CONTENT. INTRODUCTION...,,,... Mission and Vision. CONFIDENTIALITY... Confidentiality requirements Release of Information

Transcription

1 PROVIDER MANUAL 2016

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3 CONTENT INTRODUCTION....,,,... Mission and Vision CONFIDENTIALITY.... Confidentiality requirements Release of Information THE CO-OP PROVIDER.... Primary Care Provider and Specialty Provider Rights & Responsibilities Service Standards Provider Engagement Liaisons Information Updates Provider Portal QUALITY MANAGEMENT.... Quality Improvement QI Program Committees CREDENTIALING.... Initial Credentialing Re-credentialing Delegated Credentialing Organizational Credentialing PEER REVIEW.... MEDICAL MANAGEMENT.... Care Management Chronic Disease Management PHARMACY MANAGEMENT.... Formulary Pharmacy Utilization Office Administered Injectables UTILIZATION MANAGEMENT.... Prior Authorization Concurrent Review and Lenth of Stay Authorization Denials and Appeals of Authorizations BILLING AND PAYMENT.... Claims Submission Claim Reconsideration and Appeal Coordination of Benefits Clinical Editing Hold Harmless Overpayment Locum Tenens Interim Billing Readmissions PROVIDER QUICK REFERENCE TOOL

4 Introduction Oregon s Health CO-OP Oregon s Health CO-OP is a new type of nonprofit health insurance company a Consumer Operated and Oriented Plan enabled under the Affordable Care Act of We are building a movement with providers, individuals, families and employers who believe the insurance industry can do better; where health insurance is driven by the members in their communities; where everyday people have a voice and health insurance companies listen; and where profits are returned to the members through lower premiums, more benefits and improved services. Our Mission To be a member driven voice for meaningful change in the health of our communities. Vision Creating partnerships in our communities for driving positive change and personal choice in the accessibility and affordability of quality health care. Values Honesty, Respect, Integrity, Listen, Innovate, Collaborate Oregon s Health CO-OP Priorities Prevention Member access to the information and care they need Patients and Providers working together for better health Cultural competence Strategies to reduce providers administrative burden Clear, predictable medical costs for members Improved health for all Oregonians Oregon s Health CO-OP Mission and Care Philosophy Guided by our members and our board of directors, Oregon s Health CO-OP provides excellent health coverage that is easy to use and understand. By reinvesting profits in our members, we improve services, reduce costs and ensure that members are protected for the long term. Our role is to give a voice to our members and facilitate their engagement with you, their health care professionals. Members, providers and the health plan will take the best possible care of each other and keep costs down through low administrative, medical and pharmacy costs. All may choose to have a role in governing and operating this health plan. Thank you for caring for our Members Oregon s Health CO-OP looks forward to being partners in improving the health and well-being of Oregonians. 4 Oregon s Health CO-OP -

5 Confidentiality HIPAA Requirements Health Care providers who transmit or receive health information in one of the Health Insurance Portability and Accountability Acts (HIPAA) transactions must adhere to the HIPAA Privacy and Security regulations. Providers must provide privacy and security training to any staff members who have contact with individually identifiable health information. All individually identifiable health information contained in the medical record, billing records or any computer database is confidential, regardless of how and where it s stored. Examples of stored information include clinical and financial data in paper, electronic, magnetic, film, slide, fiche, floppy disk, compact disk or optical media formats. Patients must have access to, and be able to obtain copies of their medical and financial records from the provider. Release of Information Providers must obtain an authorization to release individually identifiable health information whenever information is released about the patient, unless the release is for payment, treatment or healthcare operations. There is an example of a Release of Information form on the Oregon s Health CO-OP website or the provider s release form may be used. In general, most authorization forms are not valid for information regarding HIV, sexually transmitted diseases, genetic, mental health or alcohol and drug treatment information. Do not release this information unless the member signs an authorization specifying that these types of records may be released or the form has check off boxes to specify the release of this confidential/protected information. Oregon s Health CO-OP staff adheres to the HIPAAmandated confidentiality standards. The CO-OP Primary Care Providers These are physicians and non-physicians who render primary care services. Such providers may include nurse practitioners, physician assistants and some other health care providers. Primary Care Providers (PCPs) have the responsibility for the leadership of the health care team and the comprehensive, ongoing healthcare of the patient. PCPs may serve as the patient s first point of entry into the health care system and as the continuing focal point for all needed health care services. Primary care practices provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). We encourage our members to select and work closely with a PCP who provides all routine care, refers to specialty care when needed and arranges for any urgently required care. The following Network Providers can be PCPs in Oregon s Health CO-OP: Physicians who specialize in family medicine, general practice, internal medicine, osteopathic medicine or pediatrics Oregon s Health CO-OP - 5

6 Nurse Practitioners who specialize in adult practice, family practice, pediatrics or women s healthcare Physician Assistants Naturopathic Doctors Specialty Care Providers Oregon s Health CO-OP contracts with Specialty Care Providers to assure that members have access to a comprehensive panel of specialty care services when it is needed. In addition, we have alternative care providers available to our members. Specialty Care Providers have the same obligations to our members as PCPs in terms of confidentiality, service standards, prior authorization requirements and other responsibilities as described in the following section. Provider Rights and Responsibility Provider Rights As a contracting Provider with Oregon s Health CO-OP, you can expect a health insurance company that listens to you with respect. In our Plan, you have a voice and may choose to have a role in the decision and operations of this organization by becoming a member of the Board of Directors or participating in quality improvement committees. You can expect to have an honest discussion of appropriate or medically necessary treatment options for the patient s condition regardless of cost or benefit coverage. You can expect ethical and fair business operations from all of our employees, from the CEO to the person answering the phones at the front desk. You can expect fair credentialing and re-credentialing processes and an explanation of your rights with regard to those procedures. You can expect support in your care of your patients and our members with the availability of patient education tools and Care Management services. Provider Responsibilities All clinicians will provide the following level of service to Oregon s Health CO-OP members seeking care from them: Maintain a comprehensive medical record which includes a problem list, medication record, allergies, and detailed record of office visits and other communications Provide accessible clinical care according to the Service Standards Matrix provided in the following section Provide appropriate evidence-based medicine within the scope of license Provide comprehensive management of chronic disease according to evidence-based medicine Provide access to the on-call provider for member inquiries 24 hours per day Have a policy and/or procedure that arranges for and provides access to an appropriate back-up physician or practitioner for any leave of absence Primary Care Providers Additional Responsibilities Maintain in the member s medical record a comprehensive problem list which lists all medical, surgical and psycho-social issues for that patient Maintain a comprehensive medication list that includes all prescription medications that the member is taking and any medication allergies, including medications prescribed by specialists Provide access to telephone advice for member questions 24 hours per day Provide preventive services as recommended by the U.S. Preventive Services Task Force. www. uspreventiveservicestaskforce.org Provide immunizations as recommended by the Centers for Disease Control and Prevention. Arrange specialty consultation with a network consultant within 24 hours for any member with an urgent problem needing such consultation and with 4 weeks for a non-urgent issue Service Standards Appointment Access It is the policy of Oregon s Health CO-OP to ensure that our members have access to timely and appropriate preventive and curative health services that are delivered in a patient-friendly and culturally competent 6 Oregon s Health CO-OP -

7 manner. Oregon s Health CO-OP requires practitioners to have policies and procedures that prohibit discrimination in the delivery of health care services. Appointment Access Time Frames Type of Appointment/Access Request Outpatient care for any routine visit/preventive care Routine specialty care (i.e., colonoscopy) Non-emergent problemspecialty care Member with urgent/emergent problem Service Standard Within 4 weeks Within 4 weeks Within 4 weeks Within 24 hours Standard Scheduling Procedures Appointments for initial history and physical assessment should be scheduled in longer appointment slots to allow for preventive care and health education as needed. Members should wait no longer than 20 minutes for scheduled appointments. 24-Hour Telephone Access Oregon s Health CO-OP has a commitment to its members to provide 24-hour phone access to health care. Our contracted primary care providers must have a telephone triage system. During Office Hours A primary care provider or registered nurse should triage member calls to determine appropriate care and to assist the member with advice, an appointment or a referral. After Hours The Provider Engagement team will conduct an annual after-hours survey to ensure that the following criteria are met. If you have questions, contact a Provider Engagement Liaison at After-hours access includes: Answering Service Urgent situations: The person who answers the phone must offer to either page the provider on call (with the provider then calling the member) or to transfer the member s call directly to the on-call provider. Emergency situations: The person who answers the phone must tell the member to call 911 or go to the nearest emergency room if the member feels the situation is too emergent to wait for the provider call. Answering Machine Urgent situations: The outgoing message must instruct callers on how to page the provider in urgent situations. Emergency situations: The outgoing message must provide information to callers about accessing emergency services, i.e., to call 911 or go to the nearest emergency room if the member feels the situation is emergent. Provider Engagement Liaisons Provider Engagement Liaisons are available to call on or phone consult with Providers to assist with questions and issue resolution. Use this phone number to reach a Provider Engagement Liaison: If you want to become a contracted individual clinic, facility or vendor with Oregon s Health CO-OP You are already contracted and have questions about your agreement or resources available to you. If you need: -- Orientation to health plan operations, policies and procedures -- Refresher orientations for a new clinic, billing or management staff -- Targeted in-depth training on specific topics -- Training on using our online resources such as the Provider Portal that verifies member eligibility, authorization and claims/payment details -- Training on using Oregon s Health CO-OP website Keep your information updated: or fax updates to the Provider Engagement team about changes in your practice such as new or terminated providers, locations, phone and fax numbers, addresses. Timely updates facilitate accurate directory listings, mailings, correct claims payment and system access for your staff. Our address is providerengagement@ohcoop.org and our fax number is Oregon s Health CO-OP - 7

8 Provider Portal The Oregon s Health CO-OP Provider Portal is a secure and confidential online system that allows individual providers and clinics to verify member eligibility and to check the status of their authorizations and claims. It will allow access to up-to-date clinical information and programs. The link requires the provider to self-register and log in. Go to QUALITY MANAGEMENT The Oregon s Health CO-OP s Quality Improvement Program focuses on improvements that make health care: Safer More effective More patient-centered More timely More efficient More equitable Program Objectives Our Quality Improvement (QI) process is driven by the Oregon s Health CO-OP mission and vision. Our Objectives are to: Ensure that members receive maximal health benefits from the resources available to Oregon s Health CO-OP Monitor the health status of our members to identify areas that most significantly impact health status and/or quality of life Ensure the optimal use of health strategies known to be effective, including prevention, risk reduction and evidence-based practices Develop population-based health improvement initiatives that can best be implemented at a health plan level Ensure quality and accountability through measurement of performance and utilization Provide enhanced support for those with special health care needs Proactive identification of those at risk Case management and coordination of fragmented services Promotion of improved chronic care practices Support integrated models of mental and physical health care services Participate in efforts that improve health care for all Oregonians by: Supporting community, state and national health initiatives Building partnerships with other health care organizations Pursuing research on new models of health care design and delivery Seeking collaboration within the community to identify and eliminate health care disparities QI Programs Committees Quality Improvement Committee An advisory committee that provides oversight and direction for Oregon s Health CO-OP initiatives that impact the quality of care for our members Peer Review Committee Accountable for monitoring and ensuring the quality of care and service provided by individual contracted providers Service Quality Committee Accountable for identification of issues impacting the satisfaction of our members through the analysis and integration of information from multiple sources 8 Oregon s Health CO-OP -

9 Pharmacy and Therapeutics Committee Accountable for oversight of the Oregon s Health CO-OP pharmacy program, the development and maintenance of the Oregon s Health CO-OP formulary and programs that impact utilization Health Benefits Assurance Committee Accountable for oversight of the Oregon s Health CO- OP Health Benefits Assurance activities and approval of clinical (medical and pharmacy) policies and new technology assessments. Subcomittee Clinical Policy and Criteria is accountable for development of clinical policies and criteria ISSUES REVIEWED HEDIS Indicators Access to Care Member Satisfaction Outcomes of Care Member Safety Compliance with Government Regulations DATA SOURCES Claims data Medical records Member complaints (grievances) Care management reports Pharmacy data Other satisfaction surveys Credentialing Committee Accountable to evaluate healthcare professional s credentialing applications based on established criteria: both intial and re-credentialing. Also accountable for delegation oversight Scope of Service, Issues Reviewed and Data Sources Our Quality Improvement Program defines the processes that we measure and monitor. Major plan components include processes involved with quality outcomes, patient safety and services as they pertain to access, availability and satisfaction. The scope of service also includes any and all regulatory requirements. Clinical Best Practices and Health Promotion Guidelines Oregon s Health CO-OP, through its Quality Improvement Committee (QIC), reviews and adopts evidence-based practice guidelines. These define standards of practice that pertain to improving the quality of health care for certain disease diagnoses and preventive services. These are reviewed annually by the QIC. To review the guidelines, go to CREDENTIALING Oregon s Health CO-OP considers it essential to maintain a provider panel that has the legal authority, relevant training and experience to provide care for our members. We require all providers to meet our credentialing criteria prior to contracting and remain in compliance with that criteria at all times. Initial Credentialing This is the first point of contact for all providers that do not hold a current contract directly with Oregon s Health CO-OP or any of our affiliated delegated entities. Upon receipt of a required complete standard application, Oregon s Health CO-OP will verify the information through our contracted Credentialing Verification Organization (CVO). They will be verifying national and state data sources before our review for final approval. An incomplete application will delay the process. Re-Credentialing This is the process of periodically re-evaluating current panel providers for continuing competency to provide high quality services to members. All credentialed providers must remain in compliance with credentialing criteria at all times and must complete the re-credentialing process every three (3) years to continue network participation. Providers whose contract status has lapsed more than 30 days will be required to submit a credentialing application. Oregon s Health CO-OP - 9

10 Physicians and Other Health Care Professionals Providers who are subject to the credentialing process include: Certified Nurse Midwife Physician Assistant Doctor of Medicine Occupational Therapist Doctor of Naturopathy Speech Therapist Doctor of Osteopathy Physical Therapist Doctor of Podiatric Medicine Audiologist Doctor of Chiropracty Optomitrist Nurse Practitioner Licensed Acupuncturist Behavioral Health/Chemical Dependency Specialist Note: When locum tenens services are needed, participating credentialed providers must register the substitute with the CO-OP. This process must be completed prior to the provision of any services by the locum tenens. Locums are not directly credentialed by the CO-OP. Provider Rights Credentialing Process The Oregon s Health CO-OP Credentialing process adheres to the following provider rights and notifies each provider of these rights during initial credentialing and at the beginning of each recredentialing cycle: To be free from discrimination in terms of participation or indemnification solely on the basis of licensure, as long as providers are acting within the lawful scope of licensure/certification To be notified in writing of any decision that denies participation on the Oregon s Health CO-OP panel To be aware of applicable credentialing policies and procedures To review information submitted by the provider to support the credentialing process To correct erroneous information submitted by third parties that does not fall under the Oregon Peer Review Statute protections (Section ) To be informed of the status of their credentialing or re-credentialing application on request and to have request granted within a reasonable period of time To be notified of these rights If you have questions about the process or the status of your application, please contact us at credentialing@ohcoop.org Delegated Credentialing Oregon s Health CO-OP may delegate credentialing activities to contracted provider groups. Provider groups must demonstate the ability to meet our performance standards. Oregon s Health CO-OP retains the right to approve new providers and facilities and to terminate or suspend individual providers as necessary and appropriate. Organizational Credentialing Oregon s Health CO-OP credentials institutional providers or suppliers such as hospitals, skilled nursing facilities, home care agencies, behavioral health services, clinical laboratories, outpatient speech and physical therapists, ambulatory surgery centers, end-stage renal disease services, outpatient diabetes programs, self-management training, portable X-ray providers, rural health centers and Federally Qualified Health Centers. A standardized application is used for this process. 10 Oregon s Health CO-OP -

11 PEER REVIEW Peer Review Process It is the policy of the CO-OP to identify and review potentially serious quality of care issues that occur within the provider network. The Peer Review Committee exists to determine whether current acceptable practice is met and to recommend a course of remediation or action if needed. The Peer Review Function Monitors and evaluates clinical quality Determines and evaluates the appropriateness of patient care Actively promotes the delivery of high quality professional practice Investigates selected practice-related incidents Reviews selected studies which show aggregated practice patterns Recommends remediation or actions to be taken and requires on-going monitoring as needed Sources of Quality of Practice Concerns The CO-OP may identify a quality of care concern from any of the following sources: Clinical complaints by members Facility site audits Utilization Management cases Sentinel events Abnormal pharmacy utilization Clinical practice that does not meet the standard of care Readmissions-recurrent hospitalizations Re-operations, recurrent hospitalizations Medical record documentation audits Clinical concerns expressed by a practitioner Concerns regarding practitioner s conduct Other relevant sources Medical Chart Review As part of the CO-OP s Quality Improvement Program, a review of clinical records of contracted primary care providers is scheduled on a regular basis. The staff performing these reviews adheres to HIPAA-mandated confidentiality standards. MEDICAL MANAGEMENT Care Management Program The Oregon s Health CO-OP Care Management Group can help providers in caring for members with complex or co-morbid health care needs, including mental illness and chemical dependency. The team of registered nurse case managers, behavioral health specialists and health care coordinators offers case management and care coordination services. The team s goals are to help members achieve the best possible outcomes from care, despite any physical and/or mental health challenges or economic obstacles that may exist. Potential candidates for Care Management service referrals include: Members with complex care needs and difficulty with self-management skills Members transitioning home from a hospital or other inpatient facility Members who need support in establishing and maintaining provider relationships Members who have difficulty in accessing appropriate health care Members who have social support needs that interfere with their health care Members who suffer from mental health and/or substance abuse issues Oregon s Health CO-OP

12 To make a Care Management Referral, call the Care Management CO-OP Group. Explain the reason for the call and the Health Care Coordinator will either address the service need or forward the referral to a Case Manager. Care Management: Chronic Disease Management Currently, chronic disease management programs in Asthma and Diabetes are offered. Patients who would benefit from these comprehensive and supportive services are identified through Care Management and claims processing data. Providers play an active role in the coordination of services for these patients. More information on these programs may be found at PHARMACY MANAGEMENT The CO-OP Formulary The OHC Formulary is a list of covered drugs selected by the Pharmacy and Therapeutics Committee to treat medical conditions that are covered by Oregon s Health CO-OP. Formulary decisions are based on critical review of the available scientific evidence for efficacy, safety, outcomes, cost effectiveness and value. In general, the following are not covered: Brand name drugs for which FDA approved and equivalent generic drugs are available, except select narrow therapeutic index drugs Experimental or investigational drugs, or drugs used in a research study or in another similar investigational environment Over-the-counter (OTC) drugs or medications or vitamins that may be purchased without a prescription, or prescribed drugs that is available in an OTC therapeutically similar form Drugs not listed in the formulary Drugs removed from the formulary throughout the years by the Pharmacy and Therapeutics Committee. The formulary list is updated periodically to reflect these changes Drugs used for non-medically accepted indications Drugs used to promote fertility or to treat sexual dysfunction or disorder in either men or women Drugs used for cosmetic purposes or hair growth Drugs used for treatment of obesity or weight loss Drugs used as a preventive measure against the hazards of travel Growth hormone except to treat documented growth hormone deficiencies Other drugs specifically excluded from coverage, such as drugs not approved the FDA, including compound drugs from bulk power and DESI drugs The Formulary applies only to drugs provided by a pharmacy and do not apply to drugs used in an inpatient setting or furnished by a provider. The drugs listed in the CO-OP formulary might have copays or coinsurance that may change from year to year. The current formulary is on our website at Contact Oregon s Health CO-OP Customer Service at toll-free if: You would like a paper copy or additional copies of the formulary book You have questions or concerns about the pharmacy benefit or formulary You have suggestions for formulary changes or have questions related to pharmacy claims Pharmacy Utilization The CO-OP uses the following to help ensure access to medically necessary and appropriate, cost-effective drug therapy: Prior Authorization & Medical Necessity Determination Dispensing or Quantity Limits (including age and gender limits) Drug Utilization Review 12 Oregon s Health CO-OP -

13 Drugs that require prior authorization, step therapy, or quantity limits are designated as PA, ST and QL, respectively. Drugs labeled PA or PA required must have a prior authorization before a member can fill the prescription at a network pharmacy. Drugs labeled ST or Step Therapy are limited to coverage only when certain conditions have been met for example, the member has an approved claim for a formulary alternative in his or her prescription profile. The member or provider must submit a Formulary Exception form if ST criteria are not met and the member does not have claims history of the prerequisite drug. Drugs labeled QL or quantity limits are restricted to specific quantities. If a provider or member wants to exceed the limit, a Formulary Exception form must be submitted. To obtain prior authorization or request a formulary exception, fax a completed Prior Authorization or Formulary Exception form available at on our website under Pharmacy. Providers will receive a faxed response which may include an approval, denial or request for additional information in support of medical necessity, no later than 72 hours of receipt. Office Administered Injectables Requiring Prior Authorization Some drugs require prior authorization when furnished by and administered in a clinic or facility. For more information, please refer to the Injectables/ Medications Administered under the Medical Benefit Authorization Policy at To request prior authorization, complete the Injectables Billed to the Medical Benefit Form and attach medical record information in support of medical necessity. For complete pharmacy PA criteria and for more information, please visit: pharmacy or call Pharmacy Prior Authorizations at (all days, all hours). UTILIZATION MANAGEMENT Utilization Management programs and activities of the CO-OP aim to ensure our members receive the right care or medications at the right time and in the right amount. Prior Authorization Prior Authorization is approval given by Oregon s Health CO-OP in advance of a proposed or requested hospitalization, treatment, supply purchase or other covered service, in accordance with Oregon s Health CO-OP Policies and Procedures. For a current listing of services requiring prior authorization and to access printable authorization request forms, go to Failure to obtain a prior authorization for any service that requires one, including a facility length of stay, will result in claim payment denial. Primary Care Providers are responsible for obtaining any required authorizations for specialty or ancillary services if the specialist or ancillary provider has not previously seen the member. Specialists or Ancillary Providers are responsible for obtaining any required authorizations once they have seen the member and the service that will be provided requires authorization. For elective ambulatory surgery and facility admissions, the admitting or performing provider is responsible for obtaining the authorization. The facility is responsible for verifying that an authorization was issued. For urgent/emergent facility admissions, inpatient stays, obstetrics admissions and deliveries, the facility is responsible for notifying Oregon s Health CO-OP and for obtaining an authorization. The facility is also responsible for providing the CO-OP with ongoing clinical review information daily or as requested in order to authorize the length of stay. Prior authorization requests that are submitted with complete information, including correct coding, and Oregon s Health CO-OP

14 with relevant chart notes attached allow the CO-OP to make timely authorization determinations. For requests that are complete, the determination is made in fourteen (14) calendar days. Retroactive Authorization The CO-OP accepts retroactive authorization requests. When requests are submitted, an authorization decision is based on the member s coverage, benefit rules and medical appropriateness criteria in effect at the time of service. Concurrent Review The CO-OP may conduct reviews for the extension of previously approved ongoing care. An example is the review of inpatient care as it is occurring. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care being provided and supports the health care provider in coordinating a member s care across the continuum of health care service. The determinations of urgent concurrent reviews are made within twenty-four (24) hours of notification. The CO-OP may deny continuing the services or days if requested information is not provided in a timely manner. Review determinations are based on Interqual criteria for both the level of care and the length of stay. Retrospective Review The CO-OP may conduct post-service decisions to determine medical necessity and/or appropriate level of care when the care has aready been received. All potential post-service denial decisions based on medical necessity or appropriate level of care are reviewed by the Medical Director and a determination made by her or her designee. Notification of postservice denial determinations are given electronically or in writing to the practitioner and member within 30 calendar days of the request. In all cases, authorization determinations are based solely on plan benefits, medical appropriateness and the least costly alternative for the service requested. Denials and Appeals of Authorizations Denial determinations are made based on plan benefits and limitations, appropriateness of care and medical necessity. The CO-OP UM Department uses standard and evidence-based clinical guidelines and criteria to assess medical necessity. The CO-OP reviewers are available to discuss denial decisions. Contact Customer Service 7:00 am to 6:00 pm (Pacific Time) Monday through Friday to schedule a time to speak with a reviewer. Customer Service: at A provider appeal is an official request for reconsideration of a previous denial issued by the CO-OP. This type of appeal is different from the claim review request process. Appeals may be initiated in writing by completing the appeals form found at Non-expedited appeals determination may take up to 90 days, with a minimum of 30 days. Urgent or expedited appeals may be requested if the non-approval of the requested service may seriously jeopardize the member s health. The physician or facility may request an expedited appeal by directly contacting the CO-OP. This may take less than 72 hours for a determination. A brief description of the various appeal categories are listed below: A clinical appeal is a request to change an adverse determination for care or services that were denied on the basis of lack of medical necessity, or when services are determined to be experimental, investigational or cosmetic. The appeal may be preor post- service. Review is conducted by the CO- OP s Medical Director or Peer Review Committee. The medical review/clinical peer review process may take 30 days and concludes with written notification of appeal within forty-five (45) days of receipt of all documentation reasonably needed to make the determination. Further information can be found at or contact Customer Service at :00 am to 6:00 pm (Pacific Time) Monday through Friday to request a clinical appeal. A pharmacy appeal is a request to reconsider a previous denial of prescription or medication. Further information of the appeals process, please visit or contact Optum Rx Prior Authoriztion Department at Please fax the appeal form to Oregon s Health CO-OP -

15 BILLING AND PAYMENT Submit Claims The CO-OP highly encourages providers to submit and receive payment electronically. For information on billing claims electronically, contact Change Healthcare (formerly Emdeon) toll-free at for EDI medical claims. Or visit To initiate electronic billing and payment, the ERA and EFT forms may be found at under Provider Forms. To submit claims electronically, use EDI Payer ID For more information, see instructions for completing the CMS 1500 or UB04 forms at manuals/downloads/clm104c26.pdf and hhs.gov/manuals/downloads/clm104c25.pdf Claims must include the service s ICD-10 code to the highest level of specificity and the appropriate procedure code(s). See OARs and For ICD-10 information, please go to Billing Address for Paper Claims Provider Claims Oregon s Health CO-OP P. O. Box 3948 Corpus Christi, TX Timely Filing Claims for covered services must be received within one year of the date of service to be considered eligible for payment. Providers must be appropriately licensed to submit claims for health care services. Timely Payment Oregon s Health CO-OP agrees to pay a clean claim within the time required by applicable Oregon law. (ORS , ORS ) Provider Claim Reconsideration and Appeal Claim Reconsideration Claim Reconsideration is the first step in asking for review of a previously submitted and processed billing. Use this process when needing an explanation of a claim processing rationale in cases such as contracted rates, excluded benefits or authorization-related denials. The Provider or Clinic may call Or submit the Post Service Reconsideration & Corrected Claim form which is found online at This completed form should be mailed or faxed to: Claim Reconsideration Attn: Oregon s Health CO-OP PO Box 3948 Corpus Christi, TX Fax: Claim Appeal If the reconsideration is denied, the second step in the process is to submit a Post Service Claim Appeal. This is a separate form; find it under Provider Forms online at Fax or mail the completed form to: Oregon s Health CO-OP Attn: Claim Appeals Coordinator PO Box Portland, OR Fax: IMPORTANT: Oregon s Health CO-OP must receive reconsiderations and appeals no more than one year from the original processing date of the claim. Coordination of Benefits If a member has health care coverage under more than one health insurance plan, Oregon s Health CO-OP will coordinate benefits with the health insurance plan to ensure the member receives the maximum coverage allowable under Oregon law. Oregon s Health CO-OP

16 Clinical Editing Oregon s Health CO-OP uses the Optum Claims Edit System (ices) to ensure the efficiency and accuracy of our claims payments. Clinical edits are based on Optum insights Approved Sources for Edit Development, such as American Medical Association (AMA) Current Procedural Terminology (CPT) guidelines, Centers for Medicare & Medicaid (CMS) policies, National Correct Coding Initiative (NCCI) coding edits and specialty society recommendations, as well as policies developed by Oregon s Health CO-OP. Actions of the clinical editing system include, but are not limited to: Rebundling lab, X-ray, medicine, anesthesia and surgical procedure codes Denial warning message when surgery is inconsistent with the diagnosis Denial warning messages on claims when a patient s age does not fall into the normal age range for the procedure or diagnosis Denial of a procedure considered integral to another billed procedure Denial of procedures not customarily billed on the same day as surgical procedure Denial of services normally included as follow-up care associated with a surgical procedure Because valid exceptions to clinical editing exist, Oregon s Health CO-OP reviews records for unusual or extraordinary circumstances that may influence the benefit. Hold Harmless Network providers have agreed to accept our allowable fee as payment in full for covered services and supplies, whether paid by Oregon s Health CO-OP, the member or another payer. As a network provider, this means you may charge our members only for deductible, coinsurance, copayments and non-covered services. Providers must hold the member harmless for any amounts considered contractual adjustments, such as: Charges above the maximum allowable fee: You must not bill a member for any amount of your charge that is greater than the maximum allowable fee per your provider agreement. Charges deemed not medically necessary: You must not bill a member for any amount deemed a provider write-off based on Oregon s Health CO- OP policies, including any services and supplies determined to be not medically necessary Please refer to your provider agreement for further clarification. Overpayment Recovery Oregon s Health CO-OP will conduct retrospective reviews of claims and reimbursements to Providers. Except in the case of fraud or abuse billing, any request for refund of a payment previously made to Providers shall be made in writing within 18 months or, if for reasons relating to coordination of benefits, within 30 months after payment was made, and shall specify why Oregon s Health CO-OP believes the refund is owed. If the refund is requested for reasons relating to coordination of benefits, Oregon s Health CO-OP will include in the written request the name and mailing address of the other insurer or entity that has primary responsibility for payment of the claim. If a request for a refund is not disputed in writing within 30 days, Providers must pay the refund within 30 days after the request is deemed accepted. Overpayments identified by Providers shall be refunded within 60 days of identification of the overpayment by Providers Notwithstanding the foregoing, Oregon s Health CO- OP may at any time request a refund of a claim it has previously paid if liability is imposed by law on a third party and we are unable to recover from the third party because the third party has paid or will pay Providers for the services covered by the claim. If Providers fail to refund an uncontested overpayment within the time periods set forth in this section, Oregon s Health CO-OP may withhold any overpayment amount from future payments for services rendered by Providers. If a refund is not timely received and the CO-OP 16 Oregon s Health CO-OP -

17 is unable to withhold overpayments from future payments, Oregon s Health CO-OP may initiate a collection or legal proceeding to recover overpayment amounts. In a collection or legal proceeding to recover overpayment, Oregon s Health CO-OP is entitled to recover reasonable attorneys fees and costs incurred in such a proceeding. Locum Tenens Claims and Payments Oregon s Health CO-OP allows licensed providers acting in a Locum Tenens capacity to temporarily submit claims under another licensed provider s NPI number when that provider is on leave from his/her practice. The Locum Tenens provider must have the same billing type of specialty as the provider on leave, e.g. a physician must substitute for another physician. Readmissions to Diagnosis Related Group (DRG) Hospitals The following readmissions within 15 days of discharge are considered part of the initial admission and are included in payment for the initial admission: Additional surgery or follow-up care that was planned at the time of discharge Readmission for treatment of the same condition Provider Quick Reference Guide For a helpful guide to Oregon s Health CO-OP resources visit the Provider Form and Resources page on our website Oregon s Health CO-OP is not responsible for compensation arrangements between the provider on leave and the Locum Tenens provider. Oregon s Health CO-OP sends a payment to the billing office of the provider on leave. Per CMS guidelines, Oregon s Health CO-OP allows Locum Tenens to substitute for another provider for 60 days. Providers serving in a Locum Tenens capacity should bill with Modifier Q6 to indicate the Locum Tenens arrangement. Interim Billing Oregon s Health CO-OP reimburses for the first and subsequent interim billings for facilities not reimbursed at Diagnosis Related Group (DRG) rates. Interim claims must be submitted in sequential order and in 30-day increments or on a monthly basis. Each claim must include all applicable diagnosis and procedures. Facilities reimbursed based on DRG methodology are paid when the patient is discharged and the final billing is received. All Authorization guidelines apply. Oregon s Health CO-OP

18 Oregon s Health CO-OP One Pacific Square 220 NW 2nd Ave #600, Portland, OR (844)