Administrative Provider Manual for MI Health Link

Transcription

1 Administrative Provider Manual for MI Health Link Page 1 of 52

2 MISSION STATEMENT... 5 GENERAL OVERVIEW... 5 CONTACT INFORMATION... 5 MEMBERS RIGHTS AND RESPONSIBILITIES... 6 TRANSPORTATION... 8 LANGUAGE INTERPRETATION AND SERVICES FOR HEARING AND SPEECH IMPAIRED... 9 ENROLLEE INFORMATION... 9 MI HEALTH LINK PROGRAM ELIGIBLE POPULATION... 9 ENROLLMENT AND DISENROLLMENT PROCESS... 9 MEMBER ID CARD ELIGIBILITY CO PAYMENTS PHILOSOPHY OF CARE MODEL OF CARE OVERVIEW PROVIDER NETWORK COMMUNICATION WITH THE PCP MEMBER ADVOCACY PCP REPORTING REQUIREMENTS PCP PERFORMANCE AND PAY FOR PERFORMANCE (P4P) BONUS PROGRAM PCP ACCESSIBILITY AND AVAILABILITY ACCESS TO CARE STANDARDS CREDENTIALING NETWORK DEVELOPMENT/CONTRACTING PROCESS PROVIDER TERMINATIONS DEMOGRAPHIC CHANGES HEALTH SERVICES REFERRALS AND AUTHORIZATIONS REFERRALS HEALTH CARE REFERRAL FORM SERVICES REQUIRING PLAN NOTIFICATION (REFERRAL)/APPROVAL (PRIOR AUTHORIZATION) HOSPITAL ADMISSIONS AMBULATORY SERVICES/OUTPATIENT AUTHORIZATIONS SKILLED NURSING Page 2 of 52

3 SECOND OPINION APPEALS PROCESS DEFINITIONS PHARMACY BENEFIT PHARMACY DRUG PLAN COVERAGE OBTAINING A DRUG PRIOR AUTHORIZATION CLAIMS MANAGEMENT CLAIMS SUBMISSION METHODS PAPER CLAIMS CLAIM FORMATS AND VERSIONS CLEAN CLAIMS SUBMISSION REQUIREMENTS CMS 1500 (02 12) SUBMISSION GUIDELINES UB 04 SUBMISSION GUIDELINES CLAIM CORRECTION AND RESUBMISSION HOW TO CHECK CLAIMS STATUS ON THE HAP MIDWEST HEALTH PLAN WEBSITE PAYMENT PROCEDURE EXPLANATION CODES POST PAYMENT REVIEW FILING LIMITATIONS BALANCE BILLING BALANCE BILLING BY PROVIDER TYPE BILLING INSTRUCTIONS COORDINATION OF BENEFITS (COB) DME/PROSTHETICS/ORTHOTICS E & M BILLING TIPS EMERGENCY ROOM NATIONAL CORRECT CODING INITIATIVE OUT OF NETWORK PROVIDERS URGENT CARE SERVICES MODIFIER GA PRE SERVICE NOTICE OF NON COVERAGE WAS PROVIDED BY THE PLAN RECONSIDERATION OF CLAIMS PAYMENT DECISIONS PROVIDER CLAIM PAYMENT DISPUTES AND PAYMENT APPEALS (RECONSIDERATIONS) PROVIDER APPEALS PROCESS BINDING ARBITRATION PROCESS RAPID RESOLUTION PROCESS CUSTOMER SERVICE Page 3 of 52

4 NEW MEMBERS MEMBER REQUEST FOR PCP TRANSFERS MEMBER COMPLAINTS AND GRIEVANCE RESOLUTION QUALITY MANAGEMENT MEMBER MEDICAL RECORDS MEDICAL RECORD MAINTENANCE REQUIREMENTS CONTINUITY OF CARE DISEASE MANAGEMENT PROGRAMS ASTHMA DISEASE MANAGEMENT PROGRAM DIABETES DISEASE MANAGEMENT PROGRAM HYPERTENSION DISEASE MANAGEMENT PROGRAM HEALTH OUTREACH SMOKING CESSATION PROGRAM HEALTH EDUCATION MATERIALS CONFIDENTIALITY POLICY NOTICE OF PRIVACY PRACTICES CORPORATE COMPLIANCE PROGRAM ABUSE, NEGLECT, EXPLOITATION & CRITICAL INCIDENTS FRAUD/WASTE/ABUSE WHISTLEBLOWER PROTECTION Page 4 of 52

5 MISSIONSTATEMENT HAP Midwest Health Plan is committed to providing excellence in our managed care product lines for our members, through fiscally responsible programs that assure access to and the delivery of cost effective and quality medical services. GENERALOVERVIEW HAP Midwest Health Plan is a for profit, licensed Health Maintenance Organization (HMO), wholly owned subsidiary of Health Alliance Plan (HAP), and is based in Detroit, Michigan. HAP Midwest Health Plan was first licensed in 1998 and has been continuously accredited by the National Committee for Quality Assurance (NCQA). HAP Midwest Health Plan serves over 8,000 covered lives through offerings in Medicaid, Children s Special Health Care Services (CSHCS), Medicare Dual Special Needs Plan, and the Medicare Medicaid Dual Demonstration Project (MMP). HAP Midwest Health Plan contracts with Primary Care Physicians (PCPs), and Specialty Care Physicians (SCPs) who are licensed in the state of Michigan as either a Medical Doctor (MD) or a Doctor of Osteopathic Medicine (DO). PCPs in the plan include Internal Medicine, Family/General Practice, Pediatrics, and OB/GYN physicians. SCPs include cardiologists, gastroenterologists, rheumatologists, endocrinologists, surgeons, etc. All physicians in the HAP Midwest Health Plan program must meet the credentialing standards and uphold the managed care philosophy of the plan. HAP Midwest Health Plan MI Health Link provides high quality, seamless and cost effective care through coordinated, person centered services meeting the unique needs of all enrollees who are dual eligible for both Medicare and Medicaid. HAP Midwest Health Plan will work collaboratively with Pre Paid Inpatient Health Plans (PIHP), Long Term Support Services (LTSS) and Primary Care Physicians (PCP)/Specialists to improve the quality of care while limiting duplication of services and ensuring cost effective plans of care. All services provided are consistent with the Medicare and Medicaid manuals, guidance, memoranda, and other related documents. CONTACTINFORMATION Department Phone Fax Customer Services (888) (248) Claims (888) (248) Compliance/Fraud, Waste & Abuse (877) Credentialing (313) Health Outreach/Disease Management (248) (248) HEDIS Activities (248) (248) NetworkDevelopment/Contracting (313) (313) (313) (313) Quality Management (248) (248) Utilization Management (248) (248) Page 4 of 52

6 MEMBERS RIGHTS AND RESPONSIBILITIES MI Health Link Enrollee Rights Members of HAP Midwest MI Health Link are guaranteed the rights on the following list. Specifically, as you are guaranteed: The right to be treated with dignity and respect. The right to be afforded privacy and confidentiality in all aspects of care and for all health care information, unless otherwise required by law. The right to be provided a copy of your medical records, upon request, and to request corrections or amendments to these records, as allowed. The right not to be discriminated against based on race, ethnicity, national origin, religion, sex, age, sexual orientation, medical or Claims history, mental or physical disability, genetic information, or source of payment. The right to have all plan options, rules, and benefits fully explained, including through use of a qualified interpreter if needed. Access to an adequate network of primary and specialty providers who are capable of meeting your needs with respect to physical access, and communication and scheduling needs, and are subject to ongoing assessment of clinical quality including required reporting. The right to choose a plan and provider at any time, and have that choice become effective the first calendar day of the following month. This includes choosing a plan other than ours. The right to have a voice in the governance and operation of the integrated system, provider or health plan. The right to participate in all aspects of care, including the right to refuse treatment, and to exercise all rights of Appeal. You have a responsibility to be fully involved in maintaining your health and making decisions about your health care, including the right to refuse treatment if desired, and you must be appropriately informed and supported to this end. Specifically, you must: o Receive a Health Risk Assessment upon enrolling in our plan and to participate in the development and implementation of your Individual Integrated Care and Supports Plan. The assessment will include considerations of social, functional, medical, behavioral, wellness and prevention domains, an evaluation of your goals, preferences, strengths and weaknesses, and a plan for managing and coordinating your care. You, or your authorized representative, also have the right to request a Reassessment by the Integrated Care Team and be fully involved in any such Reassessment. o Receive complete and accurate information on your health and functional status by the Integrated Care Team. o Be provided information on all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking in to consideration your condition and ability to understand. If you are unable to participate fully in treatment decisions you have the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible. o At the time your needs necessitate the disclosure and delivery of such information in order to allow you to make an informed choice. o Be encouraged to involve caregivers or family members in treatment discussions and decisions. o Have advance directives explained and to establish them, if you so desire. Page 5 of 52

7 o o o o o o o o Receive reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer. Be afforded the opportunity file an Appeal if services are denied that you think are medically indicated, and to be able to ultimately take that Appeal to an independent external system of review. The right to receive medical and non medical care from a team that meets your needs, in a manner that is sensitive to your language and culture, and in an appropriate care setting, including your home and community. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. You are free to exercise your rights and that the exercise of those rights does not adversely affect the way our plan, our providers or the State Agency treats you. The right to receive timely information about plan changes. This includes the right to request and obtain the information listed in the orientation materials at least once per year, and the right to receive notice of any significant change in the information provided in the orientation materials at least 30 calendar days prior to the intended effective date of the change. The right to be protected from liability for payment of any fees that are the obligation of the ICO. The right not to be charged any cost sharing for any services you receive as part of this plan. You have a right to: Be treated with respect and your right to privacy and confidentiality Get care that meets your health needs Get information about HAP Midwest Health Plan s services and providers, practitioners and rights and responsibilities Work with doctors in decision making about your health care Choose or change your PCP A candid talk of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage Decide what type of care you would want if critically ill. This is called Advance Directive Get medical care through a Federally Qualified Health Center (FQHC) Take part in decisions about your health care including refusing treatment or asking about treatment options Ask for advice from another doctor when you are not sure about the care your doctor suggests Ask for a copy of your medical records, ask for amendments or corrections Get timely service from Customer Service Voice complaints or appeals about HAP Midwest Health Plan or the care HAP Midwest Health Plan provides Call or visit the Customer Service department to file an oral or a written grievance or appeal Ask for an administrative fair hearing with the Department of Community Health Ask for your grievance to be reviewed by the State Office of Financial and Insurance Regulations if you are unhappy with the decision made by HAP Midwest Health Plan Page 6 of 52

8 To get information about HAP Midwest Health Plan operations, structure, or make suggestions regarding HAP Midwest Health Plan s services and providers. Make suggestions about HAP Midwest Health Plan member rights and responsibilities Be free of any form of restraint or seclusion used as a way to coerce, discipline, convenience or retaliation You have a responsibility to: Keep good health habits Learn how HAP Midwest Health Plan works Follow HAP Midwest Health Plan policies for getting health care services Choose a PCP Show your HAP Midwest Health Plan card(s) when you need care Make sure no one else uses your HAP Midwest Health Plan card(s) Treat other members, HAP Midwest Health Plan staff, and providers with respect Give information (to the extent possible) that HAP Midwest Health Plan and your doctors need in order to give you the care you need Understand your health problems and work with your doctor to develop care that you both agree on Follow plans and advice for care that you have agreed to with your doctor Keep scheduled appointments. Arrive on time. If you cannot keep your appointment, call your doctor as soon as you can Report any suspected fraud and abuse Know what to do when your PCP s office is closed If you move or change your phone number, call us at (888) to give us the new address and phone number You must call your caseworker at your local Department of Human Services (DHS) office. If you have a baby, or if your family size changes for any reason, call your DHS worker and let them know about the changes. Call HAP Midwest Health Plan and let us know too. TRANSPORTATION If a HAP Midwest Health Plan member is unable to obtain transportation for medical services, HAP Midwest Health Plan may provide transportation for them. In order to obtain transportation, the member must declare that there are no resources available to them. The members should be advised to contact HAP Midwest Health Plan Customer Service Department toll free at (888) at least four (4) business (Monday through Friday) days prior to their scheduled appointment to request transportation services. Transportation will typically be provided by public bus service, if available, or cabs if medically necessary or bus routes are not available. For members who need cabs or other specialized transportation for an extended period of time, written documentation substantiating the need for the transportation may be requested from the PCP. Page 7 of 52

9 LANGUAGE INTERPRETATION AND SERVICES FOR HEARING AND SPEECH IMPAIRED HAP Midwest Health Plan is committed to maintaining open lines of communication with all members and providers. To support that goal, HAP Midwest Health Plan has contracted with vendors to provide language interpretation services, as well as services for communicating with hearing and/or speech impaired members, for all HAP Midwest Health Plan members. HAP Midwest Health Plan also has support staff available that can provide interpretation services in Arabic and Spanish. For more information on using these services, please contact the Customer Service Department at (888) ENROLLEE INFORMATION MI HEALTH LINK PROGRAM ELIGIBLE POPULATION The MI Health Link Program is available to individuals who meet all of the following criteria: Age 21 or older at the time of enrollment; Eligible for full benefits under Medicare Part A, and enrolled under Parts B and D, AND receiving full Medicaid benefits. (This includes individuals who are eligible for Medicaid through expanded financial eligibility limits under 1915(c) waiver or who reside in a nursing facility and have a monthly pay amount); AND Reside in a Demonstration region. The following populations will be excluded from enrollment in the MI Health Link Program: Individuals under the age of 21 Individuals previously dis enrolled due to Special Disenrollment from Medicaid Managed Care Individuals not living in the Demonstration region Individuals with Additional Low Income Medicare Beneficiary/Qualified Individuals (ALMB/QI) Individuals without full Medicaid coverage (spend downs or deductibles) Individuals with commercial HMO coverage ENROLLMENT AND DISENROLLMENT PROCESS The MI Health Link program allow individuals to Opt In for participation, or they may be Passively enrolled into the program by the state Enrollment Broker. Eligible individuals will be notified of their right to select among contracted Integrated Care Organizations (ICOs) no fewer than thirty (30) days prior to the first effective date of enrollment. For eligible individuals who do not participate in the optin period, either by choosing and ICO or expressing a preference not to participate in the MI Health Link program, enrollment into an ICO may be conducted using a seamless, passive enrollment process. Individuals eligible for passive enrollment will be notified no fewer than 60 days prior to the enrollment effective date of plan assignment, the opportunity to choose among ICOs, choose not to participate in the MI Health Link Program, or choose to dis enroll from an ICO at any time after enrollment. Prior to the effective date of their enrollment, beneficiaries who would be passively enrolled will have the opportunity to opt out until the last day of the month, and will receive sufficient notice and information with which to do so. Disenrollment from ICOs and enrollment from one ICO to a different ICO shall be allowed on a month to month basis any time during the year; however, coverage for these individuals will continue through the end of the month. Page 8 of 52

10 MEMBER ID CARD ELIGIBILITY A member s eligibility may change monthly; therefore, it is the responsibility of all providers rendering services to verify a beneficiary s eligibility at the time of service. Services provided when a member is not enrolled with HAP Midwest MI Health Plan program will not be covered. The following resources should be utilized to check the eligibility status of a member: CHAMPS Web portal Community Health Automated Medicaid Processing System (CHAMPS) (800) HAP Midwest Customer Service Department (888) CO PAYMENTS There are no co payments for MI Health Link Program covered services PHILOSOPHY OF CARE HAP Midwest Health Plan health care providers will deliver services consistent with these philosophies: Person Center Planning The principle of Person centered planning are: o Each member has strengths, and the ability to express preferences and to make choices. o The member s choices and preferences shall always be honored and considered, if not always granted. o Each member has gifts and contributions to offer to the community, and has the ability to choose how supports, services and/or treatment my help them utilize their gifts and make contributions to community life. o Person centered planning processes maximize independence, create community connections and work towards achieving the individual s dreams, goals and desires. o A person s cultural background shall be recognized and valued in the decision making process. Revised: 7/1/17 Page 10 of 52

11 Self Determination All individuals, regardless of whether or not they have a disability, have the civil right to live the way they want to live. The principals of self determination are: o Freedom to decide how one wants to live his or her life. o Authority over a targeted amount of dollars. o Support to organize resources in ways that are life enhancing and meaningful to the individual. o Responsibility for the wise use of public dollars and the recognition of the contribution individuals across disability and aging can make to their community. Recovery An individual s journey of healing and transformation to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential. It is not the role of providers to make decisions for member, but to have a responsibility to provide education about the possible outcomes that may result from various decisions. Independent Living Living just like everyone else having opportunities to make decisions that affect one s life, being able to pursue activities of one s own choosing, and being limited only in the same ways as one s non disabled neighbors. HAP Midwest Health Plan health care providers are accountable for: Member satisfaction Health care access to comprehensive and quality medical care / preventative services; Promote sharing of the responsibility of heath care decisions with members and their families, caregivers, etc. Providing culturally competent care by seeking to listen to and make accommodation for patients' diverse beliefs and practices Being aware of their own assumptions including those related to the "culture" of medicine and attempt a posture of cultural humility and respect toward those who hold different and perhaps conflicting assumptions from their own. MODEL OF CARE OVERVIEW The target population for HAP Midwest Health Plan MI Health Link Program consists of Medicare & Medicaid Eligible individuals which are defined as Medicare beneficiaries who are also eligible for full Medicaid benefits. The service area for HAP Midwest MI Health Link product is Macomb and Wayne Counties in Michigan. Specially Tailored Services Geared Toward the Most Vulnerable Population HAP Midwest understands how vulnerable the MI HEALTH LINK population is and therefore, has added benefits specific to the known unique needs of our population. These value added services and benefits include: The beneficiaries pay $0 co pay for generic and brand drugs Additional benefits through HAP Midwest Health Plan: Care Coordinator nurse or social worker to help the beneficiary obtain optimal health and assist in navigating the managed care system. All beneficiaries receive a health risk assessment and inter disciplinary plan of care. Health and Wellness Programs: smoking cessation, preventive health outreach (services due like vaccinations, colorectal cancer screening, etc.) and disease management programs for Diabetes, Asthma and Hypertension. 24/7 Health Information Line Page 11 of 52

12 Emergency Response Service benefit for high risk individuals. Persons must meet certain criteria and must be approved by Medical Director. Podiatry for medically necessary foot care. Vision one routine eye exam every two years and up to one pair of glasses every two years (lenses and frames). Hearing test Dental that includes an oral exam, fluoride treatment, X rays and cleaning. The additional services that HAP Midwest provides to our most vulnerable beneficiaries are dependent upon the beneficiary s needs and goals. The following examples show some of the vulnerable beneficiary categories and the additional services: Frail: in home physical therapy and occupational therapy assessments and treatment, transportation to and from medical appointments, in home safety assessment, Emergency Response System, Disabled: in home physical therapy and occupational assessments and treatment, transportation to and from medical appointments, in home safety assessment, Emergency Response System, End Stage Renal Disease: nutrition counseling, transportation to and from dialysis and medical appointments, educational materials on cooking/renal disease/medications, medication reconciliation program Beneficiaries near the end of life: hospice information, home health aides, nursing care in home, transportation to medical appointments, Emergency Response System Beneficiaries having multiple and complex conditions: The beneficiary s personal care coordinator works with them to obtain optimal health and assist in navigating the managed care system, Emergency Response System, Health and Wellness Programs: smoking cessation, preventive health outreach (services due like vaccinations, colorectal cancer screening, etc.) and disease management programs for Diabetes. Integrated Care Bridge / Electronic Care Bridge HAP Midwest maintains an Integrated Care Bridge to facilitate timely and effective information flow between the plan, provider, MiHIN, and the PIHPs. The Care Bridge has the capability to directly exchange information between all members of the healthcare team to improve the efficiency of care. Care Coordination Every beneficiary is assigned to a HAP Midwest Care Coordinator based on the beneficiary s assigned risk level and individual needs. HAP Midwest will allow the beneficiary or his or her authorized representative a choice in the selection of a HAP Midwest Care Coordinator. The Care Coordinator can be a registered nurse or licensed social worker with experience, education and training who interacts with the special needs population. The RN Care Coordinators have experience in a variety of settings such as acute care, long term care, home care, behavioral health, infusion centers, social work and Area Agencies on Aging to meet the needs of the MI Health Link population. The SW Care Coordinator is a Master s level social worker eligible for State of Michigan certification as a Certified Social Worker. He/she has knowledge of community resources and problems unique to the Medicare/Medicaid population, such as that acquired during one to two years of work experience. He/she has a professional level of analytical skills in order to analyze and solve problems and develop viable plans of intervention. Page 12 of 52

13 The Care Coordinator reports to the Manager of Health Services and has the following responsibilities: Conducting, collecting and reviewing the Health Risk Assessment. Includes analyzing and stratifying the beneficiary s health care needs based on the HRA. Contacting beneficiary and reviewing the HRA with them Identifies any medical or social impediment to care issue Determines the beneficiary s ability to follow a prescribed plan of care Initiates and implements a plan of care with attainable goals in conjunction with all health care providers and community agencies Modifies the plan as necessary through monitoring and re evaluation to accommodate changes in treatment or progress. Contacts the beneficiary on a predetermined schedule to evaluate interventions. Presents questionable cases to the Medical Director for review. Enters authorizations for approved services into the system per HAP Midwest procedures Assures maintenance and sharing of records and reports Assures HIPAA compliance Maintains paper based and/or electronic information systems The HAP Midwest Care Coordinator will use the results of the Level I and Level II assessment (when indicated) to develop a person centered Individual Integrated Care and Supports Plan (IICSP) with the beneficiary and ICT chosen by the beneficiary. The plan of care will include a review and analysis of the following: Current Health Status: including at risk for falls, multiple chronic conditions such as Diabetes, COPD, CHF and cancer. Clinical History: disease onset, hospitalizations, treatment history and medications and past surgical and psychiatric conditions, acute exacerbations due to non adherence to medications and polypharmacy. Activities of Daily Living: functional ability to perform ADL s identified deficiencies in vision, hearing or speech limitations, toileting, incontinence issues, bathing, transferring and mobility including fall risk, eating and swallowing, and dressing. It includes assessment of instrumental activities of daily living (housework, shopping, use of phone, money management) Mental Health Status: psychosocial and cognitive functions such as checking for orientation to person, place and time, wandering issues, threat to self or others, and displaying unsafe or extreme bizarre habits. This includes a check for depression (administer the screening tool), and history of other psychological conditions Life Planning: when appropriate; can facilitate the completion of the living will, advanced directives, power of attorney and forward the documents to the PCP Cultural or Religious limitations preferences: language, treatment choices and facilitation of access to culturally acceptable heath care for the beneficiary such as informing beneficiary of providers who are located close to their home and speak the same language. Caregiver Resources: family involvement and identification of care giver who is able to participate in developing and implementing plan of care. Communication occurs with the beneficiary and if one has been identified, their caregiver. Benefits: eligibility issues, financial barriers. This includes identification of resources that are available in the community and special programs for treatment of conditions including hospice. The beneficiary s Care coordinator ensures that referrals are for covered services and facilitates the accessing of these services. They also educate the beneficiary on the benefits for both Page 13 of 52

14 Medicare and Medicaid and help resolve any LIS eligibility issues. The Case Manger facilitates the coordination of the beneficiary to work with Michigan Medicare/Medicaid Assistance Programs (MMAPS) in our service area to also assist them in understanding their benefits. Case Management Plan with Goals Short and Long Term Goals: Upon completion of the HRA and the welcome call, the Care coordinator works with the beneficiary to develop short term goals (ones that can be achieved with 3 6 months) and long term goals (ones can be achieved within 9 12 months). The goals are mutually agreed upon with the Care Coordinator, the beneficiary and with consultation with the PCP. These goals are based on the immediate needs identified by the beneficiary including beneficiary preferences for care, as well as their future goals to improve their health status. These goals include the members life goals Additional Resources: When completing the care plan, at times additional resources may be identified during the care plan development. For example, for those that are at risk for falls or have mobility issues the additional resources may include PT, a home safety evaluation, and vision and hearing testing in order to successfully address the plan of care. These additional resources are communicated to the PCP by the Care Manager. Transition of Care Plan, when a beneficiary s care is transitioned to another setting, such as transfer to hospital or skilled nursing facility the care plan is adjusted to reflect their current environment and outcome possibilities. For example when a home bound beneficiary is transitioned to a skilled nursing facility, the plan of care will be adjusted to include elements of care in that setting and include discharge goals and outcomes and associated time frames. Near End of Life Issues: the plan of care in CCMS includes the documentation of completion of the beneficiary s Advance Directives and Power of Attorney. Add on services include MMAP counselors, hospice counselors, and other disease related foundations. Barriers: lack of understanding, motivation to change, financial, transportation In order to help beneficiaries understand the plan of care, the Care Coordinators spend time on the phone discussing the plan of care and send them the ICT brochure. It is written at a 6th grade reading level to assist in the comprehension of the information. The beneficiary receives a welcome packet that informs them of the Medicare and Medicaid benefits. They receive a welcome call from the Customer Service Representatives who answer their questions and discuss the Medicaid and Medicare benefits. The benefit of free transportation is discussed with the beneficiaries upon enrollment to assist in addressing transportation barriers. All contacts with the beneficiaries are done to motivate them to follow the plan of care. While their financial costs for medical care are covered through either Medicare or Medicaid, financial incentives are offered for completion of preventive services such as mammograms. Follow up Schedule: documentation of appointments; counseling, specialty physician, wound clinic; etc. to reflect beneficiary s status on adherence to the plan (making the appointments, keeping the appointment and any follow up of appointments) are documented in McKesson CCMS system. The results of the appointment and recommendations made by the referral provider are also documented in the CCMS system. For example, a PCP provides a referral to home care for extensive wound dressing changes and IV infusion of antibiotics. The Care coordinator facilitates the referral for that care and set ups the arrangements with wound care and IV infusion. The Care Coordinator would document wound dimension over time and ensure self care instructions are given to the beneficiary to assist in self management care. This would also be reflected in the plan of care and in CCMS and include updating the PCP of beneficiary s current status. Page 14 of 52

15 Self Management Plan: monitoring of symptoms, activity, BP, blood sugars; etc. Beneficiary s self management is an integral part of the care plan. The Care Coordinator re affirms the beneficiary understands of monitoring their symptoms as it relates to their specific disease process. Referrals to home care are made to assist in educating the beneficiaries on selfmanagement activities such as blood pressure monitoring, sugar level monitoring, daily weights, temperature monitoring, wound appearance monitoring, etc. It includes education on reporting significant findings of their symptoms to their PCP. Progress Assessment: Upon completion of the HRA, the HAP Midwest Care Coordinator works with the beneficiary to develop short term goals (ones that can be achieved with 3 6 months) and long term goals (ones can be achieved within 9 12 months). The goals are mutually agreed upon with the Care Coordinator, the beneficiary and with consultation with the PCP. These goals are based on the immediate needs identified by the beneficiary including beneficiary preferences for care, as well as their future goals to improve their health status. Timeframe for re evaluation is individualized based on the beneficiary s plan of care. Automatic prompts are displayed in the reminder log in the McKesson CCMS system based on the timeframes identified in the beneficiary s care plan. If the beneficiary does not meet their goal, the goal is revised or a new goal is established with the beneficiary based on their input. An annual, all encompassing reevaluation will be conducted after the annual HRA is completed. Interdisciplinary Care Team The beneficiary is the center of the Interdisciplinary Care Team. The HAP Midwest Care Coordinator ensures that the beneficiary has access to and input in the development of an Integrated Care Team (ICT) to ensure the integration of his/her medical, behavioral health, and psychosocial care, and LTSS based on the HRA. The ICT is person centered, built on the beneficiary s specific preferences and needs, and delivers services with transparency, individualization, accessibility, respect, linguistic and cultural competence, and dignity. The ICT honors the beneficiary s choice about his or her level of participation. This choice will be revisited periodically by the Care Coordinator as it may change. The Care Coordinator will include a person familiar with the needs, circumstances and preferences of the beneficiary when the beneficiary is unable to participate fully in or report accurately to the ICT. It is the beneficiary s right to determine the appropriate involvement of other members of the ICT based on the needs identified in the HRA in accordance with applicable privacy standards. It is the responsibility of the Care Coordinator and the beneficiary to set and facilitate ICT meetings as well as facilitate communication among ICT members. LTSS and PIHP Supports Coordinators will be members of ICTs (as applicable) to encourage communication and collaboration between ICOs, PIHPs and other providers. The HAP Midwest Care Coordinator is responsible to assure the ICT process, but the beneficiary may request his or her LTSS or PIHP Supports Coordinator remain his or her main point of contact regarding his or her care Page 15 of 52

16 PROVIDER NETWORK HAP Midwest Health Plan maintains a Provider Network sufficient to provide all beneficiaries with access to the full range of Covered Services, including the appropriate range of preventive, primary care, and specialty services, behavioral health services, other specialty services, and all other services. HAP Midwest ensure that its network providers are responsive to the linguistic, cultural, ethnic, racial, religious, age, gender and other unique needs of any minority, homeless population, beneficiaries with disabilities (both congenital and acquired disabilities), or other special population. HAP Midwest beneficiaries have a choice of providers. The plan received notification that it had successfully passed the Network Provider submission for 2015 on January 14, A semi annual review of the HAP Midwest network is conducted to determine if beneficiaries have access to a Provider network that is sufficient in size to meet the cultural diversity of the population, provider appointment times meet HAP Midwest s standards and the number and types of providers meet its requirements: Access: Annual appointment wait time and after hours accessibility studies are conducted. The appointment wait time study monitors the time for urgent, routine and preventive visits in provider offices. The availability studies monitor the Primary Care Physician (PCP) availability 24 hours a day/7 days a week to ensure that the beneficiaries have access 24 hours a day to their PCP. HAP Midwest ensures beneficiaries have adequate access to PCPs by conducting access mapping to ensure that there are contracted providers within 30 minutes or 30 miles from the beneficiary s home. The PCPs work closely with HAP Midwest and the beneficiaries to coordinate needed care and services for the beneficiaries. HAP Midwest ensures that providers physical sites are accessible to all beneficiaries. Adequate number of Primary Care Providers: HAP Midwest contracts with over 1400 Primary Care Providers (PCPs). Their specialties include Geriatric Medicine, Internal Medicine, Family Practice, General Medicine, and Pediatrics. Adequate number and types of Specialists: HAP Midwest contracts with over 4,000 specialists to care for beneficiaries. The specialties include but are not limited to: Mental Health, Cardiology, Gastroenterology, Hematology, Infectious Disease, Endocrinology, Nephrology, Neurology, oncology, Ophthalmology, Pain Management, Urology, Physical Medicine and Rehabilitation, Podiatry, Psychiatry, Pulmonary Disease, Rheumatology, all Surgical Specialties, Wound Care, etc. As stated above, access studies are conducted annually to ensure the providers meets and exceeds HAP Midwest s standards for numbers and types of specialists in its provider network. Geriatric Focused Care: HAP Midwest reviews the network to ensure contracts are in place with Geriatric Centers and Geriatric Providers. Currently HAP Midwest works with two large Geriatric Centers (Oakwood and Detroit Medical Center) to provide coordinated care for beneficiaries. HAP Midwest also contracts with a large outpatient day clinic for the behavioral health, emotionally and developmentally disabled beneficiaries. Facilities: HAP Midwest reviews the entire network of ancillary providers to ensure there are inpatient, outpatient, rehabilitation and long term care, and psychiatric facilities. It also reviews the network to be sure there are laboratory services and radiology facilities in service areas. Behavioral Health Specialists and Mental Health Specialists: HAP Midwest contracts with Behavioral Health facilities. This includes drug counselors, clinical psychologists, psychiatrists, etc. Nursing Professionals: HAP Midwest encourages Providers to have registered nurses, nurse practitioners, nurse managers and nurse educators in their offices to be available for the beneficiaries. Page 16 of 52

17 Allied Health Professionals: HAP Midwest ensures contracting has occurred with speech pathologists, pharmacists (through 4 D Pharmacy PBM), physical therapists, occupational specialists, speech pathologists, laboratory specialists and radiology specialists in its service areas. Cultural Diversity: HAP Midwest will ensure it is fully prepared to meet the cultural uniqueness of its beneficiaries. HAP Midwest contracts with providers who speak Arabic and the provider network also includes physicians who speak Spanish, French, Hmong, Hindi, Urdu, etc. HAP Midwest Customer Service Department also has representatives who speak Arabic and Spanish. HAP Midwest has access to the ATT language line. The HAP Midwest Provider Directory lists the languages spoken by the providers, their office hours, after hour s phone number, address, hospital affiliations and any age limitations. Disabled beneficiaries: HAP Midwest ensures that its network providers are responsive to the unique needs of their population. Enrollees with disabilities (both congenital and acquired disabilities), or other special population. Providers have the capacity to communicate with beneficiaries in languages other than English, when necessary, as well as those with a vision or hearing impairment. HAP MIDWEST ensures providers have a TDD/TTY phone line available for use with the hard of hearing and Deaf beneficiaries and will use interpreters qualified in American Sign Language (ASL) for beneficiaries. Frail/disabled beneficiaries, Multiple chronic illnesses, Near the end of life: As a part of the network analysis, HAP Midwest wants to be sure the network includes providers trained in areas of expertise that range from Pediatrics to Geriatrics and Podiatry to Psychiatry. These providers have the clinical expertise and combined with the resources from HAP Midwest, have the training and resources to use to meet the needs of the frail/disabled beneficiaries, beneficiaries with multiple chronic illnesses and beneficiaries near the end of life. Providers are experienced in treating beneficiaries with multiple chronic and disabling illnesses and conditions. o Ancillary Providers: HAP Midwest ensures the beneficiaries have adequate access to dialysis facilities, inpatient hospitals, specialty outpatient clinics, home care, and DME providers. COMMUNICATION WITH THE PCP HAP Midwest Health Plan strives to keep the entire care team (including PCPs and SCPs) informed of any changes within HAP Midwest Health Plan and/or the State of Michigan Medicaid Program. Our website provides the most up to date information for Providers. This information includes, but is not limited to : Provider Newsletters, pertinent policies and procedures, member eligibility, financial information (pay for performance information, financial reports, remittance advices, opportunity reports, etc.), and clinical guidelines. Page 17 of 52

18 MEMBER ADVOCACY HAP Midwest Health Plan does not prohibit any Participating Practitioner or Allied Health Professional from discussing treatment options with members, regardless of benefit coverage, or from advocating on behalf of a member in any grievance or utilization review process, or individual authorization process to obtain health care services. Practitioners may freely communicate with patients about their treatment, including medication treatment options, regardless of benefit coverage limitations. HAP Midwest Health Plan encourages the PCP along with all health providers to develop plans of care with their patients (or patient s guardian or representative) since the member s participation is an integral part of the decision making for their treatment and care options. PCP REPORTING REQUIREMENTS PCPs and SCPs participating with HAP Midwest Health Plan are contractually obligated to submit documentation of all encounters (visits) with assigned members. The Plan is mandated to provide encounter information to the Michigan Department of Health and Human Services (MDHHS) and the Centers for Medicare and Medicaid Services (CMS). PCP PERFORMANCE AND PAY FOR PERFORMANCE (P4P) BONUS PROGRAM HAP Midwest Health Plan may pay providers additional money for increasing the quality of patient care received by enrollees of HAP Midwest Health Plan. Payment is based on quality outcomes for specific measures as outlined by the Plan. Each year HAP Midwest Health Plan reviews its Pay for Performance program and may make revisions to the program based on goals set for the upcoming year. PCPs are notified of P4P changes through their contract (found on our website in the financial section) as well as the HAP Midwest Health Plan website. The P4P criteria, Opportunity Reports, and remittance advices for these programs are found in the Provider s secure financial section of the website. HAP Midwest Health Plan reserves the right to use practitioner performance data for quality improvement activities designed to improve quality of care and services and the member s overall experience. PCP ACCESSIBILITY AND AVAILABILITY Every PCP site shall provide twenty four (24) hours per day, seven (7) days per week, three hundred sixty five (365) days per year, and physician on call coverage to their assigned recipients. Every physician contracted as a PCP must be available to see patients a minimum of twenty (20) hours per location/per week. The PCP shall give written prior notice to HAP Midwest Health Plan of alternative coverage arrangements during times of non availability. PCP's should encourage their members to contact them whenever possible, prior to seeking health care services outside of their office. HAP Midwest Health Plan requires the hours of operation that providers and practitioners offer to Medicaid members be no less than those offered to commercial members and comparable to those for Medicaid Fee for Service (FFS) members. Page 18 of 52

19 ACCESS TO CARE STANDARDS All HAP Midwest Health Plan PCPs are available (or will make the appropriate coverage available in their absence) for all HAP Midwest Health Plan members, on a 24 hours per day/7 days per week/52 weeks per year basis for urgent care and emergency care. Appointment Type Standard Description Preventive/Routine Care 14 days of member request Routine, non symptomatic care Urgent Care 48 hours of member request Symptomatic problems Emergency 24 hours of member request Life threatening situations Wait Time in the Office 30 minutes After checking in with the receptionist to being seen by the practitioner CREDENTIALING HAP Midwest Health Plan has delegated its credentialing activities to its parent organization, Health Alliance Plan (HAP). Questions regarding Credentialing should be directed to (313) NETWORKDEVELOPMENT/CONTRACTING PROCESS Providers may join the HAP Midwest Health Plan provider network by contacting the Network Development/Contracting department at (313) or e mail to Provider_Development@hap.org PROVIDERTERMINATIONS HAP Midwest Health Plan may immediately terminate a provider contract, pursuant to the termination provisions set forth in the provider agreement. Grounds for immediate termination include: Suspension or exclusion from the state Medicaid program, federal Medicare program or any other governmental public sector program. Failure to meet or comply with HAP Midwest Health Plan s credentialing requirements. In instances where HAP Midwest Health Plan reasonably believes that the Member s safety or care would be adversely affected by continuation of the contract. Conviction of Medicaid or Medicare fraud or any other fraudulent activity. An exclusion found via a background check DEMOGRAPHIC CHANGES The Provider is responsible to contacting the Network Development/Contracting department of changes in demographics, including: Address changes (additions and deletions) Addition of new providers under existing tax ID Updating providers who have voluntarily or otherwise terminated their contract. Change in Tax IDs, NPI numbers, etc. Updates in billing and remittance addresses Correction of incorrect provider demographic information Page 19 of 52

20 HEALTH SERVICES REFERRALSANDAUTHORIZATIONS HAP Midwest Health Plan has a vast network of specialists and ancillary providers. It is expected that referrals for services are made to in network providers whenever possible. A list of contracted providers and specialists is available online. If there is a question regarding the status of a provider or if it is felt a referral out of network is necessary, the Plan should be contacted. REFERRALS The Health Care Referral Form should be used when requesting services requiring HAP Midwest Health Plan notification/approval. In order to provide a timely decision, HAP Midwest Health Plan requests clinical documentation accompany the referral form to support the service being requested. HAP Midwest Health Plan does not require a referral to a contracted specialist. Only specified procedures require a referral and approval by HAP Midwest Health Plan. (See list of services below requiring plan notification (referral) and approval/prior authorization). HEALTH CARE REFERRAL FORM The Health Care Referral form was developed by the Michigan Association of Health Plans to simplify the PCP s duties in requesting services from all of the Michigan Health Plans. HAP Midwest Health Plan accepts the Health Care Referral Form for services requiring plan notification. HAP Midwest Health Plan expects the Referral form to be complete, timely, and legible. SERVICES REQUIRING PLAN NOTIFICATION (REFERRAL)/APPROVAL (PRIOR AUTHORIZATION) Plan notification and approval must occur prior to a member receiving the following services: Inpatient Hospital Care Chiropractic Care Inpatient Rehabilitation Care Cochlear Implant Skilled Nursing Facility Admission Cosmetic Procedures Non Custodial Nursing Home Care Genetic Testing Custodial Nursing Home Care Home Health Care (Skilled Nursing, PT, OT, Speech Therapy) Long Term Acute Care (LTAC) Long Term Support Services Ambulance (Non Emergency Service) Outpatient Therapy (PT, OT, & Speech) Bariatric Surgery Enteral & Parenteral Therapy Blepharoplasty (Eye Lid Surgery) Transplant Services Breast Reconstruction Vein Procedures (Sclerotherapy, Stripping/Ligation) Cardiac Rehabilitation Durable Medical Equipment ** refer to the plan website for detailed Authorization Grid Prior Authorization from HAP Midwest Health Plan for the above services must be obtained by the member s PCP or the Provider of the service (DME Company/Surgeon). In order to provide a timely decision, HAP Midwest Health Plan requests supporting clinical information accompany the referral form. Plan authorizations will be issued directly to the Provider of Service and the PCP. The Plan may contact the member s PCP or Specialist for information prior to issuing the authorization. Revised: 7/1/17 Page 20 of 52