Provider Materials. 1 Campus Martius, Suite 700 Detroit, MI Phone: Fax:

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1 Provider Materials 1 Campus Martius, Suite 700 Detroit, MI Phone: Fax:

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3 ABOUT MERIDIAN 4 SERVICE AREA 6 PROVIDER NETWORKS 7 PLAN OPTIONS 8 ENROLLING 10 CLAIMS 11 MEMBER ENGAGEMENT 12 PROVIDER MANUAL 15 PHARMACY BENEFITS 15 REFERRAL PRE-SERVICE CLINICAL REVIEW 16 REFERRAL GUIDE 17 REFERRAL FORM 19 FRAUD, WASTE & ABUSE 20 QUICK REFERENCE/CONTACT INFORMATION 23 PAGE 3

4 ABOUT MERIDIAN Our Mission To continuously improve the quality of care in a low resource environment Our Visions To be the premier service organization in healthcare To be the #1 health plan in Michigan based on quality, innovative technology and service to our Meridian Family Corporate History Meridian was formed from the merger of two plans, Central Michigan Health Plan (CMHP) and American Preferred Provider Plan of Michigan (APPPM). In August 1997, Dr. David B. Cotton acquired a majority position in CMHP and assumed fiscal and administrative responsibility for the plan, which had approximately 1,400 members. CMHP acquired APPPM in January 1999 and ultimately became operational as Health Plan of Michigan (HPM) in May Operation as a full service HMO since January 2000, HPM obtained National Committee for Quality Assurance (NCQA) accreditation in May 2002 and URAC accreditation in March On January 1, 2012, Health Plan of Michigan became Meridian Health Plan. The name change represents Meridian s expanding horizons, yet the plan remains a physician-owned and physician-managed health plan. Recognizing the opportunities for expansion with the passage of the Affordable Care Act, MeridianChoice was established as a qualified health plan listed in the federal Health Insurance Marketplace. Offering both individual and family plan options in southeast and southwest parts of Michigan. MeridianChoice began operation in 2014, bringing its extensive experience from the Michigan Medicaid market. PAGE 4

5 ABOUT MERIDIAN NCQA Excellence Meridian brings its nationally recognized quality health plan and services to the Marketplace. Meridian Health Plan of Michigan, Inc. and Meridian Health Plan of Illinois, Inc. are rated among the top Medicaid plans in Michigan and Illinois according to the National Committee for Quality Assurance s (NCQA) Medicaid Health Insurance Plan Ratings Meridian Health Plan of Michigan, Inc. is one of the top-rated Medicaid plans in Michigan with an overall rating of 4 out of 5. It was also rated 4 out of 5 for both consumer satisfaction and prevention. Meridian Health Plan of Illinois, Inc. is one of the top-rated Medicaid plans in Illinois with an overall rating of 3.5 out of 5. Additionally, it was rated 4 out of 5 for prevention. These ratings are among the highest for each state. Meridian was recognized by NCQA for being the top Medicaid HMO in Michigan and Illinois, along with both HMOs earning top 10 rankings nationally. Meridian Health Plan of Michigan, Inc. was ranked 9 and Meridian Health Plan of Illinois, Inc. was ranked 10. NCQA is the most widely recognized accreditation program in the United States. Their commitment to comprehensive research and dedication to quality has helped improve the managed care experience for health plans, patients care providers and employers. To learn more about NCQA and its accreditation standards, please visit Service Description MeridianChoice is a qualified health plan listed on the Health Insurance Marketplace. Together, MeridianChoice offers four plan options through the Marketplace. All plans offer services in the 10 Essential Health Benefits (EHB) categories, including: Outpatient care Trips to the emergency room Treatment in the hospital for inpatient care Care before and after birth Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy Prescription drugs Services and devices to help members recover if they are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and more Lab tests Preventive services including counseling, screenings, and vaccines to keep members healthy and care for managing a chronic disease. Pediatric services: This includes dental care and vision care for kids PAGE 5

6 SERVICE AREA PROVIDER NETWORK DEVELOPMENT REPRESENTATIVES Jackie DuPuy Manager Kristen Michels Manager TBD Manager Erica D Ambrosio Genesee & Lapeer Amanda Gherardini Oakland Laura Godzwon Wayne Melissa Kuiper Allegan Alexandra Leas Oakland Christian Nienhaus Macomb Jennifer Peyerk Macomb Anne Marie Salliotte Kalamazoo & Van Buren TBD Calhoun and Hillsdale Emmet Cheboygan Presque Isle Charlevoix Otsego Antrim Leelanau Crawford Benzie Grand Kalkaska Traverse Montmorency Oscoda Alpena Alcona Manistee Wexford Missaukee Roscommon Ogemaw Iosco 2017 Service Area Expansion 2016 Service Area Not Covered Mason Oceana Muskegon Arenac Clare Gladwin Lake Osceola Bay Isabella Midland Mecosta Newaygo Saginaw Montcalm Gratiot Tuscola Huron Sanilac* Ottawa Kent Ionia Clinton Shiawassee Genesee Lapeer* St. Clair Allegan Barry Eaton Ingham Livingston Oakland* Macomb* Van Buren Kalamazoo Calhoun* Jackson Washtenaw Wayne Branch Berrien Cass St. Joseph Hillsdale Lenawee Monroe *Partial Counties: Calhoun, Lapeer, Macomb, Oakland and Sanilac PAGE 6

7 PROVIDER NETWORKS MeridianChoice s provider network services both southeast and southwest areas in Michigan. MCHO MI Subscriber Subscriber Name: Subscriber ID: DOB: Dependents Plan ID: MCHO MI Effective Date: Member Services: RxBIN: RxPCN: MRXMIMCH Prescriptions: MCHO MI Member Name: Member ID: DOB: Plan ID: MCHO MI Effective Date: Member Services: RxBIN: RxPCN: MRXMIMCH Prescriptions: PAGE 7

8 PLAN OPTIONS MeridianChoice is proud to be a reliable resource for people trying to understand Health Care Reform. With many plan options to meet health needs and budget, MeridianChoice gives our members the chance to take advantage of Health Care Reform programs. All of our health plans have comprehensive provider networks, allowing our members to get the right care at the right time by the right provider. Most importantly, MeridianChoice plans meet the minimum essential benefits and provide free preventive health care. CATASTROPHIC PLAN For individuals and families who want the lowest monthly premium for coverage Covered for three primary care visits per plan year, but you will pay for all other care out-of-pocket until the deductible is met Catastrophic plans provide protection from medical costs related to catastrophic illness or injury Only people under 30 years old or those who are eligible for a hardship exemption through the Marketplace can enroll in a Catastrophic plan HEALTHY BRONZE PLAN For individuals and families wanting to keep costs low from month-to-month while keeping reasonable coverage Low monthly premiums means out-of-pocket expenses (deductible, copayment, coinsurance) may be high Healthy Bronze plans offers lower, competitive premium rates, making us one of the lowest priced options STANDARD SILVER, SMART SILVER AND HEALTHY SILVER PLAN For individuals and families looking to save money with a reduced monthly premium While monthly premiums are moderately priced, out-of-pocket expenses (deductible, copayment, coinsurance) may be higher when you get care than it is for Gold plans Healthy Silver plans offer the same great coverage as our Silver plans at a lower, competitive premium rate, making us one of the lowest priced options HEALTHY GOLD PLAN For individuals and families who want to balance monthly premium costs and other household expenses These plans have high monthly premium and reasonable out-of-pocket expenses (deductible, copayment, coinsurance) Healthy Gold plans offers lower, competitive premium rates, making us one of the lowest priced options PAGE 8

9 PLAN OPTIONS ADVANCED PREMIUM TAX CREDITS Part of the Affordable Care Act (ACA) grants an Advanced Premium Tax Credit (APTC) to those who qualify. Eligibility for the APTC tax credit is determined through the Centers for Medicare and Medicaid Services (CMS). Members who are designated as APTC eligible can select plans that offer lower premiums. Non-APTC members do not qualify for the tax credit and are not eligible for the APTC. If APTC members miss a premium payment, they have a three-month grace period to pay what they owe. Non-APTC members who miss paying their premium only have a standard 30-day grace period to pay their premium in full. If either type of members do not pay their premiums, they will lose coverage and will be responsible for payment of healthcare services received after the last day of the last month the premium was paid. MeridianChoice will send you notices when one of your patients has missed a premium payment. If you receive a notification and the member presents in your office, please encourage the member to pay their premium as soon as possible so health coverage is not lost. COST-SHARING REDUCTIONS In addition to tax credits to help with premium payments, the ACA established cost-sharing reductions to help with other health-related costs. A cost-sharing reduction is a discount that lowers the amount a member has to pay out-of-pocket for deductibles, coinsurance and copayments. This reduction is available if a member gets health insurance through the Marketplace, has an income between % of the federal poverty level and selects a Silver level plan. Members of federally recognized tribes (e.g. Native Americans, Alaskan Native) may qualify for additional cost-sharing benefits. PAGE 9

10 ENROLLING Now everyone has access to affordable care with Health Care Reform. It may seem complicated, but MeridianChoice is here to help. Whether you have patients looking for an individual or family plan, MeridianChoice has a plan that fits their needs and budget. Our unique plan options, unsurpassed quality care and personalized service to members make MeridianChoice the best choice for health insurance. Member can enroll in MeridianChoice during annual open enrollment by: 1. Visiting to sign up directly through us 2. Visiting to enroll through the Marketplace 3. Working with an Enrollment Broker near them 4. Calling MeridianChoice at Key Enrollment Dates November 1, 2016: Open enrollment for 2017 begins December 15, 2016: Last day to enroll and have coverage starting January 1, 2017 December 31, 2016: Coverage ends for this year January 1, 2017: First day for 2017 coverage January 31, 2017: Open enrollment ends for 2017, except under special circumstances Special Enrollment Periods Life can change quickly. There are some situations when patients can still enroll in a plan after open enrollment ends. Some examples of these qualifying events include: Losing minimum essential coverage A change in eligibility or enrollment in another qualified health plan Gaining or becoming a dependent (birth, marriage, divorce) Member of a federally recognized American Indian or Alaska Native tribe Legal status in the United States changes Eligibility for premium tax credit changes Eligibility for cost sharing reduction changes Who Can Purchase a Plan? MeridianChoice plans only appear as an option to those living in our service area (see page 4). If eligible for any public insurance program like Medicare, Medicaid or Military insurance, a MeridianChoice plan cannot be purchased. Depending on the plan selected, family or others in your household may also be covered. MeridianChoice offers family plans in addition to individual coverage. PAGE 10

11 CLAIMS Payments, Status & Billing Visit Meridian s is dedicated to processing your claims in under 10 days. You may status your claims several ways: Meridian s secure Provider Portal at Call or fax our Claims department Tel: Fax: Send by By Mail: Meridian ATTN: Appeals Department P.O. Box Detroit, MI FAST CLAIMS PROCESSING Average claims processing time - 3 days Claims Appeals Process In cases where a claim has been denied, providers may submit an appeal in writing within 30 days of the denial. Please include the following: Patient name and ID# number Reason for appeal Any relevant clinical information to support your appeal The Meridian Appeals Committee meets regularly to review these appeals. You will receive a written response within 30 days. EDI Submission Meridian currently accepts EDI from all of our providers through the following vendors: SSI Group: Payer ID: Availity: Payer ID: PayerPath: Payer ID: Relay Health: Payer ID: WebMD (Emdeon): Payer ID: Blue Cross Blue Shield MI Payer ID: Special instructions: PROFESSIONAL PIN must be the NPI #. FACILITY Use the NPI # for provider ID (locator 51), attending physician ID (Locator 82) and the other physician ID (Locator 83). Claim Billing Requirements Facility UB04 Professional CMS 1500 Laboratory CMS 1500 PAGE 11

12 MEMBER ENGAGEMENT As part of the enrollment process, Meridian utilizes claims data and various risk assessments to automatically enroll members in outreach programs that meet their level of need. Providers can refer members to the Disease Management, Care Coordination or Complex Case Management programs as needed by: Clicking the Notify Health Plan button on our Provider Portal Calling Meridian at Faxing the Care Coordination/Complex Case Management Referral Form to Meridian. This form can be found online at in the Documents and Forms section Member Welcome Call Claims Data Risk Assessments Stratification Low Medium High Health Outreach Program Care Coordination Program Complex Case Management Program Disease Management Program (included at all stratifications) Preventive Care Reminders (phone and mail based) and Condition-Specific Education Program Descriptions Health Outreach Program Low Intervention Level Periodic outreach, as applicable, to remind members of important preventive services such as well visits and important screenings. Disease Management Program Low Intervention Level + Self- Management Needs Available to all eligible members. Includes education for the following conditions: Asthma Diabetes Emphysema/COPD Congestive Heart Failure PAGE 12

13 MEMBER ENGAGEMENT Care Coordination Program Medium Intervention Level Meridian s Care Coordination program uses interdisciplinary approaches to focus on members (and their families) that have special health care, community support, facility services and behavioral health needs. Coordinated efforts link members with needed services and resources to achieve: Better access Skilled navigation through the complex health care and community supports system Increased self-management and self-advocacy skills A member s personal Care Coordinator works with clinical and non-clinical consultants to arrange the right care at the right time for all services, including home and community based (HCBS), nursing and other facility services. Care Coordination Program The Care Coordinator collaborates with the member, his/her family and the member s care team to create a tailored person-centered plan of care. This plan of care includes: A personal health record Problems, life goals and outcomes HCBS service plan summary authorization (if applicable) The plan of care is developed by tailoring to the member s specific preferences and needs, delivering service with transparency, individualization, respect, linguistic and cultural competence, quality care, quality of life and dignity. THE CARE COORDINATOR IS THE MEMBER S SINGLE POINT OF CONTACT. INTEGRATED CARE TEAM MEMBER & FAMILY C A R E C O O R D I N AT O R (clinical & non- clinic al) PAGE 13

14 MEMBER ENGAGEMENT Care Coordination Program Depending upon member population, specialized subprograms may include: Adults and Children with Special Needs Behavioral Health High ER Utilizers Home and Community-Based Waiver Programs, Nursing and other Facility Care Maternity (all members) Medicare Smoking Cessation Weight Management Long Term Services & Supports (LTSS) Program A more specialized form of Care Coordination, the Meridian LTSS Program is for members who are eligible for Home and Community Based Service (HCBS) waiver programs or the Nursing Facility program. Key strategies to improving the well-being of members in this program include: Avoiding hospital re-admission Assisting members in returning to or remaining in the residence of their choice (including home and community) Increasing quality of life Complex Case Management Program High Intervention Level Using the same consultant resources as Care Coordinators, Case Managers provide more intensive counseling and management to high-risk members. These members often have multiple, serious comorbidities. Members have the option to accept or decline Complex Case Management for their care; it is not a requirement. PAGE 14

15 PROVIDER MANUAL MeridianChoice would like to inform our providers about the availability of the Provider Manual. The Provider Manual offers detailed information about Meridian s policies and procedures and the rights and responsibilities of our providers and members. You can access the Provider Manual by: Downloading it from the MeridianChoice website located at Requesting a CD version or a printed copy from your Provider Network Development Representative PHARMACY BENEFITS MeridianChoice uses MeridianRx to manage our pharmacy benefit. MeridianRx provides MeridianChoice with a pharmacy network, pharmacy claims management services, a drug formulary and pharmacy claims adjudication. Member eligibility is determined prior to authorizing any drug benefit. eprescribring - allows for accurate, error-free electronic submissions of prescriptions to pharmacies MeridianRx Specialty Pharmacists and clinical staff assist providers in prescribing appropriate medications based on efficiency and cost control. Consumers receive friendly, clinically-accurate support: Encouraging the taking and/or administration of medications as prescribed Managing any medication side effects Monitoring symptoms and responses to therapy Counseling on health conditions Coordinating new and refill prescriptions Working with insurers to verify benefits For more information, visit Comprehensive drug formulary and licensed pharmacists are available through MeridianRx for consultation PAGE 15

16 REFERRAL PRE-SERVICE CLINICAL REVIEW Referrals Referral processing is the primary activity performed by our Utilization Management Specialist staff. If you have a referral request or question, please contact us. We are glad to help you. Meridian offers three easy ways to submit referrals: 1. Electronically through Meridian s secure Provider Portal 2. By fax Refer to Utilization Management s referral type fax numbers. Please include pertinent clinical documentation with the request if indicated 3. By phone for urgent * requests. Urgent requests must always be submitted by calling the team based on the request type. Make sure you identify the request as urgent to expedite the pre-service review process *According to NCQA, an Urgent Request is a request for medical care or services where application of the time frame for making routine or non-life threatening care determinations could seriously jeopardize the life, health or safety of the member or others, due to the member s psychological state OR in the opinion of a practitioner with knowledge of the member s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. Pre-Service Clinical Review Program Meridian clinical staff must review select services before they are provided. Clinical review assists in determining whether the service is clinically appropriate, is performed in the appropriate setting and is a covered benefit. Please forward the pertinent clinical information with your request via fax or the secure Meridian Provider Portal services to expedite a response. Refer to the MeridianChoice Referral Guide for services that require clinical review. Utilization Management clinical staff use plan documents for benefit determination and Medical Necessity Coverage Guidelines to support Utilization Management decision-making. All utilization review decisions to deny coverage are made by Meridian s Medical Directors. In certain circumstances, external reviews of service requests are conducted by qualified, licensed physicians with the appropriate clinical expertise. PAGE 16

17 REFERRAL GUIDE MeridianChoice Referral Guide PRIOR AUTHORIZATION IS REQUIRED FOR THE FOLLOWING SERVICES: Acute Inpatient Admissions (Including Acute Rehab and LTAC) Inpatient Mental Health and Substance Abuse Enteral and Parenteral Services Genetic Testing Skilled Nursing Facility Partial Hospitalization Intensive Outpatient Program Electro Convulsive Treatment Elective Inpatient Admissions Behavioral Health Outpatient Services Ambulance Transportation Non-Emergent Elective Cesarean Sections Chemotherapy Dialysis Prenatal Care Deliveries Dental Anesthesia in Facility >6 years of age DME In-Network and Out-of-Network DME Rentals Assistive and Augmentive Communication Podiatric Visits/Services All other Services provided by an In-Network Specialist + Experimental & Investigational Procedures Sterilization Procedures Hearing Aids Home Health Care Hospice Care Home Infusion Orthotics and Prosthetics Outpatient Surgeries & Procedures* PT/OT/ST(excluding initial evaluation) Pulmonary and Cardiac Rehabilitation Pain Management Chiropractic Services Specialty Pharmacy (Subject to Formulary) Radiation Therapy Transplants Nutritional Counseling Wound Vac All Services by an Out-of-Network Provider/ Facility+ Diagnostic Testing/Imaging +Excludes emergency department services, women s health, family planning & obstetrical services, child & adolescent health center services, local health departments, other services based on State requirements PAGE 17

18 REFERRAL GUIDE Phone All Authorizations Fax Behavioral Health Services Plan Phone Fax MeridianChoice Case Management: Claims Plan Phone Fax All Plans Diabetic Testing Supplies Plan Phone Fax MeridianChoice Healthy Living Medical Supply is the exclusive vendor Healthy Living Medical Supply is the exclusive vendor Pharmacy PA Requests Plan Phone Fax MeridianChoice Provider Services Plan Phone Fax MeridianChoice The prior authorization process is easy and provides faster decision making and turnaround time. To submit an authorization go to our website, and select Prior Auth Fax Form under Provider Tools. Meridian will no longer accept previously utilized PA forms. If you have any questions, please contact Meridian Provider Services or your local Provider Network Development Representative. PAGE 18

19 REFERRAL PRE-SERVICE CLINICAL REVIEW PAGE 19

20 FRAUD, WASTE & ABUSE Healthcare fraud, waste and abuse (FWA) affect every one of us. It is estimated to account for between 3% and 10% of the annual expenditures for health care in the U.S. Healthcare fraud is both a state and federal offense. Based on the HIPAA regulations of 1996, a dishonest provider or member may be subject to fines or imprisonment of not more than 10 years, or both (18USC, Ch. 63, Sec 1347). THE FOLLOWING ARE THE OFFICIAL DEFINITIONS OF FRAUD, WASTE AND ABUSE: 42 CFR Definitions. Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Waste involves the taxpayers not receiving reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by players with control over or access to government resources (e.g. executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight from the Inspector General. Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the healthcare system, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the healthcare system. HERE ARE SOME EXAMPLES OF FRAUD, WASTE AND ABUSE: Fraud Providers billing for services not provided Providers billing for the same service more than once (i.e., double billing) Providers performing inappropriate or unnecessary services The misuse of a Member ID card to receive medical or pharmacy services Altering a prescription written by a doctor Waste & Abuse Going to the Emergency Room for non-emergent medical services Threatening or abusive behavior in a doctor s office, hospital or pharmacy PAGE 20

21 FRAUD, WASTE & ABUSE MeridianChoice encourages members, providers and employees to report all cases of fraud, waste and abuse. If you know of any members or providers, including doctors, hospitals and pharmacies, who have committed actions of fraud, waste or abuse, you can report them using the process described below. You may report them anonymously if you choose. TO REPORT POTENTIAL FRAUD, WASTE AND ABUSE: Contact MeridianChoice s Provider Services department at Ask to speak with the Director of Provider Services. You can explain details of the possible fraud, waste or abuse; MeridianChoice will investigate and file a report with the Office of the Inspector General, if necessary. Meridian members, providers or employees can also report potential instances of fraud, waste and abuse directly to the State of Michigan at the following address. You can report anonymously if you choose. Office of Inspector General PO Box Lansing, MI Phone: 855-MI-FRAUD ( ) Meridian members, providers or employees can also report potential fraud, waste or abuse anonymously in writing to MeridianChoice at the following address: Compliance Officer MeridianChoice 1 Campus Martius, Suite 700 Detroit, MI Phone: Fax: fwa.mi@mhplan.com PAGE 21

22 FRAUD, WASTE & ABUSE THE FALSE CLAIMS ACT The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government s damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud. The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a qui tam case, but it is more commonly referred to as a whistleblower case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer. For more information on the False Claims Act, please contact the MeridianChoice Corporate Compliance Officer at ANNUAL TRAINING PROGRAM MeridianChoice follows the CMS guidelines to deliver the appropriate educational pieces to our provider network. Together, we can achieve outstanding quality and increased value in the care provided to our members. Fraud, Waste & Abuse Our FWA training module assists providers in participating in fraud, waste and abuse prevention and detection. CMS requires the completion of FWA training by all MeridianChoice network providers on an annual basis. Cultural Competency Our cultural competency training provides important information to support providers in caring for our members. PAGE 22

23 QUICK REFERENCE/CONTACT INFORMATION DEPARTMENT PHONE FAX Member Services Provider Services MeridianRx (PBM) Behavioral Health Claims Utilization Management Quality Improvement WEBSITES PAGE 23

24 Provider Orientation December 2016