Welcome to AlohaCare

Transcription

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2 Welcome to AlohaCare 2

3 Overview Introduction QUEST Integration Service Coordination Medicare Plan Claims Provider Roles and Responsibilities Referral, Authorization, and Notification (RAN) Process Member Rights and Responsibilities Fraud and Abuse Grievance and Appeals Resources and Tools 3

4 Who is AlohaCare? Our health plans: Organizational background Mission Philosophy of care AlohaCare QUEST Integration AlohaCare Advantage Plus (HMO SNP) 4

5 Provider Relations Department Active main interface between AlohaCare and the provider community. We also invite providers to work directly with us on our advisory committees. Focus is on recruiting, retaining and maintaining a robust provider network that meets the healthcare needs of our members. We offer a variety of orientation and training opportunities to provide clarity on our processes and plan requirements. We provide support and assistance to providers to enable them to give efficient and effective care. 5

6 QUEST Integration 6

7 AlohaCare QUEST Integration QUEST Integration (QI) is a Medicaid managed care program under the Hawaii Department of Human Services (DHS). Managed care means that the DHS has contracted with AlohaCare to help members manage their health care needs. Our health plan assists members in receiving the highest quality of health care in the right care setting and at the time that they need the care. AlohaCare QI provides coverage for those who qualify. We offer: Coverage for medical, behavioral health and long-term care supports and services Medical coverage Services to help in daily activities Independent living and input on a member s health care decisions Service coordinators to help members get the care that they need 7

8 Eligibility for QUEST Integration Be a Hawaii resident Be a U.S. citizen or legal immigrant Not reside in a public institution Meet certain asset and income requirements 8

9 QUEST Integration Covered Services Inpatient Care Outpatient Care Preventive Services Pregnancy and Maternity Care Behavioral Health Services Emergency Services Vision Care Prescription Drug Coverage Long Term Services and Supports (LTSS) - for members that meet the appropriate level of care 9

10 QUEST Integration Member ID Card Unique member ID number Plan type indicated Assigned PCP name/phone number Assigned Service Coordinator (if applicable) 10

11 QUEST Integration Marketing Activities Providers are allowed to: Make health plan material available in your offices regarding annual plan changes. Share with your members which health plans you are contracted with. Providers are not allowed to: Encourage members to choose a specific health plan. Complete Annual Plan Change forms for members. 11

12 Special Needs Plan (SNP) 12

13 Medicare Advantage Plus Plan AlohaCare Advantage Plus (ACAP) (HMO SNP) ACAP is Medicare Advantage Prescription Drug plan Special Needs Plan (SNP) For people who qualify to receive both Medicare and Medicaid coverage (Medi-Medi) 13

14 Medicare Member ID Card Unique member ID number assigned 3-digit alpha and 12-digit numeric e.g., MEM PCP name 14

15 Service Coordination 15

16 Service Coordination AlohaCare has several service coordination programs to address the needs of our members which include: Service Coordination for members with complex care needs requiring intensive care management. Disease Management for members with one or more chronic diseases and do not meet the criteria for intensive care management. Population Health Management general preventive health member outreach and education services. 16

17 How to Access Service Coordination Services Medical Triggers Behavioral Health Triggers Other Child/Adolescent Triggers Pharmacy Triggers Activities of Daily Living/Social Triggers Referral 17

18 Referral to Service Coordination Members may be referred into Service Coordination programs through a variety of ways including the following: Identification through a Member Survey that AlohaCare performs on all newly enrolled members for any special health care needs Direct member referral Referral by the member s family or representative Referral by the member s Primary Care Provider (PCP) or other involved health care provider Internal referrals from AlohaCare Utilization Management (UM), Pharmacy Drug Utilization Review or Behavioral Health activities Departments such as Member Services or Enrollment 18

19 Role of Service Coordinators AlohaCare members identified as having special health care needs (including LTSS) will receive field service coordination activities performed in the community. Members in this category will have a dedicated nurse or social worker assigned as their single point of contact with AlohaCare. When assigned, the field Service Coordinator will become the primary coordinator for all activities being performed to meet the member s needs, ensuring services are delivered effectively, monitoring goals and following-up on urgent problems. 19

20 Long Term Supports and Services How does a member qualify? The member must meet certain level of care requirements and have an assessment performed by an AlohaCare Service Coordinator. The Service Coordinator will work with the member and providers to determine what services are necessary based on the assessment. There are different types of LTSS: Home and Community Based Services (HCBS) provided in an individual s home or other community residential setting. At-risk services are certain HCBS services that are provided to an individual if an assessment indicates that the individual is at-risk for worsening and going into a nursing facility or other type of care outside of their home. They do not meet the criteria for all HCBS services. Institutional Services provided in a setting such as a nursing facility 20

21 Home and Community Based Services Adult day care Adult day health Assisted living facility services Community Care Management Agency (CCMA) services Community Care Foster Family Home (CCFFH) services (Adult foster care) Counseling and training Environmental accessibility adaptations Home delivered meals Home maintenance Moving assistance Non-medical transportation Personal assistance services Level I and Level II Personal Emergency Response Systems (PERS) Residential care services in an Expanded Adult Residential Care Home (EARCH) Respite care Specialized medical equipment and supplies 21

22 Institutional Services Acute Waitlisted (ICF/SNF) Services Skilled Nursing Facility Services Intermediate Care Facility Services Sub-Acute Facility Services 22

23 Claims 23

24 Claims Submission All encounters for AlohaCare members must be submitted as a claim, regardless of whether the services are covered under a capitation or feefor-service payment arrangement. Electronic Data Interchange (EDI) Hardcopy Claims 24

25 EDI (Electronic Data Interchange) EDI allows for faster claim payment and reduction of paperwork Must use approved AlohaCare vendors: Legacy/Administep RelayHealth Gateway/Trizetto Claim Remedi 25

26 Online Submission Electronic submission allows for faster claim payment and reduction of paperwork The turn-around-time for EDI claims is about 1 week faster than paper claims 26

27 Hardcopy Claims Paper claims must be printed with a font size between 10 and 12. All submissions must be on original claim forms; no copied forms are accepted for claim submission. Please see Appendix A of our provider manual for additional information regarding requirements and helpful tips on the CMS 1500 claim and the CMS 1450 (UB-04) forms. Mail claims to: AlohaCare Claims Department 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI All claims must contain required information and all data must be consistent and valid. Omission of required information will result in a denied claim. Missing information should be provided via claim resubmission. 27

28 Claims Filing Guidelines Claims must be submitted within 1 year from date of service Hard copy claims must be submitted on the original red and white CMS 1500/UB04 forms Claim resubmissions should also be submitted on original red and white CMS 1500/UB04 forms and should be clearly marked resubmission NPI numbers should be reflected in all appropriate fields on claims submitted 28

29 Claims Processing for EPSDT Early Periodic Screening, Diagnostic, and Treatment (EPSDT) claims must include an EPSDT exam form (8015, 8015A, & 8016) Providers must submit EPSDT claims with the appropriate information and EPSDT exam form for reimbursement. Claims submitted without an EP modifier, but with an EPSDT exam form will be returned to verify if EPSDT services were rendered and the modifier should be added as appropriate. Claims submitted with an EP modifier, but no EPSDT exam form will be denied as missing form. If the EP modifier is not billed with the CPT code, payment will be made at the regular non-epsdt fee schedule rate. The EPSDT Manual is available on 29

30 No Direct Billing To Members Providers cannot: Bill or make any attempt to collect payment directly from a member or through a collection agency Bill the member for services where payment was denied due to provider s failure to follow plan procedures 30

31 Exceptions to Direct Billing Member has a share in the cost of health care or support services. This is based on their Medicaid financial eligibility. Med-QUEST determines the cost sharing amount and informs AlohaCare of the amount. Non-covered services were performed. QUEST Integration Adult members can be billed for services exceeding benefit limitations. Member self-referral to a specialist or other provider within the network without following Plan procedure. Member had primary coverage through a prepaid benefits plan (examples include: HMSA Health Plan Hawaii, Kaiser Health Plan) but did not go to a primary payer s designated facility for treatment. The Individual was not eligible for QUEST Integration Program on date of service. Note: In cases where a member is retro-enrolled and made payment directly to a provider, AlohaCare will work with the member and provider to ensure that the member is reimbursed. 31

32 Medicare Billing Guidelines Follows Medicare guidelines for determining eligible services Facilities must submit claims on CMS-1500 or UB04 forms Part D claims will require a Universal Claim Form (UCF) Note: AlohaCare Accepts HIPAA Compliant EMC (Electronic Medical Claims) 32

33 Provider Roles and Responsibilities 33

34 Roles & Responsibilities PCPs: Provide primary care services Maintain continuity of care by coordinating all: Care Referrals Follow-up treatment PCPs & Specialists: Assure that emergency services are available 24 hours a day/7 days a week Have backup coverage for when the provider is not available during regular hours Inform AlohaCare about alternative coverage (locums) Must accept members for treatment unless the provider has requested a waiver from this provision in writing 34

35 Americans with Disabilities Act (ADA) Providers are responsible for maintaining an accessible office environment conducive to the regulations and standards of the Americans with Disabilities Act (ADA) including the provision of assistance with interpreter (oral or sign), assistive listening devices, or other acceptable means of alternate communication for language or hearing impaired individuals 35

36 Availability of Interpreter, Auxiliary Aids and Services If access is needed to language interpretation, auxiliary aids, sign language services, or specialized communication such as Braille or translation services, please contact AlohaCare Provider Relations. These services are provided free to our members. Oahu: (808) Toll Free: TTY/TTD users:

37 Medical Record Keeping Standards Complete Records HIPAA Compliant Retained and available for 10 years from termination of Provider Agreement Claims or encounter data must be tied to documentation Records for minor patients should be kept for 7 years after they have reached 18 years (25 years old) 37

38 Reporting Requirements Timely Claims Submission-365 Days to file claims from date of service Member Eligible for Long Term Care or Disability Qualifying Circumstance that Effects Member s QUEST Integration Eligibility Third Party Liability (TPL) Member Pregnancy Newborn Coverage Arrangements Objections to Performing Health Services Other Circumstances Stipulated in Provider Agreement 38

39 HEDIS HEDIS (Healthcare Effectiveness Data and Information Set) Data collection required by Med-QUEST for Medicaid and by CMS for Medicare Annually in April - May Providers are contractually required to participate Mail or Fax requested records Onsite review for high volume Member s benefit 39

40 PCP Assignment and Network Providers Members choose their PCP from our network of providers Provider Directory Doctor Finder Tool ( Members are auto assigned only when they do not select a PCP. QUEST Integration members are assigned on the 25 th day Medicare members are assigned after 30 days 40

41 Access to Care Providers are required to meet the following appointment standards based on levels of care: Primary Care Provider (PCP) and Specialist Appointments Behavioral Health Appointments within 24 hours for urgent care and for PCP pediatric sick visits Appointments within 48 hours for urgent care Appointments within 72 hours for PCP adult sick visits Appointments within 21 days for PCP s (routine visits for adults and children) Non-life threatening emergency appointment within 6 hours Routine behavioral visits for adults and children with 10 business days Appointments within 4 weeks for visits with a specialist or non-emergency hospital stays or of sufficient timeliness to meet medical necessity 41

42 Referral, Authorization and Notification (RAN) Process Used whenever a referral, prior authorization or notification is needed Ensures medically necessary and appropriate services are covered Identifies and determines medical conditions that require the expertise of a specialist to diagnose and/or treat the member 42

43 Types of Referrals Consult Consult and treat Consult, treat and follow-up 43

44 Referring In-Network Providers must refer members to other AlohaCare network providers Find a current listing of providers on our website at Provider Directory Doctor Finder Tool Call our Customer Service Department for a list of network providers 44

45 Referring Out-of-Network Members may be referred out-of-network in special situations: A network specialist is not available or accessible within a reasonable time period. The member s medical condition is such that a contracted specialist does not have the specialized expertise to effectively diagnose or treat the condition. When referring out-of-network, the following must be completed: Provide the member with advance written notice of financial liability for payment of non-covered services prior to services being performed. Submit the RAN form prior to services being provided. Network providers must maintain documentation. 45

46 Prior Authorizations Ensures medically necessary and appropriate services are covered Requests for procedures requiring authorization Include clinical information for the prior authorization request 46

47 Referral, Authorization, Notification (RAN) Form AlohaCare s RAN form can be located on our website. Under the Providers tab, select Authorization from the drop down selections: 47

48 Services That Require Notification and/or Prior Authorization Key: PA=Prior Authorization N=Notification Ambulatory/Outpatient Surgical Procedures (billing location other than office ) Chemotherapy Dialysis DME Rentals Emergency Inpatient Stay Home Health Services Home IV Therapy and Injectables Hospice Hyperbaric Oxygen Therapy Hysterectomy with DHS 1145 Form Lodging Meals MRI & MRA Non-Emergent Inpatient Stays including Elective Surgeries and Inpatient Rehabilitation Non-Formulary Medications OB Ultrasound (after 3 rd ) Observation Stays Obstetrical Services (Global OB services includes 3 Ultrasounds) Notification within 24 hours of First Obstetrical Encounter. Occupational Therapy (including for cognitive rehabilitation purposes) Out-of-State Referrals PA N N PA N PA PA N PA PA PA PA PA PA (prior) and N (upon admission) PA PA N N PA PA 48

49 Services That Require Notification and/or Prior Authorization PET Scans (Brain Only) Key: PA=Prior Authorization N=Notification Physical Therapy (including Aqua Therapy and for cognitive rehabilitation purposes) Purchased DME, Prosthetic and Orthotics (if less than $xxx purchasing price) PUVA Therapy Radiation Therapy Sleep Studies Specialist (PCP referring to specialist) Speech Therapy (including for cognitive rehabilitation purposes) Sterilizations with DHS 1146 Form Telemedicine Services performed by Specialist Translation Services Transportation, Air and Ground (non-emergent) Behavior Health Services Acute Inpatient Admissions Electroconvulsive therapy (ECT) Facility Based Mental Health & Chemical Dependency Services (e.g., IOP, LIOP, day treatment) Neuropsychological Testing Psychological Testing PA PA PA PA N PA R PA PA PA N PA N PA PA PA PA 49

50 Services That Require Notification and/or Prior Authorization Long Term Supports and Services Adult day care PA Adult day health PA Assisted living facility services PA Community Care Management Agency (CCMA) services PA Community Care Foster Family Home (CCFFH) services PA Counseling and training PA Environmental accessibility adaptations PA Home delivered meals PA Home maintenance PA Moving assistance PA Non-medical transportation PA Personal assistance services Level I and Level II PA Personal Emergency Response Systems (PERS) PA Residential care services PA Respite care PA Skilled (or private duty) nursing PA Specialized medical equipment and supplies PA PA Intermediate Care Facility (ICF), Skilled Nursing Facility (SNF), Nursing Facility (NF) Services 50

51 Prior Authorizations Referral/Prior Authorization/Notification Request is available on in the Provider Forms Section. Submit Prior Authorizations Electronically through AC Online or, Fax to or toll free at or, Mail to 1357 Kapiolani Blvd., Ste 1250, Honolulu, HI If you have questions, you can contact the Prior Authorization Line at (808)

52 Prior Authorization Time Frames Prior Authorizations are processed within 14 days for standard requests and 72 hours for expedited requests AlohaCare will notify the provider seeking authorization by telephone and/or fax if additional information is needed AlohaCare requests the provider to send the additional information within 24 hours for an expedited request and 2 days for a standard request. 52

53 OB/Prenatal Notifications Notification Process Obstetric (OB) Services Notification is required when seeing a pregnant member for the first time. Used to inform Med-QUEST and ensure the continuation of benefits. Complete the Referral, Authorization, Notification form Prenatal Care Appointments First trimester: within 14 days Global OB Payment Policy Certain services are not included and should be billed with the appropriate E&M code. 53

54 Cultural Competency Plan Identifies health practices and behavior of members Designs programs and services to address the cultural and language barriers to deliver appropriate and necessary care. All services are provided in a culturally competent manner to all members, including those with limited English proficiency and diverse cultural and ethnic backgrounds Providers are expected to provide health care services (including language assistance if requested) that respond effectively to the cultural and linguistic needs of our members Annual training is available and additional resources for information and ongoing training is available on our website, 54

55 Member Rights and Responsibilities 55

56 Member Rights & Responsibilities Member have the right to: Access to Care Receive services in a timely manner as specified in appointment standards (See Appointment and Accessibility policy and procedure). Receive services out-of-network if AlohaCare is unable to provide services in-network for as long as AlohaCare is unable to provide them in-network. Receive services in a culturally competent manner and with appropriate interpreter assistance. Receive services in a coordinated manner. Have direct access to specialists for special health care needs. Not have services arbitrarily denied or reduced in amount, duration or scope solely because of diagnosis, type of illness, or condition. Receive medical care and services regardless of member s age, race, creed, sex, sexual preference, national origin or religion. AlohaCare will not deny or allow fewer services solely based on the member s diagnosis, type of illness or health condition. Have an adequate provider network within a member s geographic service area that is available and accessible, and takes into consideration, distance and travel time. Have direct access to a women s health specialist within AlohaCare s provider network. Respect and Dignity Be treated with respect and with due consideration for the member s dignity and privacy at all times and under all circumstances. Identity Know the identity and professional status of individuals providing service, and to know which physician is primarily responsible for member s care. 56

57 Member Rights & Responsibilities Members have the right to: Privacy and Confidentiality Have all records and medical and personal information remain confidential and protected, including: Being interviewed and examined in surroundings designed to assure reasonable audio/visual privacy. Any discussion or consultation involving care is conducted discreetly. Individuals not directly involved with the member s care will not be present unless permission has been given by the member. Having the member s medical record read only by individuals directly involved in their care or watching over the quality of member s medical care, and by other individuals only when the member gives such permission. Expecting all communications and other records pertaining to care, including the source of payment for treatment, to be treated as confidential. Limit, restrict or prevent disclosure of member s personal health information. 57

58 Member Rights & Responsibilities Members have the right to: Information Obtain from member s physician or other health care practitioners, or clinics, complete and accurate information concerning diagnosis (to the degree known), treatment and any known prognosis. This information is communicated in terms the member can reasonably be expected to understand. When it is not medically advisable to give such information to the member, the information is given to a legally authorized representative. Be included in treatment plan development if member has a special health care need. Appoint a representative to act for member. Participate in decisions regarding member s health care, including the right to refuse treatment. Receive copies of member s medical records and Protected Health Information (PHI), unless the member s physician or AlohaCare believes something in member s records would jeopardize member s health, safety or security or that of someone else. Request AlohaCare or provider amend or correct member s medical records. If a member s request is denied, member has the right to get the reason for denial in writing. Know who sees member s medical records and Protected Health Information, unless the review is for the treatment, payment, health care operations, or some other reasons written in the law. Use advance medical directives. 58

59 Member Rights & Responsibilities Members have the right to: Communication Access to interpreter services when member does not speak or understand the major language of the community. Members also have the right to have that same person in the room during an exam. Interpreter or translation services are provided at no cost to the member. Have written materials made available to members in the languages prevalent in the State of Hawaii as determined by Med-QUEST. These languages include, but are not limited to Korean, Vietnamese, Ilocano and Chinese. Ask AlohaCare to send mail and call member at the address or telephone number of member s choice, to protect their privacy. If AlohaCare cannot honor the request, the member will be informed of the reason why the request cannot be honored. Have timely response for prior authorization and referral requests. File Grievances and Appeals Freely exercise member s rights, including those related to filing a grievance or appeal, and that the exercise of these rights will not adversely affect the way the member is treated. 59

60 Member Rights & Responsibilities Members have the right to: Consent Reasonable information and participation involving member s health care. In cases where a minor is being treated, the parent(s) or legal guardian(s) are afforded the same information and participation rights regarding the minors care, condition and/or treatment plan (except where, by law, a minor is emancipated and has the right to make his or her own treatment decisions). To the degree possible, this is based on a clear, concise explanation of the condition and all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to recuperation, and the probability of success. Not be subjected to any procedure without voluntary, competent, and understanding consent, or the consent of a legally authorized representative. To be informed of medically significant alternatives for care or treatment where it exists. The member has the right to know who is responsible for authorizing and performing the procedures or treatment. Second Opinion Receive a second medical opinion, at no cost to member, when deciding on medical treatment. Be Informed Know about any experimental, research or educational activities having to do with their care. After a member is given this information, they can choose to participate or not. Refusal of Treatment Refuse treatment to the extent permitted by law. AlohaCare members are responsible for their actions if treatment is refused or if the physician s or other health care practitioner s or clinic s instructions are not followed. 60

61 Member Rights & Responsibilities Members have the right to: Freedom from Restraint or Seclusion Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, unless it is necessary for treatment or the safety of others as specified in federal regulations on the use of restraints and seclusion. Payment Be free from payment for covered services unless co-payment or deductibles are required by the State of Hawaii Med-QUEST rules. Be free from payment for covered services provided to member in the event of AlohaCare s insolvency. Be free from payment for covered services provided to member when the MQD does not pay AlohaCare. Be free from payment for covered services provided to member when the MQD or AlohaCare does not pay the service provider. Be free from payment for covered services provided to member under a contract, referral, or other arrangement to the extent that those payments are in excess of the amount the member would owe if AlohaCare provided the services directly. Suggestions and Comments Make comments or suggestions about AlohaCare including suggestion regarding our policies and procedures. 61

62 Member Rights & Responsibilities Members have the responsibilities: To share health information To report other medical insurance To be compliant with instructions To know the name of their PCP To treat others with respect and dignity To keep appointments To provide immunization records to their PCP To be responsible To report suspected fraud and abuse To make medical wishes known via an advance health care directive To select a PCP 62

63 Fraud & Abuse Fraud: Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. Abuse: Practices that are inconsistent with sound fiscal, business or medical practices. Result in an unnecessary cost to the Medicaid/Medicare programs, reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. 63

64 Common Types of Fraud & Abuse Provider billing for services not provided Provider falsifying information to justify payment of a non-covered service Pharmacy providing less than the prescribed quantity but billing for the fully-prescribed amount Pharmacy altering the prescription without the prescriber s permission Member letting another person to use the member s ID card Member selling or giving someone else supplies, equipment or drugs paid for by AlohaCare It is everyone s responsibility to report suspected or confirmed fraud and abuse. Please report to AlohaCare as soon as you become aware by contacting us via: Phone: AlohaCare Compliance Hotline Mail: AlohaCare Compliance Department 1357 Kapiolani Blvd. Honolulu, HI

65 Definitions of Member Abuse Child abuse or neglect: The acts or omissions of any person who, or legal entity which, is in any manner or degree related to the child, is residing with the child, or is otherwise responsible for the child's care, that have resulted in the physical or psychological health or welfare of the child, who is under the age of eighteen, to be harmed, or to be subject to any reasonably foreseeable, substantial risk of being harmed. Vulnerable Adult: A vulnerable adult is a person eighteen years of age or older, who because of mental, developmental, or physical impairment, is unable to: communicate or make responsible decisions to manage the person s own care or resources; carry out or arrange for essential activities of daily living; or protect oneself from abuse. The law defines vulnerable adult abuse or neglect as " any of the following, separately or in combination: physical abuse, psychological abuse, sexual abuse, financial exploitation, caregiver neglect, or self-neglect. 65

66 Who Should Report Member Abuse? Licensed or registered professionals of the healing arts and any health-related occupation who examines, attends, treats, or provides other professional or specialized services including, but not limited to, physicians, including physicians in training, psychologists, dentists, nurses, osteopathic physicians and surgeons, optometrists, chiropractors, podiatrists, pharmacists and other health-related professionals are mandated by law to report suspected child or vulnerable adult abuse. Licensed social workers or non-licensed persons employed in a social worker position are also mandated by law to report suspected child or vulnerable adult abuse. Persons who are not mandated reporters are encouraged to report. Any person who has reason to believe that a child vulnerable adult has been abused or is in danger of abuse if immediate action is not taken may report the concern to Child Welfare Services or Adult Protective Service or to the Police Department. 66

67 Report Suspected Child Abuse Report suspected Child Abuse or Neglect to Child Welfare Services at the numbers below: East Hawaii (Hilo) West Hawaii Kau (West Hawaii Intake Hotline) Kamuela Maui Molokai Lanai Kauai Oahu (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Kona) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (Toll Free-24 hours) (Toll Free-24 hours FAX line) (24 Hours) (24 hours) (24 hours FAX line) In case of immediate threat of violence, call the Police,

68 Report Suspected Vulnerable Adult Abuse Report suspected Vulnerable Adult Abuse to Adult Protective Services at the numbers below: Oahu (808) Kauai (808) Maui/Molokai/Lanai (808) East Hawaii (Hilo/Hamakua/Puna) (808) West Hawaii (Kau/Kona/Kohala/Kamuela): (808) In case of immediate threat of violence, call the Police,

69 Reporting to AlohaCare It is everyone s responsibility to report suspected or confirmed fraud and abuse. Please report to AlohaCare as soon as you become aware by contacting us via: Phone: AlohaCare Compliance Hotline Mail: AlohaCare Compliance Department 1357 Kapiolani Blvd. Honolulu, HI

70 Grievances and Appeals 70

71 Provider Grievance A written communication made by a provider expressing dissatisfaction pertaining to the following: Benefits and limits, for example, limits on behavioral health services or formulary; Eligibility and enrollment, for example long wait times or inability to confirm enrollment or identify the PCP; Member issues, including members who fail to meet appointments or do not call for cancellations, instances in which the interaction with the member is not satisfactory; instances in which the member is rude or unfriendly; or other member-related concerns; and Health plan issues, including difficulty contacting the health plan or its subcontractors due to long wait times, busy lines, etc.; problems with the health plan s staff behavior; delays in claims payments; denial of claims; claims not paid correctly; or other health plan issues. Issues related to availability of health services from the health plan to a member, for example delays in obtaining or inability to obtain emergent/urgent services, medications, specialty care, ancillary services such as transportation, medical supplies, etc.; Issues related to the delivery of health services, for example, the PCP did not make referral to a specialist, medication was not provided by a pharmacy, the member did not receive services the provider believed were needed, provider is unable to treat member appropriately because the member is verbally abusive or threatens physical behavior; and Issues related to the quality of service, for example, the provider reports that another provider did not appropriately evaluate, diagnose, prescribe or treat the member, the provider reports that another provider has issues with cleanliness of office, instruments, or other aseptic technique was used, the provider reports that another provider did not render services or items which the member needed, or the provider reports that the plan s specialty network cannot provide adequate care for a member. 71

72 Provider Appeal An appeal is a written request made by a provider for review of an adverse decision of a grievance. 72

73 How to File a Grievance or Appeal Written grievances or appeals should be sent to: AlohaCare Attention: Grievance Coordinator 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI Grievances or appeals must be filed within one year from the date of the occurrence generating the grievance or appeal. Upon receipt of the grievance or appeal, written notification of receipt will be sent to the provider within ten (10) calendar days. AlohaCare will render a decision and notify the provider in writing within sixty (60) days of receipt of the grievance or appeal. 73

74 Member Grievance and Appeals Member Grievance Members or their representatives have the right to file a grievance if they are dissatisfied with regard to anything other than an adverse action (see Member Appeal section below). This could include the following: Health Plan s or provider s operations Health Plan s or provider s activities Health Plan s denial of an expedited appeal request Health Plan s or provider s failure to respect the recipient s rights Health Plan s or provider s or staff behavior Member Appeals Members, or a member s authorized representative or a provider with the members written consent, may file an appeal within thirty (30) calendar days of the notice of an adverse action made by AlohaCare. The denial, or limited authorization, of a requested service including the type or level of service The reduction, suspension, or termination of a previously authorized service The denial, in a whole or in part, of payment for a service 74

75 Member Grievance and Appeals Members can send written grievances or appeals to: AlohaCare Attention: Grievance Coordinator 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI Fax: Members or their representatives may call the Customer Service Department and we will assist in filing a grievance or appeal. A provider calling to file an oral grievance or appeal on behalf of the member must provide written authorization from the member. Customer Service Department Tel: (808) Toll Free: TTY/TDD Users Toll Free

76 Member Grievance Process Each grievance will be thoroughly investigated by gathering all documentation, records, or any other information submitted by all relevant parties and using the applicable statutory, regulatory and contractual provisions, as well as AlohaCare s policies and procedures. AlohaCare will render a resolution of the grievance as expeditiously as the member s health requires but no longer than thirty (30) calendar days from the receipt date. AlohaCare will take into account all documents, records, or other information submitted by the grievant, provider or facility rendering the service relating to the case. A letter of resolution will be mailed to the grievant and copies are sent to all parties whose interest has been affected by the decision. The date of the letter is considered the decision date. If the disposition of the grievance does not meet the satisfaction or expectations of the member, the member has the right to request a Grievance Review from the State within 30 calendar days of the grievance decision date. Members must exhaust AlohaCare s internal grievance system prior to requesting a State Grievance Review. To request a Grievance Review by Med-QUEST, the member may call (808) , or the member may submit the request in writing to: Med-QUEST Division Health Care Services Branch PO Box Kapolei, HI The Med-QUEST Division (MQD) will review the grievance and contact the member with a determination within 30 calendar days from the day the request for a grievance review is received. The grievance review determination made by the MQD is final. 76

77 Member Appeal Process All appeals will be thoroughly investigated by gathering all documentation, records, or any other information submitted by all relevant parties, without regard to whether such information was submitted or considered in the initial consideration of the case, and using the applicable statutory, regulatory and contractual provisions, as well as AlohaCare s policies and procedures. AlohaCare will render a resolution of the appeal as expeditiously as the member s health requires, but no longer than thirty (30) calendar days from the receipt date of the appeal except in the case of expedited appeal. AlohaCare will take into account all documents, records, or other information submitted relating to the case. A letter of resolution will be mailed to the member and copies are sent to all parties whose interest has been affected by the decision. The recipients will include any provider that may be affected by the decision. The effective date of the decision will be the postmarked date of the mailing. AlohaCare may grant an extension of the resolution deadline of up to fourteen (14) calendar days if the member requests the extension or if additional information is needed. If AlohaCare determines that additional information is needed, a letter will be sent to the member and other affected parties including the provider. The content of the notification will include the following details: Nature of the appeal Reason for the extension of the decision and how the extension is in the member s best interest 77

78 Member s Right to Receive Benefits If the appeal relates to an action that reduced, stopped or delayed care that had previously been approved, the member has the right to receive benefits while the appeal is pending if: The member requests that AlohaCare continues the benefits; The member files the request for an appeal in a timely manner. This means: Within 10 days of the date AlohaCare mailed the notice of the unfavorable action, or On or before the effective date of the unfavorable action (whichever is later); The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; The services we approved were ordered by an authorized provider; and The amount of time covered by our original approval has not expired. The member may have to pay for the services if AlohaCare s final decision is to uphold the denial. 78

79 State Administrative Hearing If the appeal is not resolved wholly in favor of the member, the member may access the State Administrative Hearing process by submitting a letter to the Administrative Appeal Office (AAO) within thirty (30) calendar days (or an expedited review if applicable) from the date of the member s appeal determination. Members must exhaust AlohaCare s internal appeal system prior to requesting an administrative hearing. The member has the right to representation during such hearing. Members are permitted to speak for themselves, or have a lawyer, friend, relative or someone else speak for them to say why they are not satisfied with the resolution. The address for the AAO is: State of Hawaii Department of Human Services Administrative Appeals Office P.O. Box 339 Honolulu, HI

80 State Administrative Hearing The member has the right to continue to receive benefits from AlohaCare while waiting for the hearing if: The member requests that we continue the benefits; The member files the request for continuation of benefits in a timely manner. This means: Within 10 days of the date AlohaCare mailed the notice of the unfavorable action, or On or before the effective date of the unfavorable action (whichever is later); The request for a hearing involves stopping, delaying or reducing a course of treatment that we had authorized; The services were ordered by an authorized provider; and The amount of time covered by our original approval has not expired. The member may have to pay for services that AlohaCare denied if the State administrative hearing or external review denies the appeal. The State shall reach its decision within ninety (90) days of the date the member filed the request for an administrative hearing with the State. 80

81 Medicare Part C Appeals 60 calendar days to file Appeal from notice of denial Standard Process Pre-Service: Resolved in 30 Calendar Days Payment: Resolved in 60 Calendar Days Auto-forwarding to IRE* if AlohaCare upholds initial denial decision Expedited Process Pre-Service: Resolved in 72 hours Payment: Cannot be expedited First Level Appeal IRE* reconsideration Pre-Service: Resolved in 30 Calendar Days Payment: Resolved in 60 Calendar Days IRE* Reconsideration Pre-Service: Resolved in 72 hours Payment: Cannot be expedited Second Level Appeal 60 calendar days to file Office of Medicare Hearings & Appeals ALJ** Hearing Amount in controversy must be > $150 No statutory time limit for processing Third Level Appeal 60 calendar days to file Medicare Appeals Council (MAC) No statutory time limit for processing Fourth Level Appeal *IRE = Independent Review Entity **ALJ = Administrative Law Judge 60 calendar days to file Federal District Court Amount in controversy must be > $1,500 Judicial Review 81

82 Medicare Part D Appeals 60 calendar days to file Appeal from notice of denial Standard Process AlohaCare Appeals Process Resolved in 7 Calendar Days Part D IRE* reconsideration Resolved in 7 Calendar Days Office of Medicare Hearings & Appeals ALJ** Hearing Amount in controversy must be > $150 Resolved in 90 Calendar Days 60 calendar days to file 60 calendar days to file Expedited Process AlohaCare Appeals Process Resolved in 72 hours Part D IRE* Reconsideration Resolved in 72 hours Office of Medicare Hearings & Appeals ALJ** Hearing Amount in controversy must be > $150 Resolved in 10 Calendar Days First Level Appeal Second Level Appeal Third Level Appeal Medicare Appeals Council (MAC) Resolved in 90 Calendar Days 60 calendar days to file Medicare Appeals Council (MAC) Resolved in 10 Calendar Days Fourth Level Appeal *IRE = Independent Review Entity **ALJ = Administrative Law Judge 60 calendar days to file Federal District Court Amount in controversy must be > $1,500 Judicial Review 82

83 Grievance and Appeals Information Available in Provider Manual at Grievance and Appeals - Toll Free Complete policies and procedures available upon request 83

84 Resources and Tools 84

85 AC Online Check 24 hours a day/7 days a week: Member eligibility PCP information Claim status and history Third Party Liability (TPL) Referral, Authorization and Notification Electronic Submissions Drug Finder (Formulary) Member Prescription Information 85

86 Checking Member Eligibility 86

87 Provider Manual Extension of the AlohaCare Provider Agreement Resource for our health plan processes and our policies and procedures Most current version of our Provider Manual is available on our website at 87

88 Provider Updates AlohaCare Website Provider Newsletter (Quarterly) Provider Advisories (As needed) Direct Mailings (As needed) 88

89 Contact Us Customer Service QUEST Integration: Toll Free Customer Service Medicare: Toll Free Provider Relations: Toll Free Pharmacy: Toll Free Medical Management: Toll Free Behavioral Health: Toll Free Claims, Complaints, Grievances & Appeals, Expedited Appeals: Toll Free

90 Questions? 90