CHAPTER 1: INTRODUCTION... 9

Transcription

1 PROVIDER MANUAL 2017

2 Table of Contents CareMore Health Plan Table of Contents CHAPTER 1: INTRODUCTION... 9 Welcome to CareMore... 9 Using This Manual... 9 CareMore Service Area... 9 How to Access Information and Forms on the Provider Portal Website...10 Legal and Administrative Requirements...10 Disclaimer Third Party Websites Privacy and Security Statements Confidentiality and Disclosure of Medical Information...11 Collection of Personal and Clinical Information Maintenance of Confidential Information Member Authorization Member Access to Medical Records Disease Management Organizations Release of Confidential Information...13 Archived Files/Medical Records Misrouted Protected Health Information CHAPTER 2: IMPORTANT CONTACT INFORMATION CareMore Care Centers Contact Information, Services and Programs...17 CareMore Contact Information...18 CHAPTER 3: MEMBER BENEFITS CareMore Health Plan Overview...19 Outpatient Ancillary Services...19 Pharmacy Services...19 Overview Formulary Requests for Formulary Changes Notification of FDA Recalls Page 2

3 Table of Contents CareMore Health Plan Preferred Diabetic Supplies Vision Services...22 CHAPTER 4: MEMBER SERVICES Member Services...23 Health Risk Assessments...23 Appointment Scheduling...24 Routine Podiatry Services Appointment Line Transportation Scheduling CHAPTER 5: MEMBER ENROLLMENT AND ELIGIBILITY Member Enrollment...26 Member Eligibility...26 Eligibility Verification Process Eligibility/Discrepancy Member Identification Cards...27 Overview Health Plan Identification Card CHAPTER 6: CLAIMS PROCESSING Claims Submission Guidelines...30 Overview Electronic Claims...30 Paper Claims...31 Claims Processing Timelines...32 National Provider Identifier...32 Claim Timely Filing Limits...34 Filing and Reimbursement Limits for Medi-Cal Claims...34 Other Filing Limits...35 Claims and Encounter Data Inquiries...35 Encounter Data Claim Payment Options offered through Change Healthcare Electronic Remittance Advice Electronic Funds Transfer Direct Pay Page 3

4 Table of Contents CareMore Health Plan Virtual Credit Card Procedure for Processing Overpayments...37 Provider Payment Disputes...37 Hold Harmless...38 Coordination of Benefits...39 Claims Filed With Wrong Plan...40 CHAPTER 7: Billing Members & Balance Billing Cost Sharing...41 Cost-Sharing Responsibility for Special Needs Plan Members...41 Contracted provider...42 CHAPTER 8: UTILIZATION MANAGEMENT Utilization Management Program...44 Medical Review Criteria...45 The Referral Process...45 Self-Referral Services...46 Service Requests...46 Service Request and Service Request Form Services Requiring Pre-service Review Services That Do Not Require Pre-service Review Service Request Function Determination Definitions Medical Necessity Authorization Expiration Timeframe Unauthorized Care Retrospective Review Information for Specialists Only...50 Additional Services Current Procedure Terminology (CPT) Codes New Medical Problem Written Report to PCP Medically Necessary Services...51 Emergency Room Utilization...51 Second Opinions...52 Page 4

5 Table of Contents CareMore Health Plan UM Committee...52 CHAPTER 9: CASE MANAGEMENT Case Management...55 Overview Case Management Components Role of Case Managers...56 Case Management Interventions Extensivist Program...57 Communicable Disease Services...57 CHAPTER 10: HEALTH PROGRAMS AND EDUCATION CareMore Programs & Services...58 Anti-Coagulation Program Chronic Kidney Disease Care Program Chronic Obstructive Pulmonary Disease Program Congestive Heart Failure Care Program Diabetes Management and Prevention Program Exercise and Strength-Training Program Fall Prevention Program Foot Care Program Healthy Start Program Extensivist Program Hypertension Program Transition of Care Team Pre-Op Program Wound Care Program Health Education...61 Health Education Services...61 Health Education Materials...61 Newsletters Cal Mediconnect...62 Individual Health Education and Behavioral Assessment (IHEBA) Tobacco Prevention and Cessation Services CHAPTER 11: PROVIDER ROLES AND RESPONSIBILITIES Page 5

6 Table of Contents CareMore Health Plan Provider Relations Department...64 The Primary Care Provider (PCP)...64 Primary Care Provider Role...64 Provider Specialties...65 Responsibilities of the Primary Care Provider...65 Provider Access and Availability...67 Member Missed Appointments...68 Noncompliant Members...69 Primary Care Provider Transfers...69 Provider Disenrollment Process...69 Covering Physicians...70 Continuity of Care...70 Delivery of Primary Care Coordination of Services Specialty Care Providers...74 Reporting Changes in Address and/or Practice Status...74 Provider Termination Notification...75 Americans with Disabilities Act Requirements...75 Disclosure of Ownership and Exclusion from Federal Health Care Programs...75 Health Insurance Portability and Accountability Act (HIPAA)...76 Medical Records...77 Confidentiality of Information Misrouted Protected Health Information Security Storage and Maintenance Availability of Medical Records Medical Record Documentation Standards...79 Clinical Practice Guidelines...80 Advance Directives...81 Prohibited Activities...81 Coding...81 Medicare Risk Adjustment...81 Concurrent Review...82 Page 6

7 Table of Contents CareMore Health Plan Patient Annual Health Assessment Form (PAHAF)...82 Chart Reviews...82 Education and Training...82 Healthcare Effectiveness Data Information Set (HEDIS) Requirements...83 CHAPTER 12: PROVIDER GRIEVANCES AND APPEALS Provider Appeals and Disputes...84 CHAPTER 13: CREDENTIALING AND RE-CREDENTIALING Credentialing Department...88 Overview Credentialing...88 Credentials Committee...90 Nondiscrimination Policy...92 Initial Credentialing...92 Practitioners...93 HDOs...93 Recredentialing...94 Health Delivery Organizations...94 Ongoing Sanction Monitoring...95 Appeals Process...95 Reporting Requirements...96 Credentialing Program Standards...96 Behavioral Health Rehabilitation CHAPTER 14: MEMBER RIGHTS AND RESPONSIBILITIES Member Rights and Responsibilities CHAPTER 15: MEMBER GRIEVANCE AND APPEALS Member Complaints Member Grievances: Filing a Grievance Member Grievances: Resolution Member Appeals Page 7

8 Table of Contents CareMore Health Plan Member Appeals: Expedited Appeals Member Appeals: Response to Appeals Cal MediConnect CHAPTER 16: MEMBER TRANSFERS AND DISENROLLMENT Provider-Initiated Member Disenrollment CHAPTER 17: FRAUD, WASTE AND ABUSE Fraud, Waste and Abuse Detection CHAPTER 18: QUALITY MANAGEMENT Quality Management Program Quality Management Committee CHAPTER 19: CULTURAL AND LINGUISTIC SERVICES Overview Hour Access to Interpreter Services Documenting Language Services Facility Signage Materials in Other Languages and Alternative Formats Disability Access Cultural Competency Trainings and Resources Page 8

9 CHAPTER 1: INTRODUCTION Welcome to CareMore At CareMore, our goals are to assist you in providing unequaled care to your patients while making the practice of medicine more rewarding in terms of better patient outcomes, better practice economics and diminished practice difficulties. We want you to be proud to have joined us. Improvement in health care delivery results in the thoughtful implementation of added CareMore services such as our Diabetes Management Program and Anti-Coagulation Center, to name a few. These CareMore programs and patient benefits offered at our neighborhood care centers serve as tools to assist you to provide unparalleled patient care. Take the time to review them and you will see how the integration of these services has the effect of both reducing the stress of your professional life and improving your patients outcomes. Dr. Sachin Jain, M.D. Using This Manual Designed for CareMore physicians, hospitals and ancillary Providers who are participating with CareMore, this manual is a useful reference guide for you and your office staff. We recognize that managing our Members health can be a complex undertaking. It requires familiarity with the rules and requirements of a system that encompasses a wide array of health care services and responsibilities. We want to help you navigate our managed health care plan to find the most reliable, responsible, timely and cost-effective ways to deliver quality health care to our Members. This manual is available to view or download on our portal website at providers.caremore.com. Providers may view it online, download it to their desktop or print it out from the site. If you are unable to print a copy from the website, please contact our Provider Relations team at (select Option 3, Option 5) to request that a printed copy be mailed to you. There are many advantages to accessing this manual at our website, including the ability to link to any section by clicking on the topic in the Table of Contents. Each section may also contain important phone numbers, as well as cross-links to other sections, our website or outside websites containing additional information. Bold type may draw attention to important information. Providers with questions about the content of this manual should contact the Provider Relations team at (select Option 3, Option 5). CareMore Service Area The definition of a service area, as described by the Member Handbook, is the geographic area approved by the Centers for Medicare and Medicaid Services (CMS) in which a person must live Page 9

10 Chapter 1: Introduction CareMore Health Plan to become or remain a member of CareMore. Members who temporarily (as defined by CMS as six months or less) move outside of the service area are eligible to receive emergency and urgently-needed services outside the service area. How to Access Information and Forms on the Provider Portal Website A wide array of valuable tools, information and forms are available on the secure Provider Portal page of our website. Throughout this manual, we will refer you to items located on the Provider Portal page. To access this page, please visit providers.caremore.com. If you have questions about Provider Portal access or training, please contact the Provider Relations Department at (select Option 3, Option 5). Legal and Administrative Requirements Disclaimer The information provided in this manual is intended to be informative and to assist Providers in navigating the various aspects of participation with CareMore programs. Unless otherwise specified in the Provider contract, the information contained in this manual is not binding upon CareMore and is subject to change. CareMore will make reasonable efforts to notify Providers of changes to the content of this manual. This manual, as part of your Provider Agreement and related Addendums, may be updated at any time and is subject to change. In the event of an inconsistency between information contained in this manual and the Agreement between you or your facility and CareMore, the Agreement shall govern. In the event of a material change to the Provider manual, CareMore will make all reasonable efforts to notify you in advance of such changes through fax communications and other mailings. In such cases, the most recently-published information shall supersede all previous information and be considered the current directive. The manual is not intended to be a complete statement of all CareMore policies or procedures. Other policies and procedures not included in this manual may be posted on our website or published in specially-targeted communications. These communications include, but are not limited to, letters, bulletins and newsletters. Throughout this manual, there are instances where information is provided as a sample or example. This information is meant to illustrate only, and is not intended to be used or relied upon in any circumstance or instance. This manual does not contain legal, tax or medical advice. Please consult other advisors for such advice. Third Party Websites Page 10

11 Chapter 1: Introduction CareMore Health Plan The CareMore website and this manual may contain links and references to internet sites owned and maintained by third party entities. Neither CareMore nor its related affiliated companies operate or control, in any respect, any information, products or services on these third party sites. Such information, products, services and related materials are provided as is without warranties of any kind, either express or implied, to the fullest extent permitted under applicable laws. CareMore disclaims all warranties, express or implied, including, but not limited to, implied warranties of merchantability and fitness. CareMore does not warrant or make any representations regarding the use or results of the use of third party materials in terms of their correctness, accuracy, timeliness, reliability or otherwise. Privacy and Security Statements CareMore s latest privacy and security statements related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) can be found on the CareMore website, by going to Current Members, then Member Materials, then click on About HIPAA. CareMore s latest data collection and use practice for its website (s) can also be found on the CareMore website. To find its privacy policy, go towww.caremore.com, scroll down to the bottom of the page and select Privacy Policy or you can access the policy at Please be aware that when you leave from the CareMore website to another website, whether through links provided by CareMore or otherwise, you will be subject to the privacy policies (or lack thereof) of the other sites. We caution you to determine the privacy policy of such websites before providing any personal information. Confidentiality and Disclosure of Medical Information Collection of Personal and Clinical Information CareMore will collect, create, use, and disclose personal and clinical information related to Members in accordance with state and Federal laws, including HIPAA, court orders, and/or subpoenas. Release of records according to valid court orders or subpoenas are subject to the provisions of that court order or subpoena. The person or entity that is seeking to obtain medical information must obtain a valid authorization from the Member, unless otherwise permitted by HIPAA and is to use that information only for the purpose it was requested and retain it only for the duration needed. The individual physician or provider may not share, sell, or otherwise use any medical information for any purpose not necessary to provide health care services to the Member, obtain reimbursement for such services, or for the physician s or provider s health care operations as defined by HIPAA. Only the minimum necessary amount of information shall be collected and maintained. Reasons for collecting medical information may include but are not limited to: Page 11

12 Chapter 1: Introduction CareMore Health Plan To review for medical necessity of care To perform quality management, utilization management and credentialing/re-credentialing functions To determine the appropriate payment under the benefit for covered services To analyze aggregate data for benefit rating, quality improvement, chronic disease management programs, and oversight activities, etc.; To comply with statutory and regulatory requirements Maintenance of Confidential Information CareMore maintains confidential information as follows: Clinical information received verbally may be documented in CareMore s database. This database includes a secured system restricting access to only those with authorized entry. Computers are protected by a password known only to the computer user assigned to that computer. Computers with any computer screen displaying Member or Provider information shall not be left on and unattended. Electronic, facsimile, or written clinical information received is secured, with limited access to employees to facilitate appropriate Member care and reimbursement for such care. No confidential information or documents are left unattended (e.g., open carts, bins or trays at any time). Hard copies of all documents are not visible at any workstation during the employees breaks, lunch or time spent away from desks. Written clinical information is stamped Confidential, with a warning that its release is subject to State and Federal law. Confidential information is stored in a secure area with access limited to specified employees, and medical information is disposed of in a manner that maintains confidentiality (e.g., paper shredding and destroying of recycle bin materials). Any confidential information used in reporting to other departments or to conduct training activities, which may include unauthorized staff, will be sanitized (i.e., all identifying information blacked out), to prevent the disclosure of confidential medical information. Any records related to quality of care, unexpected incidence investigations, or other peer review matters may be privileged communications under state law. As such, these records are maintained as confidential. All such written information is stamped Confidential, with a warning that its release is subject to state and federal law. Information is maintained in locked files. Member Authorization Member authorization is not required for treatment, payment and healthcare operations. Direct treatment relationships (e.g., the provision and/or coordination of health care by providers) require Member consent. Page 12

13 Chapter 1: Introduction CareMore Health Plan When a member is enrolled in more than one Managed Care Organization (MCO) (i.e., employer group and Medicare or Medicare and Medi-Cal) all such MCOs are not considered third parties for the purposes of sharing information. To ensure continuity and coordination of care,, identifiable personal information pertaining to Members health and health care may be released, to the extent allowed under State and Federal law, without the prior consent of the beneficiary, to any other MCO. Member Access to Medical Records Members may access their medical records upon proper request. The Member may also provide a written request for amendment to their records if they believe that the records are incomplete or inaccurate. No written request is required for information/documents to which a Member would normally have access, such as copies of claims, etc. CareMore substantiates the identity of the individual Member (e.g., subscriber number, date of service, etc.) before releasing any information. A written request signed by a Member or the Member s authorized representative is required to release medical records. An initial consent to treat may be signed at the point of entry into services prior to the provision of those services, but does not allow records to be released for any reasons other than those delineated in that original consent (e.g., payment and specialty referral authorization processes). CareMore will assist the Member who has difficulty obtaining requested medical records. Disease Management Organizations CareMore and its contractors/vendors that administer disease management programs for conditions such as congestive heart failure, diabetes, chronic obstructive pulmonary disease and cardiovascular disease are prohibited from disclosing a Member s medical information without physician authorization, except as expressly permitted by law. Disease management organizations are restrained from soliciting or offering for sale any products or services to a health plan Member while providing disease management services unless, as specified, he or she elects to receive such information. CareMore staff may contact the Member as needed with information regarding the disease management program(s). Release of confidential member information to disease management organizations may be given for the purpose of providing disease management services, without the authorization of the treating physician, as long as the following is done: The disease management organization otherwise maintains the information as confidential as required by law. Notice of the disease management program (description of the disease management services) must be given to the treating physician for members whom information will be provided to the disease management organization. Release of Confidential Information Page 13

14 Chapter 1: Introduction CareMore Health Plan Members Consent to Medical Treatment Incompetent members include: A Member/conservatee who has been declared incompetent to consent to treatment by a court A Member/conservatee who has not been declared incompetent to consent to treatment, but whom the treating physician determines lacks the capacity to consent A Member who is not capable of understanding the nature and effect of the proposed treatment CareMore will consult with legal counsel, as appropriate. The Durable Power of Attorney or Letters of Conservatorship may need to be reviewed by legal counsel to determine who may consent to the release of Member information. Release to Employers CareMore and its contracted/delegated medical groups/ipas do not share Member-identifiable information with any employer without the Member s written authorization. The member must identify himself/herself by providing key information such as: subscriber number, provider name and date of service, etc. Detailed claims reports will be encrypted or all individually identifiable information blanked out. Requests for reports for individual information may be forwarded to legal counsel for review to ensure employers protect the data from internal disclosure for any use that would affect the individual in compliance with state law. Release to Providers Provider requests may be honored if the request pertains to that provider s services and the released is allowed by HIPAA, 45 CFR (c) (disclosures for treatment, payment or health care operations).. All other requests require the Member s or Member representative s signed release for the information. Electronic, facsimile, or written clinical information sent is secured with limited access to those employees who are facilitating appropriate patient care and reimbursement for such care. Release to Disease Management Organizations Release of confidential Member information to disease management organizations may be given for the purpose of providing disease management services, without the authorization of the treating physician, as long as the following is done: The disease management organization maintains the information as confidential as required by law. The disease management organization does not attempt to sell its services to members. Page 14

15 Chapter 1: Introduction CareMore Health Plan Notice of the disease management program (description of the disease management services) is given to the treating physician for members whom information will be provided to the disease management organization. The disease management organization obtains the treating physician s authorization prior to providing home health care services or prior to the dispensing, administering or prescribing of medication. All other requests require the treating physician s authorization for release of Member information to a disease management organization for provision of disease management services. Electronic, facsimile, or written clinical information sent is secured with limited access to those employees who are facilitating appropriate Patient care and reimbursement for such care. Release of Outpatient Psychotherapy Records Anyone requesting Member outpatient psychotherapy records for any use or disclosure must obtain an authorization from the Member, except where specifically permitted by HIPAA (45 CFR (a)(2)) The written authorization must be signed by the Member and must identify: What information is requested The purpose of the request The name or other specific identification of the person(s) or class of persons authorized to make the requested use or disclosure The name or other specific identification of the person(s) or class of persons to whom the provider may make the requested use or disclosure An expiration date or an expiration event that relates to the Member or the purpose of the use or disclosure The signature of the Member and date A statement to place the Member on notice of their right to revoke the authorization in writing and either (a) the exceptions to the right to revoke and a description of how the Member may revoke the authorization or (b) to the extent that this information is included in the Notice of Privacy Practices (NOPP), a reference to the NOPP A statement to place the Member on notice of the ability or inability of the provider to condition treatment, payment, enrollment, or eligibility for benefits on the authorization by stating either (a) the provider may not condition treatment, payment, enrollment, or eligibility for benefits on whether the individual signs the authorization or (b) the consequences to the individual of a refusal to sign the authorization when the provider can condition treatment, enrollment, or eligibility for benefits on failure to obtain an authorization. Page 15

16 Chapter 1: Introduction CareMore Health Plan A statement adequate to place the Member on notice of the potential for information disclosed pursuant to authorization to be subject to re-disclosure by the recipient and no longer be protected Release of Records Pursuant to a Subpoena Member information will only be released in compliance with a subpoena duces tecum by an authorized designee in Administration as follows: The subpoena is to be accepted, dated and timed, by the above person or designee. The subpoena should give CareMore at least 20 days from the date the subpoena is issued to allow a reasonable time for the Member to object to the subpoena and/or preparation and travel to the designated stated location. All subpoenas must be accompanied by either a written authorization for the release of medical records or a proof of service demonstrating the Member has been served with a copy of the subpoena. Alcohol or substance abuse records are protected by both Federal and State law and may not be released unless there is also a court order for release which complies with the specific requirements. Only the requested information will be submitted, (HIV and AIDS information is excluded). HIV and AIDS or AIDS related information require a specific subpoena per state law. Should a notice contesting the subpoena be received prior to the required date, records will not be released without a court order requiring so. If no notice is received, records will be released at the end of the 20 day period. The record will be sent through the US Postal Service by registered receipt or certified mail. Archived Files/Medical Records All medical records are retained by CareMore and/or the delegated/contracted medical groups as well as individual practitioner offices, according to the following criteria: Adult patient charts 10 years X-Rays 10 years Misrouted Protected Health Information Providers and facilities are required to review all Member information received from CareMore Health Plan to ensure no misrouted protected health information (PHI) is included. Misrouted PHI includes information about Members that a Provider or facility is not treating. PHI can be misrouted to Providers and facilities by mail, fax, , or electronic remittance advice. Providers and facilities are required to immediately report any misrouted Member/Patient information to the sender and then destroy or safeguard the PHI for as long as it is retained. In no event are Providers or facilities permitted to misuse or re-disclose misrouted PHI. If Providers or facilities cannot destroy or safeguard misrouted PHI, please contact Provider Relations at (Select Option3, Option 5). Page 16

17 CHAPTER 2: IMPORTANT CONTACT INFORMATION CareMore Care Centers Contact Information, Services and Programs CareMore Care Centers are an integral part of our care model and offer various services and specialized programs for our Members that are not usually available or covered by other medical groups or health plans. Please refer to Chapter 11: Health Programs and Education for an overview of services and programs CareMore has available. A list of the programs and services can be found below. Please contact your local CareMore Care Center to find out which services and programs are offered there, or reference a current list of CareMore Care Centers and their services and programs available on our portal under the User Manual/Form section. CareMore Programs and Services Anti-coagulation Clinic End Stage Renal Disease Program Back Pain Program Fall Prevention Center Brain Health Healthy Journey Cardiology Healthy Start Cardiac Imaging Center Hypertension Clinic Congestive Health Failure Care Program Nutrition Counseling Chronic Kidney Disease Program Pre-Op Clinic Chronic Obstructive Pulmonary Disease Program Pulmonology Dermatology Smoking Cessation Diabetes Management Program Touch Management Program Wound Care Page 17

18 CareMore Contact Information Name and Address Phone/Fax Hours of Operation and Website Info CareMore Health Plan Park Plaza Drive, # 150 Cerritos, CA Provider Customer Service- Member Eligibility Ph: a.m. 5 p.m. Monday through Friday Ph: (Option 3, Option 1) Fax: a.m. 5 p.m. Monday through Friday Case Management Ph: hours a day, 7 days a week After hours Case Manager: Nights and Weekends: Ph: Electronic Claims Submission Ph: hours a day, 7 days a week Fax CareMore Payor ID: CARMO Fraud Hotline Ph: hours a day, 7 days a week Extensivist Ph: hours a day, 7 days a week (Option 1, Option 1) Pharmacy Department CareMore Health Plan MS Park Plaza Drive #150 Cerritos, CA Disease Management Programs Ph: a.m. - 5 p.m. Monday through Friday Fax: Ph: After hours line with a clinician Monday through Friday 5 p.m. 12 a.m. Saturday - Sunday 8 a.m. - 5 p.m. Page 18

19 CHAPTER 3: MEMBER BENEFITS CareMore Health Plan Overview CareMore Health Plan provides comprehensive, coordinated medical services to members on a prepaid basis through an established provider network. HMO members must choose a Personal Physician (or PCP) and have all care coordinated through this physician provider. Medicare Advantage plans are regulated by the Centers for Medicare and Medicaid Services (CMS), the same federal agency that administers Medicare. Outpatient Ancillary Services All laboratory, radiology, therapy*, DME and medical soft goods services must be performed at a contracted facility. *Therapy services include physical therapy, occupational therapy and speech therapy. Co-pay Guidance for Outpatient Services Please refer to the appropriate Evidence of Coverage (EOC) document for information regarding applicable co-pays for outpatient services. This information is available at Pharmacy Services Overview Our pharmacy benefit provides coverage for medically necessary medications from licensed prescribers for the purpose of saving lives in emergency situations, during short-term illness, sustaining life in chronic illness, or limiting the need for hospitalization. Members have access to most national pharmacy chains and many independent retail pharmacies. Monthly Limits All prescriptions are limited to a maximum 90-day supply per fill, except for Tier 5 Specialty Drugs, for which a 30-day supply is all that is availabe. For Long Term Care prescriptions are limited to a maximum of 31-day supply per fill. Formulary CareMore s formulary for our members has been reviewed and approved by CMS as well as our Pharmacy and Therapeutics Committee. The formulary consists of generic and brand Medicare covered medications that may be prescribed for CareMore Members. As noted in the formulary, some of these medications may require a prior authorization. Throughout the year, there may be additions and deletions to the CareMore formulary. Your office will be notified when these changes take place. Page 19

20 Requests for Formulary Changes Providers are encouraged to submit requests for formulary changes if you feel that a drug is not covered but is needed for a particular reason. To request these formulary changes, please submit the following information in writing to the Pharmacy Department address listed in Chapter 2: Other CareMore Contact Information: Name of drug Drug class Dosage (if more than one available, cite the one you are requesting) Justification for your request Your name Your contact number Medical Group affiliation, if appropriate Our Pharmacy and Therapeutics Committee will review your request and the pharmacy department will notify you of the results. Prior Authorization/ Exception Requests Prior authorization/exception Requests are used for formulary drugs that require a Prior Authorization or to request non-formulary drug coverage. National Pharmaceutical Services (NPS) serves as the Pharmacy Benefit Manager to review the drug requests. Please fully complete and sign the Prior Authorization form available on the CareMore On-Line Provider Portal to include the 1) diagnosis; 2) previously tried and failed formulary medications; and 3) why other formulary options are not acceptable or would be less effective or harmful to the patient s medical condition. Virginia providers are excluded from the above process and will need to sumbit to Express Scripts. (ESI). Page 20

21 Notification of FDA Recalls CareMore Health Plan will notify you and any affected Members of any Food and Drug Administration recalls that may impact Members. Preferred Diabetic Supplies The following are CareMore s preferred diabetic supplies: Freestyle monitors (Lite, Freedom, Insulinx) Freestyle lancets and test strips Precision XTRA monitors and test strips New Diabetes Test Strip Quantity Limit There are new diabetes test strip quantity limits for These limits are still more generous than what Original Medicare offers. If more is needed, a prior authorization is required. Please refer to the table below for the new quantity limits: Note: The previous 180-days of claims data is used to determine insulin use. Scripts Provider Newsletter Scripts is a newsletter directed to all our providers. The newsletter contains updates on brand and generic drugs, formulary changes, and pertinent clinical articles. If you have any suggestions or comments related to our newsletter, please call Part B Medication Rx Copay Calculations CareMore s authorizations do not include the member s cost sharing for Medicare Part B drugs. We will continue to provide the coinsurance so that your office staff may calculate the copay dollar amount to collect. Page 21

22 If you are accustomed to serving Medicare Fee-For-Service patients, your office staff may be familiar with determining a patient s cost sharing responsibility. To assist in the calculation, please visit the following links: Part-B-Drugs/McrPartBDrugAvgSalesPrice/2017ASPFiles.html and enter keyword search "2017 ASP Drug Pricing Files. OR If you need assistance in understanding how to calculate the copayment for Medicare Part B Medication Rx, please contact Provider Relations at (888) (Select Option 3, then Option 5), Monday Friday, 8am 5pm (PST). Vision Services Vision benefits are offered to all CareMore Members through our contracted vision vendor. For vision vendor contact information specific in to your state, please reference the CareMore at Arizona and California: UniView Vision Insight Nevada: Nevada EyePA Cal MediConnect: VSP Page 22

23 CHAPTER 4: MEMBER SERVICES Member Services Member Services Department: Cal MediConnect Hours of Operation: 8 a.m. to 8 p.m. Monday through Friday (except holidays) The CareMore Health Plan (CareMore) Member Services Department is designed to assist Members with all of our value-added services and health plan benefit coordination. The department s friendly, knowledgeable and bilingual representatives are available to answer Member questions regarding, but not limited to General benefits Assigned physician Hospital information Pharmacy locations Status of referrals and authorizations Network Providers Billing questions Hospital Coverage and Locations Prescription Drug Coverage Grievances and Appeals process ID card replacements Health Risk Assessments Within 60 days of enrollment in CareMore, Members are encouraged to come into a CareMore Care Center to receive an initial Healthy Start health risk assessment (HRA). For those enrolled in a SNP plan, they will then receive a Healthy Journey HRA on an annual basis thereafter. These face-to-face assessments include: A complete medical history A head-to-toe physical examination An assessment of health behaviors On-site lab testing with a complete metabolic panel, additional tests may include A1C, PT/INR, random urine microalbumin, if needed Depression Screening to identify Members requiring treatment for depression. Page 23

24 Mini-Cognitive or Mini-Mental State Exam (MMSE) to identify if the Member suffers from dementia. Community Assessment Risk Screening (CARS) to identify those Members at an increased risk of hospitalization. A fall risk screen to identify Members at risk of falling. Pain assessment screening to identify if the Member requires additional treatment. Functional screening to identify the Member s ability to perform daily activities, such as bathing, dressing and preparing meals. These HRAs are fundamental to understanding and improving our Members health status, access to care, health outcomes and utilization. Information gained in the HRA process is used by the Interdisciplinary Team (ICT), which includes the Member and family Member(s) when appropriate, to develop the Member s plan of care. Appointment Scheduling Routine Podiatry Services Appointment Line Most plans will include routine podiatry as part of their benefit package. Members within those plans may self-refer to the CareMore Foot Centers for routine foot care, such as toenail clipping and callous removal. To schedule an appointment for routine foot care, Members or the physician office staff may call the nearest Foot Center-equipped CareMore Care Center. For a list of the CareMore Care Centers, their contact information and the services offered at each location, please refer to CareMore s online Provider Portal at providers.caremore.com. Transportation Scheduling The Member Services Department coordinates the transportation benefit for Members. The transportation benefit does not apply to medical transportation services such as ambulance service, pharmacy, dental appointments, Member Services/Sales Events, or to pick up medical records to take to another doctor s office. Transportation services must be scheduled one business day in advance of a Member s medical appointment and may only be used to travel to and from scheduled medical appointments at CareMore approved locations. Transportation is available for members who are ambulatory or use standard-sized wheelchairs, and do not have any limiting medical condition that would restrict them from normal means of public transportation. Each member is allowed one escort. All escorts must be 17 years or older. Transportation must be coordinated through CareMore. Members must notify CareMore of any cancellation one business day prior to the scheduled trip. Same-day cancellations may count as a one-way trip taken toward their annual transportation benefit limit. In order to receive covered transportation services, Members must be able to use standard means of transportation, such as buses, vans, or taxicabs, and must be able to ride with others. Page 24

25 Our drivers are scheduled to meet Members 30 to 60 minutes prior to their appointment time. When the Member is ready to return home, the Provider s office staff will call CareMore Health Plan so that a ride may be arranged. Standard wait time for pick-up upon completion of Member s medical appointment is approximately 60 minutes. Cal MediConnect Only Members who are eligible for LTSS are approved for trips to additional locations. Please contact Member Services for more information. Transportation may be scheduled by the Member or by the Provider s office CareMore recognizes that some Members may experience communication barriers when accessing benefits and services. We do the following to help remove those barriers: Ensure Members with limited English proficiency (LEP) have meaningful access to services Make available (upon request) written Member materials in Braille, large print, audio and in languages other than English. Provide Member materials written at the appropriate reading and/or grade level Provide interpreter services to communicate with LEP Members Call Member Services at the numbers listed at the beginning of this chapter to access translation services for more than 150 languages. CareMore has contracted with several language services companies to assist both Members and Providers in those instances where interpreter services, including American Sign Language, are needed to ensure adequate health care communication. These interpreter services, which include over-the-phone and face-to-face interpreters, are available at no cost to both Provider and Member. Providers must notify Members of the availability of interpreter services and strongly discourage the use of friends and family, particularly minors, to act as interpreters. It is important that you or your office staff document the Member s language, any refusal of interpreter services, and requests to use a family Member or friend as an interpreter in the Member s medical record. When Language Services or Sign Language Services are required by the Member at their assigned Primary Care Physician or Specialist office, the office must contact the Member Services. Page 25

26 CHAPTER 5: MEMBER ENROLLMENT AND ELIGIBILITY Member Enrollment Eligibility Department: (Option 3, Option 1) Hours of Operation: 8 a.m. to 5 p.m. Monday through Friday (except holidays) CareMore Health Plan s benefit plans are open to all Medicare beneficiaries, including those under age 65 who are entitled to Medicare on the basis of Social Security disability benefits, who meet all of the applicable eligibility requirements for membership, have voluntarily elected to enroll, have paid any premiums required for initial enrollment to be valid, and whose enrollment in CareMore Health Plan has been confirmed by the Centers for Medicare and Medicaid Services (CMS). Member Eligibility Eligibility Verification Process All primary care physicians (PCPs), specialists, ancillary providers, and facilities must verify eligibility prior to rendering services to Members. Providers may verify a Member s eligibility by logging onto CareMore s online Provider Portal or by calling CareMore s Eligibility Department. On-Line: Providers who have been trained on CareMore s On-Line Provider Portal may verify a Member s eligibility by using this site: providers.caremore.com. For additional information regarding the Provider Portal please contact Provider Relations at (Select Option 3, then Option 5). By telephone: When contacting the Eligibility Department to verify a Member s eligibility, please be prepared to give the following information: Member s name Member s date of birth Member's ID number Eligibility/Discrepancy In the event that eligibility and/or your capitation report are not accurate, please contact the Eligibility Department or investigation and resolution. Please include: Member s Name ID Number Date of Birth Primary Care Provider Explanation of discrepancies to include the months in question. Page 26

27 In cases where members change PCP assignment retroactively, members may be omitted from the eligibility webpage or capitation report for that particular PCP. The retroactivity will appear on the following month s eligibility/capitation reports. The Capitation Department will work with your Regional Performance Manager on any capitation related issues Medicare has specific rules in place for Hospice and although the member is still technically assigned to CareMore, all payments for medical services related to their condition are handled thru Hospice. CareMore will not issue Capitation payment on members who have elected Hospice. Please contact Eligibility if one or more of the following discrepancies occur: The patient is eligible with the health plan but is not listed on the eligibility webpage The patient is not eligible with the health plan but is listed on the eligibility webpage The PCP assignment is not accurate The patient is listed on the eligibility webpage but is not listed on the capitation report The identification information on the eligibility webpage is not accurate Once the Eligibility Department is contacted and made aware of the discrepancy, the Eligibility staff conducts its internal investigation of the discrepancy and submits a response and corrective action plan to the Provider within two (2) business days. You may contact the Eligibility Department directly to check on the status of your discrepancy or if you require additional information. Member Identification Cards Overview Primary care physicians, specialists, ancillary providers, and facilities are responsible for verifying each Member s eligibility prior to rendering services, unless it is an emergency. All Members have a health plan identification card, which must be presented each time services are requested. Health Plan Identification Card The Health Plan Identification Card should contain, but not be limited to, the following information: Health Plan Member Name/Subscriber Name* Member Health Plan Identification Number Effective Date Primary Care Physician - name and phone number Page 27

28 Pharmacy Information, including Pharmacy Benefit Manager (PBM) help desk and phone number, PCN ID, BIN#, Group#, Pharmacy ID and person code Member Services - toll-free number Copayments for PCP office visit, Specialist Office Visit, Emergency Room and Urgent Care *For some service areas, the card may also include the name and phone number of the assigned Ophthalmology Provider. For more information, contact Provider Relations. MEMBER IDENTIFICATION CARD SAMPLE Page 28

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30 CHAPTER 6: CLAIMS PROCESSING Claims Department: (Option 3, Option 2, Option 2) Hours of Operation: Claims Submission Guidelines Overview 8 a.m. to 5 p.m. Having a fast and accurate system for processing claims allows Providers to manage their practices, and our Members care, more efficiently. With that in mind, CareMore Health Plan (CareMore) has made claims processing as streamlined as possible. The following guidelines should be shared with your office staff, billing service and electronic data processing agents, if you use them. Submit clean claims, making sure that the right information is on the right form. Submit claims as soon as possible after providing service. Submit claims within the contract filing time limit. All claims information must be accurate, complete, and truthful based upon the Provider s best knowledge, information and belief. Electronic Claims We encourage the submission of claims electronically through Office Ally. All Providers must submit claims within the timeframes listed in their agreement or contract with CareMore. The advantages of electronic claims submission are as follows: 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 Strategic National Implementation Process (SNIP) Compliance Levels In January 2009, the U.S. Department of Health and Human Services published final rules requiring the health care industry to upgrade electronic standard transactions under HIPAA to Page 30

31 version 5010 and support the international classification of diseases version 10 (ICD-10) for diagnosis and hospital inpatient procedure coding. The new rules apply to the health care industry health plans, hospitals, doctors and other health care professionals and impact others who currently use the HIPAA version 4010 to transmit data. The implementation date for version 5010 was January 1, CareMore will conduct compliance checks for SNIP Levels 1 through 5 for claims transactions sent as an 837I (institutional electronic claim) and 837P (professional electronic claim). Paper Claims Paper claims are scanned for clean and clear data recording. To get the best results, paper claims must be legible and submitted in the proper format. Paper claims are acknowledged with fifteen (15) business days of receipt. Follow these requirements to speed processing and prevent delays: Use the correct form and be sure the form meets Centers for Medicare and Medicaid Services standards. Use black or blue ink (do not use red ink, as the scanner may not be able to read it). Use the Remarks field for messages. Do not stamp or write over boxes on the claim form. Send the original claim form to CareMore, and retain a copy for your records. Separate each individual claim form. Do NOT staple original claims together; CareMore will consider the second claim as an attachment and not an original claim to be processed separately. Remove all perforated sides from the form; leave a ¼-inch border on the left and right side of the form after removing perforated sides. This helps our scanning vendor scan accurately. Type information within the designated field. Be sure the type falls completely within the text space and is properly aligned. Don't highlight any fields on the claim forms or attachments; doing so makes it more difficult to create a clear electronic copy when scanned. If using a dot matrix printer, do not use draft mode since the characters generally do not have enough distinction and clarity for the optical scanner to read accurately. If you submit paper claims, you must include the following Provider information: Provider name Rendering Provider Group or Billing Provider Federal Provider Tax Identification Number (TIN) The CareMore Health Plan Payer Identification Number National Provider Identifier (NPI) Medicare number Page 31