TOGETHER PROVIDER HANDBOOK MAY 27, 2015

Transcription

1 PROVIDER HANDBOOK MAY 27, 2015 TOGETHER ADMINISTRATION OFFICE phone: toll free: fax: web:

2 ContinuUs Provider Help Desk WPS / Family Care Contact Center Claims Support ContinuUs Provider Services Staff - /Provider-115/Provider-Services-Staff-Contacts South & East Region Office US HWY 14, Lone Rock, WI North Region Office Stein Blvd, Suite 1, Eau Claire, WI East Region Counties South Region Counties Columbia, Dodge, Green Lake, Jefferson, Marquette, Walworth, Waukesha, Waushara Crawford, Grant, Green, Iowa, Juneau, Lafayette, Richland, Sauk North Region Counties Chippewa, Dunn, Eau Claire, Pierce, St. Croix ContinuUs Administration US HWY 14, Lone Rock, WI phone: fax: Program Integrity Violation Reporting Tony Ring, Director of Compliance phone: fax: Member Rights Specialist North Region - TJ (Tashai) Atkins phone: fax: South/East Regions - Mari Wipperfurth phone: fax: ContinuUs Office Location Maps and Directions - /Contact-us Office Hours - All Offices, 8:00 am to 4:30 pm, Monday-Friday

3 Table of Contents INTRODUCTION...1 Family Care...1 Overview of ContinuUs and the Flexible Family Care Benefit We Offer...1 Family Care Roles: The Interdisciplinary Team...3 Definition of Outcomes...4 MEMBER ELIGIBILITY...5 Eligibility for Family Care...5 Member Enrollment Process...6 COVERED AND NON-COVERED SERVICES...7 Covered Services...7 Non-Covered Services...9 PROVIDER NETWORK...10 In-Network Provider Out-of-Network Provider Out-of-Network Provider SDS Requests to Add a Provider Member Choice CONTRACT PROCESS...12 Documentation Requirements Change of Contact Information Criminal Background Checks Record Retention Disaster Planning Room and Board in Residential Facilities BILLING FOR SERVICES...16 Claim Submission Deadlines and Timely Filing Clean Claims Electronic Filing Submitting Paper Claims Third-Party Payer Claims Reimbursement Information Corrected Claims ContinuUs Provider Handbook, 05/27/2015 I

4 Claims Appeals Claims Support PRIOR AUTHORIZATION...25 Prior Authorization Request Prior Authorization Processing Prior Authorization for Emergency Services COMMUNICATION...27 Reporting Contact Information Confidentiality ContinuUs Website PROVIDER QUALITY STANDARDS...28 Overview of the Provider Quality Program Member Satisfaction Survey Provider Satisfaction: Community Work Plan Provider Comment Form Access Standards Quality Assessments PROGRAM INTEGRITY...32 Definitions Program Integrity Compliance Investigating CRITICAL INCIDENTS AND ADVERSE EVENTS...34 Definitions MEMBER RIGHTS...35 List of Member Rights from the Member Handbook Additional Member Rights Procedures to Follow if Rights are Limited or Denied MEMBER GRIEVANCES AND APPEALS...38 Definitions Grievances or Appeals Against You as a Provider Assisting a Member with a Grievance or Appeal RESTRAINT AND SECLUSION...41 Use of Isolation, Seclusion, and Physical Restraint ContinuUs Provider Handbook, 05/27/2015 II

5 MEMBER SAFETY AND RISK...41 Risk Assessment & Risk Reduction CULTURAL COMPETENCY...41 Cultural Values Cultural Competency Cultural Preference CONFIDENTIALITY...42 Provider Requirement Confidentiality in Communications APPENDIX: DEFINITIONS...44 ContinuUs Provider Handbook, 05/27/2015 III

6 INTRODUCTION Family Care Wisconsin s Family Care program serves people with physical disabilities, people with developmental disabilities, and frail elders, with the following specific goals: Giving people better choices about where they live and what kinds of services and supports they get to meet their needs Improving access to services Improving quality through a focus on health and social outcomes Creating a cost-effective system for the future Family Care has two major organizational components: Aging and Disability Resource Centers (ADRCs): Designed to be a single entry point where individuals and their families can get information and advice about a wide range of resources available to them in their local communities. Managed Care Organizations (MCOs): Manage and deliver the Family Care benefit, which combines funding and services from a variety of existing programs into one flexible longterm care benefit, tailored to each individual s needs, circumstances, and preferences. ContinuUs is currently the sole Family Care MCO for two regions comprising a total of thirteen counties: ContinuUs South (Crawford, Grant, Green, Iowa, Juneau, Lafayette, Richland, and Sauk) and ContinuUs North (Chippewa, Dunn, Eau Claire, Pierce and St. Croix). ContinuUs coordinates and is responsible for care management, quality assurance, and billing, as well as for contracting with service providers throughout the thirteen counties. ContinuUs also provides Family Care services in eight counties that are served by one to three additional Family Care MCOs: ContinuUs East (Columbia, Dodge, Green Lake, Jefferson, Marquette, Washington, Waukesha, and Waushara). Overview of ContinuUs and the Flexible Family Care Benefit We Offer Family Care improves the cost-effective coordination of long-term care services by creating a single flexible benefit that includes a large number of health and long-term care services that otherwise would be available through separate programs. A member of ContinuUs has access to a large number of specific health services offered by Medicaid, as well as the long-term care services in ContinuUs Provider Handbook, 05/27/2015 1

7 the Home and Community-Based Waivers, and the very flexible state-funded Community Options Program. Most of these services can be provided through self-directed supports as well as through agency contracts. In order to assure access to services, ContinuUs develops and manages a comprehensive network of long-term care services and supports through contracts with providers. Services provided must be high-quality, person-centered, cost-effective, and outcome-based. ContinuUs is responsible for assuring and continually improving the quality of care and services members receive. ContinuUs receives a monthly per-person payment to manage and purchase care for its members, who may be living in their own homes, group living situations, or nursing facilities. Some highlights of the Family Care benefit include: People receive services where they live. ContinuUs members receive Family Care services where they live, which may be in their own home or supported apartment, or in alternative residential settings, such as residential care apartment complexes (RCACs), community-based residential facilities (CBRFs), adult family homes, nursing homes, or intermediate care facilities for people with developmental disabilities. People receive interdisciplinary care management. Each member has support from an interdisciplinary team that consists of, at a minimum, a care manager and a registered nurse (RN) care manager. Other professionals, as appropriate, also participate as members of the team. The interdisciplinary team conducts a comprehensive assessment of the member s needs, abilities, preferences, and values, with the member and his or her representative, if any. The assessment looks at areas such as: activities of daily living, physical health, nutrition, autonomy and self-determination, communication, and mental health and cognition. People participate in determining the services they receive. Members or their authorized representatives take an active role with ContinuUs care managers in developing their care plans. ContinuUs provides support and information to assure members are making informed decisions about their needs and the services they receive. Members have two options for choosing service providers: My Care, My Choice, the SDS component of ContinuUs Family Care, allows members the freedom to hire and/or purchase services on their own within a budget. ContinuUs offers five levels of SDS for members, with varying amounts of member participation in the management of their providers and services. ContinuUs Standard Plan involves choosing services through ContinuUs s network of qualified providers. Family Care Services Include: Long-Term Care Services ContinuUs Provider Handbook, 05/27/2015 2

8 These are services that have traditionally been part of the Medicaid Waiver programs or the Community Options Program, including adaptive aids, home modifications, home delivered meals, and supportive home care, to name a few. Health Care Services These are services that help people achieve their long-term care outcomes, including home health, skilled nursing, medical equipment and supplies, outpatient mental health services, nursing home care, and occupational, speech, and physical therapy. For Medicaid recipients, health care services not included in Family Care are available through the Medicaid fee-forservice program. Help Coordinating Member s Primary Health Care In addition to assuring that people get the health and long-term care services in the Family Care benefit package, ContinuUs care managers also help members coordinate all their health care, including, if needed, helping members get to and communicate with their physicians and helping them manage their treatments and medications. Services to Help Achieve Member s Employment Objectives Services such as daily living skills training, day services, prevocational services, and supported employment are included in the Family Care benefit package. Other Family Care services such as transportation and personal care also help people meet their employment goals. Services that Best Achieve Member s Outcomes The interdisciplinary team may decide to utilize creative options for services, treatments, or supports (other than just the benefit package services) that are more likely to help the member achieve his or her outcomes, and ContinuUs may then authorize those services and include them in the member s care plan. A listing of Family Care benefit services can be found in the Covered and Non-Covered Services section of this handbook. Family Care Roles: The Interdisciplinary Team The Interdisciplinary Team (IDT) is a group of people who work together with the care managers to reach a common goal. Each person on the IDT contributes his or her own ideas. When an individual becomes a member of ContinuUs, they become the center of the team. In general, the goal of the IDT is to provide the member with supports and services so that he or she can live a more independent and healthy life. A member identifies his or her personal outcomes and, along with the IDT, creates a plan that lists the member s outcomes and needs along with the resources they will need. (Note: the IDT is referred to as a care team in the Family Care Member Handbook.) ContinuUs Provider Handbook, 05/27/2015 3

9 The member s team includes the following: Member The member is the most important part of the interdisciplinary team. His or her involvement and contribution are critical to ensure that long-term care outcomes are achieved and the member s needs are met. The member s team will involve the member in the process to identify personal goals or outcomes: from assessment to plan development, provider arrangements, service delivery, and evaluation of member satisfaction with services provided. Care Manager The care manager helps the member identify and address the member s support needs as identified in their assessment. Examples of areas the member may evaluate with the care manager are employment, transportation, supportive home care, or outpatient mental health services. All of the services the member receives through ContinuUs are driven by the Member-Centered Plan and resulting Individual Service Plan that is written with the member. The care manager helps to arrange and monitor the services and supports included in the member s plan. RN Care Manager The RN care manager (a registered nurse) evaluates the member s health care needs and coordinates health care services with members. The RN care manager helps or works with others to make sure the member receives ongoing tailored support for the member s long-term care and health care concerns. The RN care manager will provide prevention and wellness education to members and other people in the member s life and will also encourage the use of influenza and pneumonia vaccines, if applicable and appropriate. Note: The term care management team is generally used to refer to the Care Manager and RN Care Manager that are assigned to a member s IDT. Guardian If a guardian has been appointed for a member, that person is always part of the interdisciplinary team. Others as Member Determines Members may wish to include other people as part of the interdisciplinary team. Adult children or therapists are examples of others that members may choose to be part of their team. Definition of Outcomes Care managers work with members/guardians to identify what is important to the member and identify the member s personal outcomes. Outcomes drive the Member-Centered Plan. ContinuUs supports members in meeting their outcomes. Some examples of outcomes we frequently hear ContinuUs Provider Handbook, 05/27/2015 4

10 include: I want to live at home, and I want to work. There are many outcomes they are personal and individual-specific. When services are purchased to meet an outcome they are expected to be cost-effective as well as help achieve the outcome. Family Care may not be able to help members obtain everything they want out of life. In addition, ContinuUs may not always purchase services to help the member achieve their outcomes. The things members do for themselves, or that a member s family and friends do for them, are still a very important part of any plan to help members achieve their personal outcomes. The personal outcomes that Family Care does help members achieve are: Members are treated fairly. Members have privacy. Members have personal dignity and respect. Members choose their services. Members choose their daily routine. Members achieve their employment objectives. Members are satisfied with services. Members choose where and with whom to live. Members participate in the life of the community. Members remain connected to informal support networks. Members are free from abuse and neglect. Members have the best possible health. Members are safe. Members experience continuity and security. MEMBER ELIGIBILITY Eligibility for Family Care An individual/guardian can choose to enroll in ContinuUs if the potential member is a resident of a participating county, at least 18 years old, and has a long-term care need. The individual must also be functionally and financially eligible for Family Care, and must agree to sign the enrollment form. Family Care is a voluntary program. Individuals can enroll by calling or visiting an Aging and ContinuUs Provider Handbook, 05/27/2015 5

11 Disability Resource Center (ADRC). For more information about ADRCs, including location and contact information, visit dhs.wisconsin.gov/ltcare/adrc, or contact your local county human services office. Functional Eligibility Individuals must be functionally eligible for Family Care. ADRC staff will work with the individual to see if they meet functional eligibility criteria. Individuals must have a physical disability, developmental disability, or be over the age of sixty-five years and have a long-term health condition. Financial Eligibility Individuals must be financially eligible for Family Care. The income maintenance agency in the person s county of residence will assign a worker to determine financial eligibility for individuals desiring to enroll in Family Care. This worker will determine if the individual meets the financial eligibility criteria. Eligibility Verification Individuals interested in enrolling in Family Care will be asked to provide the following information to verify eligibility: Information about the individual s health and support needs Information about the individual s income and assets A signed Authorization for Disclosure of Information form for medical records, to better understand the individual s long-term care and health needs Member Enrollment Process Individuals are enrolled in Family Care after they have gone through the financial and functional eligibility process with an ADRC and a county income maintenance office. Once these have been completed, the individual will meet with an enrollment counselor to talk about what enrollment means. An enrollment counselor will discuss the individual s options and try to answer any questions the individual/guardian may have about the Family Care program as well as other programs available to him or her. The ADRC and the county income maintenance office will let the individual know if he or she will have a cost share. The ADRC will refer the individual to ContinuUs if that is the program in which the person chooses to enroll. ContinuUs Provider Handbook, 05/27/2015 6

12 COVERED AND NON-COVERED SERVICES Covered Services The following services are included in the Family Care Benefit Package. Services available to an individual member may vary, depending on that member s level of care. See the Family Care Member Handbook, part 4, The Family Care Benefit Package, for more information. The handbook is available on the Member Handbook page in the Members & Families section of our website. Adaptive Aids Adult Day Care Services AODA Day Treatment Services (all settings, except hospital-based or physician provided) AODA Services (not inpatient nor physician-provided) Assistive Technology/Communication Aids Care/Case Management Services (includes assessment and care planning) Community Support Program (except physician provided) Consultative Clinical and Therapeutic Services for Caregivers Consumer Education and Training Services Counseling and Therapeutic Services Durable Medical Equipment and Medical Supplies Environmental Accessibility Adaptations (home modifications) Financial Management Services Habilitation Services - Daily Living Skills Training - Day Habilitation Services Home Delivered Meals Home Health Housing Counseling Mental Health Day Treatment Services (in all settings) Mental Health Services Nursing Home Services ContinuUs Provider Handbook, 05/27/2015 7

13 Nursing Services (including respiratory care, intermittent and private duty nursing) Occupational Therapy (in all settings except inpatient hospital) Personal Care Services Personal Emergency Response System (PERS) Physical Therapy (in all settings except inpatient hospital) Prevocational Services Relocation Services Residential Care - Adult Family Home (AFH) - Certified Residential Care Apartment Complex (RCAC) - Community-Based Residential Facility (CBRF) Respite Care Services Self-Directed Personal Care Services Skilled Nursing Services (RN/LPN) Specialized Medical Equipment and Supplies Speech/Language Pathology Services (in all settings except inpatient hospital) Support Broker Supported Employment - Individual Employment Support Services - Small Group Employment Support Services Supportive Home Care Training Services For Unpaid Caregivers Transportation Services (except ambulance) Transportation, Specialized: - Community Transportation - Other Transportation Vocational Futures Planning and Support ContinuUs Provider Handbook, 05/27/2015 8

14 Non-Covered Services The Family Care benefit package does not include the following services: Ambulance Transportation Audiology Chiropractic Crisis Intervention Services Dentistry Emergency and Urgent Care Services End-Stage Renal Disease Services Eyeglasses Family Planning Services Hearing Aids (including batteries, accessories, and assistive listening devices; and repair and maintenance of hearing aids and assistive listening devices) Hospice Care Hospital: Inpatient Hospital: Outpatient (except physical therapy, occupational therapy, speech and language pathology, mental health services, and substance abuse treatment) Independent Nurse Practitioner Services Lab and X-ray Mental Health Services (provided by a physician or provided in an inpatient hospital setting) Nurse Midwife Services Optometry Prescription Drugs Physician Services Podiatry Prenatal Care Coordination Prosthetics (including repair and maintenance) School-Based Services Substance Abuse Services (provided by a physician or provided in an inpatient hospital setting) ContinuUs Provider Handbook, 05/27/2015 9

15 PROVIDER NETWORK In-Network Provider ContinuUs is committed to ensuring that our provider network is adequate to meet the needs of our members. We are equally committed to ensuring that our providers demonstrate competency and quality in the provision of service to our members. We add providers to the ContinuUs provider network when all of the following standards are met: The service is a Family Care benefit. The proposed service is not adequately available within the current provider network or additional providers in a specific service area would offer needed choice for members. The provider s specialized knowledge, expertise, or cultural diversity is needed. The provider s mission statement and/or philosophies complement Family Care outcomes and the mission of ContinuUs. The provider meets all applicable licensing/certification requirements as they apply to the service(s) to be provided. The provider has demonstrated education and/or experience with proposed services and target group served. The provider has demonstrated competency with personnel practices related to hiring, training, monitoring, and supervision of employees. The structural setting of services is of sufficient capacity and is safe for service provision. The provider has a demonstrated ability to meet other applicable standards that are required by law or per their contract with ContinuUs. The provider is able to demonstrate the ability to ensure the health and safety of members. The provider has demonstrated adequate financial stability to operate a business. The provider has positive references that illustrate competency and quality services. The provider is willing and able to sign and adhere to all components of the ContinuUs contract and/or agreement. The provider is willing to submit other materials as requested by ContinuUs to illustrate quality, competency, and fiscal soundness. ContinuUs Provider Handbook, 05/27/

16 Out-of-Network Provider Under certain circumstances, a care manager may need to request for a member the use of a provider other than a provider already in the ContinuUs provider network. ContinuUs Provider Services staff will review all requests for out-of-network providers. Acceptable reasons for using an out-of-network provider include: The ContinuUs provider network does not have capacity within its current network to meet the member s identified need. The ContinuUs provider network does not include providers with the specialized expertise, specialized knowledge, or appropriate cultural diversity to meet the member s identified need. ContinuUs cannot meet the member s need on a timely basis (emergency or urgent care service). The geographic availability of contracted providers is not adequate for a specific member which results in an undue hardship for the member. Out-of-Network Provider SDS Requests by a member or guardian for a specific provider that is not in the ContinuUs provider network may be treated as self-directed supports (SDS) and processed as such. In these cases, providers that are not in the ContinuUs provider network may be set up as non-contracted SDS providers depending on the services they provide, if they are as cost-effective as other providers. Non-contracted SDS providers must meet the same qualifications and credentialing requirements as a contracted provider. Without a contract, these providers may only serve up to three members. These providers must also meet state standards for independent contractors. Requests to Add a Provider ContinuUs Provider Services will handle and process all requests to add providers to the ContinuUs provider network and all requests for out-of-network and SDS providers. Requests can be submitted by care managers, ContinuUs staff, or providers. Care managers will review member requests for a specific provider and, if appropriate, submit the request to ContinuUs Provider Services staff. Providers may contact ContinuUs Provider Services directly to apply to become part of the network. ContinuUs Provider Services staff will evaluate the application based on the standards listed under In-Network Provider (above). See the Provider Application and Contracting page in the Providers section of our website for application information. ContinuUs Provider Handbook, 05/27/

17 Member Choice Members have many choices in Family Care, including choices among services and providers. These choices among services and providers include: For critical personal services, to choose any qualified provider who will accept a rate ContinuUs is willing to pay and meets ContinuUs s provider standards. Critical personal services are services that involve intimate personal needs or include services in which a provider needs to frequently go into a member s home. For other services, to choose from among the providers within the ContinuUs provider network, and to request that ContinuUs consider adding specific providers to the ContinuUs provider network. To choose to request a provider outside the ContinuUs provider network if the network does not have providers with the specialized expertise or knowledge needed to treat a member s condition or meet a member s specific needs. To choose a self-directed supports (SDS) option to manage his/her own services, including utilization of: The member s own team of natural supports, ContinuUs in-network providers, and SDS out-of-network providers (this includes having a family member, relative, or friend paid to provide a service approved by the care management team if the family member, relative, or friend agrees to accept the rate ContinuUs is willing to pay and meets ContinuUs s requirements and provider standards). To request a second opinion from a qualified health care professional within the ContinuUs provider network, or ContinuUs will arrange for the member to obtain a second opinion from a qualified health care professional outside the ContinuUs provider network, at no cost to the member. To change the member s care managers up to two times per calendar year if ContinuUs has additional care managers to offer the member. CONTRACT PROCESS Documentation Requirements There are many documents that are required as part of the ContinuUs contracting process. These documents may differ depending on provider type, but generally include: The Purchase of Service contract or Limited Purchase Agreement entered into by and ContinuUs Provider Handbook, 05/27/

18 between you the provider and ContinuUs Financial information, such proof of days available operating funds Copies of licenses and certificates, as applicable Certificate of insurance listing amount and dates of insurance coverage Criminal Background Check Information Disclosure (BID) form or Contract Checklist sign-off if provider performs own background checks (ContinuUs may ask for proof of background checks at any time) Provider references Provider Application Form Provider Disclosure Questions Form Authorization and Release Form Other documentation as requested by ContinuUs Change of Contact Information It is important that you keep us informed of any changes in your address, telephone number, or other contact information, such as address or contract administrator name. Please contact ContinuUs Provider Services to report any such changes. The best way to do this is to fill out a Provider Information Form and or fax it to us. The form is available on the Provider Forms page in the Providers section of our website. Please call the ContinuUs Provider Help Desk if you would like us to mail you a blank form. General contact information for ContinuUs Provider Services is as follows: ContinuUs Provider Services US HWY 14 Lone Rock, WI Phone: ; Fax: ; [email protected] For individual staff contact information, see the Provider Services Staff Contacts page of our website in the Providers section. ContinuUs Provider Handbook, 05/27/

19 Criminal Background Checks In order to protect the members served, providers are required to comply with the provision of applicable Wisconsin Statutes (Chapter 48 and Chapter 50), the Caregiver Background Check and Investigation Legislation, and applicable administrative rules of the State of Wisconsin, Department of Health Services. You must ensure that background checks are conducted on all employees assigned to work with Family Care members, if the employee has actual, direct contact with our members. You must retain in your personnel files all pertinent information, including the Background Information Disclosure (BID) Form and/or search results from the Wisconsin departments of Justice, Health Services, and Regulation and Licensing, as well as out-of-state records, Tribal Court proceedings and military records. After the initial background check, you must conduct a new background check every four years, or at any time within that period when you have reason to believe a new check should be obtained. You must maintain the results of this background check, on your own premises, for at least the duration of your contract with ContinuUs. As part of a quality check, ContinuUs Provider Services may audit your personnel files to assure compliance with the State of Wisconsin Caregiver Background Check Policy. You must refrain from assigning any individual to conduct any work under your contract with ContinuUs who does not meet the requirement of this law. This includes any employee or prospective employee of yours, and any subcontractors, agents and assigns who will perform any work with ContinuUs members. You are required to notify ContinuUs Provider Services in writing within one (1) business day if an employee has been charged with or convicted of any crime specified in Wis. Admin. Code HFS 12.07(2). Record Retention Providers must maintain and, upon request, furnish to ContinuUs any and all information relating to the quality and quantity of services rendered, including written documentation of care and services provided and the dates of service. Financial Records You must maintain clearly identifiable and readily accessible documentation of costs, supported by properly executed payrolls, time records, member attendance records, invoices, contracts, vouchers, or other official documentation (such as income statements, balance sheets, and audits) evidencing in proper detail the nature and propriety of the services provided. You must also maintain and preserve your accounting and other financial management records pertaining to ContinuUs services in a form and manner consistent with all applicable state and federal laws and principles of proper accounting and financial management. ContinuUs Provider Handbook, 05/27/

20 Member-Related Records ContinuUs member-related records must be maintained for a period of not less than six years and perhaps longer, depending on circumstances involved and applicable federal or Wisconsin state laws and regulations. Other Types of Records Records related to your HIPAA program, including training records, copies of training materials, etc., must be maintained for a minimum of six years. Records involving matters that are subject to litigation must be retained for a period of not less than seven years following the termination of litigation. Upon expiration of the seven year retention period, you may request authority from ContinuUs s Compliance department to destroy, dispose of, or transfer the records. If you have any questions about record retention, please contact your Provider Services Go-to or the ContinuUs Director of Compliance (see inside cover for contact information) before destroying any records. Disaster Planning As a ContinuUs provider, you must have formal plans and/or policies in place for dealing with physical disasters, medical emergencies, and staffing problems, that are appropriate for your services and the target group(s) you serve. You must also ensure that your staff are trained about the rules and procedures and are able to implement them safely and effectively. Room and Board in Residential Facilities For members residing in a residential facility adult family home (AFH), community-based residential facility (CBRF), or residential care apartment complex (RCAC) as part of the member s approved services plan, ContinuUs will pay for the support and supervision portion of the care, and the member/guardian will be required to pay the rent and food portion of the facility s cost. These costs are also called room and board costs. The member/guardian will be informed of the room and board rate and the member/guardian will receive a monthly bill from ContinuUs for their room and board expense. Room and board costs are a flat rate based on the location and type of facility. Room and board costs are different than a cost share, which is based on the member s income and/or assets. ContinuUs will pay providers the full daily rate for the facility (support and supervision plus room and board) and ContinuUs will then bill the member/guardian directly for room and board costs. (Note: Members that receive nourishment via enteral feeding that replaces all meals are not billed for the board portion of room and board costs.) ContinuUs Provider Handbook, 05/27/

21 Beginning July 1, 2014, for all new placements into double-occupancy ( shared ) rooms that are requested by the member, ContinuUs will only pay 70% of the room cost per person. The payment of the board portion remains at 100%. This includes members switching facilities within a corporation. Members living in shared rooms before July 1 were grandfathered in at full room cost. For more information, see the ContinuUs shared room policy, available on our website under Provider Application and Contracting. BILLING FOR SERVICES As a provider, it is your responsibility to make sure that you submit clean claims within the required filing timelines. Claims for services provided to ContinuUs members are considered timely if they are submitted within 90 days of the date of service, or 90 days from the date on the explanation of benefits from a third-party payer such as Medicare. All claims (except for OT/PT/ST) are submitted to Wisconsin Physicians Service Insurance Corporation (WPS), ContinuUs s thirdparty administrator. Physical, occupational, and speech therapy claims are submitted directly to ContinuUs (see Submitting Paper Claims below). Please see below for detailed information about billing for services to ContinuUs members. We also encourage you to become familiar with the Claims & Billing Information pages in the Providers section of our website, where you will find up-to-date information, reference sheets, and forms. Claim Submission Deadlines and Timely Filing Submission Deadlines: 90/30 Days. ContinuUs and WPS adhere strictly to the timely filing requirements as stated in your contract with ContinuUs, and it is your responsibility to be sure you meet submission deadlines. ContinuUs is not obligated to pay for services if the claim is not filed in a timely manner. Claims must be submitted within 90 days of the date of service, or 90 days from the date on the explanation of benefits (EOB) from a third-party payer such as Medicare. Corrected Claims: If a claim that was submitted in a timely manner is denied, paid incorrectly, or the original billed amount needs to be increased due to additional units of service and the provider needs to correct the claim, the corrected claim must be submitted within thirty (30) days of the Provider Remittance Advice (PRA) date assigned by WPS. Other Payers: Who to Bill First ContinuUs is the payer of last resort. You must bill other primary third party payers first. In the event the primary payer denies the claim or makes only a partial payment on the claim, you must make sure that you submit invoices to ContinuUs within 90 days of receiving the denial or partial payment. ContinuUs will then determine the appropriate additional payment, if any. ContinuUs Provider Handbook, 05/27/

22 How often to Submit Claims ContinuUs strongly recommends that providers submit their claims at least monthly if not more frequently, to ensure that the 90-day timely filing requirement is met. Providers are also responsible to perform routine and ongoing claim reconciliation processes to ensure that appropriate reimbursement for services provided is made. This means that if a claim is rejected or partially paid by WPS, you need to follow up in a timely manner to resolve the problem. Reconciling Payments with Claims It is critical that you reconcile your payments and claims as soon as possible after payment is received. If for some reason you need to correct a claim that was submitted timely the first time but was denied, paid incorrectly, or the original billed amount needs to be increased due to additional units of service, it must be submitted within 30 days of its Provider Remittance Advice (PRA) date from WPS to be considered for payment. (See Corrected Claims below for more information.) What to do if You Can t Submit Claims on Time There are a variety of circumstances that could prevent you from submitting your claims in a timely manner. Some examples include a change in billing staff, a new computer system, and computer software changes. As soon as you are aware of a potential delay in filing your claims, you should submit an extension request using the Claim Submission - Request for 90-Day Timely Filing Extension form. You can find the form on our website, or contact the Provider Help Desk for a paper copy. Your request will be reviewed for consideration, after which you will receive a response from ContinuUs Provider Services. Do not wait until the 90-day time limit has elapsed. Our goal is to ensure that all authorized services you have provided are reimbursed in a timely manner. Appropriate and timely communication from you is essential in order to achieve that goal. If untimely filing occurs due to claim re-processing issues with WPS and the claim was originally submitted on time, please contact the ContinuUs Provider Help Desk for further assistance. Please note: To avoid having to file claim appeals, you must submit your request for a filing extension before the timely-filing limit has elapsed. Formal claim appeals must be submitted for all claims whose dates of service are outside the claim filing limits. Submitting a request for an extension after the filing limit has elapsed will not exempt you from this requirement. Clean Claims Claims that do not contain the required elements will be rejected and the provider will be required to resubmit after making the necessary corrections. Most information needed to submit clean claims is available in the authorization detail on the ContinuUs Provider Portal. Rate information for negotiated rate services is available on the Services, Rates, and Special Provisions Letter (SRSP). ContinuUs Provider Handbook, 05/27/

23 Elements of a clean claim are as follows: Member name Member number (Social Security Number) Member date of birth Provider TIN (tax identification number, i.e., EIN, SSN) Provider NPI (National Provider Identifier) number, if applicable Provider name and address Dates of service (if the claim is for multiple months of service, you must use a separate line for each month) Service code Modifier, if applicable Authorization number Number of units of service provided Rate per unit Total units cost Total of all charges submitted If the service provided is a Medicaid service, the clean claim must also be submitted in a format and coding system acceptable to Wisconsin s Medicaid program. Electronic Filing WPS offers two methods to submit your claims electronically: the WPS PC-Ace Pro32 software, which is available free of charge, or an Excel spreadsheet submitted via a secure WPS MoveIt account. If you use other electronic claim software and would like to find out if it is compatible with WPS/ ContinuUs claim processing, you may either call the WPS EDI Help Desk at or refer to the EDI Connection ( for a list of billing services, clearinghouses, and software vendors for electronic claims. These firms products have been tested and are approved to submit claims for ContinuUs and other Family Care MCOs. PC-Ace If you are filing claims electronically using the PC-Ace Pro 32 software, please refer to ContinuUs Provider Handbook, 05/27/

24 the user guide which can be found online at or contact the EDI Help Desk if you need assistance. To get started with PC-Ace, contact the EDI Help Desk. Spreadsheet via MoveIT WPS offers an option for uploading claims data for authorized services using a Microsoft Excel spreadsheet through a WPS secured MoveIT account. If you are already using the spreadsheet via MoveIT and need assistance, please contact the WPS / Family Care Contact Center. If you would like to get set up to submit claims using the spreadsheet, please contact WPS at [email protected] and include your business name, a contact person, and contact phone number. For more information, see the WPS Excel Claim Form - Submission Instructions document on our website s Claims & Billing Information page. Note: The spreadsheet submission and other electronic methods are only available for claims with ContinuUs as primary payer. Providers who submit Medicare or other insurance crossover claims must still do so on the appropriate paper claim forms. WPS is unable to accept these types of claims through any electronic filing method. Submitting Paper Claims The WPS/ContinuUs Claim Form can be found on the Claims & Billing Information page in the Providers section of our website, and also on the ContinuUs Provider Portal under Home > User Documents. Please call the WPS / Family Care Contact Center or the ContinuUs Provider Help Desk if you would like us to mail you a blank form. Our medical providers (Medicaid/Medicare services) should use the CMS 1500 or UB-04 forms to submit claims. Paper claims should be mailed directly to the following WPS address: ContinuUs c/o WPS Insurance Corporation PO Box El Paso, TX There is no option to fax claims to WPS. All paper or fax claims that are received at the ContinuUs office in Lone Rock will be returned to the provider by mail. The provider will be instructed to mail the claims directly to WPS, which will result in a delay in payment. ContinuUs Provider Handbook, 05/27/

25 Physical, Occupational, and Speech Therapy claims The exceptions to the above policy are Physical, Occupational, and Speech Therapy claims. Claims for these services should be mailed to the following address (there is no option to fax therapy claims to ContinuUs): ContinuUs Attn: Claims US HWY 14 Lone Rock, WI Third-Party Payer Claims All claims previously billed to a third-party payer must be submitted to WPS on a paper claim form with a copy of the Remittance Advice/Explanation of Benefits (EOB) or Explanation of Medicare Benefits (EOMB) attached. If there is an EOB/EOMB that has multiple members on it, each claim submitted needs a copy of the EOB/EOMB attached. WPS will use a medical coding file that will indicate which procedure codes are Medicare and/or other insurance eligible. There may be instances when one of these services could be covered by Medicare or other insurance, but Medicare or other insurance was not billed because the service is not eligible in a particular circumstance. For these claims, WPS will recognize the following codes as an EOB/EOMB in the absence of an EOB/EOMB and should be used as appropriate, subject to audit. Medicare Disclaimer Codes: M5 Provider is not Medicare certified. M7 Medicare disallowed or denied payment. M8 Non-covered Medicare service. Other Insurance Disclaimer Codes: OI-P PAID by commercial health insurance or commercial HMO. EOB will be provided. OP-D or OI-D DENIED by commercial health insurance or commercial HMO following submission of correct and complete claim or payment was applied towards the coinsurance and deductible; EOB from primary carrier may not be provided OP-Y OI-Y YES, the recipient has commercial health insurance or commercial HMO coverage, but it was not billed because the provider knows the service in question is not covered by the carrier; EOB is not required ContinuUs Provider Handbook, 05/27/

26 Placement of disclaimer codes when appropriate: UB-04 format in field #80 CMS 1500 format in field #11 WPS claim form in column #16, next to the service code Excel spreadsheet in column titled Disclaimer Code It is a requirement that providers must accept payment made by ContinuUs and/or any third-party payers as payment in full. Providers are prohibited from billing, charging, or seeking remuneration or compensation from ContinuUs members. (See Prior Authorization Request below for description of limited exceptions to this restriction.) Reimbursement Information WPS/ContinuUs will pay all clean claims (for services that received advance authorization) within 30 days of receipt of the claim. Direct Deposit of Payments (EFT) ContinuUs providers are required to sign up for direct deposit to receive claim payments. This service is also known as electronic funds transfer (EFT). To sign up for direct deposit, complete the WPS Electronic Funds Transfer (EFT) Authorization Agreement and send to WPS along with a voided check or bank letter verifying your account information (fax to , or to edi@ wpsic.com). After you sign up for direct deposit, you will continue to receive a paper Provider Remittance Advice (PRA) in the mail, unless you choose to sign up for Electronic Remittance Advice (ERA). Note: As of May 1, 2015, providers newly added to our network are required to sign up for EFT to receive claim payments. Any providers contracted prior to that date who are still receiving paper checks must sign up for direct deposit by 08/01/2015. Electronic Remittance Advice (ERA) You can make your claim experience more efficient by receiving your Provider Remittance Advice (PRA) as an Electronic Remittance Advice (ERA), which is an electronic version of payment explanation. With direct deposit and ERA, you will find out about your payments via ERA about two days prior to the funds transfer. You can also request to suppress your paper PRAs and only receive the information electronically. To begin using ERAs, send a completed Electronic Remittance Advice (ERA) Authorization Agreement to WPS (fax or edi@ wpsic.com). For more more information about direct deposit or electronic remittance advice, and fillable PDF versions of the agreement forms, visit the WPS ContinuUs Providers page at ContinuUs Provider Handbook, 05/27/

27 Corrected Claims A corrected claim is a claim that has been previously submitted and resulted in a partial payment. The purpose of submitting the secondary, or corrected, claim is to add additional charges to the original claim. Corrected claims must be submitted within 90 days of the date of service or, if not within 90 days of the date of service, within 30 days of the initial partial payment. In order to make the process of submitting corrected claims easier and more consistent for providers working with more than one Family Care organization, WPS developed a standard form for submitting these claims, the WPS Corrected Claim Form. Using this form, corrected claims are sent directly to WPS. The form is available on the Corrected Claims page in the Providers section of our website. Use of the WPS Corrected Claim form is mandatory. Corrected claims received by WPS that do not use the form will be returned to the provider unprocessed, with instructions to submit the proper form. ContinuUs providers should send the WPS Corrected Claim form to the ContinuUs address listed at the bottom of the form: ContinuUs c/o WPS Insurance Corporation PO Box El Paso, TX If you have questions about why your claim was not paid at the amount you were expecting, and for assistance with corrected claims, please contact the WPS / Family Care Contact Center. Reminder: A claim that was submitted and rejected, resulting in a zero payment, should still be resubmitted to WPS as an original claim after necessary corrections are made. This is not considered a corrected claim. Claims Appeals All claim payments and/or denials are accompanied by a PRA (Provider Remittance Advice) or a rejection notice, which gives the specific explanation of the payment amount or specific reason for the payment denial. If you have questions about your PRA, please contact the WPS / Family Care Contact Center. If your questions regarding the partial payment or denial cannot be resolved by the WPS / Family Care Contact Center please contact the ContinuUs Provider Help Desk. Your situation will be reviewed and you will be advised of your options. If you have a dispute and it cannot be resolved with ContinuUs Help Desk staff, you will be instructed to file a formal appeal to the ContinuUs Provider Services department. ContinuUs Provider Handbook, 05/27/

28 If you wish to file a formal appeal you must submit the ContinuUs Claim Appeal Form (available on our website Claims Appeals page), or a separate letter or form that is clearly marked Appeal and includes the following: Provider name Member name Date of service Procedure code Copy of the WPS Provider Remittance Advice (PRA) Copy of the Explanation of Medicare Benefit (EOMB) or other insurance PRA, if applicable Reason(s) your claim merits reconsideration (please provide detailed explanation) Any other documentation to support your appeal Your appeal must be submitted in writing within 60 calendar days of the initial WPS denial or partial payment to: Provider Services Appeals ContinuUs US Hwy 14 Lone Rock, WI If ContinuUs fails to respond to the appeal within 45 calendar days, or if you are not satisfied with ContinuUs s response to the reconsideration request, you have the right to appeal to the Wisconsin Department of Health Services (DHS). All appeals to DHS must be submitted in writing within 60 days of ContinuUs s final decision or failure to respond. The submission must be clearly marked as an Appeal and indicate provider name, address, date of service, date of billing, date of rejection, and reason(s) for the request for reconsideration or appeal. DHS appeals should be sent to: MCO Contract Administrator Office of Family Care Expansion 1 West Wilson Street Room 518 P.O. Box 7851 Madison, WI ContinuUs Provider Handbook, 05/27/

29 Claims Support WPS / Family Care Contact Center For general claims support questions, claim and payment status, corrected claims, assistance with electronic filing, and to sign up for direct deposit Staffed from 8:00 a.m. - 4:30 p.m., Monday - Friday Before you call WPS, you should be prepared to answer questions regarding the claim you are inquiring about, such as the member s name, social security number, and date of birth. WPS is required by HIPAA privacy standards to ask the provider for at least two specific details about a member. They are only assuring that the caller is legitimate before they give out personal health information (PHI). Since the authorization you receive for services contains this information, as well as other information you may need, such as the authorization number, it is also a good idea to have the authorization handy when calling. ContinuUs Provider Help Desk: When to Contact ContinuUs Directly We ask that you contact the member s care manager for assistance with authorizations, and the WPS / Family Care Contact Center for assistance with claims. For assistance with issues that have not been resolved through these initial steps, you may contact the ContinuUs Provider Help desk. Send to [email protected]* or call *Note: When sending from your own account to providerhelpdesk@ ContinuUs.org or any other ContinuUs.org address, please remember that this is not a secure communication, and you must be careful to not include any protected member information. See the Confidentiality in Communications section of this handbook for more information. Claim Support Feedback At ContinuUs we are committed to providing a high level of service to our providers. Our Claim Comment Form is an opportunity for you to share feedback negative or positive regarding your experience with the WPS / Family Care Contact Center or the ContinuUs Provider Help Desk. The Claim Comment Form is available on the Claims & Billing Information page in the Providers section of our website, and also on the ContinuUs Provider Portal under Home > User Documents. If you would like us to mail you a copy of the form, please call or [email protected]. ContinuUs Provider Handbook, 05/27/

30 PRIOR AUTHORIZATION Prior Authorization Request All services provided to members must be authorized by ContinuUs (via entry by ContinuUs staff into ContinuUs s MIDAS system) prior to the delivery of services. In addition, the total amount of services provided may not exceed the amounts authorized in writing by ContinuUs. ContinuUs has the final authority in determining member eligibility for services and amount of services to be provided. Providers will not be reimbursed for unauthorized services provided to members or provided in amounts that exceed those authorized. Please notify all of your employees of our prior authorization requirements. You must only provide services to members in the amounts authorized by ContinuUs. You will be responsible for the cost of any services provided that exceed the authorized amount. Under no circumstances are you able to seek payment from the member or their family for the cost of services exceeding the total amount(s) authorized by ContinuUs. See the 2014 Family Care Programs Contract (dhs.wisconsin.gov/mltc), Article VII.J. Department Policy for Member Use of Personal Resources, for a discussion of the limited circumstances when a member, the member s family, or significant other may choose to voluntarily use personal resources for the member s benefit, and the required procedures for such use of personal resources. All such uses of personal resources must be reviewed by the member s interdisciplinary team to ensure that the expenditure is allowed and proper procedures are followed. For example, in some cases the member must be counseled to ensure that the use of personal resources is voluntary. Prior Authorization Processing A member/guardian can request services from the member s care management team. Upon receipt of such request, the team will discuss the reasons for the service with the member, and authorize if appropriate. When services are authorized, a MIDAS authorization entry for every service to be provided will be created, specifying the specific service to be provided, the amount of service (number of units) to be provided, and the duration of services to be provided. Providers can then view the authorization information on the ContinuUs Provider Portal. Members/guardians may request service authorizations for new or additional services, or extensions of existing authorizations, by contacting the member s care management team. The team will consider all such requests. However, the mere fact of a request does not in any way imply that there will be any change in service level, service type, or duration of service. ContinuUs Provider Handbook, 05/27/

31 Prior Authorization for Emergency Services You must notify the care management team immediately in an emergency situation. They will work with you to immediately authorize any services that are needed. For after-hours assistance, use the contact number for your region as listed below. East Region Columbia, Dodge, Green Lake, Jefferson, Marquette, Washington, Waukesha, and Waushara counties: Call North Region Chippewa, Dunn, Eau Claire, Pierce, and St. Croix counties: Call South Region Crawford, Grant, Green, Iowa, Juneau, Lafayette, Richland and Sauk counties: For after-hours emergency authorizations: 1. Call , , or your local area ContinuUs office number. (Local office numbers can be found on the Our Locations page in the Contact Us section of our website.) 2. Listen to entire message for the correct prompt. The auto attendant will state, If you have an urgent Family Care need, press Press 2 and you will be routed to the ContinuUs after-hours phone. 4. Gold Cross, ContinuUs s On-Call Answering Service, will pick up the call. The Gold Cross staff person will say: This is the answering service for ContinuUs, how can I help you? Gold Cross staff are instructed to obtain caller name, address, return call number, and any other return call instructions. Gold Cross staff will then call the work phone number of the ContinuUs on-call worker scheduled at that time. ContinuUs also has a secondary, back-up number to use after hours, only when: Caller receives a BUSY SIGNAL when calling or local office number, or Caller DOES NOT RECEIVE a return call within 30 minutes. The ContinuUs Back-up Number is: Again, this number is only to be used in the two cases listed above. ContinuUs Provider Handbook, 05/27/

32 COMMUNICATION Reporting ContinuUs strives to ensure good communication between agencies. The care management team is the first place to turn when you need to communicate about a member. Care manager contact information is available when viewing the authorization detail in the ContinuUs Provider Portal. Here are a few communication guidelines: For questions regarding a member contact the member s care management team. To seek authorization for services contact the member s care management team (see above for after-hours emergency services). For questions relating to your contract or if you have any concerns or complaints contact ContinuUs Provider Services. You are required to report any changes in a member s condition, and any injury, illness, hospitalization, or deterioration. These reports should be made to the member s care management team. Events that take place after business hours or on a holiday should be reported to the member s care managers as soon as possible the next business day. (Certain types of events have specific reporting requirements. See the Critical Incidents and Adverse Events section of this handbook for details.) Contact Information See the inside front cover of this handbook for ContinuUs Provider Services office locations, the ContinuUs Provider Help Desk, the WPS / Family Care Contact Center, and other commonly-referenced contact information. Detailed Provider Services staff information is available on the Provider Services Staff Contacts page in the Providers section of our website. The Our Locations page in the Contact Us section of our website has contact information and maps for all ContinuUs office locations. The ContinuUs Provider Portal lists care manager names and contact information for each authorization in the authorization detail. Confidentiality All communications must meet confidentiality requirements to maintain member privacy. See the Confidentiality section of this handbook for more information. ContinuUs Provider Handbook, 05/27/

33 ContinuUs Website Please visit our website at, which contains information for providers, members, and the general public. The Providers section includes forms, links to useful references, the ContinuUs Provider Bulletin, Provider Services staff contact information, and the Provider Event Calendar. The Our Locations page in the Contact Us section lists ContinuUs office locations and contact information. PROVIDER QUALITY STANDARDS Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution. William A. Foster Overview of the Provider Quality Program Provider quality is of utmost importance, as it is providers that provide the hands-on care and services to our members. ContinuUs has developed service standards and service-specific quality measurement tools to ensure quality of care and services. We continue to work with providers to further develop our Provider Quality Program and will provide resources and information to providers related to their area of service provision. The Provider Quality Program currently focuses on provider credentialing/licensing, cultural competency, ethics, program integrity, member safety, accessibility, provider satisfaction, recognizing excellent provider performance, empowerment, service standards, and education. Member Satisfaction Survey ContinuUs performs an annual member satisfaction survey to measure how satisfied members are with ContinuUs. In addition, ContinuUs has providers that send out their own member satisfaction surveys as part of their quality program and provide the results to ContinuUs as a quality update. We encourage all providers consider participating in this type of quality process. Provider Satisfaction: Community Work Plan ContinuUs considers service providers an integral part of assisting members in achieving their individual outcomes. Though they are technically not part of the interdisciplinary team, providers are certainly part of each member s larger team. It is of the utmost importance to ContinuUs that we seek and listen to feedback from providers on organizational changes that may impact them, as well as to providers input on the individual members that they serve. Based on suggestions from provider focus groups conducted during the summer of 2012, ContinuUs has developed a community work plan which includes the following elements. ContinuUs Provider Handbook, 05/27/

34 Quarterly Provider Meetings ContinuUs facilitates regular meetings of service-specific provider groups. These meetings are a place where ContinuUs can solicit feedback for its planning, and all parties can discuss common issues and concerns. The current groups and meeting frequency are as follows: Supportive Home Care, Personal Care, Self-Directed Supports (quarterly) Employment and Day Service providers (quarterly) AFH (all), CBRF, RCAC (North region; quarterly) 3-4 Bed AFH, CBRF, RCAC (South region; quarterly) 1-2 Bed AFH (South region; quarterly) Nursing Home providers (as needed/requested) Meetings for ContinuUs East region providers are also held quarterly, and are not currently organized by service type. Meetings are held in three different locations each quarter, and all providers are welcome at each meeting. Additional groups or meetings will be added as needed. Provider meeting dates and times are published in the ContinuUs Provider Bulletin and listed on our website Provider Events Calendar. Most meetings can be attended via conference call; call-in information is provided in the Provider Events Calendar event detail. Any changes to meeting dates, times, or location are also published in the website calendar. We encourage providers to check this calendar to confirm meeting details before traveling to attend. See the Provider Meetings & Trainings page to view the full schedule and download a printfriendly version. You can also subscribe to announcements and updates for a particular meeting group on this page. Provider Education ContinuUs educates providers on key communication tools that we all need to utilize if our communication is to be optimal, including: the ContinuUs Provider Portal, for viewing authorization and claim processing information and accessing resources and information provided by various ContinuUs departments; and the ContinuUs Provider Bulletin, news and notes for ContinuUs providers. ContinuUs Provider Handbook, 05/27/

35 Provider Bulletin Contributions ContinuUs seeks provider participation in the ContinuUs Provider Bulletin, including the development of a provider guest column in the ContinuUs Provider Bulletin. This will be an opportunity for participants in provider-related ContinuUs meetings to speak directly to their colleagues, as well as for other peer-to-peer information sharing. Provider Work Groups An ongoing ContinuUs-WPS-Provider work group meets regularly to talk about systems problems providers may have with billing for services through WPS. The group includes representatives from WPS, ContinuUs Provider Services, and provider staff. ContinuUs Provider Help Desk [email protected] The ContinuUs Provider Help Desk was created in response to provider comments at our 2012 provider focus groups. This one-stop shop gives providers a single contact point for general questions, as well as assistance with: MIDAS Provider Portal ContinuUs Residential Facilities Inventory (vacancy listing) Provider Applications Provider Information Updates Meeting Announcement Subscriptions Authorization questions that cannot be answered by the care management team Claims and billing questions that cannot answered by contacting the WPS/Family Care Contact Center (including over/underpayments, denials, and corrected claims) Who to contact for a specific issue or concern Providers are encouraged to contact ContinuUs staff directly when appropriate. Care management team contact information can be found in the authorization detail screen on the Provider Portal. Provider Services department staff contact information is available at / Provider-115/Provider-Services-Staff-Contacts. Provider Recognition Each quarter, care management teams nominate providers for recognition of exceptional service provision. Awards are made for each ContinuUs region, and the selected providers are recognized at the ContinuUs all staff meeting. ContinuUs Provider Handbook, 05/27/

36 Provider Comment Form A Provider Comment Form is used when a care manager or others would like to comment about a provider that he or she feels has gone above and beyond in service provision. ContinuUs recognizes providers that perform services in a manner that exceeds our expectations. The form is also used as a quality alert when a care manager or other person has concerns relating to a specific provider. Provider Comment forms are completed by care managers or other persons and submitted to ContinuUs Provider Services for processing and follow-up. The form is available on our website in the Members & Families section under Provider Directory. Access Standards ContinuUs is committed to ensuring that members have access to providers that are part of the ContinuUs provider network. Access is defined as members having timely access to the services they need (within 72 hours) and that they also have physical access to providers, which includes provider availability and the physical structure of provider facilities. While supporting access to services for all of our members, ContinuUs has special concern for vulnerable populations who may have special health needs or who may be at risk for adverse health outcomes. These populations require targeted interventions and tailored programs to achieve improvements in health status. ContinuUs is committed to ensuring that members have access to specialized services. ContinuUs Provider Services will work with providers to ensure adequate access to services. Quality Assessments ContinuUs Provider Services staff conduct provider quality assessments on a random sample of providers each year, as well as assessments on any facilities that have had statements of deficiency (SODs) in the previous year. The assessment includes contact with the member/guardian, care manager, and service provider, and helps ensure that members and care managers are satisfied with the provider s services and staffing. The provider portion of the assessment also includes: Discussion of training provided to staff at time of hire as well as on an ongoing basis. Review of provider s policies and procedures on topics such as abuse/neglect, client rights, complaints and grievances, critical incidents/adverse events, confidentiality, criminal background checks, emergency procedures/evacuation plan, and medication administration. Suggestions provider has for how ContinuUs can improve our processes that impact providers, such as trainings, billing, contracts, communication, care management teams, etc. ContinuUs Provider Handbook, 05/27/

37 PROGRAM INTEGRITY ContinuUs is committed to protecting the integrity of its managed care program. ContinuUs follows operational initiatives that were created to prevent, detect, and correct instances of fraud, misuse, and abuse. Instances of fraud, misuse, and abuse could be detrimental to ContinuUs, our members, and our personnel, and would violate our commitment to program integrity. Fraud, misuse, and abuse could harm ContinuUs s viability. ContinuUs has developed policies and procedures specifically relating to program integrity and will investigate all allegations of fraud, misuse, and abuse. Definitions Provider any individual or entity that receives funds from ContinuUs in exchange for providing a service. It should be noted that ContinuUs funds paid to a provider, then passed on to a subcontractor, are still ContinuUs funds from a fraud, misuse, and abuse perspective. Fraud any intentional deception made for personal gain or to damage another individual, group, or entity. It includes any act that constitutes fraud under applicable federal or state law. Examples include: Falsification of provider credentials Falsification of member needs Intentionally performing or billing for services improperly (including false claims) and/or intentionally denying appropriate services Misuse an incorrect, improper, or unlawful use of something; this is typically unintentional, and errors would fall under this category. Abuse a practice that is inconsistent with sound fiscal, business, or medical practices, and results in unnecessary program costs or any act that constitutes abuse under applicable federal or state law. Underutilization when an organization shows a pattern of failing to provide ContinuUs members with medically-necessary, adequate health care services in a timely manner. Cherry-Picking selecting the healthiest segment of the enrollment population that could result in higher profits for ContinuUs or the provider, and also could result in individuals who require the most care receiving inadequate care. Forms of cherry-picking include: Misuse of health needs questionnaires Attempts by employees, such as during health fairs, to discourage individuals with potentially high utilization needs from joining Family Care Choosing to hold a health fair, etc., in a location that would not enable or would discourage disabled individuals from attending ContinuUs Provider Handbook, 05/27/

38 Distributing marketing materials in locations where only healthy potential enrollees are likely to access them Program Integrity Compliance As a ContinuUs provider, you must not provide services or submit billing claims in a manner that would be considered a violation of our program integrity policies, including committing fraud, misuse, and/or abuse. In addition, you must report all alleged program integrity violations to ContinuUs. Program integrity compliance for ContinuUs providers includes the following elements: Providers shall monitor their operations to prevent the fraudulent misappropriation of ContinuUs funds. (For example, the intentional submission of false claims such as billing for products or services authorized, but not actually provided, to the member.) Providers will immediately notify ContinuUs of any suspected fraudulent activities within the provider s organization, employees, or subcontractors. Providers shall take steps to immediately mitigate any ongoing fraud and to prevent future fraud. Providers will notify ContinuUs of steps taken related to countering fraud. Providers who fail to take proactive measures to prevent or, if necessary, mitigate fraudulent activities may have their contracts terminated solely at ContinuUs s discretion. All instances of alleged program integrity violations should be reported directly to the ContinuUs Director of Compliance: ContinuUs Director of Compliance US HWY 14 Lone Rock, WI ; Fax: Investigating There are specific timelines established in investigating program integrity violation allegations. Investigations of all violation allegations will be conducted within 30 days of the Director of Compliance receiving the complaint. Every effort will be made by the Director of Compliance to resolve the complaint within 60 days of notification. ContinuUs Provider Handbook, 05/27/

39 CRITICAL INCIDENTS AND ADVERSE EVENTS All individuals or entities providing services to ContinuUs members are required to report critical incidents and adverse events to the care management team within 24 hours from the time the provider becomes aware of the situation. See definitions below for details on what must be reported. All deaths of members must be reported to the care management team within 24 hours, whether unexpected or not. It is acceptable to make a report by phone within 24 hours by speaking with the care manager, or to leave a message on the care manager s voice mail. If a written report is requested by ContinuUs as a follow-up to a report made by phone, the written report must be provided within seven days of the request (or by the next business day after the seventh day if the seventh day falls on a weekend or holiday). Written reports should be faxed to the office of the care management team. See the Our Locations page in the Contact Us section of our website for ContinuUs office fax numbers. Providers may use the ContinuUs Unintended Events Report Form to report incidents and events (available on our website in the Providers section on the main Providers page and also under Provider Forms ), or the provider s own incident report form if it contains the same information as the ContinuUs form. You must ensure immediate safety of the member and take any necessary steps to assure that the member is protected from risk of continued harm. Guardians should be notified. If appropriate, Adult Protective Services, the Wisconsin Department of Quality Assurance, and/or law enforcement should also be contacted. You are required to cooperate with ContinuUs and the care management team in investigating an alleged unforeseen event through access to records, staff, and any other relevant sources of information requested. Definitions Critical Incident Any circumstance, event or condition in the following categories: Accident (other than a fall) Abuse or assault of a member (includes physical, sexual, and/or verbal abuse; any property loss related to abuse; may or may not be related to a member s known behavior concerns) Harm caused by a member (includes harm to another s property or to person(s), physical or sexual assault; may or may not be related to a member s known behavior concerns) Elopement (regardless of whether the member was harmed) Fall Neglect of a member (includes self-neglect) ContinuUs Provider Handbook, 05/27/

40 Member rights violation (includes but is not limited to unplanned, unapproved use of restrictive measures) Medication error (errors which cause injury, illness, or death to a member are considered critical incidents; all errors [i.e., omission of medication, wrong dose, wrong drug, wrong route, wrong person, wrong time] must be documented and corrective action taken per medication administration standards of practice) Property loss not due to abuse (includes property damage to a member s property caused by a member or other person(s), or loss due to an event such as a fire or flood or due to poor physical maintenance of the member s residence, or a random theft) Unexpected death (any death other than suicide that occurred without warning and was not anticipated or considered probable, or that is reportable to the coroner or medical examiner under Wis. Stat ) Suicide or attempted suicide Other (includes anything not captured within the above listed categories that the provider thinks could be considered a critical incident) Adverse Event Any circumstance, event, or condition resulting from either action or inaction that: was undesirable and unintended, and did not result in any serious harm to a member s health, safety or well-being, and indicates or may indicate a quality issue with the services provided by ContinuUs or any of its providers. MEMBER RIGHTS At ContinuUs, it is our duty to safeguard and honor members rights. As one of ContinuUs s contracted providers, you are charged with this same duty. List of Member Rights from the Member Handbook The following excerpt from the Family Care Member Handbook, Section 6. My Rights, lists the rights of ContinuUs members. We must provide information in a way that works for you. To get information from us in a way that works for you, please contact your care team. We must treat you with dignity, respect, and fairness at all times. You have the right: ContinuUs Provider Handbook, 05/27/

41 To get compassionate, considerate care from ContinuUs staff and providers. To get your care in a safe, clean environment. To not have to do work or perform services for ContinuUs. To be encouraged and helped in talking to ContinuUs staff about changes in policy that you think should be made or services that you think should be provided. To be encouraged to exercise your rights as a member of ContinuUs. To be free from discrimination. ContinuUs must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person s race, mental or physical disability, religion, gender, sexual orientation, health, ethnicity, creed (beliefs), age, national origin, or source of payment. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. This means you have the right to be free from being restrained or forced to be alone in order to make you behave in a certain way or to punish you or because someone finds it useful. To be free from abuse, neglect, and financial exploitation. Abuse can be physical, emotional, financial or sexual. Abuse can also be if someone gives you a treatment such as medication, or experimental research without your informed consent. Neglect is when a caregiver fails to provide care, services, or supervision which creates significant risk of danger to the individual. Self-neglect is when an individual who is responsible for his or her own care fails to obtain adequate care, including food, shelter, clothing, or medical or dental care. Financial exploitation can be fraud, enticement or coercion, theft, misconduct by a fiscal agent, identity theft, forgery, or unauthorized use of financial transaction cards including credit, debit, ATM and similar cards. What can you do if you are experiencing abuse, neglect, or financial exploitation? Your care team is available to talk with you about issues that you feel may be abuse, neglect, or financial exploitation. They can help you with reporting or securing services for safety. You should always call 911 in an emergency. If you feel that you or someone you know is a victim of abuse, neglect or financial exploitation, you can contact Adult Protective Services. Adult Protective Services help protect the safety of seniors and adults-at-risk who have experienced abuse, neglect or exploitation. They also help when a person is unable to look after his or her own safety due to a health condition or disability. To report incidents of witnessed or suspected abuse, call Adult Protective Services. See Appendix J on page 67 for the address and phone number of your local Adult Protective Services Department. ContinuUs Provider Handbook, 05/27/

42 We must ensure that you get timely access to your covered services. As a member of ContinuUs, you have a right to receive services listed in your care plan when you need them. Your care team will arrange for your covered services. Your team will also coordinate with your health care providers. Examples of these are doctors, dentists, and podiatrists. Contact your team for assistance in choosing your providers. We must protect the privacy of your personal health information. If you have questions or concerns about the privacy of your personal health information, please call your care team. See Appendix G on page 59 for ContinuUs s Notice of Privacy Practices. We must give you access to your medical records. Ask your care team if you want a copy of your records. You have the right to ask ContinuUs to change or correct your records. We must give you information about ContinuUs, our network of providers, and available services. Please contact your care team if you want this information. We must support your right to make decisions about your care. You have a right to know about all of your choices. This means you have the right to be told about all of the options that are available, what they cost and whether they are covered by Family Care. You can also suggest other services or supports that you think would meet your needs. You have the right to be told about any risks involved in your care. You have the right to say no to any recommended care or services. You have the right to get second medical opinions. You have the right to give instructions about what you want done if you are not able to make decisions for yourself. Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means if you want, you can develop an advance directive. There are different types of advance directives and different names for them. Documents called living will and power of attorney for health care are examples of advance directives. Contact your care team if you want to know more about advance directives. You have the right to file a grievance or appeal if you are dissatisfied with your care or services. Chapter 8, page 32, includes information about what you can do if you want to file a grievance or appeal. ContinuUs Provider Handbook, 05/27/

43 Additional Member Rights Residential Placement In addition to the rights listed above, members residing in any residential placement have additional rights. Please see the following sections of the Wisconsin Administrative Code for information about these additional rights: Adult Family Home-Certified, DHS (docs.legis.wisconsin.gov/code/admin_code/ dhs/030/82/10) Adult Family Home-Licensed, DHS (docs.legis.wisconsin.gov/code/admin_code/ dhs/030/88/10) Community Based Residential Facilities, DHS (docs.legis.wisconsin.gov/code/ admin_code/dhs/030/83/vi/32) Nursing Homes, DHS (docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/ III/31) Residential Care Apartment Complexes, DHS (docs.legis.wisconsin.gov/code/ admin_code/dhs/110/132/iii/31) Cognitive Delay or Mental Illness Members who are cognitively delayed or who have a mental illness have rights in addition to those listed above. Please see the following sections of the Wisconsin Administrative Code for information about these additional rights:: DHS (docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/iii/31) DHS 94 (docs.legis.wisconsin.gov/code/admin_code/dhs/030/94.pdf) Procedures to Follow if Rights are Limited or Denied If there is a limitation or denial of any of these rights, please follow the procedures outlined in the Critical Incidents and Adverse Events section of this handbook. MEMBER GRIEVANCES AND APPEALS ContinuUs members have the right to register a grievance or appeal when they are not satisfied with any aspect of their care. ContinuUs maintains policies and procedures to ensure that every member s concerns are heard and responded to in a timely manner. There are two ways that the grievance and appeal process might touch you as a provider: the member has a grievance related to your services, or the member needs your assistance in filing a grievance or appeal related to ContinuUs or another provider. This section will provide a general overview of grievances and appeals, and then describe your role and responsibilities in the two situations mentioned above. ContinuUs Provider Handbook, 05/27/

44 To learn more about the member grievance and appeal process, see the Family Care Member Handbook, which is available on the Member Handbook page of the Members & Families section of our website. Please contact the ContinuUs Provider Help Desk if you would like us to mail you a copy of the handbook. Definitions Grievance A grievance is a communication submitted by or on behalf of a member, expressing dissatisfaction regarding issues other than actions as defined below. Grievances can be oral or written, and are submitted to ContinuUs or to the Wisconsin Department of Health Services (DHS). Subjects for grievances include any act, decision or omission by ContinuUs or a ContinuUs provider, including but not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member s rights. Appeal A request for review of an action, as action is defined below. Action Actions are taken by the care management team or ContinuUs in relation to member services or the Member-Centered Plan. A Notice of Action is sent to the member when this occurs. Under the terms of ContinuUs s contract with DHS, Action is defined one of the following: The denial or limited authorization of a requested service, including the type or level of service. The denial of functional eligibility as a result of administration of the long-term care functional screen, including a change from nursing home level of care to non-nursing home level of care. The reduction, suspension, or termination of a previously authorized service. The denial, in whole or in part, of payment for a service. The failure to provide services and support items included in the member s Member- Centered Plan in a timely manner, as defined by DHS. The failure of ContinuUs to act within the time frames as defined in the DHS Family Care Contract for resolution of grievances or appeals. The development of a Member-Centered Plan that is unacceptable to the member because any of the following apply: The plan is contrary to the member s wishes insofar as it requires the member to live in a place that is unacceptable to the member. The plan does not provide sufficient care, treatment, or support to meet the member s needs and support the member s identified outcomes. ContinuUs Provider Handbook, 05/27/

45 The plan requires the member to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the member. Notification by ContinuUs of a decision made in response to a member s grievance. An Action is not: A change in provider A change in the rate ContinuUs pays a provider A termination of a service that was authorized for a limited number of units of service or duration of a service as defined by DHS An adverse action that is the result of a change in state or federal law Grievances or Appeals Against You as a Provider If a member approaches you regarding a complaint or grievance against you or your organization, direct the member to call the ContinuUs Member Rights Specialist for their region for assistance. (See inside cover of this handbook for contact information.) In the event a member files an appeal with ContinuUs regarding the services your organization provided, someone from ContinuUs s Provider Services department will be in contact with you. You must fully cooperate with ContinuUs in researching and resolving grievances and appeals regarding your services. Such cooperation will include furnishing information to ContinuUs on member grievances and appeals within five days of the request. Assisting a Member with a Grievance or Appeal If a member approaches you for assistance regarding a grievance or appeal that is not about you as a provider, a good place to start is to review with them the instructions in the member s copy of the Family Care Member Handbook. You may also direct the member to call the ContinuUs Member Rights Specialist. A member or a member s legal representative may file the grievance or appeal directly, or anyone acting on the member s behalf with the member s or guardian s written permission may file a grievance or appeal. You may file a grievance or appeal on behalf of a member if you have the member s written consent. Please contact the ContinuUs Member Rights Specialist for assistance with any grievance, appeal, or member rights matter. ContinuUs Provider Handbook, 05/27/

46 RESTRAINT AND SECLUSION Use of Isolation, Seclusion, and Physical Restraint ContinuUs must uphold the rights of all members to live their lives in the least restrictive manner possible, in an environment that treats them with respect, and assures health, safety, dignity and liberty. However, in rare situations and as a last resort, the use of restrictive measures may be necessary to protect the health and safety of a member. If this type of intervention is determined necessary, all providers must comply with: Wis. Stat (1)(i) and Wis. Adm. Code (DHS), as well as numerous other standards prescribed by law, and the Wisconsin Department of Health Services (DHS) Family Care Programs Contract, all of which address the use of isolation, seclusion, and physical restraints. Before any restrictive measure can be implemented, providers and interdisciplinary teams (which always include the member) must follow a very prescriptive assessment and approval process. This process requires that the support and intervention plan be approved by both ContinuUs and DHS. If restrictive measures are used and no approved plan is in place, this occurrence must be reported to ContinuUs. See the Critical Incidents and Adverse Events section of this handbook for reporting instructions. MEMBER SAFETY AND RISK Risk Assessment & Risk Reduction ContinuUs care management units utilize a process which promotes the health and safety of members while respecting the dignity of risk the member s right to refuse services or engage in risky behaviors. Please refer to ContinuUs Policy CM 16.2, Risk Assessment & Risk Reduction, for more information. The policy is available on the Provider Resources page in the Providers section of our website. CULTURAL COMPETENCY Cultural Values ContinuUs providers must provide services in a manner that honors a member s beliefs and is sensitive to cultural diversity. You must foster an attitude and communicate in a way that respects members cultural backgrounds, including members with limited English proficiency and diverse cultural and ethnic backgrounds. ContinuUs Provider Handbook, 05/27/

47 Cultural Competency As a ContinuUs provider, you must foster and encourage cultural competency in yourself and any staff you employ. There are essential elements that contribute to the ability to become more culturally competent. These elements include: Value diversity Be conscious of the dynamics inherent when cultures interact Institutionalize cultural knowledge Develop adaptations to service delivery reflecting an understanding of diversity between and within cultures These elements must be manifested at every level of service delivery. They should be reflected in attitudes, structures, policies, and services. Being competent means learning new patterns of behavior and effectively applying them in the appropriate settings. Cultural Preference Members have a right to choose providers from the ContinuUs provider network based on cultural preferences. CONFIDENTIALITY ContinuUs is committed to maintaining the confidentiality, integrity, and availability of protected health information (PHI) and protecting against any reasonably anticipated threats, hazards, and/or inappropriate uses or disclosure. ContinuUs is also dedicated to preventing, detecting, containing, and correcting HIPAA-related security violations. Provider Requirement As a ContinuUs provider, you must maintain confidentiality of all ContinuUs member information you generate or receive. You must also be in compliance with all state and federal confidentiality requirements. This includes compliance with the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), to the extent those regulations apply to the services you provide or purchase with funds provided under contract with ContinuUs. You must immediately report all allegations of confidentiality violations to ContinuUs Provider Services and include your plan of action to address the violation if substantiated. ContinuUs Provider Services will work with you in investigating any instances of alleged violation of confidentiality, and will work with you to resolve substantiated violations. ContinuUs Provider Handbook, 05/27/

48 Confidentiality in Communications ContinuUs providers must be careful not to use any personal identification information about a member within the subject line or body of an message sent via regular . This includes but is not limited to social security number, full member name or initials of member name, member address or phone number, and Medicaid or Medicare numbers. The ContinuUs Business Partner Use Policy contains details about legal risks and requirements, best practices, confidentiality, and system monitoring when using to communicate with ContinuUs. You may view the policy on the Member Privacy and HIPAA Compliance page in the Providers section of our website. To have a copy of the policy sent to you, please contact the ContinuUs Provider Help Desk. Provider use of the HIPAA ID in The ContinuUs Provider Portal HIPAA ID function allows providers to create a unique identifier for use in identifying a specific member in a non-secure communication to ContinuUs staff, such as . The HIPAA ID is used instead of the member s name or other identifying characteristics. When a ContinuUs staff member receives an message that contains a HIPAA ID, they are able to use the MIDAS system to look up the ID and determine the member to which it refers. ContinuUs Secure with ZixCorp For situations that require sending protected member information we use a secure (encrypted) service called ZixCorp to ensure the confidentiality of communications between ContinuUs staff and our providers. Once you register at the ContinuUs Secure Message Center, you will be able to securely compose and receive , and view your sent messages. You can also use the address book to store the addresses of ContinuUs staff you communicate with on a regular basis. When a ContinuUs staff member sends you a secure message, you receive a notification with instructions on how to open the message. The notification message arrives in your regular inbox. You select Open Message in the notification message to go to the ContinuUs Secure Message Center and view your . If you have not yet registered, you will be able to do so when you select Open Message. However, with this system you do not have to wait to receive a message from ContinuUs staff in order to communicate securely you can compose and send a new secure message to our staff at any time. There are several ways to get to the ContinuUs Secure Message Center: Type the following address in your web browser: web1.zixmail.net/s/e?b=continuus& Click ContinuUs Secure Message Center in the Provider Quick Links on our main Providers page at /Provider-115 Click the link in the secure section of the Member Privacy and HIPAA Compliance page of our website at Learn more about ZixCorp at ContinuUs Provider Handbook, 05/27/

49 APPENDIX: DEFINITIONS For additional information, see the Wisconsin Dept. of Health Services Glossary of Terms, Acronyms and Abbreviations at and the Family Care page at Action Actions are taken by the care management team or other ContinuUs department in relation to member services or the Member-Centered Plan. A Notice of Action is sent to the member when this occurs. (See the Member Grievances and Appeals section of this handbook for a list of action types.) Appeal An appeal is a request for review of an action, as action is defined above. (See the Member Grievances and Appeals section of this handbook for more information about appeals.) Business Hours/Days Business Hours/Days are defined as 8:00 a.m. to 4:30 p.m. Monday through Friday. Care Management Team The Care Management Team refers to the ContinuUs Care Manager and RN Care Manager that are assigned to a member s interdisciplinary team. Clean Claim Clean Claims are those claims that are submitted to WPS/ContinuUs which are completely and accurately filled out, and do not require correction, editing, or resubmission by the provider agency. (See the Billing For Services section of this handbook for elements of a clean claim.) Contract The contract/agreement between a provider and ContinuUs and all addendums, attachments, schedules, amendments, and exhibits attached thereto. Culturally Competent Honoring members beliefs, being sensitive to cultural diversity, and fostering attitudes and interpersonal communication styles in provider staff which respect members cultural backgrounds. This includes both members with limited English proficiency and those of diverse cultural and ethnic backgrounds. Cultural competence will be demonstrated in written and verbal communications with the member and the member s family and in the training of provider staff. DHS Wisconsin Department of Health Services, 1 West Wilson Street, Madison, Wisconsin General phone number: ; TTY phone number: Emergency An emergency is when something occurs that threatens the member s health or level of function that may necessitate ContinuUs to immediately authorize service. ContinuUs Provider Handbook, 05/27/

50 Family Care The name given to the Wisconsin Long-Term Care Re-design Project including the provision of long-term care services, referrals, and eligibility determination by an Aging & Disability Resource Center and managed care organization. To learn more about Wisconsin s Family Care program, visit Grievance A grievance is a communication submitted by or on behalf of a member, expressing dissatisfaction regarding issues other than actions as defined above. Grievances can be oral or written, and are submitted to ContinuUs or to the Wisconsin Department of Health Services. Subjects for grievances include any act, decision or omission by ContinuUs or an ContinuUs provider, including but not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member s rights. (See the Member Grievances and Appeals section of this handbook for more information about grievances.) Interdisciplinary Team The Interdisciplinary Team (IDT) is a group of people who work together to provide a ContinuUs member with supports and services so that he/she can live a more independent and healthy life. The IDT includes the member, ContinuUs Care Manager, ContinuUs RN Care Manager, the member s guardian if one has been appointed, and other individuals that the member may wish to include. (Also known as the Care Team. ) Managed Care Organization (MCO) A Managed Care Organization (MCO) is an entity that has been certified by the Wisconsin Department of Health Services (DHS) as meeting the requirements for a managed care organization as defined in Wisconsin statutes. ContinuUs is an MCO that has been certified by DHS to make available to members, in consideration of periodic fixed payments, certain long-term care and health care services. Member A member is a person voluntarily enrolled in the ContinuUs MCO after having been found to be financially and functionally eligible for services from ContinuUs. Service Authorization A service authorization is an official record indicating that the ContinuUs is willing to pay for the requested service(s) that will be provided to the member by the provider. A service authorization will indicate the name of the member authorized to receive the service, the type of service to be provided, the number of units (amount of service) to be provided, and the duration of the authorization. ContinuUs providers can view their service authorizations online using the ContinuUs Provider Portal. ContinuUs Provider Handbook, 05/27/