Card.. Page 23 iii

4 Referrals to American Eldercare... Page 24 Member Disenrollment.. Page 24 Hospice.. Page 26 Section 4 Care Management. Page 27 Authorizations.. Page 27 Chronic/Complex Conditions. Page 28 Abuse, Neglect, Exploitation. Page 29 Critical Incident Reporting Page 30 Member Rights and Responsibilities.. Page 30 Section 5 Provider Responsibilities Page 33 Credentialing Committee.. Page 33 Initial Credentialing.. Page 33 Re-credentialing. Page 34 Provider Monitoring. Page 35 Right to Review and Correct Information Page 35 Right to Appeal Adverse Credentialing Determination Page 35 National Provider Identification Page 36 Provider Orientations and Education Page 36 Notice Obligation.. Page 36 Provider Handbook Page 37 Provider Directory Page 37 Participating Agreement Standards... Page 37 Accessibility & Availability. Page 38 Provider Satisfaction. Page 38 Provider Medical/Case Record Review.. Page 38 Termination of Provider Contract Page 39 Out-of-Network/Non-Contracted Services Page 39 Community Outreach/Marketing. Page 40 Provider Responsibilities. Page 41 Provider Complaints. Page 41 Cultural Competency.. Page 43 Section 6 Claims/Billing... Page 44 iv

5 Claims Submission Page 44 Electronic Claims. Page 44 Paper Claims. Page 45 Encounter Data. Page 46 Assisted Living Facilities Providers.. Page 47 Skilled Nursing Facility Providers Page 48 Home Health Providers.. Page 49 Claims Acknowledgement.. Page 49 Payments Page 50 Balance Billing Page 51 Claim Inquiry.. Page 51 Claim Denial.. Page 51 Claims Reconsideration of Payment. Page 52 Formal Grievance/Appeals Page 52 Formal Appeal. Page 52 Expedited Appeals Page 54 Beneficiary Assistance Program.. Page 54 Unresolved Grievance/Appeals- Medicaid Fair Hearing.. Page 55 Section 7 Forms Page 57 Authorization Forms. FORMS Claims Form.. FORMS Provider Complaint Form. FORMS Provider Change of Notice Form.. FORMS Section 8 Appendix. Page 58 AEC Locations.. Appendix CARES Offices Appendix Denial Codes. Appendix Remittance Advice.. Appendix v

6 1 INTRODUCTION American Eldercare Inc. (AEC) is a Provider Service Network (PSN) and home health agency that provides services to our members in the most appropriate care setting. Our Long-Term Care Managed Care Plan works directly with the State of Florida to provide our members with quality community and/or facility care with a focus to coordinate the member s primary care through his/her primary insurance. American Eldercare, Inc. was the only company to be chosen as a state-wide contractor of this program, allowing our membership to freely move to any county they choose in the state. Our first goal is to keep our members in their home and provide quality home health care and community-based services to delay or avoid long-term placement in a nursing facility. If our members needs a more supervised environment or wants more socialization we will assist to subsidize and monitor them to receive services in an Assisted Living Facility or an Adult Family Home. We understand that some of our members will require nursing home care, and we ensure that they transition to this level of care when it is no longer safe to remain in a community setting. We offer care to meet the individual needs of each of our members. The State of Florida s goals for this program are: Coordinated long-term care across different health care settings. A choice of the best long-term care plan for their needs. Long-term care plans with the ability to offer more services. Access to cost-effective community-based long-term care services. American Eldercare, Inc. has established guidelines to assist you in understanding the goals of our program. This handbook will provide you with vital information in order to develop and maintain an effective partnership in meeting our members needs. As American Eldercare, Inc. (AEC) is a Provider Service Network (PSN) that is contracted with 6 P a g e

7 the State of Florida to participate in the Long Term Care Managed Care Program. Our primary goal is to identify members that may safely remain in their home environment and provide them with quality community-based services in order to delay or avoid long-term placement in a nursing home. We accomplish this by completing a comprehensive assessment and creating a care plan that meets the individual needs of our members. If members are no longer able to safely remain in their home we coordinate services for them to reside in an assisted living facility, adult family home or a nursing home that meets their level of care. We are successful in having our members remain in the least restrictive environment that safely meets their needs by having a care manager specifically assigned to each individual member to coordinate both their acute and long-term care needs. LONG-TERM CARE MANAGED CARE PROGRAM American Eldercare, Inc. is proud to participate as a contractor for the State of Florida to operate a Medicaid funded program known as the Long-Term Care Managed Care Program. Medicaid is a program for eligible individuals and/or families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid must be U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States. The Long-Term Care Managed Care Program is designed to care for all eligible individuals over the age of 18 who meet a level of care to require nursing home care as well as a financial criterion; both qualifications are determined by the state. The program provides eligible individuals to access care in a nursing home or a less restrictive environment in the community. The goal is to reduce the number of individuals residing in nursing homes that can be cared for in a less restrictive environment in order to create cost savings for the state. 7 P a g e

8 PRACTICE GUIDELINES American Eldercare, Inc. has adopted practice guidelines that are embedded within our policy and procedures and our daily business practices. Practice Guideline Requirements: a) Are based on valid and reliable clinical evidence or a consensus of healthcare professionals in the field of disabilities and geriatric industry. b) Considers the needs of the members. c) Are adopted in consultation with contracted health care professionals when deemed necessary. d) Are reviewed and updated periodically as appropriate. e) AEC will disseminate the guidelines to all affected providers and upon request to members and potential members. f) Decisions for utilization management, member education, coverage of services, and other areas to which these guidelines apply will be consistent throughout the Policy and Procedure Manual and daily business practices. MISSION STATEMENT Our mission is to provide comprehensive, effective, cost-efficient health care and related services, through a community-based program tailored to the individual. Core Values: A - Advocacy E - Ethics C - Compassion 8 P a g e

9 OFFICE HOURS Our dedicated staff is available to answer any questions between the hours of 8:00 am - 8:00 pm, Monday Friday. If you have questions regarding services or benefits, you can call the Provider Help Line at (888) Our provider help-line is available twentyfour (24) hours a day seven (7) days a week including weekends and holidays. For a complete listing of our offices, please refer to Section 8, Appendix of this handbook. AMERICAN ELDERCARE WEBSITE ( The American Eldercare, Inc. website is designed to give providers quick access to current provider and member information twenty four (24) hours a day, seven days a week. You will also find information about other programs and useful information and resources about American Eldercare, Inc. Please contact your local Provider Relations Specialist with any questions or concerns regarding the website. CONFIDENTIALITY STATEMENT American Eldercare, Inc. maintains a policy to ensure that medical records, claims information and grievances pertaining to members and providers will remain confidential. The authorized release of any information is used only for the resolution of medical problems or to enhance a member s health. American Eldercare, Inc. will ensure compliance with the Privacy and Security provisions of the Health Insurance Portability and Accountability Act (HIPAA). 9 P a g e

10 2 COVERED SERVICES American Eldercare, Inc. provides coverage for members who are enrolled in our Long- Term Care Managed Care Program. Coverage is limited to those services authorized in writing by the member s Care Manager and in accordance with the Agency for Health Care Administration Medicaid Services Coverage & Limitations Handbooks. A summary of these services is below: Adult Companion Care Adult Day Health Care Assistive Care Services Assisted Living Attendant Care Behavioral Management Caregiver Training Care Coordinator/Case Management Home Accessibility Adaptation Services Home Delivered Meals Hospice Intermittent and Skilled Nursing Medical Equipment and Supplies Medication Administration Medication Management Nutritional Assessment/Risk Reduction Services Nursing Facility Services Personal Care Personal Emergency Response System (PERS) Respite Care Occupational Therapy Physical Therapy Respiratory Therapy Speech Therapy Transportation* *Non-emergent transportation services will be offered in accordance with the member s plan of care and coordinated with other service delivery system. 10 P a g e

11 MEDICAL NECESSARY/NECESSITY Medical Necessary or Medical Necessity is determined as per 59G-1.010(166) as described below: Medically necessary or medical necessity means that the medical or allied care, goods, or services furnished or ordered must: (a) Meet the following conditions: 1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; 2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient s needs; 3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; 4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and 5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. (b) Medically necessary or medical necessity for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. (c) The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services do not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service. EMERGENCY SERVICE RESPONSIBILITIES If a member requires emergency acute care services, contact their primary insurance for pre-certification or send them to the emergency room as deemed appropriate. Please contact their assigned Care Manager or AEC Customer Service department once the emergency is addressed so the Care Manager may follow up to coordinate care. 11 P a g e

12 If a member requires emergency care that is a covered long-term care service, please contact the Care Manager or AEC Customer Service Department to receive precertification. If it is after business hours, please follow the prompts to reach our after-hours staff. ADULT DAY CARE (ADC) This service provides member with supervision, socialization and therapeutic activities in an outpatient setting. This also provides caregiver with respite. Meals are included as part of this service when the member is at the center during meal times. Adult Day Care health services include but not are limited to the following: 1. Licensed nurse full-time 2. Supervised, recreational activities at least 80% of the day 3. Physical exercises 4. Cognitive exercises 5. Lunch and snacks 6. Coordination of transportation 7. Medication administration and management 8. Vital signs monitoring 9. Basic health monitoring, to include glucose level checks 10. Referral to physical therapy screening (conducted on-site) 11. Hands-on assistance with personal care, such as toileting, eating, ambulating and grooming ASSISTIVE CARE 24-hour services for Members in assisted living facilities, adult family care homes and residential treatment facilities. ASSISTED LIVING (ALF) This service provides member with an alternative living arrangement where there is access to 24-hour staff. Meals, personal care and housekeeping services are provided by staff. Facility may be used for respite care. The facility provides a home-like environment to 12 P a g e

13 members. The Community will provide member with the following services or as indicated in each individual provider contract: hour access to staff 2. Bathing assistance 3. Medication management 4. Three meals per day, plus snacks 5. Incontinence management 6. Incontinence supplies 7. Nutritional supplements 8. Housekeeping 9. Personal laundry & linen service 10. Utilities 11. Transportation or coordination of transportation 12. Alarmed doors or locked unit 13. Personal hygiene items 14. Escort to dining room 15. Emergency/Disaster Plan 16. Dementia care Respite Care Provides caregivers with relief, for short periods of time. (May be provided by an Assisted Living Community) Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist. Transportation All AEC contracts with ALFs require the ALF to coordinate transportation for our members. AEC enrollees are eligible for transportation trips to long-term care covered services as authorized by AEC. Please contact the enrollee s Care Manger for authorization approval. Our members will use their Medicaid gold card or their current acute Medicaid health plan ID card respectively for all trips to non-ltc covered services (including emergent transportation) as they do now. 13 P a g e

14 AEC Welcome Home Program Discharge planning from Hospital & Rehabilitation AEC has a Welcome Home Program in place in order to assist our members to return to your facility as soon as their needs can be met in your community. Our Care Management staff will assist in the coordination of their discharge including access to Medicare Home Health services if needed. The success of this program requires your facility to participate by evaluating your residents in a timely manner to coordinate a safe return. Facilities that are not willing to participate in the Welcome Home Program may not be eligible for a bed-hold payment. Hospice Providers are required to inform AEC staff of any changes or concerns they may identify while providing services to a member in order to ensure their needs are being met. This includes notification of a member being admitted to a hospital and/or enrolling in a Medicare Hospice program. Notification must be provided within twenty four (24) hours of the admission. Medicaid Hospice services require pre-authorization from AEC. BEHAVIORAL MANAGEMENT This service provides behavioral health care services to address mental health or substance abuse needs of long-term care members. The services are used to maximize reduction of the member s disability and restoration to the best functional level. HOME ADAPTATIONS ACCESSIBILITY These services provide member with home modifications, which promote safety. This Includes installation of grab bars, ramps and widening of doors. Services do not include home modifications, which are considered home improvements. All services must be provided in accordance with applicable state and local building codes. 14 P a g e

15 Members or caregivers will be contacted within two (2) business days of receipt of authorization from the AEC Care Manager to schedule an appointment. Installation will take place within two (2) weeks. HOME DELIVERED MEALS This service provides members who are unable to shop or cook with nutritionally sound meals that are delivered to the home hot, cold, frozen, dried, or canned with a satisfactory storage life. Each meal is designed to provide 1/3 of the Recommended Dietary Allowance (RDA). A signature must be obtained from the member or caregiver upon delivery of meals. Members must go through their Care Manager to make any changes to their meal delivery. Services will begin within five (5) business days of receiving a written authorization from the AEC Care Manager. HOME HEALTH CARE (HHC) As a contracted provider for AEC the following procedures will be adhered to when providing services. a) AEC reserves the right to determine the plan of care for its members, and will send a request of specific services and frequency in order to meet the member s needs. Services may be provided in a member s home or an assisted living facility on an hourly or per visit fee as authorized by AEC. The HHC provider has a maximum of two (2) days to inform AEC staff if the requested services can be provided and the anticipated start date. b) HHC staff is required to have the Agency s designated form signed by the member verifying that the services were provided at the time of each visit, including date/time of service and direct care staff that provided the service. A copy of this form must be submitted to AEC when the claim is submitted. 15 P a g e

16 c) If an AEC member is entitled to Medicare Home Health benefits, these benefits will be utilized prior to services being authorized under your contract with AEC. Home Health services are authorized by the Care Manager on a weekly basis (Sun Sat). Pre-authorization is required by the Care Manager to provide services that exceed the number of hours authorized in a day or in a week. The only variation that is allowable without a pre-authorization is to switch the days of services within the same week, with prior authorization of the member (patient). If the schedule change is permanent, the provider should inform the Care Manager of the change. Adult Companion Companions can perform tasks such as meal preparation, laundry and shopping, while providing socialization for the member. This includes light housekeeping tasks incidental to the care and supervision of the member. Services do not include hands-on nursing care or bathing assistance. Family Training This service provides training to family members in order to promote safety while caring for the member. This includes education on diabetic management, transferring a person, and how to use safety equipment properly. Homemaker Services This service provides member assistance with general household activities to include meal preparation, laundry and light housekeeping. Occupational Therapy This service provides member with treatment to restore, improve or maintain impaired function in regards to daily living tasks. (E.g. using a fork, shower chair, or cooking from a wheel chair) 16 P a g e

17 Personal Care This service provides member with assistance with bathing, dressing, eating, personal hygiene and other activities of daily living. A personal care worker can do incidental housekeeping, such as making beds and cleaning up areas where they have performed services. Physical Therapy This service provides member with treatment to restore, improve or maintain impaired function in regards to ambulation and mobility such as walking, transferring, or using a walker or wheel chair. Respite Care This service provides caregivers with relief, for short periods of time. Respite care may be provided by a Home Health Agency, Assisted Living Community or a Skilled Nursing Facility. Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist. Speech Therapy This service provides member with evaluation and treatment with regards to oral motor functions. (E.g. difficulties swallowing or speaking) This service also includes treatment to restore, improve or maintain impaired functions in order to promote a member s independence and capacity to live safely in the home setting. This includes physical, occupational and speech therapies. HOSPICE This service provides forms of palliative medical care and services designed to meet the physical, social, psychological, emotional and spiritual needs of terminally ill members and their families. Care Managers will coordinate this care with members enrolled in Medicare Hospice services. If a member requires any hospice service traditionally covered by Medicaid, pre-authorization is required from the Care Manager. 17 P a g e

18 MEDICAL SUPPLIES (CONSUMABLE) These services provide member and caregiver with supplies that assist in meeting the member s needs. Items include incontinent supplies and diabetic supplies not covered by Medicare. These services do not include personal toiletries, over the counter medications or household items. Consumable medical supplies include adult disposable diapers, tubes of ointment, cotton balls and alcohol for use of injections, medicated bandages, gauze and tape, colostomy and catheter supplies, and other consumable supplies. Not included are supplies covered under Home Health service, personal toiletries, and household items such as detergents, bleach, paper towels, or prescription drugs. Services require written authorization from the AEC Care Manager. Supplies will be delivered to the member s home and the member or caregiver will sign an itemized receipt. Members must go through their Care Manger to make any changes to their order. Nutritional supplements require both a Physicians prescription and pre-authorization from the AEC Care Manager. Members authorized to live in a contracted facility will receive this service directly from the facility. MEDICAL SUPPLIES (DURABLE MEDICAL EQUIPMENT) Durable Medical Equipment is medical equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose; is generally not useful in the absence of illness or injury; and is appropriate for use in the recipient's home. Medicare and Medicaid Acute Care Programs cover most DME equipment that AEC members need. Any items needed by AEC members that are not covered by Medicare require preauthorization from the AEC Care Manager. 18 P a g e

19 NURSING FACILITY SERVICES (SNF) This service provides twenty-four (24) hour assistance and nursing services for the member, when they can no longer remain in the community. Member must be evaluated by American Eldercare, Inc. staff to determine if they can be maintained in a less restrictive environment. Skilled nursing facility services will be coordinated with the members acute care coverage. If a member is dual eligible for Medicare/Medicaid, AEC is responsible for coinsurance as per the Medicaid crossover guidelines. Claims must be submitted with Medicare EOB. The SNF staff is expected to inform AEC staff of any changes or concerns they may identify while providing services to a member in order to ensure that their needs are being met. Respite Care Provides caregivers with relief, for short periods of time. (May be provided by a Skilled Nursing Facility Respite care does not substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist. Transportation All AEC contracts with SNFs require the SNF to coordinate transportation for our members. AEC enrollees are eligible for transportation to long-term care covered services, as authorized by AEC. Please contact the enrollee s Care Manager for authorization approval. Our members will use their Medicaid gold card or their current acute Medicaid health plan ID card, respectively, for all transportation trips to non-ltc covered services (including emergent transportation) as they do now. Hospice Providers will inform AEC staff of any changes or concerns they may identify while providing services to a member in order to ensure their needs are being met. This includes notification of a member being admitted to a hospital and/or going to a Medicare or Medicaid Hospice program. Medicaid Hospice services require pre-authorization from AEC. Notification must be provided within twenty-four (24) hours of a significant change in the member s health care needs. 19 P a g e

20 Custodial Care All members requiring this service must be assessed and determination must be made by American Eldercare, Inc. that the member can no longer live in a less restrictive setting. Members who receive approval for placement in a contracted Nursing Facility for custodial care are required to pay the facility a patient responsibility based on their income, which is determined by the Department of Children and Families. Prior authorization is required by AEC. AEC Welcome Home Program Discharge planning from Hospital & Rehabilitation AEC has a Welcome Home Program in order to assist our members to return to the least restrictive environment that safely meets their needs. Our Care Management staff will assist in the coordination of our members discharge plan (including access to Medicare Home Health and/or Assisted Living Placement services if needed). The success of this program requires your facility to partner with the American Eldercare, Inc. staff in order to implement a safe discharge plan. NUTRITIONAL ASSESSMENT/RISK REDUCTION This service provides member with an assessment, hands-on care and guidance for the caregiver and members with respect to nutrition. (Provided by a dietitian usually from a Home Health Agency) AEC reserves the right to determine the plan of care for its members and will send a request of specific services and frequency in order to meet the member s needs. Services may be provided in a member s home or an assisted living facility on an hourly or per visit fee as authorized by AEC. The provider has a maximum of two (2) days to inform AEC staff if the requested services can be provided and the anticipated start date. PERSONAL EMERGENCY RESPONSE SYSTEM (PERS) The installation and service of an electronic device that enables members at high risk of institutionalization to secure help in an emergency. The PERS is connected to the 20 P a g e

21 member's phone and programmed to signal a response center once a "help" button is activated. The member may also wear a portable "help" button to allow for mobility. PERS services are generally limited to those members who live alone or are alone for significant part of the day and who would otherwise require extensive supervision. Provider will train AEC members on the use and monthly testing of the unit upon installation and will notify AEC via telephone or fax if a member utilizes the system. Provider is expected to install a medical alert system within five (5) business days after receiving written authorization from an AEC Care Manager. PHARMACY BENEFITS American Eldercare, Inc. provides a $15 over the counter (OTC) benefit for our members. OTC formulary is available upon request. Members must have a physician s order to receive OTC under this benefit. TRANSPORTATION All AEC contracts with SNFs, requires the SNT to coordinate transportation for our members. AEC enrollees are eligible for transportation trips to long-term care covered services, as authorized by AEC. Please contact the enrollee s Care Manager for authorization approval. Our members will use their Medicaid gold care or their current acute Medicaid health plan card, respectively, for all transportation trips to non-ltc covered services (including emergent transportation) as they do now. Transportation for non-medical appointments can be provided for services AEC preauthorized only. Please contact the member s assigned Care Manager for more details. QUALITY ENHANCEMENTS Quality enhancement is education and/or community-based services will be coordinated by the Care Manager to address any concerns related to: safety and fall prevention, disease management, education on end of life issues, advance directives, and domestic violence. 21 P a g e

22 3 ELIGIBILITY Enrollment in American Eldercare, Inc s. Long-Term Care Managed Care Program is based on standards of eligibility established by the Department of Elder Affairs (DOEA), Comprehensive Assessment and Review for Long Term Care Services (CARES) unit and financial eligibility by the Florida Department of Children and Families (DCF). CONDITIONS OF ENROLLMENT Recipients eligible for enrollment must be: 18 years of age or older; Reside in the State of Florida; Determined by CARES to be at risk of nursing home placement, meet specific clinical criteria, and can be safely served with home and community-based services; DCF determines a person s financial eligibility. Financial eligibility for the program is the same as Medicaid Institutional Care Program (ICP). For specific information on the eligibility criteria, you may contact your Provider Relations Specialist or the Care Management Department near your local office. If you know someone that may qualify for the program, you may have him or her contact your local Care Management staff or call the CARES office directly to apply. CARES Referrals If a member believes they may qualify, the member or their representative must contact their local CARES office to apply for the AEC Long-Term Care Managed Care Program Plan. As a professional, if you decide to assist a potential enrollee in the application process, first make sure to obtain written consent from the enrollee or their representative. 22 P a g e

23 MEDICAID PENDING These are individuals who have applied for the Program and have been determined medically eligible by CARES but not been determined financially eligible for Medicaid by DCF. These individual are designated at Medicaid Pending. American Eldercare, Inc. has elected to provide services to these individuals who reside in the community, and assist them with completing and returning their application to DCF. If DCF determines the individual is not financially eligible for Medicaid, American Eldercare, Inc. will terminate services and seek reimbursement from the individual that signed the Financial Agreement on the member s behalf. The individual will receive an itemized bill for services received from AEC during the ineligible span. If a Medicaid pending enrollee resides in a nursing home, the facility is required to assist with the Medicaid pending process. MEMBERSHIP IDENTIFICATION (ID) CARD Each member of American Eldercare, Inc. Plan receives an American Eldercare, Inc. Plan member identification (ID) card. If the card is lost or stolen, the member should contact their Care Manager. A copy of the member s identification card is below. MEMBERSHIP CARD Member & Care Management Services Toll Free#: RX BIN # RX Group # AEC00001 Name: AEC ID# Medicaid ID# Person Code: 01 SAMPLE American Eldercare is your long-term care service provider only. Utilize your primary insurance for acute care services. All long-term services are required to have pre-authorization contract your Care Manager at the number listed on the front of this ID card. After hours: American Eldercare Member Help Line: American Eldercare Provider Help Line: Claims: American Eldercare Plan: Sims Road, Delray Beach, FL ProCare PBM Pharmacy Network (800) Member: OTC Drugs that are covered by your plan may be filled by participating pharmacies per your plan requirements. This card is for identification purposes only, and you may be required to provide additional ID at the time your prescription is filled. Presentation of this card does not guarantee eligibility. Unauthorized or fraudulent use of this card is punishable by law. ProCare PBM reserves the right to revoke this ID card at any time Pharmacy: ProCare PBM is not responsible for payment of claims to a nonparticipating Pharmacy SAMPLE 23 P a g e

24 REFERRALS TO AMERICAN ELDERCARE If a person believes he/she may qualify to participate in the program, the person or their representative must contact the local CARES office to apply for American Eldercare, Inc. Long-Term Care Managed Care Program Plan. As a provider, if you decide to assist the person in the application process, you must obtain their consent. The person or the provider is always welcome to contact AEC prior to or after contacting CARES to obtain information about our program. To locate the CARES office in your area, please refer to Section 8, Appendix, of this handbook. MEMBER DISENROLLMENT Disenrollment with Cause If a member is a mandatory enrollee and want to change plans after the initial ninety (90) day period ends or after open enrollment period ends, the member must have a state-approved good cause reason to change plans. State will review and determine approval of the member s request. Please contact the Enrollment Broker at (877) for more information. The following are potential good cause reasons to change managed care plans: 1) The enrollee does not live in a region where the Managed Care Plan is authorized to provide services, as indicated in FMMIS. (2) The provider is no longer with the Managed Care Plan. (3) The enrollee is excluded from enrollment. (4) A substantiated marketing or community outreach violation has occurred. (5) The enrollee is prevented from participating in the development of his/her treatment plan/plan of care. (6) The enrollee has an active relationship with a provider who is not on the Managed Care Plan s panel, but is on the panel of another managed care plan. Active relationship is defined as having received services from the provider within the six (6) months preceding the disenrollment request. 24 P a g e

25 (7) The enrollee is in the wrong Managed Care Plan as determined by the Agency. (8) The Managed Care Plan no longer participates in the region. (9) The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR (a)(3). (10) The enrollee needs related services to be performed concurrently, but not all related services are available within the Managed Care Plan network, or the enrollee s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk. (11) The Managed Care Plan does not, because of moral or religious objections, cover the service the enrollee seeks. (12) The enrollee missed open enrollment due to a temporary loss of eligibility, defined as sixty (60) days or less for LTC enrollees and one hundred eighty (180) days or less for MMA enrollees. (13) Other reasons per 42 CFR (d)(2) and s (2), F.S., including, but not limited to: poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee s health care needs; or fraudulent enrollment. Some Medicaid recipients may change managed care plans whenever they choose, for any reason. To find out if a member may change plans, call the Enrollment Broker at (877) Disenrollment without Cause (1) During the ninety (90) days following the enrollee s initial enrollment, or the date the Agency or its agent sends the enrollee notice of the enrollment, whichever is later; (2) At least every twelve (12) months; (3) If the temporary loss of Medicaid eligibility has caused the enrollee to miss the open enrollment period; 25 P a g e

26 (4) When the Agency or its agent grants the enrollee the right to terminate enrollment without cause (done on a case-by-case basis); or (5) During the thirty (30) days after the enrollee is referred for hospice services in order to enroll in another managed care plan to access the enrollee s choice of hospice provider. Without cause, for members not subject to open enrollment, is at any time. HOSPICE Members can be simultaneously enrolled in American Eldercare, Inc. and Hospice. Medicaid Hospice services require prior approval from AEC. Dual eligible may enroll in Medicare hospice, and the Care Manager will assist to coordinate services. Members or their representative is required to contact their American Eldercare, Inc. Care Manager, prior to enrolling in a hospice program. 26 P a g e

27 4 CARE MANAGEMENT The Care Management team provides assistance to members and families to gain access to community services in order to delay or avoid nursing home placement. If a member needs can no longer be met safely in a community, the Care Manager will assist in placement and supervision in a community setting or a nursing home that can safely meet their needs. The Care Manager is responsible for developing an individualized plan of care that meets each member s needs in a safe environment. Most Long-Term Care services and supplies must be pre-authorized by our Care Management team before they can be provided to an American Eldercare, Inc. member. Please contact the local Care Management team with requests for prior authorizations. Care Managers can assist members with: Authorization for services (See Procedures for Authorization of Services ) Change in services Coordination of acute care services Discharge planning from inpatient services Disenrollment Eligibility Obtaining replacement ID Card Answer any questions Concerns about their care AUTHORIZATIONS If a member requires specialized treatment or services, a Care Manager will issue an authorization for services to a participating provider. Our Care Managers will assess our member s needs prior to ordering any services. 27 P a g e

28 Procedures for Authorization of Services 1. Upon determination that a member needs services from a facility or agency, the Care Manager will contact your staff to inquire if the services can be provided. If so, the Care Manager will fax a Request for New Services form. A sample of this form can be found in Section 7, Forms of this handbook. This authorization is good for one year of services unless otherwise indicated at the time of authorization. If dates of services are not established, your staff is responsible to follow up with the Care Manager with the date services will begin. 2. If a member needs to stop services for a short period of time (e.g. due to a hospitalization), the Care Manager will fax a Hold/Resume Services Request form. A sample of this form can be found in Section 7, Forms, of this handbook. 3. If a member no longer needs services from your agency, the Care Manager will fax a Termination of Services Request form. A sample of this form can be found in Section 6, Forms of this handbook. 4. If a member needs an increase or decrease in services, the Care Manager will fax a Change of Services Request form. A sample of this form can be found in Section 7, Forms of this handbook. If you have any questions or concerns about a member, please contact our Care Management team in your local area. Chronic/Complex Conditions All AEC covered services including but not limited to treatment for chronic and complex conditions requires pre-authorization from a Care Manager. AEC staff will coordinate those services with a provider of the member s choice. If the member requires a service which is available through Medicaid or Medicare but is not covered by American Eldercare, Inc., the member may receive the service through other coverage they are enrolled. A Care Manager will assist with the coordination if it is determined there is a need for the service. 28 P a g e

29 Service Limitations: Services must be pre-approved Services must be provided by an active provider in AEC s provider network Services must be a covered benefit or approved expanded benefit (see below Covered Services ) Services must be medically necessary: o Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; o Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient s needs; o Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; o Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available; statewide; and o Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider. ABUSE, NEGLECT, EXPLOITATION American Eldercare, Inc. must notify government authorities if we suspect that one of our members is a victim of abuse, neglect or exploitation. Our network providers are expected to report any incidents or concerns regarding our members. Please report any suspected cases of abuse, neglect, and/or exploitation to Adult Protective Services toll free: (800) 96ABUSE ( ), should you have any questions please call our local office for assistance. American Eldercare, Inc. requires all direct service providers who provide hands-on care to our members to attend and complete Abuse, Neglect & Exploitation Training. If your 29 P a g e

30 licensure does not require Abuse, Neglect and Exploitation Training and you would like American Eldercare Inc. s staff to assist you in developing a program for your staff, please contact your local Provider Relations Specialist. CRITICAL INCIDENT REPORTING Critical incidents are required to be reported to American Eldercare, Inc. staff at the time they are identified by a provider. A critical incident is defined as an adverse or critical event that negatively impacts the health, safety, or welfare of a member. Critical incidents may include events involving abuse, neglect, exploitation, major illness or injury, involvement with law enforcement, elopement/missing, or major medication incidents. Critical incidents involving abuse, neglect or exploitation must also be reported by the provider to Adult Protective Services. Providers are expected to work with AEC staff in resolving all identified critical incidents in a timely manner to ensure the safety and wellbeing of our members. MEMBER RIGHTS AND RESPONSIBILITIES: Care Managers provide all members with this information at the time of enrollment and annually. You have the right: To be fully informed in advance of all care and treatment to be provided by the agency, and changes in care or treatment; the right to receive a copy of his/her plan of care if he/she so requests. To be fully informed of services available from the agency and how to access care. To be fully informed by a physician of health status unless medically contraindicated. To be afforded the opportunity to participate in the planning of the care plan and to refuse treatment without retribution, while fully informed of the possible medical consequences of his/her refusal. To be assured of confidentiality of records and to approve or refuse the release of information not authorized by law. 30 P a g e

31 To be treated with consideration, respect, full recognition of dignity and individuality, including privacy in treatment and in care for personal needs; to have property treated with respect. To file a grievance without fear of discrimination or reprisal from the agency; to be informed of the State Hotline number with hours of operation and purpose for obtaining information on home health agencies. To be assured qualified personnel who provide proper identification at time of visit. To be served without regard to race, color, creed, sex or age, national origin, ancestry or handicap/disability. To be advised, before care is initiated, of the cost of services and the extent to which payment may be required by the patient. To receive home and community-based services in a home-like environment and participate in his or her community regardless of his or her living arrangement. To direct your care with your own staff and/or providers. You have a responsibility: To provide accurate and complete medical and health history information as he/she understands it. To participate with the plan of treatment, when possible, and make available an informal caregiver to assume primary care, as appropriate. To have a primary care physician who will provide orders (as required) for skilled home care treatments and services. To inform agency staff about any changes in health status, medications or treatments; to inform the agency of any change in financial status that may affect reimbursement for home care. To have a plan for management of emergencies and to access this plan if necessary for safety. To inform the agency of the presence of advance directives and provide copies, as appropriate. To accept services of agency staff, without regard to race, creed, color, religion, national origin, handicap, sex or age. To report fraud, abuse, and overpayment : 31 P a g e

32 (a) To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at : FL General Hotline: : AEC Compliance Hotline: or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at: (b) If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General s Fraud Rewards Program (toll-free or ). The reward may be up to twentyfive percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section , Florida Statutes). You can talk to the Attorney General s Office about keeping your identity confidential and protected. 32 P a g e

33 5 PROVIDER RESPONSIBILITIES The Provider Relations Department has designed this handbook to assist network providers with an overview of our operational policies and procedures. As a participating provider, you and your staff will have a dedicated Provider Relations Specialist who will be a key contact. They are responsible for ensuring services are available to our members by obtaining contracts, providing ongoing community and provider training and education about American Eldercare, Inc. s Long-Term Care Managed Care Program. They also assist our network providers in understanding the terms of our contract and resolve any problems you may encounter. You are encouraged to contact your Provider Relations Specialist whenever you have any questions, comments or concerns. To locate your local Provider Relations Specialist, please refer to the list of offices located in Section 8, Appendix of this handbook. CREDENTIALING COMMITTEE The Credentialing Committee has the responsibility to establish and adopt, as necessary, criteria for provider participation and termination and direction of the credentialing procedures, including provider participation, denial and termination. Committee meetings are held at least monthly and as deemed necessary. Failure of an applicant to adequately respond to a request for assistance may result in termination of the application process. INITIAL CREDENTIALING Providers seeking participation with American Eldercare, Inc. must complete an application with required documentation and a signed contract. It is required that all providers maintain active status with licensure and insurance coverage and will provide proper documentation annually as documents expire. It is required that American Eldercare, Inc. be immediately notified of any changes in your licensure, status of insurance coverage, disciplinary actions, and/or ownership. AEC credentialing review includes but not limited to the following criteria: 33 P a g e

34 1) Copy of current provider s medical license, or occupational or facility license as applicable to provider type, or authority to do business including documentation of provider qualification as outline by governing Agency; 2) No revocation, moratorium or suspension of license; 3) A satisfactory Level II background check pursuant to guidelines for all treating providers not currently enrolled in Medicaid s fee-for service program; 4) Medicaid ID number for enrollment by state Medicaid program for compliance with data submission. AEC will take the necessary steps necessary to ensure that your business is recognized by the state Medicaid program including its enrollment broker as a participating provider and that your submission of encounter data is accepted by the Florida MMIS and/or the state s encounter data warehouse. 5) Certificate of Insurance a) Proof of General Liability, Professional Liability (as applicable) b) Proof of Workers Compensation (as applicable); c) American Eldercare Inc. should be listed as notify agent or Certificate Holder on the certificate of insurance; 6) Licensure Inspection/AHCA survey as applicable; 7) W-9 indicating Taxpayer Identification Number. Site Visits Site visits evaluate appearance, accessibility, recordkeeping practices, and safety procedures. These visits are performed at assisted living facilities and adult family care homes to evaluate a home-like environment. Other site visits will be performed as deemed necessary. RE-CREDENTIALING Re-credentialing is the process of re-verifying the credentialing information of all providers previously credentialed. The purpose of this process is to identify any changes in the provider s licensure, sanctions, certification, competence or health status, which may affect the ability to 34 P a g e

35 perform services the provider under contract. Each provider will be re-credentialed at a minimum every three years. A notification will be sent to the provider for re-verification of credentialing. All network providers must submit updated documents as it expire. Failure to provide updated documentation may delay payment. A provider s agreement may be terminated if at any time it is determined the credentialing requirements are no longer being met or the provider fails to complete the re-credentialing process.. PROVIDER MONITORING American Eldercare, Inc. will routinely monitor providers to ensure any changes in licensure status, sanctions or other adverse actions are reviewed by the Credentialing Committee. Providers whose license was suspended or revoked are subject to termination. RIGHT TO REVIEW AND CORRECT INFORMATION All providers participating with American Eldercare, Inc. have the right to review information obtained to evaluate their credentialing and/or re-credentialing application. This includes information obtained from any outside primary source such as the National Practitioner Data Bank, insurance carriers and other sources as appropriate. This does not allow a provider to review references, recommendations or other information that is peer review protected. RIGHT TO APPEAL ADVERSE CREDENTIALING DETERMINATIONS Providers who are declined participation have the right to request a reconsideration of the decision in writing within fourteen (14) days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant s reconsideration for participation in American Eldercare, Inc. Reconsiderations will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but in no case later than sixty (60) days from the receipt of the additional documentation. The applicant will be sent a written response to the request within two (2) weeks of the final decision. 35 P a g e

36 NATIONAL PROVIDER IDENTIFIER (NPI) The National Provider Identifier is a unique government-issued standard 10 digit identifier mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This identifier will replace all current health care providers numbers that are used in HIPAA standard transactions. American Eldercare, Inc. will require participating provider as appropriate to comply with this mandate. Please refer to the CMS website at for additional information and assistance with applying for a NPI. PROVIDER ORIENTATION AND EDUCATION Your Provider Relations Specialist is available to provide an initial orientation within thirty (30) calendar days of completing the credentialing process to review American Eldercare, Inc. s policies and procedures. These personalized meetings are scheduled at your convenience, including any staff you would like to attend. Additional educational trainings can be scheduled anytime by contacting your local Provider Relations Specialist. NOTICE OBLIGATION The network provider is responsible for giving the appropriate notices as outlined in this provider handbook and under the terms of your contract with American Eldercare, Inc. Changes in your Office Notify your Provider Relations Specialist immediately of any changes in your office such as: Physical address change Tax identification/billing address change (W-9 required) Demographic changes (e.g. telephone, fax, , and administrative staff changes) Name and Ownership change (60-day notice) This will ensure your information is properly listed in the Provider Directory and all payments made are properly reported to the Internal Revenue Service. A Provider Notice of Change form 36 P a g e

37 is located in Section 7, Forms of this handbook. Failure to comply with this section could lead to a delay in payments. Providing Covered Services In the event there are changes in your office that will affect your company s ability to provide services to American Eldercare Inc. s members, please notify the Provider Relations Department immediately. PROVIDER HANDBOOK The Provider Handbook provides comprehensive information to assist you with information on American Eldercare Inc s. process and procedures. You will be notified of updates to this handbook via bulletins and notices posted on our website. You can access the Provider Handbook by visiting our website at and click on the Provider tab. If you would like to receive a hard copy of this handbook mailed to your office at no charge, please contact your Provider Relations Specialist. While visiting our website, you will find other educational materials and resources to assist you with the program. PROVIDER DIRECTORY The Provider Directory is a monthly listing of all participating network providers with American Eldercare, Inc. A copy of this document is available upon request from the Provider Relations Department. You can also access the Provider Directory on our website at PARTICIPATING AGREEMENT STANDARDS By signing an American Eldercare Inc. contract, providers are required to comply with all applicable federal and state laws and licensing requirements. Providers are required to maintain back up procedures for absent employees to ensure services are not interrupted and sufficient staff. American Eldercare, Inc. may exercise its options to terminate a participating provider from the provider network with the appropriate notice. 37 P a g e

38 ACCESSIBILITY AND AVAILABILITY American Eldercare, Inc. has adopted service standards regarding the availability of participating provider services. All providers are expected to maintain these standards as outlined in your contract. Accessibility Monitoring Compliance with the availability and accessibility standards are monitored on a regular basis through random sampling, review of member concerns, and member satisfaction surveys to ensure members have reasonable access to providers and services. PROVIDER SATISFACTION SURVEY American Eldercare, Inc. conducts an annual provider satisfaction survey which includes questions to evaluate provider satisfaction with our services such as claims, communications, utilization management, and provider services. Providers are randomly selected and are kept anonymous. We encourage you to participate and respond to the survey as the results are analyzed and used to form provider related quality improvement initiatives. PROVIDER MEDICAL/CASE RECORD REVIEW 1. AEC staff will conduct reviews at all the following provider and facility provider sites every other year: a. Adult Family Care Homes b. Assisted Living Facilities c. Adult Foster Care Facility Sites d. Home Health Agencies 2. For service providers with multiple office locations, staff will conduct reviews at each practice site at least every three (3) years. 38 P a g e

39 3. Specific review tools applicable to each type of provider will be shared with the provider and utilized to conduct the reviews after establishment of inter-rater reliability. 4. A minimum of five (5) records or 5% of the member census (whichever is greater) will be reviewed per site. The cases will be selected randomly and be evaluated for compliance in meeting nationally recognized accrediting body medical/case record review standards. 5. Medical Record confidentiality will be maintained by use of patient ID numbers and records will not be removed from the provider or facility provider location for security reasons. 6. After each provider review is complete, the data will be submitted to the Corporate Q/I department where it will be analyzed, aggregated and compared. 7. On a quarterly basis, the Q/I department will report the results of the record reviews to the COO, Senior Management team and the Provider Relations department with recommendations for further action if indicated. TERMINATION OF PROVIDER CONTRACT Each provider has the right to terminate his/her contract with American Eldercare, Inc. You must submit your request in writing and provide a sixty (60) days notice. All termination requests should be mailed to the following: American Eldercare, Inc Sims Road Delray Beach, FL Attention: Provider Relations Department OUT-OF-NETWORK / NON-CONTRACTED SERVICES An out-of-network provider is any provider that is not directly contracted with American Eldercare, Inc. American Eldercare, Inc. is not responsible for payment of any services provided by an out-of-network provider without written prior authorization. Non-contracted services are any services not defined on Schedule B of your contract. American Eldercare, Inc. is not responsible for payment of non-contracted services. If you or your staff identifies a service that a member may require that is not listed in your contract please contact the members Care Manager to evaluate the members needs and determine if the service can be 39 P a g e

40 authorized by AEC. If the Care Manager determines the services should be authorized by AEC, they will contact your local Provider Relations Specialist to discuss adding an addendum to your contract. American Eldercare, Inc. is not responsible for payments of any services ordered by a member from a participating provider, without written pre-authorization from an American Eldercare, Inc. Care Manager. Please contact the member s assigned Care Manager to request authorization prior to providing services. COMMUNITY OUTREACH/MARKETING All providers must comply with the following standards regarding outreach marketing activities in your office or at sponsored events: 1. Providers may display health plan specific materials in their own offices. 2. Providers cannot orally or in writing compare benefits or provider networks among Plans, other than to confirm whether they participate in a Plan s network. 3. Providers may announce a new affiliation with health plan and include it on a list given to their patients with plans with which they contract. 4. Health care providers may co-sponsor events, such as health fairs and advertise in indirect ways; such as television, radio, posters, fliers, and print advertisement. 5. Providers may not furnish lists of their Medicaid patients to another Plan with which they contract, or any other entity, nor can providers furnish other health plans membership lists to the health plan, nor can providers take applications in their office. 6. Providers may distribute information about non health plan-specific health care services and the provision of health, welfare and social services by the State of Florida or local communities, as long as any inquiries from prospective members are referred to member services or the Agency enrollment broker. The use of American Eldercare, Inc. name will require written notice prior to use in television, radio, posters, fliers, and print advertisement. 40 P a g e

41 PROVIDER RESPONSIBILITIES The Provider should adhere to the following: Provide all services in a culturally competent manner accommodate those with disabilities and not discriminate against anyone based on his/her health status. Treat all members with respect and dignity, provide them with appropriate privacy and treat member disclosures and records confidentially, giving members the opportunity to approve or refuse their release. Maintain a safe environment and comply with City, State, and Federal regulations concerning safety and public hygiene. Ensure accessibility and availability of services to members. Participate and cooperate in quality management, utilization review, and continuing education with other similar programs to provide quality care in a responsible and cost effective manner. Participate in and cooperate with grievance procedures when notified of any member complaints or grievances. Comply with all applicable federal and state laws regarding the confidentiality of member records. Maintain communication with the appropriate agencies to provide quality member care. Ensure enrollment by state Medicaid program for compliance with data submission. American Eldercare, Inc. providers should refer to their contract for complete information regarding providers responsibilities and obligations. Failure to comply with could result in contract termination. PROVIDER COMPLAINT SYSTEM Providers have the right to register a provider complaint involving a dispute with American Eldercare, Inc. policies, procedures or any aspect of the Plan s administrative function. Every effort will be made to resolve the issue informally. In the event the issue cannot be resolved 41 P a g e

42 informally, a complaint may be filed telephonically at (561) or toll free at (888) You can also submit the compliant in writing by mailing to the Provider Relations Department at: Provider Complaint Review American Eldercare, Inc Sims Road Delray Beach, FL ATTN: Provider Relations Provider Complaint Upon receipt of a complaint, American Eldercare, Inc. will thoroughly investigate each complaint using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Plan s written policies and procedures. A provider complaint may be filed using the following steps: Verbal Complaint A Provider Relations Specialist will receive the initial call and attempt to resolve any issues or concerns at the time of the call. If the Provider requests to file a complaint, the Provider Relations Specialist will log the details in the Provider Relations Module immediately. All complaints will be acknowledged in writing within three (3) business days from the initial call. The provider will be notified verbally or in writing that the complaint has been received and the expected date of resolution. The Provider will be notified in writing regarding the results of the inquiry within fifteen (15) calendar days from receipt of the initial complaint. Written Complaint The Provider will complete the Provider Complaint Form (see Section 7 Forms) and fax or mail the form. The complaint will be logged in the Provider Relations Module on the same day of receipt. 42 P a g e

43 All complaints will be acknowledged in writing within three (3) business days from the initial call. The provider will be notified verbally or in writing that the complaint has been received and the expected date of resolution. The Provider will be notified in writing regarding the results of the inquiry within fifteen (15) calendar days from receipt of the initial complaint. The Provider has forty-five (45) calendar days to file a written complaint for issues that are claims related. CULTURAL COMPETENCY American Eldercare, Inc. expects our members will receive understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. AEC encourages participatory and collaborative partnerships with communities to be utilized in a variety of formal and informal mechanisms to facilitate community and member involvement in designing and implementing culturally and linguistically appropriate services. AEC staff will coordinate language assistance to our members who have a limited English proficiency. Providers may access the full AEC Cultural Competency Plan on our website or you can request a hard copy of the Cultural Competency Plan at no charge by contacting the Provider Relations Customer Service Line at (888) P a g e

44 6 CLAIMS/BILLING American Eldercare, Inc. maintains and complies with HIPAA standards for the submission and adjudication of claims. This section will provide you information regarding the submission and payment process. CLAIM SUBMISSION A clean claim is a claim that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity, pursuant to 42 CFR All claims should be submitted to American Eldercare Inc. within six (6) months from the date of service. If AEC is the secondary payer, claims should be submitted within ninety (90) calendar days after the final determination of the primary payer. The Managed Care Plan shall not deny claims submitted by a non-participating provider solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three-hundred sixty-five (365) days. Claims that are incomplete, illegible or missing any identifiable information may delay payment or could result in a denial of payment. ELECTRONIC CLAIMS American Eldercare, Inc. is capable of receiving electronic claims submission. The acceptable formats include X institutional, professional, and dental formats. American Eldercare, Inc. also allows for direct data entry (DDE) through our company portal. To be set up with electronic claim submission, please contact the ebilling department below: Address: [email protected] Phone Number: P a g e

45 PAPER CLAIMS Please submit claims on one of the following claim form types: Form CMS 1500 (Adult Day Care, Assisted Living Facility, Home Health, Home Delivered Meals, Consumable Medical Supplies, Environmental Adaptation) Form UB04 (Skilled Nursing Facility, Hospitals) Please make sure that the description of services listed on your claim form matches the Service Requests authorization document forwarded by the Care Manager. To avoid a delay in processing your claims, please include the following information on claims: Member s name (Last, First) Member s date of birth Member s address Provider information (Provider s name, address and tax identification) Provider signature Description of service and code provided Service / Procedure/ HCPCS code Date(s) of service Units of Service (amount of service hours provided or quantity of items provided) Total number of units billed and total dollar amount billed Amount of hours services provided or quantity of items provided AEC Member ID or Medicaid ID, if available Plan Identification Mail all paper claims to the following address: American Eldercare, Inc. Attn: Claims Department Sims Road Delray Beach, FL P a g e

46 If you have any questions or require training regarding submitting claims, please contact your local Provider Relations Specialist. ENCOUNTER DATA Transportation and capitated providers will need to submit encounter data claims and encounter data is also required for any service American Elder Care directly pays (not claims processed through the Medicaid fiscal agent). American Eldercare is authorized to take the necessary steps to ensure that providers are recognized by the state Medicaid program, including its enrolment broker contractor(s) as a participating provider of the Plan and your submission of encounter data is accepted by the Florida MMIS and/or the state s encounter data warehouse. Protocols for submitting encounter data: 1) All Transportation providers and any provider that has services directly paid by American Eldercare, Inc. are required to submit encounter data to AEC to reflect the authorized services provided to our members. 2) All Transportation providers and any provider that has services directly paid by American Eldercare, Inc. who bill AEC via paper claims (HCFA1500, UB92), or electronically need to ensure all the required fields are completed in their submission in order for AEC to extract the encounter data information. 3) All Transportation providers and any provider that has services directly paid by American Eldercare, Inc. who submit claims that are not submitted in one of the above formats for payment, are required to submit the appropriate 837i, 837p or 837d for their line of business for encounter data purposes. (applies to PBM only) 4) Please review required fields for claims submissions in the AEC companion guide. 5) If you have any questions on what is required of your agency/company please contact your Provider Relations Specialist or call the Provider Customer Service number at (888) P a g e

47 ASSISTED LIVING FACILITY PROVIDERS Assisted Living Facilities are encouraged to participate in our automatic payment process. Any provider participating in this process will be paid for existing members by the 10 th of the current month without submitting a claim. Any existing members that were enrolled by the previous month and have an open care plan in the current month will be paid. Please note that if a member leaves your facility for any reason that would require American Eldercare, Inc. to recoup money, your facility will see a debit adjustment on the following month s payment and/or will receive an invoice for payment. Also note that a claim is required prior to payment for the first month that a member enters the facility or the first month of enrollment. All providers that do not participate in the automatic payment process must submit claims after the end of the current month. These claims will be paid within thirty (30) days of receipt. Room and Board Rate Members are responsible to pay their room and board rate (as indicated in the provider s contract) plus patient responsibility (as determined by the Department of Children and Families). Prorated fees will be determined for members who do not reside in the community for a full month. AEC will be responsible for payment using the following formula: Contracted ALF Rate minus Room & Board Rate minus Patient Responsibility = AEC Payment These amounts will be reflected on each member s individual Service Requests sent by the Care Managers. The patient responsibility is subject to change based on the Notice of Case Action (NOCA) received by DCF or estimated member responsibility until the appropriate NOCA is completed. 47 P a g e

48 The provider is required to notify AEC within twenty-four (24) hours of a member hospitalization or leave of absence from the community. Bed-Hold Payments AEC Plan will pay up to a fourteen (14) day bed-hold when our member is not in your community except in the following occurrences: 1. Member loses Medicaid Eligibility 2. Member expires 3. Member is placed in a Skilled Nursing Facility for Long-Term Care 4. The community fails to notify AEC Plan within twenty-four (24) hours of a hospitalization or leave of absence from the community. 5. Prorated fees will be determined for members who reside in a facility for less than a full month. Bed-holds OR stop payment begins the day the member leaves the facility. The facility will not be paid for the day of discharge unless the member is eligible for a bed hold. If the facility fails to notify AEC of a member leaving the community within (24) hours of discharge, this will result in a forfeit of payment for the bed-hold. The facility may not charge the member for AEC s portion of their bill during this time. SKILLED NURSING FACILITY PROVIDERS (SNF) Custodial Care All members requiring custodial care must be assessed and determination must be made by American Eldercare, Inc. that the member can no longer live in a less restrictive setting. Members who receive approval for placement in a contracted Skilled Nursing Facility for custodial care are required to pay the facility a patient responsibility based on their income, which is determined by the Department of Children and Families. Prior authorization is required. 48 P a g e

49 Bed-Holds for Custodial Care Members AEC follows the same guidelines as Medicaid. If your facility is requesting payment for a bedhold on an AEC member, please submit a copy of your census along with your claim for the time-frame in question. Custodial Care Payments The facility will be reimbursed by AEC at the current Medicaid Per-Diem Rate established with the State minus any patient responsibility determined by the Department and Children and Families. HOME HEALTH PROVIDERS Home Health providers must attach, to all claims submitted, a form signed by the member verifying what services were provided including date/time of service and direct care staff who provided the service. If billing electronically, this information must be made available to American Eldercare, Inc. on demand. It is recommended that services are not billed in a date range format. Each service should be listed separately by date of service. Ranges should only be used if billing consecutive days with the same units and amount for each day billed. If you bill in a date range format, appropriate documentation such as time sheet or nurses notes must be accompanied to ensure prompt and accurate payment for services rendered. CLAIM ACKNOWLEDGEMENT Paper Claims: Within fifteen (15) business days after receipt of all paper claims submitted to AEC for noncapitated services, AEC will provide the provider or designee with acknowledgement of receipt of the claim. AEC will provide access to a web portal and allow the provider or designee to check the status of all submitted claims. AEC will also provide provider with a provider services telephone number to call and check the status of their submitted claims. 49 P a g e

50 Within fifteen (15) business days after receipt of all paper claims submitted to AEC for noncapitated services, AEC will authorize and forward the claim to the Medicaid fiscal agent or notify the provider or designee that the claim is contested or denied. The notification to the provider of a contested or denied claim will include an itemized list of additional information or documents needed to process the claim. Electronic Claims: Within twenty-four (24) hours after the beginning of the next business day after receipt of all electronically submitted claims for non-capitated services, AEC will provide electronic acknowledgment of receipt of the claim to the provider or the electronic source submitting the claim. Within ten (10) business days after receipt of all electronically submitted claims for noncapitated services, AEC will authorize and forward the claim to the Medicaid fiscal agent or notify the provider or designee that the claim is contested or denied. The notification to the provider or designee of a contested or denied claim will include an itemized list of additional information or documents needed to process the claim. PAYMENTS Payments for transportation services will be made by the Medicaid fiscal agent. Reimbursement will be made for correct, authorized, clean claims according to the Florida Medicaid fee schedules for reimbursement for covered services provided to enrollees. The Agency or its fiscal agent will also reimburse non-participating providers on a FFS basis for Provider Service Network (PSN) authorized services. 50 P a g e

51 All claims payments made by American Eldercare, Inc. to a provider will be accompanied by an explanation of payment. The explanation of payment will contain an itemized accounting of the individual claims included in the payment including the enrollee's name, the date of service, the procedure code, service units, the amount of reimbursement and the identification of American Eldercare, Inc. The date of the check will also be included on the explanation of payment. The date of the check will be considered the date of payment. BALANCE BILLING Payments made by or processed through American Eldercare, Inc. are in accordance with the terms of your agreement. Providers may not balance bill members of American Eldercare, Inc. for any covered, authorized service. CLAIM INQUIRY Providers are encouraged to contact the Claims Customer Service Department to inquire about the status of a claim, status of reconsideration, or explanation of a denial. A Customer Services Representative can be reached from 8:00am-7:00pm Monday-Friday at (561) Extension If you are calling during peak or after-hours, please leave a message and a representative will return your call within one (1) business day. CLAIM DENIALS All denials include an explanation of denial and/or explanation of adjustment when applicable. Denial codes are subject to change and/ additional codes utilized, please contact the claims Customer Service Department for any questions or concerns regarding a denial or partial denial of payment. A copy of denial codes performed by American Eldercare, Inc. and descriptions of denial codes can be found in Section 8 of this handbook. American Eldercare will not deny Medicare crossover claims solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three (3) years. A copy of denial codes performed by the Medicaid Fiscal Agent may be found in the applicable Medicaid General Provider Reimbursement Handbook. If you disagree with a denial received, you have the right to reconsideration. 51 P a g e

52 CLAIMS RECONSIDERATION OF PAYMENT A provider has the right to request reconsideration if they do not believe the determination on a claim is correct. Parties not involved in the initial determination will review the reconsideration. All reconsiderations, should be submitted in writing within sixty (60) days of the denial notice and include any additional information needed. Claims Reconsideration of payment should be mailed to the following address: American Eldercare, Inc. Attn: Claims Department (Reconsiderations) Sims Road Delray Beach, FL FORMAL GRIEVANCES/APPEALS A provider may file a grievance or an appeal for denial of payment on behalf of an American Eldercare, Inc. member. Grievances are filed as complaints about services provided or about the appeal process itself. These may be filed by the member, member representative, or a provider on behalf of a member. The formal grievance must be submitted orally or in writing either by letter or by completed grievance/appeal form to the Grievance/Appeal Coordinator within 365 days from the date of the event that caused your concern or grievance. Formal Appeals are filed in response to American Eldercare, Inc. s decision to: Deny payment; Deny or limit the authorization of a requested service; Or Reduce, suspend, or terminate a previously authorized service. Formal appeals must be made within thirty (30) days of written notice of American Eldercare Inc. s decision to reduce, deny services, or payments. Appeals may be made orally or in writing. Oral appeals must be followed up with a signed, written appeal. American Eldercare, Inc. considers the member or member s representative as parties to an appeal or a grievance. We encourage them to explore the informal complaint process first in an 52 P a g e

53 attempt to work out the issue directly with the Care Manager and/or their supervisor. If the concern or complaint was not resolved satisfactorily with the Care Manager, a grievance or appeal may be filed with American Eldercare, Inc. Grievance/Appeal Coordinator located address: American Eldercare, Inc. Plan Attn: Grievance/Appeal Coordinator Sims Road Delray Beach, Florida Toll Free (866) If the member or representative wish to write a letter to the Grievance/Appeal Coordinator addressing the concern, the letter should include the member s name, address, member ID number, date, and signature. The Care Manager is available to assist with this process if needed. If the member or representative prefers to call the Grievance/Appeal Coordinator, office hours are 9:00 a.m. 5:00 p.m. Eastern Standard Time, Monday Friday. Telephone messages are forwarded twenty-four (24) hours a day. The Grievance/Appeal Coordinator will return the phone call, provide the member or representative with a complete explanation of our procedures, and mail a grievance/appeal form within three (3) working days. The immediate member or representative will need to complete this grievance form and mail it back to the Grievance/Appeal Coordinator at the address provided above. Upon oral receipt of the grievance or completed grievance form, the Grievance/Appeal Coordinator will have the concern investigated and a written decision will be mailed to the member within ninety (90) days. Upon oral receipt of the appeal (followed by a signed written copy), the Grievance/Appeal Coordinator will have the concern investigated and a written decision will be mailed to the member within forty-five (45) days. The person(s) who originally made the decision to reduce or deny services will not be a decision maker in the determination process. To request a complete description of American Eldercare, Inc. Plan s Grievance /Appeals Procedure, you may call our corporate office toll free at (866) P a g e

54 Expedited Appeals If the request is deemed urgent by American Eldercare, Inc., an expedited review will take place. This process can only be utilized if an AEC member is being denied access to services. The person(s) who originally made the decision to reduce or deny services will not be a decision maker in the determination process. Within seventy-two (72) hours (or sooner, if warranted) of the receipt of the request, a decision will be determined and the member or representative will be notified by phone. The final determination will be sent to the member in writing. American Eldercare, Inc. will continue the member s benefits if: The appeal is filed timely, meaning on or before the later of the following: Within ten (10) days of the date on the notice of action (or fifteen (15) days of the notice is sent via U.S. mail). The intended effective date of Plan s proposed action. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment. The services were ordered by an authorized provider. The authorization period has not expired. The member requests extension of benefits. At the conclusion of the appeal process, in the event of a ruling in favor of American Eldercare, Inc. the member may have to pay for those services rendered during the appeal process. Beneficiary Assistance Program In the event you have received a notice of resolution after your American Eldercare, Inc. internal appeal, you may request review of that decision within one (1) year by the Beneficiary Assistance Program. You may not request the review if you have already requested a Medicaid Fair Hearing. The program is operated by AHCA and may be contacted at: 54 P a g e

55 Agency for Health Care Administration Beneficiary Assistance Program Building 1, MS # Mahan Drive Tallahassee, Florida (850) (888) (toll-free) Unresolved Grievances/Appeals Medicaid Fair Hearing To appeal the decision made by American Eldercare, Inc. Plan s Grievance/Appeal Committee in response to their grievance/appeal, the member or their representative may request a Medicaid Fair Hearing within ninety (90) days from the notice of resolution. An enrollee who chooses to seek a Medicaid Fair Hearing without pursuing the Managed Care Plan s process must do so within ninety (90) days of receipt of the Managed Care Plan s notice of action. The member or member representative must contact: Office of Public Assistance Appeals Hearing 1317 Winewood Boulevard Building 5, Room 203 Tallahassee, FL (850) In the event a member or provider wishes to contact the Agency for Health Care Administration, you can call the State-Wide Consumer Center at (888) IMPORTANT INFORMATION REGARDING GRIEVANCES/APPEALS 1. Continuation of Benefits a. American Eldercare, Inc. shall continue the enrollee s benefits if: (1) The enrollee or the enrollee s authorized representative files an appeal with the American Eldercare, Inc. regarding American Eldercare, Inc. s decision: (a) Within ten (10) business days after the notice of the adverse action is mailed; or 55 P a g e

56 (b) Within ten (10) business days after the intended effective date of the action, whichever is later. (2) The appeal involves the termination, suspension or reduction of a previously authorized course of treatment; (3) The services were ordered by an authorized provider; (4) The original period covered by the original authorization has not expired; and (5) The enrollee requests extension of benefits. b. If, at the enrollee s request, American Eldercare, Inc. continues or reinstates the benefits while the appeal is pending, benefits must continue until one (1) of the following occurs: (1) The enrollee withdraws the appeal; (2) Ten (10) business days pass after American Eldercare, Inc. sends the enrollee the notice of resolution of the appeal against the enrollee, unless the enrollee within those ten (10) days has requested a Medicaid Fair Hearing with continuation of benefits; (3) The Medicaid Fair Hearing office issues a hearing decision adverse to the enrollee; or (4) The time period or service limits of a previously authorized service have been met. c. If the final resolution of the appeal is adverse to the enrollee and American Eldercare, Inc. s action is upheld, American Eldercare, Inc. may recover the cost of services furnished to the enrollee while the appeal was pending to the extent they were furnished solely because of the continuation of benefits requirement. d. If the Medicaid Fair Hearing officer reverses American Eldercare, Inc. s action and services were not furnished while the appeal was pending, the American Eldercare, Inc. shall authorize or provide the disputed services promptly. e. If the Medicaid Fair Hearing officer reverses American Eldercare, Inc. s action and the enrollee received the disputed services while the appeal was pending, American Eldercare, Inc. shall pay for those services in accordance with this Contract. 56 P a g e

57 7 FORMS Authorization Forms: Change of Services Request Hold/Resume Service Request Request for New Services Termination of Services Request Claim Forms: CMS 1500 UB-04 Provider Complaint Form Provider Change of Notice Form 57 P a g e

58 8 APPENDIX AEC Locations CARES Offices Denial Codes Remittance Advice 58 P a g e

59 Administrative Office Sims Road Delray Beach, FL Local Toll Free Fax Provider Relations Department Local Fax Palm Beach Office Serving Counties of: Indian River, Palm Beach, Martin, Okeechobee & St. Lucie Sims Road Delray Beach, FL Local Toll Free Fax Clearwater Office Serving Counties of: Pasco & Pinellas th Avenue North, Suite 150 Clearwater, FL Local Toll Free Fax Tampa Office Serving Counties of: Hillsborough, Manatee, & Polk 204 S. Hoover Blvd, Suite 200 Tampa, FL Local Toll Free Fax Ocala Office Serving Counties of: Alachua, Citrus, Dixie, Hernando, Lake, Levy, Marion, Gilchrist, Lafayette & Sumter 3306 SW 26th Ave, Unit 301 Ocala, FL Local Toll Free Fax Ft. Lauderdale Office Serving County of: Broward 3320 NW 53rd Street, Suite 203 Fort Lauderdale, FL Local Toll Free Fax 59 P a g e

60 Jacksonville Office Serving Counties of: Baker, Duval, Columbia, Clay, Nassau, Putnam, Bradford, Hamilton, Suwannee, Union & St. Johns 644 Cesery Boulevard, Suite 106 Jacksonville, FL Local Toll Fax Ormond Beach Office Serving Counties of: Flagler & Volusia 533 North Nova Rd., Suite 205 & 207 Ormond Beach, FL Local Toll Free Fax Orlando Office Serving Counties of: Orange, Osceola, & Seminole 1080 Woodcock Road, Suite 200 Orlando, FL Local Toll Free Fax Melbourne Office Serving Counties of: Brevard 1600 Sarno Road, Suite 108 Melbourne, FL Local Toll Free Fax Pensacola Office Serving Counties of: Bay, Gulf, Escambia, Franklin, Holmes, Okaloosa, Santa Rosa, Jackson, Walton, Calhoun & Washington 7282 Plantation Blvd. Suite 301 Pensacola, FL Local Toll Free Fax Doral Office Serving County of: Miami-Dade & Monroe 8260 NW 27th Street, Suite 410 Doral, FL Local Toll Free Fax 60 P a g e

61 Ft. Myers Office Serving Counties of: Collier, Charlotte, DeSoto, Hardee, Highlands, Lee, Hendry & Sarasota S Cleveland Ave, Suite 505 Ft. Myers, FL Local Toll Free Fax Tallahassee Office Serving Counties of: Gadsden, Jefferson, Liberty, Leon, Madison, Taylor & Wakulla 2888 Remington Green Lane #C Tallahassee, FL Local Fax Visit our website If you need assistance after office hours, our provider and member help-line is available twentyfour (24) hours a day seven (7) days a week. Provider Toll Free Help Line: (888) Member Toll-Free Help Line: (888) P a g e

62 Department of Elder Affairs Comprehensive Assessment and Review for Long-Term Care Services CARES OFFICES COUNTY SERVED PHONE NUMBER PSA Office Escambia, Okaloosa, Walton, Santa Rosa Bay, Calhoun, Gulf, Jackson, Washington, Holmes Leon, Franklin, Gadsden, Madison, Taylor, Wakulla, Liberty, Jefferson Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, Union Citrus, Hernando, Lake, Marion, Sumter Baker, Clay, Duval Nassau & St. Johns (850) (850) A (850) B (352) A ( B (904) A Flagler & Volusia (386) B Pinellas (Central and Southern) (727) A Pasco & Pinellas (North) (727) B Hillsborough & Manatee (813) A Polk, Hardee, Highlands (863) B Orange, Osceola & Seminole (407) A Brevard (321) B 62 P a g e

63 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, & Sarasota (239) Palm Beach (561) A Indian River, Martin, (772) B Okeechobee & St. Lucie Broward (954) Miami-Dade (North & Central) (786) A Miami-Dade (South), Monroe (305) B 63 P a g e

64 CLAIMS DENIAL CODES A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 B01 B02 B03 B04 B05 B06 B07 B08 C01 C02 C03 C04 C05 C06 D01 D02 D03 D04 E01 Code DESCRIPTION Service type not specified. Duplicate claim already in process. Duplicate claim: payment already issued. Resubmit complete claim and E.O.B.: Claim and/or E.O.B. unreadable, altered, or do not match Rate billed is inconsistent with contracted rate. Patient allowance changed. Claim lacks the anesthesia configuration in minutes needed for processing. Payment for this claim must be adjudicated by primary insurance prior to submission. Payment issued to another provider due to change of ownership notification. Incorrect Federal Tax Identification. Lack of correct W-9 on file for provider. Incomplete provider file. Service not covered. Co-pay not covered. Coverage not in effect at the time the service was provided. Claim denied as patient cannot be identified as our insured. Exceeds Medicare/Medicaid maximum allowable or Plan maximum allowable. Service not covered due to determination by primary insurance. Not covered under Medicaid Waiver, covered under Medicaid Feefor-Service. Denied: Effective July 1, 2007 (Senate Bill 2800), exceeds Medicaid Maximum allowable. Service not authorized. Service not authorized for this date(s). Exceeds authorized number of days or hours per week. Service authorized for once a month. Service authorized for once every two months. Service authorized for once every three months. Services billed prior to date of service. Service not rendered on this date(s). Time limit for filing has expired. Date of death precedes date of service. Mail order prescription refills and supplies are not reimbursed. 64 P a g e

65 E02 E03 E04 E05 E06 Z01 Reimbursement is made for copayments on medications that are covered by your Medicare Part D provider. You are not enrolled with a Medicare Part D provider for which copays are reimbursed. Receipts not submitted within 30 days of purchase. Receipts submitted do not match claim total. Resubmit claim including AEC Reimbursement Form, original receipt(s) and pharmacy label. Provider improperly refuses access to members. 65 P a g e

66 REMITTANCE ADVICE Date: 1/3/2011 Check #: Remittance: 7047Q00009 Page: 1 of 2 Vendor ID: Sample Provider 123 Fake St. Somewhere, FL American Eldercare, Inc Sims Road Delray Beach, FL (561) , ext 1987 Invoice # Receive Date Type of Bill Member's Name (ID) DOS-From DOS-Thru Service Code Modifier Amount Billed Amount Paid Amount Denied Reason Code W 11/3/ Jane Doe (9999) 3/18/ GW $50.00 $0.00 $ W 11/3/ John Doe (9998) 3/18/ , GW $90.00 $73.18 $ P a g e

67 Right of Reconsideration - If you believe the determination on this claim is incorrect, you have the right to request a reconsideration. The reconsideration will be reviewed by parties not involved in the initial determination. In order to request a reconsideration, you must submit your request in writing within 60 days of this notice. Once you have completed the request, you should mail it to the Claims Department. CONFIDENTIALITY NOTICE: This Remittance Advice is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Any unauthorized review, use, disclosure, or distribution is prohibited. If you have received this document in error, please do not distribute it. Please notify the sender by the United States Postal Service at the address shown above. Date: 1/3/2011 Check #: Remittance: 7047Q00009 Page: 2 of 2 Vendor ID: Sample Provider 123 Fake St. Somewhere, FL American Eldercare, Inc Sims Road Delray Beach, FL (561) , ext 1987 Reason Codes 042: Charges exceed Medicaid maximum allowable amount. 67 P a g e

68 Corporate office: American Eldercare, Inc Sims Road Delray Beach, FL Approved 5/17/13 08/01/13 68 P a g e