2017 Provider Manual Foreword

Transcription

1 Prvider Manual

2 Frewrd Welcme t Keystne VIP Chice. This Prvider Manual was created as a guide t assist yu and yur ffice staff in prviding services t ur members, yur patients. Prviders can use this Keystne VIP Chice Prvider Manual as a reference pertaining t medical services fr members f Keystne VIP Chice. N cntent fund in this publicatin r in Keystne VIP Chice s participating Netwrk Prvider Agreement is intended t be interpreted as encuraging prviders t restrict medicallynecessary cvered services r limit clinical dialgue between prviders and their patients. Regardless f benefit cverage limitatins, prviders shuld penly discuss all treatment ptins that are available. The prvisins f this Prvider Manual may be changed r updated peridically. Revisins will be psted n ur website at Keystne VIP Chice will prvide thirty (30) days ntice f the updates and prviders are respnsible fr checking regularly fr updates. Yur review and understanding f this manual is essential, and we encurage yu t cntact ur Prvider Netwrk Management department with any questins, cncerns and/r suggestins regarding this Prvider Manual. Thank yu fr yur participatin with Keystne VIP Chice. Headquartered in Philadelphia, Pennsylvania, Keystne VIP Chice is a missin-driven managed care rganizatin. 2

3 Our Missin We Help Peple: Get Care Stay Well Build Healthy Cmmunities We have a special cncern fr thse wh are pr. 3

4 Table f Cntents FOREWORD... 2 OUR MISSION... 3 I. OVERVIEW ABOUT OUR PROGRAMS PROGRAM ELIGIBILITY PLAN OVERVIEW MEMBER ENROLLMENT MEMBER ID CARD MEMBER IDENTIFICATION AND ELIGIBILITY VERIFICATION MEMBER RIGHTS AND RESPONSIBILITIES Member Rights Member Respnsibilities PLAN PRIVACY AND SECURITY PROCEDURES II. PROVIDER AND NETWORK INFORMATION BECOMING A PLAN PROVIDER KEYSTONE VIP CHOICE MEDICARE PROVIDER ELIGIBILITY PROVIDER CREDENTIALING AND RE-CREDENTIALING CREDENTIALING/RE-CREDENTIALING CRITERIA AND STANDARDS INITIAL SITE VISIT REVIEW SITE VISITS RESULTING FROM RECEIPT OF A COMPLAINT AND/OR ONGOING MONITORING 19 Member Dissatisfactin Regarding Office Envirnment Cmmunicatin f Results Fllw-Up Prcedure fr Identified Deficiencies Fllw-Up Prcedure fr Secndary Deficiencies RE-CREDENTIALING FACILITY CREDENTIALING CRITERIA PRACTITIONER CREDENTIALING RIGHTS STANDARDS FOR PARTICIPATION ACCESS TO CARE OFFICE ACCESSIBILITY APPOINTMENT SCHEDULING Missed Appintment Tracking Mnitring Appintment Access and After-Hurs Access PANEL CAPACITY/NOT ACCEPTING NEW PATIENTS NOTIFICATION PRACTITIONER & PROVIDER RESPONSIBILITIES RESPONSIBILITIES OF ALL PROVIDERS PRIMARY CARE PROVIDER (PCP) RESPONSIBILITIES SPECIALIST RESPONSIBILITIES

5 PROVIDER DIRECTORY DATA RESPONSIBILITIES COMPLIANCE RESPONSIBILITIES THE AMERICANS WITH DISABILITIES ACT (ADA) AND THE REHABILITATION ACT28 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) FRAUD, WASTE AND ABUSE (FWA) Fraud Waste Abuse FALSE CLAIMS ACT REPORTING AND PREVENTING FWA REPORTING ABUSE, NEGLECT AND EXPLOITATION ADVANCE DIRECTIVES PROVIDER MARKETING ACTIVITIES AND COMPLIANCE Acceptable Marketing Practices Prvider Affiliatin Infrmatin PROVIDER NETWORK MANAGEMENT NEW PROVIDER ORIENTATION ORIENTATION TRAINING PROVIDER EDUCATION AND ONGOING TRAINING PLAN-TO-PROVIDER COMMUNICATIONS PROVIDER COMPLAINT SYSTEM Cmplaints PROVIDER CONTRACT TERMINATIONS Prvider Initiated Keystne VIP Chice Initiated Fr Cause Keystne VIP Chice Initiated Withut Cause Mutual Terminatins CONTINUITY OF CARE III. PROVISION OF SERVICES SUMMARY OF BENEFITS SUPPLEMENTAL BENEFITS Dental Visin Services Over the Cunter (OTC) Pharmacy Items Transprtatin Services Health Management Prgram OUT-OF-NETWORK USE OF NON-EMERGENCY SERVICES PRIVATE PAY FOR NON-COVERED SERVICES EMERGENCY SERVICES NON-COVERED SERVICES IV. MODEL OF CARE INTEGRATED CARE MANAGEMENT

6 INTEGRATED CARE MANAGEMENT COMPONENTS PCP/MEDICAL HOME CHRONIC CARE IMPROVEMENT PROGRAMS CLINICAL PRACTICE GUIDELINES Annual Preventive Physical Examinatin Care Management Keystne VIP Chice Staff PCP Hspital CARE COORDINATION WITH THE PCP CARE COORDINATION WITH OTHER PROVIDERS TREATMENT PLANS MODEL OF CARE EVALUATION Data Surces Methds f Cmmunicating Updates and Outcme V. UTILIZATION MANAGEMENT REFERRALS PRIOR AUTHORIZATION Services that Require Prir Authrizatin** by Keystne VIP Chice Services that D Nt Require Prir Authrizatin Services that Require Ntificatin ORGANIZATION DETERMINATIONS Standard Expedited MEDICAL NECESSITY STANDARDS NOTICE OF ADVERSE DETERMINATION PEER TO PEER REVIEW RECONSIDERATION VI. MEMBER GRIEVANCES AND APPEALS VII. STANDARD AND EXPEDITED GRIEVANCES QUALITY OF CARE GRIEVANCES RECONSIDERATION Standard Recnsideratin f a Pre-Service Request Standard Recnsideratin f a Request fr Payment Expedited QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM65 QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT COMMITTEE PRACTITIONER INVOLVEMENT QAPI PROGRAM ACTIVITIES Health Status Prevalence Dcumentatin and Baseline Assessment Ensuring Apprpriate Utilizatin f Resurces Chrnic Care Imprvement Prgrams

7 Measuring Member and Prvider Satisfactin Participant and Prvider Dissatisfactin Prmting Member Safety PREVENTIVE HEALTH AND CLINICAL GUIDELINES HEALTH CARE EQUITY PLANNED QUALITY IMPROVEMENT PROJECTS CREDENTIALING PROGRAM AVAILABILITY AND ACCESSIBILITY AUDITS MEDICAL RECORD REQUIREMENTS MEDICAL RECORD AUDITS ADVERSE ACTION REPORTING REPORTING & MANAGING UNUSUAL OCCURRENCES Critical Incidents, Sentinel Events and Never Events Managing Unusual Occurrences Reprting Prvider Preventable Cnditins POTENTIAL QUALITY OF CARE CONCERNS FORMAL SANCTIONING PROCESS Ntice f Hearing Cnduct f the Hearing and Ntice Practitiner/Prvider s Hearing Rights Appeal f Keystne VIP Chice Decisin SUMMARY ACTIONS PERMITTED Prhibitin n Payments t Excluded/Sanctined Persns VIII. CULTURAL COMPETENCY PLAN INTRODUCTION CULTURAL AND LINGUISTIC REQUIREMENTS CONTACT INFORMATION IX. CLAIMS SUBMISSION PROTOCOLS AND STANDARDS VISIT REPORTING COMPLETION OF ENCOUNTER DATA/ CLAIM SUBMISSION GENERAL PROCEDURES FOR CLAIM SUBMISSION ELECTRONIC CLAIMS SUBMISSION (EDI ELECTRONIC DATA INTERCHANGE). 84 PAPER CLAIM MAILING INSTRUCTIONS CLAIM FILING DEADLINES PROSPECTIVE CLAIMS EDITING POLICY IMPORTANT BILLING REMINDERS CLAIMS INQUIRY BALANCE BILLING MEMBERS REQUESTS FOR ADJUSTMENTS CLAIM DISPUTES

8 REFUNDS OR RECOVERIES FOR IMPROPER PAYMENT OR OVERPAYMENT OF CLAIMS 89 THIRD PARTY LIABILITY/SUBROGATION ADDITIONAL INFORMATION FOR ELECTRONIC BILLING INVALID ELECTRONIC CLAIM RECORD REJECTIONS/DENIALS Mnitring Reprts fr Electrnic Claims PLAN SPECIFIC ELECTRONIC EDIT REQUIREMENTS ELECTRONIC BILLING EXCLUSIONS COMMON REJECTIONS RE-SUBMITTED CORRECTED CLAIMS PROVIDER PREVENTABLE CONDITIONS MANDATORY REPORTING OF PROVIDER PREVENTABLE CONDITIONS FOR PROFESSIONAL CLAIMS (CMS-1500) FOR FACILITY CLAIMS (UB-04 OR 837I) INPATIENT CLAIMS INDICATING PRESENT ON ADMISSION (POA) ELECTRONIC BILLING INQUIRIES CREDENTIALING OF BEHAVIORAL HEALTH PROVIDERS BEHAVIORAL HEALTH PRACTITIONER / PROVIDER CREDENTIALING RIGHTS BEHAVIORAL HEALTH PROVIDER APPLICATION PROCESS CONTRACTING AND RATE NOTICES COVERED BEHAVIORAL HEALTH SERVICES ACCESS TO BEHAVIORAL HEALTH CARE BEHAVIORAL HEALTH SERVICES REQUIRING PRIOR AUTHORIZATION BEHAVIORAL HEALTH SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION103 BILLING FOR BEHAVIORAL HEALTH CARE SERVICES BEHAVIORAL HEALTH PROVIDER CONTRACT TERMINATIONS AND FORMAL SANCTIONING

9 SECTION I OVERVIEW and MEMBER ELIGIBILITY 9

10 I. Overview Keystne VIP Chice is a member f the AmeriHealth Caritas Family f Cmpanies, a leader in managing medically cmplex members. Thrugh ur Medicare Advantage Dual Eligible Special Needs Plan, Keystne VIP Chice, we are cntinuing and reinfrcing ur visin and missin t lead in the prvisin f health care services t the underserved. Thrugh Keystne VIP Chice, ur existing Medicaid members wh are als eligible fr Medicare will be able t receive the same quality health care services withut disruptin. Keystne VIP Chice members will be enrlled in Keystne VIP Chice s care management and disease management prgrams. They will be assigned a care manager wh will fllw the member s treatment plan, cntinually reaching ut t the member t mnitr cmpliance with the treatment plan, and be available t the member when needs arise. Our crdinated care apprach, leading technlgy slutins, and innvative cmmunity utreach prgrams enable ur members with debilitating cnditins t lead mre cmfrtable lives. Wrking with dedicated health care prviders, ur prgrams ffer better utcmes fr ur members. We are prud f the pprtunity t prvide health care t ur mst vulnerable members. AmeriHealth Caritas decades f experience in Medicaid managed care makes us an excellent chice fr chrnically ill members cvered by Medicare Advantage Plans. Abut Our Prgrams The Dual Eligible Special Needs Medicare Advantage Plan was created t ffer Medicare and Medicaid eligible beneficiaries the pprtunity t receive enhanced benefits in additin t the Medicare and Medicaid benefits. The Medicare prgram is administered thrugh the Centers fr Medicare and Medicaid Services (CMS). Keystne VIP Chice will prvide the Medicare benefits t these members. Prgram Eligibility Members are eligible t enrll in Keystne VIP Chice if they are: Entitled t Medicare Part A, and enrlled in Medicare Part B Live in ur service area Enrlled in the Pennsylvania Medical Assistance prgram Hwever, individuals with End-Stage Renal Disease (ESRD) generally are nt eligible t enrll in Keystne VIP Chice unless the individual meets exceptins t ESRD eligibility rules utlined in Chapter 2, Sectin 20.2 f the CMS Medicare Managed Care Manual. 10

11 Plan Overview Keystne VIP Chice is cntracted t prvide Medicare Hspital (Part A), Medical (Part B) services and Prescriptin Drug Cverage (Part D) services in the fllwing cunties: Bucks, Chester, Delaware, Mntgmery, Philadelphia. Members must live in ne f these cunties t jin the plan. Please refer t Sectin III f this Prvider Manual fr a full descriptin f Plan benefits including supplemental benefits. Member Enrllment Keystne VIP Chice will accept nly thse members with dual Medicaid/Medicare eligibility. Keystne VIP Chice will nt discriminate n the basis f religin, gender, sexual rientatin; race, clr, age, natinal rigin, health status, pre-existing cnditin, r need fr health care services and will nt use any plicy r practice that has the effect f such discriminatin. Hwever, individuals with ESRD generally are nt eligible t enrll in Keystne VIP Chice unless the individual meets exceptins t ESRD eligibility rules utlined in Chapter 2, Sectin 20.2 f the CMS Medicare Managed Care Manual. Keystne VIP Chice members will be required t select a Primary Care Prvider (PCP). If a PCP is nt selected by a member, Keystne VIP Chice will assign a PCP taking the fllwing int cnsideratin: Match f members language preference (if available). Selectin f a PCP clsest t the member s residence based n zip cde. Once the selectin r assignment has been made, Keystne VIP Chice will mail an identificatin card (ID) with the PCP s name (r grup name) t the member. Members are instructed t keep the ID card with them at all times. The member s ID card will include: The member s name and member ID number; Keystne VIP Chice s name, mailing address and member services number. 11

12 Member ID Card Member Identificatin and Eligibility Verificatin Keystne VIP Chice member eligibility varies. Therefre, each participating prvider is respnsible fr verifying member eligibility with Keystne VIP Chice befre prviding services. Eligibility may be verified by: Visiting the Prvider Center f Keystne VIP Chice s website at r Prvider Services at (800) Utilizing Keystne VIP Chice s real-time eligibility service. Depending n yur clearinghuse r practice management system, ur real-time service supprts batch access t eligibility verificatin and system-t-system verificatin, including pint f service (POS) devices. Accessing a link n Keystne VIP Chice s website via a free, web-based slutin fr prvider access t electrnic transactins and infrmatin thrugh a multi-payer prtal - NaviNet. Please nte that Keystne VIP Chice cards are nt returned t Keystne VIP Chice when a member becmes ineligible. Therefre, the presentatin f the Keystne VIP Chice ID card is nt sle prf that a persn is currently enrlled in Keystne VIP Chice. Prviders shuld request a picture ID t verify that the persn presenting is the persn named n the ID card. If prviders suspect a nn-eligible persn is using a member s ID card, please reprt the ccurrence t Keystne VIP Chice s Fraud and Abuse Htline at (866) In rder t help match members with health care that meets their needs in a cst-effective manner, Keystne VIP Chice uses a health risk assessment (HRA) t identify members wh are at risk fr chrnic cnditins and ther health care needs. The HRA cntained in the Member Welcme Packet cntains questins abut current health cnditins and health care services. Our HRA identifies actual r ptential barriers that may hinder the delivery f ptimum health care. Each questin in the HRA is designed t gather infrmatin in which a psitive respnse will trigger prgram referrals r actin t supprt a specific issue. The HRA ffers pprtunities 12

13 t quickly identify and engage members wh have chrnic cnditins, r have special healthrelated needs. Member Rights and Respnsibilities Federal law requires that health care prviders and facilities recgnize member rights. Keystne VIP Chice infrms its members f the fllwing rights and respnsibilities, but members als have the right t request and receive frm their health care prvider a cmpleted cpy f these Rights and Respnsibilities. Member Rights T be prvided with infrmatin abut Keystne VIP Chice and Keystne VIP Chice services, cverage and benefits, the netwrk cntracted practitiners and prviders delivering care, and members rights and respnsibilities. T receive infrmatin n available treatment ptins and alternatives, presented in a manner apprpriate t the member s cnditin and ability t understand. T participate in decisins regarding his r her health care, including the right t refuse treatment. Refusal f treatment is nt cnsidered a reasn t request disenrllment f the member frm a physician s practice. T be free frm any frm f restraint r seclusin used as a means f cercin, discipline, cnvenience r retaliatin. T request and receive a cpy f his r her medical recrds and t request that the recrds be amended as specified in accrdance with HIPAA privacy regulatins. T expect curteus service frm Keystne VIP Chice and cnsiderate care frm cntracted prviders, with respect and cncern fr a member s dignity and privacy. T vice his r her cmplaints and/r appeal unfavrable medical r administrative decisins by fllwing the established appeal r grievance prcedures fund in Keystne VIP Chice s Evidence f Cverage r ther prcedures adpted by Keystne VIP Chice fr such purpses. T infrm cntracted prviders that he r she refuses treatment, and t expect t have such prviders hnr his r her decisin if he r she chses t accept the respnsibility and the cnsequences f such a decisin. In this event, members are encuraged (but nt required) t: Cmplete an advance directive, such as a living will and prvide it t the cntracted plan prviders. T call r write Keystne VIP Chice any time with helpful cmments, questins and bservatins cncerning smething liked abut Keystne VIP Chice r a prblem area. Members may als make recmmendatins regarding Keystne VIP Chice members rights and respnsibilities plicies. Members shuld call the number r write Keystne VIP Chice at the address n the membership card. T expect that health care prviders wh cntract with Keystne VIP Chice will nt discriminate against members in the delivery f health care services n the basis f religin, gender, sexual rientatin; race, clr, age, natinal rigin, health status, pre- 13

14 existing cnditin, ethnicity, natinal rigin, mental r physical disability, genetic infrmatin, r surce f payment, cnsistent with the benefits cvered in their plicy. T have access t services, bth clinical and nn-clinical, regardless f whether a member has limited English prficiency r reading skills, has a diverse cultural and ethnic backgrund, r a physical r mental disability. Member Respnsibilities T understand, t the best f his/her ability, hw Keystne VIP Chice is used t receive health care. T chse a PCP as sn as pssible. T take his/her Keystne VIP Chice ID card and Medicaid ID card t all medical appintments and t the pharmacy fr prescriptins. T keep his/her scheduled appintments. T call his/her dctr s ffice at least 24 hurs in advance f his/her appintment if the appintment must be re-scheduled. T tell his/her dctr abut his/her medical prblems. T ask questins abut things he/she des nt understand. T fllw the prvider s rders and advice n care and treatment that the member has elected t receive. T assist with the transfer f his/her medical recrds. T receive services frm his/her PCP unless referred elsewhere by his/her PCP r therwise permitted by Plan plicy. T infrm Keystne VIP Chice if his/her address has changed, she is r becmes pregnant r any ther changes that culd affect his/her Medicaid eligibility r cverage under Keystne VIP Chice. T cperate with all Keystne VIP Chice inquiries and surveys. Members shuld cnsult their Evidence f Cverage fr mre infrmatin n their rights and respnsibilities. Plan Privacy and Security Prcedures Keystne VIP Chice cmplies with all Federal and State regulatins regarding member privacy and data security, including the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA) and the Standards fr Privacy f Individually Identifiable Health Infrmatin as utlined in 45 CFR Parts 160 & 164. All member health and enrllment infrmatin is used, disseminated and stred accrding t Keystne VIP Chice plicies and guidelines t ensure its security, cnfidentiality and prper use. As a Keystne VIP Chice prvider, yu are expected t be familiar with yur respnsibilities under HIPAA and t take all necessary actins t fully cmply. 14

15 SECTION II PROVIDER AND NETWORK INFORMATION 15

16 II. Prvider and Netwrk Infrmatin This sectin prvides infrmatin fr maintaining netwrk privileges and sets frth expectatins and guidelines fr Primary Care Prviders (PCPs), Specialists and Facility prviders. Please nte that, in general, the respnsibilities and expectatins utlined in this sectin pertain t all prviders, including behaviral health prviders. Additinal infrmatin pertaining t behaviral health prviders, including specific credentialing and re-credentialing requirements, is als prvided in the Behaviral Health Care sectin f this Prvider Manual. BECOMING A PLAN PROVIDER Keystne VIP Chice Medicare Prvider Eligibility Health care prviders are selected t participate in the Keystne VIP Chice Netwrk based n an assessment and determinatin f the netwrk's needs. Prviders must be enrlled with the Medicare prgram in rder t be credentialed with Keystne VIP Chice. Prvider Credentialing and Re-Credentialing Keystne VIP Chice is respnsible fr the credentialing and re-credentialing f the prvider netwrk. Additinal infrmatin pertaining t behaviral health prviders, including specific credentialing and re-credentialing requirements, is prvided in the Behaviral Health Care sectin f this Prvider Manual. Hspital-based physicians are nt required t be independently credentialed if thse prviders serve Keystne VIP Chice members nly thrugh the hspital. All prviders credentialed by Keystne VIP Chice must als be enrlled with the Medicare prgram and, as such, must agree t cmply with all pertinent Medicare regulatins. Keystne VIP Chice maintains criteria and prcesses t credential and re-credential the fllwing practitiners: Medical Dctrs (MDs) Psychlgists Dctrs f Ostepathic Medicine (DOs) Dctrs f Pdiatric Medicine (DPMs) Dctrs f Chirpractic Medicine (DCs) Certified Registered Nurse Practitiners (CRNPs) Certified Nurse Midwives (CNMs) Optmetrists (ODs) Audilgists Occupatinal Therapists Physical Therapists Speech and Language Therapists Keystne VIP Chice maintains criteria and prcesses t credential and re-credential the fllwing facility prvider types: 16

17 Hspitals (acute care and acute rehabilitatin) Ancillary facilities Hme health agencies/hme health hspice Skilled nursing facilities Skilled nursing facilities prviding sub-acute services Nursing hmes Free-standing surgical centers Sleep center/sleep lab freestanding Clinical labratries (a CMS-issued CLIA certificate r a hspital-based exemptin frm CLIA) Prtable X-ray suppliers Free-standing Imaging Centers Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Prviders f utpatient diabetes self-management training Prviders f ESRD services Cmprehensive Outpatient Rehabilitatin Facilities (CORFs) The criteria, verificatin methdlgy and prcesses used by Keystne VIP Chice are designed t credential and re-credential practitiners and prviders in a nn-discriminatry manner, with n attentin t race, ethnic/natinal identity, gender, age, sexual rientatin, specialty r prcedures perfrmed. Keystne VIP Chice s credentialing/re-credentialing criteria and standards are cnsistent with the Centers fr Medicare and Medicaid Services specific requirements and Natinal Cmmittee fr Quality Assurance (NCQA) standards. Practitiners and facility/rganizatinal prviders are required t be re-credentialed every three years. Keystne VIP Chice wrks with the Cuncil fr Affrdable Quality Healthcare (CAQH) t ffer prviders a Universal Prvider Data surce that simplifies and streamlines the data cllectin prcess fr credentialing and re-credentialing. Thrugh CAQH, prviders submit credentialing infrmatin t a single repsitry, via a secure Internet site, t fulfill the credentialing requirements f all health plans that participate with CAQH. Keystne VIP Chice s gal is t have all prviders enrlled with CAQH. There is n charge t prviders t submit applicatins and participate in CAQH. Prviders may access these frms via Keystne VIP Chice s website at and submit t Keystne VIP Chice as fllws: Submit Applicatin t Participate with Keystne VIP Chice via CAQH (PDF); Send CAQH ID number t Keystne VIP Chice via an t the Credentialing Department; r, Register fr CAQH if nt already enrlled via a link t the CAQH website. Prviders wh are nt affiliated with CAQH r prefer a paper credentialing prcess may cntact Keystne VIP Chice s Prvider Services department fr assistance at (800) r yur Accunt Executive. 17

18 Credentialing/Re-Credentialing Criteria and Standards Keystne VIP Chice verifies credentialing and re-credentialing criteria fr all prfessinal prviders that, at a minimum, meet all applicable federal requirements. T that end, Keystne VIP Chice s criteria include: 1. Current unrestricted medical licensure; 2. N revcatin r suspensin f the prvider's state license by the applicable State licensing bard; 3. Disclsure related t wnership and management (42 CFR ), business transactins (42 CFR ) and cnvictin f crimes (42 CFR ); 4. Prf f the prvider's medical schl graduatin, cmpletin f residency and ther pstgraduate training. Evidence f bard certificatin shall suffice in lieu f prf f medical schl graduatin, residency and ther pstgraduate training; 5. Evidence f specialty bard certificatin, if applicable; 6. Evidence f the prvider's prfessinal liability insurance cverage, and claims histry; 7. Satisfactry review f any sanctins impsed n the prvider by Medicare r Medicaid; 8. The prvider s Medicare identificatin number, Medicaid ID number, Medicaid prvider registratin number r dcumentatin f submissin f the Medicaid prvider registratin frm whenever applicable. In additin, Keystne VIP Chice s credentialing and re-credentialing prcesses include verificatin f the fllwing additinal requirements fr physicians: 1. Fr primary care physicians and specialists privileges in gd standing at the hspital designated by the PCP as the primary admitting facility; r, if the PCP des nt have admitting privileges, privileges in gd standing at the hspital fr anther prvider with whm the PCP has entered int an arrangement fr hspital cverage; 2. Valid Drug Enfrcement Administratin (DEA) certificate, where applicable. As part f the applicatin prcess Keystne VIP Chice will: Request infrmatin n Health Care Prvider sanctins prir t making a credentialing r recredentialing decisin. Infrmatin frm the Natinal Practitiner Data Bank (NPDB), Federatin f State Medical Bard (FSMB), Medicheck (Medicaid exclusins), and HHS Office f the Inspectr General (OIG) List f Excluded Individuals/Entities (LEIE), Federatin f Chirpractic Licensing Bards (CIN-BAD), Excluded Parties List System (EPLS) and relevant State sanctin and licensure databases as applicable. Initial Site Visit Review Keystne VIP Chice s credentialing prcess includes prvisins that new practitiners (and new practice lcatins) are required t meet minimal criteria fr ffice settings and medical recrd keeping in rder t be cnsidered fr inclusin in the prvider netwrk. These initial site visit requirements apply t practitiners jining previusly surveyed lcatins, as well as the new practice lcatins f previusly surveyed practitiners. 18

19 T address any areas f deficiency identified n the initial visit, Keystne VIP Chice requires a crrective actin plan be submitted t the Plan within ne week f the visit. Re-survey f the site will ccur within 30 days t ensure cmpliance has been met. Practitiners nt meeting the minimal perfrmance standard threshld f 85% will be reviewed by the Keystne VIP Chice s Medical Directr and Credentialing Cmmittee fr recmmendatin. In additin t the initial site visit, all practice/site lcatins will receive a re-evaluatin visit every three years. Site Visits Resulting frm Receipt f a Cmplaint and/r Onging Mnitring Member Dissatisfactin Regarding Office Envirnment The Prvider Netwrk Management r the Credentialing Department may identify the need fr a Site Visit due t receipt f a Member Dissatisfactin regarding the prvider s ffice envirnment At the discretin f the Prvider Netwrk Management Representative a site visit t address the specific issue(s) raised by a member may ccur. Fllw-up site visits are cnducted as necessary. Cmmunicatin f Results 1. The Prvider Netwrk Management Representative reviews the results f the Site Visit Evaluatin Frm (indicating all deficiencies) with the ffice cntact persn. 2. If the site meets and/r exceeds the passing scre: The Site Visit Evaluatin Frm is signed and dated by bth Keystne VIP Chice and the ffice cntact persn. 3. If the site des nt receive a passing scre, Keystne VIP Chice fllws the prcedures utlined belw t fllw-up n identified deficiencies. Fllw-Up Prcedure fr Identified Deficiencies 1. The Prvider Netwrk Management Representative requests a crrective actin plan frm the ffice cntact persn. The crrective actin plan must be submitted t Keystne VIP Chice within ne week f the visit. 2. The Prvider Netwrk Management Representative schedules a re-evaluatin visit with the prvider ffice, t ccur within 30 days f the initial site visit t review the site and verify that the deficiencies were crrected. 3. The Prvider Netwrk Management Representative reviews the crrective actin plan with the ffice cntact persn. 4. The Prvider Netwrk Management Representative reviews the results f the fllw-up Site Visit Evaluatin Frm (including a re-review f previus deficiencies) with the ffice cntact persn. If the site meets and/r exceeds the passing scre, the Site Visit Evaluatin Frm is signed and dated by bth Keystne VIP Chice and the ffice cntact persn. 19

20 If the site des nt receive a passing scre, the Prvider Netwrk Management Representative fllws the prcedures utlined belw fr fllw-up fr secndary deficiencies. Fllw-Up Prcedure fr Secndary Deficiencies The Prvider Netwrk Management Representative will re-evaluate the site mnthly, up t three times (frm the first Site Visit date). If after fur (4) mnths, there is evidence the deficiency is nt being crrected r cmpleted, then the ffice receives a failing scre unless there are extenuating circumstances. Further decisins as t whether t pursue the Credentialing prcess r take actin t terminate participatin f a prvider wh cntinues t receive a failing Site Visit Evaluatin scre will be handled n a case by case basis by the Keystne VIP Chice Medical Directr and Credentialing Cmmittee. Re-Credentialing Keystne VIP Chice re-credentials netwrk practitiners at least every three years. All practitiners invlved in the re-credentialing cycle are sent a Re-credentialing Ntificatin Letter three t six mnths prir t the re-credentialing due date. The fllwing infrmatin is needed in rder t cmplete the re-credentialing prcess: Applicatin Credentials Update Frm r CAQH Universal Prvider Data Surce Practitiner CAQH reference number Office hurs/service addresses Supprting Dcuments State prfessinal license, Federal DEA registratin, State Cntrlled Substance Certificate, Malpractice Face Sheet, CLIA certificate (if applicable) As with initial credentialing, all applicatins and attestatin/release frms must be signed and dated n mre than 180 days prir t the Credentialing Cmmittee decisin date. Additinally, all supprting dcuments must be current at the time f the decisin date. Facility Credentialing Criteria Keystne VIP Chice s credentialing criteria fr facilities include: An unrestricted and current license; Accreditatin certificate frm a recgnized accrediting bdy; Satisfactry CMS site visit reprt, fr nn-accredited facilities; Successful utcme f a quality site visit (fr facilities that are nt accredited and have nt had a CMS site visit); Evidence f eligibility with state and federal regulatry bdies, including Medicare; and A cpy f the current malpractice face sheet. Keystne VIP Chice perfrms initial site evaluatins n facility prviders wh are nt accredited and d nt have a CMS site survey. Fr thse prviders wh are either accredited r 20

21 have had a CMS site survey, a cpy f the accreditatin r site survey must be submitted with the initial credentialing dcumentatin. Additinal site visits fr accredited facility prviders may be perfrmed at Keystne VIP Chice s discretin. Practitiner Credentialing Rights During the review f the credentialing applicatin, applicants are entitled t certain rights as listed belw. Every applicant has the right t: Review infrmatin btained thrugh primary surce verificatin fr credentialing purpses. This includes infrmatin frm malpractice insurance carriers and state licensing bards. This des nt include infrmatin cllected frm references, recmmendatins and ther peer-review prtected infrmatin. Be ntified if any credentialing infrmatin is received that varies substantially frm applicatin infrmatin submitted by the practitiner. As examples, practitiners will be ntified f the fllwing types f variances: actins n license, malpractice claim histry, suspensin r terminatin f hspital privileges, r bard certificatin decisins; hwever, variances in infrmatin btained frm references, recmmendatins r ther peer-review prtected infrmatin are nt subject t this ntificatin. Practitiners have the right t crrect errneus infrmatin if the credentialing infrmatin received varies substantially frm the infrmatin that was submitted n his/her applicatin. Knw the status f his/her applicatin if the applicatin is current and cmplete, the applicant can be infrmed f the tentative date that his/her applicatin will be presented t the Credentialing Cmmittee fr apprval. Questins regarding the status f a credentialing applicatin may be directed t the Keystne VIP Chice Credentialing Department. Keystne VIP Chice s Quality Assessment and Perfrmance Imprvement Prgram (QAPI) prvides versight f the Credentialing Prgram. Fr mre infrmatin n the QAPI, refer t the Quality Prgram sectin f this Prvider Manual. Standards fr Participatin By agreeing t prvide services t Keystne VIP Chice members, prviders must: Be a Medicare-enrlled physician and agree t cmply with all pertinent Medicaid and Medicare regulatins Treat Keystne VIP Chice members in the same manner as ther patients Prvide cvered services t all Keystne VIP Chice members wh select r are referred t yu as a prvider Nt discriminate against any member n the basis f religin, gender, sexual rientatin, race, clr, age, natinal rigin, health status, pre-existing cnditin, ethnicity, natinal rigin, mental r physical disability, genetic infrmatin, r surce f payment Nt segregate members frm ther patients (applies t services, supplies, equipment) Refrain frm billing members fr cvered services, including any amunts in dispute with Keystne VIP Chice 21

22 Nt refuse t prvide services t members due t a delay in eligibility updates Access t Care Keystne VIP Chice PCPs and specialists must meet standard guidelines as utlined in this Prvider Manual t help ensure that Keystne VIP Chice members have timely access t care. Keystne VIP Chice endrses and prmtes cmprehensive and cnsistent access standards fr members t assure member accessibility t health care services. Keystne VIP Chice has established mechanisms fr measuring cmpliance with existing standards and identifies pprtunities fr the implementatin f interventins fr imprving accessibility t health care services fr members. The fllwing areas are mnitred by Keystne VIP Chice t ensure physicians access standards are cntinually met: Office Accessibility PCP ffice hurs must be clearly psted and reviewed with members during the initial ffice visit. The PCP is required t arrange fr cverage f primary care services during absences due t vacatin, illness r ther situatins that render the PCP unable t prvide services. A Medicare eligible PCP must prvide the cverage t Keystne VIP Chice members. Appintment Scheduling Timely Access Standards fr appintment availability fr PCPs and Specialists: Prvider Type Appintment Type Availability Standard Primary Care Physician (PCP) Emergency Care Immediately upn member s call- After-hurs Care Twenty-fur (24) hurs per day, seven (7) days per week Urgent, Acute Care Within twenty Fur (24) hurs Rutine Primary Care (Nn- Urgent, Symptmatic) Within ten (10) calendar days Preventive Care (Nn- Within three (3) weeks Symptmatic) Medical Fllw-Up t Within seven (7) calendar High-Vlume Specialists (Cardilgist, Onclgist, Ophthalmlgists, Orthpedic Surgens, General Surgens, Gastrenterlgists, Inpatient Care days f discharge Rutine Within thirty (30) calendar days 22

23 Pulmnlgists, Otlarynglgists and Specialists in Physical Medicine and Rehabilitatin) Emergency services must be prvided immediately upn presentatin. Missed Appintment Tracking If a member misses an appintment with a prvider, the prvider shuld dcument the missed appintment in the member s medical recrd. Prviders shuld make at least three dcumented attempts t cntact the member and determine the reasn fr the missed appintment. The medical recrd shuld reflect any reasns fr delays in prviding medical care as a result f missed appintments, and shuld als include any refusals by the member. The prvider shuld alert the member s Care Manager fr fllw up. Mnitring Appintment Access and After-Hurs Access Keystne VIP Chice mnitrs appintment waiting times using varius mechanisms, including: Reviewing prvider recrds during site reviews Mnitring administrative cmplaints and grievances Cnducting an annual Access t Care survey t assess member access t daytime appintments and after-hurs care Perfrming after-hur calls t verify cverage availability Nn-cmpliant prviders will be subject t crrective actin and/r terminatin frm the netwrk as fllws: A nn-cmpliance letter will be sent t the prvider The nn-cmpliant prvider will be re-surveyed within three t six mnths after the infractin Panel Capacity/Nt Accepting New Patients Ntificatin When members chse a prvider as their PCP, they are assigned t the prvider s panel f members. The panel remains pen unless the fllwing ccurs: The PCP is under sanctin; Keystne VIP Chice apprves a PCP request t vluntarily clse his/her panel; r, The panel is clsed by Keystne VIP Chice due t member access issues. All Keystne VIP Chice prviders wh wish t clse their panel r n lnger accept new patients must prvide a 90 day written ntice t Keystne VIP Chice. The ntice shuld include the date the prvider wuld like their panel clsed r t n lnger accept new patients and the reasns why the prvider wuld like t clse their panel r n lnger accept new patients. Prviders may nt clse their panel nly t Keystne VIP Chice members, r n lnger accept nly Keystne VIP Chice members. 23

24 Keystne VIP Chice will be prviding each PCP a mnthly member rster by paper r electrnically via the nline Prvider Prtal. PRACTITIONER & PROVIDER RESPONSIBILITIES Respnsibilities f All Prviders Keystne VIP Chice is regulated by federal law. Prviders wh participate in Keystne VIP Chice have respnsibilities, including but nt limited t: Being a Medicare enrlled prvider and agreeing t cmply with all pertinent Medicare regulatins, including all respnsibilities set frth as fllws: Be Cmpliant with all applicable Federal and/r State regulatins Treat Keystne VIP Chice members in the same manner as ther patients Cmmunicate with agencies including, but nt limited t lcal public health agencies fr the purpse f participating in immunizatin registries and prgrams, e.g. cmmunicatins regarding management f infectius r reprtable diseases, special educatin prgrams, early interventin prgrams, etc. Cmply with all disease ntificatin laws fr the State f Pennsylvania As apprpriate, wrk cperatively with specialists, cnsultative services and ther facilitated care situatins fr special needs members such as accmmdatins fr the deaf and hearing impaired, experience-sensitive cnditins such as HIV/AIDs, self-referrals fr wmen s health services, family planning services, etc. Nt refuse an assignment r transfer a member r therwise discriminate against a member slely n the basis f religin, gender, sexual rientatin, race, clr, age, natinal rigin, health status, pre-existing cnditin, ethnicity, natinal rigin, mental r physical disability, genetic infrmatin, surce f payment, type f illness r cnditin, except when that illness r cnditin can be better treated by anther prvider type Ensure that ADA requirements are met, including utilizing apprpriate technlgies in the daily peratins f the physician s ffice, e.g., TDD/TTY: (866) and language services, t accmmdate the member s special needs Prvide infrmatin t Keystne VIP Chice and/r CMS as required Infrm members abut all treatment ptins, regardless f cst r whether such services are cvered by the Medicare Prgram r Keystne VIP Chice Abide by and cperate with the plicies, rules, prcedures, prgrams, activities and guidelines cntained in yur Prvider Agreement (t which this Prvider Manual and any revisins r updates are incrprated by reference) Accept Keystne VIP Chice payment, plus any applicable member cpayment, r third party resurces as payment-in-full fr cvered services 24

25 Cmply fully with Keystne VIP Chice s QAPI, Utilizatin Management, Integrated Care Management, Credentialing and Audit prgrams Cmply with all applicable training requirements, including Medicare Cmpliance training, and FWA training Prmptly ntify Keystne VIP Chice f claims prcessing payment r encunter data reprting errrs Maintain all recrds required by law regarding services rendered fr the applicable perid f time, making such recrds and ther infrmatin available t Keystne VIP Chice r any apprpriate gvernment entity Treat and handle all individually identifiable health infrmatin as cnfidential in accrdance with all applicable laws and regulatins, including HIPAA and HITECH requirements Immediately ntify Keystne VIP Chice f adverse actins against license r accreditatin status Cmply with all applicable federal, state, and lcal laws and regulatins; Maintain liability insurance in the amunt required by the terms f the Prvider Agreement Ntify Keystne VIP Chice f the intent t terminate the Prvider Agreement as a participating prvider within the timeframe specified in the Prvider Agreement Verify member eligibility immediately prir t rendering services Obtain all required signed cnsents prir t rendering services Obtain prir authrizatin and prvide referrals fr applicable services Maintain hspital privileges when hspital privileges are required fr the delivery f the cvered service Maintain all medical and Medicare-related member recrds and cmmunicatins fr a perid f ten(10) years and in accrdance with legal, regulatry and cntractual rules f cnfidentiality and privacy Prvide prmpt access t recrds fr review, survey r study if needed Reprt knwn r suspected child, elder r dmestic abuse t lcal authrities and have established prcedures fr these cases Infrm member(s) f the availability f Keystne VIP Chice s interpretive services and encurage their use Ntify Keystne VIP Chice f any changes in business wnership, business lcatin, legal r gvernment actin, r any ther situatin affecting r impairing the ability t carry ut duties and bligatins under the Keystne VIP Chice Netwrk Prvider Agreement Maintain versight f nn-physician practitiners as mandated by state and federal law Primary Care Prvider (PCP) Respnsibilities A Primary Care Prvider (PCP) serves as the member s persnal practitiner and is respnsible fr crdinating and managing the medical needs f a panel f Keystne VIP Chice members. Practitiners in the fllwing specialties may serve as Plan PCPs: 25

26 General Practice Geriatrics Internal Medicine Ostepath Family Practice Internist Naturpathic Physician Physician s Assistant Advanced Practice Registered Nurse (APRN) Additinally, clinics, Federally Qualified Health Centers and nurse practitiners (practicing in the areas listed abve) may als serve as PCPs. A PCP is respnsible t Keystne VIP Chice and its members fr diagnstic services, care planning and Treatment Plan develpment. The PCP is expected t wrk with Keystne VIP Chice t mnitr the planning and prvisin f treatment. In additin, the PCP is respnsible fr: Fr PCPs: prvide cvered services t all Keystne VIP Chice members assigned t the PCP, and cmply with all requirements fr referral management and prirauthrizatin Fr PCPs: prvide the Keystne VIP Chice member with a medical hme including, when medically necessary, crdinating apprpriate referrals t services that typically extend beynd thse services prvided by the PCP, including but nt limited t specialty services, emergency rm services, hspital services, nursing services, mental health/substance abuse (MH/SA), ancillary services, public health services and ther cmmunity based agency services Fr PCPs: prvide cntinuus access t PCP services and necessary referrals f urgent r emergent nature available 24 hurs, seven days per week, access by telephne t a live vice (an emplyee f the PCP r an answering service) r an answering machine that must immediately page an n-call medical prfessinal s referrals can be made fr nn-emergency services r s infrmatin can be given abut accessing services r prcedures fr handling medical prblems during nn-ffice hurs Fr PCPs: request transfer f the member t anther PCP nly fr the reasns identified in the state regulatin and cntinue t be respnsible fr the member as a patient until anther PCP is chsen r assigned Fr PCPs: prvide accurate infrmatin t Keystne VIP Chice in a timely manner s that PCP infrmatin can be exchanged with CMS via the Prvider Netwrk File 26

27 Specialist Respnsibilities A Keystne VIP Chice specialist is respnsible fr: Prviding specialty care as indicated by the referral; Verifying a member s eligibility and reviewing the referral prir t the prvisin f services; Reprting clinical findings t the referring PCP; Ordering the apprpriate diagnstic tests (radilgy, labratry) related t the treatment f the member, as requested by the referring practitiner via the referral; Dcumenting all care rendered in a cmplete and accurate manner including maintaining a current medical recrd fr Plan members that meets Keystne VIP Chice s Medical Recrd Dcumentatin Requirements, as described in the Quality Assurance and Perfrmance Imprvement Prgram sectin f this Prvider Manual; and Refraining frm referring members t ther specialists withut the interventin f the member s PCP. Prvider Directry Data Respnsibilities As a Dual Special Needs Plan, Keystne VIP Chice is required t cnduct quarterly cmmunicatins with cntracted prviders t ensure the accuracy f the required prvider directry data. If there have been any changes t the prvider s ffice, such as an address, phne number, r the terminatin f a prvider, ntificatin must be made t the plan by ne f the fllwing ways: Cntacting the Prvider Netwrk Accunt Executive. Calling Prvider Services at COMPLIANCE RESPONSIBILITIES Keystne VIP Chice prviders are required t cmply with all Plan plicies and with all relevant legal r regulatry standards, as set by utside legal r regulatry authrities. Althugh nt an exclusive list, the primary areas f cmpliance with plicies and regulatins fr Plan prviders are: Americans with Disabilities Act (ADA) / Rehabilitatin Act Health Insurance Prtability and Accuntability Act (HIPAA) Fraud, Waste & Abuse (FWA) False Claims Act Advance Directives CMS Marketing Activities Guidelines 27

28 The Americans with Disabilities Act (ADA) and the Rehabilitatin Act Sectin 504 f the Rehabilitatin Act f 1973 ( Rehab Act ) and Title III f the Americans with Disabilities Act f 1990 (ADA) prhibit discriminatin against individuals with disabilities and require Keystne VIP Chice s prviders t make their services and facilities accessible t all individuals. Keystne VIP Chice expects its netwrk prviders t be familiar with the requirements f the Rehabilitatin Act and the ADA and t fully cmply with the requirements f these statutes. Health Insurance Prtability and Accuntability Act (HIPAA) Keystne VIP Chice is cmmitted t strict adherence with the privacy and security prvisins f the Health Insurance Prtability and Accuntability Act (HIPAA) and expects its practitiners and prviders t be familiar with their HIPAA respnsibilities and t take all necessary actins t fully cmply. Any member recrd cntaining clinical, scial, financial, r any ther data n a member shuld be treated as strictly cnfidential and be prtected frm lss, tampering, alteratin, destructin, and unauthrized r inadvertent disclsure. Fraud, Waste and Abuse (FWA) Keystne VIP Chice has a designated Medicare Cmpliance Officer wh carries ut the prvisins f Keystne VIP Chice s cmpliance plan, which includes Keystne VIP Chice s fraud, waste and abuse (FWA) prgrams. Designed in accrdance with Federal rules and regulatins, Keystne VIP Chice s cmpliance prgram is aimed at preventing and detecting activities that cnstitute FWA. The prgram includes FWA plicies and prcedures, investigatin f unusual incidents and implementatin f crrective actin. Keystne VIP Chice has prvider reference materials that are available by cntacting the Prvider Services department. The materials include infrmatin regarding: Fraud Fraud is an intentinal deceptin r misrepresentatin made by a persn with the knwledge that the deceptin results in unauthrized benefit t that persn r anther persn. The term includes any act that cnstitutes fraud under applicable federal r state law. As applied t the federal health care prgrams (including the Medicare and Medicaid prgrams), health care fraud generally invlves a persn r entity s intentinal use f false statements r fraudulent schemes (such as kickbacks) t btain payment fr, r t cause anther t btain payment fr, items r services payable under a federal health care prgram. Sme examples f fraud include: Billing fr services nt furnished; Submitting false infrmatin t btain authrizatin t furnish services r items t Medicare recipients; Sliciting, ffering r receiving a kickback, bribe r rebate; and/r, Vilatins f the physician self-referral prhibitin. 28

29 Waste Waste means t use r expend carelessly, extravagantly, r t n purpse. Abuse Abuse is defined as prvider practices that are incnsistent with generally accepted business r medical practice and that result in an unnecessary cst t Medicare prgrams r in reimbursement fr gds r services that are nt medically necessary r that fail t meet prfessinally recgnized standards fr health care; r recipient practices that result in unnecessary cst t Medicare prgrams. In general, prgram abuse, which may be intentinal r unintentinal, directly r indirectly results in unnecessary r increased csts t Medicare prgrams. Sme examples f abuse include: Charging in excess fr services r supplies; Prviding, referring, r prescribing medically unnecessary services r items; Prviding services that d nt meet prfessinally recgnized standards. False Claims Act The Federal False Claims Act (FCA) is a Federal law that applies t fraud invlving any cntract r prgram that is federally funded, including Medicare. It prhibits knwingly presenting (r causing t be presented) a false r fraudulent claim t the federal gvernment r its cntactrs, including Medicare Advantage plans, fr payment r apprval. The FCA als prhibits knwingly making r using (r causing t be made r used) a false recrd r statement t get a false r fraudulent claim paid r apprved. Health care entities that vilate the Federal FCA can be subject t imprisnment and civil mnetary penalties ranging frm $5,000 t $11,000 fr each false claim submitted t the United States gvernment r its cntactrs, including Medicare Advantage plans, as well as pssible exclusin frm Federal Gvernment health care prgrams. The Federal FCA cntains a qui tam r whistleblwer prvisin t encurage individuals t reprt miscnduct invlving false claims. The qui tam prvisin allws any persn with actual knwledge f allegedly false claims submitted t the gvernment t file a lawsuit n behalf f the U.S. Gvernment. The FCA prtects individuals wh reprt under the qui tam prvisins frm retaliatin that results frm filing an actin under the Act, investigating a false claim, r prviding testimny fr r assistance in a Federal FCA actin. The Fraud Enfrcement and Recvery Act f 2009 (FERA) was passed by Cngress t enhance the criminal enfrcement f federal fraud laws, including the False Claims Act (FCA). Penalties fr vilatins f FERA are cmparable t penalties fr vilatin f the FCA. FERA des the fllwing: Expands ptential liability under the FCA fr gvernment cntractrs like Keystne VIP Chice. Expands the definitin f false/fraudulent claim t include claims presented nt nly t the gvernment itself, but als t a gvernment cntractr like Keystne VIP Chice. Expands the definitin f false recrd t include any recrd that is material t a false/fraudulent claim. 29