Provider Manual. Effective December

Transcription

1 Provider Manual Effective December

2 Copyright December 2016 INTotal Health All rights reserved. This publication, or any part thereof, may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without the prior written permission of INTotal Health. How to apply for participation: If you are interested in participating in our network, please go to or call a Provider Relations Representative at

3 Dear INTotal Health Provider, Beginning April 1, 2017, we can provide our members with the new substance use disorder treatment benefit called Addiction and Recovery Treatment Services (ARTS) What is the ARTS program? The ARTS program is an expansion of substance abuse (SA)-covered services traditionally managed by Magellan that will allow INTotal Health to provide a variety of community-based addiction and recovery treatment services to our members. There are several changes to the program including: The current SA services covered under Magellan will now be managed by INTotal Health for our members. These services include SA day treatment, SA intensive outpatient, opioid treatment, SA case management and residential treatment for pregnant women. Several new services have been added for INTotal Health members, including inpatient/residential SA detox, SA residential for all members and SA peer supports. Rates have been significantly increased for several services. What are the services offered under the ARTS program? Service Type Inpatient acute detox Inpatient subacute detox SA residential treatment SA partial day treatment SA Intensive Outpatient Methadone Medication-assisted treatment (opioid treatment) SA case management SA peer support Setting Acute medical hospital Psychiatric hospital or residential facility Facility Outpatient facility Outpatient facility or professional provider Professional provider DBHDS licensed OTP clinic or professional provider setting (MDs only Suboxone) Outpatient facility or professional provider Outpatient facility or professional provider

4 What type of treatment do patients receive under the various service categories? Inpatient acute, subacute, and residential treatment services: o Offered in a hospital inpatient or community setting where patient is admitted for detox or treatment. o Prior authorization is required. Substance abuse partial day/hospitalization treatment services: o Typically offered in an outpatient hospital setting where patients receive 20 or more hours of clinically intensive programming per week to obtain stabilization. A planned format of individual and family therapy; doctor consult; direct access to psychiatric, medical and laboratory and toxicology services; and close coordination with appropriate intensive levels of care, comprehensive biopsychosocial assessments and supportive housing services. o Provider types that off er the service under this program are a team of credentialed addiction treatment professionals including licensed counselors, social workers, certified addiction registered nurses, psychologists and physicians. o Prior authorization is required. Intensive outpatient treatment services: o Offered in outpatient professional provider setting to patients receiving counseling and medication management for a minimum of three hours a day (two hours for adolescents) and nine hours a week (six hours for adolescents). o Prior authorization is required. Methadone treatment services: o Offered in DBHDS-licensed opioid-treatment programs (OTP) including medication and counseling. Medication-assisted treatment services: o Treatment with opioids, e.g. SUBOXONE (buprenorphine) may be based in an outpatient clinic or office setting (OBOT) to assist patients with opioid withdrawal or maintenance in a controlled environment. These services can be administered by a clinic contracted as a facility or by a professional provider, usually a medical doctor who has received approval from the Drug Enforcement Agency to offer these services. o Prior authorization is required

5 What are the pre-authorization requirements for these services? Pre-authorizations will be required for ASAM levels of care 2.1 through 4.0 under this program. Preauthorization forms for ARTS services are as follows and can be found under the Forms tab on ARTS Extension Services Authorization Request Form ARTS Initial Service Authorization Request Form ARTS Substance Use Case Management Registration Form Service Authorization Guidelines Fax all requests that require pre-authorization to What clinical review criteria will be used to determine eligibility and approval for specific levels of care? The American Society of Addiction Medicine (ASAM) criteria is a widely used and comprehensive set of guidelines used for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. General overview of ASAM levels: Level of Care Type of Service 1.0 Outpatient services 2.1 Intensive outpatient services 2.5 Partial hospitalization/outpatient managed withdrawal 3.1 Clinically managed, low-intensity residential services 3.3 Clinically managed, population-specific, high-intensity residential services for those with cognitive impairments 3.5 Clinically managed, population-specific, high-intensity residential service 24-hour care 3.7 Medically monitored intensive inpatient services 24-hour nursing care with physician availability 4.0 Medically managed intensive inpatient services 24-hour nursing care and daily physician care, counseling available, severe unstable withdrawal

6 What are the credentialing requirements for providers under the various categories or levels of treatment? INTotal Health will follow their standard credentialing practices for the ARTS program. Providers must attest to the ASAM level(s) of care provided and meet all applicable requirements. Professional provider contracting: opioid treatment services: Medical doctors are the only approved provider types who can off er and receive direct reimbursement for opioid withdrawal treatment. Doctors must obtain approval from the Drug Enforcement Agency and receive a designation to offer these services. Doctors must also be credentialed by INTotal Health and sign a participation agreement for the INTotal Health program to treat these members and receive direct reimbursement. How do I bill for ARTS services? The primary diagnosis code for all ARTS claims must specify a substance use disorder. If billing on a UB, you must include the appropriate revenue and HCPCS code. For additional ARTS resources, visit Scroll down to the Additional ARTS resources section INTotal Health ARTS Contracts: Type of Inquiry Contact Phone General Questions Karen Friesz Regarding ARTS Director, Behavioral Health Karen.Friesz@inova.org Mary Fountain Contracting Director, Network Questions Management Mary.Fountain@inova.org Credentialing Questions Care Coordination Sincerely, Jake Carson Manager, Credentialing Karen Friesz Director, Behavioral Health Jacob.Carson@inova.org Karen.Friesz@inova.org John Muraca Chief Executive Officer INTotal Health

7 Table of Contents 1 INTRODUCTION OVERVIEW QUICK REFERENCE INFORMATION PRIMARY CARE PROVIDERS... 6 Primary Care Provider Role... 6 Provider Specialties... 6 Primary Care Provider Onsite Availability... 7 Provider Disenrollment Process... 7 Member Enrollment... 7 Newborn Enrollment... 9 Members Eligibility... 9 Member Identification Cards... 9 Americans with Disabilities Act Requirements Medically Necessary Services HEALTHCARE BENEFITS AND CO-PAYMENTS Covered Services Starring: Baby and Me Program Well-Child Visits/Early and Periodic Screening, Diagnosis, and Treatment Well-Child Visits Reminder Program Blood Lead Screening Family Planning Services Outpatient Laboratory and Radiology Services Vision Services Pharmacy Services Formulary Patient Utilization Management & Safety (PUMS) Program for Members Behavioral Health Services Cost-sharing Information FAMIS Co-payments Self-Referral Services Member Rights and Responsibilities First Line of Defense Against Fraud, Waste, and Abuse Disclosure of Ownership and Exclusion from Federal Healthcare Programs HIPAA MEMBER MANAGEMENT SUPPORT Welcome Packet Member with Special Needs Appointment Scheduling Transportation Benefits Nurse HelpLine Interpreter Services Health Promotion Case Management Breastfeeding Support... 41

8 Women, Infants, and Children (WIC) Program Community and Member Advisory Committee (CMAC) PROVIDER RESPONSIBILITIES Responsibilities of the Primary Care Provider Primary Care Provider Access and Availability Member Missed Appointments Non-adherent Members Primary Care Provider Transfers Covering Physicians Specialist as a Primary Care Provider Reporting Changes in Address and/or Practice Status Specialty Services Second Opinions Specialty Care Providers Roles and Responsibilities of the Specialty Care Provider (Specialist) Specialty Care Providers Access and Availability Cultural Competency Member Records Patient Visit Data Clinical Practice Guidelines Advance Directives MEDICAL MANAGEMENT Medical Review Criteria Pre-authorization and Notification Process Medical Necessity Decisions Inpatient Reviews Discharge Planning Confidentiality of Information Emergency Services Urgent Care COMPLAINT, GRIEVANCE, AND APPEAL PROCEDURES Complaints Member Appeals and Grievances Definitions Member Appeal Process Expedited Appeal State Fair Hearing Continuation of Benefits Member Grievances Provider Grievances and Payment Appeals QUALITY MANAGEMENT Quality Management Program Quality Management Committee Medical Advisory Committee Credentialing... 83

9 11 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES Electronic Submission Paper Claims Submission Encounter Data Claims Adjudication Clean Claims Payment Claims Status Provider Reimbursement Procedure for Processing Overpayments Coordination of Benefits Billing Members Our Website and Provider Services Line APPENDIX A FORMS Pre-Authorization Request Form Request PCP Change Form Maternity Notification Form Specialist as PCP Request Form Counsel for the HIV Antibody Blood Test Consent for the HIV Antibody Blood Test Results of the HIV Antibody Blood Test Practitioner Clinical Medical Record Audit Living Will Durable Power of Attorney WIC Referral Form Payment Appeal Request Form Corrected Claims/Reconsideration Request Form Member Grievance Form Member/Provider Appeal Form APPENDIX B CLINICAL PRACTICE GUIDELINES

10 1 INTRODUCTION Welcome to the INTotal Health network provider family. We are pleased you have joined the network, which represents some of the finest healthcare providers in the Commonwealth. We participate in the Medicaid and Family Access to Medical Insurance Security (FAMIS) programs. Medicaid is Virginia s managed care health insurance program. FAMIS is Virginia s health insurance program for children. The Virginia Department of Medical Assistance Services (DMAS) is the administrator of these programs. We are a licensed Health Maintenance Organization (HMO). We bring the best expertise available to operate a Virginia community-based healthcare plan with experienced local staff to complement our operations. We are committed to assisting you in providing quality healthcare. We believe hospitals, physicians, and other providers play a pivotal role in managed care. We can only succeed by working collaboratively with you and other caregivers. Earning your loyalty and respect is essential to maintaining a stable, high-quality provider network. All network providers are contracted with us through a Participating Provider Agreement. If you are interested in participating in any of our quality improvement committees or learning more about specific policies, please contact us. Most committee meetings are prescheduled at times and locations intended to be convenient for you. Please call the Provider Relations Department at with any suggestions, comments, or questions you may have. Together, we can arrange for and provide an integrated system of coordinated, efficient, and quality care for our members. 1

11 2 OVERVIEW What is INTotal Health? INTotal Health is a Medicaid Managed Care Organization (MCO) that provides high-quality, member focused service in Northern Virginia, Alleghany/Roanoke, Orange/Madison counties, and southwestern regions of Virginia. We are a wholly owned subsidiary of Inova Health System, a not-for-profit healthcare system based in Northern Virginia. We are accredited by the National Committee for Quality Assurance (NCQA) and remain committed to improving the health of the Medicaid members we serve through excellent care coordination with our provider network and community partners. Vision and Values Our vision is to optimize the health and well-being of each individual we serve. Our beliefs are based on: Trust Empowerment Integrity Partnership Quality Respect Value Compassion Strategy and Service Promise Our strategy is to: Improve access to preventive primary care services by ensuring the selection of a Primary Care Provider (PCP) who will serve as provider, care manager, and coordinator for all basic medical services Improve the health status and outcomes of members Educate members about their benefits, responsibilities, and the appropriate use of healthcare services Encourage stable, long-term relationships between providers and members Encourage the medically appropriate use of specialists and emergency rooms Commit to community based enterprises and community outreach Facilitate the integration of physical and behavioral healthcare Foster quality improvement mechanisms that actively involve providers in re-engineering healthcare delivery Encourage a customer service orientation with regular measurement of member and provider satisfaction Our Service Promise is that we seek every opportunity to meet the unique needs of each person we are privileged to serve every time, every touch. 2

12 3 QUICK REFERENCE INFORMATION Please call Provider Services for pre-authorization/notification, health plan network information, member eligibility, claims information, inquiries, and recommendations you may have about improving our processes and managed care program. Important Phone Numbers Automated Provider Inquiry Line: Dental Services Smiles for Children (administered by DentaQuest): Electronic Data Interchange (EDI) Hotline: Change Healthcare (formerly Emdeon): Emdeon One (formerly Capario): Gateway (TriZetto): Availity: evicore Healthcare (formerly MedSolutions) (CAT, CT, MRA, MRI, and PET scans): Medical Management: Member Services: Nurse HelpLine: Pharmacy Services: , Opt. 3 Pharmacy Specialty Drugs: Provider Services: Provider Services Fax: Transportation Services LogistiCare: Members may call to utilize transportation options including reservations to and from their appointment, gas reimbursement when providing independent transportation, or to secure tokens for public transportation. To check on the status of a ride, member may call LogistiCare at TTY/TTD AT&T Relay Service: 711 Vision Services Superior Vision:

13 Website Our website contains a full complement of online provider resources, including tools you can use to check eligibility in real time, claims status, and claims submission. The site provides general information such as forms, our Formulary, drugs requiring a pre-authorization, provider manual, Find a Doctor directory, provider newsletters, claims status, Electronic Remittance Advice (ERA), and Electronic Funds Transfer (EFT) information, updates, clinical practice guidelines, and other information to help you work with us. The website may be accessed at. Ongoing Provider Communications To ensure providers are up to date with information required to work effectively with us or our members, we provide frequent communications to providers in the form of mailings, provider manual updates, quarterly newsletters and information posted to the website. Below you will find additional information that will assist you in your day-to-day interactions with us. Additional Information Member Eligibility Notification/ Pre-authorization Check the DMAS website at: or contact Provider Services at Must be faxed to us: Data Required for complete notification/pre-authorization: o Medicaid I.D. Number o Legible name of referring provider o Legible name of individual referred to provider o Number of visits and/or services o Dates of service o Diagnosis o Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes In addition, clinical information is required for pre-authorization. Pre-authorization Request Forms are located at and can be filled out online, printed and faxed to

14 Additional Information Claims Information Submit paper claims to: Claims, INTotal Health P.O. Box Birmingham, AL Electronic claims Payer I.D.: o Change Healthcare (formerly Emdeon) is o Emdeon One (formerly Capario) is o Availity is o Gateway (TriZetto) is INT01 Timely filing of medical claims is within 180 days of the date of service or per the terms of the provider agreement. For other claims (vision, pharmacy, and transportation), refer to the Healthcare Benefits and Co-payments section. We provide an online resource designed to significantly reduce the time your office spends on eligibility verification and claims status. Visit. If you are unable to access the Internet, you may receive claims, eligibility, and pre-authorization status over the telephone at any time by calling Provider Services at Member Appeal Information Member appeals must be filed within 30 calendar days of the date of the notice of action. File a member appeal for medical necessity at: INTotal Health Appeals Unit 3190 Fairview Park Drive, Suite 900 Falls Church, VA Payment Appeal Providers who disagree with payment may request a claim reconsideration. If a provider is dissatisfied with claims payment or a claims reconsideration resolution, the provider may submit an appeal within 90 calendar days of receipt of the Explanation of Payment (EOP). We will send a determination letter within 30 calendar days of receipt of the provider payment appeal. File a payment appeal at: Payment Appeals INTotal Health P.O. Box Birmingham, AL Grievances Grievances (for reasons other than medical necessity or other than payment appeals) should be submitted to: INTotal Health Grievances 3190 Fairview Park Drive, Suite 900 Falls Church, VA Care Managers Our care managers are available during normal business hours from 8:30 a.m. to 5:30 p.m. Please call Provider Relations Representatives For further assistance, contact your INTotal Health Provider Relations Representative at

15 4 PRIMARY CARE PROVIDERS Primary Care Provider Role The Primary Care Provider (PCP) is a network provider who has the responsibility for the complete care of his or her patient, who is an INTotal Health member. The PCP serves as the entry point into the healthcare system for the member. The PCP is responsible for the complete care of his or her patient, including but not limited to providing primary care, coordinating and monitoring referrals to specialist care and maintaining the continuity of care. The PCP responsibilities shall include at a minimum: Managing the medical and healthcare needs of members to ensure all medically necessary services are made available in a timely manner Monitoring and following up on care provided by other medical service providers for diagnosis and treatment, to include services available under Fee-For-Service (FFS) Medicaid Providing the coordination necessary for the referral of patients to specialist and for the referral of patients to services that may be available through FFS Medicaid Providing education and coordination for recommended preventive healthcare services and appropriate guidance for healthy behaviors Maintaining a medical record of all services rendered by the PCP and other referral providers A PCP must be a physician or network provider or subcontractor who provides or arranges for the delivery of medical services, including case management, to ensure all services, which are found to be medically necessary, are made available in a timely manner. The PCP may practice in a solo or group setting or may practice in a clinic [e.g., a Federally Qualified Health Center (FQHC), Rural Health Center (RHC), or outpatient clinic]. We encourage members to select a network PCP who provides preventive and primary medical care, as well as coordination of medically necessary specialty services. Members are encouraged to make an appointment with their PCP within 90 calendar days of their effective date of enrollment. Provider Specialties Physicians with the following specialties can apply for enrollment with us as a PCP: Family Medicine practitioner General Practice practitioner Pediatrician Internal Medicine Practitioner Nurse practitioners certified as specialist in family practice or pediatrics Specialist who performs primary care functions (e.g., clinics, including but not limited to FQHC, RHC, health departments, and other similar community clinics). Obstetrician/Gynecologist Indian Health Providers, if participating in the network as a primary care provider with the capacity to provide such services. Other providers approved by the Department of Medical Assistance Services (DMAS) We encourage providers to enroll in the FFS Medicaid program at the service location where he or she wishes to practice as a PCP in addition to contracting with us. 6

16 Primary Care Provider Onsite Availability We are dedicated to ensuring access to care for our members, and this requires our network providers to be accessible. Our network providers agree to abide by the following standards: PCPs must offer a 24-hour-a-day, 7-day-a-week telephone access for members. A 24-hour telephone service may be used. The service may be answered by a designee such as an oncall physician or nurse practitioner with physician backup, or an answering service or pager system; however, this must be a confidential line for member information and/or questions. An answering machine is not acceptable. If an answering service or pager system is used, the call must be returned within 30 minutes. The PCP or another physician/nurse practitioner must be available to provide medically necessary services. Covering physicians are required to follow the pre-authorization guidelines. It is not acceptable to automatically direct the member to the emergency room when the PCP is not available. We encourage our network PCPs to offer after-hours office care in the evenings and on the weekends. Provider Disenrollment Process Providers may cease participating with us for either mandatory or voluntary reasons. Mandatory disenrollment occurs when a provider become unavailable due to immediate, unforeseen reasons. Examples of this may include death or loss of license. Members are auto-assigned to another PCP to ensure continued access to our covered services, as appropriate. We will notify members of any termination of PCPs or other providers from whom they receive ongoing care. We will provide notice to affected members when a provider disenrolls for voluntary reasons such as retirement. Providers must provide written notice to us within the time frames specified in the Participating Provider Agreement. Members who are linked to a PCP that has disenrolled for voluntary reasons will be assisted in selecting a new PCP. Member Enrollment All eligible recipients, except those meeting identified exemptions, must enroll with a Managed Care Organization (MCO). During the initial 90 days following the member s effective date of enrollment, the member may disenroll from one MCO to move to another without cause. The 90-day timeframe applies to the member s initial period of enrollment and to any subsequent enrollment periods when he or she enrolls in a new MCO. Following the initial enrollment period into an MCO, members are restricted to that MCO until the next open enrollment period (Medicaid recipients) or for the remainder of their 12-month enrollment period (FAMIS recipients) unless the member requests a new MCO or delivery system for cause and receives approval from DMAS. For Medicaid, the enrollment periods are determined by DMAS based on the member s region and not the member s initial enrollment date. For updates or changes, please visit and go to Changing Health Plans or Doctors. Members may also call the Managed Care HelpLine at with enrollment questions. 7

17 Members are excluded from Medallion 3.0 participation or potential coverage if they meet any of the following criteria: Members who are inpatients in state psychiatric hospitals Members who are approved by DMAS as inpatients in long-stay hospitals* (Section 5.2 in the Medallion 3.0 Managed Care Contract), nursing facilities, or intermediate care facilities for the intellectually disabled (MCO members who became enrolled in the Technology Assisted Waiver continue to be disenrolled from the MCO) Members who are placed on spend-down Members who are participating in the tech waiver or were participating in federal waiver programs for home-based and community-based Medicaid coverage prior to managed care enrollment. Members younger than age 21 who are approved for DMAS residential facility Level C programs as defined in 12VAC Newly eligible members who are in their third trimester of pregnancy and who request exclusion by the 15th of the month in which their enrollment with the MCO becomes effective. Exclusion may be granted only if the member s obstetrical provider (e.g., physician, hospital, and midwife) does not participate with the enrollee s assigned MCO. The member, MCO, or provider may make exclusion requests during the member s third trimester. DMAS shall determine if the request meets the criteria for exclusion. Following the end of the pregnancy, these members shall be required to enroll to the extent they remain eligible for Medicaid. Members, other than students, who permanently live outside their service area of residence for more than 60 consecutive days, except those individuals placed outside their service area to receive medically necessary services funded by the MCO. Members who receive hospice services in accordance with DMAS criteria. Members with other comprehensive group or member health insurance coverage, including Medicare, insurance provided to military dependents, and any other insurance purchased through the Health Insurance Premium Payment Program. VA benefits are not considered other insurance and do not qualify as an exclusion from Managed Care. Members who request exclusion during assignment period to an MCO or who have been diagnosed with a terminal condition and who have a life expectancy of six months or less. The member s physician must certify the life expectancy. Certain members between birth and age three certified by the Department of Behavioral Health and Developmental Services as eligible for services pursuant to Part C of the Members with Disabilities Education Act (20 USC 1471 et seq.) who are granted an exception by DMAS to the mandatory Medallion 3.0 enrollment. Members who have an eligibility period that is less than three months. Members who are enrolled in the Commonwealth s Title XXI SCHIP program. Members who have an eligibility period that is only retroactive. Children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program Members who have died. Members are incarcerated (this does not include house arrest) DMAS reserves the right to exclude from participation in the Medallion 3.0 managed care program any individual who has been consistently non-compliant with the policies and procedures of managed care or who is threatening to providers, MCOs, or DMAS. There must be sufficient documentation from various providers and prompt notification by the MCO to DMAS upon learning that a member meets one or more of these exclusion criteria. 8

18 Newborn Enrollment Any newborn whose parent or guardian is enrolled in Medicaid, FAMIS MOMS, or FAMIS product with us at the time of birth will be an INTotal Health member for the birth month plus two months regardless of whether the newborn has a Medicaid or FAMIS I.D. The parent or guardian retains the right to change plans within the three-month period after the birth. In the case where the MCO terminates its contract with DMAS, the MCO is still responsible for the coverage of the newborn until the newborn receives a Medicaid or FAMIS number and is reassigned by DMAS or for the birth month plus two months time frame, whichever is earlier. With respect to each hospital admission for labor and delivery, the hospital agrees to notify us within 24 hours of admission. The notification must include identification of the covered person as well as birth information as required for reporting to the Commonwealth. While the newborn s continued enrollment is not contingent on the parent s or guardian s enrollment, the newborn must have a Medicaid or FAMIS I.D. number before at the end of the third month in order to continue coverage. In order for newborns of FAMIS MOMS to receive continued coverage, the parent or guardian must notify Cover Virginia at In order for newborns of Medicaid enrollees to receive continued coverage, the parent or guardian must notify the local DSS office of the birth. Member Eligibility Even if a patient presents an Identification Card, all providers are responsible for verifying the patient s Medicaid coverage and MCO assignment to INTotal Health as valid on the same day that services are rendered. Member eligibility runs through 11:59 p.m. on the last day of coverage. PCPs will obtain panels monthly by mail. If a member calls to change his or her PCP, the change will generally be effective either the date of the request or the following business day. The PCP should verify that each INTotal Health member receiving treatment in his or her office is on the panel listing. If a PCP does not receive the lists in a timely manner, he or she should contact a Provider Relations Representative. For questions regarding a member s eligibility, providers may access the DMAS website at or call Provider Services at Member Identification (I.D.) Cards Each member enrolled with the health plan will have an INTotal Health I.D. card as well as a Virginia Medicaid I.D. card. The INTotal Health I.D. card will include: The member s name (first and last name and middle initial) The Medicaid/FAMIS member s identification number The member s date of birth The member s enrollment effective date The member s co-payment responsibility INTotal Health address and telephone number Toll-free phone numbers for information and/or authorizations Toll-free Nurse HelpLine available 24 hours a day, 7 days a week Descriptions of procedures to be followed for emergency or special services 9

19 PCP s name and telephone number. Although we prefer the member s card to accurately reflect the correct PCP, any member can see any PCP without assignment. Please encourage your members to have their cards updated if they do not accurately reflect the correct PCP. We have an open access network. You may see a member who is not assigned to you. Please complete a PCP change form and submit to INTotal to reassign the member to your panel. INTotal Health member identification card samples are provided below: The card below is for the Medallion 3.0 program. The card below is for the FAMIS program. 10

20 Americans with Disabilities Act Requirements We have procedures designed to promote compliance with the Americans with Disabilities Act of Providers are required to take actions to remove an existing barrier and/or to accommodate the needs of members who are qualified individuals with a disability. This action plan includes: Street-level access Elevator or accessible ramp into facilities Access to lavatory that accommodates a wheelchair Access to examination room that accommodates a wheelchair Handicap parking clearly marked, unless there is a street-side parking Medically Necessary Services Medically necessary behavioral health services: Are reasonable and necessary for the diagnosis or treatment of a mental health or substance use disorder or to improve, maintain or prevent deterioration of functioning resulting from such a disorder Meet clinical guidelines and standards of practice in behavioral healthcare Are available in the most appropriate and least restrictive setting in which services can be safely provided Are at the appropriate level or supply of service that can safely be provided If omitted, would adversely affect the member s mental and/or physical health or the quality of care rendered Medically necessary health services mean health services, other than behavioral health services that are: Appropriate and necessary healthcare services which are rendered for any condition which, according to generally accepted principles of good medical practice, require the diagnosis or direct care and treatment of an illness, injury, or pregnancy-related condition, and are not provided only as a convenience. As defined in 42 CFR , services must be sufficient in amount, duration and scope to reasonably achieve their purpose. For children younger than age 21, medical necessity review must fully consider Federal EPSDT guidelines. Experimental and/or Investigational Services or Medications Experimental or investigational services, procedures or medications are not a covered benefit. 11

21 5 HEALTHCARE BENEFITS AND CO-PAYMENTS Covered Services The following list shows the healthcare services and benefits we cover for Medicaid, FAMIS MOMS, and FAMIS members. Please note that covered services for FAMIS MOMS are the same as the covered services for Medicaid members. INTotal Health members enrolled in the FAMIS product have required co-pays for certain rendered services, while FAMIS MOMS do not have cost sharing for rendered services. See Cost Sharing Information under FAMIS Co-payments later in this section. COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Abortions Not an MCO-covered benefit. Covered directly by Department of Medical Assistance Services (DMAS) FFS (if services meet federal CHIP requirements). Not an MCO-covered benefit. Covered directly by DMAS FFS (if services meet federal Medicaid requirements). Chiropractic Services Covered only when medically necessary and limited as follows: i) Spinal manipulation ii) Rendered in the outpatient setting iii) Treatment focused on identified illness/injury iv) Limited to $500/calendar year Covered only when: i) Requested for an individual EPSDT treatment for a child and is specific to developmental issues where it is determined to be medically necessary in order to correct, improve, or maintain (ameliorate) the child s medical condition (7.I.D.II) Clinical Services Covered services include preventive, diagnostic, therapeutic, rehabilitative, or palliative care. Renal dialysis clinic visits are also a covered benefit. Colorectal Cancer Screening Not a covered benefit Covered benefit Court-ordered Services Not a covered benefit unless it is medically necessary and a FAMIS covered benefit. Covered services include courtordered Medicaid services. 12

22 COVERED-SERVICES FAMIS MEDICAID & FAMIS MOMS Dental Care Dental services are provided for both children and pregnant members through Smiles for Children/DentaQuest, a dental benefit administrator contracted with DMAS. The toll-free number for Smiles for Children is Durable Medical Equipment (DME) Early Intervention Services INTotal covers medically necessary services including hospitalization or anesthesia resulting from a dental accident and medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures. INTotal also covers transportation services via Logisticare and medication for dental care. DME is a covered benefit, as well as other medically related or remedial devices, such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive services. Durable Medical Equipment and prosthetic devices and eyeglasses are covered when medically necessary. Any specialized DME authorized by the MCO will be reimbursed by the MCO, even if the member is no longer enrolled with the plan or with Medicaid. Job or education-related equipment (e.g., computers); speech devices are covered when medically necessary Medically necessary supplies and equipment are covered benefits. The following supplies are non-covered supplies: Space conditioning equipment Medical supplies for any hospital or nursing facility resident Comfort and convenience items Home or vehicle modifications Early intervention services provided to children who have been determined eligible for Part C of the individuals with Disabilities Education Act are covered directly by DMAS FFS, not by the MCO. Services must be rendered by providers certified by the Department of Behavioral Health and Developmental Services. The MCO must cover medically necessary rehabilitative/developmental therapies within EPSDT guidelines, including for Early intervention enrolled children where appropriate. 13

23 COVERED-SERVICES FAMIS MEDICAID & FAMIS MOMS Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Not Covered EPSDT program covers screening (including lead screening) and diagnostic services to determine physical or cognitive deficits in recipients from birth through age 20, as well as healthcare and other measures to correct or ameliorate any defects and chronic conditions discovered. We cover all medically necessary EPSDT services except for School-Based Private Duty Nursing Services (SBPDN). SBPDN services are covered by DMAS. Immunizations are a covered benefit through Virginia Vaccines for Children. Providers will be reimbursed for the administration of appropriate vaccinations. Emergency and Post-stabilization Services EPSDT screening services shall reflect the age of the child and should be provided according to the Recommendations for Preventive Pediatric Healthcare of the American Academy of Pediatrics. See Well-baby and Well-child Care for covered benefits All emergency services and services needed to ascertain whether an emergency exists are covered benefits. Emergency and medically necessary post-stabilization services do not require pre-authorization. An emergency medical condition is a medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention could result in the following: Physical or mental health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy Serious impairment to bodily functions Serious dysfunction of any bodily organ or part Serious harm to self or others due to an alcohol or drug abuse emergency Injury to self or bodily harm to others A pregnant woman having contractions; (i) that there is adequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child 1 14

24 COVERED-SERVICES FAMIS MEDICAID & FAMIS MOMS Family Planning Services and Coverage of family planning services and supplies are a benefit for all Supplies members of childbearing age. Family planning services and supplies include: Education and counseling necessary to make informed choices and understand contraceptive methods Initial and annual complete physical examinations, including pelvic and breast exams Lab and pharmacy Follow-up, brief and comprehensive visits Contraceptive supplies and follow-up care Diagnosis and treatment of sexually transmitted diseases Not covered: Infertility services and treatment, elective abortions, and services performed at the time of abortion. Flu vaccination Gender Reassignment Services and Surgery Hearing Aids HIV Testing and Treatment Counseling Home Health Services Hospice Inpatient Hospital Services Mental Health/Substance Abuse Services Laboratory and X-ray Services Sterilization consent form is required for claims submission. Covered benefit This is not a covered benefit. This is not a covered benefit. Hearing aids are a covered benefit twice every five years. Hearing aids and related supplies are covered if medically necessary. Covered benefit of HIV testing and treatment counseling. Required HIV testing and treatment counseling for pregnant women. Coverage of medically necessary Coverage of medically necessary home health services include: home health services include: Nursing services, Nursing services, rehabilitation therapies rehabilitation therapies and home health aide and home health aide services services Skilled home health visits Skilled home health visits are limited based on are limited based on medical necessity medical necessity Limit: 90 total visits per year Limit: 32 total visits per year Coverage of medically necessary Hospice services are not covered; hospice care for members with a MCO to notify DMAS. life expectancy of six months or less Inpatient hospital services in general acute care and rehabilitation hospitals are covered. Please see the Behavioral Health Services section. Coverage of all laboratory and x-ray services ordered, prescribed, and directed or performed within the scope of the license of a practitioner. No co-payments shall be charged for laboratory and x-ray services that are performed as part of an encounter with a physician. 15

25 COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Organ Transplants Transplant Under Age 21 and Coverage Criteria 21 * Over Kidney From Cadaver Yes Yes 12 VAC and 12 VAC or Living Donor Corneas Yes Yes 12 VAC and 12 VAC Outpatient Hospital Services Outpatient Mental Health/Substance Abuse Services Physical Therapy, Occupational Therapy, Speech-Language Pathology and Audiology Services Liver From Cadaver or Living Donor Yes Yes 12 VAC and 12 VAC Heart Yes Yes 12 VAC and 12 VAC Lung Yes Yes 12 VAC and 12 VAC Heart & Lung Yes No 12 VAC and 12 VAC Bone Marrow Yes Yes - for limited diagnoses, specifically: myeloma, lymphoma, breast cancer or leukemia 12 VAC and 12 VAC and 12 VAC Small Bowel Yes No 12 VAC and 12 VAC Small Bowel with Liver Yes No 12 VAC and 12 VAC Pancreas Yes No 12 VAC and 12 VAC Coverage of outpatient hospital services that are preventive, diagnostic, therapeutic, rehabilitative or palliative are covered benefits. Please see the Behavioral Health Services section. Coverage of medically necessary services provided at the inpatient or outpatient hospital or by a home health service. All children of school age should be evaluated for school-based speech therapy prior to preauthorization at non-school-based location. Not covered: those services rendered by a school health clinic. 16

26 COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Physician Services Coverage of all symptomatic visits to physicians or physician extenders within the scope of their licenses. Physician services, including services while admitted in the hospital, outpatient hospital department, in a clinic setting or in a physician s office are covered benefits. Copayments apply under FAMIS Coverage of all symptomatic visits to physicians or physician extenders and routine physicals for children up to age 21 under EPSDT. Annual routine physical examinations are covered for adults age 21 and older. No Copayments Apply Cosmetic services are not covered unless performed for medically necessary physiological reasons. Podiatric Services Not a covered benefit Diagnostic, medical, or surgical treatment of disease, injury, or defects of the human foot. Not covered: preventive healthcare, including routine foot care; treatment of structural misalignment not requiring surgery; cutting or removal of corns, warts, or calluses; or acupuncture. 17

27 COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Pregnancy-related Services Services for pregnant women, including prenatal and post-partum care. No preauthorization is required. Prescription Drugs Preventative Services Covered Services include: Expanded prenatal care services, including patient education: nutritional assessment, counseling, and follow-up; homemaker services; and blood glucose meters. Childbirth education Pregnancy-related and post-partum services for sixty (60) days after pregnancy ends. Case management services for high-risk pregnant women and children (up to age two). Emergency care Lactation consultation and breast pumps Tobacco cessation services, including counseling and pharmacotherapy Transfer and care of pregnant women, newborns, and infants to tertiary care facilities if necessary Network OB/GYNs, anesthesiologist and neonatologists, appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems Inpatient care and professional services related to labor and delivery for pregnant/delivering members and neonatal care for newborn members at the time of delivery up to 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated caesarean delivery No copayments apply for either program. Day and residential treatment for substance abuse are not covered services. Please contact DMAS. Prescription drugs include those prescribed by a provider during a physician visit or other visits covered by mental health provider. Please reference Pharmacy Services for Formulary information Covered benefits include: Flu vaccine, mammograms (see Women s Healthcare Services), routine physicals Covered benefits include: Colonoscopy, flu vaccine, mammograms (see Women s Healthcare Services), prostate specific antigen (PSA) screening, routine physicals. 18

28 COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Private Duty Nursing Prostate Specific Antigen (PSA) Prosthetic and Orthotic Services A covered benefit when medically necessary and provided only by a registered nurse or licensed practical nurse who is not a relative of the member. A covered benefit, when medically necessary, for children under age 21. Not covered for adults. Not a covered benefit Prostate cancer screening through PSA testing and digital rectal exams is a covered benefit for male members. Medically necessary prosthetic services and devices that include artificial arms, legs, internal body parts, breast (including reconstructive breast surgery) and eyes. Medically necessary orthotics, regardless of member s age when recommended as part of an approved intensive rehabilitation program. Medically necessary orthotic services and devices are covered for children younger than age 21. School-Health Services Skilled Nursing Facility Services Tobacco Cessation Transportation Vision Services Copayments apply under FAMIS The Contractor is not required to cover school health services. School health services that meet the Department s criteria will continue to be covered as a carve-out service through the Medicaid fee-for-service system. School-health services are defined under the DMAS school-health services regulations and Medicaid school provider manual. The Contractor is responsible for covering EPSDT screenings for the general Medicaid student population. Reference Section 1 Definitions for more details. The Contractor shall not deny medically necessary outpatient or home setting therapies based on the fact that the child is also receiving therapies in a school. Medically necessary nursing facility services up to 180 days per stay. Skilled nursing facility services are not covered by MCO. Covered benefit under FFS. Counseling and pharmacotherapy are covered. FAMIS members can receive up to 20 oneway trips to medically necessary appointments. Emergency and nonemergency transportation to and from all Medicaid covered services, gas reimbursement or public transport tokens. This includes visits to and from the doctor s office, hospitals, pharmacy and other providers, including community mental health and outpatient rehabilitation services. Members can contact LogistiCare for assistance in scheduling transportation. Coverage of routine eye exams, frames and lenses every 24 months through Superior Vision. Contact lenses are covered for members when medically necessary. Copayments apply under FAMIS Diabetics: An annual eye screening for diabetic retinal disease is covered. 19

29 COVERED SERVICES FAMIS MEDICAID & FAMIS MOMS Well-baby and Wellchild Care Coverage of routine well-baby and well-child care services includes routine office visits with health assessments and physical exams, routine lab work and ageappropriate immunizations. Women s Health Care Services 1 Balanced Budget Act Sec. 4704(b)(c) For female members older than 13, annual exam and routine health services (including a Pap smear and mammogram as medically necessary) do not require preauthorization. For female members age 13 and older, annual exam and routine healthcare services (including Pap smear) performed by a PCP or in-network GYN do not require pre-authorization. Mammograms for women age and older are also covered without pre-authorization. Pre-authorization is required for breast prostheses and reconstructive breast surgery. Note: We do not cover the use of any experimental or investigational procedures or medications. Starring: Baby and Me Program We offer Starring: Baby and Me to all expectant mothers. The program objective is to provide coordinated, comprehensive prenatal management with the intent of identifying members prior to an adverse health event and providing them with care management, education, and incentive gift rewards to promote healthy outcomes. Enrolling into the Starring: Baby and Me program includes education, case management services, and an incentive program that rewards members with gift cards for completing prenatal and postpartum visits. Please encourage your patients to participate. Starring: Baby and Me program goals: Improve the level of knowledge of the member about her pregnancy stage Create systems that support the delivery of quality of care Measure and maintain or improve member outcomes related to the care delivered Facilitate care with providers to promote collaboration, coordination, and continuity or care Well-Child Visits/Early and Periodic Screening, Diagnosis, and Treatment We encourage our members to contact their physician within the first 90 days of enrollment to schedule a well-child visit and within 24 hours for newborns. Our Medicaid members younger than 21 years of age are eligible to receive these services. The well-child program in Virginia provides the following: Comprehensive health and development history, including physical and mental development Comprehensive unclothed physical examination Age-appropriate immunizations Appropriate laboratory tests Lead toxicity screening Health education Vision services Dental services Hearing services Other medically necessary healthcare 20

30 Well-care services should be performed for newborns in the hospital and then in compliance with the American Academy of Pediatrics Recommendations for Preventive Pediatric Healthcare. Children older than 3 and younger than 21 should be seen by a PCP annually. We educate our members about these guidelines and monitor encounter data for compliance. Well-Child Visits Reminder Program We provide lists to our PCPs of our members who, based on our claims data, may not have received wellchild services according to schedule. Additionally, we mail information to these members, encouraging them to contact their PCPs offices to set up appointments for needed services. By enrolling with the Virginia Vaccines For Children (VVFC) program, you can get vaccines free of charge for Medicaid members. Call or or vvfc@vdh.virginia.gov to receive an enrollment packet. You cannot bill for these vaccines, but we will reimburse you for administration of the vaccine. Please note: Specific services needed for each member are listed in the report. Reports are based only on services received during the time the member is enrolled with us. Services must be rendered on or after the due date in accordance with federal EPSDT and state Department of Health guidelines. In accordance with these guidelines, services received prior to the specified schedule date do not fulfill EPSDT requirements. Refer to the Healthcare Benefits and Copayments table within this manual for covered services and to the Virginia Periodicity Schedule and the Advisory Committee on Immunization Practices (ACIP) immunization tables. FAMIS enrollees do not qualify for the free Vaccines for Children program. The PCP list is generated based on our claims data received prior to the date printed on the list. In some instances, the appropriate services may have been provided after the report run date. To ensure accuracy in tracking preventive services, please submit a completed claim form for those dates of service to our Claims Department at the following address: Claims INTotal Health P.O. Box Birmingham, AL Blood Lead Screening Providers will furnish a screening program for the presence of lead toxicity in children that consists of a screening and blood test. During every well-child visit for children between the ages of 6 months and 2 years old, the PCP will screen each child for lead poisoning. A blood test will be performed before 12 months and again prior to 24 months of age to determine lead exposure and toxicity. In addition, children old than 24 months up to 72 months should receive a blood screening lead test if there is not a past record of a test. Results of lead testing, must be reported to the Virginia Department of Health, Office of Epidemiology. Please see blood risk form located in Appendix A 21

31 Family Planning Services Members of childbearing age have direct access to both network and non-network providers for all family planning services and supplies that delay or prevent pregnancy, but not services to treat infertility or to promote fertility. Services include exams, assessments, drugs, supplies and traditional contraceptive devices. Outpatient Laboratory and Radiology Services All outpatient laboratory tests, including STAT tests, should be performed at a network facility outpatient lab or at one of our preferred network lab vendors (Laboratory Corporation of America [LabCorp] or Quest Diagnostics) unless the provider has a Clinical Laboratory Improvement Amendment (CLIA) certification and either a clinical laboratory license, a certification of waiver or a certificate of registration and an identification number. Laboratories with certificates of waiver will provide only the types of tests permitted under the terms of the waiver. Laboratories with certificates of registration may perform the full range of services for which they are certified. Visit the Centers for Medicare & Medicaid Services (CMS) website at for a complete list. When submitting a claim for lab tests, you must include your CLIA certification number on the claim submission. We have a radiology management program for outpatient scans with evicore Healthcare (formerly MedSolutions). evicore is a radiology services organization that specializes in managing diagnostic services. For all elective outpatient Magnetic Resonance Angiogram (MRA), Magnetic Resonance Imaging (MRI), Computerized Tomography (CT), Positron Emission Tomography (PET) scans and nuclear cardiology, providers must obtain pre-authorization from evicore. Contact evicore at or go online at Vision Services Members may access their eye care benefits directly by calling Superior Vision at We cover one eye examination, frames, and lenses every 24 months. Contact lenses are covered for members when medically necessary. Medicaid members are also eligible to receive medically necessary eyeglasses as a value-added benefit we offer. For FAMIS members, we will reimburse for frames and lenses up to the amounts listed below. FAMIS Members pay for costs above these amounts: Eyeglass frames $25 Single vision lenses $35 Bifocal lenses $50 Trifocal lenses $88.50 Contact lenses $100 (as medically necessary) See Healthcare Benefits and Co-payments section for the covered benefit for vision services and FAMIS copayments. Please note that diabetic retinal eye exams are a covered benefit, regardless of age or benefit package. 22

32 Pharmacy Services We seek to provide high-quality, cost-effective options for your INTotal Health patients. We work with you to make sure we cover the most important and useful drugs for all types of conditions and diseases. Our pharmaceutical benefit management program provides coverage for medically necessary medications from licensed prescribers for the purpose of saving lives in emergency situations or during short-term illness, sustaining life in chronic or long-term illness, or limiting the need for hospitalization. INTotal Health Participating Pharmacy Network Members have access to most national pharmacy chains and many independent retail pharmacies. We contract with a pharmacy benefit manager (PBM) to establish and manage a network of participating pharmacies and to adjudicate the INTotal Health pharmacy coverage rules. All members must use a network pharmacy when filling prescriptions in order for benefits to be covered. Pharmacy co-payments There are no pharmacy co-payments or deductibles for INTotal Health members with Medicaid coverage. For information about pharmacy co-payments for INTotal Health members with FAMIS coverage, please see the section in this manual titled Cost Sharing Information. 72-Hour-Supply Processing Policy Our Pharmacy Benefit Management program allows a dispensing pharmacist to dispense a 72-hour-supply of a non-preferred, prescribed medication if the physician is not available to consult with the pharmacist and the pharmacist, in his or her professional judgment consistent with standards of practice, believes that the member s health would be compromised without the benefit of the drug. This option is also available after hours, on weekends, and on holidays. The pharmacy provider must call to obtain the necessary processing information. The member may be charged a co-payment for the 72-hour supply where required. Over-the-Counter Medications We cover select over-the-counter (OTC) medications. If your patient needs a covered OTC medication, please write a prescription for the product so your patient may fill it at a pharmacy and obtain the medication under the pharmacy benefit. Please see our online Formulary and INTotal Health Over-the-Counter Drug List for more details regarding over-the-counter medication coverage. Monthly Limits Retail pharmacy prescriptions are limited to a maximum dispense quantity of a 34-day supply per fill. FAMIS members are allowed up to a 90-day supply via retail and mail order of non- Specialty drugs. Generic Substitution Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. In most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product onto the market. Prescription generic drugs are: Approved by the U.S. Food & Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different Manufactured in the same strength and dosage form as the brand-name drugs. 23

33 INTotal Health requires generic substitution where appropriate. When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). Formulary INTotal Health s Formulary is a listing of medications which are covered under INTotal Health s pharmacy benefit. The Formulary includes certain over-the-counter products which may be recommended as first-line treatment. You may refer to our Formulary on our website at. Updates to the Formulary or changes in pharmaceutical procedures will be available via the website and in written notification. Copies of the Formulary or other pharmaceutical management procedures are available upon request. INTotal Health s Formulary is a tool used to promote appropriate and cost effective prescription drugs for our members. The Formulary is comprised of a list of preferred drugs within the most commonly prescribed therapeutic categories. The Formulary is reviewed and updated quarterly by the INTotal Health Pharmacy & Therapeutics (P&T) Committee to reflect the committee s prevailing clinical opinion. The P&T Committee is comprised of network specialty, behavioral health and primary care physicians, pharmacists and other healthcare professionals, who meet quarterly to evaluate safety, efficacy, adverse effects, outcomes, and total pharmacoeconomic value for each drug product reviewed. New medications and new uses of existing medications are also considered. The P&T Committee approves medication request guidelines for agents that require prior authorization. Each quarter, we include Formulary updates in our online newsletter ProviderNews. Medication Request Process If the drug you are requesting has any of the following abbreviations (AL, HRM, PA, QL, SP, ST) next to its name on the INTotal Health Formulary, you will need to submit clinical information on the INTotal Health Pharmacy Pre-Authorization Form in order for the prescription to be covered. To request a drug authorization for your INTotal Health patient, please fax the fully completed Pharmacy Pre-Authorization form to INTotal Health s Pharmacy Benefit Manager (PBM) at (24 hours a day, 7 days a week). You may also call our PBM at When calling, please be prepared to provide relevant clinical information regarding the member s need for the requested product including the diagnosis, previously tried and failed drugs or contraindications. Decisions are based on medical necessity and are determined according to certain established medical criteria. We review requests and make initial determinations regarding pre authorization within two business days of receiving complete medical information. We will either approve or deny your request. Once we make a decision, we will notify you by telephone or fax within one business day of the decision. If we deny your request because it does not meet our pharmacy criteria, we may recommend an alternate therapy. Members and prescribers may appeal denied requests. For more information on the appeals processes, please refer to Section 9: Complaint, Grievance, and Appeal Procedures: Member Appeal Process. Prior Authorization SCRIPT Standards: We accept telephonic, facsimile, or electronic submissions of prior authorization requests that are delivered from e-prescribing systems, electronic health records, and health information exchange platforms that utilize the National Council for Prescription Drug Programs SCRIPT standards for prior authorization requests. We follow authorization procedures within the prescribed time frame and promptly notify the member, physician and the pharmacy providers of our decision. 24

34 Urgent Requests: If the pre authorization request is submitted telephonically or in an alternate method for urgent requests, we respond to the prescriber or designee within 24 hours of the urgent prior authorization request. Fully Completed Requests: we communicate electronically, telephonically, or by facsimile to the prescriber or designee within two (2) business days of a submission of a fully completed prior authorization request. Provider Responses for Supplementation: we communicate electronically, telephonically, or by facsimile to the prescriber or designee within two (2) business days of a submission of a properly completed supplementation from the provider or designee, that the request is approved or denied. Age Limits (AL) Certain drugs (denoted on the Formulary as AL) are only covered for patients of certain age(s). This usually corresponds to FDA approvals which contain age limitations. High Risk Medications (HRM) Certain drugs (denoted on the Formulary as HRM) which are noted to have a narrow therapeutic index among members age 65 years and older, will require a pre authorization. Pre-Authorization (PA) You may request pre authorization for medications indicated with PA on the Formulary. We will review each request based on individual patient need and may approve the request if a documented medical need exists, according to the following guidelines: The requested drug has an FDA-approved indication specific to the requested patient s age and demographics The use of alternate drug products in our formulary is contraindicated for the patient The patient has failed an appropriate trial of alternate, preferred formulary agents. If we deny your request because it does not meet our clinical guidelines, we may recommend an alternate therapy. Quantity Limits (QL) Certain drugs (denoted on the Formulary as QL) are only covered up to a certain quantity. This usually corresponds to FDA dosage recommendations and/or dose optimization. You may request an exception to the quantity limit restriction if there is a documented medical need. Specialty Drugs and Injectables (SP) INTotal Health has a Specialty Pharmacy Management Service, which is responsible for reviewing and supplying all requests for specialty medications. This includes high-cost, specialty and injectable drugs that are used to treat a number of conditions, including but not limited to allergic asthma, cancer, Crohn s disease, cystic fibrosis, growth hormone deficiency associated with short stature, Hemophilia, Hepatitis C, Hereditary Angioedema, HIV, Immune disorders, Lysosomal Storage Disorders, Multiple Sclerosis, Neutropenia, Primary pulmonary arterial hypertension, Rheumatoid arthritis, Respiratory Syncytial Virus (RSV) disease, or associated with transplant. Please refer to our website at, Provider Resources and Documents, Pharmacy tab for an updated listing of INTotal Health s Comprehensive Specialty Pharmacy Drug List. To obtain a listed specialty drug, please fax a Pre-Authorization Form (see Pre- Authorization Request Form section above) to , or call Step Therapy (ST) For drugs listed in the Formulary as step therapy agents, pharmacy claims are reviewed electronically to ensure a prior trial of a first-line drug. In the absence of recent claims for first-line therapy, you must get pre authorization for step therapy agents. 25

35 Requests for Non-Formulary Drugs (NF) We consider any product not in the current Formulary to be a new-to- market or non-formulary drug. Non- Formulary Drugs (NF) are not covered because there are safe, comparably effective, less expensive alternatives available. In most cases alternatives are approved by the FDA for the treatments of the particular diagnosis and are widely used and accepted by the medical community to treat the same condition. If you believe there is a medical necessity for a member to receive a non- covered drug product, a request can be submitted under the Medical Review Process. Members new to the plan are eligible for up to 90 days a Non Formulary Drug under the INTotal Health Transition Fill Program. Transition fill is available to new members for the first 90 days of eligibility. Pharmacies can contact our PBM Helpdesk at for assistance in processing a Transition Fill prescription. Drugs which are excluded from coverage Certain drugs are not covered by Medicaid and not included in the INTotal Health Pharmaceutical Benefit. These drugs are excluded from the INTotal Health Formulary. Examples of drugs that are excluded from the Formulary include but are not limited to the following: Anti-wrinkle agents (e.g., Renova) Drugs used for cosmetic reasons or hair growth Experimental or investigational drugs Drugs used for experimental or investigational indication Medications used for male or female sexual dysfunction Erectile dysfunction drugs to treat impotence Non-legend (OTC) drugs obtained without a prescription Infertility agents Medications used for adult weight loss Prescription drugs not approved by the United States Food and Drug Administration (FDA) Pre-Authorization Request Forms A Pharmacy Pre-Authorization Form (also known as Medication Request Form) is available on our website at, on the Pharmacy Resources section. Patient Utilization Management & Safety (PUMS) Program for Members INTotal Health has established a Patient Utilization Management & Safety (PUMS) Program to coordinate care and ensure that members are accessing and utilizing services in an appropriate manner in accordance with all applicable rules and regulations. The PUMS Program is a utilization control and case management program designed to promote proper medical management of essential healthcare. This program has at its core the coordination of member healthcare services, intended to: Improved the quality of care for members Curb the abuse or misuse of controlled substance medications Reduce unnecessary physician utilization Members enrolled in the PUMS Program will be restricted to one or more of the following: The use of a single pharmacy Use of a specific primary care provider (PCP) Use of a specific controlled substances prescriber Use of a specific hospital (for non-emergency hospital services only) 26

36 On a case-by-case basis, other qualified provider type as determined by INTotal Health and the circumstances of the member Once enrolled, members remain in the PUMS Program for a period of 12 months. At the end of the 12-month period, the member is re-evaluated to determine if the member continues to display behavior or patterns that indicate the member should remain in the PUMS Program. Placement into the PUMS Program may occur when any of the following trigger events occurs: The specific utilization review of the member s past (12) months of medical and/or billing histories indicates the member may be accessing or utilizing health care services inappropriately, or in excess of what is normally medically necessary, o Minimum specifications include: Buprenorphine Containing Product: Therapy in the past 30 days AUTOMATIC ENROLLMENT High Average Daily Dose: > 120 morphine milligram equivalents per day over the past 90 days Overutilization: Filling of > 7 claims for all controlled substances in the past 60 days Doctor Shopping: > 3 prescriptions OR > 3 pharmacies writing/filling claims for any controlled substance in the past 60 days Use with a History of Dependence: Any use of a controlled substance in the past 60 days with at least 2 occurrences of a medical claim for controlled Substance Abuse or Dependence in the past 720 days Use with a History of Poisoning/Overdose: Any use of a controlled substance in the past 60 days with at least 1 occurrence of a medical claim for controlled substance overdose in the past 720 days Frequent Flyer : > 3 Emergency department visits in the last 60 days Poly-Pharmacy: > 9 unique prescriptions in a 34 day period written by >3 physician s OR filled by > 3 pharmacies. o Members with a cancer diagnosis are excluded Medical providers or social service agencies provide direct referrals to the Department or INTotal Health If the member changes from another health plan to INTotal Health and was enrolled in a PUMS program at the previous health plan, INTotal Health will re-evaluate the member to ensure the member meets the minimum criteria above for continued placement in the INTotal Health PUMS Program. Upon placement of a member into the PUMS Program, a letter is sent to the member and their prescribing providers that includes the following information: A brief explanation of the PUMS program A statement that the member was selected for placement into the program, An explanation that the decision is appealable A statement that INTotal Health shall provide appeals rights to members placed in the PUMS Program, including the right to directly request a State Fair Hearing including normal appeals in addition to the issue of whether the member qualified for the PUMS based on the minimum criteria A statement clearly outlining the provisions for emergency after hours prescriptions if the member s selected pharmacy does not have 24-hour access A statement indicating the opportunity and mechanisms by which the member may choose a pharmacy, primary care provider, controlled substance provider, hospital (for non-emergency hospital services only) and/or, on a case-by-case basis, other qualified provider types. If the member 27

37 does not select the relevant providers within 15 days of enrollment into the PUMS Program, INTotal Health will select one for the member Notice that information may be requested by a licensed physician or pharmacist employed by INTotal Health from the Prescription Monitoring Program. A statement explaining the Prescription Monitoring Program (PMP) and how its use may affect the member enrolled in the PUMS program, as applicable. During administration of the PUMS Program, INTotal Health will work with the member and providers to furnish care management and education reinforcement of appropriate medication and pharmacy use. Placement in the PUMS Program may be appealed by contacting the appeals department. The member will have 30 days to appeal this action. Appeals must be submitted in writing to INTotal Health s Appeals Unit. The provider and member will be notified of the appeal decision by telephone or facsimile. In addition, in the case of a denial, the provider and member will be sent a written notice of the denial within two business days following a verbal denial. The member may also utilize the state fair hearing process. Providers requesting information on this program may call Provider Services at Prescription Monitoring Program (PMP) The Prescription Monitoring Program (PMP) is an electronic system to monitor the dispensing of Schedule II, III, and IV controlled substance prescription drugs. It is established, maintained, and administered by the Department of Health Professions. Information from the PMP about specific members may be used in order to determine eligibility and to manage the care of the specific member participating in the PUMS. 28

38 Behavioral Health Services A provider referral is not required for assessment services. Inpatient services and outpatient follow-up care must be pre-authorized. Traditional behavioral health services are managed by INTotal Health and nontraditional behavioral health services are managed by Magellan, the State s Behavioral Health Services Administrator. The table below provides a comprehensive list of which entity is responsible for each service. INTotal Health Magellan Individual, group, family therapy for mental health Day treatment/partial hospitalization for mental disorders health disorders Individual, group, family therapy for substance abuse Psychosocial rehabilitation disorders Medication management services Mental health skill-building Psychoeducational testing Intensive community treatment Neuro-psychoeducational testing Crisis intervention/stabilization services for both mental health and substance abuse Inpatient psychiatric services rendered in the Substance abuse residential treatment for pregnant psychiatric unit of a general acute care hospital women Inpatient psychiatric services rendered in Substance abuse day treatment for pregnant women freestanding psychiatric hospitals for members up to age 21 and members older than age 64 Temporary Detention Order (TDO) services except if Substance abuse intensive outpatient the members are age and admitted to a freestanding facility or a FAMIS member Emergency Custody Orders (ECO) medically Substance abuse day treatment necessary screenings, assessments and treatment services for members who are under an emergency custody order Outpatient electroconvulsive therapy (ECT) Opioid treatment programs Intensive in-home services for children and adolescents Therapeutic day treatment for children and adolescents Treatment foster care-case management* Community-based (residential) services for children and adolescents level A* Therapeutic behavioral services for children and adolescents level B* Residential treatment facility level C* Behavioral Therapy* *Not covered for FAMIS MCO members **Please note: Many services require Pre-Authorization (PA). The Pre-Authorization Lookup Tool for Providers can be found at. NOTE: If a member has been prescribed drugs for opioid treatment and obtains these drugs through an independent pharmacy, the drugs are the responsibility of INTotal Health. If the opioid treatment is administered by a substance abuse provider and the provider obtains the drugs for the member, these drugs will be covered by DMAS. Community Mental Health Rehabilitation Services (CMHRS) are covered by the Department of Medical Assistance Services. For specific service coverage, please contact DMAS or see the CMHRS manual online. 29

39 Cost-sharing Information FAMIS Co-payments The following table lists the FAMIS co-payment schedule according to family income. Co-payments for medical services or prescription drugs are paid to the healthcare provider at the time of service. No copayments are paid for preventive care such as well-child or well-baby visits, immunizations, or dental checkups. The member s health plan ID care lists the co-payments that apply to the member. The member should present their ID card at the time of the office visit or at the pharmacy to have a prescription filled. Services MEMBER COPAYMENT American Indians and Alaskan Natives VA FAMIS At or below 150 percent of Federal Poverty Levels VA FAMIS percent of Federal Poverty Levels Chiropractic $0 $2 $5 Clinic Services $0 $2 $5 Community Mental Health $0 $0 $0 Rehabilitative Services (CMHRS) Early intervention $0 Early intervention services provided to children who have been determined eligible for Part C of the Individuals with Disabilities Education Act are covered by DMAS FFS. The MCO must cover medically necessary rehabilitative/developmental therapies where appropriate. Emergency Room Use (Emergency) Hospital emergency room $0 $2 per visit $5 per visit Emergency Room Use (Nonemergency) $0 $10 per visit $25 per visit Family planning $0 $2 per visit $5 per visit Hearing aids $0 $2 $5 Home health $0 $2 per visit $5 per visit Inpatient hospital services $0 $15 per admission $25 per admission Inpatient Mental Health $0 $15 per admission $25 per admission Inpatient Physician Care $0 $0 $0 Inpatient Rehabilitation Hospitals $0 $15 per admission $25 per admission Inpatient Substance Abuse $0 $15 per admission $25 per admission Laboratory and X-ray $0 $2 per visit $5 per visit Lead Testing $0 $0 $0 Mammograms $0 $0 $0 Medical equipment (including prosthetics and orthotics) $0 $2 per item $5 per item 30

40 Services MEMBER COPAYMENT American Indians and Alaskan Natives VA FAMIS At or below 150 percent of Federal Poverty Levels VA FAMIS percent of Federal Poverty Levels Medical Supplies $0 $0 $0 Medical Transportation (Ambulance) $0 $2 $5 Outpatient hospital or doctor $0 $2 per visit $5 per visit Organ Transplantation $0 $15 per admission and $2 per outpatient visit $25 per admission and $5 per outpatient visit Outpatient Hospital Services $0 $2 per visit $5 per visit Outpatient Mental Health and Substance Abuse Services $0 $2 per visit $5 per visit Outpatient Physician Care Primary Care Specialty Care Maternity Services $0 $0 $0 $2 per visit $2 per visit $0 $5 per visit $5 per visit $0 Pap Smears $0 $0 $0 Physical and occupational therapy, $0 $2 per visit $5 per visit speech pathology and audiology Pregnancy-related care $0 $0 $0 Prescription drugs (excluding family $0 planning, pregnancy-related medications and medications provided to children) Up to a 34-day supply 35 to 90-day supply $2 per prescription $4 per prescription $5 per prescription $10 per prescription Private duty nursing $0 $2 per visit $5 per visit Prosthetics/Orthotics $0 $2 per item $5 per item Second opinions $0 $2 per visit $5 per visit Skilled nursing facility care $0 $15 per admission $25 per admission Therapy Inpatient Outpatient *Vision Routine exam Eye Glass Frames Single Vision Lenses Bifocal Lenses Trifocal Lenses Contact Lenses $0 $0 $0 $2 $25 $35 $50 $88.50 $100 $15 per admission $2 per visit $25 per admission $5 per visit $5 $25 $35 $50 $88.50 $100 Well Baby and Well Child Care $0 $0 $0 Yearly co-payment limit per family $0 $180 $350 *See Vision Services for more details on covered services. Once a family member meets the yearly co-payment limit per family, no member of that family will pay a copayment when receiving additional services. Once the cost-sharing limit is met, a new member ID card will be issued reflecting no co-payments. 31

41 Self-Referral Services Covered services do not require a referral from a PCP when provided by an in-network provider. Member Rights and Responsibilities Members have rights and responsibilities when participating with a Managed Care Organization (MCO). Member Services representatives serve as advocates for our members. The following lists include the rights and responsibilities of our members. Members have the right to: Receive information in accordance with federal guidelines Receive information about INTotal Health and our policies, services, practitioners and providers, and members rights and duties Be treated with respect and with due consideration for their dignity and privacy Receive information from their providers on available treatment options and alternatives presented in a manner appropriate to their condition and ability to understand, regardless of cost or benefit coverage Participate in decisions regarding their healthcare, including the right to refuse treatment Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion Request and receive a copy of their medical records and request that they be amended or corrected as specified by 45 CFR and Freely exercise rights; the exercise of these rights will not adversely affect the way members are treated by INTotal Health and our providers Voice grievances or appeals about INTotal Health or the care given by our providers Make recommendations regarding the health plan s members rights and responsibilities policy Receive healthcare services in accordance with contractual requirements Be free from any liability for payment for any services received if INTotal Health becomes insolvent Request a copy of the INTotal Health Member Handbook or the INTotal Health Provider Directory from INTotal Health at any time. Provider Search (Find a Doctor), Member Handbook, and Provider Manual can be found at. Members have the responsibility to: Supply information that the health plan and its practitioners and providers need in order to provide care Follow plans and instructions for care that they have agreed to with their providers Understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible 32

42 First Line of Defense Against Fraud, Waste, and Abuse General Obligation to Prevent, Detect, and Deter Fraud Waste and Abuse As recipients of funds from state and federally sponsored healthcare programs, we each have a duty to help prevent, detect and correct fraud, waste and abuse. Our commitment to detecting, mitigating, and preventing fraud, waste and abuse is outlined in our Program Integrity Program. As part of the requirements of the Affordable Care Act, each of our providers is required to have a compliance program. Guidance on how to create an effective compliance program is available on our website s provider portal under Quick Tools. Our policies on Fraud, Waste, and Abuse Prevention and Detection, as well as the Code of Business Conduct and Ethics, are part of our Compliance Program. Electronic copies of our Code of Business Conduct and Ethics are available at We maintain several ways to report suspected fraud, waste and abuse. As an INTotal Health provider and a participant in government-sponsored healthcare, you and your staff are obligated to report suspected fraud, waste, and abuse. These reports can be made anonymously by calling the external hotline at Members may report suspected fraud by calling Member Services at You may also reach out directly to our Compliance Officer via at intotalhealthcompliance@inova.org. Members may report suspected fraud by calling Member Services at or by calling our anonymous hotline. INTotal maintains a policy of non-retaliation against anyone who reports suspected fraud, waste, or abuse in good faith. We will protect the confidentiality of the person making a report to the extent possible under the law. In order to meet the requirements of the Deficit Reduction Act, you may adopt our fraud, waste, and abuse policies and distribute them to any staff members or contractors who work with us. If you have questions or would like to have more details concerning our fraud, waste, and abuse detection, prevention and mitigation program, please contact our Compliance Officer at intotalhealthcompliance@inova.org. Importance of Detecting, Deterring, and Preventing Fraud, Waste, and Abuse Healthcare fraud costs taxpayers increasingly more money every year. There are state and federal laws designed to stop the crimes of fraud, waste and abuse that impose strict penalties. Fraud, waste and abuse in the healthcare industry may be perpetuated by any party involved in the healthcare process. There are several stages to inhibiting fraudulent acts, including detection, prevention, investigation, and reporting. In this section of the provider manual, we educate providers on how to help prevent member and provider fraud by identifying the different types. You can be the first line of defense. Many types of fraud, waste, and abuse have been identified, including the following: Provider Fraud, Waste, and Abuse Billing for services not rendered Billing for services that were not medically necessary Double billing Unbundling Upcoding You can help prevent fraud, waste, and abuse by ensuring the services rendered are medically necessary, accurately documented in the medical records, and billed according to CMS s National Correct Coding Initiative guidelines. 33

43 Member Fraud, Waste, and Abuse Benefit sharing Collusion Drug trafficking Forgery Illicit drug seeking Impersonation/identity fraud Misinformation and/or misrepresentation Subrogation and/or third-party liability fraud Transportation You can help prevent fraud, waste, and abuse by educating members about the types of fraud and the penalties levied. Spending time with patients and reviewing their records for appropriate prescription mitigation can help minimize drug fraud and abuse. Another important step you can take to prevent fraud, waste and abuse is to verify the member s eligibility on the date of and prior to rendering service. Remember that an INTotal member identification card does not guarantee eligibility. We may not accept responsibility for the costs of services rendered to a patient who is not an INTotal member, even if that patient presented an INTotal Health member identification card. You should review the member s INTotal member identification card and verify the member s eligibility on our website every time you provide services to a member. Additionally, encourage members to protect their INTotal Health member ID cards as they would a credit card or cash, to carry the INTotal Health member ID card at all times and to report any lost or stolen cards to us as soon as possible. We believe awareness and action are vital to keeping the state and federal healthcare programs safe and effective. Understanding the various opportunities for fraud, waste, or abuse and working with members to protect their INTotal Health identification card can help prevent fraud, waste, and abuse. We encourage our members and providers to report any suspected instance of fraud, waste, or abuse by calling Member Services at or by contacting our Plan Compliance Officer at intotalhealthcompliance@inova.org. An anonymous report can also be made by calling the external hotline at No individual who reports violations or suspected fraud, waste or abuse will be retaliated against, and we will make every effort to maintain anonymity and confidentiality. For more information, please see helpful links on the Provider page at. 34

44 Disclosure of Ownership and Exclusion from Federal Healthcare Programs As an INTotal Health provider, you must fully comply with federal requirements for disclosure of ownership and control, business transactions, and information for persons convicted of crimes against federally funded healthcare programs, including Medicare, Medicaid, and/or CHIP programs, as described in 42 CFR 455 Subpart B. Please become familiar with federal requirements regarding providers and entities excluded from participation in federally funded healthcare programs (including Medicare, Medicaid, and CHIP programs). Screen new employees and contractors to verify they have not been excluded from participation from these programs, and verify monthly that existing employees or contractors have not been excluded. The Federal Health and Human Services Office of the Inspector General (HHS-OIG) online exclusions database is available at exclusion.oig.hhs.gov. If you discover any exclusion information, please immediately report it to us. For questions related to Disclosure of Ownership of Exclusions from Federal Healthcare Programs, please contact our Compliance Officer via at If you prefer to remain anonymous, you may call the external hotline at HIPAA The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in August The legislation improves the portability and continuity of health benefits, ensures greater accountability in the area of healthcare fraud and simplifies the administration of health insurance. In 2009, HIPAA was enhanced by the Health Information Technology for Economic and Clinical Health Act (HITECH). Provisions of HITECH improve member privacy and security by: Requiring patient notification of breaches of unsecure Protected Health Information (PHI) while creating a safe harbor for encrypted electronic PHI and shredded paper PHI Applying certain provisions of the privacy and security rules to business associates Modifying the marketing and fundraising rules Guidance regarding the breach notification rule can be found at: We strive to ensure that we and contracted participating providers conduct business in a manner that safeguards patient and member information in accordance with the privacy regulations enacted pursuant to HIPAA. Effective April 14, 2013, contracted providers shall have the following procedures implemented to demonstrate compliance with the HIPAA privacy regulations We are allowed to share member information with providers, and providers to share such information with us, for the purposes of treatment, payment, or healthcare operations as defined by HIPAA. We may request the transfer or sharing of member information (such as a member s medical record) for purposes such as to conduct business and make decisions about care, to make an authorization determination, or to resolve a payment appeal. We recognize our responsibility under the HIPAA privacy regulations to request only the minimum necessary member information from providers to accomplish the intended purpose. Conversely, network providers should only request the minimum necessary member information required to accomplish their intended purpose when contacting us. 35

45 Fax machines used to transmit and receive medically sensitive information should be maintained in an environment with access restricted to those individuals who need member information to perform their jobs. When faxing information to us, verify that the receiving fax number is correct, notify the appropriate staff at INTotal Health of the incoming fax and verify that the fax was appropriately received. If you determine the fax was sent to the wrong number, please contact the Compliance Officer immediately at Internet (unless encrypted) should not be used to transfer files containing member information to us (e.g., Excel spreadsheets with claim information). Such information should be mailed or faxed. Please use professional judgment when mailing medically sensitive information such as medical records. The information should be in a sealed envelope marked confidential and addressed to a specific individual, post office box, or department at INTotal Health. Our voic system is secure and password protected. When leaving voic messages, only leave the minimum amount of member information required to accomplish the intended purpose. When contacting us, please be prepared to verify your name, address, and Tax Identification Number (TIN) or National Provider Identifier (NPI) numbers. 36

46 6 MEMBER MANAGEMENT SUPPORT Welcome Packet As part of our member management strategy, we offer a mailed welcome packet to all new members, which includes a welcome letter, a comprehensive member handbook, and a contact card. Member ID cards are mailed separately. Member with Special Needs In addition to a welcome packet, certain groups of members have been identified by Virginia DMAS as requiring targeted outreach. Children and Youth with Special Health Care needs, Foster Care, and newly eligible Aged, Blind, Disabled members receive personalized phone calls and mailings to complete a Health Risk Assessment. The purpose of this targeted outreach is to proactively identify those members most likely to need additional services and coordination of care. Appointment Scheduling We ensure our members have access to primary care services for routine, urgent, and emergency services and to specialty care services for chronic and complex care through our participating provider network. Please respond to our members needs and requests in a timely manner. PCPs should make every effort to schedule our members for appointments using the guidelines outlined in Section 7 PCP Access and Availability. Transportation Benefits INTotal uses Logisticare as its transportation administrator. Members are able to get transportation to and from their medically needed visits. Members can call LogistiCare to set up transportation for their healthcare needs or log onto to the LogistiCare website.transportation to and from routine appointments require at least three days notice in advance. For more urgent appointments, members or providers may call LogistiCare to be transported without the 3 day notice. Logisticare will confirm with you, the provider, to determine if the appointment is urgent. In addition to transporting members to and from appointments, LogistiCare also offers reimbursement for gas if members arrange their own transportation or public transportation tokens. Please have members contact Logisticare in advance to see if they qualify for these additional transportation options. Call LogistiCare toll free for reservations Call LogistiCare toll free for reservations or help with a scheduled trip Log onto to schedule routine transportation. If the member has special transportation needs such as a stretcher, door-to-door services, trips over 50 miles, or out of state trips please let LogistiCare know as soon as possible. These special requirements require additional approval. Transportation services are only provided to and from medically necessary provider and dental appointments. If you will need to stop at a pharmacy, please tell LogistiCare when you make your reservation. 37

47 Please note: Members must provide appropriate child safety seats for any child to use when using LogistiCare transportation. Reservations cannot be made and drivers will not transport without the child safety seats available. LogistiCare can drop off and pick up from these locations: Your home A doctor or dental office A clinic or hospital Other place of medical service, including a pharmacy Nurse HelpLine Our Nurse HelpLine is a service designed to support the provider by offering information and education about medical conditions, healthcare and prevention to members outside of normal physician practice hours. The Nurse HelpLine provides triage services and helps direct members to appropriate levels of care. Our Nurse HelpLine telephone number is and is listed on the member s ID card. This ensures members have an additional avenue of access to healthcare information when needed. Features of the Nurse HelpLine include: Available 24 hours a day, 7 days a week Information based upon nationally recognized and accepted guidelines Free translation services for 150 different languages and for members with difficulty hearing Education for members about appropriate alternatives for handling non-emergent medical conditions Interpreter Services Over-the-telephone or in office interpreter services are available for no fee, including service for the hearing impaired. Call Provider Services at to arrange for the service. In office language or ASL interpreters can take more time to arrange so please notify member services prefer at least 3 days in advance of the requested date. Effective communication with the member is important to good health. Please do not hesitate to request support. We encourage providers to use a qualified interpreter in addition to or instead of a family member to promote accurate and complete communication. Health Promotion We strive to improve healthy behaviors, reduce illness, and improve the quality of life for our members through comprehensive programs. Educational materials are developed or purchased and made available to our members. In addition to the educational materials, health education classes are coordinated with contracted community organizations and network providers. We offer our members education and information regarding their health, including: A quarterly member newsletter Creation and distribution of StarPoints, our branded health education brochures used to inform members of health promotion issues and topics Health Tips on Hold (educational telephone messages while the member is on hold) A monthly calendar on our website of community events offered to members Development of health education curricula and procurement of other health education tools (e.g. breast self-exam cards) 38

48 Relationship development with community-based organizations to enhance opportunities for members Online self-management tool: Members can create a profile on our Member Portal via Once registered, members will have access to INTotal Health s My Health Coach. This wellness tool is another way members can take control of their daily health in the areas such as: o Weight o Height o Smoking and tobacco use o Physical activity o Healthy eating o Stress o Productivity or absenteeism o Breast cancer screening o Influenza vaccination o At-risk drinking o Depressive symptoms Case Management The case management process is designed to proactively respond to a member s needs when conditions or diagnoses require care and treatment for long periods of time and/or high degree of service intensity or complexity. When a member is identified (usually through pre-authorization, admission/discharge review, claims/encounter data, pharmacy data and/or provider or member request), the INTotal Health care manager helps to coordinate and facilitate services. Case Management is a voluntary program and members may choose to opt out. Your support of the member and care manager during the process is valued and necessary for successful outcomes. Current programs under our Case Management include: Complex Case Management Disease Management Maternity Case Management Starring: Baby and Me Behavioral Health Case Management You, on behalf of a member, may request participation in any of the programs. The care manager will work with you, the member and/or the hospital to identify the necessary: Intensity level of care management services needed Education Healthcare services required Equipment and/or supplies required Community-based services available Communication required between member and PCP/specialist Appropriate alternate settings where care may be delivered If you have identified a member who could benefit from any of our case management programs, please call , Monday through Friday, 8:30 a.m. to 5:30 p.m. and ask to speak to a case manager. All of our Case Management programs are based on a system of coordinated care management interventions and communications designed to assist physicians and others in managing members with chronic diseases, high-risk or complex-health coordination needs. The program includes a holistic, member-centric care management approach that allows care managers to focus on multiple needs of members. 39

49 Focused Case Management or Disease Management programs currently include, but are not limited to: Co-occurring Mental/Behavioral Health Conditions Severe and chronic mental illness Complex or catastrophic injury or illness Cancer Cardiac Disease o Coronary Artery Disease (CAD) o Congestive Heart Failure (CHF) Diabetes Pulmonary Disease o Asthma o Chronic Obstructive Pulmonary Disease (COPD) High Risk Pregnancy NICU infants Program features: Proactive population identification processes Risk stratification Evidence-based national practice guidelines Collaborative practice models to include physician and support-service providers in treatment planning for members Continuous patient self-management education, including primary prevention, and compliance/surveillance Community or home visits and case/care management for high-risk members Ongoing process and outcomes measurement, evaluation, and management Ongoing communication with providers regarding patient status as needed Starring: Baby and Me is our Maternity Management program All pregnant members receive an informational and incentive packet when we are notified of their pregnancy. In addition, outreach is attempted for all pregnant members to determine if they are high risk for complications. Members identified at high risk are offered Case Management to support a healthy pregnancy. We ask providers to address the following topics in addition to their routine care Pre-natal depression Post-partum depression HIV and Zika screening, if appropriate You can go to our website at to view our guidelines. All our members with the above diagnoses are eligible for Case Management services. Members are identified through continuous case finding efforts including, but not limited to, Health Risk Assessments, claims mining, DMAS identified populations, and member request for services. As a valued provider, you can also refer patients who can benefit from additional education and care management support. Members identified for participation in any of the programs are assessed and risk stratified based on the severity of their disease or the complexity of their condition. Based on the risk stratification, the member is provided a tiered level of intervention. Program evaluation, outcome measurement and process improvement are built into all the programs. 40

50 Breast feeding support INtotal Health supports breast feeding and covers breast pumps at no cost to our members. We can also provide support or resources to help members with breastfeeding. Please call member services at if you have questions regarding breast pumps or support for breast feeding. They can answer your questions or refer you to a nurse case manager for support. Women, Infants, and Children (WIC) Program Medicaid recipients eligible for Women, Infants, and Children (WIC) benefits include the following: Pregnant women Women who are breastfeeding infants up to one year postpartum Women who are non-breastfeeding up to six months postpartum Infants up to the first birthday Children up to the child s fifth birthday Members may apply for WIC services at their local WIC agency. Members may call the Virginia toll free WIC services line at to find out the nearest WIC office to begin the application process and request benefits. Care Management Provider Rights and Responsibilities As a participating provider with members enrolled in the care management programs, you have additional rights and responsibilities. You have the right to: Obtain information about INTotal Health, including programs and services, our staff and their qualifications, and any contractual relationships Decline to participate in or work with the INTotal Health programs and services to our members, if contractually possible Be informed of how the organization coordinates our care management-related interventions with treatment plans for individual patients Know how to contact the person responsible for managing and communicating with your patients Be supported by INTotal Health to make decisions interactively with patients regarding their healthcare Receive courteous and respectful treatment from the INTotal Health staff Communicate grievances to INTotal Health regarding case management/disease management as outlined in the INTotal Health provider grievance procedure Encourage member participation in Care Management activities by proactively referring members and supporting communication with the Care Management process. Hours of Operation/Contact Information Our care managers are licensed clinicians and are available from 8:30 a.m. to 5:30 p.m. Monday through Friday. Confidential voic is available 24 hours a day. The Nurse HelpLine is available 24 hours a day, 7 days a week for our members. Please call to reach one of our care managers and obtain information about our care management programs. 41

51 Community and Member Advisory Committee (CMAC) The Community and Member Advisory Committee (CMAC) provides advice from members to INTotal Health regarding health education and outreach program development. The committee strives to ensure materials and programs meet cultural competency requirements and are both understandable to the member and address the members health education needs. The Community and Member Advisory Committee s responsibilities are to: Identify health education needs of the membership based on review of demographic and epidemiologic data Identify cultural values and beliefs that must be considered in developing a culturally competent health education program Assist in the review, development, implementation, and evaluation of the member health education tool for the outreach program 42

52 7 PROVIDER RESPONSBILITIES Responsibilities of the Primary Care Provider The PCP is a network physician responsible for the complete care of his or her members, whether providing it himself or herself, or by referral to the appropriate provider of care within the network. FQHCs and RHCs may be included as PCPs. Below are highlights of the PCP s responsibilities. The PCP shall: Manage the medical and healthcare needs of members, including monitoring and following up on care provided by other providers including FFS Provide education and coordination for recommended preventive healthcare services and appropriate guidance for healthy behaviors Provide coordination necessary for referrals to specialist and FFS providers (both in- and out-ofnetwork); maintain a medical record of all services rendered by the PCP and other providers Provide 24-hour-a-day, 7-day-a-week coverage with regular hours of operation clearly defined and communicated to members Provide services ethically, legally and in a culturally competent manner and meet the unique needs of members with special healthcare needs Participate in any system established by INTotal Health to facilitate the sharing of records, subject to applicable confidentiality and HIPAA requirements Make provisions to communicate in the language or fashion primarily used by members Participate and cooperate with us in any reasonable internal and external quality assurance, utilization review continuing education and other similar programs we ve established Participate in and cooperate with our grievance procedures; we will notify the PCP of any member grievance Not balance-bill members; however, the PCP is entitled to collect applicable copayments for certain services Continue care in progress during and after termination of the provider s contract for up to 60 days until a continuity of care plan is in place to transition the member to another provider or through postpartum care for pregnant members in accordance with applicable state laws, regulations, and accreditation requirements Comply with all applicable federal and state laws regarding the confidentiality of patient records Develop and have an exposure control plan that is compliant with Occupational Safety and Health Administration standards regarding blood-borne pathogens Establish an appropriate mechanism to fulfill obligations under the Americans with Disabilities Act Support, cooperate, and comply with our quality improvement program initiatives, including our use of practitioner performance data for quality improvement activities, and any related policies and procedures designated to provide quality care in a cost-effective and reasonable manner Inform us if a member objects to provision of any counseling, treatments, or referral services for religious reasons Treat all members with respect and dignity; provide members with appropriate privacy and treat member disclosures and records confidentially, giving the members the opportunity to approve or refuse their release Provide members complete information concerning their diagnosis, evaluation, treatment, and prognosis and give members the opportunity to participate in decisions involving their healthcare except when contraindicated for medical reasons 43

53 Advise members about their health status, medical care or treatment options, regardless of whether benefits for such care are provided under the program or have limitations; advise members on treatments which may be self-administered Contact members when clinically indicated, as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiological findings Have a policy and procedure to ensure proper identification, handling, transport, treatment, and disposal of hazardous and contaminated materials and wastes to minimize sources and transmission of infection Agree to maintain communication with the appropriate agencies such as local police, social services agencies, and poison control centers to provide high-quality patient care Agree that any notation in a patient s clinical record indicating diagnostic or therapeutic intervention that is part of a clinical research study shall be clearly contrasted with entries regarding the provision of non-research related care Note: We do not cover the use of any experimental or investigational procedures or medications. Primary Care Provider Access and Availability All providers are expected to meet the federal and state accessibility standards and those defined in the Americans with Disabilities Act of Healthcare services provided through INTotal Health must be accessible to all members. We are dedicated to arranging access to care for our members. We have the ability to provide quality access depending upon the accessibility of network providers. You are required to adhere to the following access standards: Routine primary care visits Within 30 calendar days Routine primary care visit (FAMIS) Within 2 weeks Emergency care Immediately Urgent care Within 24 hours Pregnancy Care: First trimester Within 14 calendar days Second trimester Within 7 calendar days Third trimester Within 5 business days High-risk pregnancies Within 3 business days Behavioral Healthcare: Non-life threatening emergency Within 6 hours Urgent care Within 24 hours Routine care - initial visit Within 10 business days Routine care follow up visit Within 30 calendar days You may not use discriminatory practices such as preference to other insured or private-pay patients, separate waiting rooms, or appointment days. 44

54 We routinely monitor our providers adherence to the access care standards. To ensure continuous 24-hour coverage, PCPs must maintain one of the following arrangements for members to contact the PCP after normal business hours: The office telephone is answered after hours by an answering service, which can contact the PCP or another designated network medical practitioner. All calls answered by an answering service must be returned within 30 minutes. The office telephone is answered after normal business hours by a recording in the language of each of the major population groups served by the PCP, directing the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider s telephone; another recording is not acceptable. The office telephone is transferred after hours to another location where someone will answer the telephone and be able to contact the PCP or a designated INTotal Health network medical practitioner who can return the call within 30 minutes. The following telephone answering procedures are not acceptable: Office telephone is only answered during office hours Office telephone is answered after hours by a recording that tells members to leave a message Office telephone is answered after hours by a recording which directs members to go to an emergency room for any services needed Routinely returning after-hours calls outside of 30 minutes Member Missed Appointments Our members may sometimes cancel or not appear for necessary appointments and fail to reschedule those appointments. This can be detrimental to their health. We require you to attempt to contact members who have not shown up for or canceled an appointment without rescheduling the appointment. The contact can be either in writing or by telephone and should be designed to educate the member about the importance of keeping appointments and to encourage the member to reschedule the appointment. If a member misses an appointment for lack of transportation, please have them contact LogistiCare for transportation services at Our members who frequently cancel or fail to show up for an appointment without rescheduling the appointment may need additional education in appropriate methods of accessing care. In these cases, please call Provider Services at and request Case Management services to address the situation. Our staff will contact the member and provide more extensive education and/or care management as appropriate. Our goal is for members to recognize the importance of maintaining preventive health visits and to adhere to a plan of care recommended by their PCP. Note: Members cannot be billed for missed appointments. Non-adherent Members We recognize you may require help managing non-adherent members. If you have an issue with a member regarding behavior, treatment cooperation and/or completion of treatment, and/or making or appearing for appointments, please call Provider Services at and request Case Management services. A Case Manager will contact the member either by telephone or in person to provide the education and counseling to address the situation and will report to you the outcome of any counseling efforts. You must give 30-day notice to INTotal Health and the member before discharging a member to allow time for the member to be re-assigned to another PCP. 45

55 Primary Care Provider Transfers To maintain continuity of care, we encourage members to remain with their PCP. However, members may request to change their PCP for any reason by contacting Member Services at Members can call to request a PCP change at any time they are actively enrolled in the plan. PCP change requests will be processed generally on the same day or by the next business day. Members who change PCPs will receive a new I.D. card within 10 days of the change. The member s name will be provided to the new PCP on the monthly membership roster (panel listing) that mailed to the provider. Covering Physicians During your absence or unavailability, you need to arrange for coverage for your members. You can either: (1) make arrangements with one or more network providers to provide care for your members or (2) obtain locums tenens coverage while on temporary leave. You will be responsible for ensuring that the covering physician provides services in compliance with INTotal Health s policies and procedures. In addition, the covering provider will agree to the terms and conditions of the network provider agreement including, without limitation, any applicable limitations on compensation, billing and participation. Specialist as a Primary Care Provider When a member requires the regular care of a specialist, we may approve the specialist to serve as the member s PCP. The criteria for a specialist to serve as a member s PCP include the member having a chronic, life-threatening illness or condition of such complexity whereby: The need for multiple hospitalizations exists The majority of care needs to be given by a specialist The administrative requirements arranging for care exceed the capacity of the non-specialist PCP. This would include members with complex neurological disabilities, high-risk pregnancy, chronic pulmonary disorders, HIV/AIDS, complex hematology and/or oncology conditions, cystic fibrosis, etc. The specialist must meet the requirements for PCP participation (including contractual obligations and credentialing); provide access to care 24 hours a day, 7 days a week; and coordinate the member s healthcare, including preventive care. When such a need is identified, the member or specialist must contact our Care Management department and complete a Specialist as PCP Request Form. One of our care managers will review the request and submit it to our Chief Medical Officer. We will notify the member and provider of our determination in writing within 30 days of receiving the request. If we deny the request, we will provide written notification to the member and provider outlining the reasons for the denial of the request within one day of the decision. Specialists serving as PCPs will continue to be paid FFS while serving as the member s PCP. The PCP designation cannot be retroactive. For further information, see the Specialist as PCP Request Form located in the Appendix A Forms section of the manual. 46

56 Reporting Changes in Address and/or Practice Status Please report any status changes using the methods below: Complete the Provider Data Change Form found in Appendix A and on our website:. Fax to: Mail to: Provider Relations Department INTotal Health 3190 Fairview Park Drive, Suite 900 Falls Church, VA Specialty Services INTotal Health has an extensive provider network including specialists and specialty services. Our members can access care directly with one of our in-network providers without a referral. If a provider is needed who does not participate with the Health Plan, the provider must obtain pre-authorization through the Utilization Management department. Second Opinions A member, parent, and/or legally appointed representative or the member s PCP may request a second opinion in any situation where there is a question concerning a diagnosis or the options for surgery or other treatment of a health condition. The second opinion shall be provided at no cost to the member. The second opinion must be obtained from a network provider (see the online Provider Directory) or a nonnetwork provider (pre-authorization required) if there is not a network provider with the expertise required for the condition. The member can arrange for the second opinion visit directly or a referring physician may assist with this process. We may also request a second opinion at our own discretion. This may occur under the following circumstances: If there is a concern about care expressed by the member or the provider If potential risks or outcomes of recommended or requested care are discovered by the health plan during its regular course of business Before initiating a denial of coverage of service If denied coverage is appealed When we request a second opinion, we ll make the necessary arrangements for the appointment, payment, and reporting. We ll inform the member and the PCP of the results of the second opinion and the consulting provider s conclusion and recommendations regarding further action. 47

57 Specialty Care Providers As a part of the credentialing process for participation in the Medicaid managed care model, you will be encouraged to apply for enrollment as a licensed provider in the Virginia Medicaid program. We contract with a network of provider specialty types to meet the medical specialty needs of members and provide all medically necessary covered services. The specialty care provider is a network physician who has the responsibility for providing the specialized care for members, often upon referral from a PCP within the network (see Roles and Responsibilities of the Specialty Care Provider). In addition to sharing many of the same responsibilities to members as the PCP (see Responsibilities of the PCP), the specialty care provider provides services that include but are not limited to: Allergy and immunology services Behavioral health and social service providers Colon and rectal surgery Community services boards Dermatology services Emergency medicine Family medicine Federally-Qualified Health Centers (FQHC) General practice Health department Home health Hospitalist Indian Health care centers Internal medicine Medical genetics Neurological surgery Nuclear medicine Obstetrics and gynecology Ophthalmology services Oral surgery Orthopedic surgery services Otolaryngology services Pathology Pediatric services Pharmacy Physician assistants and advanced practice nursing providers Physician medicine and rehabilitation Plastic surgery Preventive medicine Psychiatry & Neurology Radiology Respiratory, Developmental, Rehabilitative and Restorative Service Providers Rural Health Care Clinic (RHC) Substance Abuse Treatment Surgery Thoracic Surgery Transplant Surgery 48

58 Transportation Urgent Care Centers Urology services Roles and Responsibilities of the Specialty Care Provider (Specialist) Specialist providers may treat members who have been referred to them by network PCPs or members who self-refer. Obligations of the specialist include, but are not limited to the following: Complying with all applicable statutory and regulatory requirements of the Medicaid program Accepting all members referred to them Submitting required claims information Arranging for coverage with network providers while off duty or on vacation Verifying member eligibility and pre-authorization of services (if required) at each visit Providing consultation summaries or appropriate periodic progress notes to the member s PCP on a timely basis following a referral or routinely scheduled consultative visit Notifying the member s PCP when scheduling a hospital admission or scheduling any procedure requiring the PCP s approval Coordinating care as appropriate with other providers involved in providing care for members, especially in cases where there are medical and behavioral health comorbidities or co-occurring mental health and substance abuse disorders The specialist shall: Manage the medical and healthcare needs of members, including monitoring and following up on care provided by other providers, including those engaged on a FFS basis; provide coordination necessary for referrals to other specialist and FFS providers (both in and out of network); and maintain a medical record of all services rendered by the specialist and other providers Provide 24-hours-a-day, 7-days-a-week coverage and maintain regular hours of operation that are clearly defined and communicated to members Provide services ethically and legally in a culturally competent manner and meet the unique needs of members with special healthcare requirements Participate in the systems we ve established that facilitate the sharing of records, subject to applicable confidentiality and HIPAA requirements Participate and cooperate with us in any reasonable internal and external quality assurance, utilization review, continuing education or other similar programs we ve established Make reasonable efforts to communicate, coordinate, and collaborate with other specialty care providers, including behavioral health providers involved in delivering care and services to members Participate in and cooperate with our grievance processes and procedures; we ll notify the specialist of any member grievance brought against the specialist Not balance-bill members Continue care in progress during and after termination of his or her contract for up to 60 days until a continuity of care plan is in place to transition the member to another provider or through postpartum care for pregnant members in accordance with applicable state laws, regulations, and accreditation requirements. Comply with all applicable federal and state laws regarding the confidentiality of patient records Develop and have an exposure control plan regarding blood-borne pathogens that complies with the Occupational Safety and Health Administration (OSHA) standards Make best efforts to fulfill the obligations under the Americans with Disabilities Act applicable to his or her practice location 49

59 Support, cooperate, and comply with our quality improvement program initiatives, including our use of practitioner performance data for quality improvement activities, and any related policies and procedures designed to provide quality of care in a cost-effective and reasonable manner Inform us if a member objects for religious reasons to the provision of any counseling, treatment, or referral services Treat all members with respect and dignity; provide members with appropriate privacy; and treat member disclosures and records confidentially, giving the members the opportunity to approve or refuse their release as allowed under applicable laws and regulations Provide to members complete information concerning their diagnosis, evaluation, treatment, and prognosis and give members the opportunity to participate in decisions involving their healthcare, except when contraindicated for medical reasons Advise members about their health status, medical care or treatment options, regardless of whether benefits for such care are provided under the program or have limitations; and advise members on treatments that may be self-administered When clinically indicated, contact members as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiological findings Have a policy and procedure to ensure proper identification, handling, transport, treatment, and disposal of hazardous and contaminated materials and wastes to minimize sources and transmission of infection Agree to maintain communication with the appropriate agencies such as local police, social service agencies, and poison control centers to provide quality patient care Agree that any notation in a patient s clinical record indicating diagnostic or therapeutic intervention that is part of a clinical research study is clearly distinguished from entries pertaining to non-research related care Note: We do not cover the use of any experimental or investigational procedures or medications. Specialty Care Providers Access and Availability We will maintain a specialty network to ensure access and availability to specialists for all members. You re considered a specialist if you have a provider agreement with us to provide specialty services to our members. Specialists must adhere to the following access guidelines: Service Access Requirement Urgent, non-emergency visits Within 24 hours Routine specialty care visits Within 30 calendar days Maternity care: First trimester Within 14 calendar days Maternity care: Second trimester Within 7 calendar days Maternity care: Third trimester Within 5 business days High-risk pregnancies Within 3 business days 50

60 Cultural Competency Cultural competency is the ability of healthcare providers and healthcare organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the healthcare encounter. Cultural competency assists providers and members to: Acknowledge the importance of culture and language Embrace cultural strengths with people and communities Assess cross-cultural relations Understand cultural and linguistic differences Strive to expand cultural knowledge Not assume all members within the same culture think the same way The quality of the patient-provider interaction has a profound impact on the ability of a patient to communicate symptoms to his or her provider and to adhere to recommended treatment. Some of the reasons that justify a provider s need for cultural competency include but are not limited to: The perceptions of illness and disease and their causes vary by culture The diversity of belief systems related to health, healing, and wellness Culture influences help-seeking behaviors and attitudes/expectations toward healthcare providers Individual preferences affect traditional and nontraditional approaches to healthcare Healthcare providers from culturally and linguistically diverse groups are underrepresented in the current service delivery system Cultural barriers between the provider and member can impact the patient-provider relationship in many ways, including but not limited to: The member s level of comfort with the practitioner and the member s fear of what might be found upon examination The differences in understanding diverse consumers in the United States healthcare system A fear of rejection of personal health beliefs The member s expectation of the healthcare provider and of the treatment To be culturally competent, we expect providers serving members will demonstrate the following: Cultural Assessment skills, Including the Ability to: Recognize the cultural factors (norms, values, communication patterns, world views, religion/spirituality, health/illness models) Determine the social context (supports, socioeconomic status, education) Consider the Environmental context (knowledge of healthcare system, acculturation) Modify one s own approach to respond and respect the cultural needs of others. Knowledge Needed: Culture plays a crucial role in the formation of health or illness beliefs Different cultures have different attitudes about seeking help Feelings about disclosure are culturally unique There are differences in the acceptability and effectiveness of treatment modalities in various cultural and ethnic groups Resources, such as formally trained interpreters, should be offered to and used by members on behalf of various cultural and ethnic differences. Family members may not communicate fully or accurately because of their own culture if used to interpret. 51

61 The Ability to: Understand the basic similarities and differences between and among the cultures of the persons served Recognize the values and strengths of different cultures Interpret diverse cultural and nonverbal behavior Develop perceptions and understanding of others needs, values, and preferred means of having those needs met Identify and integrate the critical cultural elements of a situation to make culturally consistent inferences and to demonstrate consistency in actions Recognize the importance of time and the use of group process to develop and enhance crosscultural knowledge and understanding Withhold judgement, action, or speech in the absence of information about a person s culture Listen with respect Formulate culturally competent treatment plans Use culturally appropriate community resources Know when and how to use interpreters and to understand the limitations of using interpreters Treat each person uniquely Recognize racial and ethnic differences and know when to respond to culturally based cues Seek out information Use agency resources Respond flexibly to a range of possible solutions Work with clients of various ethnic minority groups Ask the individual what is important to them Member Records You re required to maintain medical records that conform to good professional medical practice and appropriate health management. A permanent medical record will be maintained at the primary care site for every member and be available to the PCP and other providers and to INTotal Health upon request. Medical records must be kept in accordance with INTotal Health and state standards as follows: Medical Record Standards The records reflect all aspects of patient care, including ancillary services. Documentation of each visit must include: 1. Date of Service 2. Grievance or purpose of visit 3. Diagnoses or medical impression 4. Objective finding 5. Assessment of patient s findings 6. Plan of treatment, diagnostic tests, therapies, and other prescribed regimens 7. Medications prescribed 8. Health education provided 9. Signature and title or initials of the provider rendering the service; if more than one person documents in the medical record, there must be a record on file as to what signature is represented by which initials. 52

62 The standards will, at a minimum, meet the following medical record requirements: 1. Patient identification information. Each page or electronic file in the record must contain the patient s name or patient ID number. 2. Personal and biographical data. The record must include age, sex, address, employer, home and work telephone numbers, and marital status. 3. Date and corroboration. All entries must be dated and author identified. The author must be the provider of the services documented. 4. Timeliness. All services documented. 5. Legibility. Each record must be legible to a qualified medical record reviewer (such as a Certified Professional Coder). A second reviewer should evaluate any record judged illegible by one physician reviewer. 6. Allergies. Medication allergies and adverse reactions must be prominently noted on the record. Absence of allergies (No Known Allergies [NKA]) must be noted in an easily recognizable location. 7. Past medical history (for patients seen three or more times). Past medical history must be easily identified, including serious accidents, operations, and illnesses. For children, the history must include prenatal and postnatal care. 8. Physician examination. A record of physical examinations appropriate to the presenting grievance or condition. 9. Immunizations. For pediatric records age 13 and younger, a completed immunization record or a notation of prior immunization must be recorded including vaccines and their dates of administration when possible. 10. Diagnostic information. Documentation of the clinical findings (all applicable diagnosis codes) and evaluation for each visit. 11. Updated comprehensive medication list including end dates, medication information and instructions to patient. 12. Identification of current problems. Significant illnesses, medical and behavioral health conditions and health maintenance concerns must be identified in the medical record. A current problem list must be included in each patient s record. 13. Instructions. Record must include evidence that the patient was provided with basic teaching, instructions regarding physical and/or behavioral health condition. 14. Smoking/alcohol/substance abuse. A notation concerning cigarettes and alcohol use and substance abuse must be stated if present for patients age 12 and older. Abbreviations and symbols may be appropriate. 15. Preventive services and risk screening. The record must include consultation and provision of appropriate preventive health services and appropriate risk screening activities. 16. Consultations, referrals, and specialist reports. Notes from any referrals and consultations must be in the record. Consultation, lab, and X-ray reports filed in the chart must have the ordering physician s initials or other documentation signifying review. Consultation and any abnormal lab and imaging study results must have an explicit notation in the record of the follow-up plans. 17. Emergencies. All emergency care provided (directly by the contracted provider or through an emergency room) and the hospital discharge summaries for all hospital admissions while the patient is part of the PCP s panel must be noted. 18. Hospital discharge summaries. Discharge summaries must be included as part of the medical record for all hospital admissions that occur while the patient is enrolled and for prior admissions, as appropriate. Prior admissions pertaining to admissions that may have occurred prior to the patient being enrolled may be pertinent to the patient s current medical condition. 19. Advance directive. For medical records of adult patients, the medical record must document whether or not the individual has executed an advance directive. An advance directive is a written instruction such as a living will or durable power of attorney that directs healthcare decision making for individuals who are incapacitated. 53

63 20. Security. Provider must maintain a written policy to ensure that medical records are safeguarded against loss, destruction, or unauthorized us. Physical safeguards require records to be stored in a secure manner that allows access for easy retrieval by authorization personnel only. Staff receives periodic training in member information confidentiality. 21. Release of information. Written procedures are required for the release of information and obtaining consent for treatment. 22. Documentation. Documentation is required setting forth the results of medical, preventive, and behavioral health screening and of all treatment provided and results of such treatment. 23. Multidisciplinary teams. Documentation is required of the team members involved in the multidisciplinary team of a patient needing specialty care. 24. Integration of clinical care. Documentation of the integration of clinical care in both the physical and behavioral health records is required. Such documentation must include: Screening for behavioral health conditions (including those which may be affecting physical healthcare and vice versa) and referral to behavioral health providers when problems are indicated Screening and referral by behavioral health providers to PCPs when appropriate Receipt of behavioral health referrals from physical medicine providers and the disposition and/or outcome of those referrals At least quarterly (or more often if clinically indicated), a summary of the status and progress from the behavioral health provider to the PCP A written release of information that will permit specific information sharing between providers Documentation that behavioral health professionals are included in primary and specialty care service teams when a patient with disabilities or chronic or complex physical or developmental conditions has a co-occurring behavioral disorder 25. Destruction of records. Patient records must only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. You must post information or in some other manner inform members concerning the timeframe for record retention and destruction. 26. Closing, selling, or relocating your practice. When closing, selling, or relocating your practice, you must meet the requirements of of the Code of Virginia for giving notice that copies of records can be sent to any like-regulated provider of the member's choice or provided to the member. Patient Visit Data Documentation of individual encounters must provide, at minimum, adequate evidence of: 1. A history and physical examination that includes appropriate subjective and objective information including screening for behavioral health, chronic illness, and pertinent to the presenting complaint 2. For patients receiving behavioral health treatment, documentation that includes at-risk factors (danger to self and/or others, ability to care for self, affect, perceptual disorders, cognitive functioning and significant social health) 3. An admission or initial assessment that must include current support systems or lack of support systems 4. For patients receiving behavioral health treatment, a documented assessment that is completed during each visit relating to client status and symptoms to the treatment process and that may indicate initial symptoms of the behavioral health condition as decreased, increased, or unchanged during the treatment period 5. A plan of treatment that includes activities, therapies, and goals to be carried out 6. Diagnostic tests, if applicable 54

64 7. Documented therapies and other prescribed regimes for patients who receive behavioral health treatment and that include evidence of family involvement, as applicable, and include evidence that the family was included in therapy sessions, when appropriate. 8. Regarding follow-up care encounter forms or notes with a notation indicating follow-up care, a call or visit that must note in weeks, months, or as needed (PRN) the specific time to return with unresolved problems from any previous visits being addressed in subsequent visits 9. Referrals and results including all other aspects of patient care, such as ancillary services We will systematically review medical records to ensure compliance with our standards. We ll institute actions for improvement when standards are not met. Compliance with the medical records performance standards is a score of 80 percent including six critical elements that must be met. Clinical Medical Record Audit and Office Site Visit Forms are available upon request and can be found on our website:. We maintain an appropriate record-keeping system for services to members. The system will collect all pertinent information related to the medical management of each member and make that information readily available to appropriate health professionals and appropriate state agencies. All medical records must be retained for a minimum of seven years from the date of service. Clinical Practice Guidelines Using nationally recognized standards of care, we work with network providers to develop clinical policies and guidelines for the care of our membership. The INTotal Health Medical Advisory Committee (MAC) oversees and directs us in formulating, adopting, and monitoring guidelines. The guidelines must be reviewed and revised at least every two years or whenever the guidelines change. Clinical Practice Guidelines are located on our website at, under Provider Resources and Documents. A copy of the guidelines can be printed from the website. Advanced Directives We respect each member s right to make decisions relating to his or her own medical care, including the decision to have provided, withheld or withdrawn the medical or surgical means or procedures calculated to prolong his or her life. We adhere to the Patient Self-Determination Act and maintain written policies and procedures regarding advance directives. Advance directives are documents signed by a competent person giving direction to healthcare providers about treatment choices in certain circumstances. There are two types of advance directives a durable power of attorney for healthcare and a living will. A durable power of attorney for healthcare (durable power) allows the member to name a patient advocate to act on behalf of the member. A living will allows the member to state his or her wishes in writing but does not name a patient advocate. We encourage members to request an advance directive form and education from their PCP at their first appointment. Members over age 18 and emancipated minors are able to make an advance directive. A member s response to executing an advance directive should be documented in the medical record. We will not discriminate or retaliate based on whether a member has or has not executed an advance directive. While each member has the right without condition to formulate an advance directive within certain limited circumstances, a facility or an individual physician may conscientiously object to an advance directive. 55

65 No INTotal Health employee may serve as witness to an advance directive or as a member s designated agent or representative. We note the presence of advance directives in the medical records when conducting medical chart audits. We encourage members to discuss their advance directives with their providers. For Virginia approved advance directive forms, guidelines for discussion and information of the Virginia advance directive registry please visit, decisions/index.jsp. Should you or a member need more detailed information or assistance, please call for further assistance. 56

66 8 MEDICAL MANAGEMENT Medical Review Criteria We use review criteria that are objective and based on medical evidence and on nationally recognized standards of care as guidelines in medical decision-making. In addition to the existing clinical decision support tools, we ve added the Aetna Clinical Policy Bulletins for some outpatient medical necessity determinations. INTotal Health works with network providers to develop clinical guidelines of care for our membership. The Medical Advisory Committee (MAC) assists INTotal Health in formalizing and monitoring guidelines. If we use noncommercial criteria, the following standards apply to the development of the criteria: Criteria are developed with involvement from appropriate providers with current knowledge relevant to the content of treatment guidelines under development. Criteria are objective, based on medical evidence, review of market practice, national standards, and best practices. Criteria are evaluated at least annually by appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria of treatment guidelines under review and updated, as necessary. The criteria must reflect the names and qualifications of those involved in the development, the process used in the development, and when and how often the criteria will be evaluated and updated. Clinical Criteria We use MCG and the Aetna Clinical Policy Bulletins for clinical decision support for medical management coverage decisions. The criteria provide a system for screening proposed medical care based on memberspecific, best medical care practices and rule-based systems to match appropriate services to member needs based upon clinical appropriateness. Criteria include: Acute care Rehabilitation Home care Surgery and procedures Imagining studies and X-rays Inpatient and outpatient services Our Clinical Reviewers use these criteria as part of the pre-authorization of scheduled admission, concurrent review and discharge planning process to determine clinical appropriateness and medical necessity for coverage of continued hospitalization. Pre-authorization and Notification Process Pre-authorization is defined as the prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered and a member s severity of illness, medical history and previous treatment to determine the medical necessity and appropriateness of a given coverage request. Prospective means the coverage request occurred prior to the service being provided. Notification is defined as facsimile or electronic communication received from a provider informing us of the intent to render covered medical services to a member. Notification should be provided prior to rendering nonemergent services. For services that are emergent or urgent, notification must be within 24 hours or the next business day, and clinical information must be submitted within 24 hours of notification or the next business day to determine appropriateness and medical necessity for coverage. 57

67 Medical Necessity Decisions Medical necessity decisions are objective, based on medical evidence and are applied according to the individual needs of the member and an assessment of the local delivery system. We make utilization management criteria available to practitioners upon request. If a medical necessity decision results in a denial, practitioners are welcome to discuss the denial decision with the Chief Medical Officer or a physician designee. All denial decisions are made by appropriately licensed and qualified physicians. Practitioners can obtain utilization management criteria or speak to the Chief Medical Officer by calling the INTotal Health Provider Services at We require pre-authorization of all inpatient elective admissions. The referring primary care or specialist physician is responsible for pre-authorization. The referring physician identifies the need to schedule a hospital admission and must submit the request to our Clinical Services Department. Requests for pre-authorization with all supporting documentation should be submitted immediately upon identifying the inpatient request or at least 14 calendar days prior to the scheduled admission. This will allow verification of benefits and time to process the pre-authorization request. For services that require preauthorization, we make case-by-case determinations that consider the individuals healthcare needs and medical histories, in conjunction with nationally recognized standards of care. The hospital can confirm that an authorization is on file by calling Provider Services at If coverage of an admission has not been approved, the facility should call Provider Services at When a request is received from the provider via fax ( ) for medical services, the case specialist will verify eligibility and benefits. This information will be forwarded to the pre-authorization nurse. The utilization review nurse will review the coverage request and the supporting medical documentation to determine the medical appropriateness of diagnostic and therapeutic procedures. When appropriate, the preauthorization nurse will assist the physician in identifying alternatives for healthcare delivery as supported by the Chief Medical Officer or physician designee. When the clinical information received is in accordance with the definition of medical necessity and in conjunction with nationally recognized standards of care, an INTotal Health reference number will be issued to the referring physician. The reference number provided is valid only for services authorized and does not guarantee payment. Payment of claims is subject to eligibility, contractual limitations, provisions and exclusions. All utilization guidelines must be supported by an individualized determination of medical necessity based on the member s needs and medical history. If medical necessity criteria for the admission are not met on the initial review, the Chief Medical Officer or physician designee will send an adverse determination letter with an explanation for the denial. If the preauthorization documentation is incomplete or inadequate, the pre-authorization nurse will not approve coverage of the request but will notify the referring provider to submit the additional necessary documentation. If the Chief Medical Officer denies coverage of the request, the appropriate denial letter (including the member s appeal rights) will be mailed to the requesting provider, the referring provider and member. 58

68 Emergent Admission Notification Requirements We prefer immediate notification by network hospitals of emergent admissions. Network hospitals must notify us of emergent admissions within one business day and submit clinical information within 24 hours or one business day. Our Clinical Services staff will verify eligibility and determine benefit coverage. Coverage of emergent admissions authorization is based on review by a concurrent review nurse. When the clinical information received meets nationally recognized standards of care, an INTotal Health reference number will be issued to the hospital. Non-emergent Outpatient and Ancillary Services Pre-authorization and Notification Requirements We require pre-authorization for coverage of selected non-emergent outpatient and ancillary services (see chart below). To ensure timeliness of the authorization, the facility and/or provider must provide the following: Member name and INTotal Health ID number Name, telephone number, NPI, tax ID fax number of physician performing the elective service Name of the facility, NPI, tax ID and telephone number where the service is to be performed Date of service Member diagnosis Name of elective procedure to be performed with Current Procedural Terminology (CPT-4) code Medical information to support requested services (medical information includes current signs, symptoms, past and current treatment plans, response to treatment plans and medications) The table below contains pre-authorization and notification requirement guidelines: Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Abortion/Induced INTotal Health cannot and will not cover services for abortion. Any payment questions related to abortion or abortion related services should be referred to the Department of Medical Assistance Services. Behavioral Health/Substance Abuse Preauthorization/ notification Inpatient mental health services. Inpatient hospital services may include room, meals, general nursing services, prescribed drugs and emergency room services leading directly to admission. The MCO is not required to cover any services rendered in freestanding psychiatric hospitals to enrollees up to 19 years of age. Medicaid/ FAMIS FAMIS Moms Inpatient (IP) freestanding psychiatric facility IP state psychiatric facility Covered only for members under age 21 and older than age 64 Not covered Not covered Not covered 59

69 SERVICES Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. REQUIREMENT IP acute care All ages All ages facility covered covered Covered up to 30 days, including partial day treatment Partial hospitalization Outpatient (OP) individual, family, and group mental health and substance abuse treatment (excluding opioid treatment) Not covered All ages covered Covered up to 30 days combined with IP acute care facility All ages covered OP electroconvulsive therapy OP detoxification NOTE: If a member has been prescribed drugs for opioid treatment and the member obtains such drugs through an in-network pharmacy, the drugs are the responsibility of INTotal Health. However, if the opioid treatment is administered by the substance abuse provider and that provider obtains the drugs for the member, such drugs will be covered by the Department of Medical Assistance Services (DMAS). Transportation and pharmacy services necessary for the services) are the responsibility of INTotal Health. Community Mental Health Rehabilitation Services (CMHRS) are covered by DMAS. For specific service coverage, please contact DMAS or see the DMAS CMHRS manual online. 60

70 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Breast Pumps No Preauthorization All pump specialties are covered. Cardiac Rehabilitation Preauthorization Pre-authorization is required for coverage of all services. Chemotherapy Inpatient: Preauthorization Chiropractic Services Outpatient: No preauthorization Preauthorization Pre-authorization is required for coverage of inpatient chemotherapy services. No pre-authorization is required for coverage of chemotherapy procedures when performed in outpatient settings by a participating facility, provider office, outpatient hospital or ambulatory surgery center. For information on coverage of and pre-authorization requirements for chemotherapy drugs, please see the Pharmacy section. Medicaid Not covered unless recommended at an EPSDT visit and meets medical necessity FAMIS Covered up to $500 per calendar year as medically necessary. Dental Services We cover medically necessary services resulting from a dental accident or for medically necessary procedures to the mouth where the main purpose is not to treat or help the teeth and their supporting structures. We also cover hospitalization and anesthesia related to these services. Pre-authorization is required for coverage of trauma to the teeth and oral maxillofacial medical and surgical conditions including TMJ. Dental services are provided through Smiles for Children, a dental benefits administrator contracted with the Department of Medical Assistance Services. The toll-free number for Smiles for Children is Dermatology Services No pre-authorization is required for E&M, testing or most procedures. Services considered cosmetic in nature or related to previous cosmetic procedures are not covered. See the Diagnostic Testing section below. Visit our website to look up specific service codes for pre-authorization/notification requirements. Diagnostic Testing No pre-authorization is required for routine diagnostic testing. Pre-authorization is required for video EEGs. evicore Healthcare provides diagnostic radiology management services and will pre-authorize the following: CAT and PET scans, MRA, MRI, and nuclear cardiology. 61

71 SERVICES Dialysis Durable Medical Equipment Contact evicore at or Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. REQUIREMENT Early and Periodic Screening, Diagnosis, and Treatment Visit Early Childhood Intervention Preauthorization Pre-authorization is required for dialysis procedures. Non-standard laboratory tests require preauthorization. For code-specific pre-authorization requirements for DME, prosthetics and orthotics, please visit our website or fax your request to The following items require a Certificate of Medical Necessity (CMN) along with pre-authorization: o Continuous positive airway pressure devices o Enteral and parenteral nutrition devices o External infusion pumps o Hospital beds o Lymphedema pumps o Oxygen o Osteogenesis stimulators o Power operated vehicles o Seat lift mechanisms o Support surfaces o Transcutaneous electrical nerve stimulator units o Wheelchairs, motorized, and manual All customized wheelchair pre-authorization require a Chief Medical Officer s review. Miscellaneous items must include a manufacturer invoice with pre-authorization request and claim submission. INTotal Health and provider must agree on HCPCS and/or other codes for billing covered services. See the Medical Supplies section for more information. Use EPSDT schedule and document visits. Preauthorization and certificate of medical necessity Self-referral Services are covered under the DMAS Fee-For-Service (FFS) Program. Educational Consultation No notification or pre-authorization is required. Emergency Room Self-referral No notification is required. If emergency care results in an admission, notification is required within 24 hours or the next business day. See the Observation section for more information. 62

72 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT ENT Services (Otolaryngology) No preauthorization adenoidectomy, nasal, nasal/sinus surgery, and Pre-authorization is required for tonsillectomy and/or Is required for cochlear implant surgery and services. E&M, testing See the Diagnostic Testing section for more or procedures information. Family Planning/STD Care Self-referral Covered services include pelvic and breast examinations, drugs, biological, genetic counseling, and devices and supplies related to family planning (e.g., IUD). Infertility services and treatment, elective abortions, and services performed at the time of abortion are not covered. Gastroenterology Services No pre-authorization is required for E&M, testing or most procedures. Pre-authorization is required for upper endoscopy and bariatric surgery, including insertion, removal, and/or replacement of adjustable gastric restrictive devices and subcutaneous port components See the Diagnostic Testing section for more information. Gender Reassignment Services This is not a covered benefit. and Surgery Gynecology Self-referral No pre-authorization is required. Hearing Aids Hearing Screening Home Healthcare (see also Rehabilitation Therapy) Preauthorization Preauthorization Pre-authorization is required for hearing aids. Medicaid EPSDT members 0-20 years of age only FAMIS All ages covered No notification or pre-authorization is required for coverage of diagnostic and screening tests, hearing aid evaluations, or counseling. Medicaid Home health aide services are limited to 32 visits per year. Skilled home health visits, nursing services and rehabilitative therapy are covered based on medical necessity. FAMIS Covered services include skilled nursing, personal care, home health aide, physical, occupational, speech, hearing and inhalation therapy services. Limit: 90 total visits per year. Drugs and DME require separate pre-authorization. 63

73 Hospital Admission Laboratory Services (Outpatient) Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Hospice Services Preauthorization Preauthorization Medicaid Not a covered benefit Hospice services are covered through the FFS Medicaid Program. For assistance, contact FAMIS Pre-authorization is required for coverage of inpatient hospice services. Notification is required for outpatient hospice services. If services are provided in the member s home and/or DME is provided, see the DME and Home Health Services section for more information. Elective admissions required pre-authorization for coverage. Emergency admissions require notification within 24 hours or the next business day. Pre-admission testing must be performed by an INTotal Health preferred lab vendor or network facility outpatient department. See the Provider Directory for a complete listing of participating vendors. Same-day admission is required for surgery. Preadmission services are not permitted. All laboratory services furnished by non-network providers require pre-authorization, except for hospital laboratory services provided for an emergency medical condition. For offices with limited or no office laboratory facilities, lab test should be referred to one of the INTotal Health preferred lab vendors. See the Provider Directory for a complete listing of participating lab vendors. Medical Supplies No pre-authorization is required for coverage of disposable medical supplies. Disposable medical supplies are disposed of after one use by a single individual. 64

74 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Neurology No pre-authorization is required for network providers for E&M, testing or procedures. Pre-authorization is required is required for the following: o Neurosurgery o Spinal fusion o Artificial intervertebral disc surgery See the Diagnostic Testing section of this QRC for more information. Observation No preauthorizationetwork observation. No pre-authorization or notification is required for in- or notification If observation results in an admission, notification is is required for required within 24 hours or on the next business day. in-network or Clinical information must be provided within 24 hours out of network of notification or on the next business day for medical observation. necessity review. If admission occurs, all charges for observation services roll up into the admission. Obstetrical Care Notification is required at the FIRST prenatal visit. Notification of delivery is required within 24 hours with newborn information. No pre-authorization is required for coverage of obstetrical (OB) visits, diagnostic tests and laboratory services. Coverage includes labor, delivery, and circumcision up to 12 weeks, ultrasounds, biophysical profile, nonstress test and amniocentesis. Certified nurse midwives Ophthalmology No pre-authorization is required for E&M, testing or most procedures. Pre-authorization is required for repair of eyelid defects. Services considered cosmetic in nature are not covered. See the Diagnostic Testing section for more information. Oral Maxillofacial See the Plastic/Cosmetic/Reconstructive Surgery section for information. Otolaryngology (ENT) See the ENT Services (Otolaryngology) section for Services information. Out-of-Area/Out-of-Plan Preauthorization emergency care (including Pre-authorization is required except for coverage of Care self-referral). Outpatient/Ambulatory Surgery Pre-authorization requirement is based on the service performed. Please visit our website for procedure specific preauthorization requirements. 65

75 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicted. SERVICES REQUIREMENT Pain Management Preauthorization services and procedures related to pain Pre-authorization is required for coverage of all management. Pharmacy The Pharmacy benefit covers medically necessary prescription and Over-The-Counter (OTC) medications prescribed by a licensed provider. Exceptions and restrictions exist as the benefit is provided under a closed Formulary. Please refer to the Formulary for the preferred products within therapeutic categories as well as requirements around generics, prior authorization, step therapy, quantity edits and the prior authorization process. Most self-injectable medications and selfadministered oral specialty medications and many office administered specialty medications are available through Caremark Specialty pharmacy and require Prior-Authorization (PA). To initiate a PA request, please fax a Medication Request/Prior Authorization Form to Please contact Caremark at to schedule delivery once you receive a PA approval notice. For a complete list of drugs available through Caremark Specialty, please visit the Pharmacy section of our website. Injectable drugs and their counterparts in the same therapeutic class require pre-authorization through INTotal Health when administered from a provider s supply. Please contact Provider Services at Physiatry, Physical Medicine See the Pain Management section for information. and Rehabilitation Plastic/Cosmetic/Reconstructive Surgery (including Oral Maxillofacial Services) No pre-authorization is required for coverage of E&M codes. Pre-authorization is required for services related to trauma to the teeth, oral maxillofacial, medical and surgical conditions including TMJ. Services considered cosmetic in nature or services related to previous cosmetic procedures (e.g., scar revision, keloid removal resulting from pierced ears) are not covered. Reduction mammoplasty requires an INTotal Health Chief Medical Officer s review. Breast Reconstruction status post mastectomy is a covered benefit 66

76 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Podiatry No pre-authorization is required for coverage of E&M, testing and procedures. Pre-authorization requirement is based on the service performed. See the DME section for more information. Please visit our website for procedure-specific preauthorization requirements. Private Duty Nursing Pre-authorization is required. Radiation Therapy No pre-authorization is required for coverage of radiation therapy procedures when performed in the following participating provider settings: office, outpatient hospital and ambulatory surgery center. Radiology See the Diagnostic Testing section. Rehabilitation Therapy: OT, RT, PT, and ST (Short Term) Skilled Nursing Facility Early Intervention Services are covered under the DMAS FFS Program. Notification is not required for initial evaluation. Pre-authorization is required for coverage of subsequent visits. You may fax your requests to All children of school age should be evaluated for school-based speech therapy prior to preauthorization at a non-school based location. Medicaid Not an MCO covered benefit Skilled nursing facility services are covered through the FFS Medicaid program. For assistance, call provider help line. FAMIS Pre-authorization is required for coverage. Medically necessary services provided in a skilled nursing facility are covered for up to 180 days per confinement. Sleep Study Preauthorization Pre-authorization is required. Sports Physicals Sports physicals are a value-added benefit for FAMIS and Medicaid members. Coverage is limited to one sport physical exam per year for members between the ages 10 and 18. Maximum allowable reimbursement of $30 with no applicable member copayments. 67

77 Pre-authorization/Notification Coverage Guidelines All services are for FAMIS and Medicaid members unless otherwise indicated. SERVICES REQUIREMENT Sterilization Sterilization services are covered benefit for members ages 21 and older and require a 30-day waiting period. No pre-authorization or notification is required for coverage of sterilization procedures including tubal ligation and vasectomy. Reversal of sterilization is not covered. Sterilization consent form is required for claims submission. Transportation Services Medicaid FAMIS Unlimited nonemergent benefit, FAMIS As a value-added transportation to members receive 20 medically necessary one way trips per year appointments is to medically necessary provided through appointments through LogistiCare. LogistiCare. Providers and members may contact LogistiCare for assistance in scheduling transportation with three days prior notice. Members may call to make a reservation. To check the status of a ride, members may call LogistiCare at No pre-authorization or notification is required except for coverage of air transport (airplane or helicopter). Urgent Care Center No Notification or pre-authorization is required for participating facility. Vision Care (Routine) Self-referral Members may call Superior Vision at Well-woman Exam Self-referral Well-woman exams are covered once per calendar year when performed by a PCP or in-network GYN. Exam includes routine lab work, STD screening, Pap smear. Screening mammograms are covered for women ages and older). Revenue Codes To the extent the following services are covered benefits, pre-authorization or notification is required for all services billed with the following revenue codes: All inpatient and behavioral health accommodations 0023: Home health prospective payment system : All-inclusive ancillary psychiatric 0632: Pharmacy multiple source : Adult daycare and foster care 68

78 If the notification documentation provided is incomplete or inadequate, we will not approve coverage of the request but will notify the hospital to submit the additional necessary documentation. If the Chief Medical Officer or physician designee denies coverage of the request, the appropriate denial letter will be mailed to the hospital, member s PCP and member. Inpatient Reviews Inpatient Admission Reviews All inpatient hospital admissions, including urgent and emergent admissions, will be reviewed within 1 business day. Our utilization review clinician determines the member s medical status through communication with the hospital s Utilization Review department. Appropriateness of the stay is documented, and concurrent review is initiated. Cases may be referred to the Chief Medical Officer or physician designee, who renders a decision regarding the coverage of hospitalization. Diagnoses meeting specific criteria are referred to the care management program. Affirmative Statement about Incentives We require employees who make Utilization Management (UM) decisions to adhere to the following principles: UM decision-making is based only on appropriateness of care and service and existence of coverage. We do not reward practitioners or other individuals for issuing denials of coverage or service. Financial incentives for our UM decision makers do not encourage decisions that result in underutilization. Medical Review Criteria Admission approval and continuing Length-of-Stay (LOS) approvals are determined using nationally recognized criteria. Upon request, providers can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which a denial decision is based by calling Inpatient Concurrent Review Each network hospital will have an assigned UM clinician. The UM clinician will conduct a concurrent review of the hospital medical record by fax or phone to determine the authorization of coverage for a continued stay. The UM clinician will conduct continued stay reviews and evaluate discharge plans, unless the patient s condition is such that it is unlikely to change within the upcoming 24 hours and discharge planning needs cannot be determined. When the clinical information received meets medical necessity criteria, approved days and bed-level coverage will be communicated to the hospital for the continued stay. The INTotal Health UM clinician will help coordinate discharge planning needs with the hospital utilization review staff and attending physician. The attending physician is expected to coordinate with the member s PCP regarding follow-up care after discharge. The PCP is responsible for contacting the member to schedule all necessary follow-up care. In the case of a behavioral health discharge, the attending physician is responsible for ensuring that the member has secured an appointment for a follow-up visit with a behavioral health provider to occur within seven calendar days of discharge. 69

79 We will authorize covered length of stay as appropriate utilizing Milliman Care Guidelines (MCG) as our decision making tool. Exceptions to the one-day length of stay authorization are made for confinements when the severity of the illness and subsequent course of treatment are likely to be several days or are predetermined by state law. Examples of confinement and/or treatment include the following: Intensive Care Unit (ICU) Cardiac Care Unit (CCU) Behavioral health rehabilitation C-section or vaginal deliveries Exceptions are made by the Chief Medical Officer or the physician designee. If after several attempts to speak with the attending physician, the Chief Medical Officer denies coverage for an inpatient stay request, the appropriate denial letter will be mailed to the hospital, member s PCP and the member. Discharge Planning Discharge planning is designed to assist the provider in the coordination of the member discharge when acute care (hospitalization) is no longer necessary. When long-term care is necessary, we work with the provider to plan the member s discharge to an appropriate setting for extended services. These services are not necessarily covered through the MCO or may not be a covered benefit. When you identify medically necessary and appropriate services for the member, we ll help you and the discharge planner in providing a timely and effective transfer to the next appropriate level of care. Discharge plan authorizations follow nationally recognized standards of care. Authorizations include and are not limited to transportation, home health, DME, pharmacy, follow-up visits to practitioners or outpatient procedures. Confidentiality of Information Processes including utilization management, case management, disease management, discharge planning, quality management and claims payment activities are designed to ensure that patient-specific information, particularly protected health information obtained during review, is kept confidential in accordance with applicable laws, including HIPAA. Information is used for the purposes defined above and is shared only with entities who have the authority to receive such information and only with those individuals who need access to such information in order to conduct treatment, payment, and healthcare operations. 70

80 Emergency Services We provide a 24-hour-a-day, 7-day-a-week Nurse HelpLine service with clinical staff to provide triage advice and referral. We do not discourage members from using the 911 emergency system or deny access to emergency services. Emergency services do not require pre-authorization. Emergency services coverage includes services that are needed to evaluate or stabilize an emergency medical condition. Criteria used to define an emergency medical condition are consistent with the prudent layperson standard and comply with all applicable federal and state requirements. An emergency medical condition is defined as a physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) 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 the following: (1) 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; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. Emergency response is coordinated with community services, including the police, fire and Emergency Medical Services (EMS) departments, juvenile probation, the judicial system, child protective services, chemical dependency, emergency services and local mental health authorities, if applicable. When a member seeks emergency services at a hospital, the determination as to whether the need for those services exists will be made for purposes of treatment by a physician licensed to practice medicine or to the extent permitted by applicable law, by other appropriately licensed personnel under the supervision of, or in collaboration with a physician licensed to practice medicine. The physician or other appropriate personnel will indicate in the member s chart the results of the emergency medical screening examination. We ll compensate the provider for the screening, evaluations and examination of our members that are reasonable and calculated to assist the healthcare provider to determine whether or not the patient s condition is an emergency medical condition. If there is concern surrounding the transfer of a patient (i.e., whether the patient is stable enough for discharge or transfer or whether the medical benefits of an unstable transfer outweigh the risks), the judgment of the attending physician actually caring for the member at the treating facility prevails and is binding. If the emergency department is unable to stabilize and release the member, we ll help in coordination of the inpatient admission regardless of whether the hospital is network or non-network. All transfers from non-network to network facilities are to be conducted only after the member is medically stable and the admitting facility is capable of rendering the required level of care. If the member is admitted, an INTotal Health concurrent review nurse will implement the concurrent review process to ensure coordination of care. 71

81 Urgent Care We encourage our members to contact their PCP in situations when urgent, unscheduled care is necessary. Preauthorization is not required for a member to access a participating urgent care center. Utilization review timeline standards: Service request Definition Timeline to review for decision Pre-service - urgent Prior to service being provided. Urgent Care 3 business days is any care that without could seriously jeopardize the life and health of the member or the member s ability to regain maximum function, based on a prudent layperson s judgment or it is the opinion of the practitioner with knowledge of member s medical condition, would subject the member to severe pain that cannot be adequately managed without intervention. Pre-service - non-urgent Service that must be approved whole or in 14 calendar days part, in advance of the member obtaining medical services. Concurrent urgent An extension of previously approved services ongoing treatment usually associated with inpatient care or ongoing ambulatory care. 1 calendar day Extensions of up to 14 calendar days to the standard time frames may be appropriate and can be used: o For pre-service urgent care, if the member requests an extension or the INTotal Health justifies to DMAS a need for additional information and how the extension is in the member s interest. o For pre-service non-urgent care, if the member or the provider requests extension; or INTotal Health justifies to DMAS upon request that the need for additional information and how the extension is in the member s interest. 72

82 9 COMPLAINT, GRIEVANCE, AND APPEAL PROCEDURES INTotal Health is committed to ensuring quality care and services for our providers and members. We recognize that you strive to provide high-quality care to all of your patients, and we appreciate your partnership with us. We understand the important relationships you have with your patients and know that a member may designate you to exercise rights on their behalf as a designated representative. All INTotal Health providers and members have a right to: Voice complaints or grievances about INTotal Health, the care provided, and those providing care File an appeal regarding any adverse action made by INTotal Health, including service coverage determination, as well as administrative denials File an appeal as a member, or as a provider acting on behalf of a member, with DMAS after an adverse action resulting from a final determination (final level of INTotal Health review) related to a medical necessity or service coverage determination File an appeal with DMAS as a provider after exhausting all INTotal Health payment appeal levels as a result of a final determination Complaints Any participating provider or member may voice a complaint by calling INTotal Health Member or Provider Services at , Monday through Friday, from 8 a.m. to 6 p.m. We will address all complaints we receive and work to promptly resolve the issue. Member Appeals and Grievances Definitions: Adverse Action refers to the: Denial or limited authorization of a requested service, including the type or level of service Reduction, suspension, or termination of a previously authorized service Denial, in whole or in part, of payment for a covered service for a member (except where the provider s claim is denied for administrative reasons including but not limited to service preauthorization rules, timely filing, invalid billing codes, etc.) Failure to render a decision in the required timeframes Denial of a member s request to exercise the right to obtain services outside the network under the federal regulations Designated Personal Representative a person authorized in writing or allowed by law to act on a member s behalf regarding a specific grievance, grievance decision review, appeal, or external review. The member may select a family member, caregiver, provider or other person or agency designated to act on behalf of the member, including the state s Medicaid managed care division or the Managed Care Ombudsman. Member Appeal (INTotal Health) an oral or written request, made by a member or designated personal representative, for INTotal Health to review any adverse action/determination. Member appeals exclude Provider appeals for denied or reduced reimbursement for administrative reasons. Member External Appeal (State Fair Hearing/FAMIS External Review Organization) a request for an external review agency to review INTotal Health s final member appeal adverse decision. 73

83 Expedited Appeal an oral or written request for an expedited review of an adverse action/determination when a member s life, health, or ability to attain, maintain, or regain maximum function will be at risk if we follow our standard time frames for reviewing the member s request. Member Grievance an unresolved dissatisfaction, expressed verbally or in writing, with our operations or a provider s operations (with the exception of a request for review of an adverse action, which is addressed by Member Appeals). Member Appeal Process A member, or a designated representative, may appeal an INTotal Health adverse action or denial within 30 calendar days from the date of the notice of adverse action. If we do not receive the appeal request within 30 calendar days, we will consider the adverse action final. When we receive a member appeal, we ll notify the party filing the appeal in writing that we ve received the member appeal request and all information that is required to evaluate the member appeal within 5 business days. The member or designated representative will also be notified of the right to present evidence and allegations of fact or law in person, as well as in writing. The medical appeal process also affords the member or designated representative the opportunity before and during the appeal review process to examine the member s case file, including medical records and any other documentation considered during the appeal review process. If the member appeal is initiated via the telephone or in person, INTotal Health will send the member a onepage Appeal Form. The member must complete the form, sign it and return it to us along with a copy of the notice of adverse action within 10 calendar days in order for us to complete our review of their request for a medical appeal. If we do not have enough information to make a decision about the internal appeal, we will ask the member or the designated representative for it. If we do not receive the completed, signed appeal form or if we do not get the additional requested information, we may deny the member appeal. Please note: We will not take action on a member s appeal from someone other than the member unless the member signs a Designated Personal Representative Form selecting an authorized representative. For expedited appeals, or when a member is in the hospital, we will allow the appeal process to proceed without the Designated Personal Representative Form. However, we may ask that members complete a Designated Personal Representative Form as documentation that the member had, in fact, authorized a representative to file the expedited appeal on the member s behalf. Appeals that occur while a member is an inpatient are processed as expedited and do not require a designated representative form to be completed for the appeal process to proceed. A clinical peer will be designated to review each medical appeal. Each appeal, due to the nature of the medical or clinical matters, will be reviewed by an appropriate healthcare professional that is in the same or similar specialty as the health care provider who typically manages the medical condition, procedures or treatment under review. The clinical peer will not have had any involvement or be a subordinate of anyone involved in the initial action that is the subject of the medical appeal. The total time of acknowledgement, investigation and resolution of the appeal will be made no more than 30 calendar days from receipt of appeal. We ll notify the party filing the appeal, the member, and any other healthcare provider who recommended the healthcare service involved in the medical appeal review of its decision via a written notice of determination. 74

84 The written determination letter will provide the following information: The date and decision reached along with a clear and detailed reason for the determination The medical or clinical criteria for the determination, which is based on sound clinical evidence and is reviewed on a periodic basis Notification that the member can obtain a copy upon request of the actual benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based Notice that the member is entitled to receive upon request reasonable access to and copies of all documents relevant to the member s appeal A list of titles and qualifications including specialties of individuals participating in the appeal review In the case of an upheld action, the member rights to request a State Fair Hearing (Medicaid members) or External Review Organization (FAMIS) within 30 calendar days of the receipt of the letter and how to do so The right to continue to receive benefits pending the outcome of the state fair hearing and how to do so Information explaining that the member may be liable for the cost of any continued benefits if the adverse determination is upheld in a state fair hearing Expedited Appeal A member can request an expedited appeal in cases where time expended in a standard resolution could jeopardize the member s life or health or ability to attain, maintain or regain maximum function. An expedited medical appeal concerns one of our decisions or actions that relate to: Healthcare services including, but not limited to, procedures or treatments for a member with an ongoing course of treatments ordered by a healthcare provider, the denial of which in the provider s opinion could significantly increase the risk to a member s health or life A treatment referral, services, procedure or other healthcare service, the denial of which could significantly increase the risk to a member s health or life The member, or a designated representative, can request an expedited appeal orally or in writing. We ll notify the party filing the expedited appeal and the member, member s PCP and any healthcare provider who recommended the healthcare services involved in the expedited appeal of the decision orally within 3 business days of receipt of the appeal for Medicaid members and within 3 business days for FAMIS members. Following the oral notice, a written notice of the determination will occur within two calendar days. The written determination letter will provide the following information: The date and decision reached along with a clear and detailed reason for the determination A reference to the medical or clinical criteria for the determination, which is based on sound clinical evidence and is reviewed on a periodic basis Notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, upon request A list of titles and qualifications, including specialties of individuals participating in the appeal review In the case of an upheld action, additional appeal rights The right to continue to receive benefits pending the outcome of the appeal The way to request the continuation of benefits Information explaining that the member may be liable for the cost of any continued benefits if the adverse determination is upheld 75

85 FAMIS External Review FAMIS members have the option to request an external review after the INTotal Health internal appeal process has been exhausted. We ll notify the member or responsible party in writing that a final adverse decision has been rendered and that the member or responsible party may submit a request to DMAS within 30 calendar days of receipt of our final decision and the accompanying notice regarding the member s right to request an external review. If not initiated within 30 days, the member waives his or her right to an external review. Send requests to: FAMIS External Review Request c/o KePro 2810 N. Parham Road Suite #305 Henrico, VA Phone number: or via the KePro website at: The decision by the independent reviewer is final and binding. If the external independent reviewer determines the coverage of healthcare service to be medically appropriate, we ll pay the allowable reimbursement for the healthcare service. State Fair Hearing Medicaid members have the right to request a fair hearing from DMAS to review an adverse decision. The member, or the member s provider on behalf of the member, may request a fair hearing at the same time that the member appeals or after he or she has exhausted his or her appeal rights with us or instead of appealing to us. The member has a right to representation at a State Fair Hearing. To request a fair hearing, the member or the member s representative can submit a written request within 30 calendar days of the member s receipt of notice of any action to deny, delay, terminate, or reduce a service authorization to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA Phone: Fax: A member may have longer than 30 days to request a fair hearing in the following situations: The member was seriously ill and was prevented from contacting us The member did not receive notice of our decision The member sent the request for appeal to another government agency in good faith within the time limit Unusual or unavoidable circumstances prevented the filing If a member or his or her designee requests a fair hearing, we ll promptly provide an appeal summary describing the basis of denial to DMAS. The fair hearing decision is final and binding. If the decision deems coverage of the healthcare service to be medically appropriate, we ll pay the allowable reimbursement for the healthcare service. 76

86 Continuation of Benefits Our members may request a continuation of their benefits during the medical appeal process by contacting Member Services at To ensure continuation of currently authorized services, the member or person acting on behalf of the member must file a medical appeal on or before the latter of 10 calendar days following our mailing the notice of action or the intended effective date of the action. We will continue the member s coverage of benefits if the following conditions are met: The member or the provider files the appeal in a timely manner (as defined above) The appeal involves the termination, suspension or reduction of a previously authorized course of treatment The services were ordered by an authorized provider The original period covered by the initial authorization has not expired The member requests extension of benefits If, at the member s request, we continue or reinstate the member s benefits while the appeal is pending, the benefits will continue until one of the following occurs: The member withdraws the medical appeal or request for the State Fair hearing Ten calendar days pass after we mail the medical appeal determination letter unless the member has, within the 10 calendar days, requested a state fair hearing with continuation of benefits until a state fair hearing decision is reached The time period or service limit of a previously authorized service has been met The member may be responsible for payment for the continued benefits, if the final determination of the medical appeal is not in the member s favor. If the final determination of the medical appeal is in the member s favor, we will authorize coverage and arrange for disputed services promptly and as expeditiously as the member s health condition requires. If the final determination is in the member s favor and the member received the disputed services, we will pay the allowable reimbursement for those services. Submit a member appeal to: INTotal Health Appeals Unit 3190 Fairview Park Drive, Suite 900 Falls Church, VA Member Grievances Any member, or a designated representative acting on behalf of a member, has a right to file a grievance as a result of an unresolved dissatisfaction with our operations or a provider s operations that is not related to an adverse action or denial. You cannot file a grievance on behalf of a member unless the member has granted written permission for you to act as his or her designated representative. We will acknowledge all grievances within five business days of receipt, and we will address the grievance in writing within 30 calendar days of receipt. We will attempt to resolve all member grievances to the member s satisfaction. Member grievances will be resolved consistent with Plan policies, covered benefits and member rights and responsibilities. We fully investigate each grievance, including any clinical aspects of the grievance and document the substance of the grievance. The total time for acknowledgement, investigation and resolution of the grievance will be within 30 calendar days from the date we received the grievance from the member or designated representative. 77

87 If delays are outside of the health plan s control (e.g., the result of a third party s failure to provide documentation in a timely manner or waiting response from the complainant for additional information), we may extend the time for resolution an additional 14 calendar days. We will notify the member in writing of the cause for the extension before the 30th day for Medicaid members and by the 14th day for FAMIS members and issue a written decision regarding the grievance within an additional 14 calendar days. The member will be notified in writing of our resolution containing the following information: The decision we reached The reason and policies or procedures or other criteria that are the basis for our decision The right to further remedies allowed by law The address and telephone number through which a member may contact a quality management representative to obtain more information about the decision or the right to an appeal Tracking and Reporting Grievances will be tracked and trended by our Quality Management department. Grievance records will include, but information is not limited to: Date grievance filed Date and outcome of all actions and findings Date and decision of any appeal proceeding Date and proceedings of any litigation All letters and documentation submitted regarding the grievance The Quality Management department will maintain grievance records and keep them readily available for state inspection. Grievances (for reasons other than medical necessity or payment appeals) should be submitted to: INTotal Health Member Grievances 3190 Fairview Park Drive, Suite 900 Falls Church, VA

88 Provider Grievances and Payment Appeals Provider Grievances As a provider, you may file a grievance if you are dissatisfied with any unresolved interaction in the process of doing business with us. We will address the grievance in writing within 30 calendar days of receipt. Provider grievances will be resolved promptly, fairly and consistently with our policies and covered benefits. You are not penalized for filing grievances. Any supporting documentation should accompany the grievance. File grievances in writing to: INTotal Health Provider Grievances 3190 Fairview Park Drive, Suite 900 Falls Church, VA Provider Payment Appeals Providers may file a payment appeal if they are dissatisfied with INTotal Health regarding a claims payment. Reasons for the claims payment appeal may include, but are not limited to: Denials for timely filing Contractual terms Failure to request pre-authorization when required before rendering service Lost or incomplete claim forms or electronic submissions Requests for additional information as to services or treatment rendered by a provider Reimbursement amount No action is required by the member. Provider payment appeals do not include member appeals due to an adverse action. You will not be penalized for filing a provider payment appeal. The INTotal Health Appeals Department will review and coordinate all payment appeals. To submit a payment appeal, please complete the Provider Payment Appeal Submission form located in Appendix A Forms or online at and submit to: INTotal Health Attn: Payment Appeals P.O. Box Birmingham, AL As a contracted network provider, you must file a payment appeal so it is received by us within 90 calendar days of the date of the Explanation of Payment (EOP). Submit a written request with an explanation of what is in question and why, including supporting documentation such as an EOP, or a copy of the claim, medical records or contract page. A Level I determination will be sent to you within 30 calendar days from receipt of the payment appeal. If the decision is to adjust the claim to allow full reimbursement, we ll mail you an adjusted EOP. If the decision is to partially adjust the claim or uphold the previous decision, we ll mail you a payment appeal determination letter. The determination letter will include the following information: Provider name Member name, ID number and date of birth 79

89 Date of service Claim number Date of initial filing of concern Written description of the concern Decision Further appeal options If you re dissatisfied with the Level I payment appeal resolution, you may file a Level II appeal. This must be a written payment appeal submitted and received by us within 30 calendar days of the date of the Level I determination notice. Providers also have the right to appeal adverse decisions to DMAS once the provider has exhausted our internal appeal process. If you disagree with our final determination, you may appeal this decision to DMAS in writing within 30 days of the date of our final determination letter. To request an appeal, submit your written request to: Appeals Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA Upon receipt of notification of a dispute by DMAS, we will prepare and submit appeal summaries to DMAS Appeals Division, the DMAS Contract Monitor and the provider involved in the payment appeal. We will attend all appeal hearings or conferences, whether informal or formal, in person or by telephone, as deemed necessary by the DMAS Appeals Division. 80

90 10 QUALITY MANAGEMENT Quality Management Program Overview We maintain a comprehensive Quality Management (QM) program to objectively monitor and systematically evaluate the care and service provided to members. The scope and content of the program reflects the demographic and epidemiological needs of the population served. Members and providers have opportunities to make recommendations for areas of improvement. The QM program goals and outcomes are available, upon request, to providers and members. Studies are planned across the continuum of care and service, with ongoing proactive evaluation and refinement of the program. The initial program development was based on a review of the needs of the population served. Systematic reevaluation of the needs of the health plan s specific population occurs at least annually. This includes not only age and sex distribution, but also a review of utilization data inpatient, emergent, urgent care and office visits by type, cost and volume. This information is used to define areas that are high-volume or that are problem-prone. Healthcare Effectiveness Data and Information Set (HEDIS) performance is evaluated annually and compared against national benchmarks. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is evaluated for member satisfaction and experience annually. Performance is analyzed for barriers and best practices and interventions are developed to improve performance. There is a comprehensive committee structure in place with oversight from the INTotal Health governing body. These committees include the Medical Advisory Committee (MAC) and Credentialing Committee that have participation from network physicians and practitioners Quality of Care All physicians, nurse practitioners and physician assistants are evaluated for compliance with pre-established standards as described in our credentialing program. Review standards are based on medical community standards, external regulatory and accrediting agencies requirements, and contractual compliance. Reviews are conducted by QM coordinators and associate professionals who strive to develop relationships with providers and hospitals that will positively impact the quality of care and services provided to our members. Results are submitted to our QM department and incorporated into a profile. Our quality program includes review of quality of care issues identified for all care settings. QM staff use member grievances, reported adverse events and other information to evaluate the quality of service and care provided to our members. In accordance with DMAS guidance, we adhere to the Provider Preventable Condition guidelines found in the Federal Register, available online at Quality Management Committee The purpose of the Quality Management Committee (QMC) is to maintain quality as a cornerstone of our culture and to be an instrument of change through demonstrable improvement in care and service. 81

91 The QMC s responsibilities are to: Establish strategic direction and monitor and support implementation of the QM program Establish processes and structure that ensure NCQA compliance Review planning, implementation, measurement and outcomes of clinical, service quality improvement studies Coordinate communication of QM activities throughout the health plans Review HEDIS data and action plans for improvement Review and approve the annual QM program description Review and approve the annual work plans for each service delivery area Provide oversight and review of delegated services Provide oversight and review of subordinate committees Receive and review reports of utilization review decisions and take action when appropriate Analyze member and provider satisfaction survey responses Monitor the health plan s operational indicators. Medical Advisory Committee The Medical Advisory Committee (MAC) has multiple purposes. It assesses levels and quality of care provided to members and recommends, evaluates, and monitors standards of care. The MAC identifies opportunities to improve services and clinical performance by establishing, reviewing and updating clinical practice guidelines based on review of demographics and epidemiologic information to target high-volume, high-risk and problem-prone conditions. The committee oversees the peer review process that provides a systematic approach for the monitoring of quality and the appropriateness of care. The MAC conducts a systematic process for network maintenance through the credentialing and recredentialing process. The MAC advises the health plan administration in every aspect of the health plan policies and operations affecting network providers or members. The MAC provides oversight of the peer review, QM and utilization review programs. In addition to this oversight, the committee also oversees and makes recommendations regarding health promotion activities. The MAC responsibilities are to: Oversee and monitor the quality and cost-effectiveness of medical care provided to INTotal Health members. Oversee the clinical compliance with local, state and federal requirements, as well as Accreditation Bodies (e.g., NCQA). Review and make recommendations for corrective action based upon sub-committee reports including: o Credentialing Committee (CC) o Utilization Management Committee (UMC) o Pharmacy and Therapeutics Committee (P&T) Review and approve all clinical practice policies and procedures. Make recommendations for health plan policy and protocol changes based on guidelines and standards of practice. Review and approve Clinical Practice and Preventive Health Guidelines. Advise and assist the Chief Medical Officer (CMO) as needed. Review issues from departments as appropriate, including but not limited to: o Quality Management o Clinical Services o Provider Relations o Operations o Appeals/Grievances 82

92 Credentialing Our credentialing policies and procedures incorporate the current NCQA standards and guidelines for the accreditation of MCOs, as well as DMAS and Federal requirements for the credentialing and recredentialing of licensed independent providers and organizational providers with whom the MCO contracts. Each contracted provider agrees to submit for verification all requested information necessary to credential or recredential in accordance with the standards we ve established. Each provider will cooperate with us as necessary to conduct credentialing and recredentialing pursuant to our policies, procedures and rules. Credentialing Requirements Each provider, facility and/or and hospital will remain in full compliance with our credentialing criteria as set forth in our credentialing policies and procedures as well as all applicable laws and regulations. The provider, facility or hospital will complete the Council for Affordable Quality Healthcare (CAQH) or INTotal Health application form when seeking credentialing. It is important that providers update their CAQH application as necessary and keep the attestation current. You must notify us of any changes to information that could affect your credentialing status. This includes, without limitation, any actions taken against your professional license such as revocation, suspension, or terms imposed. Providers will comply with other such credentialing criteria as may be established by INTotal Health. Credentialing Procedures We re committed to operating an effective, high-quality credentialing program. We credential the following provider types: medical doctors, doctors of osteopathy, doctors of dental surgery, doctors of podiatric medicine, doctors of chiropractic, physician assistants, optometrists, nurse practitioners, certified nurse midwives, licensed professional counselors and social workers, psychologists, physical and occupational therapists, speech and language therapists and other applicable or appropriate midlevel providers as well as hospitals and allied service (ancillary) providers. During recredentialing, you must show evidence of satisfying recredentialing requirements and must have satisfactory results relative to our measures of quality of health care and service. We have established a Credentialing Committee and a Medical Advisory Committee (MAC) for the formal determination of recommendations regarding credentialing decisions. The Credentialing Committee, under the guidance of the Chief Medical Officer or physician designee, will make decisions regarding participation of initial applicants and their continued participation at the time of recredentialing. This oversight rests with the MAC and with INTotal Health Executive Leadership. Our credentialing policies are revised periodically based on input from several sources including, but not limited to, the Credentialing Committee, the health plan Chief Medical Officer, Network Management, state, NCQA and federal requirements. These policies will be reviewed and approved as needed, but at a minimum biennially. Your application contains your actual signature that serves as an attestation of the credentials summarized on and included with the application. Your signature also serves as a release of information to verify credentials externally. INTotal Health or its designee is responsible for externally verifying information attested to on the application. Any discrepancies between information included with the application and information obtained during the external verification process will be investigated and documented and may be grounds for refusal of acceptance into the network or termination of an existing provider relationship. The signed participating provider agreement documents compliance with the established managed care policies and procedures. 83

93 You have the right to inquire about the status of your application. You may do so by the following methods: (1) telephone, (2) facsimile, (3) contact through your Provider Relations representative or (4) in writing. As an applicant for participation with us, you have the right to review information obtained from primary verification sources during the credentialing process. Upon notification from us, you have the right to explain information obtained that may vary substantially from that provided during the submission and to provide corrections to any erroneous information submitted by another party. You must submit a written explanation or appear before the credentialing committee if deemed necessary. Currently, the following verifications are completed as applicable prior to final submission of a practitioner file to the health plan Chief Medical Officer, physician designee or Credentialing Committee. To the extent allowed under applicable law or state agency requirements per NCQA standards and guidelines, the Chief Medical Officer or physician designee has authority to approve clean files without input from the credentialing committee. All files not designated as a clean file will be presented to the Credentialing Committee for review and decision regarding participation. In addition to the submission of an application and the execution of a participating provider agreement, the following must be reviewed and approved by the Credentialing Committee, the Chief Medical Officer or physician designee. 1. Board Certification: MDs and DOs must have completed post-graduate education recognized by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA), or the Federation of the Royal College of Physicians and Surgeons of the UK (RCPSG), or the College of Family Physicians of Canada (CFPC), or the Royal College of Physicians and Surgeons of Canada (RCPSC). Equivalent experience shall be considered for those General Practice providers graduating from medical school before Foreign Medical School Graduates must also be certified by the Educational Commission for Foreign Medical School Graduates (ECFMG); Board certification is not a requirement as a qualification of network participation but it is preferred. 2. Verification of Education and Training: Verification by referencing board certification, educational institutions or the appropriate state-licensing agency. 3. Verification of Work History: The practitioner must submit a curriculum vitae documenting work history for the past five years. Any gaps in work history greater than six months must be explained in written format and brought to the attention of the Chief Medical Officer, physician designee or Credentialing Committee as applicable. 4. Hospital Affiliations and Privileges: MD s and DO s must hold and maintain unrestricted clinical privileges at an INTotal Health participating hospital within their specialty. Exceptions to this policy may be granted pursuant to INTotal Health s credentialing policies and procedures. 5. State Licensure or Certification: Verification of state license information to ensure that the practitioner maintains a current legal medical license or certification to practice in the State. This information can be verified by referencing data provided to INTotal Health by the state via roster, telephone or the Internet. 6. DEA Number: Verification of the Drug Enforcement Administration (DEA) number to ensure that the practitioner is currently eligible to prescribe controlled substances. This information is verified by obtaining a copy of the DEA certificate or by referencing the National Technical Information Service 84

94 (NTIS) data. The same policy applies to (Controlled Dangerous Substances) CDS certificate, if applicable. 7. Professional Liability Coverage: The practitioner s malpractice insurance information is verified by obtaining a copy of the professional liability certificate of insurance from the practitioner or from the malpractice insurance carrier. Practitioners are required to maintain professional liability insurance in specified amounts. 8. Professional Liability Claims History: Verification of an applicant s history of professional liability claims, if any, reviewed by the Health Plan Credentialing Committee to determine whether acceptable risk exposure exists. The review is based on information provided and attested to by the applicant and information available from the National Practitioner s Data Bank (NPDB). The Credentialing Committee s policy is designed to give careful consideration to the medical facts of the specific cases, total number and frequency of claims in the past ten years and the amounts of settlements and/or judgments. 9. CMS Sanctions: Verification that the practitioner s record is clear of any sanctions by Medicare/Medicaid. This information is verified by accessing the OIG and SAM websites. 10. Disclosure of Ownership and Controlling Interest Statement Verification that the provider, the group practice, or anyone with 5% or greater ownership or a control interest in the practice is clear of any sanctions by Medicare/Medicaid. This information is verified by accessing the OIG and SAM. 11. Disclosures Attestation and Release of Information: The CAQH/ INTotal Health provider application will require responses to the following: Reasons for the inability to perform the essential functions of the position with or without accommodation Any history or current problems with chemical dependency, alcohol or substance abuse History of license revocations, suspension, voluntary relinquishment, probationary status or other licensure conditions or limitations History of conviction of any criminal offense other than minor traffic violations History of loss or limitation of privileges or disciplinary activity, including denial, suspension, limitation, termination or nonrenewal of professional privileges History of grievances or adverse action reports filed with a local, state or national professional society or licensing board History of refusal or cancellation of professional liability insurance History of suspension or revocation of a DEA or CDS certificate History of any Medicare/Medicaid sanctions Current signed attestation by the applicant confirming the correctness and completeness of the application Any issue identified must be explained in writing. These explanations are presented with the provider s application to the credentialing committee. 12. The NPDB is queried against applicants and INTotal Health contracted providers. The NPDB will provide a report for every practitioner queried. These reports are shared with the Chief Medical Officer, physician designee or the Credentialing Committee for review and action as appropriate. The appropriate state-licensing agency is queried for all providers. All sanctions are investigated and documented, including the health plan s decision to accept or deny the applicant s participation in the network. INTotal Health reports information to the NPDB as required. 85

95 You will be notified by telephone or in writing if any information obtained in support of the assessment or reassessment process varies substantially from the information you ve submitted. You have the right to review the information submitted in support of the credentialing process and to correct any errors in the documentation. The decision to approve or deny initial participation will be communicated in writing within 60 days of the Credentialing Committee s decision. In the event your participation is denied, you will be notified by mail and allowed 30 days to appeal the decision. Recredentialing All providers will be recredentialed every 36 months. A review of any applicable changes to the information submitted with the initial application during that period will be completed. This includes, but is not limited to, licensure/certification status and actions, valid DEA, general and professional liability insurance information. This information, along with any quality improvement activities or member grievances is presented for the Chief Medical Officer, physician designee or Credentialing Committee review. In the event your continued participation is denied, you will be notified by mail, and you will be allowed 30 days to appeal the decision. Credentialing Organizational Providers The application contains an actual signature that serves as an attestation that the healthcare facility agrees to the assessment requirements. Examples of organizational providers requiring assessments are as follows: hospitals, urgent care centers, home health agencies, DME, skilled nursing facilities, nursing homes, imaging centers, ambulatory surgical centers and behavioral health facilities providing mental health or substance abuse services in an inpatient, residential or ambulatory setting. Your signature also serves as a release of information to verify credentials externally. Currently, the following steps are completed in addition to the application and network provider agreement before approval for participation of a hospital or organizational provider is considered: State licensure is verified by obtaining a current copy of the state license from the organization or by contacting the state-licensing agency. Primary source verification is not required. Any restrictions to a license are investigated and documented, including the decision to accept or deny the organization s participation in the network. We contract with facilities that meet the requirements of an applicable, unbiased and recognized authority. Hospitals (e.g., acute, transitional or rehabilitation) should be accredited by The Joint Commission (TJC) or Healthcare Facilities Accreditation Program (HFAP). The Commission on Accreditation of Rehabilitation Facilities (CARF) may accredit rehabilitation facilities. Home health agencies should be accredited by TJC or the Community Health Accreditation Program (CHAP). Nursing homes should be accredited by The Joint Commission. TJC or the Accreditation Association for Ambulatory Healthcare (AAAHC) should accredit ambulatory surgical centers. If facilities, ancillaries or hospitals are not accredited, we will accept a copy of a recent state or CMS review in lieu of performing an onsite review. If accreditation or a copy of a recent review is unavailable, an onsite review will be performed by the Health Plan. A copy of the certification of insurance is required. Organizational providers are required to maintain general and professional liability insurance in the amounts specified in the provider contract and according to our policy. We will track a facility s or ancillary s reassessment date and reassess every 36 months as applicable. Requirements for recredentialing of organizational providers are the same as they are for the initial assessment. 86

96 Your organization will be notified either by telephone or in writing if any information obtained in support of the assessment or reassessment process varies substantially from the information your organization has submitted. Your organization has the right to review the information submitted in support of the assessment process and to correct any errors in the documentation. This will be accomplished by submission of a written explanation or by appearance before the Credentialing Committee if so requested. The decision to terminate your organization s participation as a credentialed provider or practitioner will be communicated in writing via certified mail. Delegated Credentialing In some instances, we will delegate the credentialing functions to a qualified provider organization. We will ensure the quality of its credentialing program through direct verification. If your provider group is believed to have a strong credentialing program, we may evaluate a delegation of credentialing and recredentialing. To do this, your provider group must have a minimum of 150 participating providers. The Credentialing Department will review the written credentialing policies of your group for adequacy. Any steps will be identified where your group s credentialing policies do not meet our standards. We will perform or arrange for your group to perform our credentialing steps not addressed by your group. We will perform a pre-delegation audit of your group s credentialing practices. A passing score is considered to be an overall average of 90 percent compliance. Your group is expected to submit an acceptable corrective action plan within 30 days of receipt of the audit results. If there are serious deficiencies, we may deny the delegation or restrict the level of delegation. At our discretion, we may waive the need for the pre-delegation on-site audit if the delegated entity s credentialing program is NCQA accredited or certified to include all credentialing and recredentialing elements. We are responsible for oversight of any delegated credentialing arrangement and schedule appropriate reviews. The reviews are held at least annually. Peer Review The peer review process provides a systematic approach for monitoring the quality and appropriateness of care. Peer review responsibilities are: To participate in the implementation of the established peer review system To review and make recommendations regarding individual provider peer review cases To work in accordance with the Chief Medical Officer If an investigation of a member grievance results in concern regarding a physician s compliance with community standards of care or service, elements of peer review will be followed as appropriate. Dissatisfaction severity codes and levels of severity are applied to quality issues. The Chief Medical Officer assigns a level of severity to the grievance. Peer review includes investigation of physician actions by or at the discretion of the Chief Medical Officer. The Chief Medical Officer takes action based on the quality issue and the level of severity, invites the cooperation of the physician, and then consults and informs the MAC and the peer review committee. The Chief Medical Officer informs the physician of the committee s decision, recommendations, follow-up actions and/or disciplinary actions to be taken. Outcomes are reported to the appropriate internal and external entities which include the quality management committee. The peer review process is an important component of the MAC s monthly agenda. The peer review policy is available upon request. 87

97 11 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES Electronic Submission We encourage the submission of claims electronically through Electronic Data Interchange (EDI). Submit claims within 180 days from the date of discharge for inpatient services or from the date of service for outpatient services or according to the terms outlined in your contract. Electronic claims submission is available through: Change Healthcare (formerly Emdeon) Claim Payer ID Emdeon One (formerly Capario) Claim Payer ID Gateway (TriZetto) Claim Payer ID INT01 Availity The advantages of electronic claims submission are: Facilitates timely claims adjudication Acknowledges receipt and rejection notification of claims electronically Improves claims tracking Improves claims status reporting Reduces adjudication turnaround Eliminates paper Improves cost-effectiveness Allows for automatic adjudication of claims The guide for EDI claims submission is located at. The EDI claim submission guide includes additional information related to the EDI claim process. To initiate the electronic claims submission process or obtain additional information, please contact our Clearinghouse for further information: Change Healthcare (formerly Emdeon) Gateway (TriZetto) Emdeon One (formerly Capario) Availity Paper Claims Submission You also have the option of submitting paper claims. We use Optical Character Recognition (OCR) technology as part of our front-end claims processing procedures. The benefits include the following: Faster turnaround times and adjudication Claims status availability within five days of receipt Immediate image retrieval by our staff for claims information, allowing more timely and accurate response to your inquiries 88

98 To use OCR technology, claims must be submitted on original red claim forms, (not black and white or photocopied forms) laser printed or typed (not handwritten) in a large, dark font. Submit a properly completed CMS-1450 (UB-04) or CMS-1500 (02-12) within 180 days or the terms outlined in your agreement from the date of discharge for inpatient services or from the date of service for outpatient services, except in cases of Coordination of Benefits (COB)/subrogation or in cases where a member has retroactive eligibility. For cases of COB/subrogation, the time frames for filing a claim will begin on the date that the third party documents resolution of the claim. In accordance with the implementation timelines set by CMS and the National Uniform Claim Committee (NUCC), we require the use of the current CMS-1500 (02-12) for the purposes of accommodating the National Provider Identifier (NPI). In accordance with the implementation timelines set by CMS and the National Uniform Billing Committee (NUBC), we require the use of the current CMS-1450 (UB-04) for the purposes of accommodating the NPI. CMS-1500 (02-12) and CMS-1450 (UB-04) must include the following information (HIPAA compliant where applicable): Patient s ID number Patient s name Patient s date of birth International Classification of Diseases (ICD-10) diagnosis code/revenue codes Date of service Place of service Procedures, services or supplies rendered, CPT-4 codes/hcpc codes/diagnosis Related Group (DRGs) with appropriate modifiers, if necessary Itemized charges Days or units Provider tax ID number and state Medicaid ID number Provider name according to contract NPI of rendering provider NPI of billing provider when applicable COB/other insurance information Authorization/pre-authorization number Name of referring physician Taxonomy code NPI of referring physician when applicable CLIA Certificate Number Any other state required data We cannot accept claims with alterations to billing information. Claims that have been altered will be returned to you with an explanation of the reason for the return. We will not accept entirely handwritten claims. 89

99 Submit paper claims within 180 days of the date of service or per the provider agreement of the date of service to the following address: INTotal Health Attn: Claims P.O. Box Birmingham, AL Encounter Data We have established and maintain a system to collect member encounter data. Due to reporting needs and requirements, network providers who are reimbursed by capitation must send us encounter data for each member encounter. Encounter data can be submitted through EDI submission methods or on a CMS-1500 (02-12) claim form unless we approve other arrangements. Data will be submitted in a timely manner, but no later than 180 days from the date of service. The encounter data will include the following: Member ID number Member name (first and last name) Member date of birth Provider name according to contract INTotal Health provider number COB information Date of encounter Diagnosis code(s) Types of services provided (using current procedure codes and modifiers if applicable) Provider tax ID number and state Medicaid ID number NPI and Taxonomy code Encounter data should be submitted to the following address: INTotal Health Attn: Claims P.O. Box Birmingham, AL Through claims and encounter data submissions, HEDIS information is collected. This includes but is not limited to the following: Preventive services (e.g., childhood immunization, mammography, Pap smears) Prenatal care (e.g., low birth weight, general first trimester care) Acute and chronic illness (e.g., ambulatory follow-up and hospitalization for major disorders) Compliance is monitored by our utilization and quality improvement staff, coordinated with the Chief Medical Officer and reported to the QM committee on a quarterly basis. PCPs are monitored for compliance with reporting of utilization. Lack of compliance will result in training and follow-up audits and could result in termination. 90

100 Claims Adjudication We are dedicated to providing timely adjudication of your claims for services rendered to members. All network and non-network provider claims submitted for adjudication are processed according to generally accepted claims coding and payment guidelines. The guidelines comply with industry standards as defined by the CPT-4, HCPCS, and ICD-10 manuals. Institutional claims should be submitted using EDI submission methods or a CMS-1450 (UB-04) and provider services using the CMS-1500 (02-12). You must use HIPAA-compliant billing codes when billing INTotal Health. This applies to both electronic and paper claims. When billing codes are updated, you re required to use appropriate replacement codes for submitted claims. We will not reimburse any claims submitted using noncompliant billing codes. We reserve the rights to use code-editing software to determine which services are considered part of, incidental to or inclusive of the primary procedure. We use a code auditing system to ensure consistent physician and facility reimbursement. The system automatically evaluates provider claims in accordance with CPT guidelines, accepted industry coding standards and corporate policies. This aligns with our fraud, waste and abuse program, which ensures correct coding and billing practices are followed. The system is updated periodically to conform to changes in coding standards and to include new procedures and diagnosis codes. For claims payment to be considered, adhere to the following time limits: Submit claims within 180* days from the date the service is rendered or for inpatient claims filed by a hospital within 180 days from the date of discharge In the case of other insurance, submit the claim within 180* days of receiving a response from the third-party payer Claims for members whose eligibility has not been added to the state s eligibility system must be received within 180* days from the date the eligibility is added and we are notified of the eligibility/enrollment Claims submitted after the 180*day filing deadline will be denied * Or per the terms outlined in your contract After filing a claim with us, review the Explanation of Payment (EOP). If the claim does not appear on an EOP within 30 business days as adjudicated or you have no other written indication that the claim has been received, check the status of your claim using our website at or telephonically on the Provider Services Line at If the claim is not on file, resubmit the claim within 180 days from the date of service. If filing electronically, check the confirmation reports that you receive from your EDI or practice management vendor for acceptance of the claim. As part of an audit or any other effort to assess proper payment, INTotal Health may use software, including but not limited to, RAT-STATS statistical software provided by the Office of the Inspector General of U.S. Department of Health and Human Services, to extrapolate claims to come up with payment amounts. In the event that improper payments are identified, INTotal Health reserves the right to use statistical sampling methods available through RAT-STATS or similar software to select random samples to extrapolate final claims amounts owed. 91

101 Clean Claims Payment A clean claim is a request for payment for a service rendered that: Is submitted in a timely manner Is accurate Is submitted on a HIPAA-compliant standard claim form including a CMS-1500 (02-12) or CMS-1450 (UB-04) or successor forms thereto or the electronic equivalent of such claim form Requires no further information, adjustment or alteration by you or by a third party in order for us to process and pay it Clean claims are adjudicated within 30 calendar days of receipt. If we do not adjudicate the clean claim within the time frames specified above, we will pay all applicable interest as required by law. We produce and mail EOPs on a weekly basis, which delineate for you the status of each claim that has been adjudicated during the previous week. Upon receipt of information we ve requested from you, we must complete processing of the clean claim within 30 calendar days. Paper claims that are determined to be unclean will be returned to the billing provider along with a letter stating the reason for the rejection. Electronic claims (EDI) determined to be unclean will be returned to the INTotal Health contracted clearinghouse that submitted the claim. Claims Status Use the INTotal Health online resources located at or call Provider Services at to check claims status. Provider Reimbursement Electronic Remittance Advice and Electronic Funds Transfer We offer Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) with online viewing capability. You can elect to receive INTotal Health payments electronically through direct-deposit to your bank account. In addition, you can select from a variety of remittance information options, including: ERA presented online and printed in your office HIPAA-compliant data file for download directly to your practice management or patient accounting system Paper remittance printed and mailed by us Some of the benefits for electronic participation are: Faster receipt of reimbursement from us The ability to generate custom reports on both payment and claim information based on the criteria specified Online capability to search claims and remittance details across multiple remittances Elimination of the need for manual entry of remittance information and user errors To register for ERA/EFT, please visit our website at. 92

102 Primary Care Provider Reimbursement We reimburse PCPs according to their contractual arrangement. Specialist Reimbursement Reimbursement to network specialty care providers and network providers not serving as PCPs is based on their contractual arrangement with us. Specialty care providers will obtain authorization prior to rendering or arranging any service that requires pre-authorization. Procedures requiring pre-authorization can be found at under Provider Resources. Specialty care provider services will be covered only when there is documentation of notification or preauthorization for those services requiring it and receipt of the required claims and encounter information. Procedure for Processing Overpayments Refund notifications may be identified by two entities, our Cost Containment Unit (CCU) or the provider. The CCU researches and notifies the provider of an overpayment requesting a refund check or the option to retract from future payments. The provider may also identify an overpayment and proactively submit a refund check to reconcile the overpayment amount. Once we ve identified an overpayment, the CCU will notify the provider of the overpayment by letter. If a provider identified the overpayment and returns the INTotal Health check, please include all supporting documentation specifying the reason for the return. Coordination of Benefits State-specific guidelines will be followed when COB procedures are necessary. We agree to use covered medical and hospital services whenever available or other public or private sources of reimbursement for services rendered to members in our plan. We and our providers agree that the Medicaid program will be the payer of last resort when third-party resources are available to cover the costs of medical services provided to Medicaid members. When we are aware of these resources prior to paying for a medical service, we will avoid payment by either rejecting your claim and redirecting you to bill the appropriate insurance carrier or, if we do not become aware of the resource until sometime after payment for the service was rendered, by pursuing post-payment recovery of the expenditure. You must not seek recovery in excess of the Medicaid payable amount. You re obligated to report these cases to us. We will avoid payment of claims where third-party resources are identified prior to payment. Paid claims are reviewed and researched post payment to determine likely cases with letters and phone calls being made to document the appropriate details. The filing of liens and settlement negotiations are handled internally and externally via a vendor. We will require members to cooperate in the identification of any and all other potential sources of payment for services. Any questions or inquiries regarding paid, denied or pended claims should be directed to Provider Services at

103 Billing Members You may not bill, or take recourse against, a member for denied or reduced claim payment for services that are within the contracted reimbursement amount, duration and scope of benefits of the Medicaid program. Providers are not allowed to balance bill a member as a result of: Failure to follow pre-authorization requirement Failure to submit a claim in a timely manner, including claims not received by us Submission of an incomplete or incorrect claim Failure to submit a corrected claim within the timely filing resubmission period Failure to appeal a medical necessity review decision within 30 days of a coverage denial notice Failure to appeal a claim payment with the 90-day administrative payment appeal period Errors made in claims preparation, claim submission, or the appeal process If you choose to provide a member with services that are not covered by INTotal Health or that have been denied as not medically necessary, you must tell the member before providing the service that the cost of non-covered services will be charged to them. Before providing a service that has been denied as not medically necessary or is not a covered benefit, you must obtain and keep a written acknowledgement as follows, signed by the member and by you, stating that the member: Requests the service, and Will be responsible for payment of non-covered services Client Acknowledgment Statement 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 INTotal Health as being reasonable and medically necessary for my care or are not a covered benefit. I understand that INTotal Health has established the medical necessity standards for 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 medically necessary standards for my care or are not a covered benefit. Member Signature: Provider Signature: Date: Date: 94

104 Our Website and Provider Services Line Our website provides a host of online resources at, featuring our online provider portal for real-time claim status and eligibility verification. Our toll-free Provider Services Line, , offers real-time member status, claim status and preauthorization status. This option also offers the ability to be transferred to the appropriate department for other needs, such as seeking advice in care management. 95

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106 AUTHORIZATION REQUEST Phone # , option 4 Fax # Urgent Pre-Authorization Requests are assigned a 72-hour timeline from date of request. Plan urgent criteria must be met with documentation to validate medical necessity for defined urgency. (Prior to service being rendered. Urgent Care any care that without could seriously jeopardize the life and health of the member or the member s ability to regain maximum function, based on a prudent layperson s judgment or it is the opinion of the practitioner with knowledge of member s medical condition, would subject the member to severe pain that cannot be adequately managed without intervention.) Non Urgent Pre-authorization Requests are assigned a 14-calendar day timeline from date request receipt. TODAY S DATE PROVIDER RETURN FAX # MEMBER INFORMATION (Please verify eligibility prior to rendering service) Name (Last name, First name) Date of Birth Address City, State Medicaid # Member Phone ZIP code Other insurance/workers comp REFERRING PROVIDER INFORMATION Name Medicaid Provider # Office contact name NPI/Tax I.D. Number (TIN) Phone Other phone Fax RENDERING PRACTITIONER (complete if applicable) Practitioner (Last name, First name, Provider specialty) NPI Phone Address/City/State/Zip RENDERING FACILITY (complete if applicable) Facility Name NPI Phone Address/City/State/Zip REQUESTED SERVICES Is the service a result of an ED visit? Yes No ICD-10 code/diagnosis/reason for referral CPT/HCPCS/RV Code(s) Number of visits/units requested PMH/previous studies/treatment Date of ED Visit: Tax I.D. Number (TIN) Fax Tax I.D. Number (TIN) Fax Date(s) of Service: Service location: Inpatient Outpatient Extended stay Home Office Other (please specify) Service type: Durable Medical Equipment Home Health Hospice Other (please specify) MATERNITY CARE For initial notification of pregnancy, please use the Maternity Notification form. For all other service related to pregnancy, please use this form (e.g., ultrasound, fetal non-stress test). **Note: Participating providers requesting authorization for advanced imaging services such as PET scans, MRI s and CAT scans must submit these requests through Medsolutions at phone or fax **PLEASE ATTACH CLINICAL INFORMATION TO SUPPORT MEDICAL NECESSITY. **This referral is valid only for services authorized by this form. Only completed referrals will be processed. If the consultant/provider recommends another service or surgery, additional authorization is required. Certification does not guarantee that benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions and exclusions. 97

107 Request PCP Change Form Member Information ID Number First Name Last Name Date of Birth Address City State Zip Telephone Number Previous PCP Name New PCP Name New PCP Address Effective Date: Name of person requesting the change Relationship to Member INTotal Health Attn: Member Services P.O. BOX BIRMINGHAM, AL Fax: