HEALTH CHOICE. Leading the Way to Quality Care. Provider Manual

Transcription

1 HEALTH CHOICE Leading the Way to Quality Care Effective February 2017

2 Foreword This Prestige Health Choice contains proprietary information. Providers agree to use this Medicaid exclusively as a reference pertaining to medical services for Prestige Health Choice members. No content found in this publication or in the Prestige Health Choice s participating network provider agreement is intended to be interpreted as encouraging providers to restrict medically necessary covered services or limit clinical dialogue between providers and their patients. Regardless of benefit coverage limitations, providers may openly discuss all treatment options that are available. The provisions of this provider manual are applicable to the Medicaid programs implemented by the Agency for Health Care Administration (AHCA) in 2014, and may be changed or updated periodically. Providers are encouraged to review prior provider manuals related to previous Medicaid programs. Prestige Health Choice will provide notice of the updates, and providers are responsible for checking regularly for updates. The most current can be found online at Privacy and Security Standards The Health Insurance Portability and Accountability Act - Administrative Simplification of 1996 (HIPAA-AS) was impacted by the Health Information Technology for Economic and Clinical Health Act (HITECH), which was passed as part of the American Recovery and Reinvestment Act. HITECH imposes new health information obligations on HIPAA-AS covered entities (Prestige, physicians and other providers and healthcare clearinghouses) and our business associates. As covered entities, we are required to understand how the HIPAA-AS and HITECH privacy and security standards directly apply to our specific type of business. Please be aware of these requirements to ensure that member s protected health information (PHI) is safeguarded in accordance with the HIPAA-AS and HITECH requirements.

3 Table of Contents I. Overview... 7 Purpose of this... 7 Medicaid Program Overview... 7 Prestige Health Choice... 7 Community Care of Florida... 8 Medicaid Eligibility... 8 Prestige Enrollment... 9 Members with Medicare Coverage (Dual Eligible)... 9 Newborn Enrollment... 9 American Recovery and Reinvestment Act of Member Identification and Eligibility Verification Prestige Health Choice Member ID Card Member Rights and Responsibilities Patient's Bill of Rights and Responsibilities II. Provider and Network Information Prestige Medicaid Provider Eligibility Initial Credentialing and Re-Credentialing Criteria and Standards Provider Rights Site Visit Evaluation Facility/Provider Site Evaluation New Provider Orientation Provider Relations Orientation Training Provider Education and Ongoing Training Secure Provider Portal Fraud, Waste and Abuse (FWA) False Claims Act Provider Responsibilities Related to Fraud, Waste and Abuse Reporting and Preventing Fraud, Waste and Abuse Risk Management Provider Responsibilities Procedures for Adverse Incident Reporting Page 1

4 Procedures for Adverse Incident Summary Reporting Provisions of the Risk Management Program Provider Responsibilities Related to Reporting Abuse, Neglect and Exploitation of Members Provider Roles and Responsibilities Primary Care Provider (PCP) Roles and Responsibilities Specialist and Other Provider Roles and Responsibilities Direct Access to Women s Health Provider Prohibited Activities Access to Care Office Accessibility Appointment Scheduling Missed Appointment Tracking Access to After-Hours Care Monitoring Appointment Access and After-Hours Access Cultural and Linguistic Requirements Medical Record Requirements Provider Communications Compliance Provider Marketing Activities Provider Contract Terminations Provider-Initiated Termination Prestige Initiated For Cause Termination Prestige Initiated Without Cause Termination Mutually-Agreed Upon Terminations Continuity of Care (COC) Closing of a Provider Panel Provider-Initiated Request to Terminate a Member Provider Services Provider Complaint Process Claim Underpayments, Claim Denials, and Administrative Complaints Provider Communications III. Member Benefits Prestige Expanded Benefits Non-Covered Services Page 2

5 Emergency Services IV. Utilization Management Prior Authorization Department Concurrent Review and Discharge Planning Prior Authorization Specific to Pregnancy-Related Services Pregnancy Notification Form Services Requiring Prior Authorization or Notification Exceptions to Prior Authorization Standard Authorization Decisions Expedited Authorization Decisions Urgent Concurrent Review Decisions Authorization Request Forms How to get in touch with UM Medical Necessity Standards For authorization request denials based on lack of medical necessity Individuals with Special Health Care Needs Second Medical Opinion V. Case Management Integrated Health Care Management (IHCM) Bright Start (Maternity Management) Prior Authorization Prenatal Care Obstetrical Delivery Newborn Care Postpartum Care Rapid Response VI. Member Complaints, Grievances and Appeals Member Complaints Grievance Process Appeals Process Standard Appeal Expedited Appeal Appealing a Decision to the Subscriber Assistance Program (SAP) Page 3

6 Medicaid Fair Hearing Continuation of Benefits VII. Healthy Behaviors Program Weight Loss Smoking Cessation Alcohol and Substance Use Recovery Well-Child Visits Behavioral Health Follow-Up Diabetes Care Maternity VIII. Quality Enhancements IX. Quality Improvement Program (QIP) Quality Improvement Committee (QIC) Quality Improvement Program Activities Performance Improvement Projects Ensuring Appropriate Utilization of Resources Measuring Member and Provider Satisfaction Member Safety Programs Preventive Health and Clinical Guidelines Potential Quality of Care Concerns HEDIS/Performance Measures Preventive Care/Immunizations Immunization Schedules (Childhood, Adolescent and Adult) Vaccines for Children Program (VFC) Child Health Check-Up Program (CHCUP) CHCUP Schedule for Exams Reporting & Evaluation Medical Record Audits Documentation of Care/Medical Record Keeping X. Cultural Competency Plan National Culturally and Linguistic Services (CLAS) XI. Claims Submission Visit Reporting Page 4

7 Completion of Encounter Data Procedures for Claim Submission Prospective Claims Editing Policy Claim Mailing Instructions Claim Filing Deadlines Child Health Check-up Common Causes of Claim Processing Delays, Rejections or Denials Refunds for Improper Payment or Overpayment of Claims Electronic Data Interchange (EDI) for Medical and Hospital Claims Electronic Claims Submission (EDI) Hardware/Software Requirements Contracting with Change Healthcare and Other Electronic Vendors Contracting the EDI Technical Support Group Specific Data Record Requirements Electronic Claim Flow Description Invalid Electronic Claim Record Rejections/Denials Exclusions Common Rejections Resubmitted Corrected Claims XII. Pharmacy AHCA Preferred Drug List (PDL) Coverage Limitations Generic Substitution Informed Consent for Psychotropic Medications Injectable Over-the-Counter (OTC) Medications Specialty Medications Working with our Specialty Pharmacy Provider Prior Authorization XIII. Behavioral Health XIV. Provider Resources Page 5

8 SECTION I OVERVIEW Page 6

9 I. Overview Purpose of this This is intended for Prestige Health Choice s contracted (participating) Medicaid providers delivering health care service(s) to Prestige members. This manual serves as a guide to the policies and procedures governing the administration of Prestige Health Choice. It supplements, and is an extension of, the Provider Participation Agreement (the Agreement) between Prestige Health Choice and providers, who include, without limitation: primary care providers, specialty providers, facilities, and ancillary providers (collectively, providers). This manual is available at A paper copy may be obtained, at no cost, upon request by contacting Provider Services at or your Provider Account Executive. Medicaid Program Overview Medicaid provides medical coverage to eligible, low-income children, seniors, disabled adults and pregnant women. The state and federal government share the costs of the Medicaid program. Medicaid services in Florida are administered by the Agency for Health Care Administration (AHCA). In 2011, the Florida Legislature created Part IV of Chapter 409, Florida Statutes, directing the Agency to create the Statewide Medicaid Managed Care (SMMC) program. The SMMC program has two key components, including the Managed Medical Assistance (MMA) program. Per federal regulations, certain services must be offered by all states, but each state can place some limits on the services. There are also optional services that a state may choose to offer, variations in eligibility groups, different limits on income and assets to decide eligibility, and differences in reimbursement to their Medicaid providers. These key policy decisions are all made by the Florida Legislature. For more information about Medicaid covered services, view the Agency website at Each state operates its own Medicaid program under a state plan that must be approved by the federal Centers for Medicare & Medicaid Services (CMS). The Agency periodically updates and files the Medicaid state plan with CMS to ensure the state program receives matching federal funds. Prestige Health Choice Prestige Health Choice participates in the Statewide Medicaid Managed Care Program by offering coverage to all Medicaid recipients eligible to be enrolled in the managed care programs. Prior to October 1, 2015, Prestige Health Choice, LLC operated as a provider service network. As of October 1, 2015, Florida True Health, Inc. acquired 100% of the ownership interest of Prestige Health Choice, LLC and Prestige was converted to an HMO. Florida True Health, Inc. continues to operate the health plan as Prestige Health Choice. Prestige contracts with Community Care of Florida (CCF), whose purpose is to provide network operation services to Prestige providers and select Florida Blue providers. Prestige Health Choice s goal is to ensure the greatest level of Medicaid member satisfaction and health care outcomes by providing access to high-quality services. Prestige Health Choice s focus is on its members and providers. Page 7

10 Prestige Health Choice herein referred to interchangeably as Prestige and the Plan will provide a broad choice of primary care providers (PCPs) and managed care capabilities to ensure members receive appropriate care when and where they need it. Prestige is dedicated to providing health care services exclusively to low-income families and people with disabilities. Our mission is to operate a provider-centric managed care company with an emphasis on efficient, cost-effective, quality care in our communities. Prestige is a step ahead of the rest with the medical home model. We strive to improve preventive primary care services and early prenatal care by closing the gaps in a fragmented service system building a personalized care management program for unmanaged health problems. In addition: Encouraging stable, long-term relationships between providers and members; Discouraging medically inappropriate use of specialists and emergency rooms; Committing to community-based safety nets and community outreach; Enhancing quality improvement mechanisms; Involving providers in an integrated healthcare delivery system; and Encouraging the provider network to become involved with positive health outcome measures and regular measurement of member satisfaction. We are dedicated to the vision of improving access to care for our members and partnering with our providers to build a better healthcare model. Prestige brings extensive experience in Medicaid managed care operations and is committed to supporting our providers in providing high-quality care to our members. Community Care of Florida Community Care of Florida supports the Prestige Health Choice (HMO) Medicaid Plan and select providers (FQHCs) under the Florida Blue Medicare and Exchange products. Community Care of Florida is jointly owned by Florida True Health and a group of Federally Qualified Health Centers. Medicaid Eligibility Medicaid eligibility in Florida is determined by the Department of Children and Families (DCF) or the Social Security Administration (for Supplemental Security Income [SSI] recipients). AHCA (herein, referred to interchangeably as the Agency ) or its agent monitors the Florida Medicaid Management Information System (FMMIS) on a regular basis and notifies all potential members of their eligibility. Potential members can be assigned to health plans effective the day their Medicaid eligibility is approved. If the potential member fails to select a Florida Medicaid Plan, the Agency or its agent auto-assigns the individual to a Florida Medicaid Plan. Medicaid recipients who meet the eligibility requirements for enrollment must also live in counties where Prestige is an authorized Plan to be able to enroll and receive services. Page 8

11 Prestige Enrollment The Agency for Health Care Administration (AHCA) utilizes a process called Express Enrollment for Medicaid recipients who enroll in an MMA plan. Through Express Enrollment, health plan enrollment will be effective the same day the individual s Medicaid application is approved. It is important to verify Medicaid eligibility and plan enrollment at the time of service delivery, especially since individuals can be enrolled in a plan any time during the month. Prestige will accept Medicaid recipients without restriction and in the order in which they enroll. Prestige will not discriminate on the basis of religion, gender, sexual orientation, race, color, age, national origin, health status, pre-existing condition, or need for health care services and will not use any policy or practice that has the effect of such discrimination. Prestige members will be required to select a PCP. If a PCP is not selected, Prestige will assign a PCP based on a variety of factors, including but not limited to: The member s last PCP (if known). Closest PCP to the member s ZIP code location. Children/adolescents are assigned to the same PCP as other family members. Members with Medicare Coverage (Dual Eligible) Prestige will not require the member to choose a new PCP through the Plan. Prestige will not prevent the member from receiving primary care services from the Member s existing Medicare PCP. Prestige will not assign a PCP to a member who has an existing Medicare PCP (No PCP indicated on Prestige member ID card). Prestige will assist the member in choosing a PCP, if the member does not have a Medicare assigned PCP. Eventually, quality indicators will also be used in the auto-assignment process. Once the selection or assignment has been made, a Prestige member identification card (ID) with the PCP s name (or group name) is mailed to the member. Members are advised to keep the ID card with them at all times. The member s ID card includes: The member s name and Medicaid ID number; The Plan s name, address, member services phone number; and A phone number that a provider may call for information. Newborn Enrollment Providers must adhere to the Florida Medicaid newborn delivery notification requirements. Hospitals must notify Prestige when a pregnant member presents to the hospital for delivery (via notification of delivery). Prestige shall determine if the newborn has a record on the Florida Medicaid Management Information System (FMMIS) that is waiting activation (Unborn Activation Process). Upon notification of a member s delivery, Prestige shall notify the Department of Children and Families (DCF) of the delivery. Page 9

12 If a pregnant member presents for delivery without having an unborn eligibility record that is awaiting activation, the Plan shall submit the spreadsheet to DCF immediately upon birth of the child. The newborn will automatically become a Plan member retroactive to birth. If the mother has not previously identified a PCP for her newborn, a PCP will be assigned by Prestige no later than the beginning of the last trimester of gestation. American Recovery and Reinvestment Act of 2009 In accordance with the American Recovery and Reinvestment Act of 2009, Prestige may not impose enrollment fees, premiums, or similar charges on Indians served by an Indian health care provider, Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health service. Member Identification and Eligibility Verification Prestige member eligibility varies daily. Therefore, each participating provider is responsible for verifying member eligibility with Prestige before providing services. Eligibility may be verified by visiting the provider portal (Availity) of Prestige s website at or by calling Provider Services at The presentation of a Prestige member ID card is not sole proof that a person is currently enrolled in Prestige. For example, when a member becomes ineligible for Medicaid, the member does not return the member ID card. Providers should request a picture ID to verify that the person presenting is the person named on the member ID card. Services may be delayed being rendered, if the provider suspects the presenting person is not the card owner and no other ID can be provided, except for emergent situations. If providers suspect a non-eligible person is using a member s ID card, please report the occurrence to Prestige s Fraud and Abuse Hotline at Prestige will contact each new member at least twice, if necessary, within ninety (90) calendar days of the member s enrollment to offer to schedule the initial appointment with the PCP. This appointment is to obtain an initial health assessment including a Child Health Check-Up (CHCUP) screening, if applicable. Prestige Health Choice Member ID Card Page 10

13 Member Rights and Responsibilities In accordance with 42 CFR , Florida law requires that health care providers and facilities recognize member rights. Providers must post a copy of the summary of Florida s Patient s Bill of Rights and Responsibilities. Members have the right to request and receive from their health care provider, a complete copy of the Florida Patient s Bill of Rights and Responsibilities. Patient's Bill of Rights and Responsibilities Section , Florida Statutes, addresses the Patient's Bill of Rights and Responsibilities. The purpose of this section is to promote the interests and well-being of patients and to promote better communication between the patient and the health care provider. Florida law requires that a patient s health care provider or health care facility recognize those rights while the patient is receiving medical care and that the patient respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. Patients may request a copy of the full text of this law from their health care provider or health care facility. A summary of patients rights and responsibilities follows. A patient has the right to: Be treated with courtesy and respect, with appreciation of his or her dignity, and with protection of privacy. Receive a prompt and reasonable response to questions and requests. Know who is providing medical services and who is responsible for his or her care. Know what patient support services are available, including if an interpreter is available if the patient does not speak English. Know what rules and regulations apply to his or her conduct. Be given by the health care provider information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis. Refuse any treatment, except as otherwise provided by law. Be given full information and necessary counseling on the availability of known financial resources for care. Know whether the health care provider or facility accepts the Medicare assignment rate, if the patient is covered by Medicare. Receive prior to treatment, a reasonable estimate of charges for medical care. Receive a copy of an understandable itemized bill and, if requested, to have the charges explained. Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment. Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such research. Express complaints regarding any violation of his or her rights. Page 11

14 A patient is responsible for: Giving the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and any other information about his or her health. Reporting unexpected changes in his or her condition to the health care provider. Reporting to the health care provider whether he or she understands a planned course of action and what is expected of him or her. Following the treatment plan recommended by the health care provider. Keeping appointments and, when unable to do so, notifying the health care provider or facility. His or her actions if treatment is refused or if the patient does not follow the health care provider s instructions. Making sure financial responsibilities are carried out. Following health care facility conduct rules and regulations. Page 12

15 SECTION II PROVIDER AND NETWORK INFORMATION Page 13

16 II. Provider and Network Information Prestige s Provider Network is composed of quality primary health care providers, specialists, ancillary, and facility providers to administer health care to its Medicaid members. This section provides information for establishing and maintaining network privileges and sets forth expectations and guidelines for participating PCPs, specialists, ancillary and facility providers. Prestige Medicaid Provider Eligibility Health care providers are selected to participate in the Prestige network based on an assessment and determination of the network's needs, and the application of Plan and Agency guidelines. All providers must be registered with the Medicaid program and have a valid provider Medicaid ID number prior to being enrolled with Prestige, and as a condition to being paid for services rendered. The criteria, verification methodology and processes used by Prestige are designed to credential and re-credential providers in a non-discriminatory manner, with no attention to race, ethnic/national identity, gender, age, sexual orientation, specialty or procedures performed. Prestige does not discriminate against particular providers that serve high-risk populations or who specialize in conditions that require costly treatments. Initial Credentialing and Re-Credentialing Criteria and Standards Prestige conducts background screening and verifies initial credentialing and re-credentialing criteria for all professional providers that, at a minimum, meet the Agency's Medicaid participation standards. The criteria includes, but is not limited to: Current medical licensure pursuant to s , F.S. No revocation or suspension of the provider's state license by the Division of Medical Quality Assurance, Department of Health, and/or the Agency. Disclosure related to ownership and management (42 CFR ), business transactions (42 CFR ) and conviction of crimes (42 CFR ). Proof of the provider's specialty board certification or evidence of medical school graduation, residency and other post-graduate training. History of the provider's professional liability claims. Evidence of the provider s professional liability insurance coverage or a Financial Responsibility Form. Satisfactory review of any sanctions imposed on the provider by Medicaid, Medicare and /or any Federal or State Regulatory Agencies. Receipt of the provider s Medicaid valid ID number, Medicaid application registration number or documentation of submission of the Medicaid application registration form. The initial credentialing and re-credentialing process also includes, but is not limited to, background screening and verification of the following additional requirements for providers in order to ensure compliance with 42 CFR : Attestation to the correctness/completeness of the provider's application. Page 14

17 Good standing of privileges at a participating hospital designated as the primary admitting facility by the provider, or if the provider does not have admitting privileges, good standing of privileges at a participating hospital by another provider with whom the provider has entered into an arrangement for hospital coverage. Must have admitting privileges in their specialty at a participating hospital, or have a plan for hospital admission by using a Hospital Inpatient Team or having an arrangement with a credentialed Prestige participating provider that has the ability to admit Prestige s patients to a hospital. Valid Drug Enforcement Administration (DEA) certificates, where applicable. Attestation that the total active patient load (all populations with Medicaid Fee-For-Service [FFS], Children s Medical Services Network, Health Maintenance Organization [HMO], Provider Service Network [PSN], Medicare and commercial coverage) is no more than three thousand (3,000) patients per PCP. An active patient is one that is seen by the provider a minimum of three (3) times per year. Complete a site visit evaluation for each office location submitted by the PCP or Obstetrician/Gynecologist (OB/GYN). See more information below in the Site Visit Evaluation sections. Statement regarding any history of loss or limitation of privileges or disciplinary activity as described in s , F.S. A statement from each provider applicant regarding the following: o Any physical or mental health problems that may affect the provider's ability to provide health care. o Any history of chemical dependency/substance use. o Any history of loss of license and/or felony convictions. o The provider is eligible to become a Medicaid provider. o Current curriculum vitae, which includes at least five (5) years of work history. All applications and attestation/release forms must be signed and dated one hundred eighty (180) days prior to the credentialing committee decision date. Additionally, all supporting documents must be current at the time of the decision date. Initial credentialing process may take up to 90 days after receiving a complete application form and supporting documentation in the Prestige credentialing department. If there is missing and/or incomplete information, provider will receive notification either from Provider s account executive or Credentialing department. Once the time included in the notification expires or credentialing department has not received the missing information within 90 days from the date the credentialing process started, the credentialing application will be discontinued. If provider is the only provider in the group being credentialed, the group contract will also terminate. Re credentialing process occurs every three (3) years and starts at least 90 days prior to the credentials expiration date. Several attempts will be made prior to the credentialing expiration date to obtain the application and/or any missing documentation (as applicable). In the event the application or missing documentation is not received by credentialing department prior to the credentialing expiration date, the Page 15

18 provider will be terminated from Prestige s network on the credentialing expiration date. If provider is the only provider in the group being re-credentialed, the group contract will also terminate. Provider Rights During the credentialing process, every applicant has the right to: Review information contained in their credentialing file. This does not include information collected from references, recommendations, peer review and other protected information. Providers have the right to be notified and to correct erroneous information if the credentialing information received varies substantially from the information that was submitted on the application. However, variances in information obtained from references, recommendations, peer review and other protected information are not subject to this notification. Be informed of the status of their application upon request. Receive notification of these rights. Questions regarding the status of a credentialing application may be directed to the Prestige Credentialing Department at , option 6. Prestige s Quality Improvement Program (QIP) provides oversight of credentialing. For more information, refer to the Quality Improvement Program section of this manual. Site Visit Evaluation Prestige s credentialing and re-credentialing process requires PCPs and OB/GYNs to have a site visit evaluation for each credentialing location in accordance with Prestige and Agency standards outlined below: The site evaluation will verify the following provider requirements, including but not limited to: Upholding Prestige organizational standards. Accessibility to persons with disabilities. Adequate space for waiting area and examination rooms. Adequate operating supplies. Proper sanitation and clean, smoke-free facilities. Proper fire and safety procedures are in place. Medical record keeping practices conform to Prestige s organizational standards and state and federal regulations. Posting of the following documents in the provider s office: o The Agency s statewide consumer call center number, including hours of operation o A copy of the summary of the Florida Patient s Bill of Rights and Responsibilities, in accordance with s F.S. The provider must have a completed copy of the Florida Patient s Bill of Rights and Responsibilities, available upon request by a member, at each provider s office. o Prestige s Grievance Department number. Page 16

19 Evidence that the provider is maintaining adequate access standards. Prestige Health Choice Facility/Provider Site Evaluation Prestige performs a site visit evaluation on each ancillary or facility/provider location submitted for credentialing who are not accredited or do not have an Agency or CMS site survey. For providers who are either accredited or have had an Agency or CMS site survey, a copy of the accreditation or site survey must be submitted with the initial credentialing documentation. Additional site visits for accredited facility providers may be performed at the discretion of Prestige. Site Visits Resulting from Receipt of a Complaint, On-Going Monitoring, Member Dissatisfaction, or Regarding Office Environment or Facility Prestige may identify the need for additional site visits upon receipt of member dissatisfaction or other complaint regarding the provider s office environment or facility. Prestige s Provider Account Executive (or other representative) may conduct a full or focused site visit to address the specific issue(s) raised. Follow-up site visits are conducted on an as needed basis. Focused site visits, where the full site evaluation is not performed, do not count toward the every three (3) year site visit requirement. Final disposition is at the Plan s discretion. Communication of Results 1. The Provider Account Executive reviews the results of the site visit evaluation with the office contact person. 2. If the site meets or exceeds Prestige s requirements, the site visit evaluation is signed and dated by both Prestige and the office contact person. If the site does not meet Prestige s requirements, Prestige adheres to the follow-up procedure for initial deficiencies outlined below. Follow-Up Procedure for Initial Deficiencies 1. The Provider Account Executive requests a corrective action plan from the office contact person (to be received within one week of the visit). 2. Each follow-up contact and visit is documented in the provider s file. 3. The Provider Account Executive schedules a re-evaluation visit with the provider s office within sixty (60) days of the initial site visit to review the site and verify that the deficiencies were corrected. 4. The Provider Account Executive reviews the corrective action plan and the results of the followup site visit (including a re-review of any deficiencies) with the office contact person. 5. If the site meets or exceeds Prestige s requirements, the site visit evaluation form is signed and dated by both Prestige and the office contact person. 6. If the site does not meet Prestige s requirements, the Provider Account Executive follows the follow-up procedure for Secondary Deficiencies outlined below. Page 17

20 Follow-Up Procedure for Secondary Deficiencies 1. The Provider Account Executive will re-evaluate the site monthly, up to three (3) times (from the date of the first site visit). 2. If after four (4) months there is evidence that the deficiency is not being corrected or completed, then the site does not meet Prestige s evaluation requirements, unless there are extenuating circumstances. 3. Further decisions on whether to pursue the credentialing process or terminate participation of providers who do not meet Prestige s site visit requirements, will be handled on a case-by-case basis by the Prestige Medical Director and the credentialing committee. New Provider Orientation Upon completion of Prestige s contracting and credentialing processes, the Plan sends each new provider a welcome letter, which includes the effective date and information on how to access online resources, including provider orientation training information and the. The serves as a source of information regarding Prestige s covered services, policies and procedures, relevant statutes and regulations, phone access and special requirements to ensure all Agency contract requirements are met. The welcome letter explains how a hard copy of the may be obtained by contacting Provider Services at Provider Relations Prestige s Provider Account Executives function as a provider relations team to advise and educate Prestige providers. Provider Account Executives assist providers in adopting new business policies, processes and initiatives. Providers will be contacted by Prestige representatives to conduct meetings that address topics such as, but not limited to: Credentialing or re-credentialing site visits. Orientation, education and training. Provider complaints. Training self-service tools. Contract negotiations. Program updates and changes. Health management programs. Quality enhancements. Please notify your Provider Account Executive immediately if there have been, or will be, any changes to your demographic information, including, but not limited to: address, phone or fax number, office hours and/or whether you are accepting new Prestige patients. Orientation Training Prestige conducts initial training within thirty (30) days of placing a newly contracted PCP provider or PCP provider group on active status, Prestige shall also conduct ongoing training, as deemed necessary in Page 18

21 order to ensure compliance with program standards and the AHCA contract. Orientation training will include, but is not limited to: Re-credentialing. Provider responsibilities. Cultural competency. Policies and procedures. Utilization Management, Quality Improvement and Integrated Health Care Management Programs. Medicaid compliance. Covered services, benefit limitations and value-added services. Provider inquiry and complaint process. Billing and claims filing, and encounter data reporting. Electronic funds transfers/remittance advice. Quality enhancement programs/community resource capability. Children s programs including immunizations, nutrition and Child Health Check-Up (CHCUP). Substance use screening. Adverse incident reporting. If you are a PCP or PCP group and your Provider Account Executive has not scheduled your orientation training within thirty (30) days of becoming active with Prestige, call Provider Services at Provider Education and Ongoing Training Training and development are fundamental components of continuous quality and superior service. Prestige offers on-going educational opportunities for providers and their staff. Prestige has a commitment to provide all appropriate training and education to help ensure providers maintain compliance with Prestige standards, Agency standards and other state requirements as well as applicable federal requirements. This training may occur in the form of an on-site visit or in an electronic format, such as online training sessions or interactive training sessions. Detailed training information is available at Prestige providers may obtain information from Provider Account Executives or Provider Services at Secure Provider Portal Prestige utilizes Availity as our portal for providers to review claims and submit and review authorizations, as well as other important information. Detailed services provided via the provider portal are as follows: Claims Status Inquiry - Claim Status Inquiry service is a fast, easy way to check the status of claims, including denial reasons. Page 19

22 Authorizations - With the Authorization functionality, providers can easily submit requests for procedural inpatient or specialist visits as required and to check the status of existing authorizations in real time. Eligibility and Benefits Inquiry - Providers can submit an electronic request for verification of a patient's eligibility and benefits information and get instant results, including covered services, co-pays and deductibles, if applicable. Clinical Information Exchange - Clinical information is available via the portal, such as: PCP Panel Reports, Care Reminders, Clinical Patient Summaries, and Care Gap Alerts (which will be presented when the provider checks a member s eligibility) and other reports. If not already using the provider portal, please visit and click on Get Started. If you need assistance with registration, please contact Availity at AVAILITY. For more information, please visit the Prestige website at Fraud, Waste and Abuse (FWA) Prestige has a designated Compliance Officer who is primarily responsible for all Prestige Compliance and Special Investigations Unit (SIU) activities, and is qualified to oversee the Fraud and Abuse program to ensure program integrity. Designed in accordance with state and federal rules and regulations, Prestige s Anti-Fraud Plan addresses the detection and prevention of overpayments, abuse, and fraud related to the provision of, and payment for, Medicaid Services. The Anti-Fraud Plan includes FWA policies and procedures designed to help prevent, reduce, detect, investigate, correct, and report known or suspected fraud, waste, and abuse activities, and to implement corrective action. For more information on reporting fraud, waste and abuse visit our website at Fraud Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to that person or another person (FS Fraud Definition Section 2 paragraph C ). The term includes any act that constitutes fraud under applicable federal or state law. As applied to the federal health care programs (including the Medicaid program), health care fraud generally involves a person or entity s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for, items or services payable under a federal health care program. Some examples of fraud include: Billing for services not furnished. Soliciting, offering or receiving a kickback, bribe or rebate. Violations of the provider self-referral prohibition. Waste Waste, though not specifically defined by Florida Statute, is the overutilization of services or other practices that result in unnecessary costs. Generally not considered caused by criminally negligent actions, but rather the misuse of resources. Page 20

23 Abuse Abuse is defined as provider practices that are inconsistent with generally accepted business or medical practice that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid program (FS Abuse Definition Section 1 paragraph A, subparagraph 1). In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicaid program. Some examples of abuse include: Charging in excess for services or supplies unintentionally. Providing medically unnecessary services. Providing services that do not meet professionally recognized standards. Overpayment Overpayment defined in accordance with s , F.S., includes any amount that is not authorized to be paid by the Medicaid program, whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse or mistake. False Claims Act The Federal False Claims Act (FCA) is a federal law that applies to fraud involving any contract or program that is federally funded, including Medicare and Medicaid. Health care entities that violate the Federal FCA can be subject to civil monetary penalties ranging from $5,500 to $11,000 for each false claim submitted to the United States government or its contactors, including state Medicaid agencies. The Federal FCA contains a qui tam or whistleblower provision to encourage individuals to report misconduct involving false claims. The qui tam provision allows any person with actual knowledge of allegedly false claims submitted to the government to file a lawsuit on behalf of the U.S. Government. The FCA protects individuals who report under the qui tam provisions from retaliation that results from filing an action under the Act, investigating a false claim, or providing testimony for or assistance in a federal FCA action. Effective in 2007, the Deficit Reduction Act of 2005 (DRA) increased the states requirements to fight fraud, waste, and abuse activities within their state Medicaid plans and introduced incentives for the states to enact their own False Claims Acts. Florida has a False Claims Act, codified at F.S et seq. The purpose of the Florida FCA is to deter persons from knowingly causing or assisting in causing state government to pay claims that are false or fraudulent, and to provide remedies for obtaining treble damages and civil penalties for state government when money is obtained from state government by reason of a false or fraudulent claim. No proof of intent to defraud is required for liability to attach, but an innocent mistake may be a defense to an action under the Florida FCA. Florida s FCA includes provisions similar to the federal FCA, allowing for qui tam actions by relators; the Florida Department of Legal Affairs may also bring an action under the Florida FCA. A portion of the amount recovered from prosecuting Medicaid false claims in Florida is deposited to the Medicaid Operating Trust Fund in order to fund rewards for persons who report and provide information relating to Medicaid fraud. Page 21

24 Provider Responsibilities Related to Fraud, Waste and Abuse Providers agree to include in their compliance program provisions regarding these statutes and provisions protecting whistleblowers in these matters. The object of the False Claims Act is to prevent and detect fraud, waste and abuse. Prestige, providers, and all group providers shall comply with the False Claims Act to the extent applicable and assist in the detection and prevention of fraud, waste, and abuse in connection with the provision of services under the Agreement and the State Contract. All suspected or confirmed instances of internal and external fraud and abuse relating to the provision of, and payment for, Medicaid services including, but not limited to, Prestige employees/management, providers, subcontractors, vendors, delegated entities, or enrollees under state and/or federal law, must be reported to MPI within fifteen (15) calendar days of detection. Upon request, and as required by state and/or federal law, providers shall adhere to the following: Records maintenance, providers/facilities are required to maintain an adequate record system for recording services, charges, dates and all other commonly accepted information elements for services rendered to Medicaid members under the Agreement. Providers/Facilities shall maintain and shall provide access to such records as required by state and federal law until the expiration of six (6) years from the close of the Contract or, if longer, until the resolution of any ongoing review or audit with respect thereto is complete. Providers/ Facilities shall request and obtain prior approval from Prestige for the disposition of records if the Agreement is continuous. Providers/Facilities shall make available to the Secretary of the Department of Health and Human Services (DHHS) and AHCA and their designee(s) upon request, the Agreement, this Addendum and all books, documents and records necessary to inspect and certify the quality, appropriateness and timeliness of services performed the cost of those services, payment thereof and for any other lawful purpose. Further, Providers/Facilities shall make available to DHHS and AHCA, including Medicaid Program Integrity (MPI) and Medicaid Fraud Control Unit (MFCU), for inspection, evaluation and audit all (i) pertinent books; (ii) financial records; (iii) medical records and (iv) documents, papers and records of any transactions, financial or otherwise, related to the Contract. Providers/Facilities shall fully cooperate in any investigation by AHCA, MPI or MFCU or any subsequent legal action that may result from such investigation. Failure to fully cooperate in investigations, reviews, or audits conducted by Prestige, the Agency, MFCU or any other authorized entity, including but not limited to, allowing access to the premises, allowing access to Medicaid related records, or furnishing copies of documentation upon request may constitute a material breach of this contract and render it immediately terminated. Providers/Facilities shall (i) safeguard information about members in accordance with 42 C.F.R ; and (ii) comply with applicable HIPAA privacy and security provisions. Reporting and Preventing Fraud, Waste and Abuse Compliance with state and federal laws and regulations is a priority. If providers, or any other entity you contract with to provide health care services on behalf of Prestige beneficiaries, identify potential FWA, please contact the Prestige Fraud, Waste and Abuse Hotline at Additionally, you may Page 22

25 report suspected fraud or abuse by contacting the Florida Attorney General s Office at or the Agency Consumer Complaint Call Center at To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline tollfree at If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General's Fraud Rewards Program at The reward may be up to twenty-five (25) percent of the amount recovered, or a maximum of $500,000 per case (Florida statutes Chapter ). You can talk to the Attorney General's Office about keeping your identity confidential and protected. Below are examples of information that will assist Prestige with an investigation: Contact information (i.e., name of individual making the allegation, address, phone number). Type of item or service involved in the allegation(s). Place of service. Nature of the allegation(s). Timeframe of the allegation(s). As situations warrant, Prestige may make referrals to appropriate law enforcement and/or the Medical Education Development in Communities (MEDIC). Risk Management Prestige recognizes the importance of minimizing risks to members during the provision of health care services. In order to achieve this goal, Prestige utilizes a formal risk management program. The purpose is to promote the delivery of optimal and safe health care for members. The program allows objective monitoring, evaluation and correction of situations that may occur in the administration and delivery of health care services. Provider Responsibilities In accordance with Attachment II, Section VII F(1)(b) of the AHCA Contract, providers and subcontractors are required to report adverse incidents or injuries affecting members to Prestige immediately upon the incident occurrence, and no later than forty-eight (48) hours of detection or notification. Prestige Health Choice subcontractors are also required to complete an Adverse Incident Summary Report for the previous month s incidents, involving Prestige Health Choice members. The report shall be submitted to the Prestige Risk Management by the 5 th of each month. Procedures for Adverse Incident Reporting Providers and subcontractors must report adverse incidents or injuries affecting Prestige members using the AHCA approved Provider Adverse Incident Form. The form can be located on the Prestige website at Reporting will include information such as the member s identity, description of the incident, and outcomes including current status of the member. After completion, the form must be submitted to Prestige Risk Management at or phcriskmanagement@prestigehealthchoice.com. The incident report should be maintained in a secure confidential file. Page 23

26 For reporting purposes the State of Florida defines an adverse incident as a critical event that negatively impacts the health, safety, or welfare of Prestige members. Adverse incidents may include events involving abuse, neglect, exploitation, major illness or injury, involvement with law enforcement, elopement/missing, or major medication incidents. Furthermore, adverse incidents are events that occur during the delivery of Prestige covered services and are: 1) Associated in whole or in part with service provision rather than the condition for which such service provisions occurred, and 2) Is not consistent with or expected to be a consequence of service provision (see example A) or 3) Occurs as a result of service provision to which the patient has not given informed consent (see example B) or 4) Occurs as a result of any other action or lack thereof on the part of the staff of the provider (see example C) and 5) Result in one of the following injuries: a. Death. b. Brain damage. c. Spinal damage. d. Permanent disfigurement. e. Fracture or dislocation of bones or joints. f. A condition requiring specialized medical attention which is not consistent with the routine management of the patient s case or patient s preexisting physical condition. g. A condition requiring surgical intervention to correct or control. h. A condition resulting in transfer of the patient, within or outside the facility, to a unit providing a more acute level of care. i. A condition that extends the patient s length of stay. j. A condition that results in a limitation of neurological, physical, or sensory function which continues after discharge from the facility. Examples of reportable events: Example A The performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the Prestige member s diagnosis or medical condition. Example B Required surgical repair of damage resulting to a Prestige member from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the Prestige member and documented through the informed-consent process. Example C A procedure to remove unplanned foreign objects remaining from a surgical procedure. Procedures for Adverse Incident Summary Reporting All subcontractors of Prestige Health Choice are required to complete an Adverse Incident Summary Report for the previous month s incidents, involving Prestige Health Choice members. To complete the Page 24

27 report, enter the month, year, and total number of events by incident type under the MMA tab of the AHCA approved Adverse and Critical Incident Summary Report. Subcontractors must also complete and submit an attestation with the report. Details on the attestation can be found in the SMMC Report Guide. The report and attestation are sent to Prestige Risk Management, by the 5th of each month. Delegation Oversight should be copied on the . Provisions of the Risk Management Program Providers and subcontractors will be trained by Provider Network Management on reporting requirements and timeframes for adverse incidents, abuse, neglect and exploitation upon initial orientation with Prestige and at monthly visits. The Risk Management Program has processes to comply with contractual and reporting requirements. The Risk Manager will report allegations of abuse, neglect and exploitation of members to the Department of Children and Families for children and Florida Adult Protective Services for elders and individuals with disabilities. The Compliance Department will keep separate, confidential electronic files and/or paper records of investigations of alleged abuse, neglect, and exploitation of elders and individuals with disabilities. The Risk Manager will prepare a monthly Adverse and Critical Incident Summary Report for submission to AHCA. All potential quality of care concerns will be investigated by the Quality Department. The Provider Adverse Incident Report Form can be found on the Plan s website at Provider Responsibilities Related to Reporting Abuse, Neglect and Exploitation of Members All participating and direct service providers are required to report suspected cases of abuse, neglect, or exploitation of vulnerable adults to the Department of Children and Families Central Abuse Hotline, ABUSE ( ), in accordance with s and Chapter 415, F.S. Abuse means any willful act or threatened act by a caregiver that causes or is likely to cause significant impairment to a member s physical, mental or emotional health. Abuse includes acts and omissions. Neglect of an adult means the failure or omission on the part of the caregiver to provide the care, supervision, and services necessary to maintain the physical and behavioral health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision and medical services, that a prudent person would consider essential for the well-being of the vulnerable adult. The term neglect also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult from abuse, neglect or exploitation by others. Neglect is repeated conduct or a single incident of carelessness that produces, or could reasonably be expected to result in, serious physical or psychological injury or a substantial risk of death. Page 25

28 Neglect of a child occurs when a child is deprived of, or is allowed to be deprived of, necessary food, clothing, shelter or medical treatment. Additionally, when a child is permitted to live in an environment where such deprivation or environment causes the child s physical, behavioral or emotional health to be significantly impaired or to be in danger of being significantly impaired. Exploitation of a vulnerable adult means a person who: Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use, a vulnerable adult s funds, assets or property for the benefit of someone other than the vulnerable adult. Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use, the vulnerable adult s funds, assets, or property with the intent to temporarily or permanently deprive the vulnerable adult of the use, benefit, or possession of the funds, assets or property for the benefit of someone other than the vulnerable adult. Provider Roles and Responsibilities Prestige is regulated by Florida State law under the Agency. Please refer to your Prestige Network Participation Agreement or contact your Provider Account Executive for clarification of any of the following. Providers who participate in Prestige have responsibilities, including but not limited to: Coordinate with applicable State agencies for any members receiving service or under conservatorship from DCF. Provide covered services to members with Plan coverage. Provide timely covered services to members at all times. Abide by and cooperate with the policies, rules, procedures, programs, activities and guidelines contained in your Provider Agreement (which includes the most current Prestige Provider Manual). Accept Prestige payment as payment-in-full for covered services. Copayments are waived as part of the Plan s expanded benefits; the provider must not charge enrollees copayments for covered services. Adhere to guidelines for usage of all electronic self-service tools. Comply fully with the Prestige Quality Improvement, Utilization Management, Integrated Health Care Management, Risk Management and Audit Programs. Comply with all applicable training requirements, including training for Fraud, Waste and Abuse, as required by CMS. Promptly notify Prestige of claims processing payment or encounter data reporting errors. Maintain all records required by law regarding services rendered for the applicable period of time, making such records and other information available to Prestige or any appropriate government entity. Treat and handle all individually identifiable health information as confidential in accordance with all laws and regulations, including HIPAA-AS and HITECH requirements. Immediately notify Prestige of adverse actions against license or accreditation status. Comply with all applicable federal, state, and local laws and regulations. Page 26

29 Maintain liability insurance in the amount required by the terms of the Provider Agreement. Notify Prestige of the intent to terminate the Provider Agreement as a participating provider within the timeframe specified in the Provider Agreement. If the Provider Agreement is terminated: o Continue to provide services to members who are receiving inpatient services until they are appropriately discharged and/or the specific episode of care is completed. o Accept payment at rates in effect under the Agreement immediately prior to termination. Verify eligibility immediately prior to rendering service. Obtain signed consents prior to rendering service. Obtain prior authorization for applicable services. Maintain hospital privileges when required for the delivery of the covered service. Maintain all medical and Medicaid-related member records and communications for a period of ten (10) years according to legal, regulatory and contractual rules of confidentiality and privacy. Provide prompt access to records for review, survey or study if needed. Cooperate fully in any investigation or review by Prestige, Agency, Medicaid Program Integrity (MPI), Medicaid Fraud Control Unit, Office of the Attorney General (MFCU), or other state or federal entity and in any subsequent legal action that may result from such an audit, investigation or review. When presenting a claim for payment to Prestige, the network provider is indicating an understanding that the provider has an affirmative duty to supervise the provision of, and be responsible for, the covered services claimed to have been provided, to supervise and be responsible for preparation and submission of the claim, and to present a claim that is true and accurate and that is for Prestige covered services that: o Have actually been furnished to the recipient by the provider prior to submitting the claim. o Are medically necessary. Report known or suspected child, elder or domestic abuse to local law authorities and have established procedures for these cases. Provide encounter data accepted by the Florida Medicaid Management Information System (FMMIS), as either actively enrolled Medicaid providers or as Prestige registered providers and/or the State s encounter data warehouse. Inform members of the availability of Prestige s interpreter services and encourage their use. Notify Prestige of any changes in business ownership, business location, legal or government action, or any other situation affecting or impairing the ability to carry out duties and obligations under the Prestige Network Provider Agreement. Maintain oversight of non-physician practitioners as mandated by state and federal law. Post or display a copy of the summary of the Florida Patient s Bill of Rights and Responsibilities (in accordance with s , F.S.) and have a complete copy available upon member request at each of the provider s offices. Obtain consent from the parent or guardian for children under thirteen (13) years old who are prescribed psychotropic medicines, and maintain documentation in the child s medical record. Provide a copy of the signed consent with the hard copy of the prescription to be taken to the pharmacy. Consent forms are located at Page 27

30 Notify Prestige promptly of patient member pregnancies. Do not discriminate in any manner between Prestige members and non-prestige members. Primary Care Provider (PCP) Roles and Responsibilities Additionally, Prestige s participating PCPs are responsible for providing or coordinating medical services including, but not limited to: Inpatient admissions. Case management for non-surgical admissions. Nursing home visits. Provider hospital care. Office visits. Education on preventive health. Injections and immunizations. Laboratory and X-ray services per the Prestige contractual arrangement. Minor office surgeries/procedures. Periodic health assessments. Smoking cessation program screenings. Substance use and domestic violence screenings. Screening EKGs ordinarily performed in a provider s office. Well-child care, including CHCUP services. Outpatient services. Emergency services. Home health care. Therapy. Other medical care normally rendered by the provider. Prestige PCPs must provide, or arrange for coverage of services, consultation or approval for referrals twenty-four hours a day, seven days a week (24/7) by Medicaid-enrolled providers who will accept Medicaid reimbursement. This coverage will consist of an answering service, call forwarding, provider call coverage or other customary means approved by the Agency. The chosen method of 24/7 coverage must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. The after-hours coverage must be accessible using the medical office s daytime phone number. The PCP is responsible for arranging coverage of primary care services during absences due to vacation, illness or other situations that render the PCP unable to provide services. A Medicaid-eligible PCP must provide coverage. Members with chronic or disabling illnesses or children with special health care needs may request a specialist to act as their PCP. Pregnant members are also allowed to choose an obstetrician as their PCP to the extent that the obstetrician is willing to participate as a PCP. Please refer to your Prestige Network Participation Agreement or contact your Provider Account Executive for further clarification. Page 28

31 Specialist and Other Provider Roles and Responsibilities The member s PCP may refer the member to a specialist to diagnose and treat medical conditions that are outside of the PCP s range of practice. Specialty and ancillary care is limited to the Plan s covered benefits and may require prior authorization. Prestige s benefit coverage and prior authorization list can be found at Specialists who are designated as a PCP are required to adhere to the PCP responsibilities. Direct Access to Women s Health Female members can directly access a women's health specialist within the network for covered services necessary to provide women's routine and preventive health care services. This is in addition to a member s designated PCP, if that provider is not a women's health specialist. Prestige ensures access to certified or licensed nurse midwife services for low-risk members, licensed in accordance with Chapter 467, F.S. Provider Prohibited Activities Prestige providers are prohibited from the following activities: Discriminating against any member on the basis of race, color, religion, sex, national origin, age, health status, participation in any governmental program, source of payment, marital status, sexual orientation or physical or mental handicap. Segregating members from other patients (applies to services, supplies, equipment). Billing members for covered services including disputed amounts. Refusing to furnish a member with a covered Medicaid service solely because the member s eligibility has not yet transmitted to Florida Medicaid Management Information System (FMMIS) when the member possesses one form of acceptable proof of eligibility. Access to Care Prestige providers must meet standard guidelines to help ensure Prestige members have timely access to care. Prestige endorses and promotes comprehensive and consistent access standards for members to assure member accessibility to health care services. Prestige establishes mechanisms for measuring compliance with existing standards and identifies opportunities for the implementation of interventions for improving accessibility to health care services for members. The following areas are monitored by Prestige to ensure provider access standards are continually met: Office accessibility. Appointment scheduling timeframes. After-hours care. Office Accessibility PCP office hours must be clearly posted and reviewed with members during the initial office visit. The PCP is required to arrange for coverage of primary care services during absences due to vacation, illness Page 29

32 or other situations that render the PCP unable to provide services. A Medicaid-eligible PCP must provide the coverage to Prestige members. Appointment Scheduling Prestige monitors the following access standards on an annual basis per Medicaid Managed Care guidelines. General Appointment Scheduling for PCPs and Specialists Urgent examination Routine sick patient care Well-care visit Postpartum exam Within 1 day Within 1 week Within 1 month Within 6 weeks of delivery Emergency services must be provided immediately upon presentation, twenty-four hours a day, seven days a week (24/7). Missed Appointment Tracking If a member misses an appointment with a provider, the provider must document the missed appointment in the member s medical record. Providers must make at least three (3) documented attempts to contact the member and determine the reason. The medical record should reflect any reasons for delays in performing the examination and should also include any refusals by the member. Access to After-Hours Care Prestige members will have access to quality, comprehensive health care services twenty-four hours a day, seven days a week (24/7). PCPs must have either an answering machine or an answering service for members during after-hours for non-emergent issues. The answering service must forward calls to the PCP or on-call provider, or instruct the member that the provider will contact the member within thirty (30) minutes. When an answering machine is used after hours, the answering machine must provide the member with a process for reaching a provider after hours. The after-hours coverage must be accessible using the medical office s daytime phone number. For emergent issues, both the answering service and answering machine must direct the member to call 911 or go to the nearest emergency room. Prestige will monitor access to after-hours care by conducting a survey of PCP offices after normal business hours. Monitoring Appointment Access and After-Hours Access Prestige monitors appointment waiting times using various mechanisms, including: Reviews conducted by Account Executives during routine visits Reviewing provider records during the initial and triennial facility site review. Monitoring administrative complaints and grievances. Conducting an annual Access to Care survey to assess member access to daytime appointments and after-hours care. Non-compliant providers will be subject to corrective action and/or termination from the network. A non-compliance letter will be sent to the provider. Page 30

33 The noncompliant provider will be re-surveyed within three (3) to six (6) months after the infraction. Cultural and Linguistic Requirements Communication, whether in written, verbal, or "other sensory" modalities is the first step in the establishment of the patient/ health care provider relationship. The key to ensuring equal access to benefits and services for Limited English Proficiency (LEP), Low Literacy Proficiency (LLP) and sensory impaired members is to ensure that our providers can effectively communicate with these members. To ensure accurate, objective and confidential communication, Prestige never requires or suggests family, friends or other unqualified individuals be utilized as interpreters. Prestige contracts with competent interpreters and translators that utilize internal quality control measures to ensure the accuracy of the language services provided. This service provides a fast and easy way to communicate with our members with interpreters in more than two hundred (200) languages that are available twenty-four hours a day, seven days a week (24/7). Please call Member Services at to access this free service. To ensure that all Prestige members are served in a way that is responsive to their cultural and linguistic needs providers are required to: Provide Prestige members verbal and/or written notice (in their preferred language or format) about their right to receive free language assistance services from Prestige. o The assistance of friends, family and bilingual staff is not considered competent, quality interpretation services. These persons should not be used for interpretation services except where a member has been made aware of his/her right to receive free interpretation and continues to insist on using a friend, family member or bilingual staff for assistance in his/her preferred language. Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents, such as patient information forms and treatment consent forms, must be made available in other languages and formats. Additionally, under the National Standards for Culturally and Linguistically Appropriate Service (CLAS), as set forth by the U.S. Department of Health and Human Services, Prestige providers are strongly encouraged to: Provide effective, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. Implement strategies to recruit, retain and promote a diverse office staff and organizational leadership representative of the demographics in your service area. Educate and train staff at all levels, across all disciplines, in the delivery of culturally and linguistically appropriate services (CLAS). Establish written policies to provide interpretive services for Prestige members upon request. Page 31

34 Routinely document preferred language or format (such as Braille, audio, or large type) in all member medical records. Prestige s Cultural Competency Plan is outlined in Section X of this manual. Providers may request a full copy of the cultural competency plan free of charge by contacting Member Services at or by visiting Medical Record Requirements Providers must follow the medical record standards outlined below, for each member s medical record, as appropriate: Include the member s identifying information including name, member ID number, date of birth, sex and legal guardianship (if any). Each record will be legible and maintained in detail. Include a summary of significant surgical procedures, past and current diagnoses or problems, allergies, untoward reactions to drugs and current medications. All records shall contain an immunization history. All entries will be dated and signed by the appropriate party. All entries will indicate the chief complaint or purpose of the visit, the objective findings, diagnoses, medical findings or impression of the provider. All entries will indicate studies ordered (e.g., laboratory, X-ray, EKG) and referral reports. All entries will indicate therapies administered and prescribed. All entries will include the name and profession of the provider rendering services (e.g., MD, DO, OD), including the signature or initials of the provider. All entries will include the disposition, recommendations, instructions to the member, evidence of follow-up and outcome of services. All records will contain an immunization history. All records will contain information relating to the member s use of tobacco products, alcohol, and drugs/substance use. All records will contain summaries of all emergency services and care and hospital discharges with appropriate medically indicated follow-up. Include all services provided. Such services must include, but not limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases. All records will reflect the primary language spoken by the member and any translation needs of the member. All records will identify members needing communication assistance in the delivery of health care services. All records will contain documentation that the member was provided with written information concerning the member s rights regarding advance directives (written instructions for living will or power of attorney) and whether or not the member has executed an advance directive. Neither Prestige, nor any of its providers will, as a condition of treatment, require the member to execute or waive an advance directive. Copies of any advance directives executed by the member. Page 32

35 Include copies of any consent or attestation form used or the court order for prescribed psychotherapeutic medication for a child under the age of thirteen (13). Include documentation regarding missed/canceled appointments. Include an update of medications at each visit, including any changes in prescription and nonprescription medication with name and dosage. Diagnostic or therapeutic intervention as part of clinical research is clearly contracted with entries regarding provision of non-research related care. When proposed course of treatment involves risks, there is evidence of discussion with member regarding risks, alternatives incorporated into the clinical record. Document referral services in the member s medical/case record. Include copies of Pre-admission Screening and Resident Review (PASRR) and evaluations competed in accordance with rule 59G-1.040, F.A.C. for members admitted to or residing in a nursing facility under any provision of this contract. Nursing facilities providing services to enrollees under the age of eighteen (18) years, must notify DCF of the admission to and discharge: (a) The nursing facility provider must submit a completed DCF #2506A Form (Client Referral/Change) to DCF within ten (10) business days of the admission to a nursing facility of an enrollee under the age of eighteen (18) years. (b) The nursing facility provider must submit a completed DCF #2506 Form (Client Discharge/Change Notice) to DCF within ten (10) business days of the discharge from a nursing facility of an enrollee under the age of eighteen (18) years. Providers must maintain medical records for at least ten (10) years from the close of the Agency Contract and retained further if the records are under review or audit until the audit or review is complete. Prior approval for the disposition of records must be requested and approved by Prestige if the provider contract is continuous. Providers are required to adhere to the requirements of 42 CFR Part 431, Subpart F, in safeguarding the confidentiality of member medical records. Ensure compliance with the privacy and security provisions of the Health Insurance Portability and Accountability Act (HIPAA). Ensure the confidentiality of medical/case records in accordance with 42 CFR, Part 431, Subpart F. A member or authorized representative shall sign and date a release form before any clinical or case records can be released to another party. Clinical/Case record release shall occur consistent with state and federal law. Providers are also required to comply with the privacy and security provisions of HIPAA; and are further required to maintain the confidentiality of a minor s consultation, examination and treatment for a sexually-transmitted disease, in accordance with s (2) F.S. Page 33

36 Provider Communications Compliance Providers must comply with the following requirements: Providers may display health-plan specific materials in their offices. Providers may not orally or in writing compare benefits or provider networks among health plans, other than to confirm whether they participate in a health plan s network. Providers may announce a new affiliation with a health plan and give their patients a list of health plans with which they contract. Providers may co-sponsor events, such as health fairs, and advertise with Prestige, such as television, radio, posters, flyers and print advertisement, only after approval from the Agency. Providers are not permitted to furnish lists of their Medicaid patients to Prestige or any other Medicaid health plan with which they contract, or any other entity, nor can providers furnish other health plan s membership lists to Prestige, nor can providers assist with Prestige enrollment. Providers may distribute information about non-health-plan-specific health care services and the provision of health, welfare and social services by the State of Florida or local communities as long as any inquiries from prospective members are referred to the member services section of the Plan or the Agency s choice counselor/enrollment broker. Provider Marketing Activities Prestige will ensure, through continuing provider education, outreach and monitoring that its providers are aware of and comply with the following guidelines: Providers are permitted to make available Prestige marketing materials as long as the provider and/or the facility distributes or makes available marketing materials for all Managed Care Plans with which the provider participates. If a provider agrees to make available and/or distribute Managed Care Plan marketing materials, it should do so knowing it must accept future requests from other Managed Care Plans with which it participates. AHCA, however, does not require providers to proactively contact all Plans. Providers may display posters or other materials in common areas such as waiting rooms. Long-term care facilities are permitted to provide materials in admission packets announcing all Managed Care Plan contractual relationships. A provider may assist a recipient in an objective assessment of his/her needs and potential options to meet those needs. Providers may engage in discussions with recipients should a recipient seek advice. However, providers must remain neutral when assisting with enrollment decisions. Providers are prohibited from the following, and may not: Offer marketing and/or appointment forms. Make phone calls or direct, urge or attempt to persuade potential enrollees to enroll in Prestige based on financial or any other interests of the provider. Mail marketing materials on behalf of Prestige. Offer anything of value to induce potential enrollees to select them as their provider. Page 34

37 Offer inducements to persuade potential enrollees to enroll in Prestige. Conduct health screenings as a marketing activity. Receive direct or indirect compensation from Prestige or another plan, for marketing activities. Distribute marketing materials within an exam room setting. Furnish Prestige with lists of their Medicaid patients, or the membership of any Managed Care Plan. Provider may: Provide the names of the Managed Care Plans with which they participate. Make available and/or distribute Prestige marketing materials outside of an exam room. Refer their patients to other sources of information, such as Prestige, the enrollment broker, or the local Medicaid Area Office. Share information with patients from the Agency s website or the CMS website. Provider Contract Terminations Prestige Provider Agreements specify provider contract termination requirements in compliance with Agency requirements. Provider terminations are categorized as follows: Provider Initiated. Plan Initiated For Cause. Plan Initiated Without Cause. Mutual. Aside from those requirements identified in the Provider Agreement, Prestige will comply with the following guidelines, based on category of termination. Provider-Initiated Termination The Provider must provide ninety (90) days written notification, unless otherwise agreed, to Prestige of intent to terminate from the Prestige network by certified mail, hand delivered or faxed letter with authorized signature. If the provider is a PCP, Prestige will send a written notification to the Bureau of Medicaid Plan Management Operations (the Agency) and affected members who have chosen the provider as their PCP no less than fifteen (15) calendar days after receipt of the termination notice. For other provider types, Prestige will send written notification to the Agency. If a Prestige member has a prior authorized, on-going course of treatment with a provider who becomes unavailable to continue to provide services, (such as resulting from contract termination), Prestige will notify the member in writing within ten (10) calendar days from the date Prestige becomes aware of the unavailability. Unless otherwise agreed to by Prestige, the effective date of the termination will be on the last day of the month. Prestige Initiated For Cause Termination Prestige may initiate termination when the provider fails to abide by the material terms and conditions of the Agreement, when the provider fails to come into compliance with the Agreement within fifteen (15) Page 35

38 calendar days after receipt of notice from Prestige specifying such failure and requesting the provider abide by the terms and conditions thereof, or at the sole discretion of the Agency. Prestige will: Send applicable termination letters by certified mail or by other means as noted in the Network Provider Agreement. Notify provider, the Agency and Medicaid Program Integrity (MPI) immediately in cases where a Prestige Plan member s health is subject to imminent danger or a provider's ability to practice medicine is effectively impaired by an action by the Board of Medicine or other governmental agency. Provide the Agency with reason(s) for termination for cause. Prestige Initiated Without Cause Termination Prestige may initiate a without cause termination for various reasons (e.g., provider relocation, going out of business). Prestige will: Send applicable termination letters by certified mail or Express Mail Delivery. Notify Prestige Network provider, the Agency and members in active care at least sixty (60) calendar days before the effective date of the termination (when feasible.). Offer coordination of care to transition members to new providers. Mutually-Agreed Upon Terminations Prestige and a provider may mutually agree to terminate their contractual relationship, whereby the effective date of termination is agreed upon by both parties. The termination date may be other than the required days notice specific to the Prestige Network s Provider Agreement language. All mutually-agreed upon termination letters require signatures by both parties. The mutually-agreed upon termination date should provide a minimum number of required days in order to provide notice to members. A mutually-agreed upon termination date should not be a retroactive date. Prestige will notify the Agency and members in active care at least sixty (60) calendar days before the effective date of the termination. Continuity of Care (COC) Unless the provider has been terminated for cause, Prestige members who are in active treatment will be allowed to continue care with a terminated treating provider: Through completion of treatment for a condition for which the member was receiving care at the time of the termination. Until the member changes to a new provider. For MMA services, continuation shall be provided for a minimum of sixty (60) days after the termination of the provider s contract for the provision of services. None of the above may exceed six (6) months after the termination of the provider's contract. Page 36

39 Prestige will allow pregnant members who have initiated a course of prenatal care, regardless of the trimester in which care was initiated, to continue care with a terminated treating provider until completion of postpartum care. Notwithstanding the provisions in this section, a terminated provider may refuse to continue to provide care to a member who is abusive or noncompliant. For continued care, Prestige and the terminated provider will continue to abide by the same terms and conditions as outlined in the Network Provider Agreement and in the Quality section of this publication. Prestige will honor any written documentation of prior authorization of ongoing covered services during the continuity of care period. Providers should complete the Continuity of Care (COC) form and submit it along with this written documentation, to ensure proper claims payment. The form can be found at For members new to Prestige, the continuity of care period is defined as a period of sixty (60) days after the effective date of enrollment, or until the enrollee's PCP or behavioral health provider (as applicable to medical care or behavioral health care services, respectively) reviews the enrollee's treatment plan, whichever comes first. During this period, Prestige will cover any ongoing course of treatment (services that were previously authorized or prescheduled prior to the enrollee s enrollment in the plan) with the recipient s provider, even if that provider is not enrolled in the Prestige network. In addition, the following services may be covered beyond the initial sixty (60) day continuity of care period: Prenatal and postpartum care. Transplant services (through the first year post-transplant). Radiation and/or chemotherapy services (for the current round of treatment). Full course of therapy Hepatitis C treatment drugs. The COC form should be submitted along with any prior written documentation to ensure proper claims payment. Please contact Provider Services concerning the approval process at Closing of a Provider Panel When requesting closure of a panel to new and/or transferring Prestige members, providers must: Submit the request in writing at least sixty (60) days (or such other period of time provided in the Agreement) prior to the effective date of closing the panel; Maintain the panel to all Prestige members who were provided services before the closing of the panel; Provide documented evidence that the provider has closed or is requesting to close the panel of all Medicaid plans the provider is contracted with, for the same period of time. Page 37

40 Provider-Initiated Request to Terminate a Member A Prestige provider shall not seek or request to terminate his/her relationship with a member, or transfer a member to another provider of care, based upon the member s race, national origin, religion, medical condition, amount or variety of care required, or source of payment, in accordance with F. S (4)(d)(1). A health care provider may terminate a patient relationship at any time; however, the provider may not abandon a patient. Reasonable efforts should always be made to establish a satisfactory provider and member relationship in accordance with practice standards. The provider should have three (3) documented attempts in the member s medical record to support his/her efforts to develop and maintain a satisfactory provider and member relationship. If a satisfactory relationship cannot be established or maintained due to member noncompliance, abuse, violence, or the threatened violence, the provider shall continue to provide medical care for the Prestige member until such time that verbal or written notice is received by the member. The Florida Board of Medicine, Florida Medical Association, and American Medical Association s Council on Ethical and Judicial Affairs recommends providers remain available to the patient for at least 30 days to provide emergency services, referrals, prescriptions, and assistance in locating another practitioner for the patient to ensure the continuation of care. (F. S ) Assistance may include referring the member to the Plan to locate an in-network provider. Provider Services Prestige operates a toll-free phone line to respond to your questions, comments and inquiries. Provider services representatives strive to respond to your inquiries thoroughly and in a timely manner. If our representative is unable to resolve your concern and you do not agree with a decision, please follow the provider complaint process below. Provider Complaint Process Prestige maintains a provider complaint system that allows the provider to dispute the Plan s policies, procedures, or any aspect of the Plan s administrative functions, including proposed actions, claims, billing disputes, and service authorizations. Complaints are reviewed and resolved by the Provider Complaint department. The below process outlines the Provider Complaint System for Prestige Health Choice. Note: If specific contract wording differs from the guidelines below, the contract takes precedent. Claim Underpayments, Claim Denials, and Administrative Complaints Please complete the Provider Complaint Form, located at and submit to Provider Complaints via one of the following methods: Page 38

41 Prestige Health Choice Attn: Provider Complaints Department Mail: PO Box 7366 London, KY Fax: If you have already submitted a provider complaint, you may call us for a status update at Providers may also contact the Provider Complaints department to request an in-person meeting. Provider complaints should include supporting documentation which includes but is not limited to, fee schedules, copy of contract, payment calculations, proof of timely filing, etc. In order to be considered for review, all complaints must be received within 120 days of the Remittance Advice (or 120 days from the incident for Administrative Complaints). Complaints will be reviewed and resolved within 60 days from the date of receipt. In order to protect our members, please be sure to use secure encryption when transmitting complaints containing member PHI and PII via , and clearly indicate such in the subject line; and use an appropriate cover sheet for complaints that are submitted via fax. To request authorization for service, or for reconsiderations of denied authorizations, please refer to the UM Section (Section IV) of this manual. Provider Communications Providers will receive, or have access to, regular communications from Prestige including, but not limited to: policies, procedures and guidelines, operations, roles and responsibilities and education opportunities. Communications will be available either in hard copy format and/or electronically and include, but are not limited to the following: Provider manual. Provider newsletters. Website postings. Provider bulletins. Surveys. Forms. Faxes. s. Miscellaneous printed materials. Page 39

42 SECTION III MEMBER BENEFITS Page 40

43 III. Member Benefits Prestige covered benefits are listed below. Covered benefits, as well as authorization requirements, are also found on our website at Prestige covered benefits will never be less than the benefits outlined in the Florida Medicaid Coverage and Limitations Handbooks and the Provider Reimbursement Handbooks. Covered Benefits All Services and Procedures rendered by a Non-Par Provider Require a Prior Authorization. Ambulatory Surgical Center Services Assistive Care Services Behavioral Health Services Birth Center and Licensed Midwife Services Child Health Check-up Chiropractic Services Clinic Services Rural Health Centers (RHC) - Adult Health Screenings, Child Health Check-Up Screenings, Chiropractic Services, Family Planning Services, Family Planning Waiver Services, Immunizations Services, Medical Primary Care Services, Mental Health Services, Optometric Services, and Podiatry. County Health Department Services (CHD) Primary and Preventative Health Care, related diagnostic Services and Dental Services. Federally Qualified Health Centers (FQHC) - Adult Health Screenings, Child Health Check-Up, Chiropractic Services, Dental Services, Family Planning Services, Medical Primary Care, Mental Health Services, Optometric Services and Podiatric Services. Dental Services Emergency Services Emergency Behavioral Health Services Family Planning Services and Supplies Healthy Start Services Hearing Services Home Health Services and Nursing Care Hospice Services Hospital Services, including medically necessary transplants and related services Immunizations Laboratory Imaging Services - Radiology - Advanced (CT Scan, MRI, MRA, PET Scan) Durable Medical Equipment (DME), Medical Supplies, Prostheses and Orthoses Nursing Facility Services (under 18 years of age) Optometric and Vision Services Provider Services, Physician Assistant Services, and Advanced Registered Nurse Practitioner Services Podiatry Services Prescribed Drugs Services Renal Dialysis Services Page 41

44 Therapy Services Occupational (under the age of 21). Occupational (age 21 and older). Physical (under the age of 21). Physical (age 21 and older). Speech (under the age of 21). Speech (age 21and older). Transportation Services Prestige Health Choice Prestige must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if Prestige does not cover a service or the service has a limit. As long as the services are medically necessary, services have: No dollar limits; or No time limits, like hourly or daily limits. Prestige Expanded Benefits Expanded Benefits are Agency approved services that are additional benefits specified in the AHCA Contract. These expanded benefits may be subject to medical necessity and prior authorization. The following expanded benefits are available to Prestige members: Approved Expanded Benefit Coverage and Limitations Managed Medical Assistance (MMA) Approved Benefit Approved Limitations Authorization Requirements Primary Care Visits (Non-Pregnant Adults) Unlimited visits. No prior authorization is required. Home Health Care Two (2) visits per day; subject to medical necessity Prior authorization is required. (Non-Pregnant Adults) and prior authorization. Provider Home Visits Unlimited visits; limited to homebound enrollees; must be provided by a participating provider; subject to medical necessity and prior authorization. Prior authorization is required. Prenatal/Perinatal Visits Outpatient Services Unlimited visits; must be provided by a participating provider; subject to medical necessity and prior authorization. One (1) outpatient physical therapy exam for each unique acute condition per year; One (1) outpatient speech therapy exam for each unique acute condition per year; Maximum of twelve (12) outpatient physical therapy visits for each unique acute condition per year; Maximum of twelve (12) outpatient speech therapy visits for each unique acute condition per year; One (1) in-home physical therapy exam per year; Maximum four (4) in-home physical therapy visits per year; subject to medical necessity and prior authorization. Prior authorization is required. Prior authorization is required. Page 42

45 Approved Expanded Benefit Coverage and Limitations Managed Medical Assistance (MMA) Approved Benefit Approved Limitations Authorization Requirements Over-The-Counter (OTC) Medication/Supplies Adult Dental Services Waived Copayments Vision Services Hearing Services Newborn Circumcision Maximum fifty dollars ($50) per year, per household; enrollee purchases limited to an approved list of products. Two (2) comprehensive exams per year; One (1) x-ray every two (2) years; Two (2) cleanings per year; Four (4) simple extractions per year; Two (2) surgical extractions per year; Three (3) amalgam fillings per year; Subject to medical necessity and prior authorization. Enrollees shall not be subject to co-payment charges; services must be provided by a participating provider, subject to medical necessity. One (1) set of glasses per year; subject to medical necessity. One (1) hearing aid every two (2) years; subject to medical necessity. Available upon request during initial hospital stay and in the provider s office for ninety (90) days after birth. No prior authorization is required, purchases are limited to an approved list of products. Prior authorization is required, contact dental provider at Prior authorization is required, contact vision provider at Prior authorization is required, contact hearing vendor at No prior authorization is required. Adult Pneumonia Vaccine Adult Influenza Vaccine Adult Shingles Vaccine Nutritional Counseling Medically Related Lodging and Food Administered as medically advised. Administered as medically advised. Administered as medically advised. Unlimited visits; subject to medical necessity; prior authorization required after three (3) visits. One-thousand dollars ($1,000) per enrollee per year; benefit only available if traveling more than one hundred (100) miles from the enrollee s home for medically necessary treatment; enrollee must receive treatment from a participating provider in Florida; benefit cannot be used to purchase alcohol; subject to prior authorization. No prior authorization is required. No prior authorization is required. No prior authorization is required. Prior authorization is required. Prior authorization is required. Non-Covered Services Prestige will provide services which are identified as a covered service, in accordance with the AHCA Contract, Coverage and Limitations Handbooks and/or Provider General Handbook, and the Medicaid Fee Schedules. Prestige has processes in place for the authorization of any medically necessary service to enrollees under the age of twenty-one (21), in accordance with Section 1905(a) of the Social Security Act, when Page 43

46 (1) The service is not listed in the service-specific Medicaid Coverage and Limitations Handbook or fee schedule, or is not a covered service of the plan; or (2) The amount, frequency, or duration of the service exceeds the limitations specified in the servicespecific handbook or the corresponding fee schedule. A provider must inform the recipient of their responsibility for the payment of any services received that are not covered by Medicaid. The provider must discuss this with the member prior to rendering the service and include documentation of this conversation in the member s medical record. Emergency Services Prestige is available for emergency services and care inquiries twenty-four hours a day, seven days a week (24/7) for members and caregivers. You may contact our 24-Hour Nurse Call Line at Prestige does not deny claims for emergency services and care received at a hospital due to lack of parental consent. In addition, Prestige does not deny payment for treatment obtained when a representative of Prestige instructs the member to seek emergency services and care in accordance with s , F.S. Prestige provides emergency services and care without any specified dollar limitations. Emergency services and care under Prestige will not: Require prior authorization for a member to receive pre-hospital transport or treatment for emergency services or care. Specify or imply that emergency services and care are covered by Prestige only if secured within a certain period of time. Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered. Deny payment based on a failure by the member or the hospital to notify Prestige before, or within a certain period of time after, emergency services and care were given. Prestige covers pre-hospital and hospital-based trauma services and emergency services and care to members. When a member presents at a hospital seeking emergency services and care, the determination that an emergency medical condition exists is to be made, for the purposes of treatment, by a provider of the hospital or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a hospital provider. The provider or the appropriate personnel must indicate on the member's chart the results of all screenings, examinations and evaluations. Prestige covers all screenings, evaluations and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member's condition is an emergency medical condition. If the provider determines that an emergency medical condition does not exist, Prestige is not required to cover services rendered subsequent to the provider's determination unless authorized by the Plan. Page 44

47 If the provider determines that an emergency medical condition exists, and the member notifies the hospital, or the hospital emergency personnel otherwise have knowledge that the patient is a member of the Plan, the hospital must make a reasonable attempt to notify: The member's PCP, if known; or Prestige, if the Plan has previously requested in writing that it be notified directly of the existence of the emergency medical condition. If the hospital, or any of its affiliated providers, do not know the member's PCP, or have been unable to contact the PCP, the hospital must: Notify Prestige as soon as possible before discharging the member from the emergency care area; or Notify Prestige within twenty-four (24) hours or on the next business day after the member s inpatient admission. Prestige will cover any medically necessary duration of stay in a non-contracted facility which results from a medical emergency until such time as Prestige can arrange to safely transport the member to a participating facility. Prestige may transfer the member, in accordance with state and federal law, to a participating hospital that has the service capability to treat the member's emergency medical condition. Notwithstanding any other state law, a hospital may request and collect from a member any insurance or financial information necessary to determine if the patient is a member of Prestige, in accordance with federal law, so long as emergency services and care are not delayed by the process. Page 45

48 SECTION IV UTILIZATION MANAGEMENT Page 46

49 IV. Utilization Management Utilization Management activities are designed to assist our providers with the organization and delivery of appropriate health care services to members within the structure of the member benefit plan. Under their participating provider agreements with Prestige, providers are required to comply fully with medical management programs administered by Prestige and its agents, including: Obtaining authorizations and/or providing notifications, depending upon the requested service. Providing clinical information to support medical necessity when requested. Permitting access to the member's medical information. Including Prestige s medical management nurse in discharge planning discussions and meetings. Providing a plan of treatment, progress notes and other clinical documentation as required. Prior Authorization Department Prior authorization is processed through Prestige s Prior Authorization Department. The most up-to-date listing of services requiring prior authorization or notification will be maintained on the Prestige website at You may also request a listing by contacting Provider Services at Providers may request prior authorization by sending a fax request for authorization to or online via our secure provider portal at Prior authorization is not a guarantee of payment for the service authorized. Prestige Health Choice reserves the right to adjust any payment made following a review of the medical record and determination of the medical necessity of the services provided. Concurrent Review and Discharge Planning If medical necessity is established, an authorization will be issued to the facility for the days where medical necessity is met. In order to expedite our review, clinical information must be received with the request for authorization. Please note that a finding of lack of medical necessity for the inpatient stay or any part thereof will result in claims denials for both the facility and admitting provider. The admitting provider is further responsible for assistance with discharge planning to the next level of care for the member. Prior Authorization Specific to Pregnancy-Related Services Pregnancy Notification Form All OB care requires a Pregnancy Notification Form in order for proper and expedient payment to be made to OB providers. Once approved, this authorization includes three (3) OB ultrasounds, all regularly scheduled pre-natal visits, and four (4) post-delivery follow up appointments. In addition, for high risk pregnancies, unlimited ultrasounds are allowed if provided by network Maternal/Fetal Medicine specialists. For the member, this authorization initiates Prestige Care Management follow up from a team who works closely with pregnant members. Page 47

50 The Pregnancy Notification Form is located at and can be faxed to the Prestige Bright Start Department at or submitted on-line via the secure provider portal at Services Requiring Prior Authorization or Notification Prior authorization is required for select elective or non-emergency services as designated by Prestige. Certain services may also require notification even if authorization is not required. Guidelines for prior authorization and/or notification requirements by service type may be found in the Prior Authorization Reference Guide at under Provider resources. Prior authorization allows for efficient use of coordinated services and ensures that members receive the most appropriate level of care, within the most appropriate place of service. Prior authorization may be obtained by the member s PCP, treating specialist or facility. Reasons for requiring prior authorization may include: Review for medical necessity; Ensure services are coordinated with appropriate provider; Appropriateness of place of service; and/or Case and disease management considerations. Some prior authorization guidelines to note are: The prior authorization request should include the diagnosis to be treated and the CPT and HCPCS code describing the anticipated procedure or service. If the procedure performed and billed is different from that on the request, but within the same family of services, a revised authorization is not typically required. If an adjustment is needed following delivery of the service, please contact Utilization Management on the next business day at An authorization may be given for a series of visits or services related to an episode of care. The authorization request should outline the plan of care including the frequency and total number of visits requested and the expected duration of care. Emergency room admission and related services do not require prior authorization. Exceptions to Prior Authorization For a list of services that do not require prior authorization review, please refer to the provider benefit grid at under Provider Resources. Standard Authorization Decisions Prestige will notify the provider and give the member written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. Page 48

51 For standard authorization decisions, Prestige will: Provide notice as expeditiously as the member s health condition requires. Provide notice within no more than seven (7) calendar days following receipt of the request for service. The time frame can be extended up to seven (7) additional calendar days if: The provider or the member requests an extension; or Prestige justifies the need for additional information and how the extension is in the member s interest. Expedited Authorization Decisions Prestige will expedite authorization decisions when a provider indicates, or Prestige determines, that following the standard timeline could seriously jeopardize the member s life, health or ability to attain, maintain, or regain maximum function. Requests that do not meet this definition or that are incomplete will be moved to the standard authorization process and worked under the timeframes outlined above. An expedited decision must be made no later than forty-eight (48) hours after receipt of the request for service. Prestige may extend this time by an additional two (2) business days for expedited requests, if the member requests an extension or if Prestige justifies the need for additional information and how the extension is in the member s interest. Urgent Concurrent Review Decisions Concurrent review determinations will be made within 24 hours of receipt of a request for authorization with clinical information. Authorization Request Forms Prestige Health Choice requests providers use our standardized request forms to ensure receipt of all pertinent information and to enable a timely response to your request, including: DME Prior Authorization Request Form. Home Care Services Prior Authorization Request Form. Hospital Discharge Prior Authorization Form. Continuity of Care (COC) Form. Pharmacy Prior Authorization Form. Prenatal Notification Form. Authorization Request Form (to be used for any request not specifically covered by the forms above). Page 49

52 To ensure timely and appropriate claims payments, forms must: Have all required fields completed and coded properly. Be typed or printed in black ink for ease of review. Contain a clinical summary or have the supporting clinical information attached. Incomplete forms are not processed and will be returned to the requesting provider. If prior authorization is not granted, all associated claims will not be paid. Providers must immediately notify Prestige of a member s pregnancy. A Prenatal Notification Form should be completed by the OB/GYN or Primary Care provider during the first visit and faxed to Prestige as soon as possible after the initial visit. Notification of OB services enables Prestige to identify members for inclusion into the Healthy Behaviors Prenatal Program and for reporting pregnancies to DCF. All Prior Authorization forms, as well as the benefit grid, are located on the Prestige website, under Provider Resources. All forms should be submitted via fax to the number listed on the form. Providers may also request authorization, attach clinical information, and review the status of an existing authorization request by utilizing our secure portal at How to get in touch with UM Providers can reach the Utilization Management department by calling during normal business hours Monday through Friday from 8:30am to 6:00pm (Eastern). After hours staff is available to assist with urgent or discharge needs at the same number after 6pm, on holidays, or weekends. If a Prestige associate needs to reach out to a provider for information on a request, they will identify themselves by name, title, and plan they are calling from. Members needing assistance with UM issues are referred to Member Services at (TTY/TDD ). Interpretation services are also available through Member Services, as needed. Medical Necessity Standards Medically Necessary or Medical Necessity is defined as meeting the following conditions: Be necessary to protect life, to prevent significant illness or significant disability or to alleviate severe pain. Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under treatment and not in excess of the patient's needs. Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not be experimental or investigational. Be reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide. Page 50

53 Be furnished in a manner not primarily intended for the convenience of the member, the member's caretaker or the provider. For those services furnished in a hospital on an inpatient basis, medical necessity means that appropriate medical care cannot be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. The fact that a provider has prescribed, recommended or approved medical or allied goods or services does not, in itself, make such care, goods or services medically necessary, a medical necessity or a covered service/benefit. Prestige uses the following screening tools for Utilization Management (UM) determinations related to Medical Necessity: McKesson InterQual Adult Criteria (Condition Specific- Responder, Partial Responder, Nonresponder). McKesson InterQual Pediatric Criteria (Condition Specific- Responder, Partial Responder, Nonresponder). McKesson InterQual Outpatient Rehabilitation and Chiropractic Criteria. McKesson InterQual Home Care Criteria. McKesson InterQual Procedures Criteria. McKesson InterQual DME Criteria. McKesson InterQual Imaging Criteria. McKesson InterQual Long-Term Acute Care (LTAC) Criteria. McKesson InterQual Rehabilitation (Acute Rehab) Criteria. McKesson InterQual Subacute/SNF Criteria. American Society of Addiction Medicine (ASAM) Patient Placement Criteria. When applying UM Medical Necessity criteria, UM staff also considers the individual member factors and the characteristics of the local health delivery system, including: Member Considerations. o Age, comorbidities, complications, progress of treatment, psychosocial situation, and home environment. Local Delivery System. o Availability of sub-acute care facilities or home care in the Prestige service area for post discharge support. o Prestige benefits for sub-acute care facilities or home care where needed. o Ability of local hospitals to provide all recommended services within the estimated length of stay. The Prestige Medical Director will review service authorizations and confirm medical necessity based on the Agency s definition of medical necessity. Additional guidelines used in the review include, but are not Page 51

54 limited to, Prestige Clinical Policies, Medicare LCD and NCD Guidelines, and other nationally accepted and approved medical guidelines. Providers can request a copy of the UM criteria used in any determination by contacting the UM Department at The decision to deny, limit the amount, scope and/or duration of a service will be made by the Prestige Medical Director, or other designated practitioner under the clinical oversight of the Chief Medical Officer. At the discretion of the Prestige Medical Director, participating board-certified providers from an appropriate specialty, other qualified healthcare professionals, or the requesting practitioner/provider may offer input on a decision. The Prestige Medical Director makes the final decision. Prestige will not arbitrarily deny or reduce the amount, duration, or scope of required services solely because of the diagnosis, type of illness, or condition of the member. Prestige does not reward health care providers for denying, limiting, or delaying benefits or health care services, give incentives to staff or providers for making decisions about medically necessary services, or give rewards to provide less health care coverage and services. Prestige Health Choice has processes in place for the authorization of any medically necessary service to enrollees under the age of twenty-one (21), in accordance with Section 1905(a) of the Social Security Act, when: (1) The service is not listed in the service-specific Medicaid Coverage and Limitations Handbook or fee schedule, or is not a covered service of the plan; or (2) The amount, frequency, or duration of the service exceeds the limitations specified in the servicespecific handbook or the corresponding fee schedule. For Authorization Request Denials Based on Lack of Medical Necessity (where a Notice of Adverse Benefit Determination letter is mailed to the provider and member) If you receive an authorization request denial from Prestige, you have forty-five (45) calendar days from the date of the Notice of Adverse Benefit Determination (NABD) to request reconsideration as follows: Contact Prestige Utilization Management at and request reconsideration. Fax a request for reconsideration along with additional clinical information to Please include the reference number from the NABD letter on your fax cover sheet. During the reconsideration process, the provider may request a peer-to-peer discussion by contacting Prestige Utilization Management at Be prepared to provide a convenient time to receive a call from the Prestige Medical Director. Page 52

55 1. If our decision is to overturn the original denial, Prestige Utilization Management will notify of the approval and provide an authorization number. You should expect a response within fourteen (14) calendar days from the date we receive your reconsideration request. 2. If our decision is to uphold the original denial, Prestige Utilization Management will notify of the upheld denial. You should expect a response within fourteen (14) calendar days from the date we receive your reconsideration request. If you still disagree with our decision, you have the right to file an appeal on the member s behalf. The appeal will require the member s signature (for hospital claims we will accept the member s signature on the hospital admission consent forms). You may file the appeal on the member s behalf within thirty (30) days of notification of the upheld denial decision. Individuals with Special Health Care Needs Individuals with special health care needs are adults and children/adolescents who face physical, mental or environmental challenges daily that place at risk their health and ability to fully function in society. Factors include: (a) individuals with mental retardation or related conditions; (b) individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders; (c) individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; and (d) children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to placement in foster care. In order to support our members with chronic, complex care needs, Prestige has implemented special processes within Medical Management. If your members have these needs, please contact the UM or CM department for additional assistance. For the UM Department, call , Monday through Friday, 8:30 a.m. to 6:00 p.m., and for the Complex Care and Disease Management Programs contact Rapid Response at , Monday through Friday, 8:00 a.m. to 6:30 p.m. Second Medical Opinion A second medical opinion may be requested in any situation where there is a question related to surgical procedures and diagnosis and treatment of complex and/or chronic conditions. A second opinion may be requested by any member of the health care team, a member, parent(s) and/or guardian(s) or a social worker exercising a custodial responsibility. The second opinion must be provided at no cost to the member by a qualified health care professional within network, or a non-participating provider if there is not a participating provider with the expertise required for the condition. In accordance with Florida Statute , the member may elect to have a second opinion provided by a non-contracted provider located in the same geographical service area of Prestige. Prestige may require that any tests deemed necessary by a non-contracted provider be conducted by a participating Prestige provider. Prestige s provider s professional judgment concerning the treatment of a subscriber derived after review of a second opinion shall be controlling as to the treatment obligations of the health maintenance organization. Page 53

56 SECTION V CASE MANAGEMENT Page 54

57 V. Case Management Integrated Health Care Management (IHCM) There are five core components to our IHCM program: Complex Care Management (CCM), Chronic Condition Management, Bright Start (Maternity Management), and Rapid Response (RROT) and Child Health Check-Up (CHCUP)/Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). The scope of Prestige s program incorporates specific goals which are supported by Case Management Society of America as well as nationally approved accrediting body standards and they are as follows: Minimize fragmentation of health care. Use of evidence-based guidelines as practice. Appropriately navigate transitions of care. Incorporate adherence guidelines and other standard practice tools. Expand the interdisciplinary team in planning care; the medical home is primary. Improve member safety. The Prestige IHCM program integrates physical health, behavioral health and social/environmental aspects of the member s care into one plan of care. Health plan employees include nurses and social workers with backgrounds and expertise in behavioral health, physical health and social services in the community. Complex Care Management (CCM) Program The IHCM Program coordinates services for new adult and pediatric members of the plan and existing members with short-term and/or intermittent needs who have single problem issues and/or co-morbidities. Members identified with Complex Needs receive comprehensive and disease-specific assessments and reassessments, along with the development of goals and an individual plan of care, created with input from the member/caregiver and the physician. The IHCM process includes reassessing and adjusting the care plan and its goals as needed. Care Connectors are assigned tasks to assist the member with various interventions under the direct supervision of the Care Manager. The Care Manager supports members in the resolution of pharmacy, DME and/or dental access issues, transportation needs, identification of and access to specialists, or referral and coordination with behavioral health providers or other community resources. The IHCM team consists of both RN and MSW Care Managers. IHCM employees provide support for regulatory and contractual requirements by serving as a contact for AHCA employees, members and providers. Complex Care Management Services available to members are: Clinical assessments and development of a self-management plan. Medication reconciliation and resolution of pharmacy issues. Assistance with DME, home care services, home infusion, health supplies. Dental access issues. Assistance with transportation needs. Care Coordination with access to specialists, or referrals. Coordination with behavioral health providers or other community resources. Page 55

58 Chronic Condition Management/Disease Management Prestige Health Choice s Chronic Condition/Disease Management programs are integrated with each of the IHCM components. Chronic Condition Management programs and/or Chronic Disease Blueprints exist for: Asthma. Diabetes. Heart disease including hypertension. COPD. Members identified with Complex Needs receive comprehensive and disease-specific assessments and reassessments, along with the development of goals and an individual plan of care, created with input from the member/caregiver and the provider. The goals of the IHCM Program are: To fully engage and actively case manage targeted members in the IHCM Program. To integrate clinical guidelines into the management of high risk members with Asthma, Diabetes, Heart Disease including Hypertension, and COPD. To facilitate member education and awareness through multidisciplinary initiatives. To improve member access to PCP, Specialists and other medically necessary services through collaboration with providers. To improve compliance with clinical guidelines. To assure timely access to the appropriate level of care based on member acuity level. To improve clinical outcomes and increase the quality of life for our members. To improve HEDIS rates for targeted measures. To reduce hospital admissions/1000 members. To reduce inappropriate emergency room visits. To empower the member to accept responsibility for their ongoing health care needs including: self- managed and informed medical decision making. To improve collaborative efforts between Physical Health and Behavioral Health needs. To identify and implement programs that address health care disparities. The IHCM Program is designed to support the patient centered medical home model by improving member and provider engagement, care transitions from the specialist office and hospital, and their overall care within the member s medical home. For more information or to refer a member for Complex Care and Disease Management Programs contact Rapid Response at , Monday through Friday, 8:00 a.m. to 6:30 p.m. Bright Start (Maternity Management) Prestige will provide the most appropriate and highest level of quality care for pregnant members. The Prestige Bright Start Maternity Program is designed to assist pregnant mothers to adopt healthy Page 56

59 behaviors, control risk factors, and educate on infant care and health needs. The Bright Start Program consists of care managers, nurses and care connectors with expertise in the area of maternal management. Bright Start provides nursing review and counseling, nutrition review, prenatal (pre-birth), delivery, postpartum (after birth) services and nursery care services in the hospital. Bright Start combines scheduled written and telephonic outreach with state-of-the art informatics that provides point-of-contact notification of health needs to members. Bright Start uses provider and community programs, partnerships and creative outreach strategies to facilitate member access to required services. For more information or to refer a member, contact Bright Start at Monday through Friday, 8:30 a.m. to 6:00 p.m. Processes required for administering care include: Participating providers must contact Prestige immediately after it is determined that a member is pregnant. Complete the Prestige Pregnancy Notification Form and fax it to the Bright Start Maternity Management Program. Faxing this form will serve as notification to the Prestige Bright Start Maternity Management Program of the pregnancy and authorization for services. Notifications may be faxed to o Providers must offer Florida's Healthy Start prenatal risk screening to each pregnant member as part of her first prenatal visit. o Providers must use the Department of Health (DOH) -approved Healthy Start (Prenatal) Risk Screening Instrument available from the local County Health Department (CHD). o Providers must keep a copy of the completed screening instrument in the member s medical record and provide a copy to the member. o Providers must submit the completed DH Form 3134 to the CHD in the county where the prenatal screen was completed within ten (10) business days of completion. o Prestige will collaborate with the Healthy Start Care Coordinator within the member s county of residence to assure delivery of risk-appropriate care. Prior Authorization All OB care requires a Pregnancy Notification Form in order for proper and expedient payment to be made to OB providers. For full details, please see prior authorization in the Utilization Management section of this manual. Prenatal Care Require a pregnancy test and a nursing assessment with referrals to a physician, PA or ARNP for comprehensive evaluation. Require case management through the gestational period according to the needs of the members. Require any necessary referrals and follow-up. Schedule return prenatal visits at least every four (4) weeks until week thirty-two (32), every two (2) weeks until week thirty-six (36), and every week thereafter until delivery, unless the member s condition requires more frequent visits. Contact members who fail to keep their prenatal appointments as soon as possible, and arrange for their continued prenatal care. Assist members in making delivery arrangements, if necessary. Page 57

60 Providers must screen all pregnant members for tobacco use and ensure availability of smoking cessation counseling and appropriate treatment as needed. Providers supply nutritional assessment and counseling to all pregnant members. Ensure the provision of safe and adequate nutrition for infants by promoting breastfeeding and the use of breast milk substitutes. Offer a mid-level nutrition assessment. Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a nurse or physician following the nutrition assessment. Ensure documentation of the nutrition care plan in the medical record by the person providing counseling. Florida hospitals contracting with Prestige must electronically file the Florida Healthy Start Infant (Postnatal) Risk Screening Instrument (DH Form 3135) and the Certificate of Live Birth with the CHD in the county where the infant was born within five (5) business days of the birth. If the provider is a birthing facility not participating in the DOH electronic birth registration system the provider must file required birth information with the CHD within five (5) business days of the birth, keep a copy of the completed DH Form 3135 in the member's medical record and mail a copy to the member. Pregnant members or infants who do not score high enough to be eligible for Healthy Start care coordination may be referred for services, regardless of their score on the Healthy Start risk screen, in the following ways: o If the referral is to be made at the same time the Healthy Start risk screen is administered, the provider may indicate on the risk screening form that the member or infant is invited to participate based on factors other than score; or o If the determination is made subsequent to risk screening, the provider may refer the member or infant directly to the Healthy Start care coordinator based on assessment of actual or potential factors associated with high risk, such as the human immunodeficiency virus (HIV), hepatitis B, substance use or domestic violence. Providers must refer all infants, children under the age of five (5), and pregnant, breast-feeding and postpartum women to the local office of Women, Infants and Children (WIC). o Provide a completed Florida WIC program medical referral form with the current height or length and weight (taken within sixty (60) calendar days of the WIC appointment); o Hemoglobin or hematocrit; and o Any identified medical/nutritional problems. Each time the provider completes a WIC referral form, a copy must be kept in the member s medical record and given to the member. For subsequent WIC certifications, providers must coordinate with the local WIC office to provide the above referral data from the most recent Child Health Check-Up (CHCUP). Providers must offer all women of childbearing age HIV counseling and testing at the initial prenatal care visit and again at twenty-eight (28) and thirty-two (32) weeks of pregnancy. Providers must attempt to obtain a signed objection if a pregnant woman declines an HIV test. Pregnant women who are infected with HIV are to be counseled about and offered the latest antiretroviral regimen recommended by the U.S. Department of Health & Human Services. Page 58

61 Providers must screen all pregnant members receiving prenatal care for the hepatitis B surface antigen (HBsAg) during the first prenatal visit. o Providers are to perform a second HBsAg test between twenty-eight (28) and thirty-two (32) weeks of pregnancy for all pregnant members who tested negative at the first prenatal visit and are considered high-risk for Hepatitis B infection. This test will be performed at the same time that other routine prenatal screening is ordered. o All HBsAg-positive women will be reported to the local CHD and to Healthy Start, regardless of their Healthy Start screening score. Infants born to HBsAg-positive members should receive hepatitis B immune globulin (HBIG) and the hepatitis B vaccine once they are physiologically stable, preferably within twelve (12) hours of birth, and will complete the hepatitis B vaccine series according to the vaccine schedule established by the Recommended Childhood Immunization Schedule for the United States. o Providers must test infants born to HBsAg-positive members for HBsAg and hepatitis B surface antibodies (anti-hbs) six (6) months after the completion of the vaccine series to monitor the success or failure of the therapy. o Providers must report to the local CHD a positive HBsAg result in any child age twentyfour (24) months or less within twenty-four (24) hours of receipt of the positive test results. o Infants born to members who are HBsAg-positive are to be referred to Healthy Start regardless of their Healthy Start screening score. Providers must report all HBsAg-positive prenatal or post- partum women to the Hepatitis B Prevention Coordinator at the local CHD. This reporting includes the name, date of birth, race, ethnicity, address, infants, contacts, laboratory test performed, date the sample was collected, the due date or estimated date of confinement, whether the member received prenatal care, and the immunization dates for infants and contacts. The provider will use the Practitioner Disease Report Form (DH Form 2136) for such reporting. Providers must maintain documentation of Healthy Start screenings, assessments, findings and referrals in the members medical records. Obstetrical Delivery The provider will use generalized accepted and approved protocols for both low-risk and high-risk deliveries reflecting the highest standards of the medical profession, including Healthy Start and prenatal screening. The provider will document preterm delivery assessments in the member s medical record by week twenty-eight (28). If the provider determines that the member is high-risk the care manager will ensure that the provider s obstetrical care during labor and delivery includes preparation by all attendants for symptomatic evaluation and that the member progresses through the final stages of labor and immediate postpartum. Newborn Care The provider supplies the highest level of care for the newborn beginning immediately after birth. Such level of care should include, but not be limited to, the following: Page 59

62 Installing of prophylactic eye medication into each eye of the newborn; When the mother is Rh negative, securing a cord blood sample for type Rh determination and direct Coombs test; Weighing and measuring of the newborn; Inspecting the newborn for abnormalities and/or complications; Administering one half (.5) milligrams of vitamin k; American Pediatric Gross Assessment Record (APGAR) scoring; Any other necessary and immediate need for the referral in consultation from a specialty provider, such as the Healthy Start (postnatal) infant screen and; Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant Chapter 468, F.S, or an individual who has completed documented training specifically for newborns hearing screenings and who is directly or indirectly supervised by a licensed provider or a licensed audiologist). Postpartum Care The provider shall: Provide a postpartum examination for the member within six (6) weeks after delivery. Ensure that its providers supply family planning, including a discussion of all methods of contraception, as appropriate; and Ensure that continuing care of the newborn is provided through the CHCUP program and documented in the child s medical record. Rapid Response Prestige s Rapid Response Department addresses the immediate and urgent needs of our members. Rapid Response is a call center with dedicated individuals available to serve members in a personalized way. Both members and providers can call for assistance. The Rapid Response Department consists of a team of energetic, multilingual care connectors (nonclinicians) and nurses who coordinate care for members addressing all their immediate needs. The department is responsible for identifying barriers to care, navigating the healthcare system, educating the importance of preventive care services, connecting members with useful community resources and facilitating access to care to meet healthcare needs. Along with care connectors and nurses, the department also consists of EPSDT Care Connectors (Early and Periodic Screening, Diagnostic and Treatment) who are responsible for Child Health Check-Up (CHCUP) outbound campaigns to parents/guardians to educate on the CHCUP services available for their children. Upon receiving a member or provider call, Rapid Response will work diligently with all necessary departments and network providers to address and resolve member needs. Rapid Response services members and providers as follows: Assist members with scheduling PCP and specialist appointments. Page 60

63 Arrange transportation and interpreter services. Complete Health Risk Assessment with member. Identify and refer high risk and special needs members to Integrated Health Care Management. Refer pregnant members to Bright Start. Collaborate with Member Services, Prior Authorization, Provider Operations along with participating providers to coordinate service for members. Coordinate DME and home health care services. Assist members with obtaining medications at the pharmacy. Identify members in need of mental health care and dental services. Identify care gaps (HEDIS /missing preventive services). Refer qualified members to Healthy Behaviors Program. Transition of care follow-up. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) The Rapid Response Department is responsible for the Child Health Check-Up Program (CHCUP) member outreach campaigns targeting children under the age of 21. CHCUP is defined as a set of comprehensive and preventive health examinations provided on a periodic basis to identify and correct medical conditions in children and adolescents. Guidelines are described in the Florida Medicaid Child Health Check-Up Services Coverage and Limitations Handbook. (EPSDT- Early and Periodic Screening Diagnostic and Treatment Program.) Prestige Health Choice will identify children who are missing CHCUP preventive services for the EPSDT Care Connectors to contact their parents/guardians. The CHCUP program consists of educating parents/guardians on the CHCUP services that include comprehensive and preventive health examinations along with other necessary services such as immunizations, dental, vision, hearing, behavioral health, laboratory testing including lead screening and any other CHCUP related services that are important to keep their children healthy and that all of these are free of charge to them. The EPSDT Care Connectors will attempt at least three (3) outreach calls to the parents/guardians. If unsuccessful the parents/guardians will be mailed an Unable to Contact letter. All outreach calls and attempts are documented When the EPSDT Care Connector effectively reaches a member s parent/guardian the following services are offered: Offer to arrange the PCP pediatrician office visit Arrange transportation services if needed Arrange interpreter services if needed Address Care Gaps (any HEDIS preventive services) indicated in our system Offer behavioral health, dental, vision services Educational CHCUP materials can be mailed to the parents/guardians Assistance with any other services needed by the member and/or issues related to pharmacy, etc. Contact Rapid Response at , Monday through Friday, 8:00 a.m. to 6:30 p.m. Page 61

64 SECTION VI MEMBER COMPLAINTS, GRIEVANCES AND APPEALS Page 62

65 VI. Member Complaints, Grievances and Appeals Member Complaints Complaints allow Prestige to resolve a problem without it becoming a formal grievance. If a member has a concern or question regarding care or coverage under Prestige, he/she should contact Member Services at the toll-free number on the back of his/her ID card. A member services representative will answer questions and/or concerns. The representative will try to resolve the problem. If the member services representative does not resolve the problem to the member s satisfaction, he/she has the right to file a grievance. A complaint that is not resolved by close of business the day following its receipt is automatically moved into the Prestige Grievance System. Grievance Process A grievance is an expression of dissatisfaction about any matter other than an adverse benefit determination. Possible subjects for grievances include, but are not limited to, the quality of care, the quality of services provided and aspects of interpersonal relationships such as rudeness of a provider or Managed Care Plan employee, failure to respect an enrollee s rights, or an enrollee dispute of an extension of time proposed by the Managed Care Plan to make an authorization decision. The enrollee can file a grievance orally or by phone at any time. A grievance may be filed about such things as the quality of the care the member receives from Prestige or a provider, rude behavior from a Prestige employee or a provider s employee, a lack of respect for their rights by Prestige or a provider, or anything else with which the member may be dissatisfied. To file a grievance, the member may call Member Services at or TTY/TDD at Hours of operation are twenty-four hours a day, seven days a week (24/7). Or write to: Prestige Health Choice P.O. Box 7368 London, KY If the member needs assistance in completing forms and following the procedure for filing his/her grievance or needs the help of an interpreter, the member may call Member Services at or TTY/TDD at The interpreter services are free of charge to the member. Prestige will send the member an acknowledgement letter within five (5) business days of receiving the grievance. Prestige will send a decision letter within ninety (90) days of receiving the request. In some cases, Prestige or the member may need more information. If the member needs more time to get information, he/she may request up to fourteen (14) additional days. If Prestige needs more time, the member will be informed of the reason for the extension, in writing, within two (2) calendar days. Appeals Process If Prestige decides to deny, reduce, limit, suspend, or terminate a service that the member is receiving, or if Prestige fails to act in a timely manner, the member will receive a written Notice of Adverse Benefit Determination (NABD). For the termination, suspension or reduction of a previously authorized covered service, the NABD will be mailed at least ten (10) calendar days before the action takes place. For denial of payment, the NABD will be given at the time of any action that affects the claim. For standard service Page 63

66 authorization decisions that deny or limit services, notices will be given within seven (7) days following receipt of a request for a standard authorization or within forty-eight (48) hours following receipt of a request for an expedited authorization, unless an extension is given. If the member does not agree with Prestige s determination as outlined in the NABD, the member may file a non-administrative appeal. These appeals are clinical in nature and require medical review. The member can file the appeal or ask their doctor, a family member, or friend to file the appeal for them. If someone helps the member file an appeal, he/she must be the member s authorized representative, or he/she may have his/her provider file with the member s written consent. The member or his/her authorized representative, with the member s written permission, may ask for a Medicaid Fair Hearing only after exhausting the plan s internal appeal process. Standard Appeal A standard appeal asks Prestige to review a decision about the member s care. An appeal may be filed orally or in writing within sixty (60) calendar days of the member s receipt of the NABD and, except when expedited resolution is required, must be followed with a written notice within ten (10) calendar days of the oral filing. The date of oral notice shall constitute the date of receipt. To file an appeal, the provider (with the member s written consent) or the member may call Member Services at or TTY/TDD at Hours of operation are twenty-four hours a day, seven days a week (24/7). To file an appeal, the member or authorized representative may send a letter to: Prestige Health Choice P.O. Box 7368 London, KY Prestige will assist the member in completing documentation and following the appeal procedure. The review begins the day Prestige receives the oral request. Prestige will send a written acknowledgement to the member within five (5) business days of receipt of the appeal. Prestige has thirty (30) calendar days in which to make a decision regarding the case. Before Prestige makes a decision, the member and/or the person helping the member with the appeal can give information to Prestige. The new information may be in writing or in person. If the member needs more time to get information, he/she may have it. The member or Prestige may request an extension up to fourteen (14) calendar days. If Prestige asks for more time, a letter will be sent within two (2) calendar days to inform the member why Prestige needs extra time. The member may review his/her file any time while Prestige is reviewing the appeal. The member and his/her authorized representative may look at the case file. In the event the member expires prior to, or during the appeal process, the member's estate representative may review the file after the member's death. The member s estate representative may review the file after the member s death. Prestige will send the member or his/her authorized representative a letter with the decision explaining how Prestige made its decision. Page 64

67 Expedited Appeal A member or his/her authorized representative, with the member s written consent, can request an expedited appeal when taking the time for a standard resolution could jeopardize the member s life, health or ability to attain, maintain or regain function. Expedited appeals are for health care services, not denied claims. To ask for an expedited appeal, the member or his/her authorized representative may call If Prestige denies a request for an expedited resolution of an Appeal, Prestige shall provide oral notice by close of business on the day of disposition, and written notice within two (2) calendar days after the disposition. The appeal will immediately be moved into the standard appeal timeframe, if it does not meet the criteria for an expedited appeal. Prestige shall resolve each expedited appeal and provide notice to the member as quickly as the member s health condition requires, within state established time frames, not to exceed seventy-two (72) hours after the request for expedited appeal is received. Prestige also shall provide oral notice by close of business on the day of disposition, and written notice within two (2) calendar days of the disposition. Appealing a Decision to the Subscriber Assistance Program (SAP) The member or his/her authorized representative has the right to appeal an adverse decision to the Subscriber Assistance Program (SAP). The member must complete the Prestige appeal process first. The member has one (1) year after the date of the final decision letter from Prestige to submit their appeal. The SAP will not consider an appeal that has been to a Medicaid Fair Hearing. The member can call or write with his/her request for review: Agency for Health Care Administration Subscriber Assistance Program Building 3, Mail Stop Mahan Drive Tallahassee, Florida Phone: Toll-Free: Fax: SAP@ahca.myflorida.com Medicaid Fair Hearing The member, or his/her authorized representative, may seek a Medicaid Fair Hearing s after exhausting the plan s internal appeal process and within one hundred twenty (120) days of the NABD. If the member does not pursue the Prestige appeal process, the member will not be eligible to file for the Medicaid Fair Hearing. If the member participates in the MediKids Program, they cannot request a Medicaid Fair Hearing. Page 65

68 The address to send the request for a Medicaid Fair Hearing is: Agency for Health Care Administration Medicaid Hearing Unit P.O Box Ft. Myers, FL (Toll-free 1-877) (toll-free) Fax: (fax) MedicaidHearingUnit@ahca.myflorida.com For more information on Appeal Hearings, please visit Continuation of Benefits A member may continue to receive services while waiting for Prestige s decision if all of the following apply: The appeal is filed within ten (10) days after the notice of the adverse action is mailed. The appeal is filed within ten (10) days after the intended effective date of the action. The appeal is related to reduction, suspension or termination of previously authorized services. The services were ordered by an authorized provider. The authorization has not ended. The member requested the services to continue. The member s services may continue until one (1) of the following happens: The member decides not to continue the appeal. Ten (10) days have passed from the date of the notice of resolution unless the member has requested a Medicaid Fair Hearing with continuation of services within those ten (10) days. The time covered by the authorization has ended or the limitations on the services are met. The Medicaid Fair Hearing office issues a hearing decision adverse to the member. The member may have to pay for the continued services if the final decision from the Medicaid Fair Hearing is against them. If the Medicaid Fair Hearing Officer agrees with the member, Prestige will pay for the services received while waiting for the decision. If the Medicaid Fair Hearing or the SAP decision agrees with the member and he/she did not continue to get the services while waiting for the decision, Prestige will issue an authorization for the services to restart as soon as possible and Prestige will pay for the services. Page 66

69 SECTION VII HEALTHY BEHAVIORS PROGRAM Page 67

70 VII. Healthy Behaviors Program Prestige encourages and rewards member behaviors to improve health outcomes. Healthy Behaviors programs are available to Prestige members and focus on helping change unhealthy behaviors by achieving certain health milestones. For complete details about each program, visit or call Prestige Provider Services at Prestige offers several programs to reward members for healthy behaviors: Weight Loss The program provides members with weight loss resources and support, as well as rewards for dietary and nutritional counseling, following up with a healthcare provider and having a documented reduction in body mass index (BMI). Smoking Cessation The program provides members with resources designed to reduce the health risks associated with smoking and/or tobacco use. The program also offers resources for support from well-trained quit coaches, as well as rewards for smoking cessation counseling group sessions and seminars. Alcohol and Substance Use Recovery The program provides support and resources for members with alcohol and substance use challenges, as well as rewards for counseling sessions and maintaining sobriety. The program has multiple components to address the needs of members, from identification of an existing substance use clinical issue or diagnosis, through the treatment phase of the interventions, to the abstinence and recovery period. Well-Child Visits The program provides rewards for members who complete six (6) or more well-child visits between thirty-one (31) days and fifteen (15) months of age. Behavioral Health Follow-Up The program provides rewards for members six (6) years of age and older who were hospitalized in an acute inpatient setting with a principal diagnosis of mental illness and who followed up with a mental health provider within seven (7) and thirty (30) days of being discharged. Diabetes Care The program provides rewards for members with diabetes years of age who complete the diabetes testing series, including an annual diabetes eye exam. Maternity The program provides rewards for pregnant members who complete a minimum of 10 out of 13 prenatal visits, as well as a postpartum visit within 21 to 42 days after giving birth. Page 68

71 SECTION VIII QUALITY ENHANCEMENTS Page 69

72 VIII. Quality Enhancements Prestige coordinates access for members to certain health-related, community-based services for children s programs, domestic violence, pregnancy prevention, prenatal/postpartum pregnancy programs and behavioral health programs. A complete list and additional detail on these quality enhancements are available by visiting The following services are available to our members and may be accessed by providers: Prestige Health Choice offers Quality Enhancements (QE) in community settings and as components of established programs. Prestige will make a good faith effort to work with the following agencies and community organizations to coordinate access to already established QE services: 1. Healthy Start Coalitions. 2. County Health Departments. 3. Early Intervention Programs. 4. Local domestic violence agencies. 5. United Way. 6. Community Hospitals. 7. Federally Qualified Health Centers QE referrals (made by Integrated Health Care Management case managers/care connectors or other staff such as member service staff) and follow-up related to the services received are documented in Prestige Health Choice s Medical Management system. Providers are notified through the provider handbook that QE referrals and follow up on the members receipt of services must be documented in members' medical records. Prestige Health Choice offers the following QEs: a. Community based educational sessions for the mothers of infants and children addressing self-care for common childhood illnesses. Alternatively, Prestige Health Choice may involve or refer members in existing community children s programs. b. Health Fairs Prestige Health Choice participates in local member-only events to promote general wellness programs, prevention and early -intervention services for children c. Provider Education Offerings Provider education programs to promote health and wellness screenings, immunizations, and CHCUP. d. Domestic Violence In addition to the provider education offerings mentioned above, Prestige Health Choice s care managers/care connectors educate female members on available community resources and support for victims of domestic violence. In addition, members receive information regarding domestic violence in the member handbook and member web site. e. Pregnancy Prevention Prestige Health Choice partners with the Abstinence Education Program to promote program attendance to Members. Alternatively, Prestige Health Choice may involve members in existing community pregnancy prevention programs. f. Prenatal and postpartum pregnancy programs Prestige Health Choice care managers/care connectors will Page 70

73 utilize local community based services to support a woman and her baby during her pregnancy and the post-partum period. Prestige provides information regarding the availability of these services to members through documentation in the Member Handbook, on Prestige s website, and through the provision of educational materials. Members also have access to this information by calling Prestige Member Services at , where a Member Service Representative will be available to provide the information and answer any questions the member may have. Prestige Health Choice offers substance use screening training to all of its providers on an annual basis. Page 71

74 SECTION IX QUALITY IMPROVEMENT PROGRAM Page 72

75 IX. Quality Improvement Program (QIP) Prestige s Quality Improvement Program (QIP) provides a framework for the evaluation of the delivery of health care and services provided to members. The QIP description sets out the quality improvement structure, function, scope and, goals defined for Prestige. The Board of Directors provides strategic direction for the QIP and retains ultimate responsibility for ensuring that the QIP is incorporated into Prestige s operations. Operational responsibility for the development, implementation, monitoring, and evaluation of the QIP is delegated by the Board of Directors through the Prestige President and the Quality Improvement Committee (QIC). The purpose of the QIP is to provide a formal process to systematically monitor and objectively evaluate the quality, appropriateness, efficiency, effectiveness and safety of the care and service provided to Prestige members by providers. The QIP also provides oversight and guidance for the following: Determining practice guidelines and standards on which the program s success will be measured. Complying with all applicable laws and regulatory requirements, including but not limited to, AHCA, other applicable state and federal regulations, AAAHC and NCQA accreditation standards. Providing oversight of all delegated services. Ensuring through the credentialing/re-credentialing process that a qualified network of providers and practitioners is available to provide care and service to members. Conducting member and practitioner satisfaction surveys to identify opportunities for improvement. Reducing health care disparities by measuring, analyzing, and redesigning services and programs to meet the health care needs of our diverse membership. Prestige develops goals and strategies considering applicable state and federal laws and regulations and other regulatory requirements, AAAHC and NCQA accreditation standards, evidence-based guidelines established by medical specialty boards and societies, public health goals, and national medical criteria. The goals, objectives and related measures used to monitor and evaluate performance are incorporated into the QIP work plan. The work plan identifies annual objectives and program scope, quality improvements, and monitoring activities for the coming year, planned monitoring of previously identified issues and a scheduled annual evaluation. The work plan also identifies the responsible party and a time frame for completion of all activities. The work plan is revised as necessary to add new initiatives. Quality Improvement Committee (QIC) The QIC oversees Prestige s efforts to measure, manage, and improve quality of care and services delivered to Prestige members, and evaluate the effectiveness of the QIP. The scope of committee activities includes utilization management, clinical practice guideline review, member service metrics, provider service metrics, provider satisfaction, delegation oversight, cultural competency program plan, monitoring of member complaints, grievances, appeals and satisfaction. Additional committees and councils support the QIP and report to the QIC: Page 73

76 *Pharmacy and Therapeutics Committee (P&T) - monitors drug utilization patterns, preferred drug list (PDL) composition, pharmacy benefits management procedures and quality concerns. *Credentialing Committee - reviews practitioner and provider applications, credentials and profiling data (as available) to determine appropriateness for participation in the Prestige network. *Peer Review Committee - reviews special cases for further evaluation. Discussion regarding cases for best clinical practices. Quality of Service Committee (QSC) develops, review and revise all aspects of service delivery at Prestige. *Medical Policy, Technology & Bioethics Committee (MPTBC) - evaluates best medical practice and coverage guidelines. *Clinical Quality Improvement Committee (CQIC) reviews investigation of quality of care issues and clinical practice guidelines. *Provider involvement We encourage provider participation in our QIP. Providers who are interested in participating in one of our quality committees should contact their Provider Account Executive directly. Provider Advisory Council - solicits input from provider and community stakeholders regarding the structure and implementation of new and existing clinical policies, initiatives and strategies. Quality Improvement Program Activities The QIP is designed to monitor and evaluate the quality of care and service provided to members. QIP activities are conducted using the Plan-Do-Check-Act (PDCA) methodology: Plan Plan: Establish objectives and processes necessary to meet performance or outcome goals. Do: Implement Prestige processes; Act Do collect data for further analysis. Check: Evaluate and compare the Check results to the performance/outcome goal; identify differences between the actual/expected/target outcomes. Figure 1: PDCA Quality Process Act: Develop and implement corrective action to address significant differences between the actual and planned results; conduct root cause analysis; as necessary, return to Plan step. Page 74

77 Performance Improvement Projects Prestige develops and implements Performance Improvement Projects (PIPs) focusing on areas of concern or low performance, both clinical and service-related, identified through internal analysis and external recommendations. Ensuring Appropriate Utilization of Resources Prestige monitors utilization of key indicators, including inpatient admission rates and length of stay, emergency room utilization rates, and clinical guideline adherence for preventive health and chronic illness management services to identify those areas that fall outside the expected range to assess over or under utilization. Measuring Member and Provider Satisfaction Prestige uses the standardized Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to assess member satisfaction. Prestige also conducts provider satisfaction studies annually. Survey results, along with analysis and trends on dissatisfactions and member opt-outs are reported to the QIC for review and identification/prioritization of opportunities for improvement. Member Safety Programs The QIP is responsible for coordinating activities to promote member safety. Initiatives focus on promoting member knowledge about medications, home safety and hospital safety. Members are screened for potential safety issues during the initial assessment. Preventive Health and Clinical Guidelines Prestige adopts guidelines established by nationally recognized professional organizations for use by Prestige providers. Guidelines are distributed via the provider portal, with hard copy available upon request. The Preventive Clinical Guidelines are reviewed bi-annually by the Prestige QIC. Potential Quality of Care Concerns All potential quality of care concerns are fully investigated via medical record review audit. The Medical Director s determination of the quality of care concern may render a referral to the Peer Review Committee for further review. If the concern is referred to the Peer Review Committee, follow-up actions are conducted based on the Peer Review Committee s recommendation(s). If the Peer Review Committee decision/recommendation includes any reportable action, the practitioner/provider s case information is reported to the National Practitioner Data Bank (NPDB), and State regulatory agencies as appropriate. Based on the recommendation(s) of the Peer Review Committee, the practitioner/provider is notified by letter of the issue and the actions recommended by the Peer Review Committee. The letter must be delivered in an appropriate time period whereby the practitioner/provider must conform to the recommended action. o The letter is clearly marked: CONFIDENTIAL: PRODUCT OF PEER REVIEW. Page 75

78 o Repeated non-conforming behavior will subject the practitioner/provider to a second notification letter and potential suspension of panel/authorizations pending additional investigation. Failure to conform thereafter is considered grounds for the initiation of the Formal Sanctioning Process. o o The practitioner/provider needs to submit an explanation of the quality of care event. The provider will outline the controls and/or changes that have been made to processes to prevent similar quality issues from occurring in the future. In the event that the practitioner/provider does not provide this explanation, the Peer Review Committee reserves the right to impose further actions. Require written documentation that the practitioner/provider agrees to conform to a Corrective Action Plan which may include continued monitoring by Prestige to ensure that adverse events do not continue. A Corrective Action Plan may also include provisions that the practitioner/provider maintain an acceptable pass/fail score with regard to a particular performance metric or sanctions can be imposed. Adverse Action Reporting In accordance with Title IV of Public Law , the Health Care Quality Improvement Act of 1986, with governing regulations codified at 45 CFR Parts 60.9.a.3 - Prestige s Credentialing Department reports to the appropriate State Board of Medical or Dental Examiners, as appropriate, and to NPDB: o Any adverse action that affects practitioner/provider s participation status in Prestige s network for a period longer than thirty (30) days. o Acceptance of the surrender of practitioner/provider s participation status or any restriction of such participation status: a. While the practitioner/provider is under investigation by Prestige relating to possible incompetence or improper professional conduct; or b. In return for not conducting such an investigation or proceeding. o Civil judgments against the practitioner/provider in which Prestige is the prevailing party and other adjudicated actions or decisions, whether or not the practitioner/provider availed itself of Prestige s hearing procedures. o Other adjudicated actions or decisions, and their bases, as promulgated by the NPDB. o Prestige will report following the procedure set out in 45 CFR Parts 60.9.c o Upon advice from Prestige s Legal Counsel and at the direction of the Prestige Medical Director, Prestige s Credentialing Department reports: a. Adverse actions to the State Board of Medical or Dental Examiners, as appropriate, within fifteen (15) days from the date the adverse action was taken; and b. Other adjudicated actions and decisions to NPDB within thirty (30) days from the date of the final action or decision. HEDIS/Performance Measures Healthcare Effectiveness Data and Information Set (HEDIS) are Performance Measures utilized to evaluate the quality of care given to our members. National Committee for Quality Assurance (NCQA) provides the national standards for these performance measures. These standards must be collected, Page 76

79 validated and submitted to NCQA and AHCA annually. Prestige strives to improve the quality of care as quantified in the Performance Measures. Preventive Care/Immunizations Preventive care includes a broad range of services (including screening tests, counseling, and immunizations/vaccines). Providers are required to administer immunizations in accordance with the Recommended Childhood Immunization Schedule for age birth through eighteen (18) years for the United States, or when medically necessary for the member s health. All vaccines for which a member is eligible at the time of each visit should be administered simultaneously. Providers are required to participate in the Vaccines for Children Program (VFC). PCPs are encouraged to provide immunization information about members requesting Temporary Cash Assistance program (TCA) from DCF, upon request by DCF and receipt of the member s written permission. This information is necessary in order to document that the member has met the immunization requirements for members receiving temporary cash assistance. Prestige has adopted the recommended immunization schedules for age birth up to twenty-one (21) years for immunization for children and adults that is published by the Advisory Committee on Immunization Practices (ACIP) from the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP). Immunization Schedules (Childhood, Adolescent and Adult) For the recommended vaccines and immunization schedules, please visit for children and adolescents and for adults. Visit for the Guide to Clinical Preventive Services for recommendations made by the U.S. Preventive Services Task Force (USPSTF) for clinical preventive services. Vaccines for Children Program (VFC) The Vaccines for Children Program (VFC) is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of an inability to pay. The CDC buys vaccines at a discount and distributes them to grantees, e.g., state health departments and certain local and territorial public health agencies, that then distribute them at no charge to those private providers' offices and public health clinics registered as VFC providers. Children who are eligible for VFC vaccines are entitled to receive pediatric vaccines that are recommended by the Advisory Committee on Immunization Practices. For more information visit Florida Medicaid requires vaccines for Medicaid children from birth through eighteen (18) years of age. Providers for Medicaid members must use his/her Vaccines for Children Program (VFC) supply and bill Prestige for the administrative fee only. The VFC program covers children from birth through eighteen (18) years of age. Page 77

80 MediKids are not covered under the VFC program. Members nineteen (19) through twenty-one (21) years of age should receive their vaccinations from their PCP. Prestige will provide reimbursement for these members to the participating provider for immunizations covered by Medicaid but not provided through VFC. Providers are expected to plan for a sufficient supply of vaccines. Prestige will pay the immunization administration fee for continuation of care services at no less than the Medicaid rate from non-participating providers as follows:. o The non-participating provider contacts Prestige at the time of service delivery; and o The non-participating provider submits a claim for the administration of immunization services and provides medical records documenting the immunization to Prestige. Child Health Check-Up Program (CHCUP) The State of Florida s CHCUP is a program for Medicaid members under the age of twenty-one (21). Prestige coverage includes CHCUP and participating providers are required to adhere to the following CHCUP service standards: Conduct a comprehensive health screening evaluation that includes a past medical history, developmental history and behavioral assessment. The screening evaluation should also include: o A nutritional assessment o Comprehensive unclothed physical exams o Developmental assessment o Growth measurements o Appropriate immunizations based on the Recommended Childhood Immunization Schedule for the United States o Laboratory testing (including blood lead testing as outlined below) o Health education (including anticipatory guidance) o Dental screening (including a direct referral to a dentist for members beginning at age three (3) or earlier as indicated) o Vision screening (including objective testing as required) o Hearing screening (including objective testing as required) o Diagnosis and treatment o Referral and follow-up as appropriate o Blood lead testing: All providers are required to screen all enrolled children for lead poisoning at the age of twelve (12) months and twenty-four (24) months. Children between the ages of twelve (12) months and seventy-two (72) months must receive a screening blood lead test if there is no record of a previous test. Prestige will provide additional diagnostic and treatment services determined to be medically necessary to a child/adolescent diagnosed with an elevated blood lead level. If children or adolescents are identified as having abnormal levels of lead through blood lead screenings, Prestige will provide case management follow-up services. Page 78

81 Providers are required to inform members when tests or screenings are due based on the periodicity schedule in the CHCUP Handbook. Prestige does not require authorization for a member to be seen by a participating specialist when determined that it is needed by the PCP. PCP is to refer to the appropriate provider within four (4) weeks of these examinations for further assessment and treatment of conditions found during the initial examination. Providers are expected to cooperate with Prestige to accommodate new member appointments within 30 days of the member s enrollment with Prestige. Provide assistance with scheduling for members to ensure they keep medical appointments. Provide or coordinate other important health care diagnostic services and treatment including necessary referrals as they relate to physical and mental illnesses and/or conditions discovered through screening services in accordance with EPSDT contractual requirements. CHCUP Schedule for Exams Birth or neonatal examination; 3-5 days for newborns discharged in less than 48 hours after delivery; By 1 month, and at 2, 4, 6, 9, 12, 15, 18 months, 24 months and 30 months; and Once per year for 3-year-olds through 20-year-olds. Full CHCUP schedule is available at ahca.myflorida.com/medicaid/childhealthservices/chcup/index.shtml. Reporting & Evaluation The QIP is evaluated, as needed and at least annually, to measure its effectiveness. The evaluation assesses all aspects of the QIP including clinical and service PIPs, quality studies and activities, and the rationale, methodology, results and subsequent improvement associated with each study. The evaluation includes recommendations for improvement in the QIP, proposes goals and objectives for the following year and identifies the resources needed to accomplish the proposed goals and objectives. Medical Record Audits Prestige conducts medical record audits to assess the provision and documentation of high quality primary care according to established standards. PCP sites with ten (10) or more linked members undergo a Medical Record Review (MRR) a minimum of once (1) every three (3) years. A PCP practice may include both an individual office and a large group facility site. Ad-hoc reviews of OB-GYNs and specialists may also be conducted, as needed, using the same process. A minimum of five (5) records are reviewed for each site. Records are selected using a random number methodology among members assigned to the PCP for a minimum of six (6) months. The Plan has the right to issue a retrospective review. These reviews may be conducted on a quarterly, semiannually, annually, or as otherwise permitted contractually. Page 79

82 Documentation of Care/Medical Record Keeping The Documentation of Care (DOC) review component of the Prestige Quality Program provides a mechanism to monitor and evaluate the quality and appropriateness of professional providers documentation of office medical records. Prestige providers must maintain a medical records system that is consistent with professional standards. Prestige complies with all legal requirements and all federal, state and other laws, regulations, and contractual obligations (e.g., Agency, Balance Budget Act of 1997, CMS, HIPAA, Medicare Modernization Act of 2003, OIG, OIR and major account service specifications). All medical records, Medicaid-related member cards, and communications are to be maintained for a period of ten (10) years according to legal, regulatory, and contractual rules of confidentiality and privacy. Providers are to deliver prompt access to records for review, survey or study if needed. Medical record standards are available via the online. Prestige providers are required to develop and implement confidentiality procedures to protect member PHI in accordance with HIPAA privacy standards. Providers must store medical records in a secure manner that permits easy retrieval. Only authorized personnel may have access to patient medical records. Florida licensed nurses perform the documentation-of-care medical record review using guidelines that are updated annually and include at a minimum, the following: o Two medical conditions. o Two behavioral health conditions (preventive or non-preventive). o Preventive guidelines for health evaluations, education and immunizations. Documentation of whether a member has executed an advance directive must be contained in the member s medical record. If the member provides his/her PCP with a copy of an advance directive, it will be made a part of the member s medical record. This information may be obtained by contacting Member Services at Medical records should reflect all services and referrals supplied directly by all providers. This includes all ancillary services and diagnostic tests ordered by the provider, and the diagnostic and therapeutic services for which the provider referred the member. Members medical records must be treated as confidential information and be accessible only to authorized persons. Prestige Medical Record Standards are distributed to providers during Prestige s orientation and are also available through the following sources: Provider manual. Prestige website. Upon request through Provider Network Management. Providers may access Prestige Medical Record Standards and Medical Record Review Criteria in the appendix section of this manual. Page 80

83 SECTION X CULTURAL COMPETENCY PLAN Page 81

84 X. Cultural Competency Plan At Prestige, we recognize the increasing population growth of racial and ethnic groups in our communities, each with their own cultural traits, linguistic needs and health profiles. Prestige acknowledges the responsibility to engage the provider network, to effectively connect with our diverse patient population. Therefore, all network providers are responsible for their active participation with Prestige s Cultural Competency Plan. Embedded in all of our efforts is a culturally and linguistically appropriate approach to the delivery of health care services. We foster cultural awareness both in our staff and in our provider community by leveraging ethnicity and language data to ensure that all cultures in our membership are reflected to the greatest extent possible. The role and overall objective of the Cultural Competency Plan is to assure that all members are served in a way that is responsive to their cultural and linguistic needs, monitor for disparities among plan members, and carry out corrective actions. National Culturally and Linguistic Services (CLAS) The plan utilizes the fifteen (15) National Culturally and Linguistically Appropriate Services (CLAS) Standards, developed by the United States Department of Health and Human Services Office of Minority Health, as its guide and baseline. The fifteen (15) National CLAS Standards are: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources. Recruit, promote, and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area. Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organization's planning and operations. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. Page 82

85 Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public. Providers must adhere to the Cultural Competency Plan as set forth above. All member materials may be translated in any language or format requested by a member. The member handbook and welcome kit are readily available for members in Spanish, Creole, large print format, braille and audio, as these are prevalent in Prestige s areas of operation. Providers may request a full copy of Prestige s Cultural Competency Plan free of charge by contacting Member Services at or by visiting For Language assistance services, please contact Member Services at Page 83

86 SECTION XI CLAIMS SUBMISSION Page 84

87 XI. Claims Submission Visit Reporting CMS defines an encounter as "an interaction between an individual and the healthcare system." Encounters occur whenever a Prestige member is seen in a provider s office or facility, whether the visit is for preventive health care services or for treatment due to illness or injury. An encounter is any health care service provided to a Prestige member. Encounters must result in the creation and submission of an encounter record (CMS-1500 or UB-04 form or electronic submission) to Prestige. The information provided on these records represents the encounter data provided by Prestige to the Florida Medicaid Program. Completion of Encounter Data PCPs must complete and submit a CMS-1500 form or file an electronic claim every time a Prestige member receives services. Completion of the CMS-1500 form or electronic claim is important for the following reasons: It provides a mechanism for reimbursement of medical services, including payment of inpatient newborn care and attendance at high risk deliveries. It allows Prestige to gather statistical information regarding the medical services provided to Prestige members, which better support our statutory reporting requirements. It allows Prestige to identify the severity of illnesses of our members to better case manage them. Prestige can accept claim submissions via paper or electronically (EDI). For more information on electronic claim submission and how to become an electronic biller, please refer to the "EDI Technical Support Hotline" topic in the manual. In order to support timely statutory reporting requirements, we encourage PCPs to submit claims within thirty (30) days of the visit. However, all claims must be submitted within the allowed time frame posted in your contract, or as otherwise permitted by law, from the date services were rendered or compensable items were provided. The following mandatory information is required on the CMS-1500 form for a primary care visit: Prestige Health Choice member's ID number. Member's name. Member's date of birth. Other insurance information: company name, address, policy and/or group number, and amounts paid by other insurance, copy of EOBs. Information advising if patient's condition. is related to employment, auto accident, or liability suit. Name of referring provider, if appropriate. Dates of service, admission, discharge. Primary, secondary, tertiary and fourth ICD-10 diagnosis codes, coded to the highest degree of specificity. Authorization or referral number. CMS place of service code. HCPCS procedures, service or supplies codes; CPT procedure codes with appropriate modifiers, if applicable. Charges. Days or units. Provider/supplier federal tax identification number or Social Security Number. National Practitioner ID (NPI) and Taxonomy Code. Individual Prestige assigned practitioner Number. Name and address of facility where services were rendered. Provider/supplier billing name, address, zip code, and phone number. Invoice date. Page 85

88 Prestige monitors encounter data submissions for accuracy, timeliness and completeness through claims processing edits and through network provider profiling activities. Encounters can be rejected or denied for inaccurate, untimely and incomplete information. Network providers will be notified of the rejection via a remittance advice and are expected to resubmit corrected information to Prestige in the allowed timeframe listed in the provider s contract. Network providers may also be subject to sanctioning by Prestige for failure to submit accurate encounter data in a timely manner. Contact Provider Services at to address questions concerning claims submission. Rejected claims are defined as claims with invalid or required missing data elements, such as the provider tax identification number or member ID number, that are returned to the provider or EDI* source without registration in the claim processing system. Rejected claims are not registered in the claim processing system and can be resubmitted as a new claim. Denied claims are registered in the claim processing system, but do not meet requirements for payment under Prestige guidelines. They should be resubmitted as a corrected claim. Denied claims must be resubmitted in the allowed timeframe in the provider agreement, or as otherwise permitted by law, for participating providers and as outlined in federal/state statues (whichever is more stringent) for nonparticipating providers. These requirements apply to claims submitted on paper or electronically. *For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital Claims in this manual. Procedures for Claim Submission Prestige is required by state and federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims. When required data elements are missing or are invalid, claims will be rejected by Prestige for correction and re-submission. Claims for billable services provided to Prestige members must be submitted by the provider who performed the services. Claims filed with Prestige are subject to the following procedures: 1. Verification that all required fields are completed on the CMS 1500 or UB-04 forms. 2. Verification that all diagnosis and procedure codes are valid for the date of service. 3. Verification of member eligibility for services under Prestige during the time period in which services were provided. 4. Verification that the services were provided by a participating provider or that the nonparticipating provider has received authorization to provide services to the eligible member. 5. Verification that the service being performed is a covered service and that member has not exhausted their benefits. Page 86

89 6. Verification that the provider is eligible to participate with the Medicaid Program at the time of service. 7. Verification that an authorization has been given for services that require prior authorization by Prestige. 8. Verification of whether there is Medicare coverage or any other third-party resources and, if so, verification that Prestige is the payer of last resort on all claims submitted to Prestige. Prospective Claims Editing Policy Prestige claim payment policies, and the resulting edits, are based on guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), the American Medical Association (AMA), State regulatory agencies and medical specialty professional societies. In making claim payment determinations, Prestige also uses coding terminology and methodologies that are based on accepted industry standards, including the Healthcare Common Procedure Coding System (HCPCS) manual, the Current Procedural Terminology (CPT) codebook, the International Statistical Classification of Diseases and Related Health Problems (ICD) manual and the National Uniform Billing Code (NUBC). Other factors affecting reimbursement may supplement, modify or in some cases, supersede medical/claim payment policy. These factors may include, but are not limited to: legislative or regulatory mandates, a provider s contract, and/or a member s eligibility to receive covered health care services. Claim Mailing Instructions Submit claims to Prestige at the following address: Prestige Health Choice P.O. Box 7367 London, KY Prestige encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Change Healthcare s (formerly Emdeon) Provider Support Line at to arrange transmission. Prestige is authorized to take whatever steps are necessary to ensure that the provider is recognized by the state Medicaid program, including its choice counseling/enrollment broker contractor(s), as a participating provider of Prestige Health Choice and that the provider s submission of encounter data is accepted by the FMMIS and/or the state s encounter date warehouse. Claim Filing Deadlines Original invoices must be submitted to Prestige as set forth in your provider contract, or as otherwise permitted by law, from the date services were rendered or compensable items were provided. Resubmission of previously denied claims with corrections and requests for adjustments must be submitted within the allowed time frame listed in the participating provider s contract, or as otherwise permitted by law, or as outlined in federal/state statues (whichever is more stringent). Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within ninety (90) days of the date of the primary insurer s EOB. Page 87

90 Requests for adjustments may be submitted electronically, on paper or by phone. By phone: Provider Services Prestige Health Choice On paper: If you prefer to write, please be sure to stamp each claim submitted corrected or re-submission and address the letter to: Prestige Health Choice P.O. Box 7367 London, KY Refer to Section VI of this manual or look online at the provider portal of the Prestige website, for complete instructions on submitting appeals. Claims originally rejected for missing or invalid data elements must be corrected and re-submitted in the allowed timeframe in the provider agreement, or as otherwise permitted by law, for participating providers and as outlined in federal/state statues (whichever is more stringent) for non-participating providers. Rejected claims are not registered as received in the claim processing system. Prestige Health Choice EDI Payer ID# Child Health Check-Up Child Health Check-Up services are the CPT Preventive Medicine Services Codes. In some cases, one or two modifiers are required to uniquely identify the service provided. Both the procedure code and modifiers listed must be completed on the claim in order to receive proper reimbursement. No modifiers other than the ones listed below are allowed when billing these services. *Note: The EP modifier must be used with Procedure Code and to identify children 18 through 39 years of age. *Note: The FP modifier must be used with Procedure Code or when the appropriate diagnosis is billed for Family Planning services. Each Preventive Medicine Service code billed will be required to have a referral code with the exception of Modifier FP for codes or No referral code is required. Code Description New Patient Under One Year New Patient Ages 1-4 years New Patient Ages 5-11 Years New Patient Ages Years Page 88

91 99385 EP New Patient Ages Years Established Patient Under One Year Established Patient Ages 1-4 years Established Patient Ages 5-11 Years Established Patient Ages Years EP Established Patient Ages Years Valid Referral Codes: U Complete Normal - Indicator is used when there are no referrals made. 2 Abnormal, Treatment Initiated - Indicator is used when a child is currently under treatment for referred diagnostic or corrective health problem. T Abnormal, Recipient Referred - Indicator is used for referrals to another provider for diagnostic or corrective treatments or scheduled for another appointment with check-up provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic check-up (not including dental referrals). V Patient Refused Referral - Indicator is used when the patient refused a referral. Common Causes of Claim Processing Delays, Rejections or Denials Authorization or Referral Number Invalid or Missing - A valid authorization number must be included on the claim form for all services requiring prior authorization. Attending Provider ID Missing or Invalid Inpatient claims must include the name of the provider who has primary responsibility for the patient's medical care or treatment, and the medical license number on the appropriate lines in field number 82 (Attending Provider ID) of the UB-04 (CMS 1450) claim form. A valid medical license number is formatted as two (2) alpha, six (6) numeric, and one (1) alpha character (AANNNNNNA) OR two (2) alpha and six (6) numeric characters (AANNNNNN). Billed Charges Missing or Incomplete A billed charge amount must be included for each service/procedure/supply on the claim form. Diagnosis Code Missing 4 th, 5 th, 6 th, or 7 th Digit Precise coding sequences must be used in order to accurately complete processing. Review the ICD-10-CM manual for the 4 th, 5 th, 6 th, and 7 th digit extensions, and to determine when additional digits are required. Diagnosis, Procedure or Modifier Codes Invalid or Missing - Coding from the most current coding manuals (ICD-10, CPT or HCPCS) is required in order to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. Page 89

92 EOBs (Explanation of Benefits) from Primary Insurers Missing or Incomplete A copy of the EOB from all third party insurers must be submitted with the original claim form. Include pages with run dates, coding explanations and messages. External Cause of Injury Codes External Cause of Injury E diagnosis codes should not be billed as primary and/or admitting diagnosis. Future Claim Dates Claims submitted for medical supplies or services with future claim dates will be denied, for example, a claim submitted on October 1 st for bandages that are delivered for October 1 st through October 31 st will deny for all days except October 1 st. Handwritten Claims Non-legible Legible handwritten claims are acceptable on resubmitted claims. Illegible handwritten claims will be rejected (See Illegible Claim Information) Illegible Claim Information Information on the claim form must be legible in order to avoid delays or inaccuracies in processing. Review billing processes to ensure that forms are typed or printed in black ink, data is lined up correctly in appropriate fields, that no fields are highlighted (this causes information to darken when scanned or filmed), and that spacing and alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. Member Plan Identification Number Missing or Invalid Prestige s assigned identification number must be included on the claim form or electronic claim submitted for payment. Member Date of Birth Does Not Match Member ID Submitted a newborn claim submitted with the mother s ID number will be pended for manual processing causing delay in prompt payment. Newborn Claim Information Missing or Invalid Always include the first and last name of the mother and baby on the claim form. If the baby has not been named, insert Baby Girl or Baby Boy in front of the mother s last name as the baby s first name. Verify that the appropriate last name is recorded for the mother and baby. Payer or Other Insurer Information Missing or Incomplete Include the name, address and policy number for all insurers covering the Prestige member. Refunds for Improper Payment or Overpayment of Claims Prestige encourages providers to conduct regular self-audits to ensure receipt of accurate payment(s) from Prestige. Medicaid program funds must be returned when identified as improperly paid or overpaid. If a plan provider identifies improper payment or overpayment of claims from Prestige, the improperly paid or overpaid funds must be returned to Prestige within 60 days from the date of discovery of the overpayment. Providers may return improper or overpaid funds to Prestige by: 1. Completing page one of the Provider Claim Refund Form. (available online at 2. Using page two of the form or attaching your own spreadsheet with the pertinent fields from the form, as needed, to list multiple claims connected to the return payment. Page 90

93 3. Submitting the completed form, attachments and refund check by mail to the claims processing department: Prestige Health Choice Attn: Provider Refund Unit PO Box 7367 London, KY Electronic Data Interchange (EDI) for Medical and Hospital Claims Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry s efforts to reduce administrative costs. The benefits of billing electronically include: Reduction of overhead and administrative costs. EDI eliminates the need for paper claim submission. It has also been proven to reduce claim re-work (adjustments). Receipt of clearinghouse reports makes it easier to track the status of claims. Faster transaction time for claims submitted electronically. An EDI claim averages about twentyfour (24) to forty-eight (48) hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that occur when completing paper claim forms. Quicker claim completion. Claims that do not need additional investigation are generally processed quicker. Reports have shown that a large percentage of EDI claims are processed within ten (10) to fifteen (15) days of their receipt. All the same requirements for paper claim filing apply to electronic claim filing. Electronic Claims Submission (EDI) The following sections describe the procedures for electronic submission for hospital and medical claims. Included are a high-level description of claims and report process flows, information on unique electronic billing requirements, and various electronic submission exclusions. Prestige Health Choice EDI Payer ID# Hardware/Software Requirements There are many different products that can be used to bill electronically. As long as you have the capability to send EDI claims to Change Healthcare (formerly Emdeon), whether through direct submission or through another clearinghouse/vendor, you can submit claims electronically. Contracting with Change Healthcare and Other Electronic Vendors If you are a provider interested in submitting claims electronically to Prestige, but do not currently have Change Healthcare EDI capabilities, you can contact Provider Services at You may also Page 91

94 choose to contract with another EDI clearinghouse or vendor who already has Change Healthcare capabilities. Contracting the EDI Technical Support Group Providers interested in electronic claims submission may contact the EDI Technical Support Group via Provider Services at Specific Data Record Requirements Claims transmitted electronically must contain all the same data elements identified within the EDI Claim Filing sections of this booklet. EDI guidance for Professional Medical Services claims can be found at the beginning of this claims section. EDI guidance for Facility Claims can be found at the beginning of this claims section. Change Healthcare or any other EDI clearing-house or vendor may require additional data record requirements. Electronic Claim Flow Description In order to send claims electronically to Prestige, all EDI claims must first be forwarded to Change Healthcare. This can be completed via a direct submission or through another EDI clearinghouse or vendor. Once Change Healthcare receives the transmitted claims, the claim is validated for HIPAA compliance and Prestige s Payer Edits as described in Exhibit 99 at Change Healthcare. Claims not meeting the requirements are immediately rejected and sent back to the sender via a Change Healthcare error report. The name of this report can vary based upon the provider s contract with their intermediate EDI vendor or Change Healthcare. Accepted claims are passed to Prestige, and Change Healthcare returns an acceptance report to the sender immediately. Claims forwarded to Prestige by Change Healthcare are immediately validated against provider and member eligibility records. Claims that do not meet this requirement are rejected and sent back to Change Healthcare, which also forwards this rejection to its trading partner the intermediate EDI vendor or provider. Claims passing eligibility requirements are then forwarded to the claim processing queues. Claims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Change Healthcare, or other contracted EDI software vendors, must be reviewed and validated against transmittal records daily. Since Change Healthcare returns acceptance reports directly to the sender, submitted claims not accepted by Change Healthcare are not transmitted to Prestige. For assistance in resolving submission issues reflected on either the Acceptance or R059 Plan Claim Status reports, contact the Change Healthcare Provider Support Line at For assistance in resolving submission issues identified on the R059 Plan Claim Status report, contact Provider Services at Page 92

95 Invalid Electronic Claim Record Rejections/Denials All claim records sent to Prestige must first pass Change Healthcare HIPAA edits and Plan specific edits prior to acceptance. Claim records that do not pass these edits are invalid and will be rejected without being recognized as received at Prestige. In these cases, the claim must be corrected and re-submitted within the required filing deadlines. It is important that you review the Acceptance or R059 Plan Claim Status reports received from Change Healthcare or your EDI software vendor in order to identify and resubmit these claims accurately and timely. Requests for adjustments may be submitted electronically, on paper or by phone. By phone: Provider Services On paper: If you prefer to write, please be sure to stamp each claim submitted corrected or re-submission and address the letter to: Prestige Health Choice Attn: Claims Department P.O. Box 7367 London, KY Administrative or medical appeals must be submitted in writing to: Prestige Health Choice Attn: Grievance and Appeals Department P.O. Box 7368 London, KY Please refer to the Provider Dispute Process on page 37 for more information on administrative or medical appeals. Plan Specific Electronic Edit Requirements Prestige currently has specific edits for professional and institutional claims sent electronically. 837P X098A1 Provider ID Payer Edit states the ID must be less than thirteen (13) alphanumeric digits. 837I X096A1 Provider ID Payer Edit states the ID must be less than thirteen (13) alphanumeric digits. Member Number must be less than seventeen (17) AN. Date submitted must not be earlier than date of service. Plan Provider ID is strongly encouraged. Page 93

96 Exclusions Certain claims are excluded from electronic billing. These exclusions fall into two groups: These exclusions apply to inpatient and outpatient claim types. Excluded Claim Categories At this time, these claim records must be submitted on paper. Claim records requiring supportive documentation; for example, sterilization claims requiring a consent form. Claim records for medical, administrative or claim appeals. Excluded Provider Categories Claims issued on behalf of the following providers must be submitted on paper. Providers not transmitting through Change Healthcare or providers sending to vendors that are not transmitting (through Change Healthcare) NCPDP Claims. Pharmacy (through Change Healthcare) Common Rejections Invalid Electronic Claim Records Common Rejections from Change Healthcare Claims with missing or invalid batch level records Claim records with missing or invalid required fields Claim records with invalid (unlisted, discontinued, etc.) codes (CPT-4, HCPCS, ICD-10, etc.) Claims without member numbers Invalid Electronic Claim Records Common Rejections from Prestige (EDI edits within the claim system) Claims received with invalid provider numbers Claims received with invalid member numbers Claims received with invalid member date of birth Effective April 1, 2015, paper claims that do not meet new HIPAA 5010 X12 format requirements will be rejected. Summary: All electronic healthcare transactions are to be transmitted in compliance with standards set forth by The Health Insurance Portability and Accountability Act (HIPAA) and the United States Department of Health and Human Services (HHS). Prestige Health Choice must convert paper claims data into electronic claim information. This federal mandate requires health plans, clearinghouses and providers to use new standards when electronically submitting information. Effective, April 1, 2015 paper claims that have been completed improperly will be rejected. Prestige Health Choice must adopt the required HIPAA 5010 X12 electronic claims submission format for both the CMS-1500 and UB-04 paper claim forms. Reference the below communication for both the CMS-1500 and UB-04 required fields and billing guidelines for the mandated formats to ensure your claims are submitted correctly. Page 94

97 Field # 33 Field # 1 1 CMS-1500 (02/12) Field/Data Element Billing provider information & phone number UB-04 Field/Data Element Billing provider name, address and phone number Billing provider name, address and phone number Prestige Health Choice "Reject Statement" (Reject Criteria) Effective April 1, 2015 "Field 33 of the CMS1500 claim form requires the provider s physical service address." (If a PO Box is present, claim will reject.) "Reject Statement" (Reject Criteria) Effective April 1, 2015 "Billing Provider name and/or address missing or incomplete." (If the name and/or street # and/or street name and/or city and/or state and/or zip are missing, claim will reject.) "Field 1 of the UB04 claim form requires the provider s physical service address." (If a PO Box is present, claim will reject.) Resubmitted Corrected Claims Providers using electronic data interchange (EDI) can submit institutional and professional corrected claims electronically rather than paper claims to Prestige. A corrected claim is defined as a re-submission of a claim with a specific change that you have made, such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review the processing of a claim. Your EDI clearinghouse or vendor needs to: Use 6 for adjustment of prior claims or 7 for replacement of a prior claim utilizing bill type or frequency type in loop 2300,CLM05-03 (837P or 837I). Include the original claim number in segment REF01=F8 and REF02=the original claim number; no dashes or spaces. Do include Prestige s claim number in order to submit your claim with the 6 or 7. Do use this indicator for claims that were previously processed (approved or denied). Do not use this indicator for claims that contained errors and were not processed (rejected upfront). Do not submit corrected claims electronically and via paper at the same time. NPI Processing Prestige s Provider Number is determined from the NPI number using the following criteria: Plan ID, Tax ID and NPI number. If no single match is found, the Service Location s ZIP code is used. If no service location is include, the billing address ZIP code will be used. If no single match is found, the Taxonomy is used. If no single match is found, the claim is sent to the Invalid Provider queue (IPQ) for processing. If a plan provider ID is sent using the G2 qualifier, it is used as the provider on the claim. Page 95

98 SECTION XII Pharmacy Page 96

99 XII. Pharmacy Pharmaceutical management is a critical component of Prestige s success. Prescription services are one of the largest service and expenditure areas under the Florida Medicaid program. The Plan s goal is to manage pharmacy costs while effectively maintaining optimal health outcomes for our members. The pharmacy benefit is administered by the Pharmacy Benefit Manager (PBM). There are certain medications on the AHCA Preferred Drug List that require prior authorization. For the latest version of the prior authorization forms, AHCA Preferred Drug List (PDL), or other pharmacy information, please visit You may also call the PBM at The information below is provided as a reference for Prestige providers to assist with requests and/or issues related to the Plan s pharmacy program. AHCA Preferred Drug List (PDL) Prestige has adopted the AHCA PDL and provides all prescription drugs and dosage forms in congruence with the Agency s direction. The PDL is a clinical reference of medications that are selected by the AHCA Pharmacy and Therapeutics Committee (P&T Committee). We encourage our providers to prescribe generic medications when the generic is preferred by AHCA and to adhere to the PDL. A complete list of covered drug products can be found at Coverage Limitations Prestige covers the medication categories that are listed on the PDL. Excluded items are as follows: Anti-hemophilia products. o Factor products are distributed through the Comprehensive Hemophilia Disease Management Program. Cough and cold medications for members age twenty-one (21) and over. Drug Efficacy Study Implementation (DESI) ineffective drugs as designated by AHCA. Drugs used to treat infertility. Experimental/Investigational pharmaceuticals or products. Erectile dysfunction products prescribed to treat impotence. Hair growth restorers and other drugs used for cosmetic purposes. Prostheses, appliances and devices (except products for diabetes and products used for contraception). Nutritional supplements. Oral vitamins and minerals (except those listed in the PDL). Over-the-counter (OTC) drugs (except those listed in the PDL). Weight loss/gain medications. Additionally, Prestige does not reimburse for early prescription refills, duplicate therapy, or medication dosages that exceed the Food and Drug Administration (FDA) maximum dose. Page 97

100 Generic Substitution Prestige requires that brand medications be substituted for generic medications when an equivalent generic is available, and when the formulary allows for coverage of the generic. There are some medications for which the brand medication is preferred by AHCA.. Informed Consent for Psychotropic Medications Prestige requires that prescriptions for psychotropic medications prescribed for a member under the age of thirteen (13) be accompanied by the express written and informed consent of the member s parent or legal guardian. Psychotropic (psychotherapeutic) medications include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity disorder (ADHD) medications (stimulants and non-stimulants) are not included at this time. The prescriber must document the consent in the child s medical record and provide the pharmacy with a signed attestation of the consent with the prescription. The prescriber must ensure completion of an appropriate attestation form. The completed form must be filed with the prescription (hardcopy or scanned) in the pharmacy and held for audit purposes for a minimum of six (6) years. Pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form. Every new prescription will require a new consent form. The consent forms do not replace prior authorization requirements for non-pdl medications or prior authorized antipsychotics for children and adolescents from birth through age seventeen (17). For consent forms and resources visit ahca.myflorida.com/medicaid/prescribed_drug/med_resource.shtml. Injectable Prestige covers limited self-administered, injectable medications (e.g., Imitrex, EpiPen). For a complete list, please reference the PDL. Most other injectable medications will require prior authorization. Over-the-Counter (OTC) Medications Prestige covers several OTC products. Our members receive an OTC benefit of $50/year per household. A list covering OTC products can be found at Specialty Medications Several specialty and injectable medications are listed on the PDL. Additionally, Prestige also adheres to the AHCA medication criteria for specialty, injectable and other medications requiring prior authorization. The majority of the specialty and injectable medications listed on the PDL will require a prior authorization. Please call the Prestige Pharmacy Benefit Manager at to obtain more detailed information about these medications. Working with our Specialty Pharmacy Provider Prestige utilizes an exclusive specialty pharmacy, PerformSpecialty to fill most specialty and some injectable medications. Most of these medications require a prior authorization. Please call Page 98

101 PerformSpecialty at or fax the prescription request or prior authorization form to Once approved PerformSpecialty will call the member for delivery confirmation. If you prefer the medication be delivered to your office instead please note that in your request. More information can be found at Prior Authorization Please refer to the links below for the most up-to-date PDL. The links define the AHCA preferred medications and those requiring prior authorization. For the PDL visit ahca.myflorida.com/medicaid/prescribed_drug/pharm_thera/fmpdl.shtml. For prior authorization criteria visit ahca.myflorida.com/medicaid/prescribed_drug/drug_criteria.shtml. Prior Authorization Fax: Prior Authorization Phone: Mailing Address: PerformRx PO Box 516 Essington, PA Please refer to the provider website for the most current information. Page 99

102 SECTION XIII BEHAVIORAL HEALTH Page 100

103 XIII. Behavioral Health The member has access to a full range of medically necessary behavioral health services. If assistance is needed finding a behavioral health provider, access the online provider directory at or contact Provider Services at Covered behavioral health services may include, but are not limited to: Individual, family or group therapy. Individual and family assessments and evaluations. Psychosocial rehab / Clubhouse Day treatment for adults and children. Psychiatric evaluations. Treatment planning. Case management. Inpatient hospital services for behavioral health conditions. Therapeutic behavioral on-site services for children, and teenagers and adults. State Inpatient Placement Program. Residential services for mental health and substance use. The access to care standards for behavioral health services and referrals are as follows: Urgent care will be seen within one (1) day. Routine patient care will be scheduled within one (1) week. Well-care visits will be scheduled within one (1) month. The member does not need a referral from their PCP. Prestige s behavioral health services are delegated. For additional information, please contact Provider Services at Page 101

104 SECTION XIV PROVIDER RESOURCES Page 102