COVENTRY HEALTH CARE OF ILLINOIS, INC. COVENTRY HEALTH CARE OF MISSOURI, INC. Medical Management Policy and Procedure PROPRIETARY

COVENTRY HEALTH CARE OF ILLINOIS, INC. COVENTRY HEALTH CARE OF MISSOURI, INC. Medical Management Policy and Procedure PROPRIETARY Policy: On-Call Procedure Number: MM 1015 Date Effective: 6/17/11 Page: 1 of 5 Approved By: Utilization Management Committee Approval Date: 1/24/13 1/24/13 1/24/13 VP, Medical Affairs Date VP, Health Services Date Policy Review: 6/17/11 2/17/12 1/24/13 Policy Revisions: Replaces Illinois Policy #: UM 1300.13A Replaces Missouri Policy #: MM M-12 Applicable Health Plans: Coventry Health Care of Missouri, Inc. Coventry Health Care of Illinois, Inc. Policy and Procedure has been reviewed for compliance with all HIPAA policies and procedures Scope: This policy applies to Medical Management Staff taking on-call.

of 5 Purpose: To ensure the Health Plan s Members receive medically necessary care after business hours and access to all providers for continuous and effective assistance in providing the highest quality care in the most appropriate setting. Definitions: Term or Acronym GHP SNF QIO CHC-IL Definition Group Health Plan Skilled Nursing Facility Quality Improvement Organization Coventry Health Care of Illinois Policy: Medical Management Department will provide licensed healthcare professionals for after hour coverage from 5 p.m. to 8 a.m. weekdays and 24-hour coverage on weekends and holidays. The on-call nurse will provide assistance for discharge planning, home health care, preauthorization, fast track appeals for Medicare Advantra members who are in a Skilled Nursing Facility or an Acute Inpatient setting, utilization review issues and urgent care requests. For Coventry Health Care of Illinois, the on-call nurse will be paged through the CHC-IL Answering Service. For Coventry Health Care of Missouri, the on-call nurse is paged directly. Procedures: 1. On-call coverage must be provided by a licensed healthcare professional. 2. Nurses will be assigned one week of service. On-call assignments will be distributed to staff as well as the CHC-IL answering service. 3. Nurses are responsible for filing a Nurse On-Call Pay Calculation Sheet and turning it into their Director/Manager for reimbursement of on-call pay. 4. If the nurse is not able to fulfill his/her duties, it is his/her responsibility to find another nurse to cover that assignment. The nurse must also notify the Manager/Supervisors of Concurrent Review and Pre-authorization of the change in assignment, as well as the answering service for CHC-IL coverage. 5. On-call nurses must meet their department audit standards for documentation. On-call staff not meeting department audit stands may be removed from the on-call rotation.

of 5 6. Every Thursday afternoon the on-site Concurrent Review Coordinators should report potential weekend activities to the on-call nurse. 7. The nurse will maintain the On Call Master Log. The nurse will document all calls on the master log, and forward sheet to the Manager of Concurrent Review / Pre-authorization. 8. The nurse will follow-up with the concurrent review coordinators with information on any interventions completed while being on-call. 9. The nurse will have sole responsibility for all equipment in his/her possession during the time of services. This may include: laptop computer and accessories, cell phone and accessories, on-call pager and Master Logs. 10. The Medical Director will be accessible by cell phone for reviews and determinations. 11. The nurse on-call will be responsible on weekends, holidays and after business hours for coordinating responses to all Fast-track appeals following issuance of a Notice of Medicare Non-Coverage (SNF) and coordinating the Medicare Hospital Discharge Appeal process. Appeal requests will be received from the QIO. The nurse will contact the nursing facility, home health agency or hospital to obtain the member s complete medical record. If the medical record is not available due to the weekend or holiday a rescind notice must be completed and faxed to the facility/member. (See attachment) The on-call nurse will contact a supervisor, manager, or director of Medical Management if the response is required on a weekend or holiday; otherwise, the appropriate management staff will be notified the next working day after receipt of a Fast-track Appeal. 12. The on-call nurse may receive requests for expedited member appeals. The nurse will then page the member appeals representative responsible for processing expedited member appeals during non business hours. All information will be relayed to the member appeals representative for processing. Attachments: (2) For printing purposes, use the attached icons. For visual purposes, see documents below. MM 1015.01 MM 1015.02 On-Call Procedure M... RESCIND NOTIFICATIO...

of 5 MM 1015-01 ON CALL MASTER LOG DATE TIME CALLER ISSUE FOLLOW- UP NURSE

of 5 MM 1015-02 RESCIND NOTIFICATION [Date] RE: [Member Name]] [Member ID] [Facility Name] Dear [Member Name] This is to inform you that the Notice of Medicare Non Coverage issued to you on [date] has been rescinded (cancelled). Coventry Health Care of Missouri, Inc. will continue to cover your skilled nursing facility stay until further notice. Sincerely, Medical Management Department I acknowledge that I have received the Rescind Notice issued on [date] by Coventry Health Care. Signature of Medicare Enrollee or Authorized Representative Date Please Fax Copy of Signed Rescind Notice to Coventry Health Care at 866-603-5531. H2663/Letter/05093 NOMNC Rescind Letter Submitted to CMS 07/22/05 CMS Approved: 07/29/05 A Coordinated Care Plan with a Medicare Advantage contract