22 Medicare Provider Manual

Transcription

1 22 Medicare Provider Manual Table of Contents Title Page Introduction 2 Important Contact Information 4 Member Eligibility & Plan Design 5 ID card sample 8 Provider Reconsideration Process 9 Member Grievance or Medicare Appeals Process 10 Quality Improvement Organization 17 Outpatient Services 19 Inpatient Services 21 Other Covered Services 21 Special Status Medicare Members 23 Claim Submission 25 Precertification 26 CMS Requirements 34 Forms (Precertification, ABN, Reconsideration) 38 1

2 Introduction ADVANTRA from Coventry Health Care Medicare Advantage Plans WHAT IS MEDICARE? Medicare is a Federal Health Insurance Program established in 1965 as an amendment to the Social Security Act. It provides hospital (Part A) and supplemental medical (Part B) coverage for people 65 years of age and older, certain disabled people, and those of any age with End Stage Renal Disease (ESRD). The Medicare Program is administered by The Center for Medicare and Medicaid Services (CMS), formerly Health Care Financial Administration (HCFA), of the U.S. Department of Health and Human Services (DHHS). COVENTRY HEALTH AND LIFE INSURANCE COMPANY, INC. MEDICARE ADVANTAGE PLANS: Coventry Health and Life Insurance Company, Inc. (Coventry) has entered into a contract with the CMS that authorizes Coventry to provide comprehensive health services to persons who are entitled to Medicare benefits and who choose to enroll in the Medicare Advantage (MAPD) plans, called Advantra. WHAT IS ADVANTRA? Advantra is an Medicare Advantage Prescription Drug (MAPD) Plan that includes Medicare Part A, Part B and Part D benefits and enhanced benefits not covered by traditional Fee for Service Medicare. Enhanced benefits may include preventive care, vision benefits, hearing benefits and dental benefits. Coventry currently offers one PPO plan called Advantra. Advantra is not a Medigap policy or a Medicare Supplement Plan Advantra Service area includes the following North Carolina counties: Alamance, Alexander, Caldwell, Caswell, Catawba, Chatham, Durham, Franklin, Guilford, Gaston, Orange, Person, Randolph, Rockingham and Wake. 2

3 HOW DOES THE PROGRAM WORK? Advantra offers a new approach, with greater flexibility, freedom and savings. Members are not required to select a primary care physician. If Advantra PPO members choose providers outside the network, they are still eligible for benefits, but their cost sharing will be higher. Advantra members must be eligible for Medicare Part A and are required to continue paying their Medicare Part B premium. Advantra PPO is underwritten by Coventry Health and Life Insurance Company (CHLIC) and administered by WellPath. Coventry has entered into a MAPD Contract with CMS. This contract authorizes Coventry to provide comprehensive health services to people who are eligible for Medicare benefits and who choose to enroll into Coventry s MAPD Program. 3

4 Important Contact Information for Advantra Plan Information Advantra Customer Service Department Telephone Fax Health Services Department Precertification Telephone Fax Pharmacy Prior Authorization Telephone Fax Prescription Drugs Medco PO Box Lexington, Kentucky Claims & Claims Reconsiderations Medical Necessity Member Appeals & Medical Necessity Provider Reconsiderations Advantra Claims c/o Coventry Health Care P.O. Box 7102 London, KY Please use this address when submitting paper claims Electronic Claims Payer Number Return Checks Advantra 2801 Slater Road, Suite 200 Attention: Provider Reconsideration Coordinator Morrisville, NC Fax: Refunds Advantra Coventry Health Care The Recovery Dept 120 East Kensinger Drive Cranberry Twp, PA Mailing Address Advantra- Coventry Health Care P.O. Box Atlanta, GA Advantra from Coventry Health Care 2801 Slater Road Suite 200 Morrisville, NC Network Management Department 2801 Slater Road Suite 200 Morrisville, NC Telephone or Fax Web Site Addresses Advantra = WellPath = 4

5 Advantra PPO Plan design Below is a sample of benefits of Advantra compared to Original Medicare. This is not a complete listing of benefits. Benefit 2011 Original Medicare. Monthly Part B Premium is $ Yearly deductible is $162. Advantra Bronze (PPO) In-Network Advantra Gold (PPO) In-Network Monthly Premium n/a $0 $23 Maximum Out-of- No Maximum Out-of- $6700 in-network. $3400 in-network. Pocket Pocket. Days 1-60: $1,132 Days 1-6: $265 copay Days 1-10: $223 copay Deductible. per day. per day. Days 61-90: $283 per Inpatient Days 7-90: $0 copay Days 11-90: $0 copay day. per day. per day. Days : $566 per lifetime reserve day. Skilled Nursing Facility Inpatient Mental Health After at least a 3-day covered hospital stay: Days 1-20: $0 per day. Days : $ per day. 100 days each benefit period. Same deductible and copay as inpatient hospital care. Days 1-100: $50 copay per day. Plan covers up to 100 days each benefit period. Days 1-6: $265 copay per day. Days 7-90: $0 copay per day. Lifetime reserve of 190 days. Days 1-12: $0 copay per day. Days : $100 copay per day. Plan covers up to 100 days each benefit period. Days 1-10: $215 copay per day. Days 11-90: $0 copay per day. Lifetime reserve of 190 days. PCP Copay 20% coinsurance. $35 copay. $15 copay. Specialist Copay 20% coinsurance. $50 copay. $35 copay. 20% coinsurance for 20% of the cost for each Medicare-covered ASC 20% of the cost for each Medicare-covered ASC Outpatient the doctor. visit and the cost for each visit. and the cost for Services/Surgery 20% of outpatient facility charges. Medicare-covered outpatient hospital facility visit. each Medicare-covered outpatient hospital facility visit. 5

6 Benefit Physical Exams 2011 Original Medicare. Monthly Part B Premium is $ Yearly deductible is $162 0% coinsurance for one routine physical exam each year. Advantra Bronze (PPO) In-Network $0 copay for routine physical exams. Limited to 1 exam every year. Advantra Gold (PPO) In -Network $0 copay for routine physical exams. Limited to 1 exam every year. Ambulance 20% coinsurance. $125 copay $100 copay $50 for Medicarecovered emergency room $50 copay for Medicare-covered 20% coinsurance for emergency room visits. Waived ER the doctor. visits. Waived if if admitted within 24 hours for 20% of facility charge. admitted within 24 hours same condition. for same condition. Urgent care 20% coinsurance. $25 copay. $25 copay. 20% coinsurance for the 20% coinsurance for the cost of DME / Prosthetics 20% coinsurance cost of Medicare-covered Medicare-covered items. items. Home Health Care Lab Radiology $0 copay. $0 copay for Medicare covered lab services. Medicare does not cover most routine screening tests, like checking your cholesterol. 20% coinsurance for diagnostic tests and X- rays. $0 copay for Medicarecovered home health visits. $0 copay for Medicare-covered home health visits. Appropriate office visit Appropriate office visit copay copay would apply if would apply if billed in billed in conjunction with conjunction with Medicare Medicare covered lab covered lab services. services. Office visit copay may apply; Medicare-covered X- rays. 20% of the cost for Medicare-covered diagnostic radiology and therapeutic radiology services $0 copay for Medicarecovered screening mammograms. Office visit copay may apply; Medicare-covered X-rays. 20% of the cost for Medicarecovered diagnostic radiology and therapeutic radiology services. $0 copay for Medicare-covered screening mammograms. 6

7 Benefit Vision Hearing Dental Rx 2011 Original Medicare. Monthly Part B Premium is $ Yearly deductible is $162 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. No Preventive Benefit. 20% coinsurance for Medicare covered diagnostic hearing exams. No Preventive Benefit. Part B drugs only. Advantra Bronze (PPO) In-Network $50 copay for exams to diagnose and treat diseases of the eye. No routine eye exam coverage. Non-Medicare-covered eye exams and glasses not covered. $50 copay Medicarecovered diagnostic hearing exam. No preventive Dental Benefits. $50 copay for Medicarecovered dental benefits. $5 Generic $36 Preferred Brand $69 Non-Preferred Brand 33% Specialty. Advantra Gold (PPO) In -Network $35 copay for exams to diagnose and treat diseases of the eye. No routine eye exam coverage. Non-Medicare-covered eye exams and glasses not covered. $35 copay for Medicarecovered diagnostic hearing exam. No preventive Dental Benefits. $35 copay for Medicarecovered dental benefits. $7 Generic $33 Preferred Brand $63Non-Preferred Brand 33% Specialty. MEMBER INPUT IN TREATMENT PLAN Physicians should always consider member input in the proposed treatment plan. It is the right of enrollees to be represented by parents, guardians, family members or other conservators for those who are unable to fully participate in their treatment decisions. The physician is expected to educate members regarding their health needs, share findings of history and physician examinations, discuss potential options (without regard to plan coverage), side effects of treatment and management of symptoms; and recognize the member has the final course of action among clinically accepted choices. 7

8 Member Identification Card: Coventry provides every Advantra member with an identification card shortly after joining the Plan. The identification card contains the following information: Member name Advantra ID Number Plan Name Office Visit Copayment Address and Instructions for claims submission ADVANTRA Front of card Back of card 8

9 PROVIDER RECONSIDERATION PROCESS OVERVIEW The Provider Reconsideration process is primarily for issues that would concern a provider independent of the Member. This process is intended for issues when only the provider requires further review or consideration. The Member Appeal and Grievance process is for issues that involve the Member - primarily, precertification issues or instances where the provider wishes to appeal or grieve on behalf of the Member. Issues related to contracts or claims processing under the participating provider agreement with the Plan must be addressed under the Provider Reconsideration Process and are not appropriate to be reviewed under the Member Appeal or Grievance Process. Provider Reconsideration Process The Plan recognizes that providers may encounter situations in which the operation of our company does not meet their expectations. When this occurs, the provider is encouraged to call the matter to our attention. It is the policy and practice of the Plan to promptly and fairly consider all the complaints and grievances of its providers. Initial Informal Attempts for Resolution When a provider has a concern, inquiry or complaint, every effort will be made to resolve the issue informally via telephone, correspondence (Informal Claims Reconsideration Request Form) or personal visit. Such informal issues will not be considered formal reconsiderations. The provider should attempt to resolve issues through the following means before submission of a formal reconsideration: 1. Contact the Plan Customer Service Department by telephone or by utilizing the informal claim reconsideration form to attempt to resolve the issue. 2. In the event the Plan Customer Service Department fails to resolve the issue to the satisfaction of the provider, the provider should contact his or her designated Network Management Department representative to initiate an additional request to resolve the issue. 9

10 Submission of a Formal Reconsideration If the issue cannot be resolved informally to the satisfaction of the provider, the provider may submit a formal reconsideration. This reconsideration should: 1. Be sent in writing to 2801 Slater Road, Suite 200, Morrisville, NC or faxed to Attention: Provider Reconsideration Coordinator; 2. Outline the disagreement with the Plan; 3. Document the past attempts at informal resolution; 4. Include appropriate documentation to support the disagreement with the Plan; 5. Be submitted within 180 days from the date of the event related to the reconsideration for non-claims payment disputes; and 6. Be submitted within one year from the date of receipt of the initial Remittance Advice or processing date for claims payment issues. Once the written reconsideration is received, the Plan will investigate the specific details of the situation. The Provider Reconsideration Coordinator will respond to the provider within thirty (30) days of receipt of the written request. PROVIDER INQUIRIES AND COMPLAINTS In order to ensure a high level of satisfaction, Coventry shall provide a mechanism for Providers to express dissatisfaction with Plan decisions. Providers may express questions or dissatisfactions through our Provider Inquiry and Complaint Process. Member Grievance or Medicare Appeals Process Overview The provider shall cooperate and comply with the Plan and Medicare requirements regarding the processing of member appeals and grievances, including the obligation to provide information within the timeframe reasonably requested for such purpose. The Plan has established a separate Customer Services Department dedicated to Advantra members. If a member has a concern or complaint, Coventry has developed the following steps to resolve them. There are two types of procedures for resolving member complaints: the Advantra Internal Grievance Process the Medicare (CMS) Appeals Process Medicare (CMS) Appeals Process Every Advantra member has the right to appeal any decision made by the Plan about their coverage or health care. An appeal is the type of complaint made when a member wants us to reconsider and change a decision we have made about what services are covered or what we will pay for a service. For example, if we refuse to 10

11 cover or pay for services the member thinks we should cover, they can file an appeal. If Coventry Health Care or one of our plan providers refuses to give them a service they think should be covered, the member can file an appeal. If Coventry or one of our plan providers reduces or cuts back on services the member has been receiving, they can file an appeal. If they think we are stopping their coverage for a service too soon, the member can file an appeal. A grievance is the type of complaint a member makes if they have any other type of problem with Coventry or one of our plan providers. For example, the member would file a grievance if they have a problem with things such as the quality of care, waiting times for appointments or in the waiting room, the way the doctors or others behave, being able to reach someone by phone or get the information they need, or the cleanliness or condition of the doctor s office. Specifically, a member can use the Medical Appeals Process whenever they think the Plan: has not paid a bill; for example, bills for Urgently Needed Care outside the service area or worldwide emergency coverage or denied a non- Plan provider that should have been provided, arranged, or paid by Coventry has not paid a bill in full will not approve or deliver care that the member believes is covered. a reduced or denied service that the member believes is medically necessary and a covered service. In addition, a member may appeal any decision to discontinue covered services or discharge the member from a Home Health Agency (HHA), Skilled Nursing Facility (SNF) or Comprehensive Outpatient Rehabilitation Facility (CORF). Notice of Medicare Non-Coverage (NMNC) must be given by the provider of service two (2) days prior to the end of services. This notice must include the necessary information on how the member can appeal to the Quality Improvement Organization (QIO). Coverage of provider services continues until the date and time designated on the termination Notice of Medicare Non-Coverage or if the member appeals to the QIO, until the QIO completes review of the case and issues a decision. The Medicare Appeal Procedure has two distinct processes which a member may use: the 72 Hour Urgent Appeal Process the 30 Day Appeal Process 11

12 When members think they are being discharged from the hospital too soon When members are hospitalized, they have the right to get all the hospital care covered by Coventry that is necessary to diagnose and treat their illness or injury. The day the member leaves the hospital ( discharge date ) is based on when their stay in the hospital is no longer medically necessary. Information members should receive during their hospital stay When Advantra members are admitted to the hospital, the facility is responsible to provide the member a notice called the Important Message from Medicare. This notice explains the members rights: to get all medically necessary hospital services covered; to know about any decisions that the hospital, their doctor, or anyone else makes about their hospital stay and who will pay for it; that their doctor or the hospital may arrange for services they will need after they leave the hospital; to appeal a discharge decision. Expedited 72 Hour or Fast Appeal Process This is the process a member may use if he/she or the doctor believes that their health, life or ability to regain maximum function may be jeopardized by using the standard 30 or 60-Day Appeal Process. However, members may not use this process to appeal claim payment denials. Any provider may provide oral or written support for a member s request for an Expedited Appeal. Unless the physician makes a request for a Expedited Appeal on behalf of a member, the Plan makes the determination as to whether the request for a 72 Hour Appeal will be sent through that process or the standard 30 Day Appeal Process. 30 Day Appeal Process This is the standard process that a member should use when he/she requests that the Plan change any decisions made related to: Health Services, provided by a non-advantra contracted provider that the member believes should have been provided, arranged or 12

13 reimbursed by Coventry. Services not yet rendered, but which the member believes are covered by Coventry and should be provided. Claims for services in which no written notice has been issued (60 days) after submission. This process should be used when the member believes that the issue they are appealing is not time sensitive. The member may file the appeal or may appoint a representative to file the appeal on their behalf. Please note that the member may appoint any provider, whether contracted or non-contracted to service Advantra, as their representative. In such cases, the appointment must be submitted to Advantra Customer Services in writing and it must contain: the member s name and Medicare number a short statement appointing the representative the member s signature and date the representative s signature and date The member can also submit an appeal to the Social Security Administration or the Railroad Retirement Board within 60 days of the date of the notice of the initial decision by Coventry. If Coventry upholds its decision to deny either in whole or in part, the entire file is forwarded to the CMS Appeals contractor for their review. All CMS Appeals contractor decisions are binding to the Plan. Advantra members making complaints (appeals) if they think their coverage for SNF, Home Health or Comprehensive Outpatient Rehabilitation Facility (CORF) service is ending too soon. When a patient in a SNF, home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF), members have the right to get all the SNF, HHA or CORF care covered by Coventry that is necessary to diagnose and treat their illness or injury. The day the provider decides to end their SNF, HHA, or CORF coverage is based on when their stay is no longer medically necessary. Information members should receive during their SNF, home health agency (HHA) or CORF stay If the provider decides to end the member s coverage for SNF, HHA, or CORF services, the member will get a written notice from the provider at least 2 calendar days before their service ends. The member (or someone they authorize) will be asked to sign and date this document, to show that they received the notice. Signing the notice does not mean that they agree 13

14 that coverage should end it only means that they received the notice. How members can appeal their coverage to the Quality Improvement Organization Members have the right by law to ask for an appeal of termination of their coverage. As explained in the notice, members can ask the Quality Improvement Organization (the QIO ) to do an independent review of whether terminating the coverage is medically appropriate. If members want to have the termination of the coverage appealed, they must act quickly to contact the QIO. The written notice they get from the provider gives the name and telephone number of the QIO and tells them what they must do. If members get the notice 2 days before the coverage ends, they must be sure to make their request no later than noon of the day after they get the notice from the provider. If members get the notice and have more than 2 days before the coverage ends, then they must make their request no later than noon the day before the date that the Medicare coverage ends. What will happen during the review? Once the QIO receives the member s request for an appeal, they notify Coventry and the provider of the request. The QIO may ask for the member s opinion about why they believe the services should continue. Members do not have to prepare anything in writing, but may do so if they wish. The QIO will also look at their medical information, talk to the doctor, and review other information that is given to the QIO. After reviewing all the information, the QIO will give an opinion about whether it is medically appropriate for their coverage to be terminated on the date that was originally set for them. The QIO will make this decision by close of business of the day after it receives all the information it needs to make a decision. What happens if the QIO decides in the member s favor? If the QIO agrees with the member, then coverage will continue for the SNF, HHA or CORF services for as long as medically necessary. 14

15 What happens if the QIO denies the member s request? If the QIO decides that the decision to terminate coverage was medically appropriate, the member will be responsible for paying the SNF, HHA or CORF charges after the termination date on the original advance notice given to the member. Neither Medicare nor Coventry will pay for these services. If the member stops receiving services on or before the date given on the notice, they can avoid any financial liability. 60 Day Appeal Process This is the standard process that a member should use when he/she requests that the Plan change any decisions made related to: Claims for services in which no written notice has been issued (60 days) after submission. Payment for care the member already received The member may file the appeal or may appoint a representative to file the appeal on their behalf. Please note that the member may appoint any provider, whether contracted or non-contracted with Coventry for participation in the Advantra plans, as their representative. In such cases, the appointment must be submitted to Advantra Customer Services in writing within 60 calendar days from the date of the notice of the organization determination and it must contain: the member s name and Medicare number a short statement appointing the representative the member s signature and date the representative s signature and date The member can also submit an appeal to the Social Security Administration or the Railroad Retirement Board within 60 days of the date of the notice of the initial decision by Coventry. If Coventry upholds its decision to deny either in whole or in part, the entire file is forwarded to the CMS Appeals contractor for their review. All CMS Appeals contractor decisions are binding to the Plan. Advantra Internal Grievance Process Members have the right to file a grievance with Coventry if they are in any way dissatisfied with the Plan or its contracted providers. The following is a list of examples in which the Advantra Grievance Procedure could be used: 15

16 Service complaints including waiting times, provider behavior and any complaint that does not include a liability for payment decision. Complaints about the quality of the services rendered. A member is encouraged to resolve the complaint informally by working with their Customer Services Representative. A Customer Service Representative will review, research and resolve member complaints in a timely and equitable manner. Members will be informed of the resolution in writing within 30 days. An exception to the 30-day resolution process is the expedited or fast grievance process in which Coventry will respond to member s complaint within 24 hours, if this issue is in regards to Coventry s decision to give them a fast appeal or if Coventry takes an extension to our initial decision to appeal. If a complaint cannot be informally resolved, members have the option to file a written complaint for review by the plan s grievance committee. If a member wishes to appeal the decision of the Initial Grievance Committee, they can request a second level review. Important Information on Member Request for a Service As a Advantra provider, you will be responsible for forwarding any medical records or necessary information when requested by the Advantra Customer Services Department. If you are informing a member that you are not authorizing a service or telling a member that the service is not covered, you must provide to the health plan a copy of the Member Request form and inform the member that they have a right to appeal. Please direct any members with questions regarding the Medicare Appeals Process or the Plan s Internal Grievance Process to the Customer Services Department. 16

17 MEDICARE PROCESS QUALITY IMPROVEMENT ORGANIZATION (QIO) NOTICE OF NON-COVERAGE HOSPITAL DISCHARGE OR Notice of Non-Coverage Issued OR Member agrees and is discharged Member requests QIO Review by noon of 1st working day after noncoverage notice received (Member is no longer financially responsible until QIO decision is made) Member fails to request QIO review by noon of the 1st working day after notice of non-coverage received (Member becomes financially liable, but may request an Expedited Appeal) End QIO determines confinement should continue (Plan remains liable) Determination End QIO determines confinement should end (Member responsibility begins noon of following day) 17

18 Quality Improvement Organization QIO-Review The Quality Improvement Organization (QIO), an independent agency, has contracted with the Secretary of the Department Health and Human Services (DHHS) to review records of the medical care provided to Advantra members when they register complaints concerning quality of access or to care. Members also have the right to an Immediate Review by the QIO if the member believes that they are being discharged from the Hospital, Skilled Nursing Services, Home Health Services or Rehabilitation Services too soon. When Coventry issues a member a Notice of Discharge, the notice is subject to QIO Review. Coventry will contact your office to obtain medical records upon Quality Improvement Organization s request. All reviews will be performed by board-certified physicians of like specialty not involved in the original determination and having no relationship to Coventry. Please direct any questions regarding the Quality Improvement Organization and the Review Process to our Network Operations Department. Independent Quality Review Coventry maintains an agreement with The Carolinas Center for Medical Excellence a Quality Improvement Organization approved by CMS. The purpose of this agreement is to focus on the development and implementation of cooperative projects as a method to improve the quality of care in the State and to help Medicare risk beneficiaries make informed health care choices. Quality of care includes access, appropriateness and desired outcomes to care and consumer satisfaction. 18

19 Unique Services Advantra offers a more comprehensive benefit package for its members compared to Fee-For- Service Medicare, Medigap or Medicare Supplement Plans. Examples of these service enhancements are described below. Please note that Advantra products have coverage limitations that are different from the Coventry commercial HMO, POS & PPO products. In most cases, the coverage limitations follow Medicare Fee for Service coverage guidelines. Advantra Precertification rules may apply to certain services. For the most current Precertification Guide please visit Please note: Members are subject to the copayment indicated on their identification card for certain services. Outpatient Services Preventive Care Routine Physicals are covered once per year. A copayment or coinsurance may apply. Diagnostic X-Ray Mammograms are covered annually. Advantra members should seek care at a contracted facility for the annual screening mammogram. Coventry does remind each member that they should also have a breast exam by their Primary Care Physician or a contracted gynecologist in conjunction with obtaining a mammogram. A copayment or coinsurance may apply. Durable Medical Equipment (DME) and Prosthetic Appliances Coventry follows Medicare guidelines for coverage of DME, Prosthetics and Orthotic devices. Prosthetic devices must be on the Medicare s list of approved prosthetic devices. A copayment or coinsurance may apply. Diabetic Supplies Diabetes and self-monitoring training and supplies includes coverage for glucose monitors (Lifescan Models), test strips, lancets and self-management training. A copayment or coinsurance may apply. Gynecological Visit Members are entitled to one office visit per year for a routine annual exam including a pap smear without a referral from the PCP when using a Advantra contracted gynecologist. A copayment or coinsurance may apply. 19

20 Immunizations and Vaccinations Influenza and pneumococcal vaccines and their administration and are covered in full. Hepatitis B is a covered service for a copayment. Oral Surgery Members have coverage for initial treatment received within 24 hours of an accidental injury. Benefits also include non-dental treatment relating to medically diagnosed congenital defects, birth abnormalities, or treatment for tumors and cysts (including pathological examination) of jaw, cheeks, lips, tongue, roof and floor of mouth. A copayment or coinsurance may apply. Extraction, replacement and restoration of teeth are not covered. Podiatry Advantra follows Medicare guidelines for Podiatry Services. A copayment or coinsurance may apply. Chiropractic Care Advantra follows Medicare guidelines for Chiropractic services. A copayment or coinsurance may apply. EMERGENT/URGENT CARE/RENAL DIALYSIS SERVICES Emergency Care Emergency services for both inpatient and outpatient services are covered if: (1) furnished by a qualified provider and; (2) needed to evaluate or stabilize an emergency condition. Emergency care requires no prior authorization. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate attention to result in (1) serious jeopardy to the health of the individual (or an unborn child); (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. Medically needed emergency services and post-stabilization care are covered no matter where members are, even if they are provided by a doctor or facility that is not contracted to participate in the Advantra plans. 20

21 Post-Stabilization Care is medically necessary, non-emergency services needed to ensure that the enrollee remains stabilized from the time that the treating hospital requests authorization from Coventry until (1) the member is discharged, (2) a contracted physician arrives and assumes responsibility for the enrollee s care, or (3) the treating physician and Coventry agree to another arrangement. Coverage for Renal Dialysis Services Renal dialysis services are covered from qualified dialysis providers when the member is temporarily absent from the Plan s service area. It is the responsibility of the provider to coordinate these services; however, no authorization is required. Urgent Care For a listing of Urgent Care Clinics, please contact Customer Service at (866) or visit our website at Inpatient Services Skilled Nursing Medically necessary coverage is limited to 100 days per Medicare Benefit Period. The three (3) day hospital stay will be waived. No prior hospitalization is required. A copayment or coinsurance may apply. Inpatient Behavioral Health Mental Health: Members have a lifetime limit of 190 days for care in a psychiatric hospital. Benefit limitations follow Medicare guidelines. The telephone number is Other Covered Services The following services are not routinely covered, but may be covered under Advantra. Vision Care Members, regardless of the benefit plan selected are also entitled to benefits for eyeglasses or contact lenses after cataract surgery. This benefit follows the Medicare guideline for coverage. 21

22 Hearing Coverage: Members are entitled to Medicare covered diagnostic hearing exams. A copayment may apply. Pharmacy: Individual members have a pharmacy benefit that is subject to limitations. Please contact the Customer Service Department for more information on prescription drug coverage for Advantra members. For a copy of the most current formulary, please visit Laboratory: Advantra follows Medicare guidelines for Laboratory services. A copayment or coinsurance may apply. All procedures not payable by Medicare should be sent to any Advantra participating reference lab or participating hospital lab. 22

23 SPECIAL STATUS MEDICARE MEMBERS The Center for Medicare and Medicaid Service (CMS) reimburses contractors at different rates for each member based on age, sex, county of residence, and also on the classification into one of five special Status Categories. The Special Status Categories include: Institutional Status End Stage Renal Disease Medicare/Medicaid Dual Eligible Hospice Working Aged It is important that you understand the different Special Status Categories and take the actions defined below when you identify a member who meets the Special Status definition. Institutional Status is defined as an individual enrolled in a Medicare Advantage who has been a resident in a skilled nursing facility, nursing facility, ICF/MR, psychiatric hospital, rehabilitation hospital, long-term care hospital, swing-bed hospital for at least 30 consecutive days. If you are making rounds on a member in one of these facilities and the member has been there for more than 30 days, please make sure your Utilization Management contact is aware of this member. These types of members must be submitted to CMS each month for CMS to provide the Plan with a higher reimbursement rate. End Stage Renal Disease (ESRD) is defined by CMS as the state of renal impairment that appears to be irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life. If 36 months or more has elapsed since a kidney transplant, the person is no longer considered to have ESRD status. It is very important that you inform your Utilization Management contact of any enrolled members who now meet the ESRD definition. The Plan receives a higher reimbursement from CMS for members who are ESRD. ESRD status is reported to CMS through the ESRD Network Organization located in 18 geographic areas in the United States. The provider, usually a contracted nephrologist or renal dialysis facility submits the completed CMS 2728-U4, Medical Evidence Report Form, to the applicable ESRD Network Organization. The ESRD Network Organization reviews the form and transmits the data to CMS electronically. CMS will notify the Plan of members who are ESRD and pay the Plan at a higher rate. (NOTE: Coventry may be secondary payor for individuals who have both Medicare coverage and Employer Group Health Plan coverage.) 23

24 Medicare/Medicaid Dual Eligible is an individual who is covered under both the Medicare and Medicaid programs. A qualified Medicare beneficiary (QMB), has the state Medicaid program pay for annual Medicare Part A deductible, Medicare Part A coinsurance, monthly Medicare Part B premium, annual Part B deductible and Medicare Part B coinsurance. Hospice is a member who has selected Medicare certified Hospice coverage. Prospective members are entitled to enroll in Advantra if they are receiving Hospice coverage. An Advantra member becomes Medicare certified for Hospice when he/she completes a Hospice Election Form. This form is usually provided by a Medicare certified Home Health or Hospice provider. The provider then submits the form along with the provider bills to the fiscal intermediary. The fiscal intermediary pays the Hospice claims, not Coventry. Coventry receives a lower reimbursement rate from CMS for members that are Medicare certified for Hospice since the fiscal intermediary is paying the claims. Working Aged is defined as the CMS Medicare Advantage risk payment category for an individual who is defined as eligible for Medicare and (1) is either working for an employer with more than 20 employees or (2) has a spouse with coverage under an Employer Group Health Plan which covers the Advantra member. The Plan receives a lower payment rate from CMS for these members. If you identify a member with Employer Group Health Plan coverage in addition to their Advantra coverage, please inform Advantra Customer Services. If a member is Working Aged, you should bill the other carrier as primary and Coventry as the secondary payor. Record Retention As a requirement of Medicare, all providers must maintain for a period of 6 years books and in certain instances described in the Medicare Advantage regulation, periods in excess of 6 years for more records, documents and other evidence of accounting procedures and practices, physical facilities and equipment and records related to Medicare enrollees and any additional relevant information CMS may require. 24

25 Claims Submission It is recommended that you submit Claims within 180 days from the date of service on a CMS 1500 or a UB-04 Form. Coventry Health Care has adopted the standard billing guidelines so that completion of the CMS Form is consistent with Medicare Guidelines. You must include your NPI number on each Claim Form submitted. All hospitals (inpatient & outpatient) services and physician services information are required to be submitted to CMS. The mailing address for Advantra claims is: Advantra P.O. Box 7102 London, KY For Electronic submission, please use Payor ID #25133 ** Reminder that you do not bill Original Medicare. For additional information regarding claims, please reference Section 12 - Claims and Reimbursement Policies. Importance of Medical Record Documentation Accurate risk adjusted payment relies on complete medical record documentation and diagnostic coding. CMS annually conducts risk adjustment data validation by Medical Record Review. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. Resources - ICD-9-CM Coding 1. for a computer-based course on ICD-9-CM 2. (Conduct a site search for ICD-9-CM)

26 Precertification Precertification (approval by the Plan) is required for coverage of a limited number of specific diagnostic and therapeutic services. Payment will not be made to participating providers, including physicians, hospitals and ancillary providers, for services that require precertification unless precertification is obtained and the services are authorized. A list of procedures and services requiring precertification is attached to this section of the manual and on our website or contact our Health Services Department if you have a question about whether a particular service requires precertification. If a Member should ask about the likelihood of coverage, please refer Member to the Customer Service Department telephone number. Authorization only verifies that the requested service meets the benefit plan's definition of medical necessity and is not a guarantee of payment. Whether the requested service is covered by the health plan is subject to all of the terms and conditions of the Members benefit plan, including but not limited to, member eligibility, benefit coverage at the time the services are provided and any pre-existing condition exclusions referenced in the Members benefit plan. Obtaining Precertification 1. The ordering physician or his/her staff designee contacts our Health Services Department seven (7) to ten (10) days prior to the elective admission or services, when possible, By calling the telephone number found in this manual in Section 2 Important Contact Information or by faxing a precertification request form to the Health Services Department. This form is included at the end of this manual in Appendix A. For HMO plans, it is the ordering physician's responsibility to obtain precertification. Providers (including physicians, facilities and laboratories) will not be reimbursed unless precertification has been obtained and the services are authorized for payment by the Plan. The facility is responsible for ensuring that precertification has been obtained by the ordering physician. 2. The Plan Precertification Nurse will need the following information: patient s name patient s identification number hospital/facility name date of admission (if applicable) type of service surgical procedure (if applicable) attending physician s name referring physician s name diagnosis 26

27 estimated length of stay (if applicable) CPT-4 and ICD-9 codes (required) reason for admission (if applicable) sufficient clinical information to determine whether coverage guidelines have been met 3. When sufficient information is submitted with the request for precertification, the attending physician will receive notification of approval or denial within three days of receipt of complete information. Provider receives a verbal notification followed by written notification sent to the provider and the Member. Requests for precertification that are submitted with insufficient information may be pended for additional information (thus lengthening the process). The Member will be notified that the request has been pended for additional information. 4. Once an inpatient admission is approved by the Plan, an initial length of stay is assigned using the Plan s guidelines for inpatient admissions. 5. The ordering physician and the patient receives a precertification number. When considering a precertification request, the Plan precertification personnel verifies the following: The Member is eligible for coverage at the time of the request. The services requested are covered under the Member's benefit plan. The services are medically necessary and are provided by participating providers in participating facilities, to the extent possible. The services requested are not excluded from coverage for the stated diagnoses. If the admitting physician does not obtain precertification or the precertification for elective admission or services has been denied, payment for services rendered will be withheld from the provider, including the physician and facility. The Plan will not rescind a precertification approval decision unless there has been a material misrepresentation or incomplete disclosure of information, or the Member is later determined to be ineligible for coverage at the time the service is rendered. Requesting Precertification by Fax The Plan does accept requests for precertification of services by fax or in addition to telephone. The physician completes the information on the Precertification / Admission Program Physician Request for Services form and faxes it to the Health Services Department. A copy of the form can be found at the end of this manual under Appendix A. Please feel free to make copies of this form or call the Health Services Department to request additional forms. The submittal of a faxed precertification request follows the same timeframes for response from the Plan as telephonic requests. Fax request forms should be accompanied by sufficient clinical information to determine whether coverage guidelines have been met. 27

28 Appendix A Advantra Precertification Requirements All elective inpatient admissions and the following services require prior authorization. Additions to the list are noted in BOLD. These changes are effective October 1, Ambulance Services (Non-Emergency) Selected Outpatient Surgery (See Attachment A) Cosmetic and Reconstructive Services Durable Medical Equipment, Prosthetics, and Orthotics (greater than $1000) Elective Inpatient Admissions, including Acute, Skilled Nursing Facility, Hospice, Rehabilitation and Elective Observations Stays Infertility (Diagnosis and Treatment) Services Considered Experimental or Investigational Neuropsychiatric Testing Testing and Treatment of Sleep Disorders Speech Therapy Home Health Services, including Hospice and Home Infusions Selected Injectable Drugs (See Attachment B) Specific Oral Drugs as Indicated on Formulary Transplant Services Referrals to Non-Participating Providers for In-Network Benefits Radiology Services/Imaging Studies: (NON-Emergent) Diagnostic Nuclear Medicine Nuclear Cardiology Studies MRI/MRA CT Scans (See Attachment A) CT Angiograms Total Body Scans PET Scans/PET Fusion 28

29 Attachment A Precertification Requirements CT Head/Brain CT Orbit CT Chest CT Cervical Spine CT Thoracic Spine CT Lumbar Spine CT Pelvis CT Upper Extremity CT Lower Extremity CT Abdomen CT Scans Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography) Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT CT Heart CT Heart congenital studies, non-coronary arteries Follow Up, Limited or Localized CT Unlisted Computed Tomography Procedure Outpatient Surgery Abdominoplasty/Panniculectomy/Lipectomy Adenoidectomy Arthroscopy - TMJ Blepharoplasty/Brow Lift/Ptosis Repair Breast Augmentation or Reduction Colonoscopy Colposcopy (If performed in Outpatient Hospital) Cryoablation Dental and Oral Procedures and Services Endoscopic Sinus Surgery Enhanced External Counterpulsation (EECP) Gastric Bypass/Bariatric Surgery Hiatal Hernia Repair-(Nissen or Other) Hysterectomy Hysteroscopy Hysterosalpingography Laminectomy/Discectomy/Corpectomy/Decompressi on Laminectomy for Implantation of Neurostimulator Laparoscopy-Diagnostic Mastopexy Neurostimulators (Spinal/Peripheral) Otoplasty Orthognathic Surgery Panniculectomy Pectus Carinatum/Excavatum Repair Radiofrequency Ablation Reduction Mammoplasty Shockwave Therapy (Not including Lithotripsy for urinary stone in renal pelvis or ureter) Somnoplasty or any procedure for snoring Rhinoplasty Tonsillectomy Uterine Artery Embolization Uvulectomy Uvulopalatopharyngoplasty (UPPP) Varicose Vein Treatments and Procedures Vasectomy (If performed in Outpatient Hospital) Ventral Hernia Repair/Diastasis Recti Repair 29

30 Attachment B Injectable Drugs Precertification Requirements Injectable drugs (other than insulin, epinephrine, glucagon, and Imitrex) when a prescription is presented to a retail, hospital or mail-order pharmacy. Injectable drugs given in the physician s office if one or more of the following conditions applies: The drug is normally self-administered in the home setting and is usually dispensed from a retail, hospital or mail-order pharmacy (example: Avonex, Betaseron, Growth Hormone and Biosynthetic Growth Hormones, Enbrel, Humira, Kineret, Aranesp etc.). Any injected or implanted medication that has an average wholesale price (AWP) greater than $75 per prescribed dose. Any new injectable drug released after January 1, Repeated administration of the drug in the physician s office is contemplated, excluding routine cold and allergy shots. The drug is potentially experimental or lacks FDA approval for the indication for which it is given. The following drugs given in the physician s office, or in the home by self-administration. Amevive (Alefacept) Apokyn Review for Procurement Only Aldurazyme Aranesp(Darbepoetin alfa) Avonex Aralast Arcalyst Arixtra Betaseron, Extavia Blood clotting factors (i.e. Factor VIII, etc.) Botulinum Toxin, Type A & B (Myobloc, Botox) Dysort Ceredase (Alglucerase injection) Cerezyme (Imiglucerase) Cimzia Cinryze Copaxone (self injectable) Dacogen Elaprase Enbrel (Etanercept) Euflexxa Fabrazyme Forteo (Teriparatide) Fragmin Fuzeon (Enfuvirtide) Growth Hormones and IGF-1 (Increlex, Iplex, etc.) Humira (Adalimumab) Ilaris Innohep Interferon alfa-2b (Intron A) Interferon Alfacon-1(Infergen) Intravenous Immune Globulin (IVIG) IM Gamastan Kineret (Anakinra) (self injectable) Leukine Lovenox Naglazyme N Plate Orencia Pegylated Interferon Alfa 2a (Pegasys) Pegylated Interferon Alfa 2b (Peg-Intron) Prolastin - C Rebif (Interferon beta-1a) Remicade (Infliximab) Rituxan Sandostatin (Octreotide acetate) Simponi Somatuline Depot Somavert Subcutaneous Immune Globulin (Vivaglobin) Tysabri Unclassified Drugs Vidaza Vivitrol Xolair (Omalizumab) Zemaira 30

31 When Precertification is NOT Required Chemotherapy drugs that are not considered experimental or investigational Injectable drugs given while the patient is an inpatient in any hospital, nursing home or rehabilitation facility. Injectable drugs given in an emergency room or an urgent care center unless the urgent care center is acting as the patient's primary physician. Emergency use drugs (example: Epinephrine) Injectable Pain medication (example: Demerol) Drugs given for chemotherapy associated nausea (example: Zofran) unless quantity limit exceeded Injectable antibiotics (example: Rocephin) Options for Supply of Injectable Drugs The Plan has made arrangements with preferred vendors for the supply of expensive injectable drugs. While many of these drugs do not require Precertification by the Plan, please call us at (800) to make arrangements for the delivery of these medications to your office. You can also submit requests by fax at (877) The preferred pharmacy vendor will supply the dose for administration to the covered member or the dose may be used replenish office stock used on behalf of a Plan member. Drugs Available from Medco include, but are not limited to : Apokyn Pegasys and Peg-Intron Epogen, Procrit, Aranesp Neupogen Neulasta Humira Kineret Lupron Neumega Sandostatin Growth Hormones Raptiva Rebif 31