Welcome To CeltiCare Health Plan of Massachusetts

Transcription

1 Welcome To CeltiCare Health Plan of Massachusetts CeltiCare Health Plan of Massachusetts (CeltiCare) is a managed care organization (MCO) contracted with the Massachusetts Commonwealth Health Insurance Connector Authority (Connector Authority) to serve Commonwealth Care members. CeltiCare has the expertise to work with Commonwealth Care members to improve their health status and quality of life. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. CeltiCare works to accomplish this goal by partnering with the primary care providers (PCP) who oversee the healthcare of CeltiCare members. Celtic Group, Inc., parent company of CeltiCare, has been providing health insurance to individuals for more than 30 years and is backed by its parent company, Centene Corporation (Centene). For 25 years, Centene has provided comprehensive managed care services to individuals receiving benefits under Medicaid and other governmentsponsored healthcare programs. The Company operates local health plans and offers a wide range of health insurance solutions to individuals and the rising number of uninsured Americans. It also contracts with other healthcare and commercial organizations to provide specialty services. CeltiCare is a physician-driven organization that is committed to building collaborative partnerships with providers. CeltiCare will serve our Massachusetts members consistent with our core philosophy that quality healthcare is best delivered locally. Headquartered in the greater Boston area, any CeltiCare employee that works with members, providers or regulators will be based in Massachusetts. CeltiCare has been designed to achieve the following goals: Ensure access to primary and preventive care services Ensure care is delivered in the best setting to achieve an optimal outcome Improve access to all necessary healthcare services Encourage quality, continuity and appropriateness of medical care Provide medical coverage in a cost-effective manner At CeltiCare, we strive to provide our members with improved health status, outcomes and member and provider satisfaction in a managed care environment. All of our programs, policies and procedures are designed with these goals in mind. We hope that you will assist CeltiCare in reaching these goals and look forward to your active participation.

2 Table of Contents WELCOME TO CELTICARE HEALTH PLAN OF MASSACHUSETTS...1 CELTICARE GUIDING PRINCIPLES... 5 CELTICARE APPROACH... 5 CELTICARE SUMMARY... 5 CELTICARE OF MASSACHUSETTS AT A GLANCE... 6 IVR SYSTEM... 7 WEBSITE... 7 PROVIDER RESPONSIBILITIES...8 PRIMARY CARE PROVIDER (PCP)... 8 COVERED PCP SERVICES... 8 PCP AVAILABILITY... 9 PCP ACCESSIBILITY HOUR ACCESS PCP COVERAGE PCP APPOINTMENT ACCESS STANDARDS TELEPHONE ARRANGEMENTS PCP TO PCP REFERRALS SELF-REFERRALS MEMBER PANEL CAPACITY PROVIDER TERMINATION OTHER PCP RESPONSIBILITIES SPECIALIST RESPONSIBILITIES SPECIALIST APPOINTMENT ACCESS STANDARDS HOSPITAL RESPONSIBILITIES ADVANCE DIRECTIVES PROVIDER ASSISTANCE WITH PUBLIC HEALTH SERVICES CULTURAL COMPETENCY...17 CULTURAL COMPETENCY OVERVIEW NEED FOR CULTURALLY COMPETENT SERVICES CULTURAL COMPETENCY DEVELOPMENT INTERPRETIVE AND TRANSLATION SERVICES MEDICAL RECORDS...20 MEDICAL RECORDS REQUIRED INFORMATION MEDICAL RECORDS RELEASE MEDICAL RECORDS TRANSFER FOR NEW MEMBERS MEDICAL RECORDS AUDITS MEDICAL MANAGEMENT...23 OVERVIEW AND MEDICAL NECESSITY SERVICES REQUIRING CELTICARE AUTHORIZATIONS COVERED SERVICES PLAN TYPE I...38 PLAN TYPE II...39 PLAN TYPE III...40 COMMONWEALTH CARE BRIDGE...42 CELTICARE CASE/CARE MANGEMENT SERVICES CONTINUITY OF CARE CELTICARE MEMBERCONNECTIONS PROGRAM

3 VALUE ADDED BENEFITS FOR CELTICARE MEMBERS NURSEWISE START SMART FOR YOUR BABY DOMESTIC VIOLENCE CELTICARE DISEASE MANAGEMENT PROGRAMS ASTHMA PROGRAM DIABETES PROGRAM CLINICAL PRACTICE GUIDELINE ROUTINE, URGENT...51 AND EMERGENCY SERVICES...51 NON-SYMPTOMATIC, SYMPTOMATIC NON-URGENT, URGENT AND EMERGENCY CARE SERVICES DEFINED 51 ELIGIBILITY AND ENROLLMENT...53 ELIGIBILITY FOR CELTICARE VERIFYING ENROLLMENT NEWBORN ENROLLMENT NON-COMPLIANT MEMBERS...55 NON-COMPLIANT MEMBERS BILLING AND CLAIMS...56 GENERAL BILLING GUIDELINES ELECTRONIC CLAIMS SUBMISSION PAPER CLAIMS SUBMISSION EFT AND ERA IMAGING REQUIREMENTS CLEAN CLAIM DEFINITION NON-CLEAN CLAIM DEFINITION WHAT IS AN ENCOUNTER VERSUS A CLAIM? PROCEDURES FOR FILING A CLAIM/ENCOUNTER DATA COMMON BILLING ERRORS CLAIM PAYMENT UNSATISFACTORY CLAIM PAYMENT BILLING FORMS THIRD PARTY LIABILITY COMPLETING A CMS 1500 FORM CMS 1500 STANDARD PLACE OF SERVICE CODES COMPLETING A UB 04 CLAIM FORM UB 04 INPATIENT DOCUMENTATION UB 04 HOSPITAL OUTPATIENT CLAIMS/AMBULATORY SURGERY BILLING THE MEMBER MEMBER ACKNOWLEDGEMENT STATEMENT CREDENTIALING...64 CREDENTIALING REQUIREMENTS CREDENTIALING COMMITTEE RE-CREDENTIALING RIGHT TO REVIEW AND CORRECT INFORMATION RIGHT TO APPEAL ADVERSE CREDENTIALING DETERMINATIONS QUALITY IMPROVEMENT...67 QUALITY IMPROVEMENT PROGRAM PROGRAM STRUCTURE PRACTITIONER INVOLVEMENT QUALITY IMPROVEMENT PROGRAM SCOPE AND GOALS PERFORMANCE IMPROVEMENT PROCESS HEALTH EMPLOYER DATA INFORMATION SET (HEDIS)

4 PROVIDER SATISFACTION SURVEY CONSUMER ASSESSMENT OF HEALTHCARE PROVIDER SYSTEMS (CAHPS) SURVEY PROVIDER PROFILING AND INCENTIVE PROGRAMS WASTE ABUSE AND FRAUD (WAF) SYSTEM AUTHORITY AND RESPONSIBILITY MEMBER SERVICES...74 MEMBER SERVICES MEMBER MATERIALS MEMBER RIGHTS & RESPONSIBILITIES MEMBER RIGHTS...75 MEMBER RESPONSIBILITIES...77 MEMBER SATISFACTION INTERNAL INQUIRY PROCESS INTERNAL GRIEVANCE PROCESS HOW TO FILE A GRIEVANCE MEMBER SHOULD INCLUDE: INTERNAL APPEAL PROVIDER RELATIONS ASSISTANCE...85 PROVIDER RELATIONS DEPARTMENT PROVIDER UPDATES PROVIDER COMPLAINTS PHARMACY...87 CELTICARE PHARMACY PROGRAM

5 CELTICARE GUIDING PRINCIPLES High quality, accessible, cost-effective member healthcare Integrity, operating at the highest ethical standards Mutual respect and trust in our working relationships Communication that is open, consistent and two-way Diversity of people, cultures and ideas Innovation and encouragement to challenge the status quo Teamwork and meeting our commitments to one another CeltiCare allows open provider/member communication regarding appropriate treatment alternatives. CeltiCare does not penalize providers for discussing medically necessary, appropriate care or treatment options with the members. CELTICARE APPROACH Recognizing that a strong health plan is predicated on building mutually satisfactory associations with providers, CeltiCare is committed to: Working as partners with participating providers Demonstrating that healthcare is a local issue Performing its administrative responsibilities in a superior fashion All of CeltiCare programs, policies and procedures are designed to minimize the administrative responsibilities in the management of care, enabling the provider to focus on the healthcare needs of their patients, our members. CELTICARE SUMMARY CeltiCare s philosophy for Massachusetts Commonwealth Care members is to provide access to high quality, culturally sensitive healthcare services by combining the talents of PCPs and specialty providers with a highly successful, experienced managed care administrator. CeltiCare believes that successful managed care is the delivery of appropriate, medically necessary services, rendered in the appropriate setting - not the elimination of such services. It is the policy of CeltiCare to conduct its business affairs in accordance with the standards and rules of ethical business conduct and to abide by all applicable federal and Massachusetts laws. CeltiCare takes the privacy and confidentiality of our members health information seriously. We have processes, policies and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Massachusetts privacy law requirements. If you have any questions about CeltiCare privacy practices, please contact our Privacy Officer at

6 CELTICARE OF MASSACHUSETTS AT A GLANCE For your ease, we have included this reference guide to assist you in the day-to-day operations of your office. CELTICARE 1380 SOLDIERS FIELD ROAD BRIGHTON, MA DEPARTMENT TELEPHONE NUMBER FAX NUMBER Provider Services/Claims Member Services (TDD/TTY) Case Management Prior-Authorization Pregnancy Notification (Prior-auth) NurseWise (option 7) N/A (24/7 Availability) Cenpatico Behavioral Health Pharmacy-Caremark (Specialty (help desk) (prior auth) Drugs) CareCentrix N/A US Script (prior auth) SUBMIT PAPER CLAIMS TO: CELTICARE HEALTH PLAN OF MASSACHUSETTS Attn: Claims PO Box 3080 Farmington, MO SUBMIT APPEALS RE: PLAN UTILIZATION MGT DECISIONS CELTICARE HEALTH PLAN OF MASSACHUSETTS Attn: Utilization Mgt 1380 SOLDIERS FIELD ROAD BRIGHTON, MA SUBMIT PHARMACY CLAIMS TO: US SCRIPT PBM 2425 W. SHAW AVE FRESNO, CA SUBMIT BEHAVIORAL HEALTH CLAIMS TO: CENPATICO BEHAVIORAL HEALTH Attn: Claims PO Box 7200 Farmington, MO SUBMIT MEDICAL CLAIM DISPUTES TO: CELTICARE HEALTH PLAN OF MASSACHUSETTS Attn: Claim Disputes PO Box 3000 Farmington, MO ELECTRONIC CLAIMS SUBMISSION CELTICARE HEALTH PLAN OF MASSACHUSETTS c/o Centene EDI Department , ext or by to: EDIBA@centene.com SUBMIT DME CLAIMS TO: CARECENTRIX NATIONAL CLAIMS CENTER 1100 FOUNDERS PLAZA SUITE 801 E HARTFORD, CT Submit Behavioral Healh Claim Disputes To: Cenpatico Behavioral Health Attn: Claims Disputes PO Box 6000 Farmington, MO

7 IVR SYSTEM A new Interactive Voice Response (IVR) system has been designed to make our great provider service even better. What's great about the IVR system? It's free and easy to use! Provides you with greater access to information. Through the IVR you can: o Check Member Eligibility o Check Claims Status Available 24 hours, 7 days a week Most subscribers may begin using our IVR system by calling WEBSITE By visiting you can find information on: Provider Directory Preferred Drug List Frequently Used Forms EDI Companion Guides Billing Manual Provider Office Manual Submit Claims On-Line Managing EFT CeltiCare also offers our contracted providers and their office staff the opportunity to register for our secure provider website in just 3-easy steps. Here, we offer tools which make obtaining and sharing information easy! Through the secure site you can: View and print member eligibility Check claim status Submit claims Request and view prior-authorizations Contact us securely and confidentially We are continually updating our website with the latest news and information so save to you favorites and check our site often. 7

8 PROVIDER RESPONSIBILITIES PRIMARY CARE PROVIDER (PCP) The primary care provider (PCP) is the cornerstone of CeltiCare. The PCP serves as the medical home for the member. The medical home concept assists in establishing a member-provider relationship, supports continuity of care, leads to elimination of redundant services and ultimately more cost effective care and better health outcomes. The PCP will provide or direct all medical care except for those services for which the member is permitted to self refer. The PCP is required to adhere to the responsibilities outlined below. COVERED PCP SERVICES PCP is responsible for supervising, coordinating and providing all primary care to each assigned member. In addition, the PCP is responsible for coordinating and/or initiating referrals for specialty care (both in and out- of -network), maintaining continuity of each member s healthcare and maintaining the member s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services, including an initial assessment for behavioral health. The PCP shall arrange for other participating physicians to provide members with covered physician services as stipulated in their contract. Each participating PCP provides all covered physician services in accordance with generally accepted clinical, legal and ethical standards in a manner consistent with practitioner licensure, qualifications, training and experience. These standards of practice for quality care are generally recognized within the medical community in which the PCP practices. Covered services include: Professional medical services, both inpatient and outpatient, provided by the PCP, nurses and other personnel employed by the PCP. Periodic health assessments and routine physical examinations (performed at the discretion of the PCP, and consistent with Commonwealth Care and nationally recognized standards recommended for the age and sex of the covered person). All supplies with a payment amount of less than $500 and covered medications used or provided during an eligible member s office visit. High cost specialty/injectable drugs, as listed on the prior-authorization list, require a prior authorization and must be obtained from Caremark to ensure payment. Please call Caremark at to obtain these drugs (See page 33 for details). All tests routinely performed in the PCP s office during an office visit. 8

9 The collection of laboratory specimens. Family planning services such as examinations, counseling, contraceptive management and pregnancy testing. Referral to specialty care physicians and other health providers with coordination of care, follow-up after referral and oversight of member s drug regiment. PCP s supervision of home care/home infusion regimens involving ancillary health professionals provided by licensed nursing agencies. These services are subject to prior authorization by CeltiCare. Any other outpatient services and routine office supplies normally within the scope of the PCP s practice. A treatment plan developed collaboratively with CeltiCare, member and the specialist, as appropriate, for all members who need an extended or complex course of treatment or regular care monitoring. Health Risk Assessment. PCP AVAILABILITY Availability defined as the extent to which CeltiCare contracts with the appropriate type and number of PCPs necessary to meet the needs of its members within defined geographical areas. CeltiCare has implemented several processes to monitor its network for sufficient types and distribution of PCPs. PCP availability is analyzed semi-annually by the CeltiCare Provider Relations (PR) Department. At least semi-annually, the PR department computes the percentage of PCPs with panels open for new members versus those PCPs accepting only members who are already-existing patients in their practice. The Member Services Department analyzes member surveys and member complaint data to address CeltiCare and federal requirements regarding the cultural, ethnic, racial and linguistic needs of the membership. The Quality Improvement Department tracks and trends member and provider complaints quarterly and monitors other data (such as appointment availability audits, after hours use of the member hotline and member and provider satisfaction surveys) that may indicate the need to increase network capacity. Summary information is reported to the Clinical Quality Committee for review and recommendation and is incorporated into CeltiCare annual assessment of quality improvement activities. The Clinical Quality Committee will review the information for opportunities for improvement. PCP ACCESSIBILITY Accessibility is the extent to which a patient can obtain available services at the time they are needed. Such service refers to both telephone access and ease of scheduling an appointment, if applicable. The Plan monitors access to services by performing access audits, tracking applicable results of the HEDIS/CAHPS survey, analyzing member complaints regarding access, and reviewing telephone access. 9

10 24-HOUR ACCESS Each PCP is responsible to maintain sufficient facilities and personnel to provide covered physician services and shall ensure that such services are available as needed twenty-four hours a day, 365 days a year. This coverage must consist of an answering service, call forwarding, provider on-call coverage or other customary means. The chosen method of twenty-four hour coverage must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. The after hours coverage must be accessible using the medical office s daytime telephone number. The PCP or covering medical professional must return the call within thirty (30) minutes of the initial contact. CeltiCare will monitor physicians offices through scheduled and un-scheduled visits through our Provider Relations staff. PCP COVERAGE The PCP shall arrange for coverage with a physician who has executed a Primary Care Physician Services Agreement with CeltiCare. If the participating physician is capitated for PCP compensation for the covering physician is considered to be included in the capitation payment. If the participating physician is paid a fee-for-service by CeltiCare, the covering physician is compensated in accordance with the fee schedule in his/her agreement. PCP APPOINTMENT ACCESS STANDARDS The following schedule should be followed regarding appointment availability: Emergency Services immediately upon presentation 24-hours a day, seven-days a week. Urgent Care within 48 hours of the member s request. Routine Sick Patient or Non-urgent, Symptomatic Care within 10 days of the members request. Well Care or Non-Symptomatic Visit within 45 calendar days. CeltiCare will monitor appointment and after-hours availability on an on-going basis through its Quality Improvement Program. TELEPHONE ARRANGEMENTS Providers are required to develop and use telephone protocol for all of the following situations: Answering the member s telephone inquiries on a timely basis. Response time for telephone call-back waiting times: o After hours telephone care for non-emergent, symptomatic issues within thirty (30) minutes. o Same day for non-symptomatic concerns. Prioritizing appointments. 10

11 Scheduling a series of appointments and follow-up appointments as needed by a member. Identifying and rescheduling broken and no-show appointments. Identifying special member needs while scheduling an appointment (e.g., wheelchair and interpretive linguistic needs, or for non-compliant individuals or those people with cognitive impairments). Scheduling continuous availability and accessibility of professional, allied and supportive personnel to provide covered services within normal working hours. Protocols shall be in place to provide coverage in the event of a provider s absence. After-hour calls should be documented in a written format in either an after-hour call log or some other satisfactory method, and then transferred to the member s medical record. Note: If after-hour urgent care or emergent care is needed, the PCP or his/her designee should contact the urgent care center or emergency department in order to notify the facility. Notification is not required prior to member receiving urgent or emergent care. CetliCare will monitor appointment and after-hours availability on an on-going basis through its Quality Improvement Program. PCP TO PCP REFERRALS It is CeltiCare s preference that the PCP coordinate healthcare services. However, members may self-refer for certain services (see below). PCPs are encouraged to direct the member to the appropriate specialty care services within the CeltiCare network, when medically necessary care is needed that is beyond the scope of the PCP. Those referrals which require authorization by the plan are listed below under prior authorization. Out-of-network referrals are discouraged, and claims will not be paid unless services cannot be provided in-plan, and prior authorization has been received. Please see information described herein. A provider is also required to notify CeltiCare promptly when they are rendering prenatal care to a Commonwealth Care member. If the PCP is capitated, referrals from a capitated PCP to another PCP will not be authorized or covered except for the following circumstances: Members who are auto-assigned to another PCP in the second or third trimester of their pregnancy when they become eligible for services under CeltiCare. Members having chronic medical conditions with ongoing healthcare needs that require continuity of care transition. Examples include, but not limited to, hemophilia, HIV/AIDS, sickle cell anemia, neoplasm, and organ transplant. Members who have been inappropriately auto-assigned, until a new PCP can be assigned. Members who have moved more than 15 miles or 30 minutes from their previous residence, until a new PCP can be assigned. No paper referral is required for a referral or prior-authorization. A Referral Specialist will issue the referral authorization number immediately upon approval. Referral requests can be made by telephone or fax. To verify whether an authorization is necessary or to obtain a prior authorization, call: Medical Management/Authorization Department Telephone Fax

12 CeltiCare has the capability to perform the ANSI X 12N 278 referral certification and authorization transaction through Centene. For more information on conducting this transaction electronically contact: CeltiCare c/o Centene EDI Department , extension or by at: EDIBA@centene.com SELF-REFERRALS The following services do not require PCP authorization: Emergency services including emergency ambulance transportation. OB services, including those of a Certified Nurse Midwife (CNM). GYN services, including those of a Certified Nurse Midwife (CNM). Women s health services provided by a Federally Qualified Health Center (FQHC) or Certified Nurse Practitioner (CNP). Most mental health and chemical dependency/substance abuse services. Please consult the Cenpatico Behavioral Health (CBH) Provider Manual for a full description of Behavioral Health programs. Family Planning Services and supplies from a qualified family planning provider. Except for emergency and family planning services, the above services must be obtained through network providers or prior authorized out-of-network providers. MEMBER PANEL CAPACITY All PCPs reserve the right to state the number of members they are willing to accept into their panel. CeltiCare DOES NOT guarantee that any provider will receive a set number of members. If a PCP does declare a specific capacity for his/her practice and wants to make a change to that capacity, the PCP must contact the CeltiCare s Provider Services Department at A PCP shall not refuse to treat members as long as the physician has not reached their requested panel size. Providers shall notify CeltiCare at least 30 days in advance of his or her inability to accept additional Commonwealth Care covered persons under CeltiCare s agreements. CeltiCare prohibits all providers from intentionally segregating members from fair treatment and covered services provided to other non-commonwealth Care members. 12

13 PROVIDER TERMINATION Providers should refer to their CeltiCare contract for specific information about terminating from health plan. OTHER PCP RESPONSIBILITIES Educate members on how to maintain healthy lifestyles and prevent serious illness. Provide culturally competent care. Maintain confidentiality of medical information. Obtain authorizations for all inpatient and selected outpatient services as listed on the current Prior Authorization List, except for emergency services up to the point of stabilization. Provide screening, well care and referrals to Community Health Departments and other agencies in accordance to CeltiCare provider requirements and public health initiatives. CeltiCare providers should refer to their contract for complete information regarding their PCP obligations and reimbursement. SPECIALIST RESPONSIBILITIES Specialty services are obtained within the CeltiCare Network upon request from the PCP. The specialist may order diagnostic tests without PCP involvement by following CeltiCare referral guidelines. The specialist must abide by the prior authorization requirements when ordering diagnostic tests. However, the specialist may not refer to other specialists or admit to the hospital without the approval of a PCP, except in a true emergency situation. All non-emergency inpatient admissions require prior authorization from CeltiCare. The specialist provider must: Maintain contact with the PCP. Obtain referral or authorization from the member s PCP and/or CeltiCare Medical Management Department as needed before providing services. Coordinate the member s care with the PCP. Provide the PCP with consult reports and other appropriate records within five (5) business days. Be available for or provide on-call coverage through another source twenty-four hours a day for management of member care. Maintain the confidentiality of medical information. CeltiCare providers should refer to their contract for complete information regarding providers obligations and mode of reimbursement. 13

14 SPECIALIST APPOINTMENT ACCESS STANDARDS The following schedule should be followed regarding appointment availability: Urgent Care within 48 hours of the member s request Non-urgent, Symptomatic Care within 30 calendar days of the members request Well Care or Non-Symptomatic Visit within 60 calendar days CeltiCare will monitor appointment and after-hours availability on an on-going basis through its Quality Improvement Program. HOSPITAL RESPONSIBILITIES CeltiCare utilizes a network of hospitals to provide services to Commonwealth Care members. Hospitals must: Notify the PCP immediately or no later than the close of the next business day after the member s appearance in the Emergency Department. Obtain authorizations for all inpatient and selected outpatient services as listed on the current Prior Authorization List, except for emergency stabilization services. Notify CeltiCare Medical Management Department of all maternity admits upon admission and all other admissions by close of the next business day. Notify CeltiCare Medical Management Department of all newborn deliveries on the same day as the delivery and notify MassHealth of the birth. CeltiCare hospitals should refer to their contract for complete information regarding the hospitals obligations and reimbursement. ADVANCE DIRECTIVES CeltiCare is committed to ensuring that its members know of, and are able to avail themselves of, their rights to execute advance directives. CeltiCare is equally committed to ensuring that its providers and staff are aware of and comply with their responsibilities under federal and Massachusetts law regarding advance directives. PCPs and providers delivering care to CeltiCare members must ensure adult members 18 years of age and older receive information on advance directives and are informed of their right to execute advance directives. Providers must document such information in the permanent medical record. CeltiCare recommends to its PCPs and physicians that: The first point of contact for the member in the PCP s office should ask if the member has executed an advance directive; the member s response should be documented in the medical record. If the member has executed an advance directive, the first point of contact should ask the member to bring a copy of the advance directive to the PCP s office and document this request in the member s medical record. 14

15 An advance directive should be included as a part of the member s medical record, including mental health directives. If an advance directive exists, the physician should discuss potential medical emergencies with the member and/or designated family member/significant other (if named in the advance directive and if available) and with the referring physician, if applicable. Discussion should be documented in the medical record. If an advance directive has not been executed, the first point of contact within the office should ask the member if they desire more information about advance directives. If the member requests further information, member advance directive education/information should be provided. Member Services and Connections Representatives will assist members with questions regarding advance directives. However no employee of CeltiCare may serve as witness to an advance directive or as a member s designated agent or representative. CeltiCare Quality Improvement Department will monitor compliance with this provision during ambulatory medical record audits. If you have any questions, regarding advance directives, contact: Quality Improvement Department Telephone: PROVIDER ASSISTANCE WITH PUBLIC HEALTH SERVICES CeltiCare is required to coordinate with public health entities regarding the provision of public health services. Providers must assist CeltiCare in these efforts by: Complying with public health reporting requirements regarding communicable diseases and/or diseases which are preventable by immunization as defined by Massachusetts law. Assisting in the notification or referral of any communicable disease outbreaks involving members to the local public health entity, as defined by Massachusetts law. Referring to the local public health entity for tuberculosis contact investigation, evaluation and the preventive treatment of persons with whom the member has come into contact. Referring members to the local public health entity for STD/HIV contact investigation, evaluation and preventive treatment of persons whom the member has come into contact. Provide all women of childbearing age HIV counseling and offer them HIV testing at the initial prenatal care visit. All women who are infected with HIV are counseled about and offered the latest antiretroviral regimen. Screen all pregnant members for the Hepatitis B surface antigen. 15

16 Referring members for Women, Infant and Children (WIC) services and information sharing as appropriate. Assisting in the coordination and follow-up of suspected or confirmed cases of childhood lead exposure. Assisting in the collection and verification of race/ethnicity and primary language data. 16

17 CULTURAL COMPETENCY CULTURAL COMPETENCY OVERVIEW Significant gaps remain in healthcare despite efforts to reduce disparities through the provision of culturally competent medical care. Lack of awareness about cultural differences can make it difficult for both providers and patients to achieve the best, most appropriate care. In spite of all our similarities, fundamental differences among people arise from nationality, ethnicity, and culture, as well as from family background and individual experiences. These differences affect health beliefs, practices, and behavior on the part of both patient and provider, and also influence the expectations that patient and provider have of each other. Miscommunication results and patient-provider relationships are affected when understanding of each other's expectations is missing. The provider may not understand why the patient does not follow instructions: for example, why the patient takes a smaller dose of medicine than prescribed (because of a belief that Western medicine is "too strong"); or why the family, rather than the patient, makes important decisions about the patient's healthcare (because in the patient's culture, major decisions are made by the family as a group). Likewise, the patient may reject the provider (and the entire system) even before any one-on-one interaction occurs because of nonverbal cues that do not fit expectations. For example, "The doctor is not wearing a white coat - maybe he's not really a doctor; or, "The doctor smiles too much. Doesn't she take me seriously?". It is the goal of CeltiCare to provide services in a manner that recognizes values, affirms and respects the worth of the individual members and protects and preserves the dignity of people of all cultures, races, ethnic backgrounds and religions. Members are entitled to dignified, appropriate and quality care and CeltiCare is committed to the development, strengthening and sustaining of healthy provider/member relationships. When healthcare services are delivered without regard for cultural differences, members are at risk for sub-optimal care. Members may be unable or unwilling to communicate their healthcare needs, reducing effectiveness of the entire healthcare process. CeltiCare s Cultural Competency Program is based on the Georgetown University National Center for Cultural Competence model framework. NEED FOR CULTURALLY COMPETENT SERVICES The Institute of Medicine report entitled Unequal Treatment 1 along with numerous research projects reveal that when accessing the healthcare system, people of color are treated differently. Research also indicates that a person has better health outcomes when they experience culturally appropriate interactions with medical providers. The path to developing cultural competency begins with self-awareness and ends with the realization and acceptance that the goal of cultural competency is an on going process. Providers should note that the experience of a member begins at the front door. Failure to use culturally competent and linguistically competent practices could result in the following:

18 Feelings of being insulted or treated rudely Reluctance and fear of making future contact with the office Confusion and misunderstanding Non-compliance Feelings of being uncared for, looked down on and devalued Parents resisting to seek help for their children Unfilled prescriptions Missed appointments Misdiagnosis due to lack of information sharing Wasted time Increased grievances or complaints CULTURAL COMPETENCY DEVELOPMENT The road to developing a culturally competent practice begins with the recognition and acceptance of the value of meeting the needs of your patients. CeltiCare is committed to helping you reach this goal. As first steps toward providing culturally competent care, we suggest completing this free web-based CME course: Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency 2 and conducting a Cultural Competence Health Practitioner Assessment 3. Additionally the following information and references may be of assistance to you: Take into consideration the following as you provide care to the CeltiCare membership: What are your own cultural values and identity? How do or can cultural differences impact your relationship with your patients? How much do you know about your patient s culture and language? Does your understanding of culture take into consideration values, communication styles, spirituality, language ability, literacy, and family definitions? Do you embrace differences as allies in your patients healing process? L-E-A-R-N Model of Cross Cultural Encounter Guidelines for Health Practitioners 4 Listen with sympathy and understanding to the patient's perception of the problem Explain your perceptions of the problem Acknowledge and discuss the differences and similarities Recommend treatment Negotiate agreement Culturally and linguistically competent practices require providers to modify approaches to: Assessment and diagnostic protocols Treatment & interventions Medication protocols Health education & counseling Consulting with tradition/indigenous practitioners & natural healers Berlin EA. & Fowkes WC, Jr.: A teaching framework for cross-cultural healthcare--application in family practice, In Cross-cultural Medicine. West J. Med. 1983, 12: 139, 93~98 18

19 INTERPRETIVE AND TRANSLATION SERVICES CeltiCare is committed to ensuring that staff and subcontractors have the necessary resources to facilitate effective communication to its members with special linguistic needs and cultural differences. CeltiCare does not advocate the use of patients family or friends as an interpreter during medical appointments. Children should NEVER be used to interpret. These ad-hoc interpreters are often not trained as medical interpreters and may not be familiar with legal and ethical issues, such as confidentiality. While ad hoc interpreters may be better than none, they may not understand their neutral role in the interaction and may even try to spare the patient from bad news. Trained interpreters have the skills and knowledge to assure an effective and accurate interpretation. In order to meet this need, CeltiCare provides the following interpretive and translation services: TDD/TTY access for members who are hearing impaired through Language Line services that will be available 24 hours a day, seven days a week in 140 languages to assist providers and members in communicating with each other during urgent/emergent situations, non-urgent/emergent appointments as requested, or when there are no other translators available for the language requested. Accessed through Member Services during regular business hours or through NurseWise, medical triage advice line, after normal business hours. In-person interpreter services (including sign-language) to assist providers with discussing technical, medical or treatment information as needed to allow for a more positive encounter between the member and provider. Providers must call Member Services at in-advance to arrange in-person interpreter services for scheduled appointments. Please have the member s ID number, date and time service is requested and any other documentation that would assist in scheduling interpreter services. Member Services and health education materials in alternative formats as needed to meet the needs of the members, such as audio tapes or language translation; all alternative methods must be requested by the member, provider or designee. *** The entire CeltiCare Cultural Competency Plan can be viewed from the index of this manual as an attachment as well as on line at 19

20 MEDICAL RECORDS MEDICAL RECORDS CeltiCare providers must keep accurate and complete medical records that comply with all statutory and regulatory requirements applicable, including but not limited to those contained in 130 CMR and Such records will enable providers to render the highest quality healthcare service to members. They will also enable CeltiCare to review the quality and appropriateness of the services rendered. To ensure the member s privacy, medical records should be kept in a secure location. Massachusetts administrative regulations requires providers to maintain all records for members for at least six years after the date of medical services for which claims are made or the date services were prescribed. See Member Rights section of this manual for policies on member access to medical records. REQUIRED INFORMATION Medical records means the complete, comprehensive member records including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the member s participating primary care physician or provider, that document all medical services received by the member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable CeltiCare rules and regulations, and signed by the medical professional rendering the services. General Requirements: 1. Medical records must be maintained in a manner that is current, detailed and organized and that permits effective member care and quality review; 2. All entries must be legible and maintained in detail; 3. Include sufficient information to identify the member, date of encounter and pertinent information which documents the member s condition. 4. Describe the appropriateness of the treatment/services, the course and results of the treatment/services; and 5. Be consistent with current professional standards for providing treatment/services as well as systems for accurately documenting care. Specific Documentation Elements: Personal/biographical data (i.e. employer, home telephone number, spouse, next of kin, legal guardianship, primary language, etc.). Notation of any spoken language translation or communication assistance. Member s name and date of birth on all chart pages. 20

21 All entries must be dated and signed, or dictated by the provider rendering the care. If care is rendered by someone other than the physician, entry must include name and title of the person performing the service. Significant illnesses and/or medical conditions are documented on the problem list and all past and current diagnoses. Medication, allergies, and adverse reactions are prominently documented in a uniform location in the medical record (medication list); if no known allergy, NKA or NKDA is documented. An up-to-date immunization record is established for members or an appropriate history is made in chart for adults. Past medical history including any serious accidents, operations and/or illnesses, discharge summaries, and ER encounters. Diagnosis or chief complaint including appropriate subjective and objective information pertinent to the member s presenting complaints. Clear indication of all findings, whether positive or negative, on examination. Any medication administered or prescribed, including strength, dosage, and regimen. Description of any treatment given, including instructions given to the member. Recommendations for additional treatments or consultations, when applicable. Any medical goods or supplies dispensed or prescribed. Any tests administered and their results. When additional information is necessary to document the reason for the visit, the basis for diagnosis, or the justification for future diagnostic procedures, treatments, or recommendations for return visits or materials, such information must also be contained in the medical record. Basic data collected during previous visits (for example, identifying data, chief complaint, or history) need not be repeated in the member's medical record for subsequent visits. However, data that fully document the nature, extent, quality, and necessity of care provided to a member must be included for each date of service or service code claimed for payment, along with any data that update the member's medical course. Abnormal lab and imaging study results have explicit notations in the record for follow up plans; all results should be initialed by the primary care provider (PCP) to signify review. Referrals to specialists and ancillary providers are documented including follow up of outcomes and summaries of treatment rendered elsewhere including family planning services, preventive services and services for the treatment of sexually transmitted diseases. Health teaching and/or counseling is documented. Appropriate notations concerning use of tobacco, alcohol and substance use (for members seen three or more times). Documentation of failure to keep an appointment. Encounter forms or notes have a notation, when indicated, regarding follow-up care calls or visits. The specific time of return should be noted as weeks, months or as needed. Evidence that preventive screening and services are offered in accordance with evidence-based practice guidelines. Documentation of prenatal risk assessment for pregnant women. 21

22 Signed and dated required consent forms. Documentation that the member was provided written information concerning the member s rights regarding advance directives (written instructions for living will or power of attorney) and whether or not the member has executed an advance directive. (Providers shall not, as a condition of treatment, require the member to execute or waive an advance directive. MEDICAL RECORDS RELEASE All member medical records shall be confidential and shall not be released without the written authorization of the covered person or a responsible covered person s legal guardian. When the release of medical records is appropriate, the extent of that release should be based upon medical necessity or on a need to know basis. Written authorization is required for the transmission of the medical record information of a current CeltiCare member or former CeltiCare member to any physician not connected with CeltiCare. MEDICAL RECORDS TRANSFER FOR NEW MEMBERS All PCPs are required to document in the member s medical record attempts to obtain historical medical records for all newly assigned CeltiCare members. If the member or member s guardian is unable to remember where they obtained medical care, or they are unable to provide addresses of the previous providers then this should also be noted in the medical record. MEDICAL RECORDS AUDITS Medical records are required to be audited to determine compliance with CeltiCare Plan standards for documentation and Massachusetts regulations. CeltiCare annually monitors compliance with these medical records standards through random ambulatory medical record audits. The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services also may be assessed during a medical record audit. 22

23 MEDICAL MANAGEMENT OVERVIEW AND MEDICAL NECESSITY The CeltiCare Medical Management Department hours of operation are Monday through Friday (excluding holidays) from 8:00 a.m. to 5:00 p.m. Authorization may be requested via telephone, the web, or fax. For telephone authorizations during business hours, the provider should contact: Utilization Management Web address: Plan Fax Number: CeltiCare Utilization Management (UM) program is designed to ensure members of Commonwealth Care receive access to the right care at the right place and right time. Our program is comprehensive in scope to ensure services provided are covered benefits, medically necessary, appropriate to the member s condition, rendered in the most appropriate setting, timely, and meet professionally recognized care standards. CeltiCare s UM program includes referrals, prior authorization, notification (authorizations), admission, concurrent, retrospective review, discharge planning, pharmacy management, high-cost services, end-of-life care coordination, and case/disease management. Our program goals include: Monitoring utilization patterns to guard against over- or under- utilization. Development and distribution of clinical practice guidelines to providers to promote improved clinical outcomes and satisfaction. Identification and provision of intensive care and/or disease management for members at risk for significant health expenses or ongoing care. Development of an infrastructure to ensure that all CeltiCare members establish relationships with their PCPs to obtain preventive care. Implementation of programs that encourage preventive services and chronic condition self-management. Creation of partnerships with members/providers to enhance cooperation and support for UM program goals. Services and specialty referrals as listed on the authorization list require CeltiCare authorization. A Referral Specialist will enter the demographic information and will then transfer the call to a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) for the completion of medical necessity screening. During heavy call volumes a nurse may answer the telephone and complete the medical necessity screening during the call. For all services on the Authorization list Medical Necessity will be required. All referrals to non-participating providers or out-ofnetwork providers require CeltiCare authorization. Some services such as term pregnancy delivery do not require plan authorization but do require plan notification. 23

24 CeltiCare clinical staff request clinical information minimally necessary for clinical decision making. All clinical information is collected according to federal and state regulations regarding the confidentiality of medical information. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), CeltiCare is entitled to request and receive protected health information (PHI) for purposes of treatment, payment and healthcare operations, with the authorization of the member. Information necessary for authorization of covered services may include but is not limited to: Member s name, ID number. Physician s name and telephone number. Facility name, if the request is for an inpatient admission or outpatient facility services. Provider location if the request is for an ambulatory or office procedure. Reason for the authorization request primary and secondary diagnoses, planned surgical procedures, surgery date. Relevant clinical information past/proposed treatment plan, surgical procedure, and diagnostic procedures to support the appropriateness and level of service proposed. Admission date or proposed surgery date, if the request is for a surgical procedure. Requested length of stay, if the request is for an inpatient admission. Discharge plans. For obstetrical admissions, the date and method of delivery, estimated date of confinement, and information related to the newborn or neonate. If additional clinical information is required, a CeltiCare nurse or medical service representative will notify the caller of the specific information needed to complete the authorization process. CeltiCare affirms that UM decision making is based only on appropriateness of care and service and the existence of coverage. CeltiCare does not specifically reward practitioners or other individuals for issuing denials of service or care. Consistent with 42 CFR 438.6(h) and , delegated providers must ensure that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The treating physician, in conjunction with the member is responsible for making all clinical decisions regarding the care and treatment of the member. The PCP in consultation with the CeltiCare Medical Director and other clinical staff is responsible for making UM decision in accordance with the member s plan of covered benefits and established medical necessity criteria. Failure to obtain authorization for services that require plan approval may result in payment denials. SECOND OPINION Members or a healthcare professional with the member s consent may request and receive a second opinion from a qualified professional within CeltiCare. If there is not an appropriate provider to render the second opinion within the network, the member may obtain the second opinion from an out-of-network provider at no cost to the member. Out-of-network and in-network specialty provider types on the prior authorization list will require prior authorization. ASSISTANT SURGEON Assistant Surgeon reimbursement is provided when medically necessary. CeltiCare utilizes guidelines for assistant surgeons as set forth by the American College of Surgeons. 24

25 Hospital medical staff by-laws that require an Assistant Surgeon be present for a designated procedure are not grounds for reimbursement. Medical staff by-laws alone do not constitute medical necessity, nor is reimbursement guaranteed when the patient or family requests an Assistant Surgeon be present for the surgery. Coverage and subsequent reimbursement for an Assistant Surgeon s service is based on the medical necessity of the procedure itself and the Assistant Surgeon s presence at the time of the procedure. MEDICAL NECESSITY Medical necessity is defined for Commonwealth Care members as healthcare services that: (1) are consistent with generally accepted principles of professional medical practice as determined by whether: (a) the service is the most appropriate available supply or level of service for the member in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence and (2) are the least intensive and most cost-effective available. REVIEW CRITERIA CeltiCare has adopted utilization review criteria developed by McKesson InterQual Products to determine medical necessity for non-emergency inpatient and outpatient services. InterQual appropriateness criteria are developed by specialists representing a national panel from community-based and academic practice. InterQual criteria cover medical and surgical admissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria are established and periodically evaluated and updated with appropriate involvement from physician members of the CeltiCare Utilization Management Committee. InterQual is utilized as a screening guide and is not intended to be a substitute for practitioner judgment. Utilization review decisions are made in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria. Criteria are used for the approval of medical necessity but not for the denial of services. The Medical Director reviews all potential denials of medical necessity decision. Providers may obtain the criteria used to make a specific adverse determination by contacting the Medical Management Department at Practitioners also have the opportunity to discuss any medical or behavioral health UM denial decisions with a physician or other appropriate reviewer at the time of notification to the requesting practitioner/facility of an adverse determination. The Medical Director may be contacted by calling the CeltiCare s main toll-free phone number and asking for the Medical Director. A Case Manager may also coordinate communication between the Medical Director and requesting practitioner. members or healthcare professional with the member s consent may request an appeal related to a medical necessity decision made during the authorization or concurrent review process orally or in writing to: CeltiCare Appeals Coordinator 1380 Soliders Field Road Brighton, MA

26 NEW TECHNOLOGY CeltiCare evaluates the inclusion of new technology and the new application of existing technology for coverage determination. This may include medical procedures, drugs and/or devices. The Medical Director and/or Medical Management staff may identify relevant topics for review pertinent to the CeltiCare population. The Clinical Policy Committee (CPC) reviews all requests for coverage and makes a determination regarding any benefit changes that are indicated. In the instance where the request is made for coverage for new technology, which has not been reviewed by the CPC, the CeltiCare Medical Director will review all information and make a onetime determination within two (2) business days of receipt of all information. This new technology request will then be reviewed at the next regular meeting of the CPC. If you need a new technology benefit determination or have an individual case review for new technology, please contact the Medical Management Department SERVICES REQUIRING CELTICARE AUTHORIZATIONS The member s PCP is responsible to coordinate healthcare services. PCP s should refer members when medically necessary services are beyond their scope of practice. Services that require authorization by CeltiCare are listed in the Authorization Table section. Members are allowed to self-refer for certain specific services (for example, family planning) and as listed elsewhere under SELF-REFERRALS in this manual. PCPs are not required to issue any paper referrals to participating specialist or for any service on the Authorization list. CeltiCare does not use paper referrals. If a service listed on the Authorization List is needed, the PCP should contact the CeltiCare Utilization Management Department via telephone, fax or through our website to request an authorization. The PCP may request a standing referral in certain circumstances, such as a prolonged course of treatment or very specialized care, CeltiCare will issue a standing referral for up to six months. All standing referral requests and out-of-network referral request require CeltiCare Medical Director review and approval. CeltiCare encourages specialists to communicate to the PCP the need for a referral to another specialist, rather than making such a referral themselves. This allows the PCP to better coordinate their members care, and to make sure the referred specialist is a participating provider with CeltiCare and the PCP is aware of the additional service request. For pregnant members remaining with CeltiCare, the managing physician must notify the Case Management Department via fax submission of the CeltiCare Maternity Risk Assessment and prenatal vitamin order request within five days of the first prenatal visit. Providers will be expected to identify the estimated date of confinement and delivery facility. CeltiCare will facilitate the physician s order a 90 day supply of prenatal vitamins for the member to be delivered to the obstetrical provider s office by the member s next prenatal visit. See Maternal/Newborn Health Section for additional services available for pregnant members. Providers are prohibited from making referrals for designated health services to healthcare entities with which the provider or a member of the provider s family has a financial relationship. Referrals for Home Health, durable medical equipment, and orthotics and prosthetics require CeltiCare authorization. CeltiCare has contracted with CareCentrix to manage services provided in the member s home, durable medical equipment and orthotics and prosthetics. 26

27 Participating providers may provide medical equipment, supplies, splints, orthotics and prosthetics in their office to CeltiCare members. If the cost of the item is over $500 the provider is required to obtain the service, supply, splint or esthetics or prosthetic through CareCentrix. For home health services, durable medical equipment, orthotics and prosthetics, call CeltiCare UM and follow the prompts to Home Health Services. Referrals for Therapy Services are covered for medically necessary evaluation and individual physical, speech-language, occupational and respirator therapy for short-term rehabilitative services. The initial evaluation does not require CeltiCare approval. Once the evaluation is completed and a treatment plan outlined, additional services require CeltiCare referral authorization. PRIOR AUTHORIZATION AND NOTIFICATION AUTHORIZATION Prior authorization is a request to CeltiCare UM Department for approval of elective services on the Authorization List before the service is delivered. Prior authorization should be requested at least fourteen (14) calendar days before the requested service delivery date, or within five (5) business days for an inpatient elective admission. For standard services requests, CeltiCare decisions shall be made within two (2) working days of receipt of the information necessary to make a decision. Verbal notification is offered to the requesting Provider within twenty four (24) hours of the decision. A provider and member written notice of approval is sent within two (2) working days of the verbal notification and within one (1) business day of an adverse determination. Failure to obtain prior authorization can result in an administrative denial. For urgent/expedited requests, a decision is made within 24 hours or 1 working day of receipt of the information necessary to make a decision, whichever comes first. Providers are notified verbally of the decision within one (1) business day of the decision. A provider and member written notice of approval is sent within two days of the verbal notification. Notification/Authorization applies to services that normally require CeltiCare prior authorization, but due to the emergent nature of the service CeltiCare will accept the notification request within one (1) business day of the service having been rendered. In order to ensure payment the provider must submit the required medical necessity information at the time of the request. Maternity admissions require notification as do admission through the emergency department. Failure to obtain notification authorization may result in administrative denial. Emergency room/urgent care services never require prior authorization. Providers should notify CeltiCare of post stabilization services within one (1) business day of the service. Clinical information is required for ongoing services. Services listed on the Authorization list require CeltiCare approval. For urgent/emergency services such as but not limited to the weekend or holiday provision of home health, durable medical equipment, or urgent outpatient surgery the provider should notify CeltiCare within one (1) business day and be prepared to provide clinical information. Failure to obtain notification/authorization may result in administrative denials. CeltiCare providers are contractually prohibited from holding any Commonwealth Care member financially liable for any service administratively denied by CeltiCare for the failure of the Provider to provide timely and complete notification of the provided service. 27

28 Notification of birth is required to be submitted to MassHealth as well as CeltiCare. For all births to members, hospitals that deliver the newborn are required to submit a properly completed Notification of Birth (NOB) form to the MassHealth Enrollment Center (MEC) NOB Unit. Such form shall be submitted by the hospital within 60 days after the birth. Notification of Observation Stays is required by CeltiCare. In the event that a member s clinical symptoms do not meet the criteria for an inpatient admission, but the treating physician believes that allowing the patient to leave the facility would likely put the member at serious risk, the member may be admitted to the facility for an observation period. Observation Bed Services are those services furnished on a hospital s premises, including use of a bed and periodic monitoring by a hospital s nurse or other staff. Observation admissions must be authorized by CeltiCare Authorization Department. These services are reasonable and necessary to: Evaluate an acutely ill patient s condition Determine the need for a possible inpatient hospital admission Provide aggressive treatment for an acute condition An observation may last up to a maximum of forty-eight (48) hours. In those instances that a member begins their hospitalization in an observation status and the member is downgraded to an inpatient admission, all incurred observation charges and services will be rolled into the acute reimbursement rate, or as designated by the contractual arrangement with CeltiCare, and cannot be billed separately. It is the responsibility of the hospital to notify CeltiCare of the observation stay and the transition to an inpatient admission. Providers should not substitute outpatient observation services for medically appropriate inpatient hospital admissions. CONCURRENT REVIEW Case Managers perform ongoing concurrent review for targeted inpatient admissions. The Case Manager will concurrently review the treatment and status of all members who are inpatient through contact with the hospital s Utilization and Discharge Planning Departments and when necessary, the member s attending physician. On-site and telephonic models are utilized to conduct utilization review in collaboration with the hospital utilization department. An inpatient stay will be reviewed as indicated by the member s diagnosis and response to treatment. The review will include evaluation of the member s current status, proposed care plan, discharge plans, and any subsequent diagnostic testing or procedures. Routine uncomplicated vaginal or c-section delivery does not require concurrent review. The hospital must notify the plan within one (1) business day of delivery with complete information regarding the delivery status and condition of the newborn. CeltiCare will assist with the transfer of the newborns to the MassHealth eligibility process. CeltiCare is not responsible for any for costs associated with newborns on or after the date of birth as they are retrospectively enrolled in the MassHealth program effective the date of birth as soon as practicable. The CeltiCare Medical Management Department may contact the member s admitting physician s office or primary care physician s office prior to the discharge date established during the authorization process, to check on the member s progress, and to make certain the member receives medically necessary follow up services. For concurrent review on ongoing inpatient admission, the Case Manager review decisions are made within one (1) calendar day and providers and verbally informed of the decision within one calendar day. Written or electronic notification includes the number of days of service approved, and the next review date. For routine ongoing services such as outpatient rehabilitation services, home care, or ongoing specialty care, a concurrent decision is rendered within fourteen (14) calendar days of receipt of 28

29 the request or within 2 working days of obtaining all necessary information, depending on which comes first. Providers are verbally informed of the decision within one (1) business day of the decision and written notices are sent to the provider and member within two (2) business days of the verbal notification. In the case of adverse determination, written adverse determinations are sent within one (1) business day of the verbal notification and no later than the overall timeline. All existing approved services will be continued without liability to the member until the member has been notified of an adverse determination. All adverse determination notices contain information on how to appeal the adverse determination. DISCHARGE PLANNING Discharge planning activities are expected to be initiated upon admission. The CeltiCare UM staff will coordinate the discharge planning efforts with the hospital s Utilization and Discharge Planning Departments and when necessary the member s attending physician/pcp in order to ensure that CeltiCare members receive appropriate post hospital discharge care. Home health services that are provided post-hospitalization require prior authorization as do services provided to prevent a hospitalization or shorten the length of stay. For more information, refer to the section on Home Health Services. RETROSPECTIVE REVIEW Retrospective review is an initial review of services provided to a member, but for which authorization and/or timely Plan notification was not obtained due to extenuating circumstances. Routinely this process encompasses services performed by a provider when there was no opportunity for concurrent review. However, retrospective review is also performed on active cases where an appropriate decision cannot be made concurrently within the required timeframe due to lack of clinical information. For services cases that qualify for retrospective review once all necessary information is received a decision is made within thirty (30) calendar day. 29

30 CELTICARE SERVICES REQUIRING PRIOR PLAN AUTHORIZATION 2009 Authorization must be obtained prior to the delivery of certain services. For authorization assistance, please contact CeltiCare UM Department at and follow the prompts to Referral/Authorization Unit. You may also complete the appropriate CeltiCare Authorization request form and fax to the number designated on the form. NurseWise staff is available 24/7 for after hour s calls. All notifications of admission must be followed by submission of clinical information by the next business day via fax or telephone. Emergency room or urgent care visits are not subject to plan prior authorization requirements. Failure to obtain the required prior approval or pre-certification may result in a denied claim(s). This guide is not intended to be an all-inclusive list of covered services but it substantially provides current referral and prior authorization instructions. All services are subject to benefit coverage, limitations and exclusions as described in applicable plan coverage guidelines. Unless indicated otherwise below, Authorization or Notification of services may be obtained by contacting the CeltiCare Referral/Authorization at Services provided by an out-of-network, nonparticipating, or out-of-state provider requires prior authorization EXCEPT laboratory and radiology services other than those noted as requiring authorization (i.e. MRI, CT, PET). Service Authorization Notification Comments Abortion X Non-participating/out-of-network providers only. Consideration when part of a substance abuse Acupuncture X treatment program only. Contact Centpatico Behavioral Health at for authorization. Cochlear Implants X Dialysis Services X Non-participating/out-of-network providers only. Home: Durable medical equipment and supplies for home use are provided by CareCentrix network providers and require authorization. These include residential place of service billing codes 04, 12, 13, 14, 16, 33, 99. To obtain authorization contact CareCentrix via phone or fax at: Phone: Fax: Initial Authorizations: Fax Re-authorizations: Office: Durable Medical Equipment (DME) X Certain durable medical equipment and supplies may be provided in a physician office or clinic by a physician such as splints and braces. These include place of service billing codes 11, 22, 50, 49, 72. Authorization is required for durable medical equipment (splints and braces) over $500 billed by a physician office or clinic. Rental items, walkers, wheelchairs, IV poles, nebulizer machines, and the like are for home use. Items for home use are provided by CareCentrix network providers and require authorization by CareCentrix. (See Home: contact information above). Enteral and Parental Nutrition for home use is provided by CareCentrix Network providers and requires authorization. The place of service billing code accepted is 12. Other billed place of service codes are Enteral and Parenteral Nutrition X not accepted. To obtain authorization contact CareCentrix at: Phone: Fax: Initial Authorizations: Fax Re-authorizations:

31 Service Authorization Notification Comments Genetic Testing X Breast and Ovarian, Colorectal, and Melanoma Home Care Services X Contact CareCentrix via phone or fax to obtain authorization for DME, Home Care (i.e. nursing, aid/assistant, therapy) and Home Supplies: Phone: Fax: Initial Authorizations: Fax Re-authorizations: Hospice X Hospice coverage is not provided for the Commonwealth Bridge population. Inpatient admissions Medical, Pregnancy, or Surgical Inpatient X X Authorization is required for elective admissions and must be submitted five (5) calendar days prior to the scheduled date of admission. Admissions for post-stabilization require authorization of the initial admission and subsequent days and must be submitted within one (1) business day of the admission. Behavioral Health Inpatient Mental Health & Substance Abuse Rehabilitative Inpatient Skilled, Sub-Acute Rehab, Chronic Disease Investigational and Experimental Services Observation Stays Orthotics X X X X X Notification required for all normal deliveries. Emergency admissions require notification within one (1) business day of the admission. For mental or substance abuse admissions contact Centpatico Behavioral Health at Covered for up to 100 days combined for Skilled Nursing (SNF) and Rehabilitation/Sub Acute Rehabilitation. (Coverage for Skilled nursing services is not provided for the Commonwealth Care Bridge program) Any health care service, supply, procedure, therapy or device in which health safety and/or efficacy has not been established and/or is unproven for the condition or disease in which it is being used. Requires authorization prior to the service being rendered. Observation requires Plan notification within one (1) business day of services being rendered. These services are reasonable and necessary to: Evaluate an acutely ill patient s condition Determine the need for a possible inpatient hospital admission Provide aggressive treatment for an acute condition An observation may last up to a maximum of fortyeight (48) hours. Providers may not substitute outpatient observation services for medically appropriate inpatient hospital admissions. Orthotics are provided by CareCentrix network providers and require authorization. The place of service billing code accepted is 12. Other billed place of service codes are not accepted. To obtain authorization contact CareCentrix at: Phone: Fax: Initial Authorizations: Fax Re-authorizations: EXCEPTION: Participating CeltiCare podiatrist and orthopedic physicians may provide orthotics in the office location (place of service billing code 11) with authorization from CeltiCare. To obtain authorization contact CeltiCare via phone or fax at: Phone: Fax:

32 OTHER INFORMATION: Diabetic Shoes and inserts are limited to members with diabetes only. Service Authorization Notification Comments Out-of-Network, Nonparticipating provider, Out-Of- State providers Pain Management (Out-patient) Pregnancy Care Pharmacy Prosthetics Pulmonary Rehabilitation Radiology: (Non-emergent outpatient) CT/CTA MRI/MRA Nuclear Cardiology Imaging Studies Obstetrical Ultrasound PET Scans Surgery - Includes but not limited to: Bariatric Surgery Blepharoplasty Breast Reconstruction Breast Reduction Surgery Mastectomy for Gynecomastia Potentially Cosmetic Procedures Septoplasty Varicose Vein Treatments X X X X X X X X Except for the treatment of an emergency medical condition; or services received due to an urgent or emergent condition while traveling outside of CeltiCare s service area or laboratory and radiology services unless otherwise noted as requiring authorization (i.e. MRI, CT, PET). Office visits, consultations, services, treatments, and procedures. Fax the notification of expectant mother s prenatal assessment within 5 days of first prenatal visit to Refer to the Biopharmaceutical Prior Authorizations section immediately following this section. Prosthetics are provided by CareCentrix network providers and require authorization. The place of service billing code accepted is 12. Other billed place of service codes are not accepted. To obtain authorization contact CareCentrix at: Phone: Fax: Initial Authorizations: Fax Re-authorizations: CT/CTA, MRI, MRA, Cardiac Nuclear Scans, PET - Includes non-emergent outpatient/office radiology services only. OB Ultrasound - services greater than one in the first trimester (<14 weeks 0 days) and one after the first trimester (> or = 14 weeks 0 days). Authorization is required for elective surgical procedures and must be submitted five (5) calendar days prior to the scheduled date of surgery. Temporomandibular Joint Disorder (TMJ) X Surgery, devices, or treatments. Therapy: (Outpatient): Initial evaluations do not require pre-authorization Physical X by an in-network provider. Follow-up services Occupational require a treatment plan & goals. For Home Speech Therapy, see Home Care Services. Transplants X All transplants services including pre, transplant, and post transplant services. Transportation - Non-emergent X Facility to facility. 32

33 Biopharmaceutical Prior Authorizations CeltiCare works with Caremark Specialty Pharmacy to provide biopharmaceuticals and injectables. Most biopharmaceutical and injectables billed for more than $250 require a Prior Authorization (PA) to be approved for payment by CeltiCare. However, PA requirements are programmed specific to the drug as indicated in the table below. Since the list of drugs requiring PA changes over time (due to additions and new drug arrivals), the $250 amount is used as a reference gauge to help in determining whether to apply for prior authorization. While the CeltiCare Medical Director and CeltiCare Director of Pharmacy Services oversee the clinical review, Caremark Specialty Pharmacy is responsible for administering the PA process. Below is a list of the most commonly prescribed Biopharmaceuticals products requiring PA. Due to changing market conditions this list is not all inclusive. ACTHAR ELAPRASE InFED* NEXAVAR REMICADE TEMODAR ACTIMMUNE ELIGARD INFERGEN NORDITROPIN REMODULIN TEV-TROPIN ADAGEN* ENBREL INNOHEP NOVANTRONE REVATIO THALOMID ADVATE EPOGEN INTRON A NOVOSEVEN REVLIMID THYMOGLOBULN ALDURAZYME EPOPROSTENOL IPLEX* NUTROPIN RHOPHYLAC THYROGEN ALFERON N EUFLEXXA IRESSA* OCTAGAM RIBAPAK TOBI ALPHANATE EXJADE IVEEGAM OCTREOTIDE RIBASPHERE TRACLEER ALPHANINE SD FABRAZYME KINERET OMNITROPE RIBATAB TRELSTAR AMEVIVE FEIBA VH KOATE-DVI ORENCIA RIBAVIRIN TRETINOIN* ARALAST FERRLECIT* KOGENATE FS ORTHOVISC RISPERDAL TYKERB ARANESP FLEBOGAMMA LETAIRIS PANGLOBULIN RITUXAN TYSABRI ARIXTRA FLOLAN* LEUKINE PANHEMATIN* ROFERON-A VANTAS ATGAM FORTEO LEUPROLIDE PEGASYS SAIZEN VENOFER* AVONEX FRAGMIN LOVENOX PEG-INTRON SANDIMMUNE VENOGLOBUL AZASAN FUZEON LUCENTIS POLYGAM SANDOSTATIN VENTAVIS BEBULIN VH GAMASTAN LUPRON DEPOT PRIALT SENSIPAR VESANOID BENEFIX GAMMAGARD LUPRON PROCRIT SEROSTIM VIADUR BETASERON GAMUNEX MACUGEN PROFILNINE SIMULECT VISUDYNE BONIVA* GENOTROPIN MITOXANTRONE PROGRAF SOLIRIS VITRASERT* BOTOX GLEEVEC MONARC-M PROLASTIN* SOMATULINE* VIVAGLOBIN CARIMUNE HELIXATE MONOCLATE-P PROLEUKIN SOMAVERT VIVITROL CELLCEPT IV HEMIN* MONONINE PROPLEX T SPRYCEL XELODA CEREDASE HEMOFIL-M MYOBLOC PULMOZYME SUPARTZ XOLAIR CEREZYME HUMATE-P MYOZYME RAPTIVA SUPPRELIN ZAVESCA* COPAXONE HUMATROPE NAGLAZYME REBETOL SUTENT ZEMAIRA* COPEGUS HUMIRA NATRECOR* REBIF SYNAGIS ZENAPAX CYCLOSPORINE HYALGAN NEULASTA RECLAST* SYNVISC ZOLADEX IMMUNE CYTOGAM GLOBULIN NEUMEGA RECOMBINATE TARCEVA ZOLINZA DEXFERRUM* INCRELEX NEUPOGEN REFACTO TASIGNA ZORBTIVE * Indicates the product is not provided by Caremark. Requests for these products should be faxed to CeltiCare at or call CeltiCare at Use the following guidelines for efficient processing of your PA request.physicians can request that Caremark Specialty Pharmacy deliver the biopharmaceutical product or specialty injectable to their office or to the member s home: 1. Call Caremark Specialty Pharmacy at or fax Caremark Specialty Pharmacy the Caremark Enrollment Form to for Prior Authorization. 2. If approved, Caremark will contact the physician or member for delivery confirmation. 33

34 Exclusions from Coverage The following services are not covered benefits by CeltiCare. Acupuncture Excluded Benefit Alternative Medicine Benefits from a Another Source Biofeedback Chiropractic Services Commercial Diet Programs, Foods, and Supplements Cosmetic Services and Procedures Custodial and Personal Care Services Dental Services Description Benefit coverage is not provided for acupuncture except if authorized as part of a substance abuse program. Benefit coverage is not provided for alternative medicine such as but not limited to homeopathy, naturopathy, traditional Chinese medicine, and Ayurveda. Benefit coverage is not provided for services and supplies to treat an illness or injury for which you have the right to benefits under government programs. These include services from the Veterans Administration for an illness or injury connected to military service, schools, or programs set up by other local, state, federal or foreign laws or regulations that provide or pay for healthcare services and supplies or that require care or treatment to be furnished in a public facility. No benefit coverage is provided if you could have received governmental benefits by applying for them on time. Additionally, no benefit coverage is provided for services which payment is required to be paid by a Workers Compensation plan or an employer under state or federal law. Benefit coverage is not provided for biofeedback except if authorized for urinary incontinence. Benefit coverage is not provided for chiropractic services including but not limited to evaluation, treatment procedures, equipment, and supplies. Benefit coverage is not provided for commercial diet plans and foods (i.e. Jenny Craig, Weight Watchers, Seattle Sutton), weight loss or weight control programs and clinics, and any service related to such plans or programs (such as required foods or nutritional, vitamin, or mineral supplements). Benefit coverage is not provided for services performed solely for the purpose of making you look better whether or not these services are meant to make you feel better about yourself or treat a mental condition are not a covered. Such services include but are not limited to acne surgery, brachioplasty, hair removal or restoration, liposuction, panniculectomy, rhinoplasty, spider veins treatment, tattoo removal, whitening treatments or procedures for teeth, wrinkle treatment, vitiligo or melasma treatment. No benefit coverage is provided for cosmetic surgery unless required to restore bodily function or correct a functional physical impairment following an accidental injury, prior surgical procedure, or congenital/birth defect. Benefit coverage is not provided for care that is furnished mainly to help a person with activities of daily living and does not require day-to-day attention by medically trained persons. Benefit coverage is not provided for non-emergent dental services for Plan Type II or III or the Commonwealth Care Bridge population.. Nonemergent dental services include diagnostic, endodontic, exodontic, orthodontic, preventative, periodontal, or restorative dental services, and dentures. Benefit coverage is provided for all Plan Types for emergent/emergency dental services. Covered emergent/emergency dental services include treatment related to traumatic injury to sound, natural and permanent teeth caused by a source external to the mouth AND the emergency services are provided by a physician in a hospital emergency room or operating room within 48 hours of the injury. Services covered for emergent/emergency include x-rays and emergency oral surgery related to the repair of damaged tissues and/or the repositioning of displaced or fractured teeth. 34

35 Educational Evaluation, Testing, and Treatment Services Exams and Services Required by a Third Party Excluded locations Exercise Equipment and Supplies Experimental or Investigational Procedures and Related Services Foot Care Health Club Memberships and Personal Trainers Hearing Aids Hospice Hypnotherapy and Hypnosis Infertility Treatment Lodging and Transportation Massage Therapy Maternity Non-participating Providers Orthodontics Benefit coverage is not provided for educational services or evaluation provided solely to enhance educational achievement (e.g. subject achievement testing, IQ testing ); resolve problems regarding school performance; treat learning disabilities, behavior problems, and/or developmental delays; or school based services to treat speech, language, and/or hearing disorders. Benefit coverage is not provided for physical, psychiatric and psychological examinations, testing, or other services required by a third party, including but not limited to employment, insurance, licensing, recreational or sport activities, and court-ordered or school ordered exams and drug testing that are not Medically Necessary, considered evaluations for work related performance, or are for paternity, forensic, or post-mortem purposes. Benefit coverage is not provided for services provided to members in jail, prison, a house of correctional or custodial facility or in long-term residential treatment. Benefit coverage is not provided for charges related to the use, rental, or purchase of exercise equipment and devices or related supplies such as but not limited to treadmills, weights, or other gym equipment. Benefit coverage is not provided for healthcare services that are received for or related to care that is determined by CeltiCare as or related to an experimental or investigational service or procedure. Benefit coverage is also not provided for services provided pursuant to a qualified clinical trial as set forth in M.G.L. Chapter 175, section 110L. Benefit coverage is not provided for routine foot care services such as trimming of corns and calluses, trimming of nails, and other hygienic care; foot orthotics, arch supports, shoe inserts, fittings, castings and other services related to devices, or orthopedic or corrective shoes that are not part of a leg brace except when your care is Medically Necessary due to systemic circulatory diseases (such as diabetes). Benefit coverage is not provided for charges related for joining or the use of health clubs, gyms, sports clubs, related physical fitness facilities, or services provided by a personal trainer, unless a specific discount or reimbursement is offered as part of your benefit plan with CeltiCare. Benefit coverage is not provided for hearing aid devices and supplies, examinations to prescribe, or fittings. Benefit coverage is not provided for hospice care for the Commonwealth Care Bridge population. Benefit coverage is not provided for hypnotherapy or hypnosis. Benefit coverage is not provided for the diagnosis or treatment of infertility, including, but not limited to diagnostic procedures or testing; oral and injectable drug therapy; artificial insemination; egg and inseminated egg procurement and placement; in-vitro fertilization; gamete or zygote intra-fallopian transfers; intracytoplasmic sperm injection; sperm, banking of sperm or inseminated eggs; services and fees related to achieving pregnancy through surrogate; or reversal of voluntary sterilization. Benefit coverage is not provided for lodging and non-emergent or unauthorized transportation associated with receiving medical services. Benefit coverage is not provided for massage or relaxation therapy. Benefit coverage is not provided for routine maternity services for prenatal and postpartum care when you are temporarily traveling outside of the CeltiCare service area and/or are provided without CeltiCare; or planned home births. Benefit coverage is not provided for services provided by a nonparticipating provider except those provided due to an emergency medical condition or authorized by CeltiCare. Benefit coverage is not provided for the prevention or correction of abnormally positioned or aligned teeth. 35

36 Other Non-Covered Services Personal Comfort and Convenience Items or Services Benefit coverage is not provided for: Any service or supply that is not a described as a Covered Benefit for your Plan Type. A provider s charge for shipping and handling or taxes. Any service or supply that is not medically necessary. A provider s charge to file a claim. A provider s charge for copies of your medical records. A provider s charge for missed appointments. Medications, devices, treatments and procedures that have not been demonstrated to be medically effective. Routine Care when traveling outside the CeltiCare service area. Services for which there would be no charge in the absence of insurance. Special equipment needed for sports or job purposes. Services or supplies provided by an immediate family member. Services related or provided in conjunction with a non-covered service, such as professional fees, medical equipment, medications, and facility charges. Services received when not enrolled with CeltiCare. Services that can safely and effectively be obtained in a less intensive setting or level or care or for which a more cost-effective alternative exists. Benefit coverage is not provided for personal comfort or convenience items or services that are furnished for your personal care or for the convenience of your family. The following items are generally deemed personal comfort or convenience items: Air conditioners Air purifiers Bath/bathing equipment such as aqua massagers and turbo jets Bed lifters that are not primarily medical in nature Beds and mattresses and non-hospital type adjustable beds Chair lifts 1) Computers and/or computer software 2) Computerized communication devices 3) Cushions, pads and pillows except those described as covered 4) Dehumidifiers 5) Elevators 6) Electronic or myoelectronic limbs 7) Heating pads and/or hot water bottles 8) Home type bed baths requiring installation 9) Hospital beds in full, queen and king sizes 10) Hygienic equipment that does not service a primary medical purpose. 11) Non-medical equipment otherwise available to the member that does not serve a primary medical purpose 12) Private room charges greater than the rate for a semiprivate room except when a private room is medically necessary. 13) Pulse tachometers 14) Replacement or repair of durable medical equipment, prosthetic, or orthotic devices due to loss, intentional damage, negligence, or theft. 15) Room humidifiers 16) Spare or back-up equipment 17) Special clothing except medically necessary equipment or devices such as gradient pressure support aids, mastectomy bras, stump socks, and therapeutic molded shoes for diabetic foot disease. 18) Whirlpool equipment generally used for soothing or comfort measures. 19) Telephones, radios and televisions 36

37 Pre-implantation Genetic Testing Private Duty Services Refractive Eye Surgery Respite care Reversal of Voluntary Sterilization Benefit coverage is not provided for pre-implantation genetic testing or related services performed on gametes or embryos. Benefit coverage is not provided for private duty services including but not limited to those provided by a nurse (Licensed Professional Nurse or Registered Nurse) nursing assistant, nursing aid, private care attendant, or personal care attendant. Benefit coverage is not provided for eye surgery such as but not limited to laser surgery, radial keratotomy, and orthokeratology to treat conditions such as myopia, hyperopia, and astigmatism which can be corrected by means. Benefit coverage is not provided for respite care except when provided as part of a hospice program authorized by CeltiCare. Benefit coverage is not provided for the reversal of voluntary sterilization. Self-Monitoring Devices Benefit coverage is not provided for self-monitoring devices except: Blood glucose monitoring devises for enrolles with diabetes (insulin dependent or non-insulin dependent) and gestational diabetes. CeltiCare determines a device would give a member, having particular symptoms the ability to detect or stop the onset of a sudden life-threatening condition. Peak flow meters used in the monitoring of asthma control. Sexual/Gender Reassignment Benefit coverage is not provided for sexual reassignment surgery (sex change or reversal of a sex change) and all related drugs and procedures. Skilled-Nursing Benefit coverage is not provided for skilled nursing services for the Commonwealth Care Bridge population. Snoring Treatments and Procedures Benefit coverage is not provided for the treatment or reduction of snoring such as laser-assisted uvulopalatoplasty, somnoplasty, and snore guards. TMJ Syndrome Benefit coverage is not provided for services to treat temporomandibular joint syndrome. Vision Services Benefit coverage is not provided for routine or non-routine vision services for the Commonwealth Care Bridge population.. These services include routine eye exams, prescriptions eyeglasses, contact lenses and all eye exams for the treatment of medical conditions of the eye. 37

38 COVERED SERVICES The following offers information regarding Commonwealth Care covered benefits, applicable co-payments and benefit limitations. The member is responsible for co-payments, if required, at the time of service and fully responsible for any non-covered services. Some covered services may require prior authorization by CeltiCare before services are provided. The benefit year is from July 1 to June 30. Please refer to the preceding Services Requiring Authorization and Exclusions From Coverage grids for more information. Plan Type I Covered Benefit Co-Payment Outpatient Medical Care Community Health Center Visits (PCP/Specialists) $0 Office Visits (PCP/Specialists) $0 Outpatient Surgery (Hospital and Ambulatory Surgery Centers) Abortion Services $0 X-rays/Labs $0 Inpatient Medical Care Room and Board (deliveries/surgery/x-rays/labs) $0 Prescription Drugs Medication via Pharmacy (1 month supply) * Generics for treatment of high blood pressure, high cholesterol, and diabetes Generics* $1 Generic $2 Brand $3 Emergency Care $0 Inpatient Mental Health & Substance Abuse $0 Outpatient Mental Health & Substance Abuse $0 Methadone Treatment (dosing, counseling, labs) $0 Rehabilitation Services Cardiac Rehabilitation $0 Home Health Care $0 Inpatient Rehabilitation Services (combined 100 days per Contract Year) Skilled Nursing Facility $0 Inpatient Rehabilitation or Chronic Disease Hospital $0 Short-term outpatient rehabilitation (Physical/Occupational/Speech Therapy) $0 Other Benefits Ambulance (emergency only) $0 Dental (restorative/preventative/radiography/diagnostic/prosthodontic/oral surgery) $0 DME/Supplies/Prosthetics/Oxygen & Respiratory Therapy Equipment $0 Hospice $0 Orthotics (diabetics only) $0 Routine foot care (for diabetics) $0 Vision (exam and glasses every 24 months) $0 Wellness (family planning/nutrition/prenatal/nurse midwife) $0 Annual Out-of-Pocket Expenses per benefit year Maximum amount Pharmacy $200 38

39 Plan Type II Covered Benefit Co-Payment Outpatient Medical Care Community Health Center Visits (PCP/Specialists) $10/$18 Office Visits (PCP/Specialists) $10/$18 Outpatient Surgery (Hospital and Ambulatory Surgery Centers) $50 Abortion Services $50 X-rays/Labs $0 Inpatient Medical Care Room and Board (deliveries/surgery/x-rays/labs) $50* Prescription Drugs Medication via Pharmacy (1 month supply) Generic $10 Brand Preferred $20 Brand Non-Preferred $40 Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) Generic $20 Brand Preferred $40 Brand Non-Preferred $120 Emergency Care $50** Inpatient Mental Health & Substance Abuse***** $50* Outpatient Mental Health & Substance Abuse ***** $10 Methadone Treatment (dosing, counseling, labs) $0 Rehabilitation Services Cardiac Rehabilitation $0 Home Health Care $0 Inpatient Rehabilitation Services (combined 100 days per Benefit Year) Skilled Nursing Facility $0 Inpatient Rehabilitation or Chronic Disease Hospital $50* Short-term outpatient rehabilitation (Physical/Occupational/Speech Therapy)*** $10 Other Benefits**** Ambulance (emergency only) $0 DME/Supplies/Prosthetics/Oxygen & Respiratory Therapy Equipment $0 Hospice $0 Orthotics (diabetics only) $0 Routine foot care (for diabetics) $5 Vision (exam and glasses every 24 months) $10 Wellness (family planning/nutrition/prenatal/nurse midwife) $0 *Co-pay waived if transferred from another inpatient unit. **Co-pay waived if admitted to an inpatient unit. ***20 combined sessions of PT/OT/ST unless waived with prior authorization. ****Plans may offer additional benefits, but the additional costs are not part of the rate submission. Annual Out-of-Pocket Expenses per benefit year Maximum amount All Services (excluding Pharmacy) $750 Pharmacy $500 39

40 Plan Type III Covered Benefit Co-Payment Outpatient Medical Care Community Health Center Visits (PCP/Specialists) $15/$22 Office Visits (PCP/Specialists) $15/$22 Outpatient Surgery (Hospital or Ambulatory Surgery Center) $125 Abortion Services $100 X-rays/Labs $0 Inpatient Medical Care Room and Board (deliveries/surgery/x-rays/labs) $250* Prescription Drugs Medication via Pharmacy (1 month supply) Generic $12.50 Brand Preferred $25 Brand Non-Preferred $50 Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) Generic $25 Brand Preferred $50 Brand Non-Preferred $150 Emergency Care $100** Inpatient Mental Health & Substance Abuse $250* Outpatient Mental Health & Substance Abuse $15 Methadone Treatment (dosing, counseling, labs) $0 Rehabilitation Services Cardiac Rehabilitation $0 Home Health Care $0 Inpatient Rehabilitation Services (combined 100 days per Benefit Year) Skilled Nursing Facility $0 Inpatient Rehabilitation or Chronic Disease Hospital $250* Short-term outpatient rehabilitation (Physical/Occupational/Speech $20 Therapy) Other Benefits**** Ambulance (emergency only) $0 DME/Supplies/Prosthetics/Oxygen & Respiratory Therapy 10% of cost Equipment Hospice $0 Orthotics (diabetics only) $0 Routine foot care (for diabetics) $10 Vision (exam and glasses every 24 months) $20 Wellness (family planning/nutrition/prenatal/nurse midwife) $0 *Co-pay waived if transferred from another inpatient unit. **Co-pay waived if admitted to an inpatient unit. ***20 combined sessions of PT/OT/ST unless waived with prior authorization. ****Plans may offer additional benefits, e.g. dental, but the additional costs are not part of the rate submission. Annual Out-of-Pocket Expenses per benefit year Maximum amount All Services (excluding Pharmacy) $1,500 Pharmacy $800 40

41 41

42 Commonwealth Care Bridge Outpatient Medical Care Covered Benefit Co-Payment Community Health Center Visits (Primary Care and Specialist) $0/$25 Office Visits (Primary Care and Specialist) $0/$25 Outpatient Surgery (Hospital and Ambulatory Surgery Centers) $50 Abortion Services $50 X-rays/Labs $0 Inpatient Medical and Maternity Care Room and Board (includes deliveries/surgery/x-rays/labs) $250* Prescription Drugs Medication via Pharmacy (1 month supply) Generic $0 Brand Preferred $50 Non-Preferred Brand $50 Maintenance Medication via CeltiCare Mail-Order Plan (3 month supply) Generic $0 Brand Preferred $100 Non-Preferred Brand $100 Emergency Care $100 Inpatient Mental Health & Substance Abuse***** $250 Outpatient Mental Health & Substance Abuse ***** $25 Methadone Treatment (dosing, counseling, labs) $0 Rehabilitation Services Cardiac Rehabilitation $0 Home Health Care $0 Inpatient Rehabilitation (combined 100 days per Contract Year) Inpatient Rehabilitation or Chronic Disease Hospital $250 Short-term outpatient rehab (Physical, Occupational, &/or $25 Speech Therapy)*** Other Benefits**** Ambulance (emergency only) $0 Durable Medical Equipment, Supplies, Prosthetics, Oxygen & $50 Respiratory Therapy Equipment Orthotics (for diabetics) $0 Routine foot care (for diabetics) $10 24/7 Nurse Triage Hotline**** $0 CentAccount Healthy Rewards Program****** $0 Wellness (Family Planning, Nutritional Counseling, Prenatal, and $0 Nurse Midwife) Annual Out-of-Pocket Expenses per benefit year Maximum amount All Services (excluding Pharmacy) $1000 Pharmacy None *Co-pay waived if transferred from another inpatient unit. **Co-pay waived if admitted to an inpatient unit. ***20 combined sessions of PT/OT/ST unless waived with prior authorization. ****Plans may offer additional benefits, but the additional costs are not part of the rate submission. *****Inpatient and Outpatient Mental Health & Substance Abuse services are covered in accordance with medical necessity and may be subject to pre-authorization. ******Members can earn up to $150 in the first year by completing healthy behaviors. Funds may be used towards copays or other healthcare related expenses.. 42

43 CELTICARE CASE/CARE MANGEMENT SERVICES Case management or care coordination is a collaborative process of assessment, planning, coordinating, monitoring, and evaluation of the services required to meet an individual member s needs. Case management serves as a means for achieving member wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. The goal of case management is provision of quality healthcare along a continuum, decreased fragmentation of care across settings, enhancement of the member s quality of life, and efficient utilization of patient care resources. CeltiCare s case manager works with the member and the PCP to help identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner. In order to optimize the outcome for all concerned, case management services are best offered in a climate that allows direct communication between the case manager, the member, and appropriate service personnel, while maintaining the member s privacy, confidentiality, health and safety through advocacy and adherence to ethical, legal, accreditation, certification and regulatory standards or guidelines. The PCP maintains responsibility for the patient s ongoing care needs. CeltiCare s care manager supports the physician by tracking compliance with the case management plan and facilitating communication by actively linking the member to the PCP and other members of the care management team where support services are needed. The case manager also facilitates referrals and linkages to community practitioners such as local health departments, specialty clinics, social and other support services where needed. Case Management Process for CeltiCare for high risk, complex or catastrophic conditions contains the following key elements: Screen and identify members who potentially meet the criteria for case management. Assess the member s risk factors to determine the need for case management and obtain member s agreement. Notify the member and their PCP of the member s enrollment in the CeltiCare case management program. Develop and implement a care plan that accommodates the specific cultural and linguistic needs of the member. Ensure timely and coordinated access to all Medically Necessary Covered Services. Ensuring the use of clinical protocols and approaches to the provision of medical care when choosing treatment and medications; and ensuring the development of a hospital inpatient discharge protocol appropriate to the member when followup services are needed. Establishment of care objectives and monitoring of outcomes. Refer and assist the member in ensuring timely access to providers. Coordinate and establish linkages with other agencies, medical, residential, social, behavioral, and other support services. Monitor care/services. Revise the care plan as necessary. Track plan outcomes. Follow-up post discharge from case management. The following are short descriptions of programs implemented for CeltiCare to assist members in applicable circumstances. 43

44 CONTINUITY OF CARE In some instances CeltiCare will authorize payment of services performed by a provider other than the CeltiCare PCP. The services initiated prior to the member s enrollment with CeltiCare must have been covered under a previous carrier or government sponsored program and be covered services under CeltiCare. These services shall be continued until the member is evaluated by their PCP and a new plan of care is established. Authorization is typically for a period of no longer than 30 days, or until a participating provider with equivalent expertise can be identified. Transplant Case Management Transplant Case Management is provided for all members considered as potential transplant candidates. Providers should contact the CeltiCare an Case Management Department for assessment and case management services. Each candidate is evaluated for coverage requirements and will be referred to the appropriate agencies and transplant centers. Services will be communicated to and coordinated through the PCP. Chronic and Complex Conditions. CeltiCare provides individual case management services for members who have chronic, complex, high-risk, high-cost or other catastrophic conditions and end-of-life care. Members with special healthcare needs are included in the chronic and complex case management-care coordination program. The CeltiCare case manager will work with all involved providers to coordinate care, provide referral assistance, and other support as required. Members who qualify for chronic or complex case management services have an ongoing physical, behavioral or cognitive disorder, including chronic illnesses, impairments and disabilities. These limitations are expected to last at least twelve (12) months with a resulting functional limitation, reliance on compensatory mechanisms such as medications, special diet, or assistive device, and require service use or need beyond that which is normally considered routine. The CeltiCare case manager will coordinate care needs including behavioral health needs, assist in identifying and obtaining supportive community resources, and arrange for long-term referral services as needed. The case manager may identify (and a member may request) a specialist with whom a member with a chronic condition and an on-going relationship who may serve as the PCP and coordinate services on the member s behalf. These requests must be reviewed and approved by the CeltiCare Medical Director. Members determined to need a course of treatment or regular care monitoring may have direct access to a specialist as appropriate for the member s condition and identified needs, such as through a standing referral or an approved number of visits. A member s PCP will develop a treatment plan with the member s participation and in consultation with any specialists caring for the member. The CeltiCare Medical Director oversees these processes in accordance with Massachusetts standards. CeltiCare encourages all PCPs and physicians to notify CeltiCare Case Management when a member is identified that meets the criteria for a chronic or complex condition. Such conditions may include but are not limited to comorbid physical and behavioral health conditions, expected poor birth outcome, infectious diseases, sexually transmitted diseases, nutrition, child development, physical and sexual abuse, substance abuse, severe disability, frostbite, hypothermia and psychosocial issues. 44

45 Maternal/Perinatal Program Pregnancy, labor and delivery often account for a large proportion of complications of care. For members who remain with CeltiCare after a diagnosis of pregnancy, those at high risk for complications of pregnancy and poor neonatal outcomes are provided care coordination services through our Start Smart for Your Baby perinatal program. The goals of the program are to screen all pregnant women, identify and coordinate care for pregnant women who are at high-risk for complications of pregnancy and assure that all members have access to appropriate care for diagnosis, monitoring and treatment of pregnancy. Any high-risk ancillary service must be authorized by the CeltiCare perinatal program nurse. Ancillary services include but are not limited to home pregnancy monitoring, home infusion therapy, provision of 17alpha-hydroxyprogesterone caproate (17-P), education or testing, provision of DME, and more than two OB routine ultrasounds. To contact our perinatal case manager call or fax CeltiCare will provide educational opportunities to inform our members about the benefits and risks associated with behaviors that may affect the outcome of their pregnancy and facilitate transitions to home when outcomes are less than ideal. We will provide educational opportunity and support for pregnant women and their partners about appropriate care of newborns as well as identifying pediatric providers for their newborns and access to care for their newborn. When an event occurs resulting in an early delivery and resultant admission to a Neonatal Intensive Care Unit, our Case Manager will work with the hospital neonatal providers, discharge planners, and managing pediatric provider to ensure a smooth transition to MassHealth as well as coordination of ongoing follow-up care as needed with MassHealth. CeltiCare offers a premature delivery prevention program by supporting the use of 17-P. When a physician determines that a member is a candidate for 17-hydroxyprogesterone, which use has shown a substantial reduction in the rate of recurrent preterm delivery among women who were at a particularly high risk for preterm delivery, he/she will write a prescription for 17-P. This prescription is sent to the CeltiCare Case Manager who will check for eligibility. The CM will coordinate the ordering and delivery of the 17-P directly to the physician s office. A perinatal case manager will contact the member and do an assessment regarding compliance. The nurse will remain in contact with the member and the prescribing physician during the entire treatment period. Contact the CeltiCare perinatal nurse for enrollment in the 17-P program. Providers are asked to contact a CeltiCare Case Manager to refer a member identified in need of care coordination intervention: Emergency Department Diversion Program CeltiCare has developed a program in conjunction with Nurse Wise, our 24/7 Nurse Line, to review services for emergency department usage on members who frequent the emergency department (ED) three or more times in six months. If NurseWise receives a call from a member with intent to visit the ED, but triage criteria point the member to the PCP s office, the NurseWise nurse will refer this information on the member to the CeltiCare for follow-up the next day. CeltiCare will also run claim reports to identify members who frequent the ED three or more times within six months with a diagnosis that does not appear to meet the prudent layperson definition. The Case Management Team will follow up with these members, and will notify the assigned PCP of the members frequent use of the ED so that the PCP can request the member to schedule an annual visit or arrange for follow-up care. 45

46 Case Management Program Fax CELTICARE MEMBERCONNECTIONS PROGRAM CeltiCare believes that it is important to provide education to our members on how to access healthcare and develop healthy lifestyles in a setting where they feel most comfortable. CeltiCare s MemberConnections program is an outreach program designed specifically to accomplish this goal. The MemberConnections program has several existing components all of which can be modified to meet the needs of the area of service. The Connections Representatives are visible liaisons between CeltiCare and the community served. The program recruits staff from the communities served, at times providing jobs for former Medicaid recipients. In addition, Connections Representatives establish grassroots support and awareness of CeltiCare within the community. Various program components are provided depending on the needs of the members. Community Connections Community Connections include presentations within the community served about the services of CeltiCare, Commonwealth Care program, and a variety of community resources. Examples of topics covered during Community Connections include but are not limited to: Preventive health measures How to use Commonwealth Care Programs Accessing Prenatal and Post Partum Care Parenting classes How to obtain assistance in money management Members will be notified of the presentations through mailings, newsletters, and informational materials placed in health clinics and providers offices. When possible, a schedule will be generated and will be made available to all the CeltiCare staff for distribution to the community. At settings when permissible and feasible, the Health Plan will offer: Food/snacks Educational materials Promotional items Home Connections Home Connections are one-on-one meetings with members in their homes. Home Connections are most commonly done for new members, new moms and those members identified by case management and providers as needing outreach in their home environment. As part of a Home Connection, members will be encouraged and assisted with making appointments for medical services if they have not already done so. This will include appointments with physicians, Women s Health Care Providers, Behavioral Health Providers, Dentists, and Optometrists. Representatives will educate members on how to find or access medically necessary transportation services and will review important Health Plan phone numbers with members. Representatives will also provide members with information on available community resources, including provisions for emergency food, shelter, clothing and utility assistance. Please call the 46

47 MemberConnections department for information on how to access the home connections program. Phone Connections Phone Connections are outreach calls to members who do not wish home visits, cannot make the next Community Connection, or prefer interacting with CeltiCare by telephone. When staff initiates the Phone Connection, all efforts will be made to complete the presentation during that contact. Connections Plus CeltiCare will delivery a limited use cell phone to members referred by the PCP or case manager, screened as lacking other viable reliable phone access. Phones are preprogrammed with the case manager s number, the PCP, NurseWise, emergency contact, and others depending on the member s condition. To access any services provided by a Connections Representative, call CeltiCare at: MemberConnections FAX VALUE ADDED BENEFITS FOR CELTICARE MEMBERS CeltiCare has developed a package of Value Added Services for its members that includes benefits in addition to the Massachusetts Covered Services. The Value Added Services were designed to improve members well being, encourage responsible and prudent use of healthcare benefits and enhance the cost effectiveness of the Commonwealth Care Program. NURSEWISE Our members have many questions about their health, their primary care provider and access to emergency care. Our health plan offers a nurse line service to encourage members to talk with their physician and to promote education and preventive care. NurseWise is our 24-hour nurse line for members. The Registered Nurses provide basic health education, nurse triage and answer questions about urgent or emergency access, all day long. The staff often answers questions about pregnancy and newborn care. In addition, members with chronic problems, like asthma or diabetes, are referred to case management for education and encouragement to improve their health. Members may use NurseWise to request information about providers and services available in your community after the health plan is closed. Providers can use it to verify eligibility any time of the day. The NurseWise staff is conversant in both English and Spanish and can offer the Language Line for additional translation services. The nurses document their calls in a web-based data system using Barton Schmitt, M.D. triage protocols for pediatrics and McKesson proprietary of products to perform triage services for adults. These protocols are widely used in nurse call centers and have been reviewed and approved by physicians from around the country. 47

48 We provide this service to support your practice and offer our members access to an RN everyday. If you have any additional questions, please call Provider Services or NurseWise at START SMART for YOUR BABY Start Smart for Your Baby (Start Smart) is CeltiCare s program for women who are pregnant. This program provides educational materials that tackle the most critical issues affecting the child s development during pregnancy. Start Smart offers a preventive approach that encourages prenatal education for the expectant mother in an effort to achieve the best possible outcome. Start Smart encourages pregnant women to keep their prenatal care appointments; educates members and their families about pregnancy; identifies members who may be at high risk for developing complications; and provides support in dealing with medical, socioeconomic and environmental issues that may contribute to complications or inherit a member s ability to receive optimal healthcare. Identifying pregnant members as early as possible, providing them with adequate prenatal care and guidance as well as addressing complications as effectively as possible should result in improved outcomes for both the mother and the newborn baby. DOMESTIC VIOLENCE CeltiCare members may include individuals at risk for becoming victims of domestic violence. Thus, it is especially important that providers are vigilant in identifying these members. Member Services can help members identify resources to protect them from further domestic violence. For Massachusetts residents, you may refer victims of domestic violence to the National Domestic Violence Network hotline, at SAFE (7233) for information about local domestic violence programs and shelters within the state of Massachusetts. Providers should report all suspected domestic violence as described. Providers should comply with mandatory state reporting requirements relating to child abuse and neglect, gunshot wounds and other events as may required under Massachusetts law. CELTICARE DISEASE MANAGEMENT PROGRAMS CeltiCare also uses disease management programs and associated practice guidelines and protocols for members with chronic conditions, including conditions such as asthma and diabetes. As a part of the CeltiCare medical management quality improvement efforts, disease management programs are offered to members. Components of the programs available include but are not limited to: Increasing coordination between the medical, social and educational communities. Severity and risk assessments of the population. Profiling the population and providers for appropriate referrals to providers, including dental and/ or behavioral health providers. 48

49 Ensuring active and coordinated physician/ specialist participation. Identifying modes of delivery for coordinated care services such as; home visits, clinic visits, and phone contacts depending on the circumstances and needs of the member and his/her family. Increasing the member s and member s caregiver ability to self-manage chronic conditions. Coordination with CeltiCare case manager for intensive case management program. ASTHMA PROGRAM The asthma disease management program targets CeltiCare members with asthma who are over-using rescue medications, who are having repeated visits to the ED or are being admitted to the hospital with a primary diagnosis of asthma. Case managers will contact these members and provide additional education. The case manager may coordinate care with the member s PCP. The goals of this program include increasing positive clinical outcomes for the member and controlling the asthma in order to improve the quality of life for the member. CeltiCare asthma disease management program utilizes evidence-based guidelines sponsored by the National Asthma Education and Prevention Program, education, care assessment, in home visits for high risk members unable to be reached by telephone, initial phone visits, physician communication, and follow-up visits as indicated by the member s ability to self-manage and remain compliant with the plan of care. DIABETES PROGRAM This program targets CeltiCare members who have been diagnosed and treated for diabetes mellitus. Members are then stratified based on the severity of their illness so that interventions can be targeted to the appropriate population. Through this program, CeltiCare members can receive additional education, case management and support from the medical management team to enhance positive clinical outcomes. CLINICAL PRACTICE GUIDELINE CeltiCare preventive and clinical practice guidelines are based on the health needs and opportunities for improvement identified as part of the Quality Improvement Program (QIP).The guidelines are based on valid and reliable clinical evidence formulated by nationally recognized professional organizations or government institutions, such as the NIH or a consensus of healthcare professionals in the applicable field. The guidelines consider the needs of the members, are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. CeltiCare preventive and clinical practice guidelines are available on its website and are mailed to practitioners as part of disease management or other utilization or quality program initiatives. The guidelines are available on request to members. CeltiCare utilization management, member education, coverage of services, and other areas to which the guidelines apply are consistent with these guidelines. These guidelines are used for both preventive services as well as for the management of chronic diseases. Preventive and Chronic disease guidelines include, but are not limited to: Guidelines for Adult Preventive Care 49

50 Guidelines for Diagnosis and Management of Asthma Clinical Practice Guidelines for General Diabetes Care Clinical Practice Guidelines for Special Management Considerations in Gestational Diabetes Clinical Practice Guidelines for Preventive Health Maintenance of Sickle Cell Patients Guidelines for Detection of Chronic Kidney Disease Guidelines for Routine Antepartum Care The CeltiCare website provides access to new clinical practice guidelines as well as any updates or revisions to existing guidelines. 50

51 ROUTINE, URGENT AND EMERGENCY SERVICES NON-SYMPTOMATIC, SYMPTOMATIC NON-URGENT, URGENT AND EMERGENCY CARE SERVICES DEFINED Members are encouraged to contact their PCP prior to seeking care, although it is not required in an emergency. The following are definitions for non-symptomatic, symptomatic non-urgent, urgent, and emergency services. Non-Symptomatic Care: A non-symptomatic medical visit for one of the following: family planning, routine follow-up to a previously treated condition or illness, adult physicals or any other routine visit for other than the treatment of an illness. Care should be provided within 45 days of the members request to their PCP and 60 days to a specialist. Symptomatic, Non-Urgent Care: Non-urgent problems that do not substantially restrict normal activity, but could develop complications if left untreated. Requests for symptomatic care are to be provided by their PCP within 10 days of their request or by a specialist with 30 calendar days of a member s request. Examples include treatment of a cold, flu, or mild sprain or a complaint regarding a chronic disease. Urgent*: Services for conditions, which, though not life-threatening could result in serious injury or disability unless medical attention is received or do substantially restrict a member s activity. Urgent services are provided within 48 hours by a PCP or Specialist. Examples include high fever, animal bites, fractures, severe pain or infectious illnesses. Emergency* Medical Condition: An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson, who 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 or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, or serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. With respect to a pregnant woman: (1) that there is inadequate time to effect safe transfer to another Hospital prior to delivery; (2) that a transfer may pose a threat to the health and safety of the patient or fetus; (3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency Services area covered inpatient and outpatient services that are as follows: (1) furnished by a provider that is qualified to furnish these services under this title; and (2) needed to evaluate or stabilize an emergency medical condition. An emergency medical condition shall not be defined or limited based on a list of diagnoses or symptoms and should be treated immediately upon member presentation at the delivery site. 51

52 *Urgent or Emergency Care is not subject to prior authorization or pre-certification. Emergency Services must be provided by a qualified provider regardless of network participation. The PCP plays a major role in educating CeltiCare members about appropriate and inappropriate use of hospital emergency rooms. The PCP is responsible to follow up on members who receive emergency care from other providers. For billing information please refer to the General Billing Information and Guidelines section. The attending emergency room physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on CeltiCare However, CeltiCare may establish arrangements with a hospital whereby CeltiCare may send one of its own physicians with appropriate emergency room privileges to assume the attending physician s responsibilities to stabilize, treat, and transfer the member, provided that such arrangement does not delay the provision of emergency services. CeltiCare will not retroactively deny a physician claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergency in nature. However, the prudent layperson test will be applied to the payment to the facility for charges. Emergency services will be covered if an authorized representative, acting on behalf of CeltiCare referred the member to the ED. The facility should verify member eligibility as soon as possible after the member presents to the ED. In emergency medical conditions the facility should use its best efforts to contact the PCP, or in the case of a pregnant woman, the member s attending provider. The facility should document all attempts to contact the PCP or the obstetrician and determinations made on appropriate care. At no time should emergency services be withheld or delayed. When a member is admitted to the facility from the emergency room, either as an observation or inpatient admission, clinical data is required within two business days of the admission. For specific necessary information to submit, see the Inpatient Notification section of this manual. 52

53 ELIGIBILITY AND ENROLLMENT ELIGIBILITY FOR CELTICARE Members who qualify for eligibility under CeltiCare must be individuals who meet eligibility requirements through Commonwealth Health Insurance Connector Authority (Connector). The Connector determines eligibility in Commonwealth Care. Members are eligible for CeltiCare through Commonwealth Care s guidelines as follows: Must be a Massachusetts resident Family income before taxes is at or below 300% of the FPL Individual is uninsured (not eligible to obtain subsidized insurance from employer or a spouse s employer, school union or from another government program) Individual is a US citizen/national, qualified alien, or alien with special status Individual is 19 or older (eligible persons under age 19 may receive benefits through MassHealth) Member enrollment with CeltiCare is good for as long as their eligibility through Commonwealth Care is effective. Members are obligated to pay required premiums to Commonwealth Care for Plan II and III. To inquire about Commonwealth Care eligibility, enrollment options and benefits please have members contact the Connector. Commonwealth Care Health Insurance Connector Authority PO Box Boston, MA Telephone: MA-ENROLL ( ) TTY: :00 am to 5:00 pm Monday through Friday VERIFYING ENROLLMENT 53

54 Providers are responsible for verifying eligibility every time a member schedules an appointment, and when they arrive for services. PCPs should also verify that a member is their assigned member. Eligibility can be verified through the Recipient Eligibility Verification System (REVS) or: Call to reach the IVR System for quick eligibility verification or check online at (must have provider login) CeltiCare has the capability to receive an ANSI X12N 270 health plan eligibility inquiry and generate an ANSI X12N 271 health plan eligibility response transactions through CeltiCare. Providers also may verify member enrollment through CeltiCare s website at For more information on conducting these transactions electronically contact: CeltiCare c/o Centene EDI Department or by at: EDIBA@centene.com Until the actual date of enrollment with CeltiCare is not financially responsible for services the prospective member receives. In addition, CeltiCare is not financially responsible for services members receive after their coverage has been terminated. However, CeltiCare is responsible for those individuals who are CeltiCare members at the time of a hospital inpatient admission and change health plans during that confinement. NEWBORN ENROLLMENT CeltiCare will not be responsible for costs associated with newborns on or after the date of birth as they will be retroactively enrolled in the MassHealth program effective the date of birth, as soon as practicable. 54

55 NON-COMPLIANT MEMBERS NON-COMPLIANT MEMBERS There may be instances when a PCP feels that a member should be removed from his or her panel. A PCP may find that a satisfactory patient/provider relationship cannot be developed with a particular member. The PCP may request a member be transferred to another practice for any of the following reasons: Repeated disregard of medical advice Repeated disregard of member responsibilities Personality conflicts between physician and/or staff with member Disruptive behavioral impairs the providers ability to provide service to the member The PCP may discharge a member from his/her care after CeltiCare receives appropriate notification. First, the PCP must complete and send a request to discharge a member from their practice stating the reasons for the proposed discharge to: CeltiCare Provider Relations/Network Department 1380 Soldiers Field Road Brighton, MA After CeltiCare receives notification from the provider, the PCP must provide written notice to the member and send a copy of the notice to the Provider Relations Department. The PCP must provide at least thirty (30) days notice to the member to allow time for the Member Services Department to contact the member and assist them in selecting another PCP. The PCP is obligated to provide covered services to the member until the change is completed. CeltiCare will provide a listing of other available PCPs to the member. A PCP should never request a member be dis-enrolled for any of the following reasons: Adverse change in the members health status or utilization of services which are medically necessary for the treatment of a member s condition. On the basis of the member s race, color, national origin, sex, age, disability, political beliefs or religion. Previous inability to pay medical bills or previous outstanding account balances prior to the member s enrollment with CeltiCare. 55

56 BILLING AND CLAIMS GENERAL BILLING GUIDELINES Physicians, other licensed health professionals, facilities, and ancillary provider s contract directly with CeltiCare for payment of covered services. It is important that providers ensure CeltiCare has accurate billing information on file. Please confirm with your Provider Relations Department that the following information is current in our files: Provider Name (as noted on his/her current W-9 form) Provider National Provider Identifier (NPI) Tax Identification Number Taxonomy Code Physical location address (as noted on current W-9 form) Billing name and address (if different) Providers must bill with their NPI number in box 24Jb. We encourage our providers to also bill their taxonomy code in box 24Ja to avoid possible delays in processing. CeltiCare will return claims when billing information does not match the information that is currently in our files. Claims missing the requirements in bold will be returned, and a notice sent to the provider, creating payment delays. Such claims are not considered clean and therefore cannot be entered into the system. We recommend that providers notify CeltiCare in advance of changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a Provider s Tax Identification Number and/or address are NOT acceptable when conveyed via a claim form. Claims eligible for payment must meet the following requirements: The member is effective on the date of service, The service provided is a covered benefit under the member s contract on the date of service, and Referral and prior authorization processes were followed, if applicable. Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual. Providers must submit, all claims and encounters within 90 days of the date of service, unless CeltiCare or its vendors created the error. The filing limit may be extended where the eligibility has been retroactively received by CeltiCare, up to a maximum of 365 days. When CeltiCare is the secondary payor, CeltiCare must receive the claim within ninety (90) days of the final determination of the primary payor. For additional information on CeltiCare billing guidelines, please refer to our Billing Manual. 56

57 All requests for reconsideration or adjustment to paid claims must be received within 45 calendar days VERIFY from the date the notification of payment or denial is received. ELECTRONIC CLAIMS SUBMISSION Network providers are encouraged to participate in CeltiCare Electronic Claims/Encounter Filing Program. The plan has the capability to receive an ANSI X12N 837 professional, institution or encounter transaction. In addition, it has the ability to generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). For more information on electronic filing and what clearinghouses CeltiCare has partnered with, contact: CeltiCare c/o Centene EDI Department , extension or by at: Providers that bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims. Providers that bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters. PAPER CLAIMS SUBMISSION For CeltiCare members, all claims and encounters should be submitted to: CeltiCare ATTN: CLAIMS DEPARTMENT P.O. BOX 3080 Farmington, MO EFT AND ERA CeltiCare has partnered with Payformance to provide an innovative web based solution for Electronic Funds Transfers (EFT s) and Electronic Remittance Advices (ERA s). Through this free service, providers can take advantage of EFTs and ERAs to settle claims electronically. For more information, please visit our provider home page on our website at or to sign up for this quick and efficient service you may go directly to IMAGING REQUIREMENTS CeltiCare uses an imaging process for claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules: 57

58 Do s Do use the correct PO Box number Do submit all claims in a 9 x 12, or larger envelope Do type all fields completely and correctly Do use typed black or blue ink only Do submit on a proper original form... CMS 1500 or UB 04 Don ts Don t submit handwritten claim forms Don t use red ink on claim forms Don t circle any data on claim forms Don t add extraneous information to any claim form field Don t use highlighter on any claim form field Don t submit photocopied claim forms Don t submit carbon copied claim forms Don t submit claim forms via fax CLEAN CLAIM DEFINITION A clean claim means a claim received by CeltiCare for adjudication, in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider of the services in order to be processed and paid by CeltiCare. NON-CLEAN CLAIM DEFINITION Non-clean claims are submitted claims that require further investigation or development beyond the information contained therein. The errors or omissions in claims result in the request for additional information from the provider or other external sources to resolve or correct data omitted from the bill; review of additional medical records; or the need for other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues regarding medical necessity and include claims not submitted within the filing deadlines. WHAT IS AN ENCOUNTER VERSUS A CLAIM? You are required to submit an encounter or claim for each service that you render to a CeltiCare member. If you are the PCP for a CeltiCare member and receive a monthly capitation amount for services, you must file a proxy claim (also referred to as an encounter ) on a CMS 1500 for each service provided. Since you will have received a pre-payment in the form of capitation, the proxy claim or encounter is paid at zero dollar amounts. It is mandatory that your office submits encounter data. CeltiCare utilizes the encounter reporting to evaluate all aspects of quality and utilization management, and it is required by the state of Massachusetts and by Centers for Medicare and Medicaid Services (CMS). 58

59 A claim is a request for reimbursement either electronically or by paper for any medical service. A claim must be filed on the proper form, such as CMS 1500 or UB 04. A claim will be paid or denied with an explanation for the denial. For each claim processed, an Explanation of Payment (EOP) will be mailed to the provider who submitted the original claim. PROCEDURES FOR FILING A CLAIM/ENCOUNTER DATA CeltiCare encourages all providers to file claims/encounters electronically. See Electronic Claims Submission for more information on how to initiate electronic claims/encounters. Please remember the following when filing your claim/encounter: All documentation must be legible. PCPs and all participating providers must submit claims or encounter data for every member visit, even though they may receive a monthly capitation payment. Provider must ensure that all data and documents submitted CeltiCare, to the best of your knowledge, information and belief, are accurate, complete or truthful. All claims and encounter data must be submitted on either an original CMS 1500 or UB 04 form or by electronic media in an approved format. Review and retain a copy of the error report that is received for claims that have been submitted electronically, then correct any errors and resubmit with your next batch of claims. Providers must submit all claims and encounters within 90 days of the date of service, unless CeltiCare or its vendors created the error. All requests for reconsideration or adjustment to paid claims must be received within 45 days from the date the notification of payment or denial is received. When submitting claims where other insurance is involved, a copy of the EOB or rejection letter from the other insurance carrier must be attached to the claim. CeltiCare members must never be billed by any provider for covered services unless the criteria listed under Billing the Member is met. In a Worker s Compensation case for which CeltiCare is not financially responsible, the provider should directly bill the employer s Worker s Compensation carrier for payment. COMMON BILLING ERRORS In order to avoid rejected claims or encounters always remember to: Always bill the primary diagnosis in the first field. Use SPECIFIC CPT-4 or HCPCS codes. Avoid the use of non-specific or catchall codes (i.e ). Use the most current CPT-4 and HCPCS codes. Out-of-date codes will be denied. Use the 4 th or 5 th digit when required for all ICD-9 codes. Submit all claims/encounters with the proper provider number. Submit all claims/encounters with the member s complete CeltiCare ID number. Verify other insurance information entered on claim. 59

60 CLAIM PAYMENT Clean claims will be adjudicated (finalized as paid or denied) within thirty (30) business days of the receipt of the claim. CeltiCare will send providers written notification via the Explanation of Benefits for each claim that is denied, including the reason(s) for the denial; the date contractor received the claim. CeltiCare shall process, and finalize, all appealed claims to a paid or denied status within (30) business days of receipt of the Appealed Claim. CeltiCare shall finalize all claims, including appealed claims. Appealed claims mean claims regarding which a provider files a request for informal claims payment adjustment or a claim complaint CeltiCare. Note: It is the provider s responsibility to check their audit report to verify that CeltiCare has accepted their electronically submitted claim. UNSATISFACTORY CLAIM PAYMENT If a provider has a question or is not satisfied with the information they have received related to a claim, they should contact: Provider Services Department When submitting a paper claim for review or reconsideration of the claims disposition, the claim must clearly be marked as RE-SUBMISSION and [include the original claim number]. Failure to mark the claim as a resubmission and include the claim number or EOP may result in the claim being denied as a duplicate, or for exceeding the filing limit deadline Providers may discuss questions with CeltiCare Provider Services Representatives regarding amount reimbursed or denial of a particular service; providers may also submit in writing, with all necessary documentation, including the EOP for consideration of additional reimbursement Any response to approved adjustments will be provided by way of check with accompanying explanation of payment All disputed claims will be processed in compliance with the claims payment resolution procedure as described herein. For an explanation regarding how to request an informal claim payment adjustment or file a complaint, refer to the process described herein. BILLING FORMS Submit claims for professional services and durable medical equipment on a CMS The following areas of information on CMS 1500 claim forms are common submission requirements of a clean claim accepted for processing: Full member name Member s date of birth Valid member identification number Complete service level information: 60

61 o Date of service o Diagnosis o Place of service o Procedural coding (appropriate CPT-4, ICD-9 codes) o Charge information and units Servicing provider s name, address and NPI number Provider s federal tax identification number All mandatory fields must be complete and accurate Submit claims for hospital based inpatient and outpatient services as well as swing bed services on a UB 04. THIRD PARTY LIABILITY Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker's compensation) or program, that is, or may be, liable to pay all or part of the healthcare expenses of the member. CeltiCare is always the payer of last resort CeltiCare providers shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to CeltiCare members. If the provider is unsuccessful in obtaining necessary cooperation from a member to identify potential third party resources, the provider shall inform CeltiCare that efforts have been unsuccessful. CeltiCare will make every effort to work with the provider to determine liability coverage. If third party liability coverage is determined after services are rendered, CeltiCare will coordinate with the provider to pay any claims that may have been denied for payment due to third party liability. COMPLETING A CMS 1500 FORM All medical claims are to be submitted on the CMS The CMS 1500 claim form is required for: All professional services including specialists Individual practitioners Non-hospital outpatient clinics Transportation providers Ancillary Services Durable Medical Equipment Non-institutional expenses Professional and/or technical components of hospital based physicians and Certified Registered Nurse Anesthetists (CRNAs) Home Health Services 61

62 CMS 1500 STANDARD PLACE OF SERVICE CODES Place of Service Codes Not in Use 11 Office 12 Home Not in Use 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility Not in Use 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice Not in Use 41 Not Valid 42 Not Valid Not in Use 51 Inpatient Psychiatric Facility 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 54 Immediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center Not in Use 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 63, 64 Not in Use 65 End Stage Renal Disease Treatment Facility Not in Use 71 Massachusetts or Local Public Health Clinic 72 Rural Health Clinic Not in Use 81 Independent Laboratory Not in Use 99 Other Unlisted Facility COMPLETING A UB 04 CLAIM FORM A UB O4 is the only acceptable claim form for submitting inpatient or outpatient hospital (technical services only) charges for reimbursement by CeltiCare. In addition, a UB 04 is required when billing for nursing home services, swing bed services with revenue and occurrence codes, ambulatory surgery centers (ASC) and dialysis services. Incomplete or inaccurate information will result in the claim/encounter being rejected or denied for corrections. 62

63 UB 04 INPATIENT DOCUMENTATION The following information should be submitted along with the UB 04: Consent forms for hysterectomies, abortions, and sterilizations Specific additional information upon request by CeltiCare UB 04 HOSPITAL OUTPATIENT CLAIMS/AMBULATORY SURGERY The following information applies to outpatient and ambulatory surgery claims: Professional fees must be billed on a CMS 1500 claim form Include the appropriate CPT-4 code next to each revenue code BILLING THE MEMBER CeltiCare reimburses only services that are medically necessary and covered through Commonwealth Care. Providers can bill a member only if they provide proof that they attempted to obtain member insurance identification information within one hundred and eighty (180) days of service. MEMBER ACKNOWLEDGEMENT STATEMENT A provider may bill a member for a claim denied as not being medically necessary, not a covered benefit, or the member has exceeded the program limitations for a particular service only if the following condition is met: Prior to the service being rendered, the provider has obtained and kept a written Member Acknowledgement Statement signed by the client that Massachusetts: I understand that, in the opinion of (provider s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Commonwealth Care program as being reasonable and medically necessary for my care. I understand that CeltiCare through its contract with the state of Massachusetts determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care. For more detailed information on CeltiCare billing requirements, please refer to the Billing Guide. 63

64 CREDENTIALING CREDENTIALING REQUIREMENTS Fax: The credentialing and re-credentialing process exists to ensure that participating providers meet the criteria established by the CeltiCare, as well as government regulations and standards of accrediting bodies. Notice: In order to maintain a current provider profile, providers are required to notify the CeltiCare of any relevant changes to their credentialing information in a timely manner. Physicians must submit at a minimum the following information when applying for participation with CeltiCare: Complete signed and dated Massachusetts Standardized Credentialing application or CAQH (Council for Affordable Quality Health Care) see Attachment x for CAQH application. Signed attestation of the correctness and completeness of the application, history of loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions; lack of current illegal substance registration and/or alcohol abuse; mental and physical competence, and ability to perform the essential functions of the position, with or without accommodation. Copy of current malpractice insurance policy face sheet that includes expiration dates, amounts of coverage and provider s name, or evidence of compliance with Massachusetts regulations regarding malpractice coverage. Copy of current Massachusetts Controlled Substance registration certificate (if applicable). Copy of current Drug Enforcement Administration (DEA) registration Certificate. Copy of W-9. Copy of Educational Commission for Foreign Medical Graduates (ECFMG) certificate, if applicable. Copy of cultural competency training certificate, if applicable. Copy of current unrestricted Medical License to practice in the state of Massachusetts. Current copy of specialty/board certification certificate, if applicable. Curriculum vitae listing, at minimum, a five-year work history. Signed and dated release of information form. Proof of highest level of education copy of certificate or letter certifying formal post-graduate training. Copy of current Patient Care Compensation Fund (if applicable). Copy of Clinical Laboratory Improvement Amendments (CLIA) (if applicable). Copy of enumeration letter issued by NPPES (National Plan and Provider Enumeration System), depicting the providers unique National Provider Identifier (NPI). 64

65 CeltiCare will verify the following information submitted for Credentialing and/or Recredentialing: Massachusetts license through appropriate licensing agency Board certification, or residency training, or medical education National Practitioner Data Bank (NPDB) and HIPDB claims Hospital privileges in good standing at a participating CeltiCare hospital Review five (5) years work history Review federal sanction activity including Medicare/Medicaid services (OIG- Office of Inspector General and EPLS- Excluded Parties Listing) Once the application is completed, the CeltiCare Credentialing Committee will render a final decision on acceptance following its next regularly scheduled meeting. Providers must be credentialed prior to accepting or treating members. PCPs cannot accept member assignments until they are fully credentialed. CREDENTIALING COMMITTEE The Credentialing Committee has the responsibility to establish and adopt, as necessary, criteria for provider participation, termination, and direction of the credentialing procedures; including provider participation, denial and termination. Committee meetings are held at least quarterly and more often as deemed necessary. FAILURE OF AN APPLICANT TO ADEQUATELY RESPOND TO A REQUEST FOR INFORMATION MAY RESULT IN TERMINATION OF THE APPLICATION PROCESS. Site visits are performed at practitioner offices within 60 days any member complaints related to physical accessibility, physical appearance, and adequacy of waiting and examining room space. If the practitioner s site visit score is less than 80 percent, the practitioner may be subject to termination and/or continued review until compliance is achieved. A site review evaluates appearance, accessibility, record-keeping practices and safety procedures. RE-CREDENTIALING To comply with Accreditation Standards, CeltiCare conducts the re-credentialing process for providers at least every two years from the date of the initial credentialing decision. The purpose of this process is to identify any changes in the practitioner s licensure, sanctions, certification, competence, or health status which may affect the ability to perform services the provider is under contract to provide. This process includes all practitioners; primary care providers, specialists, and ancillary providers/ facilities previously credentialed to practice within the CeltiCare network. Additionally, between credentialing cycles, a provider may be requested to supply current proof of any credentials such as Massachusetts licensure, malpractice insurance, DEA registration, a copy of certificate of cultural competency training, etc. that have expiration dates prior to the next review process. A provider s agreement may be terminated if at any time it is determined by the CeltiCare Board of Directors or the Credentialing Committee that credentialing requirements are no longer being met. 65

66 RIGHT TO REVIEW AND CORRECT INFORMATION All providers participating with the CeltiCare have the right to review information obtained by CeltiCare to evaluate their credentialing and/or re-credentialing application. This includes information obtained from any outside primary source such as the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank, malpractice insurance carriers and the Massachusetts Board of Medical Examiners and Massachusetts Board of Nursing for Nurse Practitioners. This does not allow a provider to review references, personal recommendations, or other information that is peer review protected. Should a provider believe any of the information used in the credentialing/re-credentialing process to be erroneous, or should any information gathered as part of the primary source verification process differ from that submitted by a practitioner, they have the right to correct any erroneous information submitted by another party. To request release of such information, a written request must be submitted to the CeltiCare Credentialing Department. Upon receipt of this information, the provider will have fourteen (14) days to provide a written explanation detailing the error or the difference in information to the CeltiCare. The CeltiCare Credentialing Committee will then include this information as part of the credentialing/re-credentialing process. RIGHT TO APPEAL ADVERSE CREDENTIALING DETERMINATIONS New provider applicants who are declined participation for reasons such as quality of care or liability claims issues have the right to request a reconsideration of the decision in writing within fourteen (14) days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant s reconsideration for participation in the CeltiCare network. Reconsiderations will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but in no case later than 60 days from the receipt of the additional documentation. The applicant will be sent a written response to his/her request within two (2) weeks of the final decision. 66

67 QUALITY IMPROVEMENT QUALITY IMPROVEMENT PROGRAM CeltiCare culture, systems and processes are structured around its mission to improve the health of all enrolled members. The Quality Improvement Program (QIP) utilizes a systematic approach to quality using reliable and valid methods of monitoring, analysis, evaluation and improvement in the delivery of healthcare provided to all members, including those with special needs. This system provides a continuous cycle for assessing the quality of care and service among plan initiatives including preventive health, acute and chronic care, behavioral health, over- and under-utilization, continuity and coordination of care, patient safety, and administrative and network services. This includes the implementation of appropriate interventions and designation of adequate resources to support the interventions. CeltiCare recognizes its legal and ethical obligation to provide members with a level of care that meets recognized professional standards and is delivered in the safest, most appropriate settings. To that end, CeltiCare will provide for the delivery of quality care with the primary goal of improving the health status of its members. Where the member s condition is not amenable to improvement, CeltiCare will implement measures to prevent any further decline in condition or deterioration of health status or provide for comfort measures as appropriate and requested by the member. This will include the identification of members at risk of developing conditions, the implementation of appropriate interventions and designation of adequate resources to support the interventions. Whenever possible, the CeltiCare QIP supports these processes and activities that are designed to achieve demonstrable and sustainable improvement in the health status of its members. PROGRAM STRUCTURE The CeltiCare Board of Directors (BOD) has the ultimate authority and accountability for the oversight of the quality of care and service provided to members. The BOD oversees the QI program and has established various committees and ad-hoc committees to monitor and support the QI program. The Quality Improvement Council (QIC) is a senior management committee with physician representation that is directly accountable to the BOD. The purpose of the QIC is to provide oversight and direction in assessing the appropriateness and to continuously enhance and improve the quality of care and services provided to members. This is accomplished through a comprehensive, plan-wide system of ongoing, objective, and systematic monitoring; the identification, evaluation, and resolution of process problems, 67

68 the identification of opportunities to improve member outcomes, and the education of members, providers and staff regarding the QI, UM, and Credentialing programs. The following sub-committees report directly to the Quality Improvement Committee: Credentialing Committee Pharmacy and Therapeutics Committee Utilization Management Performance Improvement Team Member and Community Advisory Committee Peer Review Committee (Ad Hoc Committee) PRACTITIONER INVOLVEMENT CeltiCare recognizes the integral role practitioner involvement plays in the success of its quality improvement program. Practitioner involvement in various levels of the process is highly encouraged through provider representation. CeltiCare encourages PCP, Behavioral Health, Specialty, OB/GYN representation on key quality committees such as, but not limited to, the QIC, Credentialing Committee, P&T Committee and select ad-hoc committees. QUALITY IMPROVEMENT PROGRAM SCOPE AND GOALS The scope of the QI Program is comprehensive and addresses both the quality of clinical care and the quality of service provided to the Plan s members. CeltiCare s QI program incorporates all demographic groups, care settings, and services in QI activities, including preventive care, primary care, specialty care, acute care, short-term care, long-term care (depending upon the Plan s products), and ancillary services, and the Plan operations. CeltiCare primary quality improvement goal is to improve members health status through a variety of meaningful quality improvement activities implemented across all care settings and aimed at improving quality of care and services delivered. To that end, CeltiCare QI program monitors the following: Compliance with preventive health guidelines and practice guidelines Acute and chronic care management Provider network adequacy and capacity Selection and retention of providers (credentialing and recredentialing) Behavioral healthcare within Massachusetts benefits Delegated entity oversight Continuity and coordination of care Utilization Management, including under and over utilization Compliance with member confidentiality laws and regulation Employee and provider cultural competency Provider appointment availability Provider and Plan after-hours telephone accessibility Member satisfaction Provider satisfaction Member Grievance System Provider Complaint System Member enrollment and disenrollment 68

69 PCP changes Department performance and service Patient Safety Pharmacy Marketing practices PERFORMANCE IMPROVEMENT PROCESS CeltiCare s QI Council reviews and adopts an annual QI Program and QI Work Plan based on managed care Medicaid appropriate industry standards. The QIC adopts traditional quality/risk/utilization management approaches to problem identification with the objective of identifying improvement opportunities. Most often, initiatives are selected based on data that indicates the need for improvement in a particular clinical or nonclinical area, and includes targeted interventions that have the greatest potential for improving health outcomes or the service. Performance improvement projects, focused studies and other QI initiatives are designed and implemented in accordance with principles of sound research design and appropriate statistical analysis. Results of these studies are used to evaluate the appropriateness and quality of care and services delivered against established standards and guidelines for the provision of that care or service. Each QI initiative is also designed to allow Plan to monitor improvement over time. Annually, CeltiCare develops a Quality Assessment Performance Improvement (QAPI) Work Plan for the upcoming year. The QAPI Work Plan serves as a working document to guide quality improvement efforts on a continuous basis. The Work Plan integrates QI activities, reporting and studies from all areas of the organization (clinical and service) and includes timelines for completion and reporting to the QI Committee as well as requirements for external reporting. Studies and other performance measurement activities and issues to be tracked over time are scheduled in the QI Work Plan. CeltiCare communicates activities and outcomes of its quality improvement program to both members and providers through avenues such as Member Newsletter, Provider Newsletter and CFHP Plan web-portal. At any time, Plan providers may request additional information on CeltiCare quality program including a description of the QI Program and a report on the Plan s progress in meeting the QAPI Program goals by contacting CeltiCare Quality Improvement Department. HEALTH EMPLOYER DATA INFORMATION SET (HEDIS) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of NCQA Health Plan Accreditation and the Massachusetts contract. As both the Massachusetts and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. Massachusetts purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a Health Insurance Company s ability to demonstrate an improvement in preventive health 69

70 outreach to its members. Physician specific scores are being used as evidence of preventive care from primary care office practices. The rates then serve as a basis for physician incentive programs such as pay for performance and quality bonus funds. These programs pay providers an increased premium based on scoring of such quality indicators used in HEDIS. How are HEDIS rates calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data and submission of appropriate CPT II codes can reduce the necessity of medical record reviews (see CeltiCare s website and HEDIS brochure for more information on reducing HEDIS medical record reviews). Measures typically requiring medical record review include: diabetic HgA1c, LDL, eye exam and nephropathy, controlling high-blood pressure, and prenatal care and postpartum care. Who will be conducting the Medical Record Reviews (MRR) for HEDIS? CeltiCare will contract with a national medical record review vendor, to conduct the HEDIS medical record reviews on its behalf. Medical record review audits for HEDIS are usually conducted March through May each year. At that time, you may receive a call from a medical record reviewer representative if any of your patients are selected into HEDIS samples for CeltiCare. Your prompt cooperation with the representative is greatly needed and appreciated. As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR ) and does not require consent or authorization from the member/patient. The Medical Record Review vendor will sign a HIPAA compliant Business Associate Agreement with CeltiCare which allows them to collect PHI on our behalf. What can be done to improve my HEDIS scores? Understand the specifications established for each HEDIS measure. Submit claim/encounter data for each and every service rendered. All providers must bill (or report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation. Ensure chart documentation reflects all services provided. If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact CeltiCare Quality Improvement Department at

71 PROVIDER SATISFACTION SURVEY CeltiCare conducts an annual provider satisfaction survey which includes questions to evaluate provider satisfaction with our services such as claims, communications, utilization management, and provider services. The survey is conducted by an external vendor. Participants are randomly selected by the vendor, meeting specific requirements outlined by CeltiCare, and the participants are kept anonymous. We encourage you to respond timely to the survey as the results of the survey are analyzed and used as a basis for forming provider related quality improvement initiatives. CONSUMER ASSESSMENT OF HEALTHCARE PROVIDER SYSTEMS (CAHPS) SURVEY This is a member satisfaction survey that is included as a part of HEDIS and NCQA accreditation. It is a standardized survey administered annually to members by an NCQA certified survey vendor. The survey provides information on the experiences of CeltiCare members with health plan and practitioner services and gives a general indication of how well we are meeting the members expectations. Member responses to the CAHPS survey are used in various aspects of the quality program including monitoring of practitioner access and availability. PROVIDER PROFILING AND INCENTIVE PROGRAMS Over the past several years, it has been nationally recognized that pay-for-performance (P4P) programs, which include provider profiling, have emerged as a promising strategy to improve the quality and cost-effectiveness of care. CeltiCare currently uses a pay-forperformance program that includes physician profiling to improve care and services provided to CeltiCare members. The P4P program promotes efforts that are consistent with the Institute of Medicine s aims for advancing quality (safe, beneficial, timely, patient-centered, efficient and equitable) as well as recommendations from other national agencies such as CMS-AMA Physician Consortium, NCQA and NQF. Additionally, CeltiCare will provide an opportunity for financial reward to PCPs and specialists using an incentive payment that encourages accurate and timely submission of preventive health and disease monitoring services in accordance with evidence-based clinical practice guidelines. The goals of CeltiCare s P4P program are: Increase provider awareness of his/her performance in key areas. Motivate providers to establish measurable performance improvement processes relevant to CeltiCare s member populations in their practices. Use peer performance data and/or other established benchmarks to identify outlier provider practices that reflect best practices or less than optimal performance. Increase opportunities for CeltiCare to partner with providers to achieve measurable improvement in health outcomes by developing, implementing, and monitoring practice-based performance improvement initiatives. CeltiCare will accomplish these goals by: Producing and distributing provider-specific reports containing meaningful, reliable, and valid data for evaluation by CeltiCare and the provider. 71

72 Creating incentives for provider implementation of practice-based performance improvement initiatives that are pertinent to CeltiCare s member populations, are linked with adopted evidence-based clinical practice guidelines and that yield measurable outcomes. Establishing and maintaining an open dialogue with profiled providers related to performance improvement. Physicians, meeting a minimum panel threshold, will receive a quarterly profile report with an individual score for each measure and a weighted composite score. Scores will be benchmarked per individual measure and compositely to the CeltiCare network average and as applicable, to the then available NCQA Medicaid Mean. Provider profile indicator data is not risk adjusted and scoring is based on provider performance within the service area range. The weighted composite score, which will counteract any numerator and denominator deficiencies, allows practitioners to be compared to providers delivering similar types of services within CeltiCare s network provider community. Basing the incentive on the network average encourages continuous improvement as the average improves over time. PCPs who meet or exceed established performance goals and who demonstrate continued excellence or significant improvement over time may be recognized by CeltiCare in publications such as newsletters, bulletins, press releases, and recognition in our provider directories as well as being eligible for applicable financial incentive programs. Additionally, CeltiCare offers several financial incentive programs such as claim based incentives and participation in quality bonus fund programs. More information on our incentive programs can be found on the Provider Web Portal or by contacting CeltiCare s Contracting/Provider Relations department. 72

73 WASTE ABUSE AND FRAUD (WAF) SYSTEM CeltiCare takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a waste, abuse and fraud (WAF) program that complies with Massachusetts and federal laws. CeltiCare in conjunction with its management company, Centene, successfully operates a waste, abuse and fraud unit. CeltiCare performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system, please review the Billing and Claims chapter of this manual. The Special Investigation Unit (SIU) performs back end audits which in some cases may result in prosecution and/or recoupment of previously paid monies. Some of the most common errors seen are: Unbundling of codes Up-coding Add-on codes without primary CPT Diagnosis and/or procedure code not consistent with the member s age/gender Use of exclusion codes Excessive use of units Misuse of Benefits If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential hotline at CeltiCare and/or Centene take all reports of potential waste, abuse or fraud very seriously and investigate all reported issues. AUTHORITY AND RESPONSIBILITY The CeltiCare Director of Regulatory Affairs & Compliance has overall responsibility and authority for carrying out the provisions of the compliance program. CeltiCare is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse. The CeltiCare provider network will cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations. 73

74 MEMBER SERVICES MEMBER SERVICES CeltiCare committed to providing its members with information about the health benefits that are available to them through the CeltiCare program. An important service of CeltiCare is to satisfactorily respond to member s questions and issues that may arise. CeltiCare encourages members to take responsibility for their healthcare by providing basic information to assist with making decisions about their healthcare choices. As a provider for CeltiCare, please remember that it is your obligation to identify any member who requires translation, interpretation, or sign language services. CeltiCare will pay for these services whenever you need them to effectively communicate with a CeltiCare member. CeltiCare members are not to be held liable for these services. To arrange for any of the above services, please call the CeltiCare Provider Services Department at MEMBER MATERIALS Members will receive various pieces of information from CeltiCare through mailings and through face-to-face contact. The Evidence of Coverage is printed in English and Spanish and can be requested in other languages identified by the Connector. These materials include: Evidence of Coverage which includes: o Benefit information, including pharmacy network information and how to get transportation o Member rights and responsibilities Quarterly Newsletters Provider Directory Healthy Rewards Account Information Connections Brochure NurseWise and Emergency Information Emergency Room Information Providers interested in receiving any of these materials may contact: Member Services Department Fax TDD/TYY

75 MEMBER RIGHTS & RESPONSIBILITIES Member Rights Members, legal guardians of members, and legally authorized surrogates for members have certain rights and responsibilities. It is important that you know your rights and responsibilities. Information: You have the right to get from your PCP information about what might be wrong (to the level known), treatment and any known likely results. Your PCP can tell you about treatments that may or may not be covered by the plan, regardless of the cost. You have a right to know about any costs you will need to pay. This should be told to you in words you can understand. When it is not appropriate to give you information for medical reasons, the information can be given to a legally authorized person. Your doctor will ask for your approval for treatment unless there is an emergency and your life and health are in serious danger. You have the right to see your medical records. You have the right to be informed of changes within our CeltiCare network. You have the right to be kept informed of CeltiCare and Commonwealth Care covered and non-covered services, program changes, how to access services, PCP assignment, providers, Advance Directive information, referrals and authorizations, benefit denials, member rights and responsibilities, and other CeltiCare rules and guidelines. You have a right to information about CeltiCare and the Commonwealth Care system. You have the right to a current list of CeltiCare providers. You can also get information on your providers education, training, and practice. You have the right to know, upon request, of any financial arrangements or rules between CeltiCare and its providers that may restrict your treatment options. You have the right to talk to your provider about new uses of technology. You can also ask CeltiCare for information on our quality plan, how members use the plan and how we review new technology. Respect & Dignity: You have the right to have considerate, respectful care at all times. You have the right to have assistance in a prompt, courteous and responsible manner. You have the right to be treated with dignity when receiving care. You have the right to be free from harassment by the health plan or the plan's providers if there are any business disagreements between the plan and provider. You have the right to select a health plan or switch health plans, within the Commonwealth Care guidelines, without any threats or harassment. Access: You have the right to adequate access to qualified health professionals. You have the right to access treatment or services that are medically necessary regardless of age, race, creed, sex, sexual preference, national origin or religion. You have the right to access medically necessary urgent and emergency services 24 hours a day and 7 days a week. If you have a disability, you have the right to receive information in a different format in compliance with the Americans with Disabilities Act. Informed Consent: Members or their legal guardians or legal representatives have the right to join in decision making about their healthcare. This includes working on any 75

76 treatment plans and making care decisions. You should know any possible risks, problems related to recovery, and the likelihood of success. You shall not have any treatment without consent freely given by you or your legally authorized surrogate decision-maker. You will be informed of your care options. You have the right to know who is approving and who Is performing the procedures or treatment. All likely treatment and the nature of the problem should be explained clearly. You have a right to refuse treatment. Grievance: You have the right to file an Appeal or Grievance if you have had an unsatisfactory experience with CeltiCare or with any of our contracted providers or if you disagree with certain decisions made by CeltiCare. External Review: You have the right to apply for an independent external review with the Massachusetts Department of Public Health s Office of Patient Protection for appeals or grievances not resolved by CeltiCare to your satisfaction. The Independent External Review process is not available for Grievances regarding routine vision and routine dental services. Rights and Responsibilities Policies: Members have a right to make recommendations regarding the organization s Member Rights and Responsibilities policies. Refusal of Treatment: You may refuse treatment to the extent the law allows. You are responsible for your actions if treatment is refused or if the PCP s instructions are not followed. You should discuss all concerns about treatment with your PCP. Your PCP can discuss different treatment plans with you, if there is more than one plan that may help you. You will make the final decision. PCP: You have the right to pick your PCP within the plan network. You also have the right to change your PCP or request information on CeltiCare doctors close to your home or work. Identity: You have the right to know the name and job title of people giving you care. You also have the right to know which doctor is your PCP. Language: You have the right to an interpreter when you do not speak or understand the language of the area. Second Opinions: You have the right to a second opinion by an in-network doctor, at no cost to you, if you believe your provider is not authorizing the requested care, or if you want more information about your treatment. Advance Directives: All CeltiCare members have a right to make Advance Directives for healthcare decisions. CeltiCare members also have the right to refuse to make Advance Directives. You should not be discriminated against for not having an Advance Directive. (see page 14) 76

77 MEMBER RESPONSIBILITIES All members are responsible for learning how the CeltiCare plan works by reading the Evidence of Coverage. Giving Information: You should give accurate and complete information about present conditions, past illnesses, hospitalizations, medications, and other matters about your health. You should make it known whether you clearly understand your care and what is expected of you. You need to ask questions of your doctor until you understand the care you are receiving. You need to review and understand the information you receive about CeltiCare. You need to know the proper use of services covered by CeltiCare. Your Doctor s Advice: You should follow the treatment plan suggested by providers of medical care. You should ask questions if you do not understand any part of the treatment plan. You should work with your PCP to develop treatment goals. If you do not follow the treatment plan, you have the right to be advised of the likely results of your decision. ID Card: It is important that you show your CeltiCare ID card before you receive care. Emergency Room Use: You should use any emergency room only when you think you have a medical emergency. For all other care, you should call your PCP. Appointments: You need to keep appointments. If you cannot keep an appointment, you must call to cancel or reschedule. You should schedule appointments during office hours whenever possible. PCP: You should know the name of your assigned PCP. You should establish a relationship with your doctor. You may change your PCP verbally or in writing by contacting our Member Services Department. Treatment: You should treat all CeltiCare staff, providers, and other members with respect and dignity. Any concerns that you have about your care should be given to CeltiCare in a useful manner. Changes: You need to tell the Connector about any changes in your address, name, telephone number, or any changes in your family. Other Medical Insurance: When you enroll in the CeltiCare, you need to give all information about any other medical insurance coverage you have. If, at any time, you get other medical coverage besides your CeltiCare coverage, you must tell the Connector. Costs: If you access care without following CeltiCare rules, you may be responsible for the charges. You are responsible to pay your portion of the Commonwealth premium if applicable (due monthly) and all copayments at the time of service. 77

78 MEMBER SATISFACTION We hope our members will always be happy with us and our providers. If our members are not happy, CeltiCare wants to know. CeltiCare has steps for handling any problems our members may have. CeltiCare offers our members the following processes to achieve Member Satisfaction: Internal Inquiry Process Internal Grievance Process Internal Appeal Process External Review by the Office of Patient Protection INTERNAL INQUIRY PROCESS CeltiCare offers an Internal Inquiry process for members. An inquiry allows members the opportunity to voice concerns regarding any action, policy or procedure of CeltiCare, a CeltiCare affiliate or healthcare provider. Most inquiries can be resolved immediately. However, if a member is not satisfied or CeltiCare has not been able to provide resolution within three business days of the initial inquiry, they have the right to utilize our formal Internal Grievance process. The Inquiry process may not be used for review of a Quality of Care issue or an Adverse Determination (involving Medical Necessity). If the member concern involves the Quality of Care received from a network provider, Member Services will refer the member concern directly to our Internal Grievance Process. If the member concern involves an Adverse Determination, Member Services will refer the member concern directly to our Internal Appeals Process. INTERNAL GRIEVANCE PROCESS We want our members to use the grievance steps to solve problems or concerns. CeltiCare will not hold it against our members or treat them differently if they file a grievance. A grievance is a formal complaint about actions taken by CeltiCare or a provider. Grievances can be any oral or written complaint submitted to CeltiCare that has been initiated by a member, or the member s Authorized Representative, concerning any aspect or action of CeltiCare relative to the member, including, but not limited to, review of Adverse Determinations regarding scope of coverage, denial of services, quality of care and administrative operations. Grievances involving the review of an Adverse Determination (this agreement with the Medical Necessity determination) is an Appeal and the steps for an Internal Appeal are followed. HOW TO FILE A GRIEVANCE Filing a grievance will not affect our member s healthcare services. We want to know our member concerns so we can improve the services we deliver. By knowing their concerns, we are able to give better services. To file a Grievance, members should call Member Services at They can also write a letter or fax your grievance to CeltiCare at Member should include: Member first and last name Member ID number Member address and telephone number 78

79 What the member is unhappy with What the member would like to have happen (desired outcome) Members have up to 180 calendar days to file a grievance. The 180 calendar days start on the date of the situation they are unhappy about. CeltiCare would like for our members to contact us right away so we can help with their concerns as soon as we can. Once a member first calls with a grievance, we will summarize the grievance in writing and send back to the member within 48 hours of receipt of the grievance. 79

80 This summary serves as both a written record of the grievance as well as an acknowledgement. If the member files a written grievance, the AGC will send a letter within ten days letting them know that we have received the grievance and the expected date of resolution. If there is any proof or information that supports the member grievance, they may send it to us and it will be added to their case. This information can be supplied to a CeltiCare staff by , fax, in person, or other written method. Members may also request to receive copies of any documentation that CeltICare used to make the decision about their care, grievance, or appeal. We will answer or resolve the grievance within 30 days. If CeltiCare needs more than 30 days to resolve the grievance, we will contact the member to receive approval and inform them within two working days. Members may request an extension up to 14 days. If someone else is going to file a grievance for the member, we must have written permission for that person to file their grievance or appeal. Members can call Member Services to receive a form or go to This form is to assign a members right to file a grievance or appeal to someone else. There will be no retaliation against the member or your representative for filing a grievance or appeal. Mail the letter to: Appeals and Grievance Coordinator CeltiCare 1380 Soldiers Field Road Brighton, Massachussets INTERNAL APPEAL An Internal Appeal is a form of grievance for review of an adverse determination. An adverse determination is a decision that was made, based on review of information that was provided, to deny, reduce, modify or terminate an admission, continued inpatient stay, or the availability of any other healthcare services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of healthcare setting and level of care, or effectiveness. An Internal Appeal is reviewed as either a Standard/Non-expedited Internal Appeal or as an Expedited Internal Appeal. If a decision on an appeal is required immediately due to the member s health needs which cannot wait with the standard resolution time, an expedited appeal may be requested. The following outlines the process for each. Standard/Non-expedited Internal Appeal Internal Appeal Submission and Acknowledgement An Internal Appeal can be filed by the member or member s authorized representative (with written consent from the member) up to 180 days after the receipt of an Adverse Determination letter. An Internal Appeal may be submitted in writing by mail at the address below, electronically by fax at by calling us at or in person at the address below. CeltiCare Appeal and Grievances Department 1380 Soldiers Field Road Brighton, MA

81 An Internal Appeal submitted by phone or in person will be received by a Member Services Representative who will write a summary of the Internal Appeal request and forward a copy to the member or authorized representative within 48 hours (unless the time limit is waived or extended by mutual written agreement between the member or the member authorized representative and CeltiCare). An Acknowledgement letter will be sent within 15 working days of receipt of the internal appeal. Internal Appeal Continuation of Care If the member is still receiving the services that are under appeal and the services are covered services, the services may continue until a decision is made on the Internal Appeal. CeltiCare will pay for the cost of continued services regardless of the outcome minus any applicable co-pays or deductibles. This continuation of coverage or treatment applies only to those services which, at the time of the service initiation, were approved by CeltiCare and were not terminated because benefit coverage for the service was exhausted. Internal Appeal Review The content of the Internal Appeal request including all clinical care aspects involved will be fully investigated and documented. The member or the member s authorized representative will have the right to submit comments, documentation, records and other information relevant to the Internal Appeal in person or in writing. A physician or other appropriate clinical peer of a same-or-similar specialty will evaluate medical necessity decision of a Final Adverse Determination. CeltiCare will review, resolve, and provide the member or member s authorized representative with written notification of the decision for a pre or post-service nonexpedited Internal Appeal within 30 working days of receipt of the Internal Appeal, or within 30 working days of the submission of a signed authorization for the release of medical records and treatment information. Internal Appeal Determination Notification A standard Internal Appeal is resolved and a written response sent to the member or member s authorized representative within 30 days of our receipt of the Internal Appeal or if medical information is needed within 30 days of receiving a signed Authorization to Release Medical Records form. If the Internal Appeal request was not over-turned or resolved to the member or member s authorized representative satisfaction an External Review by an independent external review agency may be requested. The external review agency contracts with the state of Massachusetts Department of Public Health/Office of Patient Protection. Information for pursuing an External Review is included in the Internal Appeal determination letter. If the member or member s authorized representative does not receive a response to the Internal Appeal within the timeframes outlined or those that are mutually agreed upon, the appeal will be deemed to be decided in the member s favor. The written notification of the resolution of the standard Internal Appeal will include: The specific medical and scientific reasons for the adverse determination; A discussion of the member s presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical; evidence fails to meet the relevant medical review criteria; Other covered alternative treatment, service(s), or supplies if applicable; Criteria and/or clinical guidelines or standards of care used in making the determination; 81

82 Information for obtaining an independent external review through the Office of Patient Protection including the timeframe for filing. An Internal Appeal not handled timely will be deemed over-turned. Internal Appeal Reconsideration CeltiCare may offer the member or the member s authorized representative the opportunity for reconsideration of a Final Adverse Determination where relevant medical information: Was received too late to review within the 30 working day timeframe; OR Was not received but is expected to become available within a reasonable time period following the written resolution. When the member or member s authorized representative chooses to request reconsideration, the member or member s authorized representative must agree in writing to a new time period for review, but in no event greater than 30 working days from the agreement to reconsider the Internal Appeal. If reconsideration is requested, the time period for requesting an external review will begin the date of the resolution of the reconsideration. Should the member or member s authorized representative request reconsideration, the time period for requesting an external review will begin the date of the resolution of the reconsideration. Expedited Internal Appeal Expedited Internal Appeal Qualifying Conditions If a decision on an appeal is required immediately due to the member s health needs which cannot wait with the standard resolution time, an Expedited Internal Appeal may be requested. An Expedited Internal Appeal may be requested if: A provider certifies a delay in receiving the requested service would result in a substantial risk of serious or immediate harm to the member; The member is currently admitted as a patient in a hospital; or The member has a terminal illness; or A provider certifies a delay in receiving durable medical equipment would result in substantial risk of serious or immediate harm to the member. Expedited Internal Appeal Submission An Expedited Internal Appeal is requested in the same manner as a Standard Internal Appeal. For an Expedited Internal Appeal in which the member is currently an inpatient in a hospital, a healthcare worker or hospital representative may act as the member s authorized representative without a signed written consent from the member. Expedited Internal Appeal Continuation of Care A member who is currently receiving covered services may continue to receive services at the expense of CeltiCare through the completion of the Expedited Internal Appeal process if the Expedited Internal Appeal is filed timely and was previously authorized by CeltiCare. Expedited Internal Appeal Review The content of the Expedited Internal Appeal request including all clinical care aspects involved will be fully investigated and documented. A member or the member s authorized representative will have the right to submit comments, 82

83 documentation, records and other information relevant to the Expedited Internal Appeal in person or in writing. A physician or other appropriate clinical peer of a same-or-similar specialty will evaluate medical necessity decision of a Final Adverse Determination. Expedited Determination Notification An Expedited Internal Appeal will be reviewed, resolved, and written notification of the decision provided to the member or the member s authorized representative within: Within 48 hours if a delay in receiving the requested service would result in a substantial risk of serious or immediate harm; Before discharge if the member is currently admitted as a patient in a hospital; Within 5 days if the member is terminally ill; and Within less than 48 hours if a delay in receiving requested durable medical equipment would result in a substantial risk of serious or immediate harm. Written notification of the resolution of an Internal Expedited Appeal will include: The specific medical and scientific reasons for the adverse determination; A discussion of the member s presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical; evidence fails to meet the relevant medical review criteria; Other covered alternative treatment, service(s), or supplies if applicable; Criteria and/or clinical guidelines or standards of care used in making the determination; Information for obtaining an expedited external review and continuation of services through the Office of Patient Protection including the timeframe for filing. An Expedited Internal Appeal not handled timely will be deemed over-turned. If the request for continued services is approved by the Office of Patient Protection, CeltiCare will continue coverage at our expense minus applicable co-pays and deductibles. Expedited Appeal Reconsideration - Services for Member s with Terminal Illness If the Expedited Internal Appeal is not overturned for a member with a terminal illness, the member or member s authorized representative may request a conference. The member or member s authorized representative may request the conference in the same manner as an Internal Appeal. If a conference is requested, it will be scheduled within 10 working days of CeltiCare s receipt of the request unless the provider after consulting with CeltiCare s Medical Director decides the effectiveness of the requested service(s) would be materially reduced; in which case the conference will be scheduled within 5 working days. The member and/or the member s authorized representative may attend the conference. A written determination will be sent to the member or member s authorized representative following the conference. External Review If a member or the member s authorized representative is not satisfied with the final outcome of the Internal Appeal or Expedited Internal Appeal an External Review of the 83

84 decision through the Office of Patient Protection (OPP) of the Massachusetts Department of Public Health may be requested. The member or the member s authorized representative may request the External Review. Forms and instructions for submitting the request will be included with the Final Adverse Determination sent. The required forms must be completed then submitted to OPP within 45 days of the receipt of the Final Adverse Determination we sent along with the applicable filing fees ($25.00). External Reviews will be completed and a decision sent within 60 business days of the external agency receipt of the request unless extended or accepted as an Expedited External Review. An Expedited External Review may be requested if: A physician certifies in writing a delay in receiving the requested service would result in a substantial risk of serious or immediate harm to the member; The member is currently admitted as a patient in a hospital; The member is terminally ill; and A physician certifies in writing a delay in receiving requested durable medical equipment would result in a substantial risk of serious or immediate harm to the member. The request for an Expedited External Review must be made by the end of the second business day following receipt of the Final Adverse Determination. If OPP determines the request qualifies for Expedited Review, a determination will be made within 5 business days of the external review agency receipt of the request. If the External Review relates to the denial of ongoing services, the member or member s authorized representative may request from OPP for services to continue during the External Review process. Such a request must be made before the end of the second working day following the receipt of the Final Adverse Determination letter sent. If OPP decides coverage should continue because substantial harm could occur to the member if coverage ended, CeltiCare will continue coverage at our expense minus applicable copays and deductibles. If you have questions, concerns, would like additional information regarding member rights, or have questions about the External Review process you can contact the Office of Patient Protection: Mail: Department of Public Health Office of Patient Protection 250 Washington Street Boston, MA Phone (800) Fax: (617) Website 84

85 PROVIDER RELATIONS ASSISTANCE PROVIDER RELATIONS DEPARTMENT The Provider Relations Department at CeltiCare is designed around the concept of making your experience with CeltiCare a positive one by being your advocate within CeltiCare Provider relations is responsible for providing the services listed below which include but are not limited to: Contracting Maintenance of existing CeltiCare Provider Manual Eligibility distribution Development of alternative reimbursement strategies Researching of trends in claims inquiries to CeltiCare Pool settlement updates/status Network performance profiling Individual physician performance profiling Physician and office staff orientation Hospital and ancillary staff orientation Ongoing provider education, updates, and training The goal of this department is to furnish you and your staff with the necessary tools to provide the highest quality of healthcare to CeltiCare enrolled membership. To contact the provider relations specialist for your area contact: Provider Services Department The Provider Services toll free help line staff is available to you and your staff to answer questions, listen to your concerns, assist with members, respond to your CeltiCare inquiries, connect you to the CeltiCare Provider Relations Specialist for your area and other services as you request. Provider Services Representatives work with Provider Relations Specialists to serve as your advocates to ensure that you receive necessary assistance and maintain satisfaction with CeltiCare. PROVIDER UPDATES To ensure that we can communicate with you effectively and to avoid any possible delay in claim payment, it is important that you notify us, in writing, as soon as you are aware of any of the following situations: Addition or Termination of an Office Location Addition, Change, or Termination of Tax Identification Number (W-9 Required) Name Change (W-9 May Be Required) 85

86 Change in Ownership Update Phone, Fax or Change in Office Hours, Panel Capacity or Age Limitation Notification may be sent via mail, fax or through the secure contact us mailbox: CeltiCare 1380 Soldiers Field Road Brighton, MA Fax PROVIDER COMPLAINTS Providers have the right to request a formal review of any decision made by CeltiCare. A complaint may be filed telephonically or in writing by contacting CeltiCare Provider Services at: CeltiCare 1380 Soldiers Field Road Brighton, MA Complaints must be filed within 45 days of the decision and should include all information supporting your complaint. Medical Management complaints will be reviewed by qualified medical professionals. Claims complaints should be filed according to the appeals guidelines set forth in the billing section of this manual. 86

87 PHARMACY CELTICARE PHARMACY PROGRAM CeltiCare covers prescription drugs and certain over-the-counter drugs when ordered by a CeltiCare doctor. Some medications require prior authorization (PA) or have limitations on age, dosage and/or maximum quantities. This section provides an overview of CeltiCare Pharmacy Program. For more detailed information, please visit our website at The CeltiCare Preferred Drug List (PDL) The CeltiCare PDL describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to member covered under the program. The PDL does not: Require or prohibit the prescribing or dispensing of any medication; Substitute for the independent professional judgment of the physician/clinician or pharmacist, or Relieve the physician/clinician or pharmacist of any obligation to the patient or others. The Pharmacy & Therapeutics committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all participants covered under the CeltiCare pharmacy program. If a patient requires medication that does not appear on the PDL, the clinician can submit a Prior Authorization Request for a non-preferred medication. It is anticipated that such exceptions will be rare and that currently available PDL medications will be appropriate to treat the vast majority of medical conditions encountered by CeltiCare providers. Pharmacy and Therapeutics Committee (P&T) The CeltiCare P&T Committee continually evaluates the therapeutic classes included in the PDL. The committee is composed of the CeltiCare medical director, pharmacy program director, and several community-based primary care physicians and specialists. The primary purpose of the committee is to assist in developing and monitoring the CeltiCare PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least quarterly during the year and coordinates therapeutic class reviews with the parent company s national P&T Committee. Prior Authorization (PA) Process The CeltiCare PDL includes a broad spectrum of generic and brand name drugs. Clinicians are encouraged to prescribe from the CeltiCare PDL for their patients who are members of CeltiCare. Some preferred drugs require PA. Medications requiring PA are listed with a "PA" notation throughout the PDL. 87