Evercare Health and Home Connection

Transcription

1 Evercare Health and Home Connection Physician and Health Care Professional Administrative Manual Evercare Health and Home Connection, 2010 DOEA-E-N /10

2 Section Table of Contents Page Introduction Purpose of Manual 3 Overview 3 How to Reach Us Contacts 6 Provider Services 6 Enrollee Identification Enrollee Identification 8 Evercare Health and Home Connection ID Card Sample 8 Benefits Covered Services 9 Evercare Health and Home Connection Covered Level of Benefits 9 Expanded Benefits 13 Medicare/Medicaid Covered Services 13 Exclusions 15 Post Stabilization, Emergency & Urgently Needed Services 15 Enrollment Enrollment Eligibility 17 Enrollee Orientation 17 Disenrollment 18 Notification Requirements 19 Physician and Provider Primary Care Physician 20 Credentialing 20 Level 2 Background Screening 21 Adverse Credentialing Determination Appeals 21 Termination 21 Resolving Disputes 21 Arbitration 22 Data Collection 22 Protect Confidentiality of Patient Data 22 Evercare Health and Home Connection, 2010 i

3 Health Services and Quality Improvement Programs Health Services 23 Initial Assessment 24 Complex or Serious Medical Condition 25 Enrollee Medical Records 25 Access to Care Standards 27 Access for Enrollees with Disabilities 27 Direct Access to Care 28 Enrollee Rights 29 Sanctions 30 Enrollee Survey 30 Billing and Payment Billing and Claims 31 On the Web 31 Electronic Claim Submission 31 Paper Claims Submission 31 Payment Information 32 No enrollee payment liability 32 Common Claim Administration Issues 34 Claim Completion Requirements 34 Claims Paid and/or Denied in Error 36 Claim Denials 36 Overpayment 36 Durable Medical Equipment-DME 37 Filling Covered Claims 37 Adjustment Request Form 38 Adjustment Request Form Instructions 39 How to Bill a UB04 40 How to Bill a HCFA Claim Submission Address 43 Claim Forms Use 43 Provider Remittance Advice 43 Physician and Provider Risk Arrangements 48 Coordination of Benefits 48 Appeals and Grievances Enrollee Appeals and Grievances 49 Comments 53 Evercare Health and Home Connection, 2010 ii

4 Introduction Purpose of Administrative Manual Evercare welcomes you as a participating physician, provider or facility. You play a key role as we pursue our commitment to improve the health and well-being of the enrollees we serve. The purpose of the Administrative Manual is to serve as a resource and reference guide for participating physicians and providers. The manual contains information regarding, health services and quality improvement programs, billing and claim procedures, and ID cards and eligibility verification. Please share it with others in your office or organization. The information contained is current as of the date it was published, and may be modified by Evercare at any time. This manual was designed so that updates and changes from time to time can be done efficiently. If a section is updated or enhancements to contents made, you will be provided with the material to replace the respective section. For your ease, we have included a Comments section at the end of this manual for you to provide feedback or make recommendations. See the Comments section at the end of the manual. What is Evercare Health and Home Connection? Overview Evercare Health and Home Connection is a program for people aged 65 and older, who need assistance to remain at home. We help the primary physician, enrollee and family choose and arrange the care needed for an enrollee to remain independent. The goal of the Evercare Health and Home Connection program is to improve the ability of life by supporting an enrollee s ability to live independently. We consult with the primary doctor, enrollee and family to decide what kind of services are needed to keep the Evercare Health and Home Connection enrollee well, at home, and independent for as long as possible. The Evercare Health and Home Connection program arranges for the home, community, and medical services that are tailored to an individuals needs. In Evercare Health and Home Connection, an enrollee may keep their current doctor or choose to select a new doctor to coordinate their medical health care needs. Evercare Health and Home Connection s array of home and community service options are coordinated with many professional and medical care services. This section of your manual provides helpful information you will need to facilitate the delivery of health care for Evercare Health and Home Connection enrollees. Unless there is a Evercare Health and Home Connection

5 discrepancy, the information contained in this section does not replace the information contained in other sections of this manual, but highlights information pertinent to Evercare. How Evercare Health and Home Connection Works. Evercare operates under a contract with the State of Florida Department of Elder Affairs (DOEA). Evercare is committed to support and coordinate all Medicaid covered benefits for eligible Florida residents using a plan of care that is intended primarily for home and community based enrollees who are 65 years or older, need financial assistance and assistance with activies of daily living in order to remain at home. Evercare is required to comply with any new Medicaid coverage decisions. Evercare and Physicians and Providers. The success of Evercare depends on strong relationships with physicians, providers and facilities. We encourage enrollees to use their Evercare Health and Home Connection Care Manager to coordinate their care and help them access their covered benefits. Medicare is primary, the Evercare Health and Home Connection beneficiary has access to any Medicare approved provider without authorization. The Enrollee and Evercare. Voluntary enrollment in the Evercare Health and Home Connection program is open to Medicare Part A&B recipients age 65 and over meeting financial and clinical eligibility requirements. The Florida Department of Children and Families (formerly the Department of Health and Rehabilitative Services) and the federal Social Security Administration determine a person s financial and categorical Medicaid eligibility. Financial eligibility for the project will be up to the Medicaid ICP income and asset level. The Department s CARES program determines a person s clinical eligibility for the project. Enrollees need to be eligible for both Medicare and Medicaid to be in the program. Evercare will make every reasonable attempt to contact and notify all affected enrollees of the termination of any contracted provider within 30 days. Evercare and its contracted physicians and providers will treat all enrollees with dignity and respect and will recognize the enrollee s right to privacy, regardless of race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age, religion or national origin, cultural or educational background, economic or health status, English proficiency, reading skills or source of payment. Primary Care Physicians (PCP) and the Enrollee. Evercare s goal is to reinforce the physician-patient relationship, so the PCP can spend his or her time practicing medicine and delivering high quality care to each enrollee. The role of the PCP is critical to the overall management of the enrollee s health care. The PCP is responsible for coordinating the enrollee s health services, and ensuring continuity of care. The PCP should advise the enrollee about their health status, medical care and treatment options, including the risks, benefits and consequences of treatment and non-treatment and provide the enrollee with the opportunity to refuse treatment and to express preferences about future treatment decisions. From time to time, the Evercare Evercare Health and Home Connection

6 Care Manager may discuss an enrollee s need for various services to ensure that the enrollee is receiving the assistance needed. An Evercare Health and Home Connection enrollee is a Medicare recipient and can therefore access any Medicare approved provider without authorization from Evercare for services covered by Medicare. If you are unable to provide treatment to an enrollee, including counseling or referral services, because of religious grounds or moral reasons, please contact Provider Services at the number found on the How to Reach Us page of this section. Evercare Health and Home Connection

7 How to Reach Us Contacts Administrative Office Provider Relations Customer Service Plan Address: Customer service representatives are available between 8:00 a.m. And 7:00 p.m. Eastern time, Monday through Friday at or TTY 771 for the hearing impaired Evercare NW 12 th St Sunrise, Fl Claims Submission Address P.O. Box 31362, Salt Lake City, UT Or electronically Payer ID Customer Service Department Provider Services Evercare Health and Home Connection s Customer Service Department is available between 8:00 a.m. and 7:00 p.m. Eastern time, Monday through Friday at or TDD 771. You may call Customer Service for physician, facility and other provider questions such as: Claim status Claim denial Claim submission information needed Claims payment address (verification or change) New contract status Provider Remittance Advice (PRA) Resubmission of corrected claims Unreconciled claims Enrollee eligibility Evercare Health and Home Connection

8 Provider Relations Contact your Provider Relations Department for questions regarding: Changes in physician and provider information, including name, address, telephone number or Federal Tax Identification number If you open or close an office If you have reached capacity and you are no longer accepting new patients. Please provide the effective date and date anticipated for accepting new patients. Contract administration issues Credentialing and re-credentialing issues Reimbursement issues, fee schedules, coding questions Specific information about Evercare s policies and procedures Training for billing and claim submission Evercare Health and Home Connection

9 Enrollee Identification Enrollee Identification Each Evercare Health and Home Connection enrollee receives an identification card to present to physicians and providers when seeking health care services. See below for a sample enrollee identification card. This card identifies the enrollee as an Evercare Health and Home Connection enrollee. Medicaid will not be responsible for claims for the enrollee while they continue to be enrolled in Evercare Health and Home Connection. During that time, all claims need to be submitted to Evercare. Medicaid recipients receive a gold plastic, Medicaid identification card, issued by the State of Florida. This card will allow providers instant access to Medicaid recipient eligibility information. Enrollee ID Card Sample Evercare Health and Home Connection Enrollee Identification Card FRONT Evercare Health and Home Connection

10 Benefits Covered Services Medical Care Services Medicare is the primary payor of most covered medical services. Evercare Health and Home Connection enrollees retain the right to receive Medicare-covered services that are determined to be medically necessary and which are performed, prescribed, or directed by their primary doctor. To receive full coverage, the enrollee must follow the proper Medicare procedures to obtain approval for services or they may be responsible for payment and continue to use their Medicare ID card to assure authorization and payment for Medicare-covered services. However, because they are eligible for Medicare and Medicaid, Evercare Health and Home Connection is responsible for payment of any co-payments or deductibles for authorized Medicare-covered services that are also Medicaid-covered services. Post stabilization services are provided without prior authorization. Evercare Health and Home Connection Covered Level of Benefits In Home and Community Long Term Care Services The following services are included in the Evercare Health and Home Connection benefit plan. The Care Manager will work with the primary physician and enrollee to determine which of these services best meet their care plan needs. All services require a prior authorization by the Care Manager. The level of services authorized is based on each enrollee s personal needs which is predetermined by Evercare Health and Home Connection established guidelines. Evercare Health and Home Connection

11 Adult Companion Services Adult Day Health Services Attendant Care Chore Services Consumable Medical Supplies Environmental Accessibility Adaptation Services Non-medical care, supervision and socialization. This service does not include hands-on nursing care. Social and therapeutic activities in an organized program located in a community setting. Attendant care services are a combination of several long term care services provided during a specified period of time. These services include Companion, Homemaker, Respite and Personal Care. The enrollee has the ability to choose which services are to be performed during the time that the worker is in the enrollee s home. *Attendant Care workers do not assume any responsibility for the enrollee s banking, bill paying or ATM card usage and must have the ability to reconcile change when doing any shopping on behalf of the enrollee. Services necessary to maintain an enrollee s home as a clean and safe living environment, such as heavy cleaning. Disposable supplies essential to adequately care for the needs of the enrollee. These supplies enable the enrollee to perform activities of daily living or stabilize or monitor a health condition. Consumable medical supplies include adult disposable diapers, tubes of ointment, cotton balls and alcohol for use with injections, medicated bandages, gauze and tape, colostomy and catheter supplies, and other consumable supplies. Not included are items covered under the Medicare / Medicaid home health service, personal toiletries, and household items such as detergents, bleach, and paper towels, or prescription drugs covered by Medicare Part D. Physical adaptations to an enrollees home to assure safety or enable enrollee to function with greater independence. This service does not include those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit, such as carpeting, roof repairs, and modifications to electrical or plumbing systems or central air conditioning. Adaptations that add to the total square footage of a home are not included in this benefit. Evercare Health and Home Connection

12 Escort Services Family Training Services Financial Services Home-Delivered Meals Homemaker Services Nutritional Assessment and Nutritional Risk Reduction Services Personal Care Services Emergency Response System (PERS) Respite Care Services Physical Therapy Services Speech Therapy Services Assistance to travel to medically necessary appointments. Escorts are not permitted to transport enrollees in individual vehicles. Training and instruction for family members who provide care to an enrollee. Assessment, guidance, and/or instruction in the performance of routine financial tasks such as bill paying. Nutritionally sound meals delivered to the enrollee s place of residence. Service includes general household activities. Included is meal preparation and routine household tasks provided by a trained homemaker. *Homemakers are not to assume any responsibility for the enrollees banking, bill paying or ATM card usage and must have the ability to reconcile change when doing any shopping on behalf of the enrollee. Assessment, education, and guidance to enrollee and family about nutritional needs. Service includes assistance with eating, bathing, dressing, and personal hygiene needs. An electronic device that enables the enrollee to secure emergency help while in the home. Assistance to an enrollee, on a short-term basis, when family or caregivers normally providing care will be absent. Treatment to restore, improve or maintain impaired functions by using activities and chemicals with heat, light, electricity or sound, and by massage and active, resistive, or passive exercise when determined through a multi-disciplinary assessment to improve an enrollee s capability to live safely in the home setting. Services covered under the Medicare provision are not covered. The identification and treatment of neurological deficiencies related to feeding problems, congenital or trauma-related Evercare Health and Home Connection

13 Occupational Therapy Services Assisted Living Facilities Services Nursing Facility Services maxillofacial anomalies, autism, or neurological conditions that effect oral motor functions. Therapy services include the evaluation and treatment of problems related to an oral motor dysfunction when determined through a multi-disciplinary assessment to improve an enrollee s capability to live safely in the home setting. Services covered under the Medicare provision are not covered. Treatment to restore, improve or maintain impaired functions aimed at increasing or maintaining the enrollee s ability to perform tasks required for independent functioning when determined through a multi-disciplinary assessment to improve an enrollee s capability to live safely in the home setting. Services covered under the Medicare provision are not covered. Evercare Health and Home Connection works to provide services to support the choice to remain safely in the own home. If it is determined that Assisted Living Services are needed, Evercare Health and Home Connection will reimburse the facility for personal care services. The enrollee is responsible for the cost of the room and board. Evercare Health and Home Connection will work to provide services to support the choice to remain safely in the home. Should permanent nursing home placement become necessary and enrollee moves to a nursing home, Evercare Health and Home Connection coverage will pay based on the State Medicaid assigned bed rate for the Long Term Care Facility. Evercare Health and Home Connection

14 Expanded Benefits Vision Services Hearing Services Expanded Prescription Drug Coverage Vision services are provided by Spectera. Care Management will work with the enrollee to coordinate vision services. The enrollee s Care Manager can be reached at or TDD 771. All hearing services need prior authorization through Evercare Health and Home Connection by calling or TDD 771. A special benefit that allows enrollees to obtain certain medications not covered by Medicare Part-D or Florida Medicaid as well as select overthe-counter medications. The providers in the network can change at any time. You can ask for an updated Provider Directory at any time by calling our toll-free number or TDD 771. Medicare/Medicaid-Covered Services The following is a summary of Medicare/Medicaid covered services. Each service indicates whether Medicare or Evercare Health and Home Connection is the primary payor. Remember, Evercare Health and Home Connection is responsible for the payment of any co-payments or deductibles for authorized Medicare-covered services that are also Medicaid-covered services up to the Medicaid limitations. Evercare Health and Home Connection reimburse providers up to the Medicaid rate of reimbursement. Medicaid does not pay balances for services that are not covered by Medicaid. Medicaid does not pay the deductible and coinsurance for medical supplies and durable medical equipment that are covered by nursing facility services and included in the nursing facility s per diem payment. Inpatient Hospitalization: Inpatient includes all items and services necessary to provide appropriate care during a stay in a hospital. Provision includes room and board, nursing care, medical supplies, and all diagnostic and therapeutic services. Medicare is the primary payor for these services. Outpatient Services: Outpatient includes all diagnostic procedures, therapeutic care, and items of service provided in an outpatient hospital setting. Medicare is the primary payor for these services. Evercare Health and Home Connection

15 Urgent and Emergency Medical Services: Medical services Include urgent care when received at an emergency facility. Provision includes emergency services to prevent serious damage to the body or body function. Examples are loss of consciousness, intense and uncontrollable pain, severe shortness of breath that prevents you from talking etc. Medicare is the primary payor for these services. Physician Services: Services Include all services and procedures rendered by a doctor when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness, or disease. Provision excludes clinically unproven procedures and cosmetic surgery. Medicare is the primary payor for these services. The physician must participate in the Medicaid program and agree to accept reimbursement under those guidelines. Home Health Care: Care includes intermittent or part-time nursing services (R.N. or L.P.N.), personal care services by a home health aide, and medical items limited to approved supplies, appliances, and durable medical equipment suitable for use in the home. All services, supplies, and equipment must be prescribed by a doctor. Medicare is the primary payor for these services. Laboratory and X-ray Services: Service includes laboratory and radiological services ordered by a doctor. Medicare is the primary payor for these services. Therapy: Physical, occupational, speech, and respiratory therapies are covered on a case-by-case basis. Medicare is the primary payor for these services. Mental Health & Substance Abuse Services: Service includes outpatient treatment of mental health and substance abuse or inpatient treatment when the condition would present a danger to the person or to others. Services must be under the care of a psychiatrist. Medicare is the primary payor for these services. Evercare Health and Home Connection is the primary payor for non-medicare covered Mental Health and Substance Abuse Services. United Behavioral Health, a subsidiary of UnitedHealth Group, provides the managed mental health and substance abuse care for Evercare. Transportation: Emergency transportation services are covered. In the event of a medical emergency, please call 911. Medicare is the primary payor for these services. Non-emergency medical and non-medical transport is covered by Medicaid and the enrollee is responsible for the co-pay. Transportation services are accessible through the enrollee s Medicaid Gold Card. Chiropractic Services: Chiropractic services are covered under Medicare. Evercare Health and Home Connection

16 Podiatry Services: Podiatry services, other than routine foot care are covered under Medicare. Hospice Hospice care is a comprehensive set of services that provides Physical, psychosocial, spiritual and emotional service needs to a person who is terminally ill. Evercare Health & Home Connection will coordinate Hospice services with the enrollee s Hospice Provider. Medicare is the primary payer for these services. Exclusions Certain services and/or service categories are excluded from coverage under Evercare. The Evercare Health and Home Connection Evidence of Coverage (EOC) lists many of the excluded services. For a complete list of exclusions, contact Customer Service at the number found on the How to Reach Us page of this section. In addition to the specific excluded services, Evercare may deny coverage if: The service is not a Medicaid covered benefit. Post-Stabilization, Emergency and Urgently Needed Services Inpatient and outpatient emergency health services are covered inside or outside of the Evercare Health and Home Connection service area. In the event of an emergency, the enrollee should seek immediate care, or call 911 for assistance. Prior authorization is not required, and Evercare may not deny payment if an Evercare contracted physician or provider instructs an enrollee to seek emergency services. Evercare Health and Home Connection enrollees are covered by Medicare for the treatment of an emergency medical condition, which is defined by DOEA as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, which possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part Evercare Health and Home Connection becomes the secondary payor and processes the claims for Medicaid covered services. Evercare Health and Home Connection includes coverage for post-stabilization care. Post-stabilization care is defined as a non-emergency services needed to ensure that the enrollee remains stabilized after an emergency. The attending physician or Evercare Health and Home Connection

17 provider determines when the condition is no longer an emergency and the enrollee is considered stabilized for discharge or transfer. Continuation of care after the condition is no longer an emergency will require coordination with Evercare. Post-stabilization care is covered if: Prior authorized by Evercare Evercare did not respond to the request by the physician or provider of post-stabilization services for prior authorization within one hour after Evercare was asked to approve poststabilization care, or Evercare could not be reached for prior authorization despite reasonable efforts Such automatic approval of post-stabilization care continues to be covered until Evercare has responded to the request and arranged for discharge or transfer. Evercare Health and Home Connection includes the same coverage for urgently needed health services and symptomatic office visits as Medicaid. Medicare is primary. A symptomatic office visit is an encounter associated with a presentation of medical symptoms or signs, but not requiring immediate attention. Urgent Care services are medical services required promptly to prevent impairment or health due to symptoms that do not constitute an Emergency condition, but that are the result of unforeseen illness, injury, or condition for which medical services are immediately required. Urgent care is appropriately provided in a clinic, in a physician s office, or in a hospital emergency department if a clinic or physician s office is inaccessible. Enrollees are encouraged to notify Evercare as soon as possible after receiving post-stabilization, emergency or urgently needed health services. The Evercare contracted physicians or providers are required to notify Evercare if an enrollee is admitted to the hospital. Questions or Concerns You or your patient may contact the customer service at or TDD 771 for further clarification of covered benefits. Evercare Health and Home Connection

18 Enrollment Enrollment Eligibility Eligiblity Requirments: 65 years of age or older. Medicare Parts A & B eligible or a Medicare Advantage Plan. Medicaid eligible - Institutional Care Program level (ICP). Reside in the project service area. Determined by CARES to be at risk of nursing home placement and meet one or more of the following clinical criteria: 1. Require some help with five or more activities of daily living (ADL s); or 2. Require some help with four ADL s plus requiring supervision or administration of medication; or 3. Require total help with two or more ADL s; or 4. Have a diagnosis of Alzheimer s disease or another type of dementia and require some help with three or more ADL s; or 5. Have a diagnosis of a degenerative or chronic condition requiring daily nursing services. 6. Be determined by CARES to be a person who, on the effective date of enrollment, can be safely served with home and community-based services. Eligibility Determination: The Florida Department of Children and Families (formerly the Department of Health and Rehabilitative Services) and the federal Social Security Administration determine a person s financial and categorical Medicaid eligibility. Financial eligibility for the project will be up to the Medicaid ICP income and asset level. The Department s CARES program determines a person s clinical eligibility for the project. Enrollee Orientation Once the Evercare Health and Home Connection enrollment application is processed, each new enrollee receives a letter stating the effective date of coverage and a packet of information about the Evercare Health and Home Connection program. The following documents are provided to new enrollees: Evercare Health and Home Connection

19 Welcome Letter Member Handbook Enrollee ID Card Provider Directory HIPAA Privacy Notice Evercare will contact new enrollees via telephone and conduct a Health Risk Assessment. The enrollee orientation is completed during a visit to the enrollee by the assigned Care Manager and includes the following topics: The role of the enrollee s primary care practitioner (PCP) PCP/Plan selection and change options How to access routine care, specialists, and long term care services Behavioral and substance abuse services How to access Urgent Care and emergency care Using non-contracted providers and practitioners Filing a Grievance or Appeal Enrollee rights and responsibilities Enrollee right to self-determination The Care Manager s role with the enrollee and his or her PCP How to disenroll voluntarily Customer service number and use Disenrollment An enrollee may disenroll from Evercare Health and Home Connection at any time. The effective date for disenrollment is the last day of the month in which disenrollment was effectuated by the Agency for Health Care Administration. In certain circumstances, DOEA regulatory guidelines permit Evercare to terminate an enrollee s coverage. These terminations are considered involuntary disenrollments. Reasons for involuntary disenrollment include: Loss of Medicaid eligibility Permanent move out of the approved service area Fraudulent use of ID card Failure to follow a recommended plan of health care Evercare may disenroll an enrollee if the individual s behavior is documented to be disruptive, unruly, abusive, or uncooperative to the extent that his or her continued enrollment in Evercare seriously impairs our ability to furnish services either to the individual or to other enrollees. Evercare Health and Home Connection

20 DOEA must approve all involuntary disenrollments. If you encounter any instances of this type of behavior, please notify us by calling the customer service number. Evercare will properly communicate all involuntary disenrollments to the enrollee. This includes providing the enrollee with a written notice in accordance with the timelines set out by DOEA. Call the enrollee s Care Manager or Customer Service prior to: Procedures and Services Facility Admissions (Hospital, & SNF) Out of Network Services Home and Community Based Services Durable Medical Equipment (DME)/ Supplies (DMS) Mental Health Services Therapy Services Explanation Notification Requirements All in-patient admissions (except maternity), including acute hospital, rehabilitation facilities, and skilled nursing facilities. Referrals to providers that are not contracted with Evercare Health and Home Connection. All home-based services, including nursing, respiratory therapy, IV infusion services, hospice services, physical, speech and occupational therapies and social work. All DME/DMS services must be coordinated with the Care Manager. Mental Health services must be coordinated with the Care Manager. Any Physical Therapy (PT), Occupational Therapy (OT), and/or Speech Pathology Therapy (ST) services This list does not signify coverage for benefits. If you have questions about a patient s benefit coverage, please call customer service. Refer to the How to Reach Us Page Evercare Health and Home Connection

21 Physician and Provider Primary Care Physician The PCP will: Conduct face-to-face initial and ongoing assessments of medical needs Provide primary care services Create and maintain an individualized care plan (ICP), including establishing goals of the enrollee Provide medical oversight to the care management process and, be fully aware of all services delivered through care plan *Medicare is Primary Payer of Services Credentialing All in-home and community care service providers delivering authorized services to Evercare Health and Home Connection enrollees must be credentialed in accordance with Evercare s policies and procedures. Under DOEA regulation, the credentialing process and approval must be completed or a Letter of Agreement with intention to contract with Evercare complying with regulatory requirements under DOEA must be completed, before providing services to an Evercare Health and Home Connection enrollee. Re-credentialing will occur every three years thereafter for all contracted physicians, providers, facilities, and hospitals. The following items are required to complete primary source verification: Providers Completed Application Business License Occupational License if applicable Copy of W9 Copy of Work History Copy of Background Check Copy of Professional Liability Claims History Past 5 years Copy of Liability Insurance If applicable, Attestation to compliance with level 2 Background Screening If applicable, Abuse/Neglect/Exploitation Training Attestation Medicaid ID number Evercare Health and Home Connection

22 The credentialing process is considered complete when the credentialing application is completed and approved.. Level 2 Background Screening The laws governing background screening of individuals who work with certain vulnerable Floridians, including elders, were significantly modified during the 2010 legislative session (visit to learn more). As a result, the Florida Department of Elder Affairs is requiring NHD and PACE Program providers such as Evercare to obtain affidavits of compliance from subcontractors indicating that their direct service provider employees are in compliance with the new background screening law. Adverse Credentialing Determination Appeals Providers receive written notice of such protocols in the contract between the provider and Evercare (Provider contract), in Evercare s credentialing policies and procedures, and in other communication vehicles from time to time. If Evercare makes an adverse determination regarding a Provider s continued participation, the Provider will be notified of such decision in writing and given an opportunity to initiate a formal appeal. Physician and Provider Termination Termination For information regarding contracted provider termination, please refer to your provider agreement. You may also contact your local provider relations representative by referring to the How to Reach Us page. Contract concern or complaint Resolving Disputes If you have a concern or complaint about your agreement with us, send a letter containing the details to the address note on the How to Reach Us section of this document. A representative will look into your complaint and try to resolve it through informal discussions. If you disagree with the outcome of this discussion, an arbitration proceeding may be filed as described below and in our agreement. If your concern or complaint relates to a matter, which is generally administered by certain United Healthcare procedures, such as the credentialing or care management process, we will follow the procedures set forth in those departments to resolve the concern or complaint. After following those procedures, if one of us remains dissatisfied, an arbitration proceeding may be filed as described below and in our agreement. If we have a concern or complaint about our agreement with you, we ll send you a letter containing the Evercare Health and Home Connection

23 details. If we can t resolve the complaint through informal discussions with you, an arbitration proceeding may be filed as described below and in our agreement. Arbitration Evercare will conduct any arbitration proceeding under your agreement under the auspices of the American Arbitration Association, as further described in our agreement. For more information on the American Arbitration Association guidelines, visit their Web site at In the event that a customer has authorized you to appeal a clinical or coverage determination on their behalf, that appeal will follow the appropriate government regulatory process governing customer appeals outlined on page of this manual. Data Collection Evercare Health and Home Connection is required to maintain a health information system that collects, analyzes and integrates all data necessary to compile, evaluate and report certain statistical data related to costs, utilization and quality, and such other matters as DOEA may require from time to time. As an Evercare contracted physician or provider, you are required to submit all data necessary to fulfill these obligations in a timely manner. Providers are required to certify in writing at the time of submission to Evercare or its designee, that all data including, but not limited to, encounter data and other information that DOEA may specify, is truthful, reliable, accurate and complete. Protect Confidentiality of Patient Data Evercare Health and Home Connection enrollees have a right to privacy and confidentiality of all records and information about their health care. We disclose confidential information only to business associates and affiliates that need that information to fulfill our obligations and to facilitate improvements to our enrollees health care experience. We require our affiliates and business partners to protect privacy and abide by privacy law. If an enrollee requests specific medical record information, we will refer the enrollee to you as the holder of the medical records, Evercare requires that all physician and providers comply with standards under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for privacy and protection of enrollee data. Evercare Health and Home Connection

24 Health Services and Quality Improvement Programs Health Services Evercare Health and Home Connection Care Management Model The care management model is a clinically grounded, mission-driven model that focuses on optimizing the health and well being of the Evercare Health and Home Connection enrollee and builds upon existing community relationships. The following principles guide the direction and focus of care management activities: Enrollees are at the center of all care decisions Care and services should be provided in a variety of settings at differing levels of intensity Care management activities must emphasize the provision of the right services, at the right time, in the right place, for the right reason, and at the right cost Care management guidelines and practices are built from evidence-based practices This unique innovative model utilizes advanced technology to improve communications and streamline day-to-day operations. The model incorporates health risk screening, medical/social assessment, care planning and ongoing service plan monitoring to identify and address enrollee needs. This model is founded upon principles for the care of geriatric, chronically ill and frail individuals. Following is a description of the health services delivery model and it s description at each level of care. Primary Care Physician (PCP) The PCP will: Provide primary care services Together with care manager (CM), create and maintain an individualized care plan (ICP), including establishing goals of the enrollee Provide medical oversight to the care management process and, be fully aware of all services delivered through the care plan Evercare Health and Home Connection

25 Care Manager Interface with the PCP Care managers (CM) interface with the PCP on an ongoing basis. The CM will assist the PCP in implementing the care plan by, for example, scheduling appointments or arranging for home and community based services (HCBS). Initial Assessment Initial Assessment Process All Evercare Health and Home Connection (EHHC) enrollees will receive initial and ongoing face-to-face Care Management assessments. This, along with the physician s assessment, will be the medical portion of the overall Evercare initial and ongoing assessment process. The care manager will develop and implement an individualized care plan for enrollees requiring services, review the enrollee s progress and adjust the care plan as necessary to ensure that the enrollee continues to receive an appropriate level of care. The care manager documents all of the orientation; health assessments, reassessment, and care plan findings in the enrollee s EAH care management system software program. Evercare Health and Home Connection

26 Evercare Health and Home Connection Assessment Process Complex or Serious Medical Condition The PCP will identify the potential for complex care needs through the assessment process. The enrollee s level of care is determined by the CARES Unit during the enrollment process. Evercare is required to have in place DOEA approved policies and procedures to identify enrollees with complex or serious medical conditions and to assess, diagnose and monitor those conditions on an ongoing basis. An individualized care plan (ICP) must be established and implemented that is appropriate to the condition, and allows direct access visits to participating specialists to accommodate the care plan. The ICP must be time-specific and be updated periodically by the Primary Care Physician/Evercare Care Manager. Evercare health services management staff will work closely with you to identify enrollees with complex or serious medical conditions and to develop appropriate care plans and monitor them on an ongoing basis. Enrollee Medical Records Evercare Health and Home Connection will make use of the usual and customary protocols within the medical community by utilizing the medical records maintained by primary care physicians (PCP) and nursing facilities. These records will include patient s diagnoses, medical conditions, medications, scheduled appointments and progress notes. Confidentiality and accuracy of an enrollee s medical record must be maintained at all times. Evercare requires that all physician and providers comply with standards under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for privacy and protection of enrollee data. The privacy of any information that identifies a particular enrollee must be safeguarded. Information from or copies of an enrollee s medical record may only be released to authorized individuals. Physicians and other providers must ensure that unauthorized individuals cannot gain access to or alter an enrollee s medical record. Original medical records may only be released in accordance with state laws, court orders or subpoenas, and timely access by enrollees to the information that pertains to them must be ensured. Additionally, physicians, other providers and Evercare must abide by all federal and state laws regarding confidentiality and disclosure of mental health records, medical records, and other health and enrollee information. All medical records must be maintained for six years. Additionally, there must be prominent documentation in the medical record demonstrating whether or not an enrollee has executed an advance directive. Evercare, DOEA, and any Federal or State agency, and their designees, must have access to enrollee medical records. Evercare Health and Home Connection

27 Every patient must have an individual medical record which meets the following standards: 1. Identifying information on the enrollee, including name, identification number, date of birth, sex, and legal guardianship (if applicable); 2. The record is legible and maintained in detail; 3. A summary of significant surgical procedures, past and current diagnosis or problems, allergies, untoward reactions to drugs and current medications; 4. All entries are dated and signed; 5. All entries indicate the chief complaint or purpose of the visit; the objective findings of practitioner; diagnosis or medical impression; 6. All entries indicate studies ordered (for example lab, x-ray, EKG, and referral reports) 7. All entries indicate therapies administered and prescribed; 8. All entries include the name and profession of the practitioner rendering services (for example M.D., D.O., O.D., including signature or initials of practitioner); 9. All entries include the disposition, recommendations, instructions to the patient, evidence of whether there was follow-up, and outcome of services; 10. All records contain an immunization history 11. All records contain information on Smoking/ETOH (ethyl alcohol)/substance abuse; 12. All records contain record of emergency care and hospital discharge summaries; 13 All records reflect the primary language spoken by the enrollee and translation needs of the enrollee; 14. All records identify enrollees needing communication assistance in the delivery of health care services; 15. All records contain documentation that the enrollee was provided written information concerning the enrollee s rights regarding advanced directives (written instructions for living will or power of attorney), and whether or not the enrollee has executed an advance directive. The Provider shall not, as a condition of treatment, require the Member to execute or waive an advance directive in accordance with section , F.S Evercare Health and Home Connection

28 Access to Care Standards Evercare Health and Home Connection is offered in a defined service area approved by the State of Florida Department of Elder Affairs. Within the service area, Evercare must offer a uniform benefit package and maintain a network of contracted providers to meet access needs. Evercare must ensure that all covered services are available and accessible through Evercare, and available 24 hours a day, seven days a week. Evercare also ensures that the hours of operation of contracted providers do not discriminate against the enrollee, and that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities. Providers are contractually bound to provide appropriate assistance to enrollees that may have a limited English proficiency or reading skills. If the provider is unable to accommodate the enrollee, the provider must contact Evercare for assistance by calling the Customer Service number in the How to Reach Us section in this manual. A translation service using AT&T is available at the request of the enrollee or the provider. Access for Enrollees with Disabilities Physical and telephone access to services must be available for individuals with disabilities. Providers must reasonably accommodate enrollees with disabilities and ensure that physical and communication barriers do not prevent individuals with disabilities from obtaining your services. If you have any difficulty meeting this standard please contact your provider relations representative to note your office inaccessibility and for us to help you meet this requirement. Evercare Health and Home Connection

29 Direct Access to Care Evercare Health and Home Connection enrollees may seek direct access for all Medicare covered health care services. Evercare Health and Home Connection

30 Enrollee Rights The State must ensure that each enrollee is free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way the health plan and its providers or the State agency treat the enrollee. We tell our customers they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you. These rights and responsibilities are reprinted from our customer handbook. Customers have the right to: Receive information about UnitedHealthcare, our services and network physicians and healthcare professionals in accordance with federal and state regulations. To be treated with respect and with due consideration for his or her dignity and privacy by United Healthcare personnel, network physicians, and health care professionals as well as privacy and confidentiality for treatments, tests or procedures received. Voice concerns about the service and care they receive as well as register complaints and appeals concerning their health plan or the care provided to them and receive timely responses to their concerns. Receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee s condition and ability to understand, regardless of cost or benefit coverage. Participate with their doctor and other caregivers in decisions about their healthcare including the right to refuse treatment. Be informed of, and refuse to participate in, any experimental treatment. Have coverage decisions and claims processed according to regulatory standards. Choose an advance directive to designate the kind of care they wish to receive should they be unable to express their wishes. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Request and receive a copy of his or her medical records, and request that they be amended or corrected. Customers have the responsibility to: Know and confirm their benefits before receiving treatment Contact an appropriate health care professional when they have a medical need or concern. Show their identification card before receiving health care services Verify that the physician or health care professional they receive service from is in the UnitedHealthcare network Pay any necessary co-payment at the time they receive treatment Evercare Health and Home Connection

31 Use emergency room services only for injury or illness that if not treated immediately, could pose serious threat to their life or health. Keep scheduled appointments Provide information needed for their care Follow the agreed upon instructions and guidelines of physicians and health care professionals. Notify UnitedHealthcare Customer Service of a change in address, family status or other coverage information. Evercare Health and Home Connection enrollees receive a complete list of their enrollee rights and responsibilities in their Enrollee Information Guide. Sanctions Upon written notification from DOEA -- by letter or the lists published by the OIG and GAO-- of a physician s or other provider's exclusion from original Medicare or Medicaid, Evercare will send a letter to the provider stating the provider will be removed from the Evercare list of contracted providers as of a given date. Except for post-stabilization, emergency and urgently needed care, no payments will be made to the provider after the exclusionary effective date. Enrollees are notified that the provider is no longer contracted and are advised to select a new provider, if appropriate. Enrollees with claims pending for items or services from an excluded provider, or enrollees submitting claims for items or services from an excluded provider for the first time, will receive a letter notifying the enrollee of the following: The enrollee is accessing a sanctioned provider. Payments to a Medicare Medicaid-excluded provider is prohibited. Payments will not be made for items or services rendered after the date of exclusion or after notification to the enrollee (whichever date is later). Providers are also prohibited from employing or contracting with an individual who is excluded from participation in Medicaid, or with an entity that employs or contracts with such an individual, for the provision of health care, utilization review, medical social work or administrative services. Reinstatement Upon reinstatement by DOEA, the provider is responsible for notifying Evercare and applying for reinstatement. Enrollee Survey Evercare Health and Home Connection

32 DOEA requires an annual enrollee satisfaction survey. Enrollees will be polled to determine satisfaction with the care manager, customer service, sales and written information. A survey or focus group may be conducted with enrollees that are non-english speaking, or have physical disabilities, or are part of a minority ethnic group. Summarized data is available on request to the physician, provider or the enrollee. Billing and Payment Billing and Claims On the Web At United Healthcare Online, you can: Check enrollee eligibility Check claims status Submit claims (HCFA 1500) electronically, for faster claims payment. This website is a service provided free to participating network providers. To register, call UHC-FAST ( ) or your local Evercare provider representative. Electronic Claim Submission In addition to United Healthcare Online, you can also submit electronic claims through Electronic Data Interchange (EDI) using a claims clearinghouse. For more information about EDI, contact your claims clearinghouse vendor or United Healthcare at For electronic claim submissions please use or have the clearinghouse use Payer ID *There may be costs associated with EDI submission. Please check with the clearinghouse for details. Paper Claim Submission For claims submit via standard mail, claims should be completed on either a HCFA 1500 or UB04 claim form. Use a UB04 for facility or hospital claims Evercare Health and Home Connection

33 Use a HCFA 1500 for physician and ancillary claims Detailed directions for completing the HCFA 1500 and UB04 can be found on pages Additionally, a listing of all required fields is included in the Claim Completion Requirements section on page 29. Once the claims are completed accurately with all required information, mail paper claims to the claims address on the enrollee s ID card, which is: Evercare P.O. Box Salt Lake City, UT Please do not bill Medicaid directly Payment Information It is Evercare s policy to encourage physician and providers to submit claims for covered benefits as soon as possible and no later than the time frames set forth in your participation agreement. Unless otherwise specified in your contract, Evercare must receive all information necessary to process the claims no more than 90 days from the date of discharge from a facility; or 90 days from the date, the services are rendered to the Evercare Health and Home Connection enrollee. Any claims received after this time period may be rejected for payment, at Evercare s discretion. Evercare will pay claims for health services provided to an enrollee in accordance to the contractual agreement. No Enrollee Payment Liability Participating physicians, providers, and facilities, must submit claims on the enrollee s behalf and work directly with Evercare for reimbursement. Enrollees should not be asked to submit claims for services rendered. Providers cannot bill the enrollee for health services provided if the provider fails to submit a claim. The enrollee cannot be balance billed for services covered under the contractual agreement at a pre-determined contracted rate. If a claim is filed within the time period allowed under Medicaid the service is Evercare s liability, the claim must be paid by Evercare even if the contract between DOEA and Evercare is no longer in effect; or if the enrollee has disenrolled from Evercare Health and Home Connection, provided that the enrollee was enrolled and effective at the time that the service(s) Evercare Health and Home Connection

34 were rendered and that the service was a covered benefit through Evercare Health and Home Connection. Evercare Health and Home Connection

35 Common Claim Administration Issues If two identical claims are received for the same service, on the same date (for the same enrollee), one will be denied as an exact duplicate. The correct Evercare Health and Home Connection enrollee ID number should be legible and included on the claim. For HCFA 1500 claims, only valid procedure codes should be used. Consult your contract when submitting claims for payment. For UB04 claims, only valid revenue codes and/or HCPCS codes must be used.. Consult your contract when submitting claims for payment. Coding Reference Manuals CPT code books are available at most book stores or they can be ordered by contacting the American Medical Association at (312) or toll free at ICD-9-CM diagnosis codebook can be found at most bookstores or by contacting the American Hospital Association at (312) or toll free at HCFA 1500 claim forms may be obtained by contacting the American Medical Association at (312) or toll free at UB04 claim forms may be obtained by contacting the American Medical Association at (312) or Claim Completion Requirements Patient information required for each claim Enrollee s 16-digit Evercare Health and Home Connection identification number (unique for each enrollee) Patient s name enter the patient s last name, first name and middle initial, if any as shown on patient s Evercare Health and Home Connection ID card Patient s address Patient s birth date and sex Patient s authorization (signature on file) Other health insurance coverage, if applicable Physician and provider/facility information required on each claim Name of physician/provider providing service Name of the clinic or facility Evercare Health and Home Connection

36 Name of the referring physician, if applicable Federal Tax ID Number Medicare Assignment for HCFA 1500 claims Physician Signature/Date for HCFA 1500 claims Service information required on each claim Itemization of Services Date(s) of service CPT/Revenue codes or HCPCS procedure code ICD-9-CM diagnosis code and description specified to the 4 th and 5 th digit Procedure code modifiers when applicable Charges/Total Charges Days or units Service location for HCFA 1500 claims Standard CMS site codes are required to indicate where services were rendered. Guidelines for submitting claims to Evercare Claims should be submitted for only one enrollee and one physician or provider/facility per claim form. For HCFA 1500 claims, multiple visits rendered by a physician or provider over several days (such as hospital visits) should be itemized, by date of service. (See section on How to Bill HCFA ) For UB04 see section on How to Bill UB04 Procedure codes from the Physicians Current Procedural Terminology (CPT) book or the HCPCS Manual, CMS Common Procedural Coding System should be used. Unlisted procedure codes should be submitted only when a specific code to describe the service is not available or when indicated in the contract. Submit these codes with complete description indicated on the HCFA Modifiers are located at the beginning of each major section of CPT. The modifiers provide a means by which the definition of a particular service can be modified to better describe the circumstances of the service. When appropriate, the two-digit modifier should be used immediately following the five-digit procedure code. (Do not insert a space or a dash.) Evercare Health and Home Connection

37 When submitting modifiers, which require further explanation, supporting documentation should be included, such as operative report, progress notes, etc. (i.e., 22 unusual service). Examples of reasons Evercare would return claims Original claim submittals will be returned for any of the following reasons: Enrollee s Evercare Health and Home Connection ID number is invalid for date of service and/or missing Enrollee s Evercare Health and Home Connection ID number does not match patient name Bill Type is missing ICD-9 diagnosis code is invalid and/or missing the 4 th and 5 th digit Revenue or CPT code is invalid and/or missing Claim was not submitted on appropriate form (i.e., HCFA 1500 or UB04) Date span for services requiring authorization does not match dates authorized Missing the Medicare EOB Claims Paid and/or Denied in Error Claims receiving partial/incorrect payments or inappropriate denials must be resubmitted using the Adjustment Request Form (page 30). Failure to use the Adjustment Request Form may cause a delay in adjusting the claim. See sample form and instructions on page 34. Claim Denials Claims denied for any inaccurate or missing information will be noted on the Provider Remittance Advice, see section for Remittance Advice on page 39. The denied claims will be listed with a denial code. The denial code will identify the error that must be corrected prior to resubmitting the claim. The claim must be resubmit noting Corrected Claim in the comments section to assure the claim will be reprocessed appropriately. For questions concerning the resubmission of claims, contact your local Provider Relations Representative. Overpayment If you receive an overpayment from Evercare, you can return the original UHG/Evercare check by mailing it to the local Evercare office c/o Operations Manager with the reason for the return. (See How to Reach Us section) To properly credit any returned check or refund check please include a copy of the PRA with your correspondence. Evercare Health and Home Connection

38 If you wish to mail a refund check to Evercare on your own check stock paper, please mail it to: COSMOS Refunds 1355 S West Suite 100 Salt Lake City UT Prior authorization is required for all DME products. Durable Medical Equipment (DME) Billing If you are a supplier of DME products, please verify the appropriate billing source for your products. It is your responsibility to identify the skill level of the enrollee before the provision of services. This knowledge of the level of care provided will assure the appropriate party is billed for the services. Filing Corrected Claims 1. Submitting Corrected Claims by Mail: Complete the Adjustment Request Form below and submit completed form along with required documentation to: Evercare P.O. Box Salt Lake City, UT Submitting Corrected Claims at unitedhealthcareonline.com: Complete the UnitedHealthcare Claim Reconsideration request form, Check the appropriate reason for submission and attach required documents. orwardtoken=preloginmain Click on Claims and Payments > Choose Claim Reconsideration > Log In to complete the process. Evercare Health and Home Connection

39 ADJUSTMENT REQUEST FORM Physician or provider Name Evercare Number Billing Address Claim Information: Hospital/SNF Physician/Allied/Ancillary CLAIM/AUDIT NUMBER (One Adjustment Request Form per audit number) ENROLLEE NAME EVERCARE HEALTH AND HOME CONNECTION ENROLLEE ID NUMBER DATE (S) OF SERVICE Reason for adjustment request: Attach a copy of the physician and provider remittance advice (PRA) to expedite adjustment. Requested by: Phone Number: Date Send all adjustment requests to: Evercare P.O. Box Salt Lake City, UT ****Evercare Adjustment Department Use Only**** Adjustment Code: Amount: New Audit #: Comments: Adjusted By: Date: Evercare Health and Home Connection

40 Adjustment Request Form Instructions The physician or provider will complete the Adjustment Request Form for all partial payments or inappropriate denials. When completing the Adjustment Request form please be as specific as possible and include a copy of the Provider Remittance Advice along with the following information: 1. Physician or provider name 2. Physician or provider number 3. Physician or provider address 4. Appropriate type of service (Hospital/SNF or Physician/Allied/Ancillary) identified. 5. Claim audit number of original claim (from the Provider Remittance Advice). Use one Adjustment Request Form per audit number. 6. Enrollee Name 7. Evercare Health and Home Connection Enrollee ID Number 8. Date(s) of Service 9. Specific explanation of why payment was made inappropriately, including any clinical documentation as appropriate. 10. Appropriate contact name and phone number if there are questions 11. Record the date the Adjustment Request Form was prepared Adjustment request form must be mailed to the address on the document and also include a copy of the PRA to help expedite the adjustment. Evercare Health and Home Connection

41 How to Bill a UB04 This list contains the information required to process a claim on a UB04. Any missing/invalid data will result in the claim not being paid. Claim information must match authorization information. Field Name Physician or provider s name and address Box Description of information to provide Number 1 Name and Billing address Bill Type 4 3 digit type of bill Federal Tax ID 5 Facility Federal Tax ID Date of Service (start and end 6 From and To dates of services authorized date) Patient Name 12 Enrollee s Name Patient Address 13 Nursing Home Address Birth date 14 Enrollee s date of birth Sex 15 Enrollee s Gender Revenue Code* 42 Revenue Codes and HCPC codes (as required by contract) For 0360 revenue code please enter each surgery (0360 rev code) on its own line. Correct Example: Rev code dates units charges 0360 DOS 1 Total charge for that surgery 0360 DOS 1 Total charge for that surgery 0360 DOS 1 Total charge for that surgery Incorrect: 0360 DOS 3 Total charge for the 3 surgeries Description 43 Write in skilled level # as authorized. Therapy Discipline (OT, PT, ST) * Service as authorized HCPCS rates 44 Rates as determined in contract (Optional) Service Date 45 Service Dates (Optional) Evercare Health and Home Connection

42 Service Units 46 The number of days at the specific level. Total Charges 47 Total dollars for service dates Payer 50 Evercare DO NOT BILL MEDICAID Enrollee ID Digit Evercare Health and Home Connection Enrollee ID Number Procedure Codes ICD-9-CM diagnosis code and written diagnosis with 4 th and 5 th digit as required Physician or provider Name 82 Provider Name and Provider Number Evercare Health and Home Connection

43 How to Bill a HCFA 1500 This list contains the minimum amount of information required to process a claim on a HCFA Any missing/invalid data will result in the claim not being paid. Claim information must match authorization information. Field Name Box Description of information to provide Number Insured ID number 1a 16 Digit Evercare Health and Home Connection ID Number Name 2 Evercare Health and Home Connection Enrollee Name Patients Birth Date 3 Date of Birth and Gender Patients Address 5 Enrollees Address Origin of patients condition 10 Please select appropriate response (For Electronic claims only) Patients Authorization 12,13 Enrollees Authorization (Signature on File) Name of Referring Physician 17,17a Physician or provider Name and Provider number Outside lab 20 Please select if you are an outside lab provider Yes or No (For Electronic claims only) ICD-9-CM e ICD9 diagnosis codes and written diagnosis. Include the 4 th and 5 th digit specificity as appropriate Itemization of Services 24 Itemize the services provided to Evercare Health and Home Connection enrollee 24 a,b Dates of Service 24c Type of Service (For Electronic claims only) 24 d CPT or HCPCS codes, with modifier when applicable 24e ICD-9 Diagnosis Code- specific to the procedure with 4 th and 5 th digit specificity as appropriate 24 f Charges 24 g Days or Units Federal Tax ID number 25 Federal Tax ID number must match W9 submitted Patient account number 26 Patient account number or last name (For Electronic claims only) Accept Medicare Assignment 27 Should be Yes Total Charges 28 Total charges from column 24 f Physician Signature/Date 31 Physician or provider signature and date Evercare Health and Home Connection

44 Facility information 32 Address where services were rendered Physician or provider Name, Address and ID 33 Physician or provider name, payment address and 7 digit Evercare number ALL PAPER CLAIMS MUST BE SUBMITTED TO: Claim Submission Address Evercare P.O. Box Salt Lake City, UT DO NOT SUBMIT CLAIMS TO MEDICAID Claims submitted to Medicaid are denied and returned to you, delaying payment for services. ALL ELECTRONIC CLAIMS MAY BE SUBMITTED USING: EDI: Through a clearinghouse using payer ID 87726* Web: (HCFA 1500 claims only) *Please see Billing and Claims section for additional information concerning electronic submission of claims. Physician claims.... HCFA 1500 Ancillary claims.....hcfa 1500 Facility claims...ub04 Claims Forms Used Provider Remittance Advice A Provider Remittance Advice (PRA) is a summary of payments made on all claims processed. This statement is called an Explanation of Benefits (EOB) when it is sent to the Evercare Health and Home Connection enrollee. (An EOB is a statement sent to a covered person by the health plan listing services provided, amount billed, and the payment made. It is not a bill.) A PRA is issued for each unique physician or provider number for which a claim was paid/denied. A PRA is included with each check sent to a physician or provider. Evercare Health and Home Connection

45 The PRA provides the information needed to accurately post the payments received. See the PRA sample that follows in the next three pages. What information can be found on a PRA? The PRA is a patient-by-patient accounting of the amount billed, the amount disallowed (if any), as well as the amount paid. An amount disallowed is a denial for portions of the claimed amount. (Examples of amount disallowed: not-covered benefits or amounts over the fee maximum.) Patients are listed alphabetically by last name and identified by the physician or provider/facility s own in-house account number if this information was included on the original claim at the time of submission. Evercare sends payment to the address listed in Evercare s claim processing system. The claim form address must match either the place of service or the billing address listed in Evercare s claims processing system in order for the claim to be processed in a timely manner. Evercare Health and Home Connection

46 Remittance Advice Key 1. CHECK DATE: The date the check was issued 2. CHECK NO: The number of the check that was generated 3. AMOUNT: The total amount of the check 4. TAX ID NO: Provider s Federal Tax Identification number 5. PROVIDER/ALT PAYEE: The mailing name and address for the provider of alternate payee 6. PROV NO: 7-digit number identifying the provider 7. NAME: The name of the provider who performed the services 8. MEMBER: The name of the member receiving services 9. NUMBER: The 16 digit number for the member receiving services 10. ACCOUNT NO: Member s account number assigned by the provider and submitted on the claim 11. ADJUSTMENT: The word Adjustment is displayed on a separate line above the claim number if the claim was modified from the original. In addition to the word Adjustment, the original payment date is displayed if the claim was paid on a previous checkwrite 12. PCP NAME/NO: The member s Primary Care Physician name and number displays when applicable 13. CLAIM NO: The audit number assigned to the claim 14. DOS: Date of service - date the service was performed 15. PROC: The code identifying the procedure/service provided 16. U: The number of units for each detail line 17. CLAIMED: The total amount claimed for the procedure performed 18. COPAY: Amount that the member is required to pay for services 19. DEDUCT: Amount of deductible specified under the member s contract 20. INELIG MEM: Services that are not covered by the member s policy and are member responsibility (These are generally services not covered by Medicare) 21. INELIG PROV: Services that are not covered and are the provider responsibility 22. CODES: Reason codes that define any claim adjustments, disallows or denials. The code explanations are listed on the last page or end of the PRA. 23. DISCOUNT: Amount of discount defined within a provider s contract (Difference between claimed amount and contract rate - YOU MUST WRITE THIS OFF) 24. AMOUNT PAID: Net amount paid to the provider for services after all deductions have been taken 25. CLAIM TOTAL: The total dollars paid on the claim Evercare Health and Home Connection

47 Provider Remittance Advice Page 1 of 2 UNITED HEALTHCARE INSURANCE COMPANY CHECK DATE Ref # 0858 P.O. Box /13/1997 MSP B Minneapolis, MN CHECK NO. 3 AMOUNT a member of the United HealthCare Corporation family of services $ Sample Provider Medical Clinic TAX ID NO EverCare: a product of 123 Main Street United HealthCare Insurance Company Anytown, MN PROV NO NAME Sample Provider Medical Clinic UPIN NO. Plz Submit 8 MEMBER Doe, Jane 9 NUMBER ACCOUNT NO CLAIM No ICD9 DIAG PCP NAME GERIATRIC PHYSICIANS ASSOCIATION, INC. PCP NO DOS PROC U CLAIMED COPAY DEDUCT Inelig-mem Inelig-prov Code Discount Withhold Amount Paid 3/17/ CLAIM TOTAL DOS PROC U CLAIMED COPAY DEDUCT Inelig-mem Inelig-prov Code Discount Withhold Amount Paid PROVIDER TOTAL The Above Totals are included in Check # Evercare Health and Home Connection

48 PROVIDER REMITTANCE ADVICE Page 2 of 2 CODE DESCRIPTIONS CHECK DATE REF # /23/1997 MSP BR1 500 PROV NO NAME GERIATRIC PHYSICIANS ASSOCIATES, Inc. INELIGIBLE EXPLANATION CODES 32 CHARGES EXCEED FEE SCHEDULE Evercare Health and Home Connection

49 Physician and Provider Risk Arrangements Evercare is required to disclose their physician incentive arrangements to DOEA on request. The purpose of this disclosure is to allow DOEA to monitor those entities that hold their physicians and providers at substantial financial risk. In addition, Evercare is required to disclose to current and potential enrollees upon request information regarding physician incentive arrangements. Disclosed information will describe the plan s arrangements in general, but will not disclose incentive arrangements specific to any physician or physician group. Your cooperation is necessary for Evercare to comply with these DOEA requirements. Please respond promptly to our requests for information as required. Evercare Health and Home Connection is the secondary payor for: Coordination of Benefits Enrollees who have Medicare benefits Workers Compensation insurance Black lung benefits Automobile medical insurance No fault insurance Any liability insurance The enrollee may receive a request from Evercare for information about other insurance he/she may have. In no event will payment exceed 100 percent of billed charges or possible amount required by state regulation, after the primary carrier and Evercare have reached final claim disposition. Evercare Health and Home Connection

50 Appeals and Grievances Enrollee Appeals and Grievances Grievance Process If an enrollee has a concern or question regarding care or coverage under the plan, he/she should contact the Customer Service Department at the toll-free number on the back of their identification card, Monday through Friday. A customer Service Representative will answer questions or concerns. The representative will try to resolve the problem. If the customer Service Representative does not resolve the problem to the enrollee s satisfaction, he/she has the right to file a grievance. The enrollee may file a grievance in writing or by phone. It must be filed within one year from the date of the concern. It may be filed by you, with the enrollee s written consent. A grievance may be filed about such things as the quality of the care the enrollee receives from the Plan or a provider, rudeness from a Plan employee or a provider s employee, a lack of respect for their rights by the Plan or a provider or anything else the enrollee may be dissatisfied with. To file you or the enrollee may call Customer Service at or TDD Or write to: Appeals and Grievances National Service Center P.O. Box Tampa, Florida Or fax to: (Office hours 8:00am - 5pm, Monday - Friday) The Plan will send the enrollee a letter when the Plan receives the grievance. The Plan will send a decision letter usually within 60 days of receiving the request. In some cases, the Plan may need to ask for more information. Then it may take up to 90 days to issue a resolution letter. It will not take longer than 90 days. If the enrollee wants a Grievance Committee Hearing, he/she or their doctor, with the enrollee s written permission, may ask for it within 90 days after they receive the Plan s decision. If the enrollee needs assistance in filing his/her grievance or need the help of an interpreter, they may call the Customer Service number: Toll-free or the TDD The interpreter services are free. If the enrollee needs more time to get information, he/she may get up to 14 days more. If the Plan needs more time then it will tell the enrollee why in writing. The enrollee may also ask for a Medicaid Fair Hearing. The enrollee or his/her doctor with the enrollee s written permission, may ask for a hearing. To ask for a hearing write to: Office of Appeals Hearings 1317 Winewood Boulevard, Building 5 Rm 203 Tallahassee, Florida I. Appeals Process Evercare Health and Home Connection

51 If Evercare Health and Home Connection decides to reduce, put on hold or stop a service the enrollee is receiving he/she will get a written Notice of Action at least ten (10) days before the action takes place. If the enrollee does not agree, they may file an appeal. Or, they may have their provider file with the enrollee s written consent. II. Standard Appeal A Standard Appeal asks Evercare Health and Home Connection to review a decision about the enrollee s care. The enrollee must file an appeal within thirty (30) days after he/she gets notice of action. If the enrollee does not get a written notice from Evercare Health and Home Connection, the enrollee has one (1) year to file an appeal. The enrollee can ask their doctor, a family member or friend to file the appeal for them. If someone helps the enrollee file an appeal, that person must be the enrollee s authorized representative. To file an appeal, the enrollee or representative may fax a letter to: : (Office hours 8:00am - 5pm, Monday - Friday) Or mail it to: Appeals and Grievances National Service Center P.O. Box Tampa, Florida Or call or TDD The enrollee may also ask for a Medicaid Fair Hearing. The enrollee or his/her provider may ask with the enrollee s written consent. To ask for a hearing the enrollee may write to: Office of Appeals Hearings 1317 Winewood Boulevard, Building 5 Rm 203 Tallahassee, Florida If the enrollee calls, he/she must also send the appeal in writing. The review begins the day the Plan receives the request. The Plan will send a written notice to the enrollee within 5 days. Evercare Health and Home Connection has 45 days to look at the case. The Plan will send the enrollee a letter with the decision, explaining how the Plan made our decision. The Plan indicates the laws or health plan policies reviewed to decide the case. Before the Plan makes a decision, the enrollee and/or the person helping the enrollee with the appeal can give information to Evercare Health and Home Connection. The new information can be in writing or in person. The enrollee and his/her representative may look at the case file. The enrollee s estate representative may review the file after the enrollee s death. The file may have medical records or other papers. The enrollee can review his/her file any time while the Plan are reviewing the appeal. If the enrollee needs more time to get information, He/she may have it. The enrollee or the plan can request up to fourteen (14) calendar days. If the Plan asks for more time, it will send a letter informing the enrollee you why the Plan need the extra time. The enrollee may also ask for a Medicaid Fair Hearing while waiting for a decision from Evercare Health and Home Connection or within 90 days of the notice of action. The enrollee or a provider acting on the enrollee s behalf and with the enrollee s written consent may request a hearing. To request a Medicaid Fair Hearing, the enrollee should send a letter to: Evercare Health and Home Connection

52 Office Appeals Hearings 1317 Winewood Boulevard, Building 5 Rm 203 Tallahassee, Florida An enrollee may continue to receive services while waiting for the Plan s decision if all of the following apply; The appeal is filed on or before the effective date of the action The appeal is related to reduction, suspension or termination of previously authorized services The services were ordered by an authorized provider The authorization has not ended, and The enrollee requested the services to continue. The enrollee s services may continue until one (1) of the following happens The enrollee decides not to continue the appeal 10 days have passed or 15 if the request is sent by mail, from the date of the Notice of Action and the enrollee has requested a Medicaid Fair Hearing but did not request continuation of services The time covered by the authorization is ended or the limitations on the services are met. The enrollee may have to pay for the continued services if the final decision from the Medicaid Fair Hearing is against them. If the Medicaid Fair Hearing agrees with the enrollee, Evercare Health and Home Connection will pay for the services received while waiting for the decision. If the Medicaid Fair Hearing decision agrees with the enrollee and he/she did not continue to get the services while waiting for the decision, Evercare Health and Home Connection will issue a authorization for the services to restart as soon as possible and the Plan will pay for the services. If the decision from Evercare Health and Home Connection, the Medicaid Fair Hearing or the Subscriber Panel is in the enrollee s favor and the services were not continued during the reviews, Evercare Health and Home Connection will start the services and pay for them. III. Expedited Appeal An enrollee or their representative, with the enrollee s written consent, can request an Expedited Appeal. Expedited Appeals are for health care services, not denied claims. To ask for an Expedited Appeal the enrollee or their representative may call: The new information can be in writing or in person. The Plan will send a written decision within seventy-two (72) hours. If the enrollee needs more time to get information, he/she may ask for up to 14 more days. If the plan asks for more time, the Plan will let the enrollee know why in writing. If the Plan determines that taking more time to decide an appeal will be harmful to the enrollee, the Plan will notify the enrollee of the decision by phone and in writing within 2 days. Evercare Health and Home Connection

53 COMMENTS Evercare welcomes your comments and suggestions about this manual. If you need information about the material covered in this manual or expansion on topics not addressed or if you find incorrect or inaccurate information, please complete this form, and mail to: Evercare Provider Relations NW 12 th St Sunrise, Fl Comments and Recommendations Please provide the following information so we can contact you if we need to clarify your request. Evercare Health and Home Connection

54 Name: Address: Phone: Evercare Health and Home Connection