ALOHACARE QUEST INTEGRATION PROVIDER MANUAL

Transcription

1 ALOHACARE QUEST INTEGRATION PROVIDER MANUAL 2017

2 Welcme Prviders! The ffers yu ur cntracted prviders and yur staff with helpful infrmatin and details n ur AlhaCare QUEST Integratin health plan. We recmmend that yu read this manual and keep it n hand fr yur staff t reference. The QUEST Integratin Prvider Manual is als available n ur website: If yu have truble accessing the infrmatin, please cntact ur Prvider Relatins Department. Table f Cntents Welcme Prviders!... 1 Table f Cntents... 1 SECTION 1 INTRODUCTION TO ALOHACARE QUEST INTEGRATION HEALTH PLAN... 5 Welcme... 5 Our Stry... 5 AlhaCare Missin... 5 Our Cmmitment... 5 Cultural Cmpetency... 6 AlhaCare Visin... 6 We envisin empwered healthy cmmunities living in the spirit f Alha Cre Values... 6 Organizatin and Administrative Structure... 6 What is QUEST Integratin?... 7 Prvider Relatins Department... 7 Cntact Us... 7 Imprtant Phne Numbers... 8 SECTION 2 IMPORTANT INFORMATION FOR PROVIDERS... 9 AlhaCare Publicatins... 9 QUEST Integratin Prvider Manual... 9 Prvider Newsletters and Advisries... 9 Quick Reference Guide... 9 Prvider Web Prtal - AC Online Electrnic Data Interchange (EDI) Prgram Electrnic Fund Transfers Access t Language Interpretatin, Auxiliary Aids, Sign Language r Specialized Cmmunicatin SECTION 3 PROVIDER ROLE AlhaCare s Respnsibility t Our Prviders Prvider Respnsibilities Rle f the Primary Care Prvider (PCP) Wh May Serve as a Primary Care Prvider (PCP) PCP Respnsibilities PCP Patient Capacity Member Request t Change PCP Requesting PCP Re-Assignment Immediate Transfer f Member Specialist and Ancillary Prvider Rles Credentialing/Recredentialing AlhaCare s Subcntracting Plicy Medical Recrds Requirements Appintment and Accessibility Standards Reprting Requirements Marketing Guidelines

3 Fraud and Abuse SECTION 4 QUEST INTEGRATION PROGRAM AND BENEFITS Prgram Intrductin Administratin f QUEST Integratin Benefits Primary and Acute Medical Services Standard Behaviral Health Services Evaluatin, prescriptin and maintenance f psychtrpic medicatins Nn-Cvered Services Services cvered under the Medicaid fee-fr-service prgram Services frm ther agencies in the cmmunity SECTION 5 MEMBER SERVICES Member Rights and Respnsibilities Member ID Cards Member Eligibility Verificatin Newbrns Prvider Verificatin Cnfidentiality and Privacy f Prtected Health Infrmatin SECTION 6 UTILIZATION MANAGEMENT/MEDICAL MANAGEMENT (UM/MM) New Technlgy Medical Request fr Prir Authrizatin and Ntificatin Prir Authrizatin Prcess Ntificatin Prcedure Newbrns Prir Authrizatin, Ntificatin and Registratin Matrix Prir Authrizatin Fact Sheet Services That D Nt Require a Prir Authrizatin r Ntificatin Emergency Services Retractive Authrizatin r Ntificatin Apprvals Inpatient Cncurrent Review and Cntinued Stay Inpatient Stays f Less than 24 Hurs Discharge Planning Specific Prcedures fr Sterilizatin Specific Prcedures fr Hysterectmy Specific Prcedures fr Induced Terminatin f Pregnancy (ITOP) and Related Services Telemedicine Clinical Decisin Supprt Tls and Clinical Practice Guidelines SECTION 7 PHARMACY SERVICES Frmulary Frmulary Limitatins Hw t Request a Frmulary Exceptin After Hurs Drug Access/Emergency Medicatin Supply Plicy Excluded Drugs Hw t Request a Cpy f the AlhaCare QUEST Integratin Frmulary SECTION 8 BEHAVIORAL HEALTH Mental Health and Chemical Dependency Self-Referral t BH Services Behaviral Health Service Crdinatin Cvered and Nn-Cvered Services Cvered Services That D Nt Require Prir Authrizatin Outpatient Prfessinal and Facility-Based Acute BH Inpatient Services that Require a Ntificatin

4 Other General Infrmatin related t Inpatient Admissins Discharge Planning Terminatin f Treatment Behaviral Health Special Needs Ppulatins Supprt fr Emtinal and Behaviral Develpment (SEBD) Prgram Eligibility Criteria fr SEBD Prgram Cmmunity Care Services (CCS) Prgram fr Adults with a Serius Mental Illness (SMI) r Serius and Persistent Mental Illness (SPMI) Qualifying Diagnses fr the CCS prgram: Excluded Diagnses fr the CCS prgram: Additinal Intensive Behaviral Health Services fr Members enrlled in the CCS prgram: SECTION 9 SERVICE COORDINATION Prgram Intrductin Health Prmtin Prgram Service Crdinatin Service Crdinatin fr members with Special Health Care Needs (SHCNs) Rle f Service Crdinatr Medicatin Therapy Management Disease Management Transitin f Care Early and Peridic Screening, Diagnstic and Treatment (EPSDT) Prgram EPSDT Screening Examinatins Childhd Immunizatins Childhd Lead Testing EPSDT Educatin and Outreach EPSDT Claims Prcessing Immunizatin Requirements Vaccine Matrix Dental EPSDT Services t be perfrmed by the PCP Crdinatin with Other Services Early Interventin Services (EIS) prgram WIC Prgram SECTION 10 LONG TERM SERVICES AND SUPPORTS Lng-term Services and Supprts (LTSS) Hme and Cmmunity Based Services (HCBS) When persnal assistance services Level II activities are the primary services, persnal assistance services Level I activities identified n the service plan, which are incidental t the care furnished r that are essential t the health and welfare f the member, rather than the member s family, may als be prvided At-risk services Self-Directin Institutinal Services SECTION 11 BILLING AND REIMBURSEMENT Claim Submissin Filing Deadlines Resubmissins Prper Billing Claims Review Newbrn Claims Member Direct Billing Third Party Liability (TPL) / Crdinatin f Benefits Pharmacy Claim Submissin Standard Imprving Claim Submissins/Crrecting Cmmn Errrs

5 Reimbursement Apprpriate billing and reimbursement methdlgy Remittance Advice Electrnic Funds Transfers Claim Adjustments and Recveries Prvider Initiated Recveries SECTION 12 VISION SERVICES AlhaCare Visin Guidelines Descriptin Amunt, Duratin, and Scpe Exclusins Limitatins Cataracts Crneal Transplants Visin Eyewear Prir Authrizatin SECTION 13 PROVIDER GRIEVANCES AND APPEALS Definitins: Hw t File a Grievance r Appeal Filing a Grievance r Appeal n Behalf f a Member Peer Review Prcess SECTION 14 MEMBER GRIEVANCES AND APPEALS Member Grievance Written Grievance Oral Grievance Prcess Member Appeals Written Appeals Oral Appeals Prcess Expedited Member Appeal SECTION 15 QUALITY IMPROVEMENT Gals QAPI Activities Quality Imprvement Oversight Value-Based Healthcare APPENDIX A APPENDIX B APPENDIX C

6 SECTION 1 INTRODUCTION TO ALOHACARE QUEST INTEGRATION HEALTH PLAN Welcme Alha! Thank yu fr partnering with us t imprve the health f ur AlhaCare members and ur cmmunity. Our Stry AlhaCare is a lcal, nn-prfit health plan funded in We wrk with Hawaii s vulnerable ppulatins, including lw-incme senirs, t prvide Medicaid and Medicare cverage t ver 65,500 members. We serve Hawaii s Medicaid and Medicare ppulatins thrugh a QUEST Integratin cntract with the State f Hawaii. Hawaii s cmmunity health centers jined tgether t frm AlhaCare when the State launched the Medicaid QUEST prgram fr lw-incme families. We were ne f the first QUEST health plans. Our service area is statewide, which includes the islands f Oahu, Kauai, Lanai, Maui, Mlkai, Lanai and the Big Island. Apprximately ne ut f every tw f ur health plan members are children. Mre than 48 percent f ur health plan members live n a Neighbr Island. AlhaCare Missin Our missin is t serve individuals and cmmunities in the true spirit f alha by ensuring and advcating access t quality health care fr all. This is accmplished with emphasis n preventin and primary care thrugh cmmunity health centers that funded us and cntinue t guide us as well as with thers that share ur cmmitment. Our Cmmitment By "empwered, healthy cmmunities" and by "ensuring and advcating access t quality health care fr all", we mean that: AlhaCare's cre business will fcus n being recgnized as the best and mst successful plan in serving the Medicaid and the dually-eligible Medicaid and Medicare ppulatins f Hawaii; and, AlhaCare's cre rle will be that f a facilitatr in helping cmmunities t becme mre empwered t ensure access t quality health care fr all. By "serve individuals and cmmunities", we mean that we must cnstantly build and maintain special health plan expertise and capabilities that can successfully and effectively slve the mst persistent challenges in meeting the health care needs f individuals within this ppulatin in the cmmunities in which they live. By the "spirit f alha", we mean that the principles f alha by which we cnduct ur cre business will result in the highest levels f member and prvider satisfactin and f member retentin amng thse rganizatins wh serve these ppulatins. By "with emphasis n preventin and primary care thrugh cmmunity health centers", we mean that ur main emphasis as a health plan in achieving ur missin will cme abut largely thrugh ur cre partnership and cllabratin with the cmmunity health centers and a fcus n primary care and preventin. 5

7 By "with thers that share ur cmmitment, we mean that, in additin t ur emphasis in wrking with cmmunity health centers, we will als wrk in clser partnership and cllabratin with physicians, ther health care prviders, scial service rganizatins and cmmunities that share ur missin cmmitment. Cultural Cmpetency Embracing cultural cmpetency and diversity enables AlhaCare t meet the culture and linguist diverse needs f ur members. In ding s, we can direct the develpment f systems, plicies and prcedures t reflect the needs f ur culturally diverse members, prviders and emplyees. This philsphy ultimately imprves member satisfactin and health utcmes. We are cmmitted t building and maintaining a prvider netwrk as well as ur emplyee wrkfrce t reflect the diversity f Hawaii s unique ppulatin. AlhaCare s Cultural Cmpetency Plan identifies health practices and behavir f members and designs prgrams and services t address cultural and language barriers t deliver apprpriate and necessary care. All services are prvided in a culturally cmpetent manner t all members, including thse with limited English prficiency and diverse cultural and ethnic backgrunds. AlhaCare prviders are expected t prvide health care services (including language assistance if requested) that respnd effectively t the cultural and linguistic needs f ur members. Annual and nging training is available. The AlhaCare Cultural Cmpetency Plan is available upn request, at n charge. Please cntact us fr mre infrmatin. AlhaCare Visin We envisin empwered healthy cmmunities living in the spirit f Alha. Cre Values We prmise t demnstrate ur cre values each time we interact with yu: Fairness Hnesty Lyalty Respect/Dignity Trust Organizatin and Administrative Structure AlhaCare is an IRS 501(c) (4) nn-prfit crpratin headquartered in Hnlulu, Hawaii. We have ffices n Oahu and the Big Island. We have ver 200 emplyees, all f whm wrk within the State f Hawaii. As a health plan funded and gverned by Cmmunity Health Centers (CHCs), AlhaCare is deeply rted in Hawaii s diverse cmmunities. The cmmunity-gverned CHCs and their bard members bring a great depth f experience and expertise serving ppulatins challenged with financial, cultural, ethnic, linguistic, gegraphical and scial barriers. AlhaCare s relatinship with the CHCs prvides a gvernance structure which has pwerful ties t Hawaii s underserved cmmunities. The CHC CEOs and Executive Directrs wh serve n AlhaCare s bard are, in turn, under the directin f their wn bards f directrs, which are dminated by cnsumers, advcates and prminent members f their lcal cmmunities. This brings int AlhaCare the 6

8 unique vices f each f thse cmmunities, which represent the diverse ppulatin f ur entire state, and particularly cmmunities which have traditinally nt been the fcus f the mainstream health system. What is QUEST Integratin? QUEST Integratin (QI) is a Medicaid managed care prgram under the Hawaii Department f Human Services (DHS). Managed care means that the DHS has cntracted AlhaCare t help members manage their health care needs. Our health plan assists members in receiving the highest quality f health care in the right care setting and at the time that they need the care. AlhaCare QI prvides cverage fr thse wh qualify. We ffer: Cverage fr medical, behaviral health and lng-term services and supprts Medical cverage Services t help in daily activities Independent living and input n a member s health care decisins Service crdinatrs t help members get the care that they need Prvider Relatins Department The Prvider Relatins Department prvides an active main interface between AlhaCare and the prvider cmmunity. We strive t treat prviders with respect and dignity as these are imprtant values t AlhaCare. Our effrts will result in a netwrk f prviders that will prvide a cmprehensive cntinuum f quality health care and wh will embrace the AlhaCare philsphy f delivering care t the underserved with Alha. The Prvider Relatins Department s fcus is n recruiting, retaining and maintaining a viable prvider netwrk that meets the health care and service needs f ur members. We prvide supprt and assistance t prviders t enable them t give efficient and effective care. We ffer a variety f rientatin and training pprtunities t prvide clarity n ur prcesses and plan requirements. We als invite prviders t wrk directly with us n ur advisry cmmittees t assure that ur quality imprvement and utilizatin management prgrams, clinical guidelines and plicies, and ther prgrams supprt the delivery f quality health care t ur cmmunity. Cntact Us We are here t answer yur questins and prvide supprt t yur ffice. Yur telephne calls will be answered by a live Prvider Relatins representative. Our ffices are pen Mnday - Friday, 7:45 a.m. 5:00 p.m. Our after-hurs answering service can prvide member eligibility infrmatin. Calls made afterhurs that need fllw up are returned the next business day. Answers and questins may als be accessed thrugh ur TDD/TTY system. Language assistance is als available upn request. 7

9 Imprtant Phne Numbers Department Phne Tll-free Fax Tll-free Fax QUEST Integratin Member Services Medicare Member Services Prvider Relatins Prir Authrizatin Service Crdinatin Pharmacy Behaviral Health (Prir Auth Requests) Quality Imprvement Mailing Address: AlhaCare 1357 Kapilani Blvd, Suite 1250 Hnlulu, HI

10 SECTION 2 IMPORTANT INFORMATION FOR PROVIDERS AlhaCare Publicatins AlhaCare is cmmitted t prviding clear, accurate and timely cmmunicatins t ur prvider netwrk. We publish the QUEST Integratin Prvider Manual, an annual Prvider Newsletter, Kui Ka Ln and peridic Prvider Advisries. Our prvider publicatins are available nline at QUEST Integratin Prvider Manual The QUEST Integratin Prvider Manual is an extensin f the AlhaCare Prvider Agreement. Updates are made when the Department f Human Services (DHS) updates the QUEST Integratin prgram r when AlhaCare updates ur wn plicies and prcedures. The Prvider Manual helps yu and yur staff t understand the QUEST Integratin Prgram and AlhaCare plicies and prcedures. The nline Prvider Manual always represents the mst current infrmatin. Fr additinal printed cpies f the QUEST Integratin Prvider Manual at n cst t yu, cntact ur Prvider Relatins Department at r tll free at The Prvider Manual will als be psted nline at the AlhaCare website and will be updated nt mre than five (5) days fllwing any change t the manual. Written ntificatin t prviders will cme thrugh the Prvider Newsletter, prvider advisries r direct mailing. Prvider Newsletters and Advisries The Prvider Newsletter and Prvider Advisries are designed t keep yu infrmed f plicy changes (such as changes t billing guidelines and authrizatins), prgram changes (such as QUEST Integratin benefit changes), frmulary updates, and tips fr claim submissin, nline tls and mre. The newsletter serves as the primary vehicle fr cmmunicating any changes that may have a substantial impact n the rights r respnsibilities f ur netwrk prviders. It is mailed directly t yur ffices. Please ntify Prvider Relatins f any changes in yur address r cntact infrmatin. Quick Reference Guide AlhaCare Quick Reference Guide is an easy, ne page guide that cntains infrmatin mst useful t yu in yur day-t-day interactins with AlhaCare and ur members. In the Quick Reference Guide, yu will find infrmatin n the fllwing: Office lcatins and addresses Imprtant phne numbers Plan Operatins Infrmatin fr Prviders AlhaCare s Secure Prvider Prtal AC Online The Quick Reference Guide can be fund n and is peridically included in AlhaCare s Prvider Newsletter. 9

11 Prvider Web Prtal - AC Online AC Online is a prvider web prtal designed just fr yu. It cntains the mst up t date infrmatin abut yur members and can be accessed 24 hurs a day, 7 days a week at Yu can lg in and gain access t the fllwing: Member Infrmatin Find an assigned AlhaCare member Check n a member s eligibility, TPL and Primary Care Prvider infrmatin Find the Primary Care Prvider Rster Receive Primary Care Prvider Quality (HEDIS ) Reprts Prescriptin Drug Utilizatin Claim Infrmatin Lk up a claim yu billed and track its status Prir Authrizatin Infrmatin Submit, authrizatin r ntificatin n line Lk up authrizatin r ntificatin and track its status Administrative Access (Designated Administratr) Administrative Access is given t a primary user authrized by a Prvider, Grup r Facility t perfrm the fllwing functins: Add new user accunts Delete user accunts Change a user s access in the prtal Re-set and change user passwrds Administrative Access is autmatically given t the requesting Prvider, Administratr r Manager reflected n the frm. If there is n Designated Administratr reflected in these field, administrative access will autmatically default t the Prvider. Register fr an AC Online Accunt The AC Online Registratin Frm is available n ur website r yu can request the frm by cntacting Prvider Relatins. Cmplete the frm and fax t (808)

12 Electrnic Data Interchange (EDI) Prgram If yu are interested in faster claims payment and reducing paperwrk, cnsider submitting yur claims electrnically via ur Electrnic Data Interchange (EDI) prgram. This service is available t prviders wh meet the fllwing requirements: Yu wn yur wn billing sftware which is capable f submitting data files r use a third-party billing service that can prcess and submit yur claims fr yu. Cmplete a HIPAA Transactin Set Frm. The HIPAA Transactin Set Frm is available n ur website r request the frm by cntacting Prvider Relatins. Cmplete the frm and fax t (808) Please allw 5 t 7 business days fr us t set up yur accunt. Our Prvider Relatins Department will cntact yu t discuss any details. Electrnic Fund Transfers Electrnic Fund Transfer (EFT) is available fr thse prviders wh chse t have payments autmatically depsited int their bank accunt. A depsit slip r canceled check (which includes the bank ruting number) is required t set up the prcess and verify accunt infrmatin. T set up EFT payment, cntact Prvider Services at r tll-free at Access t Language Interpretatin, Auxiliary Aids, Sign Language r Specialized Cmmunicatin If yu need t access language interpretatin, auxiliary aids (example: telephne handset amplifiers, assistive listening devices), sign language services, r specialized cmmunicatin such as Braille r translatin services t cmmunicate with an AlhaCare patient, please cntact AlhaCare Prvider Relatins. These services are prvided free t ur members. Oahu: (808) Tll Free: TTY/TTD users:

13 SECTION 3 PROVIDER ROLE AlhaCare has a netwrk that includes a brad range f prviders PCPs, APRNs, specialists, hspitals, facilities, pharmacies, lng-term service and supprt prviders and ancillary services t prvide ur members with the full range f QUEST Integratin cvered services. We appreciate the willingness f the prvider cmmunity t partner with us t assure access t quality care fr the disadvantaged members f ur cmmunity. This sectin addresses AlhaCare s respnsibilities t cntracted prviders as well as cntracted prviders rles and respnsibilities. AlhaCare s Respnsibility t Our Prviders AlhaCare recgnizes that a successful partnership depends n acceptance f respnsibility and a cmmitment t pen, effective cmmunicatin by bth parties. AlhaCare has a respnsibility t ur netwrk f prviders t: Seek prvider input t imprve the quality f care fr AlhaCare members Seek prvider input t imprve the quality f prvider relatins with AlhaCare Keep prviders infrmed f any changes in AlhaCare s plicies and prcedures that may affect the prvider netwrk Prvide a dispute reslutin/arbitratin prcess fr disagreements regarding cntracts and a grievance/appeal prcess fr ther disagreements Nt discriminate against the participatin, reimbursement r indemnificatin f any prvider wh is acting within the scpe f his/her license r certificatin under applicable State law, slely n the basis f that license r certificatin Nt discriminate against particular prviders wh serve high-risk ppulatins r specialize in cnditins that require cstly treatment Nt cntrl, direct, supervise nr intervene in any way in the rendering f medical and ther health services by the prvider Prcess claims timely and accurately in accrdance with cntract requirements Prvide access t accurate eligibility infrmatin telephnically r electrnically t allw eligibility verificatin Prvider Respnsibilities All AlhaCare netwrk prviders have respnsibilities t: Successfully cmplete AlhaCare s initial credentialing prcess, as well as subsequent recredentialing prcesses Verify member eligibility, current PCP assignment and third party liability (TPL) cverage n the date f service via AC Online r by calling the Prvider Services Department Maintain an accessible ffice envirnment cnducive t the regulatins and standards f the Americans with Disabilities Act (ADA) including the prvisin f assistance with interpreter (ral r sign), assistive listening devices, r ther acceptable means f alternate cmmunicatin fr language r hearing impaired individuals 12

14 Accept members fr treatment unless the prvider has requested a waiver frm this prvisin frm the health plan Prvide culturally cmpetent care based n an individual s backgrund, ethnicity, cultural beliefs and language preference Schedule appintments in cmpliance with the AlhaCare appintment accessibility standards Maintain health r medical recrds that dcument all medical r supprt services prvided t AlhaCare members in accrdance with AlhaCare s medical recrd keeping plicies Ensure cnfidentiality f member infrmatin in cmpliance with State and Federal regulatins Ntify AlhaCare f ptentially high-risk and cmplex cases r members with Special Health Care Needs, s ur Service Crdinatin staff can assist with resurces t ensure cst effective and apprpriate care fr the member Ntify AlhaCare if, in the pinin f the prvider and as defined by the Plan r the DHS, a cvered member meets the criteria fr the fllwing designatins: Members Requiring Lng-Term Services and Supprts: The prvider will assist in and supprt the Plan s effrt t identify, crdinate, and manage members wh are in need f lng-term services and supprts. Members with Supprt fr Emtinal and Behaviral Develpment (SEBD) status: The prvider will assist in and supprt the Plan s effrt t identify, crdinate, manage and/r transitin the care f members wh meet criteria fr this designatin. Submit all claims/encunters t AlhaCare within required timeframes (within 365 days f date f service), with accurate and valid cdes (i.e., ICD-9 r ICD-10 (as apprpriate, based n date f service), r DSM-4 diagnsis) and CPT/HCPCS/mdifier cdes Lk slely t the health plan fr cmpensatin fr services rendered, with the exceptin f nminal cst sharing pursuant t the Hawaii Medicaid State plan (d nt seek payment frm the member fr any cvered services prvided within the terms f the cntract). Members may have t share in the cst f health care r supprt services. This is based n their Medicaid financial eligibility. Med QUEST determines the cst sharing amunt and infrms AlhaCare f the mnthly amunt due frm the member. If a member has a cst share, they must make payments t ne f their prviders every mnth. This is usually a lng-term care facility r a hme and cmmunity based prvider. Cperate with all AlhaCare Quality Imprvement initiatives, cmplaint r grievance inquiries, cmpliance investigatins, fraud and abuse investigatins, and ther state r federal reviews, including prviding cpies f medical recrds when requested Agree t allw access upn reasnable ntice, during regular business hurs, t members recrds fr the purpses f quality imprvement, cmplaint/grievance/appeal investigatins, cmpliance investigatins, fraud and abuse investigatins and ther state r federal reviews Cmply with all applicable Federal and State laws prhibiting discriminatin against any recipient r emplyee n the grunds f race, clr, sex, sexual rientatin, gender identity, natinal rigin, age, mental and/r physical handicap r disability and nt use any plicy r practice that has the effect f discriminating n the basis f race, clr, natinal rigin, sex, sexual rientatin, gender identity, r disability. Participate in AlhaCare Crprate Cmpliance Prgram, and reprt any ptential cmpliance issues, including fraud and abuse Cmply with AlhaCare s medical service guidelines, plicies and prcedures, cntractual agreements and guidelines set frth in this manual Cmply with the federal physician self-referral law, 42 CFR Part 411, subpart J, as 13

15 applicable, which generally prhibits a physician frm referring a member fr designated health services t an entity with which the physician r a member f the physician s immediate family has a financial relatinship unless statutry r regulatry exceptin applies In the event f terminatin f prvider agreement, the prvider shall cntinue t prvide, treat, crdinate r assist in the transitin f patient care until AlhaCare makes reasnable and apprpriate arrangements fr the assumptin f such cvered services by anther prvider In the event that prvider refuses t prvide any cvered service based n mral r religius bjectins, the prvider shall ntify the cvered member wh requires such service(s) and make arrangements t refer the member t anther participating prvider wh will prvide the service Rle f the Primary Care Prvider (PCP) In AlhaCare s QUEST Integratin Prgram, every member selects r is assigned t a primary care prvider (PCP) apprpriate t the member s needs. The PCP is respnsible fr assessing the member s health care needs and prvides r directs the services t meet these needs in all aspects f care (care management, service crdinatin, delivery f primary care services, etc.). Wh May Serve as a Primary Care Prvider (PCP) The fllwing may serve as Primary Care Prviders: Primary Care Prviders wh are licensed in the State f Hawaii as either an M.D. (Dctr f Medicine) r a D.O. (Dctr f Ostepathy) and be either a Family Practitiner, General Practitiner, General Internist, Pediatrician, Geriatrician r Obstetrician/Gyneclgist. Advanced Practice Registered Nurses with prescriptive authrity (APRN-Rx) wh are licensed and registered by the state t practice as a nurse practitiner in accrdance with State Law and sectin subchapter 16, HAR, are certified as a nurse practitiner by a natinal certifying bdy that has established standards fr a nurse practitiner, and pssesses a master s degree in nursing. Physician s Assistants recgnized by the State Bard f Medical Examiners as a licensed physician assistant. AlhaCare may allw specialists r ther health care practitiners t serve as PCPs fr members with chrnic cnditins prvided that the member has selected a specialist with whm he r she has a histrical relatinship as his r her PCP. AlhaCare will cnfirm that the specialist agrees and understands the respnsibilities f the PCP. Such cnfirmatin may be in writing, electrnically, r verbally. AlhaCare will mnitr the perfrmance f a specialist wh is serving as a PCP t ensure that PCP respnsibilities are met. AlhaCare will allw a clinic t serve as a PCP as lng as the clinic is apprpriately staffed t carry ut PCP functins. PCP Respnsibilities As the key prvider fr AlhaCare members, the PCP has additinal respnsibilities: Serve as an nging surce f primary care fr the member, including supervising, crdinating, and prviding all primary care services. The member s medical recrd shuld include a treatment plan that dcuments the prvider s assessment and services t address and treat the member s medical cnditin(s). 14

16 Being primarily respnsible fr crdinating ther healthcare services furnished t the member, including crdinating and initiating specialty care (including in and ut f netwrk), maintaining cntinuity f care; and maintaining the member's medical recrd (this includes dcumentatin f services prvided by the PCP as well as any specialty services). Maintain cntinuity f care fr members by crdinating all care, and fllw-up treatment f the member. Cllabrate with AlhaCare t develp a care plan that facilitates integrated, crdinated, and cntinued care. Cmplete an initial histry and physical assessment n all assigned members n later than the third ffice visit. Hnr member requests fr secnd pinin, when reasnable, and crdinate services perfrmed by anther specialist r ancillary prvider and prir authrizatin requests that may be required. Refer members t a netwrk specialist and manage and crdinate the member s specialty care t avid duplicated, unnecessary r fragmented care. Cmmunicate AlhaCare s utilizatin review decisin t the member. Prvide preventive health services, nging health maintenance and disease preventin services accrding t established clinical guidelines and best practices. Prvide timely prvisin and dcumentatin f Early and Peridic Screening, Diagnsis, and Treatment (EPSDT) health care services, including screenings, preventive care and apprpriate services prvided by specialists an ancillary prviders fr members under the age f 21. If applicable, and where cntractually stated, maintain hspital admitting privileges at a licensed acute care hspital within the service area, r in the absence f direct hspital privileges, have n file with AlhaCare, a written agreement utilizing anther AlhaCare prvider fr admissin and treatment privileges, r have an arrangement with a hspital that uses hspitalists t admit patients. Identify backup cverage when unavailable during regular ffice hurs (i.e., ut f twn r n vacatin) and prvide written ntice t AlhaCare f the cverage arrangements including the name f the cvering prvider and the dates f cverage. The backup prvider des nt need t be an AlhaCare participating prvider. The use f a cvering prvider wh is nt participating with AlhaCare is subject t apprval, and at minimum the prvider must be eligible fr participatin in the Hawaii Medicaid prgram. When making cverage arrangements, please ensure that the cvering prvider understands the payment arrangement under which he/she will be reimbursed fr submitted claims while prviding cverage. All cvering prviders wh are nt a part f AlhaCare s netwrk f participating prviders will be required t cmplete and submit a ne-page prfile t the Prvider Relatins Department. Prvide telephne access 24 hurs a day, 7 days a week. An answering machine r answering service must indicate hw t cntact yu r an n-call prvider in a medical emergency. It shuld nt direct the member t g t the Emergency Rm fr nn-emergent care. Fllw AlhaCare s plicies when referring members t specialists r ther prviders (refer t Sectin 6, under Utilizatin Management: Prir Authrizatin and Ntificatin ). Cmply with Federal and State law regarding advance directives fr adult members. At a minimum the prvider shall: Maintain written plicies regarding a member s rights t make decisins abut their medical care. 15

17 PCP Patient Capacity Dcument in the medical recrd whether r nt the member has executed an advance directive, and include a cpy in recrd if the member has dne s. Nt discriminate against a member because f member s decisin t execute r nt execute an advance directive. Prvide staff educatin n issues cncerning advance directives. Individual PCPs nt practicing within a clinic are subject t a maximum AlhaCare QUEST Integratin member panel size f 300 per DHS requirements. Once an individual PCP has met their maximum panel size f 300, members may cntinue t chse that PCP; hwever, AlhaCare will n lnger include that PCP fr aut-assignment. A waiver frm this requirement may be granted based n gegraphic lcatin, specialty and member needs. Please cntact yur Prvider Relatins representative fr mre infrmatin regarding a waiver. AlhaCare will mnitr patient capacity f its PCP netwrk, t ensure that there is acceptable access t medical services fr AlhaCare members. Such mnitring may include: The ttal number f AlhaCare members assigned t the practice The ttal number f cmmercially-based patients assigned t the practice The ttal number f private-pay patients treated at the practice In additin t the verall vlume f patients seen n an average weekly r mnthly basis, AlhaCare may factr in the number f health care prfessinals (physicians and mid-level prviders) utilized within the PCP ffice. Member Request t Change PCP Members may request t have their PCP changed due t gegraphic restrictins (i.e. mving t far away t see their current PCP), wanting t see the same PCP as ther family members, r ther reasns. A member can call AlhaCare Member Services t change their PCP. The change will take place n the same day the member calls with the change request and the member will receive a new member ID card with the new PCP indicated. There are n limits t the number f times a member may change their PCP. Requesting PCP Re-Assignment At times, it may be necessary fr a PCP t request a member re-assignment t anther PCP. PCPs may request member re-assignment fr a variety f reasns, including but nt limited t: abusive, disruptive r dangerus behavir tward ffice persnnel; nncmpliance with treatment recmmendatins; repeated failure t keep r cancel scheduled appintments; family cntinuity. The PCP must send a certified letter t the member infrming him r her f the intent t terminate the relatinship and that care will be extended fr 15 days. This will allw time t find anther prvider. The PCP is asked t prvide urgent care during thse 15 days r until a new prvider is identified. A cpy f the certified letter and any additinal details f the prblem must be mailed r faxed t the AlhaCare Custmer Service Manager. In cases f extremely serius r dangerus situatins, the PCP shuld call AlhaCare and request expedited cnsideratin. AlhaCare s Member Services staff will assist the member in selecting anther PCP and will ntify the member by phne r in writing f the new PCP assignment. A new member ID card will be sent t the member with the new PCP indicated. The member s failure t exercise the ptin f chsing a new PCP shall result in autmatic assignment f the member t anther PCP by the end f the 15-day perid. The new PCP will be cntacted t btain 16

18 his r her apprval fr the member assignment. The member will be ntified by phne r in writing f the new PCP assignment and a new ID card will be sent t the member with the new PCP indicated. Cpies f all crrespndence are retained by the Member Services Department. Immediate Transfer f Member AlhaCare will immediately transfer a member t anther PCP, health plan, r prvider if the member s health r safety is in jepardy. Specialist and Ancillary Prvider Rles In mst situatins, members access t specialty and ancillary care services are crdinated by their PCP. T facilitate the prvisin f health care and prmte timely prcessing f claims, specialty care and ancillary prviders are asked t bserve the fllwing additinal respnsibilities: Cmply with AlhaCare s prir authrizatin plicies fr nn-pcp services (see Medical Prir Authrizatin and Ntificatin sectin f this manual). Crdinate the member s care with the PCP and prvide the apprved specialty r ancillary care. As a standard f care, AlhaCare expects the specialist t reprt in writing t the PCP the findings and recmmendatins fr additinal care after the visit. If additinal visits, testing, r surgeries are recmmended, the specialist will fllw AlhaCare s Prir Authrizatin plicies and prcedures as reflected within this manual. (see Prir Authrizatins and Ntificatin sectin f this manual) Identify backup cverage fr AlhaCare members in active treatment when yu are unavailable during regular ffice hurs (i.e., ut f twn r n vacatin) and prvide written ntice t AlhaCare f the cverage arrangements including the name f the cvering prvider and the dates f cverage. The backup prvider des nt need t be an AlhaCare participating prvider. The use f a cvering prvider wh is nt participating with AlhaCare is subject t apprval, and at minimum the prvider must be eligible fr participatin in Medicaid prgrams. When making cverage arrangements, please ensure that the cvering prvider understands the payment arrangement under which he/she will be reimbursed fr submitted claims while prviding cverage. If yu are a capitated prvider and the cvering prvider submits a claim fr a capitated service, the claim will be prcessed and reimbursed as a capitated encunter and the cvering prvider will lk t yu fr reimbursement; if yu are a fee-fr-service prvider the cvering prvider will be paid fee-fr-service. All cvering prviders wh are nt a part f AlhaCare s prvider netwrk will be required t cmplete and submit a ne-page prfile t the Prvider Netwrk Department. 17

19 Credentialing/Recredentialing The purpse f credentialing is t ensure that AlhaCare members receive medical, behaviral health care, and Lng-Term Supprts and Services (LTSS) frm qualified prviders. Prvider credentialing is a quality initiative that assures prviders have met apprpriate levels f educatin, training, certificatin and licensing and are qualified t deliver care t members. AlhaCare has established prcedures t credential qualified prviders interested in jining ur netwrk. The credentialing prcess is based n standards develped by the Natinal Cmmittee fr Quality Assurance (NCQA). All netwrk prviders must be credentialed by either AlhaCare r their parent facilities befre prviding services t AlhaCare members. Thse prviders cmpleting credentialing thrugh AlhaCare must submit a credentialing applicatin that cntains infrmatin pertinent t evaluating the prvider s ability t prvide care. Applicatin infrmatin is verified by an independent agency. In additin, an ffice site review and medical recrd review will be cnducted by AlhaCare fr specific prvider categries prir t the AlhaCare Credentials Cmmittee rendering a credentialing decisin. AlhaCare credentialing plicy: 1. AlhaCare ensures that prvider credentialing/re-credentialing is cnducted in a nndiscriminatry manner. AlhaCare will nt discriminate against any prvider requesting netwrk participatin n the basis f the applicant s race, ethnic/natinal identity, gender, age, sexual rientatin, r the type f diagnses r prcedures the prvider specializes in. 2. AlhaCare has the sle right and respnsibility t determine netwrk need based n existing access and availability standards, participatin criteria and ther business and cntractual requirements f AlhaCare subject t market r gegraphic needs. If a need des nt exist, AlhaCare reserves the right nt t accept the applicatin. In the event that an applicant practitiner des nt meet participatin criteria, the applicatin will nt be cnsidered. 3. The credentialing prcess verifies that prviders have the legal authrity, training, experience and facilities required t prvide apprpriate care t AlhaCare members. The infrmatin btained frm the prvider is verified thrugh a primary surce as recgnized by accrediting bdies t ensure that the infrmatin is accurate and current. 4. Explicit minimum criteria fr prvider participatin with AlhaCare are delineated and each prvider s file cntains sufficient dcumentatin that the criteria are evaluated in the credentialing prcess. 5. AlhaCare will ntify prviders abut infrmatin btained during the credentialing prcess that varies substantially frm the infrmatin prvided t the Plan by the prvider. 6. In accrdance with AlhaCare plicies cncerning infrmatin practices and cnfidentiality, the infrmatin gathered will be treated in a cnfidential manner and the disclsure f such infrmatin will be limited t thse parties mandated t receive such infrmatin by law. 7. All credentialing verificatins and the attestatin signature must be current within 180 days at the time the Credentials Cmmittee apprves the credentialing applicatin. 8. Recredentialing f prviders ccurs every 3 years (36 mnths frm the date f the last credentialing apprval) and will fcus n verificatin f specific credentialing infrmatin, and additinal cmpnents including member cmplaints and quality issues. The prvider must cntinue t meet AlhaCare standards in all areas. The recredentialing prcess must be cmpleted within 36 mnths f the date f the last credentialing apprval. 18

20 9. AlhaCare is slely respnsible fr making initial credentialing and recredentialing decisins based n the apprval f the practitiner by the AlhaCare Credentials Cmmittee. 10. Prviders will be ntified f the credentialing r recredentialing decisin rendered by the AlhaCare Credentials Cmmittee within 10 calendar days f the decisin. In certain cases, prvisinal credentialing may be granted fr a maximum f 60 days, with a gal f cmpleting the full credentialing prcess by the end f the 60 th day. AlhaCare s Subcntracting Plicy The AlhaCare Prvider Agreement specifies that a prvider may nt subcntract duties under the cntract withut AlhaCare s written cnsent. If permissin is granted, the prvider must submit a cpy f the subcntract t us s that we may ensure that its language cmplies with state and federal requirements. A prvider remains fully respnsible fr all duties and bligatins under the cntract and must ensure that subcntractrs perfrm accrding t apprpriate standards, laws and regulatins. If yu are cnsidering entering int a subcntractr agreement, please call the Cntract Manager at (808) t discuss yur bligatins under the AlhaCare Prvider Agreement. Medical Recrds Requirements (fr PCPs, Specialists, and Ancillary Prviders fr Credentialing and Onging QI Reviews) Fr credentialing purpses, the plicy requires an assessment f medical recrd-keeping practices and an nsite visit be perfrmed fr each f the prvider s service lcatins that did nt underg such an evaluatin in the past. This applies t each new PCP, OB/GYN specialist r high-vlume Behaviral Health prvider. AlhaCare cnsiders high-vlume Behaviral Health prviders t be any prvider wh practices in a clinical setting that ffers a cntinuum f care with an array f services (i.e. utpatient and inpatient services). The value f rganized, accurate, detailed and cmprehensive patient medical recrds is a fundamental part f delivering and dcumenting quality, timely and medically necessary patient care. In accrdance with NCQA guidelines and ur credentialing plicy, an evaluatin f a practitiner s medical recrd keeping practices is necessary in rendering an initial credentialing decisin. Recrd reviews are als perfrmed t evaluate AlhaCare quality initiatives. Fr example, pediatric recrds are reviewed t assess cnfrmance with EPSDT requirements and PCP recrds are reviewed t assess Preventive Health care guidelines. AlhaCare hlds its cntracted prviders t medical recrd keeping standards in accrdance with cntractual bligatins and any State and Federal laws. Belw are standards fr prvider dcumentatin and maintenance f members medical recrds. These standards are mnitred thrugh the AlhaCare review prcess. Medical Recrd Standards: 1. Medical recrds are maintained in a current, detailed, rganized and cmprehensive manner that cnfrms t gd medical practice and permits effective prfessinal medical review and cmpliance audit prcesses. 2. Medical recrds are systematically rganized and legible t smene ther than the writer, and reflect all aspects f patient care. 3. All medical recrds must be maintained and accessible t AlhaCare, ur representatives, and the representatives f the Med-QUEST Divisin. Upn reasnable ntice and during prvider s regular business hurs, AlhaCare and the Med-QUEST Divisin have the right t prmpt access t inspect, review and make cpies f all recrds maintained by the prvider with respect t all services rendered and payments received by the prvider frm all surces 19

21 fr Cvered Services rendered t members during the term f the prvider s agreement with AlhaCare. 4. AlhaCare, DHS and any applicable state r federal agencies r their designees shall have the right t cnduct peridic audits f such recrds fr quality reviews, fraud and abuse investigatins r ther purpses that may be delineated in state r federal regulatins. In accrdance with HIPAA requirements, the prvider will make requested medical recrds available t the afrementined withut patient cnsent. 5. The medical recrd f a member is the prperty f the prvider wh generates the recrd. Members are entitled t a cpy f their recrds. When members change PCPs, their medical recrds will be frwarded t the new PCP within 7 business days frm receipt f a written request. Prviders are required t make the medical recrds f AlhaCare patients available t requesting hspitals, specialists, lng term service and supprt prviders, and new PCPs at n charge t the member. 6. All medical recrds are maintained in a cnfidential manner. Access t a member s medical recrd must be restricted nly t individuals directly invlved in the member s treatment r mnitring f the quality f care, r by ther individuals specifically authrized r permitted by law t have such access. 7. Medical recrds are preserved and maintained fr a minimum f 7 years frm the last date f entry in the recrds. Fr minrs, prviders will preserve and maintain all medical recrds during the perid f minrity plus a minimum f 7 years after the age f majrity. Medical recrds shuld cntain the fllwing cmpnents: All entries are legible, signed and dated, and the prvider is identified n each entry Each page f the paper r electrnic recrd includes the patient s name r ID number Demgraphic infrmatin including name, address, date f birth, sex, marital status, next f kin, hme and wrk telephne numbers, and emplyment status, if applicable Any adverse drug reactin and/r fd r ther allergies, r the absence f knwn allergies, are recrded in a prminent area f the medical recrd Current medicatins are nted/listed and updated apprpriately There is an apprpriate past medical histry in the recrd that is easily identified including serius accidents, hspitalizatins, peratins and illnesses. Fr children less than three years ld the medical recrd shuld als include a prenatal and birth histry. All pediatric recrds include a cmpleted immunizatin recrd r dcumentatin that immunizatins are up t date Fr each patient encunter: The chief cmplaint r purpse f the visit is dcumented Current prblems, including health maintenance cncerns are dcumented A physical examinatin apprpriate t the patient s cnditin is dcumented Labratry r ther studies rdered as apprpriate Diagnses r clinical impressins are dcumented cnsistent with findings There is a dcumented care plan There is dcumentatin f treatments, prcedures and tests with results Recmmendatins and instructins t patient are nted, including a date fr return visit r ther fllw-up plan fr each applicable encunter Reasns fr and results f specialist and ancillary prvider services are dcumented 20

22 Cnsultant summaries, lab and ther imaging study results reflect prvider review Dcumentatin f fllw-up care including telephne calls Dcumentatin that unreslved cncerns frm previus visits are addressed at subsequent visits Hspitalizatin if applicable t include discharge summaries fr all hspital admissins Emergency care rendered t include recrds and discussin f requirements fr physician fllw-up Infrmatin n ancillary services Fr patients 12 years and lder, apprpriate ntatins cncerning the use f tbacc, alchl, and ther substances are t be dcumented. Apprpriate health management and cntinuity f care are clearly reflected in the medical recrd. Where apprpriate, evidence f fllw-up t previus encunters, hspital discharge summaries, dcumented services and results prvided by specialist, and dcumentatin f emergency encunters and fllw-up are recrded. Fr patients 18 years f age r lder, dcumentatin as t whether the patient has executed an advance directive, including an advance mental health care directive. During initial credentialing, the medical recrd review is nt a review f actual clinical dcumentatin. Rather, it is a review f the cmpnents and frms used t recrd a patient s clinical infrmatin. The medical dcumentatin shuld be rganized, cmprehensive and detailed. They shuld include patient identificatin, and demgraphics and clinical aspects f care. AlhaCare s benchmark fr cmpliance with credentialing-related medical recrd reviews is 100%. Fr quality review purpses nt related t credentialing, AlhaCare is required t peridically review the medical charts fr specific categries such as EPSDT and Maternity Care. Prir t a review, we will cntact yur ffice t let yu knw which charts will be reviewed, and t establish a review date and time. Fr the clinical review, if the prvider desn t have any current AlhaCare members, he/she will be asked t select five medical recrds f chice and blind the recrds fr cnfidentiality purpses. Fr thse prviders with current AlhaCare patients, a randm selectin f ten members is made frm claims/encunter data. Fr a high-vlume PCP, with mre than 300 members, a minimum f 20 recrds will be reviewed. AlhaCare s benchmark fr cmpliance t clinical reviews is 80%. Fr prviders wh scre 80% r better, we will send a letter indicating the results. All future reviews will be crdinated with any quality assurance/imprvement needs r as quality f care issues arise. AlhaCare will wrk with prviders scring belw 80% and prvides feedback t prviders f ur findings. Prviders nt in cmpliance at the time f review will be asked t submit a written actin plan and are scheduled fr a fllw-up review within six mnths. Prviders wh d nt submit a written actin plan and/r are nt in cmpliance n the secnd review will be presented t the Credentials Cmmittee and/r Quality Imprvement Advisry Cmmittee fr cnsideratin f remedial actins. Fr serius deficiencies, the time interval fr fllw-up review and/r the number f fllw-up reviews prir t referral t the AlhaCare Credentials Cmmittee r the Quality Imprvement Advisry Cmmittee may be reduced, at the Medical Directr s discretin. Appintment and Accessibility Standards Ensuring that AlhaCare members have availability and access t timely medical care and supprtive services is a fundamental quality principle. Adequate appintment availability ensures that PCPs are able t accmmdate ur members in a timely manner, based n the urgency f the patient s medical 21

23 cnditin r have an alternative prvider wh can render care in the event that yu are unavailable. Appintment availability is als ne f the dimensins AlhaCare examines t determine netwrk adequacy. AlhaCare will maintain accessibility t an adequate prvider netwrk, taking int accunt reasnable distance and travel times fr members. We mnitr appintment availability and accessibility by reviewing cmplaints, cnducting member satisfactin surveys and Appintment and Accessibility surveys. We als perfrm ffice site reviews, cnduct clinical reviews fr quality f care and review medical recrds. In additin, AlhaCare cnducts secret shpper phne calls that are measured against the member s respnses frm the Appintment and Accessibility survey. When issues arise, AlhaCare cntacts prviders t determine whether smething is preventing timely access t medical appintments. If appintment standards are nt being met, a crrective actin plan is initiated. AlhaCare als evaluates whether accessibility barriers may be adversely affecting appintment availability. If it is determined that barriers exist, AlhaCare wrks cllabratively with the prvider s ffice t crrect the prblem. Prviders are required t meet the fllwing appintment standards based n levels f care: Primary Care Prvider (PCP) and Specialist Appintments: Appintments within 24 hurs fr urgent care and fr PCP pediatric sick visits Appintments within 72 hurs fr PCP adult sick visits Appintments within 21 days fr PCPs (rutine visits fr adults and children) Appintments within 4 weeks fr visits with a specialist r nn-emergency hspital stays r f sufficient timeliness t meet medical necessity Emergency Care Immediately Member may receive services that are urgent in nature at any FQHC withut prir authrizatins. The Health Plan requires the FQHC t refer the patient back t and infrm the assigned PCP, r help the member select a new PCP. Prenatal Care Appintments: First trimester: within 14 days Secnd trimester: within 7 days Third trimester: within 3 days High Risk OB: within 3 days f identificatin f high risk Behaviral Health: Appintments within 24 hurs fr urgent care Appintments within 21 days fr rutine nn-urgent care Emergency Care Immediately Prvider must infrm members that they shuld g t the Emergency Rm if needed, either by answering service r a recrded message. Backup cverage must be arranged when the prvider is nt available during regular hurs (i.e., ut f twn r n vacatin). The backup prvider des nt have t be a participating AlhaCare prvider. The use f a cvering prvider wh is nt participating with AlhaCare is subject t apprval prir t the prvider s leave f absence/vacatin. At a minimum, the cvering 22

24 prvider must be eligible fr participatin in the Hawaii Medicaid prgram. T ensure timely claims prcessing and payment (if applicable), AlhaCare must be infrmed regarding alternative cverage. Plan shall ensure that emergency rm services are available fr immediate care fr emergency medical situatins withut prir authrizatin [available twenty-fur (24) hurs a day, seven (7) days a week]. Reprting Requirements All prviders are required t adhere t the fllwing reprting requirements: Submit claims/encunters t AlhaCare in an accurate and timely manner. Timely claim submissins means that claims (either hard-cpy r electrnic) are submitted within 365 days f the last date f service. Ntify AlhaCare if a member is r may be eligible fr lng-term services and supprts r disability; Ntify AlhaCare if a member has had a qualifying circumstance that may affect their QUEST Integratin membership; Ntify AlhaCare when a member has ther insurance r third party liability (TPL). The QUEST Integratin prgram is always deemed as the payer f last resrt. AlhaCare is cntractually bund t pursue ther existing primary payers prir t paying a claim; Ntify AlhaCare when a member is diagnsed as pregnant. We will, in turn, ntify Med- QUEST t ensure apprpriate QUEST Integratin cverage; Ntify AlhaCare f a newbrn. We will, in turn, ntify Med-QUEST t ensure timely enrllment f the newbrn int the QUEST Integratin plan; Ntify AlhaCare when yu are ging t be away and ensure that cverage arrangements have been made; Ntify AlhaCare if yu have bjectins t perfrming any health services that are within the scpe f yur respnsibilities and make arrangements thrugh the AlhaCare s prir authrizatin prcess fr members t receive thse services frm anther prvider if required; Ntify AlhaCare if yu are invlved in a malpractice r ther actin that has bearing n yur ability t prvide health services r impact the scpe f yur practice; Ntify AlhaCare f ther circumstances as stipulated in yur Prvider Agreement with AlhaCare. Marketing Guidelines AlhaCare is subject t QUEST Integratin cmmunicatin and marketing guidelines. All marketing material and member-related cmmunicatins are reviewed and apprved by Med-QUEST prir t distributin. All member-related cmmunicatins include a Language Blck that infrms the member that the dcument cntains imprtant infrmatin and directs the member t call AlhaCare t request the dcument in an alternative language r t have it rally translated. The Language Blck is printed in English and nn-english languages identified by Med-QUEST: English Chinese (Traditinal) Krean Vietnamese Ilcan 23

25 Prviders are subject t cmpliance with the QUEST Integratin marketing guidelines. Any marketing material develped and distributed by prviders relating t the QUEST Integratin prgram must be submitted AlhaCare t submit t Med-QUEST fr apprval prir t distributin. Prviders must allw equal access t all QUEST Integratin plans t display plan-related marketing materials in their ffice (such as a sign indicating participatin in the netwrk f a specific QUEST Integratin health plan). Fraud and Abuse As a Medicaid Managed Care Organizatin, AlhaCare is required by state and federal law t have a frmal Fraud and Abuse Prgram. This prgram addresses the preventin, detectin, and reprting f fraudulent and abusive situatins. Such situatins include, but are nt limited t: the abuse, neglect, r explitatin f any individual receiving r prviding QUEST Integratin eligible services; and the lss, theft, misapprpriatin r verpayment f state and federal Medicaid funds Fraud is an intentinal deceptin r misrepresentatin made by a persn with the knwledge that the deceptin culd result in sme unauthrized benefit t him/her r sme ther persn. It includes any act that cnstitutes fraud under applicable federal r state law. Abuse means practices that are incnsistent with sund fiscal, business, r medical practices, and result directly r indirectly in an unnecessary cst t the Medicaid prgram, r in reimbursement fr services that are nt medically necessary r that fail t meet prfessinally recgnized standards fr health care. It als includes beneficiary practices that result in unnecessary cst t the Medicaid prgram. Cmmn Types f Prvider Fraud and Abuse Accepting payments r ther unlawful remuneratin fr rdering r prescribing certain supplies r drugs Billing fr items r services nt prvided Billing fr drug samples received fr free Falsifying infrmatin t justify payment f a nn-cvered service Prviding substandard r lw quality care, r expired supplies r drugs Ordering and/r billing fr medically unnecessary services Pr r incmplete dcumentatin fr services billed Cmmn Types Pharmacy Fraud and Abuse Prviding less than the prescribed quantity but billing the health plan fr the fully-prescribed amunt Altering the prescriptin withut the prescriber s permissin Cmmn Types f Member Fraud and Abuse Letting anther persn t use the member s ID card Selling r giving smene else supplies, equipment r drugs paid fr by AlhaCare Theft r alteratin f prescriber s prescriptin pad Failure t reprt ther medical r drug cverage Misrepresenting facts cncerning a medical cnditin t btain higher dses and r unnecessary drugs. Prviders are required t participate in AlhaCare s Fraud and Abuse Prgram, which includes prviding training t yur staff, and reprting instances f suspected fraud and abuse cmmitted by anyne receiving payment r services frm the Medicaid prgram including a member, anther prvider r prvider grup, facility r supplier. Annymus submissins can be accepted and ample detail shuld be 24

26 prvided t ensure that an apprpriate and effective investigatin can ensue. Reprts f suspected fraud and abuse are cnfidential and shuld be sent t: AlhaCare Attentin: Crprate Cmpliance Officer 1357 Kapilani Blvd, Suite 1250 Hnlulu, HI AlhaCare takes many measures t detect false claim submissins and prevent incrrect payments, and initiates a full investigatin if any irregularities are fund. Current methds used t avid fraudulent payments include, but are nt limited t: Autmated edits in the claim system t deny duplicate claims Member identity validatin by matching the AlhaCare ID number and birth date as prvided by Med-QUEST t what is submitted n the claim frm Review f claims fr unbundling f services Randm verificatin with members as t whether billed services were furnished Retrspective anti-fraud and recvery services prvided by Optum, a subcntractr fr AlhaCare that perfrms peridic data analytics t identify irregular billing patterns r strategies Under ur QUEST Integratin cntract with the State f Hawaii, AlhaCare is required t reprt all incidents f suspected fraud and abuse t the state Medicaid agency within thirty (30) days f discvery. Penalties fr false claim submissin may include fines f $5,000 but nt mre than $10,000 plus three times the amunt f damages fr all federal vilatins and state claims nly if the claim amunt is $5,000 r mre. Fr claims under $5,000, vilatrs will be required t pay interest at the maximum legal rate n the excess amunts and $1,000 fr each fraudulent claim. Any persn r entity with evidence f fraud may file a qui tam (whistleblwer) lawsuit n behalf f the gvernment. Under these prvisins, this persn, r persns, may be eligible t receive between 15 and 30 percent f Federal and State prceeds recvered. The federal and state law prhibits retaliatin against anyne wh in gd faith reprts and/r participates in an investigatin f a false claim vilatin. Anyne wh feels they have been unlawfully retaliated against shuld cntact the state r federal gvernment immediately. 25

27 SECTION 4 QUEST INTEGRATION PROGRAM AND BENEFITS Prgram Intrductin The QUEST Integratin Prgram is a statewide Medicaid demnstratin prject (Sectin 1115 waiver) that prvides cverage fr medical, behaviral health and lng-term services and supprts fr eligible Hawaii residents thrugh cntracted health plans, such as AlhaCare. QUEST Integratin is administered by the Department f Human Services, Med-QUEST Divisin and is financed thrugh the State f Hawaii and federal Centers fr Medicare and Medicaid Services (CMS). Fr detailed infrmatin regarding Lngterm Services and Supprts benefits please see Sectin 10 Lng Term Services and Supprts later in this manual. Administratin f QUEST Integratin Benefits In the administratin f QUEST Integratin benefits, AlhaCare requires that certain services be prir authrized and/r underg cncurrent r retrspective review. The reviews ensure that the services are cvered health interventins and meet the definitin f medical necessity under 432E-1.4 f the Hawaii Revised Statutes. See Appendix C fr the text f HRS 432E-1.4. During each review, a decisin is made regarding the medical necessity f services being requested, prescribed r rendered. AlhaCare s determinatin is based n the medical infrmatin submitted by the prvider, r available in medical recrds. AlhaCare uses natinally develped clinical criteria (such as InterQual Level f Care Criteria, InterQual Imaging Criteria, InterQual Prcedures Criteria, InterQual Level f Care Behavir Health Criteria, and American Sciety f Addictive Medicines) fr systematic medical necessity determinatins. Fr prir authrizatin requests r cncurrent review, AlhaCare requests that the treating physician r ther licensed prvider supply additinal infrmatin t assist AlhaCare in the determinatin f medical necessity. Fr retrspective review, payment denials may be determined by the review f recrds received. In these cases, prviders have the pprtunity t submit additinal infrmatin and request recnsideratin thrugh the grievance and appeals prcess. Peer review is available if the prvider and AlhaCare s Medical Directr d nt agree n whether a health interventin is medically necessary. AlhaCare s decisin is a determinatin f benefit cverage and payment nly, and nt a determinatin f whether services shuld be rendered. The decisin t prvide medical services is made by the prvider using his/her prfessinal judgment. Sme benefits have established limits fr the benefit year(s). The benefit year runs January 1 st thrugh December 31 st. 26

28 Primary and Acute Medical Services NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Medically necessary emergent grund and air Ambulance Services ambulance transprt services. Air (fixed wing and air) ambulance N limit Grund ambulance Chemtherapy Outpatient hspital services fr radiatin therapy and related services, supplies and N limit drugs. Cgnitive Rehabilitatin Educatin and training t help with daily activities after a brain injury N limit Diagnstic Tests Diagnstic and therapeutic radilgy and Office and Outpatient imaging Pathlgy/labratry services Other diagnstic services/tests N limit Diabetic Supplies Lancets Syringes N limit Test strips Dialysis Dialysis in a hspital, renal dialysis facility r hme setting N limit Durable Medical Equipment and Medical Supplies Emergency Medical Services and Pst Stabilizatin Services Family Planning Services Equipment and supplies fr medical purpse such as: Cntinence supplies Crutches and canes Orthtic devices Oxygen tanks and cncentratrs Pacemakers Prsthetics devices Surgical dressings Ventilatrs Wheelchairs Medical emergency care and care after an emergency t keep member stable. May include: Emergency eye and hearing exams Emergency rm services Pathlgy/lab services, diagnstic tests, radilgy services, medical supplies and drugs within the ER visit Physician services prvided during the ER visit Surgery and anesthesilgy services prvided during the ER visit Educatin and cunseling Family planning drugs and supplies Office visits Pregnancy testing N limit N limit N limit 27

29 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Cmprehensive examinatins Fster Care/Child Develpment and Behaviral Assessment Welfare Services (CWS) Services in additin t EPSDT N limit Children Medicatin Pre-placement physicals Habilitative Services Hearing Services Hearing Aids Hearing Aids Hearing Services Fitting/ Orientatin Hearing Services Hearing Aid Check Medically necessary services and devices t develp, imprve r maintain skills such as: Audilgy services Occupatinal therapy Physical therapy Speech therapy Visin services Fitting/rientatin Hearing aid check N limit Des nt include cverage fr rutine visin Limited t ne (1) every twenty fur (24) mnth perid Limited t tw (2) every three (3) years fr Keiki Limited t ne (1) every three (3) years fr adults Limited t fur (4) per ne (1) year perid fr Keiki 0-3 years ld Limited t tw (2) every three (3) years fr Keiki 4-20 years ld Hearing Services Rutine Hearing Exams Limited t ne (1) every three (3) years fr adults Hearing exam Limited t ne (1) exam per year 28

30 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS N limit fr keiki Hme Health Care Hspice Care Hysterectmy Services Immunizatins Audilgy and speech pathlgy Hme health aide Hme health visits Medical supplies and durable medical equipment Skilled nursing Therapeutic rehab services such as physical and ccupatinal therapy Hspice prvides care t terminally ill patients wh are nt expected t live mre than six (6) mnths. Children under age twenty-ne (21) may receive treatment t manage r cure diseases while cncurrently receiving hspice care. Diphtheria and tetanus Influenza Pneumcccal Other medically necessary vaccines Hme health visits fr adults wh are hmebund include: Daily visits fr hme health aide and nursing services in the first tw (2) weeks if part f care plan N mre than three (3) visits per week fr each service in the third t seventh week f care N mre than ne (1) visit per week fr each service in the eighth t fifteenth week f care N mre than ne (1) visit every ther mnth fr each service frm the sixteenth week f care Additinal visits are based n medical necessity N limit Apprpriate State frm must be cmpleted by prvider and signed by member wh must be 21 years ld at time f cnsent. N limit 29

31 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Diagnstic tests, lab and radilgy Maternity and newbrn care Medical supplies, equipment and drugs Nursing care Inpatient Hspital Care Physical therapy, ccupatinal therapy, audilgy and speech-language pathlgy Medical and Surgical N limit services Services Physician visits and services Pst stabilizatin services Rm and bard Surgery and anesthesilgy services Other medically necessary services Intentinal Terminatin f Pregnancy (ITOP) Elective terminatin f pregnancy (abrtin) is nt paid under the QI plan; it is paid under the Medicaid FFS prgram. Refer prvider t Xerx/ACS (State s claims prcessing agent) fr infrmatin and claims submissin. Cntact infrmatin: r Cntact infrmatin fr cvered drugs: Interpretatin/ Translatin Services Kapilani Cleft Palate and Cranifacial Clinic Medical Nutritinal Therapy (MNT) Services t help a member talk t us r their dctr/caregiver Services that we prvide s that a member can have infrmatin in their preferred language Audilgist services Services prvided by specialists in dentistry, ral surgery and ther specialties that treat defects f the cleft palate, skull and/r face Speech and feeding specialist services An evidence-based nutritinal service prvided by a registered dietitian t help manage certain diseases and cnditins Includes cmprehensive nutritinal assessment, pssible nutritinal interventin, and mnitring and an evaluatin f prgress Direct the member t their prvider if there are questins regarding ITOP cverage under Medicaid s FFS prgram. N limit N limit Must be rdered by member s PCP. Limited services: 3 hurs first year 2 hurs annually thereafter 30

32 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Nutritin Cunseling Diabetes self-management training Nutritin cunseling fr besity Nutritin cunseling fr ther metablic cnditin if medically necessary Prvided by a licensed dietitian Fr diabetes, limited services per benefit year per AC Medical Plicy Medical and surgical services perfrmed Oral Surgery by an ral surgen r physician in a medical facility (e.g., inpatient hspital and N limit Outpatient Hspital Services Outpatient Services and Ambulatry Surgical Center Practitiner (ther than Physician) Services Physician Services Pdiatry Services ambulatry surgical center). Diagnstic services Medical supplies, equipment and drugs Minr surgical prcedures Sleep labratry services Surgeries perfrmed in a free-standing r hspital ambulatry surgical center Therapeutic services including chemtherapy & radiatin Outpatient surgical r ther interventinal prcedures Other medically necessary services Urgent care services Behavir health prvider, such as psychlgists Certified nurse midwife services Certified substance abuse cunselrs Licensed advanced practice registered nurse services including family, pediatric and psychiatric health specialists Marriage and family therapists, Mental health cunselrs Physician ffice and utpatient facility visit Physician visits in the hme r ther residential setting Services fr the ft and ankle such as: Bunin remval Diabetic ft care in hspital r utpatient facility Surgical prcedures N limit N limit N limit N limit 31

33 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Breast pump (rental r purchase) Delivery f the infant Diagnstic tests Inpatient hspital services Labratry Pregnancy-Related Lactatin cunseling Services Services fr Outpatient hspital services related t pregnancy Pregnant Wmen and Physician services Expectant Parents Prenatal care N limit Pstpartum care and prenatal vitamins Radilgy Treatment f missed, threatened and incmplete abrtins Other practitiner Services Prescriptin Drugs Preventive Services Adult (21 years r lder) Preventive Services Keiki (Less than 21 years f age) Preventive Services Pregnant Wman Medically necessary medicatins Medicatin management and cunseling Bld pressure Breast cancer screening Cervical cancer screening Chemprphylaxis Clrectal cancer screening Health educatin and cunseling Immunizatins Prstate cancer screening Rubella serlgy r vaccine Hx Ttal chlesterl measurements Tuberculin skin testing Weight/height measurements Age apprpriate dental referral and ral fluride Age apprpriate health educatin EPSDT services Hspital stay fr nrmal, term and healthy newbrn Immunizatins Newbrn screening Other age apprpriate labratry screening tests Screening t assess health status Tuberculin skin testing Diagnstic amnicentesis, diagnstic ultrasund, fetal stress and nn-stress Diagnsis f premature labr Health educatin and screening Hspital stays Prenatal labratry screening tests Prenatal visits Prenatal vitamins including flic acid Testing N limit N limit N limit N limit 32

34 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Prsthetics and Orthtic devices Orthtics N limit Prsthetic devices Radiatin Therapy Outpatient hspital services Related services, supplies and drugs Occupatinal therapy Rehabilitatin Services Physical therapy Speech therapy Diagnsis & treatment f sleep disrders Sleep Labratry Perfrmed by sleep labratries r sleep Services disrder center Smking Cessatin Cunseling Medicatin Sterilizatin and Hysterectmy Services Services that prevent pregnancy Transplants Crneal Transplants and Bne Grafts Transplants Other (SHOTT prgram) Transprtatin (Nn- Emergent) Urgent Care Services N limit N limit N limit Crneal and bne graft transplant services N limit Transplants nt included abve are cvered under the SHOTT prgram. (e.g. Transplants Heart, Lung, Small Bwel with r withut Liver) Meals and ldging fr ff-island services Transprtatin fr ff-island r ut-f-service area appintments Transprtatin t medically necessary cvered medical appintments fr members wh have n means f transprtatin and wh reside in areas nt cvered by public transprtatin r cannt access public transprtatin Transprtatin, meals and ldging fr an escrt (if medically necessary) Fr members under the age f 18, ne escrt t accmpany the member t and frm medically necessary visits Fr sudden prblems that are nt emergencies. Fr example, burns, wunds r a brken bne. After-hurs care Urgent care centers At least fur (4) cunseling sessins per quit attempt Limited t tw (2) quit attempts per year Must be 21 years ld at the time f cnsent. Nt a cvered benefit fr adults N limit N limit Visin Services Cataract Remval Cataract remval N limit 33

35 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Eye exams and Visin exams fr medical diagnsis Visin Services Limited t exams t diagnse and treat Medically Necessary Eye Exams diseases and cnditins f the eye (nt fr services t crrect pr visin/visual acuity) N limit Visin Services Rutine Eye Exams (t crrect pr visin/visual acuity) Visin Services Visin Appliances and Prsthetics Visin exams Refractin Cntact lenses Frames Prescriptin lenses Prsthetic eye Limited t ne (1) exam per year fr keiki Limited t ne (1) exam every tw (2) years fr adults Frames, lenses, and cntacts are limited t ne (1) every tw (2 ) years Children under 21: Frames and lenses ne every 12 mnths. Additinal services may be available if needed 34

36 Standard Behaviral Health Services Behaviral health services are prvided t members wh have emtinal prblems, mental illness r addictins t drugs r alchl. NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS 24-hur access line Crisis management Ambulatry Mental Crisis residential services Health Services Crisis stabilizatin N limit Mbile crisis respnse Inpatient Psychiatric Hspitalizatins Medically necessary alchl and chemical dependency services Methadne management services Prescriptin Drugs Psychiatric r psychlgical evaluatin and treatment Ancillary services Diagnstic services Medical supplies and equipment Medicatins and medicatin management Nursing care Other medically necessary services Psychiatric and ther practitiner services Rm/bard Substance abuse treatment Inpatient substance abuse services Outpatient substance abuse services Acute piate detxificatin and maintenance Medically necessary medicatins. Medicatin management and patient cunseling are als included in this service Antipsychtic medicatins and cntinuatin f antidepressant and antianxiety medicatins Members suffering frm the human immundeficiency virus, acquired immune deficiency syndrme, r hepatitis C, r a member in need f transplant immunsuppressive, shall be able t receive any medicatins apprved by the FDA, that are eligible pursuant t the Omnibus Budget Recnciliatin Rebates Act, and necessary t treat the cnditin Individual and grup cunseling and mnitring Neurpsychlgical and psychlgical testing N limit N limit N limit N limit N limit Psychtrpic Medicatins and Medicatin Management Cunseling and educatin Evaluatin, prescriptin and maintenance f psychtrpic medicatins Medicatin management Prmtin f algrithms and guidelines N limit 35

37 Nn-Cvered Services Services nt cvered under QUEST Integratin (QI) Activities that are primarily custdial, r part f nrmal existence, r undertaken primarily fr the cnvenience f the patient, family, r practitiner, are nt cnsidered cvered benefits. These services are typically excluded but in extenuating circumstances upn request we will review a treatment r service fr medical necessity. Please review the exclusins list carefully fr these and ther types f exclusins: Acupuncture Alternative Practices Bifeedback Christian Science services Faith healing Naturpathic services Beds Beds that d nt meet the criteria as a hspital bed accrding t durable medical equipment guidelines Certain Drugs Drugs nt apprved by the FDA Brand name drugs (except single surce drugs and name brand drugs when required by statute) Chirpractic services Csmetic surgery Csmetic rhinplasty (fr example, nse surgery primarily t imprve appearance) Piercing f ears and/r ther bdy parts Electrlysis (hair remval) Hair transplantatin (fr example, fr baldness) Reductin and augmentatin mammplasties (reducing r increasing breast size) Panniculectmies ( tummy tuck ) and ther bdy sculpturing Acne treatment; excisin r destructin f benign skin r subcutaneus lesins (withut medical necessity) Experimental r investigatinal services Prcedures, drugs, devices and treatments Treatment f cmplicatins caused by a previus experimental r investigatinal service Fertilizatin treatments In vitr fertilizatin Reversal f sterilizatin Artificial inseminatin Sperm banking prcedures Prcedures and drugs t treat infertility r enhance fertilizatin Fd including Fd supplements Health fd Hansen's disease treatment after diagnsis (Except fr surgical r rehab prcedures t restre useful functin) Hypnsis Massage treatment (Frm masseurs) Nn-medical items Fr example: bks, televisin, cmputers, air cnditiners, husehld items, mtr vehicle, furnishings, r air purifiers and fans (unless medically necessary). Orthtic training (unless medically necessary) Prgrams and memberships Gym membership 36

38 Summer camp Swimming lessns Penile and testicular prsthesis and related services Psychiatric care and treatment fr: Sex prblems Emplyment cunseling Primal therapy Lng-term character analysis Marathn grup therapy Persnal care items Fr example: shamps, tthpaste, tthbrushes, muth washes, denture cleansers, shes, slippers, clthing, laundry services, baby il, sanitary napkins, diapers fr babies, saps, lip balm, Band-Aids, and cntact lens slutin. Physical exams, psychlgical evaluatins, and/r immunizatins Fr emplyment (when the member is self-emplyed r as a requirement fr cntinuing emplyment) Fr state driver's license Fr securing life and ther insurance plicy/plans Pulmnary TB treatment (When treatment is available at n cst t the general public) Rutine ft care Treatment f flat feet Sexual dysfunctin treatment Related services Supplies and drugs Shts and physical exams fr travel Stand-by services by physician Telephne calls Writing f prescriptins Stat charges Treatment f persns cnfined t public institutins Tpical applicatin f xygen Visin appliances Cntact lenses fr csmetic purpses Over-sized lenses (unless medically indicated) Blended and prgressive bifcal lenses (unless medically indicated) Deluxe frames and lenses Tinted r absrptive lenses Trifcal lenses & variable Spare glasses Other visin aids (unless medically indicated) Visin services Orth ptic training Prescriptin fee Prgress exams Radial kerattmy Visual training Lasik prcedure Services cvered under the Medicaid fee-fr-service prgram Sme services are nt cvered by QUEST Integratin, but are cvered under the State Medicaid fee-frservice prgram. Prir authrizatin is nt required fr mst services. 37

39 Rutine dental care fr children under 21 years ld Members must get dental care frm a dentist wh sees Medicaid patients. Fr mre infrmatin, call Cmmunity Case Management Crpratin (CCMC) at r call tll-free at Benefits include: Diagnstic and preventive services nce every six mnths Emergency and palliative treatments Eliminate acute infectin Relief f dental pain Treat acute injuries t the teeth and supprting structures Enddntic therapy Oral surgery Peridntics therapy Prsthdntic services Restratins Emergency dental care fr adults 21 years ld and lder Members must get dental care frm a dentist wh sees Medicaid patients. Fr mre infrmatin, call CCMC at r tll-free at Benefits include: Acute injuries t the teeth and supprting structures Treatment f eliminatin f acute dental infectin Relief f dental pain Intentinal terminatin f pregnancies (ITOP) Members must get ITOP services frm a dctr wh sees Medicaid patients and accepts Medicaid fee-fr-service. Prviders shall cntact us r Medicaid fiscal agent fr mre infrmatin. In additin, Cmmunity Case Management Crp. (CCMC) may arrange transprtatin fr ITOP services. CCMC may be reached at (n Oahu) r tll free at State f Hawaii Organ and Tissue Transplant (SHOTT) Prgram The Department f Human Services prvides transplants which are nt experimental r investigatinal. The SHOTT prgram cvers adults and children fr liver, heart, heart-lung, lung, kidney, kidney-pancreas and bne marrw transplants. Children will be cvered fr transplants f the small bwel with r withut liver. Children and adults must meet medical criteria as determined by the State and the SHOTT prgram. Prviders shall cntact us fr mre infrmatin. Services frm ther agencies in the cmmunity Sme services are nt cvered under the QI prgram r the State Medicaid prgram. Members may be able t get them frm ther agencies r prgrams in the cmmunity. Fr Adults with Serius and Persistent Mental Illness (SPMI) If a member has been diagnsed with Serius and Persistent Mental Illness (SPMI), they may be eligible fr additinal behaviral health services frm the Cmmunity Care Services (CCS) behaviral health prgram, which include: Face-t-face care management and crdinatin services thrugh cntracted prviders Crisis services, including utreach Integrated services fr members wh have c-ccurring substance abuse and mental health prblems Psych-scial rehabilitatin grups Other specialized services Prviders shall cntact us fr mre infrmatin. 38

40 Child and Adlescent Mental Health Divisin (CAMHD) fr Children Ages 3 thrugh 20 CAMHD is part f the Department f Health and ffers behaviral health services fr children with emtinal, mental health and behaviral disrders. CAMHD FAMILY GUIDANCE CENTERS Big Island Hil 88 Kanelehua Ave, Ste A-204 Hil, HI Big Island Kealakekua Halekii St, Ste 101 Kealakekua, HI Big Island Kamuela Mamalaha Hwy, Ste. A-11 Kamuela, HI Kauai Kuhi Hwy, Rm 104 Lihue, HI Maui Kahului 270 Waiehu Beach Rd, Unit 213 Wailuku, HI Maui- Lahaina 1830 Hnapiilani Hwy, Rm 5 Lahaina, Hi, Maui- Mlkai 65 Makaena St. Kaunakakai, Hi Maui- Lanai C/O Lanai High & Elementary Schl 555 Fraser Avenue Lanai, City, Hi Oahu Central 860 Furth St, 2nd Flr Pearl City, HI Oahu Family Curt Liaisn Kalanianale Hwy Kailua, HI Oahu Hnlulu 3627 Kilauea Ave, Rm 401 Hnlulu, HI Oahu Leeward 601 Kamkila Blvd, Rm 355 Kaplei, HI Oahu Windward Keahala Rd Kanehe, HI Child and Adult Prtective Services Child and Adult Prtective Services prvide crisis interventin, including investigatin and emergency services fr children and adults wh are reprted t be abused, neglected r explited by thers. Child Prtective Services (CPS). Fr mre infrmatin, call the CPS Htline at r tll-free at Child Welfare Services (CWS). Fr mre infrmatin, call Adult Prtective Services (APS). Fr mre infrmatin, call the APS Htline at Develpmental Disability/Intellectual Disability (DD/ID) Services The DD/ID prgram helps peple with intellectual r develpmental disabilities. These services include habilitatin, behaviral assistance, husing, daily tasks and huse chres. Fr mre infrmatin, call DD/ID at (808) Supplemental Nutritin Prgram Fr Wmen, Infants, and Children (WIC) The WIC prgram helps individuals get free milk and ther gds and services fr themselves and their children. Fr mre infrmatin n WIC services, call r tll-free at

41 Zer-T-Three Early Interventin Prgram Zer-t-Three is fr children between the ages f 0 and 3 years wh need special health care and services. Fr mre infrmatin, call the Hawaii Keiki Infrmatin Services System (H-KISS) at r tll-free at Head Start Prgrams Head Start Prgrams are fr children between the ages f 3 and 5 years that prvides educatin, health and family supprt services. Fr mre infrmatin, call Hnlulu Cmmunity Actin Prgram Head Start at r Parent & Child Center Head Start at

42 SECTION 5 MEMBER SERVICES Member Rights and Respnsibilities Members have the fllwing rights: Access t Care T receive services in a timely manner as specified in AlhaCare s appintment standards. T receive services ut-f-netwrk if AlhaCare is unable t prvide services in-netwrk, fr as lng as AlhaCare is unable t prvide them in-netwrk and nt pay mre than he r she wuld have if services were prvided in-netwrk T receive services in a culturally cmpetent manner based n an individual s backgrund, ethnicity, cultural beliefs and language preference T receive services in a crdinated manner. T receive direct access t specialists fr special health care needs. T nt have services arbitrarily denied r reduced in amunt, duratin r scpe slely because f diagnsis, type f illness, r cnditin. T receive medical care and services regardless f member age, race, creed, sex, sexual preference, natinal rigin r religin. AlhaCare will nt deny r allw fewer services slely based n the member s diagnsis, type f illness r health cnditin. Chse a service prvider f their chice amng thse rganizatins in AlhaCare s prvider netwrk. T have an adequate prvider netwrk within a member s gegraphic service area that is available and accessible with regard t distance and travel time. T have direct access t a wmen s health specialist within AlhaCare s prvider netwrk. T be included in service plan develpment, if applicable T receive services in accrdance with the Cde f Federal Regulatins Sectins thrugh Respect and Dignity Identity T be treated with respect and with due cnsideratin fr the member s dignity and privacy at all times and under all circumstances. T knw the identity and prfessinal status f individuals prviding service and which physician is primarily respnsible fr a member s care. Privacy and Cnfidentiality Members have the right t have all recrds and medical and persnal infrmatinal remain cnfidential and prtected, including: Being interviewed and examined in surrundings designed t assure reasnable audi/visual privacy. Having any discussin r cnsultatin invlving care cnducted in a discreet manner. Individuals nt directly invlved with the member s care will nt be present unless permissin has been given by the member. Having the member s medical recrd read nly by individuals directly invlved in his/her care, individuals ensuring the quality f their medical care, r ther individuals t whm the member gives such permissin. 41

43 Infrmatin Expecting all cmmunicatins and ther recrds pertaining t care r services, including the surce f payment fr treatment, t be treated as cnfidential. Limiting, restricting r preventing disclsure f his/her persnal health infrmatin. T btain cmplete and accurate infrmatin cncerning diagnsis (t the degree knwn), available treatment ptins and alternatives and any knwn prgnsis frm the member s physician, ther health care practitiners r clinics. This infrmatin is t be cmmunicated in a manner apprpriate t the patient s cnditin and in terms the patient can reasnably be expected t understand. When it is nt medically advisable t give such infrmatin t the patient, the infrmatin is t be given t a legally authrized representative. T appint a representative t act n his/her behalf. T receive cpies f his/her medical recrds and Prtected Health Infrmatin (PHI), unless the member s physician r AlhaCare believes smething in the recrds wuld jepardize the member s health, safety r security r that f smene else. T request that AlhaCare r an AlhaCare prvider amend r crrect the member s medical recrds. If a member s request is denied, the member has the right t btain the reasn fr denial in writing. T knw wh sees their medical recrds and Prtected Health Infrmatin, unless the review is cnducted fr treatment, payment, health care peratins, r sme ther reasn written in the law. Cmmunicatin T have access t interpreter services when the member des nt speak r understand the majr language f the cmmunity. T have access t sign language and TDD services fr members with hearing impairments. Members als have the right t have an interpreter in the rm during an exam. Interpreter, translatin, sign language and TDD services are prvided at n cst t the member. T have written materials made available t the member in the languages prevalent in the Hawaii, as determined by Med-QUEST. These languages include, but are nt limited t English, Vietnamese, Krean, Ilcan and Chinese (Traditinal). T ask AlhaCare t send mail and call the member at the address and telephne number f his/her preference, t prtect his/her privacy. If AlhaCare cannt hnr the request, the member will be infrmed f the reasn. T receive a timely respnse fr prir authrizatin requests. File Grievances and Appeals Cnsent T freely exercise his/her rights, including thse related t filing a grievance r appeal; the exercise f these rights will nt adversely affect the way the member is treated. This includes the right t have a prvider r authrized representative file a grievance r appeal n the member s behalf when authrized in writing t d s. After exhausting AlhaCare s appeal rights, the right t request a State administrative hearing and t request t receive benefits while the hearing is pending. The member may be held liable fr the cst f thse benefits if the hearing decisin uphlds the health plan s actin. T have reasnable infrmatin and participatin invlving his/her health care. In cases where a minr is being treated, the parent(s) r legal guardian(s) are affrded the same infrmatin and participatin rights regarding the minr s care, cnditin and/r treatment plan (except where, by law, a minr is emancipated and has the right t make his r her wn 42

44 treatment decisins). T the degree pssible, this infrmatin is based n a clear, cncise explanatin f the cnditin and all prpsed technical prcedures, including the pssibilities f any risk f mrtality r serius side effects, prblems related t recuperatin, and the prbability f success. T nt be subjected t any prcedure withut vluntary, cmpetent, and understanding cnsent, r the cnsent f a legally authrized representative. T be infrmed f medically significant alternatives fr care r treatment when they exist. The member als has the right t knw wh is respnsible fr authrizing and perfrming the prcedures r treatment. Secnd Opinin Be Infrmed T receive a secnd medical pinin, at n cst t the patient, when deciding n medical treatment. T knw abut any experimental, research r educatinal activities having t d with his/her care. After a member is given this infrmatin, the member can chse t participate r nt. Decisin Making T participate in decisins regarding the member s health care, including the right t refuse treatment. Refusal f Treatment T refuse treatment t the extent permitted by law. An AlhaCare member is respnsible fr his/her actins if treatment is refused r if the instructins f the physician, ther health care practitiner(s) r clinic are nt fllwed. Freedm frm Restraint r Seclusin Payment T be free frm any frm f restraint r seclusin as a means f cercin, discipline, cnvenience r retaliatin, unless it is necessary fr treatment r the safety f thers as specified in federal regulatins n the use f restraints and seclusin. T be free frm payment fr cvered services prvided t the member unless cpayment r deductibles are required by Med-QUEST rules. T be free frm payment fr cvered services prvided t the member in the event f AlhaCare s inslvency. T be free frm payment fr cvered services prvided t the member in the event that the Department f Human Services (DHS) des nt pay AlhaCare. T be free frm payment fr cvered services prvided t the member in the event that the DHS r AlhaCare des nt pay the service prvider. T be free frm payment fr cvered services prvided t the member under a cntract, referral, r ther arrangement t the extent that thse payments are in excess f the amunt the member wuld we if AlhaCare prvided the services directly. Advance Directives T execute an Advance Directive and t give instructins abut his/her health. T name smene t make health treatment decisins n his/her behalf. T express member s wishes regarding the designatin f his/her health care prviders. Suggestins and Cmments T make cmments r suggestins abut AlhaCare including suggestins regarding ur 43

45 plicies and prcedures. Members have the fllwing respnsibilities: Infrmatin T prvide infrmatin that is, t the best f the member s knwledge, accurate and cmplete with regard t present cmplaints, past illnesses, hspitalizatins, medicatins and ther matters relating t his/her health. The member has the respnsibility t make it knwn whether he/she clearly understands a cntemplated curse f actin and what is expected f him/her. The member is als respnsible fr letting his/her physician knw if he r she is taking part in any medical research tests. T ntify Med-QUEST and AlhaCare f any change in status, such as marriage, divrce, birth r adptin f a child, death f a spuse r child r acceptance f a jb. Other Medical Insurance T prvide all pertinent infrmatin related t the medical insurance cverage available at the time f a member s eligibility determinatin and subsequent enrllment. If, at any time, the AlhaCare member receives medical cverage beynd his/her QUEST Integratin cverage, the member is respnsible fr reprting this infrmatin t his/her QUEST Integratin enrllment ffice and AlhaCare. Prvider s ffices als are required t reprt knwledge f new third party payer infrmatin t AlhaCare. T prvide infrmatin t AlhaCare and Med-QUEST pertaining t a wrker s cmpensatin claim, persnal injury r medical lawsuit r if the member has been invlved in a car accident. Cmpliance with Instructins T fllw the treatment plan recmmended by his/her physician r ther health care prviders. PCPs T knw the name f his/her PCP. The member shuld call AlhaCare if he/she des nt knw this infrmatin. T call his/her PCP first befre seeing ther dctrs. AlhaCare may nt pay if a member receives medical services frm a nn-netwrk prvider withut btaining the apprpriate authrizatins. Respect and Dignity T treat AlhaCare staff, prviders and ther members with respect and dignity and t cperate with them. Appintments T keep any appintments the member has made. If a member is unable t keep an appintment, it is the member s respnsibility t ntify the prvider in advance. Immunizatins T prvide immunizatin recrds t his/her PCP. Be Respnsible T use his/her AlhaCare ID card prperly and respnsibly. A member shuld identify himself/herself as an AlhaCare member t his/her dctrs and have his/her membership 44

46 card available when visiting his/her dctr. Members must nt lend their membership card r allw ther peple t use the card. T stay healthy T cntact his/her Med-QUEST eligibility wrker if subject t an annual QUEST Integratin eligibility review. Any cst-sharing requirements as required by State and Federal guidelines Fraud and Abuse T reprt suspected member r prvider fraud r abuse. Make Medical Wishes Knwn T make his/her medical wishes knwn in the event that he/she is n lnger able t make infrmed health care chices. This is knwn as an Advance Directive, which is defined as a set f written instructins abut the member s wishes regarding medical care. Examples f Advance Directives include Living Wills, D Nt Resuscitate Orders, Medical Durable Pwers f Attrney, Appintment f Health Care Prxy, and Curt-appinted Surrgates and Guardians. An Advance directive is used if the member is unable t make medical decisins fr himself/herself and shuld be referred t by the member s PCP r caregiver. The member s dctr r caregiver will refer t these dcuments if necessary; the member des nt need t carry it with him/her. When there are n written directives and the member is unable t make medical decisins, family members may be asked t make the decisins abut the care and treatment the member receives. Member s Selectin f Primary Care Prvider (PCP) T select a PCP within 10 days f receiving his/her QUEST Integratin New Member Packet. PCP selectin instructins are included in the new member packet. If a member des nt chse a PCP within 10 days f receiving his/her QUEST Integratin New Member Packet, AlhaCare will assign the member t a PCP based n criteria such as gegraphic service area, PCP availability, member/pcp histry, member s medical needs, gender and age, family cntinuity and PCP panel restrictins. Members assigned a PCP thrugh this prcess are infrmed f their PCP assignment upn receipt f his/her permanent AlhaCare ID card that identifies the PCP. Members can cntact ur Member Services Department t select anther PCP. Members are nt limited in the number f their PCP selectins r changes. 45

47 Member ID Cards AlhaCare members receive tw identificatin cards, a temprary ID card fllwed by a permanent ID. The QUEST Integratin New Member Packet, which is sent t new enrllees shrtly after enrllment int AlhaCare by Med-QUEST, cntains a temprary ID card with the member s name and QUEST Integratin ID number. As a PCP has nt yet been selected, this card des nt cntain PCP infrmatin. The temprary ID card is used by new members t btain medical services in situatins f immediate need. If a new QUEST Integratin member des nt have an AlhaCare ID card, prviders shuld accept the State f Hawaii Department f Human Services letter f cnfirmatin f enrllment int a QUEST Integratin plan as a temprary ID card. The AlhaCare ID card includes the members eligibility renewal date. Members that d nt have a member under 19 years ld in their husehld must return their yearly renewal packet. AlhaCare will be actively engaging members in this categry t ensure that they return their packets. We ask that prviders nte this date and as a curtesy remind the member t return their renewal packet. Pssessin f an AlhaCare ID card des nt guarantee QUEST Integratin eligibility. Member Eligibility Verificatin Always verify eligibility and PCP assignment befre rendering services. Prviders can check eligibility with AC Online r by calling ur Prvider Relatins Department. Failure t cnfirm eligibility and PCP assignment may result in denial f payment fr services prvided t ineligible members. A member s AlhaCare eligibility status, PCP assignment and third party liability (TPL) cverage may change at any time. Prir t rendering each service, the prvider must verify: Current member eligibility Current PCP assignment TPL/ther cverage availability 46